“When you walk in, you’ll be awe-struck,” Dr. R claimed while excitedly waving around her hands. “The floors are sparkling clean. Each patient has a private fan and access to two full bathrooms, a kitchen always stocked with fresh fruits, new television sets, and even a lovely vegetable garden in the patio. There’s a well-trained nurse roaming the building 24/7, checking in on the patients every hour while they relax; it’s a paradise for pregnant women!”
In rapid-fire Spanish, Dr. R described the services of Casa Materna, a nearby health center for at-risk pregnant women. We were enjoying our lunch break out “en terreno” in the dirt yard of a family who had voluntarily lent out their house to allow us to use it as a health post to conduct patient consultations outside of the main Centro de Salud Monimbo. Earlier that morning, we set up a small picnic table, lined up a few plastic lawn chairs, and laid out our small cooler of vaccinations and a box of medical supplies and began seeing patients seconds after we arrived. Wave after wave of patients came, and Dr. R did not get a break until lunchtime. After watching how these sick patients had to travel by foot in hot weather to wait in long lines at the health post and at the main health center, I was convinced by Dr. R’s pitch of Casa Materna. What at-risk pregnant mom would turn down FREE 24-hour air conditioning and private, constant medical attention to address her needs?
Flash forward less than 24 hours.
I’m in the main health center, sitting across from a very pregnant woman, only two years younger than me – 17 years old. She is explaining her precarious medical situation to Dr. M, the primary care doctor I am shadowing. We’re all sweating in the small, cramped room with no A.C.
She’s 35 weeks into her pregnancy and is complaining of serious chest pain and shortness of breath that has been bothering her over the past week. She says she has diarrhea and is pre-eclamptic. I take her blood pressure and confirm- her systolic is 170, higher than it should be, a sign of pre-eclampsia, a dangerous condition for pregnant women. Dr. M. asks her if she has been taking her blood pressure medicine, and she confirms that she’s taking it. How often? Every hour. She did not realize the medication is only supposed to be taken every 12 hours.
By now Dr. M is worried. She tells her that she needs to go to the hospital right away. At the word “hospital”, the girl cringes. Dr. M also refers her to stay at the Casa Materna, the “paradise center” for at-risk pregnant women that Dr. R had just described to me the day before, to wait out the next few weeks before her pregnancy, and to my complete surprise, she responds with a flat-out, “no”.
She tells us that someone – she won’t tell us who – gave her the advice not to go. She had heard from his person that all of the women at Casa Materna are forced to water the garden, clean the bathroom, and mop the floors, and she doesn’t want to be to be over-exerted while pregnant and clean up after others for no pay. Dr. M calls someone she knows who helps direct the Casa Materna and puts her on speaker-phone to help clear up the false rumor. The lady on the phone says that mother’s who aren’t physically capable of helping out with chores are definitely not forced to do anything. But the girl’s still unconvinced.
With nothing else for us to try or say and with 5 more pregnant patients waiting impatiently outside, all Dr. M could do was prescribe her more hypertension medicine and vitamins and send her off to the hospital, hoping that she will go quickly and that she will receive the advanced immediate care needed and follow-up care with her family in her home so that she can safely deliver a health baby.
The day before, Dr. R mentioned to me that Casa Materna was self-run and sustainable, with patients helping upkeep the center to keep them active during their pregnancy. It sounded like a fantastic program to me. However, apparently a past patient or perhaps a friend or acquaintance of a patient or who knows what spread a bad rumor that convinced the girl that it was a horrible place.
Casa Materna is a wonderful humanitarian project that has been backed by Americans and Nicaraguans alike and to-date has helped so many women. Unfortunately it’s hard to change the way patients think or combat rumors like these. People will more often than not listen to their friends and family over licensed medical professionals – sometimes blatantly refusing to change their behavior in front of the doctor or pretending to agree to make lifestyle changes in front of the doctor but then going home and not doing anything differently at all.
This was one striking situation over my past week and a half working in the Centro de Salud that I wanted to share. It just goes to show how extremely hard it is to change people’s daily health practices. To get people to change their ideas about what they think works is difficult. We failed at influencing the teenage girl to decide against staying at home and waiting out a dangerous pregnancy in a rural area where there are not nearby available midwives or medical services in the middle of the night if something unwanted were to (God forbid) happen. From her point of view, living in a strange place with negative reviews where she would have to perform work for strangers for a few weeks just to deliver her baby was not worth it.. even with the bribes of free modern medical attention and a free stay in a nice facility.
Making strides in maternal health is definitely a tough business.
Over the last week and a half, I have learned from many patient cases like these. I have met inspiring health professionals doing wonderful work for their communities with limited supplies and time and have been extremely impressed by the community-based healthcare delivery model that the Centro de Salud operates by. My time here has been filled with unexpected twists and turns, and I have learned and absorbed more than I ever thought I could from these adventures.
