Maternal Mortality

Nepal is one of only two countries in the world where women have a lower life expectancy than men. The Maternal Mortality Rate (MMR) in Nepal is 1 in 21, which is the lifetime risk of death due to factors associated with female reproduction. In Canada, it is 1 in 12500.

Yesterday, a 16 year old mother was brought in to the hospital by her two women neighbours. They had been with her at home 5 days ago when she delivered twins, a boy and a girl, who both died within an hour of the birth. The mother had very little bleeding, and the neighbour told us that both placentas delivered. The mother’s blood pressure and temperature were low and her pulse was high. An iv was started with antibiotics, since she likely had a postpartum infection. She had crackling sounds in her lungs and complained of back pain. She was so anemic and septic that she couldn’t lift her head off the bed.

There was a delay to transport to a larger hospital that could manage her care. Once we decided that I would pay for the ambulance ($1.40), we couldn’t find the driver for the ambulance. Then once we got an ambulance, we carried her to it as by this time, she had become unconscious and there is no stretcher. The feeling of holding an unconscious live person is different than holding a person who had just died...something intangible changed the moment she died. Trying to co-ordinate CPR inside a small ambulance, without the proper equipment, on someone who has no reserves to pull her back to this world, felt like a second and an eon. Along with 1410 other women worldwide that day,Kanchhi Lama died.

The Bandh

There has been a two-day strike (Bandh) called by the Maoists following an attack north of us. The Maoists are the Nepali rebels fighting against the Royal Military-following the Maoist political philosophy of Communism. During the attack-apparently Maoist on Military, five police officers were killed. The Maoist called the strike in protest of the disappearances of their cadre and general dissatisfaction with the Nepali Monarchy. By not closing down, businesses and schools risk reprisals. Nepal is a Hindu Kingdom with an elected or appointed Parliament that may or may not be dissolved on any given day-depending on the mood of the King.

From our perspective, the strike has been uneventful. The kids were dressed in their uniforms and heading out the door to go have breakfast when a student arrived to tell us that there was a strike and the school would be closed for 2 days. They were only too happy to get out of their uniform and play badminton in the front lane-the cricket match grew steadily throughout the day, but we’ve yet to join in. The stores are closed, their corrugated metal grate pulled down and locked. The traffic is only private cars (few), bicycles, and roaming cows. No public transport is running. But the thriving market economy takes place down the alleyways. The internet café is open from the back but the power has been out off-and-on. The vegetables sellers arrive from their day picking in the fields to lay out there fresh produce for the night market. And the butcher shops (there are 4 in a row-chicken, goat, buffalo, and fish) open their wooden flaps from the red painted wooden shacks for an hour (and everyone seems to know which hour that is going to be) to do brisk business. Schools are closed. Banks and Government offices are closed. But where we are, there are only occasional visits from an entourage of military police. It is mercifully quiet and the Valley could benefit in a decrease in smog from the two day break. It actually feels like a ‘snow day’ with an edge.

The hospital is running for emergency cases and deliveries only. And staff arrive by bicycle or on foot-or don’t show, depending on how far away they live. All the surgery booked in the brand new OR has to be delayed until the strike is over. But construction keeps going-apparently, guys carrying loads of brick up stairs are exempt from any Maoist retaliation.

Stupa Sangha Hospital

The hospital is under the same co-operative board as the Nepal Institute of Health Sciences and KEBS Academy. The co-operative is made up of 265 members who have donated their time and money to build the three institutions in their community. This past Saturday, the hospital opened its operating room and they performed the first surgery.

The top of the building is still under construction. Now, there are piles of brick and gravel in front. Young guys spend the day loading baskets and hoisting them on their back, securing them in place with a tumpline. They then carry the load up the 5 flights of stairs to the final floor, which is just being constructed. There is a stack of concrete slabs in the center of the building, waiting to be carried up as well. The building is a five storey square donut, with a wrap around balcony on each floor that looks down on the centre area, where an ambulance can drive directly in (or tractor, motorbike, taxi, whatever the case).

