MR INTERVIEW

Fernando Domínguez, MD PhD, FAAP
Neonatologist
Vice President of the Cuban Society of Pediatrics

By Michele Frank, MD

Dr. Fernando Dominguez is chief of the Neonatal Intensive Care Unit at Havana's Ramón González Coro Maternity Hospital, Professor of Pediatrics and Neonatology at the Higher Institute of Medical Sciences, and honorary member of the American Academy of Pediatrics. In recent years, he has been a key member of the team that has developed a nationwide program for follow-up and support of high risk infants, and at the forefront of specialized care for babies born with problems for whom it is particularly important to anticipate sequelae and potential neurodevelopmental challenges, to promote early detection and apply timely and individualized interventions during the first year of life.

MR : Tell me a bit about the national program for maternal-child health.

FD: Yes, we call it "PAMI" or "Programa Nacional de Atencion Materno-Infantil." It's taken very seriously, and one important aspect is to guarantee adequate and appropriate care for children, particularly during their first year of life when they are most vulnerable. The Ministry has issued a detailed document serving as a guide for health professionals that outlines the program, its objectives and also requirements and policy in terms of providing for the health of Cuban children. Periodically it is revised and the oversight and monitoring responsibilities rest with the PAMI program departments-nationally at the ministerial level, and then at provincial and municipal levels of the health system.

MR: I understand that PAMI monitoring includes case-by-case analysis-especially in the case of infant deaths. Is this kind of detailed review unusual internationally?

FD: I suppose so, compared to other countries. For example, every infant death is thoroughly discussed, analyzed in detail, investigated. The reports must meet rigorous standards and involve all levels, to seek the answer to what went wrong-and to learn from the experience to prevent it in the future.

One of the things that I find most interesting about the program is that it begins before women get pregnant - in fact, before conception. In this sense, it emphasizes primary care and early risk-factor identification. So it's a program not just involving obstetricians, pediatricians or neonatologists: the family doctor has a critical role to play. ( Family doctors cover 99.2% of the Cuban population, according to Ministry of Public Health data fro 2003, Eds .) So, for example, one goal is for women in their reproductive years to have their children at the best possible time for them, in terms of their health situation. At the primary care level, this means family physicians and community health promoters work with families and particularly with women, the mothers-to-be, to try to ensure that each one has her child (or children) in the best possible conditions. This can be very important in the case of a woman who is diabetic, for instance, or for the woman who has already had one or two low-birth weight babies - women who have risk factors, whatever they may be. It relies on health education, planning, family involvement, sometimes even community support, helping to ensure that she is at her healthiest, that everything is in balance and that all the necessary precautions are thought through.

The idea is (for the woman and her health care providers) to be well prepared from a biological, psychological and social point of view. This is the preconceptual early risk identification program. The system is mobilized to guarantee the best possible outcome individually for each woman: to prevent another low-birth weight, to help a woman with diabetes be able to have her baby - there is even a special program for women who are HIV-positive and who want to have children.

And for women without risk factors, counseling and medical attention are of course available to plan for a healthy pregnancy.

This is what I meant when I said that well-baby care begins before conception. This is important, of course, since these circumstances and good pre-natal care significantly impact the quality of the baby's first year of life.

MR: How is pre-natal care implemented?

There are national guidelines for the basic components, as I mentioned. (In terms of education), child-birth classes are encouraged, for mothers and the fathers, too. We have a program called conscientious parenting, an educational program, and parents get time off from work to attend the classes. From early on in their pregnancies, women also receive health education concerning the importance of breast-feeding.

Early detection of potential problems receives special attention. So, in addition to regular visits to each woman's family doctor where her health is monitored, she will have consultations with her obstetrician and other specialists as required, including pediatricians.

Regular monitoring of each pregnancy ensures early detection of difficulties. We carry out a number of routine screenings, such as alfafetoprotein for neural tube defects, ultra-sound, and other diagnostic tests. Thus, the program makes it possible for a mother to decide whether or not she wants to interrupt the pregnancy if there is a problem clearly incompatible with life. There are certain conditions that can be detected in the fetus, whose prognosis indicates that the fetus will perish in utero or the infant will die soon after birth. In such cases, the mother can choose to interrupt her pregnancy. Also when the mother's life is clearly in danger, that choice is available. (In the early stages of pregnancy), an woman can choose to have an abortion (for a variety of reasons). But when the pregnancy is farther along than 10-12 weeks, having an abortion is only an option in these kinds of extreme cases.

MR: What about an unplanned pregnancy or an unwanted pregnancy? What is the Cuban policy in terms of abortion in these cases?

