Tuesday, 29 October 2013

North to South

Now the Advocacy workshop is over, I am concentrating on the mid-term evaluation of our Global Midwifery Twinning Project.  This has taken me out of Kampala, past the Equator, to visit midwives up-country where our GMTP volunteer midwives have been based, learning about Ugandan midwifery, providing training in Emergency Obstetric and Newborn Care and role-modelling woman-centred care.
At the centre of things - passing the Equator on Sunday
Yesterday we visited three private midwives clinics all providing community-based midwifery services, many in remote areas currently in poverty until the rains come.  All of these small centres are providing 'gold-standard' midwifery care with continuity, privacy, cleanliness, good clinical standards and geographical accessibility.  However, they are often under-utilised for maternity services as women have to pay.  Instead, women stay at home to deliver with a Traditional Birth Attendant, or use the government health posts which are under-resourced and under-staffed.
Delivering the beds donated by one of our volunteers to a Level 4 Health Facility in rural Uganda (near Masaka)
We visited one such government district hospital; the one doctor was overwhelmed with patients and had no time to examine them or provide proper diagnosis and treatment.  As we toured the wards, an old man died in the corner died without ceremony from pneumonia.  He was peripherally shut-down and staff couldn't find a vein to start the IV antibiotics he desperately needed.  There was no oxygen and no nurse by his bedside.  In the out-patients' department a baby, no more than 4 months old, was breathing too fast with a chest infection. He should have been admitted for intensive nursing; instead he saw the doctor for 30 seconds and was sent away.  The maternity unit was quiet as the operating theatre was temporarily closed for building works.  Women are referred there for caesarean section, only to be referred onto another place.  One of our volunteers had donated some beds for the hospital and conducted some training for the midwives there.  However, maternal mortality rates in Uganda are still rising.  Political will, cultural issues and system transformation are required for sustainable change.

With Maria (UNFPA Country Midwifery Advisor for Uganda) and John (Registrar, Uganda Nurses and Midwives Council - at today's workshop

Today I attended a workshop with the Ugandan Nurses and Midwives Council, reviewing the final draft of their new midwifery handbook.  I my presentation this afternoon I urged midwives to join together in lobbying the government to introduce free midwifery care for women at any centre with skilled birth attendants and appropriate equipment.  The private midwives have so much to offer.  A voucher scheme entitling women to free services would enable many more women to benefit from this gold-standard care - and save lives.  Financial incentives such as these have contributed to a drastic reduction in the maternal mortality rates in Nepal and Cambodia (our other twin countries) in recent years.
With Elizabeth, Rose and Jemima - all senior Ugandan midwifery educators with Masters Degrees or PhDs - at the Nurses and Midwives Council workshop today
I have mentioned before that Ugandan Midwives are very spiritually minded - we had four prayers today at the workshop (I am trying to imagine an NMC workshop in the UK with prayer before each coffee break...!).  I decided to go with the flow and end my presentation using some words from the Bible, exhorting midwives in Uganda to work together, to be strong and courageous and not to give up.
'Be strong and very courageous as you lead these people.. that you may have success.  Do not be afraid or discouraged, for the LORD your God will be with you wherever you go'.
                                                                                                    (Joshua Chapter 1)

It was all a bit much for this participant at the Uganda Nurses and Midwives Council Workshop
The afternoon finished (after another prayer!) with over 40 midwives joining hands and singing:
"We are together again, in one accord.
Something good is going to happen, something good is in store".

Friday, 25 October 2013

The sound of singing in Kampala

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So our workshop finished yesterday with the sound of singing. There is nothing quite like African voices raising the roof and the song was our GMTP anthem, developed originally for the RCM staff conference back in July.

It’s a round in three parts with words about the need for more midwives across the world (written with help from my creative husband), set to a hymn tune I first learned from American Mennonites in Cambodia!

The words to the song are:
1.    Worldwide midwives far too few, ­­ worldwide midwives far too few.
2.    Twinning, training, building capacity, changing lives
3.    Education, regulation and association.

 Follow this link to listen to a recording http://www.youtube.com/watch?v=W1LD-gOlrpU.

According to the State of the World’s midwifery Report (UNFPA, 2011 http://www.unfpa.org/sowmy/report/home.html) there is a global shortage of three hundred and fifty thousand skilled midwives.  Three hundred thousand women die in childbirth each year and more than thirty times that number suffer long-term damage to their health and well-being.   Women have a right to good quality, accessible maternity care.  Investing in midwives makes sense and yet the 58 countries with 91% of global maternal deaths have less than 17% of the world's midwifery workforce.  The International Confederation of Midwives states that effective midwifery regulation, good quality midwifery education and a strong professional midwifery association are the keys to a strong midwifery profession.  Our Global Midwifery Twinning Project focuses on these three areas, working alongside the midwifery associations in Cambodia, Nepal and Uganda.  Working with organisations and bureaucracy can be frustrating.  However, in our workshop we were reminded of an African Proverb:

‘If you want to go fast, go alone.
If you want to go far, go together’.

