So am well and truly on my way! Currently at Dubai airport on route to Dhaka. Wrote a first post at Heathrow but it seems to have disappeared! Maybe should have mastered posting on here before I left!
Feeling pretty good - flight was good, had an aisle seat (a must for those of us who are claustrophobic), struggled into my flight socks (forgot to put them on before take off), watched two films, ate a very nice curry and had a couple of hours sleep. Feeling very excited now - can't wait to get my first glimpses of Bangladesh - hoping I get the opportunity to see some of the greener parts of the country as well as the very heavily populated capital city. Really looking forward to finally getting there and getting started! Hoping I can be of some help, that I can support the great work that has already been done in establishing a regulated midwifery profession, and help to embed and enhance the continuing professional development of the midwives.
Feeling slightly worried about how I will cope with the poverty I will see, the working conditions I will encounter and the context of maternity services and maternal health I will be confronted with. Bearing in mind that the maternal mortality rate is around 176 per 100,000.
Also pretty anxious about the high temperatures, the monsoon rains, the pollution (I have asthma) and the mosquitos - there is a high incidence of dengue fever in Bangladesh at the moment. But one step at a time...a short layover and another flight first.
Arrived at the Green Goose Guest House after being collected from the airport by car. I was accompanied by Susan - a very friendly woman from the USA who has lived in Dhaka for 9 years and who is a friend of Joy's (Joy is the global lead at the RCM). Susan is one of my main points of contact whilst I am staying. The journey from the airport was interesting as the roads are packed, there is no or very little lane control and every other driver was honking his horn! Alongside the cars were motorbikes, tuk tuks and buses - lots of the buses seemed to be pretty ancient, a touch battered but painted beautifully in vivid colours and patterns. Apparently the distance we were travelling was not far but quite lengthy because of the extent of the traffic. Although it was getting dark I could see that the air was smoggy. We arrived and I was shown to my room which is very nice - large, clean and comfortable. I unpacked, had a hot shower, a cup of herbal tea (in a glass because there wasn't a cup or mug) and then I negotiated the mosquito net and crawled into the bed...hoping for a peaceful night and a good sleep.
After a good sleep ...despite my fight to get out of the mosquito net to use the bathroom at midnight, and being woken by the call to prayer at 0430 (actually a very lovely sound which I found very soothing) I started my first day in Dhaka. Breakfast was fresh fruit followed by an omelette....a very spicy hot omelette...which appeared to have jalapeno peppers in! Susan told me later that the Bangladeshi people like spicy green chilli peppers in a lot of their food - it certainly woke me up but I think it may be an acquired taste!
My first meeting was with Sharmin who is the Bangladesh Midwifery Society (BMS) project manager responsible for facilitating the twinning project between the BMS and the RCM. At the meeting we discussed the project in some detail and went through my itinerary for the duration of my trip. I found out I would be making three in country visits two of which will have overnight stays. I will be flying to Chittagong and staying overnight, then flying to Barishal for another overnight stay and then visiting Mymensingh for the day by car. Exciting stuff! It will be fascinating to see other parts of the country and I am looking forward to visiting some of the midwifery schools and having the opportunity to speak to the students, midwife teachers and midwives. I will be carrying out educational audits at the various public and private institutions and it will be interesting to compare the process to that in the UK.
Later on I was I introduced to the president of the society Momtaz Begum and to the treasurer Rehena Khanom. Apparently it is common practice to call midwife teachers by their first name followed by madam...not sure my students would be comfortable calling me Lesley madam! 🤔 We spoke about my itinerary and discussed the differences and similarities between our midwifery programmes. Momtaz told me that the programme they have adopted was written by Judith McAraCouper from AUT in New Zealand - I read quite a lot of Judith's PhD thesis when I was writing mine as we utilised the same methodology ...strange coincidence. Later we had a Skype meeting with other members of the society and shared lunch which was a mix of Thai, Indian and Japanese offerings.
My itinerary was changed meaning that I had a day off on Friday. Apparently Friday and Saturday are the weekend here. I was pleased as I was starting to feel the effects of jet lag. I decided not to set an alarm and ended up waking up at 1130 when someone knocked on my door! I finally managed to struggle out of bed at 1200. The plan had been to go out for a walk in the morning but clearly I did not achieve that goal.
Susan came to meet me at the hotel and our first task was to visit the British and Guest House Association and apply for membership. The BAGHA club is a meeting point for British people either visiting or living in the city. The club has a library, restaurant, bar, swimming pool, gym and tennis courts. The cost is about £15 per week ro use the facilities - it was a recommendation from Joy at the RCM that I join so that I could find some quiet in the very heavily populated city.
Susan has been a wonderful support helping me to navigate this very different culture, its people and spaces. Whenever we are out and about she takes great pains to try and orientate me and to help me recognise landmarks so that ultimately I will feel confident enough to move around on my own. I am not sure however if she fully recognises the limitations of my inner compass!!
After the BAGHA club we went for a walk and then we went shopping! We went to a beautiful shop which sold hand painted and worked silks and cotton, Bangladeshi art, homeware and jewellery - heaven! I bought some bits and pieces and then we visited another shop selling colourful Bangladeshi wares. I would not have realised that the shops were there - they were up some stairs in a building on a very dusty road and were not overly visible from the street.
Nothing is as you expect here - the area where I am staying is called Gushan - the diplomatic area - assumedly it is more up market than other areas of the city but it is pretty basic, there is a lot of building work taking place as well as lots of roads, pavements and buildings in need of repair and maintenance. Above each street is a mass of black cables and boxes apparently servicing the internet. On each corner are rickshaws and tuk tuk vehicles and lots of groups of men. The hotels and bigger buildings have security and there are guards manning gates and entrances. There are open sewers in places, rubbish and rubble in areas and beggars asking for help. It is quite intimidating and as I walked with Susan I wondered whether I would ever have the courage to move around on my own.
On Friday evening I decided I needed to summon up my courage and venture out on my own. I decided to go to the sister hotel for a swim and for dinner...but how to get there? I knew it was very close but I wasn't sure I could recall what Susan had told me. I decided to take a rickshaw and asked the guard at the hotel gate to call one for me. After a bit of a struggle getting on we set off and it was really liberating if a little daunting - the driver seemed to follow his own rules of the road - but we arrived safely...thankfully.
The pool was on the roof and I was the only person using it - it was wonderful to be submerged in cool water as I was wringing wet from walking around all afternoon. The view was fabulous - lit up the city looked sparkling and polished - all of the rubble and grime magically disappeared. Whilst I was swimming at about 8pm the call to prayer started. It was an almost out of body experience floating in the water in the dark, in a strange city listening to something which is quite foreign and almost alien to me, and yet so beautiful, so moving and a reminder to take a moment, be still and appreciate the here and now. I felt mindful and at peace, centred and connected, and happy.
On Saturday morning I met with Asma who is the BMS Education Secretary. She is an amazing young woman with a Diploma in Midwifery alongside a BSc and an MSc in Mathematics! Asma qualified as a midwife in 2017 and is now working as a junior instructor at BRAC University in Dhaka. Alongside all of her other responsibilities Asma is also a mother to her son who is 18 months old.
Already in her short career as a midwife Asma has achieved so much! In her role for the BMS Asma facilitates the online learning platform which is offered free of charge to BMS members. It is one of the measures being put in place to meet the continuing professional development needs of the qualified midwives. Asma also delivers training sessions on how to use the e-platform and advocacy programmes. She is also instrumental in recruiting student midwives to the BMS. Asma is a passionate, motivated and able young leader which is just what Bangladesh midwifery needs.
Later, at the BAGHA club I met with Jennifer Stevens who is the United Nations Population Fund (UNFPA) Programme Specialist for Midwifery Education in Bangladesh. It was really useful to meet with Jennifer who was able to give me a lot more detail and context about the development of regulated midwifery in Bangladesh, and about the work being done to sustain and build on what is now in place including her role with UNFPA.
A commitment was made by the Prime Minister in 2010 to create posts for 3000 midwives across the country. There was urgent need for change as skilled birth attendants were present at only 42% of births, directly contributing to the 5200 maternal deaths per year.
Global evidence shows that midwives who are educated and regulated to international standards can provide 87% of the essential care needed for women and newborns. Investing in midwifery education and deployment to community based services can potentially yield a 16 fold return on investment in terms of lives saved and costs of caesarean sections avoided.
With this in mind post-basics trainings were offered to nurses to qualify them as midwives and a three year direct entry diploma course was established to educate professional midwives. 597 midwives graduated from the three year diploma programme in late 2015 and were officially licensed in February 2016. 600 certified midwives (nurse-midwives who completed the 6 month post basic training) were posted to sub district level health facilities.
