'Making it Happen' in Bangladesh.

Just write for ten minutes, he said. ‘Set your alarm, and when it goes off, just finish your sentence and you’ll be started’. I haven’t actually set my alarm, but it was enough encouragement to enable me to make a start on this rather delayed update on my time in Bangladesh.

 I travelled with Alice, a UK midwife who has taught many times with Liverpool School of Tropical Medicine (LSTM). We went to Bagerhat in south Bangladesh, near the mangrove swamps, to facilitate two short courses in obstetric emergency care training in October 2014. It was my first trip with LSTM, and I loved every minute.

My first attempt at working with LSTM went delightfully pear shaped when my two sons found themselves in a cricket final at Lord’s. I had cold sweats with the dilemma of wanting to be in two places at the same time. How could I pull out from my commitment to LSTM for that initial trip to Nairobi? But how could I, after all the whites washes, tubs of ‘Vanish’, the re-used bags of frozen peas, not to mention the many miles of driving them for county matches during their early years, ever contemplate missing this once in a lifetime game? I couldn’t.

LSTM lost out this time. And so, as it happens, did my boys! They got thrashed.

Second time lucky, then. I was hoping Bangladesh would be a similar culture and climate to Nepal, which is now very familiar to me. The whole training package was going to present a fair challenge, so it was a comfort to know I’d not be out of my depth in other areas.

LSTM’s Centre for Maternal and Newborn Health run the successful ‘Making it Happen’ programme which helps developing countries work towards achieving their Millennium Development Goals (MGDs 4 and 5) for maternal and newborn health. UK obstetricians and midwives provide country specific training to health professionals in several Asian and Sub-Saharan African countries. The training of in-country master trainers means the project can move on to further areas. It is the largest DFID (Dept for International Development) funded project dedicated to maternal and newborn health, and it recently won a top award, the second year running, for its success and sustainability.

This link provides more information...

http://www.lstmliverpool.ac.uk/media/106772/mih%20general.pdf

I’d been accepted onto the course and had my pre-course training a while before, but was committed to first seeing through my project in Nepal. At last, it was great to be finally putting my learning and experience into practice. Expenses were paid this time. Yay! But my time needed to be taken during annual leave... again. My hospital trust does not fund any of my trips.

My biggest pre-trip headache by far, was whether to take anti-malarials or not. Travel advice websites all state it’s a low risk country, for most parts. Hmm, well what EXACTLY is low risk? The drugs are costly and have side effects...but then, so does malaria. Fellow travellers were split in their recommendations, but most thought I was mad not to take the meds. So, bowing to peer pressure, I took them. All was well, no side effects. I also included in my kit bag a new impregnated net and enough nasty liquid to kill anything that dared think of crawling over me. I’m relieved, and slightly deflated, to say I remained absolutely bite free.

At the airport I changed enough US dollars to Bangla taka to pay my way in the sticks. I also bought a ‘Bangorlink’ sim card (passport and photo at the ready) with adequate phone time and internet to stave off the anticipated isolation. A very comfy United Nations approved hotel had already been arranged for us in Dhaka. In fact, everything had been arranged to the last detail. I felt incredibly safe and spoilt. Dhaka was warm, and more civilized than I expected. It was newer, too. On the journey from the airport to our hotel, I saw no slums. I saw little beauty, either, and no real treasures like the exquisite little ancient shrines found at every corner in Kathmandu.

The journey really started for me and Alice once we boarded the pokey little flight to Bagerhat. It was followed by a night-time bus journey with our fellow facilitators, two of whom really didn’t take well to the humid, bumpy, and rather swervy ride. They assured us it was travel sickness rather than catching. Thankfully, Alice and I are quite obviously made with sterner stomachs, much to our companions’ surprise. We both stayed well through the entire trip.

The view I woke up to.

The training centre we found ourselves in the next morning was safe, clean and friendly. We had fantastic fresh food, even if it was served up with eyes and fins (At times like this, I’m glad I’m vegetarian).  Load sharing of electricity was an issue, but better managed than anywhere I’d previously been in Nepal. Roads were better, too. Even in the sticks, they were tarmac and wide enough for some pretty fast vehicles. This made travelling a tad exciting at times but, hey, weren’t we there for the excitement? Absolute poverty was not as evident in the few areas I saw, either.  Maybe I didn’t see enough to get a true picture, but my general feeling was that Bangladesh had more money at its disposal than Nepal was currently seeing.

The course was run well, and organisation of time and duties were a priority. A course director, eight facilitators, time keepers, and the wonderful man and answer to all our problems, Tamim, all stayed within the complex for the two courses. We met for breakfast and debriefed at the end of every day. Meal times were our social, and little time was left for anything else but prepping for the next day’s work and sleep.

Our days consisted of pre and post course assessments, lectures, and practical skills work stations. One or two facilitators were assigned to each station, and teams of eight participants rotated around the stations at the call of the 20/40 minute bell. The scenarios are learned almost word for word, and the teaching is based on World Health Organisation (WHO) and Practical Obstetric Multi Professional Training (PROMPT). It was obvious the participants were keen to learn and, I suspect, wanted to do their best in quite challenging workplace situations, but their understanding of even basic skills were, at best, patchy. I’d have loved to give more time to take things right back to basics, but this was impossible in the time allocated.

While facilitating, I was able to see obstetricians, gynaecologists, anaesthetists, paediatricians, nurses and nurse midwives all working together, and also the disciplined and didactic methods of teaching. I was surprised at the level of hierarchy (doctors over nurses, men over women, facilitators over participants), and although this is evident in Nepal, it is to a lesser extent. Now, I’m relatively old and grey and, at 5’4”, as tall as most Bengali men but, with excruciating regularity, I struggled to get my point across before being spoken over. Sarcasm is my down fall, and I worked hard to remind my tongue to remain respectful of their culture and ways. Just once, I actually raised my voice. We were all aware of the strutting cockerel and the lowly feathered fowl. I think we were all bewildered as to my place in the pecking order.

As much as I laugh at my frustration, in seriousness I believe this hierarchy is having a debilitating effect on Bangladesh’s nurse midwives. They are the front line workers both rurally and in the hospitals, but they don’t feel empowered to use the skills they have learned. The nurses generally had very limited up to date knowledge, skills, language or voice, and the doctors seemed comfortable with this. Bangladesh has made great efforts with its new midwifery profession and MGDs 4 and 5, but if it wants to make further progress, it needs to recognise and fully embrace the part midwives and women play in such issues.

So, the high points.....

Wonderful food. Getting to grips with ‘Making it Happen’ teaching. Meeting Alice and all the facilitators. Getting to know rural Bangladesh, and a smidge of its language. Having my adventures so wonderfully organised by Keri and LSTM. My family supporting itself in my increasingly frequent absence. No midwife eating spiders in the toilet (yeah, a few geckos and locusts, and quite a few mozzies, but no spiders). And all importantly, using my skills to advance the health of mothers and babies.

The low points ....go with the territory. It does me anything but harm to endure the physical challenges, and the small benefit my midwifery skills bring to such an enormous worldwide issue, helps me through the emotional journey. If my time and passion send even the smallest ripple out to affect just one person, then it’s worth it, for doing nothing isn’t an option.