Hayley travelled to Nepal to experience maternity care
"With the support of a scholarship from Cavell Nurses' Trust I was able to opt for a Professional Development Opportunity abroad, as part of the Cardiff University Midwifery Programme.
"I chose to use the funding to travel to Nepal. Nepal is a country were women have a lower status then men and as it is the men that would traditionally make the decisions it is quite difficult to advocate informed choice for women. There is the added issue that the majority of births take place at home with either traditional birth attendants (the minority) or a family member, usually the mother in law (the majority), therefore reaching communities that are also geographically isolated is difficult. I felt that working in an environment with a lack of resources would enhance my ability to give midwifery care without reliance on resources, enhancing my communication and advocacy skills.
"Additionally I hoped to gain a greater insight into high risk situations; As women can live in remote situations and as there are fewer resources in Nepal than in the UK, there tends to be an increased level of high risk situations. I also felt I could learn from how the health service in Nepal is working to safer motherhood in difficult circumstances, especially given the recent earthquakes.
"The Nepali people were the most welcoming people I have ever met. They put me at ease immediately and made me feel I belonged. In spite of this I gained a real insight into how women who do not have English as a first language must feel in the UK. Especially given that it is a foreign environment to them. Although I was made to feel very welcome I was very aware even when waiting for my transfer in Dehli, a large international airport, how much I stood out. On a couple of occasions local people wanted pictures with me and I would often be stared at. It is a very uncomfortable feeling. Not being able to speak Nepalese made me feel very helpless in the hospital setting especially in finding ways to offer the women some emotional support. This was as an observer so as a patient it must be frightening.
"Even in comfortable environments such as when I was invited for lunch with the nurses, it was very unnerving as I did not know the conventions of the Nepalese culture. The first time I went I had eaten a large breakfast and it was still early so I didn’t eat, the nurses seemed upset at this. When I investigated further it turned out it is a great insult, it is assumed that I don’t like the food. I learnt from then to have a small breakfast!
"Because of this experience I hope I have gained a greater empathy for woman for whom English is a foreign language and who are in an alien environment for them. I feel this can also be applied to all women coming into hospital as the hospital is a foreign environment to most of the public. It is easy to get complacent when it is a normal environment for healthcare practitioners.
"As well as language there were many other challenges I had to overcome in Nepal. It was hard seeing how difficult life can be in Nepal, a lot of people live in poverty and have to work long, physically demanding days just to feed their families, we would regularly see women carrying heavy loads up steep hillsides and having to walk miles to the river each morning to collect water.
"Initially seeing that practice was not women centred was very difficult"
"there was no protection of dignity and respect and no consent for procedures. Not knowing where I stood in protecting the women without causing great offence to the medical staff made me feel very helpless. I found I was upset and frustrated with myself for standing by and watching some of the practices that weren’t due to lack of resources, such as shouting at the women for getting upset if they were in pain.
"The facilities were very basic and women were expected to labour together in one room and walk into a busy concourse to get to the delivery room at the point the presenting part became visible. This made the environment the women were delivering in very harsh. It was difficult to be in a situation where I could not rely on resources to support women, such as giving them privacy and making sure they were comfortable with something as basic as clean, dry bedding. However it did force me to think outside the box and use core midwifery skills to support the women.
"The biggest step in overcoming these barriers was having language lessons, I found learning a few key phrases helped me to build rapport and offer some comfort to the women. Building rapport with the women as my Nepalese improved, increased my satisfaction as I could engage with the women more. By the end of the two weeks I had built a bond with some of the Nepali midwifery students, to the point they invited me home for tea.
"To overcome practices differing to those in the UK I found by asking open questions around the medical care in a non-judgemental way opened up discussions; As I showed an interest in Nepali healthcare; lecturers, staff and students were interested in how we do things in the UK. Over time I gained confidence in advocating for the women, especially when observing certain levels of care were possible. For example depending on the woman staff would not always use lidnocaine for an episiotomy (episiotomy’s were given to all women with blunt scissors). Therefore I started to ask why the lidnocaine wasn’t on the delivery trolley when it was forgotten. One lecturer also took on board we do not give routine episiotomies in the UK anymore and delivered a baby without an episiotomy with an intact perineum.
"With the lack of dignity and respect I led by example where possible. Using sheets to cover women and block the view of others were I could. I found that as I was doing this some of the Nepali students and staff nurses would follow suit.
"To offer emotional support for the women I followed my instincts and stayed close to the women. This was made easy by the fact I was observation only, consequently I could spend the whole time holding a woman’s hand and supporting her.
"My biggest high in Nepal was being able to support a woman across three days of labour and remain with her in theatre."
"One to one care she would not otherwise have received and the difference this seemed to make to her during a difficult labour.
"I also learnt some phrases to communicate about breathing through contractions. As there is no pain relief available to the women and they are shouted at to be quiet if they are crying out, I found helping the women to breathe through contractions offered some support.
"Spending time with students helped me to see changes are happening with women’s welfare in mind. The passion of some of the staff made me feel very optimistic. However there is a hierarchy that stands in the hospital, it is frowned upon for junior staff to question senior staff, therefore many practices are followed because midwives and junior doctors are told to do it that way, even if they know evidence goes against the actions. Therefore implementing change is very difficult.
"Doctors are seen as miracle workers and an ability to intervene is seen as a great thing. This results in a lot of unnecessary intervention, for example all women are induced or have their labour augmented on arriving at the hospital as long as they are approximately term. Therefore if there isn’t very quick progress the staff believe there is a failure to progress. Maternity care seemed focused on an ability to intervene with little faith in women’s bodies. All the staff I spoke to that had children, had elective caesarean sections.
"Nevertheless I found my confidence grew over the two weeks and by the end I felt more able to question medical practitioners (in a sensitive manner) and act as the women’s advocate. It was really satisfying to make a positive difference to the women even if it was something as small as holding their hand when they were scared. Furthermore I had many discussions with the lead lecturer comparing practices in the UK and Nepal. It was really positive to hear her talk about a more holistic approach to care and that she is training her students in that way. As I had built trust with the teaching team I was invited to sit in on two final year student presentations, I came away feeling confident that although it is a long journey changes are being pushed to make care more women centred.
"Outside of placement I was lucky to be able to volunteer to teach art to a group of children in need on the Saturday I was there. I came away covered in glitter but I thoroughly enjoyed being able to give something back to the community.
"This was the best opportunity I could possibly have been given. As I was a put in a situation where care sometimes opposed my beliefs I found a greater passion for advocating for women then I had before and this increased my confidence and ability to advocate for women. I saw a lot of high risk situations and although the care was different to what I would expect in the UK, it has given me a real insight into my own feelings in these situations and how I believe women should be cared for.
"The experience put into perspective the importance of woman centred midwifery care. And the importance of trusting a woman’s body has the ability to give birth. It likewise highlighted the importance of core midwifery skills such as verbal and nonverbal communication and how much they can do without other resources. Furthermore I gained a lot of confidence in overcoming language barriers. I have come away with a real appreciation of the care I am able to give women in the UK, something I will certainly never take for granted.
"The passion of the staff and the students to improve care also made me see even with an uphill struggle, with passion and the right attitude improvements can be made. The whole experience strengthened my own passion for women to receive the best possible maternity care."