Penny for your thoughts....

I was just considering updating where I'm at with my midwifery and travelling. I'd hoped to get a more personal reflection of my findings and usefulness after the Dunkirk trip, but I've been thrown into preparations for another pending trip to Nepal. Hopefully, I'll spend some time with colleagues over the next two weeks, and we'll share experiences, challenges, high and low points of our midwifery volunteering in France, and where this might lead us.


Other events demanding my attention are International Women's Day on march 8th, International Day of the Midwife on May 5th and, as mentioned, a trip to Kirtipur, Kathmandu on 2nd April to support the opening of a Normal Birth Unit. Busy!


I'm writing right now because I'm intrigued to find out who is doing all the sharing of my blog. It's had over 2000 hits, from France alone, in the last few days. Who are you, and what are your thoughts? Midwives, legal, political, humanitarian always, as well as polite. I'd love for you to share in the comments, below. You might just have to add your name as 'anonymous' in order to post, but feel free to include your name when you comment. Thank you.

Another fun and messy evening.

Practical Crafts Evening.

Beginners welcome.

Tuesday 15^th March, 7pm til 9.30pm. Kirtlington Village Hall.

Tickets £20.

Select from drop spindle spinning, basic knitting/crochet, woodcarving, pottery, and glass/wood/pebble painting. Ticket includes sessions at 2 work stations of your choice (First come first served), a glass of wine or a cuppa, and nibbles. All materials are included and you’ll have your own masterpiece to take home.

Proceeds will go towards

Midwifery needs in Dunkirk Refugee Camp.

'With Woman', and much more, in Dunkirk Refugee Camp.

So, first trip to Dunkirk refugee camp is out of the way. Much learning and processing is still to be done, though. This sprawling of findings feels like I'm sifting through a tin of spaghetti alphabet letters. In order to explain to another, I need a level of understanding myself, and I don't yet have that. But I CAN tell you of the practicalities, and with so many midwives considering getting out there to support the refugees, this is good enough.

The team. A mix of characters, but we worked really well together.
Thank you, Maggie, Verity, and Sharon, for joining me.

Practicalities of the trip

Obviously, up to date passport, E111, travel insurance. A few euros are always handy, too.

Channel tunnel

Cost £154 and shared by the four of us, booked on line (see channel tunnel bookings). Ferry is much cheaper, and takes about 2 hours. Needed to put passport details of fellow travellers online. We got to the tunnel quite early, after leaving plenty of time to travel down to Folkstone, and managed to get on the earlier shuttle. You need to get there 30 minutes before. Actual time in the shuttle was about 35 minutes.

Driving in France.

Verity, amidst all the donated goods.

I checked my car insurance covered my driving in France. In fact, it covered anywhere in Europe for 30 days. I bought a bag full of the necessary car accessories for driving in France (GB sign, headlight diffusers, two breathalyser tests. Spare bulbs, a small first aid kit, a warning triangle, a high visibility tabard....but you now need one for EVERY passenger. Fire extinguisher is advised but not compulsory) by last minute online shopping. I filled my car with fuel when I left home in Oxford, and didn't need to fill up until I got back into UK. So, fuel for the duration of our stay cost us around £70 tops.

The sat nav was so helpful, and I'd already copied out maps of where we needed to go. However, there wasn't very clear info on finding the actual camps. Having three mates in the car who relentlessly shouted 'On The Right' to me, meant we got there and back in one piece. The most challenging times were giving way at roundabouts, and coming off them, flowing onto a dual carriage way (because you can't easily see with a right hand drive car) and moving out of or into junctions. Talking myself through where I planned to drive, while I was doing it, helped all of us stay focussed. I did have to turn around at one point, because I'd missed a turning. When I pulled back out, I was briefly on the WRONG side of the road, and moving towards the right turn that I'd missed. I totally ignored the panicked shouts of 'On The Right'. I thought they were over zealously telling me where I needed to turn. Hairy moment, but the only one. I found I quickly became accustomed to it.

