Rato mato chiplo bato, mero sati and alpeshor gufa

May 21 –  Red mud slippery, my friend and alpeshor cave.

Today my Canadian comrades have fallen ill. This sucks immensely as we had planned for hiking today with our friend Kripa from the hospital. I went alone to meet her at the hospital gate. I did not make yesterday’s mistake of failing to make coffee before I left, and instead I waiting for tatopani (hot water) so I could mix myself Via before leaving. I made it in a metal cup and drank it at the hospital while I waited for her to meet me. Once she arrived we set off to take a local bus to Kushma where we would begin our day by crossing the longest and highest suspension bridges. I had yet to travel by local bus so was pleased when we climbed aboard with its fancy painting and coloured window shades. On the bus Kripa met the healthpost in charge of Pusma and we were able to walk with him through town until we reached a cable car. 

After some consultation we paid the fare for the cable car and climbed in. This was a fancy cable car – one car on each side, operating similar to a gondola and passing slowly in the middle. After the cable car ride we walked by an old aiport, now a grassy field, and wound our way up a narrow track past people’s farms. On the way we saw monkeys in the fields, a gorgeous pine forest and mysterious, beautiful mists. After we walked for some time and met a few people we started to make our way down over a hill, into the forest and eventually to the bridge. Here there was a curious restaurant and we had a masala omelet that was very tasty with onions, red and green peppers and chilis mixed in. The theme of the restaurant seemed to be fairytale woodlands meets Greek mythology and our stools were made to look like carved stumps. After this we had a pleasantly swaying walk across the bridge. On the other side we walked through a pine forest that smelled so fresh and clean. The smell reminded me of home, but the pines looked different – they had few branches near their bottoms and all the foliage near the top. We then crossed another big suspension bridge, this one the longest. This led to a cave we had decided to visit. On the other side we saw the sign for the cave and headed off.

As we were walking we heard drumming and singing. We decided to check it out. It was a large gathering of people, mostly women sitting in the group, men hanging back. A woman on the road told us they were a Christian group. I was surprised. Nepal has less than 0.45% of its population following Christianity. We were curious so we got closer. The men were preparing a goat as we approached. Other men spoke to Kripa and laughed at the suggestion that they were Christian, assuring us that no, they were a Hindi group and they met every Saturday to sing and pray and feast on a goat. Frankly, I was relieved. There are challenging things about all religions and belief systems, and Hinduism has its share of undesirable qualities are well. However, I find the Mission work somehow unethical. It isn’t fair to come to another county and culture and build nice hospitals and schools and provide desperately poor people with the necessities of life and then tell them everything about their religion and culture is wrong and they need to convert to be saved.

We continue on towards the cave. When we got there we were met by a yogi. He offered to lead us through the cave. He had two flashlights for us and a headlamp for himself. After Kripa made prayers we made our way down into the cave. It kept dropping, down and down we went. After some ways and at least 3 long ladders we got to see some impressive stalactites and stalagmites. Some of them he identified as the various Hindu deities, Shiva and Parvarti, Ganesha etc. It was a very nice cave. Then Kripa informed me he said we needed to go through thigh deep water or go back. I thought we had gone quite far and was under the false assumption that wading through water would result in getting out sooner so I agreed and removed my boots and socks. Barefoot we walked down over a cliff holding onto ropes for support. Then we began to wade. At times the water was at the base of my bottom. I preferred when I could see the bottom at least to place my feet as I was afraid I would step off into some abyss or roll my ankle. Around 45-50min. later we finally saw light! Boy were we relieved. As much as we loved the cave after about 15min. of stepping on precariously slippery rocks covered in bat faeces or alternatively wading barefoot through water down rocky steps we were ready to be finished. After seeing light however, we were very excited we had done it. After confirming with the yogi we are certain we came down 750m inside the cave! And then we traveled down the steep hill to a bridge at the bottom of the cliffs, at least another 200m.

