Funds helping Nepal's midwives to help mothers.

 

Good grief! I hadn’t even realised I’d not finished the short series of daily blogs written during my trip to Nepal in 2020. I have only just re-read my experiences, and again feel the dis-ease and panic of the yet to evolve Covid pandemic, and our hastened exit from Kathmandu. I remember, while still there, feeling deprived but entertained by the excitement of fighting over loo roll, and of queuing at the supermarkets. On return to my village, I felt quite alien. I knew places and people were the same, but I deeply understood that everything had already changed.

 

We fared pretty badly, eh? There were incomprehensible accounts of women here in UK facing traumatic birth without their partners, facing heartbreaking loss at times, too. We saw photos of birth workers sweating and fearful behind swathes of plastic gowns and alienating armour. They learnt to 'hold' each other from 2 meters away, and to smile and reassure through their eyes.

Antenatal care and education was dropped like hot potatoes. Phone lines were jammed and midwives were unreachable. Breastfeeding support was via zoom, if you were lucky. New parents tried to hold it together, together, because there was no family, no well meaning aunts or grandmas. Nobody.

Like here, Nepal had waves of Covid. Many of the cases arrived from the Indian border, with migrant workers forced to return home to their remote villages. Who knows how they fared in their isolated villages, many without medicine. Lockdown in Kathmandu was enforced by the army, and I think it had to be so. There was no luxury of ‘working from home’, and socially distancing in a small 570 sq km space with 2,220,436 people must have been near impossible.

I saw photos of the Kathmandu hospitals managing PPE. I heard stories of women being denied entry to birth in the hospitals. The Covid Delta strain is particularly severe for pregnant women, and we saw scenes of wood being sourced for the many funeral pyres. I think we all imagined ourselves in the position of having to find black market Oxygen for our mothers, and of caring for loved ones with a concern that no help would arrive.

Maternal and neonatal mortality has obviously taken a huge knock, and the chances of reaching the Sustainable Development Goals seem ever more remote (It does for us all!), but there were heart warming stories and the potential for providing true midwifery care was grabbed with both hands by a few of Nepal’s new midwives.

Sabita, Prasansha, and Rukumani. Three of Nepal's first midwives.

During lock down there was no transport for women, and no advice for emergency care. So, a few of the midwives started up an emergency hotline, and counselled almost 3,000 women. They also provided video and zoom, gave antenatal education, and carried out some face to face care where necessary.

At first, the midwives shared their personal phone numbers, but help came in the way of Midwifery Society of Nepal (MIDSON), and Dr Laxmi Tamang, and the service became a national, toll free hotline. UNFPA and other organisations supported the midwives to continue this work. Other projects stepped up to support families isolated during the pandemic. My midwife friends Prasansha Budha, and Sabita Kadka put their energies into an organisation called ‘Rural Community Healthcare Nepal’. They created a large project supporting childbirth education for young people. Prasansha and Sabita came across many situations of isolation and deprivation, and I wanted to help them to help these families. My funds from selling hand painted advent candles the previous year were still unused because the return trip I’d planned and hoped for, didn't happen. I took the decision to send this money out to the organisation, and for the midwives to oversee how it was spent.

Here are a few heart warming cases Prasansha, Sabita, and the families involved, are happy to share.

Case 1.

Twin girls born naturally to a second time 20 year old mother, at 38 weeks gestation, and into a very poor family. They weighed 2300g and 1800g, and the parents had no clothes for them. They were given blankets and clothes. Travel restrictions sadly denied Sabita the chance to support the family further, or ask about the welfare of the little baby girls.

Case 2.

Prasansha was made aware of a 19 year old deaf woman. The young woman had grown up in an orphanage and had no memory of her birth place or family. She married a lad, also from the orphanage, but he died recently. Prasansha oversaw her pregnancy care, and liaised with doctors and social workers to get the birth, transport costs, clothes and food the mother required. Through what sounds like a long latent labour, Prasansha offered overnight support before advising hospital, and the baby boy was born ‘on the bed’ (this presumably means without lithotomy?? Or does it mean vaginal birth rather than CS? I’ll find out!), without episiotomy, after having back and thigh massage to help with the pain. The female staff supported the new mum with postnatal care that would have normally been given by family.

The young mother was set up with a rented room, money to buy food, and found support from a women’s group. She was also gifted a small street cart by another donor, to start her own self sufficient business. What a lovely, positive, story.