Twinning can be frustrating, but working together – even if slow – will surely make a difference in the long term.  Florence, Head of the Midwifery Chapter of the Uganda Nurses and Midwives Union, encouraged us to persevere, through the words of another African midwifery anthem:

“I will never give up until things are done.
I will never give up until God says ‘Well Done’.”
Mary, President of UMPA; Me; Florence, Head of Midwifery Chapter of Uganda Nurses and Midwives Union
One of the key advocacy messages highlighted at the workshop was the need for more male involvement around reproductive health in Uganda. Robina, National Coordinator for the White Ribbon Alliance in Uganda reminded us that women are dying because society has not decided that their lives are worth saving. The workshop helped UPMA to develop a clear action plan to target local community leaders, developing ‘model districts’ where men value women’s reproductive health rights and ensure that barriers preventing access to good quality services are broken down. 
 Robina, National Coordinator for the White Ribbon Alliance in Uganda

 Sarah, a midwife and politician, ended the conference with the inspiring thought that one life saved has huge impact.   Another African proverb: ‘sticks collected one by one make a bundle’.
Sarah, Midwife and Politician who officially opened and closed our conference - and participated in many of the discussions

 The challenge for UPMA, and the Global Midwifery Twinning Project, is to ensure that the energy and momentum generated by the workshop will be continued for the next 18 months and beyond.  Putting firm plans in place for this will be the focus of my remaining time in Uganda. 

I’ll finish this blog with some words from Elizabeth, a senior midwifery lecturer from Mokono University who I interviewed this morning:

 ‘Surely if we follow up these messages and the activities planned the voice of midwives will be heard.  Sometimes I feel we must have faith in the little people.  I don’t despise small beginnings.  Midwives have standing and connections in their communities; investing in them has great potential for impact.  The GMTP project has made UPMA midwives visible and given them recognition.  For me personally, my interaction with the GMTP volunteers has given me more skills and knowledge and the confidence to move forward as the leader of our Masters in Midwifery programme.  GMTP has also connected me with midwives and others, allowing me to grow socially and understand the bigger picture of midwifery. I am grateful for the opportunity to participate in the project.’

Wednesday, 23 October 2013

Wednesday in Uganda

It’s been a great day but I feel like I’ve been run over by a bus.  So much has been happening, so many people have been coming and going and there has been so much information to take in.  Bertha is doing a great job and is working everyone really hard!  Today was all about refining the problems facing midwifery in Uganda and identifying (a) what is feasible to address with an advocacy strategy and (b) what is outside the remit of a professional association.  Some concepts were shelved as it became apparent they were being addressed by others or were too complex for this organisation at this stage.  Others, were subjected to fierce critical analysis and came out completely changed!  I personally have learned much about the theory of advocacy and how to facilitate learning about it - I know this will be really useful for the life of the project and beyond.  Bertha has a ‘bag of tricks’ that keeps the conversation lively and different people are appointed each day as timekeeper, energiser and spiritual leader.  The prayer times before, during and after proceedings are a defining feature of any UPMA gathering.  It is not a religious organisation, and the midwives come from all different faiths and denominations, but prayer is recognised as essential to progress – perhaps there is a lesson here for midwifery in the UK! 
Bertha's bag of tricks

Trying to agree on what comes first in adovcacy - building your alliances, developing your message, analysing your environment.....
 Some really important people attended today from the Uganda Nurses and Midwives Council, the big state university (Makarere) in Kampala, the White Ribbon Alliance, newspaper correspondent and Mildmay Uganda – as well as some additional midwives from UPMA who couldn’t be with us yesterday.   At times I joined in the discussion; other times I observed the interaction between participants or acted as photographer.  It was great to see everyone participating and working well together; the president, the CEO and all the executive committee were completely engaged in the process and were helping to facilitate their groups, thus developing their leadership skills.  Sometimes they were shouted down – democracy is alive and well in the UPMA!

The UPMA president stating her case!

Who goes first - rock, paper, scissors

I am trying to pace myself, aware that this is only the beginning of a 12 day trip.  After the workshop I still have much work to do, interviewing many people for the project evaluation and making up-country visits.  I am looking forward to a day off on Sunday.  Meanwhile, there is limited internet but I will try to blog and Facebook when I can and keep you all updated.
Looking about as tired as I feel...

Njakkulaba enkya – see you tomorrow!

Hello from Uganda

I’m in Uganda for 12 days with the Global Midwifery Twinning Project.  It’s my second time here – what a joy to meet these midwives again, and those who are working alongside them.  This time I knew the face meeting me at the airport, Bonne, UPMA’s driver.  I was carrying a very special parcel for him, a set of binoculars from my colleagues Helen and Breedagh who came to Uganda with me in April.  Bonne had taken them to the Botanical Gardens where they looked at the birds through Helen’s binoculars.  Bonne was amazed – and now he has his own pair.  He was overjoyed with his present and I was happy to have carried it for him from the UK. My suitcase was mostly filled with midwifery teaching materials. I also carried an extra suitcase for another charity that had to be collected at Heathrow.  This was arranged by e mails via Malaysia, France and Leamington Spa…  happily all made it through customs without incident.  Note to self: must travel lighter!

