Diary update Sunday 1st December.

 I see things. I don’t just mean in a sixth sense kind of way. I see things on a daily basis, some of them are beautiful and some of them are sad. Some of those who have the sadness are blessed to find there is beauty in there too.

Most of the time, I’m happy in my own power. My job is to hold people, inform them, sometimes direct them, but ultimately hold them. It takes quite a lot of energy, and sometimes when I come home, I want to be held. It’s not a weakness or especially a woman thing. It’s just a way of re-fuelling. You see, if I’m running on empty, I shall have nothing to give. It doesn’t mean I want you here forever. It means, simply human to human, I want to feel safe and loved in the moment.

This evening, I held a young couple who lost their first baby. Their grief is mine, too. Communication and understanding is everything.

Update Saturday 8th December.

Don't they say you have to have the bad times to appreciate the good? Emotions/ luck/ outlook/ directions can do full circle within the space of a minute. They're mini ecosystems of life. Do you feel them? The benefit is that when the going gets tough, they have literally 'upped' and left before you have time to dwell on it.

Driving home from a birth this morning, I received my payback for the challenging time I had during the week; I'd given my all, and needed refuelling. An absolutely stunning and gentle birth, nothing for me to do except 'be' with this couple and keep them all safe. There was just a faint red glow on the edge of the sky promising today's sunlight as I pootled homewards in a bleary eyed, sleep deprived, oxytoxic state. Classic FM was playing the kind of low key but uplifting music I'd want to wake up to, but today I left a contented young family and was heading towards my bed and a WHOLE WEEK of annual leave. The chocolate biscuit I'd thrown into my basket as I left the house in the early hours had never tasted so delicious. It wasn't hard to imagine my hands around a warm cup of tea, and my grandmother's stone hot water bottle next to my feet.

I needed that hug. I actually wanted it from a gentle gorilla of a man who could hold me tight and safe for a short while. I received it from a newborn baby girl, and her parents, and one of my colleagues, who shares those life and sometimes death moments that bring such awesome transition. The sneaky suggestion of a rising sun, and the cello playing, and the chocolate melting, and a ridiculous and trivial radio fact about the average calorie consumption we attempt to achieve on christmas day made me giggle out loud.

Gifts come in very different wrappings.

Hmmm, maybe I'm on a roll... two posts in two days? am I sickening for something?

I'm absolutely delighted to see that this last post has had 170 views since yesterday morning, and it's only 11am now. Isn't that fantastic. But who's reading it? I'm intrigued to know what the most important/ influential/ inspiring aspects are for you.

In the past, this blog has helped fellow UK and global midwives/students gain insight into Nepal's state of midwifery, and I've received emails requesting specific information, or just in support of networking. Almost all of those midwives have followed our contact up with a trip out to Nepal.

I've also had a few western families who are living out there and are looking for midwives to attend them during their births. This is tricky as I know of NO independently practicing midwives in the Kathmandu valley. What I suggest to these families, is that I forward their details to the wonderful nurse-midwives at APS. Rashmi and her colleagues are, time permitting, generally happy to discuss options for place of birth, and are familiar with our preferences. Water birth in Kathmandu is no easy task, but it HAS been done!

If YOU are catching babies in Nepal, and especially if you can help other western families out, please do get in touch. If you are passionate about respectful maternity care, and women's issues in general, consider getting in touch with White Ribbon Alliance Nepal. If you have a story to share about your birth experience in Nepal, what made it good/traumatic, I'd really like to hear about it.

Lad born into family of carvers at Baktapur. There are carvers,
artists painting 'Thanka', and potters. All in Baktapur belong to
one of these crafts. An amazing place to visit.

Boudhanath

View from bridge at Kalanki crossroads. This is the dirtiest, stinkiest, noisiest, most nepaliest place
 in the Kathmandu valley. And I LOVE it!

Village mass-production in a Baktapur street. There are potters and basic wheels in the back streets. These pots are laid out to dry before being fired in a massive outside kiln of wood and straw.

