UNIT 14:
ADOLESCENT BIRTH, POSTPARTUM CARE, AND PARENTING
INTRODUCTION:
Every year, 16 million women aged 15 to 19 and 1 million girls under the age of 15 give birth. The birth of a child is both an exhilarating and an exhausting experience, and sometimes a dangerous one. Complications during pregnancy and childbirth are the second most common cause of death for women aged 15 to 19 years old globally, and children born to adolescent mothers face a substantially higher risk of dying before their fifth birthday than children born to women over the age of 19. Moreover, the risk of prolonged labor and therefore obstetric fistulas is higher among young women. Young mothers are also more likely to have long-term complications (such as urinary incontinence) and to experience postpartum depression. Adolescent mothers may face discrimination and often struggle to finish their education, find meaningful work, or to get the support they need to ensure their own and their childrenÕs health. To successfully help the adolescent through pregnancy, childbirth and motherhood, providers need to distinguish how an adolescent's emotional and physical needs are different from those of an adult woman and develop appropriate responses. 
     	UNIT TRAINING OBJECTIVE:
To help providers understand and respond to the emotional and physical needs of the adolescent during pregnancy, labor and delivery, and the post-partum period.
     	SPECIFIC LEARNING OBJECTIVES:
By the end of the unit, participants will be able to:
1. Identify the essential components of routine antenatal care for adolescents.
2. Identify the psychosocial and SRH needs of adolescents during birth and the immediate postpartum period.
3. Discuss challenges facing adolescent parents, parenting skills, and infant feeding.
TOTAL TIME: 2 HOURS 40 MINUTES





UNIT OVERVIEW: 
Session
Methods
Materials
Time
14.1

Group brainstorm
Quiz 

Flipcharts and markers
TrainerÕs Tool 14a
Slides 14.1-14.8
1 hour
14.2 
Trainer presentation
Slides 14.9-14.13
20 minutes
14.3 
Small group activity
Trainer presentation
Group discussion
Flipcharts
Extra markers, art supplies, magazines, tape
Slides 14.14-14.24
1 hour
Unit Summary
Reflection

20 minutes

     	WORK FOR TRAINERS TO PREPARE IN ADVANCE:
* Review Slides 14.1-14.24 and localize content as needed.
* Prepare TrainerÕs Tool.
* SO 14.3: Collect extra markers, art supplies, magazines, and tape or glue.

     	MAJOR REFERENCES AND TRAINING MATERIALS:
EngenderHealth. 2008. Youth-friendly Services for Married Youth: A Curriculum for Trainers. New York, NY: EngenderHealth. 
London School of Hygiene and Tropical Medicine (LSHTM). 2019: Access to health services for 1 billion people with disabilities: https://www.lshtm.ac.uk/research/centres/international-centre-evidence-disability/missing-billion 
Office of the High Commissioner on Human Rights (OHCHR), et al. 2014. Eliminating forced, coercive and otherwise involuntary sterilization: An interagency statement Ð OHCHR, UN Women, UNAIDS, UNDP, UNFPA, UNICEF and WHO). https://apps.who.int/iris/bitstream/handle/10665/112848/9789241507325_eng.pdf?sequence=1 
Pathfinder International. 2016. Providing Reproductive Health Services to Young Married Women and First-time Parents: A Supplemental Training Module for Facility-based Health Care Providers. Watertown, MA: Pathfinder International.
World Health Organization (WHO). 2016. Guideline updates on HIV and infant feeding: the duration of breastfeeding, and support from health services to improve feeding practices among mothers living with HIV. Geneva: WHO. 
World Health Organization (WHO). 2014. Adolescent Pregnancy: Factsheet. Geneva: WHO. http://www.who.int/mediacentre/factsheets/fs364/en/
World Health Organization (WHO). 2010. Adolescent job aid: A handy desk reference tool for primary level health workers. Geneva: WHO. 