So in order to meet the unfulfilled need for maternal health provisions Bangladesh has embraced midwifery and is committed to strengthening educational quality.
Jennifer"s role at UNFPA is in ensuring the effective management of UNFPA's support in establishing the midwifery profession in Bangladesh with special focus on midwifery education. The RCM's roll in Bangladesh, as a twinning partner with the BMS, is to strengthen the National Midwifery Programme in the country and to increase the demand for midwifery services.
My role as a midwife educator working with the RCM is to support BMS members to implement the capacity development project with specific attention to education, in particular to the professional development of midwives, and continued learning of members.
On Sunday I visited the BMS office for the first time. Sharmin who is the Twinning Project Manager collected me from the hotel in an Uber. I had been warned about the Dhaka traffic jams and told that any journey across the city was likely to be lengthy. I didn't mind because it was an ideal opportunity for me to have a really good look at the city.
On route Sharmin told me there had been reports of mosquitos carrying Dengue in the hospital and she said we should expect to see some cleaning going on. I think I was expecting to see something like a deep clean of a hospital ward - as you would in the UK if there was an outbreak of something infectious. Instead as we arrived Sharmin pointed out some men working outside the hospital building who were shoveling soil and debris onto a van. The level of cleaning required was certainly greater than anything I could have envisaged!
We went into the office and I had a look around - the office is clean, immaculately presented, secure and fairly well equipped - everything BMS need to fulfil their remit is available. We had not been at the office very long before two student midwives arrived to meet me. I was delighted! The two students were members of the Midwifery Student Welfare Organisation and were keen to share their experience of training with me and their hopes moving forward.
The students showed me their curriculum documents which were very comprehensive and we discussed their programme and their learning experience. The three year diploma meets the competencies laid out by the International Confederation of Midwives and so it is comparable to the programmes in the UK and is of high quality. The students were keen to hear about the programme in thr UK and we discussed the differences and similarities. We also spoke of some of the challenges they face and spoke about potential strategies to overcome these. I told them that there was potential for them to join BMS and the benefits of doing this.
I explained that global evidence shows that the prerequisites for a thriving midwifery service are education, regulation and a professional organisation to promote midwifery and make sure the midwifery voice is part of the conversation with stakeholders and the government - hence the twinning project between the RCM and the BMS.
Later more guests arrived at the office and we celebrated the 9th anniversary of the foundation of the BMS. It was a virtual feast with a celebratory cake! Last but not least a visit to a shopping mall with Sharmin so that I could buy a salwar kamaz - a traditional combination dress worn by many women in South Asia. I was staggered by the variety of fabrics, styles and patterns available and as I could not make a choice I had no option but to buy two!!
On Monday I made my first solo trip to the office using Uber - it seemed like a pretty straightforward plan - I would book the Uber and give the destination as Dhaka Nursing College. Then when the driver arrived I would phone Sharmin at the BMS office and let her give more specific directions to the driver....
It was a long and interesting ride through the busy traffic - I was able to take lots of photos of the route and of the city which I was grateful for. I was desperate to get some pictures to document my trip but had been advised not to get my phone out on the street. As we neared our destination the driver asked to speak with my friend and so I called Sharmin....this happened three or four times before we finally arrived at our destination. I felt hopeless as I could not direct the driver as I do not speak Bangla and I was not able to recognise where we were. Finally we arrived and despite the driver's understandable frustration it was good to have made my way there independently.
Sharmin and I started to work on the implementation plan (which is one of my deliverables) and then we had a visitor. Dr Irtifa Aziz Oishee from 'Save the Children' who is working as a clinical mentor supporting the student midwives in practice. It was great to meet with Irtifa who is an extremely friendly and motivated young woman who was keen to share her experience with me and to tell me about the work being done to strengthen midwifery in Bangladesh.
Than Rehena Khanom arrived - I had met with Rehena previously as the treasurer of BMS - on this occasion I learnt that Rehena is also a nursing instructor in midwifery at Dhaka Nursing College. All the BMS committee work on behalf of BMS as volunteers and have substantive posts at the educational institutes. Asma (Education Secretary) is the exception as she works at a private institution as a junior instructor. Rehena is a very kind and compassionate person, softly spoken and she has been extremely friendly and welcoming towards me.
If I understand correctly, most instructors wish to work at a public institution as the salary is considerably higher and government positions have benefits which the private sector do not including a very generous pension - also employees are normally guaranteed a job for life which of course is highly coveted. An issue with this system, which is something I discussed with Jennifer from UNFPA, is that junior staff tend to start teaching in the private sector but then as they become more established, competent and senior, they move to the public sector. Hence the private sector has a high turnover of staff meaning that they are in a perpetual cycle of needing to up skill and train their employees.
Along with Sharmin, Rehena, Irtifa and myself then went on a visit to the college to see the facilities and meet the students. In Bangladesh there are 38 public institutions facilitating the Midwifery Diploma programme and 17 private schools. All the institutions support 25 students per year with the exception of Dhaka Nursing College which supports 50 students per year.
I met with the nursing and midwifery teachers and toured the college. I was shown the computer lab, the skills lab and the classrooms. The institution is currently being updated and the building housing the classrooms is very new. It has good sized classrooms which are furnished with IT and multi media equipment. I was lucky enough to meet the first and second year students who were very pleased to meet me.
Tourism is still very new in Bangladesh and I had noticed that there are hardly any foreigners around - the people are therefore fascinated when they see me! I have been asked repeatedly where I am from and have also being asked to pose for selfies when out and about - it is a strange concept for me but the people are so friendly and personable, polite and respectful it is not an issue.
The students were interested to see me because I am foreign but also, of course, because I am a midwife. They were all very attentive when I told them about myself and about midwifery in the UK. However I am not sure whether they fully understood what I was saying. I encouraged them to ask questions but they were quite shy. Sharmin told me later that students tend to behave in quite a deferential way and would not like to appear too bold. I asked whether I could see the student log book (for recording the competencies they had achieved) and one student was very proud to show me her log. It was a wonderful visit - I was delighted to meet the students and to see how engaged and motivated to learn they were.
After a tasty Bengali lunch in the office Sharmin, Rehena and I went to visit BRAC University. BRAC is funded by the UK government and has seven institutions across the country. We met with Selima Amin the Head of Midwifery Education and the Project Manager for the Developing Midwives Project and with Kalpana Roy the Team Leader. It was interesting to hear about some of the differences between the public and private institutions. BRAC follows the same curriculum as the public schools but with added content, for instance they offer modules to help with English language development. During the visit Selima and Kalpana invited me to visit the Dhaka Urban Academic site at Mirpur. I am looking forward to my visit to the site on Sunday the 1st September.
Since arriving in Dhaka I have been trying to understand how the Bangladesh health service is organised .....it is not easy!! This diagram shows the various levels of the health service from the national to the 'ward' level. Even with the diagram I think it is quite complex to navigate! The network is an intricate web of public health departments, non-government organisations (NGOs) and private institutions. Responsibilities and functions range from policy planning, regulation, implementation, and healthcare delivery to medical education. The Ministry of Health and Family Welfare (MOHFW) is responsible for formulating national-level policy, planning, and decision-making in the provision of healthcare and education. The healthcare infrastructure under the DGHS comprises six tiers: national, divisional, district, upazila (subdistrict), union, and ward.
Community clinics provide a basic healthcare package to the community people, including maternal and child healthcare, reproductive health and family-planning services, immunization, nutrition education, health education, communicable disease control, treatment for minor ailments and first-aid, and referral to higher-level health centres.
The Directorate General of Nursing and Midwifery (DGNM) is the central body and focal point from which all activities related to public sector nursing are managed in Bangladesh. This includes all involved in nursing and midwifery education and practices. Although regulation of nursing education and practice is the responsibility of the Bangladesh Nursing and Midwifery Council (BNMC), the BNMC works closely with the DGNM in regulating nursing and midwifery services.
A Midwifery Services Framework (MSF) is being implemented in Bangladesh to ensure that newly trained midwives are able to work in an enabling environment. This is part and parcel of the health sector plan which calls for equity, quality and efficiency for improving the present healthcare facilities and services and is in line with the Sustainable Development Goals (SDGs). The SDGs build on the principle of “leaving no one behind”, emphasing a holistic approach to achieving sustainable development for all. SDGs three and five, which promote good health and well being and gender equality, are pertinent to women's health, wellbeing and access to health care services. The implementation of the MSF is also evidence of Bangladesh's committment to fulfilling its pledge to the “Every Woman Every Child” strategy of the United Nations and in reducing the maternal mortality rate to 70 per 1,00,000 live births by 2030 as per its SDG commitment. In a country where there are 5,090,000 pregnancies per year (with an expected rise of 20% by 2030) and where 72% of child-bearing women live in rural areas where healthcare access is limited or non-existent, achieving access to sexual, reproductive, maternal and newborn care is a huge task.