After crossing the lowest bridge of the day we headed up the other side. At one fork in the path Kripa decided we should go left. Soon our little foot path got steeper, then it disappeared. Just before this I had commented, “Kripa, I think this is not the people path, this is the goat path.” Sure enough, soon I was leading us across an unstable small waterfall and edging us along the cliff using semi stable stones and tufts of grass to get us to a path again. With relief we made it to the other side laughing. After a switch back we then had one last steep climb and we were in Kushma town again. We drank a very refreshing cool Coca Cola as Kripa told the young women and children at the shop about our adventure. They had a hard time believing we had come through the whole cave. They also asked if Kripa was my guide, to which she assured them, no I was her friend. Later on the bus (after she had been asked about being a guide again) we had a laugh about this and decided that I guess it made sense, not a lot of visitors probably become good friends with the locals in their travels. I am glad that I have been able to make such a wonderful friend here in Baglung. We had such an excellent adventure today! Oh and I should mention, I wore hiking boots and bare feet today. Kripa wore flip flops and bare feet and managed just as well or better than I!

a blog for the birth lovers

We have now caught 12 beautiful babies between us! I should've posted sooner after our workshop as it has now been a week and things are starting to string together in my mind. I am hoping this post will suffice for now, especially for those who are interested in the clinical aspects of the placement, and I will try and share more stories later.

So the highlights include that all the births we have attended are SVDs, this is perhaps a bit misleading as we don't attend CS when they happen ;). Mostly G1s and G2s and a few G3s (amount of times they have been pregnant). We have encouraged all of the women to deliver side lying to prevent or limit tearing. We have had many intact perineums, even with primips, and some small 1st degree perineal tears and labial grazes. Each birth I feel like we make an impression on one of the nurses on how birth can be different and how even primips can deliver intact if you slow down the delivery. This part has been incredibly satisfying for me as we know by reading the birth ledger that most of the primips here are given an episiotomy and this really needs to change as it is harmful and painful and not at all necessary. We all have had new clinical situations to manage and have had to expel clots from the cervix. All of us have had the opportunity to suture at least twice - most of the suturing has been for tears we might even leave in Canada but due to infection risk and the likelihood of hard work shortly after birth we have been asked to suture the small tears. We don't mind. Our goal is an intact perineum but when there is suturing we (or at least some of us!) really enjoy doing it. It has the satisfaction of any other sewing project I think. There is a rhythm to it and a satisfaction when things are well approximated. Krista and Kristi have both done initial steps of a resus and Krista had to suction one baby.

This week we had a 3 baby day! After a normal SVD, Krista had retained membranes that needed to be teased out with gauze and clamps very slowly. While she was working on this with Cathy, Kristi had a bleed right after delivery. Her and I clamped and cut the cord, worked together to drain bladder, got oxytocin in the IV running wide open, delivered the placenta quickly and took care of baby (as he didn't need to be suctioned and it seems to be done routinely when we are not there). Although both things, retained membranes and postpartum bleed had the potential to result in a hemorrhage it is sort of a juxtaposition that as one team was moving so slowly and carefully the other needed to move quick. Midwives are so skilled and adaptable! We have patience and can move rapidly when needed. I was so proud of us this week.

My delivery that day was a primip who came into the ward in labour and 8cm dilated. This is very rare here. Most women come early because they do not want to travel in labour. Most women have an induction for postdates or end up being augmented with oxytocin for 'slow progress'. Unfortunately, I think that many of them are put on the partograph too early. They are supposed to be at least 4cm dilated with regular strong contractions. As the midwives reading this know, multips can sit at 4cm for weeks and not be in labour. Although the use of oxytocin is overused, we are not blind to why this is happening. Many women fear birth and travelling during birth or having a roadside delivery. After travelling to the rural health clinic and birth centre this week we really understand how difficult that would be in labour. It is very very bumpy and in the rainy season trecherous. The staff also want women to deliver in a reasonable time and when there is more staff (daytime) the doctor is around and doing a C/S is possible. This results in more inductions and deliveries during the day and less at night. We can see the parallels between here and rural Canada where staffing and transportation also play a role in clinical decision making. (more on this later)