SPECIFIC OBJECTIVE 14.1: IDENTIFY THE ESSENTIAL COMPONENTS OF ROUTINE ANTENATAL CARE FOR ADOLESCENTS  
     	TIME
       1 hour
     	METHODS
* Group brainstorm
* Trainer presentation
* Quiz
     	MATERIALS NEEDED
* Flipcharts and markers
* Slides 14.1-14.8
* TrainerÕs Tool 14a: Quiz Game Questions
* Tape
     	STEPS

	Time: 10 minutes 
1. Set up a flipchart at the front of the room. Introduce the topic to participants with Content: Introduction below. 

       Content: Introduction
The World Health Organization reports that every year, 16 million women aged 15 to 19 and 1 million girls under the age of 15 give birth. The birth of a child is both an exhilarating and an exhausting experience, and sometimes a dangerous one. Complications during pregnancy and childbirth are the second most common cause of death for women aged 15 to 19 years old globally, and children born to adolescent mothers face a substantially higher risk of dying than those born to women over the age of 19. 
2. Write the word ÒRiskÓ at the top of the flipchart page. Ask participants to brainstorm reasons why pregnancy and childbirth in adolescence is more dangerous.  Record their responses, supplementing as needed from Supplemental Content: Adolescent Pregnancy Risks below. 

       Supplemental Content: Adolescent Pregnancy Risks
Pregnant adolescents have a higher clinical risk of: 

* Premature labor
* Hemorrhage 
* Obstructed or prolonged labor 
* Iron-deficiency anemia
* Spontaneous abortion/miscarriage
* Fistula

Pregnant adolescents also have higher risks for: 
* Stigmatization of pregnancy
* Unsafe abortion
* Malnutrition
* Violence from families or partners

3. Ask participants to review the flipchart with the risks.

Time: 20 minutes 
4. Introduce the presentation Content: Antenatal Care for Adolescents (Slides 14.1-14.8) below by telling participants that while the bulk of antenatal care for adolescents is the same as antenatal care for women over the age of 20, there are specific risks require some additional attention.  

       Content: Antenatal Care for Adolescents 

Slide 14.1: Steps of Antenatal Care
1. Assess the pregnant adolescent
2. Respond to observed signs or volunteered problems
3. Give preventive measures
4. Advise and counsel on nutrition and self-care
5. Develop (or review) the birth and emergency plan
6. Advise and counsel on contraception after delivery
7. Advise on routine and follow-up visits
(Source:  WHO Job Aid 2010)

5. Pause and ask participants for a few examples of things they should include in a history to assess risk for a pregnant adolescent. Return to the presentation with Slide 14.2: Adolescent Risk Assessment below. 

Slides 14.2-14.3: Adolescent Risk Assessment
Assess whether you think your client is at high risk. In addition to her age, some factors to look for include: 
* Parity: Is this her first pregnancy?  Is this a closely spaced pregnancy (less than 2 years after a previous birth?  Less than 6 months after a miscarriage or abortion?)
* Delivery site: Has she planned and/or prepared where she will deliver?  
* Family support: Does she have enough food, money, help with work/chores and adequate opportunities to rest and attend ANC clinics?  
* Interpersonal violence: Are their signs of domestic or intimate partner violence?
* Does she have any type of disability that might require additional attention or accommodation?
* Is there a history of:
o Anemia
o Abdominal surgery
o Genital tract surgery
o Female genital mutilation/female genital cutting
o Blood transfusion
o STIs, including HIV
o Sickle cell, heart disease, diabetes, epilepsy, asthma, or tuberculosis
o Drug or alcohol use
o Malnutrition

6. Pause and ask participants to think about what else to include in a standard adolescent antenatal visit. Return to the presentation with Slide 14.4: The Antenatal Visit below. 

