20% of babies are exclusively breastfed at 6 months of age

WHO suggests that babies should be exclusively breastfed for the first 6 months of life.  UNICEF data for Liberia for 2013 suggests that 55% of babies 0-5 months of age are exclusively breastfed although it’s only 34% for the whole West African region:

I can’t find the accurate figure of percentage of babies who are still being exclusively breastfed at 6 months of age in Liberia but it might be around 20%.  We’ve been hearing today that lots of babies get “gripe water” in the first few days of life.  I think it still has alcohol in it here.  Besides formula, they are also fed corn and rice cereals from a very young age.

Breastfeeding should be initiated within the first hour of birth and one of the issues in Liberia which might be contributing to the poor breastfeeding rates is the birth practice which removes the baby from the mother for the first vital minutes to clean and dress it.  Instead of this, the newborn – whilst being kept warm of course – should be delivered on to the mother’s abdomen, dried except for the hands and he/she will “commando crawl” up to the breast on its own.  This is shown beautifully in one of the excellent Global Media videos that I’ve mentioned before.  Have a look at it here:   https://globalhealthmedia.org/portfolio-items/early-initiation-of-breastfeeding/?portfolioCats=191%2C94%2C13%2C23%2C65.  We played this video to the learners (who were all midwives) on the first Newborn Care Course earlier this week.  They went away with good intentions to change their practice.  I think it could do with being shown in a few centres in the UK too.


Low birthweight and neonatal mortality

One of the slides from the NCC lecture on Nutrition and Feeding


This is a slide from one of the early lectures on the Newborn Care Course.  It outlines WHO’s priorities in the fight to bring down neonatal mortality (number of deaths per 1,000 live births) to “at least as low as 12 per 1,000” by 2030.

Liberia’s neonatal mortality rate is 25 per 1,000 [UNICEF 2018 data].  3 babies have died in the hospital in Zwedru since we’ve been here; 2 term babies born with severe hypoxic ischaemic encephalopathy (lack of oxygen around the time of birth) and 1 preterm baby weighing 900g who looked quite well when we arrived but died on day 6 of life during our second course – despite 2 of the local instructors leaving the course to go to the hospital to try and help save the baby.

Not many babies under 1.5kg survive here.  Kola’s been discussing this this evening and showing us pictures of his successes – including one little lad called Success, born by perimortem Caesarean section to a mother with severe eclampsia, at 1kg.  Now, developmentally normal and with adoptive parents, the family recently came back to the unit to celebrate his second birthday.  Kola’s smallest survivor weighed just 600g at birth at 29 weeks gestation.  He is now over 1 and also developmentally normal.  I suspect that although the survival rates at different gestational ages are very much lower than in the UK, the percentage surviving without severe disability is probably higher.


“Apart from getting money, are we not also blessed?” [Kola on the “noble” profession of nursing]

Kola’s turns of phrase when he’s lecturing have been delighting Jo and I all day.  The title of this and the previous posts are good examples of the fervour with which he plays his role as MCAI’s on the ground neonatal trainer.  And he is not alone.  Gertrude, Agnes and Christina are equally dedicated to their patients and their unit, totally committed to the patients they look after.  And totally engaged in their roles today as instructor candidates on the Newborn Care Course.

Gertrude doing Stage 2 of the 4-stage procedure in how to tie a kalafong wrap for the baby to be skin-to-skin with its mother.
Christina overseeing resuscitation skills training.
Agnes (gesticulating with her hands) running an animated discussion workshop on pain in babies and how to manage the baby who won’t live long.

“God put all these good things into titty water so why are we deviating?” [Kola on being asked about using formula milk]

There is nothing, nothing so heartening as watching someone you’ve just trained as an instructor teaching better than you.

This is Kola putting his all into his lectures, carrying his learners with him on a wave of enthusiasm.  A truly inspirational educator.

He was good last year but, not only is he even better this year now that’s he been trained but he also keeps to time!  Just about….



First GIC courses in Liberia successfully completed!

Here are our 4 local instructors with their certificates of completion of the Generic Instructor Course in Zwedru. Well deserved. They put so much energy into the course and really developed as teachers over the 2 days.
And here are the 5 newly trained instructors in Monrovia where Colin and Alistair are running parallel courses to Jo and Julia. 1 X GIC followed by 2 x NCCs.













These neonatal clinicians and 1 doctor now have to teach on two Newborn Care Courses supervised in order to complete their training as instructors.  The NICHE International volunteer instructors should be able to complete this whole process in the one 10-day trip.  We will also be leaving a teaching set (4 manikins, scenario teaching sets and a projector) with the new Liberian faculty so that they can start to organise and run their own courses.  It would be nice to be invited back to help out though!

