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.

NEXT:

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