Resistance and challenges in producing a Midwife in Nepal

It is really frustrating to hear from the Ministry of Health and Population (MoHP) Chief Nurse Administrator Madam Ishwori Devi Shrestha that Nepal Nursing Council (NNC) President Daya Laxmi Vadiya and Madam Ishwori had dispute yesterday (4 Sep) about the need of Midwife in the country during the workshop on Development of Manual and Assessment Tool for Bachelor Midwifery Education Program organized by Nepal Nursing Association from 3-7 September, 2012 funded by UNFPA Nepal.

Very sad to hear that NNC President madam is totally against Midwifery Education Program in Nepal and even during the MoHP dignitaries meeting held in the chairmanship of Health Secretary few weeks before to discuss about the Midwifery Education Program she has strongly opposed in producing such human resource in the country. However, very glad to know that all MoHP dignitaries had strong support to produce a high quality midwife in the country as per the Long term plan of National Policy on Skilled Birth Attendants 2006 in improving pregnant mothers and newborn's health in rural Nepal. The policy has recognised the need to produce separate cadre of professional midwives as a crucial human resource for safe motherhood, providing service and leadership in midwifery for the country. 

However, according to Madam Ishwori sounds to me that NNC President has no idea about the importance of midwifery services in reducing maternal and newborn deaths in rural and resource poor settings that's why NNC President madam was insisting to provide only 9 months midwifery training to Auxiliary Nurse-Midwife who had obtained 18 months pre-service training after grade 12 passed.

Our health policy planners and decision-makers are ALWAYS after easy and quick fix strategies and those mid-level planners and decision-makers who are appointed due political affiliation are ALWAYS after LOW QUALITY HUMAN RESOURCE for Health so that they can make Happy to their followers/Puchhar. This really disgusted me and feel very sad and bad to rural people who always have to depend upon low level and quality human resource for health and because of that they have to sacrifice their lives. WHAT an insensitive so-called health professional seniors and leaders we've who even don't deserve to call seniors and leaders. Really appreciated the Government of Nepal who had thought about producing HIGH quality Human Resource for Health as stated in the National Policy on Skilled Birth Attendants developed in 2006: 4.1.3 Long-Term (Pre-service) Measures: MoHP is in the process of initiating a new cadre of Professional Midwife (PM) as a crucial human resource for safe motherhood, providing service and leadership in midwifery for the country. Towards Skilled Birth Attendance in Nepal: Rapid Appraisal of the Current Situation and Outline Strategy, WHO, February 2005, “PM is proposed that this programme will be of three year duration with entry requirement of 10+2 and the trainees as far as possible be selected and recruited from and by their own communities, to ensure that these midwives will take up assignments where they are most needed. They should be skilled to deal with normal pregnancy, birth and postpartum (including neonatal) care and identification and referral of complications of mother and baby. They must also know at minimum first line management, but when referral remains problematic, they will need more skills to manage complications to a large extent.”

In the facebook discussion my nurse friend, Sushila Karki  from UK working as a Registered Nurse said "Nepal really need speciality education system such midwifery ,paediatric and adult. Policy maker should keen about professional value rather than commercial .talking from outside is very easy but I was involved in Nepal nursing education system so to be an honest am not happy et al how is our educational system. After 3-years Proficiency Certificate Level (PCL) in Nursing program after grade 10 passed must have post registration degree, midwifery, adult n paediatric rather than Bachelor in Nursing (BN) and Master in Nursing (MN). We have high mortality and morbidly . I don't want explain about our PCL production ,it's self explanatory due to commercial production .once u done BN and MN, you are not touching patient but when you see developed country. If you do degree, you are providing quality care in compared of junior. I don't want to discuss more than this public forum .i personally strong stand for speciality degree after PCL or registration for quality care."

My response to her concern was "Exactly Sushila Karki you are absolutely right but our conservative mindset and fear of change mentality is not allowing us to move forward and sadly nursing leaders are not in favour of such education to introduce in Nepal because of FEAR and Threat that they might have in their mindset. Ishwori Devi Shrestha madam has given me permission to share this message in public because she was so much frustrated to hear such negativity of our regulatory body president against the sensitive issues."

