Manma Hospital from a Western midwife's perspective, by Rebecca Brady

Spy Manma Hospital in the bottom right hand corner

My first impression of Manma District Hospital was a bit of a shock.  Coming from working in the UK, I don't think you can ever be prepared for this, as really you are so blessed with the luxury and availability of seemingly inexhaustible resources in a flat favourable urban environmental setting. 

Manma Hospital. hanging to the side of the cliff above the Karnali River

The 3hr steep climb straight up to Manma from the River Karnali in Gite should have prepared me, but good old naive me, what did I know.  The initial shock was not for the lack of staff, skill, technology, modern comforts or lack of bedside televisions and readily available, hot, (arguably) mediocre but regular meals, but more the sheer remoteness of the cliff edge environment which only reinforced the obstacle-like conditions which seriously limited the long term management, transfers and availability of care for the community.

The hospital itself is perched on a steep mountain cliff side, in good repair and fairly well presented; appearing organised with an outpatient and inpatient department facilities of 15 mixed surgical and medical beds.

My biggest shock was seeing the delivery room for obstetrics; initially I thought, fine, ok, bed, light, equipment, smell of bleach, lovely, just like the UK - until I started to ask questions: How do you manage a major obstetric haemorrhage? and caesarean sections? sorry? you have to transfer to Surkhet, an 12hr journey by bus or stretcher down the perilous road of landslides and sheer drops into the river? As our guide said, it is just not possible, we do not have the trained staff to perform this.

The sluice room, interesting sanitation for those who are in the know...

And what about pre eclampsia and eclampsia, I asked? The same, he said, and with this I became so angry, mostly at the injustice this district hospital faces and what the women's journey into motherhood must be, as if coming in or out of giving birth was an emergency in a rural setting. Most women are okay, but the minority suffer a heavy toll.

The delivery room, the place for imminent delivery after a bumpy bus ride

 What made me angry was that some people in the UK are so completely ungrateful for the things they had at their fingertips, when  here, they make do with little or nothing. Through the assessment in Manma, almost all of the people interviewed had known a family or friend who had died in childbirth.

The male only ward, a mix of medical and surgical beds

It appears to be a way of life - when women actually travel miles into hospital on basic and treachourous transport after a long first labour, or have bled a lot postpartum and you cannot help - this must be the most horrible and difficult thing to face as a health care professional in these settings, as well as the heart weighted angst and responsibility one feels after the prospect of losing the life of a mother and/or child in circumstances beyond your control. 

The last left overs of MSF's prolonged stay here

All over the delivery room were posters of contraception, availability and methods in all shapes and sizes, which only highlighted the fact that maybe, we can save many lives through some foreward planning, education, enlightenment and ultimately empowerment, giving the gift of choice to women and their families.

Although this weighed heavy, I was very impressed with many other aspects of the hospital.

The autoclaving room, where instrument sterilisation happens

The highlights were an amazingly well organised and stocked antenatal clinic in which the nurse midwives provided care within a four antenatal appointments system, with family spacing and some health promotion with contraception, nutrition and infant care with vaccinations.There was a good evident system of a birth and death register, as well as a log of all appointments attended for the women.

What you see on your way out of the delivery room, thank you US Aid

The wards beds were clean, organised although basic and the nursing station was pristine and organised. The nurses shone with pride in their roles and I had the privilege to meet one amazing one when I helped the bus driver involved in the bus accident over to be assessed at the hospital. Later, when she had us over for dinner on our last night, she laughed at my physical Nepali signing attempts and pathetic lack of Nepali to convey 'bus accident'. She understood - my mime was apparently effective as she called the on call doctor quite quick...

Manma's hard working nurses who help keep the hospital going

My favorite was a brilliant laboratory sufficient with well staffed skilled lab technicians in microscopy, culture and most blood work with most bedside HIV and Hepatitis B kits provided from the Ministry of Health. Coming as a 'inexperienced newbie' straight from a six month tropical nursing course, I could happily manage in the lab and the lab technicians and assistants were very well informed and happy to answer with ease and humour with all my rapid fire questions.

My favourite bit, the lab!

Slowly I could see the health needs being mostly met; with the bigger challenges being sanitation, location, location and location; and a steady lack of resources namely being skilled doctors to be retained to pass on the baton of knowledge in the District Hospital, as well as the cultural boundaries that will always need to be respected and considered.

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Tikka here, tikka there: Welcome to Mugraha, Nepal, by Christine Bottine

Have you ever heard of family planning? By Dr Kate Yarrow

Even the youngest in Lalit's village wanted to hear about family planning

 On our first day at Manma hospital, I was introduced to the District Health officer (DHO) and formally asked permission to undertake the health needs assessment (the formality of the occasion being somewhat out of sync with our surroundings). The idea is to gain a detailed insight into the family planning use and potential unmet need of the locals in Kalikot district.

