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After all, Nepal has STUDENT MIDWIVES (Wahoo!). Independent midwifery still has a very unpredictable future. NHS has ever decreasing resources. I have ever increasing age. My parents are older, too. My grandchildren are frustratingly yet to manifest.... and so it felt time to place a few eggs in another basket. Best thing to do was to chill out, smell the coffee, plant nasturtiums, and make undies during lazy sunny mornings and candlelit tucked up nights, so that I might have more flexibility for the things I love....One of them being midwifery.
(Hmm...maybe I’m beginning to reach full circle?)
I’ve been scrolling through a dusty notepad for scant scribblings, and spending time over the photos I uploaded and then ignored. The memories aren’t quite ‘flooding back’, but I am piecing together events from March, and themes that now have a repeated importance.
My goodness, the hardship and the pain of sitting here
trying to harness my menopausal mind, and my trying to make the best of a
negative poetic kinda flow! But I know it’s a small price to pay, considering
the difference our trips have made, and the generosity of friends and
acquaintances here in UK who have made these trips possible. So, onwards I
shall go...
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| The very necessary midwifery art of 'eating cake'. |
But that’s FAR too big a subject to start writing about.
So...
Kirtipur Hospital
We held a workshop for the nurse midwives and obstetricians,
and Dr Deepak Sunita, a caring paediatrician, joined us too. Dr Peru Pradhan did so well to
gather as many of the busy hospital team to join us. We felt there
should be shared consensus and decisions where this birth centre was concerned.
Doctors needed to trust the nurse midwives, and give them space to promote
normality. The nurse midwives needed to reassure the doctors they were fully
able to utilise their skills to keep things normal, but would recognise complications
in a timely manner. Communications between the teams, including paediatrics,
needed to be encouraged so that in the event of an emergency, transfer would be
smooth and everyone would feel comfortable with their own roles.
During the workshop, small groups considered how they would care and react in certain scenarios, decided when obstetric help was (and wasn’t) required and how they would make the transfers smooth. As a team, we then reviewed, discussed, and agreed changes to the Birth Centre admission criteria and guidelines. We also explored ways of encouraging women to birth in the new centre. Identifying a woman as ‘low risk’ in the antenatal period, and having midwives perform their antenatal checks, were just two suggestions.
Tribuvan University
Teaching Hospital
We couldn’t go to Kathmandu and not visit the wonderful
Mangla Devi Birth Centre at Tribuvan University Teaching Hospital. Again,
figures of last year’s normal birth and transfer rates are marvelous. From the
feedback survey, staff could tell us that women were very happy with the care
they received. We were delighted to hear that the Hospital’s caesarean rate had
fallen from 45% to 39%. I wonder if the presence of the Birth Centre had a
positive impact on care in the labour ward?
We met with birth centre staff. Members of the obstetric
team, Dr Mita Singh and Dr Gurung also joined us and we were thrilled to have
their company and hear their thoughts. Professor Kiran Bajracharya, president of MIDSON,
Joined us too. After hearing the report on last year’s figures, we reviewed the
birth centre admission criteria and guidelines. Several changes were suggested,
discussed, and agreed by all. It will be lovely to return this next March to
see how the changes are working out.
Sadly, when we visited in March, the centre was still not open at
night, and from the 4,500 births that took place in the hospital, only 5% occurred
in the birth centre. The reason for this was thought to be lack of uptake or
introduction in the antenatal period. Having the birth centre midwives
providing antenatal care for low risk women, and this being supported
wholeheartedly by the doctors, would increase births in the centre. With such
wonderful figures and happy women, how can they not bring this into being?
Again, like at Kirtipur, there were concerns raised
regarding appropriate and timely transfer of women. Having looked in detail at
some cases, the issue could simply be lessened with better communication. The
use of synthetic oxytocin to hasten labour was discussed. We strongly felt this
was not appropriate for a low risk birth centre (especially with no available
means of continuous fetal heart monitoring), and that if natural hormone and
mobilisation wasn’t getting baby budged, a transfer was the right decision.
Sadly, TUTH Mangla Devi birth centre doesn’t take midwifery
students. What better place in Kathmandu to see and respect the normal
process?? Normal birth, with midwifery support, happens rarely in Nepal. TUTH
are missing out on a HUGE opportunity here.
Model Hospital
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| Stevie's fantastic homemade dungarees. |
As much as we try to organise our time BEFORE the trip, there is easily as much ‘ad hock’, and this has to be anticipated so that we can best provide materials for learning. Several evenings were spent in our ‘@home’ guest house in Jhamsikhel (fantastic place, great breakfast, comfy beds, lovely hosts), preparing for our next day, while delving into whatever savoury nibbles we’d harvested from the local ex-pat mini supermarket, and enjoying the ‘winding down’ hastened by a not-so-chilled gin and tonic.
We even took time for a day out. We were tired and although we were ten times more tired after hiking for hours from Nagarkot, our spirits were lifted by the fresh air, amazing views and sense of freedom. How could we not feel a spiritual over flow, when we had a guide called 'Santa'.
And now for the
nitty gritty, the real purpose for our presence in Nepal...
...the delightful midwifery students!
Twelve students are studying with the National Academy of
Medical Science (NAMS). This is a three year course, started in November 2016,
and all students are already nurse midwives, SBAs or community nurses. The
placement area for clinical practice is the Paropakar Maternity and Women’s
Hospital, Thapathali.
Maiya and Durgesori are the NAMS midwifery teachers, and
Maya from UNFPA passionately and magnificently mentored them all. The students are
in two groups for clinical placement. Their teachers cannot oversee all
students, so there is much observation of each other’s practice.
