S5: MATERNAL CHILD HEALTH

Key unit competence:

Provide counselling in reproductive health

By looking at the above picture A, B and C, respond to the following questions:

4.1. Definition of key concepts

Learning Activity 4.1

Using different source of information (internet, books or any other source of
information) search for the definition of the following terms and be prepared for
class presentation:
Reproductive Health is defined as a state of complete physical, mental and social

well-being and not merely the absence of disease or infirmity, in all matters relating 

to the reproductive system and its functions and processes.
Reproductive health therefore implies that people are able to have a satisfying
and safe sex life, and that they have the capability to reproduce and the freedom
to decide if, when and how often to do so. Implicit in this last condition are the
right of men and women to be informed of and to have access to safe, effective,
affordable and acceptable methods of family planning of their choice, as well as
other methods of birth control which are not against the law. Men and women have
the right to access the appropriate health-care services that will enable women
to go safely through pregnancy and childbirth and provide couples with the best
chance of having a healthy infant.

A face-to-face communication or interactive process that a healthcare provider have
with a client or couple in order to help them arrive at voluntary and informed decisions
is defined as Counselling. Counselling is used in many different ways including but
not limited to counselling for maternal and new-born health, reproductive health

family planning, therapy, during crisis and adolescent health. 

Reproductive counselling supports individuals and couples in their journey to
become parents; provides an opportunity to receive support, better understand the
reproductive options and choices, and explore the impact of these events on client

relationships.

Self-assessment 4.1

Define the following terms:
4.2 The process, principles, skills of counselling in Reproductive

Health

Learning Activity 4.2

Discuss in groups of 5 the following activities:
1. The key steps in counselling process.

2. The principles for a successful counselling

The counselling process takes place within a counselling context and it is important
to be familiar with it as it provides the guidance on how to act, what is appropriate
and the situation, culture and norms of the person that is being counselled. There
are a number of guiding principles and counselling skills which support the

counselling process. 

1. The Counselling process
There are six steps for counselling. Through these steps, the counsellor can give
support and guidance
Steps of counselling:
1. Assess the situation: Engage the individual in interactive discussion. Ask
questions to
better understand the situation and the needs of the client
2. Define problems, needs and information gaps: Review with the client what it
is
about the situation that prevents from addressing the needs. What makes the
situation a problem, what are the causes of the problem? What does the client 
know already? Assess the need of additional information.
3. Generate alternative solutions: Review with the client how can better address
the needs by looking at what is currently being done, and what else could be done.
Identify what other information, resources or support is needed.
4. Prioritize solutions: by reviewing the advantages and disadvantages of the
various
alternatives, work out with the client which of the alternatives are most feasible to
address the problem and/or meet the needs. Assist the client to work out how to
overcome potential disadvantages.
5. Develop a plan: make a plan together
6. Review and evaluate: in the following counselling sessions review implementation
of the plan with the client. Is the plan working or should another alternative be
required?
2. The principles of counselling
These are values and process that are used in provision of professional assistance

and guidance in resolving personal or psychological issues.

Principle 1. Establish and maintain rapport with the client
Establishing and maintaining rapport with a client is vital to the encounter and
achieving positive outcomes. This can begin by creating a welcoming environment

and should continue through every stage of the client encounter, including follow up. 

Principle 2. Assess the client’s needs and personalize discussions accordingly

Each visit should be tailored to the client’s individual circumstances and needs.

Principle 3. Work with the client interactively to establish a plan
Working with a client interactively to establish a plan, including a plan for follow-up,
is important. Establishing a plan should include setting goals, discussing possible
difficulties with achieving goals, and developing action plans to deal with potential
difficulties.
The amount of time spent establishing a plan will differ depending on the client’s
purpose for the visit and health-care needs. A client plan that requires behavioral
change should be made on the basis of the client’s own goals, interests, and

readiness for change.

Principle 4. Provide information that can be understood and retained by the
client
Clients need information that is medically accurate, balanced, and nonjudgmental
to make informed decisions and follow through on developed plans. When speaking
with clients or providing educational materials through any medium (e.g., written,
audio/visual, or computer/web-based), the provider must present information in a
manner that can be readily understood and retained by the client. 

