Friday, 4 May 2018

Time to look back, and see how far we've come.

I shoved my suitcases back into the loft, downloaded my photos, scrubbed Kathmandu off my skin with the help of some blissfully hot running water, amended my paperwork, and put away my overseas gadgets. This, within 24 hours of jumping from the plane into UK’s cold and dreary ‘spring’ time weather.... Phew! Such eagerness to get the trip compartmentalised, and a desire to plan my return to Nepal, I’ve never known.
 Not bad going, considering this time last year I had deep and personal questions about actually going back. I’m so pleased to tell you, this latest trip has refuelled and inspired me.

As ever, my intention of getting the blog done and dusted, were good enough. But as life so often does, it got in the way. I entertained the idea of blogging a daily report while I was out there. There were some evenings spent relaxing, G&T aided (Thanks, Stevie), in our guest house, where I could have done that. My midwife sisters, Sarah and Stevie, and our new recruit Diana did their utmost to get me hooked on The Archers. Had my brain been in a place to digest the events of the day, I could have used the excuse of writing my blog. In reality, Nepal is complicated, and I needed a clearer grasp of things before I wrote.

So, again, there was much to get our midwife mitts into. This year we gave up trying to plan an agenda. Our time is so limited, and it seemed to make sense to plan our mornings, afternoons and evenings as precisely as we could, but Nepal has other ideas and they are flexible and spontaneous ones.
Our intention was to..

1. Catch up with NAMS second year midwifery students, and meet the first year cohort, too.
2. Update and support the faculty in whatever area they felt they needed.
3. Get out to Dhulikhel hospital to meet the midwifery students at KUSMS, now in their second year.
4. Provide multi-professional update training on respectful, woman-centred care to nurse-midwives and obstetricians.
5. Introduce/share the latest WHO guideline. A wonderful read! ( )

The 'One Born Every Minute' art of eating cake!
We managed all of this (Well...almost), and more!  Sadly, we didn’t get around to all of the places and all of the wonderful contacts who have become dear friends over the years. But, looking back now, how we squashed so much into our short time, I’ll never know. The big news is that Nepal’s government has decided to commence training for 9,000 more midwives from direct entry to diploma level. Sustainable Development Goals (SDGs) for reducing maternal and neonatal mortality have to be met, and midwifery is the one profession that will keep Nepal moving in the right direction. Skilled Birth Attendants played a fantastic part in quickly reducing the number of deaths but, at the risk of sounding like a broken record, it's rather like shutting the stable door after the horse has bolted. Midwifery will not only stop so many obstetric emergencies happening in the first place, but it will empower and educate the women to make decisions about their own health and that of their families. It’s likely the bachelor students will be the teachers of tomorrow’s students, and that the diploma students will be encouraged to work in the rural areas.
Thank you, Sanu, Gyanu, and KM Hospital
 for our stunning saris.

We were happy to be invited to the Ministry of Health offices to support the structuring of the ICM based diploma curriculum. In reality, the 23 all female committee managed to get the job done very well. Much of this has been thanks to UNFPA and GIZ, in funding permanent midwifery advisors to the chief educators, faculty, and students.

Checking out a donated TENS machine.
On arriving in Kathmandu, we met the NAMS college first year midwifery students (14 of them). They were under no illusion about the challenges ahead. Some of their concerns were around becoming a student again, after already being a qualified nurse-midwife for some time (Diana, I think your talk with them, on returning to student status, was really appreciated). Others voiced concerns about being able to practice midwifery in a clinical setting that doesn’t naturally lend itself to what they have come to understand midwifery to be (To put this into context, out of these 14 nurse-midwives, and with all of the collective experience they have in childbirth, only one in the group has supported a woman for upright birth).

Caste, age, and gender are still real issues for nurses in Nepal. Questioning and learning from practice, is always good, but it’s not so easy to question when you’re a young female nurse in Nepal. (Interesting, and not for discussion right now, but there is currently NO place for a male nursing student in Nepal).

Year 2 NAMS students say 'Hi' and 'Bye'
It was delightful to meet up again with last year's students, now in their second year of training. What a transformation! (Well done students and teachers). It truly felt like I was in a room full of midwives. I was particularly pleased to hear that our last year’s learning exercise of researching different issues in midwifery and obstetrics had empowered them to question and find things out for themselves.

