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.

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   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.