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.

Thursday, 2 February 2017

Midwifery REALLY Matters.

A rather hurried update for my blog this morning. The coffee in my system is only mildly adding to the stress I’m feeling at recent events affecting UK midwifery.’s supposed to be a blessed day off! Give me strength! I joke that I’ll die fighting for midwifery but surely, and not so slowly, I’m wanting to walk away before it takes my last breath.
We’ve all had that feeling of not being wanted? Been excluded by an unfriendly and ‘clique’ gang in the playground? Every single working day I fight to provide the kind of midwifery I want to see provided by the UK National Health System. You know the kind of thing, woman centred care, compassion, continuity of carer etcetera. It works, it saves money, and it really isn’t rocket science. Our model of midwifery care within the failing and tired NHS system is no longer fit for purpose. But instead of embracing a good old shake up, they seem to be happy for us just to creep off into the quiet and dark to be forgotten about. Who needs midwives anyway?
Hmmm. That’s ONE winge over, but not the one that’s spurred my need to take action this morning.

You may have seen my earlier posts, a couple of years ago, about midwives working OUTSIDE of our National Health Service having to find professional indemnity or insurance? Before this ruling, that all health care professionals have some form of insurance in order to legally practice, independent midwives (IM) mostly had NO insurance.
Many moons ago, before NHS, midwives would be paid minimally or ‘in kind’ by the locals they cared for. With the arrival of NHS, midwives were directly employed, but still collected a small payment by those who could afford to pay. This independence has remained, but numbers have massively dwindled. This decline brought with it a decline in provision of indemnity for midwives, and at their level of pay (excruciatingly less than obstetricians) they couldn’t afford the massive expense of obstetric insurance. Royal College of Midwives provided some indemnity cover only until 1994. So, midwives just informed clients that they had no indemnity should the family wish to sue for negligence. This was legal, but left the family very much wanting for compensation, should birth damage occur.
So, our government forced ANY midwifery being provided outside of the NHS (and this, by rights, includes even phone advice not given within an NHS midwife’s working hours) to have full indemnity. Some midwives have agreed contracts with certain NHS trusts. This could arguably NOT be independent midwifery. IMUK, the biggest independent body of midwives, thankfully rallied together and made funds available for the necessary insurance. Lawyers at the time deemed this cover to be adequate. End of story, you might think.
However, at the end of last year the NMC ‘decided’ this indemnity cover was inappropriate. Worryingly, they couldn’t actually tell midwives what level they thought WAS appropriate. From the moment of that decision, they deemed independent midwives would be acting illegally if they continued to support their clients in labour. They were not even ‘allowed’ to be present at the birth. They could not ‘Doula’, they could not even be a comforting friend.
Can you imagine the panicky situation this is leaving women in? Women pay quite a whack of money to have an IM provide their care, and they’ve often taken this choice because they feel the NHS has failed them. To suddenly be ‘told’ they can’t have their choice of birth companion is utterly abusive to that woman’s birth choice. I’ve no doubt that incidents of women deciding to birth alone will increase directly because of the NMC’s decision. This is helping nobody.
In my mind, independent midwifery is the most woman centred, holistic, continuous, compassionate care a woman can get. If the NMC do not work with midwives to provide this, we may as well kiss midwifery as we know it goodbye.
Do we just go? Quietly? Kicking and fighting? Is it a struggle just for midwifery? Or for the whole blinking lot of us?
Today I’ve written to the NMC. I’ve heard a lot from friends and colleagues, and would like to know more facts and check out the reasoning behind this madness. It feels like a witch hunt. Women birth. It’s what they do. It keeps the human race going. I bet you’ve noticed. How women birth is their choice, and it is essential that rights and choice isn’t taken away.
I’ll let you know the response....

''Dear NMC,
I am shocked, panicked, and totally disheartened by recent issues between yourselves and independent midwives.
I have been a midwife for many years and follow a family tradition. It’s in my blood. I struggle on a DAILY, even hourly, basis to provide true woman centred care within the current NHS. I view independent midwifery as the absolute essence of being ‘with woman’. I provide a small amount of antenatal and postnatal care, I volunteer my skills and services, and provide overseas training to low income countries. I thought I would spend my last breath fighting for midwifery (It speaks volumes that we should see continuation of our profession as a constant battle, eh?).
The way I am feeling about NMC’s lack of support and positive direction for my profession and colleagues, is indeed taking my breath away. Do we say ‘OK, you win’, and walk away? Does anyone WANT a country without midwifery? I would freebirth before I put my body and birth in the hands of an obstetric nurse, and this is what we’ll end up with.
I’d welcome any statements and facts you can provide for me, which supports your actions. My goodness, I pay enough every year to warrant your time and attention. Please can you forward these links and information.
Thank you.
Trudy Brock''

Please, share your thought with NMC, your MP's, RCM, hospital trusts, and here.

Independent Midwives UK
Nursing and Midwifery Council
Royal College of Midwifery

Wednesday, 21 September 2016

Bimala's Story.

Here is Bimala's account of her baby's birth. As you'll read, Bimala worked at Midwifery Society of Nepal (MIDSON) and was incredibly helpful and supportive to me during my first visit to Kathmandu, and during the follow up visits with Royal College of Midwives. She was instrumental in 'looking after' all the volunteers with the GMTP programme. We are all indebted to her for making our visits so relaxed and pleasant.

