Neonatal resuscitation training in Liberia – also june 2021!

Not to be outdone, Kola has been busy in Liberia with neonatal resuscitation training at the same time as the Cameroonian course was running. WhatsApp was alive with photos coming in for a couple of days – heartening stuff to our NICHE team still unable to leave the UK to train more instructors.

Neonatal technicians in Liberia lecturing on Newborn Life Support during a resuscitation training session, June 2021

It’s official! skin to skin care saves lives

https://www.nejm.org/doi/full/10.1056/NEJMoa2026486 takes you to the full text of this 2021 publication from WHO comparing survival data of low birth weight infants nursed skin to skin from birth with a cohort who only received a couple of hours a day of skin to skin care. The trial had to be cut short because the babies in the control group (couple of hours a day) had a significantly higher risk of dying than the babies in the intervention group (around 17 hours a day skin to skin).

Keeping babies warm workshop, Neonatal Care Course, Mutengene, Cameroon. June 2021

Grace gathered 9 of the trained instructors in Cameroon this month for a Neonatal Care Course which trained 36 more healthcare workers in the care of the newborn baby in the first 28 days of life. Quite a feat in a country battling with Covid and political unrest. Immensely rewarding for NICHE volunteers and trustees to see the programme up and running without much direction from us. Julia did try to “drop in” to some of the sessions via zoom on day 2 but the internet connection was so bad that, in the end, she gave up and let the Cameroonian faculty get on with it themselves. There’s only so much one can do remotely.

Today is International women’s day

Dr Alison Earley

It’s a day for dressing up in much of the world, a day to celebrate the work women do to make the world go round, a day of empowerment. The picture here is of Cameroonian women on International Women’s Day in 2018, learning how to resuscitate babies dressed in their International Women’s Day material that they make into powerfully beautiful dresses every year. We should make more of it in the UK really.

There are many achievements to celebrate on International Women’s Day, but we mustn’t forget that in resource poor areas of the world, maternal mortality (death related to pregnancy and childbirth) is still 5 – 10 times higher than in richer countries.

Many mothers still give birth in unclean or unsafe places, and without skilled help or adequate facilities.   This has a direct result on the survival of their babies; two of the leading causes of neonatal mortality are infection and intra-partum related events.

Education for healthcare workers and sustainable improvements in maternal and newborn care are the key to improving this situation.   NICHE International has a mission to improve the care of newborn babies, by the training we give and by supporting nurses, doctors and midwives to maintain their skills and improve the care they give to mothers and babies.

Training (predominantly female) nurses and midwives to be instructors on the Neonatal Care Course (NCC) empowers them to “Choose to Challenge” and make changes to their own healthcare systems from the bottom up.

Miller’s hierarchy of learning

Dr Jarlath O’Donohoe

To truly know whether our learners are achieving what we want them to achieve we should assess them in the setting that we expect these skills to be delivered.

Miller’s pyramid depicts four levels of learning which a student of a subject must pass through to truly perform: “knows”, “knows how”, “shows how” and “does”.

In the Neonatal Care Course, our novice learners gather facts and take an MCQ paper to “show that they know”. Workshops, discussion groups, skills sessions and simulations get them to the orange and green levels. The local champion and trained instructors then take over from NICHE for the “Performance Integrated into Practice” level at the top of the pyramid, completing the trainees’ journey from novice to expert.

I would like to see time better represented in this model. International NICHE instructors can skim the surface of the first 3 bands in one course but to achieve the competence and automacity inherent in the blue band at the top of the hierarchical model requires time, experience and supervised practice that only a local faculty can contribute to.

Maintenance, booster and refresher training

Dr Jarlath O’Donohoe, always in pursuit of the Holy Grail – a solution to the “skills decay” problem….

Resource: Sullivan, Anne & Elshenawy, Summer & Ades, Anne & Sawyer, Taylor. (2019). Acquiring and Maintaining Technical Skills Using Simulation: Initial, Maintenance, Booster, and Refresher Training. Cureus. 11. 10.7759/cureus.5729.

Learning Curve: shows a relationship between the amount of practice / experience of a skill and the degree of competence achieved.

Forgetting Curve: the relation between the decay of a learned skill and the time elapsed since the skill was learned.

Experience Curves: combines the learning and forgetting curves.

Activities to overcome skill decay can be qualitatively classified as maintenance , booster or refresher, according to the diagram below:

Note the amount of time spent “deficient” with “refresher” activities. An example of this is paediatricians in the UK re-certifying in APLS every 4 years. “Booster” training is possibly achieved by statutory mandatory training paediatric basic life support every year and keeps the average paediatrician “proficient”. Would lower intensity but more frequent “maintenance” activities do a better job eg. weekly simulation training sessions?

Here is Kola delivering his “booster” training sessions in neonatal resuscitation to nurse technicians in Liberia this week, using equipment left by NICHE after the first batch of instructors were trained in 2019.

Kola (centre) teaching neonatal resuscitation in Liberia, February 2021

How often does he need to run these sessions to make this maintenance training and not refresher sessions? The quest continues….

International day of education

Dr Alison Earley

On January 24th 2021, the UN General Assembly proclaimed the ‘International day of Education’ to celebrate the role of education for peace and development.

“At the peak of the pandemic, schools were actually closed for 91% of learners, or 1.5 billion pupils and students. It then became apparent to everyone that education was a global public good and school was more than just a place of learning: it was also a place that provided protection, well-being, food and freedom. (…) On this International Day of Education, UNESCO invites you to promote education as a fundamental right and the most powerful aid to development that we have. Defending the future of this right means defending the right to the future.” – Audrey Azoulay, UNESCO Director General, on the occasion of International Day of Education 2021.

