Sister Seema Yadav, a twenty-four-year-old, round-faced nurse three years out of school, was one of the trainers. (Nurses are called “sisters” in India, a carryover from the British usage.) Her first assignment was to follow a thirty-year-old nurse with vastly more experience than she had. Watching the nurse take a woman through labor and delivery, she saw how little of the training had been absorbed. The room had not been disinfected; blood from a previous birth remained in a bucket. When the woman came in—moaning, contractions speeding up—the nurse didn’t check her vital signs. She didn’t wash her hands. She prepared no emergency supplies. After delivery, she checked the newborn’s temperature with her hand, not a thermometer. Instead of warming the baby against the mother’s skin, she handed the newborn to the relatives. When Sister Seema pointed out the discrepancy between the teaching and the practice, the nurse was put out. She gave many reasons that steps were missed—there was no time, they were swamped with deliveries, there was seldom a thermometer at hand, the cleaners never did their job. Sister Seema—a cheerful, bubbly, fast talker—took her to the cleaner on duty and together they explained why cleaning the rooms between deliveries was so important. They went to the medical officer in charge and asked for a thermometer to be supplied. At her second and third visits, disinfection seemed more consistent. A thermometer had been found in a storage closet. But the nurse still hadn’t changed much of her own routine. By the fourth or fifth visit, their conversations had shifted. They shared cups of chai and began talking about why you must wash hands even if you wear gloves (because of holes in the gloves and the tendency to touch equipment without them on), and why checking blood pressure matters (because hypertension is a sign of eclampsia, which, when untreated, is a common cause of death among pregnant women). They learned a bit about each other, too. Both turned out to have one child—Sister Seema a four-year-old boy, the nurse an eight-year-old girl. The nurse lived in the capital, a two-hour bus ride away. She was divorced, living with her mother, and struggled with the commute. She’d been frustrated not to find a hospital posting in the city. She worked for days at a stretch, sleeping on a cot when she got a break. Sister Seema commiserated, and shared her own hopes for her family and her future. With time, it became clearer to the nurse that Sister Seema was there only to help and to learn from the experience herself. They even exchanged mobile-phone numbers and spoke between visits. When Sister Seema didn’t have the answer to a question, she made sure she got one. Soon, she said, the nurse began to change. After several visits, she was taking temperatures and blood pressures properly, washing her hands, giving the necessary medications—almost everything. Sister Seema saw it with her own eyes. She’d had to move on to another pilot site after that, however. And although the project is tracking the outcomes of mothers and newborns, it will be a while before we have enough numbers to know if a difference has been made. So I got the nurse’s phone number and, with a translator to help with the Hindi, I gave her a call. It had been four months since Sister Seema’s visit ended. I asked her whether she’d made any changes. Lots, she said. “What was the most difficult one?” I asked. “Washing hands,” she said. “I have to do it so many times!” “What was the easiest?” “Taking the vital signs properly.” Before, she said, “we did it haphazardly.” Afterward, “everything became much more systematic.” She said that she had eventually begun to see the effects. Bleeding after delivery was reduced. She recognized problems earlier. She rescued a baby who wasn’t breathing. She diagnosed eclampsia in a mother and treated it. You could hear her pride as she told her stories. Many of the changes took practice for her, she said. She had to learn, for instance, how to have all the critical supplies—blood-pressure cuff, thermometer, soap, clean gloves, baby respiratory mask, medications—lined up and ready for when she needed them; how to fit the use of them into her routine; how to convince mothers and their relatives that the best thing for a child was to be bundled against the mother’s skin. But, step by step, Sister Seema had helped her to do it. “She showed me how to get things done practically,” the nurse said. “Why did you listen to her?” I asked. “She had only a fraction of your experience.” In the beginning, she didn’t, the nurse admitted. “The first day she came, I felt the workload on my head was increasing.” From the second time, however, the nurse began feeling better about the visits. She even began looking forward to them. “Why?” I asked. All the nurse could think to say was “She was nice.” “She was nice?” “She smiled a lot.” “That was it?” “It wasn’t like talking to someone who was trying to find mistakes,” she said. “It was like talking to a friend.” That, I think, was the answer. Since then, the nurse had developed her own way of explaining why newborns needed to be warmed skin to skin. She said that she now tells families, “Inside the uterus, the baby is very warm. So when the baby comes out it should be kept very warm. The mother’s skin does this.” I hadn’t been sure if she was just telling me what I wanted to hear. But when I heard her explain how she’d put her own words to what she’d learned, I knew that the ideas had spread. “Do the families listen?” I asked. “Sometimes they don’t,” she said. “Usually, they do".
Posted on: Mon, 29 Jul 2013 08:57:50 +0000
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