Bimala shared with us her interest and concern regarding childbirth, and women's issues in general. She is a well educated, well informed, compassionate and incredibly generous woman. With the knowledge she received from the international midwives while working with MIDSON, she set her mind on that 'beautiful birthing room' picture we had described. It saddened me to read her words '...volunteer midwives whom I had worked with during my tenure in Midwifery Society of Nepal had messed it up for me.' But here is a strong woman. She held firmly the belief that her body could birth her baby, and remained questioning of  local protocol versus 'best evidence'.

How many birthing women believe they don't have choices? Or that their bodies are objects for healthcare professionals to do with what they choose? I think a realistic answer to this question would astound us. There is learning to be done, always, for women and care givers worldwide. Bimala has received criticism for bringing the hospital concerned into 'disrepute'. I believe the treatment she received during early labour is, sadly, the norm and widely practiced in Nepal. This birth story could have happened anywhere in Kathmandu. Surely it is helpful to focus less on the 'disrepute' and blaming of an informed mother, and more on improving respectful, evidenced based, woman centered care?

Excuses have been attempted.... No money. Women don't mind. They want a safe birth. It has to be this way. We are too busy. This Is Protocol.

I've listened to the excuses, and provided direction for change. It is slow. There is no justifiable reason for disrespectful care. The next generation are dependent on strong mothers, and we continue to allow...even perpetuate..this abuse. If this isn't okay treatment for your mother, sister, wife, daughter, then it isn't okay.

Thank you, Bimala, for having the strength and conviction to write this account of your little girl's birthday. I hope your message travels far and wide. Blessed be. xxx

My childbirth experience

Bimala Rai

[Hospitals in Nepal do not have the environment, both physically and psycho-socially, suitable for normal births. I had first-hand experience of the abuse of healthcare professionals during my childbirth in one of the reputed hospitals. Apart from unprofessional attitude and behaviour, there was lack of informed consent, client's privacy, therapeutic communication, autonomy for decision making, and respecting client's decision in their practice. Instead of an environment of calmness and happiness to give birth to my first baby, I was distressed and losing confidence in myself. Delivering a live baby seemed to be their only aim. Whether I as a mother would have a wonderful experience giving birth was far far far from their minds. 

Thankfully, because of few nurses, who were expert in normal births and strongly promoted it, I was able to deliver my baby the way I wanted to. They made me realize the importance of strong will and confidence mothers needed to have for normal birth, and of the role midwives played in helping mothers to do so. During 9 months of follow-up, my obstetrician never bothered to mention different exercises, positions, comfort measures that helped in progression of labour which these nurses taught me during 20 hours of my time with them. Follow-up of 9 months with these nurses would have been far better. It is unfortunate that theses nurses who dedicated their life to normal birthing do not have autonomy to practice as independent healthcare provider and do not have the title of ‘Midwife’ in Nepal.] 

I woke up when my water broke around 4:30 in the morning of March 13th. I went to the washroom to check for certain and I saw blood stain in my panty. I was excited, “Yay!!! Finally, the time has come!” No sign of labour pain but another gush of water leak all over my dress. I changed into a new dress and used a sanitary pad. I did not feel like sleeping, so watched music videos on TV and whistled along. I was in a happy mood. At about 7:30 am I woke my husband up and informed him of the incident. We collected our bags that we had prepared for birthing and went to the hospital. My mother-in-law accompanied us as well.

