Bill & Melinda Gates Foundation

A New Way to Combat Maternal Mortality in Guatemala's "Corridor of Death"

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January 09, 2013

A pregnant Kekchi woman arrives, clearly in pain, at a primary health center in Alta Verapaz, Guatemala.  Her trusted midwife accompanied her on the three-hour ride from their village. Julio, a male Nurse’s Aide, receives the two women. He interviews the women in their native language, examines the patient, and jots down some notes for future reference. He writes on a single piece of paper: “Patient at term, early labor, blood pressure 110/70 (normal); fever (102 F).” The midwife adds that "her waters broke 15 hours ago."

He asks for assistance from another nurse aide colleague, Maria, and says to her, “We have a case of preeclampsia at term with ruptured membranes! Her blood pressure is very high at 170/110.” Maria glances at the paper with Julio’s notes. The patient’s normal blood pressure and high temperature are clearly written there. She says nothing.

Josefina, the new professional nurse on call joins them. She receives the same information and reads Julio’s notes. Julio tells her, “Her blood pressure is very high. She needs medication right now to bring it down. Set up an intravenous and give her magnesium sulfate, stat."

Despite realizing that something is not quite right and an error is being made, both Maria and Josefina keep quiet. After all, Julio is seen as the lead nurse and the most experienced practitioner in the clinic.

After a brief hesitation, Josefina helps Maria draw up the medication and administers it to the patient, who in minutes begins to complain of feeling dizzy and light-headed.

Cut!

The case above has all the elements of the daily tragedy of maternal mortality in Guatemala’s “corridor of death,” a geographical area where maternal mortality triples the national average. This tragedy and similar “corridors” still abound in many developing countries.

In this case, however, the Kekchi woman was a patient actor. The Nurse’s Aides are front-line workers attending a simulation-based training in Emergency Obstetrics called PRONTO (a Spanish acronym for “Obstetric and Neonatal Training Program”).

PRONTO is a simulation-based training program specifically designed for poor regions that uses low-tech simulation scenarios, like the one described above, to teach health care teams how to respond optimally to obstetric and neonatal emergencies.

Different types of scarcity --resources, knowledge, and skills for instance-- are well-known obstacles to saving mothers’ and children’s lives. A less understood, but key challenge on the path to impact is that frontline workers oftentimes don’t get to practice life-threatening emergencies in safe environments. Normally they may get a few hours of classroom-based training, and the expectation that being aware of clinical guidelines will help them acquire life-saving, practical, knowledge.

Research has shown that when an emergency actually happens, front line workers oftentimes have a hard time coordinating their actions and communicating among themselves and with their clients. Simulations in PRONTO have proven to be effective at improving teamwork, optimizing the use of scant resources, and leading to timely, correct responses to life-threatening emergencies.   

In PRONTO’s experience, learning from simulations always requires some form of after-action reflection. In the case described above, facilitators helped the team reflect upon the salient lessons they had learned from the experience.

As the debrief unfolded, the entire clinic staff, including the simulation participants, agreed that the patient did not have high blood pressure at all but rather an infection that, if not treated promptly, was life-threatening for both mother and baby.

They discussed and shared their knowledge of the consequences of such infections, oftentimes leading to severe and irreversible brain damage for the newborn. Finally, the participants acknowledged that they knew Julio was making an error and it was also an error on their part to nothave intervened.

The team spoke of the importance of leadership, shared knowledge, mutual support and a work environment in which all team members have a voice and responsibility to speak up without fear of contradicting their “superior.”

This simulation took 7 minutes to unfold.  The 40 minute debrief covered material that is delivered over 1-2 days of learning sessions and skills stations.  Simulation leads to valuable learning experiences that can lead to unforgettable practice.

In this clinic in Alta Verapaz, the next Kekchi women who arrive with either signs of an infection or elevated blood pressure, will, no doubt, receive the urgent care they require.

 
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