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.

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.

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.

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.

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.

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

12 candidates for instructor training were selected at the first Neonatal Care Courses that were run in Bwindi in February 2022. They were supposed to be trained in November 2022 but the Ebola outbreak (in a different part of the country) put pay to NICHE International’s travel plans and we had to disappoint the group by postponing the training.

We have been doing some preliminary pre-course training with the candidates via a Zoom link. The Pocket Guide to Teaching for Clinical Instructors is the manual for the internationally taught and recognised Generic Instructor Course. Our educator, Jo Lawrence, arranged for some to be sent to Bwindi and the candidates have been busy reading about the “Set, Environment, Dialogue and Closure” structure of all teaching modalities.

Last week, the “Green group” of four each presented their prepared 5 minute lectures for Grace and I, their group mentors. The tropical rain was hammering down on Bwindi’s tin roof and the temperate wind was howling around my house in the UK. Only Cameroon’s weather sat quietly and listened to our four enthusiastic learners teaching us about hypoglycaemic fits, neonatal resuscitation and the risks of being born too early.

This is exciting and ground breaking work. The Advanced Life Support Group started to run “remotely enhanced” GICs during the pandemic in the UK but we are not aware of anyone else doing pre-course GIC training with overseas instructors. Our Cameroonian colleague, Grace, was instrumental in driving this forwards as she pointed out that the ethos of the GIC is new to many African healthcare workers and it takes time to get used to the GIC educational theories and practices.