Time to look back, and see how far we've come.

I shoved my suitcases back into the loft, downloaded my photos, scrubbed Kathmandu off my skin with the help of some blissfully hot running water, amended my paperwork, and put away my overseas gadgets. This, within 24 hours of jumping from the plane into UK’s cold and dreary ‘spring’ time weather.... Phew! Such eagerness to get the trip compartmentalised, and a desire to plan my return to Nepal, I’ve never known.

 Not bad going, considering this time last year I had deep and personal questions about actually going back. I’m so pleased to tell you, this latest trip has refuelled and inspired me.

As ever, my intention of getting the blog done and dusted, were good enough. But as life so often does, it got in the way. I entertained the idea of blogging a daily report while I was out there. There were some evenings spent relaxing, G&T aided (Thanks, Stevie), in our guest house, where I could have done that. My midwife sisters, Sarah and Stevie, and our new recruit Diana did their utmost to get me hooked on The Archers. Had my brain been in a place to digest the events of the day, I could have used the excuse of writing my blog. In reality, Nepal is complicated, and I needed a clearer grasp of things before I wrote.

So, again, there was much to get our midwife mitts into. This year we gave up trying to plan an agenda. Our time is so limited, and it seemed to make sense to plan our mornings, afternoons and evenings as precisely as we could, but Nepal has other ideas and they are flexible and spontaneous ones.

Our intention was to..

1. Catch up with NAMS second year midwifery students, and meet the first year cohort, too.

2. Update and support the faculty in whatever area they felt they needed.

3. Get out to Dhulikhel hospital to meet the midwifery students at KUSMS, now in their second year.

4. Provide multi-professional update training on respectful, woman-centred care to nurse-midwives and obstetricians.

5. Introduce/share the latest WHO guideline. A wonderful read! (http://www.who.int/reproductivehealth/publications/intrapartum-care-guidelines/en/ )

The 'One Born Every Minute' art of eating cake!

We managed all of this (Well...almost), and more!  Sadly, we didn’t get around to all of the places and all of the wonderful contacts who have become dear friends over the years. But, looking back now, how we squashed so much into our short time, I’ll never know. The big news is that Nepal’s government has decided to commence training for 9,000 more midwives from direct entry to diploma level. Sustainable Development Goals (SDGs) for reducing maternal and neonatal mortality have to be met, and midwifery is the one profession that will keep Nepal moving in the right direction. Skilled Birth Attendants played a fantastic part in quickly reducing the number of deaths but, at the risk of sounding like a broken record, it's rather like shutting the stable door after the horse has bolted. Midwifery will not only stop so many obstetric emergencies happening in the first place, but it will empower and educate the women to make decisions about their own health and that of their families. It’s likely the bachelor students will be the teachers of tomorrow’s students, and that the diploma students will be encouraged to work in the rural areas.

Thank you, Sanu, Gyanu, and KM Hospital
 for our stunning saris.

We were happy to be invited to the Ministry of Health offices to support the structuring of the ICM based diploma curriculum. In reality, the 23 all female committee managed to get the job done very well. Much of this has been thanks to UNFPA and GIZ, in funding permanent midwifery advisors to the chief educators, faculty, and students.

Checking out a donated TENS machine.

On arriving in Kathmandu, we met the NAMS college first year midwifery students (14 of them). They were under no illusion about the challenges ahead. Some of their concerns were around becoming a student again, after already being a qualified nurse-midwife for some time (Diana, I think your talk with them, on returning to student status, was really appreciated). Others voiced concerns about being able to practice midwifery in a clinical setting that doesn’t naturally lend itself to what they have come to understand midwifery to be (To put this into context, out of these 14 nurse-midwives, and with all of the collective experience they have in childbirth, only one in the group has supported a woman for upright birth).

Caste, age, and gender are still real issues for nurses in Nepal. Questioning and learning from practice, is always good, but it’s not so easy to question when you’re a young female nurse in Nepal. (Interesting, and not for discussion right now, but there is currently NO place for a male nursing student in Nepal).