We arrived at the hospital at around 8:15 am. My water kept leaking every couple of minutes. We went to the maternity ward. I was well acquainted with the former Nursing Director of the hospital who was still working there in another department. I gave her a call and told her about my condition. She said she would come visit me.  My husband was not allowed into the ward. It was a bit upsetting but nothing I could do about it. So he waited outside the ward. I was directed to a room with two beds which probably was the ‘Triage Room’. There were about 4-5 person there, no introduction were given but from my experience working as a nurse I deduced that they were a couple of student nurses, one junior nurse and two senior nurses. I gave them previous records of the latest fetus ultrasounds, lab tests, and follow-up with the obstetrician. One of the senior nurses asked me why I was there. “Well, I am pregnant and,” I started to answer her when she interjected in an annoyed tone, “I know you are pregnant, don’t tell me that. Tell me why you have come.” “Not a good start at the hospital to an exciting day,” I thought, a bit upset that she didn’t let me finish first. Calmly, I told her my water had broken, so I had come. She asked me a couple of other questions including my profession. I told her I am a nurse. She asked me to lie down on the bed, inserted a speculum per-vagina and swabbed my leaking fluid for sample. She did not use the curtains to maintain privacy, so my private parts were exposed for all there to see.  Very moment I had a flashback of my conversation with one of the UK Midwife. 
[After observing per vaginal exams done on mothers-to-be without privacy in front of other care providers, the UK midwife had asked the doctor if the mothers were okay with that. The doctor had replied that it was normal in Nepal and that women did not mind. Since, women in UK liked their privacy and as midwife they ensured that, she was curious to know if it was not mandatory in other countries with different cultures. I had replied to her by saying-“Where respect, privacy, confidentiality, informed consent and decision making are concerned, there is no such thing as culture/country context. Period. Women in Nepal cover their body flesh with clothing as much as possible for propriety, how is she okay when Doctor/nurse she has never met before comes in and exposes her most private body parts and stick fingers in? Majority of women in Nepal are not empowered to speak up for their needs and rights. So, though internally they are shocked, disgusted they try to cope with it by mentally establishing the idea that Health care professionals are allowed to do what they do without her consent. So, these pregnant mothers are normalizing unacceptable conduct from Health care professionals which in return is fostering discrimination, disrespect, and acceptance/expectation of low level of care for women in general in Nepal.”]
And here I was in similar situation. I hesitated to ask the nurse to use the curtain. Not because I felt helpless or underpowered to do so, but because I thought my asking her to do so might make her upset that I had pointed out her bad nursing practice, (keeping in mind they knew I am a nurse as well.) They could have taken it in a positive way i.e. mindfully use curtains for privacy in future, or could take it in negative way which was to see me as a threat, preaching to them about their practice throughout my hospital stay. I wanted to focus on giving birth in that hospital and the last thing I wanted was to be viewed as an annoying patient to my healthcare providers. So, I refrained from making any comments. However, whatever the reason was for not commenting, was I normalizing that misconduct by doing so? As someone educated, bold and a health care professional myself was I doing wrong by not speaking up? I had internal conflict. 
After a couple of minutes a doctor came in and asked me why I had come, looked at my previous records and asked me to lie down again. She then inserted her fingers per-vagina. Again, no curtains! I was also thinking that it would have been nice if the doctor had done the per-vaginal examination while the nurse had speculum inserted for swab test. But I was afraid my comment would upset both the nurse and the doctor; so I kept it to myself. Then I felt sharp pain shooting up into my abdomen and felt like peeing while the doctor was doing her examination. After the doctor was done with PV exam, I went to the washroom to pee with that abdominal pain still lingering. When I came out the former Nursing Director had arrived and with a smiling face asked me how I was feeling. It was so nice to see a smiling face in such an occasion.  I greeted her and said, “I was fine but now, for some reason, I have pain in my lower abdomen after the doctor did per vaginal exam on me.” The doctor, writing something on the table beside us looked at the former Nursing Director and said, “Oh! I performed a membrane sweep on her to induce labour!” Again, it was upsetting that the doctor had not informed me about the procedure she was about to perform on me. And again, I held myself back from commenting fearing unpleasant relationship between us, and the internal conflict I had started building up.

Next I was taken to a room with eight beds. It was a bright room. There were three more mothers-to-be, one without IV, one with IV running and one on continuous FHR monitoring machine. The one without IV was crying in pain, looked restless and trying to get out of bed while the nurses were telling her to stop crying and lie down on bed. The other two mothers-to-be were quietly lying on their respective beds. There were same nurses and the doctor from the triage room and another lady in sari and lab coat who was ordering nurses around, assigning beds. I guessed she was the nurse in-charge/supervisor. She did not talk to me.  Not a pleasant atmosphere in the room, at least not for me.  Those international volunteer midwives whom I had worked with during my tenure in Midwifery Society of Nepal had messed it up for me. Influenced by them, I had a wonderful image of a room for my childbirth, image of a quiet room with may be a bed or chair to rest, slow calm music in the background, a birthing ball or other tools for comfortable positions during labour, and only my husband and a midwife in the room for birthing. I had wanted to stay home for birthing but my family were strongly against it, especially my husband. So, there I was in a room full of beds, medical instruments and equipment, little space to walk around, and unhappy mothers-to-be, nurses and doctors who had not talked to me after the triage. I just sat up on the bed assigned to me and watched the activities around me. 

My water was leaking about every 10-15 minutes with slight blood stain but otherwise clear fluid. A nurse came and checked fetal heart rate with a fetoscope. The junior nurse placed IV cannula on my left arm to take blood sample, but left without flushing the blood on the cannula. I called her back and asked her to flush the IV cannula which she said she would. However, she got engaged with another task. So I called the senior nurse and requested her to flush the cannula with sterile saline in case the blood blocked the cannula. She ignored my request and said, “Do not worry. Nothing will happen, we will take care of it if there is a blockage.” This time I could not keep quiet. I would be risking a blocked IV cannula which would mean opening a vein again in another place. So, I kept politely insisting on flushing it right then. The junior nurse saw me talking to the senior nurse, so she came and flushed it. 

It was about 9:30 am when the senior doctor came in for rounds. She came to my bed first and all the nurses and the junior doctor gathered around her. The junior doctor reported to her about my condition. The senior doctor ordered the junior doctor to administer Tab Misoprostol at 10:30 am if I did not get labour contraction by then. I got anxious hearing the order for artificial induction. The senior doctor did not even bother to inform me of it and started walking away. I called after her, “Excuse me doctor. Is it necessary to artificially induce labour now? I want to wait for the labour contractions to start naturally.” “We need to deliver your baby within 24 hours since there is high risk of infection to you and the baby. We cannot wait longer than 6 hours for induction of labour in cases of water break. So, we will wait only until 10:30 am which is 6 hours post your water break.” She replied and walked to the next client. Nope! What I wanted or whether I agreed to their plan for artificial induction was not in their list of priorities since they did not bother asking me or waiting for my reply. 

