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Three-month-old Omar slept peacefully in a hammock in the shade while his mother, Olga, laid beans out to dry in the sun nearby. They were at the family’s home in the rural Sierra Madre region of Chiapas, Mexico where Olga and her husband, like most families in the area, make a subsistence living growing corn, beans and coffee. The region is known for its coffee, but it’s also historically known as a highly marginalized zone where families face some of the greatest challenges in the country in their access to health care. A worn path winding up a steep embankment leads from the home to the singular dirt road that passes through the area. On the road, it is mostly foot traffic that can be found coming and going to and from the small rural community of Salvador Urbina about a twenty-minute walk south. There, and in nine other remote communities in this region, Compañeros En Salud (as Partners In Health is known in Mexico) is collaborating with the Ministry of Health on an innovative partnership to ensure meaningful access to quality medical care for families like Omar and Olga’s.
Olga had given birth to all three of her older children at home with a traditional midwife. Years earlier, when Omar’s siblings were born, there were no doctors and only a part-time health technician in the small public health outpost located near the center of the community. The next-nearest health facility is a community hospital located in Jaltenango de la Paz, nearly two hours away by vehicle, which few in this community have. Until just a few years ago, there was no public transportation option, either. Giving birth at home was not only the norm but often the only option for women in Salvador Urbina and other rural communities in this region. When asked whether she had planned to give birth to Omar in a hospital, Olga responded, “No, honestly, no. No, because, I would say, ‘Ay, what will it be like?’ I didn’t know what it was like to have a baby in a hospital, until this child.”
According to Mexico’s National Institute of Statistics and Geography (INEGI in Spanish), more than a third of births in Chiapas in 2016 took place at home. And according to the Observatory of Maternal Mortality (OMM), Chiapas had the highest maternal mortality rate in the country that same year (as is often the case). Moreover, a quarter of the women who died that year had no prenatal care during their pregnancy.
In 2011, Compañeros En Salud (CES) began an official partnership with the Ministry of Health to fortify health centers in this rural area of Chiapas. CES collaborates with several medical schools in Mexico to recruit newly-graduated physicians who come to carry out their social service year living in these remote communities, working as the primary care physicians in the clinics. The organization supports these first-year physicians (known as pasantes) with supplies, mentorship and a network of support that clinicians otherwise often lack during their social service year, especially if they are working in rural clinics. CES currently works in ten such clinics, with Salvador Urbina having become one of the most recently added in 2014. After establishing a strong primary care program to serve the 140+ small communities in its catchment area, CES launched additional programs to link patients to the spectrum of care that almost every family will need at some point in their lives, but which had long been inaccessible to most people in this marginalized area. The organization’s programs now include: a program to refer patients to specialized care (such as surgery, cancer treatment, etc.), a mental health program, a community health workers (or acompañantes) program, and a maternal health program. The maternal health program’s approach to meeting the needs of women in the area–and addressing the challenges they face in accessing respectful, quality care–begins at the community level.
It was in the community clinic in Salvador Urbina that Olga was able to receive monthly prenatal care with Dr. Adolfo Cavazos, the CES pasante who was living and working in the community that year. Olga’s pregnancy had been progressing well. “I wasn’t having any problems at all,” she says. “All the appointments I had, I went to them. They would tell me the date, and everything they checked for me, blood pressure, everything, everything came out normal. But there was one time...”
Just a few weeks before her due date, Olga arrived at the clinic for her regularly-scheduled prenatal appointment. That day, Dr. Adolfo had just returned from being away for the continuing education course that he and his colleagues at Compañeros En Salud participate in each month. The courses cover not only the world standards in evidence-based medical practices but they also give young clinicians a solid foundation in global health and social medicine: tools every bit as key as clinical knowledge when it comes to effectively treating their patients. They learn how social ills become embodied as physical ills in individuals who have been marginalized and impoverished, and how to effectively address illness with this understanding. Through strengthening the public health system, the organization’s mission is to deliver the benefits of modern medical science to those most in need, raising the standard of care for patients everywhere so that clinical outcomes are not determined by geography, political borders, race, social class, ability to pay, etc.
Returning from the month’s two-day course, Dr. Jimena Maza–the director of primary care at CES–had been the one to drive Adolfo from CES’s headquarters in Jaltenango de la Paz to Salvador Urbina. Joining Adolfo in the clinic that week was Dr. Marwa Saleh, a family medicine physician completing part of her global health fellowship with CES through the U.S.-based HEAL Initiative. Dr. Marwa is one of the dozens of specialists (from other parts of Mexico, the U.S., and beyond) who have rotated through CES’s site in Chiapas to serve as mentors and supervisors for its pasantes. After welcoming Olga into the clinic, Dr. Adolfo began his exam, and soon became concerned. He called Dr. Marwa into the exam room. Olga remembers the day well. “[The doctor] told me, ‘Your feet, ma’am, are swollen.’ ‘Why, yes,’ I said, ‘I’m swollen,’ and she checked my blood pressure.” Adolfo and his mentor decided to test Olga’s urine and, as they suspected, detected elevated protein levels.
