Institute for War and Peace Reporting | Giving Voice, Driving Change
A mother cradles her baby in Santiago de Cuba. (Photo: Joe Raedle/Getty Images)
The Cuban health system is run on very patriarchal lines. (Illustration: Baleria Mena)
Episiotomies are often performed without consent. (Illustration: Baleria Mena)
Doctors fear the new system may lead to children being starved of oxygen at birth and left disabled. (Illustration: Baleria Mena)
Laura cannot forget the first sight of her baby just after she delivered him: her newborn’s body had a greyish tone, and he seemed lifeless.
She remembers her son still covered in blood and fluids, doctors trying to search for a heartbeat. The medical file describes how the medical team tried to resuscitate the baby, who was cyanotic and had almost died for lack of oxygen after a lengthy birth.
Laura, a 22-year-old medical student, had had a model pregnancy with no gestational diabetes or high blood pressure. At 39 weeks, ultrasounds showed no anomalies. So when she was admitted to the Abel Santa María Hospital in Pinar del Río in western Cuba, she expected to give birth to a healthy baby.
But once in the hospital - where she was not allowed to bring any relatives for support - she was admitted to a small room with beds less than a metre apart, shared with five other women in labour.
Her family doctor, who asked to remain anonymous to avoid repurcussions at work, said that Laura was in labour for 21 hours but the cervix would still not dilate to the ten centimetres needed for a natural delivery. The hospital's protocols indicate that for a first-time birth, the average dilatation is a centimetre per hour. It is a phase that should take up to 12 hours.
The doctors did not consider performing a cesarean, despite Laura’s requests. Exhausted and in pain, she had no option but to wait nearly double the time she should have for a delivery.
“Hold on and push, I'm not going to take the baby out. You have to give birth by yourself,” she said she was told by the lead gynecologist every time she complained of being in too much pain.
After a whole day trying to give birth naturally, the doctors found out that the fetus was suffering and decided to perform an episiotomy to help the baby come out more quickly.
But it was already too late.
“I was always conscious, and at first sight of my baby, I knew he wasn't right,” the young mother said. “Then the neonatologist that assisted him told me there was a possibility that he would not survive, that he could die anytime from a cardiac arrest.”
Although Laura’s son survived, he suffers from irreversible cerebral paralysis. He cannot walk, move his arms or follow objects with his eyes.
“Since my boy was born, I haven't stopped thinking that if I had received different treatment back then, my reality now would be different,” said Laura, who is raising her son alone after her partner left when their child was diagnosed. “We have been stripped of our right to live a normal life.”
Doctors warn that Cuba is experiencing a crisis in obstetric care, with a recently-adopted policy intended to bring down the number of caesareans putting both mothers and babies at risk.
The situation is compounded by an absence of patient-centred care, with women left unsupported during birth and lacking systems to encourage safe vaginal delivery.
Three years ago, the Cuban authorities introduced the so-called Robson Protocol, a standardised system of classification to reduce the number of cesareans performed in the world.
Cuba’s objective was to get as close as possible to 10 to 15 per cent cesareans, the rate the WHO considers optimal. It has already managed to reduce the number of cesareans from 30.5 to 18.3 per cent.
But official statistics reveal that the number of children who died of birth-related causes increased between 2017 and 2018. The infant mortality rate for babies seven days old or less was 12.9, the worst since 2009.
The statistics on mortality does not take into account cases such as Laura’s son, who was with cyanosis and left disabled.
One gynecologist working in western Cuba told IWPR that “since these measures have been implemented, the number of babies suffering from asphyxia, cerebral palsy, fetal hypoxia and, in some cases even dying, has increased”.
CASH INCENTIVES FOR CESAREANS
For many years, planned cesarians were common practice for doctors and expectant mothers. The gynecologists benefitted from either money or gifts they received in exchange for performing these surgeries.
In Havana, the cost of a cesarean varies between 50 and 150 CUC, the convertible peso pegged to the US dollar. Monthly salaries for medical specialists in Cuba range from 1,600 to 1,800 regular Cuban pesos (64 to 72 dollars).
Another gynecologist from western Cuba explained that the health authorities also wanted to stop such covert payments in exchange for sometimes unnecessary surgery.
Natural birth is cheaper than surgical intervention; according to 2015 data from the ministry of public health, each cesarean costs four times more than a vaginal delivery.
