Now were getting somewhere...

As always, for me, it’s best to let experiences settle in my mind before trying to put them into words. Today is the perfect day to make a start at sharing the events of April, and it’s been wonderful reminiscing over the photographs. They transport me straight back to the smells, tastes, hugs, and all the other ingredients that make up my world while I’m in Nepal. I feel so overdue a visit, I could jump on a plane tonight!

I’ve given myself a break from travelling during this autumn. Had Liverpool School of Tropical Medicine not come to the end of funding for their ‘Making it Happen’ programme, I’d have happily packed my case and helped with their overseas training. But the effort I’d need to find a similar project to support, I put elsewhere...into a project of my own.

I’ve been working on getting my independent business, Birthjourneys Midwifery, up and running again. Postnatal debriefing and birth planning after previous trauma are areas I don’t think are covered with enough depth in our National Health Service (NHS). Information makes for empowered women, which in turn makes for better births. This is true wherever women live in the world.

My immediate intention is to lessen the time I spend working for the NHS, and increase my satisfaction of being ‘with woman’ by using the whole bag of skills that I have. I hope to have more flexibility and time to train overseas, too. My trust does not give me time out to support developing countries.

Take a look at the website, and feel free to pass the contact details on.

http://birthjourneysmidwifery.com/

As well as this work, I was pleased to be approached to join two longer term NGO projects overseas, but both were for at least three months duration. I had too many commitments here and wasn’t in a position to go, but it felt good to be asked. Another time, maybe...

So, it feels like a lot has happened since my return from Nepal in April. It was a brilliant trip, and Sarah, Stevie and I came back brimming with excitement about our achievements and how we might take them further.

We almost didn’t get out there. My original plan to take four of us out to the more remote areas to provide midwifery and emergency training to larger groups of nurses had to be re-thought. With the fuel crisis that Nepal was suffering very much still in evidence, we couldn’t expect the nurses to afford  black market prices for transport, AND come away from their workplaces for the two or three days we intended for training. 

However, just as I was considering targeting a potential birth centre at Kirtipur and closer to Kathmandu, Dr Peru Pradhan, an obstetrician at that same centre, was also asking her colleagues and managers for fresh input.

It was all systems go from this point. Studies, plans, purchase of equipment, flight tickets, long distance communication, and accommodation were all sorted with little time to spare.

Kirtipur Birth Centre and 3day training programme.

Kirtipur Hospital had already built a birth centre. When I visited several years ago, they were seeking advice about equipment, amount of beds, staffing, admission criteria etc. Sadly funding and staffing have been an issue, and then there was the small matter of an earthquake bringing absolute devastation to the country. The unofficial fuel embargo from India in response to Nepal’s government actions didn’t help either.  Long story shortened, it meant that another area of the hospital had been prepared for the birth centre.

Our hopes were to deliver training in the first week, and the second week we would provide practical training for staff alongside birthing women. But the centre wasn’t ready, and we are still waiting for it, but we DID manage some training of nurse-midwives who intend to work there, or in a similar low risk birthing environment.

‘Promoting normal/physiological birth with respectful and compassionate care’.

Three groups of 8 or more participants, rotating around three work stations, over the three days, meant we could cover many topics. I, Sarah and Stevie provided the training, supported by two lovely Spanish midwives, Miguel and Marta, who were visiting Nepal at the time. With a good participant skill mix, we managed to get the group sharing dynamics perfect.

We...

...Knitted.  Learnt. Listened. Taught. Discussed.

Chatted. Laughed. Reflected. Acted. Knitted. Ate. Shared. Researched.... Brainstormed...Hugged......... Knitted.

And these were the topics we covered....

Admission criteria, uptake of eligible women, respectful and compassionate care, slow progress, staying mobile in labour, hydration and bladder care, partograph, perineal care and third stage, early breastfeeding and skin to skin, breech, eclamptic fit, shoulder dystocia, postpartum haemorrhage, neonatal resus, antepartum haemorrhage, meconium, identifying small babies, documentation, teamwork and transfer, audit and records, debriefing and info sharing. Updating and moving forward, keeping our skills, managing criticism and challenging bad behaviour.

The common theme over all the workshops and three days was respectful, evidence based care. The workshops were open to obstetricians as well as nurses but, apart from the lovely Dr Peru who is central to the setting up of the Kirtipur Birth Centre, there were none. What a disappointment.