I had previously read research articles on 24 hour rule for water break and none of them had suggested that it was proven to be the best option. I rushed to the washroom with my mobile and started calling my relatives who had water break before actual labour pain had started. Of the four relatives I called, only one had artificially induced the labour and it was optional. She was given a choice to wait it out or induce labour artificially, in that too which way of artificial induction she wanted. However, all four mothers had delivered without any complications and had perfectly healthy babies. So, I went back to the doctors and so went our conversation in this way: 
Me – “Excuse me doctor. Please let me wait for a couple of hours more, may be till 2-3 pm, for labour contractions to start naturally, keeping close observations on my baby and myself.  If I do not have natural contractions by then, then I will not deny artificial induction.” 
Doctor – “No. We cannot do that. If you wanted to wait, you should have stayed home and not come here. You cannot do as you wish inside the hospital. We have specific protocols here. You have water leaking and with that there can be complications. We want to prevent such complications.”
Me – “I know you are trying to do what you think is right for me. However, I have worked with international midwives before and I have a belief of my own of what is right for me. Not all mothers have labour contractions start within 6 hours of water breaking. There are abundant cases where it started after 24 hours or more post water break and mother-baby turn out fine. There is also no guarantee that artificial inductions will work on me just fine! It has its own risks. I am not asking to wait 24 hours. My vitals are fine, I am not diabetic, fetal heart rate is good, baby is moving, and the water leaking is clear. So, I do not think waiting for a couple of hours more is going to do a lot of damage to the outcome.”
Doctor – “We saw it on your record that you are a nurse. Where did you do your nursing?”
Me – “International University of Business Agriculture and Technology in Bangladesh.”
Doctor – “Is it a Diploma or Bachelor’s Degree?”
Me – “Bachelor Degree.”
Doctor – “Where do you work?”
Me – “I used to work in Helping Hands Community Hospital at Chahabil. I had also worked in Midwifery Society of Nepal (MIDSON) where I was able to learn a lot from the volunteering international midwives regarding normal births. So, I want to have my childbirth through normal delivery. Again, please let me wait only a couple of hours more. I am also ready to sign a risk consent which could state that I had refused artificial induction at so and so time and that the health care providers would not be responsible in case any complications arise later while waiting.”
Doctor – “Look. I know in developed countries they try their best for normal births. However, in Nepal, it is a different context. Every pregnancy is a complication.”
Me – “It is also a normal phenomenon. So, depends on how you perceive it.” 
Doctor – “You are a nurse yourself so you know how it is in the hospitals. We have protocols here that we need to follow. If you want to wait you have to get discharged and go home …”
Me – “Okay then I will get discharged and wait at home.”
Doctor – “However, you have to sign Leave against Medical Advice (LAMA) paper to leave. If you do so, we will not treat you later if you come back with complications.’
Unbelievable!! I would like to believe that the doctor just worded her thoughts wrong and what she actually wanted to mean was that she would not be responsible for the complications later but would treat me nevertheless. I told them that I would leave against the medical advice. 

As I went back to my bed, they called in my mother-in-law and talked to her for couple of minutes. She came to me and said, “The doctors are upset with you. They said they had never seen such arrogant patient before, that you are being unreasonable. They asked me to make you understand.” I told her of my decision. My mother-in-law told me to do what I felt was right for me. 

By then it was 10:30 am. The doctor came to me and said if my cervix was effacing and opening well they would not use the artificial induction. I agreed and allowed them to do a PV exam. After the exam, doctor said that I was only 1.5 cm open which, in her opinion, was not a good progress. She told me it was time for induction, so I better make quick decision. I called the former Nursing Director and told her of my situation. She came and requested the doctors to let me wait for just a couple of hours. However, doctors denied. By this time I was distressed, worried, confused and starting to doubt my decision, whether I was taking risk for my baby as well.  But I strongly felt I could have normal birth without induction since both my baby and I were doing fine. So, I refused induction and signed the LAMA paper. They also needed my guardian to sign the paper (as if I was incompetent of making my own decisions.) I said my husband (who was apparently sent to arrange two pints of blood for surgery) was on his way to the hospital. She wanted my husband to meet her as well. When my husband did arrive, the doctor brought the LAMA paper, handed it to him and simply said, “We have been counselling your wife for the last two hours. Ask her what you need to know and sign it if you decide to leave.” Then she left. I had informed my husband about the incident through telephone on his way back. Poor him! He was in dilemma and asked me what he should do. I told him I would not artificially induce labour yet so we had to leave. With some hesitation he signed the paper. As we were preparing to leave, a lady (I guessed she was Nurse incharge/supervisor for the next shift) came to me and asked politely asked me why I was leaving. When I told her the reason, she did not make comments on my decision but simply warned me of the risks for infection and advised me not to wait too long before going to another facility. I was so grateful for her! Her conduct showed true professionalism of a healthcare provider. Not commenting on my decision showed she respected it, and even though I was no longer in her care she warned me of risks, and advised me of what she thought would help me after I left the hospital. I thanked her for her concern and left the hospital. 