Hotel

We stayed at the Premierre Classe Hotel, Rue de Lac, Armbouts Cappel, about 7-8 minutes drive from the camp at Grande Synthe (look up Boullevarde Pierre mendes). The rooms had a double bed and a single above. The bathroom was small but always had fiercely powerful and hot running water in the showers. The beds were comfy. For the price of £136 for five nights, the rooms were very good value. Breakfast was a pretty basic affair, with bread or cake, yogurt, juice and coffee.

For our evening's meal, we crossed the road to the Quality Hotel. Nice food, and wine. But they don't serve food on fri/sat/sun evenings.

Provision of maternity care in Dunkirk camp.

Medicins sans Frontieres have now been welcomed to provide care in the Dunkirk camp, and are there up to 7 days a week. Medicins du Monde are now there Thursdays and Fridays, and Gynaecologiques sans Frontieres are also there Thursdays and Fridays.

These guys are able to provide first aid maternity care for women who present at their caravans. Beyond this, the women, and anyone else needing further treatment, have to get to the local hospital. There was understandable frustrations within the teams, with the amount of care they were legally able to provide.

Touching base with MSF. Communication is important.

Many women are afraid of venturing out, and there is a level of mistrust towards the NGOs. Several pregnant women are known by MSF and the various voluntary organisations, but there are undoubtedly some that are unknown to the support workers, and of course there will be new pregnancies. Some more vulnerable women are removed from the camp, and placed in hotel settings or 'plasitc' housing. It was never made clear how these women access their maternity care, or who has details of their whereabouts.

Professional regulation

Not quite midwifery, but valuable all the same.

In order to practice full midwifery skills, we are required to have professional indemnity insurance. NHS covers us for our work within shift and trust time only. Royal College of Nursing, and maybe Unison(?) provide cover for some care, but not all, and certainly not intrapartum care. Royal College of Midwives cover for 'Samaritan' care only (see below).

Maggie doing a brilliant job
 in the 'shoe department'.

In order to practice midwifery in France, you also have to be registered with the French Medical Council. They cover slightly different aspects and, understandably, mastery of the French language is a necessity.

The most convenient way of providing midwifery care in the refugee camps, would be to work within an organisation (NGO). However, in order to get insurance cover, training etc, you'd have to commit to maybe three months continuous work with them, and most NHS midwives would actually have to say goodbye to their regular jobs in order to work with the NGOs.

So, what does this mean for me, as a UK registered midwife? I'm not in a position to be able to leave my job and take up a nomadic and uncertain life with the medical NGO's. I'm not either, at this point, prepared to jump through hoops to become a 'French' midwife.....

I believe many midwives are out there simply 'doing their bit'. They are providing emergency care, midwifery based or not, and are working without the support of their country or union. Yup, dodgy, but definitely raw humanitarian work where and when it is needed most. Bless them, and what a crying shame they're not getting the support they deserve.

Over the next few months, I wouldn't be surprised to see a few more positive statements creep out of the woodwork. Mostly, midwives are caring people. Why wouldn't they want to support this dreadful crisis? Legally, or illegally, they're going to help. It would fill my heart with delight to see the Royal College of Midwives providing some kind of support. Maybe there will be a statement posted soon, on their website explaining their position.

There has been debate over exactly what constitutes emergency or Samaritan care. When pushed, the RCM provided this definition....

'The policy provides for claims arising from a good Samaritan act however it is important to note that a Good Samaritan act is where medical services are provided at a scene of a medical emergency, accident or disaster who is present by chance or in response to a medical call. '

The finer detail of 'present by chance' isn't really fine enough, in my mind. It left me thinking if there did happen to be a maternity emergency, I'd be better off walking in the opposite direction, in case there were repercussions. This is wrong on all levels.

Other tips to share.

There is no legal advisory organisation that I know of, working within the Dunkirk camp. The refugees could REALLY do with this. They need to be supported to move on, and have choices regarding safe transit, asylum, and funding during this process. So many are still in camp because they don't know what to do next. They are sitting ducks for yet more trafficking.

