Summary Report of Training Programme in Newborn Resuscitation and Care Nigeria Health Care Project & Methodist Church Nigeria February March 2017 1. Over 240,000 newborn babies die in Nigeria every year. Most of these deaths can be prevented by low-cost interventions directed at the three main causes of death in the first four weeks of life: complications around the time of birth ( birth asphyxia ), infection and prematurity. 2. Nigeria Health Care Project (NHCP) is a faith-based charity that works closely with Methodist Church Nigeria (MCN) to support primary health care in rural areas of Nigeria. Since 2011, NHCP has also offered training to health workers. In 2014 and 2015 NHCP ran successful training of trainers courses in newborn resuscitation and care. 3. In previous years, evaluation of training has been immediate, with pre- and post-course questionnaires and direct observation of acquired skills. In 2017, greater emphasis was placed on longer-term evaluation - had previous trainees retained their skills? 4. Although the training coordinators workshop in vember 2015 had included plans for basic local monitoring of newborn resuscitation, this has yet to be happen and more support is needed to achieve this 5. In 2017 training took place in MCN health facilities in two areas Bende LGA, Abia State where each health centre where babies are delivered now has at least one staff member trained in neonatal resuscitation, and Oju LGA, Benue State where less than half of health facilities have such a trained person. 6. The aims of training programmes were slightly different in the two areas in 2017, with the Bende programme placing more emphasis on evaluation of those already trained. Also there had been a specific request from Bende LGA for more training in the assessment and management of neonatal jaundice, a cause of neonatal morbidity and mortality that is not emphasised in international programmes but is particularly prevalent in Nigeria. The Oju programme following similar aims to those used in 2015. 7. Evaluation of resuscitation skills of those who had been previously trained showed generally poor retention of core skills. Though disappointing, this should not have been surprising as previous trainees rarely use these skills in their everyday work, unless they are working in a busy hospital or a health centre with many deliveries. This evaluation led to immediate modifications to the planned training programmes and informed the planning in the local coordinators workshops for subsequent training. 8. Local training coordinators were resourced with notebook (laptop) computers with pre-loaded training videos and other resources. 9. The focus for the rest of 2017 will be to support local training coordinators to deliver further training and to facilitate monitoring of resuscitation activity. Communication will be via regular updates via newsletters, WhatsApp messages, phone calls or texts, with the provision of some additional funding when required. 1
Introduction and Background Deaths in the first four weeks of life account for 32% of the under-5 mortality in Nigeria. Over 240,000 newborn babies are estimated to die in Nigeria each year. (Nigeria Every Newborn Action Plan, Federal Ministry of Health v. 2016) The three most common causes of death in the newborn period in Nigeria are problems around the time of birth ( asphyxia ), infection and prematurity. There are simple, evidence-based and cost-effective ways of substantially reducing deaths from these three major causes which can be taught in a structured way to health workers. The Nigeria Health Care Project (NHCP) works in partnership with Methodist Church Nigeria (MCN). The main aim of NHCP is to support primary health care in rural areas. NHCP was established in 1992 and is a UK registered charity. It has raised over 1.5m in the UK and currently gives some support to 15 centres in Nigeria. Since 2011, NHCP has started to support and deliver training programmes, predominately in the area of newborn and child health. In each successive year, NHCP has expanded its training activities, learning lessons from previous years. Year Bethesda Hospital, Ikachi, Igede Diocese, Oju LGA, Benue State Place Royal Cross Hospital, Ugwueke, Uzuakoli Diocese Bende LGA, Abia State 2012 Newborn resuscitation (45) 2013 Newborn resuscitation & care of the sick child (123) 2014 Training of Trainers (26) 10 Training of Trainers (36) 20 in newborn resuscitation & care in newborn resuscitation & care 2015* Training of Trainers (25) 13 Training of Trainers (26) 16 in newborn resuscitation & care in newborn resuscitation & care Numbers in (brackets) are the total participants trained, Numbers in bold are those of the participants who were designated as trainers * In 2015 NHCP also trained trainers in Ekiti State where a total of 55 participants were trained, of whom 5 were designated as trainers. However, it was not possible to continue with a training programme in Ekiti. 