Good Ideas for making childbirth safer?
Comments on the New Yorker ‘How do good ideas spread? By A. Gawand 2013
The public hospital commented on in this article in rural India shows a similar story to many rural public hospitals in other developing countries. Too little funding, too few staff and monitoring and supervision lacking makes providing health care a challenge. The basics for safe childbirth are simple and inexpensive but materials, supplies, staffing and caring may be lacking. Gawande (2013) mentions that even the youngest nurse was very experienced, having done over 1000 deliveries, but once can do many deliveries without keeping up with simple evidenced based procedures such as providing medication to prevent post-partum bleeding, drying and wrapping the baby, and [placing it on the mother’s chest for warmth when it is first born. There may be reasons why the mothers are not putting the babies skin to skin. As a midwife used to working in low resource countries and providing continuing education to nurses, intern and graduate physicians and midwives, I have seen this story play itself out many times. In a recent rural hospital visit in a Asian country, I saw that babies were not placed on the mother’s chest or dried and wrapped well…they were promptly handed to a female companion who lurked outside the door, waiting for the news of the delivery and sex of the baby. There may be a multitude of reasons for this. The mother who has probably birthed on a small delivery table cannot wait to get up, stretch, and move to a cot or bed. The delivery tables are too small for mothers to hold a baby, and they are forced to lie on their backs due to the style of many delivery table. They may not have had a companion to offer food and drink in labour, as no one is allowed to enter the room, so they want to get up, and get some food. As far as warming the baby on her chest, the mother has likely not been told the reason why skin to skin contact is good for newborns.
But the question arises, why does the nurse not educate, promote and active work for changes? Peschl & Fundneider (2008) maintain that to make changes in practice, the core idea of ‘emergent innovation’ would require that a large number of individuals (all staff in the hospital and prenatal public health personnel in the area) have the understanding and skills in the basic thinking of the change for re-framing and re-generating ideas. If few people involved understand and promote the change, it will not happen. To make changes in childbirth practices, which may have been done 1000 times over, requires ‘reflecting and letting-go of predefined patterns of perception and thinking’ (Peschl & Fundneider, 2008).
Sometimes health practitioners do not want to make evidence-based changes and use denial, resistance and passive adaptation (Hanlon et al, 2011). A sense of connectedness is missing, and an ethical sense to reduce harm, such as in this example, harm in childbirth. Whether repeating the message, asking for nurses to change practice, using support supervision to follow-up and re-enforce changes, or using incentives might work depends on the situation. The most important step may be to ask if the intention to make the change is there, explore the attitudes towards change and barriers to making the change, and continue working from there. Graham et al, (2006) in ‘Lost in Knowledge Translation’ describe a cycle and steps where checking back with participants to address additional needs or barriers is a step as well as sustaining the use of knowledge. Many projects are short-lived and once project is over, change is over and participants use other practices that suit them. In health care, many repeat cycles of knowledge translation may be needed, education and ongoing work with health care workers, families and communities.
Years ago, I was teaching new methods of caring for the newly cut umbilical cord with traditional birth attendants (TBA’s). They were to refrain from putting substances on the cord (such as beef tallow). When I travelled to the rural village to see the TBA and found beef tallow on the cord, she told me that the family insisted on it. Our change was to begin community education for all the surrounding villages. Change is slow.
A second example, years later in another country, was to change the practice of holding babies upside down and shaking them to stimulate them to breathe. It took two years working with trainers in one hospital until nearly all staff would point out when they saw someone doing it, “Ah-ah, we don’t do that anymore.” Finding ways to involve the majority will help others make the change.
Atul Gawande: How Do Good Ideas Spread? : The New Yorker (2013) http://www.newyorker.com/reporting/2013/07/29/130729fa_fact_gaw
Graham I, Logan J, Harrison M, Straus S, Tetroe J, Caswell W, Robinson N. (2006). Lost in Translation: Time for a Map? Journal of Continuing Education in the Health Professions. 26(13-24).
Hanlon P, Carlisle S, Hannah M, Lyon A, Reilly D. (2011). Journal of Public Health. 33(3)335-42.