Reproductive Health Camp Bhaktapur

Today we attended a reproductive health camp with an emphasis on cervical cancer screening using VIA in a village in Bhaktapur. It was organized together with MIDSON, UBC Global Midwifery, the community health worker for the village, and the Family Planning Association of Nepal.

Sudal outside of Bhaktapur

Health Post in Sudal 

Some posters in the Health Post

VIA (Visual Inspection with Acetic Acid) is a method of screening for cervical cancer that has been proven to be very effective in low resource settings.

The procedure consists of a vaginal speculum exam, a cervical swab with normal saline, and then the application of 3-5% acetic acid solution to the cervix. This is followed by a visual inspection of the cervix using an adequate light source.In the presence of cervical cell abnormalities the acetic acid will cause the affected area to turn white with well define margins, attached to the squamocolumnar junction. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4478664/

We arrived mid-morning and spent about an hour setting up the different spaces we needed. We had two exam rooms, a room for history taking, a room for dispensing the various medications MIDSON brought and a room for Mickey to hold an education session with the community health workers. Additionally we set up a registration area where the women registered, and had their weight and blood pressure taken.

After registration the women waited to have their history taken before being sent to the exam rooms.

As we were setting up the women started trickling in. They had expected 150 but we ended up seeing 83 women. Of the 83, 2 had a positive VIA test and one screened positive for cervical abnormalities, most likely HPV.

Many of the other women reported vaginal itching, discomfort and discharge. These women were given antibiotics and some of them were counselled to have their husbands tested and treated as well. In many lower income families the husband works outside of the country, and there is a rise in STI/HPV/HIV in Nepal do to this, as the men are visiting sex workers while working away.

We took turns observing the history taking and the exam rooms and had the opportunity to see a positive VIA test. The women who screened positive were referred to the local hospital for further testing.

It was very interesting to participate and learn more about the work that goes into organizing a health camp. 

After participating in our first reproductive health camp, from our observations these are the areas of women’s health care that still need improvement:

Getting informed consent

Making sure the women understand why certain procedures are being performed

Using sterile water or lubricant for speculum exams and pelvic exams

Adopting gentle but effective insertion techniques for speculum exams

Maintaining women’s privacy 

Maintaining confidentiality 

Following the VIA protocol accurately

Use of adequate lighting

We are grateful to MDSON for organizing this opportunity for us.

Refresher Workshops in Phaplu

On May 12th we held a two-hour workshop for the ANM students at Phaplu hospital. We taught through role-playing clinical and counselling skills. First we demonstrated slow delivery of the head, active management of third stage of labour, skin-to-skin, and delayed cord clamping. The second role-play was to show how to educate mothers in the antenatal period about breastfeeding and proper latch in the postpartum. This was considered important to teach as it is common for first time mothers to experience breast abscess’s here in Nepal. Jenny brought out her brilliant tips and tricks for teaching breastfeeding.

The second day we provided a similar two hour workshop to the staff nurses at Phaplu hospital. When we asked the head nurse what topic we should focus on, she requested PPH and uterine inversion. The hospital recently had a case of uterine inversion resulting in maternal death. The nurses were keen to learn how to prevent and manage a similar situation in the future.

Our time in Phaplu has been short because of us being sick in Kathmandu and the time in which it takes to travel here. We wish we could spend more time getting to know the students, nurses and doctors. We have so many ideas and hope we can make plans for future work in the Solokhumbu region!

Back to Phaplu: Going with the transportation flow

May 11, 2018 

Our drive from Sotang to Phaplu was eventful. We had booked a jeep for 7:30 am but for a number of reasons we did not leave Sotang until 9:30. We said our goodbyes to Chaita, Shreedhowj and Babita, and off we went. 

We asked our drive to stop at the Dudh Kosi so that we could take pictures. 

We had a gorgeous view of the mountains as we drove up the mountain to our tea place.

The ride was smooth and we were making good time when we were stopped by a tractor that was blocking the road. It had run out of gas and the driver had just left it sitting there. After an attempt to make room for our jeep to drive around it (which did  not work) we suggested that the driver put the tractor into neutral and back it up and off to the side of the road. A number of young men, our driver included, pushed the tractor off the road and off we went.

