Swain began with the fourteen native Christian women that Mrs. Thomas had previously been educating. Beginning March 1, 1870, these women were given clinical experience by working with the orphaned sick and "Christian village", and were taught basic lessons in "anatomy, physiology, and materia medica," by Swain herself. They soon became "proficient in compounding and dispensing machines." Swain had spent two to three hours a day with her students, preparing them for the "examination of fourth-grade doctors," supervised under two civil surgeons and an American physician. Thirteen of her students passed the exam, and on April 10, 1873, they were bestowed "certificates for practice in all ordinary diseases." Of these graduates, Swain chose three as "Bible women" to help promote the religious mission of the hospital. In the 1890s, the Christian Medical College Ludhiana was founded to provide formalized medical courses in lieu of the basic training that the assistants were previously offered. Accommodating the constant influx of patients, outpatient visits, and the rapidly increasing work eventually took a toll on Swain's physical and mental health, causing her to return to America in March 1876. On September 25, 1879, Swain left the states, and arrived at Bombay, India on November 6. She was then appointed to resume her work, in January 1880. Her second return to America was triggered by a deterioration of health in both her sister and herself. She left Khetri, India in March 1888, and returned a year and a half later. Although there had been indigenous resistance to Western medicine and religion in India, the mission had successfully procured an estate from the Nawab of Rampur, on which to expand medical facilities. Such was not an uncommon thread of families of princely states, since many of them in this area were in favor of "mission-sponsored initiatives for female education or medical work." In allotting the gift, The Nawab of Rampur was quoted saying, "Take it! It is yours! I give it to you with great pleasure for such a purpose." On January 1, 1872, Swain moved her team over to the Nawab's former property. By May 1873, a dispensary building was erected and by January 1, 1874, the first in-estatehouse patients were treated. The completed hospital, known as the Clara Swain Hospital, was then the "first hospital for women in India." Soon after, Swain had accumulated many more visitors from neighboring states, including those traveling from as distant as Burma.