Nepali Notebook - April to May 2015 by Ibu Robin Lim

Within an hour of hearing about the April 25th 7.8 earthquake in Nepal, I was speaking with Andrew of Direct Relief International. Direct Relief has been Bumi Sehat’s (Healthy Earth Mother Foundation International) biggest support for disaster relief.  They have supported our efforts in post-tsunami Aceh, in the aftermath of earthquakes in Yogyakarta, Padang, and Haiti. Also, Direct Relief still supports the Bumi~Wadah clinic and birth center in Dulag, Philippines, in response to the super typhoon, Haiyan.  To put it simply, Direct Relief has our backs. Andrew told me I would be hearing from Arlene Samens of One Heart World-Wide, a not-for-profit organization that has been doing amazing work to lower the maternal and infant mortality rate in Nepal, in partnership with the Nepali government’s network of health centers. One Heart was the earliest responder bringing medical relief to the two districts hardest-hit by the earthquakes - Sinduhpalchowk and Dhading.  One Heart’s Nepalese team, supported by their USA board, work much like Bumi Sehat: grass-roots.  Both organizations share the vision and mission of MotherBaby and Community Healthcare as a human right, especially in low- resource, high-risk settings.  Arlene and the office in Kathmandu were keen to have me on the team due to my experience in setting up safe MotherBaby care and birth services in the aftermath of disasters.  We would leave in a few days.

I called everyone I knew who normally helps out in disasters: Laura Stachel of We Care Solar, Every Mother Counts. Life Straw Water filters. One Health Org of Australia began searching for high protein food bars. Clif bar in the USA agreed to donate.  My personal friends and family began to donate money for Nepal’s relief, directly to One Heart World-Wide.  My husband and sons in Bali organized fundraisers.  Everyone was on-board to help Nepal. Jacquelyn Aurora and the One Heart San Francisco volunteers packed our luggage, laden with precious medical supplies and food for the hungry.

One Small Child at Mamu Pushpa's Butterfly House, Kathmandu, Nepal
One Small Child at Mamu Pushpa's Butterfly House, Kathmandu, Nepal

My “Family” at Wadah Foundation in Indonesia, was busy trying to make contact with our dear friends, Anuradha Koirala of Maiti Nepal and Pushpa Basnet of Butterfly House, in Kathmandu.  There were many worry-filled hours when communication was impossible.  Finally we heard from both Maiti Nepal and Butterfly House. Anuradha and over 425 children she is responsible for on-site at Maiti Nepal, were alive. Pushpa and the children of Butterfly House were unharmed. All of them were living out of doors, it was impossible to buy food for the children, as the city had completely shut down.  Buildings 4, 5, 6 stories high were crumbling into the streets. The police and military were trying to rescue people trapped in the rubble. There was no electricity, no running water and in the first nights after the 7.8 earthquake, it was raining.  When we finally were able to confirm that Anuradha, Pushpa and the children they care for were alive, we also knew they were in despair.  I asked Gordon from Direct Relief International, who was one of the very first aid workers on the ground, to check on them. Gordon was able to organize supplies and essential medicines for Maiti Nepal right away.

near Sinduhpalchowk, Nepal
near Sinduhpalchowk, Nepal

Pushpa’s supporter from Singapore immediately sent tents, which did not arrive (likely lost in the airport).  So he purchased more tents, knowing he must get the children into dry shelter, and he flew with the tents to Kathmandu. Pushpa and the children are still living in those tents. My friends, Monique and the Nathan family, themselves living in trauma, camped in the USA Embassy, began right away to provide food and supplies for the children of Butterfly House.

The satellite schools in far-flung areas, where Anuradha and Maiti Nepal educate and protect children who have been trafficked, were all reduced to rubble. Even in the chaos, Anuradha and her team filled rice sacks with food, tarps for shelter, blankets, buckets to catch rainwater and clothing for the families who lost everything. Her son and his friends organized delivery of these relief supplies by truck, often needing to clear the road of landslides along the way.