Some of their achievements....
1. Running their own antenatal clinic for ‘low risk’ women. It goes without saying, both the women and midwives flourished.
2. Support from labour ward staff, and specifically around events of ‘nuchal cord’ presentation at birth.
3. Maintaining privacy for women.
4. Introducing themselves to women as a matter of habit.

On the down side...
 They have been discouraged from supporting women to mobilise in labour. When questioned, the reason given for this was that upright labour may cause fetal distress (Really? Is there research to support this..?). It was also described as common practice that doctors don't introduce themselves to women or respect closed curtains. We know both make enormous difference to women.

One student shared her concern about obstetricians performing too many vaginal examinations.
Imagine the scenario....A junior doctor performs a vaginal examination, but is unsure of findings....and so a more senior doctor performs a vaginal examination. Then, with anxiety induced from having to present the findings, requests a repeat examination from a senior colleague... before the consultant appears on the scene. By this time, the poor woman has hopefully got wise and has retreated to the toilet to avoid the consultant and a further examination....She'll feel totally invisible and violated, will lack any maternal hormone supposed to get that baby born, and may become poorly due to infection from so many examinations. I’d like to say I jest....

Mutual trust needs to be built between the professionals caring for women in the antenatal and labour wards. I had hoped for meetings with the obstetric team during this year’s stay, during last year’s stay, and the year before.... This is the box that I’ve so far not managed to tick.

I have to also say, I have met some truly inspirational obstetricians working in Nepal. I really hope these few individuals will inspire others and encourage learning. The tide can change so quickly if we all
work together!

With this in mind, we provided workshops on negotiation and communication skills, and respectful, evidence-based maternity care for students and faculty. Student groups received a bag of equipment (sonicaid, TENS, essential oils, 'respectful midwifery' cards, tape measures, books, journals, charts, and more). It’s hoped this ‘midwifery bag’ will be passed between the students while in their work place to support them, empower them, and give them the full tools to work their midwifery magic.

Lovely group of almost-qualified nurse-midwives ready to embark on their exciting journey

A happy mother being supported by her sister,
and a TENS machine, during early labour.
How useful computers can be in the birthing room...(!)
This one had some pretty good stats on it.
Sarah looks impressed!
Our visit to the Tribuvan University Teaching Hospital is always wonderful, mostly due to its Mangla Devi Birth Centre. We met with obstetrician, Dr Mita Singh, who is rightly very proud of the great work so far in making this centre available for women.

This beautiful centre wouldn’t be out of place in UK. It is sunny, nicely furnished, the nurse-midwives are happy, and it has fantastic figures to support good and safe care. The women LOVE it, too.

The obstetricians are seeing the benefit of a falling caesarean section rate within the hospital, and are encouraging women to birth in the centre. The delightful core members of staff are now busy enough to offer birth support around the clock. What an achievement! And what a crying shame that the midwifery students can’t learn in this setting.
Dr Mita Singh checks out a set of mini
'Respectful and Compassionate Maternity Care' cards.
Hmmm..who to give them to?

After having no pain relief to offer, there is lots of
interest in our TENS machines. Hopefully they are being used
in the labour wards.
...And while visiting the midwifery students in Dhulikhel, we were lucky enough to have our sharing session joined by a wonderful obstetrician, Sunila Shakya . To hear Dr Shakya share her uncomfortable journey through obstetrics, and her eagerness for the students to practice midwifery as we know it, brought me close to tears. For so long, I’ve felt like I’ve banged my head against a brick wall when it comes to multi-professional working in Nepal’s hospitals. Thank you, Dr Shakya. With Dhulikhel’s newly appointed and inspiring hospital principal, Kunta Pun, your student midwives will be supported to bring fantastic changes for women.

Laxmi Tamang generously gave her day up to take us into the hills with the MIDSON pick-up. It was an incredibly moving trip (hehe, in more ways than one!) A four-and-a-half-hour long bouncy journey up there, and a near shaken-head-syndrome journey back down again. But it was so worth it. Thank you, Laxmi and MIDSON.
School as usual. Behind the rubble, looks freshly built school rooms.
We stopped half way and had the opportunity to meet and eat with the area’s health ‘focaliser’. We listened to reports of gynaecological conditions, such as prolapse and fistula among the older women, and the dreadfully high number of girls still being trafficked from this area, inevitably leading to high incidences of STDs. Historically, girls have always been ‘supplied’ from this area for use as king's servants. The Nepali government are thankfully cracking down, and the roads are now guarded by soldiers.

