La idea nueva
Miguel is bringing major changes to the way that Argentinians come into the world by creating new norms and practices for the nation's large and busy maternity "megawards." Public hospitals traditionally catering to Argentina's poorer populations are set up for volume, rather than service, in the delivery of babies. Inevitably, both efficiency and quality of care suffer.
Miguel has found a way to increase the health of newborns and offer a variety of specialty services to improve the results and experience of maternity hospitals.
Through years of experience in the medical field, Miguel backs his work with concrete reasons to further develop and increase quality of care. Families play a vital support role, knowledgeable moms communicate better with staff, and sensitive staff make better listeners and better care providers. In addition, public hospitals deliver a lot of premature and underweight babies who need particularly expert care.
For all these reasons, Miguel has created a prototype "family-centered" maternity ward that can be standardized throughout the country. By retraining doctors, creating ways to promote and improve the auxiliary roles of nurses, developing specialized services, and providing a range of on-site psychological and social services to families, Miguel is showing hospitals that they can do better–largely with resources they already have. The result is that the public hospital begins to respond to the mother's actual needs, treating her as "the lady of the house," rather than a patient to be institutionally processed.
Of the 700,000 children born every year in Argentina, 60 percent are born at public maternity wards–called megawards because of their immense scale–designed to serve poorer families. The predominating attitude among staff is that because patients do not pay for services, they are not entitled to excellent care. Poor conditions at megawards are common in that physical spaces are often inadequate and equipment and maintenance are insufficient. Budgets and staff are overstretched. Compared to other countries, Argentina has many doctors but few specialized or general nurses, resulting in a shortage of maternity ward support staff. Often the management of financial and human resources is inadequate. The wards keep limited daily hours of operation, and staff absenteeism is high. There is no sense of "client services," as doctors create environments to facilitate their work but do not take into account the profound human dimension of maternity ward work. Rarely are quality reviews performed. Additionally, these wards suffer from an underappreciation of the role of auxiliary medical staff.
There is a strong correlation between the socioeconomic status of parents and problems with newborn babies. This means that in addition to handling a large caseload, megawards must be ready to deal with a variety of problematic situations. For example, at Maternidad Sardá, the largest public maternity ward in Buenos Aires that delivers 7,000 babies each year (or an average of 20 or so daily), 35 percent of pregnant women have a condition or complication needing treatment. Seven percent of the mothers are under 17, 12 percent of babies are born prematurely; and 8 percent have a low birth weight of 5-pounds-5-ounces or less. Health of newborns is highly dependent on proper predelivery conditions for the mother, handling of the delivery, and postdelivery handling of the babies. Fatalities among delivering mothers is also an issue. In Argentina most deaths during labor are the consequence of inadequate prebirth conditions. When complications do occur, mothers and families have only the overworked, undermotivated hospital staff to inform and console them. While women and families may offer support to each other, hospitals are only set up to accommodate the mothers, not entire families, so extended hospital stays and visitors become a problem in terms of space and convenience, rather than an important element of the mother and baby's recovery.
Miguel is changing the face of public maternity hospitals. He starts with the premise that women and children, the primary beneficiaries of services, should be recognized as valued but vulnerable clients, and as such, be consciously considered when determining how wards are managed. Miguel creates a conceptual space in which the expectant mother becomes the client, implying both that she deserves the respect of the doctors and staff who serve her, and that she is proactively in control of her situation. This concept underlies the pilot family-centered maternity ward that Miguel has established at Sardá in Buenos Aires. From this conceptual basis, Miguel reasons that the birthing experience at public maternity wards can be improved by making changes in three main areas. By creating specialized services for mothers and their families, broadening the definition of auxiliary medical staff and better incorporating them into patient care, and motivating and equipping maternity wards to provide better care, Miguel is looking to revolutionize the megawards.
Among the specialty services that Miguel has devised are mental health services for parents in psychological or emotional crises, a special home for mothers of premature and sick newborns where the mother may sleep and eat close to her preemie, and need-specific, service-delivery teams for particularly vulnerable or at-risk patients, like single mothers, adolescents, abused women, mothers of newborns with Down's syndrome, and HIV carriers. Miguel brings in a range of individuals in roles of auxiliary support. Fathers are asked to provide continuing presence and support after delivery in rooming-in and neonatal units, including intensive care. The babies' grandparents, aunts, and uncles are brought in to provide logistical and emotional support. An outreach program enlists volunteers in the community to provide more helping hands–Miguel has a team of 60 such volunteers at Sardá. Perhaps most significantly, mothers themselves are engaged as providers of their own services. For example, they are taught to monitor the progress of the care they receive, and of course have great incentive to do so vigilantly and precisely.
