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Mboppi hospital, Douala

The next NCC taking place in Douala, Cameroon, June 2023
Keen students on day 1
Where is Douala?

Grace and team have been busy this week with 2 Neonatal Care Courses in Cameroon. 24 keen midwives and nurses attended.

Rainy season challenges

A rainstorm threatened to bring the NCC to an early finish today as the crescendo on the chapel’s tin roof drowned out the lecturing

Undeterred, Judith found a microphone, the learners donned diocesan gowns from the vestry, moved their chairs to leeward and the lecture on the “Small Baby” continued.

The temperature dropped like a stone when the rains came. The learners were undaunted. The show went on.

Do as I Say and Do

Two instructors and two learners on this second Neonatal Care Course have breastfeeding babies with them. Look at the size of them! Great to have real life role models; we should encourage this on UK courses.

23 countries, including Uganda, have achieved exclusive breastfeeding rates above 60 per cent. The other countries are Bolivia, Burundi, Cabo Verde, Cambodia, Democratic People’s Republic of Korea, Eritrea, Kenya, Kiribati, Lesotho, Malawi, Micronesia, Federated States of Nauru, Nepal, Peru, Rwanda, São Tome and Principe, Solomon Islands, Sri Lanka, Swaziland, Timor-Leste,  Vanuatu, and Zambia. Is your country represented here? Can you do anything to get your own country on to this UNICEF list?

In Africa, nearly 70 per cent of countries have high rates of continued breastfeeding at one year, but in the Americas, only four countries have such high rates.  [Source: https://www.unicef.org/uganda/press-releases/babies-and-mothers-worldwide-failed-lack-investment-breastfeeding]

Transitioning to Ugandan instructors

Judith demonstrating insertion of an intraosseous needle into a dehydrated baby’s shin bone

Skills are taught as a 4-stage procedure – silent run through, demonstration with explanation, learners talking instructor through the skill and then all have a go. This imprints the skill on the learners’ minds. Which is why it is very important for the instructor to get it right and be consistent!

Phionah demonstrating how to make CPAP to support a premature baby’s breathing

There is no piped oxygen in Bwindi Community Hospital. The grey machine on the floor here is an oxygen concentrator. If the ensuing oxygen/air mix is then piped through a bottle of mineral water, the pressure at which it reaches the baby’s nostrils can be increased. Preterm babies’ lungs tend to collapse with each expiration and putting them on this CPAP helps to prevent that.

Dr Alex running a workshop on recognising “danger signs” and managing the sick infant in a timely fashion

We use the Global Health Media videos to illustrate much of what we are teaching. They are excellent videos on all aspects of medical care in resource poor areas of the world. Check out the breastfeeding ones which I think we should show more in the UK. Uganda has very high rates of breastfeeding so here we concentrate more on recognition of the sick infant, for which these videos are also very useful. https://globalhealthmedia.org/videos/

Looking after the mothers

Regular readers of this blog will know that we often talk about Skin to Skin Mothercare (S2SMC) or Kangaroo Mother Care (KMC) as the most appropriate way of keeping babies warm, promoting bonding, preventing infection, augmenting growth and supporting breastfeeding. Mothers can also be taught to keep an eye on their baby’s breathing and general health and alert the nurses if any apnoeas (pauses in breathing) or other concerns. But mothers too need looking after.

Washing facilities for resident mothers and mothers-to-be at Bwindi Community Hospital

Mothers need washing facilities for themselves and for their clothes and baby’s wraps. They need to be able to prepare food for themselves and to have access to clean drinking water. They need somewhere to sleep themselves. You can see the cook house in the background of this picture and the dormitory on the left. Some of these resident mothers are in the hospital for many weeks, either antenatally or postnatally if their baby is born early.

Women with high risk pregnancies come in antenatally and this project alone has had some impressive results when it comes to delivering the women before their babies run into trouble and therefore preventing hypoxic ischaemic encephalopathy (formerly “birth asphyxia”) in particular.

Having facilities like these available to the mothers of premature babies after delivery encourages them to stay on site and therefore be available to their baby for skin to skin mothercare.

And then they could fly….

We’ve just finished Day 1 of the first Neonatal Care Course being taught by Ugandan instructors. All 12 instructors passed the Generic Instructor Course yesterday and rose to the challenge of teaching the NCC today. We are running this course in the chapel. Grace is course directing and made sure everyone knew the ground rules.

