Excitement of going overseas.
Kathmandu, Nepal.
Key planning you wish you had done
I would like to have had a clearer plan of my time in Kathmandu. I spent a couple of days at the house of a nurse I’d befriended on facebook. It was a gentle and safe introduction to the culture, but also a couple of days I could have been ‘doing my bit’ or arranging meetings etc. Nepalese are very laid back about planning and it was quite a challenge to accept the flexibility with such a precious time frame ahead.
Things you wish you had when you got there
I’d fully intended to keep a daily blog, but I had no internet access except my little old phone, which was OK for emails, but not to write a comprehensive and sensitive reflection. A laptop would have been useful. I stayed in the birth centre itself, and electricity (or light, as they call it) was unpredictable.
I was completely at a loss to get myself around the valley. There are taxis, buses, and mini ‘tuc tucs’, but when you don’t speak Nepali and when there are no road signs whatsoever, or for that matter, addresses, getting to particular hospitals is a real challenge. One of the nurses in the centre drew a very basic map for me of the ring road around the valley, which gave me more confidence when travelling alone. I’ve not yet managed to find anything in print more useful than this.
On arrival
First impressions
Oh My God! Dry, noisy, dirty, and in my face. Getting out of the airport was quite an experience. Such a good job I was being met by somebody. Such a culture shock! Car horns blared out continuously, creating an impression of absolute havoc. Travel was scary, but quickly became one of the more enjoyable and amusing parts of my journey.
I felt very ‘white’ and, for the first time, like a specimen to be oggled at. The Nepali people are very gentle but also quite ‘unreadable’; combinations that can initially make you feel unsettled.
The amount of rubbish on the street is shocking. There is no refuse collection, and everything is sold individually wrapped. Even paracetamol from the pharmacy is sold one dose at a time. Sweets are bought individually. They don’t stock things in kitchen cupboards like we tend to, and all groceries are sold in plastic bags. The idea of recycling is alien to most in the valley, but there are regular demonstrations and voluntary relief workers try to clean the place up.
Getting adjusted to the culture/ climate/ way of life/ midwives
The climate is pretty pleasant in March. We had glorious thunder storms bringing rain on some days, but the ground dried quickly. Other days were too hot to go midday travelling, especially in the overcrowded buses. I spent my whole time in sandals, thin cotton dresses and trousers (it is quite a cosmopolitan area, Kathmandu valley, but with respect for the nurses etc, and to retain a professional manner, I covered my arms and legs when outside of my room.)
It was the first time I’ve had to use a hole in the floor for a toilet, and I have to say it’s an art I became quickly acclimatised to. They don’t use toilet paper, and I never really saw it sold in the shops. For those travellers with a more delicate disposition, it may be worth taking a roll with you in your luggage.
I missed my bread, cereal, chocolate and alcohol. I quickly became friends with the local grocery store man. His English was pretty good and he sold biscuits, fruit, vegetables and juice. This diet, though not healthy, kept me going between the daily meals taken in restaurants.
I went fully prepared for the dreaded ‘Delhi Belly’; medicines already stowed in my baggage (though medicines are readily available without prescription there), and put myself on a health binge before I left. I was warned not to eat unwashed fruit, any dairy products, local eating houses etc (the list is endless...), but faced with a beautiful plate of glorious fruit offered to me on arrival, I felt so bad at the thought of refusing it, that I ate it. I didn’t get poorly, and I made the decision to fully embrace the Nepali culture with only a few simple rules (water only from sealed bottles, no road side sold food, and only eat in places frequented by my hosts.). I’m sure I had very rare beginners luck, and won’t be so lucky next time.
Winning their trust, hearts and minds – things you did and wish you had not done
Showing a desire to learn the language made me many friends, and gave reason for them to laugh at and with me. I felt I’d arrived with a hoard of knowledge and skills to impart, which of course I had, but it was so useful to show them they could teach me a thing or two also.
