Yesterday we had a vacation day to Rara Lake. In the 2 days prior the fine dust had become suspended throughout the entire valley. It coated the view - almost like a thick smoke from a fire. We were hoping to get above the dust by going to Rara. We first drove up the road past the aiport and then turned off to continue up towards the lake. Have any of you ever been on the Indiana Jones ride at Disneyland? Driving here is like that, except the thrill is greater because you are not on a track and their is always a cliff to role of if the driver makes a wrong move. ;) At a certain point we got out of the jeep and then we continued on foot. The dust in the air was much less and we could breathe in the air of the forest. The lake is very large and beautiful. When we arrived the horses were grazing on an open space by the beach. Across from us there appeared to be a village - a few people were there grazing their animals. We got our feet wet in the cold lake - it was refreshing. Then Pema and I went for a hike along the lake. On our walk we were able to see some rhododendrons even though the season is almost over. It was nice to get out in nature - away from people and the dust.

Today the sky has cleared a bit and the plane came in which we are happy about, hopefully it holds and our plane will come in to take us back tomorrow. Cathy, Nani and I will go and Jill and Pema will stay to go to another community that is at least a 6hr walk away. Today we went to Karkiwada, a small village near Gamghadi where we are staying. It is a very poor community, however they have a birth centre. It was built after there were 2 maternal deaths in the community and the community then rallied together and asked for a birth centre. It is funded by a German - local NGO partnership. 2 ANMs work there. Both were in our training the other day. When we arrived no one was there, but within 10 min the place was full of women. We decided to interview them in focus groups so they would not have to wait as long. At first they thought we were there to hand out medicine...apparently white people, trekkers etc. just give out medicine. I think that is so irresponsible...to give out medicine without really understanding what the health problem is or being able to provide follow up. One of the mothers wanted us to help her baby with scabies. We told her she should take the baby to the health post or hospital as we were not providing medical care, only asking questions of the community because we believe that solutions to problems in the community will come from the community itself.

Some very engaging female leaders.

The focus groups went very well. The women seemed eager to share their stories. I have been given permission to share some general information from our research over the past week which I think you will find interesting. In the past here there has been a cultural belief that women who are menstruating or who are giving birth will pollute the household. Therefore they were not allowed to be in the house and had to go to an outside place, usually where the animals were during the time of their period or for birth. This place called the Goath, and whether it is still used is of interest to us when talking about birth planning preparedness. Because of the pollution women often delivered alone. The government of Nepal does not condone this practice and we are curious if it is still happening. Some women say, no, it is not happening anymore and others say it is. From what we gather, although some people still do use it, is is less common now, especially for birth as women are going to facilities more often to birth (where facilities exist). Women who live far from the birthing centre and those who deliver at night often still deliver at home. For menstruation, being in the Goath still happens, but for most families the women are not in the Goath with the animals, they are in a separated room on the house. We are informed that this is better because the women are in the home or very near it and there is less concern for their safety. Having seen the old Goath where the animals are and the new one attached to the house I would say so too.

Room below house is old Goath, tin room above is the new one.

                                                                                                              Gamghadi traffic jam!

One of our questions is about decision making. Who makes the decision about where a woman will give birth? Who needs to be educated about safe birth? (In my own words, who has the power?)  A few people say they make decision collaboratively. Mostly however it is Sasura, Shriman and Sasu. Father in-law, husband and mother-in-law. Women seem to have very little say in what happens in their lives. So there is change, but as always, change is slow. I keep thinking that the men must be part of the change. There has to be some men who look and say, it is not right that we control everything the women do,  that women deserve a say in what happens to them. In everything women should have a say, but especially in menstruation and birth. When we talk to women and ask questions it is very obvious that the key to a better life for women truly is education. The women who are educated, they can articulate problems and solutions - they have critical thinking skills and they are keen to make change in their communities. The ones with low education when probed for solutions to problems have a hard time understanding what we are even asking them about and find it difficult to articulate solutions. This post is dedicated to the many incredible women we have met over this past week in Mugu. It is their strength in the face of great adversity, it is their push for education for themselves and their children that will continue to improve life for women, and all people in this region.

Visit to Pinna village

April 26

Today we were able to hire a jeep and visit Pinna village to meet with mother's and FCHVs from the district. We set off in the morning - 6 of us - driver made 7 in a 5 passenger jeep. Tightly packed we headed out on the windy, one lane, road. Sometimes the road is thick powdery dust - Jill said icing sugar - and that describes it perfectly! Sometimes there are stones. We wind up and up and up - past the airport and continue on around the corners. On driver is very confident in his jeep driving skills, sometimes he talks on his phone whipping the wheel this way and that with one hand to make the very tight corners. We had been told 30min drive to Pinna. 1hr 15min later we arrived. I personally prefer walking, but  we would not have made it to the community and back in one day without the vehicle so we were glad for it!