On the ground floor, the TB clinic runs the DOTS program where the daily dose pills are given out to community members with TB-so that they are followed, and everyone is assured that they are taking their pills and are not forgetting them or losing them or deciding not to take them any longer. The clinic also does the ‘sputum’ follow-up test to ensure that at 2 month and 5 month mark, there is improvement, and at 8 months, when the treatment is over, they no longer have TB. The whole program is free, including the hospital user fee-called the Registration Fee (about the equivalent one hour of work of the average hourly wage-or 10% of the cost of a Toblerone).

There is also an emergency room, and a room used for both immunization and family planning. There is an x-ray and ultrasound-both very old machines but are helpful in a pinch.

The Natural Birthing Unit is also on the ground floor. It has a room for prenatal assessment and a room for delivery. It is on the north facing corner of the building and the temperature in the room has not gone above 10 degrees Celsius. There are two electric heaters that are rotated around to the different units, depending on need. However, even during a delivery, with a very warm labouring woman and heater in the room, the steam can still rise off the newborn baby as he is handed to his mother.
Women arrive for prenatal care late in pregnancy, or just arrive in labour. Most are from the community but some come from the rural areas and come in for one check-up, then leave after discussing whether they will return for the birth or deliver at home in their village. Pregnancy and birth is so normal here. Women who have never breastfed before know how to breastfeed. Women are discharged 3 to 24 hours after delivery. In that time, very little teaching goes on as there is an assumption that either the woman knows how to take care of herself and the baby or her family does. The woman must provide everything she needs while in hospital-food, change of clothes, and peri-pads. Women are also instructed to buy iron and calcium supplements to take home with them. The hospital participates in the National Vitamin A supplementation program to prevent blindness that can occur in pregnancy and postpartum due to vitamin A deficiency, so women receive one free dose at discharge.

The average level education of the women is between illiterate and grade 3. The small group of staff have finished grade 10 and then went on to complete the 15 month Community Health Assistance certificate-two did 3 months additional training in midwifery, and they are called Auxiliary Nurse Midwives. So the level of income and education is different between the staff and patients but there seems to be no ‘attitude’. The attitude of the staff towards the patients is one of mutual respect. I was surprised since Hinduism and the caste system is cited as the biggest inhibitor of social development in this country, yet on an individual level, the staff people are kind and the patients trust the information and care they receive.



All female staff play a role at a birth. But the woman who really runs the hospital is the cleaning woman. She comes and goes from the labour room as she likes. She makes tea for everyone. She makes suggestions to assist the labouring woman. She cleans up (and if the woman is staying over, washes the woman’s one outfit, wrapping her in the 5 m patuka wrapped around her abdomen, and tucking her in with blankets until her clothes dry on the roof). And (my favourite), she chastises the family if they are late with the woman’s dinner, and teases them that the food is not good enough for the new mother.

KEBS Academy

When we settled in Boudha, we arranged for the kids to attend KEBS Academy. It is part of the co-operative that also has the Health Institute, and Stupa Community Hospital under the same board. It is a school, for ages 3 to 18 years, located behind the Health Institute where I teach on Fridays. We can take a short cut from our hostel to the school through the Stupa Square. On the way home from school, we have developed a habit of buying fresh Tibetan barley bread (the only bread we’ve found that is edible) and fried pretzels for snack. We walk home with a group of unattended school children. There is a batch of 23 ‘sponsor’ kids who live at a hostel past ours. They are orphans, most from villages in the valley, whose school fees are paid for by Europeans. This batch of kids is very impressive-I want to meet their hostel mother for parenting tips-one kid in Kai’s class is the class monitor, first in his class (this academic competition is constantly stressed), and he is so sweet. His English is impeccable, and he is great at soccer. There are many more ‘sponsor’ kids like him. Some live with their families and some live in orphanages.

The school uniform is-as in the photos-but Tuesday and Friday is white day. Yes, they have white uniforms. The impracticality of this doesn’t seem obvious when you see the kids line up in their clean, pressed uniforms for morning assembly. They line up, stand at attention, stand at ease, about face, callisthenics, morning prayer in English and Nepali, and the National Anthem. By noon however, everyone is covered with the dust kicked up from 2 simultaneous soccer games taking place.

‘Tiffin break’ is lunch. Kids bring their own lunch in these stacked metal tins with handles on the top, or they can eat at the canteen. There are noodles, samosas, fried cauliflower balls, soup, and fried chips called papul (I mistakenly called them japul-which means ‘slap’, the guy at the canteen graciously corrected me). The canteen is run by a family who live at the school-in the kitchen actually, and their kids attend the school.