I was very much out of my depth, culturally, and needed support of the nurses in the centre. When I wasn’t at the different hospitals teaching, I spent time in the pharmacy with the girls chatting and getting to know them. Some of the chat was shared information about each other’s systems of care, and this was invaluable for me. I learned how it was for them, their backgrounds and upbringing, aims and desires for the future. I made very good friends with all the girls, and the learning and trust was mutual. I wouldn’t have had this time with them if I’d been based in a hotel.
I wish I had not left so soon.
Stay in the country
Accommodation/ facilities/ essential to take with you
My personal space for the duration was a consulting room in the Birth Centre. There was no running water at the time I stayed, so my ration came from containers. I washed myself, hair, and my clothes from half a bucket of cold water each day. The kitchen had a gas ring for tea or rice in the morning. The Centre was locked up at night and two nurses also slept there for ‘out of hours’. Plugs needed an all-in-one world adaptor. There were lovely, friendly cleaning ladies who brought tea and swept floors from the constant dust all day. For the times of ‘blackout’ a head torch was essential. Some places have large batteries, or generators, but they didn’t seem to use torches etc (wouldn’t these be so useful during a delivery?)
Hotels are not particularly cheap, in comparison to eating and travelling, but they obviously have more facilities. There didn’t appear to be any decent hotels close to the Birth Centre, so I chose to stay local, rather than spend money and get lost in transit. The money I saved, I donated to the centre.
As mentioned above, tissues were hard to find, as were face wipes (very useful in such a dusty place). Many locals, probably a quarter of all people, used a face mask when on the street. I found this distracting. For the short duration of my stay, I decided not to wear one.
Photocopying facilities are limited. It’s not expensive, but of poor quality and very time consuming, assuming the electricity is on at the time. I would have liked copies of papers, diagrams, etc to back up my teaching of physiological birth, and will prepare wads of notes to take with me next time.
Things to buy when you get there
It became apparent once I arrived that my time was to be spent teaching support of normal birth; the very thing hospital nurses attending birth are lacking. I thought birthing balls would be too bulky to take from UK, and that I’d find them cheaper in Nepal. In order to demonstrate props and room layouts that encourage birth, I really wanted a ball. I searched high and low, had shop keepers cracking their sides at my attempt at Nepali language to find a ball. I paid five times higher than I would have in UK eventually for one ball, but it was really useful, and I’m glad I found it. I’d like to think it is still being used in the Centre, but I have my doubts.
Personal shopping was great for beautiful cotton print fabrics. Most sellers will sew a sari or kurta and trousers promptly, precisely and relatively cheaply. Bartering for trinkets and gifts is expected and the norm, but the skilled workers offering high class goods, and working so hard for their livelihoods, I felt deserved to be paid appropriately. There are shops offering beautiful gifts made by women’s centres and Tibetan refugees. So it is possible to spend your money with green and ethical issues in mind.
Compromises you had to make while there
Nepal doesn’t have mattresses like we know them. They are hard, thick cotton pads. The first couple of nights left me with bruises on my hips. I learnt to improvise with whatever padding I could find, and eventually slept fitfully.
I found it difficult to be part of a conversation in which I had absolutely no idea what was being discussed. For the sake of being ‘accepted’ and less isolated, I learnt to just ‘be’ in company. It was enlightening in itself.
I found it really frustrating to want to bring change in the short time I had. For instance, because of the dreadful amount of rubbish in the valley, I thought it would be a good idea to replace the Birth Centre’s incinerator, which was falling to pieces. I had the money in my purse, and the time to spend arranging it. But because of my lack of communication skills, I couldn’t just go out into the street and buy one. These things are probably made up to order by a metal worker, and certainly cannot be ordered by internet. I, therefore, needed someone local to find the materials and labour, to request the work, and then to have it delivered. Hard as I tried, I couldn’t get the job completed. I handed the money to the centre in the hope it would go to this purpose. Nothing happens quickly! When I return, I’ll see if it’s been replaced. Maybe they’ll have considered another use more important.
