Sarah Ardizzone and I met in Nepal previously during a project with the Royal College of Midwives. We are midwives from the UK and were selected to promote midwifery and support Nepal’s progress towards establishing profession competency, qualifications and regulation (Globally Recognised Standards for Midwifery, International Confederation of Midwives). Nepal has a high maternal and neonatal mortality rate, but is making great efforts to reach the Millennium Development Goals in these areas.
Before I move into the joys and trials of our recent trip with PHASE, I would like to set the midwifery scene for you…
Many women in Nepal give birth without the safety of a skilled attendant. The reason for this is partly cultural, but is much more due to the challenging mountainous terrain. PHASE Nepal employs Auxiliary Nurse-Midwives (ANMs) to live in villages as part of the work to support some of the most remote communities. The nurses’ skills are wide and varied, in fact rather than being called a nurse or a midwife, they might be more accurately described as GPs. Through PHASE, volunteer GPs from the UK visit the villages to provide ANMs with skill sharing and clinical supervision, which is invaluable.
PHASE places great emphasis on midwifery skill sharing – improving midwifery in a country reduces mortality rates far greater than just working to support Skilled Birth Attendants (SBA) (Lancet Series on Midwifery, June 2014). SBAs provide valuable obstetric emergency care, but midwifery helps to prevent those emergencies from occurring. PHASE has had regular support from midwives from Rotherham who have run intensive Obstetric Emergency courses for PHASE staff three years running. PHASE is now exploring the possibility of also involving UK volunteer midwives in direct on the job training for PHASE ANMs in the villages.
Sarah and I are staunch supporters of the natural birth process and the impact of midwifery on the whole family. This is not just about difficult births but also about risk prevention, education, emotional well-being, family spacing, etc. We negotiated our return to Nepal to pilot a midwifery teaching programme for PHASE which would be based in the villages, to create an essential on the job learning experience.
Our initial placement was in Hagam, Sindhupalchok, situated at an altitude of 2183m, with a population of 4,000 stretched over many miles, it was simply stunning. We stayed with Renuka and Suprina, both PHASE ANMs. They looked after us well and wouldn’t allow us to help with cooking, prep or water collection. The facilities were basic, as expected, but we were made comfortable. A wash bowl in the morning was really appreciated as our skills at the public water tap were limited and could have left (too) much to be desired! An electricity pole (read ‘rotten tree trunk’) collapsed during a storm, causing days of darkness, our head torches became even more precious. You don’t realize just how reassuring a mobile phone is until you don’t have one.
We joined Renu and Suprina for their regular community visits. Renu took with her a register and picture books to help with health education. We met a woman pregnant with her second child who planned to give birth at home. All was well, but her first baby arrived in a hurry. I wonder if our nurse midwife arrived in time for the second birth, and how it all went…
For nurses like Renu and Suprina, stuck in the outer regions of nowhere, prevention and early recognition of complications is paramount. PHASE Staff are encouraged to build on their understanding of how a birth should work, and how they can support the natural process.
Suprina administered drugs to a woman who arrived hardly able to breathe for chronic COPD (Chronic Obstructive Pulmonary Disease), caused in part by the continuous presence of wood smoke in the house, she was supported to stand by two men. This, and childhood complaints, seemed to be the theme of the day. The few antenatal checks carried out in the clinics allowed us to discuss how listening to women and giving verbal prompts to gain information can add to diagnosis and timely referral.
Some visits definitely had a social slant. The community were wonderfully accommodating of our quirky English ways.
We travelled on foot to an outpost for training with traditional healers. The men, and one woman, embraced the opportunity to learn from Renu and Suprina. Many locals would prefer to consult a traditional healer before seeking medical help and therefore it is important that things like hygiene, dangerous practices and early warning signs for prompt referral are discussed openly with the healers.
The second part of our journey, after a brief couple of days to freshen up in Kathmandu, took us to Ryale which was nowhere near as far or nerve wracking a trek as to Hagam. We travelled with several newly employed PHASE nurse-midwives, and a very big bag of training gear. Sarah and I were given a little room close to the village eating house. We were woken every morning by the bus letting EVERYONE know it was leaving for the city. By the end of our stay, we did appreciate the importance of this community service.
Our training sessions were extensive over the three-four days. Practical skills, theory, but also risk factors for prompt referral and prevention of birthing problems, were dealt with. We used the models and talked through scenarios relating to birth emergencies within the Nepali home setting. There would be no drip stands or emergency buzzers. There would be no doctors prescribing a magnesium sulphate regime for fitting eclamptic women. There may be just ONE pair of hands to deal with a serious haemorrhage. Hygiene facilities, lighting, space, back up plans would all be limited in these homes.
As much as possible, we used the actual equipment the nurses carry in their substantial kit bags for training. We could identify, while going through scenarios, exactly what was surplus to requirement, and what might be better kept together in the different compartments, to ease finding equipment in a hurry. We ALL had fun working through the Eclampsia regime, and we resorted to ‘phoning a friend’ when the dosage of magnesium sulphate couldn’t be worked out from the vitals. We played with making up a homemade condom tamponade for uterine haemorrhage. It got messy (and slightly raucous)! In seriousness, this is exactly why regular training and ongoing education is necessary for these nurses, indeed for us all!
Overall, I felt our trip was incredibly productive and worthwhile. Short blasts of training feel the right way to go when these nurses are busy with community needs. Hanging around to support at births is probably not the best use of our time as, thankfully, real emergencies are few and far between.
Sarah and I look forward to repeating similar work early in 2015, and I hope PHASE will consider giving not only us another opportunity to work with them, but encourage other UK midwives to offer their knowledge and skills too. It was an honour to support those small communities, and their fantastic ANMs who are out there, away from their families, putting their hearts and souls into making a difference. Those girls are real life, every day heroes.
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