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.
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.:)
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