Shortly afterward we stopped again as there was a line of jeeps parked on the side of the road.

We quickly learned that there was a large landslide the day before and they were still working to clear the road. The jeeps in front of us had been waiting in their jeeps all night for the road to reopened. 

We got out and walked around. We met a local woman, who recognized Pema as the nurse who had taken care of her sick relatives at the hospital. She made us coffee and gifted Pema with a bag of her home grown millet. Our driver told us it would be cleared in 1 hour, almost 4 hours later we were on the road again. It was just about dark and our driver was clearly impatient to get to Phaplu. We had to remind him to drive slowly after he drove too fast around a corner and almost hit another jeep.

There was lots of traffic and the road was very dusty. We finally made it to Phaplu by 7:45 pm. Just in time for a delicious dinner of chicken momos prepared for us by Rashmita. We were so happy to be able to shower and sleep in extremely comfortable beds after being in the jeep all day.

Distance travelled 80 km. Duration of travel: 10 hours

Sotang Womens Group

We really enjoyed our time in the remote, yet very lively village of Sotang. We spent time meeting with different people and groups including the local health council discussing future plans for a maternity waiting home, and the possibility of having cesarean section at the health centre in the future. By chance we also had the opportunity to interview the new ANM from another very remote village called Gudel. She started working at the Gudel Health Post 8 months ago and has assisted in 18 deliveries. She shared with us her challenges, her successes, and reasons she refers women to higher centres like Sotang, Phaplu or Kathmandu. The main complication she has dealt with is women arriving with retained placentas after giving birth at home. Using her oxytocin, experience, and clinical skills she is usually able to save these women's lives.

Jenny, Cathy, Pema, Hari (ANM from Gudel), and Emma 

One evening we hosted the local women's group for snacks, conversation and to watch global health initiative videos. We learned that the women's group began when a local woman needed to be helicoptered out for an emergency cesarean section and had no money to pay for the up front cost. The government will reimburse people for these expenses, but it is more money than most people have available ,and the government delays, sometimes never paying the money back. This group of women came together and started a community based lending program for women in their community in similar situations. The group meets each month and is also fundraising to build their own women's centre.

The 15 women who joined us were shopkeepers, teachers, university students, farmers, and hair stylists. We asked them what their community of women need, and they all agreed that they want a female doctor and for women to own land. Among the different groups in their community, it is most common for land to be only owned by men and inherited by men. Their own land and centre would allow for them to create a safe place to continue supporting the women in their community.

Sotang Primary Health Centre

May 7-11th 2018
From Phaplu, we hired a private jeep to take us to Sotang. Pema, a retired Nurse and Midwife, joined us to help translate and support us. We also had a wonderful cook, Chiyta join us. All of us crowded into a jeep for a 6 hour drive through a long steep, dirt mountain roads.

We stayed with the very hospitable community health worker Shreedhowj Rai and his family. Shreedowj was originally chosen and trained to be one of the first community health workers in his village by Sir Edmund Hillary's foundation.

Mickey, Cathy, Jenny, Emma, Pima and Chiyta in Sotang

The Primary health Centre was just a 15 minute walk from where we were staying. They had 75 births at the birth centre last year and that number is lower this year, which is likely due to the fact that women in the nearby village of Gudel can now give birth at the health post there with the support of SBAs and an ANM. We met the ANMs at Sotang Primary Health Centre and were invited to observe the doctors as they conducted clinic. It was very interesting to see the different complaints. There appeared to be an outbreak of chicken pox in the community as we saw three children who were affected. According to the doctor this is common for this time of year.

Sotang Primary Health Centre as seen from the Helicopter pad. 

We also participated in antenatal visits. The women were first seen by the doctors and then went to see the ANMs for a more thorough antenatal check up. There is ultrasound at Sotang Primary Health Centre and they use it for a variety of reasons: dating of pregnancy, fetal position, to check for fluid levels, and more. They can also order full bloodwork, urine and Liver Function Tests, which makes screening women for things like pre-eclampsia much easier.