Class time seems hectic at first. In class III (grade 3), one girl brings her 2 year old sister with her to class for the day, everyday-which doesn’t seem to distract the other kids. The noise level can be deafening with the rote learning method, rocking back and forth, repeating words and answers over and over again. And kids don’t put their hand up but a few shout out the answers as quickly as possible (the same kids over and over again) and the others remain quiet. I volunteered there for a few days while Kai and Aaryn were getting settled. The principal just handed over three full days of teaching to me as 3 teachers didn’t show up. If a teacher doesn’t show up, the kids play soccer or skipping for that period. It is easy to teach the class because they have workbooks and you just follow the exercises, plus Aaryn suggested “Simon says” which ended up being a new favourite. While there, I was able to observe some telling signs about the school. Memorization is the key to success for the younger kids, and really young children have exceptional handwriting-which is highly praised. Kids can also read anything but don’t know what it means. I also had comments from the children like “Ma’am! He Is Speaking Nepali! This Is Not Nepali Class! Beat Him!” Errr, I will not beat him, please sit down, thank you.

The library holds the textbooks that are needed for the older kids for special assignments and there are 5 English story books for loan for a reading level of grade 3 to 4. However, with the amount of homework assigned from the workbooks, there really is no time for free reading.

I was asked to teach conversation to the grade 5 to 10-and I felt like I couldn’t say no after so many of the staff made such an effort to make my kids feel at home. So one afternoon a week, I teach two periods. So far, we have talked about Canada, constitutional monarchy with Parliament versus a Republic, and the English Royal family during the time of Shakespeare. Next week, we are talking about Shakespeare’s play Romeo and Juilet. I was very impressed with their knowledge on so many subjects and developed a greater respect for all the rote learning that serves as a foundation for the kids as they get older.

And to answer the common question regarding the bathrooms. This school has water and one flush toilet and 4 squat toilets. Both my kids keep a stash of toilet paper with them. Regardless, Aaryn will have none of it and holds his iron-clad bladder until we get home.

Imadol

The community south of us is called Imadol. It is a rural community, where the price of a Toblerone would be the equivalent to one or two week’s wage. Houses are three stories high, with livestock on the ground floor, bedrooms on the second floor, and kitchen, patio and bathroom on the top floor (so that you don’t walk over the kitchen-a sacred place). The property is marked off by stone walls, within which is the garden. Then beyond that, is farmed, terraced fields. Houses are tightly packed together in clusters at the single lane road/footpath. Along the road are shops that sell lentils, rice, tea, sugar, hoses, razors, coke, soap, etc. There are also a few tailors, mechanics/bicycle repair shops and a temple to Lord Krishna. The cows, goats and chicken are let loose for the day to roam anywhere they like, provided they stay out of the fields-so they rummage through garbage and along the roadside. The dogs rummage through the garbage but we’ve yet to witness a massacre of chicken versus dog.

One of a few schools in Imadol is High View. It provides schooling for 300 village kids ages 3 to 18. It is a great school managing with very little. There are annual standardized tests in which High View kids have done well, and some have gone on to College-one student this year scored in first division (I don’t know what that means exactly but it is a very big deal). They provide scholarships for 8 kids in the community and plan to provide more in the spring, with the help of Nepal Reliance Organization. Because of their low fees, and good grade results, they are well respected in the community.

The school presently has no water, and the toilets are: one open pit latrine and an enclosed concrete wall to pee against. Water for cleaning must be carried by the ‘sister’ from a well down the road. My dad is raising the money needed to put in a well, pump, taps and 4 toilets. Once the money is raised, it should take 2 months to complete. The lifetime of the well should be 10 years, after which, it can be dug deeper to extend its life.