Anyways, she came in labouring and moving and swaying on her own. I provided labour support; encouraging words, hip squeeze, sacral pressure. A first I didn't think she had a labour companion but then found out she didn't know if one was allowed! So then I invited in her sasu (mother in law) and bahini (little sister) who continued labour support with me. I kept her on the labour side of the ward as long as possible so she could have the support of her family. Here, family is not allowed in the delivery room, another thing that would be good to change, as it wouldn't affect the clinical management and it would make the world of difference for the mother's to have support. She delivered in L lateral position and I used a good portion of my strength to hold her baby in as I encouraged her to breathe "Lamo sass, chito sass" Slow breath, pant. She delivered a baby boy with a nuchal hand which I swept across his body, small labial graze with intact perineum, no suturing needed! :)  Baby took a little bit to come around so Krista and Cathy took him to the warmer after delayed cord clamping because he still had a lot of fluid and was having a hard time breathing. After suctioning they observed him for awhile. The oxygen wasn't working otherwise I think they would've done blow by oxygen. Meanwhile, I attempted to deliver her placenta and felt the cord tear (equivalent of nails on the chalkboard). I got them to add oxytocin to her IV and waited and attempted to deliver it again, more tearing. At this point I asked Cathy to come and explained the situation. I was convinced the placenta was detached. I tried again, more tearing. I then felt up the cord to find the placenta. It was in the vagina so Cathy showed me how to sandwich it and pull it out. On examination the placenta was very sick looking. It was calcified all over, the cord was very thin and due to improper connection had almost pulled off the placenta. Given how unhealthy it was, Cathy said she was lucky the baby was living. Shortly after that we tucked them in to postpartum. It was such a wonderful end to our day. The mother was so fun, between contractions she smiled at me confidently and even laughed a bit at my Nepali. After birth she was all smiles and walked to the postpartum ward as if she hadn't just given birth. I saw them shortly after and she was smiling and getting him to latch. She is 18 years old.

We are learning that oxytocin births do not progress the way not augmented ones do. We knew this of course but it is still a bit surprising when someone goes from 5 or 6cm to head at perineum in under 30min! Kristi had a 5cm to delivery in the labour ward this week in under 20min. Unfortunately due to a glove malfunction and the rapid progression the baby's head came out before she or Cathy could slow it down. Afterwards they discovered that the reason the baby came so quickly is that the mother had a 3rd degree tear in her previous home delivery that was not repaired. This made the clinical situation make more sense - her pelvic floor muscles were not intact so were unable to slow the baby. As well she wasn't even fully dilated when she pushed her baby out, likely around 7cm as evidenced by her torn and ragged cervix. Our Nepali head nurse came and did the repair which involved 2 interrupted sutures on the cervix, attempted to bring together the old 3rd degree tear from the previous birth, which you cannot really do as there are no raw edges, however she needed to try so she could suture the 1st degree from this birth. Clinically it was fascinating for us. For the mother however it is very sad. She has a rectocele and no perineum and will need surgery eventually.

Off to the hospital now! Maybe more later from one of us. :)

easy peasy nepalesey

Labour positions and labour support

The last two days we spent doing our training with a group of 12 nurses from the hospital and 10 students in the SBA (Skilled Birth Attendant) training. We covered similar topics to the training in Mugu including labour and birth positions, 3 ways to deal with nuchal cord including the somersault manouver, APH and PPH management including manual removal of placenta and bimanual compression, breech, and Helping Babies breathe. We were fortunate that Rashmi from MIDSON was able to join us to teach some of the sessions, as well as the head nurse, Janaki, from the hospital. It was an enjoyable two days, although a bit exhausting. I fell easily back into my role of labouring living mannequin and got many compliments on my acting skills. Kristi also had a turn wearing the labour pants. Unfortunately there is now a 4th degree tear in the pants and they will need a significant repair before next session!

Post hands and knees delivery by experienced nurse, Debi, in the photo controlled
cord traction after active management of 3rd stage.