It’s over an hour’s drive from Entebbe airport to the Hotel in Kampala (Kampala doesn’t have its own airport). It’s nice being back in the same hotel – the staff are so friendly and though the rooms are simple the place is clean and the food is tasty and plentiful.  The workshop is here too which makes the mornings simple!

Day one was hectic, meeting the Commissioner/Chief Nurse at the Ministry of Health as I had barely stepped off the plane.  I then spent some time with the consultant leading the workshop, as we’ve only ever met by Skype.  She’s from Bolivia and is a world expert on developing Advocacy Strategies with midwifery associations.  She’s doing a great job, and I’m enjoying her company too.  We had a pre-workshop meeting later that afternoon with UPMA, understanding everyone’s expectations of the workshop.  We carried on working through the evening, planning the rest of my time here. 
Me with Bertha, our Bolivian Consultant

Today we started our workshop and had participation not just from UPMA (Uganda Private Midwives Association) but also from parliamentarians, Ministry of Health, Universities, NGOs, UN agencies and others.  I gave a small speech about our project, and showed some photographs from the other countries.  Bertha (our consultant) helped us to understand what Advocacy is and is not, and what steps are involved.  This afternoon the participants identified potential issues around which a midwifery advocacy strategy could be developed and did some analysis of these.  One group wants an advocacy campaign to train male midwives – that led to an interesting debate! 
Elizabeth (Senior Lecturer at Mokono University), Enid (Chief Nurse/Commissioner at Ministry of Health) and Miriam (Uganda Private Midwives Association) - coming together through the Global Midwifery Twinning Project to develop a joint Advocacy Strategy for midwifery in Uganda

Bertha and I hired a driver (Wilson) this evening and went to the Kibera Country Club (very posh!) to meet Michele Ball, a British Midwife and RCM member working in Uganda who helped us access hospitals on our last visit which was hugely appreciated.  It was great to catch up with Michele and have a change of scene. 
with Michele Ball, British Midwife working in Kampala
Internet is very intermittent at the hotel and I can’t post this now (or Facetime my family L) but hopefully I can post at breakfast time and add some photos from the past 2 days.  Night night!

Saturday, 19 October 2013

Some thoughts on volunteering

Volunteering is the 'in-thing' right now.  David Cameron is promoting 'The Big Society', supposedly unleashing the social energy that exists in the UK to help build a better, healthier society. Closer to home, my daughter is undertaking The Duke of Edinburgh Award and must volunteer in the community every week for three months to qualify for the award.  My good friend and walking buddy Anita runs' My Ten Days' encouraging and supporting owners and managers of small to medium size enterprises (SMEs) to give one employee ten days paid leave to do voluntary work or fund raising (http://www.mytendays.org/what-is-my-ten-days-_48/).

Yesterday I discovered my hairdresser Heather has just returned from 4 weeks volunteering in a school in Uganda - I leave for my second trip to Uganda tomorrow so you can imagine we had a lot to talk about.
Heather, a young hairdresser in West Malling who has just returned from volunteering at a school 

Volunteering aims to benefit society.  The Royal College of Midwives' Global Midwifery Twinning Project aims to help reduce maternal and neonatal mortality in Nepal, Cambodia and Uganda by strengthening the capacity of the professional midwifery assocations in those three countries.  Our UK midwife volunteers spend up to 4 weeks in-country, helping develop midwifery education, regulation and practice (http://www.rcm.org.uk/college/policy-practice/international/twinning/).

However, volunteering also aims to benefit the volunteer - personally and in their work. The World Volunteer Website suggests that volunteering not only has a positive impact on the community but benefits to volunteer, developing their skills, giving motivation and a sense of achievement, boosting career options, opens up new interests, hobbies and experiences, allows the volunteer to meet a wide range of people and sends a positive signal to employers, teachers, friends and family  (http://www.worldvolunteerweb.org/resources/how-to-guides/volunteer/doc/benefits-of-volunteering.html).

A recent systematic review in the journal Globalization and Health  (Jones et al, 2013) showed that, despite limitations in the quality of evidence, there is a strong theoretical argument that the skills acquired through volunteering are transferable to service delivery within the NHS and that the benefits to individuals and institutions could be maximised when volunteering is formally embedded within continuing professional development processes. 

Win, win. However, could there be a negative side to volunteering?  Certainly.  Unregulated volunteering in all its aspects is harmful to children. Recent events in the UK news have highlighted the dangers of unscrupulous adults (e.g, Savile)  having access to children and others in so-called charitable activities. Overseas, the picture is similar.  Friends International and UNICEF have joined together in an initiative to stop orphanage tourism - known as 'voluntourism'  - in Cambodia. Voluntourism is often conducted by unscrupulous business operators and, despite tourists' best intentions causes more harm than good. It  can endanger the proper care of children, rendering them more vulnerable to abuse and exploitation, and contributes to the separation of Cambodian families. Instead of visiting orphanges, the initiative suggests individuals give their your support to organizations who work with marginalized young people and their families. These provide vocational training and community based initiatives such as income generating activities, where income goes to the family and to provision of social support.   http://www.thinkchildsafe.org/thinkbeforevisiting/)

Food for thought. 

