SNM hospital – Leh Sonam Nobroo Memorial Hospital (Kashmir India). Aug 2016
On my travels in Kashmir, I was keen to visit the local hospital to connect with birthing women and the local birth culture. I wondered: How does birthing happen here? What do women need? How could I be of service? So I hired a motorbike and made my way to Leh SNM Hospital.
Leh sits in the Himalayas, at 3500m altitude. Women travel from the surrounding region of Ladakh to birth here. The land is dry, rocky, and a stunningly beautiful high mountainous area. The land and lifestyle, being so different from Melbourne, I wondered how different the birth culture would be?
Arriving at the hospital, I set intentions for myself and walked in. The small labour ward was clean, organised and busy. A lovely nurse named Deshan spoke enough English to communicate my intentions. Smiles, simple English words and many a julley (hello/goodbye/happy greeting) were heartily expressed. Soon sisterly love flowed as I shared my desire to improve woman-centred maternity care.
Deshan introduced me to Sonam Dolma Sopari, the nurse supervisor who organised for me to volunteer in the labour ward the next day.
Language challenges prevented me from capturing all that these beautiful midwives and nurses said, but I kept notes and share with you what I can. I asked Sopari what words could help labouring women.
These are some phrases (spelt phonetically).
Tic dook – you’re all right.
Ole ole ole – yes yes
Kulier kulier pull – slowly push down
Koolee koolee – relax
Jigs man jigs – don’t be afraid
Nier yato jua – can I help
Ika tig raga le – is it ok here?
Neerang maa gyala inok le – You are very good
Tug dje che – thank you
The birthing ward experience
The following morning, Sopari showed me around the hospital wards. The beds were basic and families brought in extra blankets and meals to help out. Women in the caesarean post-natal recovery ward had their babies in bed with them. Midwives were assisting one woman to settle into her bed shortly after giving birth. Her grimace of pain as she processed what had just happened moved me deeply.
On this day my main intention was to observe ,and if there was opportunity, to help a woman as an Asha (Doula) then I would eagerly respond. First, I waited. I felt sure that my supporting presence, smile, and belief in the mother’s capacity to birth was of value.
At 10:30am I was shown to the labour ward. At first I felt unsure of how to integrate myself. How would I know if someone wanted my support? So I took it slowly, just observing the space. There was a labour and post-natal ward, and a delivery ward. Women arriving in the labour ward were assigned one of the ten beds, where they would labour until their delivery time, and later recuperate with their newborn. Another ward specialised in caesarean recovery. The delivery ward had three beds with curtains dividing them from each other.
The labour ward
In the labour ward, every arriving mother was given a drip. Every woman I saw laboured on her left side, rocking slightly, grimacing and groaning only a little. A public labour ward gave little opportunity for active birthing. The mothers wore a lot of clothing plus a thick blanket for privacy and warmth.
I only saw foetal monitoring once during a vaginal exam and another time in the labour ward during a delivery with a stethoscope. I didn’t notice drugs for pain relief in the labour ward and later I confirmed they are used to manage caesarean birth and suturing, not during labour.
Although friendly banter emanated through the labour ward between midwives, colleagues, mothers and helpers, when midwives spoke directly to labouring women, the tone was one of authority. Compliance from the mothers seemed assumed. I wondered, is compassion just expressed differently here? But I sensed women just didn’t have much choice.
Most labouring women had a female beside them, usually a mother, sister or friend. Everyone was quiet. Sadly an Asha was not here to speak with.
As I observed I could see women gripping their backs to relieve their pain. I went to one woman’s side and gently pressed my hands into her back. She relaxed and I smiled to engage with her. I gently said “OK?” She nodded, breathed, grimaced and quietly moaned. I continued to massage and stay quietly present. I used some of the Ladakh words to encourage, hopeful it made sense and was helpful.
At one point the matron said to me “Where is your apron”? I said “They can’t find an apron for me”. She seemed bothered, but then went away and that was that.
A young woman named Aamoor was having her first baby. She knew some English and very much liked my support. As I stroked her body she brought rhythm to her breath and became more calm. She said thank you more than I wished she would and I directed her attention to her baby.
Later on I went to another woman called Nubra. I was able to witness the birth of her second child. As I massaged Nubra’s back, a midwife came over and directed her to the labour room. I couldn’t tell from the time I had been with her at what stage of labour she was in, but the midwives were aware. They instructed her to get on the table and lie down.
With a pained face, her legs were strapped into stirrups, her eyes checked, her heart rate taken, her baby’s heart rate was checked with a stethoscope and she was put on a drip. The conversation with her seemed very functional. Again, the midwives’ authoritative tone lacked a tenderness that I felt would have been welcome under the circumstances. Despite what else was going on, this mother was in second stage and her baby was soon to be born.
Nubra stayed on her back while she grimaced and pushed with her urges. I shared that women in Australia chose their own birth position when supported by their carer. I demonstrated with my hands the different space the pelvis and baby took when lying on the back vs all fours. Deshan said they always do it this way and continued on. Before too long one midwife applied strong pressure on her fundus, another applied counter pressure on her perineum, whilst another midwife pulled the baby out. It seemed intense, forceful and painful and I wondered “Why the rush?”.
This mother had birthed before and it all seemed normal. The baby boy cried robustly as it wakened to the cool room and everyone was happy. The nurses said aloud that this was a good sized baby. She cut the cord straight away and whisked the baby straight over to the resus table for assessment. I congratulated the mother and pointed to where they had taken her baby. She had lost sight of her little one as she reeled back on the table with relief. Her baby weighed 3.3kg.