Giving our own 'gift of love' to the participant who
scored highest on the blood loss quiz

Helping Babies Breathe

We spent a lot of time focusing on normal birth including different birth positions such as left lateral and slow delivery of the head (to reduce tearing), delayed cord clamping (to increase baby's blood supply and reduce risk of anemia), and not using suction on breathing or crying babies (because it is harmful and unnecessary). Our training was very well received. We got asked lots of good questions and we found it valuable to review and demonstrate and teach as it increased our own confidence in our skills as well. Throughout the training we had lots of requests for photos and today at the end we were presented with a tika and gifts of love from the Baglung nurses. We were a bit emotional over how wonderful it was. After that there were many many photos and I believe Cathy summed it up best when she said "What are we, in a wedding or something?"

Receiving tika and gift of love

Teaching team with tika and gifts of love (L)

All the participants

Rashmi and Mickey both leave tomorrow. Rashmi back to Kathmandu and Mickey to an area affected by the earthquake where Cathy, Mickey and team went last year. His hope is to connect with a girl they met last year with severe anemia, to see how she is doing since her blood transfusions and new iron regime and to bring more iron. He will then head back to Canada. We are sad to see them go. Mickey has taken over the role of photographer since his arrival and I have appreciated not having to worry about taking too many photos. He also has an excellent sense of humour, we have had many laughs these past 2 weeks and we have learned many useful things from him, including how to play Hearts. :) Rashmi also has been a fun addition to our team and I have enjoyed learning from her and hearing her stories and it seems as if she just arrived and now she needs to go.

We also have never had our arms, legs and bottoms grabbed so much. ;) In Nepali culture it is very normal to grab the arms or bottoms or cheeks of your female friends. We take it as a compliment that our new nurse friends here feel so warmly towards us that they latch on to us the way they do with their friends here.

Our well loved women's health team

Tomorrow we will head back to the hospital to attend more births!

photos!

Heading off on our first day

 Here are some photos to go with our last two posts! The next 2 days we will be in our training course. More updates to come.

OR

Delivery room

Resuscitation/baby exam station

Teaching L lateral slow delivery

That's a baby I'm holding on the mom #birthhigh

Kristi's first Nepali catch

Krista's first Nepali catch

fresh beautiful chori (daughter)

Catching babies the Canadian way

Like the mountain that we could not see and then appears as if my magic, we feel like things have drastically shifted since our arrival at the hospital. With the language and cultural barrier in our first 2 days we felt a bit imposing and awkward and were unsure what the nurses and nursing students had been told (or not told) about our partnership. It was hard for us to even think about how to share our experiences here, because we weren't even sure about them ourselves.

Since the first few challenging days however, we have managed to work more effectively as a team with our Nepali colleagues. We discuss everything from culture, to marriage, to children, to fashion and of course clinical management with them and by doing this we all have learned so much.

We have now attended quite a few women in labour, and I have had the privilege of catching 2 babies (both multips) and Kristi caught a preeclamptic primip! Krista was about to have her first catch tonight when a weird case presented itself. All of the nurses who checked the woman had said she was fully dilated. When Krista finally checked her she thought there was a thick cervical lip but they were seeing head during contractions. Finally Cathy checked and determined her to only be 6cm even though the head was visible! Cathy said in all her career she had never seen this before and this woman likely has and will have a uterine prolapse. There's always something new in our work, even for the very experienced!

There are some differences in management here that we are learning about and working with. One is oxytocin augmentation and induction. Like in Canada, the doctor and nurses are concerned about postdates. Most of the nurses here say the protocol for induction is 41 weeks but we have seen variation in cases. One woman was augmented at 40+1 and another at 41+5. As far as I can gather when the women present and how far they travel from is impacting this decision. This is the case in Canada too. The difference here is that management decisions are generally decided for women rather than them being able to chose or reject an induction. The interesting thing about all the oxytocin/IVs in general is that we have been able to observed some skilled IV insertions and also had to monitor our own flow rates carefully, as there are no pumps to do that for us. Another reason for the daytime augments/inductions is a resource one. The doctor capable of C/S is around during the day so they would like more women to deliver (or not) during the day so if they need a C/S he is readily available. There are also less staff on at night. Yesterday there were two C/S. One had a previous C/S with a vertical scar. The other was a footling breech. It ended up being a bit exciting as they did the C/S for footling later in the day and by that point she was 8cm dilated! For those of you who are not clinicians, footling breech is a dangerous presentation because the feet are small parts and the cord could easily slip by if the mother's membranes ruptured leading to a cord prolapse and possible baby death.