Year 2 NAMS students say 'Hi' and 'Bye'

It was delightful to meet up again with last year's students, now in their second year of training. What a transformation! (Well done students and teachers). It truly felt like I was in a room full of midwives. I was particularly pleased to hear that our last year’s learning exercise of researching different issues in midwifery and obstetrics had empowered them to question and find things out for themselves.

Some of their achievements....

1. Running their own antenatal clinic for ‘low risk’ women. It goes without saying, both the women and midwives flourished.

2. Support from labour ward staff, and specifically around events of ‘nuchal cord’ presentation at birth.

3. Maintaining privacy for women.

4. Introducing themselves to women as a matter of habit.

On the down side...
 They have been discouraged from supporting women to mobilise in labour. When questioned, the reason given for this was that upright labour may cause fetal distress (Really? Is there research to support this..?). It was also described as common practice that doctors don't introduce themselves to women or respect closed curtains. We know both make enormous difference to women.

One student shared her concern about obstetricians performing too many vaginal examinations.

Imagine the scenario....A junior doctor performs a vaginal examination, but is unsure of findings....and so a more senior doctor performs a vaginal examination. Then, with anxiety induced from having to present the findings, requests a repeat examination from a senior colleague... before the consultant appears on the scene. By this time, the poor woman has hopefully got wise and has retreated to the toilet to avoid the consultant and a further examination....She'll feel totally invisible and violated, will lack any maternal hormone supposed to get that baby born, and may become poorly due to infection from so many examinations. I’d like to say I jest....

Mutual trust needs to be built between the professionals caring for women in the antenatal and labour wards. I had hoped for meetings with the obstetric team during this year’s stay, during last year’s stay, and the year before.... This is the box that I’ve so far not managed to tick.

I have to also say, I have met some truly inspirational obstetricians working in Nepal. I really hope these few individuals will inspire others and encourage learning. The tide can change so quickly if we all

work together!

With this in mind, we provided workshops on negotiation and communication skills, and respectful, evidence-based maternity care for students and faculty. Student groups received a bag of equipment (sonicaid, TENS, essential oils, 'respectful midwifery' cards, tape measures, books, journals, charts, and more). It’s hoped this ‘midwifery bag’ will be passed between the students while in their work place to support them, empower them, and give them the full tools to work their midwifery magic.

Lovely group of almost-qualified nurse-midwives ready to embark on their exciting journey

A happy mother being supported by her sister,
and a TENS machine, during early labour.

How useful computers can be in the birthing room...(!)
This one had some pretty good stats on it.
Sarah looks impressed!

Our visit to the Tribuvan University Teaching Hospital is always wonderful, mostly due to its Mangla Devi Birth Centre. We met with obstetrician, Dr Mita Singh, who is rightly very proud of the great work so far in making this centre available for women.






This beautiful centre wouldn’t be out of place in UK. It is sunny, nicely furnished, the nurse-midwives are happy, and it has fantastic figures to support good and safe care. The women LOVE it, too.




The obstetricians are seeing the benefit of a falling caesarean section rate within the hospital, and are encouraging women to birth in the centre. The delightful core members of staff are now busy enough to offer birth support around the clock. What an achievement! And what a crying shame that the midwifery students can’t learn in this setting.

Dr Mita Singh checks out a set of mini
'Respectful and Compassionate Maternity Care' cards.
Hmmm..who to give them to?

After having no pain relief to offer, there is lots of
interest in our TENS machines. Hopefully they are being used
in the labour wards.

...And while visiting the midwifery students in Dhulikhel, we were lucky enough to have our sharing session joined by a wonderful obstetrician, Sunila Shakya . To hear Dr Shakya share her uncomfortable journey through obstetrics, and her eagerness for the students to practice midwifery as we know it, brought me close to tears. For so long, I’ve felt like I’ve banged my head against a brick wall when it comes to multi-professional working in Nepal’s hospitals. Thank you, Dr Shakya. With Dhulikhel’s newly appointed and inspiring hospital principal, Kunta Pun, your student midwives will be supported to bring fantastic changes for women.