When we got there we walked down the community and ran into one of the ANMs from the course who led us to the birthing centre! We were able to meet with both the ANMs who were at our course and the health post leader and do an assessment of the birthing centre facilities, equipment and numbers. We then split into teams (I am the floating 5th wheel - learning from both Cathy and Jill) to interview the ANMs, and the mothers who came. Once that was done we split the FCHVs into 2 groups and did focus groups with them. I cannot talk about what we heard, as that will need to be analyzed as a part of the study, and will be published at a later point. But I can say that is was an interesting and rewarding experience. We got to spend the day in a rural community and hear about birth practices in the community and surrounding area. I like talking to women and hearing their stories and experiences. I even got to palpate a belly - cephalic position and hear a heartbeat! It made me excited for what is still to come - our clinical experience in Baglung.

On our way home our driver was late, he was leaving Gamghadi when he was supposed to be meeting us. So we decided to walk towards him. This time we were to talk the lower road. We had a nice walk in the valley, meandering by the river. We met a family at a stop along the way. There was a young mother there with a 3 month old baby. She told us that she had her baby at home and breastfed confidently while we were sitting there. I hope that in Nepal's efforts to reduce maternal and neonatal mortality that they don't forget that other things matter too. Respect, autonomy, choice. Our driver finally met us when we had reached a village. And then we discovered that although the lower road doesn't have the up on the side of the mountain fear factor, it has its own challenges. Steep forward pitches and side pitches were very common. And yet we made it back in good condition and lightly powdered. Showers and dinner and bed time for us as all of us except Jill are going to see Rara Lake tomorrow!

Because women matter.

April 24 & 25

Teaching in Mugu

For the past 2 days the team has been very busy in a room at Gamghadi teaching hospital. Joining us are 18 ANMs (Auxillary Nurse-Midwives), a few who are SBA (Skilled Birth Attendant) trained but most who are not.

We spent the first morning teaching about giving good care in labour, normal delivery and different positions for labour and birth, active management of the 3rd stage with delayed cord clamping. Many of the birth positions were new, as was delayed cord clamping for many. They were enthusiastic about the hands on learning. I got to be a living mannequin all day so I had many many babies! As my midwifery colleagues know even though I am a G0P0, I make a pretty convincing labouring woman. :) The rest of the day Nani worked with them through labour management and use of the partograph and a session on the 4 recommended antenatal visits. After all that was finished Nani and Cathy as a team, and Jill and Pema as a team were able to interview 6 of the ANMs for our research project.

On day 2 we reviewed the key pieces for birth planning preparedness, Helping Babies Breathe (WHO NRP), postnatal care, 8 danger signs of the newborn and care for a septic baby, management for postpartum hemorrhage and respectful maternity care. We had hands on practice today as well and had stations at the end to practice skills from the 2 days. Most people who participated seemed very interested in the training. Many were taking notes during the presentations and all were eager to do the skills practice. I enjoyed doing it. Their feedback was that they appreciated most learning the different positions in labour and delivery, somersault nuchal cord delivery and all the demonstrations and hands on learning experiences. In the future they would like more training on degrees of prolapsed uterus and treatment options as it is a major problem for women here. Afterwards we were able to do 7 more interviews.

My mood vacillates. Mostly I am so excited and grateful for this opportunity. And sometimes I am overcome with sadness over how unjust it is, this life. Some of us with so much ability to move and chose and do and be. And so many others who choices are very very limited. The mixture of teaching and research I really appreciate about our work here. We hope that the research will be useful to the government in reaching the women and babies who desperately need more resources and that it will be the voices of the women who are able to tell the government through the research project what their needs are. And I loved teaching. I have skills, they save lives and I am able to share them. It is incredible.  We have shared so many good things, all of the team, with the women. If they take even just a small amount with them I feel like it could make a difference in their practice.

After the training the project provided the required per diems, as set by the government for organizations offering training to cover the cost of travel and stay while the women are away from their communities. The longer the walk, the larger the stipend. However, the stipend is very large. From a health systems perspective I find this perplexing. I think providing a stipend to cover food and travel costs seems very reasonable. Likely none the women would be able to afford to come otherwise as they are very poor, and very remote. However, the amount that we were required to pay seemed too high for a stipend - for some it was half to one months wages.

