A meeting of great Nepali minds. Day 7

 So here we are, the last day of our Nepal trip. Qatar Airport is still open to Nepali transfers, at least, and Heathrow will let us get home. 24 hours and we’ll be on that flight. We’ll have a whistle stop time in Doha, with no time to mingle with bugs. The flight IS a worry, but the three of us have been pretty cautious during our time here, and that’s not going to change on our flight. I’ve checked in with home. My mother is self isolating, has a bucket and wipes inside and outside of her flat in the old people’s sheltered housing. She’s on 24hr oxygen and incredibly vulnerable. My father lives alone in the village and the allotment is his friend. As much as we try, he’ll do just as he sees fit, but is a bit less vulnerable. I’ll not be visiting either until I know I’m safe to.

Here, there’s still very little going on with cases of Covid-19. It’s been mentioned there may be as little as 300 tests in the whole country, so until cases start hitting the hospitals, maybe Nepal won’t really know how it’s spreading.

Dr Prasad with 'Call the Midwife' DVD set.

Rather than sharing midwifery in the bigger workshops, I’ve been able to sit at my laptop and write a couple of reports. The new midwives now have the evidence (limited as it is) to support use of TENS for labouring women, and potentially early labourers. There are now a few TENS machines int eh hospitals here, but I believe it is only Tribhuvan Teaching hospital, Mangla Devi Birth Centre that is using them on a regular basis. While there is NO pain relief, here, for labouring women, TENS offers women at least a coping ‘distraction’, and gives the very busy midwife an extra tool to support that woman. The reports have been shared with the doctors as well as the midwives, because without the doctors support for this machine, it’ll not be ‘allowed’ in the birth room.

During discussion yesterday, the availability of props in the birth room was brought up and, again, we explored getting some wooden birth stools made up. I managed to find a few model examples, get a few common dimensions, consider the sanitary requirements, and storage under the rigid metal beds. This report has gone to the midwives and doctors, too. Maybe they will investigate getting a couple of models made up, and see how they go. Plastic birth stools aren’t available here, and the Cub blow up stool is far too expensive to have flown here to have it pop on a rough concrete floor. I did request the gift of a Cub stool, or a heavily reduced cost, before i left for Nepal, but I heard nothing back.

We had the most blissful meeting of minds yesterday, over coffee in the charming ‘Of Silk and Salt’ guest house in Patan. We brought Dr Shree Prasad, chief consultant obstetrician and gyneacologist at Paropakar women's hospital, together with a couple of the new midwives, Prasansa, and Bedika. It was a very informal gathering, and we were able to hand books over to the midwives to share and circulate between them all. We gave Dr Prasad equipment for the Women’s hospital, along with some text books to remain at the midwife’s station in the labour ward. We thought he’d like a ‘Birth in Focus book’, and even a CD set of ‘Call the Midwife’. Dr Prasad is definitely a communicator, and empathetic leader. The potential for him to bring wonderful changes to the new and already changing birth centre, is great.

Prasansa, midwife in full Nepal discussion with Dr Prasad.

Our Covid-19 mindful gifts from the midwives.
Thank you!

We chatted about the busy antenatal wards on the hospital. Two wards of twenty women, and just two nurse-midwives. Ward rounds of doctors performing routine vaginal examinations with without thought for privacy or respect for the women. Too many women admitted for the amount of nursing support. The question remains how many women actually need to be there. Some are early labourers who are not sent home, due to distance. These could be given a ‘rest room’ to stay in while establishing their labour.

It’s good to ask questions. There may not be answers, but if there are problems, they need to be addressed. We all try to do the best with what we have, but fresh eyes are sometimes needed to see the wood for the trees.

A third day of no hot water. I pushed Sarah into the cold shower this morning. She woke everyone up with her gasps. The sun is already shining outside, so we should have some warm water at least tonight. We’re getting on with it. How can we not, when just below our window there are locals collecting their water from a well.

