Back home again

So we are back home again in the dark, cold UK.  I wore the traditional dress I was given by CH Rennie Hospital today to cheer me up and help me wade through the mound of paperwork that awaited me at work.

We had a very successful trip all in all.  We trained 26 midwives and neonatal nurses, further honed the course material and made friends with some wonderful people.  Working alongside MCAI (www.mcai.org.uk) worked well.  They are doing sterling work with extended skills training for midwives as well as supporting the neonatal nurse practitioner programme.   Their medical director, Professor David Southall OBE, recently spoke about MCAI’s Liberian task sharing programmes, see https://torquaymedsoc.com/liberia.

Can I practice it single-handed?

Resuscitation of the newborn is all about team work and in the UK we train people as much in how to get the best out of and support their team as we do about what to actually do in a resus situation.

Our Liberian learners have a lot of experience with trying to resuscitate very sick babies.  Much sicker than any we see nowadays in the UK thanks to better obstetric care and recognition of fetal distress before the baby is significantly deprived of oxygen.  They are used to taking responsibility for these sick babies and their clinical skills are impressive.  But when we try to get them to resuscitate in pairs or in threes, they will often ask if they can practice it “alone”.  This is because many of our learners are single-handed practitioners in remote communities with no one who will answer their call for help in an emergency situation.

 

1 breath to…

 

…. 3 chest compressions

We teach them how to balance the bag on their arm to better facilitate rhythmic chest compressions and breaths for newborns in extremis – I find their earnestness humbling.  When have I ever been in an emergency situation without 2 or 3 extra pairs of hands around me?

The 8 “danger signs” in the newborn

We are nearly at the end of our second course here in Liberia.  We have 2 doctors who are now helping with the facilitation of the course as well as Kola and Gertrude (one of the new neonatal practitioners).  This means that we have time to just sit and listen to some of the sessions which gives us a different perspective.  The role of the instructor is such that we facilitate a session, keeping an eye on the time, on our learners’ needs, on whether people can see the slides and hear us etc. and sometimes the actual content sort of passes us by.

One of our workshops is entitled “Recognising serious illness” and we use one of the Global Health Media videos as a teaching and discussion resource.  It talks about the 8 “danger signs” and it all makes so much sense.  These videos are truly superb.  Take a look at https://globalhealthmedia.org/portfolio-items/danger-signs-in-newborns-for-health-workers/?portfolioID=5638.  But also look at the other videos on that site that are all free to download.  There are videos on caring for the preterm infant, giving an im injection, expressing breast milk, cup feeding and all sorts of other absolute gems.  Filming was done in India and Nigeria and the world owes a debt of gratitude to the families who allowed their incredibly sick babies to be filmed and to the health care workers who assessed these babies for us so clearly on film.  I shall be using the one on signs of respiratory distress in teaching sessions in the UK: https://globalhealthmedia.org/portfolio-items/breathing-problems/?portfolioID=5638.

The 8 danger signs are as follows:

 

We have been stressing these “danger signs” during the scenario simulation sessions this afternoon.  It certainly helps our learners to concentrate on the things that matter when working through their scenario.  They are not used to this type of learning (role play with a manikin and some basic equipment) and tend to stand around the manikin talking rather than doing.

They are getting quite into it now though and I’m looking forward to the final simulation session tomorrow before their exam.  Once they get used to it, it becomes quite fun – and quite difficult to control as they all start making up the scenario for their colleagues regardless of what I’m trying to tell them is happening!  They are using their own experiences and some of what they are replaying is probably quite cathartic in an environment where a “team debrief” after an unsuccessful resuscitation is pie in the sky.

 

“Titty water time!”

We teach the Newborn Care Course in different countries of the world and although the language used is English, we do find that some words don’t travel very well.  Here in Liberia we have had to change the names of the babies in the case histories because they had a French flavour to them (because of our work in Cameroon) and our Liberian colleagues couldn’t work out how to pronounce “Yves” and “Mireille”.  We’ve also changed “cot” to the more American “crib” that they use here and we allow them to talk about “reflex” interchangeably with “tone” when they are assessing the newborn baby.  But today’s lexicon stumped us initially until it became clear that “titty water” is in fact breastmilk.

Just about everyone breastfeeds in Liberia.  I thought it was because the pregnant women were well educated in the antenatal clinic but it transpires that many women go nowhere near the antenatal clinic.  It’s just that formula is expensive.  Very few breastfeed exclusively for 6 months as per current WHO advice.  World Bank figures for exclusive breastfeeding in babies under 6 months of age for 2013 suggest that 54.58% of these young babies in Liberia are exclusively breastfed (https://tradingeconomics.com/liberia/exclusive-breastfeeding-percent-of-children-under-6-months-wb-data.html).  They are given corn cereal mixed with water to supplement the breast milk and sometimes from a very young age.

