Not to be outdone by Gloria knitting babies’ hats in Buckinghamshire, 14 year old Kim has turned her hand to crocheting hats for premature babies in Liberia. Beats getting out of bed to do homework over half term anyway!
United Nations Convention on the Rights of the Child
The rights of children across the world are enshrined in the United Nations Convention on the Rights of the Child, or UNCRC, signed by all UN members except the USA. The Convention has 54 articles that cover all aspects of a child’s life and set out the civil, political, economic, social and cultural rights that all children everywhere are entitled to. It also explains how adults and governments must work together to make sure all children can enjoy all their rights.
Every child has rights, whatever their ethnicity, gender, religion, language, abilities or any other status.
You can read more about it at https://www.unicef.org.uk/what-we-do/un-convention-child-rights/.
The UN rights of the child are often violated when families are in situations of conflict. In particular articles 19 (protection from violence, abuse and neglect) and article 38 (war and armed conflicts) from the UN Convention, are relevant in this regard.
Over the last 2 years, while NICHE has been working in Cameroon, West Africa, we have seen how civil unrest there has affected patients, and indeed, hear firsthand from health professionals who continue to try to care for them.
A young doctor who attended one of our Newborn Care training courses earlier this year in Cameroon, has recently written about the direct effects on children’s health that she has witnessed.
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Over the past three years, the English-speaking North West and South West Regions of Cameroon have been affected by civil unrest. Since the crisis started in October 2016 following a strike action by teacher and lawyer unions, it has escalated to an armed conflict. There has been heavy military deployment to the regions and violent attacks by the opposing forces in urban and rural areas, leading to disruption of activities in communities, displacement from homes, and loss of property and lives. Education, business and healthcare are some of the most directly hit activities in the different communities affected by the conflict. Its adverse effects are numerous, including difficulty in providing and accessing proper health care facilities, causing diseases, which had been under control, to regain grounds, become virulent and lead to increasing levels of disability and death.
Working in the Pediatric Unit of the Bamenda Regional Hospital over the past months, we have witnessed this centre, which is the only very accessible reference centre of the North West Region, struggle to manage the current challenges despite the continuing conflict. We have seen a rise in the severity of epidemic diseases like Malaria and Dysenteric illnesses, seen by the 198 cases of malaria treated from January to August 2019 as to the 168 treated in the same duration in 2018. In 2018 alone, 119 cases of meningitis were managed in our health facility. Added to these, are diseases which are now poorly managed due to lack of health facilities and personnel in the surrounding villages, notably Tuberculosis, HIV/AIDS, Sickle cell Disease, Pneumonia, and Severe Malnutrition.
Children are the most affected, with two out of every five inhabitants of our Region being under the age of 15 years old. As the conflict continues, access to hospitals and other health centres from surrounding villages remains very difficult for these populations notably the children. By the time they successfully arrive at facilities like ours, it is either too late and they expire, or they end up disabled.
The lack of adequate health infrastructure and personnel especially in the periphery of Bamenda and surrounding villages has also adversely affected vaccination coverage for children in these areas. We are therefore exposed to a high risk that vaccine-preventable diseases may resurface, with catastrophic effects on the children. We have unfortunately had cases of children as old as 1 year who haven’t received any vaccines since they were born in the bushes to displaced mothers.
On a final note, we have been witnessing an alarming rise in cases of sexual abuse on children. The numbers are on the rise, thereby increasing the risk of sexually transmitted disease infections as well as additional psychological trauma, which would both have disastrous consequences.
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The current crisis in Cameroon is complicated. Good resources to look at if you want to know the timeline of the conflict are:
https://africanarguments.org/2019/08/13/cameroon-crisis-three-deepening-divides/ and
https://www.bbc.co.uk/news/av/world-africa-44459488/cameroon-crisis-explained which has links to up to date information like the recent release of the opposition leader from prison and the current peace plan.
Vietnam, here we come!
Jarlath and Julia are in Dubai, en route to Vietnam where they are teaching Newborn Life Support and the Generic Instructor Course with a different charity, Newborns Vietnam (https://www.newbornsvietnam.org/). It is very nice to be “just instructors” and not organising the trip!
More trustee exertions!
Friends of NICHE
We are fortunate that NICHE has friends who support us in various ways.
This is Gloria, approaching her 10th decade, and an inveterate knitter!
One of WHO’s main recommendations for newborn care is prevention of hypothermia. Newborn babies quickly lose heat through their heads; drying and covering the head with a hat immediately after birth is a simple but vital step. This is equally important in hot and cold countries.
When NICHE instructors train midwives and other birth attendants in a low resource country, we leave equipment for them to use. This includes a supply of hats for babies, as mothers do not always have their own baby clothes.