Dr Kate and Lalit meet with Manma DHO

We divided into groups (family carefully divided to avoid family feuds!), each with a translator, either Lalit or Maghraj, and set to work in the hospital. Patients and relatives were asked if they would participate in a questionnaire, using Nepalese wording that they would understand. 

Carrying out our interviews in Manma Hospital with Lalit acting as translator, Christine as interrogator and Chris as scribe.

This man was lucky enough to "naturally" have a 3 year gap in between each child...
We did wonder if  his wife hadn't had a slight influence on that...

Kate and Maghraj interviewing a health worker in Manma hospital

Over a few days we interviewed about 100 men and women form all reproductive age groups. When we got to Lalit’s village, people were so intrigued and keen that we had to rope off an area for crowd control! I am relatively used to the lack of personal space in Nepal, but even for me it was overwhelming and at times intimidating.

This couple told us that had they known about family planning, they would not have had 10 children

Maghraj trying to cordon off the inquisitive crowds, a lot of enthusiasm for family planning in Lalit's village!

Most women came with a small baby on their back and the hoards of children were a sure sign of little or poor family planning.  Sadly, the general impression is that couples use little or no family planning, and often far too late; in many cases after more than 10 pregnancies and significant infant mortality.
We encountered so many misconceptions about side-effects, and after interviewing many health workers realised this is likely due to lack of training of the healthcare providers.

Trying to get privacy in Lalit's village was, to say the least, trying...

Gathering the data allowed us a unique insight into the mindset of the Nepalese. The huge number of clamouring children left us exhausted and overwhelmed. Certainly the need for improved services can be in no doubt, and I am pleased that the team was able to see this for themselves.

Was it the white faces or the family planning that attracted the crowds, we don't know but the interviews got done!

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Manma Hospital from a Western midwife's perspective, by Rebecca Brady

Finally in Manma hospital - What we are actually doing...by Dr Kate Yarrow

Doctors For Nepal aims to improve healthcare in rural Nepal. Initially this was solely through funding the training of medical students, but now – as our first student, Lalit, approaches his doctoring years, it seems appropriate we try to support our students in their professional practice.

Kate, Lalit interviewing a health post worker before the plunge down to Lalit's parents' village

My area of work in the UK is Obstetrics and Gynaecology– particularly Community Gynaecology. One of the driving forces behind my passionwas my work in MSF (Medecins Sans Frontiers) in Nepal in 2006-2007. I saw a huge amount of maternity related morbidity and mortality, and from this strongly feel that prevention may currently be better than cure in this country with such limited resources.

Welcome to Manma hospital, Kalikot,, where Dr Kate Yarrow, team leader extraordinaire was based with MSF

The aim of this visit is to assess the family planning practice in one of the most deprived and isolated areas of Nepal. Kalikot is our first medical students’ district, also where I worked with MSF.

Bex, baptised Bev by the Nepalese authorities with our family planning questionnaire

By gathering comprehensive data on current practice, beliefs and supply, we hope to positively influence the future of family planning in this district. Our report will be presented to international NGOs such the Family Planning Association of Nepal, and the Ministry of Health.

A small family by Nepalese standards...

Hopefully this will draw attention to the dire need for intervention to this vastly ignored corner of Nepal. It will also be a fantastic opportunity to visit Lalit’s family who are desperate to meet his international sponsors.

Kate and Christine planning the break down of our first pieces of data collected in Manma

Our team consists of myself – Medical doctor from the London Deanery in Community Sexual ands Reproductive Healthcare. Christine (Chrissy) Bottine – DFN’s intern, and blog-tastic geek. Maia Keeling – my cousin, who’s fluent (?) Nepalese can only serve to enhance the trip! Rebecca (Bex) Brady – Midwife from St Mary’s London who particularly enjoys Nepalese disco/strobe bathroom lighting... And last but by no means least, my long suffering parents Anne and Chris Yarrow, who have joined us to give us a ‘mature’ insight…

Meet the intrepid parents and DFN trustees extraordinaire...Anne and Chris Yarrow with our irreplaceable translator, guide and friend, Maghraj Sanjyal

Meet Maia Keeling, cousin extraordinaire flashing the locals with hair and flair alongside Lalit, our sponsored student

And Bev, midwife and recent British convert, convinced after this trip to abandon our shores to find a Nepalese husband

Do keep reading to see the how our trip pans out, and the results of the health assessment. Your support is the most important thing to keep this mission going and to enable us to achieve our goals and better healthcare for Nepal.