Slide 14.4-14.5: The Antenatal Visit
In addition to standard screening and counseling, screen the adolescent for anemia and offer specific counseling on nutrition.  Help the client to establish a birth plan. 
Nutrition: adolescents may not have much knowledge about nutrition, either for the fetus or herself. Take a diet history: ask your patient what she usually eats and how much.  Adolescents who are not yet physically mature and are still growing will need a higher nutrient intake. 
Advise the client to eat the following foods.  Counsel her not to overcook the food, because cooking food too long destroys folic acid, an important nutrient. 
* Protein: meats, fish, beans, eggs and nuts. 
* Calcium, particularly during breastfeeding: milk, yogurt, cheese, green leafy vegetables, bone meal, beans, soy, and shellfish. 
* Zinc: spinach, beef, shrimp, kidney beans, flax and pumpkin seeds. 
* Iron: egg yolk; groundnuts; dried navy and lima beans, dried apricots, peaches, prunes, figs, dates, and raisins; molasses; fish and meat; sunflower seeds; nuts; spinach, amaranth leaves. 
* Folic acid: dark green leafy vegetables, liver, fish, nuts, legumes, eggs, whole grains and mushrooms. 

Slide 14.6: Developing a Birth Plan
The place most suitable for birth may depend on many factors, including but not limited to the clientÕs age poverty, illiteracy, as well as any disability.  
In situations that require support from a caregiver to be present throughout the pregnancy and birth, the caregiver should be included in the birth plan. 
Indications for delivery at referral hospital level: 
* Age less than 14 years
* Transverse lie or other obvious malpresentation within one month of expected delivery
* Obvious multiple pregnancy
* Prior delivery by caesarean
* Documented third degree tear
* History of or current vaginal bleeding or other complication during this pregnancy
* Tubal ligation or IUD desired immediately after delivery
   (Source:  WHO 2010)
Indications for delivery at primary health care (or higher) level
* Age less than 16 years
* First birth
* Prior delivery with heavy bleeding
* Prior delivery with convulsions
* Prior delivery by forceps or vacuum
* Last baby born dead or died within first day
* More than six previous births
   (Source:  WHO 2010)
Slide 14.8: Other Considerations
Advise the client about the following considerations when making a birth plan.
* Decrease her workload and increase rest in the third trimester
* Know the signs of labor/danger signs
* Make arrangements for transport before birth, and be aware of costs
* Plan for delivery costs 
* Pack clean clothes and cloths for herself and the baby, any home-based maternal records
* Make sure there is care for other children while she is at the facility
* Identify a person who can support her during delivery
* Start thinking about whether or not she will use contraception after delivery.  Which method might be best for her contraceptive needs?  When should she plan to start?

7. Stop and ask participants to volunteer any other considerations they think should be discussed with pregnant adolescent clients. Discuss any questions or clarifications. 

Time: 30 minutes 
8. Divide participants into three teams. Have teams come up with a group name while you tape up quiz questions from TrainerÕs Tool 14A: Quiz Game Questions to a flipchart at the front of the room, with questions covered so they cannot be read. 

9. Explain that the point of the game will be to see which team can answer the most questions correctly. Point out the questions: explain that the teams will take turns choosing a question. Once the question is read, the first team to get the answer ÒwinsÓ the points. 

10. Play the game Ð have the teams alternate choosing questions from the flipchart. Accept short answers during the game.  

11. Once all questions have been answered, review the questions again, this time going into more detail about the answers using the long answer on the card. Clarify any questions from participants during the discussion. 

12. Close by asking how providing care for an adolescent is different from providing care for an older pregnant woman. Ask how the addition of other vulnerability factors (disability, HIV positive, street life, poverty, etc.) may influence the care to be provided to the adolescent client. Discuss participantsÕ responses. 



