Midwife in Nepal: Working with PHASE Nepal.

I usually have difficulty starting these updates, but this evening I feel it’s going to flow (read that as long and boring). It’s nothing to do with a particular evening beverage. Yes, my glass is mostly half full, but tonight it’s just sitting here for when the inspiration dries up. Of all things, it was the washing up, after a meal and the company of family, to Barbara Bonney’s beautiful rendition of Ave Maria that did it. You don’t have to translate the words to understand it. To me, it oozes. Every note drips with heart-felt thanks for the feminine. Sorry guys, but women really rock my world.

How does that take me back to Nepal? Well, it takes me back to the feeling of being present in such breath-taking beauty and grace, of the women and the place they live. It also takes me back to a particular flight home to my family and experiencing a high level of turbulence. I closed my eyes, turned up the volume, and thought of all the things I had to be grateful for, not least my three children. I thought, if I died, my life had been blessed and I could not ask for more. Of course, I wasn't in real danger (was I?), but find me a person who doesn't question the meaning of life at such times.

Enough said!

....And I joked this time about Sarah and I closing our eyes, and singing it at the top of our voices, while winding our way in a ram-shackled and filled-to-the-brim old bus, up the sides of those mountains towards the remote area we needed to be (No, Mum, best NOT look up ‘The world’s most dangerous roads’). I had this hope that our version of those normally dulcet tones would get us a fast-track ticket to heaven should the bus lose its grip. Either that or we’d miraculously find ourselves close to a barrel of the home brewed ‘roxy’.

March 2014, with PHASE Nepal

This trip was a 50^th birthday present to me!

Thanks to a valued old school friend, I had the idea of setting myself an even greater challenge. I certainly didn't want a party. My kids don’t need me so much (I can’t quite bring myself to write ‘at all’). I have a little time to play with (yup, only annual leave, but better than nothing). I still have the skills, confidence and passion for my work, and I now know much more about Nepal and its needs regarding maternity care. Only on reflection do I see the enormity of learning and understanding I've acquired in such a short time. There really wasn't a better time to get myself on that mission.

Quite coincidentally, I found the organization PHASE Nepal (http://phasenepal.org/) on Facebook the very same day Gerda Pohl, a GP working with PHASE, found my blog. So when I emailed her, we were already thinking along the same lines.

Just to recap after my last trip....

I returned so frustrated last September. There were just too many hold ups and obstacles in the way of getting midwifery into Nepal. No apologies for repeating myself, but we KNOW having midwives in a country brings down the maternal and neonatal mortality rates. Many more skilled birth attendants (SBAs) are being trained, thanks to funding from various government and non-government organizations, but this will only go so far towards reducing the number of deaths. In Nepal, government is dragging its feet with regards to bringing in Midwifery, and the nursing council is making it difficult on the grounds of Nepal not having a midwifery profession before, so why should it have one now! C’mon guys. Women and babies are DYING! And good money is being wasted.

I’m impatient. I want to see change. I want to see progress, even if it’s slow,... money spent in the right places,.... tasks achieved.... and dare I say performance related funding? I decided if I wasn't getting any joy at the door, I’d climb in through the window!

What peace and tranquility! Shall I spoil it and tell you
there were rather territorial and racist dogs on our trail?

PHASE stands for ‘Practical Help Achieving Self Empowerment’. By donations and volunteers and a small core of hard working individuals, it supports some of the most remote Nepal communities to take control of their own future.

Education, health, food security, discrimination, and livelihoods are the main areas focused on, depending on that community’s perceived need.

Teaching nutrition during
community visits. Hagam.

Local anaesthetic, AS WELL!

They employ auxiliary nurse-midwives (ANMs) to live in the villages and provide as good as 24/7 care to the people. Their skills are wide and varied, and more accurately described as GP, rather than nurse or midwife based. GPs visit the villages as volunteers to provide ANMs skills sharing and updates which, given what these nurses are faced with, is invaluable. However, in view of the poor maternal and neonatal mortality rates, PHASE is exploring the benefits of extending this to include midwifery skills.

Clinic at Hagam.

