OK !!! I can't put this off for ever. I have yet to explain the situation of Midwifery in Nepal, for the benefit of the lovely people who have donated to this very cause, and for the UK midwives who may find themselves in a position to support this cause in future. My time is up..... tonight!
I'd like to point out that I've juggled enough with the correct words, emotions, diplomacy, respect and reflection and now have the perfect report, but I can't. I am still struggling with the whole experience, and I’ve never been quite at such a loss for, not just words, but a total ability to express myself anything near like I’d wish to.
So, where to start.....
That’s suddenly not as difficult as I thought it would be. I saw very little Midwifery in Nepal.
Nursing as a profession is very popular for Nepalese girls. After the course, where they learn using the English language, they can choose to continue within a specialised area. If obstetric nursing appeals to them, they can study a further 7 months on this subject. The skills labs are well equipped with wonderful donated models and posters. Midwifery journals and evidence based research papers, however, are sorely lacking. All the hospitals I visited had large numbers of students who were ready and eager to learn.
Many of these girls are young, maybe looking to travel and leave Kathmandu, have never given birth, and are only just beginning to imagine the strength of their own sexuality. They work within the hospitals, and are answerable to the doctors. They are not empowered to be ‘with woman’. The women I saw giving birth were denied the support they needed, because they were attended by nurses who were also denied the support they needed. I felt the nurses were as much victims of the system as the mothers were.
Routine episiotomies (cuts) were performed on first time mums, and more often than not performed on the rest too. This is not at all in line with current research. It was incomprehensible to me that expensive suture material should be wasted, and an episiotomy be intentionally given to a woman who has to work so hard for personal hygiene and has minimal time to repair her pelvic floor before work and/or childbearing resume again.
Most of the labouring women I saw in the hospitals were laid on beds with intravenous lines attached to them. Of the women I enquired about, all were being administered oxytoxic hormones to induce or augment their labours. Every delivery I saw was in extended ‘lithotomy’ (lithotomy being a half inch diameter length of pole on the corners of the bed, that the women have positioned between their toes....ouch!), and often with the woman flat on her back. It appears the free hospitals generally encourage a female birth partner (drugs and intravenous therapy or blood have to be purchased by relatives), but some do not allow support at all.
There are no epidurals for pain relief in these hospitals. Of the student nurses I chatted to, most admitted a fear of giving birth. In a set up like this, it takes a very strong young nurse to want to be ‘with woman’, and to find the skills to hold and support women through birth, thus encouraging the necessary hormone response for normal birth, and lessening the likelihood of intervention.
Many nurses were genuinely concerned that an upright or ‘all fours’ delivery would not allow them control of the baby’s head and adequate space for performing an episiotomy. During my teaching sessions we discussed physiology and hormone response for normal birth. We used role play and set out scenes for the encouragement of normal birth (birthing balls, bean bags, mirrors in order to view stretching of the perineum).
Illiteracy level is high. Parent education is ‘pie in the sky’. Anaemia from bland diet, worm infestation, and malnourishment is high. Postpartum haemorrhage is a danger for all women. It is illegal to practice physiological delivery of placentas (although 80% population who are unattended, presumably deliver by this method).
Encouraging delivery by exerting fundal pressure is still performed, though I suspect it is performed in an attempt to avoid the doctor performing a forceps delivery. This may be a valid option given the lack of analgesia? I’ve no idea. Fundal pressure is seen as an absolute ‘no no’ here in UK, and shown to be a cause of haemorrhage.
The preferred method of contraception is by injection. However, this often causes breakthrough bleeding and in a culture that still accepts women being forced into outside sheds during times of ‘unclean’, stress on family life and ‘women’s work’ can be unbearable. Nepal currently has the highest rate of female suicide in the world. (see youtube ‘the chaupadi hut in Nepal’, and ‘Witness, birth in Nepal’).
Termination has recently been made legal, which has done much to increase safety for women, and medical termination before 12wks gestation is common. Women are still able to request and pay for early ultrasound scans to detect the baby’s sex. Female fetuses are still being aborted. Two of the six women attending an ultrasound clinic during my stay at the birth centre had paid for scans for this purpose.
I suspect you’re getting the picture of a much disorientated NHS midwife? My findings and thoughts can only suggest the reflection, evaluation and ‘what now’ I have as aftermath of this journey. It is, I admit, a rather negative reflection, and appropriate for the mood in which I returned. But in the time I’ve spent contemplating my report, I have come to enjoy some positive and inspiring thoughts too. If you have specific questions, please DO ask.
It’s late though, and I’ve done pretty well to get this far tonight. Much is happening and work is afoot...
