Trabajo, Trabajo, Trabajo!

On Monday night we went to a talk given by the two residents with whom we are working on our projects.  We went to essentially a large gazebo that serves as a community center.  A table “of honor” was set up framed by two TVs playing advertisements for a local bottled water company.  The gregarious MC for the evening was the husband of Carmen, the nurse who invited us to her house on Monday.  Dra. Rivera gave a talk on the dengue fever and Dra. Duarte gave one on cholera.  While this part of the evening was everything I expected, we left just as the party was getting started.  There were prized to be handed out and regeton to be danced.  By the time we left, it was already 9:30, we hadn’t eaten, and we were brain-dead from the length of the day up to that point.

On Tuesday, we started this morning with a breakfast at the university CURNE.  Of course, before we left, Rosa insisted we have a bite to eat to tide us over.  This consisted of coffee, fruit, cereal and ham and cheese sandwiches.  (We have certainly not been starving).  We met with the director of the university, which is the second largest public university in the country.  He has been extremely supportive of Emory’s work in the DR.  He expressed a strong interest in extending the partnership beyond maternity issues and even beyond health sciences.  While this would be wonderful, of course, Jenny herself is interested in maternity development and simply cannot take on more than her already impressive agenda.

It was interesting spending time in his office because it was clear that he was a bigwig around those parts.  His secretary was waiting on him hand and foot, brining him specially prepared coffee in delicate espresso cups with sterling silver holders.  She served him his breakfast literally on a silver platter.  She basically did everything short of wiping his mouth after each bite.  Must be nice…

We were whisked in the University’s bus to the hospital where Sheila and Cassie frantically finished their data analysis of the pilot study performed by the nurses in the hospital over the course of a month.  What Jenny found during her research a couple years ago was that doctors attended very few births.  It was the nurses and even auxiliary nurses that attended the vast majority of births on the ward.  Without formal training in the skills involved, it is no surprise that maternal and infant mortality and complication rates were much higher than they should be.  Jenny’s initial idea was to train midwives and train trainers to implement a midwifery program in the hospital.  After an intensive training session, she got tremendous pushback from the doctors in the hospital making it clear that this approach would be neither effective nor even feasible.

This pilot took a different approach by empowering the nurses themselves to document the births that they had attended and keep statistics—something which was a pretty foreign concept in the hospital previously.  An interesting cultural difference between the US and the DR is that the Dominicans represent the world in the form of individual stories rather than generalizations.  The first challenge was getting the nurses accustomed to documenting in a uniform way rather that writing long-winded narratives of each woman for whom she cared—something with which we still greatly struggle.  Then there was confusion of what we were actually documenting.  For instance, the nurses counted first and second degree episiotomies as complications when, in reality, they’re not so.  Likewise, low birth weight was not recognized as a complication, when in reality, it is.  So the data themselves are flawed, but the practice was a tremendous advancement.

Then when it came to analyzing the data, it was a challenge to try and influence the mentality of the nurses to generalize the information in to averages, ranges and medians.  They kept wanting to elaborate on each woman they saw and tell each story filled with rich details.  While it was super interesting, this sort of information sharing isn’t quite practical.  Sheila and Cassie had the task of helping them practice compiling the data and seeing the larger picture comprised by the individual stories.

Well, together they were able to put together a slideshow with a few simple charts and graphs providing descriptive data of the study’s findings.  The nurses themselves gave the presentation to other maternity nurses, the director of the hospital and other people involved in ADAMES.  Of course we had planned a 20 minute presentation with 10-20 minutes of discussion, but by the time the meeting had actually started, the information was finally presented and Jenny finally dismissed us from the meeting, 2.5 hours had passed.  And Rosa stayed another 30 minutes discussing ideas for further improvement after.

While all of these meetings can be tedious, it is wonderful how there is so much enthusiasm, energy and interest in this idea of carrying out research and finding ways to improving things on a systemic level.

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