Building connections through Midwifery in Nepal
Updated: 5 days ago
Kiley Ketchum, a midwifery student at UBC, spent 6 weeks completing an elective in nepal.
"We had the pleasure of attending over eight communities in Nepal, with the majority of our visits in the Solukhumbu district in more rural and remote locations. The sites ranged from larger centres like the Parokapar Maternity and Women's hospital in Katmandu that acts as a referral centre for labour and birth in Nepal, to small health posts as we saw in Gudel and Gorakani. As one might expect, there was a general trend towards fewer resources, services, and access to specialized clinicians the further remote we ventured.
After our initial meeting the president of the Midwifery Association of Nepal (MIDSON), we gained a better understanding of the tiers of midwifery in Nepal. This contributed towards my first goal of learning about health systems in developing countries. My interpretation is that the auxiliary nurse midwives (ANMs) had the least academic training time dedicated to midwifery and are currently being phased out now, they were nurses that had 18 months of education in nursing and midwifery after grade 10. Some had an additional 2 months of SBA training. Diploma midwives have a three-year program geared towards clinical skills in midwifery practice. Bachelor midwives have additional training in research and leadership administration and attend higher education the longest of all pathways.
Similar to rural work in Canada, the further from a referral site the more individuals are awarded broader scopes to compensate for lack of specialists. For instance, ANMs, nurses, and physicians perform the ultrasound, X-Ray, and interpret their own findings. The unanticipated finding with this is trend is the inherent continuity for a single encounter. In other words, you enter a clinic to see a care provider – that care provider is same the person that completes your history, physical exam, any investigations, then interprets their findings, provides a diagnosis, conducts a treatment and writes your prescriptions all the same day. This is a large contrast to a walk-in clinic in British Columbia. I enjoyed my placements in Sotang and Phaplu in particular for modelling what I will coin as “same day continuity.” Same day continuity honoured the patient by considering how long it takes to travel to attend a clinic visit and optimizing the services available to them during each visit. I believe this will inspire how I shape my future practice as a midwife in rural and remote communities.
We met students and educators at several of the schools in Nepal to exchange information about physiologic birth and clinical birth skills. Some of the students had attended deliveries with past experience in maternity nursing, while others had specialized in other areas of nursing before beginning their midwifery education. They were keen, they taught us about nursing and midwifery in Nepal, and had questions about the midwifery scope of practice in Canada. We discussed physiologic birth, emergency skills, and respectful maternity care. I found students and clinicians were excited to exchange contact information. I am pleased to say I have been able to continue communicating with students and interdisciplinary care members I met in Nepal still today.
We participated in postnatal care at most sites, specifically, the growth clinic in Sotang, as well as clinic visits in Gudel and Phaplu. We observed family planning practices, such as an implant placement with local anesthetic, birth control counselling, and post operative care following abortions. Alongside our Nepalese preceptors we completed physical exams, history taking, and treatment of common reproductive tract infections in pregnancy. I took note of the positive impact that health literacy, patient education, and anticipatory guidance makes on reproductive health. Women’s health falls into the hands of women, when they know about their bodies this generates patient autonomy, agency, and it is empowering.
Clinicians in Nepal are innovative problem-solvers. A lower resourced setting requires critical thinking skills beyond a practice guideline. I watched my preceptors know when to be flexible, when to advocate for change, and when to be creative with the resources available. I started this placement afraid the responsibility we inherit as registered midwives. I am leaving feeling honoured to accept this responsibility and dedicated to keep people in my care safe to the best of my ability.
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