Nurses in policy

The presentation by the nursing students about the importance of nurses with higher education and nurses in policy was incredibly interesting. If anybody knows about what goes on in hospitals and health care settings, and how patients are faring with the current health care system, it is nurses.

I read a couple of articles online, and found that there are 6 nurses in congress! I’m a little unfamiliar with politics (unfortunately), so I didn’t know this and thought it was really cool.

One Congresswoman nurse who has done influential work is Congresswoman Lois Capps.  (D-CA). On her website, she says “once a nurse, always a nurse”, and discusses how she is always using her nursing background when dealing with health care issues and policy. She is a supporter of the Affordable Care Act, and believes it is a crucial step in fixing the broken health care system in the United States. Some of her main priorities related to healthcare include heart disease, maternal, child and infant health (!!), cancer, and work-force issues. She a founding member of the Congressional Nursing Caucus, which provides a forum for congress to discuss issues affecting the nursing community. In addition, she is a strong ally of the LGBT community.

She is currently sponsoring legislation concerned with domestic violence survivors, health education in schools, and medicare, among tons of other issues. Check out her website to learn more!

Lois Capps:

Congressional Nursing Caucus:

Service Learning

I really enjoyed the final article we are reading for our last class, “Introducing Nursing Students to Childbearing Practices in Rural Guatemala”. I especially think that reading a piece like this is important for all of us, as many of us are going into nursing and other health care professions. The author outlined the ways to maximize the benefits for both students and the communities involved in service learning, and how much thought and preparation must go into a service learning trip, even a short one. The author discussed the importance of cultural competency and humility, student qualifications, the scope of work, and how to avoid making mistakes that may seem insensitive or ignorant. I would like to discuss a trip I’ve went on last summer and how it relates to each aspect of this reading.

I went to Ghana for 10 days on the Global Medical Brigades trip through Emory. Out of the 10 days, 2 were spent traveling, 1 was spent preparing medicine, 2 were spent hanging out with the community, 1 was spent sight-seeing, and only 4 were spent in the free medical clinic we set up in the rural village of Ekumfi Engo. I would have preferred a longer program, but I was familiar with this trip from friends who had gone the year before. Also, I knew everybody that was going. I am happy that I went, because I have always wanted to travel to Africa and work in a medical setting. But overall, I cannot say I was completely satisfied with the experience. Global Medical Brigades could be improved if some of the aspects the author talks about were implanted in the program. Even though the trip wasn’t specific to maternal health, it is still relevant to what is discussed in this article.

The author mentions the importance of pre-trip meetings, where they went over procedures, aspects of the culture, and expectations of the students. We had a couple of meetings before the trip, but I felt incredibly unprepared. We were only taught how to triage ONCE before the trip. I went into our first clinic day barely knowing how to use a blood pressure cuff. The people lined up outside our clinic were not going to be my guinea pigs, so I made a more experienced girl do it when we were both assigned to a triage station. I felt way too uncomfortable to learn how to take blood pressure on these people who were expecting experienced medical staff. We should have had many more training sessions. I didn’t have access to a pressure cuff to practice with on my own.

The scope of our trip was similar to what the author discussed – mainly based on observation, and helping only when we were qualified to do so (like taking temperature, measuring height and weight, and sorting medicine at the pharmacy). However, none of us knew the local language (many Ghanians who live in the big cities know English, but the people who live in small rural villages do not). The author talks about how Spanish-speakers were a high priority, and I can understand why – it is hard to be helpful when you can’t understand the people you are trying to help. We had translators at each triage station, and the Ghanian doctors, dentist, pharmacist and OBGYN all knew English and could translate for us. This aspect of the trip made me a little bit embarrassed. What were we really doing there? The entire clinic could have been run by the translators and Ghanian medical staff. So many times throughout the clinic days, I thought about how pointless we all were, in our scrubs looking useful but not actually being useful. I had to keep reminding myself that we were there to shadow Ghanian medical staff (which was an awesome experience – they were incredibly knowledgeable and also taught us about the Ghanian healthcare system) and provide free medicine to this rural community, whose nearest health clinic was an incredibly far walk away (most didn’t have cars, and even if they did, the road was barely drivable). Even though we were only there for 4 days, free medicine one time is better than nothing at all.

