Monday, 1 June 2015

Sunshine Before the Rain.



This evening, the normal start to my updates REALLY isn't happening for me, or should I admit this is my fourth 'start'?
So, a different course of action is needed. Had I just got down to it and updated my blog like good girls do, when I returned from Nepal at the end of March, I wouldn't now find I have such an explosion of events, and emotions to set into words. My brain is less like sawdust than it was four weeks ago, but I still find the enormity of events on and since 25th April hard to take.

So, I'll talk you through a picture show. That way, I hope there will be some kind of order to my spewing of facts and feelings.




This is the scene that welcomed Sarah, my midwife companion and I to Fulpingkot, Sindhupalchowk, where we spent a short time with the nurse-midwives employed by PHASE Nepal (http://phasenepal.org/). This village, at 1854m, is lower than neighbouring Hagam, where we intended to move on to afterwards, and has a completely different feel to it. I'm pleased to say there were fewer dogs around, and those we met were very friendly. There was an incredibly relaxed atmosphere here. It was such a joy to wake up to baby goats scrabbling up the tiny wooden stairs, and the chuck parading her chicks around the 'patio'.


The bus journey up the hill was uneventful, and we felt pretty used to it by now. We took a translator with us this time. Dipshikha was very useful. Her English was everything we needed to continue our training sessions, and her knowledge and thirst for learning was excellent. She is from a rural background north-west of Kathmandu, so she settled into life with the nurses very quickly (Her family home is damaged and they, too, are sleeping in tents).

This photo was taken on the way up to Fulpingkot. The view was stunning. It'll be somewhat different now. Sindhupalchowk was one of the worst hit areas, and I believe the house we spent our time in has since fallen. Let's hope the monsoon season will be gentle on Nepal this year. if it isn't, increased landslides and flooding will add to troubles.


 The girls were lucky enough to live just a stone's throw from this health post. When there are more than one family in a household, privacy goes out the window. Most UK residents would throw a fit at the door to a GP room being left open, let alone two consultations going on at the same time. But this level of care from the nurses is new to this community, and they are genuinely grateful for their healthcare. I'd say we could learn a lesson from them....in more ways than one. The nurses know all their patients, and practice holistically knowing the family/individual situations.




 We walked quite a distance, on a scorching day, to provide  antenatal care to this woman. If I remember right, it was her ninth pregnancy, she was 40 already, and previously had twins. She had never had skilled support for any of her births, and the nurses Indira and Bedika didn't doubt she would call them this time. It made me question who we are, to label this woman as a high risk grand multiparous aged mother, when the figures in my very own trust suggest at least two of those births should have resulted in C section? Should we encourage hospital when she is so fit and able? Look at her. She has more life in her than most of us will ever read about. BUT she is a mother and, as such, she is precious. She is also lucky. The nurses were prepared for her birth. Her baby was pretty much due when the earthquake struck.

These pics were taken on the highest point of the area, where a Buddhist monastery was four years in making. We had walked to a more remote health post to hold a clinic, and detoured for a spot of 'sightseeing'. The building work was taking so long because of the difficulty getting the materials up the 'hill'. Bad weather and landslides each year mean travel for many villagers is nigh on impossible.

We were treated to tea and biscuits. All the workers put down their tools and brushes, too. The love going into this place was evident. it will be a beautiful, heavenly place to worship when it's completed.

I wondered why, in such a poor and hungry community, so much time and effort would be channeled into one exquisite building, set far away, up a hill, for few to admire. Since the earthquake, I can better understand the need for these guys to nourish their faith.

What of this stunning building, and all their hard work? Can somebody answer, is it still standing?


Back at home, a meeting of community health workers was held to discuss International Water Day. The little pots, in the centre of this pic, are samples from all of Fulpingkot's 'taps'. The water runs close to the surface in this area, and therefore is easily contaminated. Every single sample (except one with filtered water!) indicated fecal contamination. Fulpingkot had not one water source safe to drink from. Filtering is essential, and the community health workers will take this message with them.


A quake of 7.8 is sizable enough to change the course of this water. The dust needs to settle, but maybe this water source will change for the better.