The group of teachers are a very dedicated. They manage formidably with cramped classrooms. Here, the common teaching style in the younger grades is rote learning. In their little sing-song voices, they say a word, spell it, and then say it again. They rock back and forth with the meter created by the repetition. A favourite class is GK-General Knowledge and IQ-it is a class on trivia. Related to the class work in social studies, health and science, they consume facts such as the capital of Bhutan, the third planet from the sun, the first US president, the speed of light, the parasite carried by mosquitoes, and so on. Every week, they have Quiz Contest (usually boys against the girls), and points are scored for your team for knowing the answers to (what on the surface appear to be inane) questions. Also once a week (they go to school Sunday to Friday), they have Friday afternoon “programme”-within the school there are four houses, denoted by four colours, so that each house contains a mix of age groups from 3 to 18. These colours make up a team for competition. The competition ranges from spelling bees to athletics.

Their health class covers personal safety and hygiene. Though there are the few statements such as my favourite; Q. Why is a drunkard hated by all? Ans: A drunkard is hated by all because he forgets his morality (you need to picture a grade 2 class asking and responding in unison). The class also covers avoiding dog bites and signs of a rabid dog, boiling drinking water and the signs and symptoms of cholera and dysentery, treatment of diarrhoea, and avoiding electrocution from fallen electrical wire.

Boudhanath

We are settled in Boudhanath in the Girls’ Hostel (student residence) of the local Medical College. We live directly behind the Stupa Community Hospital. Other than the guard dog barking, the quiet is only interrupted by the very occasional loud bus horn, heard from the street, and our Tibetan neighbour chanting from 6 am to 9 am, and then again in the evening. We have three monkeys who live on our roof but avoid us with disinterest and not fear. We live on the second floor, and they climb past our window on their assent to the roof after gathering food. Like the monkeys, most free time at home is spent on the roof.

It has a great view and is it warm throughout the day-compared to the concrete rooms, that never warm up. We sleep in our down sleeping bags, and are cosy but in the morning we can see our breath-though the leftover tea from the night before has never frozen (maybe because is has 3 tablespoons of sugar in it!).

We eat at the student canteen about a 10 minute walk from the residence and adjacent to the College. We vary our diet with daalh bhaat (lentils and rice) (served with varied curried vegetables and varied spicey pickles, for variation), roti and daalh (flat bread and daalh), and Tibetan momos (spicey dumplings in an even spicier sauce). Then we supplement this with chai tea, and an illicit stash of peanut butter, crackers, hot chocolate and Toblerone chocolate-all purchased, much to my embarrassment, at the department store in Kathmandu that carries imported everything…I really have to get it under control though. Our garbage is taken from our hostel floor to the street and left on the curb-I tried to pretend that I didn’t notice this but I have to step over it on my way to the chai latte shop-and my tell-tale Toblerlone wrapper was there perched on the pile (no one else in our neighbourhood would have a Toblerone chocolate simply because it’s cost is the equivalent of a days wage, and most Nepalis do not have a taste for chocolate). The dogs and cattle, and I presume the rats at night, scour through the garbage eating all the organic waste. Then the rag-pickers come through-children and women, who pick out the plastic bottles, containers, and cloth. At the same time, the paper-pickers come through, and pick out cardboard and paper. Then, the shopkeepers light a fire at the curb, and on our way back home, we walk past two or three fires that light up the area and illuminate the market (not to mention choke everyone). Then, I think about once a week or maybe twice a week, all the leftovers from the fire are shovelled into a pile and a truck comes to be loaded by men with shovels. It seems efficient enough, and neighbourhood doesn’t seem very dirty.



On our floor, there are 9 only students, most from outside the Kathmandu Valley, all enjoying the kids. They have graciously adopted us. Other families have been very hospitable. They pity that we exist on canteen food though we like it, and I haven’t confessed about the peanut butter to any of them. Saturdays are spent visiting families here in Boudhanath (Boudha for short), or out in the country-which is a five minute drive from here.

We spent one afternoon at the house of the Stupa Lama. The Stupa is the big dome with eyes painted on the box perched on top. Prayer flags are draped from the peak to the base, and on special nights, tiny butter candles are lit (about 100 000) and light the whole square up. One can walk around the Stupa clockwise while meditating. Though it is a major tourist attraction in the Kathmandu Valley, and on the request list as a UNESCO heritage site, it is also a neighbourhood to Hindus and Buddhist, and the major landing site for the Tibetan refugees who came after China annexed/invaded Tibet in the ‘50s. The Stupa Lama is the communities spiritual leader, presiding over births, deaths, marriages, and other things-my ignorance to it all making me unable to give you the full account of his role.