Saturday, 22 November 2014

Blog written for PHASE Nepal.

Apologies, there is some repetition in this, and the paragraphs in brackets simply explain the midwifery situation in Nepal.


Sarah Ardizzone and I met in Nepal during a previous project with Royal College of Midwives. We are UK midwives and were selected to promote midwifery and support Nepal’s progress towards establishing the profession by competency, qualification and regulation (Globally Recognised Standards for Midwifery, International Confederation of Midwives). Nepal has a high maternal and neonatal mortality rate, but is making great efforts to reach the set Millennium Development Goals in both areas.


 [Before I move head long into the joys and trials of our recent trip with PHASE into the Hills, I would like to just set the midwifery scene for all you PHASE followers...


Many women in Nepal give birth without the safety of a skilled attendant. The reason for this is partly cultural, but much is due to the challenging terrain of the hilly regions. PHASE Nepal works to support some of the most remote communities. They employ auxiliary nurse-midwives (ANMs) to live in those villages and provide as good as 24/7 care to the people. The nurses’ skills are wide and varied, and might be more accurately described as GP, and not simply nurse or midwife based. Through PHASE, GPs visit the villages as volunteers to provide ANMs with skill sharing and updates which are invaluable.
There has been recent midwifery training within Kathmandu for the ANMs. However, in view of the poor maternal and neonatal mortality rates, PHASE is exploring the benefits of extending this support to include more specific midwifery 'in-post' skill sharing. It is known that midwifery within a country reduces mortality rates far greater than just skilled birth attendants (SBA) alone (Lancet Series on Midwifery, June 2014). SBAs provide valuable obstetric emergency care, but midwifery helps to prevent those emergencies from occurring.]



Both Sarah and I are staunch supporters of the natural birth process, and the impact of midwifery on the whole family, not just at a difficult birth, but also through risk prevention, education, emotional well-being, family spacing, etc. So, we negotiated our return to Nepal to pilot a midwifery teaching programme with PHASE.


A few photos from my album....



   
This is the view from our window during our initial placement at Hagam, Sindhupalchok. Situated all of 2183m up, with a population of 4,000 stretched over many miles, it was simply stunning. We stayed with Renuka and Suprina, both PHASE ANMs. They looked after us well, and wouldn’t allow us to help with cooking, prep, or water collection. The facilities were basic, as we expected, but we were made comfortable. A wash bowl in the morning was really appreciated, as our skills at the public water tap were really limited and could well have left (too) much to be desired! An electricity pole (read ‘rotten tree trunk’) collapsed during a storm, causing days of darkness, and our head torches became even more precious. You don’t realize just how reassuring a mobile phone is, either, until it dies on you.



We joined Renu and Suprina for their regular community visits. Renu took with her a register, and picture books to help with health education. This woman was pregnant with her second child. She planned to give birth at home. All was well, but her first baby arrived in a hurry. I wonder if our nurse midwife arrived in time for this second birth, and how it all went...

 For nurses like Renu and Suprina, stuck in the nether regions of nowhere, prevention and early recognition of complications is paramount. They were encouraged to build on their understanding of how birth should work, and how they can support the natural process.

            

Suprina administered drugs to this woman who arrived in clinic, supported to stand by two men and hardly able to breathe for chronic COPD, caused in part by the continuous presence of wood smoke in the house. This, and childhood complaints, seemed to be the theme of the day. The few antenatal checks carried out in the clinics allowed us discussion of how listening to women and giving verbal prompts to gain information, can add to diagnosis and prevention, and then more importantly to timely referral.



 
Some visits definitely had a social slant. The community were wonderfully accommodating of our quirky English ways (I can’t say the same for their dogs. On more than one occasion I was decidedly more quaky than quirky!). Socializing and visibility are ways of building trust and connections through the village.



   We travelled on foot to an outpost for training with traditional healers. The guys, and one woman, were paid travel money to attend, but they embraced the opportunity to learn from Renu and Suprina. Still some locals would prefer to consult a healer before seeking medical help. It’s important that things like hygiene facilities, dangerous practices, and early warning signs for prompt referral are discussed openly.




    



The second part of our journey, after a brief couple of days to freshen up in Kathmandu, took us to Ryale which was nowhere near as far or nerve wracking a trek as Hagam. We travelled with several newly employed PHASE nurse-midwives, and a very big bag of training gear. 




