Getting past the police into camp was problematic only on the last day. We were advised we'd have to go to the town hall to request authority for access, but they then 'allowed' us in, after check all or our passports (midwives are such a dodgy gang!).

Our small team of midwives spent much of our time in the Women and Children's Tent. This seemed a pretty sensible place to hang out to get conversation started, support women emotionally, with advice and education about any issues these women had. Sadly, it's probably only the more confident women who were accessing this tent, and until word gets around that midwifery support is here, we'll have limited knowledge and access to the more vulnerable ones. It would be great to have midwifery presence on a regular basis, so that we can venture into the 'woods'.

If you're a midwife planning on going over there, be prepared to support generally. Litter picking, taking people to the hospital, gathering provisions for people, help support the new school. Vaccination programmes for measles may be up and running and you might like to help out with that. HANDS, NGO, seem to be organising this. Stay in contact with MSF etc, as these guys will be in the 'know' of recent events.

Risking life and limb (mostly limb) to get to the Women and Children's Tent.

If you want to support the Women and Children's Tent, there are a few simple ground rules. The aim is to supply women with clothes etc, and for them to collect what is needed in a safe manner. Men in the tent is a 'no-no'. Men hanging around the tent is discouraged. Only three women at a time in the tent (as some more sought after provisions disappear very fast!), children need to be accompanied. Ethos is to take only what is needed (ie, not taking half the shop in order to sell it on..). Put your personal belongings behind the 'no-go' area, or they WILL walk. Remember the guys in charge (currently Adrian and Svenja) are volunteers, too, and you're sharing THEIR space. The door opens at 11am, and closes at dusk, or when quiet.

With Adrian and Svenja, catching up after a lovely
lunch that DIDN'T consist of rice.

There IS a box labelled 'Maternity' at the back of the tent. It has multi vitamins, Iron, UTI treatments, condoms, pregnancy tests inside. We could do with Vitamin D, too. These are all 'off the counter' preps. Any translations/ communication aids can be left here. Over time, it is hoped that women know they can seek the more social/ educational aspects of midwifery support in this tent, and it can also be a base for volunteering midwives.



Cards, with Kurdish writing on the reverse, to help
 educate about pregnancy complications.

There is not enough women's leggings, jogging bottoms, sleeping bags, hair brushes, conditioners, wet wipes, small packs of tissues in the Women's and Children's tent. If you're planning on going, take provisions straight there. Do not pass Calais. Go directly to Dunkirk.

In time, there may well be a new 'Women's Tent' erected near the current tent, where women can go to cook etc. Maybe this will have more space to 'be', as supporters. The idea of a 'knitting tent' has gone. There isn't enough stability, currently, to keep this a 'safe' place.

There are many volunteer groups on Facebook etc. It's a good idea to make yourself known to a team and ensure somebody knows where you are. Loads of support is around at the weekend, and the place feels quite different. Help is best coordinated, and projects, current needs, and concerns (there were shootings in camp on the day we arrived, and demonstrations/ tear gas use on another day) can be passed about very quickly. Every day is different. More hands make less work...only by collaboration and communication.

In limbo...and an awful lot of mud!

I apologise. This is a rather sullen and humourless post. I found nothing to joke or get excited about (Best I don't mention the many firm bums in the blue Gendarme trousers every night at the hotel). The apathy and lawlessness in the camp was a real eye opener, but it was present alongside the many dreadful stories of basic survival of the fittest and the lucky. What some of these people have endured to get to this point beggars belief.

So, this is as much as I can give at the moment. Frustration, anger, disappointment, sadness...doesn't become me. I shall jiggle things and ferment ideas until I can come up with a wholly more positive picture, and update.

An answer to this whole sorry state would be good, but while the world makes noises about getting it's act together, we'll just carry on caring.

 

 

 

 

 

 

 

 

 

Midwives for Refugees.