It wasn’t long before the newly trained instructors took over from us:

Newly trained instructors teaching resuscitation skills
BCH chapel hosting the Neonatal Care Course

The paediatric ward

Murals on the children’s ward, Bwindi Community Hospital

Dr Cath Harrison:

 A visit to the paediatric ward today – an amazing set up with the ward being divided up into separate areas to allow patients needing frequent observations and management to be near the nursing station.

There is a kitchen at the end of the ward where families are taught by nursing staff the importance of nutrition and how to make nutritionally balanced meals.

There is an indoor play area and outdoor space as well for children.

We saw a variety of conditions – orbital cellulitis secondary to trauma (fall from a tree), pneumonia and malaria.

The pride was apparent in the quality of care the staff provided and the clinical space was so clean and tidy.

A good demonstration of teamworking to improve the quality of care provided to children and their families.

Uganda Nursing School, Bwindi

Bwindi nursing school is co-located with the hospital and was built in 2013

UK consultant neonatologist, Dr Cath Harrison, is part of the team in Bwindi this year and has written a couple of blog posts for the NICHE website:

During preparations for the GIC course, we were fortunate to have a visit to the Bwindi Community Hospital School of Nursing. This was set up in 2013 initially with 100 students. Now 10 years later there are 400 students. The course is 2-3 years long with students graduating with a Diploma in Nursing.

The school is about 3 minutes’ walk from the hospital entrance and is a self-contained facility with communal spaces, lecture theatres, library and on-site accommodation for the students. There is even a football pitch and the women’s team won a national competition last year!

The nursing school has improved nursing staffing for the hospital, with the best students being offered posts at BCH, thereby maintaining workforce and sustainable care provision.

Back in Bwindi

We’re back in Bwindi Community Hospital for the first Generic Instructor Course (GIC) to be run here, followed by 2 x Neonatal Care Courses (NCC) where we will be supervising the newly trained instructors as they facilitate their first 2 courses.

Dr Scott Kellerman, founder of Bwindi Community Hospital with Julia and Kirstie

U.S missionaries Dr. Scott and his wife Carol Kellerman started the hospital in 2003 when it was a simple outreach clinic under a tree for the Batwa people, who had been evicted from Bwindi Impenetrable forest when it was turned into a mountain gorilla sanctuary. That small clinic is now a fully-fledged hospital with 155 beds, which also houses the Uganda Nursing School and Uganda College of Health Sciences Bwindi.

The close proximity of the Impenetrable Forest makes it a beautiful place to come and teach.

Instructors Jo B-J and Grace waiting to go to the hospital this morning to set up the teaching rooms. Uganda is quite a bit cooler than Cameroon!
Jo L had to wait for someone else to finish using her bathroom this morning
Such a beautiful place to work
Street scene outside the hospital

Tomorrow we start work properly – 2 full days of instructor training for the 12 candidates chosen this time last year during the first 2 NCCs we ran here. There is a lot of enthusiasm from all involved and we are looking forward to getting going.

Our 5 Year Anniversary!

Five years of NICHE International

Report from the lead trustee, Dr Alison Earley

Our charity was established because too many babies in low-income countries die in their first month of life.  We wanted to reduce this by delivering training in neonatal care, and to make changes that would be owned and sustained by the healthcare workers we trained.

So, after 5 years, how are we doing?

Where have we worked?  

We have run Neonatal Care Courses in Cameroon, Liberia and Uganda.  Following each course, selected candidates undertake a ‘train the trainers’ Generic Instructor Course (GIC), so that they can train local colleagues.  GIC courses have been taught in Cameroon and Liberia, and the first one will take place in Uganda in February 2023.

How many health care workers have been trained? 

More than 300.  Candidates have come from 7 of Cameroon’s 10 Regions, from two districts in Liberia (one remote), and from districts in South West Uganda.  The learners have been nurses, midwives, nursing assistants, clinical officers, general practitioner doctors, anaesthetists, paediatricians and a paediatric surgeon.  Our courses have also been observed by public health doctors, a professor of paediatrics and nursing school tutors.

Knowledge assessment and feedback

Each course concludes with a multiple choice and practical assessment.  The pass rate is high, 80%. Nearly all candidates pass these, but occasionally someone doesn’t meet the required standard, and we try to offer a place on another course. 

Feedback has generally been very positive.  Some learners would like a longer course, in particular to practise learning from scenarios, which is a new concept to many.  Accordingly, we are planning to add a further half day to the 2 day Neonatal Care Course when we teach it in Uganda in February 2023.