You really want to view some of these roads
AFTER you've travelled them.
The UNICEF earthquake hospital tent still here three years later.
This lovely couple are deciding on the sense and safety of travelling further without benefit of Nepali language or mobile phone. They MAY still be up there. The non-verbal communication says it all.
But why wouldn't you want the experience of waking up to this!
I hope this year's rainy season is a gentle o
Samundhratar, and Routbesi is in the Dhupcheswor Rural municipality of Newakot. We visited two birth centres. The first was very basic but, due to accessibility, it took the referral cases and transfers for Kathmandu hospitals. This was an unexpected trip, and while not wanting to go empty handed, our gifts of equipment weren’t as appropriate as they might have been. The second centre was higher up and much larger than the first. The UNICEF tent, erected as a temporary health post after the earthquake, was still standing close by.
There was still a staggering amount of re-building still to be carried out. All of the houses being erected were reinforced with metal, as this is the only method supported by government funding. The houses will be safer, but they don’t look half as pretty as the old stone and wooden houses. The important thing, of course, is that they will save lives in the event of another massive quake.

Again, as last year, the student midwives were all offered and accepted a year’s membership for Midwifery Society of Nepal (MIDSON). Our delightful new team member, Diana, also gifted her unused Nepali Rupees in support of this. I seriously debated the best use of this money. Royal College of Midwives has a good rate for overseas students and the learning to be had from its website would have been really useful to the students. However, I felt MIDSON actually needs the support of its MIDWIVES, and these students will be the first ever midwives in Nepal. These midwives will be the ones to take MIDSON on to great things. The progress, thanks to MIDSON, is fantastic, but MIDSON now needs to grow and support these students better. (A bit of purposeful repetition of a couple of key words, there)

Market day, every day, in Nepal. It had all things bright and beautiful (and some things not so beautiful, too)

So...what now? For certain I’ll be going back. This trip has raised many questions and possibilities. It looks probably that, along with my wonderful team mates, Sarah, Stevie and now Diana, we'll consider focussing on a rural birth centre or area of birth centres. This maybe as a couple of teams, even, so that we can still give our support to the teaching in Kathmandu. We may be able to support students in their rural postings, too. Working with the doctors and bringing a sense of shared purpose will hopefully be less important as the midwives settle better into their own roles and responsibilities ( read that as competence and empowerment to make clinical judgements, etc)

There’s so much to do. Will we need more UK midwives? Two small groups in different areas? Can we add any UK obstetricians to our team? Should we work under the umbrella of a bigger organisation, or do we raise funds for ourselves and retain our independence? Should we look to become a registered charity? This started out as my own adventure, and has become a wonderful team of four. Through all of our trips, we work so well together, and have a real shared interest (apart from The Archers) in what we're aiming for. This has been real team work.  And then I need to ask myself what am I, personally, able to take on. Keep it small and manageable? Embrace the growth and grow with it? Or bite off only what I can chew? There are discussions afoot and plans for fundraising. The way will become clear. It always does.

Wednesday, 22 November 2017

They're on their way!

I’m not sure I’ve ever left it so long to update my blog after a midwifery trip away. But I really felt the need for a break, some time to replenish my heart space. Since I returned from Nepal earlier this year, I’ve dropped my hours as community midwife, and I’ve been directing my energies towards a little cottage industry of socks, stockings, bloomers and petticoats. We need more midwives, I know that, but I’m sure we could also do with a few more petticoats. And if the break actually keeps me doing the job I was born for, for that little bit longer, it has to be a break worth taking!

After all, Nepal has STUDENT MIDWIVES (Wahoo!). Independent midwifery still has a very unpredictable future. NHS has ever decreasing resources. I have ever increasing age. My parents are older, too. My grandchildren are frustratingly yet to manifest.... and so it felt time to place a few eggs in another basket. Best thing to do was to chill out, smell the coffee, plant nasturtiums, and make undies during lazy sunny mornings and candlelit tucked up nights, so that I might have more flexibility for the things I love....One of them being midwifery.

