Midwife in Nepal: A gentle easing of that obstetric stronghold

The ten minute writer's rule still very much applies...
You don't know where to start? So much information to share, and no idea in what order?
Me, neither.
And the more I procrastinate and work anywhere but directly towards getting this blog updated, the tougher it gets. So, here's the secret! Promise yourself just ten minutes of words. Chances are, by the end of that time, you've got your heart and brain tuned into the topic you want to write about. And if you haven't, you can walk away and leave it for another time, knowing you've at least made a start.

Best made plans.....

Sarah, Stevie and I. Trip back to Nepal in March 2019. Plans? Fairly flexible, and agreed we'd like to focus some time on the health post that we visited the previous year in the hills of Newakot. Take a few books, birthing equipment, hire the locals to splash some paint around and sew up some pretty curtains. Plans must also include the growing number of student midwives in Kathmandu (so wonderful, I could write that sentence again...). Because of this new and imminently arriving profession in Nepal, communication with the obstetric profession was very much (as ever) on the agenda, too.

Sorted. Cool. A known quantity.

The financial juggling act...

We were lucky to receive £500 from the Chipping Norton Lions (thank you, Lions, Julie and Stevie). This money went towards general equipment and books. We also had a lovely monetary gift from a neighbour (Thank you, Andy) which enabled us to buy and fill two 'home-birth' back-packs. Costs of internal transport, meetings, lunches, books, prep for lessons, 50+ flash cards on key rings for participants, participant bags, certificates, etc, have been covered by another well-wisher's gift (thank you!). A mate (Thanks, Lee) travelling to Nepal a couple of weeks before us, managed to take out a pile of books and some birthing balls with him, which meant we could fill our own 90k combined cases with a whole load more equipment and books.

Birth equipment bags, neonatal resus masks, head torches, TENS machines, leads, batteries, pads supplying last year's gifted TENS machines, sphygmomanometers, stethoscopes, delivery packs, suturing packs, gloves, masks, birthing balls, books, fob watches, EDD calculators, fetal heart dopplers, midwifery student's 'tool bags'...

Fill it to the brim, we did, with nothing to spare!

Now, if I'm honest, this trip wan't actually a 'best made plan'. We've learnt our lesson not to organise our time too inflexibly. We never really know where our work will be until we step off that plane in Kathmandu Tribhuvan Airport, and much of our days get busier over the time we're there. So, to be requested to journey many miles south, rather than the north we were heading to, just days before our departure was only a minor upheaval, and it was purely a matter of finances.

Over the years, our gifted money has rightly gone to equipment, books, transport within Nepal, MIDSON (Midwifery Society of Nepal) membership for students, etc. But Sarah, Stevie and I travel in our NHS annual leave time, and we fund our flights and accommodation ourselves. I'm lucky to have my hand painted Advent Candles to sell as a fundraiser, and some of that pot of money goes towards my flight expense. We try and keep our cost of living low. It's not a holiday. We work hard when we're there, but it's work that we love and continue to feel passionate about. This time, we were unsure our personal budgets could cover the prohibitive expense of internal flight and (now double booked) accommodation, if we agreed to support this new plan. To have a sponsor for vital projects outside of the Kathmandu valley (flights, accommodation, 'per diem' expenses..), would have eased the pressure considerably.
.....any sponsors? Please get in touch!

Nepal makes way for MIDWIVES...

Things are moving on in Nepal. The number of women giving birth in Nepal without a trained attendant, is now down to only 43%. That's fantastic. But the caesarian section rate is increasing alarmingly in the hospitals, some rates as high as 90%. Midwifery is a profession that protects normality and the physiological process of birth. New government policy states all hospitals with a birth rate over 300/month, should be working towards providing a midwifery led birth centre. Nepal still has work to do to meet the Sustainable Development Goals by 2030. The bachelor and diploma midwifery courses, will go some way to achieving this. But change within the obstetric units needs to happen to allow midwives and student midwives to carry out their work.

So, the trip to Newakot didn't happen. We left a Back-pack 'birth bag' with MIDSON to take up there when they next visited. We headed to Bharatpur Hospital, in Chitwan on the Indian border, instead. The deciding factor for agreeing to this change was that road improvements no longer necessitated an expensive internal flight.
Births average about 35/day in Bharatpur Hospital. C section rate was 15% three years ago, and it is now 33-35%. How to embrace the change that has to happen, with a pending Midwife Led Unit? How do they accommodate the midwifery students that are to train there until that time?

'Promoting Multiprofessional Teamwork and Standardised Care.'

We were driven in the MIDSON vehicle to Chitwan, a much faster and more pleasant option than bus. Thank you, MIDSON. We stayed two nights in the local Global Hotel, and walked to Bharatpur Hospital for the two training days we provided. Dr Shree Prasad and Dr Sunil Pokhrel ensured we had a good turn out of obstetricians. Goma, the regional MIDSON lead, ensured we wanted for nothing during our stay. We felt well looked after. 36 participants attended the first day, and 24 joined us for the second day.
Success.