Rita, Sujeeta and Kriti, three of the PHASE ANMs based in the area had very good understanding of our English which, given our incredibly limited Nepali, was vital for any training work. A translator would otherwise have been a necessary addition to our provisions. Due to numbers and relationship building for the new nurses, Sarah and I were given a little room close to the village eating house. We were woken every morning by the bus letting EVERYONE know it was leaving for the city. By the end of our stay, we did appreciate the importance of this community service.



  

Our training sessions were extensive over the three-four days. Practical skills, theory, but also risk factors for prompt referral and prevention were dealt with. We used the models and talked through scenarios relating to birth emergencies within the Nepali home setting. There would be no drip stands or emergency buzzers. There would be no doctors prescribing a magnesium sulphate regime for fitting eclamptic women. There may be just ONE pair of hands to deal with a serious haemorrhage. Hygiene facilities, lighting, space, back up plans would all be limited in these homes.

As much as possible, we used the actual equipment the nurses carry in their substantial kit bags for training purposes too. We could identify, while going through scenarios, exactly what was surplus to requirement, and what might be better kept together in the different compartments, to ease finding equipment in a hurry. We ALL had fun working through the eclampsia regime, and we resorted to ‘phoning a friend’ when the dosage of magnesium sulphate couldn’t be worked out from the vials. We played with making up a homemade condom tamponade for uterine haemorrhage. It got messy (and slightly raucous)! In seriousness, this is exactly why regular training and ongoing educational support is necessary for these nurses, indeed for us all!

Overall, I felt our trip was incredibly productive and worthwhile. Short blasts of training feel the right way to go when these nurses are busy with community needs. Hanging around to support at births is probably not the best use of time as, thankfully, real emergencies are few and far between. Most births go smoothly, and the ANMs are called only occasionally.

Sarah and I look forward to repeating similar work early in 2015, and I hope PHASE will consider giving not only us another opportunity to work with them, but encourage other UK midwives to offer their knowledge and skills too. It was an honour to support those small communities, and their fantastic ANMs who are out there, away from their families, putting their hearts and souls into making a difference. Those girls are real life, every day heroes.




Sunday, 19 October 2014

Supporting Women's Project, Nepal.

22.54pm on 19th October, and time for a blog update.

Really?

Yup. Seems it won’t wait. My cup overfloweth and I must have some way of pouring out the passion fueled from the feeling of community and simply giving.

That’s not to say my cup doesn’t overflow on a fairly regular basis. It does. But just recently the leaky tap washer that supplies the elixir in generous quantities had got a bit clogged up!

I don’t need to go into depth (I’ll save that for my therapist), but the process of sending funds online to Nepal recently ended in tears. My issue is with… the bane of my life…computers. 1. Lost funds due to the currency transfer site being hijacked (do they say ‘hacked’ in the computer literate world?). 2. Virus caused my computer to crash, £110 repair and real upset of losing many stored personal photos and documents. Mmm, maybe I should have backed up (notes on a post card….what is ‘backed up’?)

Mission, however, is eventually accomplished. My dear and lovely friend, Samjhana Phuyal is now in receipt of £245 funds for her project…




“Empowerment of Kath Women through Sanitary Pad Making & Awareness Raising on Menstrual Hygiene Practice”
Social Empowerment by Empowering Women (SEEW)
facebook/seew.np




(She is also responsible for directing funds towards schooling of individual young girls from deprived families, and experimenting with the laying on of ‘pink’ buses driven by women, for women, as a stand against the sexual harassment and violence occurring on Kathmandu buses.)



Training the trainers was available just for the one week, and it was a rush to plan an event to raise such an amount. Thank you ladies, we did VERY well. A few were able to join me for a craft evening. Candle dipping, crochet, knitting, singing, dream catcher manifesting, and of course eating and drinking, were all enjoyed. Most enjoyable was the connection of women here, blessed in what we have, with women on the outskirts of Kathmandu, plagued by gender discrimination, ill health and shame surrounding menstruation. Thank you to all those who couldn't make the evening, but donated regardless.



Sunday, 4 May 2014

International Day of the Midwife 2014.




Our local event for International Day of the Midwife 2014 was pretty successful. A grand sum of £195.27 was raised for International Confederation of Midwives (http://www.internationalmidwives.org). There was very little cake or quiche left from a wonderful and massive selection. I really can’t quite believe we managed to move that amount of cake so fast. Visitors bought whole cakes or a selection of slices FOR midwives. How sweet is that? And one generous member of staff fed the whole of Delivery Suite and Observation Area.



