While the nurses listened and shared, they also knitted. Over lunch we knitted with them. It’s thought (and there’s research to prove it, indeed!) our listening skills are honed while our hands are busy with simple crafts. Ancient midwifery skills probably included the art of knitting, too. (One can quietly take in events of the birthing room, and will be less likely to interfere with normal progress). On a spiritual note, the connection, love, and support for birthing women that was shared during the training, is now knitted into every stitch of a beautiful patchwork blanket. We plan to sell the blanket to provide funds for the birth centre. Any takers??? Please message me below (you may need to be ‘anonymous’ to leave a comment, but you can send an email)

As our training came to a close, we put on a performance of ‘Bimala’s Story’...of two very different attitudes and practices in two labour rooms. This true and recent birth story brought lively and emotional discussion. Some could relate to the birthing woman, others bravely admitted they had witnessed or been part of the uncaring attitudes or practices from the healthcare staff.

(For the full written edition from Bimala, of her account in a hospital labour ward and then when she transferred herself to the small community APS Birth centre in Kalanki, please go to recent post, 'Bimala's Story'.

The nurses went home from the training course with their folders, certificates, and hopefully a bit more confidence to challenge unsafe and uncaring practices, and more confidence in their own ability to support normal birth.

Progress with midwifery.

We joined a health camp in the village of Phinkot....so many pills. But the care was provided free by Midwifery Society of Nepal (MIDSON) and Direct Relief, an NGO, and it meant that women and children, who might not otherwise seek health advice, were able to leave their homes and workplaces to get checked out. 

During the consultations they received nutrition or contraceptive advice. It was really good to see the teenage girls...the next generation of mothers...having time spent on them. 

It was even better to see Laxmi Tamang (MIDSON) teaching the benefits of normal, upright birth. The main reason for the camp was to screen for cervical cancer. Colposcopy was offered the same day if samples tested positive.

With the births witnessed, I was SO PLEASED not to see routine episiotomies. I still, sadly, saw women lying on their backs to push babies out, and there was little evidence of skin to skin care. But generally, I felt a change in attitude from the care givers. They wanted to do their best and provide good care. As always, and in this country too, there is fear of comeback for NOT doing some procedures.

Nepali nurses are trained for speed. Their labour wards are incredibly busy. They also do much of their learning of surgical procedures on models. This doesn’t naturally teach compassion during placental removal or perineal suturing. I’m hoping that midwifery teaching will teach this. It is needed.

We managed to take lots of equipment out this time, including sonicaids and TENS machines (a first). It was distributed between the centres that we have come to support regularly (APS, TUTH, Kirtupur). In fact, all of our cases were crammed full with equipment, wool, journals... every square inch and ounce. Thank you so much for all you wonderful people who donated and enabled us to take this equipment out.

APS Birth Centre, Kalanki

Of course, I couldn’t go to Kathmandu and not visit my lovely second home. Sadly, the original building isn’t safe since the quake, and the staff are rattling around in a rather large alternative building along the road. It’s a splendid place, but probably too big. The ethos, and care the staff give there, is second to none, as explained so well by Bimala.

Meeting to support midwifery curriculum

We met Pramila Dewan, nursing campus chief of the Bir Hospital. A curriculum had been prepared for submission to the nursing council. Three training hospitals are at similar stages of progress, and it feels like they are not communicating the shortcuts and pitfalls they could all be learning from. The curriculum we viewed was still quite nursing focused, and possibly not in line with International Confederation of Midwives criteria. I have yet to find out if it was accepted by the council, and if teaching has indeed commenced. However, lots of work has been achieved so far, and we’re so close now to having midwifery training.....it HAS to happen.

(In recent communication with Pramila, the curriculum has been accepted, and there has been increased contact between the three universities preparing for the midwifery training. The nursing Council is supporting the training, too. Result!!! Well done Pramila and co-workers. They hope to start the training very soon)

Mangla Devi Birthing Centre

We visited the Mangla Devi Birthing Centre at the Tribuvan University Teaching Hospital again, and were invited to review the admission and transfer criteria for the centre. Their figures for the past year are great....

24% transfer to labour ward. Only 14% intact perineum, but only 9% episiotomy too, and only 0.5% third degree tears. The only postpartum haemorrhage needing transfer was a cervical tear. A most worrying figure, though, and not at all reflective of care at the centre, was that only 42% of the babies born were girls!!

A ‘strengthening’meeting, to review and increase support for the centre, was arranged with us. It was decided that women’s low choice for using the birth centre impacted on low figures, as did the lack of staffing ability to have the centre open through the night. The deputy director of TUTH was present and promised to review the necessary changes. Having the Birth Centre nurse-midwives also providing care in antenatal clinic might increase uptake by the women. Sadly, there were no doctors present at the meeting. The head of the obstetric department was called away at the beginning of the meeting, and no others from the obstetrics team could join us. This is a common and unhelpful theme throughout Kathmandu hospitals. I wonder why doctors don’t see themselves as part of this push towards midwifery care and normality in childbirth.

Doctors, midwifery care decreases maternal and neonatal mortality. Your support is crucial. As midwives must use best evidence to provide care, so must you. Not to do so could be viewed as breaking your Hippocratic Oath to ‘do no harm’.