Given the symptoms they were observing in Olga, Dr. Adolfo and Dr. Marwa were concerned for preeclampsia, a pregnancy-related condition involving high blood pressure that can result in seizures, hemorrhage, or end organ damage in the mother, putting at serious risk the life of the mother and/or the fetus. Preeclampsia often presents with headache, vision changes, dizziness, right-sided abdominal pain, and/or swelling. However, it’s not uncommon for women with this condition to be entirely free of the types of signs that could be detected by the patient herself without the assistance of medical personnel. As Dr. Jimena explains, “There are women who don’t have symptoms, and that’s why it’s so important that they go each month or month and a half for prenatal visits, which includes having their blood pressure checked.” Hypertensive disorders in pregnancy continues to be one of the leading causes of maternal mortality worldwide. According to estimates from the World Health Organization (WHO), these disorders in pregnancy were accountable for 22% of maternal deaths in Latin America between 2003–09. Conditions such as these—for which early detection is crucial—is one more reason that quality, community-based primary care is so essential.
The physicians explained to Olga that they felt it was important that she be evaluated in a hospital. They also knew how difficult this can be for their patients. For most families living in the Sierra Madre region, the decision to seek hospital-based care is a complex one, involving numerous considerations, barriers, and uncertainty: being away from work in the home and fields, finding childcare for small children who cannot be left alone, and unfamiliarity with more urban areas, among other challenges. Some communities have no public transportation, or only a single option that may leave once per day, before dawn. Public transportation from Salvador Urbina is available twice per day—once at dawn and again around midday—and often takes the form of the bed of a pick-up, sometimes (but not always) outfitted with a tarp for cover from the sun or rain. The ruta, as it’s called, can fill to the point of standing-room-only for the nearly two-hour trip to Jaltenango. Throughout this region, unpaved and poorly maintained roads can become dangerous or even impassable during the rainy season. Beyond transportation, patients face other considerations and expenditures: food, lodging and costs incurred at hospitals despite “free care.” Often patients are asked to acquire certain medications and supplies not provided by the hospital. CES strives to address logistical concerns, as well as minimize the direct and indirect costs of accessing care. The organization provides transportation and food vouchers, in addition to taking care of lodging near the hospital when needed.
In Olga’s case, the team arranged for her to travel with Dr. Jimena to the hospital in Jaltenango for evaluation. Dr. Adolfo and Dr. Marwa advised Olga to pack an overnight bag. Her mother-in-law accompanied her, as Olga’s husband was away from the home that morning, but would later join them at the hospital.
For the first time in her life, Olga set foot in a hospital “The child was who brought me there,” she says. “I had never been treated in a hospital.” When Olga had said earlier that she wondered What will it be like? at a hospital, her concern was understandable, based on what she’d heard from others. Mistreatment in hospitals has been a nationwide and worldwide problem, and women seeking obstetric care are particularly vulnerable. The concept of obstetric violence emerged in the 2000s in Latin America and Spain as part of the movement to humanize and demedicalize childbirth and empower women during pregnancy, labor and birth. It emerged as a legal term in Venezuela in 2007, was adopted by Argentina in 2009, and then by Mexico in 2014.
According to a 2016 survey by INEGI regarding the obstetric care received by Mexican women during their last childbirth, more than a third of women surveyed suffered some form of mistreatment: 11.2% reported being scolded or yelled at, 9.9% reported being ignored when they asked about their childbirth or their baby, and 9.2% reported being kept in an uncomfortable or awkward position. The fear that has arisen from this history of mistreatment is one more obstacle to care that CES is actively working to change.
At the community hospital in Jaltenango, nurse Fabiola Ortiz, a perinatal specialist, was waiting to receive Olga. Fabiola is one of Compañeros En Salud’s clinical supervisors for its team of obstetrics nursing pasantes who work in the hospital and its casa materna, a new birth center that is another part of the collaboration between CES and the Ministry of Health. Together, the joint team is committed to addressing the crisis of maternal mortality and the obstacles—including fear of mistreatment—that prevent women from accessing the care they need. Like CES’s physician pasantes, the obstetric nursing pasantes receive mentorship and continuing education to strengthen their clinical skills as well as their knowledge of social medicine and global health. For the obstetric nurses in particular, their continuing education is highly focused on best practices in providing dignified and humanized perinatal care with respect for the rights and wishes of the women they care for. These practices have been implemented with the help of an adapted version of the World Health Organization’s Safe Childbirth Checklist.