Monday, 30 September 2013

Homeward bound

Well I've just said goodbye to Cambodia for another 6 months and landed in Bangkok.  The last time I was here was 2000; Stephen and I were on our way to China to adopt our (then) 9 month old baby daughter. On the wise advice of friends, we stopped over in Bangkok for a few days to recover from jet-lag and a last few moments of being 'just us' before our lives were changed (and wonderfully blessed) for ever.  I remember staying at the YMCA (nicer than it sounds!) and enjoying a wonderful meal at the Oriental Hotel on the riverfront. We also met up with Steve and Marie Goode, veterans of the Thai/Cambodia border camps who live in Bangkok and whose lives have intersected with mine on many occasions.  I am currently sitting in an internet cafe about to meet Steve again for the first time since then - we have lots of catching up to do!  Looking forward to getting his perspective on all things related to development work across the world and exchanging news of family and our shared friends.

I've been away from home for three weeks and I'm ready for some family time and walks with my dog in the coolness of autumn.  However, it's been a great trip and I'm really encouraged by the progress our Global Midwifery Twinning Project is making, both in Nepal and Cambodia.  I have been reminded, once again, of the importance of relationships in overseas development work (and in other spheres!) and that seeds cannot be sown before the ground is prepared.  I do believe that we are now beginning to sow seeds and even nurture green shoots with the Midwifery Society of Nepal and the Cambodian Midwives Association - though relationships must continue to be built and strengthened in the same way as weeding a garden is necessary to avoid choking fragile seedlings.  Much of my work when travelling is networking - I try to meet as many people as possible who have a stake in midwifery in the host country... and some who don't but whose knowledge provides invaluable cultural or strategic context.  Thus today I found myself meeting with a professor from a UK university, based here in Thailand and working all over South East Asia, who shares some of our interests and networks in Cambodia.  We were able to offer one another useful information and contacts and who knows, maybe together we can be stronger!  Three years is such a short time-frame in which to achieve sustainable results and right now it's good to explore ways that our efforts may be continued - either by us or by others.

Never under-estimate the power of drinking tea and 'wasting time' with others in development work - such time is never truly wasted and will doubtless bear much fruit in the years to come
I'm feeling really positive about the placements we've arranged for the next few groups of volunteers in Cambodia and Nepal.  MIDSON and the CMA are more clear now about who and what they need, and how to support volunteers in country.  We are developing our knowledge too about what information they need before they go, how we can ensure their placements are as effective and fulfilling as possible, and how we can best debrief and disseminate their learning on return.  I've been developing a 'tour guide' for volunteers as I've travelled around so thanks to all those in both countries who gave me recommendations for restaurants, hotels, shops, tuk tuk drivers, hospitals, favourite outings and lots of other information besides.  Our volunteers should have plenty of options in their down-time now!

In addition to leading workshops and drinking countless cups of tea, I have also conducted a mid-term evaluation for both our project in both countries whilst on this trip.  I have met with many people, both inside and outside of the midwifery associations, and asked them questions on the successes, challenges and lessons learned from our project so far.  I have two notebooks packed with information - my challenge is now to filter and synthesise this so we can use it to capture an accurate picture of where we are now and where we want to be in April 2015.  In addition to this we have a major donor report to submit on 15 October, then I leave for 2 weeks in Uganda on 20th to undertake the same thing again.  I am feeling rather tired and overwhelmed so appreciate all the love, prayers and support that my colleagues, friends and family continue to offer via Facebook, Skype, Phone, E mail and face-to-face.  Stephen and Hannah are enormously gracious in the face of my continued absences from home, so when I get home tomorrow work will be on hold for a little while whilst I nurture those most important relationships of my own.

Meanwhile, I feel something  little stronger than tea may be required to celebrate our family reunion tomorrow so, in anticipation, cheers!
Gin Fizz, Cambodian-style!

Thursday, 26 September 2013

Prey Veng Revisited

I have just returned from 5 days in rural Cambodia.  Prey Veng province, where the Cambodian Midwives Association had organised a workshop, is a large and densely populated area with more than its fair share of poverty and over 300 midwives.  Wikipedia describes the provincial town:

 "This quaint town is off the usual tourist trail and is uncrowded. It houses several old dilapidated colonial homes. There is a large lake west of the city which is dry from March to August."

Co-incidentally, I used to live in Prey Veng from 1994-1996 and was very happy there.  Life was very simple; one of only 2 foreigners in the district town of Svay Antor we had no running water or electricity, just solar panels on the roof for lighting.  We ate Khmer food every day and wrote letters home for entertainment.  I worked with a community development programme, training traditional midwives and supporting community health services, as well as planting rice, delivering sacks of cement and drinking a lot of tea on walkabouts in the villages. 

