In an informative note published days ago on its official website, the Cuban Ministry of Public Health (MINSAP) reported the death of “eight newborns with low birth weight and prematurity” in January. It happened at the 10 de Octubre Gyno-Obstetric Hospital in Havana. Four of the babies “died after day 11 with presumptive signs of sepsis.”
The note affirms that “the necessary measures have been adopted” and that the hospital “has the necessary resources.” Finally, it clarified that a commission from the Ministry is investigating the causes of the event and that “the pertinent measures will be applied.”
What happened, due to its unusualness, has generated comments and a negative state of opinion. On the other hand, it directly affects one of the most important indicators for MINSAP: infant mortality.
For more than a century, the indicator has been considered one of the most sensitive and accepted measures of health and social well-being in the world. In fact, its reduction is part of the UN Sustainable Development Goals for 2030.
Infant mortality in Cuba
According to the 50th edition of the National Health Yearbook, the Infant Mortality Rate (IMR) in Cuba went from 38.7 per thousand live births in 1970 to 7.9 in 1996. Since then, it has continued to decrease and between 2008 and 2018 it remained below 5. Rates of 4.0 deaths per thousand live births were obtained in 2017 and 2018.
For the Ministry of Public Health and the Cuban State, having the lowest IMR in Latin America and the Caribbean, and one of the lowest in the world, has been a source of legitimate pride.
However, in 2021 and 2022 the downward trend has been reversed. Figures above 7 have been registered, which brought the country back to the results of the 1990s. The trend also occurs in a context of reduced birth rates.
On the other hand, the behavior of the IMT was not homogeneous in these years. In fact, in 2022 we can group the territories into three large groups: those that presented less than 5 deaths per thousand live births, from 5 to 9 and more than 9. The provinces that are in the last group are Camagüey (with 9.1); Havana (with 9.5); Guantánamo with (9.7); Santiago de Cuba with (9.9) and Mayabeque with (12.2).
It is striking that Havana and Santiago de Cuba, the two provinces that contribute the highest number of births in the country, are in the group.
Conditions of the perinatal period, the main cause of the increase
The main cause of death in children under twelve months of age in the last five years in Cuba has been conditions during the period that includes the first 7 days of the baby’s life, known as “perinatal.”
Dozens of pathologies of the mother and the newborn that can affect them before, during and after birth are included. The perinatal death rate experienced impressive growth from 2018 to 2021: from 231 to 469 deaths: more than double.
This behavior explains, to a large extent, the reversal of the indicator. Note that of the 754 children who died in 2021, 469 did so in the perinatal period. Congenital malformations were five times the cause of death.
In July 2022, the Minister of Public Health identified prematurity and low birth weight as the main determining factors for perinatal death, along with congenital malformations and sepsis.
In line with the above, a study carried out in Cuba found that among the risk factors for perinatal death, the first one is preterm birth (all children born alive before 37 weeks of gestation). It is not a problem only in Cuba. world, the World Health Organization (WHO), every year 15 million premature babies are born in the world; that is, 1 out of 10.
Of these, approximately one million die from complications during childbirth and a significant number are left with some type of disability. Prematurity is the leading cause of death in children under 5 years of age in the world. Hence the importance of avoiding it.
Another risk factor for perinatal death is low birth weight. The WHO defines it as “a birth weight less than 2,500 g.” Being underweight is a major public health problem, because children born with the condition have an eight to 10 times greater risk of disease and death.
In addition, they can suffer sequelae after birth due to asphyxia during childbirth, pulmonary bleeding, hypothermia (low temperature) and poor physical and mental development.
The risk factors for low birth weight are divided into three large groups: pre-conception (before pregnancy, including the mother’s educational level, weight, height, previous illnesses, etc.), those during pregnancy (series of diseases and events that can occur in the period) and, finally, environmental and behavioral risk factors (from excessive work and altitude, to habits such as excessive consumption of coffee, drugs, alcohol or tobacco).
Finally, septicemia is understood as the exaggerated response of the body to an infection. It is considered a medical emergency and has a high mortality rate in all age groups; but it is greater in the extreme ages of life. Among the causes there are both bacteria and viruses and, in the case of newborns, it is associated with a series of factors such as the aforementioned preterm delivery, infections of the mother, etc.
Decrease the Infant Mortality Rate (IMR)
To reduce the Infant Mortality Rate (IMR) in Cuba, the number of deaths due to perinatal conditions should be reduced. In turn, this will happen by reducing the number of children born prematurely and with low weight.
It is easy to say but it is tremendously complex. The roots of the problem are diverse and many of them are difficult to change. For example, the height-weight and sociocultural level of mothers and families.
On the other hand, the Ministry of Public Health has not escaped the ravages of the economic and social crisis that the island is going through. Among the causes indicated last year for obtaining results in the IMR were: “incomplete number of cadres and officials” in nine of the fifteen provinces of the country.
It would be necessary to add the lack of resources, which — although to a lesser extent since PAMI is a prioritized program — also affects. The low investment in the sector and the emigration of qualified personnel, especially in primary healthcare, the same.
Although official statistics on the subject are not public, it is clear that among the more than 200,000 Cubans who arrived in the United States in 2022, a part have been health personnel.
On the other hand, there is demotivation due to the working conditions and salaries of health workers. Despite being located above the average in the Cuban salary scale, they have suffered a significant loss of their purchasing power due to inflation.
All of the above contributes to the results.
Returning to what was achieved in the 2008-2018 decade should be the goal but it won’t be easy. Adequate maternal and child care begins long before pregnancy, with the identification of the population at risk, the carrying out of health promotion and prevention activities, the early detection of pregnant women, a timely follow-up that includes the work of a multidisciplinary team and, in some cases, admission to maternity homes or hospitals.
Continuous training of staff must be maintained, from the base to the tertiary level, in a crisis context. In addition, better care is needed at the time of delivery and the perinatal period, which requires significant organizational work throughout the country, but especially in the provinces with the worst results.
In short, what happened in a hospital in Havana in particular, and the results of infant mortality in general, reflect the crisis that the country is going through. Reaching the levels we had five years ago took decades; reversing the current ones will not be a matter of a day.