Gloria has bought wool, and knitted hundreds of baby hats for us, including tiny ones for premature infants. She says that this is her contribution to our work: it is a valuable one, for which we – and about 200 babies in west Africa so far – are very grateful.
How many health professionals do 10,000 people need?
The WHO suggests that the critical threshold is 23 doctors, nurses and midwives per 10,000 head of population. Of their 49 priority low-income countries, only 45 cross this threshold. Instead of 23, Liberia has 3.
Purely looking at doctor numbers, Liberia has 0.3 per 10,000 head of population. Which is why the work that MCAI (www.mcai.org.uk) is doing to train midwives and neonatal nurses in extended roles is so important. We are looking forward to playing our part with this when we return to Liberia in November 2019 to teach the first Generic Instructor Course and 4 more Newborn Care Courses.
Evaluation – how to avoid the “not knowing what you don’t know” trap
Dr Jarlath O’Donohoe instructs on life support courses in many different countries (he has lots of embroidered shirts to prove it). He is the educator on our Generic Instructor Courses and has been doing a lot of work on our course evaluation forms. Here are some recent thoughts from him on “pre-post evaluation”:
“No one likes to waste their time. In developing country health services this is even more important since human resources are so scarce. Equally important is to avoid thinking you are wasting your time when you are not. In evaluating a training exercise it seems obvious that asking questions before and then after the training will help identify what is worth doing and what is not worth doing. 
However, like in so many other spheres of life, what is obvious is not always true and what is true is not always obvious. It turns out (Academic Emergency Medicine: Educational Advance: Bhanj F, Gottesman de Grave W. The Retrospective Pre–Post: A Practical Method to Evaluate Learning from an Educational Program, Feb 2012) that asking questions at both the beginning and end may fail to identify useful learning. The example given is of someone who thinks himself quite knowledgeable at the beginning of a course and scores himself 7/10. Then, having learned a lot more about the topic, he again scores himself 7/10 at the end. There has been a lot of learning and the 10 at the end of the course is a much bigger 10 and therefore the 7 is a much bigger 7. This can not be shown statistically.
The term the authors use is retrospective pre-post (RPP) evaluation. Experience has shown some people scoring themselves as highly capable at the beginning of our training sessions but who are not able to do things like bag and mask ventilation. So we have moved to an RPP approach to evaluation.”
This entails giving our learners just one questionnaire at the end of the course which asks them how confident they felt before the course in certain skills and areas of knowledge and how confident they feel at the end of the course. It seems that recall bias might be a lesser evil than “not knowing what you don’t know”.
Community fundraising in the UK
Seb and Julia at the NICHE table during a recent community event in north London. Lots of people showed an interest in the charity, and in the handmade brass items from Cameroon. The artists first make the model out of beeswax, then cover it in clay, allow the wax to melt leaving a clay mould and then fill a second container with old keys, bits of car engine etc., put more clay around the whole thing and put in a homemade kiln. As the man who made my Nativity set said, you have to wait till the flames from the kiln are giving off white smoke, then you know the metal is melting and filling the moulds. When the little clay parcels come out of the fire, they are allowed to cool and then the clay is broken off, leaving a brass model in place of the original wax one. If you’re interested in seeing how scrap metal is recycled to make brass ornaments in West Africa, there’s a fascinating Ghanaian video on You Tube at https://www.youtube.com/watch?v=REutkpo3ors.
Outcome measures
The ultimate outcome measurement for the Newborn Care Course project would of course be a reduction in neonatal mortality in the areas where we work. There are so many confounding factors in any clean data that is actually collected that it is almost impossible to prove that one intervention like this has any statistically significant effect on neonatal mortality. But our funders always ask for outcome measures. This year in Cameroon we changed the feedback form a bit, bringing it more into line with the template suggested by the UK’s Royal College of Paediatrics and Child Health. This has allowed us to measure pre- and post- course confidence in the main areas identified by WHO as contributing to newborn deaths. Here are the results from last month’s course:
The challenge now, of course, is to keep that confidence up going forwards.
Di Pikin no don die
This is what we are aiming for!
It was noticeable that when Cameroonian candidates were role-playing a scenario, for example giving the baby to the mother after a successful resuscitation, they would speak to her in Pidgin English (sometimes called Kamtok in Cameroon).
One of the candidates used the sentence above. It means ‘the baby hasn’t died’.
It is a reminder that neonatal mortality in Cameroon is still 10 times that in the UK, and that the aim of teaching the Newborn Care Course is to reduce it.
48 of the 49 candidates who took part successfully completed the course in April 2019. That’s 48 more skilled birth attendants and nearly 20 trained or partially trained instructors (not all those who did the GIC last year managed to get to these courses to do their supervised teaching) who will continue to cascade the learning. That’s good news for many thousands of babies in Cameroon in the years to come.