We also managed to arrange a display of posters containing information or personal midwife accounts from quite a few different countries and settings. I had one email/ poster arrive just the day before from a midwife describing her trip to teach at a hospital via armed guards in Somaliland.
     We also had on display a beautiful photo book of a colleague’s journey to various places promoting safer motherhood. Several young girls set to task and drew the most exquisite pictures of midwives and babies (placenta and all, in one pic!).




Thank you all cake bakers, poster makers, table bringers, trolley pushers, Ma Buck, and all those who supported us. We spread the word that worldwide midwifery matters...and we spread a lot of cake.






Saturday, 26 April 2014

International Day of the Midwife

International
Day of the 
Midwife

We’re selling Cake and Quiche
Level 2, Women’s Centre
2 pm onwards Saturday 3rd May.

Info posters. Children’s drawings. Personal stories.
Money towards International Women’s Charity.


Donations of cake and quiche welcomed.

Sunday, 20 April 2014

Working with PHASE Nepal.


I usually have difficulty starting these updates, but this evening I feel it’s going to flow (read that as long and boring). It’s nothing to do with a particular evening beverage. Yes, my glass is mostly half full, but tonight it’s just sitting here for when the inspiration dries up. Of all things, it was the washing up, after a meal and the company of family, to Barbara Bonney’s beautiful rendition of Ave Maria that did it. You don’t have to translate the words to understand it. To me, it oozes. Every note drips with heart-felt thanks for the feminine. Sorry guys, but women really rock my world.











How does that take me back to Nepal? Well, it takes me back to the feeling of being present in such breath-taking beauty and grace, of the women and the place they live. It also takes me back to a particular flight home to my family and experiencing a high level of turbulence. I closed my eyes, turned up the volume, and thought of all the things I had to be grateful for, not least my three children. I thought, if I died, my life had been blessed and I could not ask for more. Of course, I wasn't in real danger (was I?), but find me a person who doesn't question the meaning of life at such times.

Enough said!
....And I joked this time about Sarah and I closing our eyes, and singing it at the top of our voices, while winding our way in a ram-shackled and filled-to-the-brim old bus, up the sides of those mountains towards the remote area we needed to be (No, Mum, best NOT look up ‘The world’s most dangerous roads’). I had this hope that our version of those normally dulcet tones would get us a fast-track ticket to heaven should the bus lose its grip. Either that or we’d miraculously find ourselves close to a barrel of the home brewed ‘roxy’.




March 2014, with PHASE Nepal

This trip was a 50th birthday present to me! 

Thanks to a valued old school friend, I had the idea of setting myself an even greater challenge. I certainly didn't want a party. My kids don’t need me so much (I can’t quite bring myself to write ‘at all’). I have a little time to play with (yup, only annual leave, but better than nothing). I still have the skills, confidence and passion for my work, and I now know much more about Nepal and its needs regarding maternity care. Only on reflection do I see the enormity of learning and understanding I've acquired in such a short time. There really wasn't a better time to get myself on that mission.

 Quite coincidentally, I found the organization PHASE Nepal (http://phasenepal.org/) on Facebook the very same day Gerda Pohl, a GP working with PHASE, found my blog. So when I emailed her, we were already thinking along the same lines.


Just to recap after my last trip....

I returned so frustrated last September. There were just too many hold ups and obstacles in the way of getting midwifery into Nepal. No apologies for repeating myself, but we KNOW having midwives in a country brings down the maternal and neonatal mortality rates. Many more skilled birth attendants (SBAs) are being trained, thanks to funding from various government and non-government organizations, but this will only go so far towards reducing the number of deaths. In Nepal, government is dragging its feet with regards to bringing in Midwifery, and the nursing council is making it difficult on the grounds of Nepal not having a midwifery profession before, so why should it have one now! C’mon guys. Women and babies are DYING! And good money is being wasted.





I’m impatient. I want to see change. I want to see progress, even if it’s slow,... money spent in the right places,.... tasks achieved....  and dare I say performance related funding? I decided if I wasn't getting any joy at the door, I’d climb in through the window!


What peace and tranquility! Shall I spoil it and tell you
there were rather territorial and racist dogs on our trail?





PHASE stands for ‘Practical Help Achieving Self Empowerment’. By donations and volunteers and a small core of hard working individuals, it supports some of the most remote Nepal communities to take control of their own future. 






Education, health, food security, discrimination, and livelihoods are the main areas focused on, depending on that community’s perceived need.


Teaching nutrition during
community visits. Hagam.