Give me a spare five minutes, and I can always think up some trouble. I've been up all night with a birthing woman, and my brain is now at half mast.....but functioning enough to wander in and out of sense. This means it's able to explore opportunities I'd otherwise know better to avoid!






Lately, I've been exploring the possibility of getting out to the French refugee camps in Calais and Dunkirk. There's not likely to be too many pregnant/lactating women, but it would be nice to offer them midwifery support. Working with NGO's generally means setting aside quite a chunk of time away from family and NHS work. This isn't possible for the majority of midwives. To go out to France, or even Greece, for just a few days, is far more manageable.




Take the idea of a few days in camp one step further....and it grows into a rotation of UK midwives, maybe every two or three weeks, providing on-going support, that doesn't eat away at annual leave or expenses.




Here lies the problem....




To practice in UK, midwives have to work completely under the 'protection' of NHS, or have professional indemnity insurance. Many are members of Royal College of Midwives, but RCM don't offer any cover. Royal College of Nursing has some amount of cover included in it's membership, and this includes some overseas volunteering.




PI insurance would be necessary to practice in France, but we also need to be registered with the French Medical Council...I think. There has been noises that this is not too difficult, but French language is a pre-requisite. There is also the possibility that registering is not necessary for short term voluntary work. I'm awaiting a definite answer from them.




It's also possible that, under EU movement of professionals, there maybe some protection and possibility for us to provide midwifery care without being registered. I'm awaiting more information on this.




I have requested, as a member, that RCM's legal department checks out the situation of UK midwives providing care in France. I'm awaiting the response.


Lastly, the question of MSF (and the like) considering taking a core of our rotating midwives, who are prepared to commit to a certain time over the year (and in short spells rather than a long one), under their umbrella and insurance, has also to be answered.




Lots of waiting, eh?






And while I wait....midwives, doctors, nurses are already out there helping people out, and mostly just providing the most basic of first aid care. Some are working with the NGO's. It's good news that MSF have recently been invited into the Dunkirk camp, which looks to be in a dire state. Other healthcare workers have just gone out there to see how they can help, regardless of legalities and registration. Most will understand that providing anything other than first aid care, or showing an 'intention to treat', leaves them open to trouble. All this red tape, just to care for people in an emergency situation. I envy the guys who will go there regardless, and I NEVER thought finding out exactly what we can and can't do, would be so incredibly challenging.




It is evident, regardless of provision of clinical midwifery, that more caring hands and hearts are needed. The essence of midwifery, and quite possibly most important to those in the camps, is being 'with woman'. Throwing a tantrum that I can't assess for hypertension is simply a symptom of what midwifery has become in our minds and our NHS. First aid care for women who have travelled away from, through, and arrived at varying levels of hell, requires compassion and kindness. Thank goodness those skills aren't yet regulated.


So, 26th January it is! I'm still not sure on numbers. One or two cars, maybe a van, ideally filled with necessary provisions, and heading most probably to Dunkirk. Another team will go out middle, maybe end of February. Things in Dunkirk are extremely fluid at the moment (in more ways than one, given all the dreadful rainfall), so a destination plan will stay fluid, too.




Now, add to that plan of rotational midwives, as yet unable to offer a full compliment of skills.....

.......a large family sized tent where women can come together in the daytime to knit and crochet donated wool into 20cm squares to make blankets, or whatever they want to make.....

......and you can address many issues all at once. Community. Empowerment. Positivity. Skills at crafts. Warmth. Language skills. Contraceptive advice and supply of condoms. Pregnancy tests. Info on domestic abuse and rape. Breastfeeding retreat....and the list goes on.

The tent can be made safe by it hosting a couple of women living there as 'housekeepers'. In any community there are wise women, and I've no doubt we'll quickly identify those who would like to support fellow refugees in this way.

20cm squares, knitted or crochet

I'm not sure I'll be able to get a tent into Dunkirk camp just now, but I can take one and store it, along with furnishings, for when access is able. It will become clear where is best to set up more long term. There's nothing to stop small groups of women (and children) learning to crochet, during my first trip. People are naturally interested, and often want to at least have a go for themselves. So, along with provisions of clothing and medical supplies, I will take wool, already made up 20cm squares, and hooks/ needles.