Meanwhile Direct Relief International packed full two FedEx airplanes (big ones) with essential medical supplies, water filtration systems and 4 by 4 meter canvas tents that would become the replacement structures for the ruined healthcare facilities in the hardest-hit mountain districts of Dhading and Sinduhpalchowk. The One Heart World-Wide Nepalese team had worked with the Nepali customs officials, so that there would be no problems receiving relief supplies and no customs fees.  At the airport we had the thrill of seeing humanitarian aid flow seamlessly, as palates labeled for One Heart and Maiti Nepal, hospitals and many organizations on the ground would receive and distribute these lifesaving supplies.

Anuradha shelters a pregnant mother, who lost her home and entire family in the earthquake
Anuradha shelters a pregnant mother, who lost her home and entire family in the earthquake

When I found Anuradha she was thinner than I had ever known her to be. When we hugged, she was trembling. I was with Thomas and Joe of Direct Relief, delivering palates of medicines and supplies to Maiti Nepal.  I learned that an additional 225 children, orphaned by the disaster were arriving day and night. Only Anuradha was ready, willing and able to accept responsibility for these children.  The Maiti Nepal school and dormitory buildings were standing, and had been declared safe. This is a miracle, and a tribute to the wisdom of this small woman, who decided to build strong, well- engineered buildings and bear the extra cost for safety. Her wisdom saved her children’s lives. These children, of all ages, rescued from human trafficking, whom no one cherished, are loved and well-fed at Maiti Nepal. In addition, they are being educated and they are safe.

Anuradha took me into the clinic that she pulled together to handle the injured and the homeless.  There I found two injured mothers, one with a broken arm, another with a cast on her leg, nursing their babies. For both women, Maiti Nepal was the only thing standing between them and being trafficked. When a woman loses her entire family, home, and her husband, the only way to support the surviving baby is often prostitution.  Anuradha makes sure these women have medical care, healthy food, shelter and a future. I met HIV positive women and children, living well at Maiti Nepal, being educated, and getting the anti-retro viral medication they need, to live normal lives. I held abandoned babies in my arms, all of them able to smile and trust humanity, because they were safe. The Maiti Nepal staff is amazing. The food being prepared was nutritious and smelled delicious.

Just as the people of Nepal felt they had survived the disaster, and were no longer in the rescue stage, but could really consider rebuilding… on May 12th 2015, a second 7.3 earthquake struck.

I cannot measure my own trauma against the trauma of the survivors of the first bigger quake. Families fortunate enough to have houses that were safe to move back into after the first earthquake, were again forced out in the open, living under tarps, tents and plastic bags, in the dividers between roadways.  The aftershocks were strong, and so many shook us day and night. It was impossible to find a tranquil moment of inner peace. I, like all the mothers of Nepal, became hyper-vigilant, wondering with each shudder of the earth, was everyone safe? Where were the children? When it struck, Dr. Sarah Averbach and I were in the kitchen of the One Heart World-Wide office in Kathmandu. Within moments we realized that this was not a small aftershock, but a very strong earthquake, the sound of buildings cracking became ear-shattering as we ran out of the building. A 2 meter high brick wall was undulating as we ran along the corridor; when it fell away from us, instead of onto us, well, we felt protected by a miracle.

We sat outdoors with the One Heart team as each of them tried to contact family via hand phones. It was surprising to find the internet was working, and I was able to send text messages to my family in Indonesia, the Philippines and the USA, letting them know we were safe for the moment. The news was spreading. Nepal was again in crisis.  Half of the One Heart team, including Arlene, Surya, Evan, were with the Direct Relief team in the mountains, erecting tents to serve as Childbirth Clinics, in Naubise, Dhading. My daughter sent me a text from the USA, saying the epicenter was in those mountains. We were stunned to silence by fear that we may have lost our people up there.

The air was as if zipped open with fear. Sarah, Bishwo and I walked to the teaching hospital to see if they needed help.  The patients had been moved to parking and lawn areas, it was like witnessing a sea of compassion and chaos. The doctors, midwives and nurses had not abandoned patients, but were there, doing their duty, even while worried about the safety of their own families.  In the labor & delivery ward, a mother was bleeding from a placental abruption. The baby’s heartbeat was undetectable.  I noticed the support beam holding up the wall was crumbling. A generator was fired up, and the mother was taken to surgery, she would likely survive, but her baby would not.

