Saving Mothers and Proximie in the Dominican Republic: Creating a legacy of surgical expertise

Saving Mothers is a nonprofit organization dedicated to improving the quality of maternal healthcare worldwide, with projects in Guatemala, Kenya, Dominican Republic, Uganda and New York City. As part of their hospital training program in the Dominican Republic, Saving Mothers integrated Proximie into their clinical pathways to enhance surgical training and mentorship in gynecologic laparoscopy. 

In 2019, Saving Mothers - founded by Dr. Taraneh Shirazian, a practicing gynecologic surgeon and Associate Professor at NYU Langone Medical Center - partnered with La Maternidad Hospital, a large, high-volume public teaching hospital in the Santiago province of the Dominican Republic, to establish the hospital’s first gynecologic laparoscopy program. Saving Mothers facilitated the donation of laparoscopic surgery equipment from Stryker, and has worked closely with a team of local doctors to build the capacity of La Maternidad to provide continued access to laparoscopic surgeries to its patients in Santiago and beyond. 

In 2022, the Proximie platform was introduced to enable Saving Mothers and the local doctors to stay connected virtually, in order to facilitate ongoing virtual training and mentorship for quality improvement and safety. The teams continue to connect virtually every Thursday morning for crucial ongoing surgical education, leveraging previous learnings archived in the Proximie platform to help shape and improve best practices and, ultimately, improve patient safety and outcomes.  Proximie is also now being used to support a new initiative that is focused on simulation training for the management of postpartum haemorrhage, with the end goal of transferring skills to local providers who can then share their expertise with other local practitioners.

Together, Proximie, Saving Mothers and La Maternidad are implementing an innovative, evidence-based training program where it is needed most. 

The state of play

According to the World Bank, between 2010 and 2016 the Dominican Republic decreased health inequities by making healthcare available to 366,236 individuals to whom it had previously been denied. Although great strides have been made, the Caribbean’s second-most populous country has the second-highest neonatal mortality rate in the region. Approximately 8,400 women - almost 3% of the global total - died from causes related to pregnancy and childbirth in Latin America and the Caribbean in 2022. Of those, 1,300 were in the Caribbean. Between 1990 and 2015, maternal mortality in Latin America decreased by 16.4%, but increased by 15% between 2016 and 2020. 

Not a drop and run endeavour

Traditionally, expert surgeons from the Global North would travel to places like the Dominican Republic in order to train local surgeons face-to-face. While these interactions remain important for ongoing development and upskilling, in-person visits carry a multitude of inefficiencies. 

Firstly, the constant need to travel - at a time when access to travel and case cancellations or rescheduling occur frequently as a result of COVID-19 - is unsustainable from a cost and environmental perspective, while often resulting in engagement with local teams being all too fleeting. Teams can be left isolated once the expert leaves, lacking the confidence to do very specific procedures for the first time without a mentor present. Worse still, isolated local surgeons who have only experienced limited hours with a specialist could end up carrying out procedures incorrectly. Proximie’s partnership with Saving Mothers ensures surgical support, training and trouble-shooting is always-on and available virtually whenever needed.

Local surgical teams and trainees can virtually scrub-in their peers from Saving Mothers - or indeed other expert clinicians from anywhere in the world - to provide those on the ground with the knowledge needed to conduct surgeries correctly and in real-time, without the need for the expert providing guidance to be physically present. 

This partnership is not a drop and run endeavour. The ultimate ambition is to create a digitised continuum of learning that means the trainees will become the trainers, and ultimately expert surgeons themselves. The old surgical teaching model of ‘See One, Do One, Teach One’, is being evolved at La Maternidad, to ‘Prepare, Perform, Perfect’, meaning surgeons are now in a constant digital cycle of learning. 

Creating a legacy of surgical expertise

Guillermo Peraza, Senior Manager of Operations at Proximie, has been instrumental in helping to coordinate the teams from Saving Mothers with clinicians and trainees at La Maternidad, and the point man for all integration and technology queries. A native Spanish speaker, he has been integral to the nuanced integration of Proximie throughout the project, spending time every week providing remote support to Saving Mothers and the surgical teams at  La Maternidad. 

“Initially there was a large variation in people’s understanding of the technology,” Guillermo explains. “You have to understand that within this hospital, there’s no internet, there’s no AC; it’s very very basic. We had to see how we could best implement Proximie with a suitable network, because there is no network. So I helped them set up the platform. We went to the mall, literally, to a telecommunication place to grab the 4G hotspot, and that's how we've been doing this. It's 100 gigs and they’re paying for it monthly. I'm advising them on how that works; if you have more feeds, you need more gigabytes per hour.