That morning I was confident, happy and excited. By the afternoon, when we were back home, I was worried and anxious, so was my family. But my strong determination and will for normal birth kept me focused. I knew of a birth centre where only normal deliveries were conducted by the expert Skilled Birth Attendants (SBA). It was called Adharbhut Prasuti Sewa Kedra (APS). I was acquainted with the birth centre and the experts there through MIDSON. I called them and informed them that I wanted to have my delivery in their birth centre. They asked me to come to their facility. I informed my family members about it. We took our lunch and went to APS Kendra. 

At 2:30 pm when we reached APS, Miss Amala Maharjan, a nurse with SBA skills and 20 years of experience working in Paropakar Maternity and Women's Hospital, was there to welcome me with a big smile on her face. We greeted each other, I introduced to her my husband and mother-in-law. I gave her the file with all the records of my previous check-ups. I also told her that I had refused artificial induction in the hospital and left it before coming to the birth centre. We discovered that the hospital had given any records or notes regarding the procedures and treatments performed during my stay there. I told her that they had performed PV exam twice and the last cervical opening measured just 1.5 cm. Nevertheless, she wanted to perform a PV exam again for official recording at the birth centre. I agreed and allowed her to do so. The cervix had opened about 3 cm, which was good progress. She said as long as both mother and baby are fine with no meconium staining in the leaking water, we could wait and watch for labour. I was relieved. She took my vital signs, foetal heart rate, and took me to the room where I was to deliver. It had two beds, baby weighing machine, two padded benches, birthing ball, a wooden birthing stool, and a cart with medical supplies for normal delivery. It was quiet in the whole building. There were few student nurses, two staff members and nurse Amala. I was starting to calm down. Nurse Amala asked me to walk around or take rest as I wished. She encouraged me to eat and drink warm fluids since I would need the energy later. So my husband and mother-in-law rested on the bench while I walked around the quiet building. I kept myself hydrated with warm milk, tea, and water. It was exactly what I wanted for my childbirth, a quiet place with my husband and nurse with me. 

At around 4 pm I felt a slight contraction in my lower abdomen. It went away very quickly. I kept walking. The after 20 minutes I had another contraction of same nature. After that I noticed it was coming and going every 25-30 minutes. I was sure then that labour pain had started, almost 12 hours after water break. If I was at the hospital I would have already consented for artificial induction of labour. So, I kept walking. Nurse Amala taught me few positions that helped in the descend of the baby in pelvis. While doing those positions, I chatted with nurse Amala about MIDSON. It was all nice and comfortable. Later, at around 6 pm, nurse Amala brought in an obstetrician who was an outpatient consultant at the birth centre. She reviewed my records and said that we could wait and watch, and left. Mrs Rashmi Rajopadhyay, founder chairperson of the birth centre whom I had known through MIDSON, came in to check on me as well. My mother-in-law went back home as it started getting dark, and my husband brought me dinner from home. After about 11 pm at night my contractions got a bit stronger, but tolerable, and lasted for about 25-35 seconds every 8-10 minutes. Nurse Amala would come to the room every hour to check FHR and my vitals, and reminded me to watch for baby’s movement and colour of the leaking fluid. She also advised considering use of Pitocin in the morning. She would encourage me to eat/drink and rest when possible. She also recorded my contraction at times. I used the wooden birthing stool a lot since it felt comfortable, while squatting could help in the decent of baby’s head in the pelvis. 

It was 10 minutes to 4am in the morning when I had my first intense and long contraction. It came back again after 2-3 minutes and lasted for about 50-60 secs. I called for nurse Amala who came right in and timed the contraction. She said she wanted to check for the progress of cervical opening and effacement which I agreed to. She found that I had effaced 80% but cervical opening was only 4cm. She advised to start me on Pitocin and I agreed to it. I had total confidence in her practice, therefore I did not hesitate to consent to her advices. She hooked up IV Pitocin on my right wrist (since my left was used by the hospital) which did not flow well because I was moving often to ease that intense labour pain. 

What intense pain!!! And how nice that my husband was there to massage my back, support me while I was squatting, or let me squeeze his arm when I was not able to tolerate the pain. He looked at me helplessly but looking at him gave me courage to bear through the pain. Yet, I was getting weaker with each contraction. At times Nurse Amala would remind me to do deep breathing which totally did not work with me. I must have practiced that during prenatal period but I did not have a midwife to inform me that then. I was almost on the verge of giving up after two and a half hours of intense labour when suddenly I had the urge to push the poop out. I told my husband to call nurse Amala who rushed in and found out that it was time. Suddenly, I had this rush of energy in my body. I got up into the bed, was on my hand and knees ready to push with all my might. After four pushes, I gave birth to my baby girl. They put her on my chest while they cut the cord and waited for placenta to come out. I had slight tear on labia minora but otherwise fine. They dried my baby, weighed her (turned out 3.5 kg), wrapped her in warm clothes and gave her to my husband. After they had cleaned me down there, my husband came and gave our daughter to me. 