Laxmi Tamang generously gave her day up to take us into the hills with the MIDSON pick-up. It was an incredibly moving trip (hehe, in more ways than one!) A four-and-a-half-hour long bouncy journey up there, and a near shaken-head-syndrome journey back down again. But it was so worth it. Thank you, Laxmi and MIDSON.

School as usual. Behind the rubble, looks freshly built school rooms.

We stopped half way and had the opportunity to meet and eat with the area’s health ‘focaliser’. We listened to reports of gynaecological conditions, such as prolapse and fistula among the older women, and the dreadfully high number of girls still being trafficked from this area, inevitably leading to high incidences of STDs. Historically, girls have always been ‘supplied’ from this area for use as king's servants. The Nepali government are thankfully cracking down, and the roads are now guarded by soldiers.

You really want to view some of these roads
AFTER you've travelled them.

The UNICEF earthquake hospital tent still here three years later.

This lovely couple are deciding on the sense and safety of travelling further without benefit of Nepali language or mobile phone. They MAY still be up there. The non-verbal communication says it all.

But why wouldn't you want the experience of waking up to this!

I hope this year's rainy season is a gentle o

Samundhratar, and Routbesi is in the Dhupcheswor Rural municipality of Newakot. We visited two birth centres. The first was very basic but, due to accessibility, it took the referral cases and transfers for Kathmandu hospitals. This was an unexpected trip, and while not wanting to go empty handed, our gifts of equipment weren’t as appropriate as they might have been. The second centre was higher up and much larger than the first. The UNICEF tent, erected as a temporary health post after the earthquake, was still standing close by.

There was still a staggering amount of re-building still to be carried out. All of the houses being erected were reinforced with metal, as this is the only method supported by government funding. The houses will be safer, but they don’t look half as pretty as the old stone and wooden houses. The important thing, of course, is that they will save lives in the event of another massive quake.

Again, as last year, the student midwives were all offered and accepted a year’s membership for Midwifery Society of Nepal (MIDSON). Our delightful new team member, Diana, also gifted her unused Nepali Rupees in support of this. I seriously debated the best use of this money. Royal College of Midwives has a good rate for overseas students and the learning to be had from its website would have been really useful to the students. However, I felt MIDSON actually needs the support of its MIDWIVES, and these students will be the first ever midwives in Nepal. These midwives will be the ones to take MIDSON on to great things. The progress, thanks to MIDSON, is fantastic, but MIDSON now needs to grow and support these students better. (A bit of purposeful repetition of a couple of key words, there)

 
Market day, every day, in Nepal. It had all things bright and beautiful (and some things not so beautiful, too)

So...what now? For certain I’ll be going back. This trip has raised many questions and possibilities. It looks probably that, along with my wonderful team mates, Sarah, Stevie and now Diana, we'll consider focussing on a rural birth centre or area of birth centres. This maybe as a couple of teams, even, so that we can still give our support to the teaching in Kathmandu. We may be able to support students in their rural postings, too. Working with the doctors and bringing a sense of shared purpose will hopefully be less important as the midwives settle better into their own roles and responsibilities ( read that as competence and empowerment to make clinical judgements, etc)

There’s so much to do. Will we need more UK midwives? Two small groups in different areas? Can we add any UK obstetricians to our team? Should we work under the umbrella of a bigger organisation, or do we raise funds for ourselves and retain our independence? Should we look to become a registered charity? This started out as my own adventure, and has become a wonderful team of four. Through all of our trips, we work so well together, and have a real shared interest (apart from The Archers) in what we're aiming for. This has been real team work.  And then I need to ask myself what am I, personally, able to take on. Keep it small and manageable? Embrace the growth and grow with it? Or bite off only what I can chew? There are discussions afoot and plans for fundraising. The way will become clear. It always does.