Expectations of the people there
Nepali people don’t queue. If they shout loudly enough, they’ll get heard. They don’t say ‘please’ or ‘thank you’ or ‘goodbye’ or ‘hello’. They only smile when they really have something to smile about. They are not being rude. In fact, once I got familiar with their ways, I found them overly polite. If you ask directions, rather than let you down, they’re likely to give you any direction they can, even an incorrect one.
I was surprised to see in the delivery suites of all the hospitals I visited that the nurses wore pale/white saris or kurtas, and the doctors wore jeans and tee-shirts. That, for me, speaks volumes. Authority is very much with the doctors.
Again, don’t expect plans to go accordingly. Traffic delays are a real problem. If a meeting is planned for 9am, it’ll probably happen by 10.30.
Cleaners are expected to clean, and you are not. If a meal is provided within a home, it’s likely you will be expected to eat your fill before the host start their meal, and the cooks will eat away from you, in the kitchen. I found this difficult to accept, and rude of myself to not offer to clean, or for others to eat with me. With give and take, and sheepish smiles, we generally met somewhere in the middle.
Control you yourself had to exercise
A very difficult situation arose for me when returning to my consulting room quarters after a visit to a particular hospital. It was the first delivery I witnessed in Nepal. The girl was in second stage with her first baby. I was offered to stand in the corner of the poorly curtained off area (from 3-4 other beds for delivering women). Finding an inability to support hard to accept, I stated I would stand by the woman’s side. She spoke good English and was obviously well educated. I held her hand while far too many (I counted a total of 14 at one point) nurses and doctors shouted, as if they were at a football match, at the business end.
This delivery was as brutal and abusive as I have seen, and there were procedures carried out that were far from evidence based. The woman had no family support and clung to my hand as if her life depended on it. I could have argued my support was out of place within the girl’s culture, but her obvious gratitude for my presence was proof enough for me that it was deeply valued.
The girls at the Birth Centre, after, asked how I had found my visit. It took a while to admit I had returned to my room and cried at the lack of empathy and basic humanity towards this young mother. It wasn’t really the depth of abuse; it was the lack of ability in those nurses to ‘be’ with that woman.
Further into my stay, and after teaching at more hospitals and chatting to the young nurses, I began to understand the difficulties these girls face. All those I spoke to said they were afraid of giving birth. They are working within a hospital setting, under the authority of doctors, who are generally men. Their training is limited, and very much within a medical model of care. They are not taught the skills of being ‘with woman’. From the moment they are born, they have challenges males in their culture do not have. If they don’t feel empowered themselves, they cannot empower others. How do I explain this to the dear girls at the pharmacy?
State of midwifery – good things and bad things
Mmm, this is an easy and interesting thing to reflect on... there wasn’t really any midwifery. 80% of births in Nepal happen outside of hospitals. I’d had intentions of getting away from the valley, but I spent my whole time in the hospital setting. There were wards for early labourers, where women were encouraged onto beds and where family members provided food. There were wards of labourers with or without family support, and almost all women had intravenous infusions. Of the women I enquired about, all the infusions contained oxytocic hormones to induce or augment labour. I saw little evidence of monitoring equipment on the wards, and the women were encouraged to lie on their beds.
Once second stage was confirmed, women were transferred to a delivery area. Lithotomy position was always used and, in more than one hospital, comprised a thin pole at each end corner of the delivery bed, with the woman’s toes positioned each side of the pole, ouch! Episiotomy was performed more often than not, and always for primiparous women. I saw fundal pressure being used in an attempt to save a woman from forceps delivery. Epidural is not available to these women unless for C sections.
It seemed all babies were whisked to the resuscitaire and often suctioned, even when they were crying. They were then wrapped in a multitude of blankets and placed in a ‘baby trough’ to await their first feed. I once saw skin to skin attempted, but the nurses were acting under instruction from the nurse teacher, and were obviously unsure of what skin to skin entailed.