I had thought, when I first see my baby, whom I had waited to meet for the last 9 months, I will have one of those emotional moments, you know, all teary or feeling super happy/wonderful, like in the movies. Nothing!! I thought she looked like a boy! And not cute at that too! I was not unhappy or anything but I had expected a little more emotion on the first meeting from my side. All I had was feeling of relaxation and relief that intense contractions were over. I took her in my arms and started breastfeeding her. I was advised to continue antibiotics for 5 days and was also counselled on breastfeeding, time for immunizations, Kegel exercises, and nutrition. Nurse Amala came to me and said, “You have a strong will. If you had not been confident and if your family members had not been supportive, we would not have been able to have a normal birth.” Deep down I knew it was true but also the fact that she had played the main role in helping me to stay strong throughout. 

In three hours post-delivery, I was back home with the whole family welcoming my baby. Nurse Amala and Mrs Rashmi Rajopadhyay, and Ms Laxmi Tamang (one of the founders of APS Kendra) kept following up on me and my baby’s condition through phone calls. They wanted to make house visit for follow-up but I did not want to waste their time for nothing. 

Today, my baby is 15 days old! She is doing fine eating, pooping and sleeping at her will while me and my husband have black eye from all those sleepless night which we understand is likely to continue for couple of months more. Oddly instead of being stressed, my husband and I are super happy. And now I find my baby girl to be the cutest of all!

The End

Tuesday, 20 September 2016

Now were getting somewhere...

As always, for me, it’s best to let experiences settle in my mind before trying to put them into words. Today is the perfect day to make a start at sharing the events of April, and it’s been wonderful reminiscing over the photographs. They transport me straight back to the smells, tastes, hugs, and all the other ingredients that make up my world while I’m in Nepal. I feel so overdue a visit, I could jump on a plane tonight!

I’ve given myself a break from travelling during this autumn. Had Liverpool School of Tropical Medicine not come to the end of funding for their ‘Making it Happen’ programme, I’d have happily packed my case and helped with their overseas training. But the effort I’d need to find a similar project to support, I put elsewhere...into a project of my own.

I’ve been working on getting my independent business, Birthjourneys Midwifery, up and running again. Postnatal debriefing and birth planning after previous trauma are areas I don’t think are covered with enough depth in our National Health Service (NHS). Information makes for empowered women, which in turn makes for better births. This is true wherever women live in the world.
My immediate intention is to lessen the time I spend working for the NHS, and increase my satisfaction of being ‘with woman’ by using the whole bag of skills that I have. I hope to have more flexibility and time to train overseas, too. My trust does not give me time out to support developing countries.
Take a look at the website, and feel free to pass the contact details on.

As well as this work, I was pleased to be approached to join two longer term NGO projects overseas, but both were for at least three months duration. I had too many commitments here and wasn’t in a position to go, but it felt good to be asked. Another time, maybe...

So, it feels like a lot has happened since my return from Nepal in April. It was a brilliant trip, and Sarah, Stevie and I came back brimming with excitement about our achievements and how we might take them further.

We almost didn’t get out there. My original plan to take four of us out to the more remote areas to provide midwifery and emergency training to larger groups of nurses had to be re-thought. With the fuel crisis that Nepal was suffering very much still in evidence, we couldn’t expect the nurses to afford  black market prices for transport, AND come away from their workplaces for the two or three days we intended for training. 

However, just as I was considering targeting a potential birth centre at Kirtipur and closer to Kathmandu, Dr Peru Pradhan, an obstetrician at that same centre, was also asking her colleagues and managers for fresh input.

It was all systems go from this point. Studies, plans, purchase of equipment, flight tickets, long distance communication, and accommodation were all sorted with little time to spare.

Kirtipur Birth Centre and 3day training programme.

Kirtipur Hospital had already built a birth centre. When I visited several years ago, they were seeking advice about equipment, amount of beds, staffing, admission criteria etc. Sadly funding and staffing have been an issue, and then there was the small matter of an earthquake bringing absolute devastation to the country. The unofficial fuel embargo from India in response to Nepal’s government actions didn’t help either.  Long story shortened, it meant that another area of the hospital had been prepared for the birth centre.

Our hopes were to deliver training in the first week, and the second week we would provide practical training for staff alongside birthing women. But the centre wasn’t ready, and we are still waiting for it, but we DID manage some training of nurse-midwives who intend to work there, or in a similar low risk birthing environment.

‘Promoting normal/physiological birth with respectful and compassionate care’.
Three groups of 8 or more participants, rotating around three work stations, over the three days, meant we could cover many topics. I, Sarah and Stevie provided the training, supported by two lovely Spanish midwives, Miguel and Marta, who were visiting Nepal at the time. With a good participant skill mix, we managed to get the group sharing dynamics perfect.
...Knitted.  Learnt. Listened. Taught. Discussed.
Chatted. Laughed. Reflected. Acted. Knitted. Ate. Shared. Researched.... Brainstormed...Hugged......... Knitted.

And these were the topics we covered....

Admission criteria, uptake of eligible women, respectful and compassionate care, slow progress, staying mobile in labour, hydration and bladder care, partograph, perineal care and third stage, early breastfeeding and skin to skin, breech, eclamptic fit, shoulder dystocia, postpartum haemorrhage, neonatal resus, antepartum haemorrhage, meconium, identifying small babies, documentation, teamwork and transfer, audit and records, debriefing and info sharing. Updating and moving forward, keeping our skills, managing criticism and challenging bad behaviour.