Principle 5. Confirm client understanding

It is important to ensure that clients have processed the information provided and
discussed. One technique for confirming understanding is to have the client restate
the most important messages in her or his own words. This teach-back method can
increase the likelihood of the client and provider reaching a shared understanding,

and has improved compliance with treatment plans and health outcomes.

4.2.1 Counselling skills

The key skills needed for counselling are: two-way communication; forming an

alliance; active listening; open questioning; providing information; facilitation.

Two-way communication: Good communication is central to good counselling
and involves the exchange of information and is most productive
when it is a two way process which offers an opportunity for each
of the parties involved to clarify issues, provide feedback and discuss topics.
 Many of the skills we discuss for good counselling are also important to good
communication. 
2. Forming an alliance: The counsellor’s first communication task is to build an
alliance, or a partnership, with the client and this alliance serves as the foundation
that encourages the client to actively participate in the session. You can help form
an alliance with a client by identifying similarities between yourselves, sharing

information about one another.

3. Demonstrating active listening: Listening is more than just hearing someone
else’s words; it involves being attentive and demonstrating that you have heard and
understood what is being communicated to you.

Demonstrating that you really are listening will increase the client’s trust and
confidence in you as a counsellor, and will make her feel more at ease thus helping
to form an alliance. Demonstrating that you have heard and understood what has
been said to you can be done by paraphrasing, whereby you repeat back what has
been said to you using different words
4. Providing information
As a counsellor, you need to provide clear and understandable information, pertinent 
to the
client, her family and their situation. it is important to make sure that the information
you provide has been understood. You can ask if there is anything that needs further
explanation or clarification, or sometimes you may wish to ask the client to repeat

back in her own words what has been discussed.

5. Facilitation

Facilitation is the word given to the process of assisting problem-solving. Facilitation
is about assisting client to find his/her own solutions, as well as supporting him/her to
take the action needed. In a counselling situation, if you make decisions for a client
then responsibility and control is taken away from her/ him and it may lead to greater
dependency and feelings of inadequacy. It is important that a client is provided with
the opportunity to think out her/his situation and try to resolve needs. One way to
facilitate is to ask the client to list all the possible solutions identified. If you can
think of others, you might suggest them to be added to the list of alternatives, but
do not push your ideas too strongly. Then explore each alternative one by one. Get
her/him to think about the advantages and disadvantages. Keep summarizing what
have discussed and feed this back. Once the client reaches a decision, you can

follow a similar process to help facilitate a plan of action to carry out the decision.

Self-assessment 4.2

Explain the principles and the skills of successfully counselling

4.3 Counselling frameworks

Learning Activity 4.3

Using different source of information (internet, libraries) answer the question
below:

What are the two different frameworks of counselling in Reproductive Health?

The REDI framework
The REDI framework (which stands for Rapport-building, Exploration,
 Decision making, and implementing the decision) and it is a client
 centered counselling framework.

Phase 1: Rapport-Building
1. Welcome the client by greeting the client warmly and helping the client to
feel comfortable and relaxed
2. Make introductions by identify the reason for the client’s visit and ask
general questions, such as name, age, number of children, category of client
(new, satisfied, etc).
3. Introduce the subject of counselling: Explain the reasons for asking
questions and explain that the client does not have to answer questions
4. Assure confidentiality: Explain the purpose of and the policy on confidentiality
and create an atmosphere of privacy by ensuring that no one can overhear

your conversation, even if you are not able to use a separate room 

Phase 2: Exploration
1. Explore the client’s needs, risks, and circumstances (Identify the reason
for the visit in detail) by assessing what the client understands about his or
her situation, what worries or concerns he or she might have, and what he or
she specifically hopes to accomplish through the visit
2. Assess the client’s knowledge and give information, as needed
by assessing the client’s knowledge of the reason of visit and correct
misinformation and fill in gaps, as needed
3. Assist the client to perceive or determine his or her own problem’s risk
by asking the client if he or she feels at risk for reproductive health problems,
help the client to recognize and acknowledge his or her risks and explore the

reasons.