One thing I’m glad our trip did right was the gift giving aspect. We all provided donations before leaving, but did not distribute them ourselves. This way, there would be no inequality in gift receiving, and we wouldn’t appear as “white-savior”-esq.

Reading this article, I realize that the trip I went on probably wasn’t the most successful service learning trip. I feel that the community did not benefit as much from the trip as the students did. We got to explore Ghana and learn about a culture completely different than our own, which was a valuable experience. But overall, the community would have benefited much, much more from students who were more experienced medically (such as nursing students!) or students who actually knew their language.

IPV Intervention Study

One of the most saddening topics we discussed in class was obstetric violence. The Han article we read was about intimate partner violence during pregnancy (IVP-P) in Latin America. While re-reading it in preparation for the exam last week, I thought about how fixing IPV-P seems almost like a lost cause. I wondered how screening for it could even be helpful, when many of the women included in the study were from low-income, underprivileged areas and probably did not have access to adequate counseling or protective services, and lacked the resources to leave their partner. In the paper, Han cited an “intervention study”, specific to LAC. I decided to read it to see if it included anything to be optimistic about.

The article is called “Intimate Partner Violence During Pregnancy: A Pilot Intervention Program in Lima, Peru”, by Cripe et al. In their study, they looked at the effectiveness of standard care and empowerment care for pregnant women who were abused. Standard care included receiving a card listing resources and other information to assist them in help seeking, and empowerment care included both a card and a therapy session (those in the standard care group received a therapy session after the post-interview). The researchers looked for differences in safety behaviors, health-related quality of life, and use of community resources by these women by comparing pre and post interviews (before and after birth). They conducted the study at the Instituto Nacional Materno Perinatal in Lima, Peru, which is operated by the Peruvian government and provides services to low-income and high risk women.

Ultimately, their results were not statistically significant, but they found a general trend showing an increase of safety behaviors, health-related quality of life ratings, and use of community resources in women in the empowerment group. While there were a couple of limitations and obstacles in the study, the overarching point is valuable; simply screening for IVP-P is important and should be a regular procedure in prenatal appointments. Even if the consulting physician, researcher, or other health personnel can’t force a woman to seek help or leave her partner immediately, planting the seed in her mind is important and may encourage her to begin thinking about her situation and what she can do to increase her safety and well-being. The authors stress that IPV is a huge problem in Peru, and abolishing it all together is a daunting task. However, it is important that steps be taken to fix this problem. In addition to evaluating existing legal policies and resources for abused women, small interventions in other spheres (in this case, the medical sphere) can help as well. To quote the authors:

“Based on our experiences working with abused women in Lima, Peru, we expect that a combination of intervention methods that include screening, counseling, and advocacy by both health care professionals and community outreach workers may empower abused women to seek help and, subsequently, reduce IPV in Peru.”

I read this hoping to see results for one intervention that worked for everyone and could be realistically employed. I knew that was an unrealistic hope, but I felt these studies mustn’t be useful unless they saw substantial results. I was wrong though – these things must start small.  The benefit of simply asking a woman about her situation, looking for suspicious markers that may indicate IPV, an delving deeper into her personal life and hardships she might be going through can really make a difference.

Citation: Cripe, Swee May, et al. “Intimate Partner Violence During Pregnancy: A Pilot Intervention Program in Lima, Peru. Journal of Interpersonal Violence, 2010 25: 2054. February 9 2010.