TRAINERÕS TOOL 14A: QUIZ GAME QUESTIONS
Preparation Instructions: Print or write each question onto a separate card or colored sheet of paper.
Question 1: Which contraceptive methods should not be used by young women under the age of 25 who have had children?
Short Answer 1: None. 
Long Answer 1: All women and young persons, including women and young persons with disabilities, have a right to equal access to voluntary family planning and modern contraceptive methods, as well as counselling on how to safely and effectively use them. Nearly all contraceptive methods are safe for women of all ages. This includes pills, injectables, implants, IUDs, condoms, and more. While age or parity is not a clinical contraindication for any method, sterilization is the only method that is considered contraindicated for most young women due to their stage of life and the permanent nature of this method. Young women who request sterilization should not be denied the method based on their age, but counseled on the permanence of the method and other options available to them to ensure informed choice. Like any other contraceptive method, sterilization should only be provided with the full, free and informed consent of the individual. However, in some countries, people belonging to certain population groups, including people living with HIV, persons with disabilities, indigenous peoples and ethnic minorities, transgender and intersex persons, continue to be sterilized without their full, free and informed consent. In particular for persons with disabilities, coercive and involuntary sterilization as well as long-term contraception are often used as a method of fertility regulation on a precautionary basis. Women with intellectual and developmental disabilities, who are often treated as if they have no controlÑor should have no controlÑover their sexual and reproductive choices, are particularly vulnerable to these practices. The United Nations Committees on the Rights of the Child and on the Rights of Persons with Disabilities have specifically addressed forced and coercive sterilization of persons with disabilities including children under the age of 18 years. They have recognized that forced and coercive sterilization is a form of violence and have called for states to revise laws and administrative measures to prohibit this practice. 
All clients should also be told that only male or female condoms alone or condoms used with another contraceptive method protect from both unintended pregnancy and STIs, including HIV. 
Question 2: When should a pregnant adolescent begin to consider postpartum contraceptive use?
Short Answer 2: During antenatal counseling, as early as possible. 
Long Answer 2: Initial counseling on postpartum contraceptive use and healthy timing and spacing of pregnancy should happen during the antenatal visits. Adolescent clients should be told that they can become pregnant again within four weeks after delivery if they are not exclusively breastfeeding and they resume sexual activity. They should at least begin to consider what contraceptive method they might wish to use and when. IUDs can be inserted within a 48-hour window post-delivery.  (After 48 hours, IUD insertion must be delayed until four weeks postpartum).  Implants can be inserted after childbirth and before discharge.  
(Source:  WHO 2010)
Question 3: Which contraceptive methods can be used while a woman is breastfeeding?
Short Answer 3: LAM, mini-pills, implants, IUDs, and condoms. 
Long Answer 3: Lactational Amenorrhea Method, or LAM, only prevents pregnancy IF the baby is less than 6 months old, the baby is exclusively breastfed (e.g. the baby is fully breastfed on average every 4 hours, and no other food is given), and the womanÕs monthly bleeding has not returned. Other methods can be combined with LAM to prevent unintended pregnancy: the woman/couple can use the mini-pill (progestin-only), implants, IUDs, and male and female condoms during the postpartum period and while breastfeeding. 

Question 4: What are symptoms of pregnancy in an adolescent client?
Short Answer 4: Missing monthly bleeding, breast tenderness, nausea or vomiting. 
Long Answer 4: Standard symptoms of pregnancy include: late or missing monthly bleeding, nausea or vomiting in the morning, and swelling or soreness of breasts. All of these symptoms are also common for adolescents going through puberty, so providers counseling clients concerned about pregnancy should also check if the client is sexually active, is using any contraceptive method, whether contraceptive use is regular or sporadic, and if the client has had sex since her last monthly bleeding. 
(Source:  WHO 2010)
Question 5: Give 3 examples of times when a provider can discuss contraception with an adolescent client. 
Short Answer 5: (Any three of the following) standard health visits, HIV voluntary counseling and testing, prenatal consultations, postnatal consultations, visits to monitor infant health, and vaccination visits.
Long Answer 5: Every interaction with an adolescent client is an opportunity for contraceptive counseling. For pregnant adolescents and young parents, counseling on the importance of spacing births should begin during prenatal consultations. If a woman wants to space her next pregnancy, she can begin to think about which contraceptive method she might want to use during the postpartum period. Postpartum checks and child health visits are also a good opportunity to provide counseling on healthy timing and spacing of pregnancy and contraception. 
Question 6: Give 4 examples of ways in which confidentiality can be maintained during a consultation with a pregnant adolescent client, a young married woman, or young mother, an adolescent client with a disability.
Short Answer 6: (Any of the following) Carry out the consultation in a separate or partitioned room, make sure no one other than members of staff required for the consultation are present, keep any notes in a locked place, do not call out the clientÕs full name or reason for her visit in the waiting area, do not discuss the consultation with anyone (including her husband, partner, family, or family-in-law, or caregiver). In the case of pregnant adolescent clients with disabilities who are accompanied by an assistant or a sign language interpreter whose presence in the consultation room is explicitly authorized by the client, remind the assistant/interpreter that the information shared during the consultation needs to be kept confidential at all times. 
Long Answer 6: Young married women will often experience significant pressure to conceive, particularly if they have not yet had a child. Young mothers may also be expected to have several children in rapid succession and may be discouraged from obtaining contraception. On the other hand, young adolescents with disabilities are often vulnerable to coercive and involuntary sterilization, abortion, as well as long-term contraception, which are often requested by parents or guardians based on the justification that it is Òfor their own goodÓ. It is important to maintain client confidentiality when counseling and treating young married women, young mothers, soon-to-be-mothers, or adolescent clients with disabilities  so that they are able to make the best decisions for their needs. 