Local anaesthetic, AS WELL!
They employ auxiliary nurse-midwives (ANMs) to live in the villages and provide as good as 24/7 care to the people. Their skills are wide and varied, and more accurately described as GP, rather than nurse or midwife based. GPs visit the villages as volunteers to provide ANMs skills sharing and updates which, given what these nurses are faced with, is invaluable. However, in view of the poor maternal and neonatal mortality rates, PHASE is exploring the benefits of extending this to include midwifery skills.

Clinic at Hagam.
This woman was weak with COPD,
likely made worse by the acrid smoke 
from inside fires.
Renuka teaching traditional healers,
Hagam.






Sarah Ardizzone and I met last March when we volunteered with Royal College of Midwives for the Global Midwifery Twinning Project. It was clear to me we had the same concerns and visions, so we planned to return and pilot a midwifery teaching programme with PHASE. Some midwifery work had been covered before, but it seemed much of it wasn't especially community based, and there was still limited understanding of the causes and prevention of emergencies. Waiting for obstetric emergencies to happen is like shutting the stable door after the horse has already bolted.



Renuka and Sabrina, both ANMs,
 looked after us so well.
The trip was completely self-funded, although PHASE covered us with its group insurance. I'd like to say a huge THANK YOU to Lisa Fitzgibbon (http://www.lisafitzgibbon.com/about_biog.php) and the Power Folk Quartet (Jane Griffiths, Colin and Johnny Fletcher) for their wonderful evening entertainment, and the donations towards the raffle by a very generous audience. Thank you, too, to all those who helped in the sale of Christmas Advent Candles. It has proved to be a very enjoyable and productive way of raising funds. Sharon Meakin, you brought a couple of very expensive candles (You’re so kind). Liz (you know who you are) managed to get her hands on a miniature model doll and pelvis perfect for my backpack. I had more hats, midwifery books and journals and many more bits and pieces donated. I had personal donations of money, from which I bought bean bag covers, pinard stethoscopes and Huntleigh dopplers. My case was every bit the 30kilos, and there wasn't a square inch left empty.



Bimala feigns an eclamptic fit. It brought such laughter,
 but also a serious side. Knowing available equipment,
and administration/route of medicines are vitally important.
Knowing there is no 'buzzer' to call for help is scary,
and these nurses want to feel prepared. Ryale.



Hmmm. I’ve written far too long a piece already, eh? And I've not even boarded the plane yet! But don't say I didn't warn you. I’ll follow this up with the report Sarah and I returned to PHASE, and I’ll fill in memorable snippets along with the photos.
Rita and Kriti attempting condom
tamponade (last resort for haemorrhage)
from the delivery kit. It wasn't successful!

Sujeeta performing and talking through
shoulder dystocia on dummy, at Ryale.
Laminated posters and prompts.
Useful when also dealing with
translation difficulty.



So, that circle I felt I was on? I'm very much back at the beginning. I get to where I aimed to be during my very first trip out to Nepal. (Forgive me for sounding a tad jaded). The story still is that women and babies are dying mostly in rural Nepal. Nurse-midwives are being trained in the Kathmandu valley hospitals. They are being taught a medical model of care, and at quite a basic level. They learn how to treat an eclamptic fit. That’s great, and it definitely saves lives. But they don’t understand which women are more likely to suffer eclampsia and therefore need more antenatal care, and they don’t always know when to refer to obstetric care.

The view from our window at Hagam  Sindhupalchok ,
2183 m up, population of 4,000 over many miles,
and simply stunning.
Nurse-midwives in Nepal know how to cut and repair an episiotomy, but they don’t know how to prevent perineal trauma. They also learn how to identify delay in labour, but they are not taught how to prevent it. Prevention is the key word. It shouldn’t just be about emergency care. Don’t get me wrong. Every nurse-midwife, without exception, has wanted to learn, but the teaching of nurse-midwives in Nepal is not at the globally recognized standard for ‘midwife'. For those nurses stuck in the nether regions of nowhere, prevention and early recognition is paramount. They need an understanding of how birth should work, and how they can support the process. Midwifery education does that.



Here’s my message for government, obstetricians, and nursing council...

 You NEED midwives. For now, you still needs skilled birth attendants, but they should be taught more midwifery based skills, because midwifery just isn’t going to happen in a day. There is still much work to do, and you all need to pull together. While those rural communities see little benefit from the time and energy and money being poured into Kathmandu, I’ll work at ground level (or should I say 2183m level?), supporting those small communities, and their fantastic ANMs who are out there, away from their families, putting their heart and soul into making a difference. Those girls are real life, every day heroes.
A well deserved and long desired 'Everest' beer, back in the dusty city, between rural posts.

But do you now want to know what our biggest challenge was?