Soon Syntocinon was given to induce the placenta without question. The midwives cleaned, weighed, dressed and wrapped the baby before being briefly showing him to mum and taking him back to the labour room to await her return. Nubra only had time to smile and give a kiss on the forehead. But she now knew the sex of her baby. An ink mark made between his eyes indicated this. They met properly once Nubra was sutured, dressed and had waddled back to her bed. I felt sad to see this. It wouldn’t take much to share new ideas of how woman/baby-centred care could be possible.
Back in the delivery room Nubra was checked for tears. She was rolled roughly onto her side and jabbed with a local anaesthetic in preparation for suturing. The tear was small. While suturing they did paper work and asked questions. I gave a smile that reflected my sentiment of ‘hang in there, you’ll be resting with your baby soon.’ I held her hand and stroked her head. Nubra smiled back and relaxed her eyes. Eventually, she got off the table, put on some leggings and walked back to her baby. I helped.
Her female companion met her there and gave her a warm drink. I could see her appreciating that labour was over. After more hand-holding and eye contact I said goodbye and moved to be with Aamoor again. It was about an hour after delivery that I noticed Nubra pick up her baby for the first time and breastfeed. There was little eye gazing and no skin on skin and I wondered how Nubra was feeling in her body.
The baby was wrapped in thick blankets. When she did pick up her baby though I saw her smile at him and look down to initiate breastfeeding. She said thank you to me many times and I felt awkward about that. I didn’t need any attention on me! She did all the hard work! But I smiled back at her and was happy to have played a part in helping her feel supported. It reminded me how much simple support matters.
Aamoor was quiet like the rest of the women there. It was busy, with about six women labouring, three already given birth, and one still pregnant. Aamoor responded well to my gentle suggestions and was progressing. She too said thank you quite often and I smiled, yet redirected her focus inward to her breath and encouraged her to relax. Because she spoke reasonable English it was easier to communicate.
I needed to learn more Ladakh if I was to do better here! Her mother was with her and Aamoor liked to hold her hand. I gave a lot of massage, soothing touch and encouragement that she softened and relaxed into. Touch is an international language. I felt a lovely bond with her and her mother and recognised my Asha support was also an international language.
Aamoor’s partner came at lunch time with food. He just smiled at me when I suggested and gestured that he could sit and hold his wife’s hand. Instead he left soon after without saying goodbye to her. Aamoor noticed him but she was very internally focused and didn’t say anything. This felt so strange to me. The expectation on partners in Australia is to be the primary support person, even if they feel out of their depth, but here, they clearly did not see it their place to offer support.
Except for one young man accommodating his labouring partner, everyone else had another woman with them. Perhaps the next generation of fathers are thinking of staying by their partners’ side? Unfortunately I was unable to stay to the end of Aamoor’s labour so I gave my contact details in case she wanted to get in touch.
I left that day, feeling inspired to learn more about what practices work well for midwives and mothers and what they would want to change. Would they be interested in further midwifery training and birth preparation? Was what I witnessed normal practice for Indian midwifes and birthing women? How could I help ongoingly? I felt keenly aware that this was a clean, organised, and efficient hospital which still offered much better service than other places. Even though I saw their potential for more woman-centred care and fewer interventions, I also acknowledged there were many good practices that benefited the women’s health care.
On my departure, the staff invited me back and I punched their What’s App numbers into my mobile. That afternoon messages from Deshan popped up, eager to stay connected to me. Leh is so isolated from the rest of the world. It took me 20 hours in a minibus, extremely bumpy roads and three mountain passes at attitudes over 4700 meters to arrive. But it was worth it. Only 40 years ago the west made the first car-accessible road in, bringing with them consumerism and western ideals to ‘desire more’.
I have come home with an appreciation of the accepting nature, simple life, patience and low pressure lifestyle of the Himalayan people I feel grateful for all I have but also humbled and aware of the simple changes I can make in my life back home: to be at peace within myself, to be more present for those I am relating to, and to keep doing good work with the birthing women and our community in Australia.
I understand that the Ladakh women and midwives are interested in more medical equipment and midwifery education. If anyone would like to help me plan ongoing support for this community please get in touch with me.
Other points of interest:
The hospital is the major medical center for the Ladakh area. It provides a good range of services including surgery and NICU. The midwives work about 8hr shifts except there seems to be a longer shift through the night.
They have need for more medical equipment such as:
•Old working equipment
•Open, unused disposable equipment
•Anything throwing away that would be useful
They promote natural birth and by the chart on the wall with stats over the last three months it looks like they have about 150 births/month and about 20% caesarean section rate. Drugs for pain relief is not the norm and is not offered. I didn’t see any statistics on birth interventions. The midwives are trained to suture any tears. They clamp and cut the cord initially but then use thread to shorten the cord further. In a home birth some thread is sterilised and used to tie the cord. The doctor comes when the midwives need them but otherwise I did not see their presence in the labour ward.
I think that they said breech birth is usually a vaginally delivery. They have a fluctuating number of midwives on shift depending on the need. There was no regular ‘in house’ midwifery training on a regular basis. They seemed enthused by support for more education for their practice. Women are given about 24hrs to birth after active labour begins and they go home around 24-48 hours after delivery.
The name for a Doula in Ladakh is Asha. Asha’s help women prepare for birth and attend them in labour. They also to help out with the birth documentation. The hospital does not provide antenatal education beyond what they get at their check up. The Asha helps with this. There was also a room especially for the Asha’s so they could sleep, refresh, eat and put their things somewhere. The midwives work in welcomed collaboration with an Asha. How lovely if doulas in Australian could be incorporated better into hospital support services.
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