Phase 3: Decision Making
1. Identify what decisions the client needs to make in this session by helping
the client to prioritize the decisions, to determine which are the most important to
address and explain the importance of the client’s making his or her own
decisions
2. Identify the client’s options for each decision by helping the client to
lay out the various decisions that a client could make and to explore the
consequences of each.
3. Weigh the benefits, disadvantages, and consequences of each option by
making sure the discussion centers on options that meet the clients’ individual
needs, taking into account their preferences and concerns; providing more
detailed information, as necessary, on the options that the client is considering;
considering who else would be affected by each decision.
4. Assist the client to make his or her own realistic decisions: Ask the client
what is his or her decision; why he or she is making this decision; check to see
that this decision is the choice of the client free of pressure and help the client
to assess whether his or her decision can actually be carried out, given his

or her relationships, family life, and economic situation, among other issue

Phase 4: Implementing the Decision

1. Make a concrete, specific plan for carrying out the decision: Be specific.
If a client says that he or she is going to do something, find out when, under
what circumstances, and what his or her next steps will be in each situation.
Asking a client “What will you do next?” is important in developing a plan to
reduce risk. For example, if a client says that he will start to use condoms, the
provider should ask, “How often?” “Where will you get the condoms?” “How
will you pay for them?” “How will you tell your partner that you want to use
them?” and “Where will you keep them so you will have them with you when

you need them?” 

2. Identify barriers that the client may face in implementing the plan: Ask
about possible consequences of the plan: “How will your partner(s) react?” “Do
you fear any negative consequences?” “How will the plan affect relationships
with your partners?” “Can you communicate directly about the plan with your
partners?” and “Will indirect communication be more effective at first?”
3. Develop strategies to overcome the barriers: Ask about social supports.
Who in the client’s life can help the client carry out the plan? Who might create
obstacles? How will the client deal with a lack of support or with individuals
who interfere with the client’s efforts to reduce risk? Make a “Plan B”—that

is, if the plan does not work, then what can the client do?

Make a plan for follow-up: Invite the client to return for a follow-up visit to provide
ongoing support with decision making, negotiation, and behavior change; explain
timing for medical follow-up visit; make referral for services not provided at your
facility
The GATHER framework
The GATHER framework (which stands for Greet, Ask, Tell, Help, Explain and
schedule a Return) ensures that providers are client-focused, since it emphasizes
learning about the client and having a dialogue together, rather than talking at the

client. Ensuring informed choice is a critical element of GATHER. 

GATHER provides a useful framework, but this does not mean that it must be
followed exactly or in sequential order during a counseling session. GATHER is
merely a suggested guide of steps and topics to cover while the provider and

client engage in an interactive two-way discussion of the client’s needs and risks.

G = GREET the client politely and warmly. This includes praising the client for
coming in and explaining that the discussion is confidential, including the facility’s
confidentiality policy, if applicable. These are both important parts of building
“rapport” with a client developing feelings of safety and trust so that clients will feel

comfortable talking with you about their concerns.

A = ASK the client about himself or herself, his or her family members, and his or
her general life circumstances. Ask the client why he or she has come to the facility.
As the client gives you information about why he or she has come
in, ask probing questions as part of the assessment process.
T = TELL the client about what kinds of services the facility offers, to make informed
choices and good decision, clients need clear, accurate, specific information about
the range of their choices. Let clients understand their possible choices. Information
should be tailored that is important to client’s decision. Information should be

personalized, put in term of client’s own life.

H HELP the client make the decision that is best for him or her, this does not mean
making the decision for the client; it means helping the client determine if he or she
is at risk and helping the client decide what he or she will do to reduce these risks.
In this way, the provider helps the client to reach a decision.
E = EXPLAIN whatever needs explanation or clarification: how the facility works,
how the decision taken works, explore how the client will follow through on a plan,
explore how the client will confront and address obstacles, the provider explains
to the client how to carry out client’s decision and tries to tailor and personalize

instructions to suit the individual client’s way of life.