We were honoured to be guests at a wedding that hadn't quite happened. In this community, much celebrating and eating and dancing happens before the man brings his wife home to the family. We were treated to joyous dancing with drums on a scorching hot day. I was grateful of the chairs offered to us as special guests.
We stuck out like a sore thumb, and it wasn't long before they realized we'd not entered into the mood of the party.....yes, we had to dance Nepali style, feeling meters taller than anyone else, heads thumping with heat and dehydration, trying to smile and laugh at ourselves with as much gusto as they were laughing at us. That was almost as challenging as peeing in a spider infested privvy, but it was appreciated more by the locals. We'll be the talk of the party, for quite a time to come.

It was challenging to find any time for the training sessions we had planned. The nurses all have their own chores and down time, as well as their nursing work with PHASE. Having midwives join them for short bursts of time is a new experience. Mostly doctors visit for months at a time, and learning and understanding occurs in a more relaxed and natural style. Until we really buckled down to our sessions (Breech, neonatal resus, eclampsia, shoulder dystocia, postpartum haemorrhage as well as antenatal care and recognition of 'normal') the nurses were a little unsure of what was expected of them.







Because of the difficulty ensuring protected time in this setting, we are considering holding the same programme, but at a venue where we can gather as many nurse-midwives as can be spared, in the Sindhupalchowk area. We shall liaise with PHASE and the Midwifery Society of Nepal (http://www.midson.org/Home.html) to bring everyone together, and make it a social event as well as learning valuable midwifery skills.

It was also the reason, partly, for returning to Kathmandu rather than travelling on up to Hagam. A nurse had fallen sick there, and been returned to a Kathmandu hospital for treatment and rest. We felt, with their reduced staff, on top of any chance for training, our time would be better spent in Kathmandu, working on a greater plan.


As always, the girls were wonderful hosts. The cooking was fantastic, and I was thankful of a smaller breakfast of something other than dahl bhat. Every now and then we weedled our way into doing the tiniest bit of washing up. One could assume they didn't allow us the chore out of politeness towards their guests, but there could have also been a fear of our skills with regard to hygiene and precious water usage!

There was a problem with the local water source drying up, due to a leak higher up the hill, apparently. The girls had a water filter for drinking water safely. I have to admit, though, I was thirsty much of the time as the filter didn't quite meet the demands of this larger group of visitors.
It didn't become evident until later, either, that while we slept at dawn, water was being fetched from a more distant source. Even with a good translator, so much information is lost in conversation.
Electricity and a small amount of internet coverage were good, but there was the usual load sharing. We found the solar charger pack I brought from UK very useful.
With funds from UK, I was able to equip some PHASE nurses with solar charger packs and wind-up head torches. They don't work for ever in these dusty and harsh environments, but while they do, they'll be worth having.




We shared a feast on the last night, of chocolate, nuts and tiny cheese portions. Both Sarah and I really appreciated the girls making us welcome and sharing their very small space with two relatively larger women. Our household worked well together, not least Shushila, one of the nurses, and her bonny babu. The peace and scenery in Fulpingkot is simply breath taking. The whole place, and it's community is beautiful.





This water hole was a short cross country walk away from our home, and where our 'emergency' source came from. After such a (self imposed) meagre volume of water to wash in back at the house, both Sarah and I thought we'd died and gone to heaven as we plunged our heads under the cold flow to wash our hair.
         And the view was even more breath taking. What I wouldn't have done to have found that place earlier, deserted and quiet, to have washed fully and without reservation. No bathroom brochure in the world, with mod con or promise of luxury, will better that place for me. When I write my book 'The World's Most Amazing Places to Greet Your Lover', this will be one of the top ten.







There are many small schools dotted around the countryside, but kiddies still often have to walk miles each day. Some will use the one daily bus up and down the hill. Every effort is made to cram the last man, woman, child, chicken, sack and piece of metal into the rickety old bus, and amazingly everyone is good natured and amused by it.








So, back into Kathmandu, and to network and meet old faces. Oh, and pick up a kurta or three sewn by lovely ladies working near Patan Square.





