Outside “helpers”. Thoughts from a wandering Jew.

Tiptoeing through a minefield

Tiptoeing through a minefield

We are a wandering species. Wandering and shared culture is mutually strengthening. One of my personal goals on this trip is to be tipped off-balance by new experiences, different people and places, and to gain personally from this. As I wrote in one of my earliest posts (“Intercultural Understanding July 29th” https://wiwok.wordpress.com/2013/07/  ) “I believe that help is a minefiled”. My whiteness and my American experience give my words and my ideas power that I do not intend. I am treated with a deference that is both natural hospitality and a discomfitting honor that belies a very mixed intercultural history.

Bringing ideas and teaching imply a negative assessment of midwives and APS Birth Center. A negative assessment does not mean criticism. There is no blame given. But I know it is felt. And that feeling weakens the confidence of those struggling here under very difficult circumstances. It disempowers them and makes them more dependent. So, what if I didn’t try to do what I am doing? What if all the do-gooders walked out of Nepal and left them to their own devices? Maybe they would be better off and midwifery, mothers and babies would figure out quite happily how to care for themselves. Such abstract questions are meaningless and absurd, however, in a globalised and interdependent world. The strength of technological systems deriving from corporate power are such that the marginalised, the midwives and normal birth would lose. So I continue to tiptoe around the minefield.

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What do you call a Nepali midwife?

As part of the promotional materials we are creating for the birth center, I asked a couple of the midwives to translate a piece called “What a midwife does”. This proved extremely difficult. Despite an online dictionary, translations were elusive. Most difficult of all…. the word “midwife”. In Nepal, English words are often used for things of a technical or maybe prestigious nature. (This sometimes leads to both the sense that an individual Nepali’s English is bettter than it is, and also sometimes to the feeling that you understand things that are being said when you actually do not). Thus, Nepali midwives like the term “midwife” to describe themselves even though it is in English and ordinary Nepalis do not really know what it is. They do know the word “daiamma” which means literally “with mother” and also the word “sudani” which means community health worker (I think). But neither of the words satisfy the midwives at APS. The “daiamma” is an untrained village traditional birth attendant and the sudani is not right either. So they choose midwife. I understand but I am sad. I am sad that the word “daiamma” which is clearly related to so many words for midwife in so many languages (partera, sagefemme, meyaledet, hebamme) has been tarnished with the reputation of the untrained. How can midwifery in Nepal be professionalised if it cannot claim it’s name?

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Prena struggling with the translation

Rashmi has decided that with my help (our help, thank you donors), she would like to make a few physical changes at the center. I am relieved. She is so modest with her ideas. We walked down the hill from the center to the carpenter’s shack. He will put up a movable partition to help the flow of the center. Currently most people walk through the pharmacy to get into the main building. It doesn’t really make sense. The carpenter and Rashmi seem to be old buddies and after planning the changes we wandered a few steps behind the shack to his house for cups of tea with his wife and sister. They have a sewing business in their home and quickly whippped out the tape measure, spread out the cloth and had me measured for a “kurta” before I knew what was going on.

Rashmi and Dev the carpenter shooting the breeze

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So that was a slice of today.

Hanging out in Kathmandu

I’m hanging out here in Kathmandu. I’m a routines kind of person.  And I’m develping my routines. My quiet breakfasts. Organizing to go over to the birth center. What will I be bringing with me? What will we be working on? Wandering through the town to the bus. Last week or so I learnt that buses make sense. A cab is a bargain at $3 but it was my biggest daily expense! At 15 cents, it’s hard not to get a bus. And it feels a lot safer than a taxi. It’s bigger and it sticks to the bigger roads (much less picturesque and less bumpy). So it takes longer to get to the birth center. But I’m in no hurry. I love my wander/walk through Tahity (called Tahity??) and via a mini-monkey temple called Kathesimbhu Stupa

Kathesimbhu Stupa

Kathesimbhu Stupa

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IMG_0573 and via the square with a temple that honors the tooth protecting deity