The delivery tables also present their own challenges. They are narrow and high and short. Designed for semi-recumbent/lithotomy position they are difficult for the women and also for us to encourage more woman friendly positions. Today however, we managed to show how left lateral position could be done. It is Cathy's favorite position for preventing/reducing tearing and it worked! The multip I delivered had an intact perineum afterwards and Kristi's primip only had a small first degree tear. We were both super happy and on a birth high this afternoon/evening! It was also exciting because our Nepali colleagues were excited about it too and were quick to share with us and each other that this position was better than lithotomy because it reduced tears. Left lateral has now been dubbed the Canadian way. :)

We also noticed at the first two births we observed/attended that there was a desire to suction breathing babies. This is not a good idea and is not a part of Helping Babies Breathe, the neonatal program that is taught here. So we have decided this is one thing worth discussing and working to change here. It will make a big difference for all the babies who do not need to be suctioned after birth as it can cause harm to their little mouths and problems with feeding as well.

The other things we have modeled are waiting for restitution, two somersaults for nuchal cord (around the neck) instead of trying to loop or cut a tight cord, delayed cord clamping, immediate skin to skin with mom and no episiotomies, which are still common here for primips.

Today is International Nursing Day so Happy Day to all the amazing nurses here and far who do so much to improve the lives of people in maternity and beyond!

Unfortunately, you will have to wait for more photos as the internet here is slow and patchy.

Baglung Hospital

(I can't upload the photos right now as our internet connection is poor, but you could visit Kristi Rose Mintz on Instagram if you are interested, I will try and get them on this post soon!)

May 11/2016
I'm sitting down to write a new post as a mid-afternoon thunder and rain storm is blowing over.  In Nepal we are just about to enter the monsoon season. In the morning we see the sun and then the intense building of humidity and pressure begins culminating finally in the relief of rain and thunder around 3pm.  It is a welcome reprieve from the heat as it is over 30 degrees every day.  The countryside has been experiencing a drought, rivers are extremely low and the farmland yellow and waiting to spring into the life that only water will bring.

The last few days we have been in Baglung and have finally started our clinical placement.  We have witnessed and participated in the births of three babies in the last two days. We have also spent a lot of time trying to overcome the language barrier so that we can get to know the nurses here who are primarily in charge of managing birth in the public facility in which we are working.  The public facilities here in Nepal are free for women.  In fact women receive a monetary incentive to give birth here.  If they also attend 4 prenatal appointments the government will give them another small additional amount.  All in an effort to have women deliver their babies with a Skilled Birth Attendant. (SBA)

The hospital we are working in has some of the best conditions for a public facility in the country and as you can see by the pictures it is still very different than a facility in Canada.  The infant resuscitation table is 30 years old, and there are no cozy beds or bathtubs.  As a healthcare worker, there isn't even water readily available to wash our hands and if there is soap that is a bonus.  We bring our own gloves, sanitizer, soap and toilet paper so that we don't use up what little of these items that the hospital may have.

We have done some teaching already with some of the nurses and student nurses.  We have brought them birthing dolls and newborn dolls so that we can teach using them.  We will also leave these tools with them so that they can continue to practice emergency skills and use them for further teaching once we go.  We have several workshops to do with these dolls in the next few weeks with Skilled Birth Attendants who live in the more remote district of Baglung.

We have been challenged, we have been brought to tears and we have found our inner momma bears roar at numerous things that we see and experience and this is only just the beginning.

Was it an adventure?

May 7 Pokhara

Today was a 'rest' day to help K + K deal with jet lag before we start our clinical placement in Baglung on Monday.

In the morning we had a lovely breakfast on our rooftop patio and then we got organized for our day. Krista and Cathy decided to go for a walk and explore this side of Fewa lake we are on, Mickey went about taking many gorgeous photos of birds, boats, people and more birds, and Kristi and I decided to rent bikes.

