pediatric

Pediatric Care And Selected Child Health
Indicators In Cuba

Dr.Fernando Domínguez Dieppa, M.D.*

Medical attention offered children from the time of birth differs from one country to another. Approximately 12% of children are born in developed countries, 18% in the least developed countries and 70% in developing countries. In the current decade, mortality rates range from 6 per 1,000 live births in developed countries, to 106 per 1,000 live births in developing and least developed countries. The positive changes in some health indicators in Latin America and the Caribbean reflect achievements in this region. This includes a decrease in mortality rates for children under 5—from 159 in 1960 to 47 in 1995; and infant mortality rates—from 106 in 1960 to 38 in 1995. Unfortunately these figures do not describe the situation in all countries: although mortality in children under 5 has decreased in some countries, in others it continues to be as high as 1960 levels. There are marked differences among countries and among social groups within a single country.

In Cuba, medical attention to children is provided in the context of the National Maternal-Child Health Program—the health system's number one priority program. Thus, from the moment of conception and even before, the system goes into action to assure the birth of a healthy child without complications, and to ensure the child's survival and continued development.

In 1998 the population was 11.1 million. Of these, 2,464,204 were under 15 years of age (22%), with a total of 151,079 live births and a birth rate of 13.6 per 1,000 inhabitants. The population density is 100 inhabitants per square kilometer.

Medical care is provided at three levels. At the primary care level, there are 440 polyclinics serving 100% of the population, and 20,000 family doctor offices. These services offer patients their first contact with the national health system. This is the level where mothers and their children are guaranteed regular medical attention and follow-up. This process begins with family planning counseling, and continues through consistent care for pregnant women (with an average of 13.5 pre-natal doctor's visits for each). Family doctors and nurses carry out health education activities for pregnant women and their families, including home visits Pregnant women also see specialists in Obstetrics and Gynecology to evaluate and re-evaluate risk factors, at different moments during their pregnancy. They receive a number of laboratory tests including hemoglobin, glucose screening, HIV, special tests for pregnancy-related disorders, and diagnostic exams to detect hereditary anomalies. Furthermore, attention is paid to the nutritional status of pregnant women, who also receive counseling on childcare and breastfeeding. Sometimes, pregnant women are admitted to maternity homes, located in their community, where there are better conditions for their care and easier access to the hospital where they will give birth. The maternity home program receives significant community support.

In cases of pregnancy-related disorders or complications, some women are referred to one of the 117 secondary level institutions with OB-GYN services, where they are seen either as outpatients or hospitalized. This process is closely coordinated with the patient's family doctor, who follows the patient's progress with the specialists.

This program has contributed to a decrease in low birth weight rates (to 6.7% in 1998) and guaranteed that 99.8% of births are institutional, under professional care. Newborns immediately receive attention, and are evaluated by pediatricians who in most cases are neonatologists. Blood samples are taken at delivery to determine TSH levels, followed by testing for phenylketonuria levels. Breastfeeding begins at birth, and is continuously promoted in well-baby doctor's visits, which average 20 during the first year of life.

When infants are born with low birth weight or a particular pathology, their progress is followed by neonatology services as well. There are 40 neonatal ICU's in Cuba. Incidence of Hyaline Membrane Disorder and of Hypoxic-Ischemic Encephalopathy is very low—0.5% of newborns register Apgar under 7 points at the fifth minute of life, and only 1% of newborns are mechanically ventilated. A high number of patients are treated with corticoids for threat of premature birth, and Cuba manufactures a natural surfactant for early, life-saving treatment of infant respiratory distress syndrome. Survival rate for infants with very low birth weight (less than 1500g) is 80%.

Progress of children discharged from neonatology services who are at high risk for neuro-developmental abnormalities is monitored by a multidisciplinary team during the first five years of life. When necessary, neurodevelopmental stimulation and special education plans are implemented. This does not substitute, but rather complements, care at the primary level.

Childhood immunization is carried out according to the vaccination periods, dosages, and application protocols recommended by the National Immunization Program, aimed at prevention and control of 13 infectious diseases. By virtue of the Program's broad coverage, the following diseases are not considered health problems in Cuba today: poliomyelitis, diphtheria, measles, tuberculous meningitis, neonatal tetanus, congenital rubella, mumps, whooping cough, rubella (German measles), tetanus, bacterial meningitis B and C, typhoid fever and hepatitis B.

Preschool and school-age children are cared for in their community and in their schools—1,486 schools and 803 childcare centers have doctors and nurses on staff, representing all such institutions with an enrollment of over 500. All other schools are covered by the School Hygiene Program, which ensures vaccinations and develops specialized programs of pediatric care for different age groups. These include health promotion and prevention activities, education programs for adolescents, sex education, and periodic medical and dental check-ups

Pediatricians are among the specialists who participate in healthy child consultations as members of medical teams based in the community polyclinic, each of which works with a certain number of family physicians in the area. These community-based pediatricians—as well as other specialists-- also see sick children whenever necessary.

Pediatric patients who need hospitalization can be taken to any of the 25 pediatric hospitals in the country, or if necessary, to any of the 11 research institutes offering tertiary care in the country in fields such as nephrology, endocrinology, cardiology, oncology, gastroenterology, angiology, and tropical diseases.

Children who require emergency care can be taken to their municipal Emergency Care Polyclinic at the primary level, or to any pediatric hospital emergency room. There are coordination centers which provide 24-hour transportation services in intensive care ambulances for children who need to be referred to emergency services, traumatology services and intensive care units in pediatric hospitals. There are 35 Pediatric Intensive Care Units in Cuba, where specialized medical and paramedical personnel care for gravely ill children.

All medical attention provided by the Cuban health care system is free of charge for Cuban children and adults.

The following health indicators reveal the progress made in the context of the healthcare model we have been discussing.

Neonatal Mortality by Weight Groups. Cuba 1998

Birth Weight (g)

Live Newborns

Mortality (%)

- 1 500

666

20,0

1500 - 1999

1900

4,4

2000 – 2499

7579

1,0

- 2500

10145

2,9

+ 2500

140776

0,18

Total

150921

0,36

Causes

1970

1980

1990

1998

All Perinatal Affections

15.0

9.4

4.2

2.9

Congenital Anomalies

3.8

3.9

2.6

1.9

Septicemia

...

1.6

0.3

0.5

Influenza and Pneumonia

5.1

1.6

0.3

0.4

Accidents

0.7

0.6

0.3

0.3

* Professor of Pediatrics, Ramón González Coro Maternity Hospital, Havana.

This article was prepared for a workshop of the Tidewater Pediatric Society of Norfolk, VA, and for presentation at the UCLA-Cedar Sanai Hospital, 1999.