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"I love to teach people about the Model for Improvement and other improvement science skills and methods. I meet so many good people who want to improve care for their patients, but they don’t know how."
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“It’s Like Going from Being in the Dark to Turning on the Lights”

By Paulo Borem | Tuesday, October 6, 2020
It’s Like Going From Being in the Dark To Turning the Lights On Photo by Luis Tosta | Unsplash

Today, I am an Improvement Advisor (IA), but maternal care was not always my focus. When I was younger, I wanted to do something meaningful for humanity, so I decided to become a surgeon. But it wasn’t until I took part in IHI’s Improvement Advisor Professional Development Program eight years ago that I learned about improvement science. That’s when everything changed for me.

In 2012, I was living in Brazil and I had to choose a topic for my improvement project. The director of the hospital and the director of the health insurance plan I was working with were very disturbed by the high neonatal intensive care unit (NICU) admission percentages associated with C-section births, but they didn’t know what to do about it.

This need for improvement turned into the first project I worked on as an IA called Projecto Melhor Parto (Better Birth) in Jaboticabal City, a municipality in the state of Sao Paulo, Brazil. This improvement project ultimately became the foundation of a national scale-up initiative called Parto Adequado. The aim of Parto Adequado is to increase the percentage of vaginal births in Brazil.

To give you an idea of the ambition of this aim, you must understand that for 20 or 30 years in Jaboticabal, a city of 100,000 habitants, the percentage of vaginal births was 0 percent. Many babies ended up in the NICU because those born by cesarean are at higher risk for complications than those born vaginally, including difficulty breathing on their own.

At the beginning, there were many people who opposed any effort to increase the percentage of vaginal births. “You just want to save money,” some of them said. In the collective memory of many Brazilians, vaginal birth is equated with pain and suffering, especially when compared to the predictability and control of a scheduled C-section. Over time, however, by teaching about the risks of C-sections and demonstrating that our goal was to put patients and families first, attitudes changed.

It also helped that we got results. In the project’s first phase, we increased the percentage of vaginal births in Brazil from 21.6 percent to 38 percent over 18 months in 26 public and private hospitals. There was also a 17.29 percent reduction in NICU admissions between 2017 and 2019.

Lessons Learned

I learned multiple lessons along the way:

  • Always put the interests of patients and families at first. That’s what should drive you.
  • Fight to reduce the gap between science and practice. You may meet a lot of resistance. Never give up on doing the right thing.
  • Use your imagination and the resources the Model for Improvement offers to transform the obstacles and barriers into problems to be solved.

In 2016, I went back to Jaboticabal with representatives from the World Health Organization to show them the progress being made. I could see how much had changed. We saw groups of mothers supporting each other and saying, “We want vaginal birth because it’s the right way to do things.” That visit was one of the best moments in my life.

I love to teach people about the Model for Improvement and other improvement science skills and methods. I meet so many good people who want to improve care for their patients, but they don’t know how. When you can help them learn the steps to take, it’s like watching them go from being in the dark to turning the lights on.

Paulo Borem, MD, is an IHI Senior Project Director and Improvement Advisor for the Latin America region.

You may also be interested in:

Quality Improvement Essentials Toolkit

Turning Grief Into a Fight for Improvement

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