Demonstrating that this training is being incorporated into participants’ daily practice, and that skills are retained is challenging.  We have collected anecdotal evidence, and have asked the course graduates to keep records of babies resuscitated at birth, and to fill in questionnaires about their confidence in various aspects of practice.  While there is some data from these, we have not yet overcome the difficulties of proving that what is learnt is retained and used.

What about sustainability? 

There are more than 25 health workers in Cameroon who have completed the Generic Instructors Course (GIC) and who are now gaining experience in teaching their own courses, without the need for international instructors to come from UK.  Despite the Covid 19 pandemic, they have run five courses successfully. One of these was in the remote Far North Region of Cameroon, where health facilities are scarce and the perinatal mortality is high.

We are confident that this success will be repeated in Uganda, where 12 candidates have been chosen for the first GIC which will take place in Feb 2023.  In Liberia, several sessions of neonatal resuscitation training have been carried out locally by nurses who attended the NICHE courses.  The University of Buea in Cameroon has asked for a course for its final year medical students.

We see maintaining the skills and enthusiasm of local Instructors as critical to the goal of making lasting improvements in neonatal care and to that end we have developed a novel Instructor Development Day course which we ran for the first time in 2022 in Cameroon.

Partnerships and friends

We have been delighted to establish partnerships – working closely and sharing expertise and knowledge with the following:

  • ALSG (Advanced Life Support Group), an educational charity
  • 2 NICHE trustees are on the Strengthening Emergency Care committee of ALSG.
  • Child Health Matters, a charity supporting health care in Uganda
  • Bwindi Community Hospital, South West Uganda
  • MCAI (Maternal and Childhealth Advocacy International), developers of the Neonatal Care Course and of neonatal clinician training in Liberia
  • Cameroon Baptist Convention Health Services, which contributes to health care in Cameroon.

In addition, we owe much to the huge amount of enthusiasm, guidance and friendship from local ‘champions’ in each country, who are passionate in taking the training forward, and with whom we are planning the next steps.

Governance

The charity is run by the six founder trustees on a voluntary basis.  Between us, we have experience working for teaching and medical charities in Cameroon, Liberia and other resource poor countries, in project management, post-graduate teaching, IT and business. We also have two co-opted members, who lend their expertise to trustee meetings. They are Irish paediatrician Dr Jarlath O’Donohoe, and Cameroonian senior neonatal nurse, Mrs Grace Ndze.

We have established a regularly reviewed safeguarding policy and code of conduct to which all trustees and volunteers adhere.

Fundraising

It has been a huge challenge to fund the delivery of our courses over the past 5 years, and our sincere thanks go to our supporters:

  • The British Medical Association
  • The Batchworth Trust
  • St Mary’s Church, Amersham
  • Calderdale and Huddersfield RCM
  • Souter Charitable Trust
  • Ashworth Trust
  • The many individuals who have raised funds through sponsored and other activities, or who have donated via our website or Just Giving.

Not forgetting our UK and international volunteers, who give their time free of charge to deliver courses for NICHE.

All funds raised go directly to NICHE projects.  We have no premises and no paid staff. 

In the next 5 years we would like to:

  1. Support local health care professionals in the areas where we work, not only in teaching the Neonatal Care Course, but also in training their own Instructors.  This means finding local experts in adult education to lead the Generic Instructor Courses.
  2. Provide robust evidence that attending courses improves practice.
  3. Work on reducing skills decay within the cohort of trained healthcare professionals.
  4. Continue to develop the online work and mentoring programme to help GIC Instructor candidates prepare for their courses.  This is being piloted currently in Uganda.
  5. Reach out and offer courses to more health sectors, such as medical schools, nursing schools and government institutions.
  6. Work towards a more globally representative senior instructor team which allows suitably trained healthcare professionals to share practices across their own continent.  Our Cameroonian colleague accompanying us to Uganda already confers credibility on the international instructor team.
  7. Withdraw from countries where we have helped to build a fully functional faculty able to run courses and train instructors, and begin the process again in new countries.  Remote support for fully functioning faculties is likely to continue for a while.

In conclusion:  NICHE International is in good health.   Over the past five years, instructors and candidates have learned much from one another.  We look forward to more years of working with our partners and local ‘champions’, developing training in neonatal care and cascading skills and knowledge to healthcare workers in poorly resourced areas of the world.  We look forward to continuing our collaborative and sustainable work on ensuring fewer babies die in the first month of life. 

AE & AG  2023