On our first morning together, we were lucky to be invited
in to the labour ward to wait the end of the clinical session. While we waited
there was a birth. For the midwives among us, this is how things evolved....
“Para 3, first hospital birth, recumbent, delayed progress
in 2nd stage, hormone drip commenced, mum pushed baby out seconds
after spontaneous rupture of membranes and thick meconium, but nuchal cord present,
so clamped and cut before delivery of body, baby flat, taken to resus next
door.”
Feeling embarrassed for the mum, we requested the curtain
around the bed to be drawn, but the common practice of staff disrespecting any
drawn curtain was very clear.
We all had lunch and drinks in the cafe close to the hospital, and we asked the students and teachers for their thoughts of how the birth had gone. We asked how they felt, what they thought could have been better, how the drummed-in practice of delayed cord clamping doesn’t sit alongside cutting a nuchal cord before the baby is born. We were thrilled when the students began to ask questions about not just nuchal cord, but the lack of mobility for the woman, about how the woman herself might have felt about the experience (having had two home births already), and about how she might have felt when they took her limp baby out of the room.
One of the most challenging things to teach in Nepal is how
to....challenge, how to nurture an inquisitive attitude.
This scenario was our bread and butter for much of our role
play and discussion for the rest of our stay.
From this....
- · One student arrived on labour ward for her next shift, and told ALL of the staff she would be closing any curtains she found open, and explained why she felt this was important. We were pleased to hear she had the support to carry this plan out.
- · A nurse midwife admitted that our discussions prompted her to introduce herself, for the first time ever, to a woman she supported in labour.
- · A reading list was provided, along with a varied list of research sites. A NAMS student Facebook page was also set up to held share useful links and experiences.
- · During role play, we explored the thoughts and feeling of mother, student midwife, and staff nurse. This was an interesting and extremely valuable exercise. Fear, embarrassment, coercion and sometimes bullying felt by all three for different reasons, and all too negative for what should be a nurturing, ‘with woman’ space. But it created some understanding of the different challenges.
- · Individual research topics chosen by each student, to explore evidence and choices for clinical practice. Management of.......suturing and perineal repair, normal progress and latent phase, nuchal cord, delayed clamping, mobilisation,.....were all topics the students chose to question and research. These findings were printed, and shared with the group. It was the plan to hijack a small part of labour room wall, or provide a folder, so that this information could be shared with the staff and obstetric team. How else are these students going to respectfully, and healthily, challenge current practice? Essential reflection was encouraged by Maya, who bought each student a reflective journal.
The question that
became painfully obvious...
...was how to support the staff nurse midwives... to support
the student midwives... to provide evidence based, respectful, midwifery care
to the women? The staff complained they didn’t have the authority to allow
students to support birth in an upright position. When asked what the actual
guidelines and ‘rules’ are for labour ward, nobody knew. Nobody had seen or
heard of them. There was a Skilled Birth Attendant’s ‘work book’ somewhere.
“There are no written rules, .......but if we don’t follow
rules we get shouted at”
We also visited, albeit briefly, the fewer students at the semi-private
Kathmandu University Hospital at Dhulikhel, who were sitting a four year course. Regina
Singh, the Nursing Education Director, welcomed us to this fairly new hospital,
with 3,000 births each year. They are building a brand new birth centre, but it
will be an obstetric unit and not midwife led.
The whole of the medical team, across the hospital, get
together each day for ‘morning meeting’ to share events, special cases, etc, of
the previous day. We were requested to introduce ourselves and explain our
purpose at the hospital. We felt very welcome, and impressed with the sense of ‘family’
among the staff. We didn’t get to see the current birth centre in action, and I
was sad not to see if these morning meetings increased multi-professional
communication.
We didn’t have time to provide workshops at the KU hospital,
but the teachers were later invited to join NAMS for teacher training.
For this session, based near Pashupati, MIDSON’s Professor Kiran Bajracharya joined us, as well as Professor Pramila Dewan, of NAMS,
We revisited...
- · How to research, and developing curiosity for evidence based practice.
- · Leadership and communication skills.
- · Decision making, and work place dynamics
- · Reflection
- · What it means to be a midwife, and identifying barriers to successfully moving student midwives into midwifery practice.
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| The art of communication! |
With the funds that friends here in UK have donated, we were
able to provide every student with a year's membership to the Midwifery Society
of Nepal. MIDSON is the one and only nurse-midwife organisation working to make midwifery
happen in Nepal. It seemed really important that these young and passionate,
and very FIRST midwifery students have access to whatever resources can be
offered to them. These are the midwives that will take our profession forward,
and potentially be MIDSON’s future management. Fresh ‘blood’ and ideas are
healthy and to be encouraged. I’m not sure how much the students have actually
benefited from this membership. I shall know more when I return in March.
So, a feeling of great achievement, for everyone who has put
effort and dedication into making midwifery happen in Nepal. Of course, we are
not there yet, but midwifery education is an incredible achievement. The essence of midwifery has yet to seep into the bones and souls of the teachers, the students and the team working around these people. That includes the obstetricians. The students are working in an environment that is almost hostile to the changes that have to happen. Respect, openness, and a combined desire to make childbirth not only
safer, but more joyful, will help turn medical and public attitudes towards respectful,
evidence based, woman centred care.
The ball is well and truly rolling.
Well done to us. Thanks to my besties, Sarah and Stevie. But a massive well done to MIDSON, UNFPA, GIZ and all the NGOs and individual passionate people who have supported Nepal's huge step towards having a midwifery profession.