3 of the 8 training facilitators who volunteered in 2015 were Nigerians working in Nigeria (Felicia Fechi Ujah from Bende LGA and Dr Omotunde Ogunlaja and Sr Eunice Akpan from Premier Specialists Medical Centre, Lagos) In 2015, a workshop for local training coordinators was held in Lagos. This enabled coordinators from Oju LGA, Ebenta College of Health Technology, Royal Cross Hospital and Bende LGA to meet together with UK-based facilitators to make realistic plans for the following year s training. As a result, Bende LGA now has at least one person trained in basic neonatal resuscitation and care in every LGA health facility that delivers babies. Unfortunately, there were major problems in transmitting the funding to the Oju LGA training coordinators so no additional training was done there during 2016. Aims for the two centres differed in 2017. The priority in Bethesda/Oju LGA was to train more staff. In Bende LGA there was more of a focus on evaluation. A system of basic monitoring of resuscitation practice is needed in both places. Training coordinators needed better resources and support to continue training. 2
Aims & Objectives (Royal Cross and Nkechi Colwill Hospitals, Bende LGA) Aims: 1. To train trainers in newborn resuscitation, essential newborn care* and danger signs in young babies. 2. To evaluate the knowledge/skills of those trained in 2014 and 2015 3. To further strengthen working links between local government health services and church health services * Essential newborn care included (at the request of Bende LGA training coordinators) the assessment and management of jaundice, and the use of chlorhexidine gel in care of the umbilical cord Objectives: 1a. Trainers will be able to train others in newborn resuscitation. 1b. Trainers will have their resuscitation training skills assessed. 1c. Trainers will be equipped with materials to train others. 2a. Trainers will be linked with each other in training teams who are able to communicate with each other. 2b. Each team of local trainers will achieve one further training event during 2017 2c. Training coordinators will be able to communicate with the UK training team for mentorship and access to more training materials. 3a. Trainers will work together with staff from church and government facilities to deliver further training Methods: As with previous years, facilitators used Neonatal Life Support methods for teaching basic newborn resuscitation, modified by MCAI for use in the Gambia and adapted by NHCP for use in Nigeria. We made good use of video material provided by Medical Aid Films (UK) and Global Health Media (USA) in large and small group teaching. In Bende we planned a two day programme at Royal Cross Hospital, to be repeated at Nkechi Colwill Hospital, followed by a half-day workshop for training coordinators. An additional day, focussing on resuscitation skills, was offered at Royal Cross on 28 th February Day 1 ( 20 th at Royal Cross, 22 nd at Nkechi Colwill) Day 2 (21 st at Royal Cross, 23 rd at Nkechi Colwill) Group 1 Group 2 Group 1 Group 2 0900- Registration and questionnaires Registration. Review of Jaundice 1000- Welcome and opening Small group work on newborn baby 1030- Introduction scenarios 1100-1300 Resuscitation training Resuscitation evaluation 1300 Lunch Lunch 1345 Resuscitation video Complete evaluations 1415 Complete evaluations 1445 Neonatal jaundice what happens at the moment 1500 tea break 1530-1630 Neonatal jaundice lecture and small groups Management of the small sick baby in your health facility Advocacy discussion and individual action plans Certificates etc, Close at about 1600 Group 1 are new participants, Group 2 those previously trained by NHCP. Training facilitators for the first week were: Dr Stephanie Govenden, Dr Chakra Vausdevan, Dr David Cundall (UK) Felicia Fechi Ujah, Chinyere Joy (Bende LGA). 3
Results Numbers of participants Royal Cross Hospital Church employees LGA employees Private Totals Group 1 (new) Group 2 (refresh) Group 1 (new) Group 2 (refresh) Group 2 (refresh) Doctor 1 1 Registered nurses/ 7 3 1 11 midwives CHEWs 3 4 7 Others 6 1 2 9 Totals 14 7 5 2 28 Nkechi Colwill Hospital Church employees LGA employees Totals Group 1 (new) Group 2 (refresh) Group 1 (new) Group 2 (refresh) Registered nurses/ midwives 2 2 CHEWs 6 6 Others 15 4 19 Totals 15 2 10 27 There was reduced attendance from LGA staff due to an unavoidable clash of dates with some State Government training LGA training coordinators had been asked to send staff who had already been trained, which is why there were no LGA staff in Group 1 (new). There were many new participants from the