During my very first trip to Nepal, I was shown an unfinished building in Tribuvan University Teaching Hospital that was to be a Birth Centre. I was only just realizing their idea of a birth centre was very different to mine. We chatted about this new concept, and what would have to happen for it to work. Eventually, after much continued and repetitive input from all, MIDSON and RCM volunteer midwives not least, we have a real Birth Centre. These ladies should be very proud of themselves.


There is so much I want to share with you regarding this wonderful centre, and how things are moving on for midwives in Nepal. The figures for the births that have taken place already, are amazing. These midwives are doing it! And I feel so happy for them.

I can go into more depth later.


It was also lovely to be part of the meeting of MIDSON educated members, to discuss their potential change of premises. Their plans to hold antenatal and women's health clinics are fantastic. Midwifery in Nepal needs to practice what it preaches, and that's incredibly difficult when a doctor is stood over your shoulder waiting to take all power and skill from you.
Here, MISDON hope to work with Paropakar Women's Hospital, just along the road, to provide good quality midwifery services. Being financially independent and therefore free from influence is challenging for a small organization like MIDSON. Much work needs to be carried out on the building, and it will only be given temporarily.

Stop press.....Oh yes, an earthquake happened.




We also managed to fit in a visit to Kirtipur Hospital. Again, during my first visit to Nepal, I was treated to discussions on how to kit out a building planned as a Birth Centre. The building, pictured here with an enchanting tree trunk in the middle of the room, hasn't changed in these years. The C Section rate is high and costly, and there aren't enough beds. Now the TUTH Birth Centre is doing so well, Kirtipur need to move on and open this building. Sarah and I will work on a feasibility study, inclusion criteria, and guidelines for the eager staff to use to convince management this has to happen.





Below, is the current maternity ward.



We also had time to meet up again with Samjhana, a friend I met a couple of years ago while trying to promote White Ribbon Alliance and its Respectful Maternity campaign (http://whiteribbonalliance.org/campaigns/respectful-maternity-care/). I think I mentioned Samjhana in an earlier blog. She does amazing work for women's rights and safety in Nepal. This time, we were able to see her work in action. I'm so proud of her.

This 'Pink Bus' is one of two rented for use on particular routes around kathmandu that have already been identified as risky for women. The aim was to have it driven by women FOR women, but there aren't enough women drivers...YET (Samjhana is sorting it ;-)) The buses are packed with women both morning and evening, and it is welcomed by the men. Most women in Kathmandu have been abused either verbally or physically at some point in time, while using public transport.
It was heart warming listening to the conversation, in Ratna Bus Park, with other bus drivers...all male. They were so supportive of this project, presumably because they've had enough of witnessing the amount of abuse that goes on (They could try giving any abusing male a hasty removal from their bus, eh? Most of the drivers are youngsters, and would need the support of other passengers to be able to carry this out). I made the executive decision to hand enough cash over to get the seats freshly covered on the bus pictured above, after it was agreed they would make a big difference.

Oh, dear lord. All eleven of the buses owned by the company, including the two Pink Buses, were destroyed in the earthquake, along with the owners whole community.




Our trip was incredibly happy and productive. We were so pleased with the amount of work MIDSON had done to move themselves further. The Global Midwifery Twinning Project and RCM had been a huge driving force for them, and many MIDSON members were fearful of what would happen now that the project had ended. I see a ball rolling with so much momentum, that it's not going to stop (even for an earthquake!!) and what I see happening SINCE the earthquake makes me SHOUT FOR JOY.




We took a day out of a very busy schedule to explore the nearest little 'hillock' of Shivapuri (2,700m). Goodness, we needed the space and the peace, just to slow our minds. 25 zillion steps upwards is a kind of walking meditation, though we were almost not walking by the end of them (and we certainly weren't floating). These steps are not significantly different to any of the others. They just kept coming...after every bend....









Finding these stones at the peak, quite obviously also meditating, made me chuckle. I suspect gravity and a bloody huge shake up means they are now sprawled in a horizontal and drunken fashion, waiting for some kind and patient soul to replace order. I also suspect their place in the list of priorities isn't very high.







Tuesday, 5 May 2015

Fun and fund raising for Nepal.