Miguel is also building the capacity of Sardá to handle its caseload with care and effectiveness. He has designed and run maternity nursing programs and other on-the-job training sessions for ward staff. He has put together special training sessions to show staff how to care for patients with greater sensitivity and respect for "the lady of the house" and her family. Medical analyses of patients passing through his pilot program have shown success to date, and Miguel is coupling these results with recently instituted patient surveys on the quality of received care. Analyses of these results will give a fuller picture of the efficacy of the program and create feedback loops. Additionally, Miguel is encouraging the modification of ward facilities whenever necessary, for example, by creating preemie nurseries, developing unique delivery and recovery areas, and by making the environment in all patient areas more pleasant. Miguel's ambition is to have his family-centered model installed in every Argentine public hospital. He already has the necessary contacts in government, as well as in the academic sphere and the citizen sector. The model has received national and international acknowledgment. UNICEF has declared the Sardá ward the "first mother-and-child-friendly hospital." And Professor John Kennell–in his chapter "It is Time for a Change"–calls the Sardá maternity "paradigmatic." In his efforts to spread the successful pilot beyond Sardá, Miguel has already replicated it in other public hospitals in Argentina, transforming the public maternity ward in Quilmes, and spreading the idea to the "Mothers' Residence" at a hospital in Tucumán in northern Argentina. Even where his model is not rolled out in full, Miguel often consults maternity wards on their physical design, implementation of technologies, and doctor and staff training. As an adviser to the National Department of Health, he is trying to shape legislation to install family-centered services in all maternities. Subsequently, he would like to replicate the model in the megawards of other Latin American countries.
Miguel has raised funds from a variety of business-sector sources and continues to use the Neonatological Foundation, which he chairs, as a fundraising unit. In addition to receiving funding, Miguel aims to secure private-sector partnerships to strengthen his capacity to replicate.
On a parallel track, Miguel is transmitting his clinical results to neonatologist and pediatricians throughout Argentina through the Perinatal Information and Neonatal Intensive Therapy System he has developed. This system consists of CD-ROMs offering basic information in such areas as symptoms, diagnoses, medication doses, and weight curves. Some 2,000 Argentine doctors access Miguel's distribution system. He has also designed a Distance Education Program offering updated medical information in which some 1,000 obstetricians and neonatologists have participated. Another initiative he has worked on is the book Integrated Neonatological Procedures, which has been made into a CD-ROM and is being distributed throughout Latin America.
For a long time, Miguel worked as a neonatologist, believing that newborns' survival was guaranteed just by the presence of the doctor and adequate technology. But one time a nurse told him, "Since you have been at Sardá, babies live longer, but suffer more," implying that his teams were not taking sufficient care of the babies emotional needs. Concerned, Miguel decided to work as a nurse for a month. He learned how to change diapers, place the baby on the mother's breast–tasks that were unknown to him as a doctor. He personally experienced the two essential components that today are the basis of his family-centered model, the need for close mother-child interaction and the significance of auxiliary services. Miguel's office at the Sardá is near a phone booth. He intentionally leaves his door open to hear the phone conversations mothers have with their families, learning much more than books can teach about mothers' mores, fears, and needs. Miguel hopes he will be able to transmit to university students what took him years to learn: doctors need a broadened perspective before they can work effectively in maternity wards.
Although Miguel grew up with pediatricians among his relatives, he did not feel that medicine was his calling until he was interning at the prestigious Children's Hospital. There, Miguel met exceptional teachers who helped him discover his own definition of health–"to be free, to have a job, to live in peace, to have a life project." Miguel continues to transmit this sentiment to medical residents he teaches, emphasizing, as well, that for a doctor it is more important to accompany patients, to provide solidarity for them, than it is to heal them. He graduated from medical school with honors and completed his education in the United States. On his return, Miguel worked at a healthcare center in the biggest slum in Buenos Aires where he experienced the social dimension of medicine, finding that a doctor's mission goes far beyond researching and even healing.
Thirty years ago, he started to work at the Sardá Public Maternity Ward, establishing a Pediatrics Department that integrated the work of pediatricians and obstetricians, thus creating a branch of medicine called Perinatology. The endeavor encountered stiff opposition among medical staff, but in spite of struggles, the Sardá is now a reference center in Perinatology, showing the best survival rates among public maternity wards and offering top medical residency programs. Miguel was the first Argentine doctor to specialize in Neonatology and published Basic Guidelines in Neonatology when this branch of medicine did not yet exist in Argentina. Pediatricians, in fact, used to have no contact with newborns. Miguel built a five-doctor neonatology team and their performance at the Sardá maternity ward had such an impact that their skills were sought by the most important private clinics in Argentina.