What an incredible couple of days! Visiting Chittagong in the company of Momtaz and Rehena was a wonderful experience. I feel so grateful to have had the opportunity to see the great work that is going on in the area to strengthen midwifery, as well as the opportunity to meet so many inspirational people.
We arrived in Chittagong at around 10.30 am and Merry Chowdhury the BMS Divisional President met us. Merry greeted us with flowers, which was a very lovely gesture. Over the course of our visit, I found that Merry is as happy and friendly as her name suggests! On arrival, we were ushered into a large taxi and for the duration of our trip a very courteous young man called Harroon drove us around. On our visits Chabu Barula, a Public Health Nurse who covers the Chattragram District, and Dr Genea Kalam a Clinical Mentor who works for ‘Save the Children’ and supports the students in practice, joined us.
Our first visit was to the Fotikchorci Upazilla Health Compex which was out in the countryside. This was some distance over busy, bumpy roads with five excited women catching up (quite loudly!) in Bangla. After a near miss with one of the CNG (compressed natural gas) auto-run rickshaws we arrived at our destination. We were warmly greeted and offered refreshments. Everywhere I have been so far people have been so kind and have offered drinks and snacks....a kind gesture but not ideal if you are trying to watch your weight!
One of the doctors at the unit told me a little about the centre and its success in promoting normal birth. The women birthing at the centre are supported by a midwife and are encouraged to birth in upright positions - I was shown a birthing stool, a birthing ball and a bed on which the women are encouraged to kneel or squat. I was delighted to hear this and to hear that the rate of normal births is rising and the rate of caesarean sections at the centre is low - in comparison to the national figure for caesareans which is currently 31%. The doctor was proud to show me a cabinet of awards given in recognition of the tremendous work being done by the centre to promote normality and to strengthen midwifery.
During our visit I met three young midwives who had qualified with one of the first batches of diploma level midwives. The midwives were very engaging and obviously took enormous pride in their work. They introduced me to their lead, a nurse-midwife with something like 20 years of experience, and explained how they worked as a team in the unit. I was shown the birth register (which documents the births that take place at the centre) and they also showed me the paperwork they use for documenting care and monitoring progress (the partograph). The midwives told me that they provide first level emergency care to women - giving primary care in an attempt to stabilise the woman and then spoke about the referral process to a tertiary unit. I was told about a case that had happened a couple of days before when a woman had suffered a large postpartum haemorrhage - the midwife concerned had managed the situation effectively, stemming the bleed, before transferring the woman. Wonderful inspiring work being done in quite difficult circumstances.
On our return to the city we drove Genea back to her home. When we arrived Genea kindly invited us in so that I could experience a Bangladeshi home - what a privilege to visit her home and receive such amazing hospitality. Our next stop, to my surprise, was to a sari shop! The very kind members of the BMS committee had decided to present me with a sari as a thank you for my visit! I was not expecting that! I tried to dissuade them...as is the British way... but they were insistent.
Sari shopping is an incredible experience...the shop is organised in such a way that the shop assistants sit on a raised platform with all the saris (in every colour, pattern and fabric you can imagine) stacked behind them. As a customer you sit on a stool facing the platform and you point to the sari you want to view - the assistant's job is to unfold the sari and show it to you. In the process of choosing a style that you like, a mountain of saris builds up in front of you. After you have made a final decision the assistant puts the sari of your choice in a box and then refolds and restocks the shelves. It is a long process as there are so many designs and also it is clearly a very sociable activity which involves the women you are shopping with discussing the merits and potential problems of each individual sari. Eventually a joint decision was made and we made our way downstairs where we purchased a petticoat and ready made blouse! I was so excited and couldn't wait to wear the sari the following day.
I obviously had no idea how to even begin to put on the sari....luckily Merry and Chabu were kind enough to help me. I found it to be quite a complex and lengthy process involving many safety pins! I cannot imagine how I will ever manage to put on my sari again...I will have to see if I can download a tutorial or some sort of instruction from the internet! Needless to say when I was finally dressed I felt really special - I felt like a queen! Wearing a sari all day, however, was not without its challenges...it reminded me of wearing a wedding dress (as most people know I have had that experience twice!!) - it is difficult to negotiate stairs, hard to get into cars and very difficult to manage in the toilet!
Our first visit was to Faujdarhat Nursing College where, once again, we were very well received and graciously shown around the facilities. At the college I was shown the computer lab where there were a number of students working on various topics - for instance one was watching an instructional video about the pelvis and another was reading about primary postpartum haemorrhage (PPH) - all the students were writing notes and seemed engaged in their learning and very well motivated. I was then shown the skills lab where it appeared that the students had more resources available than at Dhaka Nursing College. I visited the classrooms and met with the first and second year students who were excited to meet with me and to have their photograph taken with me.
Our final visit was to Chittagong Nursing College where Merry is a midwife teacher. This visit was another extremely enriching experience. We were greeted with yet more flowers, we met with the principle of the college, and then Merry gave a powerpoint presentation about the history of the nursing college and the midwifery diploma programme. I found this very helpful as it helped me to put together more pieces of the puzzle of the health system in Bangladesh and the birth of the midwifery profession. Again we visited the computer and skills lab (which was extremely well equipped) and then we were ushered into an auditorium to meet with all of the students. Momtaz, myself and Rehena were asked to sit on the stage with the principle and with Genea and Chabu. Three of the senior students then introduced us to the students in the room and we each said a few words. I was delighted to see that Merry and her team were empowering the students to embrace their learning experience and that, as a consequence, they were confident enough to lead the session. Momtaz spoke to the students in Bangla but despite this I heard her telling the students that for midwifery to thrive and be sustainable in any culture it needs good education, regulation and a professional association - a fantastic message for them to hear.
Today I had the great pleasure of accompanying Kalpana Roy, Team Leader, Strengthening Midwives Project (BRAC University), to the Dhaka Urban Academic Site in Mirpur. I was collected from my hotel and driven with Kalpana to the site where I was warmly received. Everywhere I go I am completely overwhelmed by the graciousness of the people and the quality of the work they are doing to strenghten midwifery for Bangladesh - this visit was no exception. The project manager of the site is Dr Syeda Nabin Aru Nitu, who it is obvious, is completely invested in the profession of midwifery and in her role in delivering a high quality learning experience for midwifery students.
Once again I had the opportunity to meet the midwifery and nursing instructors who deliver the programme and to tour the facilities. In this institution the library is integrated into the computer room and I was very pleased to see some of the most well known core midwifery texts on the shelves. I was shown a presentation about the university and the midwifery diploma and I heard about the six modules provided to help the students learn English (one for each semester), as well as the introduction to using a computer module, and the various community modules.These modules, alongside the rest of the programme, seem extremely comprehensive and I imagine prepare students very well for the profession.
Kalpana advised me that 30% of the places at the college are offered on a scholarship basis to students from deprived backgrounds. These students are often the first person in their family (or certainly the first female in their family) to be literate, as it is only recently that schooling for girls up until the age of 18 has been offered free of charge - this, Kalpana advised me, is one of the mechanisms being employed by the government to help improve gender equality and empower women.
I met with the students in their classrooms and was invited to tell them a little about myself and my visit to their country - I then asked the students to tell me about their experience and said I would be happy to address any questions. The students primarily asked me about higher education opportunities in the UK and then they started to share what they had been learning in clinical practice and to tell me what they were proud of in relation to their practice. One student was especially memorable - she told me that she was very proud that she was able to teach adolescent women about reproductive health and contraception and, importantly in her culture, that she was able to counsel them about waiting to be eighteen years or over for marriage and to be twenty years or over for childbirth. I was absolutely delighted to hear her talking about the issue of child marriage and to see that the students are learning to advocate for, and empower the women in their communities.
Next we went to the skills lab where the students demonstrated a breech birth using role play and a mama Natalie abdomen - it was amazing! The student facilitating the birth (with the 'woman') was speaking to the woman in a respectful way, talking through the manoeuvres she was using and instructing her colleagues in what they needed to do to support her and the woman. When the 'baby' was born it was not breathing and needed resuscitating so it was moved to a flat surface and another of the students demonstrated how to resuscitate the baby, again talking it through step by step. These were second year students and their knowledge, understanding and application of that knowledge to 'practice' was remarkable.
When moving around the building on my visit I noticed that the walls were covered in amazing artwork produced by the students - either produced as a means of learning or in celebration of different aspects of midwifery and motherhood. One of the modules I facilitate in the UK has a creative aspect and I am very interested in creative pedagogy so I was really interested to see the pictures on display and impressed with the quality of the work and the messages conveyed.