As with all of the training workshops during this trip, sessions focussed on multi-professional discussion for teams to decide their own admission and transfer criteria/ guidelines. I think, if the criteria is understood and agreed by both midwives and obstetricians, the decision making is easier, and the doctors will learn to trust midwives with more responsibility. It's valuable, too, to recap on the recognition of normal, our ability to keep things normal (and, sadly, our actions that negatively impact the birth process), and acting and communicating in a timely manner when things become abnormal.
We discussed respectful care, and embraced the idea of a midwife's 'tool kit'. We also watched the awe inspiring TED talk from Dr Evita Fernandez, from India, on the benefits of bringing midwives into being.
(https://www.ted.com/talks/dr_evita_fernandez_natural_birthing_a_promise_of_dignity_in_birth)

guilty whistle

When female participants become focussed and empassioned, the noise levels in a room can reach dangerous decibels. Nepali women are no exception to any other. So, we put a trekkers rescue whistle to good (and hilarious) use, to bring the focus back to discussions during the workshop. Stevie was mortified to realise she'd blown the whistle on Dr Sunil when he'd taken to the floor to explain a particular challenge set to the groups. He shut up and apologised immediately, which caused the whole room to collapse in laughter.

Group participation was the essential ingredient to getting these criteria set out. Dr Shree was able to ensure it remained country, and hospital, specific. We simply facilitated the work. To date, I believe the criteria is being used only occasionally, and the new midwife led birth centre is still awaiting allocation of hospital space.

Treat the Trainers...

You know that bit where I wrote that we worked so hard? Well, we thought we'd died and gone to heaven when it was arranged for us, after the training sessions, to visit the Chitwan reserve in Sauraha. We stayed at the Mona Lisa Hotel, a true breath of fresh air (https://www.monalisanepal.com ). Just what we needed to recoup some energy and sleep.

We saw several rhinos, but this was my first
sighting. chilling within yards of the truck,
and it was really special.

Early next morning saw us in a ranger's jeep, for an exhilarating misty sunrise drive into the jungle. How perfect for us to encounter a days old rhino infant with it's umbilical cord still hanging. Our 'postnatal check' showed mother and baby to be doing well. What a beautiful newborn, and what blown away midwives!

Dried fish; one option for lunch.

The seven hour bus trip back to Kathmandu next morning was lighter for us leaving the gift of equipment, a midwife's tool bag, and books with Bharatpur staff.

If you've followed my previous updates, you'll know how I've banged on and on about obstetricians needing to embrace the work and presence of midwives on the wards and in labour rooms. Remembering midwifery is a brand new profession for them, and to give up responsibility of caring for a pregnant and labouring woman, is a tricky business. But Midwifery is happening! SO, it was simply amazing to have had the company of so many doctors in Bharatpur.

2019, and obstetricians are warming to the idea of midwives...

Within hours of our return, and with the help of Laxmi Tamang (new president of MIDSON), and the equally passionate Dr Geetha Rana, who we'd yet to meet, we were thrilled to be invited to Paropakar hospital to talk with its Director, Professor Jageshwar Gautam. We were accompanied to meet Dr Gautam by Dr Geetha Rana, after meeting her first for a captivating chat over coffee. It was agreed. At Dr Gautam's request, Sarah, Stevie and I would provide two half day workshops and Dr Gautam would expect the hospital's obstetric team to attend.

'A Collaborative Workshop to Promote Midwifery Led Care in the Hospital Setting'.

We were so impressed that Dr Gautam took the time to actually introduce the workshop, and it's significance, to his staff. Among speakers, Dr Geetha shared findings of a study undertaken in their own Paropakar hospital, which identified 45% of their births induced/augmented with synthetic oxytoicn without good reason, and had directly led to the complication of meconium and neonatal intensive care admission. She spoke of the overcrowding of wards, increasing C section rates, and exhausted obstetricians; all of which could be reduced by low risk wards led by midwives.

Among lectures and group discussions..

Nuchal cord cutting versus birthing through the cord. A midwife's 'tool kit' and how to advocate for women. Informed consent, (including the 'BRAIN' acronym) and how that looks in the birthing room. WHO labour guidelines. Admission/ Transfer criteria, guidelines, and standardising care. Again, Dr Evita Fernandez silenced the room with her wonderful TED talk.

Multiprofessional groups identified limiting factors to change, and Dr savannah talked about how the hospital might bring that change, and what has to happen to make it so. Nurse-midwives and doctors got their heads together, listened to each other and worked towards decision making and being the change they all wanted to see. We were delighted to have the nurse-midwives from the TUTH Mangla Devi Birth Centre to share their successes, with positive figures and stories of happy women.
Attendance was as Dr Gautam promised. 37, including 15 doctors in the morning session, and 27 during the afternoon.

Elsewhere in kathmandu...