(Hmm...maybe I’m beginning to reach full circle?)

 I’ve been scrolling through a dusty notepad for scant scribblings, and spending time over the photos I uploaded and then ignored. The memories aren’t quite ‘flooding back’, but I am piecing together events from March, and themes that now have a repeated importance.

My goodness, the hardship and the pain of sitting here trying to harness my menopausal mind, and my trying to make the best of a negative poetic kinda flow! But I know it’s a small price to pay, considering the difference our trips have made, and the generosity of friends and acquaintances here in UK who have made these trips possible. So, onwards I shall go...

The very necessary midwifery art
of 'eating cake'.
Sarah and Stevie, my midwife companions, and I were to spend time with Nepal’s brand new student midwives (Fantastic! Way to go, Nepal!!!) The midwifery course started a few months earlier, in two teaching hospitals of Kathmandu. Thankfully, we were in communication with the wonderful Maya, midwife and technical specialist with UNFPA, and we were all agreed that our time during this visit would be best spent with the students and their teachers. We needed to try to bridge the gap between ‘nurse-midwife’ in an overly medicalised setting, and ‘midwife’ with all that we know that role embraces. We also needed to fast track the nurse-based teachers towards midwifery teaching and ethos.

But that’s FAR too big a subject to start writing about.


Kirtipur Hospital

We were invited back to Kirtipur Hospital. The new birth centre had made a little progress, but lack of funds and staff meant they were still waiting for the ‘go-ahead’.  We explored options of ‘low risk’ women using the centre to birth with minimal but safe levels of staff, remembering a full response team was so close by in event of emergency. The knowledge that midwifery led care would be better for the women and reduce the cost for the hospital was not new, but we still felt it wasn’t prioritised by all levels in the hospital. Again, repetition from last year, concerns were voiced about the time it would take to transfer women to the theatres, but we reflected distance wasn’t so much the issue as good and timely handover and communication.

We held a workshop for the nurse midwives and obstetricians, and Dr Deepak Sunita, a caring paediatrician, joined us too. Dr Peru Pradhan did so well to gather as many of the busy hospital team to join us. We felt there should be shared consensus and decisions where this birth centre was concerned. Doctors needed to trust the nurse midwives, and give them space to promote normality. The nurse midwives needed to reassure the doctors they were fully able to utilise their skills to keep things normal, but would recognise complications in a timely manner. Communications between the teams, including paediatrics, needed to be encouraged so that in the event of an emergency, transfer would be smooth and everyone would feel comfortable with their own roles.

During the workshop, small groups considered how they would care and react in certain scenarios, decided when obstetric help was (and wasn’t) required and how they would make the transfers smooth. As a team, we then reviewed, discussed, and agreed changes to the Birth Centre admission criteria and guidelines. We also explored ways of encouraging women to birth in the new centre. Identifying a woman as ‘low risk’ in the antenatal period, and having midwives perform their antenatal checks, were just two suggestions.

Tribuvan University Teaching Hospital

We couldn’t go to Kathmandu and not visit the wonderful Mangla Devi Birth Centre at Tribuvan University Teaching Hospital. Again, figures of last year’s normal birth and transfer rates are marvelous. From the feedback survey, staff could tell us that women were very happy with the care they received. We were delighted to hear that the Hospital’s caesarean rate had fallen from 45% to 39%. I wonder if the presence of the Birth Centre had a positive impact on care in the labour ward?

We met with birth centre staff. Members of the obstetric team, Dr Mita Singh and Dr Gurung also joined us and we were thrilled to have their company and hear their thoughts. Professor Kiran Bajracharya, president of MIDSON, Joined us too. After hearing the report on last year’s figures, we reviewed the birth centre admission criteria and guidelines. Several changes were suggested, discussed, and agreed by all. It will be lovely to return this next March to see how the changes are working out.

Sadly, when we visited in March, the centre was still not open at night, and from the 4,500 births that took place in the hospital, only 5% occurred in the birth centre. The reason for this was thought to be lack of uptake or introduction in the antenatal period. Having the birth centre midwives providing antenatal care for low risk women, and this being supported wholeheartedly by the doctors, would increase births in the centre. With such wonderful figures and happy women, how can they not bring this into being?