And for the tourists and Kathmandu lovers....

A few snippets to tease the mind, body, and soul....

All the cracks in the buildings! How heartbreaking. I stood on the top of Swayambhu temple, overlooking the Kathmandu valley, and imagined how it would be to feel the whole of the earth rumbling below me.

The Boudhanath bells were closed for business, and scaffolding adorned the central all-seeing eyes. 

There were long, long queues for petrol. Gas bottles were left unattended in rows, waiting for the next filling day. 

Burns units were filled with families fallen after improvising with cooking fuels.

One delightful evening was spent with Rashmi Rajopadhyaya (Midwife through and through!) and her family. Since the earthquake, she has been cooking on the ground floor. Her house, joining four others, is patiently waiting for building work to replace the huge cracks in the joining walls. While her house stands, she says, there is no hurry. Other houses around Patan Durbar Square are minimally supported by planks of wood trussed between tiny red brick houses in the tiny streets.

For this trip, as there were the three of us, Sarah managed to book a lovely AirB&B apartment in Bhainsipati. It was, admittedly, a twenty minute walk to catch the ring road bus each morning, but we were within a most enchanting community mixture of larger houses and tiny smallholdings. On our way home, we could buy fresh vegetables to cook with. Finding tonic, and worse still lemons, for our gin was a bit of an issue, and we gave up completely on the ice.  

Our apartment was comfy, and run by the most wonderful couple. Hot water, lights that need to be switched off when already off, washing machine, kitchen, and flushing toilet were all things that improved with understanding. For three grown women (and midwives at that!), Sarah, Stevie and I got on amazingly well. In fact, I think I could go anywhere in the world with those two wonderful women (I love you both).

      My moans of delight on finding hot water spewing from the shower were totally equalled by their shrieks of joy at finding enough electricity for the Archers on Radio 2.

One lucky morning, we were blessed with the cries of a dying goat to accompany our breakfast banter. We watched with fascination (and respect) as every morsel was washed and shared between the families. If one has to eat meat, THIS is the way to do it!

Taxis were expensive, and we only used them when we had to arrive very specifically for meeting etc. (thank you, kind person, for specifically donating towards keeping our transport options safe and manageable)

We saw the busy street life stop momentarily when a bright green snake chose to cross the road in front of us. A passer-by mumbled with obvious concern that was venomous. Maybe it was. It was wonderful to see it cross safely to the other side.

Stop Press!!! Earthquake felt on Patan roof top!  Yes, my first felt tremor. There were two rumbles, one straight after the other, and both too big for comfort. We were halfway down a cool beer after a productive day, overlooking the Durbar Square, contemplating Nepali life and wondering if we should eat, when the geraniums started shaking. Now, we were several flights of very tiny stairs up, on the top of a Kathmandu style ancient building, without light (electricity loadsharing time). It took a second or two to sink in, and by the time it did, all of the other rooftop guests were clambering for the stairs. It made sense to stay put.

What really shook me was the reflex response to the tremor. On the surface, Nepali folk are cool, and getting on with their day to day lives. Underneath, they are still desperately fearful. I, dare I admit, felt that my life wasn’t at an end. I was born in England, where there is little need to fear earthquakes. How could my luck run out while I was teaching in Nepal? But earthquakes don’t care where you were born, and they take no prisoners. These guys face further (to April 2015) quakes on a regular basis, and the aftershock is far more than just physical.

As Rashmi’s son, Sagan, said to us after, ‘welcome to Nepal’.

Places we ate?

Roadhouse Cafe.  Vesper Cafe (thanks for the intro, Tina). Both on the same street in Jhamsikhel, Kathmandu. And both gently Nepali.

New Orleans Cafe, now only in Thamel (the Jhamsikhel cafe...otherwise known to Sarah and I as 'Rat Cafe'. Don’t ask....recently fell in the quake). 

We spent a wonderful hour or two chatting with Samjhana Phuyal and Smiti Sharma about women’s rights in India and Nepal.

Garden of Dreams, and Kaiser Cafe(just north of Thamel), is another lovely semi western eating place, although it’s expensive for the service you receive.

We had a fantastic meal with some old friends at Jheegu Bhwoychhen, Thamel (thank you, Laxmi). This is a very welcoming traditional Nepali eating house. I’ll look forward to eating here again.

The three of us are beginning to check out dates and some longer term funding. We have a training package that works, is country specific, and we have wonderful contacts to be able to get the training directly where it can be put to use. If you would like to sponsor us, or know a programme that could use us, please drop a comment below.

Every time I’ve been to Nepal, I’ve had different experiences and outcomes. April’s trip was by far the most productive one for utilizing all that previous experience, seeing very real progress with attitudes towards midwifery, and returning with expectation that midwifery WILL actually happen, and soon.