Sarah Ardizzone and I met in Nepal during a previous project with Royal
College of Midwives. We are UK midwives and were selected to promote midwifery
and support Nepal’s progress towards establishing the profession by competency,
qualification and regulation (Globally Recognised Standards for Midwifery,
International Confederation of Midwives). Nepal has a high maternal and neonatal
mortality rate, but is making great efforts to reach the set Millennium
Development Goals in both areas.
[Before I move head long into the joys and trials of our recent trip with PHASE into the Hills, I would like to just set the midwifery scene for all you PHASE followers...
Many women in Nepal give birth without the safety of a skilled
attendant. The reason for this is partly cultural, but much is due to the challenging
terrain of the hilly regions. PHASE Nepal works to support
some of the most remote communities. They employ auxiliary nurse-midwives
(ANMs) to live in those villages and provide as good as 24/7 care to the
people. The nurses’ skills are wide and varied, and might be more accurately
described as GP, and not simply nurse or midwife based. Through PHASE, GPs
visit the villages as volunteers to provide ANMs with skill sharing and updates
which are invaluable.
There has been recent midwifery training within Kathmandu for the ANMs. However, in view of the poor maternal and
neonatal mortality rates, PHASE is exploring the benefits of extending this support
to include more specific midwifery 'in-post' skill sharing. It is known that midwifery within
a country reduces mortality rates far greater than just skilled birth
attendants (SBA) alone (Lancet Series on Midwifery,
June 2014). SBAs provide valuable obstetric emergency care, but midwifery helps
to prevent those emergencies from occurring.]
Both Sarah and I are staunch supporters of the natural birth
process, and the impact of midwifery on the whole family, not just at a
difficult birth, but also through risk prevention, education, emotional
well-being, family spacing, etc. So, we negotiated our return to Nepal to pilot
a midwifery teaching programme with PHASE.
A few photos from
my album....
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 This is the view from our window during our initial placement at Hagam,
Sindhupalchok. Situated all of 2183m up, with a population of 4,000 stretched
over many miles, it was simply stunning. We stayed with Renuka and Suprina,
both PHASE ANMs. They looked after us well, and wouldn’t allow us to help
with cooking, prep, or water collection. The facilities were basic, as we
expected, but we were made comfortable. A wash bowl in the morning was really
appreciated, as our skills at the public water tap were really limited and
could well have left (too) much to be desired! An electricity pole (read ‘rotten
tree trunk’) collapsed during a storm, causing days of darkness, and our head
torches became even more precious. You don’t realize just how reassuring a
mobile phone is, either, until it dies on you. 
We joined Renu and Suprina for their regular community visits. Renu
took with her a register, and picture books to help with health education.
This woman was pregnant with her second child. She planned to give birth at
home. All was well, but her first baby arrived in a hurry. I wonder if our
nurse midwife arrived in time for this second birth, and how it all went...
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For nurses like Renu and Suprina, stuck in the
nether regions of nowhere, prevention and early recognition of complications is
paramount. They were encouraged to build on their understanding of how birth
should work, and how they can support the natural process.
Suprina administered drugs to this woman who arrived in clinic, supported to stand
by two men and hardly able to breathe for chronic COPD, caused in part by the continuous
presence of wood smoke in the house. This, and childhood complaints, seemed to
be the theme of the day. The few antenatal checks carried out in the clinics
allowed us discussion of how listening to women and giving verbal prompts to
gain information, can add to diagnosis and prevention, and then more
importantly to timely referral.
Some visits definitely had a social slant. The community were
wonderfully accommodating of our quirky English ways (I can’t say the same for
their dogs. On more than one occasion I was decidedly more quaky than quirky!).
Socializing and visibility are ways of building trust and connections through
the village.
We travelled on foot to an outpost for training with traditional
healers. The guys, and one woman, were paid travel money to attend, but they embraced
the opportunity to learn from Renu and Suprina. Still some locals would prefer
to consult a healer before seeking medical help. It’s important that things
like hygiene facilities, dangerous practices, and early warning signs for
prompt referral are discussed openly.
The second part of our journey, after
a brief couple of days to freshen up in Kathmandu, took us to Ryale which was
nowhere near as far or nerve wracking a trek as Hagam. We travelled with
several newly employed PHASE nurse-midwives, and a very big bag of training
gear.
Our training sessions were extensive
over the three-four days. Practical skills, theory, but also risk factors for
prompt referral and prevention were dealt with. We used the models and talked
through scenarios relating to birth emergencies within the Nepali home setting.
There would be no drip stands or emergency buzzers. There would be no doctors
prescribing a magnesium sulphate regime for fitting eclamptic women. There may
be just ONE pair of hands to deal with a serious haemorrhage. Hygiene
facilities, lighting, space, back up plans would all be limited in these homes.
As much as possible, we used the actual
equipment the nurses carry in their substantial kit bags for training purposes
too. We could identify, while going through scenarios, exactly what was surplus
to requirement, and what might be better kept together in the different
compartments, to ease finding equipment in a hurry. We ALL had fun working
through the eclampsia regime, and we resorted to ‘phoning a friend’ when the
dosage of magnesium sulphate couldn’t be worked out from the vials. We played
with making up a homemade condom tamponade for uterine haemorrhage. It got
messy (and slightly raucous)! In seriousness, this is exactly why regular
training and ongoing educational support is necessary for these nurses, indeed
for us all!
Overall, I felt our trip was incredibly
productive and worthwhile. Short blasts of training feel the right way to go
when these nurses are busy with community needs. Hanging around to support at
births is probably not the best use of time as, thankfully, real emergencies
are few and far between. Most births go smoothly, and the ANMs are called only
occasionally.
Sarah and I look forward to repeating
similar work early in 2015, and I hope PHASE will consider giving not only us
another opportunity to work with them, but encourage other UK midwives to offer
their knowledge and skills too. It was an honour to support those small communities,
and their fantastic ANMs who are out there, away from their families, putting
their hearts and souls into making a difference. Those girls are real life,
every day heroes.
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