Again, like at Kirtipur, there were concerns raised regarding appropriate and timely transfer of women. Having looked in detail at some cases, the issue could simply be lessened with better communication. The use of synthetic oxytocin to hasten labour was discussed. We strongly felt this was not appropriate for a low risk birth centre (especially with no available means of continuous fetal heart monitoring), and that if natural hormone and mobilisation wasn’t getting baby budged, a transfer was the right decision.

Sadly, TUTH Mangla Devi birth centre doesn’t take midwifery students. What better place in Kathmandu to see and respect the normal process?? Normal birth, with midwifery support, happens rarely in Nepal. TUTH are missing out on a HUGE opportunity here.

Model Hospital

Stevie's fantastic homemade dungarees. 
We were requested to provide midwifery training at the Model Hospital teaching campus near Swayambhu. Teachers, Sanu and Gyanu, gave us a very warm welcome. Specifically, they wanted to revisit emergency care (and causes) of uterine inversion. We also provided role play, with discussion about respectful and evidence based care. This was a short session before being whisked off to Kirtipur, for another training session.

As much as we try to organise our time BEFORE the trip, there is easily as much ‘ad hock’, and this has to be anticipated so that we can best provide materials for learning. Several evenings were spent in our ‘@home’ guest house in Jhamsikhel  (fantastic place, great breakfast, comfy beds, lovely hosts), preparing for our next day, while delving into whatever savoury nibbles we’d harvested from the local ex-pat mini supermarket, and enjoying the ‘winding down’ hastened by a not-so-chilled gin and tonic.

We had many giggles getting to grips with ‘Mama Natalie’, the obstetric emergency scenario ‘doll’, and her baby. This was very kindly donated to Sarah by Laerdal. We also shared out the collected, donated and bought equipment between the places we taught. Books and birthing balls are always on the list. Fumbling in the dark for battery chargers and boosters for our internet access wasn’t required this year as Kathmandu now has electricity around the clock.

We even took time for a day out. We were tired and although we were ten times more tired after hiking for hours from Nagarkot, our spirits were lifted by the fresh air, amazing views and sense of freedom. How could we not feel a spiritual over flow, when we had a guide called 'Santa'.

And now for the nitty gritty, the real purpose for our presence in Nepal...

...the delightful midwifery students!

Twelve students are studying with the National Academy of Medical Science (NAMS). This is a three year course, started in November 2016, and all students are already nurse midwives, SBAs or community nurses. The placement area for clinical practice is the Paropakar Maternity and Women’s Hospital, Thapathali.

Maiya and Durgesori are the NAMS midwifery teachers, and Maya from UNFPA passionately and magnificently mentored them all. The students are in two groups for clinical placement. Their teachers cannot oversee all students, so there is much observation of each other’s practice.

On our first morning together, we were lucky to be invited in to the labour ward to wait the end of the clinical session. While we waited there was a birth. For the midwives among us, this is how things evolved....

“Para 3, first hospital birth, recumbent, delayed progress in 2nd stage, hormone drip commenced, mum pushed baby out seconds after spontaneous rupture of membranes and thick meconium, but nuchal cord present, so clamped and cut before delivery of body, baby flat, taken to resus next door.”

Feeling embarrassed for the mum, we requested the curtain around the bed to be drawn, but the common practice of staff disrespecting any drawn curtain was very clear.

We all had lunch and drinks in the cafe close to the hospital, and we asked the students and teachers for their thoughts of how the birth had gone. We asked how they felt, what they thought could have been better, how the drummed-in practice of delayed cord clamping doesn’t sit alongside cutting a nuchal cord before the baby is born. We were thrilled when the students began to ask questions about not just nuchal cord, but the lack of mobility for the woman, about how the woman herself might have felt about the experience (having had two home births already), and about how she might have felt when they took her limp baby out of the room.
One of the most challenging things to teach in Nepal is how to....challenge, how to nurture an inquisitive attitude.

This scenario was our bread and butter for much of our role play and discussion for the rest of our stay. 

From this....

  • ·         One student arrived on labour ward for her next shift, and told ALL of the staff she would be closing any curtains she found open, and explained why she felt this was important. We were pleased to hear she had the support to carry this plan out.

  • ·         A nurse midwife admitted that our discussions prompted her to introduce herself, for the first time ever, to a woman she supported in labour.