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I think this is the tooth guy but not sure. Fierce anyway

and the veggie sellers of Asan Tole, and the crazy pre-festival shoppers, to Ratna Park where the foot traffic squeezes through a toothpaste tube and up onto the footbridge where people sit and sell flip-flops and watches, and a beggar plays listlessly on a drum and someone else is begging for a kidney transplant, to my bus. They squeeze us in cozily and off we go. Kalanki is dusty, dirty and busy. I walk a few minutes towards the birth center, and today before going in, I took a few pictures of the goat market opposite. Goats to be sacrificed for the Dashain festival

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Today at the birth center, I was planning to prepare three topics for a meeting with Kiran, the president of the Midwifery Society of Nepal: 1) A presentation on Childbirth Education  (I seem, bizarrely, to be becoming an “expert” on this topic)  2) A presentation on the anti-shock garment, it’s benefits, research to support it’s use in shock secondary to postpartum hemorrhage. I really believe in this thing and hope that Kiran will be inspired to push it to the Nepali Government and 3) Some topics in evidence based maternity care. I was supposed to meet with her at 3 and worked away at my prep but then she cancelled on me till next week. That’s kind of the way things go here, so I worked with the birth center midwives on posterior babies and other topics. We’ve had a good few days at the center. A Nestle man (boo, hiss) came to present on nutrition in pregnancy, and while we were all somewhat stimulated by some of it, I was also inspired to prepare my own nutrition power point! (of course). Here are some midwives listening to the Nestle (boo, hiss) man:

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Here is more childbirth ed stuff: preparing material:

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Prena and Laxmi

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And here is a gorgeous Nepali lady smiling as she gets a depo shot!!!

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And here are two delightful midwives bravely preparing to head home on their motor bikes

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Progya and Ratna

So that’s it for today’s update folks. Happy Dashain festival.

Tourism on a rainy festival Saturday

Ferst day of the Dashain holiday which is 15 days long! It seems day 1 days 7,8,9, and 10 are the highlights. Rituals and stories seem very complicated. Durga…. one of the many mothers, is the heroine and sacrifices play a part. Lots of people travel to be with family (It’s kind of like Christmas/Seder night I think) Lots of people were out shopping. Being both Saturday and a festival, I didn’t go to the birth center but instead, dedicated myself to Kathmandu tourism. Been here 3 weeks and decided it was high time to see the monkey temple. I did a lot of walking in the rain: Up to Swayambhunath (monkeys and staring eye stupa) and then back down over the river and through the alleyways to Durbar Square which I had visited on my first day in a jet-lagged fog. Great food and alleyways clogged with festival shoppers and back wet, muddy, satisfied.

Pics:

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impossible task of cleaning

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Flowing with Nepal

Nepalis are warm, welcoming, kind, relaxed, open. They are amazing. It is not easy to live here and things don’t work well. Clean water, trash pick-up, sewage system, electricity on demand, none are functional. But Nepalis flow with Nepal. Not only are they used to it, they smile.

Most women wear saris or kurtas with loose pants, long and flowing, bright and gorgeous. On their feet, flip-flops. When it rains, the streets turn to streams of slimy mud and the women flow through the streets and emerge clean, fabulous and unscathed, while I am covered in mud and splattered up to my knees.

Through the piles and piles of urban filth you can glimpse, amazingly, nature! I saw an eagle swooping low over the black trash-strewn river, as well as egrets and butterflies. Glimpses of mountains rise behind the slums. Hurtling through the backstreets I saw empty lots in the middle of the city where people are growing rice. In addition to cows, there are also plenty of goats and chickens. The festival of Dasain is coming up and goats will be bought and slaughtered. The birth center is situated right by the goat bazaar and yesterday goats were massing among the motorbikes!

Yesterday, to my surprise the childbirth education program sprung into action. Lesson plans were going to be revised and rewritten in Nepali, staff was going to get together and review, but Rashmi decided…. no time for niceties like planning, we go for it. And they did. They did great. …. tore through 3 lesson plans in 45 minutes…. but the group was engaged and happy. Rashmi said she thinks this is the first childbirth education ever in Nepal. Maybe she is right. It deserves a press release I think.