Physiological delivery of the placenta is illegal in Nepal (though presumably not so for those 80% without a skilled attendant). Haemoglobin levels are low due to poor diet and worm infestation. Uptake of iron supplements, folic acid, and general antenatal care, is low.
Women receive a small government incentive to deliver in hospitals. If postnatal care is anticipated, an appointment is made back at the hospital. Many women cannot afford the further costs of transport.
Practicalities
Money – general cost of things
100 Nepalese rupees= roughly £1. A bottle of water= 40Nr. // Taxi most places round Kathmandu ring road= 2-400Nr and can be negotiated. Bus anywhere round ring road= 15Nr. // Filling meal of rice, dhal, vegetable curry, chapati= 1-150Nr.// admission to sights (wonderful temples), and because you’re foreigner= 500Nr. Lovely printed cotton= 1-150Nr/m.
Travel
I travelled with Qatar airways. They are not cheap (I booked when they had special offer of 20% off, return ticket was £650), but the seats are comfy, they are on time, and efficient. I’ve never travelled on my own, and if I’m honest, this was a major worry for me. I felt like I should have a sticker on my head saying ‘NEPAL’. I repeatedly asked directions and times etc. It didn’t matter that I felt daft, I got there! It seems there’s a choice of stops of either Doha or Delhi. My stop in Doha (5hrs from London) before flying on to Kathmandu (7hrs from Doha) was about an hour and half. On return, it was six and half hours, which in the early hours was gruelling. It meant a total of 25hrs travel. I will try to avoid such a long stop over next time.
Insurance for the stay was a simple matter (around £30 for 2weeks). I hadn’t intended on any ‘hands on’ work, so didn’t need anything more. Quite how clinical practice is covered, I’m not sure. UNISON used to provide overseas midwifery insurance, and it’s possible to arrange it through the Nepalese nurse organisation, but as they don’t recognise actual midwives, this could be just for nurses.
Visas for short stays (under 15days) are bought for 25 US dollars at Kathmandu airport.
They allow you to travel with a fair bit of cash (a ‘bum bag’ is really useful for this). I didn’t need to access anything more than what I took with me. Kind friends here gave me 4,000 Nr as a gift. You cannot order Nr here in UK, and the notes were really useful to have straight on landing. You can change sterling quite easily in Kathmandu, and some locals will accept this currency. Almost all will accept US dollars.
Health
Diphtheria/ tetanus/ polio/ hep B and A/ typhoid are all necessary vaccinations. I had cholera oral vaccine just in case, and necessary if you don’t have access to clean water. Rabies vaccine was an option, but because I was going to be fairly close to a hospital, I decided against it. Having it simply means you have a little more time to access treatment (worth pointing out, here, that there are many feral dogs in Nepal, and bites are common; you are strongly advised to have treatment if you’re bitten). Malaria isn’t a problem for most parts of Nepal, but NHS travel map will indicate prevalence and type of prevention advised.
Outward bound jetlag was a bit of a problem for a couple of days.
Transport
All the vehicles look like they should be on the scrap heap. They’re not designed for comfort, but are very cheap. You may have a baby plonked on your lap on the bus, or have to squeeze up impossibly to make room for others. It’s not for the faint hearted, but great fun. At first impression, it feels like there are no rules on the road but, excusing the constant horn blowing, drivers travel at slow speeds and are courteous to each other. Because of the sheer volume of traffic on the roads, getting anywhere takes a long time.
Uniforms
My time was spent teaching and meeting with teachers, and I dressed smart but casually. I wasn’t made to feel out of place when with students. I felt it was respectful to cover my arms and legs.
Food
Always tasty, often a bit too hot for my tender palate, vegetarian food was never a problem, generally healthy, a lack of fresh green vegetables in the general diet. ‘Momos’ are very tasty. Soured milk, rice flakes and chopped fruit is a really filling breakfast or pudding. Tea (chai) is generally black, slightly spiced and very sweet.