Joins us for a
Practical Crafts Evening.
Beginners welcome.




Thursday 21st May, 7pm til 9.30pm. Kirtlington Village Hall.
Tickets £20.
Select from spinning wool, basic knitting/crochet, woodcarving, pottery, dipping candles, glass/wood painting, patchwork, and making paper lanterns. Tickets include one hour sessions at two work stations of your choice (First come first served), a glass of wine or a cuppa, and nibbles. All materials are included and you’ll have your own masterpiece to take home from each station.
Proceed will go towards
midwifery needs in earthquake stricken Nepal.

Monday, 4 May 2015

Women Bleed. Let's celebrate that.

The  shedding of an unpregnant womb!   What does it mean to us women in UK?

 Messy. Heightened sensitivity. Vulnerability. Excuse for chocolate. ‘Red tent’ luxury. Acceptance of that ‘delicate’ place. Pain.  Need for holding. Emotional support. Acceptance and comfort by our partners. Sex without babies. A need for nice toilets. Emotional needs left sometimes wanting. Slightest upset could reduce us to tears. A quieter day at the office.

Then take this to a developing country...imagine how our needs will find themselves far down the list of importance for those women. What’s likely to be nearer the top?

For some women in Nepal, menstruation will be linked with Chaupadi. Banished to sheds. Not eating off the same plates as family. Not eating enough. No access to the water tap. Isolation. Snake bite and hypothermia. Untouchable and unclean, but also rape by inebriated men if found sleeping alone.


Menstruation is seen as taboo. Nobody talks about it. In 2003, the Nepal supreme law stated Chaupadi was discriminatory and a violation of women’s rights. Despite this law now being in place, the practice is still widely occurring in many rural areas. In urban areas, there is the different problem of washing and drying the protective cloths used. Because of the taboo, drying in public can be difficult. So privacy is at the expense of personal hygiene, and also clean and germ-free materials. Young girls will miss school rather than have the challenges that face them when they’re bleeding. They’ll seek isolated places to pee, rather than use unisex toilets, and rapists know this. Unsafe materials are often used to stem the blood flow.

 There is a distinct lack of health, education, dignity and gender equality. Women in Nepal still have little control over household expenses. Young girls have limited knowledge. More often taboos are passed on before, and instead of, good health information.


So, why do women bleed?

The lining of the uterus sheds to provide a brand new bed for any future baby. We bleed to make our wombs ready for growing a baby. We can’t have babies if we don’t bleed.

End of.

It’s not dirty. It’s not harmful. It’s not infectious. It’s what we do.


Samjhana Phuyal, an inspirational woman I met a couple of years ago while supporting White Ribbon Alliance (http://whiteribbonalliance.org/) has, amongst other worthy causes, funded the start-up of a business making and selling re-usable sanitary pads (http://www.seew.org.np/) Women sell pads to women. Information regarding menstrual hygiene is shared, and respect for this natural monthly process is increased.
Each pad costs 100Nr (65p). To be comfy, each woman will probably want five pads to see her through a period. Washed in soapy water and dried thoroughly in sunlight, they will only need replacing every two years. There is nothing to throw away, and no harmful chemical like disposable pads have. Extra cloth can be used for heavier periods, too. But just as important, hanging them out with family washing on the line to dry in the sunshine, they are a statement.

Thankfully, women bleed!



With funds raised by my kind friends, I bought a whole big bag of pads to give to the APS birth centre in Kalanki. All the women who birth there, will get pads. The Midwifery Society of Nepal (http://midson.org.np/) had samples and leaflets, too. As did another inspirational woman, Ishwori Devi Shrestha, chief nurse at the Ministry of Health and Population. The villages supported by PHASE Nepal (http://phasenepal.org/ ) are recently well informed and have a healthy attitude towards menstrual hygiene and although remote, do not encourage segregation of women during periods.


Here are a few links providing further information on menstrual hygiene and awareness of discriminatory acts.
..and these links, both short film clips, leave little to the imagination regarding the practical and emotional isolation of Chaupadi.





As before, you may need to use the 'anonymous' option to share your thoughts in a message.

Sunday, 5 April 2015

'Making it Happen' in Bangladesh.