Outside, there was a man holding an umbrella over his wife and new baby, to protect them from the searing midday sun. On the walkways in the corridors, on the steps in the entryways, and mostly in the open areas, everywhere one looked, patients were suffering.  A premature baby was gasping his last breaths, held in mother’s arms, an oxygen tank beside them, on the ground.  Other mothers and babies appeared healthy, but their eyes were searching to see if husbands and children would come, their hearts wondering if their families had survived. There were people in casts, with pins protruding from their arms and legs. The hospital staff was busy stringing up tarps above the patients, all of us praying that it would not rain when night fell.

Later, as we returned to the One Heart office, we came upon a family. The mother was limping, with two small, injured children in tow. The children were small, perhaps four and six years old, their bruised mouths and jaws had dried blood on them. The father was carrying a six-month-old baby.  Their wide dark eyes stopped me. I asked, “Are you ok?”

“No,” uttered the woman and she bent her head, “My children are hurt, we have nowhere to go.” Sarah, Bishwo and I took them with us. There were two tents erected in the One Heart garden, they could occupy one. When we arrived, the team had organized some food. Together we fed the family, and checked their minor, but painful injuries. We later learned that they were refugees from the conflict in Pakistan. They had been living temporarily in the UNHCR compound nearby, when the earthquake caused their room to fall on them. They had no belongings, no money, no country, and because they were strangers in a land already stressed to the limit, they could see no future.

Finally Suyra, Arlene and the One Heart team arrived safe from the mountains. They were in trauma, but they had managed to fully erect the tents for the Skilled Birth Attendants (SBAs) to resume receiving babies in Naubise, Dhading. This utterly destroyed health center had a huge catchment area.  That very first night, SBA Shanti would help a mother in labor and a baby girl was born in the tent.  The next day, Sarah and I moved to the tents in Naubise and began doing trainings.

When we arrived, we were honored with a small, lovely Nepalese ceremony of welcome. We could feel the relief of the healthcare team, someone had come to help out, to live and work beside them.

Looking after the Mothers and Babies in shattered Nepal
Looking after the Mothers and Babies in shattered Nepal

We began immediately to make the Birthing Tent feel comfortable and private, so the mothers could be safe, protected and honored in their time of labor, delivery and postpartum.  Sarah demonstrated her skill as a gifted teacher, helping the SBAs understand and use the portable ultrasound machine. Mothers came from such a huge catchment area, some walking many hours to arrive in labor. For this reason, and the fact that there was no ambulance on stand-by, and transport to Kathmandu hospitals (which were in a terrible state) would mean a delay of care for hours at best, we wished to use ultrasound to screen mothers for risks, so they would not perish far from help. The SBAs, nurses supported in their training by One Health World-Wide, were quick to learn.

The out-patients, seen mostly by paramedics, flooded the ruined health center from morning to late afternoon. People injured by the first and by the second earthquakes, were carried in by family. One stone building, where the TB Dots program had once been conducted, was completely a pile of rubble, dangerous to approach. We wondered how the tuberculosis patients would continue to be monitored. The two-story health building was actually swaying, ready to fall down at any moment. There was a giant crack all across the foundation, the concrete stairs had detached from the building, yet, there were still healthcare workers meeting in one room in the bottom story! The kitchen was utterly destroyed. If staff or patients grew hungry they could buy a lunch at a small hotel down the hill, a steep 15-minute walk away. The food bars that Sarah and I brought with us were soon gone, as hungry children and pregnant women were abundant. Once or twice a day, families who still had kitchens would offer us dhal and rice. We were told that the walk to be fed was 7 or 10 minutes, however, after 20 or 30 minutes of walking on goat trails, we would arrive to be fed wonderful delicious simple Nepalese food. The people were always happy to share what little they had.

UNICEF was conducting a 3-day nutrition education program, which given the setting, all in ruins, and the fact that the micro-nutrients had not yet even arrived in the country, we wondered why… I was scoffed at when I suggested UNICEF help us find a team to take down the dangerous ruined health center buildings. Because we were on a steep mountainside, there was only space for two 4 by 4 meter tents. If only we could make more space, One Heart was ready to erect more much-needed tents, to accommodate the overflow of patients.