I was overjoyed when the CMA wanted to conduct their workshop there, giving me the opportunity to return.  Their provincial branch had died and they had few members.  They planned to invite midwives from across the province, recruiting them to the CMA, providing some continuous professional education and vote for a new branch leader.

I travelled on the public bus ($2.50 per ticket compared to a minimum of $35 for a taxi).  It was a hot and squashed affair but got me back into the reality of Cambodia nicely after the luxury of my Phnom Penh hotel.
Getting off the Public Bus in Prey Veng with Nisay, my Khmer assistant
I stayed with Barb, a British Midwife who I have known for more than half my life and is a veteran of Cambodia.  It was wonderful to be in her traditional wooden Khmer home, sharing life with her family and having her company and invaluable input during our workshop.  Nisay, my Khmer assistant this week, is Barb's daughter so she enjoyed being back with her sister.  It was great to hear them giggling together!
Barb's House in Prey Veng

The shower at Barb's House

Kanika (Student Midwife) and Nisay (my assistant this week), Barb's daughters

Barb with her cat, Ginger
The workshop was a real milestone for the CMA and for our twinning project.  It was wonderful to see the executive team pulling together to organise an event.  Our short-term support for a part-time office administrator has meant there is someone in the office to get jobs done.  They had planned the timetable and executed it with little input from me except my speeches at the opening and closing events and my presence at the meeting with the provincial health chief.  This left me free to interview several people for our mid-term evaluation and to observe the event with a critical eye.  We visited a Health Centre in Prey Veng Town and the CMA members did some mentoring (in the very loosest sense!) with midwives there as well as meeting some mothers-to-be and engaging in some health promotion activities.  There's a whole other story in this tale but that's for another time!
Around 150 midwives (half of all the midwives in the province) attended one of the workshops and signed up for membership of the CMA and it now has a newly elected, enthusiastic branch leader.  We have negotiated with the Provincial Health Chief for two of our British midwife volunteers to come to Prey Veng sometime early next year to engage in some mentorship for the new branch leader, supporting her to support midwives across the province and training her as a trainer. 
Me with the newly elected branch leader of the CMA in Prey Veng
I have a sense of a job well-done, though there was much room for improvement.  It is real progress from the state of our project 6 months ago and I feel positive for the future.

Three of us travelled back to Phnom Penh today and decided to take a taxi so that we could stop on the way and visit some other health facilities.  It was also much more comfortable than the journey down and far quicker!  We went through Svay Antor past my old house which was unrecognisable, and though some of the villages where I used to work, all now accessible on tarmac-ed roads and much more developed.  Some people still recognised us though, and we also met some of the midwives who had been at our workshops and were delighted to show us round their workplaces.

Midwives in the newly re-furbished delivery room at Svay Antor Health Centre

My old house in Svay Antor.  When I lived there it had wooden steps, no brick-built room downstairs and an outside bathroom under the house, with no running water or electricity.  Unrecognisable now!

Barb and I meeting three midwives in Chrey Health Centre who had all been to our workshops this week and have signed up for CMA membership

The Delivery Room at Pear Reing District Hospital - 3 beds, no curtains

Operating theatre where caesarean sections are performed at Pear Reing District Referral Hospital

Barb helping a lady to breastfeed (note the heavy bag of ice on her abdomen.  They seem to use that here to prevent or treat post-partum haemorrhage!)

Sunday, 22 September 2013

Culture shock

Since I returned to Cambodia with GMTP I've been quite culture shocked. This feeling keeps revisiting me as I realise Cambodia has changed in so many ways yet, in others, it is much the same.

It first hit me flying into Phnom Penh in May. Looking down over the city I wondered if the plane had flown mistakenly to Kuala Lumpur. All those brick houses with tiled roofs, tall multi-storey buildings and just such a big place. Surely this was not Cambodia? Last time I visited in 1999 the airport was little more than a shack and was some way out of the small city of Phnom Penh, separated by acres of rice paddies. Now it's one continuous sprawl of new houses and factories.  Before, we rode pillion on 'motodups' (motorbike taxis) or pedalled cyclos. Now there are tuk-tuks and the streets are full of air conditioned top-of-the-range 4 wheel drives, many with government plates...

A new wave of culture shock hit me this time as I came directly from Nepal. Kathmandu is the most polluted city in the world; it's full of dirt and dust, clapped out taxis with zero suspension, bumpy roads, dirt and smells, mangy dogs and people everywhere. It's also vibrant, colourful, genteel and exciting.

Driving from Phnom Penh airport to the hotel late at night, the roads were smooth as a baby's bottom as I sat comfortably in a new, air conditioned taxi. The road were quiet. We passed streets of brand new flood lit buildings and complexes, tree-lined boulevards and ornate, shiny gates. There are air-conditioned coffee shops on every corner. The hotel, with pool, is a tranquil oasis next to an elegant temple. There is bacon for breakfast.