R = Schedule a RETURN visit: Whenever possible, schedule follow-up
appointments with clients to assess their ongoing progress in carrying out their plan
for reducing risk and to make changes in the plan, if necessary. Provide additional

information, resources, or referrals, as needed.

Self-assessment 4.3
Differentiate the REDI and GATHER frameworks
4.4 Premarital Counselling
Learning Activity 4.4


In groups of 5 discuss about the definition of premarital consultation and
 its objectives.
Premarital counselling helps couples to prepare for marriage. By participating
in premarital counselling prior to their wedding, couples can begin to build a
healthy, strong relationship that helps provide a healthier foundation for their union.
Premarital counselling can help couples of any gender, race, or religion identify
and address potential areas of conflict in their relationship. Additionally, counselling
can prevent small issues from escalating into serious concerns at some point in
the future. Premarital therapy also helps couples identify their expectations for the

marriage and address any significant differences they might have.

1. Goals and Objectives of Premarital Counselling
Change the view of the relationship: During the therapeutic process, the
counsellor helps each partner examine the relationship in a more objective manner
and assists the couple in learning how to perceive their interactions in a positive
light.
Understand how cultural issues affect a relationship: Family of origin and
cultural beliefs affect how the partners understand all the relationships in their lives.
It also affects day to day behaviors, such as eating, working, and managing money.
Differences in cultural expectations can cause difficulties in the relationship. The
sooner the couple learns to identify and manage these differences, the better. A
counsellor can help reveal these problems and teach the couple how to use the art

of compromise

Eliminate dysfunctional behaviour: Premarital counselling helps couples identify 
and correct dysfunctional behaviors, such as issues with dominance and control

and addiction.

Improve communication: Effective communication is one of the most important
factors in a healthy relationship. A premarital therapist helps couples learn how
to talk to each other openly and express their thoughts and feelings in a healthy,

supportive manner.

Identify strengths: A premarital counsellor can help the couple identify strengths in
the relationship as a whole or in each individual partner. A thorough understanding
of the stronger aspects of the union helps build resilience and a solid foundation
upon which to build the marriage.
Decrease emotional isolation and avoidance: Many people have difficulty
expressing their feelings, so some partners simply avoid doing so. This type of
isolation almost always leads to serious problems in the relationship. A premarital
therapist assists the couple in learning how to express their feelings in a way that
draws them together rather than further apart.
2. Benefits of premarital counselling
The many advantages of premarital therapy include:
Helps build and strengthen conflict resolution skills: Conflict resolution skills
are critical for a healthy marriage. Premarital therapy offers couples a way to
identify potential conflicts and how to develop the skills necessary to get through

tough battles.

Identifies issues early: Different expectations have a disastrous effect on most
marriages. Marriage therapy assists couples in determining and discussing their
expectations early on. If the couple has different expectations, then the counsellor
can work with them to identify ways to cope with those differences.
Helps couples avoid toxic anger: When couples believe they are no longer in
love, it’s usually simply that they have allowed anger to build up in the relationship.
Resentment is toxic to happiness, and during premarital therapy, couples learn
ways to avoid this type of emotional poison.
Reduces fears about the longevity of the marriage: Statistical evidence proves
that marriages end every day, which is concerning to a couple contemplating the
prospect. Premarital therapy helps the couple identify and confront fears about

forming and maintaining a successful relationship.

