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Women’s Healt hcare in Cuba
– Reported, February 13, 2012
In keeping with the concept of socialized medicine, the Cuban government offers a range of health-related services and programs to its citizens free of charge, with a special emphasis on maternal and infant health. My research focuses on womens health care issues; my objective was to observe what types of medical and health-related services are available to women. Statistics from the World Health Organization and the Pan American Health Organization (the Latin American regional office of the World Health Organization also known as PAHO), helped to put into perspective some of the successes and limitations of womens health care in Cuba. In addition, I obtained from the Cuban Ministry of Health some literature that defines Cubas health care strategies for combating specific health problems. I wanted to discuss with Cuban women and healthcare professionals the quality and availability of services to women.
My research centered on the central metropolitan section of Havana called Cerro, which has a population of about 600,000 (Havana City, 1997). While there, I observed different levels of Cubas highly structured healthcare system from the neighborhood family doctors office, to a special maternity home for pregnant women. My research sources included interviews with five Havana-area doctors: two doctors of obstetrics and gynecology, one resident physician, and two general practitioners, one of whom is the director of a Havana clinic in Cerro. Dr. Jorge Puentes-Corral, an obstetrician/gynecologist, acted as my host as he led me on a tour of different medical facilities where I met and spoke with patients and three of the other doctors. I observed twelve patients in the maternity home and spoke with two of the women who were resting in their beds when I arrived.
Structure of the Healthcare System
Total biological, physical, and mental well-being of the Cuban population is the goal of health care providers, said Dr. Jorge Puentes-Corral (personal communication, July 3, 2000). They achieve this through what they call community-based programs, which carry out health care strategies and educational campaigns that the Ministry of Public Health (MINSAP) directs. The health care structure in Cuba begins at the national level with the Ministry of Public Health, and extends through the provincial level, the municipal level, and to the local community . This structure is intended to guarantee that all citizens, even those living in remote locations, benefit from the health care system, a benefit that was not possible in the private medical system that existed before the Revolution.
The Family Doctor Plan
Cuba continues to evaluate and make improvements to its health care system. The Family Doctor Plan is one of these improvements. Until 1984, the levels of community-based medical care included polyclinics and hospitals.
In 1984, the Program of Integral Community Attention, better known as the Family Doctor y 3, 2000). Plan, Los médicos de las 120 familias, was initiated, adding an extra level of community care to the system.
Under this plan, an assigned family doctor attends 120 families in a given neighborhood block. The family doctor lives in the community that he serves, providing primary and preventative care to the 700-800 people in his assigned area. The family doctor carries out any special health-awareness programs that the national level directs. In addition to seeing each patient twice a year, the family doctor is also responsible for maintaining health records and seeing that his patients receive vaccinations and health screenings. Patients usually see their assigned family doctor first and, if needed, receive a referral to the hospital for specialized care, except in emergencies when patients can opt to go directly to the hospital emergency room.
Che Guevara believed that doctors should be humble in their practice of medicine, with the primary motivation being the pride of serving their neighbors. Keeping true to that belief, family doctors live in the same neighborhoods in which they are assigned to serve, and the doctor-patient relationship is a close and personal one. In Cuba, doctors are like friends; tell you their problem, said Dr. Melba-Sosa Leyva , a resident physician who is completing the three years of family medicine training required of all residents . This arrangement between doctor and patient can break down the barriers that are often present in a privatized structure where doctors live in one, usually wealthier section, and the patients live in another. In addition, the income that a Cuban doctor makes is extremely modest compared to privatized standards; Dr. Sosa-Leyva told me that she makes the equivalent of twenty-five U.S. dollars per month.
As was stated earlier, under the socialist system providing health care is the states responsibility. The doctors I spoke with emphatically stated that they take personal responsibility for their patients care. According to Dr. Florángel Urrusuno-Carbajal, it is the doctors, not the patients obligation to see that patients get the care that they need. In fact,when a pregnant woman does not show up for her pre-natal visits, one doctor said that she makes a house call to provide the services in the patients home.
The main objective at the primary care level is counseling and prevention. As an example of preventative care measures, women between the ages of 25 and 65 receive Pap tests every three years. Family doctors counsel patients in order to eliminate risk factors such as smoking, obesity and lack of exercise.
The doctors listed some of the common health problems in women. Obesity is a frequent health problem among women in Cuba . Obesity is more common in female patients than males and tends to increase with age. Other health problems which exist among women include hypertension, anemia and diabetes. In Cuba, 26.3 percent of women aged 15 and over use tobacco. The web site for the Hospital Clínico Quirúgico Hermanos Ameijeiras, located in Havana, lists dates for educational programs that help patients manage these common health problems. Cuba commonly uses mass communication in the form of public service announcements on the airwaves as a way to educate the public about prevention and control of health problems.
The family doctor practices medicine in the neighborhood doctors office called a consultorio. The consultorio is open 24 hours a day, since the doctors home usually sits above his office. J. Puentes-Corralstated that patients rarely have to wait long in the consultorio in order to see their doctor, a common complaint among patients prior to the implementation of the Family Doctor Plan .
While not working in the consultorio, the doctor is out making house calls to one of the 120 families assigned to him. He or she may also rotate shifts at the local polyclinic, which offers more specialized community health care services.
The consultorio in Cerro is relatively small and has only the most basic equipment. The consultorio contains a waiting room where patients can read some health care pamphlets from a small bookcase. An exam room around the corner contains a few medical supplies. The only air that circulates within the rooms comes from open doors and windows. A lamp located next to the exam room provides artificial light, but sunlight comes in through the high, frosted windows located near the ceiling to provide additional lighting. The exam table is a metal table with no additional padding other than a cloth. Medical equipment is laid out in the open on a metal tray. One tool, a cone-shaped object, is used as a stethoscope. Since paper is in short supply, the waiting room bulletin board is decorated with neatly placed cutouts and drawings against brown paper backgrounds, a huge difference from the slick, commercially-produced color charts and graphics that are common in U.S. hospital marketing pieces.
In spite of the lack of high-technology equipment, Cuba has managed to make remarkable strides in the quality of health care that it provides to its citizens. Today, the major health problems and causes of death in Cuba are similar to those of developed countries, including heart disease, cancer, and diabetes. This is markedly different from the main causes of death, infectious and parasitic diseases of 30 years ago .
Like the rest of Cubas population, womens life expectancy is high and comparable or even superior to that of more developed countries. The average life expectancy of women is 74.3 years .
Polyclinics and Hospitals
The polyclinic consists of a group of medical specialties that exist under one roof. The polyclinic offers social services, emergency services, pediatrics, gynecology, diagnostic ultrasound, dermatology, psychiatry, radiology, and statistics, said Dr. Urrusuno-Carbajal , director of the polyclinic in Cerro. The polyclinics are structured so that patients may visit with specialists from 8AM-12PM, and for emergencies from 8AM-4PM. After hours, two family doctors are available all night. Like the consultorio, the polyclinic in Cerro operates on relatively low-tech equipment; for example, the building relies mainly on light coming from the windows, and air circulates through windows and rotating fans. Four polyclinics, approximately 200 consultorios, and a total of 280 family doctors exist within Cerro.
Due to the chain of command required to gain permission, getting access to some of the healthcare facilities depended on the connections and influence of the doctor I was with. I was unable to visit a hospital. In total, 281 hospitals exist throughout Cuba . Dr. Puentes-Corral, however, convinced the guard to let us through as he led me and another student on a brief tour through the corridors of the University of Havanas medical school site, the same one that was converted from a nuns convent in the early years of the revolution.
The Mother and Child Plan
All [national health care programs] are important, but the most important is the Mother and Child program, said Dr. Florángel Urrusuno-Carbajal.This program places a special emphasis on the needs of pregnant women,newborns, and children. Infant mortality decreased from 62 per 1,000 live births in 1959, to 7.2 per 1,000 live births in 1998. Some of the special needs addressed in this program include attention to breast exams, cervical cancer screenings, genetic testing, pre-conception risk, low birth weight, and family planning, said Dr. Carbajal. Educational campaigns, such as breastfeeding campaigns that lowered the infant death rate from acute gastroenteritis, have increased the quality of life for Cuban women and their infants . The efforts to carry out the objectives of these educational campaigns are evident during tours of the consultorio and polyclinic: cutouts and hand-drawn signs taped against bulletin boards emphasize the importance of breastfeeding and good nutrition.
Better data collection methods and research into causes of death make it possible to provide even better medical attention to women and their newborns. Prior to 1969, the causes of prenatal death were not even investigated, but today, all prenatal deaths are recorded in hospitals. Committees at the provincial and national level analyze every maternal death. Since this maternal death analysis was initiated in 1970, the maternal death rate has decreased by more than half, from 70.5 per 100,000 in 1970, to 32.6 in 1995.
In 1996, improvements were made to the first Infant and Maternal Mortality Program, first implemented in 1995. The Ministry of Health designed strategies for dealing with maternal mortality factors, including complications from caesarian sections, pregnancy risks, toxemia, and abortions (Davis, 1998). Other statisticsshowed a decline between 1992 and 1996 in maternal death from 3.3 per 10,000 live births to 2.4.
Maternity Homes
Since Cuba places special emphasis on maternity and infant care, expectant mothers with high-risk pregnancies or other special needs can visit the maternity home where an on-duty nurse lives and is available 24-hours. A total of 209 maternity homes exist throughout Cuba. This particular house in Cerro offers 12 beds, with the majority of women arriving on an out-patient basis. One maternity home exists per municipality, said Dr. Juan Casellanos , director of Cerros maternity house. The common reasons for going to the maternity home are the need for additional nutritional supplements, the risk of carrying a low-weight baby and carrying twins which is also considered a high-risk pregnancy. Cerro is one of the lower-income areas within Havana and frequently a high number of adolescents and single mothers visit its maternity homes. Depending on how critical her needs are, a mother-to-be can visit the home during the day, or she can be admitted by doctor referral, usually at 22 weeks, until the end of her pregnancy. In-patient services are provided to the patients who are at greatest risk.
Obtaining vitamins for pregnant women in the maternity homes is not a problem in Cuba it is considered a priority, said Dr. Juan Casellanos . The supply of iron salts and folic acid in the prenatal period has reduced the incidence of underweight infants . Iron deficiency anemia is the most common nuritional problem in Cuba since 40 percent of women in the third trimester of pregnancy, 25-30 percent of women of childbearing age, and around 50 percent of children up to age three, all suffer from it (PAHO, 1998).
Cuba makes pre-natal care efforts to guarantee a diet of 2800 calories per day . The in-house nurse cooks and provides balanced daily meals to residents in their beds, all free of charge. One of the women I spoke with there told me that as the mother of a small boy, she stops by in the afternoon in order to have a place to rest, and then she leaves in the evening. She said that she found the home to be very calm and tranquil .
Two of the women I observed in the maternity home were suffering from iron deficiency and possibly malnutrition and were sleeping when I arrived. They risked delivering low birth weight infants. Both of these women seemed a little younger than the rest of the other women since they appeared to be in their late teens or early 20s. This age group is the most likely to experience these difficulties during their pregnancies, the doctors explained to me.
Not all the women in this home necessarily suffered from pregnancy difficulties or from problems with dietary deficiency. One woman was an English instructor who was pregnant with her babies, a set of twins. With the exception of two patients whose pregnancy difficulties I mentioned earlier, the patients I spoke with expressed their contentment with the healthcare they received. They appeared happy and pleased with their services that the maternity home provided. One of the things that struck me was their eagerness to make me feel welcome. For instance, in spite of my protests, they sat up out of bed, put the fan towards me, and accompanied me downstairs when I left.
When I visited this summer, this maternity home was two stories high, with patients of the higher risk pregnancies located downstairs. Their beds were metal-framed twin beds with a mattress and pillow and no bedding or sheets. There was a television in the room of the women with the low birth weight pregnancies. A rotating electric fan cooled the room. A tray next to their beds held their belongings.
Obstetrics
Pregnant women receive a number of tests in order to ensure that no complications exist. The average number of prenatal visits per woman increased from 17.2 in 1992, to 23.6 in 1996 . Prenatal screenings are free of charge and include glycemia, urine, vaginal, and ultrasound tests. As early as 1987, Cuba had included HIV testing for pregnant women . During a typical 37-40 week pregnancy, a woman sees her doctor once a month until week 30; from weeks 30-35, she sees the doctor every 15 days. At week 36, she sees the doctor once a week.
Childbirth and Delivery
The doctors goal is for at least 99 percent of all births to take place in the hospital, said Dr. Elena Martinez, a doctor at the Antonio Maceo polyclinic. Home birthing is not permitted. In fact, Cuban doctors have been so successful at this goal that PAHO lists their percentage of deliveries by trained professionals at one hundred percent .
By U.S. standards, Cuban women appear to have fewer choices in their healthcare decisions as far as where they can give birth, who can be present at the time of delivery, and whether or not an episiotomy can be performed. Some of the reasons appear to be due to lack of supplies, lack of space, and in some cases, value judgements about what is best for the patient. During labor, for example, the doctors give local anesthetic with either nidocaine or lidocaine; epidurals are not possible because anethesiologists are unavailable . A list of medicines in critical short supply include anesthetics .
The number of routine episiotomies performed in Cuba during child birth, based on M. Sosa-Leyvas explanation, sounded like more of a value judgement on the part of medical authorities: The deep laceration [of a natural vaginal tear] is too great, and it is easier to repair one cut easily . Although episiotomies are also widely performed in the U.S., the book The New Our Bodies, Ourselves expresses the opinions of those who denounce this procedure as unnecessary in most cases.
Another interesting note is the limitation of a Cuban fathers ability to participate in the delivery. Fathers are not allowed to be present at their childs birth. I received two different explanations for this. According to Dr. Sosa-Leyva, the presence of men in the delivery room might make the delivery too chaotic. A more experienced doctor whose specializes in obstetrics noted that the small delivery room makes it impossible to allow the father to attend the birth .
Maternity Leave and the Law
Two of the doctors of obstetrics and gynecology explained Cubas policies regarding maternity leave from work. The Maternity Law was modified six or seven years ago. Maternity leave is guaranteed by law, and new mothers can take up to a year and six months leave without losing their jobs . In the twelve weeks following delivery, a woman will receive 100 percent of her salary for the first child. After the twelve-week period, the woman will receive 60 percent of her salary if she decides to continue her leave. After a year, she can continue her leave without salary.
Access to Abortion
Abortion is legal, safe, and provided free of cost to Cubans. In the last ten years, one woman died from abortion complications in the entire municipality of Cerro . Abortion is encouraged when the pregnancy will result in grave health problems for the mother or when severe deformities exist for the fetus, the doctors explained. Abortions are by law limited to pregnancies at no later than 20 to 24 weeks. They are permitted only in hospitals. As the father of a five-month-old daughter, J. Casellanos expressed his personal opposition to abortion.
As a result of the economic crisis that occurred in the early 1990s, the number of abortions increased. Women, said Dr. Urrusuno-Carbajal, just did not want to give birth . To discourage abortion as a means of contraception, doctors educate their populations about family planning and contraceptive methods These educational campaigns seemed to be successful. The abortion rate decreased from 70.0 per 100 deliveries in 1992, to 59.4 in 1996.
Birth Control Options and Accessibility
As Dr. Urrusuno-Carbajal pointed out, economic hardships affected many womens decisions to terminate their pregnancies in the early 1990s. The embargo has also affected womens access to medicine and birth control options. Even though contraception is provided free of charge, it is still difficult to obtain. Until 1990, most Cuban women relied on birth control pills as a form of contraception, according to a study by the American Association for World Health . A 1995 merger between a U.S. company and a Swedish company, which supplied the lab equipment to produce the pills, cut off access to repair parts when the equipment broke down. As a result, Cuban women had no choice but to rely on donated pills from other countries that caused imbalances in their hormone levels Dr. Sosa-Leyva did not have much information to give me in relation to this merger and how it directly affected her patients, but she did acknowledge that it is difficult to access certain types of contraceptives. She stated, It is a lot of trouble, but we now are producing part of it . For example, since the IUD is not domestically produced, Cuba has to buy it from other countries, said Dr. Sosa-Leyva.Since condoms are expensive to produce in Cuba, they rely on donations of these supplies from other countries This is unfortunate, since 79 percent of women use contraception.
Effects of the Embargo on Womens Health
The embargo affects Cuban citizens because the patents on many components in special equipment are owned by U.S. companies. When machines break down, the health of the Cuban population becomes endangered. Dr. Sosa-Leyva acknowledged that U.S. policy makes it difficult for Cuba to maintain their equipment. We cannot buy components, said Dr. Sosa-Leyva.
We witness
X-ray
and other lifesaving machinery standing idle for want of US-produced spare parts, said Peter Bourne, chairman of the American Association for World Health. For example, the U.S.-owned Eastman Kodak company produces x-ray film for mammogram machines .
As a result, life-saving preventative care is available to only the highest-risk groups. X-ray screenings for breast cancer are still obligatory for women between the ages of 45 and 55 years . Until 1990, however, all Cuban women over 35 received regular mammograms. In the mid-1990s, the lack of x-ray film caused the shutdown of breast cancer screening programs .
Even access to basic but necessary medicines and supplies are affected by the crisis. According to Randal, Supplies such as rubber gloves, are reserved for surgical procedures. Peter Greenberg, M.D. of the Stanford University Medical School, found that the embargo has affected Cuban doctors patient management due to lack of antibiotics, equipment, current textbooks, and basic medical supplies (2000). One doctor admitted that the lack of medicines sometimes forces doctors to try to find substitutes for needed medicines. When you need one kind of medicine for one patient, it is hard to ask for a change .
Several researchers agree that Cubas commitment to providing health care has kept the system functioning. According to one World Health Organization official, Cuba has invested more in health services than almost any other country, and it has a higher health profile than the United States . Several studies contradict the U.S. State Departments assertion that Cuba, not U.S policy, is to blame for the crisis. The Special Period in the early 1990s forced the Cuban government to drastically reduce its spending on healthcare: from 227.3 million in 1989, to 56.9 million by 1993 . Theodore MacDonald, author of A Developmental Analysis of Cubas Healthcare System since 1959, stated that Cubas high allotment of its budget to provide healthcare to all its citizens saved the island from what he calls human catastrophe. In addition, a 1997 study by the Washington-based Association for World Health, which is affiliated with the World Health Organization, supported MacDonalds finding by acknowledging that the Cuban governments high priority to its health care system averted what they also called a human catastrophe. .
In spite of setbacks caused by economic factors, Cuba has maintained its commitment to providing free health care to its citizens. This is not to say that criticisms of the system do not exist. I found the doctors that I interviewed to be accommodating and willing to answer my questions. I sensed a strong spirit of commitment to their profession, not out of material gain, but out of concern for people. The people whom I interviewed about the Cuban health system, even casually, spoke about it with pride. By observing the health care of women in particular, it seems that Che Guevaras belief that human life is invaluable has been preserved through the decades, even during the most difficult times.
Credits: Stephanie Bernal
More Information at: http://international.csusb.edu/Pages/journal/cuba/women.html
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