The less talked about skills of midwifery.

The facebook page 'Midwives for refugees' was set up to share any information for UK midwives thinking to support refugees and migrants with voluntary reproductive healthcare. In three weeks, it has more than 200 members. It's fantastic to find so many midwives are so eager to help.

First Taste of Africa.

So, a new destination and a new adventure. Some different slants on old stories. Some conquered challenges for them, some new challenges for me, but always challenges. After all, we'll never bring change if we don't face a few challenges. All together, eight leaders, thirty two eager-to-learn carers, all eating, drinking and sleeping maternal and newborn health.

YAY!

This latest trip took me to Kenya. Third time lucky after a couple of cancellations, and the first time for me on African soil. Funded by the Centre for Maternal and Newborn Health at Liverpool School of Tropical Medicine, a retired obstetrician called Richard Kerr-Wilson who is rather more used to African ways, and I travelled out to Nairobi. It was a flying visit (ho ho), whistle-stop tour to deliver obstetric emergency care training, the CMNH way. Packing for way up in the hills (read emergency rations of individually wrapped cheeses and dried fruit/nuts) was quite unnecessary, so I filled my case with more frivolous provisions. I won't go into details here. A lady's case is quite a private affair ( until you get to British Airways security, that is...) but my case was embarrassingly heavy for such a civilized trip.

What did I worry about? I worried what kind of food they'd dish me up, being vegetarian n'all, and whether the accommodation would be isolating or at all scary. I worried how I'd get on with my travel companion, but only slightly, because midwifery depends on the ability to make quick connections, and my companion was a joy to be with. As my flight was the morning after the shootings in France, I worried about the return flight into UK and any security issues developing from that. But so many untoward events have happened just before my flights, and isn't that the safest time to fly?

Nairobi looked quite smart, but we only saw the smart bits, apparently. Our hotel was very nice, and having shared photos with friends, I suspect it's often frequented by UN and UK workers. I'm wasn't sure if all the security barriers made me feel more or less secure. Sharing breakfast with a fellow traveller who grew up in Nairobi, and hearing her stories, was enough to reassure me that security is indeed GOOD.

My first taste of 'Africa' was in the back of a car, through blackened windows. Not wanting to miss ANY of the scenes, I wound the window down and had the warm air whistling around my neck. The great Rift Valley, as it came into view with splashes of sunshine sprawling over it, was like something out of the 'Land Before Time'. It looked amazing, and I valued the reduced responsibility of having to make pleasant conversation with the rather quiet driver.

My first view of wildlife was not really so wild. A small herd of Zebra, and a few baboons sat by the tarmac roadside, with concrete box houses and electricity pylons in the back ground. It didn't quite live up to my expectations. I was mildly disappointed as well, that the shanty areas looked all too familiar to my experiences in other lands. The tidy rows of endless 'garage' size homes, all with TV antennae, were an improvement on the tarpaulin used in Nepal. But had I moved off the track, I suspect findings would have been more disturbing.

Nakuru itself was flat, tidy, and fast flowing, criss-crossed in straight lines like scars (or birth marks, I'm not up enough on the politics and history to decide which) from the army's influence. The town has apparently grown massively in the last few years.



View towards the lake, from my room.

The bed during my stay was comfy enough. There were wonderfully helpful housekeepers. The restaurant was pleasant, although staff were slightly perplexed by their non-meat-eating guest. Neighbouring dogs and passing lorries made for disturbed sleep, at times. I didn't see one mosquito, but a more than adequate net was at the ready (to hang me at any opportunity) and, oh joy, there were no midwife eating spiders. Not even little ones.

My time in the bathroom should have been luxurious given this HUGE relief (and huge caseload of goodies), but the showers were cold or, at best, tepid. When visiting Nepal, I've returned and cried into my hot shower in appreciation of such luxury, and felt so blessed for running water. But I have to confess, as I stepped under that piping hot flow at home this time, I yipped and giggled. The difference? May be no difference, but simply that I'm getting rather spoilt. I only just touched the surface of the struggles in Nakuru. Why should I have expected hot water?

