Student learning and experiences during rural Nepal placement

Britney Olivares, a midwifery student at UBC, spent 6 weeks completing an elective in rural Nepal.

"Embarking on my placement journey, spanning both rural and urban Nepal, has been an insightful journey filled with eye-opening experiences and invaluable learning in the global context of maternal and infant healthcare. Over the course of my 6-week placement, I had the privilege of delving into the diverse challenges confronted by communities in resource-limited settings. This reflective summary encapsulates my observations, the challenges encountered, and suggested areas needing improvement to enhance maternal and infant health outcomes in Nepal.

My first placement location was in Sotang; a small primary rural hospital with operative capacity in the hills of the Solukhumbu province, serving a population dispersed across vast, rugged terrains. The total area of Sotang is 103 square kilometres, consisting of five wards with a population of approximately 10,000. The hospital is modest and may lack some basic amenities, but is quite equipped with several essential services: an outpatient department, pharmacy, laboratory, x-ray, ultrasound, dentist, optometrist, maternity waiting home, antenatal/postnatal care unit, delivery ward, operating room, as well as a small

NICU/ICU. Despite any infrastructure related constraints we saw, the hospital staff, consisting of a handful of dedicated practitioners, are passionate and tirelessly cater to the needs of the community where they can.

In Sotang we witnessed the weighing of infants and young children at the maternal growth clinic, Here we saw around 40 mothers come to weigh their babies (all were in the “green” zone for weight based on age) and receive supercereal, a type of fortified porridge that consists of wheat and dehulled soybeans, milk, sugar, vitamins, and minerals. We gave out donations to the mothers and children (knitted dolls for the slightly older, and knitted hats, blankets and booties for the younger babies) and spent a long time interacting with the community and getting to chat with the nurses about their work.

We were also privileged to meet with the dedicated female community health volunteers of the Sotang area. Among them were seasoned veterans who had begun their journey as traditional birth attendants, while others were newer to the role or following in their family's footsteps. Remarkably, one volunteer had served for an impressive 47 years. They shared with us the vital work they undertake in their communities, particularly in supporting women during pregnancy and postpartum. Through their unwavering commitment, they have earned the trust of their community, often serving as the first point of contact for women seeking healthcare assistance. Additionally, they hold formal consultations with health

facilities and hospitals, and obtain respect within the healthcare sphere here.

Our collaboration with them was enriching, as we sought to learn from their expertise and understand their needs. We are especially grateful for their openness in discussing a cultural practice they noted has been impacting health outcomes, particularly umbilical cord infections. They told us how the Rai people of Nepal are sometimes abstaining from hospital birth, as it is a standard of care to apply chlorhexidine to the cord after birth. Chlorhexidine, while effective in preventing infection, often prolongs cord detachment. The Rai ethnic group have a tradition to name babies within 3-5 days after birth, but only feel

appropriate to do so if the cord has fallen off. Thus we have noted this, and have shared it with health director Shreedowz in order to ensure this health problem is addressed in the most culturally safe way to that community, and perhaps the Rai people can again feel more safe obtaining hospital care for birth.

We also were fortunate to work alongside the doctors, health assistants, staff nurses and auxiliary nurse midwives within Sotang, learning from the ways in which they provide culturally relevant care to their population. It was somewhat surprising to learn of how this community diagnoses their patients, while this hospital is well equipped with the infrastructure to do laboratory testing for more accurate diagnosis, we did find that many times a differential diagnosis was instead offered, and many broad-spectrum medications were typically prescribed. We witnessed many cases in the OPD department, such as

long-term undiagnosed bacterial vaginosis, which later inspired my case study, as well as antenatal visits, x-ray, ultrasound, and general women’s health cases that we could reflect on for teaching-related opportunities with Sotang, as well as in our own practice. Finally, we finished our work in Sotang teaching CME’s on physiologic birth, nuchal cord somersault maneuver, postpartum hemorrhage, cervical tear repair, helping babies breathe/NRP, as well as refreshers on respectful antenatal, intrapartum and postpartum care.

Sotang taught us the basis of our mission here in Nepal: to collaborate with providers, understanding their distinct needs and wishes for further learning, as well as how to be a keen and respectful observer in a space that is so culturally different to our own.

My placement then travelled to Gudel. A similar landscape of course to Sotang, but with approximately ⅓ the population and more difficulty in access, especially during the rainy season. We started by meeting the kind and outgoing staff of the Gudel Health Post and began a CME session promptly about postpartum hemorrhage management and cervical tears. We had seen enthusiastic participants in Sotang before, but we found that the health workers in Gudel were whizzes when it came to simulation-based activities. They were by no means shy, and clearly attuned to the OSCE-esque way of an emergency management simulation. We focused on teaching mainly in Gudel, and gained great interpersonal relationships with the staff. Being a health post, they often don’t see birth regularly, but

when they do, they know they have to be well versed, and we did see such enthusiasm in reciprocal learning from their team.