There was a well, but the last earthquake had lowered the water table, plus the electricity to the pump only functioned a few hours per day at best.  For nights and for births we were blessed to have the We Care Solar suitcase.  This meant there was no water for bathing, and that during the two or less hours of water availability per day, we all rushed to fill buckets. The bathroom was in the one stone building that had survived both earthquakes. It was frightening to go inside, for one always wondered if this building would hold up to the many strong aftershocks.

And then the births began…

Mother Gita, so happy to have a tent to give birth in... she hemorrhaged, and was saved
Mother Gita, so happy to have a tent to give birth in... she hemorrhaged, and was saved

Amrita was in strong labor with her first baby.  She was hard to calm down, as each contraction seemed to reignite her post-traumatic stress disorder.  Surely everyone was suffering from PTSD. For some women, facing labor and the birth of a new baby represented hope. For others, it was just too much and they spiraled into deeper despair. This was the case with Amrita, who lost much of her family in the first earthquake and shook in terror with each aftershock. She fought each contraction. She refused to eat or drink.  Progress was slow, the baby was not moving down. All day and through the night we tried to support her labor. Massaging her back was not a comfort. In the daytime the tent was hot and she did not wish to go outside. At night, the mountain air was cold, so the tent and the blankets we provided were a comfort. Before dawn another 1st time mother, Gita, arrived.  By mid morning Amrita was 7 to 8 centimeters dilated, the baby was nice and low, in perfect position, but the additional pain and increased frequency of contractions made her scream for a cesarean.  Amrita’s blood pressure had been climbing all night, and was now 150/100. Her husband, deeply saddened, went to find transport. Though we knew Amrita would find chaos, instead of the help she imagined, when she reached Kathmandu, it was her human right to go, and since her BP was heightened, we midwives felt this was the right decision. We gave her baby clothing, bottled water and food bars, and helped her on her way. We later learned that no sooner had she reached the hospital, she wished to be back at the tent in Naubise. She did have a normal delivery, a little girl, born soon after her arrival at the remains of Paten hospital.

Gita, age 20, and having her first baby, felt so happy to be at the birth tent. Since the 2nd earthquake destroyed her house, she found it impossible to relax when inside a building. We soon realized that we had to make a private outdoor place for the mothers in labor and postpartum to urinate, for they were afraid to go indoors to do their business.  They would hold their pee, rather than risk going to our indoor bathroom should another earthquake occur.

Gita’s labor was also long. She confided that she felt badly to be bringing a baby into a world that was so damaged.  Her husband’s family home and her parents’ ancestral home were both destroyed.  They had a tarp for shelter.  After two nights and a long day, Gita had her baby. We midwives sang a Gayarti mantra as the baby girl emerged. The grandmother cried tears of joy. Gita’s postpartum smile was radiant, even though Gita hemorrhaged and required some suturing.

Just two hours after Gita’s baby was born, Sapana arrived in strong labor with her second baby.  Sabina, our paramedic and best midwifery assistant plus interpreter, told us that Sapana means “Dream.” Sapana’s husband worked “out country” as a construction worker in Dubai.  When the earthquake struck and the family home was destroyed, his father was killed.  However, he was not given permission to go home to help cremate his father nor receive his new baby into the world.  As labor became stronger, Sapana and her mother-in-love, hugged and cried quietly together.  Less than three hours after Sapana arrived, her baby girl was born. As she emerged gently, Sapana reached for her and said… “Are you mine?”

By evening, Maya arrived. Having walked for three hours, she was in good labor, happy to eat the food and enjoy the water we gave her. I cannot imagine walking, in labor, in the heat, up and down goat trails, with not even a little water to drink. Maya labored through the night and in the late morning, she had a baby girl.

That same evening Laksmi, age 22, arrived in active labor.  We had helped Gita and Sapana to go home, though they had only plastic tarps for shelter since the earthquakes.

Maya was resting in the birth tent with her mother-in-love, when Laksmi arrived. It was encouraging for a first-time mother in labor, to speak to a first-time mother who just gave birth hours earlier.  Maya and Laksmi became friends. We midwives took turns doing breastfeeding support for Maya, while rubbing Laksmi’s back.