“To perform a cesarean free of charge in a public health system was unsustainable,” said the doctor.
For decades, the number of cesarean births in Cuba continued to grow. Between 1970 and 2011, the number of cesareans rose from seven to 30 per cent. According to the Annual Health Survey, the increase accelerated between 2004 and 2011, with an estimated annual growth of one per cent.
One explanation was the economic incentive attached to cesareans. But this was also a consequence of a health system that has not yet introduced the concept of humanising childbirth, common in other countries. This practice that helps mothers to give birth vaginally by following certain protocols.
These include ensuring a relative is there to support the mother during the birthing process as well as the use of painkillers, providing space to walk around in while labouring and allowing the mother an active role in decisions regarding the birth.
Gynecologist Laura Tabares, from Havana's Ramon González Coro Hospital, explained that as a cesarean is a surgical procedure it entails the risk of postpartum hemorrhage, reaction to anesthesia and strokes.
“On top of that, after the cesarean, women experience more difficulties in recovering. They need to go the toilet after they have eaten, so they need a liquid diet or food in pureed form,” Tabares said.
Patients also experienced difficulties walking, their abdominal wall was compromised and they tend to lose sensitivity around the surgical area. Physiologically, a vaginal birth involves a much faster and safer recovery.
But despite the advantages of natural deliveries compared to cesareans, the introduction of the official policy may be endangering both mothers and babies.
Marielys, another first-time mother, said that her doctor had promised her a cesarean. A microbiologist living in Consolación del Sur's municipality, she had to travel 25 kilometres each way from Pinar del Rio to see her doctor. Every time, she would take a bag filled with gifts as partial payment for the agreed cesarean.
“During the pregnancy, I gave presents all the time to everyone in the medical team that followed my case,” the 29-year old said. “Presents included cards to recharge mobile phones, perfumes, clothes, meat. My husband and I wanted to be very generous because my safety and my baby’s were at stake.”
Even though the pregnancy progressed well and the fetus was healthy, the specialist in charge of her ultrasound scans said that the baby was too large for a vaginal birth and that the best course of action would be a surgical delivery.
But when the time came to give birth, in January 2018, the planned cesarean never happened, despite all the considerations previously made regarding the baby’s size.
Marielys said that the doctor who had received the presents as partial payment for performing a cesarean did not show up at the hospital as agreed. He never answered any of the calls made by her relatives, and she said that he must have known beforehand that the cesarean would not be carried out. The final decision about performing a cesarean is not made by the gynecologist but the maternity ward director.
Marielys had to endure 22 hours of painful contractions. Doctors refused to intervene until, without her consent, they decided to perform an episiotomy and subsequently a five-point suture on both superficial and deep tissues.
Although commonly carried out during birth, the procedure has significant after effects.
“The stitching is very uncomfortable, especially during breastfeeding,” Marielys said. "If you make any physical effort, it can open up again. It can happen even while on the toilet. You have to bear with a burning sensation in that area. Also, there is a lot of itching, but you cannot scratch. Doctors think of this as a routine procedure, but for women, episiotomy does not end the day we give birth.”
Subsequently, at the Institute of Neurology in Havana, her child was diagnosed with West Syndrome, an irreversible type of epilepsy that causes seizures and severe developmental delays. The mother says he cannot grab objects, walk, laugh or communicate as other children of the same age do.
Marielys’ family doctor said that “due to medical malpractice at the time of his birth, the child will never be able to talk and walk”.
“THE PROTOCOLS TIE OUR HANDS”
Several specialists interviewed for this report said that in applying the new cesarean protocols, the country’s health authorities had gone from one extreme to the other.
“We are not allowed to do surgical operations on pregnant women,” a gynecologist who asked to remain anonymous said. “If we risk it and decide to operate on pregnant women, then we are threatened with administrative sanctions. Some colleagues have already been sanctioned because of this.”
“The protocols tie our hands,” he continued. “We have gone from doing endless cesareans to none. We disagree with this policy, and in our daily practice, we see that such a meticulous control has not been good for the patients. But going against the rules means risking our jobs.”
Between 2017 and 2018, several leading indicators related to maternal-child health worsened, according to information published in the 2018 Annual Health Survey.
