How Cuba’s Authoritarian System Enables Obstetric Violence

Cuba’s childbirth care system prioritizes infant mortality statistics but ignores quality indicators and humanized childbirth practices.

By Partos Rotos, a collaboration by Cuban journalists

HAVANA TIMES – On August 12, 2015, at two in the afternoon, Paloma López called the ambulance that would take her to Ramón González Coro, an OB-GYN hospital in Havana. Early that morning, she decided to start her labor at home, as she had heard about women being ill-treated at the hospital.

When she arrived, she was six centimeters dilated but her water had not broken. “They took me to the gurney to monitor me, they lifted me and took me to a strange room. Then, without any warning, (the doctor) took out a pointy object, and bam! She stuck it in me, and it hurt. I screamed, ‘what is that!’, and it was to break my water.”

The obstetrician threw all her weight on Paloma’s stomach and used her forearm to press on the uterus to push the baby down. Paloma was startled and struck away the doctor’s hand. As she was leaning on her with her feet practically up in the air, the doctor fell to the floor.

“Look at this bitch, she doesn’t want to be helped! She’s going to kill the baby,” Paloma recalls the doctor shouting.

“Doctor, don’t say that! You have to ask me for permission.”

“No, you don’t have a clue.”

The physician tried to apply the maneuver several more times. Paloma reacted in the same way and continued to push her off. Moments later, while trying to overcome the pain, she finally allowed the obstetrician to climb onto her stomach. “They pulled me. I felt the tearing of my baby girl, how they pulled her out,” she says. “Now I know that it was premature, that it wasn’t an organic birth. And I got a huge tear from the baby down there.”

A problem in Cuba and around the globe

Over the last two years, an increasing number of Cuban mothers have shared their childbirth experiences on social media platforms and independent news outlets. Their stories have unleashed an obstetric #MeToo on the island.

Some mothers report feeling verbally or psychologically mistreated. Others said they were denied information about what was happening to them or were never asked for consent to perform harsh interventions. Many described their childbirth as a traumatic event in which they were treated as if they had no autonomy and felt that their well-being was irrelevant.

For some, the problem was that they suffered excessive medicalization or aggressive practices. One of these practices is known as the Kristeller maneuver, which involves applying manual pressure on the ribs and has been questioned by the WHO since 1996. Another common procedure is called an episiotomy. It is performed by making an incision in the perineum, a tissue located between the vagina and the anus, to facilitate childbirth. This is often performed without consent and/or when it is not required.

Other patients said they felt neglected or ignored.

Their testimonies have helped shed a light on a problem that happens in most countries, but which had remained especially invisible and naturalized in Cuba: obstetric violence.

This study, Partos Rotos (Broken Births), shows this is a systemic problem in the country. Over 400 women from all provinces participated in the study. They filled out over 500 questionnaires that asked them about their births. Most of the births described were performed either by C-section or vaginal delivery and took place in the last two decades.

The research is not based on a representative sample and its results have no statistical validity. However, it is a broad enough sample to provide an overview of how obstetric violence is prevalent in the country.

The interviewees describe a health system in which their requests for pain management are ignored (86%) and aggressive procedures – that are no longer systematically performed in other countries – are still common practice in Cuba. Manual dilatation or tourniquet was performed in almost 50% of the deliveries, and the Kristeller maneuver was also applied in a similar percentage. On the other hand, episiotomies were carried out in three out of four cases.

Respondents also noted that lack of consent and ill-treatment were common. Nearly half of the women voiced that medical personnel acted without seeking their consent, which violates patients’ human rights, according to the United Nations (UN) Special Rapporteur on Violence Against Women.

In addition, 41% of the mothers interviewed reported suffering verbal or psychological violence, and that medical staff ignored their requests or even accused them of putting their babies’ lives at risk.

Cuba is not the only country where these and other violent medical practices against women are still common. This is a global phenomenon that originates in sexism and a patriarchal culture that permeates health systems.

According to Eva Margarita García, a doctor in Anthropology and author of the first thesis on obstetric violence in Europe, obstetric violence is the result of gender violence and medical malpractice. She defines it as the violence that health personnel exercises on women’s bodies and their reproductive life through dehumanized treatment, medicalization abuse, and pathologizing of their physiological processes.

García believes this violence is mediated by a gender bias that infantilizes women and serves as an excuse to treat them in a degrading manner. However, this is such a socially normalized practice that it is often difficult to identify it as a problem.

In Cuba, however, certain factors make this a particularly acute problem. For instance, according to health professionals interviewed for this research, the Cuban health system is a top-down organization in which physicians have little room for reform.

They are under strong pressure to maintain certain statistical indicators, especially regarding infant mortality, and have little incentive to improve the quality of care or consider the mothers’ well-being. Moreover, in a country that is regarded as a medical powerhouse and is under authoritarian rule, the scope for recognizing and addressing the problem is narrower than in other countries.

Sexist stereotypes

In carrying out this report, we interviewed eight medical specialists, four women, and four men, who are actively participating or have previously participated in the Maternal and Infant Care Program (Programa de Atención Materno Infantil, PAMI), a program that centralizes women’s reproductive health in Cuba. All eight specialists chose to remain anonymous for fear of reprisals, such as losing their jobs or being expelled from the Ministry of Public Health (Ministerio de Salud Pública, MINSAP).

Interviews with these physicians suggest that, in Cuba, gender stereotypes that influence how women are treated during childbirth are still very much prevalent in the health care system. For example, a general practitioner with decades of experience in the country’s central region justified several practices of obstetric violence, “especially in women with delayed labor or in women who are namby-pamby or stubborn.”