Just write for ten minutes, he said. ‘Set your alarm, and when it goes off, just finish your sentence and you’ll be started’. I haven’t actually set my alarm, but it was enough encouragement to enable me to make a start on this rather delayed update on my time in Bangladesh.

 I travelled with Alice, a UK midwife who has taught many times with Liverpool School of Tropical Medicine (LSTM). We went to Bagerhat in south Bangladesh, near the mangrove swamps, to facilitate two short courses in obstetric emergency care training in October 2014. It was my first trip with LSTM, and I loved every minute.

My first attempt at working with LSTM went delightfully pear shaped when my two sons found themselves in a cricket final at Lord’s. I had cold sweats with the dilemma of wanting to be in two places at the same time. How could I pull out from my commitment to LSTM for that initial trip to Nairobi? But how could I, after all the whites washes, tubs of ‘Vanish’, the re-used bags of frozen peas, not to mention the many miles of driving them for county matches during their early years, ever contemplate missing this once in a lifetime game? I couldn’t.

LSTM lost out this time. And so, as it happens, did my boys! They got thrashed.

Second time lucky, then. I was hoping Bangladesh would be a similar culture and climate to Nepal, which is now very familiar to me. The whole training package was going to present a fair challenge, so it was a comfort to know I’d not be out of my depth in other areas.

LSTM’s Centre for Maternal and Newborn Health run the successful ‘Making it Happen’ programme which helps developing countries work towards achieving their Millennium Development Goals (MGDs 4 and 5) for maternal and newborn health. UK obstetricians and midwives provide country specific training to health professionals in several Asian and Sub-Saharan African countries. The training of in-country master trainers means the project can move on to further areas. It is the largest DFID (Dept for International Development) funded project dedicated to maternal and newborn health, and it recently won a top award, the second year running, for its success and sustainability.

This link provides more information...

I’d been accepted onto the course and had my pre-course training a while before, but was committed to first seeing through my project in Nepal. At last, it was great to be finally putting my learning and experience into practice. Expenses were paid this time. Yay! But my time needed to be taken during annual leave... again. My hospital trust does not fund any of my trips.

My biggest pre-trip headache by far, was whether to take anti-malarials or not. Travel advice websites all state it’s a low risk country, for most parts. Hmm, well what EXACTLY is low risk? The drugs are costly and have side effects...but then, so does malaria. Fellow travellers were split in their recommendations, but most thought I was mad not to take the meds. So, bowing to peer pressure, I took them. All was well, no side effects. I also included in my kit bag a new impregnated net and enough nasty liquid to kill anything that dared think of crawling over me. I’m relieved, and slightly deflated, to say I remained absolutely bite free.


At the airport I changed enough US dollars to Bangla taka to pay my way in the sticks. I also bought a ‘Bangorlink’ sim card (passport and photo at the ready) with adequate phone time and internet to stave off the anticipated isolation. A very comfy United Nations approved hotel had already been arranged for us in Dhaka. In fact, everything had been arranged to the last detail. I felt incredibly safe and spoilt. Dhaka was warm, and more civilized than I expected. It was newer, too. On the journey from the airport to our hotel, I saw no slums. I saw little beauty, either, and no real treasures like the exquisite little ancient shrines found at every corner in Kathmandu.

The journey really started for me and Alice once we boarded the pokey little flight to Bagerhat. It was followed by a night-time bus journey with our fellow facilitators, two of whom really didn’t take well to the humid, bumpy, and rather swervy ride. They assured us it was travel sickness rather than catching. Thankfully, Alice and I are quite obviously made with sterner stomachs, much to our companions’ surprise. We both stayed well through the entire trip.


The view I woke up to.
The training centre we found ourselves in the next morning was safe, clean and friendly. We had fantastic fresh food, even if it was served up with eyes and fins (At times like this, I’m glad I’m vegetarian).  Load sharing of electricity was an issue, but better managed than anywhere I’d previously been in Nepal. Roads were better, too. Even in the sticks, they were tarmac and wide enough for some pretty fast vehicles. This made travelling a tad exciting at times but, hey, weren’t we there for the excitement? Absolute poverty was not as evident in the few areas I saw, either.  Maybe I didn’t see enough to get a true picture, but my general feeling was that Bangladesh had more money at its disposal than Nepal was currently seeing.