This woman was weak with COPD,
likely made worse by the acrid smoke
from inside fires.

Renuka teaching traditional healers,
Hagam.

Sarah Ardizzone and I met last March when we volunteered with Royal College of Midwives for the Global Midwifery Twinning Project. It was clear to me we had the same concerns and visions, so we planned to return and pilot a midwifery teaching programme with PHASE. Some midwifery work had been covered before, but it seemed much of it wasn't especially community based, and there was still limited understanding of the causes and prevention of emergencies. Waiting for obstetric emergencies to happen is like shutting the stable door after the horse has already bolted.

Renuka and Sabrina, both ANMs,
looked after us so well.

The trip was completely self-funded, although PHASE covered us with its group insurance. I'd like to say a huge THANK YOU to Lisa Fitzgibbon (http://www.lisafitzgibbon.com/about_biog.php) and the Power Folk Quartet (Jane Griffiths, Colin and Johnny Fletcher) for their wonderful evening entertainment, and the donations towards the raffle by a very generous audience. Thank you, too, to all those who helped in the sale of Christmas Advent Candles. It has proved to be a very enjoyable and productive way of raising funds. Sharon Meakin, you brought a couple of very expensive candles (You’re so kind). Liz (you know who you are) managed to get her hands on a miniature model doll and pelvis perfect for my backpack. I had more hats, midwifery books and journals and many more bits and pieces donated. I had personal donations of money, from which I bought bean bag covers, pinard stethoscopes and Huntleigh dopplers. My case was every bit the 30kilos, and there wasn't a square inch left empty.

Bimala feigns an eclamptic fit. It brought such laughter,
but also a serious side. Knowing available equipment,
and administration/route of medicines are vitally important.
Knowing there is no 'buzzer' to call for help is scary,
and these nurses want to feel prepared. Ryale.

Hmmm. I’ve written far too long a piece already, eh? And I've not even boarded the plane yet! But don't say I didn't warn you. I’ll follow this up with the report Sarah and I returned to PHASE, and I’ll fill in memorable snippets along with the photos.

Rita and Kriti attempting condom
tamponade (last resort for haemorrhage)
from the delivery kit. It wasn't successful!

Sujeeta performing and talking through
shoulder dystocia on dummy, at Ryale.

Laminated posters and prompts.
Useful when also dealing with
translation difficulty.

So, that circle I felt I was on? I'm very much back at the beginning. I get to where I aimed to be during my very first trip out to Nepal. (Forgive me for sounding a tad jaded). The story still is that women and babies are dying mostly in rural Nepal. Nurse-midwives are being trained in the Kathmandu valley hospitals. They are being taught a medical model of care, and at quite a basic level. They learn how to treat an eclamptic fit. That’s great, and it definitely saves lives. But they don’t understand which women are more likely to suffer eclampsia and therefore need more antenatal care, and they don’t always know when to refer to obstetric care.

The view from our window at Hagam Sindhupalchok ,
2183 m up, population of 4,000 over many miles,
and simply stunning.

Nurse-midwives in Nepal know how to cut and repair an episiotomy, but they don’t know how to prevent perineal trauma. They also learn how to identify delay in labour, but they are not taught how to prevent it. Prevention is the key word. It shouldn’t just be about emergency care. Don’t get me wrong. Every nurse-midwife, without exception, has wanted to learn, but the teaching of nurse-midwives in Nepal is not at the globally recognized standard for ‘midwife'. For those nurses stuck in the nether regions of nowhere, prevention and early recognition is paramount. They need an understanding of how birth should work, and how they can support the process. Midwifery education does that.

Here’s my message for government, obstetricians, and nursing council...

You NEED midwives. For now, you still needs skilled birth attendants, but they should be taught more midwifery based skills, because midwifery just isn’t going to happen in a day. There is still much work to do, and you all need to pull together. While those rural communities see little benefit from the time and energy and money being poured into Kathmandu, I’ll work at ground level (or should I say 2183m level?), supporting those small communities, and their fantastic ANMs who are out there, away from their families, putting their heart and soul into making a difference. Those girls are real life, every day heroes.