Part of what we were hearing when the ANMs were role playing with pregnant mothers is them trying to coerce them into coming to the birth centre for their safety or bribing them, because the government pays them if they come to 4 antenatal visits and for 'travel' if they birth in the centre. They also pay the FCHVs (Female Community Health Volunteers) a stipend when they get women to come. Coercion and bribery are not part of midwifery care. We emphasized in our training that the most important thing is to be kind to the mothers. Let them know you are there to help them and bring them to you with your kindness and care and skill. But today I felt a little bit like we bribed them to take our training. And I think if they are interested in the training we should help them attend, but if they are not what is the point in bribing them? We were sharing a gift of knowledge, which we heard many times today is lacking here. They said they rarely get new information. So then to have what seemed to me like a bribe attached makes me feel uncomfortable. Research elsewhere has demonstrated that in order to have change happen, a community needs to believe in it. No matter how much money or talk or whatever, if the community heart is not there, change will not be made. But if you can offer something the community values, and they are requesting it and get behind it then change can happen. A public health example is giving out mosquito nets in malarial communities or charging a small amount for them. In places where a small amount was charged and the education was provided, more mosquito nets were used in the correct way. When they were free, there was little value and people used them for fishing nets, other uses or not at all. I feel this is almost a universal truth. In Canada if I pay even $10 to attend a seminar, I am more likely to attend then if I sign up for a free one unless the topic really really matters to me. I would hope that all the women would have attended with only a stipend and not such a large payment, but we don't know.  This isn't a criticism of the women. If anyone deserves money it is these women who came so far for training. These women work in remote communities with little to no support and very little appreciation - they have pressure from the government and from the community and bear the responsibility from both sides for bad outcomes, even when we know that some are not preventable. They are such strong, brave, intelligent women. My concern is the system set up by the government. Why would the government put in this policy? Why do they think pregnant women and ANMs need to be bribed to come to care and to training? Should not the focus be on provided good education, resources for their work and support? As a midwife I trust women. I trust that they will make the right decision for their families, and that information should be shared kindly. I know that my role is to provide compassionate care no matter where a woman chooses to give birth. I am not sure that at a systems level the government and health sector here feels the same way. I am not sure our government or health sector does either. The challenges of doing cross-cultural cross-socioeconomic work! Global health work is definitely is a difficult, messy thing. The hardest part for me though is sitting with the knowledge that women are not valued, respected or trusted.

Now more about Gamghadi and the Mugu region. Poverty is the standard of living here. The land is very dry and does not produce much. Mugu district is very isolated from the capital of Kathmandu. And being that Nepal is a low resource country, this area sees even less resources than other parts may. As we do our research though, we are discovering that many NGOs from Germany, Korea and elsewhere are interested in helping to improve maternal and child health here and there is a patch work of programs. We have met one friend Bir Bahadur who is Nepali and working for a Korean NGO to improve facilities and equipment in them. We will know more once the research is finished but it is quite curious all the different levels of services and providers. There are pumps in the town where people get their water but most houses do not appear to have running water and the toilet facilities are outhouses with the typical squat toilet. I am not sure where the waste goes once the tank underneath is full as there is only 5 vehicles around town and perhaps 2 tractors.
No garbage services either and so the garbage is burned or dumped over the hill, with animal and some human waste as well. There is not very much water. The river is way down in the valley bottom. Some people have chickens, goats, cows and horses and they grow barley, millet, corn and potatoes primarily and other vegetables too. The main street through town, the bazaar, currently has a road-building crew. The men chop the rock out of the mountain by hand, carry it on the horses and lay it in tight rows. It is a very beautiful road. The houses are very well built out of stone, excellent craftmanship! Did I mention it is very dry and dusty?

This morning I saw large birds off our deck. Huge birds...we think they are some kind of condor! I am thrilled to have seen them (and also that they were not too close.) ;)

For the rest of the week we will visit a few communities, assess the birth facilities and do many interviews and focus groups with the community members. Hopefully we will even get to see Rara Lake.:)

Nepalgunj and beyond to Mugu!

We have arrived in Mugu and we have wifi! We are not sure where the bathroom is but we can connect with the rest of the world!