Yet I know this is not the real Cambodia and that the gap between rich and poor is getting wider as the relatively few elite profit from land-grabbing and other practices the poor have no power to redress.  I am looking forward to my trip to Prey Veng to reconnect with a Cambodia that is more familiar. To staying in a traditional Khmer house without a western bathroom; eating traditional Khmer food (though I hear Barb is planning chicken and chips this evening!) and resting my eyes on green rice fields scattered with sugar-palm trees.

Saturday, 21 September 2013

Hooray - my expenses balance!

It's always a relief when one's expenses balance - this trip involves 5 different currencies and I'm so grateful to my lovely husband for designing me a spread sheet to manage my financial nightmares.  I'm pleased to say that I have exactly the right number of reil, pounds, dollars, rupees and baht left and I'm rather proud of myself.

It's always a treat to be back in Cambodia - I worked with Cambodian refugees in Thailand in the 1980s and learned to speak, read and write the language fairly fluently.  I lived in Cambodia itself in the early 1990s with CORD (http://www.cord.org.uk/) and visited frequently when I was Tearfund's southeast Asia Desk officer, until we adopted  Hannah in the Year 2000.  It had been 14 years since I spoke any Khmer but I'm pleased to say it's all coming back to me now that I have undertaken 3 trips here with the Global Midwifery Twinning Project.  I have a network of friends and contacts here that has been invaluable.  The programme here had a slow start and we have managed to pull it round thanks to some sound in-country advice and support. 

I am here to undertake some mid-term evaluation activities and join the Cambodian Midwives Association in a regional workshop in Prey Veng Province.  They chose the location as it's a very poor province and has a low density of CMA members. Co-incidentally it is where I worked in the 1990s so I am able to stay with my friend Barb, a midwife from the UK who has lived here for over 20 years.  I will travel down to Prey Veng tomorrow (Sunday) on the Public Bus which will doubtless be a warm, dusty and bumpy ride but will enable me to see the countryside close up and observe the changes since the 1990s.  I have my traditional Khmer outfit to wear for the conference (Jacque and I had them made when we were here in July) and have packed my mini suitcase with Duchy Originals biscuits and home-made jam, treats for those who live far away from Western Supermarkets!

I had a restful day today - I needed it having worked flat out for 10 days in Nepal with no break.  I did have three meetings but they were all quite relaxed and took place over pots of tea or lovely meals.  In between times I found time to have a pedicure ($5 for a full-hour!) so I now have coral toes in time for the workshop!

The art of report-writing whilst having a pedicure
I met up with Kath Hinchcliff for tea this afternoon. She is a retired Senior NHS Commissioner who has been working as a VSO volunteer here for the past 3 years, assisting the Cambodian Midwives Association and the Cambodian Midwives Council.  Her input to our project and our own volunteers has been invaluable and I know that the impact of her work here will be felt for years to come.  Kath provided some very useful insights for my programme evaluation and feels that GMTP is beginning to yield some results here
With Kath Hinchcliff
  I dinner with Steve and Ruth Penfold and three of their four children.  Steve is a locally based healthcare consultant with fantastic expertise in reproductive and sexual health and has been enormously helpful to GMTP in Cambodia.  It was good to catch up personally and professionally and to view the new family car!

Who needs a car when you can buy a tuk tuk? Much more fun!
So, I will attend the International Church tomorrow morning then head off on my next adventure.  I have hired some help whilst I am here - Nisay is a very smart graduate who will help me with translation and other duties, leaving me free to do what I need to do.  I'm not travelling with anyone else on this leg of the trip so needed some help with the donkey work.  Let's hope we survive the bus journey tomorrow!

Friday, 20 September 2013

Leaving Nepal and on to Cambodia

What a great ten days it has been.  As usual, the pace of the days increased as we crept closer to our flights home/onwards - sometimes however much planning I try to do in advance, things all seem to come together once I'm in country.

We spent the morning of our last day in Nepal at the Midwifery Society Office, where we undertook a mid-way evaluation of the project using a tool developed by the International Confederation of Midwives. This enabled MIDSON to assess their development to date and make plans for how they want to develop in the future.  We all agreed that after such an enormous effort organising the conference, they need some time to re-group and focus internally for a while.

After a lovely lunch of Nepal Thali at a local canteen, we headed to the Tribhuvan University Hospital on the other side of town, where Kiran (President of MIDSON) is an associate midwifery professor.  We were shown around the labour ward and met some wonderful, passionate midwives who are so frustrated at their powerlessness to make changes.  Staffing levels are a real challenge - 2 midwives for a busy labour ward with 8 beds, so no chance for one to one care.  The on-call doctors are medical students who have more authority in the system than senior midwives with over 20 years' experience.  The day we were there the midwives were so sad - earlier in the day a woman had died after complications from a caesarean section, leaving 2 motherless children.  Turns out the elective caesarean was performed by a medical student.  They also showed us an adjoining building that they wish to turn into a birth centre.  It has all been nicely renovated and equipped, but they are at stalemate because the obstetricians don't think a midwife-led unit in a different building would be safe.  Our volunteer midwives have been working there trying to influen
ce practice and have clearly made a difference - the Nepali midwives all spoke warmly about what they have learned and are trying to put into practice.  However, I wonder whether a more multi-disciplinary approach is needed with some obstetric 'converts' from the UK working alongside the midwives to effect change.  Think that is probably outside the scope of this project though!
At the birth centre, currently being used as a postnatal ward

We had a lovely dinner with some of the UK volunteers and others, then breakfast with MIDSON members this morning before heading out the airport.  Now in the departure lounge at Bangkok airport waiting for my onward flight to Phnom Penh.