Saying goodbyes before we've even said hello.

Getting excited about the prospects of a midwive led
birth room for the midwives at Dhulikhel hospital

Yesterday, it felt good to work positively towards getting homes for all of the books and equipment we’ve brought with us. On the floor of our little bedsit, several piles grew for several destinations. There was no panic, or new info about airports shutting down. It was sad to hear that Everest has closed to tourists, and I wasn’t surprised to hear of the Cobra’s woolly and inadequate outcome.

Having been so impressed with the amazing work going on at the primary health post at Melamchi, (and I’ve not fully explained how this long day went) we felt it was important to continue that roll and send them new equipment and books. Laxmi, president of MIDSON, will travel past the post next week, and will drop the equipment off for us.

Piling up the wonderful donated and bought items
and books for all the centres we support.

We met three of Kathmandu University students at the MIDSON office in the afternoon. Bless them for getting the long bus journey into Kathmandu from Dhulikhel. We were to be out there on Tuesday, to meet the two midwifery cohorts, staff and obstetricians, but this had to be cancelled due to our hasty return home.

One of the books donated by midwife author, Becky Reed.
Such an inspiring book for these new midwives.

 These students are in a 4^th year of studies, so it’s actually more of an internship. They have spent time out at Melamchi, where they were ‘free’ to practice midwifery skills they are not able to practice in the hospital setting (women are all still giving birth on a bed, in lithotomy position). They told us eagerly of their desire to use a room in the hospital, that they might call ‘midwife led’. We’ll be supporting them to manifest this with the hospital managers. They also have a TENS machine donated from our last visit to them. The students practise using it in the lab, but are not allowed to use it on the women in labour. I’ll give more information for them to share with the multi-professional team, to see if the birthing women can actually benefit from this resource.

Books, balls, TENS, and other midwifery items were given to the girls for them to haul all the way back to Dhulikhel. We all felt blessed to have had this catch up time. All of these pioneering midwives face such challenges, and so many doors are still closed to them because midwifery still isn’t thoroughly understood. It’ll get better. It is getting better. But these first midwives are doing wonders, and staying so positive and strong.

Bids open for a special roll of
Nepali toilet paper.

I think I mentioned there were some purchased books already here, via a trekker friend’s luggage allowance, and these books will go to the MIDSON library that we started last year. We left more purchased and donated books and journals, as well as those, again this year. There are now 33 very useful midwifery books for MIDSON members to use as reference, or to borrow for a short time. I’ve left them with forms to fill, requesting members pay a deposit to cover any loss or damage of the books. If this system doesn’t work, and books are mislaid, we may decide to use a hospital library to donate books to in future. This would be a great shame, as we actually want to encourage members to frequent the MIDSON office, and of course, to read up to date evidence on midwifery practice.

On the 40 minute walk home, we managed a bit of gift, fabric, and food shopping. Another step more prepared for an early exit. We got back ‘home’ to wifi and no new reports of a change required to our plans. Another phew!

Walking over the decidedly unsavory Bagmati river.
You'd never guess the abuse on the senses it brings.
This photo is almost beautiful.

Today, we’ve had a lazy start. Some useful communication with the KU midwives, and we plan to meet Dr Shree Prasad from the Paropakar Women’s Hospital. We’ll give him the books and equipment for the new Birth Centre there. We heard yesterday that the six KU midwives will work at that hospital along with the 7-8 NAMS midwives. There is some anxiety felt that they’ll not be able to practice their full scope of midwifery skills, and I think Dr Prasad has the communication capacity to unite the multi-professional team towards smoother working conditions for these new midwives.  It’s such a shame we’re not able to provide the workshops we had planned.

I bought essential oils to be used at this hospital, but it would be irresponsible to gift them without providing training for their safe and correct use. So the oils will be coming back to UK with us until next year.

