On arrival I could tell Uganda was going to be interesting.

The streets of Kampala are fascinating. There is always something or someone super interesting to look at: a woman with scores of bras hanging around each arm squeezes past a man balancing several packages of toilet paper on his head and then is passed herself by a man whose bike is loaded with dead chickens hanging from the handlebars. Women wrapped in bright fabrics balance huge loads of mangoes or jugs of water on their heads. Little boys rush up to car windows eager to sell bananas as they strive to earn money for school fees. Bodas (motorcycle taxis) flood the streets driving according to their own rules, sometimes (often!) crashing into other bodas. Some guy with a couple of 12 foot poles manages to get himself positioned on a boda and they take off, and some other guy cycles by on his bike with a dresser strapped to his back. Taxi-vans cut you off every few minutes. The speed bumps are massive (our car bottoms out on the speed bumps erected on main roads!), and traffic cops seem always to urge cars forward through red lights or make you stop at green lights.

The streets are made of packed red dirt and contrast beautifully with the many green leafed trees and huge expanse of blue sky filled with white cumulus clouds perfect for staring at.

I have been in Uganda for over 2 weeks already, awaiting the start of our Ugandan placement (which begins next week). And though I hadn’t planned to have these extra weeks in Uganda, they’ve been a real gift. While here I have spent time in rural markets and urban shopping malls. I spent a weekend at a maize farm an hour out of Gulu. I visited a goat farm just outside of Kampala, and a women’s cooperative where women who survived the days of the Lords Resistance Army as well as women currently surviving HIV/AIDS create goods to sell for income (including dolls, bags, jewellery, peanut butter and honey). I got frisked going through security just to buy some KFC (which is wildly popular here, and expensive!) I helped hold, feed, and change triplets and quadruplets! I went to THE NILE! I had a visit with my friend’s friend inside her mud hut. I went swimming in a pool-with-a-view. I’ve eaten a year’s supply of pineapple and mango. I also ate part of the rooster who woke me up every day at 5:30am for the first week of my stay here…

Over these first few weeks my thoughts have regularly returned to Nepal, to the needs of the people in the aftermath of the earthquake, and to my instructor Cathy who is still there offering midwifery care in the hardest hit villages and preparing workshops through MIDSON and UNICEF to train and send nurses to deal with maternity needs in villages that are even further out. I have also been processing the maternity care we witnessed, and considering the midwife I hope to one day be. And now, as I begin to prepare for the next stage of this trip, I am beginning to consider the issues that face the women of Uganda. I wonder what issues will be the same as those we discovered in Nepal and what will be different? Will what I have read in books and articles come to life in the people I meet and the care I observe?

As I near the halfway mark of this experience I know I’m still at the beginning of what I have to learn about global maternal-infant health, and I’m grateful to be here. I miss Jacquie & Emma like crazy, but I am looking forward to reuniting with my classmates Lesley, Zahra and Nancy who arrive Monday.

We will have so much more to write in the weeks ahead, and we may even have more to process about Nepal too. Hope that’s ok. And, if any of you have any questions – feel free to ask!

One of our anticipated highlights of this Nepal placement was a teaching workshop that was supposed to happen May 5-7 in Jomsom (in Mustang.) Our anticipation for this workshop grew after we had the chance to run a few teaching sessions to a very eager and responsive group of nurses in Baglung. Due to our early departure from Nepal we were not able to complete this particular workshop… but I thought some of you might be still interested in what the workshops schedule was supposed to be! And so, here it is:

I want to take a moment to write at least a little about our experience of the Nepal Earthquake of 2015/2072. Thousands of people have died and many more have been injured. People have lost homes. Whole villages are flattened. And even now almost two weeks later, aftershocks continue causing for many a rise in pulse and fear, as well as being a constant reminder of what has happened. Many people are still unable to live in their homes; instead, they sleep outside, under tarps if they have them, and weather the monsoon rains which have started a month early this year.

Our experience does not compare with those communities that bore the brunt of the earthquake’s magnitude, but before I can move on to share stories of birth and midwifery and learning, I feel a need and desire to tell our story (from my perspective; Jac and Emma – you can write from yours too!)