“So although we have four feeds available with Proximie, it may be that we only use three or two feeds depending on bandwidth. We often cut one and focus on the main feed to save time and money. I also took the time to create a guide for them which shows the step-by-step setup, and I went there to La Maternidad to give them some classes, with all the residents and with the surgeons from Saving Mothers. I explained how each cable works, what it does, the flow of signal through the system, the input, the output, and how that could interfere with other things, or how it will be implemented and visualised into the platform. Thankfully, they understood completely. At first they were a bit overwhelmed by the technology but they soon realised it's essentially plug in and play.”

A central figure in this process over the last two months has been Dr. Kamill Marie Frías Ureña, a GP currently studying for her residency at La Maternidad. Dr. Kamill works with the hospital, Proximie and Saving Mothers to ensure the technology is correctly set up for each procedure or teaching programme, and she also acts as a translator for the various parties. She has seen first hand the response to Proximie by the surgical residents at La Maternidad.

“After I’d set up Proximie just twice, I felt completely confident in being able to do it whenever needed,” said Dr Kamill.  “I'm not the most technologically gifted person, but if I was able to learn, I think anyone would find it really easy to use. Even though we might sometimes experience challenges with the internet connection, for example, Proximie, still works great - and Guillermo has talked us through various things that can be done to improve the connection, and how things should be set up so that residents and specialists have the best view of everything that’s going on.

“I’ve seen how being able to use Proximie and receive remote assistance has really motivated the residents. They are able to dedicate a lot more study time to the questions they’re being asked, and now that we’re recording all the sessions they are able to go back and see everything that was done during a procedure. We have a practice surgery box so they are able to review the recordings and then practise those procedures in the box. It has been amazing to see how much they enjoy and benefit from doing that, and whenever they have questions for specialists it is now so much easier to ask them via Proximie.”

Proximie’s recording capabilities have been tailored to providing the best possible view of the laparoscopic surgeries being carried out at La Maternidad, and lay the groundwork for a future programme of laparoscopic training sessions.

“The video recording element of Proximie is a vital tool,” says Guillermo. “It enables us to see what has gone wrong, what went right, what procedures could be implemented in a better way and what can we tweak to make things more feasible for the surgical teams to help them have a better success rate. We’re now conducting specific laparoscopic training sessions; we've integrated a small camera into the device and Proximie is capturing every step of the training sessions, including all of the procedural information in the OR.

“At the same time, the surgeon from Saving Mothers can be present, asking questions remotely. So what do you do after this? What is that? What will be the best process after that? So the surgeon is actively training local clinicians at the same time. It’s amazing to see how receptive they are to constructive criticism, and to the implementation of new processes and procedures. I love that - it’s so inspiring to see what has been accomplished through the remote sessions using Proximie.”

Dr. Beralis Ramos was a gynaecologist assistant for the laparoscopy department at La Famidad when the partnership with Saving Mothers was being established in early 2022. She has been a key figure on the ground in the Dominican Republic, and despite currently training to get her surgical residency in the US, she remains a constant virtual presence for the local teams and those at Saving Mothers.

“The biggest question that everybody asks is how is the internet? How is the connection? Have you ever failed?,” says Dr Ramos. “But the Proximie team has made sure we understand how the technology impacts our bandwidth. The problem is largely logistical; sometimes we don't have cases because there's not a lot of laparoscopy procedures in the hospital or sometimes the case is cancelled.

“The team were initially sceptical about the amount of time it would take to set up Proximie, but for the residents this has been a hugely positive project because they're learning so much more than they were previously. Before they didn't have any resources they could study for laparoscopic cases, and now Saving Mothers has given them all of the courses and videos they can watch. We’re also recording every single case on Proximie, and carrying out Q&As about the surgeries that they're watching. It has been an amazing step forward for the medical students; they absolutely love Proximie.

“The ultimate ambition is to have successfully integrated a full laparoscopic simulation program into the hospital because we don’t currently have a laparoscopic fellowship in the Dominican Republic; if you want to do laparoscopy, you have to leave the country, and we don't have Lap rotations. Speaking for myself, my goal is to become a gynaecologist, so this has been an invaluable learning experience for me.” 

The partnership has the potential to transform the future of female healthcare in the Santiago province and, ultimately, in the Dominican Republic as a whole. This long-term engagement plan employs Proximie’s technology to enable real-time and evidence-based training, providing local clinicians with the skills they need to become experts in their own right - empowering them to train the experts of the future themselves. 

Dr. Kamill says: "I hope Proximie gets implemented in every public hospital so that we can bring together surgical expertise from all over the world to share knowledge, so that we can give women better access to healthcare that they might not otherwise have."

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