We read a short blurb in a magazine that said there were many mountain bike trails around Pohkara. full stop. At the bike shop I tried out the bikes, all of them crappy. One of them felt like the pedals were screwing themselves of the bike. I chose the least bad one I could fine. Then I asked for a map. No map. I asked for directions and was told to head out of town towards Devil's falls. So I went and saw the path and headed for it and was stopped by an army official. He informed me I could not go that way, army base. I explained I was looking for devil's falls. He said to take the main road. I told him the main road was too dangerous, I wanted to take the path. Meanwhile, there were people walking and cycling on the path I could clearly see. Finally another man came and told him to let me go in. So I did. Only to discover the path ended in less than 1km and I was in an enclosed field. After wrangling my bike through the turn style I headed back to get Kristi, a bit defeated. Then Cathy said there was a road out of town around the lake. After lunch we headed that way.

Soon we were on a stone and dirt road with a few other bikes, cars and the occasional bus but traffic was sparse and slow. The sun beat down strongly as we made our way winding around the lake through two villages. At one point we came to a fork and asked a young boy on a mountain bike how to get around Fewa lake to Pokhara. He pointed the way and we followed. Soon we crossed a footbridge. On the other side there was a driveway up and some steps down. I asked again which way and the young boy pointed down. At which point there was much laughing and an olderboy cuffed him across the head. he informed us there was no way around the lake but that there was a road and we could go for awhile and then come back.

So we did. First at the wetlands at the end where we watched cattle grazing and people farming and then we continued up and down as the track winded around the lake. It was incredible. No other vehicles, or cyclists and very few people. The people we met were mostly going about their daily life on the lake. We ran into one adorable woman who came out and hugged Kristi and patted her on the head. She then told her she was so beautiful because she was so white and tall. Kristi said "No, you are so beautiful." I told her ramro, ramro. She hugged us both and laughed and we went on our way.

We ran into a few buffalo who were startled by us and a few times we outran them on our bikes. After ascending and descending along the track a few more times we decided the road must continue around the lake and we were determined to go all the way. At this point turning around would have made for a very long trip indeed and we wanted to make it back before dark. Then we began climbing very very steeply. The rocks on the road made it especially difficult and our tires started slipping a lot. We finally had to walk the steepest parts, riding the less steep parts up and up and up. At the top of one hill there was a house and some more boys came to great us and ask for chocolate. (Aside: all the children in Pokhara are very used to tourists and demand chocolate and money - we do not oblige them. We just smile and say No, we don't have any.) They asked us if we were heading to the Stupa. I said no, Pohkara. They told me, no road to Pokhara, you need to go by boat, we can take you. I said no - the road was still going. I figured they wanted us to take a boat and so wasn't ready to believe them. So we continued down for awhile and then again climbing (and walking). Then the road descended steeply and we inched and bumped our way down. In places the road was washed out in deep groves. I should mention at this point that the entire day we were concerned our crappy bikes would split in two. They were definitely not mountain bikes although appeared deceptively to be them. Fortunately we made it. At the point we came to another fork where a young man was tending his cows. I asked for the way to Pohkara due to another fork. He said, this is the end of the road. We needed to take a boat. He said he could take us for $1000 rupees ($10US) I said, too much and tried to bargain with him. Kristi said she would pay $1000 rupees though and then the bargaining was over. We headed down the steep hill pushing our bikes after the cows. Then down some steps, then along a narrow footpath, through the barnyard and some gates, around a cornfield, up some steps and then down more steps to the beach.

At the beach his young daughter helped him bail out our boat and then his kayak and our bikes were loaded in the front. Kristi and I volunteered to help paddle and so we took turns all the way across to the dock near where we are staying.

We made it most of the way around the lake - had there been a road we think it would have been maximum another 30min of riding. But the surprise ending and experience of paddling on Fewa lake was great fun and we are glad it turned out that way!

The whole day was very enjoyable. We had a very fun adventure and got to see some beautiful countryside. After having hot showers and a good meal including our new staple, frozen lassis, we fell into a deep sleep.

This morning when we woke up the mountains were visible! So amazing! Also Jaquie, our first night here the lassis were on you, so thank you! We LOVE them! We are getting our fill because we know it'll be noodles or dahl baht and takari for the next 3.5 weeks!

