First Neonatal Care Course in the Far North Region of Cameroon

Dr Alison Earley

B marks Maroua, the main city in the far north region of Cameroon, a 36 hour journey by bus from Yaoundé

The Far North Region of Cameroon is at the Northern tip of the country, between Nigeria and Chad. Its capital is Maroua, which lies to the East of the Mandara mountains.

Pictures from the Mandara mountains

This is where Cameroonian Instructors are currently teaching the Neonatal Care course. Two of the instructors did their instructor training in Yaoundé in April this year, when NICHE International volunteers visited to facilitate the course. Other instructors are more experienced and have taught on several Neonatal Care Courses before.

Faculty member, Felicia, ready for action at Maroua CBCHS health facility

The perinatal mortality is particularly high in this remote region, and the course is much needed. The instructors travelled for 36 hours from Yaoundé, Cameroon’s capital, to reach Maroua where they are training healthcare workers in the Cameroon Baptist Convention Health Services facility. The majority of the health care workers in the Region are French speaking, and the course manual has been translated into French for them.

Felicia in action, training nurses and midwives in neonatal resuscitation

They shared their past frustrations and said this course will help them to save many lives

Grace on the learners’ feedback after course number 1 last night

Today is International Nurses’ Day!

Dr Alison Earley

International Nurses Day is celebrated around the world every May 12, the anniversary of Florence Nightingale’s birth.

Felicia with baby manikins donated to or bought by NICHE, and used for training in new born resuscitation

The theme for 2022 is ‘Nurses: A Voice to Lead – Invest in Nursing and respect rights to secure global health

Working in neonatal care in Cameroon, Liberia and Uganda it is very obvious just how crucial good nurses are to the survival of all babies, but especially those who are premature or unwell. 

We have also found ‘voices to lead’ among the nurses with whom we have worked, and seen their dedication and abilities.

Felicia is a nurse working in an isolated rural setting in Adamawa Region, one of the Regions in the North of Cameroon which has very high perinatal mortality.

Bwindi feedback

There were 29 feedback forms from the first two NCCs in Uganda. All candidates were frontline healthcare workers and 25 (86%) of them had had previous experience of neonatal resuscitation.

A good multidisciplinary mix

Proving that neonatal mortality is falling as a result of our project is our long-term aim but measuring this outcome is a challenge.  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. 

It is more productive to measure shorter term outcomes which are known to correlate positively with an improvement in neonatal survival.  We gather feedback from our learners on the usefulness of the course, their prior experience, suggestions for the future etc. but also on their increase in confidence levels in the practice of various skills taught on the course.  The template for our feedback forms is based on one promoted by the UK’s Royal College of Paediatrics and Child Health for use on training courses.

Variations in self-confidence are known to influence motivation and tend to predict performance success. The percentage of learners in Bwindi in February feeling “very confident” in keeping babies warm increased from 17% to 100%, in giving breastfeeding advice, an increase from 24% to 100% post-course and in resuscitation skills, 7% to 93% feeling “very confident” after the course. Having the confidence to try and resuscitate an unconscious newborn baby is more likely to lead to a positive outcome than not having the confidence to make the attempt. Our data consistently show an increase in confidence in the essential skills pertaining to neonatal care identified by WHO. See: for a screenshot of the questionnaires we use.

Analysis of 29 feedback forms from the first NCCs in Uganda

Kangaroo Mother Care saves lives

Sadias and Grace making more kalafong wraps for the skin to skin workshop

Keeping babies warm is one of the things that reduce neonatal mortality. We promote it strongly throughout the course. It also promotes breastfeeding, reduces the risk of hospital-acquired infection, is important for bonding and leads to faster growth.

Grace’s skin to skin workshop
Sadias, Bwindi course coordinator, taking part in the skin to skin workshop

When we went to the neonatal unit initially, there were 5 babies (including a set of twins) between 33 and 35 weeks in incubators or being held by their mothers in piles of blankets. The doctor asked for help because none of them were putting on weight. Grace went to work…

Twins in skin to skin mother care, also known as Kangaroo Mother Care (KMC)

All 5 had been discharged by the end of our week in Bwindi, all putting on weight. Well done to the nurses for being early adopters of KMC in Bwindi and for seeing the benefits straight away.

On day 3 of our visit, we noticed these pictures that had been put up in the anteroom to the neonatal unit where the mothers were waiting to see their babies.

On day 5, we did the round with the mothers actually present in the neonatal unit – the remaining 2 babies both skin to skin.

How big is the problem?

NICHE International was set up to train local health professionals to teach the Neonatal Care Course (NCC). We follow the model used by life support organisations all over the world – clinicians do the course themselves, some are recommended as instructors, they train as instructors, form their own faculty with a bit of support initially from senior instructors, start training their peers and eventually begin to train their own instructors. The NCC sits under the umbrella of the Advanced Life Support Group (ALSG) in the UK.

The overall aim of the Neonatal Care Course is to reduce neonatal mortality rates (death of a baby in the first month of life).

The statistics above taken from, show that the neonatal mortality rate in Uganda reduced from 35 per 1000 live births in 2000 to 21 in 2016. 35% of the under-5s deaths though are in the neonatal period. The NCC can help bring down the numbers of deaths caused by complications of preterm births, sepsis and pneumonia. Together, these 3 causes make up half of the deaths in the first 28 days of life. We think that’s something worth working for.

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

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:  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.


Low birthweight and neonatal mortality

One of the slides from the NCC lecture on Nutrition and Feeding


This is a slide from one of the early lectures on the Newborn Care Course.  It outlines WHO’s priorities in the fight to bring down neonatal mortality (number of deaths per 1,000 live births) to “at least as low as 12 per 1,000” by 2030.

Liberia’s neonatal mortality rate is 25 per 1,000 [UNICEF 2018 data].  3 babies have died in the hospital in Zwedru since we’ve been here; 2 term babies born with severe hypoxic ischaemic encephalopathy (lack of oxygen around the time of birth) and 1 preterm baby weighing 900g who looked quite well when we arrived but died on day 6 of life during our second course – despite 2 of the local instructors leaving the course to go to the hospital to try and help save the baby.

Not many babies under 1.5kg survive here.  Kola’s been discussing this this evening and showing us pictures of his successes – including one little lad called Success, born by perimortem Caesarean section to a mother with severe eclampsia, at 1kg.  Now, developmentally normal and with adoptive parents, the family recently came back to the unit to celebrate his second birthday.  Kola’s smallest survivor weighed just 600g at birth at 29 weeks gestation.  He is now over 1 and also developmentally normal.  I suspect that although the survival rates at different gestational ages are very much lower than in the UK, the percentage surviving without severe disability is probably higher.


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

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: and which has links to up to date information like the recent release of the opposition leader from prison and the current peace plan.

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.