Let me take a few steps backwards. Two days ago we arrived in Nepalgunj. There was a hot wind when we arrived. I was happy to get out of the pollution of Kathmandu but my joy was short lived. The night in our hotel proved very difficult as the power was cut out around 2am. It was very very hot and this Canadian was unable to sleep. The heat was suffocating. In my delirium I just kept reminding myself that the AC would come on at some point. And it did at 6am. I decided to skip breakfast because I was feeling unwell. I thought that I was feeling unwell due to the heat and a bad headache but it turn out that my next 24hrs proved to get progressively worse with diarrhea and vomiting. I will spare you the details but I did not keep anything down for over 24hrs. We spent most of the day at the airport waiting for our flight to go. The way our flight works is that the plane lands and takes people to Simikot. It then returns for us to take to Mugu. We arrived around 9am. Around 1pm our plane finally arrived to take us. We loaded up. It is a Twin Otter plane, I am informed it is made in Canada. The seats are canvas. It is very tight. 3 people across. Then we unloaded. Wind is coming from Southeast instead of the North. The pilot says we need to wait for the wind to change. So we wait. I am sleeping in the terminal because I took gravol and have already removed my stomach contents in one way or another. Then we find out the flight will not go. So we head out. Cathy, bless her, advocates that we go to hotel that has 24 hr AC so that I can sleep and recover. Everyone is happy with that. We get to our hotel. It is nice and clean and I get into bed with AC and sleep all afternoon. In the evening I wake up, just to be sick some more. The gravol obviously had worn off. At this point the nurses all congregated to decided what to do. Pema and Nani thought I should eat. Jill and Cathy could tell there was no way I could keep anything down. So instead I sipped electrolyte beverage very slowly. Eventually I took Cipro and managed to keep it down. Cipro saved me. I was able to keep some breakfast down this am.

First night arrival in Nepalgunj

Some of our porters - it was Saturday so they weren't in school.

And it is a good thing because we got to the airport and we found out our flight was likely to go. We went through security quickly. It was the same woman. We all had to rewrite our names, citizenship and passport info and a quick pat down. Then to the waiting room. I saw our plane land and we were all excited. And it went! And what a ride. I was a little nauseated still but managed on the plane. It was so cool to go over the mountains, we seemed pretty close sometimes but the pilots seemed very competent. One pilot was wearing superman sleeves. :)  I have been on small mountain planes before. Pacific Coastal has prepared me well! Our Nepali friends did not fair so well. There was much vomiting with the turbulence. Poor Pema was pretty scared on the flight but she copes well and she has been such a good companion. Her and I are roommates so she has dealt with me being sick and everything.

Anyways we landed on the little strip and unloaded and then sat on the runway for an hour, while Jill and Nani tried to sort out the taxi. I was happy, my nausea was gone and the fresh mountain breeze was so wonderful! Finally, we found out there would be no ride. So some people who were sitting with us became our porters. We all carried our backpacks but we have all sorts of training materials that needed to be carried. Cathy and I put our hiking boots on and soon we were glad. We walked down the stone and dirt path. We met many people, goats, cows and horses along the way. We even crossed a suspension bridge. The boys that were helping carry our stuff found me amusing. I was walking ahead with them and would ask them which way to go. Down there? And they repeated it back to me!

Nani and Pema on the bridge!

And then at the bridge I asked the word for it. Finally I asked my team and they said pul. So I said to the boys pul! And they said "This is my pul." So smart! And then we all laughed. Almost 3 hours later we arrived in the town of Gamghadi. We met our contact Birbadur and he informed us that the arrangements for us had not been made in advance and because of the many important people in town for VDC meetings there was no space at the hotel. Birbadur had to search very hard to find us accommodations. We are staying in a guesthouse. Our hosts are very kind and we had a nice lunch here. We are on the top floor on the side of the hill. I have taken the bed on the highest side of the house. I feel like I am camping in a tree house! I am also glad that my sickness is over as the bathroom is down 3 ladders and outside the house!

This evening we got all the materials ready for teaching the ANMs for the next 2 days. We will be reviewing things like normal delivery, immediate care postpartum, neonatal resuscitation, hand washing, postpartum hemorrhage. After the teaching we will do interviews with the ANMs on the 2 days. We hope we will get to interview at least 16 ANMs. As the week progresses I will send updates! We think it is so funny that we are in such a remote place and the electricity and wifi is better than in Kathmandu. Who would've thought?!

April 20

Last night I picked up my kirtas! I am very happy. They are very comfortable and breathable. It is as comfortable as wearing your pyjamas and yet I look very respectable. I will be very happy when I leave the city and I have them to wear in the rural and remote areas.

This morning I smiled at a mother with a baby. She then convinced me to come buy her groceries for her 4 children. She told me that things were difficult. Their house fell down in the earthquake, her husband is away working in India. She has a hard time feeding her children. I spent more on those groceries than I do on food for myself for a whole week but at least she has rice and milk for her family for awhile. Cathy teased me when I told her the story "She's a professional beggar!". As my husband knows, it’s the mothers and babies who I can’t resist. Even more sad is that her story very likely all true, and true for thousands of families more here. But my student line of credit cannot feed everyone so I will have to resist in the future. I hope that we can have more of an impact for more families by modeling respectful maternity care and advocating for women’s rights while we are here.