“The model implemented at the hospital in Jaltenango is the model of respectful maternity care, which has the support of evidence-based practices according to national and international guidelines,” says Dr. Mariana Montaño, the maternal health program coordinator at CES. “Care is provided with an intercultural approach and is focused on the needs of women, who make decisions about the care they receive. Women have the right to choose the position of childbirth, a companion to accompany them, and are allowed to move freely or change positions. They also receive support with non-pharmacological measures for alleviating pain, and have immediate skin-to-skin contact with their baby after delivery. We work as a team; in case of any complication, the medical and nursing staff of the hospital provide support to resolve it.”
Dr. Dania Molina Palacios, the director of the hospital and casa materna, describes the vision for the maternal health care that they provide: “We want to be a casa materna recognized for quality, for respectful treatment and, above all, for respecting the interculturality of the people which I believe is the important thing, and that in Chiapas it is known—and Jaltenango and the Frailesca region—that, in maternal health, we’re changing the model of care.”
Olga is one of the women who has experienced firsthand the changes that are underway at the hospital. “It was there that I saw that, yes, they take good care of you and many have told me that, no, that they let us die. I didn’t see that, but rather the opposite,” she says. “The doctors, and the nurses who are there, they were really attentive.”
The health team at the hospital evaluated Olga. They ordered labs while they began to administer magnesium sulfate as a measure to prevent eclampsia. In recounting Olga’s visit to the hospital that day, Fabiola highlighted several initiatives that the team has put in place to ensure that their patients are properly cared for. They were careful to explain to Olga what they were observing, as well as the increasing likelihood that she would need to undergo a cesarean section. Fabiola stresses the importance of being “attentive to whatever patients need, always giving guidance, informing them of what is happening, step by step, whatever is going on.” She explained several of the systems that are continually evolving to eliminate obstacles, especially in emergency situations. The hospital in Jaltenango, as a community hospital, is not equipped to handle all types of procedures, including the c-section that Olga would ultimately need. In many cases, the hospital must transfer patients to higher-level facilities, as turned out to be needed in this case. Anticipating these frequent cases, the team keeps backpacks prepped for obstetric emergencies, ready to send with patients who are being transferred. They also supply prepped surgery kits so that lack of supplies on the part of the receiving facility, and the cost to the patient, are a non-issue. Likewise, CES has transportation vouchers ready to contribute when an ambulance is needed. Fabiola adds that CES has implemented detailed record-keeping which, in each case where the team has faced challenges in ensuring the best for their patient, has helped to demonstrate the issues to health officials, and what needs to be done to address them. “The records make a difference,” Fabiola says. “Now we have a really good maternal health network that helps us a lot and women are accepted immediately [when we need to transfer them], almost the moment they arrive. It’s a practice that’s been implemented with the health team, with the Minister of Health, and the directors of the hospitals.
“We’re always one step ahead,” Fabiola explains. “We try to have everything, everything, which really helps women and their family members to remove a ton of stress, no? and being able to tell them we’re here for them and that they can trust in our services for the wellbeing of their family members and wives.” After Olga was stabilized and all the necessary arrangements were made, she was transferred to a hospital in Villaflores where, by way of a successful c-section, healthy baby Omar was born.
Diagnosing Olga’s preeclampsia and successfully facilitating her delivery in Villaflores demonstrate the impact of healthcare system strengthening, particularly in marginalized regions of the world. Of the pregnancy-related deaths in Chiapas in 2016, almost ¾ of those women lived in areas classified as marginalized or highly marginalized. Strong health systems, with high-quality prenatal care and effective collaboration between facilities at the primary, secondary and tertiary levels can ensure the timely detection and treatment of high-risk pregnancy complications. “When primary care doesn’t exist, for example, when there isn’t a clinic, a nurse, a doctor to detect [signs of alarm] in time, women realize they have a health problem only when they’re already very advanced,” says Dr. Jimena. “This puts their life at risk. That’s why it’s so important to have primary care within the community.”
After Olga’s return to Salvador Urbina, Dr. Adolfo and clinical assistant Cecilia (Ceci) Gálvez Roblero had been checking in with her closely, regularly visiting her at home for blood pressure checks to monitor for postpartum preeclampsia. Shortly after CES started its work in the community, Ceci began working as the assistant in the clinic. Having lived her entire life in the community, Ceci has witnessed the changes in these recent years. “In the community, Compañeros En Salud totally turned things around. One can see the difference between before and now,” she says. In addition to finally having access to care within their community, women’s perception of the hospital has changed, as well. “Now, it’s like everything is changing, because ask and they tell you, ‘I’m going to go to the casa materna because they take really good care of you there, the nurses are really great, you can trust them’.”