I’m hoping we’ll have a chance to meet up with our good friend, Rashmi Rajopadhaya later today. The thought of leaving before getting a chance to soak up her wonderful vibes and laughter, is too sad. She is, for me, The Honourary Midwife of Nepal. I bring a personal gift of good chocolate and coffee for her family, although Nepali coffee in recent years is quite exceptional.

Tomorrow we will visit the Teaching Hospital Birth Centre. This is the unit that is most similarly akin to what we expect of a MLU in UK. We’ll enjoy seeing the wonderful figures they have of normal births and women’s satisfaction from good, respectful, intrapartum care. Last year I had my hand slapped about pushing for the nurse-midwives to be included in provision of antenatal care. This area of care is still very much provided by obstetricians, and I suspect the numbers of women allocated or choosing the birth centre is not as healthy as it could be because of this. I was warned by the senior staff that change, albeit slow, was happening. Let’s see if there’s progress this year...

Leaving Tulsi, Anita and Puspa on the pavement to catch
their bus back to Dhulikhel. Such a shame we
couldn't meet the other girls in their cohort.

We’re keeping an ear on the news in UK, US, and Ireland, as well as the rest of the world. What an interesting time we are entering. I so want to be home to my parents, to ensure they’re going to be kept as safe as they can be. I can get bossy on my return, but I’ll not be visiting them before knowing I’ve not bought anything nasty out of the airports. Still no real change in gossip levels here in Nepal, although I may hear more news this afternoon.

Heavy Hearts. Day 5

Today follows a day of re-thinking, re-planning and a fairly high level of stress in trying to work out the best move before an enforced Covid-19 lock down.

Long story, short, we are returning home on Monday 16^th, rather than Saturday 21^st. There were reports that our entry to Qatar Airport, even for transfer, was going to be denied. Although this wasn’t backed up officially on their website, we could see they were getting twitchy about certain travellers entering the country. The lock down happened in Ireland, various international worker friends were getting hasty flights home, family at home were highlighting concerns, we decided the responsible thing was to make our exit.

Preparation for the three day workshops halted immediately, and the whole day was spent trying to get through to Opodo and Qatar airways. Both here, and from UK, hours were spent waiting on the phone. Eventually, while I kept internet vigil and email ping-pong, Sarah and Stevie found a taxi and requested eye to eye consultation at a local Qatar office we’d found an address for in Kathmandu.

The options were to purchase a brand new flight either Friday or Saturday, for around £270 each, or attempt to re-schedule our booked flight for an earlier one, at much less cost. Opodo weren’t re-scheduling any flights more than 7 days away, so this option wasn’t really going to help us, and flights were booking up fast. The only reschedule available to us by this stage, at mid afternoon, was a flight four days later, on the Monday, for a cost of £20. With the trip already being a significant demand on our personal purses, the extra expense was a real issue. This needed to be weighed against what it might cost to be potentially ‘stranded’ in Nepal, with loss of income, accommodation costs, and possible cost to our health, not to mention emotional stress of loved ones at home. The decision was made to stay put, until Monday, and hope that the situation at Qatar Airport or our own Heathrow Airport doesn’t change before then.

Although we’re not sure quite how much Covid-19 testing is being carried out in Nepal, and hence under reporting of cases, the doctors we are familiar with are not yet at a point of any panic, and haven’t mentioned any cases. This bodes well for no massive eruption of cases within the next few days. On a very selfish level, I’d prefer to be back at home before the panic hits. But I’ll leave with a heavy heart, and some guilt, knowing how the situation here could look the very near future. Italy is in the midst of a horror story. The health system in Nepal has not long ago faced the horror of the 2015 earthquake. Memories of 48+hr shifts, total exhaustion, inadequate facilities, meds, etc must be close to the surface in the minds of all the medical friends I shall be leaving.

On a lighter note, while I made a start at sorting the flight situation, Sarah and Stevie met up with Prasansa and Rukumani, two of the new midwives, and journalist Cathy. Cathy is hoping to write an article on the journey towards midwifery in Nepal, so we’ll be keeping a beady eye on this in the press. She had to leave hastily last night, back to her home in India, before the border was closed to her. I’m sure we’ll be keeping in touch.

