Emma arrived late on Wednesday night and joined us for our travels to come. It is so nice having her here. She has experience in Nepal and knows the area where we are staying well, so she has introduced us to restaurants that she loved when she was here last and has an intuitive sense of direction that none of us (except Cathy) possess, but all of us appreciate!

We leave for Pokhara tomorrow, and Cathy is quick to point out that we are not heading to the “known” Pokhara (it is known for being a very touristy destination) but the Nepali Pokhara, which like most of this country is a study in opposites. You see the most breathtaking kindness and joy in the unlikeliest areas, women dressed with care in beautiful colours against a stark backdrop, laughter and storytelling that will lift your spirits for days in places you wouldn’t think to enter. Yesterday this very amused little boy came running between Emma and I and looked me square in the face with the broadest grin and shook my hand. He just wanted to shake my hand. Then he bobbed along after someone who seemed to be his grandmother who smiled graciously. It was a brief moment in time, along a busy muddy road and yet it was something I’ll never forget.

Sure enough these experiences bring into stark relief the comfort and privilege of my own life. I feel so fortunate to have had the experiences in my life that have led me to this point. I can’t express my gratitude enough for all of my wonderful memories. Life is hard here, but people are joyful. They are quick to return a smile, easy to laugh, carry wisdom in their eyes. Life happens here because of people, not in spite of them. So, in honour of those people, I will continue to flash my big goofy grin, clasp my hands at my chest, Namaste and bow. And I will continue to tell stories and to reflect on my own memories to process everything that goes on here. It is different, to be sure, but it is lovely.

**Side note: should you not hear from us for a few days, fear not! We’ll be travelling to Pokhara and won’t have quite so easy access to the internet there. We’ll remain there until May 2, at which point we will head to Jomsom to begin a workshop and teaching trek, where we very likely won’t have any internet at all. We aim to be back in Kathmandu on May 19. We will be reflecting on our thoughts likely with pen and paper and may transcribe those thoughts onto the blog during flights between destinations once our travels here come to a close.

Day two of our travels in Nepal was fabulous. We had a chance to walk around some more and work on some MIDSON documents through the afternoon. In the early evening we headed out to Boudhnath Stupa, where one is to walk in circles and spin the prayer wheels to send up blessings for all sentient beings. You always walk with the temple on your right, and then spin the wheels with your right hand. Prayer flags adorned this temple and monks were walking as much as locals and tourists were. The temple itself is white with a gold centre mount, and eyes painted on looking in all four directions. It seems to be a fairly iconic place given that it also graces the cover of my Lonely Planet guidebook!

After our walk, and spinning of prayer wheels, we met up with our trekking guide, Bishnu to discuss plans for our trek and workshops that we’ll be doing in the Upper Mustang region in May. Bishnu was an absolute delight! He speaks perfect English and is obviously a very competent trekking guide. We thoroughly enjoyed every minute, while watching the light fade over the temple. We were so energized by the plans for our trek and workshops en route! It was a very fun night.

By Day three, we were starting to feel a bit laggy. We had a slow morning, complete with delicious breakfast once again and then headed out to visit some more of the movers and shakers in the midwifery world here in Nepal. We met with Sister Rashmi, another instrumental member of MIDSON and birth centre guru. She and another wonderful nurse and Ph.D. candidate, Laxmi spoke to us about midwifery in Nepal, its absence here and a plan for education and improving outcomes. Sister Rashmi talked about the difficulty of having a birth centre in a location where women and families think doctors are the appropriate practitioners for birth, in an area saturated with hospitals. Laxmi spoke of the need for a mindset change amongst the Nepali people to improve birth outcomes here and support the development and growth of midwifery. They made very clear the need, and special focus on reducing intervention and increasing physiologic birth by supporting things as simple as delayed cord clamping. This meeting was an excellent precursor to our upcoming work in Pokhara, as it really helped set the stage for both Rachelle and I as to where midwifery is currently in Nepal and what birth is typically like in hospital here, by comparison with the lovely birth we witnessed at the Teaching Hospital Birth Centre on Sunday.

While at the community birth centre with Sister Rashmi and Laxmi, we also met our very first male midwife, Patrick! He hailed from Sweden and is here for his seventh time. He is working with Laxmi and Sister Rashmi to put data together on the success of the care provided at the community birth centre, to help obtain and maintain funds that support that birth centre. Additionally, he’s also very well-versed on the role of midwives in Sweden. So for quite a while, in Kathmandu, we found ourselves discussing the similarities and differences of the roles of midwives in Sweden versus those in Canada. It made for a very interesting afternoon. Our brains were carefully cataloguing information from the stories we were being told, while our hearts were full from the love and laughter present throughout the afternoon.

This was an incredibly memorable day for both Rachelle and I. After we returned, Cathy was able to help us fill in some of the blanks around the who’s who of midwifery in Nepal. The most important take-home message is that there truly aren’t any midwives in Nepal, there are nurses with midwifery training, but the push is on for direct-entry midwives who practice full scope care in urban and rural settings. And the silver lining is that while there aren’t any “registered midwives” at present, there are wonderful nurses like Sister Rashmi with decades of experience who practice midwifery in its truest form, here in Nepal.

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.