We had just arrived in Baglung and were in the midst of bartering for a better price in our hotel room with the manager when it happened. The walls started shaking and the floor started rolling under my feet which I have never experienced before. We ran out of the hotel as the manager yelled “Earthquake!” – and he fell really hard on the stone stairs as we came down from the 2^nd floor. Everyone was running to the street and we followed suit. The streets in Baglung in our neighbourhood were only one lane wide (ie. very narrow!) and most of the buildings lining the streets were one, two or three storied old brick or concrete buildings, some topped with tin roofs held down with large rocks. There was also one huge glass building that no one wanted to be close to! Small groups of people huddled together, some standing in the middle of the dirt street, others crowding under tin overhangs. Cathy, Jacquie and I remained in the street and Emma ran for cover under the frame of a concrete building that was under construction. I know what she was thinking. As a child I was taught that the safest place – other than a wide, open space – is to stand in a door frame: everything will fall around it, but it is likely to remain upright and you safe under it. But – there was a huge piece of concrete overhang that seemed precarious from our vantage point, so we called her back over to us after a few moments.

It was actually pretty quiet in the streets. Some people were calling out to one another, but the stillness in the midst of such force was startling to me: this massive earthshaking power occurred, but in it’s pause people crowded together in silence, and then as you wait together, you wonder if it’s done. But then it’s not done, and the earth shakes again with a power that is impossible to articulate.

The first big aftershock (or was it simply a continuation of the original earthquake?) occurred within a minute or two and that was really the only moment I felt afraid – but I did feel afraid. The four of us huddled together as the ground shook and rolled and buildings swayed and (some) rocks fell. And oh how I prayed. It lasted for about 30 seconds if not longer (at least that is what is in my memory; who knows, maybe it was only 10 seconds, maybe it was a full minute.) After it stopped an old Nepali woman came over to us exclaiming something in Nepali with a look of gratefulness on her face and she patted our faces and grabbed Cathy for a hug. My best guess is she was glad that we – and everyone around us – were safe, that nothing had crumbled in our midst.

We spent the rest of the day in the courtyard of the hotel. Most of the town went to an open field a few blocks away and our hotel manager (clearly a leader in Baglung!) brought tea to the 2000 or so people who gathered there. We felt best remaining with other Nepali hotel guests who also stayed at the hotel. The sun was hot and the “open field” would have been crowded. Our courtyard felt open enough and offered some shade and access to bathroom facilities. Jacquie, Emma and Cathy immediately called their families (& UBC) to let them know an earthquake had occurred and we were safe. It was ~1230am back home, so I decided to wait to call mine. I wasn’t convinced the quake would make international news (little did I know…) and wanted my folks to get a full night sleep before waking them up!! Thankfully Jacquie’s husband saw news images appearing online by 1am, and he called my parents right away to let them know we were safe. I was also able to talk to them later in the day. That decision to call right away was such a good call by Cathy, and we felt grateful to know that our families knew we were safe. And it was happening all around us. Locals at the hotel and in the streets were all on cel phones, trying hard to get in touch with their loved ones around the country. All around people asked, “Is your family safe? How is your home?”

The earthquake did disturb some normal routines which ended up being a little unfortunate (for me and Jac in particular!). An older woman scooped out some of the rice from our dinner pot to feed her granddaughters. This is not a bad thing in and of itself, but we noticed that she did so with her hand… her *left* hand. We remembered this little detail later that night as I suffered from the worst diarrhea and vomiting I’ve had to date! Oh man. Jacquie suffered along with me and poor Emma had to listen to us all night long! Oh we had some good laughs about it, which provided some major comic relief in the midst of the many aftershocks! Suffice it to say, none of us slept a wink and Jac and I were pretty weak so we decided to hold off going in for our first day at the hospital. This was a good thing as there was another major aftershock (~6.7) that next day in addition to the ongoing smaller ones. I fell running from the hotel with the big shock and sent Cathy and my computers flying (which I had grabbed in haste) out of my hands and onto the pavement (thankfully they didn’t get smashed!). I also scraped my hip, knee and gauged a little chunk from my hand, but we cleaned and bandaged right away and it’s been healing nicely ever since. Our hotel manager who fell with the original earthquake pulled out a back brace, but apart from these two minor injuries we didn’t hear of anyone sustaining anything major.

The earthquake changed our trip. Over the next week we started our official clinical placement in the hospital (which was awesome, and I will write more in another post), but the ongoing aftershocks and the daily communication with UBC, DFATD, and our families made it difficult to forget. The news images that began to appear in the days to come showed us the extent of the quake which we had been blind to over that first 24 hours. The devastation and horror so many Nepali’s faced and continue to face is impossible to explain. In Kathmandu bodies were being pulled from buildings and rubble everyday over that first week. In fact bodies were being pulled from a building that crumbled right beside our guesthouse the day we returned to Kathmandu a week after the quake. All week, 24 hours a day, bodies were burned in a park in central Kathmandu. I can’t imagine this on top of all the fear and uncertainty of that first week. On our drive back to Kathmandu we saw many houses standing… but we also say many houses that had either crumbled or tipped “in tact” to the side.