New baby for Keshab and Rashmi.

Near Nagarkot

Classic example of need for dignity and respect. It isn't uncommon to have a obstetric consultation with others waiting in the same room. Women and their pregnancies become public property and they leave all possibility of dignity behind at home.

One of the oldest buildings in Nepal. Few have survived onslaught of earthquakes. This is in Baktapur, and it's beautiful.

Nurses, and students, and UK student Sophie in the
 postnatal ward at TU hospital.

At Boudhanath. White lady. White hair. I wonder who's sightseeing who!

Can I just start here? I have to start somewhere, after all. 

I’ve asked myself why start at all? Why not just uncork a bottle, put on some music, fill up the bath, and read the autumn issue of ’Country Living’? Well, it’s because I’m on that mission still (yeah, the fire hasn’t upped and left me yet). I thought, fourth trip down, I must have seen what there is to see, felt all there is to feel, succeeded in some places and inevitably failed in others. I returned this time with so much more understanding, but I also felt tiredness, a fatigue, and a desire to change my direction. As with the first trip, it’s taken me some time to compartmentalize these thoughts. I’m kind of reaching a conclusion, and as is stated in that wonderful film, ‘if it’s not alright, it’s not the end’.

So, November already! And I’m thinking again about fundraising. I need to get painting those advent candles, and get them out there by December (they’re a fiver each. Please get in touch!). But in order to ask for money, I need to explain how I want to spend it.

An original plan was to organize a project large enough to celebrate fifty whole years on this planet, by way of giving back somehow. I’d hoped that particular plan might have become clear in my mind, over time, as things do.

 There was also the faintest hope that Ewan McGregor had fallen in love with Nepal after filming the ‘vaccine run’, and would want to spend time with me saving its beautiful mothers and babies. Seems he had some fish to catch somewhere in the middle of Arabia (A likely story!!).

Truth is, there’s no definite plan yet. The only ‘definite’ is that I’m travelling back to Nepal again in March, 2014. My wider picture is, of course, to help save mothers and babies. That’s not changed. I have a fellow midwife traveller, Sarah, who intends to join me, and we’re working on how best to spend our time and efforts. It may be we’ll ‘make over’ and provide training for a particular rural birth centre. We also need to look at the possibilities of working with an NGO already out there, to provide training and support towards a specific project. The possibilities are endless. The difficulty lies in finding the most effective and efficient way to make a difference, and the more I understand about the challenges in Nepal, the more I realize there is to learn.

A bit of catching up for you...

·         Return trip. March 2013

...with Global Midwifery Twinning Project, organised by Royal College of Midwives and funded by THET. Flight = Jet Airways rather that Qatar. Delhi rather than Doha. Not quite such plush standards, but very adequate. Nice to get to Delhi with just short second flight to Kathmandu. Hotel = Hotel Clarion, Jawalakhel/ Patan area of KTM. We didn’t want for anything (within sensible range), midway between Thapatali birth centre and Patan Hospital, and office of Midwifery Society of Nepal (MIDSON). 

Twinning Project Workshop = really educational and reassuring to see how hard MIDSON had worked. Well done guys!  I understood the challenges of getting a midwifery programme up and running far greater by the end of the few days. I’d never before spent time contemplating the social, cultural, political, and therefore financial factors in play with starting a midwifery programme from absolute scratch, AND against the grain of some nursing colleagues (because don’t you just need a nurse to safely deliver a baby? Nope. You need a whole lot more than just that).

Placement = Tribhuvan Univerity Teaching Hospital. As its name suggests, it is a teaching hospital. This is where my direction shifted again, slightly (read on...).

Achievements = 
Curtains in labour ward (thank you and well done, Sangita and Uma).