church hospitals because this was the first time that Nkechi Colwill Hospital had hosted the training. Evaluation Pre and post-course questionnaires did show an increase in the knowledge of new participants at Nkechi Colwill hospital (post-course questionnaires were accidentally omitted at the end of the first Royal Cross course). However, assessment of practical resuscitation skills amongst a small number of staff attending on the first day showed poor retention of basic resuscitation skills by those who had been previously trained. Although this was a major concern, facilitators realised it was not surprising, as those previously trained had not had much opportunity to practice their skills. This led to a fundamental re-think of the content of the courses with an increased emphasis on ensuring everyone attending was competent in basic resuscitation. It was decided not to attempt to designate more trainers, but to look for a few staff members who could assist the local training coordinators Felicia and Joy. The new Matron at Royal Cross, Sister Comfort, was chosen to replace the previous Matron, Stella Chibuzor, who had been the training coordinator for the church hospitals. Coordinators workshop This was held on 24 th February at the Motherless Babies Home on the Uzuakoli site near Nkechi Colwill Hospital. The agenda focussed mainly on the practicalities of setting up a basic monitoring system. A form was devised and agreed. NHCP HP notebook (laptop) computers, pre-loaded with all the training videos and some other resources were given to Sister Comfort for the hospitals and Felicia Fechi for Bende LGA. 4
Aims & Objectives (Bethesda Hospital and Oju LGA Aims: 1. To train trainers in newborn resuscitation, essential newborn care and danger signs in young babies 2. To set up a network of trainers, supported by local training coordinators, who can continue training during 2017. 3. To evaluate the knowledge/skills of those trained in 2014 and 2015 4. To further strengthen working links between local government health services and church health services Objectives: 1a. Trainers will be able to train others in newborn resuscitation. 1b. Trainers will have their resuscitation training skills assessed. 1c. Trainers will be equipped with materials to train others. 2a. Local training coordinators will have the necessary skills, equipment and resources to work with trainers to train staff in, or close to, their own health facilities 2b. Local training coordinators will work towards having at least one staff member trained and equipped to offer basic newborn care and resuscitation in every facility that delivers babies in Oju LGA 3a. To ensure that at least 50% of those previously trained have their knowledge and skills reassessed and refreshed Methods As Oju LGA does not yet have many staff trained, and there were quite a few new staff to be trained at Bethesda Hospital, a different approach was used to that used in Bende during the previous week. The pattern of the week was more similar to that used in 2015, but compressed into 3 days rather than 4. A coordinators workshop ran in parallel with a refresher half-day on Friday 3rd. am Tuesday 28 th February Participants arrive: Registration Opening ceremony Introduction Physiology and theory of resuscitation (lecture) pm Practical resuscitation Using Neonatal Life Support (NLS) approach MAF resuscitation video MAF Medical Aid Films GHM Global Health Media Wednesday 1 st March Thursday 2 nd March Friday 3 rd March The Small Baby 6 sick newborn scenarios (lecture) reinforced by GHM Small group work videos reinforced by GHM Plenary session on videos danger signs - keeping baby warm - the small baby s feeding journey - Expressing the First Milk Infection lecture D then 3 Sick newborn scenarios: Coordinators work with other participants to teach resuscitation. Post-course questionnaire Individual action plans Certificates Staff trained in resuscitation in 2014 and 2015 return for assessment and brief refresher (about 2 hours) At the same time there will be a workshop for local training coordinators Training facilitators for the second week were: Dr Omotunde Ogunlaja, Sr Eunice Akpan and Sr Marcellina Njar-Monye (Lagos) Dr David Cundall (UK) Local training coordinators were: Mrs Maria Onah, Martha Okpoto (Oju LGA) Esther Yakubu (Galadima Health Centre, South Kaduna). Edi Iji Joshua (Ebenta College), was able to attend the coordinators workshop. 5