Out conducting patient consultations at one of the 13 community health posts outside of the Monimbo health center. There is a nurse, doctor, and community health worker assigned to each station. Here Dr. M cares for a newborn infant.
On the first day of work, I was placed into the gynecology exam room where I watched Nurse M performing Pap smears and rapid 1-minute vinegar tests on women to screen them for cervical cancer. I acted as her assistant as she used a low-cost cyroprobe to burn off some pre-cancerous lesions on a women’s cervix. It only takes 11 minutes in total for her to administer a simple procedure that can save a woman’s life.
Nurse M. in the gynecology room. The blue sheet in front of her pictures the progression of cervix lesions as cervical cancer develops. These lesions can be detected quickly by one-minute exposure to vinegar.
Nurse M. told me she has been doing this work for a very long time. She has helped save many early-stage patients, but has also diagnosed many who had come in too late. She showed me her personal record spreadsheet of patients from the past three months that she had tested, dragging her finger down the list of names and diagnoses.
“This one came in with stage three lesions. And this one, this one, this one..”. Nurse M. pointed to name after name down the list. It was terrible and all too real. The people with these advanced lesions were generally people who had never come in for a PAP smear in their entire lives beforehand. When I asked her the reasons why these patients chose not to come in, she told me that it’s due to a range of personal decisions and preferences. I personally think that with the right education and campaigning, more women might come in for regular gynecological exams.
Cervical cancer is a highly preventable cancer, easy to screen for with pre-cancerous legions that are cheap and easy to treat. However, if caught late, it’s hard to cure. Death by cervical cancer is a horrible painful one, and it happens far too often in Nicaragua, which boasts the highest morbidity rate from cervical cancer in the world.
On our second cyroprobe patient of my first day, right before Nurse Margarita was about to burn off the lesion, she let me look into a magnifying colposcopy machine to see the pre-cancerous lesion more closely. While peering into the dark depths of the stranger’s vagina, I became dizzy and suddenly blacked out.
“Michelle, Michelle..? Estás bien?” I heard a tinny Nurse M. call out my name and felt her take my arm and walk me out into the hallway where another doctor helped me sit on the bench. The next thing I remembered is vomiting in the hallway and then getting attached to an IV. While still a bit dizzy and dazed, I was questioned in Spanish, to which I had difficulty responding to.
Apparently I had fainted from the stifling heat (and also the stagnant smell of the biological liquids and cleaning chemicals, I think) from staying too long in the cramped exam area with no air circulation.
Rough first day, but I gained a whole level of new respect for Nurse M. and the other doctors who were able to work tirelessly in these conditions every day. I was thoroughly embarrassed, but the staff was very nice and understanding, having worked with foreign interns unaccustomed to the heat in the past.
In addition to becoming integrated into the health center by shadowing physicians and going out to patient consultations, I have also been starting to lay the groundwork for my development project, which is looking like it will be two-fold, involving (1) implementing a sexual ed education outreach program by creating a girl’s leadership club in a rural school (2) creating a pregnant teenager support group with workshops on maternal and infant health.
I have been trying to get a better sense of existing needs and resources. I talked to doctors and walked around the city to speak with outside organizations such as the Centro de Mujeres Masaya and Ixchen. I received some nice donations from them – condoms, power points, brochures and posters.
Yesterday, I visited the Roberto Clemente Mental Health Clinic in Malecón where I plan to start up the pregnant teenager support group. There I went through stacks of patient files and identified the names and phone numbers of all the female patients under 20 who are pregnant. I will be calling them soon to recruit them to come out.
Outside of my project work I have gotten the chance to get very close to my host family and their friends and explore the area a bit more.
My host mother and her grandson, Pierre, eating ice cream just after we picked Pierre up from pre-school.
A night filled with lively music, endless food, and dancing! A grand finish to a packed celebratory “Mother’s Day weekend”. Here’s my host mom and grandmother with their children, grandchildren, and great-grandchildren!
A memorable excursion to the Laguna de Apoyo with my host mom.
On Mother’s Day, I got to dance with all the women in the family and laugh over old family memories. During a visit to a family friend’s ranch, I learned how to pick the juiciest jocote fruit. Last weekend I gave swimming lessons to my 3-year-old host cousin and snuck into a $7 entry fee Laguna resort with my host mom to go kayaking and swimming for free. While it was pouring rain and dark outside, I spent quality time exchanging stories with my host grandma in her room.
I am very lucky and grateful to have received so much love and acceptance from my host family, other family friends and neighbors, and fellow staff at work. I hope to be able to give back.
Signing out to get back to my house before it gets dark. Thanks for reading!
Michelle