Maslow’s hierarchy of needs

We have been teaching the Generic Instructor Course today, one of the best train the trainer short courses in the world I think and it travels well.  We learnt about Maslow’s hierarchy of needs in one of the sessions.

Maslow (1943) divided this five-stage model into deficiency needs and growth needs. The first four levels are often referred to as deficiency needs (D-needs), and the top level is known as growth or being needs (B-needs).

Deficiency needs arise due to deprivation and are said to motivate people when they are unmet. Also, the motivation to fulfill such needs will become stronger the longer the duration they are denied. For example, the longer a person goes without food, the more hungry they will become.

We had a beautiful example of this here in Liberia where our learners have been a bit vexed by a misunderstanding over food provision during the courses.  They were hoping to get money to buy their food with (and no doubt save some of the money out of this allowance) and were not pleased to find out that “their” food money had been given to caterers to provide the food.  This was compounded when the caterers failed to turn up with the food!  Jo and I were trying to persuade them to prepare for the GIC course over the weekend but they could not do that because they were still animatedly discussing the issue around food allowances.  It was not until that issue had been sorted out this morning that they could start to move up Maslow’s pyramid.  In one day we’ve gone from level 1 to level 4 and will nudge our learners into level 5 by (complimentary) morning coffee tomorrow.

Rainy season

In Liberia the climate is tropical, hot and humid all year round, with a rainy season from May to October due to the African monsoon, and pretty frequent rains in the other months, except in the short dry season that runs from December to February.  This makes for a green, lush environment in most of the country as we found out on our evening walk earlier.

The rains have gone on longer than usual this year and this picture from the Liberian Observer shows just how bad the road is from the capital to the county in which we are based currently.

The health professionals coming to our Newborn Care Courses this week have to travel this road.  On motorbikes apparently because the cars that were supposed to be bringing them can not get through.

This evening, I was admiring the sunset from the UNHCR compound where we are staying.  The next thunderstorm is obvious on the horizon in this picture and is just breaking now as we are going to bed.  The rain on the corrugated iron roof is deafening and there is a leak in the ceiling just above the sofa.  How do the children study in the evenings in conditions like this?   It makes me think of Maslow’s hierarchy of needs which is one of the topics on tomorrow’s GIC.  More about that in tomorrow’s post – if the internet is still working.  A lightening strike has damaged our Wifi so we’re reliant on Kola’s data at the moment.


UK instructors, Jo and Julia, arrived in Zwedru on 2nd November along with local Liberian instructor trainees Kola, Advanced Neonatal Nurse Practitioner (ANNP) with Maternal and Child Health Advocacy International (MCAI), Agnes, Gertrude and Christina, all of whom have been trained as neonatal clinicians (nurses with extended roles) within the MCAI programme.  Kola has been training two neonatal clinicians here in Zwedru and they have set up a neonatal unit which they hope to expand.  UNICEF is collaborating with MCAI now to further develop the programme around safe delivery of babies and extend it into the rural areas around Zwedru.  Our role here this week is to help with the training of the nurses and midwives based in Grand Gedeh county.  Our 4 Liberian colleagues (well, Kola’s Nigerian actually but based here now) will do the Generic Instructor Course in the next 2 days and then – supervised by Jo and Julia – teach the Newborn Care Course to nurses and midwives here in Zwedru.

Getting here was quite fun!  The rainy season has gone on a little longer than usual in West Africa this year and the roads from the capital, Monrovia, are impassable.  So we came by twin engine plane….

Muddy, red laterite soil landing strip in Zwedru
Medical Aviation Fellowship (MAF) 10-seater twin-engine plane and a pretty impressive Australian pilot
Selfie of the instructor team on board the aircraft. 2 of them had never flown before.
Tropical rainforest from the plane window


Kalafong wraps









Kim and Julia have been busy in London (and Alison in Amersham) making these baby slings for mothers of preterm babies in Liberia.  They will be used on the training courses in November and then left in country for use on the neonatal unit.  Skin to skin mother care develops the bond between mother and baby as well as helping to prevent infection and keeping the baby warm.  You can read more about the advantages of skin to skin care at https://www.nicheinternational.org.uk/2018/11/13/skin-to-skin-mother-and-father-care/.

We call them kalafongs on the Newborn Care Course but they are not actually called kalafong wraps – even in Kalafong hospital in South Africa which is where the pattern for these (very cheap and easy to make) skin to skin wraps is from, see https://www.up.ac.za/media/shared/Legacy/sitefiles/file/45/1335/877/thariinstructionsnewkmcwrappatternmay2011.pdf.