When Ciego de Ávila headed the worst headlines, with the highest infant mortality rate in the country in 2021 —13.6 per thousand live births— we crowned the dangerous spiral that we had escalated in recent years: fewer births and more deaths.
The truth is that under the influence of COVID-19 neither the efforts nor the human resources were sufficient to effectively ensure that the Maternal and Child Program (PAMI) did not have competition in the chain of care. From the office to the hospital, the protocols became blurred and it was evident that, even when they are described, putting them into practice is not always a happy experience.
Until this March 24, the Department of Statistics of the Provincial Directorate of Health reported an infant mortality rate of 6.6 per thousand live births, which translates into 6 deaths and 911 births. For the start, these numbers are not encouraging either, especially when the country's purpose is not to exceed, as a rate, the four deaths in 2022.
At this point, not only would a sadness sweeper be needed, but control, motivation, training, and responsibility from all areas. The dialogue with Nilka Pita Alemán, provincial director of Health, in a context in which the figures do not say everything, confirms this but they bring us closer to the vortex of the problem. The PAMI indicators have to change for the better.
—What work strategy have you adopted to reverse the numbers in the red?
—We insist on training and accompaniment, more strongly after the visit of a ministerial team at the end of 2021, which pointed out deficiencies that we had not seen before, and left suggestions to resolve them. The heads of the programs and of the Basic Work Groups (GBT), obstetricians, pediatricians, nurses and neonatologists have received training.
“Due to the high maternal morbidity in the country, the follow-up of pregnant women with a group of worrying pathologies has been reviewed, including heart disease and anemia.
“We have visited the municipalities to review the strategies of the program, the boards of directors and rescue the plenary sessions, a monthly space where all the organizations converge, in order to guarantee intersect-orality. In these meetings, important decisions are made, for example, if a pregnant woman needs material support due to her economic situation or where it is necessary to influence to obtain an income in a maternity home.
“The prevention commissions have been activated based on the analyzes resulting from the plenary sessions, the same to deal with adolescent mothers who do not take good care of their children, as well as to ensure the status of a pregnant woman with wandering behavior in the main municipality. We know that part of the success lies in increasing control over processes, clinics and maternity homes.”
—What deficiencies are repeated in the controls?
—The identification of pre-conceptional risks and, consequently, the application of the protocols are still lacking. Reversing this in health areas is vital. Follow-up is not systematic; there are delays in consultations and timely admission to maternity homes, whose occupational index is around 50 percent, with better behavior in the municipality of Majagua, and worse in Chambas, Baraguá and Ciego de Ávila.
—In our context, low birth weight and prematurity determine infant morbidity and mortality. Have specific actions been designed to mitigate their prevalence?
—The Provincial Obstetrics and Gynecology Group was restructured and meetings were held to update the protocols, especially for prematurity and low birth weight. The behaviors were written, but we detected that they were not always implemented as is in the hospitals. This needs to be corrected.
“As part of the training process, ultrasound courses have been carried out, useful for the diagnosis of congenital malformations and intrauterine growth retardation. Obstetricians and neonatologists think that low weight may be related to the impact of COVID-19; in correspondence, several thematic lines are investigated. From science, we need results that guide actions. In addition, maternity homes will be opened in the municipalities where they do not exist today. In the cases of Florencia and Majagua, the premises to be used for these purposes are already well defined. It is encouraging not to report maternal deaths so far this year.
“To date we have regressed in terms of low birth weight, we have 19 more children than in the same stage of the previous year. According to experts, this condition is exponentially proportional to death. In the long run, it is almost a breath of fresh air to have such a high number of children being born with extreme weights and fewer than likely deaths.”
—Guaranteeing the training of specialists and supplying the deficit in some hospital services are challenges in the province…
—Currently, the 32 Basic Work Groups (GBT) in the territory have their chief, with control over children and pregnant women in the health area. The number of obstetricians has been completed, so only pediatricians and clinicians are missing; however, certified comprehensive general practitioners cover these functions. It happens that the very dynamics of the sector implies ups and downs in what we now consider an achievement, whether, for example, due to the exodus or maternity leave.
“Obstetrics in Secondary Care is the specialty with the greatest deficit. This affects us, in particular, the guards, because three people are needed to guarantee the third medical criterion and define the conduct to follow with hospitalized pregnant women. In addition, the number of nurses available is small, for this reason, neonatologist nurses who performed other functions have been transferred from their positions and, even, those of the intensive care service are linked to the care of the little ones. This year in the vacancy plan, we request more quotas for nurses, in the medium-technical modality to guarantee speed in training.
─Infections associated with health care were a sour crop in 2021, above all, because they were related to infrastructural problems, has the panorama changed?
—The end of 2021 was very tense. We had an outbreak of sepsis, associated with health care at the Antonio Luaces Iraola Provincial Hospital, which led to the death of several children. Since then, work has been done to solve the structural problems that caused it.
“In the Neonatology room, difficulties related to water, leaks in the delivery and cesarean sections were eliminated, and the climate capacity required by these spaces was technically evaluated.
Gradually, the areas related to the PAMI have been repaired. Thus, today work is being done in the Pregnant A Room and later it will continue in Puerperium, but it is clear that these spaces have a continuous maintenance process because they work 24 hours a day and we have to win at that.
“Similarly, the staff was trained in hygiene standards and the necessary sanitary clothing was completed. Now, we are in better conditions, the only thing missing is control so that everyone complies with what is established.
“The experiences of those difficult days allowed us to control another outbreak of sepsis in the Morón hospital in time. None of the children died and the construction problem was solved quickly”
.—When a maternal death occurs or a child dies, is the case discussed? Is the effectiveness of the followed behaviors evaluated? When do we talk about malpractice?
—At the beginning of this year, we resumed the discussion of morbidity and mortality from the base. When a woman or child becomes seriously ill, we begin monitoring and discussing the case with specialists from the Ministry of Public Health. Then, a team from the provincial Health Directorate moves to the hospital and there continue the analyzes with professionals from the municipality and Secondary Care. There are no random decisions, nor impunity.
“When we have a deceased, each of the actions followed is reviewed and how timely they were. Some measures taken have been in the organizational order and others for training; it is true that sometimes our staff have not had all the knowledge to act.
“When lack of control or administrative negligence has been demonstrated, severe measures have been taken, including the removal of people in charge and specialists from their posts.
“However, in the discussions held to date, no case has demanded to invalidate someone from the exercise of the profession. Death is always a defeat for any health professional, it saddens and hurts”.