The course accommodation was a rather quirky hotel/ function place. The four breakout sessions after each lecture/ demonstration were held in corners of the same room, and this worked very well. Some of the sessions were specific to Kenya, and I have to say, those Kenyan facilitators were the best people to teach them. I certainly learnt more about HIV protection and aseptic techniques. They have 'hand washing' procedures off to a T.

I loved the impromptu additions of little bit of rhythm and quite a lot of laughter to help drive home the learning. By the amount of leg pulling in my direction, I suspect the team members had never met a 'Veggie', but it was a great ice-breaker and made me lots of friends. The waiters were vigilant in pointing me to my daily source of protein.

Without exception, all participants were there to learn. They weren't just there because they were ordered by bosses to attend. There were some thought provoking (read scarily concerning) moments, and beautiful conversations along the way.


Learning was a two way thing, and with this project, it's measured by testing participants before and after the training, and then visiting the workplace some weeks later, to see what knowledge they have put into action.



Teaching WHO partograph. The guy in the
yellow Tshirt was a Midwife, and extremely
 wrapped up in his 'caseload woman'

Time keeping is always a major issue, especially on the longer training days. It's important for the participants to move swiftly around each of the four work stations, as most stations are allocated just 20 minutes. Anne, our time keeper, had the patience of a saint.

I find teaching the WHO Partograph so rewarding. It's where the real midwifery skills come into play, and emergencies are then avoided. I was impressed with the group's ability to define positions of baby from the presenting part, and their understanding of the three 'P's (power, Passenger, and Passage).

It wasn't any surprise to find myself BANGING on about

….Neonatal resuscitation.

….....Golden minute for baby.

….Encouragement of Mum's own birth hormones.

In this medicalised world of child birth, we don't often enough allow Nature to work FOR us. It should be a basic understanding that if there are limited drugs available to prevent postpartum haemorrhage, you do everything in nature's book to encourage a good maternal hormone response. Yet, we overlook the obvious, or don't get taught it in the first place. Protected time for baby on mother's skin straight after birth will impact on baby (and Mum) for months to come. ABCs of neonatal resus are so simple, but moving onto chest compressions before getting air successfully into the lungs, is pointless, AS is leaving a baby in a wet towel. These things are so simple to perform, when understood.

And, as ever, perineal suturing methods left a lot to be desired (excuse the pun!)

When I travel with the LSTM maternal and newborn health team, I'm providing emergency care training, but I do not believe it can be in isolation from good midwifery. While lectures don't always lend themselves to this, the follow up conversations can explore best and safe practice in midwifery.

This teeny baby, fifth in line to his family throne, was born at 36weeks.
Fast labour. Sent direct to neonatal Unit, to share a resuscitaire in the
 office with three very poorly babies. I think he'll have been fine.

On the last day of the course, Richard and I were lucky enough to be shown around the local hospital. It was sparse, but clean. I felt awe at what they were achieving with such few resources. Two women to a bed, even very poorly women. The delivery area was so cramped for space, even if there were staff for emergency procedures, I'm not sure how they'd fit in. Polythene sheets on a simple couch. All couches facing the door, meaning women were overly exposed. When they had so little, how could I suggest dignity should come into the equation? But it should.



Growth restriction and prematurity seemed to be the order of the day (two themes factoring greatly in the new Sustainable Development Goals), and the maternal mortality rate has started to increase, though they are not sure quite why.

Kenya has managed to reduce it's maternal mortality rates from 584 to 510 in 100,000 (World Bank figures) in just four years (UK figure is just 9, to give you some perspective).

Visiting the neonatal unit was by far the saddest part of my hospital trip. A third of all babies don't go home. Having said that, I saw the most scrummy...and almost healthy...42 day old twins born at 28 weeks gestation. They were having skin to skin time with their mum. That is the most amazing little story. How does that happen? And how are they now? I dearly hope they've made it home.