Maternal Health as a Priority: CMQCC

The readings and discussions from our past couple of classes have focused on maternal mortality as a political priority. Reading the Shiffman article, I thought back to a presentation given at the nursing school on October 6th by Dr. Christine Morton, a research sociologist who is part of the California Maternal Quality Care Collaborative (CMQCC). CMQCC was founded in 2006, when a study at UCLA revealed that the maternal mortality rate had increased almost 50% since 2001. The California Department of Public Health, Maternal, Child, and Adolescent Health Program and the California Perinatal Quality Care Collaborative teamed up to create CMQCC, to find reasons for this increase and how to prevent future maternal deaths. They analyzed data from many hospitals, formed a quality improvement panel, communicated using newsletters, meetings, and conferences, and formed partnerships with the government, CDC, and other funders, whom they refer to as “champions”. So far, they’ve recorded vast amounts of data for births in California, brought in many stakeholders (such as the American College of Nurse Midwives, Kaiser Health System, and California Office of Statewide Health Planning and Development), developed the California Pregnancy-Reated Morality Review Task-force, instituted quality improvement programs in hospitals, and reviewed hospitals.

This reminded me of our discussions because Dr. Morton discussed the importance of the 5C framework in their beginning stages. The 5C framework includes common purpose, cooperative structure, critical mass, collective intelligence, and community building. Their goal was to involve diverse types of organizations and individuals to bring different ideas to the table and collectively solve the problem. Various branches o CMQCC would have small group meetings with key maternity leaders throughout the state where they shared new information and pitched their ideas to obtain funding and support. This approach helped them gain the support and funding from many powerful “actors” in California. Today, they are a very successful organization with many branches working to reduce maternal mortality in California one step at a time.

Here is a link to their website for more information:

Community Mobilization

“Dr. Jim Kim, anthropologist, clinician, and former WHO advisor has commented that anthropologists have a long history of providing ‘moral witness to human suffering’. What is needed now, he argued, is ‘moral witness to human possibility'”.

The readings for this week on community mobilization for safe birth provide two different examples of how human possibility and morality can improve public health – in this case, maternal and child health.

The community-based participatory research study in the Dominican Republic found that both men and women were dissatisfied with the maternity services in the hospitals. While the Dominican Republic is a relatively developed nation, there are substantial socioeconomic inequalities. Although 97% of births occur in health facilities, an optimistic number compared to some other areas of the world, the MMR is high, at 150-160/100,000 live births. A main issue identified by the communities involved in the study is a delay in accessing care. The researchers aimed to determine why women delayed going to the hospital amidst complications.

The findings were unfortunate. The community recognized pregnancy as a vulnerable and fragile time for a woman. However, they did not receive adequate, compassionate care at health facilities. “No me hace caso” – “they pay no attention to me” – became a recurring theme throughout the study. Wait times for appointments and even surgeries were absurdly long, even though the commute was manageable. Doctors were not comforting women and their families when they were anxious. The women felt that nobody was there for them or taking care of them, and procedures and outcomes were not explained properly.

This project shows that when a team of researchers, professionals, community members, and hospital staff come together, a common goal can be reached. Since the maternity service providers have now been made aware of the dissatisfaction of the community, steps can be taken to improve the quality of care. It is unsettling that while the backbone of a potentially successful maternal health system exists, that something like staff attitudes have an impact on MMR. Hopefully, the future of maternal health services is bright in those communities.

In Humla, Nepal, a project was done by the PHASE Nepal foundation to change a harmful cultural practice – keeping a new mother and her baby in a cowshed after delivery for one month. This is very dangerous, given the high possibility of infection, in addition to uncomfortable living conditions. However, the researchers knew that changing engrained beliefs is difficult, and did not want to appear as judgmental outsiders. They came up with the idea to provide useful incentives – new clothes for the mother and baby – in exchange for a safer area for the mother and newborn to live postpartum. Another part of the initiative was increasing skilled birth attendance. The project had a successful outcome, with 50% of births being attended by skilled birth attendants and almost 100% of families accepting the clothing for safer postpartum living spaces.

This project demonstrates that changing a cultural belief is possible, when the community understands what the problems are and how to adhere to their beliefs in safer ways (i.e. separate room of the house dedicated to mother and baby, room restrictions, or a small guest house).

With the risk of sounding cultural insensitive, the underlying problems in both articles remind of me Sue Ellen Miller’s Ted Talk, when she said that women are “discriminated to death”. In both of these articles, we see that change is often needed in areas besides access to medicine and equipment. These initiatives both dealt with cultural issues, which with the right plan, can be altered to benefit not just mothers and infants, but the entire community.