Here are some pics of the class.

Prena and Rashmi having fun preparing

Prena and Rashmi having fun preparing

The class has begun!

The class has begun!

Dipshika organizing the visual aids

Dipshika organizing the visual aids

focused......

focused……

rapt attention!

rapt attention!

class is fun

class is fun

getting into it

getting into it

also in class

also in class

Some pictures around town

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mushrooms

mushrooms

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Nepali Ruminations

I’m developing my Nepali state of mind. 

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How are we going to develop the childbirth education that Rashmi wants to do? Well, if we plan classes, they won’t come…. a given. (Childbirth education is not a locally comprehensible concept.) So what about bribing them? We could give away the little stretchy panties that I brought over from the US “Come to childbirth class and get a free pair of stretchy panties!” No….. don’t think so. Maybe we could give away a baby hat? Rashmi has plenty of those. Nah… bribes unlikely to suffice. Only way it will work is to do teaching when they are here anyway. Genius. But there is no appointment schedule. The place is a drop-in center. Mmmmmm.

Solution: On Saturdays, Tuesdays and Thursdays at the very approximate time of 4pm there is doctor available time. (All women get a total of 4 prenatal appointments) (We must be wasting our time in the US with our 12 appointments.) One of these four is with the physician. So they show up at 4-ish on those days and wait to see the doctor. We can teach while they wait! No matter that the group will be constantly changing as they go in and out of the doctor’s office….. we can do it! So we design a program with 10-15 minute teaching segments with a start anywhere in the “series” approach. It will work. I believe it. Why not? More likely to work than free stretchy panties.

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Back at the birth center: Everybody is excited. Rashmi is VERY excited!

At the Birth Center

At the Birth Center

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View from the Birth Center

Ratna is excited by the chiu\ldbirth education materials I brought.

Ratna is excited by the childbirth education materials I brought. We are designing a great program….

Sapana is excited by a class on birth positions. Praticing giving birth on the birth stool!
Sapana is excited by a class on birth positions. Praticing giving birth on the birth stool!

A satisfied mamma

A satisfied mamma

Rashmi (and I) got VERY EXCITED thinking about all the wonderful things that are going to happen at the Birth Center.....

Rashmi (and I) got VERY EXCITED thinking about all the wonderful things that are going to happen at the Birth Center…..

Rashmi and I have spent quite a lot of time thinking, talking and planning and I have a MUCH clearer idea of what is needed and lots of very specific work to do.
We are designing a birth center brochure (3 or 4 of the young midwives and myself). We are planning a childbirth education curriculum and maybe it will be up and running within a few weeks. We are discussing reorganizing the flow of the birth center. We are discussing financial priorities. It is all very concrete and GOOD.

And I  am having fun! Thanks to all of you who are following me on this blog,,,,

Out of the dust towards the sky and back again

Today and the next few days are different. I was just beginning to feel a sense of routine….then…..

To explain: Hannah B was in the grade above me in High School 40 years ago. She moved to Israel about when I did and we have a mutual friend (one of my closest friends in Israel). So, she discovered that I would be in Kathmandu and she is visiting tomorrow, alone, and looking for someone to go into the mountains with her. As I am alone, it seemed like an opportunity not to forgo even though it is a little early in my trip to take off. So tomorrow I will go to the foothills at Nagarkot, take a deep breath of Himalayas and walk down to the temple town of Bakhtapur with Hannah, before going back to some birth center work on thursday.

Today I went to a birth center health post in the hills at Pharping about 1 1/2 hours from Kathmandu. It was great to escape the dust and hurtle around some hairpin bends to the beauty and quiet of this center, where Kamila, the midwife, gave another Tikka welcome and showed us around. (I was with Trudy and Amanda, UK midwives who are going home in a few days time)

Lots of photos today, the birth center is very photogenic. Being rural, it has a very different feel from APS. In some ways it is well equipped. They have a microscope! In others, strangely lacking. They have no ambubag for infant resuscitation. Such a simple, essential item. If only I had known!