I enjoyed the visit immensely and feel very honoured to have had the opportunity to share in the student's experiences of learning and to see the makings of some really exceptional midwives.
It was wonderful to have the opportunity to visit Rajshahi with the BMS. Located on the north bank of the Padma River near the Bangladeshi-India border, Rajshahi is an important administrative, educational and business centre. The city is a historic centre of silk production and a much greener city than Dhaka. There are lots of trees in the city, many of which were planted 15 years ago as one of a number of strategies to address harmful air pollution. Another strategy was the introduction of battery powered rickshaws to reduce petrol and diesel fumes, along with the banning of large trucks from the city centre. As a result the city has a very different feel to Dhaka - it is less congested, greener, the air is definitely cleaner and the city feels softer somehow.
At the airport we had a welcoming committee from Rajshahi Nursing College and the Divisional BMS. We were greeted with flowers which was a lovely gesture, and escorted to the hotel. The mini-bus we were travelling in was comfortable but it was not air conditioned; it had open windows and curtains to keep the sun out. My phone told me it was 32 degrees but that it felt like 41 - in the bus I am sure it was even hotter than that and I found the heat exhausting.
After a quick stop at the hotel to freshen up we made our way back to the bus - it was quite a long and very hot and rather uncomfortable ride to the Nursing College so that on arrival I was a bit worse for wear! I was therefore delighted to be taken to the principle's office to sit down (in the air conditioning!) and take some refreshment. On the bus we had been accompanied by many people, all of whom joined us on the visit. I was not clear who everybody was and so I asked if everyone could introduce themselves. Present were a mixture of nursing and midwifery faculty, executive members of the BMS, a public health nurse and a clinical mentor.
We were shown around the college and I met with the students and the faculty. I was impressed with the skills lab which was well equipped and by the library/computer lab which had air conditioning, providing a comfortable space for the students to study. The students gave a presentation about the college, their learning and their experiences, and finished off with a song 'We can save the world'! They were truly inspirational and their dedication and committment brought a tear to my eye.
Momtaz and I were invited to say a few words and then we answered questions. Momtaz was asked about the midwifery licensing exam. Usually students graduate in December, and take the licensure test in February each year. The licensure test is essential to achieve recognition as a midwife in Bangladesh and clearly students are anxious to take and pass the test so that they can get employment and start practising midwifery. Unfortunately it seems that last year a home health cadre (which is similar to a nursing assistant) sued the Bangladesh Nursing and Midwifery Council (BNMC) arguing that they should be able to take the nursing licensure test (after having completed a six month training programme to be a nursing assistant as opposed to having studied for three years to be a nurse). Because they sued the BNMC, the council put a freeze on all licensing tests until the high court has considered the argument. Apparently to date the court has twice reviewed the information, but have yet to make a decision. Stakeholders such as the United Nations Population Fund have been advocating for the resolution of the licensure issue, but because it is with the high court, it is has not been in the gift of any of the stakeholders to resolve the issue. The students are understandably worried about the resolution of the case and Momtaz was able to reassure them; advising them that the stakeholders are hopeful the issue will be resolved before the end of the year.
The next day we visited Charghat Upazila Health Complex where we met three midwives and the senior nurses who work as part of the practice team. The midwives proudly showed me the birthing room; although somewhat basic compared to those in the UK, the room was clean, well organised and had a fridge to store the Syntocinon (a drug used to manage the third stage of labour and to utilise in case of a haemorrhage) as well as postpartum haemorrhage and pre-eclampsia emergency boxes (including everything needed to deal with those emergencies in a primary care setting). The room also had a birthing ball and a birthing stool which the midwives use to encourage women to adopt upright positions. These are vital as the diploma trained midwives are educated to champion midwifery led care (in a facility), upright positions and normal birth as a way to address the maternal mortality rate (176) and the caesarean section rate (31%). In the room were two beds with lithotomy stirrups attached and I questioned their use - I was advised that women were encouraged to either kneel on the beds or to squat on them when labouring (as opposed to birthing in a supine position with their feet in the stirrups). I was also advised that although it was not ideal, from a privacy and dignity perspective, women sometimes birth next to each other in the room due to lack of space at the facility.
After visiting the birthing room and the postnatal recovery area (where I met a woman who had birthed in the early hours and who introduced me to her beautiful daughter) we made our way downstairs to see the antenatal area of the facility. As we turned the corner I was delighted to see that women were queuing to see a midwife! To see how invested women are in the notion of midwifery care was a real privilege. I learnt that women are encouraged to meet with the midwife a minimum of four times during their pregnancy. The midwives have a designated space for giving care and I was interested to see that the they have self standing double sided desk top information resources to prompt them when giving care to women - the resources have images on the front for the women to look at and information on the reverse for the midwives to utilise. This was of particular interest as in the global module that I facilitate for the third year students in the UK, the students are tasked with making an information resource as part of their assessment, and a number of students have previously come up with a similar concept to the desk top resource.
Later we had the opportunity to meet with the Health and Planning Officer for the complex, Dr Afsana Alamgir Khan, who asked for our impressions of the facility and gave us some further information about the midwifery provision and service. Dr Khan was one of the first people to speak openly about some of the difficulties associated with establishing and sustaining a midwifery profession in Bangladesh. She told us that in order to sustain midwifery and make it flourish everybody needs to be invested in it, telling us that there was some resistance to midwifery in the nursing and medical professions and some barriers to it inherent in Bangladeshi culture (for instance social barriers related to gender inequality). Dr Khan spoke about the huge investment the government has made in committing to, and implementing midwifery, and argued that to sustain midwifery, the government and the facilities need help and support from NGOs and other players. Dr Khan spoke about issues such as the need to understand why women might come to initial appointments with the midwife and then fail to attend for the remainder, lack of acceptance of midwives by family decision makers, professional barriers experienced by midwives, shortage of staff and the low level of autonomy experienced by midwives. It was quite refreshing to hear her speak of the challenges. Susan had told me that the Bangladeshi people do not like to speak about problems and difficulties, prefering instead to tell everyone that there are no issues. Clearly however there are bound to be challenges and it is only by identifying these, accepting they exist and endeavouring to understand them that they can begin to be addressed.
This article discusses in more detail some of the challenges associated with quality midwifery care in Bangladesh:
Whilst in Rajshahi we were lucky enough to visit the Padma River; a major river in Bangladesh and India, and the main distributary of the Ganges. When we got to the river we were advised that it was a renowned beauty spot where people came to enjoy the view and relax. As we arrived the sun was going down and starting to set, and the light on the water was beautiful. As tourism is still a relatively new concept for Bangladesh it was interesting to visit one of the country's tourist sites and see how it was developing. There were picnic chairs and tables set up on the river bank so that people could enjoy the view and a number of stallholders selling refreshments. At the water's edge there were pleasure boats with drivers eager to take people out on the river (the river was very fast moving and I am not sure I would have felt safe out on a boat even with a life jacket). It was certainly a lovely spot to enjoy the sunset, to reflect on the day, and to enjoy the breeze off the water.
Our next destination was to a local silk mill. It was absolutely fascinating - we were shown around the mill and able to see all the stages of the silk making process. Momtaz helpfully translated what the guide was saying as we moved around the mill. After our tour we ended up in the mill shop where there were many beautiful silk saris for sale....somehow though I resisted the urge to buy one!
In the evening Momtaz, Rehena and I were invited to dinner at one of the nursing instructor's homes. Jharna Khanom and her husband Badaruddin Ahmed invited us to join them for a traditional Bangladeshi home cooked meal. We were joined by their two teenage sons who spoke excellent English and who were interested to find out that I also had two adult sons. Jharna is a wonderful cook and the meal was delicious - we had rice, beef curry, a fish dish, vegetables and chutneys followed by a sweet yogurt pudding. It was a real honour to be invited into Jharna's home, to meet her family and to enjoy her food - I am very grateful to have had the opportunity to experience a Bangladeshi home and meal.
On my last day Sharmin and I visited the United Nations Population Fund (UNFPA) offices and met with Rondi Anderson, Jennifer Stevens and Farida Begum. Rondi and Jennifer are Midwifery Specialists at the UNFPA and Farida is the Programme Analyst for Midwifery. It was good to finally meet with Rondi and Farida as I had heard a lot about them and had been communicating with Rondi via email. We were meeting so that I could share my experience and think about how I could support the UNFPA work on my next visit.