These midwife gobbling beasts in the loos



Saturday, 7 December 2013

Diary update Sunday 1st December.

 I see things. I don’t just mean in a sixth sense kind of way. I see things on a daily basis, some of them are beautiful and some of them are sad. Some of those who have the sadness are blessed to find there is beauty in there too.

Most of the time, I’m happy in my own power. My job is to hold people, inform them, sometimes direct them, but ultimately hold them. It takes quite a lot of energy, and sometimes when I come home, I want to be held. It’s not a weakness or especially a woman thing. It’s just a way of re-fuelling. You see, if I’m running on empty, I shall have nothing to give. It doesn’t mean I want you here forever. It means, simply human to human, I want to feel safe and loved in the moment.

This evening, I held a young couple who lost their first baby. Their grief is mine, too. Communication and understanding is everything.


Update Saturday 8th December.

Don't they say you have to have the bad times to appreciate the good? Emotions/ luck/ outlook/ directions can do full circle within the space of a minute. They're mini ecosystems of life. Do you feel them? The benefit is that when the going gets tough, they have literally 'upped' and left before you have time to dwell on it.

Driving home from a birth this morning, I received my payback for the challenging time I had during the week; I'd given my all, and needed refuelling. An absolutely stunning and gentle birth, nothing for me to do except 'be' with this couple and keep them all safe. There was just a faint red glow on the edge of the sky promising today's sunlight as I pootled homewards in a bleary eyed, sleep deprived, oxytoxic state. Classic FM was playing the kind of low key but uplifting music I'd want to wake up to, but today I left a contented young family and was heading towards my bed and a WHOLE WEEK of annual leave. The chocolate biscuit I'd thrown into my basket as I left the house in the early hours had never tasted so delicious. It wasn't hard to imagine my hands around a warm cup of tea, and my grandmother's stone hot water bottle next to my feet.

I needed that hug. I actually wanted it from a gentle gorilla of a man who could hold me tight and safe for a short while. I received it from a newborn baby girl, and her parents, and one of my colleagues, who shares those life and sometimes death moments that bring such awesome transition. The sneaky suggestion of a rising sun, and the cello playing, and the chocolate melting, and a ridiculous and trivial radio fact about the average calorie consumption we attempt to achieve on christmas day made me giggle out loud.



Saturday, 9 November 2013

Hmmm, maybe I'm on a roll... two posts in two days? am I sickening for something?

I'm absolutely delighted to see that this last post has had 170 views since yesterday morning, and it's only 11am now. Isn't that fantastic. But who's reading it? I'm intrigued to know what the most important/ influential/ inspiring aspects are for you.

In the past, this blog has helped fellow UK and global midwives/students gain insight into Nepal's state of midwifery, and I've received emails requesting specific information, or just in support of networking. Almost all of those midwives have followed our contact up with a trip out to Nepal.

I've also had a few western families who are living out there and are looking for midwives to attend them during their births. This is tricky as I know of NO independently practicing midwives in the Kathmandu valley. What I suggest to these families, is that I forward their details to the wonderful nurse-midwives at APS. Rashmi and her colleagues are, time permitting, generally happy to discuss options for place of birth, and are familiar with our preferences. Water birth in Kathmandu is no easy task, but it HAS been done!

If YOU are catching babies in Nepal, and especially if you can help other western families out, please do get in touch. If you are passionate about respectful maternity care, and women's issues in general, consider getting in touch with White Ribbon Alliance Nepal. If you have a story to share about your birth experience in Nepal, what made it good/traumatic, I'd really like to hear about it.
Lad born into family of carvers at Baktapur. There are carvers,
artists painting 'Thanka', and potters. All in Baktapur belong to
one of these crafts. An amazing place to visit.


Boudhanath

View from bridge at Kalanki crossroads. This is the dirtiest, stinkiest, noisiest, most nepaliest place
 in the Kathmandu valley. And I LOVE it!
Village mass-production in a Baktapur street. There are potters and basic wheels in the back streets. These pots are laid out to dry before being fired in a massive outside kiln of wood and straw.
New baby for Keshab and Rashmi.



Near Nagarkot
Classic example of need for dignity and respect. It isn't uncommon to have a obstetric consultation with others waiting in the same room. Women and their pregnancies become public property and they leave all possibility of dignity behind at home.

One of the oldest buildings in Nepal. Few have survived onslaught of earthquakes. This is in Baktapur, and it's beautiful.

Nurses, and students, and UK student Sophie in the
 postnatal ward at TU hospital.
At Boudhanath. White lady. White hair. I wonder who's sightseeing who!