Prasansa and Rukumani receiving from Sarah,
one of Becky Reed's six donated books, 'Birth in Focus'.
Thank you, Becky. xx

So, what now? What happens over the next few days? I think the three of us are slightly shell shocked by yesterday’s stresses. It feels inappropriate to be planning any kind of workshop now. We are meeting some of the midwifery students from the Kathmandu University in Dhulikhel. They’re coming to the Midwifery Society office. We may get to visit the Mangla Devi Birth Centre. We have some equipment for them. We would like to meet up with Dr Shree Prasad, who we met in Bharatphur last year . He is now working as obygyn at the Paropakar Women’s Hospital in Thapathali. We have books and equipment still to give to the Birth Centre, which we will now give to him. We’ll also try to introduce him to some of the new midwives who will be working in the hospital. He is very supportive of the positive changes midwifery will bring to the unit, and could be a uniting body within the multi-professional team there. We may manage some work time in the MIDSON office before we leave, too.

So, we’re incredibly disappointed we’re here and haven’t managed what we’d hoped to achieve. In the grand scheme of things, it’s just one of life’s lemons. We’ll hopefully get home safely. We did, at least, manage to distribute the books and equipment and were welcomed by our contacts and friends. And we will be taking home thoughts and inspirations we can grow later on.

Mixed blessings. Day 3.

An early start (well, 6am) and a late finish (21.30pm), entailing 4 incredibly grueling hours up to Melamchi, Sindhupalchowk, to check out the Primary health post and the changes a recent placement of student midwives have brought. It was good to see the unit, and really good to see the incredibly productive young doctor in charge. He's brought a huge amount of change in such a short time. I'd like to go into detail, but I don't think I can face it. A few words to describe the day?

Human maracas. Landslide roads. Scrambled brains for breakfast. New faces. App for fathers. Inspired. Basic, but loved. Dreadful lithotomy. Doctors get younger, but more awesome than this? So many plans. Tasty chow mein. Sitting in meeting of foreign language?? Different route back, but lorry after lorry...after lorry... Exhausted. Completely frazzled, and late with plans for Friday's workshop.

Let's hope the dogs don't bark too much tonight.

Girls enjoying the sight of wedding
festivities across the road.

Joined by Catherine, freelance journalist from India, checking the story of our new midwives,
she enjoys snapping some improvised teaching to the community health workers.

Proud father of five girls (and a story to follow)

Because  reminder is needed.

Since hosting the student midwives, the ANMs sometimes
 get the floor mat out and try upright births.

The Langtang Mountain range in the distance.

The wonderful Auxiliary Nurse Midwives at Melamchi,
attend up to three births per day.

The pace increases tenfold. Day 2.

Breakfast, a short distance up the happy narrow red brick road, was a confusing affair this morning. Much is lost in translation and we ended up with another full breakfast. Not intended, but not altogether a bad thing that we were inadvertently fed for a busy day. Emails started pinging during our coffee, and suggestions for meetings were starting. We gave our apologies for not being able to fulfil the request of getting out to the student midwives in Jumla this time. Funds depending, we will keep the trip in our aims for next year.

A fifteen minute walk past the little front room shops, dogs, playing children, and fruit sellers, found us at Patan Dhoka for pick up to the midwifery society office (MIDSON). Around the large wooden table, we talked of a journey to Melamchi first thing in the morning, to chat about the changes midwifery students may have brought to women’s care in the area during their short placement, and to assess how a new pregnancy and birth app was being received by the women in that rural area. We’ll travel with two female doctors we met last year, and two others. Someone, maybe two of us, will be enjoying a sideways and possibly nauseating trip in the boot of the people carrier, up the windy hairpin bends out of the valley. Breakfast will be found along the way, and this will be Stevie’s first experience of the joys and scenery awaiting us. It’s likely to be a late, and dark, trip home again.