FD: There are two aspects to your question. In the first place, the life-threatening cases we were talking about, a serious disease or malformation incompatible with life: the interruption or abortion doesn't take place before the 10th or 12th week because it's really not possible to make such an early diagnosis of these problems. Usually the condition is detected between the 18th and 20th week. However, this doesn't mean that everyone chooses to abort. There are babies born with serious, often fatal congenital malformations, neural tube defects, etc. We offer genetic counseling, but the decision is made by the mother or the couple. In these cases, an abortion is permitted after week 10 and usually up to about week 20 - only when there is certainty that the condition is incompatible with life.

Now, with regards to the other type of abortion: this is a fairly straightforward and acceptable matter prior to the 10th week of pregnancy. It's an individual decision, a choice that we respect. However, we do not encourage it, and in fact a lot of work is being done to discourage it, to educate women and men about the risks and potential health consequences of abortion-especially the dangers of using it as a method of contraception. There is easy and free access to birth control and family planning in Cuba, so for the medical profession, the issue of abortion is considered a health problem that we are trying to address. We are working to reduce the number of abortions - not as a moral question, since that is up to each individual couple, but rather as a health issue.

MR: You mention family planning and education. How would you rate the public's level of understanding of genetic issues; the level of confidence in maternal-child care in general?

FD: The way I see it is that Cubans in general have a sort of "genetic consciousness". And in general, families know that children hardly ever die. They know that 99% of the babies that are born alive in Cuba reach their 5th birthday - a bit more, 99.2%. Cuban mothers know that there is a health care system in place that guarantees that their children will live to be 5 years old and they also know that most children who make it to age 5, live to be adults. There's confidence in the health care system and in PAMI, availability of information, and access to resources.

I would say there is a high standard of neonatal care in Cuba as well. Approximately 1.5% - 2% of newborns have trouble at the moment of birth, and within 5 minutes only 0.5% are still having difficulty. This is very low, extremely low, meaning these are excellent indicators. In Cuba we apply the same criteria and procedures recommended by the American Academy of Pediatrics for neonatal reanimation ("The Neo-natal Reanimation Program"). All of our personnel are trained in this program which is a very good program used in many countries.

MR: So basically, the Cuban school of neonatology is the same as the U.S. school?

FD: We are less invasive than they are in the States. We are more able to focus on each patient as an individual and assess what would be best for each baby, what will work best given the particular family. We can give very individualized care here in a manner that is more difficult to do in countries like the United States. Because we know the mother since before conception-here again the importance of the neighborhood family doctors-we have an easier time developing personalized, individualized plans for all the babies born. Our statistics are on par with the Scandinavian countries where there is a strong bio-psychosocial focus like ours.

MR: What about low birth weight?

FD: Low birth weight of less than 1500 grams is about 5.5%. It's been like that for some time now.

MR: Do the low birth weight statistics compare favorably with those of other countries?

FD: They're on par with many developed countries.At the beginning of the (economic crisis), in the early 90s, there was a rise in low birth weight babies. We caught it fast, though, and we worked on it, particularly in terms of guaranteeing better nutrition for pregnant women. But within the group of low birth weight babies, those who weigh in at less than 500 grams are the ones with real problems, and these statistics haven't improved all that much. At the beginning of the 1990's it was 0.5% and in the early 2000s it had only gone down to 0.4%.

MR: And these babies that are born with very low birth weight are they registered as abortions?

FD: No. Only babies with malformations or anomalies that are known to be incompatible with life. When the child is born alive, he or she gets full attention. We do everything we can to save them.

Again, thanks to the maternity homes and other community projects like the lunch programs for pregnant women, the statistics are improving. The other thing we've done is create specialized centers at designated hospitals for very high risk women and babies, so since we usually know ahead of time that there may be a problem, we can hospitalize these women there. This makes a big difference- the babies go to the specialized centers and neonatal care units in utero instead of later in an ambulance.

MR: So more of these babies are living?

FD: Yes, and that's where the importance and necessity for good follow-up comes in. Babies who were in critical condition at birth do not die nearly as often as before. They live, but often with neurological challenges that are important to detect and begin working on as early as possible. Neonatal mortality is way down - it's below 4 per 1000 live births.

MR: That low?

FD: Yes between 3.5 and 4. The rest of the infant mortality is in the 28 day to one year age group. So this is the challenge now. The maternity homes have helped a lot, and the advances in community-based services and pre-natal care. But really, in order to reduce the infant mortality rate much below 6 per 1000 live births, we'll have to reduce the neonatal mortality rate, which is due primarily to low birth weight.

This is why good follow-up and paying close attention to neurodevelopmental issues become very important. That's why we're putting so much emphasis on this aspect. We have trained personnel working with all the high risk cases at the community level now. The more we lower the infant mortality rate-and we're getting down to about as low as is likely to go-the more need there will be for diligent follow-up. Because many of these babies could have sequelae, consequences as a result of the difficulties they had at birth or from the procedures and treatments necessary to keep them alive.