Women in Sotang can access Family Planning and CAC/PAC (comprehensive abortion care/post abortion care) although we did see in their referral book that some women are sent to a higher centre for incomplete abortions, despite having trained staff on site. One woman did come for CAC while we were observing. She had 3 children already and did not want more. She requested a medical abortion and insertion of a IUCD (intrauterine contraceptive device) (IUD in Canada). She was counselled, had a dating ultrasound, was provided with the medication, and was counselled on what to expect in the next 48 hours, when to come in, and when she could have the IUCD inserted.

On our last day in Sotang, the plan was to teach an afternoon workshop. When we arrived at the health centre, a woman was in labour. Mickey continued to teach the workshop, while Jenny and Emma provided labour support. She was in labour with her 8th baby. Together with Pema translating for us we discovered that she had a urinary tract infection that had likely triggered her labour. We continued supporting her throughout the day and evening.

At one point we stepped out for some dal bhat, and missed the dhami (shaman) arriving and providing some rituals to encourage the baby to come. After many hours of irregular contractions with little cervical change we decided that the mother should try to sleep and maybe more active labour would pick up in the morning. We also needed some sleep since we were waking up early the next morning to drive back to Phaplu. The next morning we learned that the mother delivered a couple of hours after we left! We were disappointed to have missed her delivery, but very happy to hear that she had her baby and that it was a girl, as she had 6 boys at home!

Sotang Primary Health Centre

The labour and postpartum room before we bought new mattress and sheets. 

Us with Pema and the ANM's next to the sheets and pillows we purchased for the health centre. 

Delivery room at Sotang Primary Health Centre 

Scale and frame built by the community to weigh babies as part of the super cereal program. 

A rose bush, Shreedhowz planted outside of the Sotang Primary Health Centre

Sotang Bound

On May 7th we got up early to take a private jeep to Sotang. The jeep was not quite ready when we were but that is not untypical for Nepal.

The jeep driver was not sure if we could fit all of us and our bags on top of the jeep but he and Chaita managed to squeeze it all on top.

It was sunny and clear with only a few clouds, which was reassuring as it is not uncommon for there to be many land/mud slides on the road between Phaplu and Sotang. It is about 80 km from Phaplu to Sotang and the estimated driving time is between 5-6 hours depending on the condition of the road and how many times we stop. 

The road was quite bumpy initially and we only got about 15 minutes down the road before the driver informed us that there was something broken and he had to stop to get it fixed. So he stopped at the mechanics and we waited while they fixed the jeep. Cathy made friends with the local baby goats and Mickey and Emma went for a walk. The jeep was repaired faster than we expected it to be and by 10:30 we were on the road again. 

We passed some old Mani walls and some beautiful stupas on our way to Nele. When we got to Nele we had to stop and wait for them to clear the road. We had some dudh chiya (milk tea) and were on our way again. Two delays down and we weren't even 1/3 of the way to Sotang. The road was better after Nele. Still a dirt road but less rough. We stopped again for dudh coffee and some snacks that Pema brought and were on our way again. 

A local mule

We wound our way down to the Dudh Kosi (Milk River). It is such a beautiful shade of blue. Last year Cathy, Mickey and the students hiked down to the river and took a raft across, but now there is the new road and we drove through the river. We were looking forward to the raft so were a bit sad.

Dudh Kosi

We had a short stop as there was some construction on the road. They were breaking the big rocks into smaller pieces and then pushing them down to make the road.

Construction

We continued on our way and arrived in Sotang at about 5 pm. We were warmly greeted by Babita, our host and served more yummy dudh coffee. 

The main street of Sotang

Chaita got settled and then started preparing our dinner. It was so nice to know that we did not have to worry about eating the food served to us. Being sick is no fun and neither of us was keen to get sick again.

Distance travelled 80 km. Duration of travel 6.5 hours once the jeep was fixed.

Into the Mountains- Phaplu

Views of white-capped mountains at last! 

We arrived in Phaplu on International Day of the Midwife, after a long 11-hour jeep ride from Kathmandu. As soon as we arrived we were greeted with fresh mountain air, warm Sherpa stew, and the kindness of Pema and her family. Phaplu is a small town at 2400m, surrounded by what we call mountains, and what Nepali's call hills.