Rachelle and I arrived last night at midnight from our 13 hour layover in Hong Kong. While we were in Hong Kong, we did get out to do some sight-seeing, which included some pretty intense walking up stairs (and down stairs, and up more stairs) with our “carry-on” packs on, mine which was far too heavy for this sort of layover (I will learn one day what it means to “pack light”). Rachelle was much smarter. On arrival in Kathmandu, we were ushered off the plane and into the airport, where there was some waiting, and some more waiting. As we learned on our ride back to the guest house, there had been 5 planes that had arrived at the same time. INCREDIBLY FORTUNATELY for us, our fearless leader, Cathy was at the airport to meet us! While we didn’t see her right away, as we were accosted by 5 men trying to “help us” with our luggage and a ride, we did eventually spot her and we were reunited with hugs and smiles.

We were ushered to our vehicle (a Diesel Corolla!!! – to clarify, I have a Corolla, slightly newer, but felt right at home in the North American driver’s side while being driven busy streets at night) were assisted with our luggage, and eventually pulled away to go to our guest house. The ride was uneventful, though I’d be lying to say I wasn’t on the edge of my seat from time to time. Let’s just say there were a lot of people in cars very close together in tight streets, and driving that would rival that of most professional stunt drivers. We were duly impressed, and relieved to safely arrive at our guest house. We were warmly welcomed, offered drinking water and shown to our room.

After some unpacking, cold showers and the requisite chatting, we headed off to sleep, reflecting on just how lucky we are to have received such luxurious treatment here in Nepal. Traveling with Cathy gives me confidence that would be replaced with distress if I were doing this alone. Having friendly faces and logistical arrangements already made for us with known individuals, is such a gift. I feel so grateful to be here, and to be doing it this way. I feel so taken care of.

Yesterday was our final official day of packing at UBC. As the “lead packer” I’ve had an incredible amount of help from the other students who are travelling as well as our wonderful faculty members in sorting and packing bag after bag of beautiful donated items and much-needed medical supplies. We are so fortunate to have so much, and to have so many caring, dedicated individuals who support us in our travels abroad.

That being said, as much as yesterday was about packing, it was also about farewells. Interestingly, I found myself saying “See you in Nepal!” and “See you in Uganda!” (accompanied by big smiles and tight hugs) to many of my colleagues both yesterday and today. Reality is starting to sink in. In just over a week, some of us will be stepping on a plane, not to return home for 3 months.

The packing stages have been overwhelming at times, but I’m sure they bear no resemblance to the degree of overwhelm we’ll experience abroad. And yet, I find myself thinking more and more about my midwifery “family”; my colleagues, who I’ve come to know and love over the last three years. I feel so fortunate to find myself in a program that has brought us so close to each other, that in the absence of my own family, I know I’ll feel better being in the presence of my colleagues and teachers.

On a drive back from Vancouver tonight I heard the song “Closing Time”, which I recently discovered is actually a song about birth. What struck me were some of the final words in the tune…”Every new beginning comes from some other beginning’s end”. We are very much at the beginning, but it also feels as though something is shifting, that something is also coming to an end.

So for now, I’ll keep saying “See you in Nepal! See you in Uganda” to those fortunate few who we get to travel with, and many “I love you’s and see you soon” to those we love and will see again, come summer.

“Preparing.”

In January 2015 UBC Midwifery offered the course MIDW360: Global Maternal-Infant Health. This course was a prerequisite to the global placements in Nepal and Uganda, and I’ve got to say… it’s been one of my favourites so far in the program.

The class took place over two weeks. We arrived at 9am each day and spent 6 hours together discussing and wrestling with numerous topics. Some of these topics were:

• issues of cultural safety
• maternal mortality rates around the world
• the “three delays” involved in maternal mortality (deciding to get help for an obstetric emergency, accessing transport to an appropriate care facility, receiving adequate health care at the facility)
• traditional birth attendants vs. skilled providers
• millennium development goals post 2015
• reproductive health in refugee settings
• prenatal care & anemia
• post abortion care
• pregnancy & HIV
• issues of bribery and safety
• conflict
• emergency skills (postpartum hemorrhage, shoulder dystocia, breech, unexpected twins)
• preparing teaching topics for women and student nurses (example: neonatal sepsis, post-resuscitation care, danger signs in the newborn, estimating blood loss, providing support in labour, management of the third stage of labour)

One of my favourite moments in the course was being introduced to the following video about “Mrs. X.” (https://www.youtube.com/watch?v=gS7fCvCIe1k)

MIDW 360 was a lively course that facilitated dialogue and raised questions about what the role of Canadian students abroad could and should look like. Each of us will wrestle with different issues related to global maternity care, and I look forward to learning more as we go. Talking about all of this has been stimulating, but I look forward to landing in Nepal and Uganda and engaging with what it means to support women through pregnancy and childbirth globally in a real, tangible way.

Pictured below…

1. Learning to cut umbilical cords with razor blades instead of scissors, and tie them with string rather than clamps.

2. Practicing teaching newborn care in rural settings.

3. Estimating blood loss.

4. Packing supplies.

5. New resuscitation equipment. (We’re still fundraising for 2 resuscitators. Let us know if you’d like to contribute towards them. They cost $135 each before taxes!)

~Rachelle