UBC made the decision to call us home, and while we understand the reasons I found it difficult to leave. Selfishly, I am so disappointed to have this placement cut off short. I was loving it, and the next portion of our journey was to take us into the rural areas. We were so looking forward to both the trekking in the mountains and also (especially!) teaching in the tiny health posts. Cathy has connections in small villages from all the work she has done here over the years, and they had asked her to come and teach specifically about STIs and to address their primary concern: neonatal mortality. We were so excited to be a part of that. But even as I worked to let go of my disappointment, I found myself wishing I had the skill to be a true help, to stay and be a part of relief effort. But the truth is I know I would have been another body to feed and outsider to watch over had I remained. What makes me feel better about leaving is that because we left, our instructor “Foreign Nurse #74” Cathy and Dr. Mickey have partnered with our trekking guide Bishnu (a true leader in his community) and his “team” to provide medical aid, shelter and food/water to villages that have been drastically destroyed.

Because our trip was cancelled, they have been free to offer true help and I can’t wait to hear more of the fruit of their efforts.

Anyways, I think that’s it. I’m sure I’ll have more to share in time, but for now… this is it.

Pictured here: Our last night in Kathmandu before heading out. We have many more thoughts to blog, and will do our best to share them in the weeks to come. In the meantime let it be known that we “the girls” would like to send a huge shout out of gratitude to our awesome instructor “The Cathy” and our amazing guide, helper, and new friend “The Bish” (ie. Bishnu). You are both the best.

Why was yesterday such a great day?

1. We had our first “sleep in” day – right up to 7:30am!

2. And then we awoke to Cathy peeking her head in our room and saying, “There’s a surprise outside!” What was the surprise? A total blue sky and the first clear view of the stunning Annapurna Range of mountains. We rushed up to the roof, giddy with anticipation, and were rewarded with amazing views of the massive mountains which have so far been covered by the clouds.

3. We had fun at Antenatal clinic at Gandaki Hospital, learning from the student nurses as they performed belly palpations and listened to fetal heart rates. Dozens and dozens of women were lined up and offered us welcoming smiles. It was good to be in the midst of pregnant women.

4. Our new placement in Baglung was approved! We’ll head out tomorrow.

5. We spent the afternoon at Lakeside and had our fave – Lassi’s.

6. We got our government approved letter to officially arrange our teaching workshop in Jomsom in early May.

7. We met Dharma Shila, a MIDSON member and nurse who will present the MIDSON portion of the workshop. She was so lovely and we look forward to getting to know her better. We are also glad to be working in collaboration with MIDSON for these workshops.

8. Our “peak” of the day: sitting in the little restaurant around the corner from our guesthouse showing Dharma Shila and Neelam (another MIDSON nurse) several videos (in Nepali language) about physiologic birth and watching for danger signs in newborns  to provide timely care. As soon as the other women in the restaurant heard the Nepali language they gathered around to watch too! It was so great. Three of the women who gathered were a grandmother, mother and daughter watching what good care immediately after birth could look like (and the videos are filmed in Nepal).

I was sick yesterday (good ol’ whatchamacallit’s revenge….) so I missed our official first day on labour & delivery of Gandaki Hospital, a Western Region Referral Hospital (fyi – the levels of hospitals are: National Referral Hospitals, Regional Referral Hospitals, District Referral Hospitals, Primary Health Care Centres, and different levels of Health Posts.) I made up for it today though – by noon we had witnessed 7 births! We are still only allowed to observe at this point, but we are using this time to become familiar with the local practices and get to know the nurses and nursing students.

The birth environment here is so different than at home. Women labour in the “first stage room”, which has about 8 beds/benches. When they are fully dilated and ready to push they are brought into the delivery room which has three beds. The beds have rusty frames with black plastic cushioned tops that get wiped down between women. The walls are lined with supplies and there is a table in the corner where the nurses sit to record details from the birth.