Mickey in front of the new Phaplu Maternity Hospital

We spent our first day in Phaplu visiting their brand new maternity hospital, parts of which are still under construction, that just opened two weeks ago. The hospital was built with the supervision of a local doctor, Dr Mingma Sherpa, with international funding. There are between 250-300 births in Phaplu annually, however the cesarean section rate is 45% which is something that needs to be addressed. There are two doctors working in the hospital at this time, and only one performs cesarean sections. So if he is away, which he is frequently, then they have to refer women to other centres for cesarean. Most of the births are conducted by Auxiliary Nurse Midwives, who will consult with the doctors when required.

In addition to a new labour room, delivery room and two operating theatres, construction is also underway for a new postpartum ward and a NICU that will have one incubator and a nice room for the mother to be close to her baby. There is a nurse who has gone to Kathmandu to be trained in the care of the unwell/preterm infant. The plan is for here to be able to provide the care in the NICU. We discussed the importance of emphasizing basic skills like IV insertion, being able to insert a feeding tube and kangaroo mother care. Dr Mingma is quite passionate about providing these services in his community.

After our tour of the new facilities we sat in to observe immunizations. There were dozens of women waiting with their 18 month and older babies for immunizations, and to collect super cereal. The super cereal program occurs once a month. Babies and children are weighed, and each pregnant and lactating mother goes home with a 7kg bag of super cereal consisting of wheat, soya, sugar, and a micronutrient mix of vitamins, potassium and calcium.

Some women were carrying their babies in baskets with straps over their heads, others had modern front baby carriers, some back carriers with metal frames. The babies were so chubby and bright, healthy from the local agriculture and super cereal.

Entrance to the Maternity Ward 

Delivery Room

Delivery bed. 

Phaplu

Baby Buddha

April 30, 2018

On Buddha's Birthday we spent 6 hours at the T U Teaching Hospital Birth Centre. This birth centre is a collaboration between MIDSON and Tribhuvan University Hospital. The intention behind the birth centre is to have a centre for low-risk women to deliver with Auxillary Nurse Midwives (ANMs). Women who arrive at the hospital in labour are assessed and are sent to the birth centre if they meet the criteria for delivering there. The birth centre has about 3 births each day.

Compared to the birth centre, the labour ward of the hospital has about 20 births each day. The caesarean section rate at the hospital is 59%. The majority of nulliparous women will have an episiotomy when giving birth. It costs women and their families 5000 R (500 USD) to give birth at the hospital and birth centre.

When we entered the maternity ward we walked past the post-natal ward. All of the beds were full and there was a busy hum of noise. The women are dressed in their own clothes and many of them were wearing their red kurti or saris. It is like a room full of colourful flowers.

The birth centre is down the hall from the post-natal ward. It is much quieter but also very colourful. There are brightly coloured blankets on the mattresses, which are on the floor, and draping the equipment not in use.

The birth centre is very different from the labour and delivery wards we have seen at other hospitals. The mattresses were on the floor, with lots of comfy foam wedges and pillows. There were also several birthing balls and posters to encourage women to move around in labour. It was very refreshing to see such a warm inviting environment to give birth in.

There are two rooms in the birth centre. One room is for the women who are not yet in active labour. There are 4 mattresses on the floor for women to rest on, and  large windows, that brighten the space.

Across the hall the labour room also has 4 mattresses on the floor. There are stools for staff and family members and there is a birthing ball for each bed. Each bed has nice and clean privacy curtains that can be draw around them. It is clear that a great deal off effort has been made to create an inviting atmosphere in the birthing centre.

There are posters on the wall describing respectful childbirth, comfort measures and positions for birth, Helping Mothers Survive and Helping Babies Breathe.

Kiran, the president of MIDSON, asked us to read the policies and guidelines for the birth centre and to write an observational report of our time in the birth centre.

A woman arrived in active labour, about 30 minutes into our day. She was pregnant with her 3rd baby and was 8 cm. We introduced ourselves and with her permission began providing labour support as we were not there to provide clinical care.

She quickly progressed with the support of us, a UK student midwife, and a staff nurse. Within two hours of us being at the centre, she delivered a chubby baby boy. To us, born on Buddha's birthday, he was Baby Buddha!

After welcoming this "Baby Buddha" into the world we ventured out to Boudhanath Stupa in Kathmandu. It felt like the perfect day to visit this world UNESCO heritage site on Buddha's Birthday. It was meditative to walk around and around the giant stupa with hundreds of others. We arrived just in time to eat a late lunch with a view of the parade involving school children and monks.

Our day finished with a lively discussion with an organizer from the NGO HESS and a doctor from the government hospital in Phaplu. Health and Environmental Society of Solokhumbu is a non profit organization working towards better health care and education in rural Solokhumbu. We learned about some of the programs they have established such as a nutrition program that provides a super cereal to pregnant and breastfeeding women and children. It was important to meet these individuals and learn more about the Solokhumbu District of Nepal, where the next leg of our journey will be.

Status of Midwifery and Reproductive Rights in Nepal

Some shots from our short 2 day trek in the Annapurna Region 

As we have been sharing little nuggets of information about midwifery, childbirth, and women's rights in Nepal, we thought we should backtrack and share a short summary of the status of midwifery in Nepal.

The association of midwives of Nepal (MIDSON) was formed in 2010.

Midwives are not yet recognized in Nepal. Midwifery services are provided by nurse-midwives regulated by the Nepal Nursing Council. And most care providers delivering babies are nurses or doctors. The goal of MIDSON is to advocate for more midwives through education and advocacy of the midwifery profession.

How can midwives make a difference in Nepal?

• Midwives with the education outlined by the International Confederation of Midwives are experts in normal, physiological birth.
• Midwives provide care during pregnancy, labour, birth, and postpartum. 
• Midwives provide respectful care with the philosophy of informed choice discussions.
• Midwives usually provide continuity of care, meaning they meet and know their clients and their unique needs before they are in labour. 

The MIDSON mission statement is:
"Striving for healthy women, healthy babies and a healthy nation by strengthening the midwifery profession." 

The MIDSON website talks in detail about midwifery in Nepal.

• From 1996-2006 there was a civil war in Nepal between Maoist rebels and the government. Because of this the health care system in Nepal is poor. 
• Women are still viewed as lower status than men. 
• In the 1990's the Nepal health system invested in training of Auxillary Nurse Midwives (ANMs) and Maternal and Child Health Workers (MCHW). 
• Beginning in 2006 the Nepal Government trained thousands of nurses ANM's and physicians as Skilled Birth Attendants (SBA's) in order to provide safer childbirth in rural and urban areas. One of the main challenged has the continued education of SBA's and being able to train enough SBA's to a level of competency. 
• Currently there are two Bachelor of Midwifery educational programs in Nepal.
• There are four more programs currently being developed. 
• One of the concerns with some of these programs are that they are more of a nursing curriculum than midwifery specific. 

The women of Nepal have made great strides towards more reproductive rights over the past decade. Abortion was legalized in 2002 and is a major contributor to the reduction in the MMR from 548 maternal deaths per 100,000 in 2002 to 258 maternal deaths per 100,000 in 2015. The other factors that have contributed to the MMR reduction include: the construction of roads, empowerment of women during the tie of the maoist insurrection, and the Aama Program of Nepal that provides women with monetary incentives for attending antenatal appointments and for travel to a facility-based birth.

Although there are still so many barriers to women accessing safe effective health care in Nepal, there have been many successful initiatives. We saw first hand how the education around family planning and legalization of abortion has been successful in some communities. Our observation was in the public Baglung hospital. A young, illiterate woman from a poor family traveled over several days to access a medical abortion. She was counselled on her options and was provided with both a safe medical abortion and a hormonal contraceptive transplant that is effective for 5 years. The nurse that was providing her care is an Auxiliary Nurse Midwife with the additional SBA training. We worked closely with her during our time in Baglung. She is a very smart, compassionate, motivated individual who has well served her community with her government funded training. 

More pictures from our trek to show you the state of roads and the mere vastness of rural Nepal. 

For more information you can check out the following websites:

http://www.who.int/gho/maternal_health/countries/npl.pdf
https://www.dhsprogram.com/pubs/pdf/fr336/fr336.pdf