World prematurity day

Dr Alison Earley

The statistics on premature birth remain of great concern:  12% of babies are born too soon in the poorest countries, compared with 9% in higher income countries.  One million babies die each year from complications of premature birth, and prematurity remains a leading cause of mortality globally.

Education for health care workers, enabling them to provide better care for pregnant women and new born babies, is vital if this situation is to improve.

Kola sent these pictures from Liberia this morning – a celebration of their babies born too early! Most of the nurses in these pictures have done the Neonatal Care Course with NICHE trainers.

Celebrating World Prematurity Day at CB Dumbar, Liberia
Kola and team of nurses and neonatal technicians in their Neonatal Nursery

bag-valve-mask questionnaire

Gathering the evidence for the work we do, both for funders and to inform our direction of travel as an organisation, is not at all easy! Alison has been working with Grace in Cameroon to collect information from health clinics about their use of bag-valve-masks which NICHE International provided them with a few months ago.

3 out of the 5 units who had the questionnaire responded which doesn’t give us statistically robust information but does give us a fascinating insight into the obstetric services at these centres, the numbers of deliveries, trained staff and how many babies were born in a bad enough condition to worry the newly trained personnel.

preliminary results from the BVM questionnaire

There are a couple of things to learn from here:

1.) The very positive free text comments at the bottom that all units feel that having the bag-valve-mask over the last 8 weeks has potentially saved lives.

2.) The disappointing comment from Bafoussam that people have been reluctant to use the BVM because they can’t attach it to the oxygen supply is a reminder of the need for on-going training and refresher courses. Babies born at 32 weeks gestation and above should be resuscitated in air. The new 2021 guidelines suggest that babies between 28 and 32 weeks can be resuscitated in air to 30% oxygen. Only the very small ones, most of which do not survive in resource poor areas of the world, should be resuscitated in 30% oxygen from the outset. It is recommended to increase to 100% oxygen in any situation if the baby requires cardiac compressions.

We are looking to return to Cameroon at the end of April 2022 to train more instructors and begin training some of the Cameroonian instructors to be instructor trainers themselves. Well done to Grace and team for keeping the Neonatal Care Course training going throughout the Covid pandemic and thanks to the Cameroon Baptist Convention for continuing to fund the programme.

Teaching again after the pandemic

It is great to be back teaching face-to-face again, albeit still only in the UK. UK NICHE instructors have to teach on a certain number of life support courses per year to maintain their instructor status. Julia was teaching the UK Resuscitation council Newborn Life Support (NLS) course this week in her home hospital in London.

Scenario teaching – unexpected preterm baby delivery

There are some differences when stabilising a preterm delivery at birth. The 2021 guidelines suggest that babies born under 32 weeks gestation should be put into a plastic bag at birth and placed under a radiant heater to stop them getting cold and dehydrated. Just their heads should be dried.

In most other respects, and if there is no radiant heater available, they should be stabilised the same way one would stabilise a term baby. Here the learners are demonstrating the 2-handed BVM technique with Julia checking that the chest is actually rising!

2-person technique of bag-valve-mask use at a simulated preterm delivery

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 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.

** 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: