If there is a fact that is associated with life, it is giving birth. Nobody conceives that the birth of a child comes transmuted into a pain that exceeds the physical pain of bringing him into the world. Nobody expects it.
If modern obstetrics and gynecology have focused on anything, it is gaining ground, more and more, to the risks and imponderables on that threshold that separates life from death. The objective of doctors, nurses and other professionals, of hospitals and health systems, is that neither baby nor mother die, that they begin this path together with health and joy. Sometimes it does not happen that way. Moreover, it hurts the family deeply, and it also affects everyone involved in the process. They are all marked.
The news of the unfortunate death this month of January of eight newborns with low birth weight and prematurity at the Diez de Octubre Gynecology and Obstetrics Hospital (known as Hijas de Galicia), in Havana, shocks us and forces us to seek answers.
Because if historically there has been a prioritized program for the Cuban public health system, it is precisely the maternal-infant program, and because there are causes and conditions that are not necessarily exposed in the epidermis of a problem, but on which one must inevitably focus. In addition, the analysis.
According to the informative note issued by the Ministry of Public Health, four of the eight children died as of January 11 with presumptive signs of sepsis, and the others for other causes related to their delicate state of health.
What do we know about what happened?
Although an investigation is underway into the causes and conditions that could have gravitated on this sad event, Cubadebate spoke with Dr. Yaima Rodríguez Espinosa, a first-degree specialist in pediatrics and head of the maternal-infant section of Havana.
According to the specialist, from the second half of December 2022 there was an increase in neonatal morbidity at the 10 de Octubre Maternal and Child Gynecology and Obstetrics Hospital, especially in preterm newborns CIUR (retarded intrauterine growth or low weight).
In other words, more patients arrived at the neonatal intensive care room.
As it is already known, the events involved low-weight children or CIUR who were being cared for in the low-weight cubicle of the neonatology ward.
"Since January 11, given the clinical suspicion, deterioration and subsequent death of a baby with presumptive signs of sepsis, associated with risk factors, and which made these children more vulnerable, measures began to be taken that allowed us to identify other cases in the service”, pointed out the specialist.
She clarified that not all deaths were related to this sepsis event, which is being investigated today to determine exactly what happened. “Those deceased had other causes. Some had been treated in intensive care for more than 20 days for their health conditions," she held.
“Another case was a 29-week-old baby weighing just 1,100 grams (his mother is a critical mother who arrived at the hospital with severe eclampsia), before which we proceeded to terminate the pregnancy for the benefit of the mother. We knew from the beginning that we were facing a heroic act if we were able to save his life," the interviewee alleged.
That is, four children not associated with sepsis died due to extreme prematurity and CIUR. From birth, they went directly from the delivery room to the neonatal intensive care unit, Rodríguez Espinosa said.
The head of the maternal and child program in the capital explained that this situation did not occur in the entire hospital or in the entire intensive care unit, but was confined to the specific cubicle for low-weight babies.
“This neonatal care unit is divided into an intensive care unit, an intermediate cubicle, a low-weight cubicle (which is where preterm infants go to promote their weight gain) and a pathological cubicle.
"That is why we are talking about preterm CIUR children, cases in which, given the clinical suspicion of worsening, the alarm went off and we began to look together with epidemiology for possible causes, which generated various actions," she clarified.
The specialist explained that when talking about a pathological cubicle, it is the one intended for babies who leave the intensive care unit, who were born with a pathological condition – a bronchopneumonia – and go to that cubicle to receive antibiotic treatment. The cubicles are separated from each other, each with its nurse and its established rules.
The sepsis event manifested itself there and did not affect the rest of the cubicles, whose patients are asymptomatic. Rodríguez Espinosa pointed out that "in an emergency of this type, you observe the patient, look at the evolution, extract samples for the blood culture and at a later time, according to the results, leaving scientific evidence that there is no infection or contamination, take the necessary actions relevant.
"There is no contamination in the rest of the intensive care, and in the case of the cubicle that was exposed, there are currently four patients located in an extension created emergently, all with favorable evolution so far," she specified.
According to the specialist, with an increase in morbidity there is a greater risk of contracting an infection associated with health care. “When the patient requires more intensive care, there is more risk. If you're ventilated seven days, 10 days, you're running the risk of ventilator-associated pneumonia and that's a healthcare-associated infection. Because intrahospital germs exist, so we try to shorten the time with intensive care and have favorable results”.
Among the actions adopted, Rodríguez Espinosa mentioned the reinforcement of medical and nursing personnel in the service.
“Although the medical and nursing staff were fully in the service, the assistance and the number of nurses increased due to the suspicion of infection, since managing a critical patient in these circumstances requires greater care. We have placed a nurse per patient, regardless of the pathology, whether it is septic or not, to ensure the least manipulation of the babies”.
Given the clinical suspicion of sepsis, measures were also adopted from the clinical-epidemiological point of view. Samples were taken from all neonatology children, regardless of whether they were in the cubicle or not.
“All of them were studied and samples were sent to two microbiologies, the one at the Eusebio Hernández hospital and the one at the Pedro Kourí Institute of Tropical Medicine (IPK), for comparison. According to clinical behavior, all children currently in neonatology are asymptomatic," she specified.
Although the lack of drugs and resources such as expendable material is a reality that has a negative impact on the health system in the midst of the economic crisis that the country is experiencing, both authorities from the sector in the province and from the hospital affirmed that from the outset the insurance medical and non-medical for the neonatology service was and is guaranteed.
"We even had all the necessary availability of colistin, a state-of-the-art antibiotic used for gram-negative bacteria, as well as other antibiotics that we applied," Rodríguez Espinosa affirmed.
She added that direct communication with family members, accompaniment and continuous information have not been lacking.
What characteristics does this hospital have?
“We are in a hospital where around 5,000 births occur each year. Last year we closed with 4,800 births. Due to the magnitude of the number of births we attend, this is the second largest maternity hospital in Cuba. It provides medical care to seven of the 15 municipalities of Havana, adding as an additional task the perinatal and neonatal management of other provinces and the special municipality of Isla de la Juventud. The risk of facing events of this type is greater,” Rodríguez Espinosa said.
The head of the Maternal and Child Program (PAMI) in the capital said that among the care functions of the institution is assisting in the perinatological and neonatological management of patients under 1,500 grams, that is, of future mothers who can provide preterm infants and of children born with this condition, including those whose weight does not exceed 1,500 grams.
Rodríguez Espinosa also recalled that this hospital is one of the three reference centers in the city and nationally for the care of CIUR children.
“We are talking about children who have medical conditions, important risk factors. The normal thing is that we are born at term, between weeks 37 and 42 of life. If it is born earlier, the baby is immature and its behavior is not the same as that of other patients, since it is immunocompromised and more vulnerable to medical complications.
“If, in addition, he is born weighing less than 2,500 grams, the risk factors increase. In not a few cases we are faced with extreme prematurity: children born at 28, 30, 32 weeks of life, and whose weight ranges between 1,500, 1,900 and up to 2,000 grams, without reaching 2,500.
“Many times we have said that these are children who are already born sick. The initials CIUR [retarded intrauterine growth or low weight] are explicit in their meaning. It is a retarded intrauterine growth, the patient stopped growing inside the uterus. Of course, doctors are trained to carry out actions that contribute to modifying this condition.
"We have very good results in the management of the CIUR, but many times the result is not what we expect when faced with a patient who is vulnerable, who has risk factors and to whom you are going to apply intensive care in order to transform that reality and obtain an improvable result”, she simplified.
“It is not idle to remark –he pointed out– that they are patients with multiple punctures or with difficult vascular access, parenteral nutrition is applied to them to accelerate growth and to be able to have another type of result. When they are born immunocompromised, their response to aggression is different from that of a full-term baby with an adequate weight”.
See also “the causes of the causes”
Low birth weight and preterm delivery are two indicators that significantly affect the results of the Maternal and Child Program, authorities from the Ministry of Public Health have explained on multiple occasions.
The incidence that these conditions have on infant mortality is a global problem. Data from the World Health Organization shows that around 7,600 newborns die each day due to complications of being born prematurely.
"Two thirds of these deaths could be prevented without intensive care," says the international organization.
That the complications of premature birth are the main cause of infant mortality in the world, above other factors, is something that should not be ignored.
At the end of 2022, the low birth weight rate in Cuba was seven per 1,000 live births, and the prematurity rate has been around 5% in the last 10 years.
"Prematurity in Havana is associated, above all, with an important risk factor: arterial hypertension in pregnant women, or that which develops during pregnancy," the head of the Maternal and Child Program (PAMI) in the capital said.
"Furthermore, an important genetic factor influences this, the miscegenation, the family predisposition to suffer from it, as well as the eating habit that one has," she added.
In his article "Prematurity: a problem pending solution", published in 2021 in the Cuban Journal of Pediatrics, Professor Fernando Domínguez Dieppa, from the Ramón González Coro Gynecobstetric Teaching Hospital, affirms that prematurity is the main problem in contemporary perinatology .
“In almost 40% of premature births the cause is unknown; however, researchers have made certain advances in identifying them and it is known that prematurity has a genetic basis in many cases”, points out the specialist.
She stresses that “today it is known that the prevention of complications and deaths due to preterm birth begins with a healthy pregnancy. Quality care before pregnancy, during pregnancy, and between pregnancies ensures that pregnancy is a positive experience for all women.
“The World Health Organization guidelines on antenatal care include essential interventions that help prevent preterm birth, such as advice on healthy diet and optimal nutrition, or the use of tobacco and other substances; ultrasound measurements of the fetus, which help determine gestational age and detect multiple pregnancies, and a minimum of eight contacts with health professionals throughout the pregnancy, in order to identify and treat other risk factors such as infections that may lead to to develop hypertension.
For Dr. Rodríguez Espinosa, hypertension and CIUR are elements that come together and make it necessary to terminate the pregnancy in the face of obstetric pathologies to protect the life of the mother.
Dr. Yaima Rodríguez, Head of the Maternal and Child section of Havana, during her statements to Cubadebate. Photo: Abel Padrón Padilla/ Cubadebate.
“Gynecology and obstetrics is a very complex medical specialty, because it is the only one that has to face two situations at the same time: the life of the mother and the life of the child, and it is faced with the dilemma of having that child born before of time to save the woman's life. We are talking about eclampsia, preeclampsia," he said.At the close of January 15, 2023, the low birth weight rate in Havana was 8.04 per 1,000 live births, a figure higher than that of the same date in 2022 (7.95).
“It is an indicator that refuses to decrease and which is influenced, in addition to hypertension, by a history of previous preeclampsia, unfavorable maternal conditions, eating habits, obesity, pregnancy in adolescence, the consumption of tobacco or other substances and malnutrition…”, explained Rodríguez Espinosa.
In Cuba, more than 17% of births today correspond to women under 20 years of age and the figure is growing significantly in some provinces of the country. Babies of teenage mothers are often underweight and premature.
In the event of a preterm birth, “the most common short-term conditions are respiratory distress syndrome due to immaturity of the lungs, patent ductus arteriosus, intraventricular hemorrhage, connatal and nosocomial infections, necrotizing enterocolitis, and retinopathy of prematurity. In the long term, anemia, bronchopulmonary dysplasia, community infections, malnutrition and some neurodevelopmental disorders (motor insufficiency of cerebral origin, intellectual disability, autism, decreased vision and hearing) can be seen," Professor Domínguez Dieppa points out in his article.
According to the data provided by the expert, more than 90% of extremely premature babies born in low-income countries die in the first days of life; however, in high-income countries less than 10% die. In Havana's neonatology services, the survival rate is 95%.Individual and social determinants, a comprehensive look
Avoiding non-communicable chronic diseases such as obesity, diabetes and hypertension – which put the pregnancy at risk and can lead to the need to terminate it before term to save the life of the woman, with negative consequences for the baby – is one of the one of the main challenges on this path, which implies challenges not only for the health system, but also for the socioeconomic framework of Cuban families.
It is not possible to bet solely on treating people without changing the causes of the diseases (lifestyles, consumption habits, diets and others) if what we want and need is care for health and life.
Social determinants, those "causes of causes" including living conditions, have a direct influence on the health of the population, as predictors of health inequity, and their influence on the structure of behaviors related to health.
In other words, health is also a socially determined element, since social conditions translate into consequences for it. Health care, although relevant, is not the main force that determines people's health, but one more. The factors that make it possible to improve or maintain health are just as important as the services we go to when we get sick.
Behind the low birth weight and the prematurity rate are also the conditions in which Cuban women are getting pregnant, and which require a more holistic look. The signs are even in the statistics that show growing problems such as adolescent fertility, or the increase in non-communicable chronic diseases directly linked to lifestyles.
This does not mean that the reorganization and recovery of the health system are not essential, after a pandemic that put each of its components in tension.
The MINSAP authorities themselves have pointed out multiple problems that currently weigh on the PAMI, such as the need to close gaps in the dispensing of pre-conceptional reproductive risk, errors in the prenatal diagnosis of diagnosable congenital defects, the incidence of low birth weight, the non-use of maternity homes, the number of pregnancies in adolescence, the deficit of medicines, expendables and equipment that guarantee the sustainability of the program, non-compliance with hygienic-sanitary standards and procedures that condition the appearance of infections associated with health care and the occurrence of institutional outbreaks, and structural problems in institutions and care services for pregnant women and children.
If all these gaps were shortened tomorrow (the highest aspiration of professionals in the sector), there would still remain in that causal chain of elements that influence a healthy pregnancy as many determining areas of analysis.
Perhaps the first step is to understand that the health of mothers and babies is something more than a right to be guaranteed in hospitals or by family doctors and nurses, and that it is the responsibility of a society and its institutions as a whole and, of course, of mothers-to-be, their partners and families.
To find an answer to whether there were possible failures in the services in this unfortunate event, there is an ongoing investigation. But it does not need to conclude so that, without ceasing to attend and think about what unfortunately happened, also analyze as a country, with a more comprehensive look, the causes, which are diverse and not all precisely sanitary.