A week after Omar’s birth, Dr. Jessica Standish (another visiting family medicine specialist) accompanied Dr. Adolfo to Olga’s home in order to remove her stitches. Dr. Jessica spent two months with Compañeros En Salud during her Contra Costa/University of California, San Francisco (UCSF) Global Health Fellowship program. She had also been at the community hospital in Jaltenango, mentoring CES’s team of obstetrics nursing pasantes, when Olga had arrived there. Now in Olga’s community, Dr. Jessica helped Dr. Adolfo pack a headlamp along with a medical bag, and the two set out on foot to their patient’s home.
The home consists of an adobe kitchen and a separate, concrete block structure that the family sleeps in. Part of that structure was still in the process of being rebuilt after having been badly damaged in the 8.1 magnitude earthquake that had struck just off the coast of Chiapas almost a year earlier. The family was still without electricity. They lowered a scrap of vinyl covering the window in order to allow more light into the space, and unpacked the headlamp and the supplies they’d brought. Without a physician in the community, this simple procedure would have required several hours of travel, during the rainy season, and possibly an overnight stay, for Olga with a week-old Omar in tow. But with the CES physicians there, the process of removing the stitches and carefully re-bandaging the wound at Olga’s home took less than 30 minutes. When the rain, which had begun as they worked, hadn’t let up by the time they’d finished, Dr. Adolfo and Dr. Jessica were invited to sit and visit until the shower had passed.
“I first met Olga when she arrived at the Jaltenango emergency room,” said Dr. Jessica. “She had never been to a hospital before and was very nervous.” Serving patients in situations like Olga’s was exactly what Jessica had intended when she joined her fellowship program. Her time with CES was an opportunity to serve as a mentor for some of the young clinicians who are learning how to effectively treat patients in these situations and who will become leaders for social change, and key collaborators in the development and implementation of health systems that address the needs of the most vulnerable. “Adolfo had referred Olga to the hospital urgently after correctly identifying worrisome signs of preeclampsia,” Dr. Jessica says. “The amazing team of obstetrics nursing pasantes stabilized her elevated blood pressure and monitored her while magnesium sulfate was administered.” Having said goodbye when Olga was transferred to the hospital in Villaflores for her c-section, Dr. Jessica was glad to see her again, at home, recuperating well with her healthy baby boy.
CES’s maternal health program continues to evolve to meet the needs of women in the region. To complement the pre- and post-natal care provided in the primary care clinics where the pasante physicians work, the organization has formed a team of community health workers (acompañantes) who visit women in their homes during pregnancy and after giving birth. These acompañantes, who are local women from the communities, help to connect their patients to the care, information, resources and support that they need. These women receive ongoing training in topics ranging from signs of alarm for pregnant women and infants, to breastfeeding and family planning. Several of CES’s maternal health acompañantes are traditional midwives from the communities. To further strengthen ties with the traditional midwives of the region, who play such a vital role in the small communities throughout the area, CES collaborated with the community hospital to facilitate a series of knowledge exchange gatherings in which more than 50 traditional midwives from more than 25 communities participated. These women shared their experiences caring for women in their communities, as well as learning about the casa materna, which welcomes them to accompany patients during the birth process, with support from the hospital staff—including CES’s obstetrics nursing pasantes and their supervisors—who are at-the-ready in the event of any complications.
“Quality maternal care begins in the community, with first-level care clinics providing good prenatal care, and with the identification of risk factors and timely referral to specialized care if necessary”, says Dr. Mariana. “Ensuring that patients have meaningful access to comprehensive care requires effective coordination and communication between first, second and third levels of care. But it also requires that we address all the barriers to care at each level, whether they’re logistical, economic or regaining confidence in the health system.”
As Ceci said of her own community, women in the region are taking note of the model of care being practiced at the community hospital and casa materna in Jaltenango, thanks to what they’re learning from community health workers (acompañantes), their community clinics, and women like Olga who share their stories.
“If that day hadn’t happened that way, I don’t know, I think I might not have been able, or may not be here. I don’t know if I or my child…” Olga says. “... and yes, here we are, thanks to all of you.”
Olga and Omar are among the thousands of patients who have been able to access the care that they need thanks to the efforts of our team, and your support.
Thank you for your accompaniment.
"Lives of service depend on lives of support."
-Tracy Kidder, Mountains Beyond Mountains