More photos!

Cathy with MIDSON colleagues after her oratory speech with her "gift of love" scarf :) 

Happy International Day of the Midwife!

Lunch on our bus trip - takari, dahl and bhat yum!

Arrival in Pokhara

May 4-6 Midwifery conference and trip to Pokhara

A clear day in Kathmandu!

Greetings from Pokhara!

 May 6, five of us (Krista, Kristi, Cathy, Mickey, and I) traveled by tourist bus from Kathmandu to Pokhara. It was a beautiful drive. The landscape in this part of Nepal was much more fertile and lush than the Karnali region that we took our jeep ride through last week. Kristi kept commenting on how dry it was and I kept saying it looked great. A matter of perspective for sure!

We checked into Sacred Valley Hotel. Luckily they sent our driver in a large passenger van. We need it for our luggage. We are bringing teaching materials, donations and all our supplies for our 3 week clinical placement in Baglung so we have A LOT of luggage. It filled the back of the van and a good portion of the roof too!

Now to go back a few days. Cathy, Mickey and I were at the Midwifery conference on May 4. Cathy was the figure or oratory, which was a great honour. For us, just getting back from Mugu region, Kathmandu has been a stark contrast and even our drive up to Pokhara was a bit of a culture shock. At the conference there were hundreds of people, mostly women, many of them with lots of education and expertise in the field of maternity care. I had been feeling quite heavy about the state of women in the Mugu area and meeting leaders in the field in Nepal was good for me. So much needs to be done to improve the lives of those women, however at the conference I met many energetic passionate people who are currently working in programs and on projects that are trying to help address this. Additionally, all the midwifery leaders we already knew from MIDSON were in attendance as well and it was so nice to see them again. Especially Nani and she was the one person there who had been to Mugu with us and truly understood. In the afternoon I attended the sessions relating to uterine prolapse and violence against women. One presentation by Aruna Uprety was on acceptance and success of using pessaries for women who have uterine prolapse. They found that a majority of women still had the pessary at follow up and that it improved their quality of life - this is a great alternative to surgery and hopefully will be used in more places in Nepal as uterine prolapse here is quite common. Poverty, pregnancies early in life, lack of skilled attendant at birth, and returning to hard work too soon are some of the factors that lead to more uterine prolapse. Another presentation was on the relationship between having prolapse and spousal violence. Women were more likely to experience emotional, physical and sexual violence from their partner if they suffered from uterine prolapse. There was also a fascinating presentation by an anthropology fellow on the maternal-child health situation post-earthquake. He mentioned that in Nepal, often good results are found to please donors and alluded to the fact that some information that has been presented in the past may be focusing on all the accomplishments,perhaps even exaggerating them, whereas his work was focused on noticing what still needed to be done. Unfortunately due to the delayed schedule of the conference his presentation was cut short, but I have requested the paper when it is published and look forward to reading it! Since arriving here I have read 5-6 books, non-fiction and fiction about Nepal and many research papers - anything to learn more about the context is helping me to better understand what I am a witness to.

Nani and I

The night of the 4th we spent up on our hotel rooftop patio in Kathmandu, singing with some new friends we made here. Funny enough, many of them are Canadian! It was a good end to the night when I came down off the patio and jumped into a taxi to go the airport to get Kristi and Krista! I arrived at the airport and walked in just in time to see them walking out! It is very exciting to be with them and have comrades for the next part of our journey!

We all went to the conference on May 5th, International Day of the Midwife and got sashes that say International Day of the Midwife May 5 in Nepali! It was so nice to be able to celebrate this special day with our friends and colleagues in Nepal. It was also great to be at a midwifery conference and to learn about what is happening in Nepal in relation to maternal and child health and the development of midwifery. We were assured again at the conference that the Bachelor level Midwifery will be available in Nepal soon. We all hope this is the case and that strong, brave women take up the call to serve the women of Nepal with compassionate skilled midwifery care.

Likely (hopefully) you will be hearing less from me and more from Kristi and Krista to get a new and fresh perspective on our journey. I will continue to write occasionally though. Thank you for continuing to follow our experience. More pictures from Mickey to come!