Thursday looks to be spent preparing for a three day workshop at the Paropakar Women’s Hospital, central Kathmandu. There are upwards of 80 births a day, here, and 16-18 in the newly (earthquake) replaced birth centre. Laxmi did her magic and arranged a meeting for 1.30pm with Dr Gautham, the hospital director, who was again pleased for us to provide our encouragement for physiological birth in their birth centre. Dr Shree Prasad also attended and is keen to rally the obstetric staff for the workshops. We will hope that the brand new qualified midwives will be invited, too. They’re not yet on the payroll, but will all be working within the hospital very soon.

Hmmm....three days to include obstetric emergencies (or, how to avoid them!), physiological birth, and tools for the midwife (balls, TENS, essential oils), but quite probably to an ever rotating set of participants so that they may all attend their shifts, too. I’m keen to ensure this workshop is not a repetition of the skills we have been sharing unfailingly for the last several years. It really is time for these skills to be an accepted part of practice. So, we will be looking at the barriers to putting all of these skills to practice. I hope many of the obstetric team will attend.

Lots to sort by midday on Thursday, when we meet up with the directors of the hospital, and agree the programme. We need to search for a local printer, to get relevant papers printed, possibly certificates, reading lists, etc. We may need to set ourselves a bit of homework in prep for the teaching, too.

Saturday is the rest day in Nepal. We may need to get some prep done, but we might also take a little rest from brain ache and get some fresh hill air. We’ll have to stay flexible, though.

We managed to visit the up and running new birth centre, where they have ten relatively spacey ‘bays’ with curtains for privacy. Partners were supporting their women to birth squatting on the bed. It was airy and light. It’s hard for us to keep in our minds that any positive changes made have been the results of much challenge and debate. We will revisit provisions and actions in the birth centre over the three day workshops.

We were then invited back to the MIDSON office to join a meeting of individuals working on an information leaflet to be given to all women receiving maternity care. The leaflet will be written in Nepali, obviously, but it was fascinating to hear how many words used daily in maternity care nowadays, that are English with no simple translation. For instance, the term ‘women’s defender’ was already chosen for the leaflet, but no direct translation could be agreed. Our input was small, very small, but it was in the form of women centred care and informed choice, which is still a new concept in the country.

We were fed, and it was very tasty, too. Then we enjoyed a leisurely 30 minute wander back to our guest house. One foot in front of the other always offers a welcome time to mentally digest events. Language barriers are less in recent years, but it still takes real focus to follow conversation and sometimes we can ‘fill in the gaps’ quite wrongly. Meeting are always tiring. We reached ‘home’ about 5.30pm, sandals off, blisters treated, ice cubes retrieved from the ancient fridge upstairs (for the Gin, not the blisters), the Archers listened to by those not writing this blog (Linda died, apparently).

(Or did she? And who on earth is Tracy?)

Tonight we’ll eat nibbles in our room. We have an early start in the morning. The journey will be a brain scrambling one, and the corners will induce a few prayers, but we’ll have experience rather than ‘work’ tomorrow. The real heavy work will come when we return in the evening. Lets’ hope we’re vaguely functional.

It's feeling so good to be back. Day 1.

The end of my first day sees me sat on the bed with my midwifery travelling companions, Sarah and Stevie, listening to the replay of a radio 4 play, drinking a long G&T, and catching up on lap tops. It’s 9.30 pm, we’re well fed and still acclimatising to the time change and slight altitude difference. The guest house we’re using this year is one of a circle of traditional homes surrounding a beautiful Buddhist Stupa.

This year, I plan to provide a daily blog of our events here in Nepal. Let’s see how it goes. I’m a little concerned that after a long and very stimulating day (...and maybe a strong, long ‘refreshment’), I may not be too thoughtful or diplomatic how I replay events in my mind. But it might be an interesting and possibly more honest reflection of my time here. We’ll see....