SPECIFIC OBJECTIVE 14.2: IDENTIFY THE PSYCHOSOCIAL AND SRH NEEDS OF ADOLESCENTS DURING BIRTH AND THE IMMEDIATE POSTPARTUM PERIOD
     	TIME
       20 minutes
     	METHODS
* Trainer presentation
     	MATERIALS NEEDED
* Slides 14.9-14.13
    	STEPS

1. Introduce the topic: remind participants that adolescence is a time of immense change, and that providing support for adolescents during birth and the postpartum period will likely require patience, compassion, and understanding. 

Time: 20 minutes
2. Ask if participants can suggest ways for each other on how to supportively manage adolescent clients during birth. Transition into the presentation Content: Support during Birth and Postpartum (Slides 14.9-14.13) below. 

       Content: Support during Birth and Postpartum (Slides 14.9-14.13)

Slide 14.9: Birth 
* Adapt your demeanor to the adolescentÕs individual needs to support her efforts. Provide caring, clear and understandable explanations throughout. 
* Create an atmosphere of inclusion with family or support people. 
* When preparing to perform examinations and procedures, clearly explain to the adolescent and her support person what you will be doing and why. 
* Perform maneuvers slowly and gently. 
* Use firm but caring speech: shouting is not acceptable. 
* Please take in account that some kinds of disability can make the typical lithotomy position during actual birth not the best choice for some women. Providers must be prepared to deliver in alternate positions with the possibility of assistive devices.

Slide 14.10: Immediate Postpartum Care
* As with most new mothers, the adolescent will be concerned if the baby is not close to her.  Other mothers need rest or some time alone. Ask the mother what she wants without pressing her into immediately taking care of her baby.
* After the birth of the baby, the young motherÕs body goes through another set of dramatic, physical changes and a wide range of emotional responsesÑpride, accomplishment, fatigue, and hormonal shifts.  
* Adolescent mothers have the compound challenge of needing to establish their own identity while they adjust to their new role and identity as a mother.  
* If the adolescent has elected for immediate contraception (e.g. IUD insertion), provide contraception or contraceptive advice. 
* Before the adolescent leaves the facility, explain which signs of postpartum complications she should watch for and remind her when to for follow-up. 
3. Pause and ask participants what they can do within the first hour to facilitate mother-child bonding. Supplement their responses with Supplemental Content: Mother-Child Bonding below. 