The office we met in was high up and had amazing views over the city, including over the former airport which was a pleasant surprise. Jennifer was keen to hear what my experience had been of the health complexes and nursing colleges I had visited. As I told them about my experience and my thoughts and feelings about the various institutions - Rondi rightfully pointed out that what I had seen was not necessarily accurate, as the people and places I had been visiting had been 'putting on a show' for my benefit and that of the BMS. This was of course true to some degree - the 'red carpet' had been rolled out on a number of occasions - being welcomed with flowers at one college, the students queuing up to greet us outside another, students giving presentations, simulating skills and singing songs...but what had not been put on, was the passion for midwifery I felt, the strength of purpose demonstrated, the heart warming stories and aspirations shared and the committment to making a difference I had seen. I felt a deep sense of connection to the midwives, student midwives and educators I met, all of whom were clearly committed to the agenda of making pregnancy and childbirth safer, and women and families lives better.
We ended the meeting with a committment that I would visit the offices at the outset of my next visit. At this visit I will share my itinerary and find out if there is any specific contribution I can make to the UNFPA agenda during my travels in the country.
I started this blog post before I left Bangladesh and when I was indeed homeward bound. I have now been home for three weeks and am able to reflect back on my experience and consider what I was able to contribute whilst in-country.
I feel incredibly grateful to have had the opportunity to visit Bangladesh and for the hospitality I enjoyed whilst I was there. Everyone that I met on my trip made me incredibly welcome including everyone that I met at the various health complexes and nursing colleges. As well as taking me on ‘formal’ visits, people were keen to share some of the tourist attractions of the country and to make sure I had the opportunity to enjoy aspects of Bangladeshi culture. I had the opportunity to visit Chittagong Sea Port, Patenga Beach, the Padma River, the Sopura Silk Mill, to eat at a variety of restaurants, to shop for a sari and to have dinner with a Bangladeshi family. I feel very privileged to have had these experiences.
My itinerary was a full one, and on writing my end of visit report I realised just how many people I had met and how many places I had visited! I had a number of objectives, and the key ones were to:
- Support the twinning project between the RCM and BMS
- Establish a relationship with key members of BMS and the education sub-committee
- Familiarise myself with the education platform and help BMS to review the courses considering how appropriate they are for the context of Bangladesh
- Visit several midwifery schools (government and private) to conduct an audit and help to identify what role BMS could play to support midwifery education in Bangladesh
Whilst in-country I was able to support the twinning project by engaging with BMS and it's stakeholders and by acting as an ambassador for the RCM. I found some members of BMS easier to engage with than others. Sometimes this was because of the language barrier, sometimes it was about an individual's personal misgivings about the project, and sometimes it was because of a lack of understanding of my role in supporting the project. At the outset I was advised by Sharmin that the term ‘volunteer’ was not likely to be well received by colleagues. In Bangladeshi culture the term alludes to someone who is inexperienced and who has little authority. Bangladesh is a hierarchical society where people are respected because of their age and position and where older people are naturally viewed as wise and are granted respect (possibly why I was given the role ); In this context the title 'volunteer' was not likely to be a particularly helpful one.
To afford me authority and ensure my contributions were valued, Sharmin suggested we consider changing my title to something with more standing. After discussion (and agreement from Joy) we decided on ‘advisor’. This revised title, alongside my designation as an Associate Professor and my 'Dr' prefix, gave me the gravitas I needed. I was accepted by my colleagues, my contributions and offers of advice were welcomed and considered, and I felt respected. By the end of the trip Dr Lesley, as I became affectionately known, had succeeded in establishing effective working relationships with key members of the BMS team and with stakeholders at the upazila health complexes and the nursing colleges. I had also familiarised myself with the education platform and started to help BMS to review the courses in order to determine how appropriate they are for the Bangladeshi context.
The twinning project is ongoing and I am making another visit to Bangladesh at the end of October. Having establised the necessary working relationships and having familiarised myself with the education portal I am hoping that I will be able to make a more definitive contribution on my next visit. I hope to review the portal content in more depth and consider ease of use, topic matter, relevance and cultural congruency. I also hope to help support the education sub-committee to develop a vision and mission for their team and to start to develop a one-year strategy for the education committee.
I am excited to return and play my part (however small), in raising awareness of midwifery, developing mechanisms for keeping midwives up to date in care provision, and in advocating for women, their babies, midwives and midwifery students. I am excited to have the opportunity to revisit a country where I felt the beating heart of women and of midwifery, and where my passion for childbirth and all things birth-related was rekindled.
It hardly seems any time since I was here...and already I am back! I arrived for my second trip on Saturday morning feeling excited and much more relaxed about my visit. I feel like I 'know the ropes' and that I have some understanding of what to expect, including what my working relationships with the BMS committee members will be like.
Last time I arrived in the evening but this time I arrived early in the morning....and the airport was pandemonium! There were people everywhere - clearly a number of flights had arrived at similar times meaning that the airport was very busy, there was a long wait at immigration and a long queue to get through customs. People were pushing and shoving, they were clearly tired and tempers were frayed and a number of scuffles started up. I kept my distance and was eventually ushered through customs, but I could see that the majority of people were having to put their luggage through a scanner in the customs hall which seemed odd. Susan told me later that in the last few weeks there have been a number of instances of people smuggling gold bars into the country...so I assume that was what the customs officials were looking for. Clearly I did not look like a likely suspect!
As soon as I left the airport with the driver it was a welcome relief to realise that it is not as hot or humid as it was in August. The temperature is still around 29-32 degrees but it feels much more comfortable. I found the heat pretty stifling before, it was exhausting and I did not enjoy the feeling of sweat dripping down my back! We arrrived at the hotel which is bigger than the one I stayed in last time, with more social space, more facilities and nicely positioned next to a park with a lake and a walking track.
On this trip my responsibilities include:
1. Developing the already established relationships with key members of BMS and the education sub-committee.
2. Offering mentorship/coaching to the education secretary
3. Contributing to the achievement of the RCM/BMS Detailed Implementation Plan for the twinning project through facilitation of relevant activities with BMS.
4. Conducting an up-country visit to with a member of the BMS executive committee to visit midwifery schools (both public and private) to assess the clinical experience placements available to students.
5. Continue work developing the e-learning platform.
6. Exploring the landscape of research ethics committee approval for midwifery research in Bangladesh.
7. Continue offering mentorship and support to BMS President and Treasurer.
8. Contribute to a publication in Midwives Magazine about the Bangladesh Twinning Project.
So lots to keep me busy and out of trouble....
After an initial meeting at the hotel Sharmin and I took an Uber to the UNFPA office. We met with Rondi and Jennifer to agree some shared goals and objectives for my visit. The main priorities from the UNFPA perspective (in relation to BMS) are:
1. Membership of BMS (increasing membership numbers, encouraging re-registration and keeping members interested in the society)
2. The e-learning platform (making sure it is accessible, culturally appropriate and relevant)
3. The licensure issue (I discuss this in a separate post)
4. The continuing professional development of midwives (which UNFPA are working on but which can be complimented by the e-learning platform)
5. Hearing midwives voices (the need for a forum of some kind to listen to midwives and respond to their concerns and issues)
6. Establishing a platform where midwives can share their successes
7. The use of the BMS newsletter (to engage midwives and educate them about BMS advocacy role).
So lots more things to think about .....
I agreed to think about the membership issues, to work on the e-learning platform, to engage with the midwives on any in country visits (giving them the opportunity to talk to me about any challenges they are facing) and I also agreed to add a section to the newsletter to showcase successes and issues as identified by deployed Diploma midwives. Better get to it.....
When I was last here, I found out there was a problem relating to the licensure exam for midwives. Midwives undertaking the diploma programme study for three years, eventually graduating in December. Then in the following February, they take a licensure exam in order to register as a practising midwife. This does not happen in the UK because the Nursing and Midwifery Council (NMC) accredit the midwifery programmes - i.e. the NMC approves all programmes ensuring that they map to all the relevant competencies and meet all the necessary education standards. Therefore, once a student successfully passes all the elements of the programme, and the lead midwife for education at the university approves the student for entry to the register, they can start to practice. Presently, the Bangladesh Nursing and Midwifery Council (BNMC) does not accredit all programmes so, in order to ensure that candidates meet the relevant standards they have to undertake a separate licensure exam.
As I explained in an earlier post, last year a home health worker sued the Bangladesh Nursing and Midwifery Council (BNMC). The worker argued that they should be able to take the nursing licensure test (after having completed a six-month training programme as opposed to having studied for three years). Because the worker sued the BNMC, the council put a freeze on all licensing tests until the high court could consider the argument. Since this happened no one has been able to sit the licensure exam. This means that all the midwifery students who finished their diploma in December 2018 have yet to sit a licensure exam. Consequently, they cannot seek employment and the longer the process goes on the more out of date their skills become.