Entertainment
The whole trip, from start to finish, and from sight, to smell, sound and all the other senses, was entertaining. I had no time for leisure trips, but did see a small cinema somewhere on my travels. I was told night clubs, for locals, close around 11pm.
Shopping
Local streets will have most of the necessities, and in one street you may find 30 shops all selling the same thing. Some areas are more set up for foreigners. They don’t tend to have supermarkets. For gifts and traditional crafts, Patan and Thamel are sure winners. All of the tourist sights have stalls aplenty selling trinkets.
On departure
Promises made
I was careful to make no promises. I found my time there went really quickly, and by the end of the two weeks, I’d only just begun to understand the depth of experiences I was taking home with me. I didn’t miss my family much (my youngest is 16) because life there was just so full on. I was totally inspired and driven to do as much as I could in the time that I had.
I did, however, promise to myself that I would return. I want to see if changes can be made, and that the plan for midwifery teaching in Nepal is actually going to happen.
It is my hope that this small Birth Centre is far enough removed from the hospital culture, that nurses can be educated and supported to provide midwifery care. If this becomes so, then those confident with their new skills can take it out into the community and more rural areas of Nepal. Nurse-midwives will then also have power of conviction to practice within the hospitals and, maybe, even challenge the medics. There is never any harm in suggesting evidence base and certain research findings to a doctor, and asking why particular actions are deemed necessary by them, but it takes a whole lot of bottle!
Customs
Kathmandu airport workers will happily accept money into their pockets on accepting an overweight case. Don’t give them the opportunity of bribing you. I went out from UK with lots of heavy equipment, and slightly over the weight limit. The rate for extra baggage is, I think, about £10/k. I returned with an almost empty case. It’s worth pointing out that Kathmandu airport isn’t signed clearly and many visitors travelling weren’t aware of the need to fill in an extra customs sheet.
Transport to and from the airport
Taxi, both to and from the airport, was by far the easiest method of transport. On my return trip, it was night time, and there was a strike. But taxis local to the birth centre were very pleasant and accommodating. I did end up paying £15 sterling to my driver on this exceptional occasion as I had no local currency and he was nice.
Reflection
I wasn’t at all prepared for the enormity of emotions following this journey. I’ve left a part of myself there, and I wasn’t expecting to feel quite so ‘bereft’ on leaving the place and lovely people I’d met. I felt appreciated by all the students, nurses, teachers, doctors, and leaders, and came home with gifts and many warm wishes.
I found, and still find, it hard to describe. Friends and family wanted to know all about my trip. The lovely people who had fundraised were eagerly awaiting reports, too. It has eventually come out, in dribs and drabs, but it has been a mightily hard thing to share.
I felt isolated, and resigned to people not understanding how massive my journey had been. I felt proud to have achieved a long desired mission for myself. I felt lucky, and still do, that I was born in UK. I’m blessed not to have suffered hardships that are common in Nepal and so many other countries. But I feel so, so pleased that even if it’s just once in my life time, I have given my skills and knowledge as a midwife to help another country more in need than my own.
What has it brought to my practice? It has opened up a whole world of midwifery that is worth fighting for. The skills and training we have in UK are second to none. As a nation, we are privileged financially to be able to give by way of time and flight costs, and sharing of my skills with so many groups of eager to learn nurses was no hardship.
All over the world, women are getting a raw deal from those that insist the medical model of care, and hospital delivery is safest. What about those that can’t afford this care, or can’t access it for whatever reason? There are no emergency medicines, theatres, forceps, etc for them. Midwives can provide preventative care simply with their eyes, mouths, hands and hearts. They educate and befriend women. They empower them to have faith in their bodies, and they have the skills and knowledge to help keep birth normal. Even within UK, midwifery is becoming a dying art, but there will never be a better alternative. Women will always be best attended by midwives. I though this trip would mean I’d moan less about the state of our midwifery, but it’s made me moan so much LOUDER.