The common theme over all the workshops and three days was respectful, evidence based care. The workshops were open to obstetricians as well as nurses but, apart from the lovely Dr Peru who is central to the setting up of the Kirtipur Birth Centre, there were none. What a disappointment.

While the nurses listened and shared, they also knitted. Over lunch we knitted with them. It’s thought (and there’s research to prove it, indeed!) our listening skills are honed while our hands are busy with simple crafts. Ancient midwifery skills probably included the art of knitting, too. (One can quietly take in events of the birthing room, and will be less likely to interfere with normal progress). On a spiritual note, the connection, love, and support for birthing women that was shared during the training, is now knitted into every stitch of a beautiful patchwork blanket. We plan to sell the blanket to provide funds for the birth centre. Any takers??? Please message me below (you may need to be ‘anonymous’ to leave a comment, but you can send an email)

As our training came to a close, we put on a performance of ‘Bimala’s Story’...of two very different attitudes and practices in two labour rooms. This true and recent birth story brought lively and emotional discussion. Some could relate to the birthing woman, others bravely admitted they had witnessed or been part of the uncaring attitudes or practices from the healthcare staff.
(For the full written edition from Bimala, of her account in a hospital labour ward and then when she transferred herself to the small community APS Birth centre in Kalanki, please go to recent post, 'Bimala's Story'.

The nurses went home from the training course with their folders, certificates, and hopefully a bit more confidence to challenge unsafe and uncaring practices, and more confidence in their own ability to support normal birth.

Progress with midwifery.

We joined a health camp in the village of many pills. But the care was provided free by Midwifery Society of Nepal (MIDSON) and Direct Relief, an NGO, and it meant that women and children, who might not otherwise seek health advice, were able to leave their homes and workplaces to get checked out. 

During the consultations they received nutrition or contraceptive advice. It was really good to see the teenage girls...the next generation of mothers...having time spent on them. 

It was even better to see Laxmi Tamang (MIDSON) teaching the benefits of normal, upright birth. The main reason for the camp was to screen for cervical cancer. Colposcopy was offered the same day if samples tested positive.

With the births witnessed, I was SO PLEASED not to see routine episiotomies. I still, sadly, saw women lying on their backs to push babies out, and there was little evidence of skin to skin care. But generally, I felt a change in attitude from the care givers. They wanted to do their best and provide good care. As always, and in this country too, there is fear of comeback for NOT doing some procedures.

Nepali nurses are trained for speed. Their labour wards are incredibly busy. They also do much of their learning of surgical procedures on models. This doesn’t naturally teach compassion during placental removal or perineal suturing. I’m hoping that midwifery teaching will teach this. It is needed.

We managed to take lots of equipment out this time, including sonicaids and TENS machines (a first). It was distributed between the centres that we have come to support regularly (APS, TUTH, Kirtupur). In fact, all of our cases were crammed full with equipment, wool, journals... every square inch and ounce. Thank you so much for all you wonderful people who donated and enabled us to take this equipment out.

APS Birth Centre, Kalanki

Of course, I couldn’t go to Kathmandu and not visit my lovely second home. Sadly, the original building isn’t safe since the quake, and the staff are rattling around in a rather large alternative building along the road. It’s a splendid place, but probably too big. The ethos, and care the staff give there, is second to none, as explained so well by Bimala.

Meeting to support midwifery curriculum

We met Pramila Dewan, nursing campus chief of the Bir Hospital. A curriculum had been prepared for submission to the nursing council. Three training hospitals are at similar stages of progress, and it feels like they are not communicating the shortcuts and pitfalls they could all be learning from. The curriculum we viewed was still quite nursing focused, and possibly not in line with International Confederation of Midwives criteria. I have yet to find out if it was accepted by the council, and if teaching has indeed commenced. However, lots of work has been achieved so far, and we’re so close now to having midwifery HAS to happen.
(In recent communication with Pramila, the curriculum has been accepted, and there has been increased contact between the three universities preparing for the midwifery training. The nursing Council is supporting the training, too. Result!!! Well done Pramila and co-workers. They hope to start the training very soon)

Mangla Devi Birthing Centre

We visited the Mangla Devi Birthing Centre at the Tribuvan University Teaching Hospital again, and were invited to review the admission and transfer criteria for the centre. Their figures for the past year are great....
24% transfer to labour ward. Only 14% intact perineum, but only 9% episiotomy too, and only 0.5% third degree tears. The only postpartum haemorrhage needing transfer was a cervical tear. A most worrying figure, though, and not at all reflective of care at the centre, was that only 42% of the babies born were girls!!

A ‘strengthening’meeting, to review and increase support for the centre, was arranged with us. It was decided that women’s low choice for using the birth centre impacted on low figures, as did the lack of staffing ability to have the centre open through the night. The deputy director of TUTH was present and promised to review the necessary changes. Having the Birth Centre nurse-midwives also providing care in antenatal clinic might increase uptake by the women. Sadly, there were no doctors present at the meeting. The head of the obstetric department was called away at the beginning of the meeting, and no others from the obstetrics team could join us. This is a common and unhelpful theme throughout Kathmandu hospitals. I wonder why doctors don’t see themselves as part of this push towards midwifery care and normality in childbirth.