Clearly, this is a huge concern for midwifery students, including those due to finish their training in December of this year. Many non-government organisations (NGOs) have been lobbying the authorities to resolve this issue but the High Court has now ruled in favour of the health care worker, advising that because the country is so short of nurses and midwives, every health worker should have the opportunity to sit the exam. On Sunday, members of the Bangladesh Nursing Association (BNA) and the BMS joined a protest walk in order to protest against the verdict and raise the profile of the issue by involving the media. The president of the BMS Momtaz Begum and the treasurer Rehena Khatum accompanied students on the walk. Farida Begum, the programme analyst for midwifery at the Bangladesh United Nations Population Fund (UNFPA), has been in consultation with a number of different colleagues about the issue but the consensus is that unless the Prime Minister (PM) gets involved the matter will not be appropriately resolved. The BNA has written to the PMs Office arguing the point and BMS now need to do the same.
My first meeting at the BMS office on this visit coincided with a monthly committee meeting. This was really useful as it meant I had the opportunity to meet with a number of members for the first time. It also meant that I had a chance to speak with three midwives working in UHCs about their experiences; in particular to hear about things they enjoy about their role and things which they find more challenging.
First I spoke with Pinki, who is the joint secretary of the BMS and a midwife at the Bataighata Khulna UHC. Khulna is the fourth-largest city in Bangladesh and is a port on the Rupsha and Bhairab Rivers. A hub of Bangladeshi industry, it hosts many national companies. Khulna is served by Port of Mongla (the second-largest seaport in the country), and is one of the two principal naval-command centres of the Bangladesh Navy.
Pinki had worked a morning shift the day before, then had travelled for 12 hours on an overnight train to attend the meeting. Pinki explained that she would need to leave the meeting promply to get back for another shift. She told me that because only four midwives are deployed to the UHCs, if one of them is absent for any reason then one of their colleagues has to work a double shift. Because of the strain on their colleagues, midwives are therefore loath to take rest days, attend training for continuing professional development or take vacations. Pinki told me that the UHCs need more midwives and that currently the environment the midwives work in is poor. She said that midwives 'need a helping hand' and that in order to make the service manageable and effective a minimum of eight midwives were needed. Pinki described this as a 'systemic' problem that only the government can change.
Pinki told me that she likes helping women to birth and that she enjoys providing antenatal care and counselling women. She said that some of the challenges she faces include working with women and families who lack knowledge and understanding of the role of the midwife. She explained that generally, the wider population thinks that midwives are nurses and do not appreciate the fact that midwifery is a separate profession, that midwives are experts, and that they work autonomously. Pinki said that this is starting to change but that change is very slow. Pnki suggested that more media advocacy was required to promote the role, the benefits of midwife continuity and the value of antenatal care.
At the UHC where Pinki works there are only 2-3 normal vaginal deliveries (NVD) per month despite the fact the UHC has equipment to promote upright, normal birth such as a birthing stool and a birthing ball. Apparently the c-section rate is 42.7% in the division. I tried to find out some of the reasons for this and was told that there is a medical college hospital 20-25 minutes from the UHC and that most women choose to attend the hospital 'just in case'. Perhaps related to their lack of understanding of midwifery, but also because there is an anaethetist available at the hospital and many women want access to an anaethetist as many of them anticipate a c-section. C-section is on the rise in Bangladesh, the national rate is around 31%, it has become normalised, and the midwives describe it is a 'business' in Bangladesh. They tell me there is more money to be made from c-sections and that doctors will not take the time to support women to birth normally.
Next I spoke with Lima, who is the organising secretary of BMS and a midwife at Hatibandha UHC in the division of Rangpur. Rangpur is one of the oldest municipalities in Bangladesh, established in 1869. It is known as an important trade center and a cultural heritage gem in Bangladesh. Similarly to Pinki, Lima had travelled for 12 hours overnight to reach the meeting after completing a shift at the UHC.
Lima said that she felt women like the care provided by a midwife and that she enjoyed her role but that there were many challenges. Lima said that 'we need two midwives on every shift rather than one'. At Lima's UHC there are somewhere in the region of 70-80 NVDs per month despite the UHC not having equipment to promote NVD such as a birthing stool and/or birthing ball (a stark contrast to that of the UHC in Khulna). The rate of c-sections in the division is 26.4%. Lima said that the medical college hospital is two hours away by ambulance (if primary management at the UHC is not sufficient and a woman needs to be referred for more complex care). However there is a private medical clinic nearby to the UHC where women can be referred for c-section if necessary (the UHC has a good working relationship with the clinic).
Speaking to both of the midwives about the disparities in their statistics, the midwives said that one of the contributory factors was the cost of transfer to a facility by ambulance if a c-section is required. They said that if the ambulance service was free women would be more likely to birth at UHCs. Also they said that some of the more disreputable private clinics send 'agents' to UHCs to try to persuade women to attend and that if they are successful the agents receive commission. Both midwives spoke about corruption in the services and about the need for the government to do more to support normal birth and address the c-section rate.
Finally I spoke with Kharima, the secretary of BMS and a midwife at Kahaloo UHC. Kharima had travelled for nine hours to attend the meeting. The UHC where Kharima works is located near the city of Bogra. Bogra, officially known as Bogura, is a major city located in the Bogra District, Rajshahi Division. It is considered sacred to Buddhists, Muslims, and Hindus alike and pilgrims and visitors tour the area all year round.
Kharima told me that she felt 'very proud' to be a midwife and that she enjoyed helping women and 'making them happy'. She said that she wanted all women in Bangladesh to have the opportunity to be cared for by a midwife and that she wanted to be able to manage all complications effectively. At her UHC there are between 10-20 NVDs a month (this has built up from a starting point of 1-2 per month). There is no equipment to support upright and/or normal birth at the UHC, such as a birthing chair, stool or ball. Similar to the situation Pinki described, the medical college hospital is about a 15 minute drive from the UHC. Kharima said that approximately 250 women per month were attending for antenatal care. Kharima agreed with her colleagues that more midwives need to be deployed to the UHCs and that more needs to be done to tackle the rising c-section rate in the country.
This meeting provided me with an amazing opportunity to speak to deployed Diploma midwives and to find out more about their experience. Going forward I would like to speak to more midwives, to find out more about their experience and to try to understand more clearly the apparent dispariities in statistics between the UHCs. Improving my understanding of the socio-cultural factors impacting on NVD and c-section in the context of a new profession will help me to think about how I can start to help to improve the situation and the environment for birth.
Today I visited the Keraniganj UHC with Sharmin and Runu Rani Mandal (midwife and executive member of BMS). The UHC has 31 beds but is being upgraded and will utlimately become a 50 bed unit. At the UHC there are 60 antenatal check ups per day, 30 NVDs per month and 25 c-sections per month. There are four midwives deployed to the complex.
Sharmin, Runi and myself met with the senior staff at the unit and asked what their experience of midwifery at the complex was. The staff were very positive but told us that they needed something like 8-10 midwives to be deployed to them rather than four. They also said they felt that whilst students, the midwives need more exposure to practical experience. They suggested 3-6 month post Diploma training in a tertiary centre before deployment to the UHCs. They argued that this would enable the midwives to gain confidence as well as offering them an opportunity to consolidate their practice. They told me that during this training the priorities should be around providing antenatal care, managing NVD, and managing post partum haemorrhage (PPH) and pre-eclampsia. As it is, midwives are deployed and need significant support from the medical officers and gynaecologists before they are able to work independently, meaning that to start with they are a strain on the service rather than a help.
The midwives agreed that this would be helpful and also said that in practice they needed more equipment to facilitate normal birth. At the moment the complex does not have a birthing chair and /or a birthing stool or a birthing ball and most women birth in the lithotomy position. Similarly the complex does not have a wall hanging partograph which would be useful as a resource for training. Midwives were also concerned by the drop in attendance for antenatal care. Women are encouraged to attend for four antenatal visits. All of the UHCs I have visited so far have reported a big drop in attendance from the first visit to the fourth. I have been trying to understand this and have been advised that it may have something to do with the family influence on the women (the family and family decision makers not trusting the midwife). This would suggest that more education and counselling of the family and wider community is required on the role of the midwife, the value of midwifery led care and the importance of regular antenatal care.
The senior staff spoke about the rising c-section rate and when asked what they believed the reasons for this were, said that they believed the reasons were previous c-section, failure to progress and fetal distress. They told me there were limited facilities for neonatal care at the complex meaning that staff had a lower threshold for intervening if the fetus was perceived to be at risk. I spoke broadly about the environment for birth as a factor in the c-section rate. The birthing rooms that I have seen at most of the UHCs have limited privacy meaning that women's dignity is not assured and that women assumedly feel exposed, vulnerable and fearful (not conducive to normal birth). Similarly a lack of individual birthing space (women often birth two to a room) means that women very often cannot bring in birthing partners who would be able to offer them emotional support during the birthing process. Lack of equipment for upright birth and use of the lithotomy position I argued were also contributory factors.