The going has been slow today. It’s Holi. No wild and raucous celebrating in the Durbar Square this year, though. Corona Virus is in everyone’s thoughts and large gatherings, albeit outside in open air, have already been cancelled (To date, there has been just one official case of C-Virus.....really? How has Kathmandu contained that one case?)

We’ve collected our bought and donated equipment together in one corner of the room. Where we will distribute it, remains to be decided. We have a large stack of gifted books (thank you lovely midwifes for your precious gifts), a few of them brand new to join with a small stack of books already here. With the equipment, is a box of essential oils (thank you, friend, for your coincidental gift of money to pay for this), in enough quantity to keep a birth centre going for a while. We’ll aim to provide a short workshop so that the midwives will use them with respect and with a bit of knowledge.

Patan has changed, even within the year we were last here. There are buildings being re-built after the 2015 earthquake. These multi-story red brick and timber homes will have been left standing (many were not), but now have massive cracks causing instability. It’s heaven sent to see the houses are being replaced with new traditional woodwork and the same red bricks. Thamel is known to be the place for tourists and shops and restaurants. But if you want to feels the essence of a real and beautifully authentic Nepal, it’s Patan you need to check out.

Tomorrow looked to be a day of visiting the Midwifery office of MIDSON, and catching up on events and achievements, and making plans for our stay. A couple of times, eager to plan things and not miss a moment of opportunity to share learning and skills, I’ve made efforts to organise things. It doesn’t work for people here. Although we in UK need at least 28 days to arrange anything at all, Nepalis manage with a moment’s notice, and change plans with acceptance and even a small element of... eagerness.

Things, however, can be lost in translation. We read a request to share a week of our time with some first and second year midwifery students, who've not received support from any international midwives, to be a simple matter of hopping onto a local bus to the college campus. On reflection, it possibly entails an expensive flight (£243 each) out of the valley to stay in Jumla for the duration. Our accommodation here in Kathmandu is already paid for, and we’ll be paying for more accommodation in Jumla. We're not in a position to afford this. 

But these midwifery students haven’t had the input they deserve because they’re not in the Kathmandu valley. That just doesn't seem fair. And what's more, these remote areas are the places that need the midwifery support most. 

I wonder if we can find the funding..... 

A big concern to go to bed with.

Introducing Sabita Khadka, one of Nepal's nine brand new midwives.

Meet Sabita Khadka. As of last night, and along with her eight fellow midwifery students, Sabita became one of the first midwives to be trained and qualified in Nepal. Sabita agreed to share a few of her thoughts, and has answered the same questions I set Prasansa a few weeks ago. Sabita wrote her comments a few days ago, as a student midwife, and today she is qualified and ready to practice!

There are still some issues that the Nepali government need to sort (placement and pay, for a start...), but the joy these midwifery exam results bring, for the students, teachers, organisations, NGOs, individuals who have worked both paid and voluntarily, and not least the mothers and babies of Nepal is incredible. What a journey! If this day has been the birth of Midwifery in Nepal, the labour was three years, the pregnancy was many more, and the conception was the nervous result of several failed attempts.

Congratulations, Sabita, and ALL of your cohort! Congratulations, Nepal.

What was your most joyful moment, looking back over your three years in midwifery training?

The learning new things regarding midwifery care were the joyful moment of three years midwifery course among them postnatal visit at home which is new experience for me. It was very special to me because they give appreciation to our work and they were very happy with our care during their hospital stay which make me proud to be a future midwife.

Can you share a few of the challenges you've had to face?

I have faced some challenges during this course was the clinical setting for providing midwifery model of care due to it being the very first concept in our country.

If you could make just one change to the course, what would it be?

I want to change the posting of internship only after the completion of final exam because it helps to students to practice independently and also helps to prevent financial burden.

What do you plan to do with your midwifery degree, once you are qualified?

I want to work in a hospital and also in the community level to provide quality midwifery care to the women and improve the maternal and new born health status.