Next instalment will be from Cambodia!

With midwives on the labour ward at Tribhuvan Teaching Hospital, Kathmandu

Tuesday, 17 September 2013

What a week!

Time is flying so fast.  Haven't posted since Friday and so much has happened since then. We've been here a week and the days are getting busier and busier as we had towards our flights out on Friday.  I'm going onto Cambodia and there has been civil unrest there this week after July's elections, so I'm keeping a careful eye on the FCO website and keeping in close touch with friends in Phnom Penh - won't be taking any risks so don't worry about me!  Gillian will be flying home and I know Nepal will now hold a very special place in her heart - this trip has been full of wonderful, memorable moments making us very proud to be playing a part in developing the midwifery profession here.

The first ever midwifery conference in Nepal was a resounding success.  We both gave opening and closing speeches, and other presentations besides.  There were approximately 300 delegates and MIDSON did an amazing job of organising the conference - from registration packs, badges, freebie bags, certificates, trophies, souvenir publications... incredible to think that they have only been in existence as an organisation

 for 3 years.  It was one of the best organised conferences I have even been to!  The message was given loud and clear - Nepal needs midwives.  Midwives save lives.   Work together to change the law to allow midwives to be registered with a protected title. Finish developing educational standards that meet international standards and the country context in Nepal.  Be brave, make it happen without delay, and support the midwifery society.

Tracy, one of the GMTP Volunteer Midwives, arriving at the conference
Our fabulous Delicia giving an inspiring closing speech at the midwifery conference

Now the conference is over, our Project Adminstrator Delicia has been helping MIDSON finish up,writing letters of thanks and settling finances, plus gathering information for our next report.   
Gillian and I have been meeting stakeholders, visiting hospitals where our volunteers have been working, gathering data to evaluate project progress to date, and making plans for the future of the project.  Today we toured Thaphatali Womens' and Children's Hospital (20,000 deliveries per year) where Gillian was able to donate lots of knitted baby clothes, handmade by Grannies in Scotland!
Gillian donating knitted baby clothes in the Kangaroo care ward
Dad in the Kangaroo-care ward having some lovely skin to skin time with his lovely baby - and modelling the Scottish Grannies' hand-knits!
We met with the Matrons, took tea with the Assistant Hospital Director, visited the medical library and then spent some time in the birth centre where Gillian saw her first birth for 18 years and wept buckets at the joy of it :)  We rejoiced in seeing the small but significant changes that our programme is making through the influence of midwife volunteers from the UK: screens around the beds for privacy, encouraging women to mobilise in labour, a relatively clean environment, delivering in a (sort-of!) upright position, no episiotomy performed even though the woman was a primigravida, and - most important of all - some kindness and compassionate care.
Birthing woman in an upright position, supported by her mother, with screens around the bed
This woman had triplets by normal delivery - no caesarean section!  Two head down, one breech.  The babies are still in SCBU but Gillian was able to give her 3 hats and 3 cardigans for when they're finally reunited with Mum

Cuties on the post natal ward
We also visited the very impressive one-stop crisis management centre in the hospital where women are referred (or self refer) with domestic abuse, rape, crisis pregnancy or other difficult situations.  Staff at the women's hospital work with police, social services, housing and others to find refuge and solutions for such women. 
We then had a very fruitful meeting at the Ministry of Health and Population with the Public Health Chief and Chief Nurse, advocating for midwives and the midwives association and encouraging the ministry to act without delay.  Also asked them if they will sponsor a midwife to attend the ICM Congress in Prague in June 2014.
After lunch at the Nepal Nursing Assocation, Gillian attended a UNFPA workshop and I went to interview Ishwori, Nepal's Chief Nurse and Registrar at the Nursing Council.  Had a slightly embarrassing moment when I fell asleep on the sofa!  The evening finished with a meeting of the Perinatal Society of Nepal, hearing about UNICEF's new programme to reduce neonatal mortality and the Nepal country plan.  Responded to one of the presentations with a recommendation that Midwives will meet many of the needs in the country plan and got a standing ovation!  They laid on a lovely supper then I returned to the hotel around 9.30 to have a cuppa with Gillian and Delicia before retiring to my room to deal with e mails and write the blog.
Meeting the Public Health Chief (second from right) and Chief Nurse (rar right) at the Ministry of Health and Population


Friday, 13 September 2013

Friday 13th - definitely a lucky day!

It's been an amazing, full-on, exhausting and exhilarating day - at the end of which I am sitting in a luxury hotel room after a hot shower, fluffy towels and even a pair of those hotel slippers!  We have moved into the hotel where the midwifery conference is to be held - a beautiful, grand hotel, full of olde worlde Nepali charm but very competitively priced and with facilities big enough to host 300 conference delegates tomorrow.