We had a good discussion and then we asked what the UHC and the midwives expected from BMS. They said that they wanted BMS to lobby for more manpower and to provide more skills training (particulerly around managing emergencies such as PPH, pre-eclampsia, retained placenta, shoulder dystocia and neonatal resuscitation).
Today Asma (the education secretary of BMS) and myself met with some IT specialists to see if changes can be made to make the e-learning platform more user friendly. At present it is very cumbersome, not very intuitive and, at times, misleading. For instance when you open the education portal there are 20 courses on the front page – all of which have an advertised cost – the user does not actually have to pay for the course but it could be off putting, as a potential participant may believe that if they click on the course they will have to make a payment. It would be preferable, therefore, if there were no costs next to the courses.
Then, when you click on a course (because you are ready to participate) confusingly in the left hand margin of the page you have been directed to, there is ‘search courses’ link which states that there are 43 courses (rather than the 20 which were anticipated). Again this is confusing for the participant who should be able to navigate the system easily and to be clear, from the outset what is available. Asma and I highlighted the problems with the platform and we spoke about what we wanted it to look like. The specialists showed us a dashboard and learning platform that they have been developing for UNFPA. This looks much easier to navigate than the BMS one and also more engaging. Hopefully something similar could be designed for BMS.
However it is not just the e-learning space and navigation which needs amending. All of the courses need reviewing (in some detail) for ease of use, topic matter, relevance and cultural appropriateness; this will be a potentially lengthy process. I have started to look at the courses and will share my experience of one of them. Asma told me that no one could pass the postnatal care module and get the certificate. So I had a look, opened the module and found that it would take around five hours to complete! Clearly this is very off putting for any potential participant but especially for those whose first language is not English and who have very limited spare time. I did not take the course but I took a quick look and it was very wordy and dense and was not culturally relevant. I took the exam and I passed but I found the exam quite difficult! Some of the questions were out of date and some were very odd and did not seem overly relevant to determining that someone would be competent to provide postnatal care!
The courses offered on the second landing page are more user friendly and useful. They are shorter, seem more relevant and are more culturally appropriate. Most of these feature medical films and show the participant how to do practical things like using a uterine balloon tamponade which is extremely relevant in a low resource setting. I need to make the time to look at more of the courses and to see which should be available and which should be removed from the platform.
Our first appointment in Bogra was with the 'civil surgeon'. The civil surgeon is a senior designated post in the government medical and health service. The post signifies certain status, power and rank to the holder. A civil surgeon is a senior doctor in any of the medical branches (not necesssarily a surgeon) and is responsible for health at the district level.
We were very grateful that the civil surgeon of the Rangpur district, Dr. Abu Md. Zakirul Islam had taken the time to meet with us. We used the time to promote the right of every Bangladeshi woman to have access to a midwife as well as promoting BMS as the voice of all midwives. We had a very productive meeting discussing the numbers of midwives deployed at the UHCs (we argued the case that more were needed), the facilities and equipment required to support NVD, and strategies to increase understanding and uptake of antenatal care by women in the district. It was inspiring to see Kharima and Lima, two young midwifery leaders, engaging with the civil surgeon and advocating for better midwifery services for the local population.
Our next visit was to the Kahaloo UHC where we met with the senior team and heard about their successes and challenges. The medical officer in charge of the UHC is relatively new to post and was very passionate about making a difference for women in the catchment area of the complex. He was very clear that he wants to see more NVDs at the complex (currently 10-20 per month) and that he wants to see the number of c-sections reduce (currently about 25 per month). He also told us that he wants to see women access all four episodes of antenatal care. We spoke about some strategies which may help in this regard, in particular the need for midwives to counsel the women and their families about the importance of engaging with midwives and attending for care. We also spoke about the importance of privacy and dignity in the birthing space and the need for equipment which could help to facilitate NVD such as birthing stools and balls. It was a very positive visit and Kharima and Lima were able to open up the conversation and engage with the team about strategies going forward.
Towards the end of the day we enjoyed some leisure time, visiting Mahasthangarh which is the oldest known city of Bengal in Bangladesh, and which dates back to the 3rd century B.C. 'Mahasthan' meaning sanctity and 'garh' meaning fort. The site is the earliest and largest archaeological site in Bangladesh and encompasses the ruins of the ancient city of Pundranagara. Over the centuries, the site was home to Muslims, Hindus and Buddhists. The Buddhist Pala emperors of North Bengal ruled over this region from the 8th to the 11th centuries and it is from this period that most of the visible remains belong. Amongst the ruins, a few relics still stand tall and command attention, and the rural setting is incredibly peaceful. I really enjoyed visiting the site; as well as enjoying the history, it was wonderful to be outside in the clear air, to enjoy the peace and quiet and the green space, particularly after the smog, dust, noise and constant stimuli in Dhaka.
Our first visit today was to TMSS Nursing College.TMSS or 'Thengamara Mohila Sabuj Sangha' is a micro credit NGO from Bangladesh. It was founded by Dr Professor Hosne Ara Begum, in 1980 in Bogra, Bangladesh. It is a women-oriented Bangladeshi organisation working for alleviation of poverty, empowerment of women and improvement of the socio-economic infrastructure of Bangladesh. TMSS has partnered with a number of organisations, to help enhance services available in more rural areas. TMSS is the third largest NGO in Bangladesh and the largest women's organisation in Bangladesh.
At the visit we were advised that TMSS started a Diploma in Nursing Science and Midwifery in January 2009 with a capacity of 100 students. Then in November 2015 the college started the Diploma in Midwifery Course with a capacity of 30 students. So far 72 students have started the Midwifery Diploma programme and to date 17 have received BNMC registration as a midwife (the first batch). We visited the college and met the students who were very welcoming and pleased to meet us, saw the classrooms, the library, and the skills space. I noted that the library has very few midwifery text books and those that they do have are dated - for example the college is using the 14th edition of 'Myles Midwifery' rather than the most recent edition which is the 16th. I fed this back to the teaching team and said that I would speak to one of the editiors, Professor Jayne Marshall, about getting hold of some new editions for the college.
When we visited the skills lab I noticed that, although there is some very good equipment available, there is no equipment to teach the students about upright birth and alternative birthing positions, such as a birthing chair, birthing stools and birthing balls. I queried this with one of the teaching team who said that in the Bangladesh context the lithotomy position is normal for birth. In the discussion that followed I described the benefits for the women of being upright, mobilising and adopting alternative birthing positions. I also stressed that the curriculum being followed by the students (and endorsed by the ICM) advocates for alternate birth positions as a mechanism for promoting NVD and reducing the c-section rate. The lecturer was very receptive to these ideas and interested in improving the skills facility to ensure that the students have a good learning experience.
After our tour of the college and after taking some refreshments, we were ushered into a large reception room for the 'programme' that the TMSS team had organised. I had not been expecting this and certainly was not expecting there to be a large banner on the wall welcoming me to the college and a room full of people waiting for me to give a 'speech' as their 'guest of honour'! The programme that followed was very formal, with a number of staff members making presentations to the room (some accompanied by slides!) and then I was prompted to give my contrbution. As I had not been expecting to present to a group (and certainly not in such a formal manner) I had not prepared anything! I had to think quickly and present something suitable for the audience. As I was gathering my thoughts, the senior doctor sitting next to me took out a digital recorder and placed it in front of me! Presumably to save my words for posterity!! No pressure......
My 'speech' seemed to go OK, considering the circumstances, and then just as I finished the founder of the NGO, Dr Professor Hosne Ara Begum arrived. Apparently the Professor is extremely busy and so the fact that she had taken the time out of her schedule to come and meet with BMS was a huge honour. As the programme came to an end a number of presentaions were made. I was awarded a plaque which was completely unexpected and a great honour. Sharmin was also awarded and then myself, Sharmin, Kharima and Lima were given gifts; these were baskets full of handicrafts made by women supported by the NGO...such a lovely gesture.
During our visit we went to Bogra Nursing Institute and Bogra Nursing College. As ever we were warmly welcomed by nursing and midwifery faculty members and midwifery students. We toured the facilities and at the institute met the students who gave us a PowerPoint presentation telling us that they had 'some demand to our honorable guest'. They had a list of 20 demands which included things like:
* appropriate classrooms * an auditorium *a study room * a computer skills lab * skilled midwifery teachers * a yearly licensing examination * suitable residential accomodation * travelling facilities for clinical practice * rewards for excellent teachers and a support programme for weak teachers * a laptop for each midwifery teacher * multimedia
I found it quite humbling to hear their 'demands' bearing in mind the amazing resources and facilities enjoyed by midwifery students in the UK. Here were students desperate to learn and determined to be the best midwives they could. It was clear, however that their learning environment and learning experience was compromised and in need of significant improvement. Despite this their demands were not exclusive to their specific and individual learning experience, they clearly recognised the need for teachers to have training and support and appropriate tools to be the best educators they can.
