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.

Advent Candles as a Fundraiser.

How To...

The candles I use are mass produced dinner candles. I have occasionally painted other candles, when requested, as a means of fundraising. The method is exactly the same. As I am painting a water-based paint onto a wax surface, I need to add a teeny dollop of washing up liquid to the water colour paint (If I were a chemist, I might tell you this reduces surface tension). I could use gouache acrylics or poster paint, but I get a lot more colour for my money with proper water colours. They don't need to be artist quality and, because of being blended with washing up liquid, tubes are easier to use than blocks.

I spoil myself with sable brushes, too. The detail I have on my candles is quite delicate, and sable brushes will hold more paint than synthetic ones. So, getting down to the actual painting...it is simply a matter of working with consistency of the paint on the wax, and the amount of detail and design you want. My advent candles require only one layer, which is so much easier than adding layers (easiest with acrylics as they have a level of water-proof quality once dry).

Before painting, I check the candles thoroughly for defects and marks. Damaged candles can be used at home. Bearing in mind I paint 30 candles in one sitting, I line them all up on some soft fabric. (It's worth remembering that your painting is going onto a very soft surface. It would be silly to paint a mini masterpiece as your creation can so easily be scratched off and ruined).

I start my candles with the little dots at 1cm marks down their length. By the time I've laid down 30 x 24 dots, I know that I have my paint solution fairy close to how I like it. I've also softened and got to know my brush, and I've settled my hand and steadied my eye. The trickiest bit is obviously painting the numbers. I now don't have to think about what number comes next, and never miss a number, but I do have to try and keep the paint flowing at a consistent thickness throughout. Sometimes my paintbrush misbehaves, and sometimes my paint does, but mostly it's me that isn't paying due attention. So, although it's a pleasant evenings work, it takes a lot focus.

With all the numbers painted, I can breathe, fill my wine glass up, and enjoy mixing the Christmassy colours of greens and berry red. The holly leaves are painted with just a few strokes. When that paint has dried, I can add the teeny blobs of red and put each candle down on the fabric as complete. Phew!

You'll see, they're wrapped in bright colours and have an information slip to explain where the money from the painted candle is going.

The joy of creating these advent candles that burn down 1cm each day of December (unless, of course, you forget to blow it out!) is that people tend to be very into 'tradition' at Christmas. Advent calendars and candles are part of the ritual preparation for Christmas, and people who have bought my candles for one year, come back the following year for more. Personally, I don't want cheap chocolate, or glittery nativity scenes. A burning candle helps me focus my mind and brings reflection on the important things about Christmas (and they're not 'things').

For each of my trips to Nepal, I have been able to boost my funds with these candles. In recent years, I have directed the candle funds toward my flight costs. Donations of money always go towards books and equipment to take in my luggage or towards student education in Kathmandu. But my candles are crafted, wrapped and sold after I have given my time, skill, and expenses. Most years, I have money left from the sale of candles to go towards transport costs, etc, while in Nepal.

Most candles are sold locally, and friends have taken bundles at a time to sell on for me. Some candles are posted, which costs just under £3.00 for five candles carefully packed into a Pringles tube. This year I will see how sales fare on Ebay. If you would like to buy candles for yourself or to gift to friends, please get in touch.

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

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

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

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

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

Our intention was to..

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

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

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

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

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

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

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

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

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

Checking out a donated TENS machine.

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

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

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

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

Some of their achievements....

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

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

3. Maintaining privacy for women.

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

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

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

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

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

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

work together!

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

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

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

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

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






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




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

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

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

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

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

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

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

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

The UNICEF earthquake hospital tent still here three years later.

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

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

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

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

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

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

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

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

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