The most shocking part (to me) of the delivery room was the number of students crowding around each woman as she pushes. At one point today I counted 18 student nurses – not including us! For three women! We are so accustomed to protecting women’s privacy during birth, and it feels unusual (and to be honest, a little uncomfortable) to see so many women crowding in to watch a woman birth, and stare in between contractions. The other shocking part is that all the women who birthed today received an episiotomy – some with analgesia, some without – but none were clinically indicated. The Nepali government policy is that episiotomies should be restricted to those cases that require it (ie. emergencies or with forceps). Unfortunately, this hospital (and many others we are told) does not practice according to updated guidelines, and every woman is cut. The women were pushing beautifully. Babies heart rates were fine. Jacquie took on the role of “suturing doula”, tending to women while their epi’s (as the nurses like to call them) were sutured. Four other aspects of labour care we would like to challenge are the fact that the nurses do not wait for restitution and pull on babies heads at birth, babies are not kept skin to skin with mom, breastfeeding does not happen within the first hour, and delayed cord clamping is not carried out.

We can’t wait until we are allowed to be “hands on” so we can demonstrate a more “hands off” delivery technique. We’re feeling pretty passionate about no episiotomies unless clinically indicated! But, babies were healthy. So that is great.

(from a few days ago! internet has been a bit sparse)

We’ve been eating a lot of starch here in Nepal – my fave! The most starchy so far? Our deep fried potato sandwich! It came to $0.35 each. We enjoyed “Joyous celebration” together to celebrate our good find, lol!

Cathy got the license she needed to preceptor us after a crazy rigmarole! She was sent all over the city tracking down signatures, documents, letters of invitation, and basically sent through numerous hoops – but she worked her way through them all and we are loving her kind persistence. We’re grateful, and we have now officially bought our bus tickets and we leave for Pokhara Sunday.

One of my favourite things is waking up to the sounds of a new place. This morning was no exception. To say the birds were ‘deafening’ might be a bit extreme… but the chirping symphony was definitely a loud one, ha ha! (but it also immediately put a smile on my face 🙂

After breakfast in the courtyard Jacquie, Cathy and I taxi’d out to the local teaching hospital to meet Kiran, the president of the midwifery society of Nepal (MIDSON). She filled us in about her vision to provide a specific Midwifery education program to Nepal. Right now midwifery training is offered as part of general nursing training, but the nurses are not able to practice as autonomous care providers. Her hope is that the program will be rolled out by the end of 2015, so there is much to do and she and her team are working round the clock to get the syllabus created, government documents signed, and the never ending work of networking to get all stakeholders on board. The government is on board, but there is still a lot of work to see midwifery become a sustainable part of maternity care in Nepal. Changing a system is challenging, but the MIDSON vision is that midwifery integrates as a respected, sustainable, and accessible option of care for women, that is also supported by the medical system. I’m sure we will learn more about this as we go (and the fact that we were pretty jet lagged yesterday didn’t bode well for asking the most articulate of questions!).

Our afternoon was spent across the dusty road in a birth centre that opened just over a year ago. While we were there a woman gave birth to a 3.75kg baby boy supported by two nurses, her Didi (big sister) & husband. It was eye opening to see what a positive birth scenario can look like in what we’ve been told can be a very interventive medical system. For example, the woman who birthed her baby didn’t have an episiotomy, which is quite standard in hospital births in Nepal. In it’s first year, this birth centre has facilitated just over 70 births. In comparison, the hospital down the road sees over 100 births each day. There is a long way to go to see this kind of facility thrive.

The two women in labour yesterday were from a higher caste and had all their supplies with them – including oxytocin and misoprostil: two drugs important in case of hemorrhage. They also had brought their own syringes, saline, and catheters for the nurses to use. Both husbands were quite involved supporting their wives and both women had also received 7 antenatal visits (which is over the minimum 4 as recommended by the WHO.) Kiran wants to see more births happen like this. Until we observe the larger hospital and also the situation in the more rural parts of Nepal I’m not sure we can fully appreciate what they are trying to facilitate here. From my perspective it was a nice space with colourful curtains and comfortable beds on the floor with the option of privacy screens. The ‘delivery table’ was only used if suturing is required after the birth. But, what do women do who don’t have their own supplies? Also, the criteria to birth at the centre are very strict and offer little leeway for labour to diverge from a very defined pattern, even if that pattern is still considered ‘normal progress’ in our experience. We didn’t get a chance to ask all our questions, so I’m also not totally sure I’ve understood everything correctly.

I’m realizing this experience is going to be hard to capture as we go, but we had a wonderful first day here in Nepal and we’re eager for all we’re going to see in the weeks to come.