Women off their backs during routine fetal monitoring. Yay!  A ‘trial’ of an active labour area in the delivery room (Thank YOU again, Sangita). Eager discussions with doctors regarding use of guidelines, partograms, midwives, and evidence based care in the labour rooms. Being warmly welcomed as part of the team. Several new Facebook friends. =Need for involvement/ information sharing with other NGOs. Areas for action = Teamwork; doctors in the hospitals need to be supportive and encouraging towards midwifery. MIDSON; needs to increase membership and the services it offers, student membership should  be considered, along with offering a database of reading matter for evidence based care. Encouragement for Respectful maternity Care. Guidelines outlining ‘normality’, and what action to take when needed, so that the entire team is working to the same guideline. Change of use for the spanking new ‘birth centre’ at TU hospital, from postnatal care to .....normal birth. You can do it, friends. Keep the pressure on. Present the irrefutable facts, make up the new guidelines.

Making it happen. July 2013 
I attended a short intense study session held Liverpool School of Tropical Medicine. Developed by LSTM, with RCOG and WHO. Funded by DfID to help reduce MDGs 4 and 5 (maternal and child health). The project sends teams of facilitators (obstetricians, anaesthetists and midwives) to teach life saving skills in obstetric and newborn care to over nine different countries in Africa and Asia. They take teaching equipment, and train the trainers so that those particular areas can eventually sustain a good level of training with minimal external support.

 They are already entering phase two of the project, by pulling out of some areas and introducing new countries (Nepal is to be included in this next phase).

This short study course was amazing. It was so well organized. I am committed to returning independently to Nepal in March, but going out with these guys for periods of up to two weeks somewhere like Sierra Leone really appeals. I have a bit of work to do with my teaching skills, but as the team will include a mixed bag of skills, I think it’s just a matter of ‘biting the bullet’. I need to take the plunge within the year, or I’ll have to sit the study sessions again.

·       








    
        

   International Midwifery Group, Oxford University Hospitals.

I wanted to highlight the International Confederation of Midwives 'International Day of the Midwife' (May 5^th, 2013) within my trust, and have an excuse to share experiences and enthusiasm for global midwifery.

We met up for an evening of talks on Uganda, Ethiopia, Haiti, and Nepal. Unfortunately we ran out of time to show the ‘Freedom for Birth’ DVD, which highlights the dreadful plight of midwives, and therefore women, in many countries. A few of us commit to meeting up on a regular basis, within the hospital or over food at the local pub. It’s great to hear what each of us has been up to, or read up on relevant articles, learn of funded courses, and put pressure on our trust to support volunteering in developing countries. The latter needs working on (thanks to Tess for her support and recent plea to management).

Return trip. September 2013.

This trip was funded independently and, as with all the rest of the trips, it gobbled up all of my NHS annual leave. I went out there with Amanda, a colleague from Oxford.  We were happy to find it coincided with the first ever Nepal Midwifery Conference. MIDSON worked so so hard to pull this off, and it was a brilliant success. 

They’d arranged great speakers, there was a packed hall each day, and beautiful venue and food (Shanker Hotel, Lazimpat).

We stayed at this hotel for the first few days. It was average expense by UK standards, but extremely plush by Nepali standards. 

  The rest of our stay was spent in a more run-of-the-Nepali-mill guest house. Dogs barking, beggar bells and chanting, unpredictable light, now familiar less-than-goose-feather beds keeping us bleary eyed. We politely moaned and giggled our way through the duration. 

My networking very much paid off during this trip. I was able to get a UK obstetrician to the midwifery conference to talk about her fistula work.

There were two US/Canadian midwife volunteers out there at the same time that I’d had previous contact with. Lesley, a new friend here in UK was out there at the same time conducting research on women’s reasons for accessing (or not) medical establishments for birth.

Half way into our outward flight, we were befriended by a colonel from the British Embassy, responsible for Gurkha welfare. This led to a meeting with the Gurkha camp SSAFA nurse. The few births they have happen at the local Patan Hospital, but it was good to exchange ideas of expats birthing in the APS centre, Kalanki, with Rashmi.