We had time to pop into Kirtipur hospital and say 'Hello' to Dr Peru Pradhan. Dr Peru remains passionately in favour of midwifery led care. They are still waiting for the much planned for birth centre, but seem to be nowhere nearer to getting it. Their caesarian section rate was currently 41%.

The TUTH Mangla Devi Birth Centre retains fantastic figures for births and transfers, but the nurse-midwives employed there still have no role in antenatal clinic. We were invited to meet the hospital director and discussed the progress seen and ongoing plans. We were requested to provide a day of training for their nurse-midwives and obstetricians, but had sadly already ran out of time and were at the end of our trip.

The progress in TUTH labour ward and birth centre is steady, but their C section rate remains at 50%. It appears that of all the women attending the hospital for birth, only a small percentage of appropriate women are actually offered the low risk birth centre as opposed to the labour ward. It was explained this is due to the doctors being so busy, they cannot find the time to make the decision. There is also fear. What if they make a mistake? Not even junior obstetricians are prepared to make the decision to allocate a woman as 'low risk', and they ask for approval of their seniors. There is also the matter of doctors needing to learn, and are not keen to hand care to midwives (It's no coincidence that most C sections happen at night, when the senior doctors are not around). They still have no guidelines that could promote standardised care. Dr Bakal, head of dept, and Dr Neelam are very positive. We will make sure to offer a workshop for their staff next year.

JHPIEGO, GIZ and UNFPA are all NGOs who provide staff and funds dedicated to making space for midwifery in Nepal. The work goes on, and next year we will see fully qualified midwives. Where will they work? How will they work? Will they fit into the multi-professional teams smoothly? Is their specific role and responsibility transparent and understood by all? Will they be respected as the professionals they are? How will they be regulated? Paid? Who will ensure continued practice development? Work is in progress, but I don't have answers until we visit again in March.

And talking of students......

We had a day with all three cohorts of students at NAMS college. It was so warming to meet the new first year students, so confident and informed about their course, and future. I remember how the very first batch of students just two years before, stumbled their way through the course, along with their teachers. It's been such a gruelling learning curve. Promised funding didn't materialise. Space for the students to practice 'midwifery' wasn't particularly protected on the wards and labour unit. What disenchantment, but thankfully what passion and determination, too, from students and teachers.

We introduced ourselves to the first year students, and chatted scenarios, the midwife's 'tool kit', reflection, etc. We spent time discussing qualitative versus quantitative research topics with the second year students, and chatted about how things were going for them so far. And we got excited with the third year students. Where to from here? Did it still feel like walking into the unknown? what were their plans? Some intended to go into teaching midwifery. One planned to return to her rural district and set up a birth unit. I can't wait to see them all next year.

Each cohort received a midwifery bag of equipment. Again, we provided TENS machines and training for their use. The students sadly informed us that the doctors wouldn't allow them to use TENS on the women. Things may change now we have brought their use into our training sessions for the doctors, and it's about time the women of Nepal were offered even the mildest form of pain relief. I've still no idea why Entonox is not common place in the birthing rooms. (Well, I've a good idea that it's because women's pain relief isn't as prioritised as it should be, but I've no confirmation on that)

We didn't get to see the student midwives at Dhulikhel. Time just ran away with us. But equipment and books were left at the MIDSON office, labelled and ready to be taken to them.

Brief points from memory..

It was lovely to see the MIDSON office buzzing with familiar faces, and so busy with plans.

We said goodby to Ashok and Katrin, our @home hosts in Jhamsikhel. We'd stayed with them over the years, and wish them well with their new home in Germany. We'll miss them (and their wonderful breakfasts) in March.

It costs a LOT of dosh to transport a dear
and clingy little stray dog back to UK

Talking with previously cautious obstetricians
feels so good.

Mosquitos DO like gin and tonic.
Who said Chitwan mozzies don't bite?

Dear Rashmi and her family.
Not all Dahl Bhats are equal!

Midwifery students playing with the TENS machine.
Buzzzzzzzzzzzz

Gift swapping, after a drink,
with dear Kiran and Archana

Molly, joyfully holding her new blanket.
Thank you, friend.

The gorgeous squares knitted by participants during a workshop in Kirtipur, and sewn together to make this blanket....have at last been sold for £50 to a lovely woman called Molly.
I displayed the blanket at a festival this summer when selling 'The Witch's Britches' clothing. Molly said she'd use it to cuddle up in, and we jokingly suggested putting the £50 towards knickers for Nepali mums. She doesn't know, but I've already spent the money on midwifery books that have winged their way to Nepal last week, with a trekker friend. I couldn't refuse the offer of baggage space.

The Honey co-op shop in Souraha.

I've also been informed that the admission/ transfer criteria are being used at Paropakar women's hospital, but still not consistently. Ah well, it's a start. Really good news is that the labour ward is now 'allowing' (oh, that word!) student midwives to use their TENS machines for labouring women. That's surely great for the students, the hospital, AND especially the women.