Early breastfeeding is one of the World Health Organisation’s 4 top priorities for combating high neonatal mortality rates and we talk a lot about supporting breastfeeding mothers during the Newborn Care Course and the importance of feeding expressed breastmilk to the babies on the neonatal units.  Our co-instructor, the indomitable advanced neonatal nurse practitioner Kola, pits the mums on his neonatal unit against one another with his 3 hourly cry of “titty water time” when they all have to express 10mls of breastmilk to feed their premature baby down the baby’s nasogastric tube.  He says a bit of healthy competition leads to better neonatal outcomes!

Image result for expressing breast milk by hand
Picture from excellent cartoons on hand expressing breastmilk at https://www.fitpregnancy.com/baby/breastfeeding/how-to-hand-express-your-breast-milk

 

Image result for nasogastric tube preterm baby
Laerdal Global Health’s preterm simulator showing the correct way of gravity feeding via a nasogastric tube

 

We have changed all the “cots” to “cribs” on the Liberian version of the slides this evening but can’t quite bring ourselves to make the required changes to “breastmilk”.

The oxygen concentrator

In the UK, oxygen is piped to our wards and surgical theatres.  Resuscitaires (for neonatal resuscitation) take air and O2 cylinders in case babies are delivered in areas where there is no piped O2.  But really we only use cylinders nowadays in hospitals in the UK for teaching purposes – most resuscitation teaching rooms don’t have piped oxygen.

The hospital we are in currently in Liberia runs its electricity entirely on generators and only has running water for a few hours a day so it is unlikely to have piped oxygen any time soon.  Oxygen has to be concentrated from air.  We have a session on the O2 concentrator on day 2 of the Newborn Care Course and it gives the UK instructors’ a chance to take a break and hand over to the local instructors who are absolute whizzes on how these things work and, more importantly, how to maintain them.  It is always one of the most popular workshops in the course; many neonatal nurses have one in the corner of their unit but it often doesn’t work because no one knows how to clean the filters, change the water etc.  This demonstration can bring 4 or 5 defunct O2 concentrators back to life in one fell swoop!

This diagram shows the engineering behind it:

 

 

 

 

 

 

 

 

 

 

 

 

 

Here is Kola explaining all about the O2 concentrator in ways which even I could understand for the first time ever. The last photos are of homemade CPAP which he has made from a bottle of mineral water and some oxygen tubing attached to the O2 concentrator. CPAP ensures pressure in the baby’s nose all the time he/she is breathing out as well as in. This prevents the lungs collapsing right down and effectively treats respiratory distress syndrome in the premature babies.

This is one of the most popular demonstrations of the whole course. Most of the learners have seen one but in many places, it sits broken in the corner of their unit.  This session on maintenance will bring most of those defunct units back to life.  Kola is somewhere in the middle of this crowd!

 

Kola enthusiastically dismantling the oxygen concentrator, urging his learners to clean the back regularly with a toothbrush and change the filters.

 

Making CPAP from an O2 concentrator, bottle of mineral water, nasal prongs and some O2 tubing.

 

An oxygen concentrator can turn 21% from the air into 70 -90% O2 depending a bit on climatic conditions.  WHO has put together a FAQ sheet for people who want to know more at https://www.newbornwhocc.org/ONTOP-DATA/Equipment-PDF/Oxygen-concetrator/FAQ-Oxygen-concentrator.pdf.   Kola’s unit, courtesy of MCAI funding, has an O2 splitter which means that 3 babies can receive oxygen from the one concentrator.  They rely on electricity to work so health facilities should keep some back up cylinders as well.

 

 

Skin to skin mother (and father) care

Keeping babies warm is one of the 4 themes identified by WHO as factors which contribute to bringing down neonatal mortality rates.  The mean temperature in Liberia is 27° C (81° F ), with temperatures rarely exceeding 36° C (97° F ) or falling below 20° C (68° F ).  But our learners today were telling me about the traditional birth attendants’ habit of holding the baby upside down and slapping its feet as soon as it is born and then washing it in cold water straight away.  Mind you, I am not sure it is that long ago that babies in my own country were treated like this.