We managed to arrange a small amount of teaching in other areas. Students in Nepal are always so eager to learn and listen. It’s an absolute pleasure to be sharing ideas and skills with them.

We visited the delightful health post outside the valley, in Pharping. Kamala has student SBAs and local family planning workers with her in this centre. Unfortunately we didn’t get to spend the time I’d hoped for in Tribhuvan University Teaching Hospital, but we managed to meet up and hand over some valuable research papers and UK examples of guidelines, both for the nurse midwives and obstetricians. APS birth centre is much like it always was, with extra volunteer support nowadays. The numbers of births haven’t significantly increased, which is a shame, and it’s hard to pinpoint the reason for this.

Overall, I have to say this trip was disappointing. There are elections being worked towards this month, and it’s been so long since there has been any one party in power (and many many political parties). I suspect focus has been unconsciously directed towards this. Money and power have an unhealthy hold over countries worldwide, and Nepal is no exception.  

My biggest disappointment was not seeing a greater presence of White Ribbon Alliance (International organization for safe motherhood and respectful care in childbirth campaigners) at the Midwifery Conference, and in the workplace in general. I think it should be a ‘household’ name in Nepal, such is the situation inside and outside of hospitals there.

So, in a nutshell...

Where I’m at right now.

Trip 1. Got an overview of the situation in Nepal. 80% births outside of medical establishments. Terrain, poverty, education, health, maternal and neonatal death all intricately interwoven.

Trip 2. Supported  MIDSON to teach MIDWIFERY. The students needed to learn skills that are transferable to the rural setting (as this is where woman and babies are dying), and not at all the medical model of care they’re taught in the teaching hospitals.

Trip 3. Understood that within the teaching hospitals, it’s the obstetricians that are denying nurse-midwives the skills and practice of real midwifery. 45-95% C/S rate in some of the private hospitals!

Trip 4. I’ve fully realized what makes the country ‘tick’. Sadly, I felt midwifery wasn’t truly on the agenda this time, despite the brilliant conference. MIDSON, keep up the FANTASTIC work. You have understanding, greater than my own, to work around the powers that be. Midwifery isn’t an option in Nepal, it’s a NECESSITY, and the only way to reduce maternal and neonatal mortality further.

Full circle then,

...a hard lesson, but fuller all the same. I’d definitely bitten off more than I can chew. I’m not a political party, and money has never floated my boat. So, how do I change things? I have a voice, and a passion, but I’m just one midwife.

All enchantment has now been stripped! I’m no longer under any romantic illusion.  The desired goal for bettering women’s health in Nepal is still a long way off (but never the less improving). For a time, I lost my focus, and the ‘elephant’ got too big. For this next trip, I need to keep it SMART (Specific. Measureable. Attainable. Relevant. Time-bound.). Measurable and attainable will be the two areas to concentrate my next project on.

During my first trip, I held one woman’s hand. I told myself that if I did nothing else during that trip, I’d changed one woman’s experience of birth for the better. She’ll remember that, possibly until her last breath.

If I hold just one woman’s hand during this next trip, and that woman tells her friends, and the attending nurse-midwives also start to hold hands, and the obstetricians see the positive hormonal effect by empowerment of all those women, who knows where it will end?

Just this evening, I saw a posting. It went something like this...

Sometimes the smallest step in the right direction ends up being the biggest step of your life. Tip toe if you must, but take the step.

Staying at APS Birth Centre, Kalanki.

The Birth Centre I stayed at during my first trip to Nepal is becoming a hub of activity, and I am again asked to share my experiences of staying there. So, I thought I'd write a comprehensive report on the practicalities of a westerner 'bed and breakfasting', the available hands on/off clinical opportunities, and the potential available at our fingertips to make this center a gold-top standard and opportunity for nurses (doctors, even) to learn about real midwifery.