This is a busy unit, with 25-30 births a day. C section has reduced lately from 15 to 12. That's fantastic news. It worries me what these mums will do next time...and the next time...after section. Hospitalisation isn't the only answer. We need more midwives.

Wish I'd seen this work place before the course. (Take note, LSTM)

And...how could I go to Africa without visiting the parks? On the last day we visited Nakuru lake. I didn't expect the place to be so lush. A fresh carcass showed evidence of lions, but we weren't lucky enough to see them. There were just a few pink flamingo on the lake, because it had recently 'shifted' after volcanic plate movement, and the water was too deep for an adequate algae supply. The flamingo had flown to find tastier soup. We spent quite a while on the boggy peat, among the graveyard of trees and amazing bird sounds. It was incredibly moving, and the peace was breathtaking after such a busy and demanding course.

And then Home. Too soon. Great trip. Such potential for even better obstetrics and midwifery. And such lovely warm people. More friends. More learning.

Thank you.

Sunshine Before the Rain.

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

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

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


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

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


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




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

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

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

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

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

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


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

We were honoured to be guests at a wedding that hadn't quite happened. In this community, much celebrating and eating and dancing happens before the man brings his wife home to the family. We were treated to joyous dancing with drums on a scorching hot day. I was grateful of the chairs offered to us as special guests.

We stuck out like a sore thumb, and it wasn't long before they realized we'd not entered into the mood of the party.....yes, we had to dance Nepali style, feeling meters taller than anyone else, heads thumping with heat and dehydration, trying to smile and laugh at ourselves with as much gusto as they were laughing at us. That was almost as challenging as peeing in a spider infested privvy, but it was appreciated more by the locals. We'll be the talk of the party, for quite a time to come.

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

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

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

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

There was a problem with the local water source drying up, due to a leak higher up the hill, apparently. The girls had a water filter for drinking water safely. I have to admit, though, I was thirsty much of the time as the filter didn't quite meet the demands of this larger group of visitors.
It didn't become evident until later, either, that while we slept at dawn, water was being fetched from a more distant source. Even with a good translator, so much information is lost in conversation.
Electricity and a small amount of internet coverage were good, but there was the usual load sharing. We found the solar charger pack I brought from UK very useful.

With funds from UK, I was able to equip some PHASE nurses with solar charger packs and wind-up head torches. They don't work for ever in these dusty and harsh environments, but while they do, they'll be worth having.

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

This water hole was a short cross country walk away from our home, and where our 'emergency' source came from. After such a (self imposed) meagre volume of water to wash in back at the house, both Sarah and I thought we'd died and gone to heaven as we plunged our heads under the cold flow to wash our hair.

         And the view was even more breath taking. What I wouldn't have done to have found that place earlier, deserted and quiet, to have washed fully and without reservation. No bathroom brochure in the world, with mod con or promise of luxury, will better that place for me. When I write my book 'The World's Most Amazing Places to Greet Your Lover', this will be one of the top ten.

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

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

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

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

I can go into more depth later.

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

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

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





Below, is the current maternity ward.

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

This 'Pink Bus' is one of two rented for use on particular routes around kathmandu that have already been identified as risky for women. The aim was to have it driven by women FOR women, but there aren't enough women drivers...YET (Samjhana is sorting it ;-)) The buses are packed with women both morning and evening, and it is welcomed by the men. Most women in Kathmandu have been abused either verbally or physically at some point in time, while using public transport.

It was heart warming listening to the conversation, in Ratna Bus Park, with other bus drivers...all male. They were so supportive of this project, presumably because they've had enough of witnessing the amount of abuse that goes on (They could try giving any abusing male a hasty removal from their bus, eh? Most of the drivers are youngsters, and would need the support of other passengers to be able to carry this out). I made the executive decision to hand enough cash over to get the seats freshly covered on the bus pictured above, after it was agreed they would make a big difference.

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

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

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

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