Supplemental Content: Mother-Child Bonding
* Keep mother and baby together as much as possible.
* Conduct preliminary infant examination in the presence of the mother and include her. 
* Show her the unique aspects of her baby. 
* Have her touch the babyÕs head, count fingers and toes. 
* Point out to her the babyÕs normal reflexes. 
* Assist her to breastfeed with correct attachment
* If the newborn has any visible impairment, be reassuring and tell the young mother that she will receive the information and support needed to find the appropriate care for her child. 
* The need and importance of Mother-Child bonding is NOT impacted by disability. Do not make decisions for the mother based on the fact that she has a disability but always ask her what she feels is best for her. She is in the best position to decide as she has been living with her disability for long time or for her entire life and she knows what she can or cannot do. 

4. Return to the presentation with Slide 14.11: Postpartum Period below. 

Slide 14.11-14.12: Postpartum Period
The first 6 weeks following a birth is a time of tremendous adjustment that will affect the young mother physically and emotionally. Circumstances could be even more challenging for young mothers with disabilities. For this reason, postpartum care should not be focused on the infant only but it should also take into account the specific situation of the mother and her needs. Care should be provided according to the motherÕs needs in an enabling environment that fosters her self-confidence. Care must not be provided on the basis of assumptions about what the mother cannot do or which tasks she has difficulties with.  The young mother will need support not only from the provider but from her family and social network.  This support is not always available in a community that stigmatizes adolescent pregnancy, especially if she is not married. This can leave adolescent mothers at risk for postpartum depression. 

Many new mothers feel some sadness or Òblues,Ó usually within a week following birth, ranging from mild (feeling Òdown,Ó teary, unexplained sadness, easily upset) to more profound. Providers should watch for signs of severe postpartum depression: 
* Loss of interest in things the client used to enjoy
* Anxiety or panic attacks
* Extreme mood swings
* Development of disordered eating
* Crying uncontrollably for long periods of time
* Misery
* Trouble sleeping 
* Disinterest in the baby, family, or friends
Source: American Psychological Association, 2007

Please consider that women with disabilities face a greater risk of developing postpartum depression PPD) than women without disabilities. Screening for the main mood disorders and raising the awareness of family members on PPD are key factors for providing timely and adequate care. 

5. Pause and ask participants what they think the providerÕs role should be during the postpartum period. Return to the presentation with Slide 14.13: Clinical Care in the Postpartum Period below. 

Slide 14.13: Clinical Care in the Postpartum Period
* Home visits: Starting within 48 hours of discharge.
* Scheduled follow-up visits at 2, 4, and/or 6 weeks after birth which will address:  
o Problem-solving common physical discomforts: increased perspiration, perineal pain, breast engorgement, constipation, haemorrhoids
o Nutrition and hydration, especially if breastfeeding
o Correct breastfeeding and mother-child interaction
* At 4 or 6 weeks, take a complete history and perform a complete physical examination.
* Encourage experienced caretakers and family members to support the young mother without taking over direct care of the baby.
* Connect the new mother with other young mothers or new mother support networks within the community.
* Provide contraceptive counselling and supplies, support future planning for healthy timing and spacing of pregnancy.

6. Ask participants if they remember from the previous session which contraceptive methods are safe for breastfeeding mothers in the immediate postpartum period. Remind them of the need to include counselling on healthy timing and spacing of pregnancy during prenatal, postnatal, and follow-up visits. 
SPECIFIC OBJECTIVE 14.3: DISCUSS CHALLENGES FACING ADOLESCENT PARENTS:  PARENTING SKILLS, AND INFANT FEEDING
     	TIME
       1 hour
     	METHODS
* Small group activity
* Trainer presentation
* Group discussion
     	MATERIALS NEEDED
* Flipcharts and markers
* Extra markers, art supplies, magazines, scissors, and tape
* Slides 14.14-14.24
     	STEPS

	Time: 30 minutes
1. Ask participants to brainstorm some of the challenges that young people in their community face when they become parents keeping in mind some of the vulnerability factors mentioned earlier on in the unit such as disability, HIV, poverty, etc.  Flipchart their responses at the front of the room. 

2. Divide the participants into small groups of 3-4 people each. Give each group a flipchart page. 

3. Explain to the groups that the purpose of this exercise is to visualize the challenges and pressures on young parents. Instruct groups to draw two figures on their flipchart. These two figures represent the new parents.  