Although the focus is often on the importance of educating children, the day also emphasised how lifelong learning can empower people, and is central to meeting the sustainable development goals*.

NICHE International has had success in training nurses, doctors and midwives in resource limited settings, like Cameroon and Liberia, to improve the care of newborn babies. 

Educational levels, language and experience differ among course participants, which increases the challenge of promoting their learning.  However, even when the teaching styles are unfamiliar, the overwhelming majority are very motivated and respond with enthusiasm . 

Most importantly, although training in adult education as a discipline is recent in Africa**, local trainers have been stimulated and empowered to improve their skills as teachers.  These local trainers have taken on teaching their own courses and, while unable to travel, NICHE International is supporting them remotely.

*Education is also a powerful catalyst – for combating poverty and inequality, improving health and well-being, and overcoming discrimination.   UNESCO International Day of Education. https://en.unesco.org/commemorations/educationday

** The Psychology of Adult Learning in Africa.  Thomas Fasokun.  Anne Katahoire.  Akpovire Oduaran PsychologyAdultlearningAfricaViaUNESCO

Best breastfeeding videos!

I have linked to the Global Media videos before. Such an amazing repository of videos for parents and healthcare workers across the world. We owe the families who agreed to take part in this project a debt of gratitude.

This one has some excellent information on proper attachment of the baby to the breast: https://globalhealthmedia.org/portfolio-items/breastfeeding-attachment/?portfolioCats=191%2C94%2C13%2C23%2C65

today is world prematurity day!

What is world prematurity day?

– a global movement to raise awareness of prematurity.

Across the world an estimated 15 million babies are born too early every year, and 1 million of them die.  Some survivors live with disabilities.

As usual, low and middle income countries are the worst affected, with higher rates of prematurity and lower rates of survival.

The strategies that NICHE International teaches in the Neonatal Care Course, for example early breast feeding and skin to skin mothercare, have been shown to save as many as three quarters of premature babies.

We must continue to try to improve the care of premature babies in low resource settings, despite the current difficulties of the pandemic.

Zooming to Cameroon

Local Cameroonian instructors, who are now organising their own Newborn Care Courses, ran an NCC last week in Yaoundé, Cameroon.  Some NICHE Instructors joined them for parts of the course via zoom from UK, to try out the technology and assess the feasibility of remote training.

We were able, remotely, to:

1. Demonstrate how to run a simulation (this was management of a baby having fits).  NICHE Instructors from their homes in London and N. Ireland did this on zoom at the request of Cameroonian Instructors who watched.

2. Deliver one of the lectures on the NCC course via zoom

3. Join the faculty meetings in Cameroon at the end of each day.

4. Join the candidates for certificate presentation at the end of the course.

This was a useful exercise as we are thinking about the practicalities of training online, in particular delivering ‘Instructor Development Days’ for Cameroonian NCC Instructors, which before the pandemic, we had hoped to be able to do in person in November.

There are some technological improvements to make, but generally it was successful.

It was a pleasure to see our Cameroonian colleagues, who keep going despite pandemic and political difficulties.

Some comments from candidates on the course:

  • The training was an impacting one with lots of skills and knowledge acquired.  I could have wish that all health personnel around the world be train if possible to augment care of neonates.
  • I am confident now that I can take care of a newborn very well as compare to what i was doing in my station, especially resuscitating asphyxiated babies immediately after delivery.

Universal health coverage (UHC)

“Universal Health Coverage (UHC) means that all people can access quality essential health services, without having to suffer financial hardship to pay for health care.”  Says the World Bank which teamed up with WHO in 2017 to monitor progress with this target. https://www.worldbank.org/en/topic/health/publication/universal-health-coverage-study-series

“Each year, close to 100 million people are being pushed into extreme poverty because of health expenses, and 800 million spend more than ten percent of their household budgets on health care. Achieving UHC is not just about better health outcomes. The overarching goal of the Sustainable Development Goals (SDGs)–ending extreme poverty–will remain out of reach without UHC.” [World Bank]

Achieving UHC is one of the targets the nations of the world set when adopting the Sustainable Development Goals in 2015 but, despite this, at least half the world’s population has to pay for some or all essential health services.  People in the poorest countries are the worst affected.

Colleagues in Cameroon, who have been trained by NICHE International to teach a Neonatal Care Course, recently taught this course in Yaoundé.  An important part of the course is the teaching of skin to skin mother care, also called kangaroo care.  This has many advantages and is advocated by WHO as a way of promoting the healthy survival of babies.

Premature baby being kept warm sustainably

Candidates on the course recognised these advantages -see comment below from one candidate.

  • I must comment I learnt a lot on demonstration of S2SMC (skin to skin mothercare) which i thought i could do it but just realised I was far below standard.  This training is so empowering.  Keep up.

However, a problem that became clear during the course, is that one of the hospitals in Yaoundé asks parents for payment whenever a baby is nursed in an incubator.  The hospital management is therefore unwilling for their nurses to introduce skin to skin mother care, as when a baby is nursed with his/her mother, the hospital does not get this payment.  This is despite the fact that skin to skin care is usually better and safer than incubator care, particularly in poorer countries.

There is still much to do to advocate for safe basic healthcare for newborn babies.

Read more on UHC at:

https://www.who.int/news-room/fact-sheets/detail/universal-health-coverage-(uhc)