Results Numbers of Participants Church employees LGA employees Totals New Refresher New Refresher Doctor 3 3 Registered nurses/ 3 1 1 5 midwives CHEWs 2 4 11 9 26 Others 3 3 Totals 11 4 12 10 37 Good numbers attended from the LGA because of much improved joint working as a result of there being two local training coordinators from the LGA. There were no other LGA training programmes running at the same time (as had happened in 2015) Evaluation For new participants, the mean pre-course questionnaire score was 6.2 and the mean post-course score was 7.2. All participants, new or refresher, were able to demonstrate competence in basic resuscitation techniques by the end of their courses. Ebenta College has some major problems and was on a planned break at the time. Edi Iji Joshua, a lecturer from the College, was only able to attend for the coordinators workshop on the final day. One student, an ex-member of staff from Bethesda Hospital, attended the refresher course. Esther Yakubu, registered nurse/midwife from Galadima Health Centre an MCN health facility in South Kaduna, acted as a co-facilitator throughout the week and was designated as the local training coordinator for her area. Dr Joseph Onah, the new medical director at Bethesda Hospital, was very actively engaged in the training programme. He was designated as the local training coordinator for Bethesda Hospital and clinics Coordinators Workshop It proved difficult to allocate sufficient time to the workshop at Bethesda as it was ambitious to run it in parallel with the refresher course and it also coincided with the arrival of NHCP trustees and MCN and Diocesan representatives to inspect the hospital. However, HP notebook (laptop) computers, pre-loaded with videos and other training resources were given to Dr Onah, local training coordinator for Bethesda Hospital and clinics, Mrs Maria Onah (no relation) for Oju LGA and Esther Yakubu, for Galadima health centre. A memory stick with all the training materials and more resources for the College was given to Edi Iji Joshua. It was disappointing to hear that the College s computers are currently not in use. There was a brief discussion of monitoring but this will need more work before it can be implemented. It was very encouraging when Dr Onah proposed that he coordinates meetings of the local training coordinators from Oju LGA, the College and the hospital. The training funding for Oju LGA, which was delayed throughout 2016, was delivered by Deaconess Oworu (Health Secretary MCN) to Mrs Maria Onah to enable the further planned LGA training to take place. 6
Discussion Resuscitation Skills The evaluation of resuscitation skills on the first day of training at Royal Cross Hospital, working with Bende LGA and church staff, showed that skills were, in general, poorly maintained. This should not have been a surprise, given that most people do not have the opportunity to practice their resuscitation skills regularly, unless this is part of ongoing training. This finding resulted in a change of emphasis in the training courses themselves, and informed the coordinators workshops. Facilitators decided not to designate new participants as trainers (as had been our practice in 2014 and 2015) but to look for staff who could become coordinators, or assist the current coordinators. It is worth noting that the Neonatal Life Support course as practiced in the UK identifies participants who have the potential to be trainers, rather than designating them as trainers immediately. In 2014 and 2015, facilitators taught additional airway manoeuvres (two-person jaw-thrust). In 2017 it was decided to concentrate on the basics of resuscitation - assessment of colour, tone, breathing and heartbeat - opening the airway by putting the baby in the neutral position - giving five inflation breaths and seeing the chest move - continuing with ventilation breaths if needed During the first week of training, we also included a short drama where a senior professional colleague was trying to prevent/undermine a health worker using their newly acquired resuscitation skills and knowledge Facilitators ensured that every participant was confident in their ability to do this before the end of the course. Other aspects of newborn care The request from Felicia Fechi, local coordinator and facilitator from Bende LGA to pay more attention to neonatal jaundice was timely. ABO blood-group incompatibility, G6PD enzyme deficiency and sepsis are common causes of this potentially fatal problem in Nigeria. International initiatives tend not to emphasise the importance of neonatal jaundice as a cause of death and disability because it is less common in most other countries. Treatment options for severe jaundice (phototherapy, exchange transfusion) are not widely available. NHCP training focussed on making the distinction between normal and serious jaundice. This was greatly helped by the short video on the subject produced by the Global Health Media Project. NHCP training on other aspects of newborn care has evolved to retain a small number of lectures to the whole group and more time spent in small groups. New videos produced recently by the Global Health Media Project on the care of the small baby were an excellent addition to the programme and meant that we had something new to offer to those coming for a refresher course. Coordinators workshops Both workshops were shorter in time than originally intended and the one at Bethesda Hospital was too limited in its time and scope. The two main agenda items were to ensure that training coordinators knew how to use the NHCP training laptops provided and that some plans were in place to ensure that routine monitoring of resuscitation can take place. 7