  • ·         A reading list was provided, along with a varied list of research sites. A NAMS student Facebook page was also set up to held share useful links and experiences.

  • ·         During role play, we explored the thoughts and feeling of mother, student midwife, and staff nurse. This was an interesting and extremely valuable exercise. Fear, embarrassment, coercion and sometimes bullying felt by all three for different reasons, and all too negative for what should be a nurturing, ‘with woman’ space. But it created some understanding of the different challenges.

  • ·         Individual research topics chosen by each student, to explore evidence and choices for clinical practice. Management of.......suturing and perineal repair, normal progress and latent phase, nuchal cord, delayed clamping, mobilisation,.....were all topics the students chose to question and research. These findings were printed, and shared with the group. It was the plan to hijack a small part of labour room wall, or provide a folder, so that this information could be shared with the staff and obstetric team. How else are these students going to respectfully, and healthily, challenge current practice? Essential reflection was encouraged by Maya, who bought each student a reflective journal.

The question that became painfully obvious...

...was how to support the staff nurse midwives... to support the student midwives... to provide evidence based, respectful, midwifery care to the women? The staff complained they didn’t have the authority to allow students to support birth in an upright position. When asked what the actual guidelines and ‘rules’ are for labour ward, nobody knew. Nobody had seen or heard of them. There was a Skilled Birth Attendant’s ‘work book’ somewhere.
“There are no written rules, .......but if we don’t follow rules we get shouted at”

We also visited, albeit briefly, the fewer students at the semi-private Kathmandu University Hospital at Dhulikhel, who were sitting a four year course. Regina Singh, the Nursing Education Director, welcomed us to this fairly new hospital, with 3,000 births each year. They are building a brand new birth centre, but it will be an obstetric unit and not midwife led.

The whole of the medical team, across the hospital, get together each day for ‘morning meeting’ to share events, special cases, etc, of the previous day. We were requested to introduce ourselves and explain our purpose at the hospital. We felt very welcome, and impressed with the sense of ‘family’ among the staff. We didn’t get to see the current birth centre in action, and I was sad not to see if these morning meetings increased multi-professional communication.

We didn’t have time to provide workshops at the KU hospital, but the teachers were later invited to join NAMS for teacher training. 

For this session, based  near Pashupati, MIDSON’s Professor Kiran Bajracharya joined us, as well as Professor Pramila Dewan, of NAMS,

We revisited...
  • ·         How to research, and developing curiosity for evidence based practice.
  • ·         Leadership and communication skills.
  • ·         Decision making, and work place dynamics
  • ·         Reflection
  • ·         What it means to be a midwife, and identifying barriers to successfully moving student midwives into midwifery practice.

The art of communication!

 It appears that varied placements would be beneficial to the students. The APS Birth Centre in Kalanki, although not having many births, has an immeasurable wealth of support and expertise in the nurse midwives working there. Asha, Amala, and not least Rashmi Rajopadhyaya are as close to my kind of midwifery as I have ever known in Nepal.They have a beautiful 'way' about them, and could provide valuable training to the students. They are perfect role models.

With the funds that friends here in UK have donated, we were able to provide every student with a year's membership to the Midwifery Society of Nepal. MIDSON is the one and only nurse-midwife organisation working to make midwifery happen in Nepal. It seemed really important that these young and passionate, and very FIRST midwifery students have access to whatever resources can be offered to them. These are the midwives that will take our profession forward, and potentially be MIDSON’s future management. Fresh ‘blood’ and ideas are healthy and to be encouraged. I’m not sure how much the students have actually benefited from this membership. I shall know more when I return in March.

So, a feeling of great achievement, for everyone who has put effort and dedication into making midwifery happen in Nepal. Of course, we are not there yet, but midwifery education is an incredible achievement. The essence of midwifery has yet to seep into the bones and souls of the teachers, the students and the team working around these people. That includes the obstetricians. The students are working in an environment that is almost hostile to the changes that have to happen. Respect, openness, and a combined desire to make childbirth not only safer, but more joyful, will help turn medical and public attitudes towards respectful, evidence based, woman centred care. 

The ball is well and truly rolling.

Well done to us. Thanks to my besties, Sarah and Stevie. But a massive well done to MIDSON, UNFPA, GIZ and all the NGOs and individual passionate people who have supported Nepal's huge step towards having a midwifery profession.