Friday, March 27, 2009

Cuban Maternity Care: Worth a Closer Look

On our first trip to Cuba, one of our friends was around seven months' pregnant. She'd been told her baby was breech, and would have to be delivered by Caesarean section. For her and her family, which included some medical practitioners, this was not just bad, but frightening news.

“The hospitals in Cuba do not have proper equipment,” they told me. “You cannot count on things being clean. The material they use to stitch people up is often old, and falls apart. They often do not have the right drugs. They re-use disposable needles.” Their list of concerns was long.

I agreed to examine the woman in the presence of her husband. By my palpation, the baby was indeed breech, but it seemed mobile, and small enough to turn. I asked her if her obstetrician had suggested she do any exercises to help the baby turn to a head-down position. “No, he just says I will have to have a Caesarean section.”

I showed her the exercises, and was pleased to hear that at her next visit to the obstetrician he found that the baby had turned, and was now head down. She said that when she told him about the exercises he expressed surprise. He wanted to know who had told her about this, and what exactly she had done.

Before we left Cuba the family asked me to send some suture material, sterile gloves and needles and medications to prevent hemorrhage to them. These were the things they were concerned would not be available when the woman went, in labour, to the hospital. I sent the package, and they received it with no difficulty, and in time for the birth.

I was interested to talk with Cuban women about their childbirth experiences, and heard many stories. I was surprised by the number of women I talked to that had been delivered by Caesarean section – in my small sample of around 25 women they represented the majority.

The women were all happy to show me their scars, lifting their shirts and dresses even in the most public of places. All of the scars were vertical, from pubis to navel – the old 'classical' incision that is no longer used in the western world. Two obstetricians I met informed me that Cuban obstetricians are now performing lower segment transverse Caesarean sections.

In most western nations, women who have had 'classical' Caesarean sections are not considered good risks for subsequent vaginal deliveries as these incisions are associated with a higher incidence of uterine rupture. Repeat Caesarean section is generally the rule in these cases. Apparently it is not the rule in Cuba. Women with vertical incisions told me that they and others did go on to have subsequent vaginal deliveries. It would be interesting to know what the rate of uterine rupture is in these deliveries. Perhaps the Cubans know something we don't, or perhaps they are more willing to take these risks.

Just as disturbing as the vertical incisions these women had were the frequent signs of poor wound healing. Many of the scars were very wide and looked, even after many years, poorly healed. Several women spoke of having to go back to the hospital because their wounds had re-opened and/or become infected. Several women blamed poor quality suture materials as the reasons their incisions re-opened. Many women had taken months to recover from their surgeries, and needed mothers, sisters, aunties and friends to look after their babies for them.

But most disturbing to me of all was how little Cuban women knew about their bodies, about health and care in pregnancy, and about labour and delivery. According to them, care during pregnancy consisted of being weighed, measured and given an ultra-sound – at every visit! All of them had had blood tests done, although most of them didn't know what they were for. (In fact, from discussions I had with a Cuban geneticist, I learned that Cuba tests pregnant women for most of the same parameters, including the risk of genetic disorders, that we do.)

Women went into labour and birth with a 'knowledge' based on stories they'd been told by other women – often dreadful stories. They were fearful and distrusting. Of those who'd had Caesarean sections, not one of them knew the reason why. All of them just said “because they told me my baby was in trouble.” This is not so terribly different from women in the western world – it seems most maternity caregivers either believe that women are not capable of understanding more technical explanations or that the caregivers themselves are not prepared to disclose the real reasons, which in some cases may have little to do with the safety or health of either baby or mother.

Almost all Cuban women go to hospitals to deliver their babies. The Cuban government, like the governments of many developing nations, does not support midwifery. I neither found nor heard of any midwives practicing in Cuba. Women are cared for by perinatal nurses and doctors who generally have some obstetrical training. Cuba has many doctors – more doctors per capita than most western nations – and apparently many obstetricians. This may account for what appeared to be a rather high Caesarean section rate, although I was unable to get any statistics. (The Cuban government doesn't make such statistics easily available.)

The most impressive maternity service provided by the Cuban government is the system of 'casas de mujeres,' or maternity homes. We saw these homes in every city and town in Cuba. Women who live a distance away from a hospital, women living in 'suboptimal' domestic situations, or women with problems in their pregnancies that require observation, are given beds in these homes. They are also given three meals a day, which for some of them is more than they would get at home.

But most importantly the women in the 'casas de mujeres'' do not have to work. They have no husbands or children to look after, no chores to do. Given that almost everything is done by hand in Cuba, domestic chores often involve much heavy lifting – pots filled with water, baskets of wet laundry, toddlers who need to be carried. So for many women, their time in these homes is like a holiday.

It was wonderful to see small groups of women with big bellies sitting in rocking chairs on the verandah of an old colonial mansion with their feet up, chatting and laughing with one another. Husbands and families can visit of course, and we often saw couples sitting hand in hand watching tv.

The 'casas de mujeres' are staffed by nurses who are able to monitor the womens' health, and take the women to hospital as and when needed. This may be one of the most important things that Cuba does to achieve its very low infant mortality rates – the lowest in South America and lower even than the rate in Canada – a very impressive achievement.

Although Cuban women do get a full year's paid maternity leave when they have a baby, many of them go back to work within the first few months. It's the only way to make ends even begin to meet. The baby is either left with a mother or sister, or placed in an 'infant circle,' which used to be provided as a service by the government, but which now must be paid for.

There was little education about breast-feeding in Cuba, and little overt support for it. I was saddened to see the number of women who were bottle-feeding their babies. And I was amazed, given Castro's hostility to western capitalism, to see that Nestles appeared to have the corner on the formula market in Cuba.

1 comment:

  1. Ruby, you state yourself as a Health Care Professional. I used your material for a class presentation on OB care in Cuba and wonder if you might specify what type of HCP you are. Midwife? Nurse practitioner? Physician? Breastfeeding coach? I greatly enjoyed your post. Thank you! If you wish to reply in a private message, I am LaRee Gray on Facebook in Prescott Valley, AZ and I study at Yavapai College.