Pattern of training in 2017 Discussion in both coordinators workshops indicated that it should be possible to enable staff to practice resuscitation more frequently and regularly. Local coordinators are equipped with Neonatalie manikins, spare bags and masks. The NHCP laptops have many training resources so, for example, local training coordinator(s) and selected assistants could run a session on the feeding journey of the small baby but also ensure that every participant had the opportunity to practice their resuscitation skills as well. Coordinators could also take their resuscitation training equipment with them to other training events. LGA training coordinators at Bende LGA and Royal Cross Hospital plan to have a joint training event in the near future. A small amount of residual training funding is available, which can be applied for via Deaconess Ronke Oworu to support further training events. Oju LGA now have the financial resources from 2016 to deliver further training in their health centres in 2017. Dr Onah plans to gather the coordinators from Oju LGA for regular meetings to support and encourage the continuing programme. It is not clear what will happen at Ebenta College in the next few months as a way forward is found for that institution. The College has computers, onto which the contents of the flash-drive given to Edi Iji Joshua can be loaded once the computers are back in action. Esther Yakubu will train the staff at Galadima and Damishi Health Centres and at the local government health centre at Zonkwa Monitoring of resuscitation activity During the first week a draft form was developed to use to record resuscitation activity (Appendix 1). It was agreed at the first coordinators workshop that these forms could be completed very month, as is the pattern for many other returns completed by health centres. There was insufficient time to discuss this at the second coordinators workshop. It will be necessary to cost and resource the printing of these forms for hospitals and LGAs. Conclusions 1. A total of 92 people were trained, of whom 57 were new participants. 2. All were competent in basic newborn resuscitation skills 3. Evaluation of a small sample of previous trainees showed that resuscitation skills were poorly maintained after 1-2 years. 4. This led to a change in emphasis in the training offered, with a greater focus on ensuring basic resuscitation skills were learned and practiced. This will also affect the methods by local training coordinators in 2017. 5. The majority (5/8) of training facilitators were Nigerians based in Nigeria. There is now a strong link between staff working at Premier Medical Specialists Hospital Lagos and Bethesda Hospital. 6. The request, from Bende LGA, for specific training on neonatal jaundice was a good example of the way the training partnership is evolving. 7. A form for monitoring of resuscitation activity was devised and agreed by staff from Royal Cross Hospital and Bende LGA. Time constraints did not allow discussion of this at Bethesda Hospital but this will be followed up with local coordinators in both areas. 8. There is a renewed commitment by UK-based training facilitators to keep in regular contact with colleagues in Nigeria mainly by WhatsApp 8
Acknowledgements Training Materials: Medical Aid Films (UK) Global Health Media Project (USA) Maternal Child Health Advocacy International (UK) Local Hosting: Rt Rev OC Chiemeka (Bishop of Uzuakoli) Dr Hans van den Corput Chief Paul Okorie Revd Victor Ogbonna Revd Christian Chukwu Rt Rev JaJa Kantiyok (Bishop of Igede) Dr Joseph Onah Revd Pius Ogirinye Jonah Alaje National Hosting: His Eminence SCK Uche (Prelate of Methodist Church Nigeria) Right Rev Michael Akinwale (Secretary of Conference, ) Prof Sola Majekodunmi (Chair of the Medical Board ) Deaconess Ronke Oworu (Health Secretary ) 9
Appendix 1: Nigeria Health Care Project Resuscitation reporting for 2017 Name of the centre Baby Number Date of birth Birth attendant trained in newborn resuscitation Condition at birth Heart rate Breathing Tone Colour Fast Active Pink Slow Floppy Blue / Pale Resuscitation given Neutral position Inflation breaths (5) Ventilation breaths (15) Chest movement Outcome Alive Died Any comments 10