 The APS (basically translating as ‘birth centre’) centre is in Kalanki, a slum area west of centre in the Kathmandu valley, Nepal. It is an urban health post. There is a pharmacy which is the busiest part of the premises. Occasionally there are 'practice nurse' tasks like minor suturing. There is a family planning service, infant vaccination, ultrasound clinic, GP clinic, etc. People just drop in. I found it difficult to get a real feeling of routine to the place. 

There are a couple of lovely housekeepers who keep the place spotless. Rashmi Rajopadhyaya, nurse-midwife and most wonderful and generous lady, pops in most evenings after a full day as faculty leader at Patan Hospital. There are a core staff number of two or three nurse-midwives, and visiting students. At present there are more bills than there is money coming in.

 It is the first 'Midwife led' birth centre in Nepal, in that there is no doctor at the site. There used to be a couple of nurses staying overnight with a housekeeper in readiness for births. This may have changed in recent months. More senior nurses, including Rashmi, make themselves available at the end of the phone, should assistance be required. 

Transfer to the hospital is by means of private car or taxi. I suspect this puts many women off giving birth at the centre. There are currently, on average, two births a week.

 The centre has a very healthy and holistic approach to normal birth; more so than I have seen anywhere in Nepal.

It is thought that, if women aren’t to deliver in their own homes, they prefer to be close to a theatre and obstetric care. They have little understanding of the concept of ‘midwife’ and nurturing of the ‘normal’ birth process. For women to have the option of birthing at the centre, they are encouraged to have at least four antenatal checks. There must be no known complications in the woman’s medical or obstetric history. There may well be guidelines on admission criteria. 

There are three beds on the ground level, the first being in the treatment room. Two others are in a ‘recovery’ room, adjacent to two squat toilets, the office, and a small laboratory room. The first floor sees seven more beds, two in the labour/delivery room, one in a ‘procedures’ room, another in a consulting/ store room, and the other three in a larger dormitory-like room which has the upstairs squat toilet and basin. The kitchen and autoclave is next to this room. 

 

There is an incinerator burner on the roof top, and a covered space for washing laundry.

The first floor consulting/ store room is the most suitable room to make your own. The kitchen is opposite, and the toilet is nearby. The room is of adequate size, and ample bedding is provided for a comfy night. There is a mosquito net for the window, but I've not found bugs to be a problem. The Birth centre is on the main ring road around the Kathmandu valley and can be quite noisy at night. Nepali people love hooters and horns. There are also packs of dogs that can be heard settling disputes in the early hours.

If you choose to cook for yourself, cooking is by basic gas stove. Electricity is on load share time, and will be down for six or so hours in every 24 hour period. A head torch is priceless, although there is a generator downstairs for the main lights. There are friendly grocery stores a few doors from the centre, and a cafe/ kitchen which is very happy to cook up a ‘safe’ tasty meal for you.

In the dry season, there is no running water. Visitors are advised to use water brought to you in containers. This, however, is not drinking water. A bucket and jug is provided for your personal washing use. If you’d like to use heated water, you’ll need to use the kitchen facilities. There is adequate space on the roof top for washing clothes. It may be that, for an agreed fee, the house keeper is prepared to do your washing...

The centre is easy to access as it’s on the ring road. The next-door coffee house has local, and friendly, taxi drivers and most of the day they are ready and able to take you places. 

Although a hotel room is more peaceful and comfortable, I cherished the time I spent here. I was close by, should there be any action (be prepared for none!). I had eager and humorous exchanges of Nepali language with the nurses. They were also good company at the end of a day spent in the main hospitals. I got to understand the management and finances of a small practice, and the real hardships it brings to keep an urban centre like this available to the local people. In my heart, this place remains my home.

Be prepared to pay a sum of money for your stay. Try to help out with training, sorting of donated equipment, hands (off) support, and sharing of ideas to make this place a thriving and happy birth centre. Any library resources are useful.

My thoughts for the centre...