4. Place the art supplies, magazines, scissors, and tape at the front of room. Tell groups that they will have 20 minutes to create a picture of young parents which shows the challenges they face in their relationship, as parents, and in society. 

5. While participants are working in their small groups, go around the room and monitor their progress. If it seems like groups are getting stuck, give them some ideas from Supplemental Content: Challenges for Adolescent Parents below. 

       Supplemental Content: Challenges for Adolescent Parents
* Feelings of inadequacy 
* Feeling unprepared
* Confusion 
* Anxiety about the babyÕs health
* Social isolation or discrimination
* Resentment or depression over loss of leisure
* Family or community disapproval
* Policies barring re-entry to school 
* Loss of work 
* Concerns about being Òleft behindÓ peers
* Challenges in maintaining a relationship
* Fatigue 

6. Have one representative from each group present their flipchart to the whole group. Allow time for clarifying questions or reactions after each presentation. 

7. Facilitate a plenary discussion about the activity using the following discussion questions: 
a. Which of these challenges are internal and which are external/social?
b. Are there different challenges based on the gender of the parent?  
c. Are there different challenges for young mothers with disabilities?
d. How do the challenges affect the adolescent parentÕs physical, mental and emotional health and ability to care for a child?
e. How can providers support new parents with and without disabilities and their families and communities?

8. On a flipchart, record responses to question above, ÒHow can providers support new parents with and without disabilities and their families and communities?Ó

Time: 30 minutes
9. Ask participants to review their responses and consider what specific support adolescent fathers might need. Begin presentation Content: Adolescent Parenting (Slides 14.14-14.24) below with Slide 14.4: What Adolescent Fathers Need below. 

       Content: Adolescent Parenting

Slides 14.14-14.15: What Adolescent Fathers Need
* Acceptance and integration into antenatal, delivery and postnatal services.
* Counselling about sexual and reproductive health, including the importance of contraception to space the next pregnancy.
* Exposure to positive models of and information about positive parenting skills.
* Encouragement to learn effective parenting skills, such as feeding, bathing, changing nappies, playing, positive social interactions, and participating in health care discussions. 
* If one or both parents have a disability, it may be helpful to know where to acquire information and support for them on how to parent independently. 
* Information about the importance of breastfeeding, immunization, nutrition, and growth monitoring. 
* Continued access to economic and educational opportunity.
* Information about healthy timing and spacing of pregnancy and family health.
* Positive relationship models and information about how to best support their partner. 
* Positive fatherhood role models.
* Information has to be accessible for all, including persons with disabilities.

10. Pause and ask participants what the specific needs for adolescent mothers might be. Return to presentation with Slide 14.16: What Adolescent Mothers Need below. 
Aquire 

Slide 14.16-14.17: What Adolescent Mothers Need
* Information about the importance of antenatal care, trained providers during delivery and postpartum care.
* Social support during and after pregnancy.
* Postnatal support and health care for themselves and their infants.
* Information about the importance of breastfeeding, immunization, nutrition, and growth monitoring. 
* If one or both parents have a disability, it may be helpful to know where to acquire information and support for them on how to parent independently. 
* Encouragement to learn positive parenting skills, such as feeding, bathing, changing nappies, playing, positive social interactions, and participating in health care discussions.
* Counseling about sexual and reproductive health, including information about modern contraception to delay the next pregnancy.
* Appropriate contraceptive methods, based on her breastfeeding status.
* Information about healthy timing and spacing of pregnancy and family health.
* A confidential, private, affordable, and welcoming service environment.
* Continued access to economic and educational opportunity .
* All information has to be accessible for all, including persons with disabilities.

11. Pause and point out the overlap between what young fathers and young mothers need. Remind participants that positive and gender equal parenting skills are learned and developed during this time. Return to the presentation with Slide 14.18 Parenting: Immunization below. 