Case 3.

A mother with 4 children, and a drunken husband! She was malnourished, and had no money for food to feed herself or her children.

Case 4.

A woman with two children already, arrived from a remote region in eastern Nepal. She had no screening tests earlier in the pregnancy and admission tests found she was Hepatitis B positive. The couple couldn’t afford medication to prevent their baby becoming poorly, and the hospital had no funding to support this, so Prasansha requested the purchase of the necessary drugs to keep this baby as well as could be. She said the parents were so worried, and so grateful for the support.

Case 5.

Only relevant for the wonderful comment Prasansha sent to me..... 

She had instructed a poor birthing woman’s husband to get his wife a hot drink. He said he had no money, but was visibly drunk. His excuse was that he was ‘in stress for his wife’. Prasansha gently warned him, and then gave the couple enough money for food during their hospital stay, and ensured they had adequate clothes for the baby. I love that he was ‘gently warned’.

The midwives managed the funds by purchasing both clothing packages and food packages and ensuring they were available in a few places for the poorest mothers. There are any number of ways to spend funds to great effect in Nepal. I personally would like to see these midwives have adequate equipment and ongoing educational development. But amidst a pandemic, and faced with some of the worlds poorest women, I think my priorities could change. Maybe I can direct some funds to keeping the midwives cared for, loved, and equipped. 

Covid 19 has halted plans for so many of us. Midwifery education will resume in Nepal, and the qualifying midwives will be employed in the many birthing units that government plans to set up. Maternal mortality in Nepal must decrease from 239 to 70 in 100,00 births within just a few years if it's to meet Sustainable Development Goals. Government really needs to pull it's socks up, and recognise women's health as the serious issue that it is. I thank everyone who has helped me to help the midwives of Nepal to help women's health, one mother at a time. In doing this, they are also gently nudging the country to better, holistic, respectful care for birthing women. They are being the change we all want to see.

 

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.

Introducing Prasansa Budha, a student in first cohort of Nepal's midwifery students.

Meet Prasansa Budha. Who, over two years ago, came across as a very determined and focussed first year student in NAMS, Kathmandu. She agreed to share her experience here, as one of the very first midwifery students in Nepal. It's been one huge journey. Not just for Prasansa and her fellow students, but for the teachers, the 'teach the teachers' (GIZ/UNFPA workers Kirsten, Maya, Margaret, Maxine to name a few), and the teams in the hospitals where these amazing students have had to push and shove their way in, to be accepted as part of the brand new multi-professional force bringing change to the maternal and neonatal well-being in Nepal.The hard graft has been all theirs.

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

 I have many joyful moments if I look back to this programme.

Ready for the leap of faith.
Prasansa's cohort, with all their teachers.

Most joyful moment was when I delivered DizygoticTwins of average  weight i.e 2800gm and 2400gm normally. That was my 1^st experience of taking twins delivery. Moreover, this woman was very happy with my care and counseling. During discharge she appreciated my caring attitude and wished to take delivery from me in future as well. This made me really happy and proud.

 

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

 Firstly, We were promised for scholarship but we had to pay even for our accommodation and fooding during our clinical practicum out of valley.Many times I had to run out of my budget.

Secondly, during our clinical posting in Year one we couldn’t practice midwifery model of care as doctors and nurses were not ready to accept our practice.

 

 

 

.

 

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

 

In the context of Nepal, I would include obstetric ultrasonography course and it’s practicum because midwife should be able to diagnose abnormality especially in rural areas and refer timely.

 

 

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

I want to establish my own birthing centre and organize training programme for woman in rural Nepal regarding safe delivery.

with love

Prasansa

Experimenting with the TENS machine last year.

A very simple set of questions. I knew them, and Prasansa, and still found the answers thought provoking. How must it feel to be the first ever home grown midwife in Nepal? The students have a great command of the English language, because they have to learn in English. (That's half of us given up already, eh?). To know Prasansa has ploughed through the challenges, and plans to set up a birth centre in her own rural community is humbling. Wishing you well, my dear, and so much love. You'll stay in touch?

You can leave a message of good wishes for Prasansa below.

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.

Having a stern face during a passing encounter
with revelling youths at 'Holi' festival
 doesn't ensure your face stays white!

Great things don't come from comfort zones,
and good communication always wins the day.

Good communication didn't win the day on this occasion.

Phew, That's pretty good work for a ten minute start.