The course was run well, and organisation of time and duties were a priority. A course director, eight facilitators, time keepers, and the wonderful man and answer to all our problems, Tamim, all stayed within the complex for the two courses. We met for breakfast and debriefed at the end of every day. Meal times were our social, and little time was left for anything else but prepping for the next day’s work and sleep.



Our days consisted of pre and post course assessments, lectures, and practical skills work stations. One or two facilitators were assigned to each station, and teams of eight participants rotated around the stations at the call of the 20/40 minute bell. The scenarios are learned almost word for word, and the teaching is based on World Health Organisation (WHO) and Practical Obstetric Multi Professional Training (PROMPT). It was obvious the participants were keen to learn and, I suspect, wanted to do their best in quite challenging workplace situations, but their understanding of even basic skills were, at best, patchy. I’d have loved to give more time to take things right back to basics, but this was impossible in the time allocated.






While facilitating, I was able to see obstetricians, gynaecologists, anaesthetists, paediatricians, nurses and nurse midwives all working together, and also the disciplined and didactic methods of teaching. I was surprised at the level of hierarchy (doctors over nurses, men over women, facilitators over participants), and although this is evident in Nepal, it is to a lesser extent. Now, I’m relatively old and grey and, at 5’4”, as tall as most Bengali men but, with excruciating regularity, I struggled to get my point across before being spoken over. Sarcasm is my down fall, and I worked hard to remind my tongue to remain respectful of their culture and ways. Just once, I actually raised my voice. We were all aware of the strutting cockerel and the lowly feathered fowl. I think we were all bewildered as to my place in the pecking order.














As much as I laugh at my frustration, in seriousness I believe this hierarchy is having a debilitating effect on Bangladesh’s nurse midwives. They are the front line workers both rurally and in the hospitals, but they don’t feel empowered to use the skills they have learned. The nurses generally had very limited up to date knowledge, skills, language or voice, and the doctors seemed comfortable with this. Bangladesh has made great efforts with its new midwifery profession and MGDs 4 and 5, but if it wants to make further progress, it needs to recognise and fully embrace the part midwives and women play in such issues.




So, the high points.....
Wonderful food. Getting to grips with ‘Making it Happen’ teaching. Meeting Alice and all the facilitators. Getting to know rural Bangladesh, and a smidge of its language. Having my adventures so wonderfully organised by Keri and LSTM. My family supporting itself in my increasingly frequent absence. No midwife eating spiders in the toilet (yeah, a few geckos and locusts, and quite a few mozzies, but no spiders). And all importantly, using my skills to advance the health of mothers and babies.


The low points ....go with the territory. It does me anything but harm to endure the physical challenges, and the small benefit my midwifery skills bring to such an enormous worldwide issue, helps me through the emotional journey. If my time and passion send even the smallest ripple out to affect just one person, then it’s worth it, for doing nothing isn’t an option.

Wednesday, 21 January 2015

Title? Let's call it the Mother ship.

I’m sitting, with Dido and her ‘White Flag’ melody just audible over the speakers. The heaters aren’t working, but the cooler temperature is refreshing against my face. We’ve temporarily run out of words, and we sit, soaking up the relative silence. The tyres blaze through the pools of melted snow and as I sit gazing beyond the dark windscreen, the glare of random headlights fails to smack me back into professional mode. I’ve got a headache and, now I think about it, my throat is sore. I’m dehydrated. I sneak two pain killers into my mouth and feel guilty for the selfish acknowledgement of my own pain.

In the front, the windscreen wipers flash once in a while, and I vaguely wonder if I should say something. But it’s all been said, for now. I think we’re comfortable with our silence, and the milling over of our missions ahead. ‘There will be no white flag above my door. I will go down with this ship’. There isn’t any need for blue lighting, apparently. But I know every beat of her being craves to catch up with the blue lights that went before us. For this undocumented blissful half hour I am a mother holding another mother. No words. We’re  just sitting, with patience, faith and an unspoken understanding.





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.