Slide 14.18: Parenting: Immunization
Immunization: When to immunize
* BCG: Birth or any time after birth
* DPT: 1 ?, 2 ?, and 3 ? months
* OPV: 1 ?, 2 ?, and 3 ? months
* Measles: 9 months and 12 months

All immunizations should be completed before the child reaches 1 year. 
Slide 14.19: Parenting: Infant Feeding
Breast milk is the perfect, complete food for a baby:
* It has all the nutrients the baby needs.
* It is easy for the baby to digest.
* It gives the baby important protection from infections.
* It always fresh, clean, and ready to drink.

Breastfeeding also has advantages for the mother and her family: 
* It slows the return of the motherÕs menstruation after birth.
* It helps prevent the mother from getting pregnant again too soon.
* It does not cost anything.

Slide 14.20: Parenting: Breastfeeding
How to have enough milk: 
Breast milk is the best and only food the baby needs for the first six months. To produce enough milk, the mother needs to be healthy, drink plenty of fluids, eat plenty of nutritious food, and get plenty of rest. 
For HIV positive mothers, the combination of exclusive breastfeeding until age 1 and the use of antiretroviral treatment will ensure the baby benefits from breastfeeding with reduced risk of HIV.
(Source:  WHO 2016)
       When to stop breastfeeding: 
Babies should have only breast milk for the first 6 months but can be breastfed for at least 2 years. Most older babies wonÕt breastfeed as often as young babies. 
Slide 14.21-14.22: Adolescents and Breastfeeding
Breastfeeding can be a challenge for adolescents: it can be demanding of their time, confine their movements, and restrict their ability to return to their education or work. It can be messy and uncomfortable.  Providers can help adolescents maintain a realistic perspective of breastfeeding that helps the young mother with her planning and decision-making. 
* Emphasize that breastfeeding forms and important bond between mother and baby. 
* Offer emotional support if she feels judged or isolated for breastfeeding.  Remind her that she is doing something special and miraculous that only she can do to maintain the health of her baby. 
* Give practical suggestions to help her plan for breastfeeding, starting during antenatal care. Provide breastfeeding guidance from the moment of delivery. All information has to be accessible for all including persons with disabilities.
* Emphasize the convenience, efficiency and cost-savings of breastfeeding plus the health benefits to the child. 
* Help set short-term goals.  Breastfeeding until she returns to school is better than not breastfeeding at all, combining breastfeeding with formula or other feeding is better than not at all. 
* Connect her with social supports if they exist. Mother to mother support relationships can help adolescent mothers sustain breastfeeding. 
* Focus on positive body-image. Breastfeeding can help her return to her pre-pregnant shape. 

Slide 14.23-14.24: Parenting: Bottlefeeding
Mothers should never be pressured into any method of infant feeding but should be supported with information and evidence to make an informed choice. Bottle feeding is an acceptable choice for many young mothers. All information has to be accessible for all, including persons with disabilities.

Adolescent mothers may have the option of using commercial formula or concentrate and should learn how to prepare formula correctly.  Warn mothers to not overdilute formula, which could damage the healthy growth of the child. 
If the mother cannot afford commercial formula, she may choose to make her own formula.  She should NOT use cowÕs milk for an infant younger than 1 year because it is too high in protein and has inadequate amounts of vitamins and iron. 

She should be advised of the following: 
* How to prepare, use, and store the formula. 
* How to maintain and clean nipples, bottles, and other supplies. 
* The importance of holding and cuddling the child during bottle-feeding to support bonding. 

12. Finish the presentation by asking for clarifying questions or reflections from participants. 

13. Ask if any participants have a story they would like to share about a young mother or young parents they have worked with, what the challenges and success were. Allow time for sharing and comparison of participantsÕ experiences. 



UNIT 14 SUMMARY
     	TIME
       20 minutes
     	METHODS
       Reflection
     	MATERIALS NEEDED
       None
     	STEPS

1. Ask participants to reflect on the unit using the following questions: 

* What challenges can I help adolescent parents and pregnant adolescents get past? What about adolescent parents and pregnant adolescents with disabilities? 

* What challenges need more support from the community?