Our workshops start at 9am, but the auxiliary nurse midwives (ANMs) and skilled birth attendants (SBAs) are relying on unreliable public transport to get them here. Some are even travelling miles by foot to attend. Sampada, our interpreter, tells us the women also have many responsibilities to attend to at home, so they arrive when they’re able to. I’m struck by how patient everyone is as they wait for all the group to arrive, with no request to be informed of a start time. I’ve noticed that all Nepalese people I’ve met so far are patience personified. They live in a society full of uncertainty and appear to be masters in the art of acceptance.
We welcome them all and Jilly offers everyone a Cadbury’s chocolate. Sweet treats are very welcome here. The women are dressed beautifully in colourful saris and their smiles illuminate the room. Around 38 women attend as Gopal and his staff at the Lotus squeeze in more and more chairs. A gentleman arrives too, and a child, and some other men and women. Sampada, our interpreter, tells us the gentleman is the new public health officer for Nawalparasi and he’s keen to meet all his staff. We’re not sure who the others are. Our ice breaker isn’t needed as the public health officer asks the women to stand up one by one and introduce themselves. The women seem confident and they all appear to know each other. I sense a good atmosphere brewing.
You may already know that we are participating in a project (a collaboration between Bournemouth University, Nepal’s Tribhuvan University and Liverpool John Moore’s University) aiming to raise awareness of mental health issues and build skills among Community Maternity Care Providers so that they can recognise and assist women with mental health issues. The project aims to reduce Nepal’s increasing suicide rate among women of reproductive age and, once evaluated and designed, will deliver a curriculum to the Government of Nepal.
Two waves of volunteers have already visited Nepal in the last few months. We are the third, building on the training sessions that have already gone before. The next volunteers (in July and September) will build on our sessions further (I believe the topics will be bereavement and suicide).
We have a laptop and projector but no white board so we tape flip chart paper to the wall. The electricity comes and goes so we don’t know if we’ll have access to any of our equipment at any given time (nor air conditioning and its 35 degrees!) Due to ‘load shedding’ in Nepal, the electricity goes off daily in different regions, spreading a fair share throughout the country. Good hotel establishments, like the Lotus Resort, have a generator – so we should be okay *fingers crossed*
Dave starts by welcoming everyone and introduces the subject of mental health. He mentions this subject can be difficult to discuss and reassures the women that this is a safe place to share, and if need be, they can leave the building at any time or come and speak to us privately if they wish. We start by asking what they have learned from previous sessions and it seems ‘awareness of mental health issues’ (where they had none before) and ‘providing counselling’ to women (where they would not have spoken to them about mental health before) and ‘recognising signs of mental illness’. One had recognised psychosis and referred the woman to a psychiatrist and others say they have now referred women for medication. They say they didn’t know before that babies can be in danger when mothers are psychotic and would consider removing a baby to a safe place until the mother was better. Some go on to share desperately sad stories of how women they have known have committed suicide. Sampada, our interpreter is incredible – the group are keen to share and it’s become apparent she needs to be a mental gymnast to keep up with the variety of local dialects as well as our English.
Once the discussion is rounded up, Jilly then begins her presentation on how to detect depression and what the difference is between baby blues, depression and psychosis. She discusses the Edinburgh Perinatal Depression Scale and how they can use this to detect, measure risk and respond to women’s needs. She empowers them to be able to confidently ask difficult questions of women and the students are keen to interact with her and know more.
I then give my presentation in a story telling format from a personal point of view as a mother and midwife. I discuss that I had both positive and less positive experiences with midwives during my pregnancies and that I noticed this made me more or less likely to share my feelings and also determined pain levels in labour depending who entered the room and what they said. I discussed how health care workers and women both benefit from building positive relationships making it more likely for women to trust their health care workers and divulge their true feelings, which can dissolve maternal anxieties, fears and stress all common in pregnancy, childbirth and postnatally. I discussed the physical effects oxytocin and adrenalin have on our body and mind and how the midwife can affect this balance and how by encouraging ‘active birth’ (where women are free to move around in labour) health care workers can help women feel more in control which can lead to higher rates of normal birth and reduced morbidity, ie perineal damage, increased blood loss, reduced birth trauma. This can and also increase satisfaction rates for both mothers and health care workers.
The subject of active birth provokes a lot of interesting debate, as does water birth. They can’t seem to understand why or how. From what I’m told, here in Nepal, women are told to lie on their backs in both hospital and birth centres (a common side effect when birth moves from the home to the hospital setting, and one which persists in many instances in the UK to this day). I believe from our colleagues in MIDSON that many women are treated terribly – mostly in bigger hospitals. They say health care workers in some cases, have even been known to be physically and emotionally abusive to women in labour.
We tease out some of the issues in response to their questions. Their difficulty is especially with women carrying a ‘big baby’. They feel women must lie on their backs if a baby is big. We take time to discuss the logic behind this belief and Jilly and I demonstrate positions for what they call ‘freestyle birth’ and how health care providers can facilitate this. I feel this would be a class all of its own though and try to keep the matter on the subject in hand when the debate moves swiftly on to shoulder dystocia. (When completing evaluations, however, I will feed the interest in this back).
I then encourage the women to consider how they care for their own mental health and that of their colleagues, and how our own mental health can affect others positively or negatively. I discuss the stresses of the job and why it’s important to look after ourself in order to be able to look after others. The subject seems to strike a cord and there’s lots of nodding in agreement. I suggest they can use relaxation, meditation or simply take time for themselves to do something they enjoy each day to ensure a healthy work life balance for positive mental health. Happy midwives equals happy mothers and babies.
I wondered if culturally women in Nepal already meditated or practiced yoga, but it seems not – they say they are too busy and I don’t doubt it (a familiar story the world over). So I begin a 10 minute guided relaxation with the whole group and I’m glad (relieved?) to see how receptive they are to this (I wasn’t sure it would work and the translation into Nepali was difficult). Sitting in their chairs most allow themselves to relax, some fall asleep and some don’t close their eyes at first but do later. A couple don’t close their eyes at all – but that’s okay.
We break for lunch afterwards and then Jilly treats everyone to a tune – ‘Resham Firiri’ a local folk tune, on her Nepalese flute and the women are delighted. They clap and sing. One woman gets up to dance and takes my hands to join in. I try to copy the moves and they all laugh. We all feel very relaxed in each other’s company. We feel honoured and touched how easily they have welcomed us and how open they are with us.
After lunch the fun will begin again when Dave starts his cognitive behaviour therapy session …. I’ll tell you all about it tomorrow. We’re here for 3 days after all!
Clockwise: Relxation session, our whiteboard, Jilly and Sampada, Sampada translates for me.