Doctors, midwifery care decreases maternal and neonatal mortality. Your support is crucial. As midwives must use best evidence to provide care, so must you. Not to do so could be viewed as breaking your Hippocratic Oath to ‘do no harm’.

And for the tourists and Kathmandu lovers....

A few snippets to tease the mind, body, and soul....

All the cracks in the buildings! How heartbreaking. I stood on the top of Swayambhu temple, overlooking the Kathmandu valley, and imagined how it would be to feel the whole of the earth rumbling below me.

The Boudhanath bells were closed for business, and scaffolding adorned the central all-seeing eyes. 

There were long, long queues for petrol. Gas bottles were left unattended in rows, waiting for the next filling day. 

Burns units were filled with families fallen after improvising with cooking fuels.

One delightful evening was spent with Rashmi Rajopadhyaya (Midwife through and through!) and her family. Since the earthquake, she has been cooking on the ground floor. Her house, joining four others, is patiently waiting for building work to replace the huge cracks in the joining walls. While her house stands, she says, there is no hurry. Other houses around Patan Durbar Square are minimally supported by planks of wood trussed between tiny red brick houses in the tiny streets.

For this trip, as there were the three of us, Sarah managed to book a lovely AirB&B apartment in Bhainsipati. It was, admittedly, a twenty minute walk to catch the ring road bus each morning, but we were within a most enchanting community mixture of larger houses and tiny smallholdings. On our way home, we could buy fresh vegetables to cook with. Finding tonic, and worse still lemons, for our gin was a bit of an issue, and we gave up completely on the ice.  

Our apartment was comfy, and run by the most wonderful couple. Hot water, lights that need to be switched off when already off, washing machine, kitchen, and flushing toilet were all things that improved with understanding. For three grown women (and midwives at that!), Sarah, Stevie and I got on amazingly well. In fact, I think I could go anywhere in the world with those two wonderful women (I love you both).

      My moans of delight on finding hot water spewing from the shower were totally equalled by their shrieks of joy at finding enough electricity for the Archers on Radio 2.

One lucky morning, we were blessed with the cries of a dying goat to accompany our breakfast banter. We watched with fascination (and respect) as every morsel was washed and shared between the families. If one has to eat meat, THIS is the way to do it!

Taxis were expensive, and we only used them when we had to arrive very specifically for meeting etc. (thank you, kind person, for specifically donating towards keeping our transport options safe and manageable)

We saw the busy street life stop momentarily when a bright green snake chose to cross the road in front of us. A passer-by mumbled with obvious concern that was venomous. Maybe it was. It was wonderful to see it cross safely to the other side.

Stop Press!!! Earthquake felt on Patan roof top!  Yes, my first felt tremor. There were two rumbles, one straight after the other, and both too big for comfort. We were halfway down a cool beer after a productive day, overlooking the Durbar Square, contemplating Nepali life and wondering if we should eat, when the geraniums started shaking. Now, we were several flights of very tiny stairs up, on the top of a Kathmandu style ancient building, without light (electricity loadsharing time). It took a second or two to sink in, and by the time it did, all of the other rooftop guests were clambering for the stairs. It made sense to stay put.

What really shook me was the reflex response to the tremor. On the surface, Nepali folk are cool, and getting on with their day to day lives. Underneath, they are still desperately fearful. I, dare I admit, felt that my life wasn’t at an end. I was born in England, where there is little need to fear earthquakes. How could my luck run out while I was teaching in Nepal? But earthquakes don’t care where you were born, and they take no prisoners. These guys face further (to April 2015) quakes on a regular basis, and the aftershock is far more than just physical.

As Rashmi’s son, Sagan, said to us after, ‘welcome to Nepal’.

Places we ate?

Roadhouse Cafe.  Vesper Cafe (thanks for the intro, Tina). Both on the same street in Jhamsikhel, Kathmandu. And both gently Nepali.
New Orleans Cafe, now only in Thamel (the Jhamsikhel cafe...otherwise known to Sarah and I as 'Rat Cafe'. Don’t ask....recently fell in the quake). 
We spent a wonderful hour or two chatting with Samjhana Phuyal and Smiti Sharma about women’s rights in India and Nepal.

Garden of Dreams, and Kaiser Cafe(just north of Thamel), is another lovely semi western eating place, although it’s expensive for the service you receive.

We had a fantastic meal with some old friends at Jheegu Bhwoychhen, Thamel (thank you, Laxmi). This is a very welcoming traditional Nepali eating house. I’ll look forward to eating here again.

The three of us are beginning to check out dates and some longer term funding. We have a training package that works, is country specific, and we have wonderful contacts to be able to get the training directly where it can be put to use. If you would like to sponsor us, or know a programme that could use us, please drop a comment below.

Every time I’ve been to Nepal, I’ve had different experiences and outcomes. April’s trip was by far the most productive one for utilizing all that previous experience, seeing very real progress with attitudes towards midwifery, and returning with expectation that midwifery WILL actually happen, and soon.