The visit was a complex one from start to finish. Despite the welcome we received (staff and students welcomed us with singing and flowers and threw rose petals over us) when we were seated in the 'conference' room a senior male nursing instructor joined us and was quite hostile, demanding to know why we had visited, what we expected to achieve and what purpose BMS served. We explained that BMS was an association for midwives, an organisation that was advocating for every woman in Bangladesh to have access to a midwife and the 'voice of all midwives'. It was very difficult to get this message across as he kept interrupting, and arguing that our message was flawed, telling us that senior nurses had more experience than these 'diploma midwives' and that midwives should not expect to have a voice. He was supported by one of the senior nursing instructors who agreed that midwives should not have a voice as having a voice would mean opposing the government. It was impossible for anyone to respond to her argument as she spoke at length, without pausing and with a very loud voice.
It was an exhausting visit - clearly the students' presentation was a reflection of the attitude and potentially the practice of some of the staff at the institute. What the visit demonstrated was that the path to a midwifery profession is convoluted rather than straightforward, a journey which is complex, challenging, and which needs protecting and nurturing.
On this trip I have had the opportunity to spend time with Kharima, the secretary of BMS. Kharima is a very able, personable and bright young woman who seems keen to develop herself and to work as effectively as she can. Kharima and Lima, another very astute young midwife and the organising secretary of BMS, hosted us on our visit to Bogra. During our visit Kharima took the lead on a number of occasions, liaising with senior staff and ensuring that our trip went as seamlessly as possible. Towards the end of the visit Kharima told me that she would not be attending the first two days of the BMS review meeting (taking place this week) as she would be working as a trainer on a 'Life Saving Skills in Pregnancy and Childbirth' (LSPC) course.
I was intrigued and asked her to tell me more. Apparently some months ago Kharima attended the LSPC course as a participant and towards the end of the course was approached by the organiser (a senior obstetrician) who asked her whether she would consider doing the training to become a 'master trainer' (facilitator) on the course. The organiser was extremely impressed with Kharima's knowledge, understanding and practice and could clearly see that she would make an effective trainer. Kharima said that she was a little worried, saying to the organiser, 'but madam how will I teach doctors?' The organiser reassured Kharima that she had the necessary knowledge and practical ability for the role and assured her that she would teach Kharima how to deliver the training to all participants (regardless of their designation).
Needless to say Kharima attended the training, was successful, and the course she is helping to facilitate this week is her second as a master trainer. Understandably Kharima is proud of herself, and pleased to have the opportunity to share her knowledge and skills. As an outsider, it is wonderful to see a young educated midwife being successful to the extent that she has been asked to help develop the practice of other members of the team supporting women in childbirth. Based on what I understand about Bangladeshi culture so far e.g. the fact that it is very hierarchical, it is an incredible achievement for a young woman, and a young midwife, to be recognised as an expert and to be asked to deliver training to doctors.
This afternoon Sarah Gregson (Fellow of the RCM), Sharmin and myself had the opportunity to visit a pilot project which has been developed by the OGSB and UNFPA.The project, which will run over three years, has deployed eight Diploma midwives to Dhaka Medical College and six Diploma midwives to Midford Medical College. Up until now the Diploma midwives have only been deployed to UHCs. This project, which started in September, involves midwives working at the medical college under the mentorship of a 'Clinical Coach' who is a trained obstetrician. The project aims to 'strengthen the health system to provide accessible and affordable care', and the care is aimed at reducing the maternal mortality rate (MMR) by focusing on 'PPH, Eclampsia and standard labour room practice'.
At the college we met with Dr Fatima Shajahan, the Clinical Coach, two midwives deployed to the hospital and three student midwives in clinical practice (one third year student and two first year students). The labour room is a large square room with curtains providing some privacy (when you walk into the room the area where care is delivered is screened from the doorway). Behind the curtains we saw there were three women labouring. One woman was labouring on a birthing stool and two were labouring on lithotomy couches. One of the midwives told us that the women come to this room when they are in the second stage of labour, i.e. they are ready to push and birth their babies. Prior to this they labour in the 'first stage' room. On the walls there are informational posters which the midwives can refer to when caring for women e.g. with guidance on how to manage a PPH. In the corner there is a resuscitation area for care of the newborn. Whilst we were visiting two babies were born and taken to the resuscitation area.
Dr Fatima told us how important the project was for the future of Bangladesh - she said that the hypothesis was that it would provide the evidence needed to illustrate that midwifery care can improve the NVD rate and reduce c-section rates. Dr Fatima said that there were already notable improvements; in the two months since the project began the c-section rate (across the two hospitals) has reduced by 3%! Similarly the number of women birthing in a squatting position has increased from around 12 women to 88 and the number of women receiving information and being counselled regarding postpartum contraception (with an emphasis on the post partum intrauterine device) had improved from 25 to 65. Incredibly encouraging results at this early stage and a real incentive to keep working hard. The team we met were clearly committed to making midwifery care the norm in the medical hospital setting, and to improving outcomes for mothers and neonates. The doctors, midwives and student midwives are working effectively as a team, learning from each other, motivated by the project and motivated to make a difference to the statistics surrounding the MMR, PPH, Eclampsia and NVD. Incredible work, heartwarming, good for the soul and absolutely inspiring.
As with my last trip I set out on this one on my own. On this occasion, however, I was looking forward to Sarah and Joy joining me for the last week. But unfortunately at the last minute Joy had to cancel her plans due to family commitments. This meant that sarah and I were tasked with planning and facilitating a three day review of the twinning project! Totally unexpected and a little daunting to say the least!
As a starting point, I asked Sharmin for a copy of the itinerary for the review which took place in 2018....this proved to be an extremely helpful place to begin what seemed like a somewhat onerous task. As I understood it the purpose of the review was to take stock of progress to date, evaluate activities and determine whether the activities had led to capacity development within BMS. This meant considering what committee members had planned to do, looking at what they had achieved (and any barriers and/or facilitators they had faced) and reflecting on how they could build on this in the future. The second day of the meeting would be an opportunity to showcase BMS successes with stakeholders and ask for some feedback from them about their engagement with the society, and some suggestions for further development. The third day (which I would be unable to attend as I would be on my way home) would be for targeted training.
The first day meant all the committee coming together and was a great opportunity for me to meet those members who I had not previously met. A number of different activities took place but perhaps the most successful was the group work which aimed to answer the following questions:
1. What were the key achievements of BMS in the past 12 months?
2. What made these achievements successful? How can we build on this?
3. How have these activities helped your self-development and the development of BMS?
4. What have you find most difficult about being involved in the twinning project over the last year? For example time for meetings, how you communicate etc. Give examples.
5. What would make your involvement easier?
Sarah and I had taken advice from Susan Lloyd about how to facilitate the group work - Sarah works as a management and leadership consultant but also facilitates cultural competency workshops. Susan had suggested that rather than putting the participants into larger groups it would be more effective to get them to work in pairs. Susan suggested that in their pairs, participants could ask each other the questions, and then when asked to feedback, they could report what their colleague had said. This proved to be extremmely effective as it meant the participants had to listen carefully and ensure what they reported back was accurate. I had been at a number of different meetings with many of the group members and prior to this had found that discussion and reaching any kind of agreement or consensus had been challenging, with people interrupting and talking over each other. It was very satisying to be able to collect the required information in an orderly fashion!
In the afternoon Sarah and I facilitated a 'hot topic' workshop on normal birth. We decided to facilitate a session on this, as on visiting a number of facilities, we had both noted that often women were birthing in the lithotomy position and that there was limited privacy afforded to them. The session looked at optimum environments and positions for birth, concentrating on the relevant anatomy and physiology. We tried to make the session as lighthearted and fun as possible which involved role play and me 'birthing' in lots of different positions!!
On the second day stakeholders from organisations such as UNFPA, Save the Children, BRAC, TMSS, public nursing colleges, the BNMC and the Directorate General Office of Nursing and Midwifery were invited to attend. The day, which was facilitated by Susan Lloyd (in Joy's absence) was extremely positive with opportunitites for networking, interesting activities, and valuable discussion. The group work focused on the following questions:
1. How can BMS increase its membership? What sort of strategies would you suggest?
2. What can BMS do to improve understanding of the role of the educated midwife in Bangladeshi communities and society?
3. What sort of education and work arrangements would help to improve the capacity of the committee members?
4. Which stakeholders should BMS be liaising with on a regular basis? What should this liaison look like and how should it be facilitated?
Again the group work was effective and lots of useful suggestions and feedback were collected and collated. Importantly everybody seemed to enjoy the day, the highlight of which were the inaugural awards for outstanding effort and achievement.