Medical and nursing staff in the UK now have to undergo annual appraisals, usually with a peer who coaches them through their appraisal paperwork, discussing issues and highlights of the year with them and helping them to develop themselves as a health professional. Although there’s always a mad rush at the end of the year to get all the relevant bits of paper uploaded to one’s appraisal file in time for the allotted meeting, the process if done well encourages the health worker to focus on their goals for the next year, helps to prevent burn out and allows us all the space to reflect on our own practice.
This process is in its infancy in Liberia and Cameroon. Jarlath has put together a draft form which gathers information about skills and confidence decay, provides a method of assessing someone’s on-going competence and allows a structure for peer mentoring. We are not quite sure how this will work in the field but will be rolling it out over the next few years in Cameroon while we work out how to help support local instructors in the long term.
The Neonatal Care Course (NCC) is an educationally robust product. We teach about the four main areas that the World Health Organisation identifies as contributing maximally to neonatal mortality rates: resuscitation at birth, early breast-feeding, keeping babies warm and early recognition and management of sepsis. https://www.who.int/maternal_child_adolescent/topics/newborn/enap_consultation/en/). Our feedback forms show increased confidence of learners in all 4 of these areas. Increased clinical confidence correlates with increased performance over time.
Here is Grace, a one time NCC learner and now in-country NICHE champion and convener of their own independent NCCs, delivering a workshop on breastfeeding to local midwives. This is what empowerment of local health professionals does. This is our legacy and we are proud of it and very grateful to all who donate time, money and expertise to our charity.
We have been busy putting together suitable programmes for our on-going development and support of the local instructors in both Cameroon and Liberia. We have been asked by Grace and her team in Cameroon to return there once a year for the next 3 years to take them from Step 8 of the “10-steps to sustainability” plan to Step 10 (where they can train their own instructors). We are actively fundraising for this project at the moment if anyone wants to help out – http://www.nicheinternational.org.uk/ways-to-donate/.
We have begun to put together a tentative programme for a 2-day instructor development course, termed CIDD, which will be delivered in-country to ensure instructors are up to date in both the content and delivery of their provider course, the Neonatal Care Course (NCC), and to furnish them with the skills needed to keep themselves developing professionally after 2023.
Midwives in Bamenda this week (North West region of Cameroon) learning how to tie a “Kalafong” wrap for skin-to-skin mother care as part of their 2 day Neonatal Care Course. 22 learners with 100% pass rate in a town which is at the centre of the current sociopolitical unrest in Cameroon and to which UK instructors are no longer allowed to travel. Hats off to Grace and her team for running their first independent course and thanks to our partners, the Cameroon Baptist Convention Health Services, for their support and encouragement.
The children at the primary school where one of the trustees, Alison Grove, works are learning about charities, so she was asked to talk to the classes about NICHE International.
The children are aged between 4 and 12 – one composite class is spread across this whole age range – so there were different levels of understanding about the work we do.
We used coloured blocks to represent babies. With the help of volunteers – wearing our NICHE tee shirts – we counted out how many babies might be cared for if NICHE volunteers spent their visit working in hospitals.
And then how many if they trained local health care workers in the skills they were using so that the work could go on all year round. And finally, how many more babies might survive in good health if the local doctors and nurses learned how to train their co-workers … and so on. That made a lot of blocks.
We looked at ways to look after newborn babies:
Helping them to breathe with a bag valve mask. There were lots of ideas of how to use the one I showed the children, but we soon realised that we would all need training – even the teachers – if we were to save the life of a newborn baby who wasn’t breathing.
Keeping them warm. The children learned that babies must be kept warm even in hot countries. There were lots of suggestions about how to do this, but no-one could guess the amazing piece of equipment I held behind my back….. a knitted hat!
Skin to skin contact. We borrowed baby dolls and pieces of fabric from the nursery and the children helped each other to tie the ‘babies’ on securely.
We talked about the different ways people are supporting NICHE – the course tutors, the donors and fund raisers, the work behind the scenes in the UK as well as in the countries we visit.
And there were lots of questions, such as: How do you set up a charity? How long does it take to get to Africa? Why are the babies sick? Do lions go to hospital?
The children were shocked to learn that newborn babies die so often in poorly resourced areas of the world. Many have baby brothers and sisters of their own and began to understand now how lucky they are to live in Scotland where there are enough well trained health care workers to look after sick babies.
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.
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.
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.
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!