3. Common issues addressed in premarital counselling
Premarital counselling addresses a broad range of topics, including these typical
issues:
Conflict resolution: How does each partner resolve conflicts? How do their
perceptions of issues correspond? How can they improve their ability to come to
terms on issues on which they disagree?
Communication: How does the couple communicate? Do they currently have an
adaptive or maladaptive method for discussing important issues? How can they
enhance their ability to communicate?
Define marital expectations and beliefs: What does each partner expect from
the relationship? People sometimes enter relationships with different expectations
as to what constitutes a successful marriage. They often are unaware that their
expectations differ until they are already married, which can lead to serious issues.
A premarital therapist encourages each partner to discuss their expectations, after
which the couple can work toward finding ways to compromise.
Personal values: Do the partners have similar personal values? Research
demonstrates that shared values are more important than common interests, and
couples with the same values have a better chance of staying together.
Finances: Can the couple talk about financial issues? Many people are uncomfortable
when discussing their personal finances, and issues with spending and budgeting
often create conflicts in marriages. The counsellor helps each partner determine his
or her own financial style and then works with the couple in resolving these issues.
Family: Do both partners want to have children? If so, how many children does
each person want? For each partner, what is the optimal time to begin a family?
Sex and intimacy: Are both partners equally comfortable or uncomfortable when
discussing sex? What does each partner expect in terms of intimacy and a sexual
relationship? Couples should speak honestly and openly about sex, even if they
have chosen to remain celibate until marriage. An ability to discuss these issues

without reservations helps lead to a successful marriage.

4. Steps of premarital counselling

Marriage is an important event of life. It is an untraversed path for the most.
However, marriage has many aspects which many people are not aware of till they
experience it. Men and women both have different physical, emotional and sexual
needs. Even, their way of thinking and perceiving usually differs from each other.

Premarital counselling is a therapy which helps to prepare the couples mentally for
marriage. The counselling helps to make sure that you and your spouse can have
a strong and healthy relationship throughout your life. Premarital counselling helps
to improve a couple’s relationship before marriage.

During the counselling, the counselor a guide that is used in other counselling

especially in reproductive health. 

During premarital counselling the provider uses the steps and topics where the
couple and the provider are engaging in an interactive two ways discussions of the
couples needs following these steps:
• Welcome: welcome the couple politely and warmly. This includes thanking
the couple for coming to the health facility, and explaining the process of
counselling for couples. the provider has to ensure to the couple that the
discussion will be private and confidential. 



Self-assessment 4.4
1. What are the goals and objectives of premarital counselling?

2. What are the steps of premarital consultation? 

4.5 Voluntary Counselling and Testing

Learning Activity 4.5

Using textbooks and other resources, work in group and discuss about:
1. The definition of Voluntary counselling and testing (VCT)
2. The expected benefits of VCT for clients and society
Voluntary counselling and testing (VCT) is the process by which an individual
undergoes
confidential counselling to enable the individual to make an informed choice about
learning
his or her HIV status and to take appropriate action. If the individual decides to take
the
HIV test, VCT enables confidential HIV testing. Counselling for VCT consists of
pre-test, post-test and follow-up counselling.
Pre-test counselling includes a private session with a counsellor, who explains
the testing procedure and how the results will be given and gives an individual (or a
couple or group) the opportunity to explore and analyses their situation and consider
being tested for HIV. Each individual makes an informed decision of whether or not
to take the HIV test after they have been given information and supported to reach
an understanding of what is involved after having the chance to ask questions
about the test, and share any fears or worries. Counselling helps people identify the
implications of a negative or positive result.
Post-test counselling supports people in understanding their test result and its
implications, whether the result is positive or negative. Counselling also helps clients
explore whom they might share the test result with, and how to approach sharing
their test result. Follow-up counselling supports clients in coping with issues raised
as a result of learning HIV status, and is relevant for both clients that test positive

or negative.

Benefits of VCT for clients and society
VCT is an effective strategy for facilitating behavior change for both clients that test

negative and Positive and for the society.

To HIV NEGATIVE CLIENTS
To HIV POSITIVE CLIENTS
To society
Common barriers to VCT
In addition to the benefits of VCT, there are also barriers to VCT. It is necessary to
acknowledge and explore these barriers in order to develop strategies to overcome
them.
Stigma
HIV is stigmatized in all countries, resulting in those with the virus experiencing
discrimination or rejection. Fear of rejection or stigma is a common reason for not
wanting to know or disclose the HIV status. VCT itself can be an important strategy
in reducing stigma because, as more people become aware of their HIV status, HIV
will become more normalized.


Lack of perceived benefit
For people living in areas with few resources, there may be a perception that little
support will be available to them if they learn they are infected with HIV. Clients and
the community have to be supported in understanding that people infected with HIV
may remain healthy for many years.
Gender inequalities
Couple counselling in VCT, when conducted in a skilled manner, may play a role
in reducing gender-based violence, discrimination, isolation, or abandonment
experienced by some women who test HIV positive.
Lack of understanding of risk
Many people, particularly in low prevalence areas where knowledge levels about
HIV/AIDS may be low may not perceive that they are at risk. In high prevalence
areas, people may believe that they are already infected. VCT services can help
people understand their personal level of risk, encourage safer sex practices, and

support people to access care early if they are infected.

Principles of VCT

Steps of VCT
The steps of Voluntary Counselling and Testing for HIV as shown in the following

figure include pretest counseling; testing; post-test counseling. 

Pre-test Counselling
Pre-test counselling should be concise and brief as much as possible and provided
to all people seeking or requiring HIV testing. It may be provided individually, to a
couple, to a group of people or, if necessary, to a parent or guardian (for children
below 12 years, people not in command of all their mental faculties, and people with
disabilities).
Pre-test counselling provided in a group should utilize Information, Education
and Communications/Behavior Change Communication (IEC/BCC) approach and
should provide message about:
Individual pre-test counselling takes place in a designated counselling area,
where clients are received one at a time and must follow the following steps:
HIV Testing
HIV testing can be performed using blood or oral fluids.
HIV testing using blood: uses the finger prick method and follow national HIV
Rapid Test Algorithm approved by the MOH to provide a final HIV test result.
Clients with indeterminate/ inconclusive test results according to the testing
algorithm will return for retesting after 4 weeks with the exception of special cases
required to send sample
immediately for testing using HIV ELISA to include the following: Pregnant women
attending antenatal clinics and delivery room, Couples who seek HIV testing for
marriage, Rape cases.
HIV Testing using oral fluids: Commonly known as HIV Self-Testing, this should
be done by the client him/herself using the OraQuick test kit. A positive result does
not mean that the client is definitely infected with HIV, but additional testing for
confirmation should be done in a health facility using the HIV testing method that
uses blood. If the self‑test result is negative, the individual’s HIV status should be
considered negative. If an individual self-tests and has been recently exposed or is
at ongoing risk; then retesting should be recommended.
The age to which a person is allowed to perform HIV self-testing should be for
persons aged 18 years and above.
HIV Testing algorithm: is serial algorithm that comprises of 2 stage tests:
Current HIV Rapid Test Algorithm

Announcement of the Result
The results of an HIV rapid test are to be given the same day and communication
of the results is verbal. Clients requesting for written results for any reason must be
received/reviewed by the management of the Health facility and provide authorized
written results. Positive or negative results may change depending on many factors
(client exposure after previous test, window period, inconclusive results, sample
and human errors) therefore written results should be interpreted with cautiousness.
Post-Test Counselling
The same person who gave the pre-test counselling should provide post-test
counselling and this process must respect confidentiality. In case the client is a child
below 12 years or an adult not in command of all of his mental faculties, post-test
counselling will be given to the parents or guardian.
In case of negative results:
In case of positive results:
Self-assessment 4.5
1. What does the pre and post-test counselling includes?

2. What are the steps of VCT?

4.6. End of unit assessment

End of unit assessment

Margarita and Martin are a young couple that want to wed anytime soon. The
lady presents herself to the health center to VCT prior to her fiancé for a VCT.
later alone the man came and they want each to have VCT and premarital
counselling.
While you plan to give a session you should be able to answer the following
questions:
1. What are the common barriers to VCT?
2. What are the principles of VCT?
3. Differentiate the REDI and GATHER counselling frameworks and decide
which one to use.
4. Name each phase of REDI:
R = ______________________________
E = ______________________________
D = ______________________________
I = ______________________________
5. The benefit of following a counseling framework, like REDI, is that

it provides a structure for talking with clients