Every expectant (pregnant) mother deserve to access high quality midwifery care. No one has right to go against her rights & choice. If we have bad Karma (intentional bad thoughts & deeds) against such services then he/she will be punished sooner or later by the nature/cosmic force because of her/his bad Karma. I always Love the Logic behind KARMA and Theory of Karma as per Buddha, a spiritual leader and a pragmatic philosopher! 

"The Pali term Karma literally means action or doing. Any kind of intentional action whether mental, verbal, or physical, is regarded as Karma. It covers all that is included in the phrase "thought, word and deed". Generally speaking, all good and bad action constitutes Karma. In its ultimate sense Karma means all moral and immoral volition. Involuntary, unintentional or unconscious actions, though technically deeds, do not constitute Karma, because volition, the most important factor in determining Karma, is absent. Karma is the law of moral causation. The theory of Karma is a fundamental doctrine in Buddhism. This belief was prevalent in India before the advent of the Buddha. Nevertheless, it was the Buddha who explained and formulated this doctrine in the complete form in which we have it today.

What is the cause of the inequality that exists among mankind?
Why should one person be brought up in the lap of luxury, endowed with fine mental, moral and physical qualities, and another in absolute poverty, steeped in misery?
Why should one person be a mental prodigy, and another an idiot?
Why should one person be born with saintly characteristics and another with criminal tendencies?
Why should some be linguistic, artistic, mathematically inclined, or musical from the very cradle?
Why should others be congenitally blind, deaf, or deformed?|
Why should some be blessed, and others cursed from their births?

Either this inequality of mankind has a cause, or it is purely accidental. No sensible person would think of attributing this unevenness, this inequality, and this diversity to blind chance or pure accident. In this world nothing happens to a person that he does not for some reason or other deserve. Usually, men of ordinary intellect cannot comprehend the actual reason or reasons. The definite invisible cause or causes of the visible effect is not necessarily confined to the present life, they may be traced to a proximate or remote past birth.

According to Buddhism, this inequality is due not only to heredity, environment, "nature and nurture", but also to Karma. In other words, it is the result of our own past actions and our own present doings. We ourselves are responsible for our own happiness and misery. We create our own Heaven. We create our own Hell. We are the architects of our own fate." Source: http://www.buddhanet.net/e-learning/karma.htm

Social worker Bikesh Shrestha "Little knowledge is dangerous things so we need to educate Madam Vaidya."

 Actually Madam Ishwori Devi Shrestha is strongly stand to strengthen midwifery education and services to reach to rural women and in providing high quality midwifery services but madam Daya Laxmi Vadiya is against it unfortunately. I don't understand WHY Madam Daya Laxmi Vadiya would like misuse her power and going against MoHP Policy because few years back she was very much in support. BUT I could understand that may be her mentality has been changed because of her colleagues at Nepal Nursing Council think producing Bachelor Level Midwife is like a step to Nurse. BUT she MUST understand that she won't be in that POSITION ALWAYS. She has to understand and internalise that WE Nurses are JACK OF ALL but MASTER OF NONE because nurses learn and know everything but they are not specialized in any field of care in the context of Nepal.Nursing is a profession within the healthcare sector focused on the care of individuals, families, and communities so they may attain, maintain, or recover optimal health and quality of life. Whereas Midwives are specialists in low-risk pregnancy, childbirth, and postpartum, although they are trained to recognize and deal with deviations from the norm as well as certain high risk situations. Obstetricians, in contrast, are specialists in illness related to childbearing and in surgery. The two professions can be complementary, but may be at odds in some countries, where obstetricians are taught to "actively manage" labor, while midwives are taught not to intervene unless necessary. Most midwives are familiar with the process of physiological management and the use of gravity in aiding the process of labor.

In the change process to have resistance, which is not surprising because it challenges our mechanical routine practice and thoughts. Anyway, midwife education program will start in Nepal possibly from next year at least in 3 universities since Government of Nepal is committed to make it happened..

Reference:

1. GoN, 2006. National Policy on Skilled Birth Attendants 2006. Kathmandu Nepal. accessed from  http://www.mohp.gov.np/english/files/news_events/6-1-Safe-Motherhood-and-SBA-Policy.pdf