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Have you ever heard of family planning? By Dr Kate Yarrow

Thank you

On the road to Manma - From hell to heaven in 2h30hrs, by Christine Bottine, DFN Intern

Trekking through the hazy paddy fields

Tonight, we’re at the bottom of what to us seems to be the top of the world. We’ve been walking for three days now, thrown out of our silver car by a broken lorry, to bite the dust like everyone else in Nepal. And my lungs are suffering. I’ve developed a hearty cough, heaving and wheezing like the locals.

Welcome to shanty town Gite, our home for the night

Pollution, dust and fumes from wood ovens are not a good combination for my weak English lungs. Lalit has said I would survive if I was Nepali; it’s been 4 days now and I’m still on my feet. I do wonder however how long I would last were I Nepali. Everyone here seems to have a scathing, lung scratching, throat straining cough, otherwise called Chronic Obstructive Pulmonary disease (COPD) and a large majority of people in Nepal over 40 do end up dying from it.  

Gite's high street, between sewers, rubbish and side street fires tended by toddlers

But for now, my focus is on Manma that we reach tomorrow. Tonight, we’re staying in Gite, a small shanty bazaar town at the bottom of the valley, stuck between the Karnali and the Seti rivers. In the midst of a cacophony of rickety tin boxes, we were shown to our “hotel”, an old goat shack, with rats for neighbours and toilets….anywhere and everywhere. We have been given a special deal by the landlord. For you, tonight, go anywhere you want he said. Made it sound like an exception but it seems to be the norm in Gite, where sanitation is invisible and the cliff rolling down to the river is a giant slide of a toilet, particularly perilous in the dark.

Anne and Chris' rat infested hobbit hole, mind the loo...

And like poor sanitation is appearing as a recurrent theme, so are hoards of children roaming the streets. In Gite, like in many other towns that we have been through, the presence of young children and even younger looking mothers is overwhelming. Kate has been half joking that we should be carrying out our Family Planning survey as we go along instead of limiting our remit to Kalikot. Even if notions about contraception and family planning do hang somewhere in people’s minds, it is clear that a very large family is the norm, putting enormous pressure on every family’s living conditions.

In Nepal, over 40% of the population is under 15 and growing. Gite is but another illustration of this, with children playing in the gutter, burning rubbish to stay warm and swarming in and out of their derelict tin houses, with their own pants for only latrine. Literally being in the same pants as them for one night has really shone light on our mission; helping men and women understand the importance of family planning to improve their welfare and development.

But there is a long way to go and with every step we take, an apparently overwhelming problem seems to appear. The relevance of our work is increasingly growing on us daily but it is clear that we are tackling a tiny drop in Nepal’s ocean…

So don't forget to donate to Doctors for Nepal, as the need is so great.
http://www.justgiving.com/doctorsfornepal 

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Finally in Manma hospital - What we are actually doing...by Dr Kate Yarrow 

Making a home in the goat shed

Dahl and chapati, the culinary delights of Gite

On the road to Manma - The only “daktar” in the village by Maia

Doctors for Nepal goes down the Karnali Rivers, look to the background, that's where we are going....Manma

On day 2 to Manma, after a long walk through paddy fields and along beautiful beaches of white sand bordering the Karnali river, we stopped for lunch in a little roadside town. Instantly, a crowd of about 20 locals gathered to watch us eat. This was becoming a regular occurrence as we trekked deeper into the dusty hills, where white tourists and aid workers rarely venture.

Crossing the Karnali River where Lalit had promised us a "black road"

The beauties of the Karnali valley, nothing in comparison to what we were about to see around Manma according to Kate

Our second hotel after leaving Surket, a surprisingly cosy and welcoming place.

When Kate worked for MSF in Kalikot during the civil war, she was always flown in and out by helicopter, only authorised to leave the medical compound once a week on a trip up to the local town.

Waiting for our dahl bat as Lalit and Kate examine their patient

Dahl bat in all it's glory

As we tucked into our dahl bat, the local and nearly only means of sustenance, consisting of rice, bean or lentil soup, a small veg curry and a touch of pickle, word quickly got around that there was a doctor (or “daktar” in Nepali) in the midst and Kate and Lalit were urgently called to see a patient who had just been carried off a bus.

Doctors for Nepal, the only "dakars" in the village

Kate and Lalit’s diagnosis revealed that he had a severely fractured elbow and needed to get to a hospital asap. However, ASAP is not really an option in Nepal. Unfortunately for our patients, his only option was to get on a local bus, travel for 8hrs over the rocky track along the cliffs to get to Nepalgunj hospital.

Bhumi, one of our amazing porters with his European Commission cap

Interminable bus rides acting as ambulances were starting to become a recurrent theme the more we progressed into rural Kalikot. Our unlucky patient is just another example of the additional unnecessary trauma and insane pain that the lack of local medical facilities incurs.

I really do wonder how much people should have to suffer to get to a hospital.

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Journey to Manma - From hell to heaven in 2h30hrs, by Christine Bottine, DFN Intern