I finally shook the headache midday, which is a relief. It is hard to get motivated when you are not feeling well. Cathy was busy all morning finishing up her and Mickey’s abstract for the conference, coordinating with Jill and Nani and doing her best to get her nursing license. Bureaucracy here is very very tedious. It turns out she has to go back again tomorrow to get her license but we have a good feeling she will get it. It just takes lots of time! I did some other errands to get ready to leave tomorrow. And good news - it seems as if Jill and Ngima have secured a translator who will travel with us to Mugu! We are very pleased with this fortunate turn of events - earlier this morning we were having our doubts.

After this you may not hear from us from until end of April/beginning of May. I finally had good enough Internet to see that some of you have commented on the blog. Thank you so much for your responses. It is nice to know there are people out there reading and supporting us! Much love to all.

April 19

This morning I worked on a press release for the midwifery conference for Kiran, did some writing for the blog and some reading. A headache and mild intestinal upset is keeping me close to home until we go to meet Jill who arrived from Canada this morning. She is our Mugu project lead and as such the preparations for Mugu will begin in earnest!

We met Jill at the Bakery Café in Jawalakhel. Madhu was there too. Madhu has a history working in community health, development and research. He is currently working on writing a book about the history and changes in the Dolpo region of Nepal. At our meeting we went over some of our plan. We recently found out our translator in Mugu is no longer there. Jill will be in contact with the Development Health Office in Mugu to organize a translator for us. If we cannot arrange that in advance we may need to find and bring a translator from here.

We then went to MIDSON to meet Nani, the nurse-midwife who is coming with us to Mugu. Nani is very friendly and helpful. I am excited I get to work with her to teach the ANMs. I can’t believe we will be in Mugu in just a few days! We went through our training handouts and made edits. We needed to make sure the handouts would be simple enough for the ANMs to read in English and still cover the criteria as per SBA training guidelines.

At the MIDSON office there are midwives coming in and out. They are all busily working to get ready for the conference! I am excited to attend when we return from Mugu and when my dear friends and colleagues join me in Nepal!

I have included some pictures of the garden. There is a beautiful pomelo tree and rabbits running around while I eat my breakfast. This morning the
grandfather of the hotel came down the stairs carrying his pet turtle!

Cathy wrote a poem - I have posted it below :)

Beside fallen temples

the young midwife kneels to light 108 butter lamps

Her gaze drifts, scanning the crowds for pregnant mothers and infants.

At the guesthouse, grandfather, back bent towards stone staircase, slowly descends carrying an ancient turtle

on whose back he has lovingly drawn a tika

as blessing.

April 18

Today we went to visit Bimila and her new baby! Both of them are doing well and we had a wonderful visit. Bimila is a nurse and like me has had the fortune to be educated about normal birth and midwifery care. I find her inspirational as she stood up for herself in labour. Fortunately, she was able to choose to leave the hospital and go to a birthing centre where she was treated kindly and delivered a healthy baby girl vaginally. Without it, she may have been one of the many women in Nepal who has had unnecessary surgery. From the stories we are hearing it seems that either women have little to no care, or excessively medicalized births including high use of Pitocin inductions, episiotomies for vaginal births and Cesarean sections. Medicalization of childbirth is a global phenomenon that happens where development proceeds without midwifery style care. But even more than the over-medicalization of birth, the lack of care and compassion shown to birthing women is very disheartening. This is not a Nepali phenomenon however. All over the world, including parts of Canada, women lack autonomy, informed choice and compassionate respectful care. I feel that similar to Canada and our struggle for midwifery that was led by birthing women, it will be more Nepali women like Bimila standing up for themselves in order for birth to change here.

Our next stop was Patan Academy of Health Sciences to visit Dr. Bharal and Rashmi. Dr. Bharal is the rector of Patan Academy of Health Sciences, Rashmi, as mentioned earlier, was one of the founders of MIDSON and midwife extraordinaire. Dr. Bharal was very sick this last year and many people, including Cathy, are glad he is making a recovery. He is a community health specialist as well as a physician. We had a wonderful visit and were pleased to hear that there is a timeline of 2017 to start a midwifery program at Patan. We certainly hope it is true. If it goes ahead, Cathy will likely be able to support the program by finding volunteer experienced midwives from Canada who will help train the trainers for the program.

Our last stop yesterday was at Yangling, my favourite restaurant here so far. It is a Tibetan restaurant and Cathy and I are working through the menu. Last night I had chow mein. It was delicious and cost 140NPR about $2CAD. During our dinner there was thunder and impressive lightening! I am happy about the rain too – it will keep the dust down a bit.