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Small steps bring great changes

Small steps bring great changes

Community midwife Clare Stephen reflects on her experience as a midwife volunteer in Nepal.

I first travelled to Nepal in my youth and had always hoped to return one day to work and do something useful. I’d spent the last year looking into volunteering with various non-governmental organisations and began with rather grandiose plans, which I soon realised were perhaps a little too ambitious for a novice volunteer like me. Then the Global Midwifery Twinning Project (GMTP) came along and I jumped at the opportunity. The overall goal of the GMTP is to strengthen and stimulate the potential and scope of Nepal’s midwifery association, MIDSON, to raise standards of midwifery education and practice.

We arrived in Kathmandu after a long and fairly uneventful journey and we then travelled by taxi through the crowded streets to our hotel in Patan – a suburb of Kathmandu.

For the first two weeks I was based at the government-funded Paropakar Maternity and Woman’s Hospital (PMWH), which has over 20,000 deliveries a year. I was working in the birth centre where the low-risk women have their babies and are cared for by the nurse/midwives who have had additional training as skilled birth attendants (SBAs). Women are given a monetary incentive by the government to encourage them to birth in a healthcare facility rather than with no SBA at home. The nurses have good theoretical knowledge, but don’t have true autonomy as the doctors assess and admit the woman in labour and prescribe their care.

On the first morning, we were introduced to the matron and the nurse supervisor and given a tour of the hospital, including the ‘Kangaroo’ ward where premature babies are nursed by their mothers before being discharged home.
The birth centre had eight cubicles with metal beds separated by partitions and no curtains, providing little privacy and minimal creature comforts. However, the women were allowed their husbands and family members to be with them in labour, which is not allowed in the high-risk ward.

The nurses were quite task-orientated, carrying out the doctors’ instructions, and they didn’t seem to spend much time being ‘with woman’. Many women there have their labours augmented, with only intermittent monitoring of the fetal heart. They don’t have the equipment to continuously monitor the baby and this means that the doctors will often intervene to perform a CS if there is any delay in progress.
Our role as volunteer midwives in Nepal was to advocate respectful maternity care and the midwifery model of care, to encourage the nurses to empower and ‘be with’, rather than ‘doing to’ woman, supporting and encouraging her to have confidence in her ability to birth naturally, adopting upright active birth positions and avoiding unnecessary and potentially harmful medical interventions.

On my first day I was able to assist with a woman in second stage of labour. She was lying supine, becoming increasingly distressed and unable to push effectively. The nurses shook their heads and said ‘poor maternal effort’. I suggested we help her to turn onto all fours and massage her back, which had the instant effect of calming her and easing her pain. She could then bear down with gravity assisting and deliver her child in full control. It was beautiful to behold and the mother, the sister and I were all crying. The women looked up and smiled at me and said thank you, and I thought this is surely the best job in the world. From then on, the SBA trainees and nurses warmed to me (initially they had been a bit wary) and, by the end of my shift, we were exchanging email addresses.

The day after our arrival, we were invited to meet Kiran Bajracharya, president of Nepal’s midwifery association MIDSON, as well as Sajana Ranjit, MIDSON’s treasurer. We were presented with fruit and flowers and a white scarf, in the traditional Nepali way.

Each day I was invited at 1pm sharp to have lunch with the sisters and matrons in their office, where we were served freshly cooked food by their personal cook. There is an old-fashioned hierarchy here, based on age and credentials, so the doctors are in the highest echelons, but the matrons come not far behind.

During my time at the PMWH I was able to ‘be with’ four labouring women and witnessed their babies being born in the birth centre, as well as doing an opportunistic teaching session (by request) on breech delivery with a smaller group of SBAs and my fellow volunteer, Jaki.

We also did presentations on respectful maternity care at the PMWH, Tribhuvan University Hospital (where Jaki was based) and at Patan Hospital, linking it in with the topic hormones of labour, and combining this with a massage workshop and short yoga session. These continuing midwifery education sessions were attended by more than 70 SBAs, nurses and sisters, and resulted in much laughter and hilarity. The practical sessions were a great way to melt the ice.

We also visited the APS Birth Centre on the outskirts of Kathamandu where the nursing director of Patan Hospital and co-founder and chair of the birth centre, Rashmi Rajopadhyaya, showed us around. Established in 2007, it is the only independent nurse/midwife-led birth centre in Nepal and provides free reproductive health services to local urban poor families. Their vision is to promote natural birthing centres in Nepal, to offer a site to train and support compassionate SBAs, including nursing students, and to provide quality, cost-effective, round-the-clock maternal, child and reproductive health services. However, they are struggling financially and have recently had to stop providing a 24-hour service.

Nepal has a strongly patriarchal society and the status of women is low. This, coupled with the complexities of the caste system, means that women’s issues are low on the political agenda, especially when it comes to developing a midwifery profession, for instance. The enormity of the issues can feel overwhelming, but small steps will bring great changes. The president and members of MIDSON are passionate about midwifery and improving maternity care for women and babies in Nepal. They even held Nepal’s first midwifery conference in September, with help from the GMTP.
Volunteering with the GMTP has been an excellent and inspirational adventure.I have learnt so much about midwifery in a global context and I have been both humbled and proud in my role as a volunteer midwife. I feel we are privileged to be able to help the good women of MIDSON realise their vision in bringing midwifery to Nepal and to gain so much ourselves in the process.

Clare Stephen
Community midwife based at the Bonnyrigg Health Centre