Skin to skin mother (and father) care

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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,

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.


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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 ( 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

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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.








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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

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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:




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 (, 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 ( 

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.


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I’ve been reading a couple of books relevant to the history of Liberia.  The map in a previous post shows you where it is in West Africa, bordered by Sierra Leone to the West (where we stopped on the plane on the way here) and Cote d’Ivoire to the East.  Liberia is Africa’s oldest republic and was set up at the beginning of the 19th century as a homeland for freed American slaves.  There were 2 violent, devastating civil wars in the late 1990s up until 2003 and reading about them is harrowing stuff.  8% of the population was killed.  As we were driving today I couldn’t help looking at people on the roadside and wondering what part they may have played in those wars.  There were so many different factions, most of which recruited children as young as 7 as child soldiers.  Many will have died of course but what does that kind of trauma do to the survivors who will now be in their 20s?

43% of Liberia’s population is under the age of 15.  I wonder if the big drop down to the 15-44 year olds in the graph below partly reflects the effect of those wars.

Liberia: Age breakdown

We’ve arrived!

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After a whole day in the plane (there are no direct flights to Liberia from the UK) and another day in the car (gathering up instructors for our course, dropping off an obstetrician from Northern Ireland who is at a hospital a couple of hours north of here for a week to run the examinations for a group of midwives who have been taught extended skills), we are now ensconced in a house within the compound of CH Rennie hospital in Kakata.

Due to start the course the day after tomorrow so will be spending tomorrow setting up the room, ensuring the programme is correct and going through the content with Kola and Agnes, neonatal nurse practitioner and midwifery practitioner respectively who are going to be our co-instructors.

I’m struggling to upload pictures.  It’s been a bit rainy and heavy today so the photos won’t really do the country justice anyway.  It’s very green and lush against the red laterite soil that runs in a band across sub-Saharan Africa.  Here’s one I found on the internet which is pretty true to form except I’m not sure that I’ve seen any motorbike helmets yet.

See the source image

NICHE’s first trip to Liberia!

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Alistair and Julia are off to Liberia at the crack of dawn tomorrow to facilitate 2 Newborn Care Courses in CH Rennie hospital alongside a local neonatal nurse practitioner and some midwifery interns. My understanding is that an intern is a trained midwife who is then given extended roles which would overlap with those of an obstetrician in well resourced countries like the UK. But we’ll find out more when we’re there and have met the local faculty.

This trip is in collaboration with the charity, Maternal and Child Health Advocacy International ( who originally designed the Newborn Care Course and under whose umbrella we taught the course in Cameroon until 2016.

Welcome to NICHE International’s blog site

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Newborn, Infant and Child Health Education (NICHE) International is a small charity with 6 trustees, 3 of whom are also  Newborn Care Course instructors.  Our mission is elsewhere on the website but basically we travel to low resource countries of the world to facilitate courses on care of the newborn infant in the first 28 days of life and train local instructors.

The charity was set up in autumn 2017.  In 2018 we led a big group of 7 instructors to Cameroon in March and 2 of us are about to set out to Liberia to deliver our first NCC there.

Seb is our webmaster and says we must write blog posts while overseas to let the world know what the charity is up to.  Please do leave a comment if you want to ask us any questions!

Julia and Alistair