Putting the baby skin-to-skin with its mother as soon as he or she is born is the best way to maintain his/her temperature and has many other advantages as well.  Take a look at this list from a South African site, www.kangaroomothercare.com:

Benefits of skin-to-skin contact for babies

  • Better brain development
  • Better emotional development
  • Less stress
  • Less crying
  • Less brain bleeds
  • More settled sleep
  • Babies are more alert when they are awake
  • Babies feel less pain from injections
  • The heart rate stabilizes
  • The oxygen saturation is more stable
  • Fewer apnoea attacks
  • Better breathing
  • The temperature is most stable on the mother
  • Breastfeeding starts more easily
  • More breast milk is produced
  • Gestation-specific milk is produced.
  • Faster weight gain
  • Baby can usually go home earlier
  • Enables colonisation of the baby’s skin with the mother’s friendly bacteria, thus providing protection against infection (UNICEF Baby Friendly Initiative information)

Benefits of skin-to-skin contact for parents

  • Parents become central to the caring team
  • Better bonding and interaction with their child
  • Emotional healing
  • Less guilt
  • Parents are calmer
  • Parents are empowered and more confident
  • Parents are able to learn their baby’s unique cues for hunger
  • Parents and baby get more sleep
  • Parents (especially mothers), are less depressed
  • Cope better in NICU
  • See baby as less “abnormal”
We have a long way to go with this in the UK.  On the course we teach that babies should be skin-to-skin with a parent for most of the day when on the neonatal unit.  All treatments except phototherapy can be carried out with the baby in this position.  Have a think about your own neonatal unit; do you have parents present all day with their baby tucked into their shirt?  If not, why not?
Learning how to tie a kalafong in the S2SMC practical session.

Malaria

Malaria is endemic in Liberia and prevalence is high at the moment as the rainy season draws to a close.  One of our 2 local instructors succumbed to it this morning during the 1st lecture of the day.  Fortunately she was sitting next to one of the observing doctors when she collapsed so was admitted straight from our teaching room.  She has been discharged now on oral treatment but is not going to be up to teaching tomorrow either which is sad for her as she was quite excited to be involved in the course.

Julia’s unmade bed (a la Tracy Emin)

This is a picture of my pop-up mosquito net which I love sleeping under.  It makes me feel like I’m sleeping in a 4-poster bed!  Unfortunately not many pregnant women like sleeping under the nets they are provided with by the antenatal clinic and there is only a 55% uptake of these and malaria prophylaxis which is offered to all pregnant women in Liberia.  It reminds me of when I was in Malawi many years ago watching people fish with beautiful blue fine mesh nets – mosquito nets distributed to them free.

Malaria remains the leading cause of morbidity and mortality in Liberia, with 38% of outpatient attendance and 42% of inpatient deaths attributable to malaria (http://www.aho.afro.who.int/profiles_information/index.php/Liberia:Analytical_summary_-_Malaria). However, malaria prevalence in children aged under 5 years has been significantly reduced from 66% to 32% since 2005 and this will be largely due to distribution of free nets to households with children aged under 5 years, pregnant women and lactating mothers.  So, despite some Liberian women’s reticence and some Malawian fishermen’s initiative, free mosquito nets do save lives.

Getting stuck in

Here are a few pictures from the first day of the Newborn Care Course which went well today.  As it is the first course to be run in Liberia and there are only 2 UK trained instructors, we have kept the course numbers small.

A small, attentive group of 12 midwives and neonatal nurses, watched by the 2 doctors at the back.

We have 12 learners, all very keen midwives and nurses.  We have 2 doctors sitting in who are helping with the smooth running of the course.  It’s good to see the support for the course from the medical fraternity here at CH Rennie hospital and they add to the educational content because they can fill in the gaps for us on what certain policies are here in Liberia.  They also have some influence over the change process.  We do a session on handwashing when talking about infection control and the medical director popped in during it.  This gave the clinical staff an opportunity to tell us that the soap they use for washing their hands is dirty and to tell him by inference that they would like liquid soap.  He took the hint well and asked one of the doctors to put it on a priority ordering list.  Result!

Kola in the foreground, advanced neonatal nurse practitioner and co-instructor, with consultant obstetrician Dr Susan and general practitioner Dr Suku

We also spoke about initiating early breastfeeding which they do well here except with the mothers who are having a Caesarean section.  In the UK, the birth partner is with the mother during the C section if it is being done under spinal anaesthaesia (with Mum awake), and the baby can then be put to the breast while the obstetricians are still closing the abdomen.  There was certainly some interest expressed today in trying to start this in Liberia.

WHO identifies 4 priorities for reducing neonatal mortality rates:

  • Resuscitation at birth
  • Keeping babies warm
  • Early and exclusive breastfeeding
  • Recognition and treatment of serious infection

The Newborn Care Course is based on this agenda.  We cover the first 3 points on day 1 and then move into recognising the “Danger Signs” using simulation training for day 2.  The whole afternoon of the first day of the course is dedicated to neonatal resuscitation.

Manikins bought with money from BMA Charity Funds, hats knitted in Aylesbury, simulation equipment donated by Calderdale, Homerton and Barts Health hospitals.

 

Learning how to resuscitate a sick newborn baby. All these learners have seen many extremely unwell newborn babies. They have a hunger for learning the skills needed to help save some of them. Until antenatal care gets significantly better, there will always be babies born in a poor condition.
Alistair teaching how to tie a Kalafong for skin to skin mother care. This is a practice that the UK could usefully learn from Liberia. Skin to skin mother care (Kangaroo Care) leads to better growth of the babies, better bonding, better outcomes and faster discharge home.

 

 

 

 

 

 

GNI v. GDP v. GNP

In 1984, I took Geography A level.  I still find both physical and human geography fascinating and all 3 of my children have disappointed me by not even taking it at GCSE.  In human geography in the 80’s we referred to the “Third World”, the “North-South divide” and the “Developing World”.  Terminology has moved on now but actually there are the same number of variations and the same risk of offending at least one person in the room as there were back then.

Country classification nowadays is very much based on average incomes of their populations.  I can never remember the difference between GDP and GNP.  Here’s a summary from the Irish Central Statistics Office:

Gross Domestic Product (GDP) and Gross National Product (GNP) are closely related measures. GDP measures the total output of the economy in a period i.e. the value of work done by employees, companies and self-employed persons. This work generates incomes but not all of the incomes earned in the economy remain the property of residents (and residents may earn some income abroad). The total income remaining with Irish residents is the GNP and it differs from GDP by the net amount of incomes sent to or received from abroad.  In Ireland’s case, for many years past, the amount belonging to persons abroad has exceeded the amount received from abroad, due mainly to the profits of foreign-owned companies, and our GNP is, therefore, less than our GDP.

Just when you thought you’d mastered the terminology, I should tell you that GNP is now called GNI.  The GNI per capita is the dollar value of a country’s final income in a year, divided by its population. It reflects the average income of a country’s citizens.  Generally people living in countries with higher GNI per capita tend to have longer life expectancies, higher literacy rates, better access to safe water, and lower infant mortality rates.  The UK is currently rated 18th in the world, Liberia is 180th out of a total of 183 ranked countries.

Actually, GNI is not exactly the same as GNP for economists but can be thought of as very similar for us lay people:

  • GNP = GDP + Net Income Receipts from assets abroad less income of foreign nationals within the country.
  • GNI = GDP + payments by foreign nationals into the country for such things as investments (interest and dividends), less similar payments paid out of the country.

The World Bank and International Monetary Fund recategorise countries on 1st July each year according to factors such as their income growth, inflation, exchange rates, and population change – all of which influence GNI per capita:

Threshold GNI/Capita (current US$)
Low-income < 995
Lower-middle income 996 – 3,895
Upper-middle income 3,896 – 12,055
High-income > 12,055

Liberia is currently categorised as a low income economy and this was the term used by Kola today when he was teaching.  He is the local instructor who is still standing (his colleague collapsed with malaria in the middle of the first lecture this morning).  So that’s the terminology I’m going to use while I’m here.

Childhood mortality in Liberia

I’ve been thinking about what I wrote yesterday about the drop in percentage of population who are over 15 compared to the under 15s.  Liberia has a very high under 5s mortality rate and it is probably that that skews the chart so heavily.  In the UK, our under 5s mortality rate (expressed as the number of children under 5 dying per 1000 live births) is very similar to our infant mortality rate (number of under 1s dying per 1000 live births).  ie. if you survive till your first birthday in the UK, the likelihood is that you will survive till your 5th.  Not so in countries like Liberia and Cameroon.  Take a look at the table below (2017 data from UNICEF).  All forms of childhood mortality are expressed as the number dying per 1000 live births:

COUNTRY NEONATAL MORTALITY
INFANT MORTALITY  

UNDER 5 MORTALITY

 

UK 2.6 3.7 4.3
CAMEROON 25.5 55.1 84
LIBERIA 25.1 55.9 74.7

 

Many children die between the ages of 1 and 5 in low income (eg. Liberia) and lower middle income (eg. Cameroon) countries (World Bank classification according to GNI (more on this tomorrow I think)).  Actually, according to UNICEF statistics (https://www.unicef.org/liberia/children.html), Liberia has done rather well recently in reducing under-five child deaths, from 241 to 78 per 1,000 live births between 1990 and 2011.  This is great but still means there’s a long way to go before the UN’s sustainable development goal (SDG) of 25 per 1,000 by 2030 is achieved (https://www.un.org/sustainabledevelopment/health/). 

The SDG neonatal mortality goal which is what NICHE International is all about is “at least as low as 12 per 1,000 live births” worldwide.  Take a look at my table above again.  We have some work to do.