I was particularly excited to also have participated in antenatal visits here in Gudel, and quite amazed of how well conducted they were. Now a community in rural Nepal by no means needs to necessarily mimic the way in which us Canadian midwives have our antenatal visits, but these antenatal visits were similar to how we do ours, following the same flow, and emphasizing counselling rather than only ultrasound and blood pressure, like we had witnessed in Sotang. I saw the providers here giving clients a lot more time

and space to voice themselves, and thorough documentation was done. We were also pleased to see how the majority of the female community was safely engaging in family planning. While Gudel sees limited births, and of those births limited births that are beyond the scope of “normal”, I was so impressed to see how the staff nurses and ANM’s wished to learn it all so that in the case it occurred, they were not stumped. While they do have bigger health centres and hospitals to refer to, we know that's not always the case with birth, and it definitely triggered my reflection on how hard it is for rural health providers to feel confident and hone their skills, when they frankly are not seeing enough cases. It also allowed me to empathize with how different the scope of a provider has to be depending on what community you are in. Rural providers whether here in Nepal or within Canada have such a huge responsibility. not only do they have to be well versed in all aspects of antenatal, intrapartum, and postpartum care, they must know it without seeing it often, and be ready to handle any situation that comes their way. It frankly is a huge responsibility, and I think that rural providers here are incredibly brave to have such leadership in this regard.

Our travels then took us to Sero - a quick detour to participate in a frankly fun dental health camp, where we also screened for hypertension as well as other morbidities. We casted dental impressions, triaged patients, and made an outstanding group of friends who all shared a common goal - to selflessly aid a community that didn’t have equitable access to care. We saw lives honestly transform a bit as the community gained new smiles, and had a huge community of providers to reflect and debrief with. We discussed how communities like this feel seen, and empathized with how awful it could feel to have something like a uterine prolapse (commonly found in Nepal) in this community, and not have a female

provider to feel comfortable talking with. We learned that outreach is one of the only ways these communities can be helped, and that can be scary. Some clients who visited us had very high hypertension, never discovered before, and you only hope that they understand how important seeking care is for the particular circumstance. Continuity of care came to mind here, and how many rural communities should have it, but don’t. We also reflected on how regardless of the work outreach can contribute to their communities, we often feel stuck when there is no way to consult appropriately to a higher centre.

We ended our rural Nepal adventures in the city of Phaplu - ah our favourite city. If I had to pick a place to settle in Nepal it would be Phaplu, but while the beauty of the landscape astonished us, we had our first in person experience with the birth space , and what adversities women might face here when it comes to giving birth in Nepal. We did witness a c-section in Phaplu that had us realize the true discrepancies that might be faced here in

Nepal. When it came to the skills in resuscitation, we noticed the regression at play. Practices that are not evidence based and now deemed harmful were utilized which ultimately and unfortunately could contribute to neonatal mortality. Further, we saw a significant lack in respectful patient care. we did go onto do CME’s with the providers in Phaplu - and they were very receptive to learning and feedback, the only issue is, will this information stick with them? Will they be able to then teach others? What happens

when the hospital has a large turnover like it usually does every 6 months to a year?

In Kathmandu, although we were battling severe sickness, we were able to see two natural vaginal births. There were a lot of aspects about the two births that were good – practitioners were showing a lot more respectful care towards the patients that we had seen before and rural areas, and there was a lot of pride when it came to the utilization of correct equipment. However, we did see some of the same practices that do make it harder for mothers to birth all over Nepal, uncomfortable beds, lithotomy position, valsalva pushing encouraged, deliveries not slowed by providers, and threatened episiotomies. We advocated for more knowledge and toward the midwifery model of care when it came to these situations, slow delivery, birthing in positions recommended for descent versus slowing, in nullips and multips. We also advocated for slow delivery as while an episiotomy was threatened, the fetus had a stable heart rate and came out fast in 3 pushes - we knew it wasn’t needed. The practitioners, primarily auxiliary nurse midwives along with some diploma midwives, manage pregnancies and deliveries with minimal support. While essential practices such as the use of partographs and active management of the third stage of labor are intended to be followed, they often do not align with WHO recommendations and can sometimes be neglected. Additionally, advanced skills training is rarely utilized. Respectful maternity care is frequently not prioritized, despite the physical infrastructure

often being equipped to provide privacy and comfort. Unfortunately, providers sometimes fail to take advantage of these resources.

In terms of accomplishments, all sites excelled in ensuring skilled attendance at birth by at least one skilled provider and utilizing traditional or rural methods alongside evidence-based practices. Every mother actively delivering in hospital or health post is attended by a skilled practitioner, ensuring that mothers receive competent care during labor and delivery. This adherence aligns well with WHO and ICM Safe Motherhood goals. However, challenges persist, particularly in adherence to advanced training and supervision among peers. While family planning, maternity, and abortion services are offered, cultural and logistical barriers may hinder access for some individuals not near these more equipped areas in Nepal. The lack of adequate medical equipment and limited access to emergency obstetric care pose significant challenges. For instance, the beds used for deliveries are often narrow, short, and non-adjustable, limiting delivery positions to lithotomy, which increases discomfort and tearing. Investing in routine training for nurses, medical staff, and midwives and procuring essential medical equipment, such as pulse oximetry machines and emergency obstetric care tools, would significantly improve maternal and infant outcomes.

Continuing to establish a robust prenatal and postnatal care follow-up system with regular visits and check-ups can ensure better health for mothers and babies antenatally and post-delivery. Initiating comprehensive community education programs about the importance of postnatal care and family planning can address cultural barriers and misinformation, improving the utilization of these services. Improving hospital infrastructure to provide private and hygienic spaces for mothers and babies, along with increasing staffing levels, will enhance the overall quality of care.

In conclusion, my placement experience in rural Nepal has been both challenging and rewarding. It has deepened my understanding of the complexities surrounding maternal and infant healthcare in resource-limited settings and reaffirmed my commitment to advocating for vulnerable populations. As I reflect on the lessons learned and the connections made during my time in this community, I am inspired to continue striving towards equitable and accessible healthcare for all."