1    1.  ‘coffee morning’ or ‘woman and family’ sessions for family planning/ antenatal care/ birth education/ postnatal care/ breastfeeding support/ infant vaccinations etc. Tea, juice and fruit should be made available for the attending families (families? Women? Rate of abuse is high, keep it as woman-only space, or educate and gain trust of the men, too?). To be held two or three sessions a week, and the nurse-midwives to provide the clinical care as necessary. Students can provide education on a variety of issues including nutrition, spacing of pregnancies, contraception etc....

...In the hope that women gain a sense of belonging to the centre, call it their own, and are more relaxed and trusting of birthing there.

2     2.  Making of the first floor consulting/store room as guest room for volunteer workers. Thicker mattress and appropriate bedding, room decorated, made for purpose window screen, wardrobe, pretty wash stand, bowl and jug, desk for writing.  Head torch, universal plug...

...as a source of income and sharing of skills.

3     3.  Making of the first floor consulting/ store room as ‘western’ birthing room. Bed, ball, mats, soft lights and decoration, birthing stool, in situ resuscitaire, (is birthing pool a step too far..?). Overnight stay to establish breast feeding? Most importantly, a closed door!

.... a place for the ever increasing amount of western women to give birth safely and with privacy. A source of income. A valuable source of hands-on learning for the visiting students to experience natural birth and midwifery skills.

4    4. Financing a basic but reliable vehicle to act as ambulance in event of emergency. Basic life saving equipment inside, and a local taxi driver to agree a fee for transfer.

... wonderful selling point. Women want to know they can access emergency care promptly and without stress.

5. A complete make-over of the place. Decoration, curtains, plumbing, electricity, beds, birthing areas, etc. Permanent ‘mother’ for the place, a manager, a housekeeper, a retired Rashmi....and if we’re going to go this far?? How about a brand new centre? That is owned outright, and not rented for quite a lot of money? OK, this is a big ask. But do-able with a little coordination.

... the whole idea of a midwife led unit in Nepal is absolutely awesome. They need and deserve woman-centred care. The nurses need and deserve a gold top standard in which to learn from. I believe this centre has the potential, under Rashmi’s skilled and intuitive guidance, to provide this gold standard.

How to...knit a simple baby hat.. for charity!

Knit For Your Charity

Knit these VERY simple little brand new baby hats for your friends or for a charity (Special Care Baby Unit, Breast feeding Cafe, NHS antenatal education, teenage pregnancy groups).You may find someone is going overseas?  Or I can send them to Nepal. I'll happily take the hats or the donations. Just mail me.

   Enjoy.

Simple newborn baby hat.

I’ve used typical baby double knitting wool. One ball will make quite a few hats. For this wool, I used 3 and 3/4mm needles. You’ll also need a darning needle to sew the sides together at the end.

The idea of these hats is that they can go straight onto a cold baby straight after birth. They need to be tiny. If they are REALLY too tiny (and the eventual size will depend on the wool, the needles and your knitting style) they’ll still be welcomed for premature babies.

Cast on 40 stitches (st). Knit 6 rows. Starting stocking stitch (st st = knit one row, purl one row), continue for another 12 or so rows.

Starting the next knit row, decrease every 8^th st. Continue 3 rows st st.

Starting the next knit row, decrease every 7^th st. Continue 3 rows st st.

Starting the next knit row, decrease every 6^th st. Continue 3 rows st st.

Starting the next knit row, decrease every 5^th st. Purl one row.

Starting the next knit row, decrease every 4^th st. Purl one row.

Starting the next knit row, decrease every 3^rd st. Purl one row.

Starting the next knit row, decrease every other st. Purl one row.

You’ll be left with a very few stitches. We’ll not split hairs over the exact amount. You can either cast off at this point, or continue to decrease then cast off which will leave a little ‘pixie’ tail for a bobble. Have fun improvising with colours, stripes, blobs, different stitches and finishes. The hat then just needs to be sewn up the two sides.