Blog written for PHASE Nepal.

Apologies, there is some repetition in this, and the paragraphs in brackets simply explain the midwifery situation in Nepal.

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....

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...

 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. 

Rita, Sujeeta and Kriti, three of the PHASE ANMs based in the area had very good understanding of our English which, given our incredibly limited Nepali, was vital for any training work. A translator would otherwise have been a necessary addition to our provisions. Due to numbers and relationship building for the new nurses, Sarah and I were given a little room close to the village eating house. We were woken every morning by the bus letting EVERYONE know it was leaving for the city. By the end of our stay, we did appreciate the importance of this community service.

  

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.