More mothers died during childbirth or the puerperium, the period just after delivery. In only one year, the mortality rate went from 45 women per 100,000 births to 52, representing an increase of 15 per cent.
More infants also died in the same period, a trend which continued in 2019 with a rise from 3.96 to 4.96 per cent.
Cuba still has the lowest infant mortality rates of most of its neighbouring countries, with health indicators very similar to those in Europe.
But unlike some countries that have been improving childbirth provisions by focusing on women’s welfare and promoting natural deliveries, the Cuban health system lags behind.
A 2013 study published in the Cuban Magazine of Public Health showed that structural problems prevent hospitals from providing a humanised service for childbirths.
These are caused not only by the economic difficulties the country faces, which reduces the possibility of having more private spaces, monitoring equipment and access to medication, but also due to a lack of medical training.
Several of the gynecologists interviewed for this report, some of them recent university graduates, were not familiar with the concept of humanising childbirth because it was not taught as part of their curriculum. As a result, obstetric violence is seen as a routine part of giving birth.
In June 2019, at the annual conference of the Cuban Society of Obstetrics and Gynecology, this type of gender violence was recognised as a problem.
Members acknowledged that delivery rooms in the country's hospitals did not comply with several of the practices and protocols stipulated for humanising childbirths.
Women often have to go through childbirth sharing a small room with other patients and with no family support. They are subjected to frequent pelvic exams by more than one person, with no privacy at all.
They are given no agency during the process and are often not provided with information or asked for their consent for procedures like the use of forceps.
They are also not routinely provided with pain relief or access to any alternatives such as massages, birthing balls and breathing techniques, let alone an epidural anesthetic.
Medication is only used in selected cases. Several doctors interviewed said that access to such products was very restricted and often only given to patients with strong links to officials or hospital managers.
Thais Brandao, a Brazilian psychologist and researcher, explained that obstetric violence was a broad concept recognised by some international bodies as the most invisible form of violence against women.
“To not let women about to give birth be accompanied by someone they trust - a woman's right as recognised by the WHO - is obstetric violence,” Brandao said. “To not let pregnant women walk during the pre-delivery phase or choose a position they feel more comfortable with during birth, is also violence.”
Brandao added that the use of forceps, the Kristeller's maneuver - the defunct practice of pressing on the woman's abdomen during the final stages of birth to aid a vaginal delivery - routine episiotomy and denial of a necessary cesarean could all be considered obstetric violence.
“In Cuba's health institutions, there is a very patriarchal and chauvinistic model,” Brandao said. “Health practitioners tend to objectify women's bodies when it comes to treating them.”
That was the experience of Verónica Márquez, a first-time mother, who was admitted to hospital in September 2019 at 40 weeks pregnant. The 27-year old was showing no signs of going into labour, so doctors decided to induce her with an oxytocin drip.
“They took me to the pre-delivery room with other patients that had been there for many hours already, bearing the pain,” she said. “When you are surrounded by other women you don't know, and some are yelling because they cannot give birth, then you feel even more nervous and traumatised. I dreaded thinking that it could also happen to me.”
Márquez began to have contractions, which she found unbearably painful.
“I felt as I was being ripped from the inside,” she said. “The pain was such that I threw up seven times.”
During that time, none of the medical staff tried to assist her.
“I kept biting my hand because I didn’t know what to do to lessen the pain,” Márquez continued. “The doctors just made fun of me, and they didn't do anything to help me.”
Once in the delivery room, Verónica was accompanied by two doctors. They performed an episiotomy on her.
“They asked me to push,” she recalled. “And then they climbed onto the birth table, one at each side and started pressing down the abdomen by the sides of my ribs. They got my baby daughter out at 6.15 pm. They pulled her out using forceps while pressing my abdomen down. I know forceps can be dangerous; they didn’t warn me of the risk before; they didn't tell they were going to cut me either.”
Doctors described the birth in the medical history as “hard, traumatic, and with the use of medical equipment”.
For four months after the procedure, Marquez had to receive medical treatment due to the partial tearing of the uterus during the intervention.
“I felt as if I was at the butchers,” she said. “After that experience… I don't think I would be capable of having another child.”
Another journalist also contributed to this report, but asked to remain anonymous because she is under surveillance by Cuba´s security apparatus.
This report is the result of a workshop on in-depth journalism organised by IWPR.
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