After a quick breakfast, Gillian and I crossed town to the Tribhuvan University Teaching Hospital to observe a Training of Trainers session being run by UNFPA.  The University is one of the five government hospitals training midwives and our project volunteers have previously been placed in the Hospital's maternity department to role model women-centred midwifery care.  They have also partnered with the midwifery teachers in the University, helping to develop them to be able to teach the new midwifery curriculum currently under development. 

The training was excellent, using a relatively new birthing simulator 'Mama Natalie'.  I unexpectedly ended up doing some role play, showing how encouraging upright positions in labour can encourage normal birth and prevent complications.  It brought a few laughs - I was glad I had worn a Salwar Chemise so I could maintain my modesty throughout some interesting manoeuvres with a chair and a birthing ball!

We enjoyed a tour of the University Library, and saw what books and resources they had (or did not have) for their teaching.  In a previous job I was responsible for ordering midwifery books and resources for the University Library - what a difference between the UK and Nepal. However, we were so impressed with the chief librarian, who is also the editor of the Nepal Nursing Education Journal.  It was great to see some midwifery contributions to the journal and a strong emphasis on women's health. 

We had lunch with the ICM's regional advisor for Asia, an amazing Afghan midwife who founded the Afghan midwifery association and is now helping to strengthen midwifery throughout the region. She has flown in for the midwifery conference and is closely linked with our project.  It was emotional seeing each other again - big hugs all round - and a privilege to introduce her to Gillian.  Lunches here are great - a takeaway box with a selection of different veggie curries, rice and pickles. Yum.

We moved hotels this afternoon and then all the visiting midwives and some of MIDSON staff were invited to the home of Kirsten, UNFPA Midwifery Advisor.  We had a beautiful Nepali meal, sat on the roof terrace with a view of the mountains, and spent some time gathering around Kiran (MIDSON's president) assuring her of our support over the next few days and trying to quell her nerves about the first day of the conference tomorrow.

Taxis home, and then met with Lesley Milne, a British Midwife Teacher/Researcher from Portsmouth who is here for 4 weeks on an RCM/WOW grant to research health worker's views about why women don't access midwifery care.  Lesley will be presenting at our conference and is also staying here in the hotel.  She's been working in quite rural/remote communities, often on her own, over the past few weeks so is glad of some company and English conversation.

I'm giving a speech at the opening ceremony tomorrow then have been asked to present someone else's research who is unable to attend the conference.  I hope I do it justice!  On Sunday, Gillian and I are doing a half-hour presentation on midwifery education in the UK so I'm hoping to get some time tomorrow to refresh my knowledge of the NMC standards for midwifery education!

I'm as ready as I can be.  I've had (my first ever) Facetime conversation with my daughter and my dog, and now I'm going to fall into that luxury bed and hope to sleep until the alarm rouses me tomorrow.  Thanks for following the blog everyone - hope you're enjoying it.

Thursday, 12 September 2013

Thursday in Nepal: a day of strikes and signatures

Ruth and Tracy, UK Midwife Volunteers, helping to prepare 300 delegate bags for Nepal's first midwifery conference, being held this weekend and supported by our project.

Me signing three hundred conference certificates of attendance!

Today there was a national strike to protest about the increase in fuel prices.  It was eerily quiet on the roads; no vehicles except emergency services, and very few motorbikes.  Our hotel is on a main road so breakfast seemed so peaceful compared to the usual cacophony of horns, whistles and trucks. No taxis or buses were running so we had a lovely walk to the Midwifery Society Office, about 30 minutes away from the hotel.  It was all hands on deck to prepare for the conference - finishing the programme, signing all the certificates, packing all the delegate bags, and writing speeches.  The MIDSON staff also had a small welcome ceremony for Gillian and I, presenting us with beautiful scarves, a folder of information, and an apple for good luck!  They bought us Momos (savoury dumplings with a spicy sauce) then shortly afterwards also gave us each a takeaway lunch box which was enormous - rice, curries, dahl, spinach, poppadums, chutney, yogurt...   Couldn't possibly eat it all but thankfully the Ruth and Tracy (UK midwife volunteers) arrived back from the maternity hospital in time to help us out!

I had time for a short chat with the Kiran Bajracharya, president of MIDSON, planning the rest of our 10 day visit here and making sure that we set enough sufficient time for everything that needs to be done. 

Tomorrow morning we will go to Tribhuvan University to observe a 'Saving Mother's Lives' workshop on Post Partum Haemorrhage being run by UNFPA before the 2 day midwifery conference starts on Saturday.  The conference is at The Shanker Hotel so we are moving there tomorrow to stay for the rest of our time in Nepal.  I have just looked at the website and realised that we're definitely going up in the world http://www.shankerhotel.com.np/.  This is certainly not the project's usual style but I will enjoy it whilst it lasts!

Still writing speeches and planning evaluation tools so time to sign off for today.  Thanks for following the Blog and lending your support.

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