Do as I Say and Do

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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]

The European instructors have gone home

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THE CAMEROONIAN FACULTY ARE INTO THE LAST STRETCH OF THIS INTENSIVE TRAINING PERIOD WITH THE SECOND NCC BEING DELIVERED NOW

by Grace Ngoran

The second NCC kicked off today with 28 participants in attendance (the 4 extra being the staff who could not make it down to Yaoundé from Bamenda earlier in the week due to concerns around their safety). The excitement was evident as the instructor candidates came up again powerfully with excellent performance. The workshops were really excited particularly the breastfeeding workshop where everyone used the breast models to demonstrate proper latching technique. Participants were observed to be more involved and participatory.

Knitted visual aids in use during the breastfeeding workshop in Yaoundé today

Best breastfeeding videos!

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I have linked to the Global Media videos before. Such an amazing repository of videos for parents and healthcare workers across the world. We owe the families who agreed to take part in this project a debt of gratitude.

This one has some excellent information on proper attachment of the baby to the breast: https://globalhealthmedia.org/portfolio-items/breastfeeding-attachment/?portfolioCats=191%2C94%2C13%2C23%2C65

Breastfeeding workshop

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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.

20% of babies are exclusively breastfed at 6 months of age

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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.

 

“Apart from getting money, are we not also blessed?” [Kola on the “noble” profession of nursing]

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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.

Gertrude doing Stage 2 of the 4-stage procedure in how to tie a kalafong wrap for the baby to be skin-to-skin with its mother.

Christina overseeing resuscitation skills training.

Agnes (gesticulating with her hands) running an animated discussion workshop on pain in babies and how to manage the baby who won’t live long.

Outcome measures

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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.

 

“Titty water time!”

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We teach the Newborn Care Course in different countries of the world and although the language used is English, we do find that some words don’t travel very well.  Here in Liberia we have had to change the names of the babies in the case histories because they had a French flavour to them (because of our work in Cameroon) and our Liberian colleagues couldn’t work out how to pronounce “Yves” and “Mireille”.  We’ve also changed “cot” to the more American “crib” that they use here and we allow them to talk about “reflex” interchangeably with “tone” when they are assessing the newborn baby.  But today’s lexicon stumped us initially until it became clear that “titty water” is in fact breastmilk.

Just about everyone breastfeeds in Liberia.  I thought it was because the pregnant women were well educated in the antenatal clinic but it transpires that many women go nowhere near the antenatal clinic.  It’s just that formula is expensive.  Very few breastfeed exclusively for 6 months as per current WHO advice.  World Bank figures for exclusive breastfeeding in babies under 6 months of age for 2013 suggest that 54.58% of these young babies in Liberia are exclusively breastfed (https://tradingeconomics.com/liberia/exclusive-breastfeeding-percent-of-children-under-6-months-wb-data.html).  They are given corn cereal mixed with water to supplement the breast milk and sometimes from a very young age.

Early breastfeeding is one of the World Health Organisation’s 4 top priorities for combating high neonatal mortality rates and we talk a lot about supporting breastfeeding mothers during the Newborn Care Course and the importance of feeding expressed breastmilk to the babies on the neonatal units.  Our co-instructor, the indomitable advanced neonatal nurse practitioner Kola, pits the mums on his neonatal unit against one another with his 3 hourly cry of “titty water time” when they all have to express 10mls of breastmilk to feed their premature baby down the baby’s nasogastric tube.  He says a bit of healthy competition leads to better neonatal outcomes!

Image result for expressing breast milk by hand
Picture from excellent cartoons on hand expressing breastmilk at https://www.fitpregnancy.com/baby/breastfeeding/how-to-hand-express-your-breast-milk

 

Image result for nasogastric tube preterm baby
Laerdal Global Health’s preterm simulator showing the correct way of gravity feeding via a nasogastric tube

 

We have changed all the “cots” to “cribs” on the Liberian version of the slides this evening but can’t quite bring ourselves to make the required changes to “breastmilk”.