By the next morning Laksmi birthed her 3.5 kg baby girl.  For all of our Hindu families, we sing the Gayatri mantra while the baby is crowing. This helps everyone remember that each baby is a miracle. For all of our babies, we delayed the clamping and cutting of the umbilical cord.

As the day wore on, we prepared Maya for her return home. We soon discovered that Laksmi lived in the same direction, so we could bring both of them home together.  Once again, we learned that “home” was only a tarp for both of these families.  As we looked after the postpartum mothers, UNICEF was teaching the health workers and skilled birth attendants a nutrition seminar. The class was outdoors, under a canopy of trees housing very naughty monkeys, for the buildings had been destroyed.

Dewi says: My twins lost their home, even before birth. from the high mountain region of ruined Nepal
Dewi says: My twins lost their home, even before birth. from the high mountain region of ruined Nepal

Suddenly we hear an ambulance siren, loud and insistent.  SBA Shanti motioned me to come with her to greet the ambulance. When the door opened, we saw a pregnant woman with a belly so large, we looked at one another and said: “Twins!”

Normally, the SBAs are supposed to send multiple pregnancies on to Kathmandu, to be handled at one of the big hospitals. At the moment the hospitals were in different states of ruin, operations were being conducted in tents in parking lots, and waiting time was long and in the hot sun. This mother could not wait; the 1.5 to 2 hour drive to push on to Kathmandu would be too long, Dewi’s babies were coming fast.

We learned that Dewi was but 18 years old.  She had had one other child, who died a few months earlier from pneumonia.  She had come 3.5 hours by ambulance from the Bhumistan health center. Earlier she had walked down the mountain on a steep trail just to get to the Bhumistan health center, which was also destroyed in the earthquake.

Within 27 minutes of Dewi’s arrival, baby #1 a robust boy, was born.  We listened to baby #2 and the heart rate was good.  But within another minute, something felt wrong, paramedic Sabita said, “Let’s listen again.”  Baby #2’s heart rate had fallen to 40! We told Dewi she must quickly push, to help her baby come as soon as possible.  SBA Shanti did nipple stimulation. SBA Radika was busy trying to get an IV into Dewi, who was resisting. The second bag of amniotic fluid was bulging, and with wonderful strength, Dewi pushed her next baby into the world.  The baby was born in the caul, and both placentas came out almost simultaneously. This explains why the baby girl’s heart rate had dropped so dramatically and suddenly, the placentas had both released.  This baby was much smaller, and needed some stimulation to begin breathing. Baby #2 was only 1.700kg. Baby #1 was 2.900 kg, quite a difference. However, the smaller baby girl went right away to the breast and began sucking, while her bigger brother required some coaxing.

Dewi did hemorrhage and required IV fluids, anti-hemorrhagic medicines and expert care from our entire team. She quickly showed signs of shock, and no wonder as she was hungry and dehydrated. Her husband and mother-in-love were also malnourished, and they explained that they had been living in the open.

Dewi recovered quickly and enjoyed the shelter of our birth tent.  Before they went back to Bhumistan, we gave them a tarp, a solar lantern, food bars, a water filter, bed sheets, baby clothing and blankets.

For each MotherBaby, the Nepali government gives a “Warm Baby Packet” containing baby clothing, blankets and a warm flannel gown, made for breastfeeding for the mother. The government also gives a cash incentive of 1,000 rupee, about 10 US dollars, for coming to a health center.  In Nepal, this is a significant amount of money. It helps bring high-risk mothers from far-flung mountain regions to health centers where they can birth more safely, with the SBAs trained by One Heart World-Wide.

Thank heaven for the birth tent, and for the Skilled Birth Attendants. Both Gita and Dewi may not have survived birth without expert care.  Dewi’s second baby would not have survived.  The One Heart World-Wide team had 7 babies in the tent within the first few days after erecting it. Lives were saved. In the aftermath of such trauma and destruction in Nepal, we felt gratitude for the support that makes it possible for this and many other tent birth centers in the mountains, to bring healing and relief from the sorrow of disaster.