On the way: pond at Taudaha home to the nagas (serpent deity)

On the way: pond at Taudaha home to the nagas (serpent deity)

Pretty garden in front of birth center at Phoping

Another Tikka welcome

Kamala, the midwife at Phoping, with her birth log

Kamala, the midwife at Phoping, with her birth log

Community health workers here to be trained by Kamila

Community health workers here to be trained by Kamila

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Beautiful Birth center garden Beautiful Birth center garden

View from the birth center

View from the birth center

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Just a few hours getting a feel for the center and drinking tea, and then back to the city.

Here arae some picks I took this afternoon all yards from my guest house. Photogenic every direction

Door to an ordinary house on my street

Door to an ordinary house on my street

Drying herbs from the window

Drying herbs from the window

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mini temple near guest house. See rat god!

my local temple

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mini rat temple in situ in front of veggie shop

mini rat temple in situ in front of veggie shop

The stray dogs look dead. they are not

The stray dogs look dead. they are not

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My guest house. Balcony to right, is mine ($15 per night including enormous breakfast)

My guest house. Balcony to right, is mine ($15 per night including enormous breakfast)

(Learning, teaching, learning…. and fun)Renamed: A wild ride and more learning

Don’t want to get too obsessive about my sleep in this blog, but it’s been a major feature of my life…. Trying to sleep. The night before last I slept very well. Halleluya. I awoke, excited to feel so good! My guest house includes breakfast and it’s 2 eggs, potatoes, tomatoes, mango juice, tea and 2 pieces of toast with butter and jam. Way more food than I normally would eat, but I have been eating it all! So I have my huge breakfast and get set on my way to the birth center.

The center is about 20 minutes away by taxi. The taxis are my biggest daily expense, $3 each way. The ride is wild, scary fun, nutty, indescribable but I will try. My street which connects Poknajol to Chetrapatti, is paved, although most are not. The street is full of walkers bicycles, scooters, motorbikes, pedal rickshaws, push-carts, stray dogs (many looking much the worse for wear) and the occasional cow as well as trucks and cars (mostly taxis) and workmen with handtools doing various repair jobs in the street. I hurtle along in my vehicle as we approach Chetrapatti which is a sort of a roundabout with a temple in the middle, around which rush vehicles and pedestrians in a wild dance of weaving in a variety of directions, horns blaring constantly. We dive out onto an unpaved lane that dips downward towards the filthy river. I can practically grab pieces of fruit or a piping hot chapati as we rush by. We careen through a variety of similar turns and bumps, pass along a wider road with many pedestrians stepping out in front of vehicles as they try courageously to cross the sea of traffic, duck under a huge rusty metal bridge onto the ring road, right down a small dirt track and we reach the birth center. Deep breath. Safe and sound. What a ride for $3.

Yesterday, had a short class on oxytocin and its various functions. Then Rashmi, the head midwife showed up. She is usually so busy, but was in relaxed mood, and we chatted a lot about birth center mangaement and her challenges. Then she took me out to a super wonderful dive where we watched the women making chapatis on the fire in front of us and ate them hot hot with a spicey bean soup. Followed by spicey tea mmmmm. Good! Then back to the center for some birth drills.

Today I did a bit of a lesson with a video illustrating midwifery model of care. Very hard to get discussion with these girls. They are not used to being asked questions by the teacher and are hesitant to give wrong anwers. There are no wrong answers!. They are shy but very willing. I bought us all lunch as a treat….. they had done well. After lunch we did some more birth drill stuff. Another good day.

Here are some of the lovely girls watching the video studiously on my laptop. (The laptop has a picture of my three boys. Prena has decided that she will move to Texas and marry Amos, the oldest)

IMG_0186office workThe Birth Center has a little pharmacy