There is also an inclination to see women in labor as ignorant and/or expect them to be subordinate. Informing, asking for consent, allowing them to have companions, or simply walking around during labor is seen as an obstacle for the professionals to carry out their job. As the interviewed specialists stated, these are not common practices. “Priority is given to the baby, caring for the newborn, and that the mother does not bleed, forgetting the psychosocial being,” a gynecology and obstetrics resident in Holguín explained.

Some obstetricians also believe that childbirth is always painful, so alleviating suffering is therefore not a priority. In addition, patients who request C-sections are seen as seeking “comfort” and are “forced” into vaginal delivery.

The expectation that women obey medical indications without protesting is also common among health personnel. This notion is so deeply rooted that the women themselves have begun to tell each other that it is better to “collaborate” or “behave well” – expressions that were regularly mentioned in the questionnaires – to avoid worse forms of abuse.

Sandra Heidl, a psychologist and feminist activist who gave birth in Cuba when she was 19, believes that “the product, the fetus, is the most important thing” to the Cuban public health system, and women take a backseat as the recipient of the product. Women take or are unaware of this violence because they want the best for their unborn child, and they have been told that physicians must decide for the babies’ sake,” Heidl explains.

This subordination of the patient to the physician is a feature of what is known as the Hegemonic Medical Model (HMM). Daylis García Jordá, the author of one of the few studies on obstetric violence in Cuba, considers that the HMM tends to see the patient as ignorant or the bearer of wrong ideas, while knowledge resides only within the physician. García Jordá explains that, despite the recent criticism against this model, it continues to be in full force. As a result, it gives way to a childbirth experience in which the physician matters and the patient does not.

In fact, health systems in many countries are designed to meet the physicians’ needs, according to Dr. Matthias Sachsee, a German specialist in health care quality with experience in Mexico, and Thaís Brandao, a Brazilian researcher in sexual and reproductive health.

Cuban medical professionals acknowledged that certain violent practices are performed due to the physicians’ convenience, such as the indiscriminate use of episiotomy. “It’s the easy way for the specialists to perform the delivery, to do it quickly because they just want to get it over with,” said a Gynecology and Obstetrics in Holguin.

Other common practices such as prohibiting pregnant women from walking or having company, performing enemas, or denying them pain medication are also related to the needs of the system or the physician’s preferences, without consideration for women’s needs and suffering.

For all these reasons, researcher Brandao says obstetric violence has “institutional roots” and its main cause is the system’s unwillingness to address the problem. In her opinion, obstetric violence does not stem from a lack of resources. “You can promote healthy, non-violent births even without any resources, because (as a government or system) you understand that this is what’s important,” states Brandao.

A unique birth

Since 1975, almost 100% of births in Cuba take place in public hospitals. Unlike pregnant women in other countries, Cuban women have no say in where or how they give birth. They must give birth in the only existing system controlled by the Minsap. Thus, Minsap’s rules, priorities, and shortcomings broadly shape the experience of giving birth on the island.

That institution has shown that its main objective is to keep certain indicators low, especially infant mortality: the number of children who die during or shortly after childbirth. This is the rate that the authorities proudly present every year to showcase the success of their childbirth care system. “It is the best-kept statistic in the ministry,” assured one of the interviewed physicians.

“In Cuba, the system is structured in a way that responds more to numerical parameters and works in response to the professionals’ needs or those of Public Health as an entity when bringing a new life into this world, and not of the women and their families,” specifies academic García Jordá in her study.

The interviewed professionals agreed that the Minsap pressures them to deliver excellent statistics and comply with strict protocols, which discourages them from introducing changes or acting according to their medical judgment. It is also common for them to have to meet quotas, for example, on the maximum number of C-sections they can perform.

Many physicians condemn the pressure they are subjected to. Some feel the inflexibility of the protocols makes them mere executors of policies designed by bureaucrats who don’t know the reality in which they work.

“It is unacceptable that a program involving human management is based on meeting indexes and parameters. Physicians cannot be thinking about numbers, figures, or emulations while caring for a patient’s life. So, you work under a lot of pressure”, states a retired obstetrician who worked in the field for over 20 years.

A recently graduated physician agrees. “For me, (OB-GYN) is one of the specialties where you have to be most careful because heads are cut off at any moment for any reason.”

From the authorities’ perspective, the system works because they achieve the statistics they aim for. Fewer mothers and newborns die in Cuba than in most countries in the region, which allows the government to boast about its system. The infant mortality rate is very similar to the rates presented in countries such as the United States. In addition, maternal mortality, although much higher than in the countries in the Northern Hemisphere, is among the lowest in Latin America.

However, there no statistics are collected on obstetric violence or the absence of humanized childbirth. Despite the abundance of Minsap protocols, the professionals interviewed agreed that the principles of humanized childbirth, which some countries are now starting to apply, are little known in Cuba.

“If you refer to the international bibliography, you learn about it, but the practical course does not mention it. It’s not a topic that’s even discussed,” says a gynecology and obstetrics resident from Holguín.

In 2018, the World Health Organization (WHO) established a series of recommendations for labor. The first element it recognizes is that childbirth cannot be subject to strict protocols, such as those applied in Cuba. Instead, care should focus on the woman’s state and her baby’s, “their wishes and preferences, and respect for their dignity and autonomy.”

WHO recommends encouraging pregnant women to move around and give birth in an upright position. It also suggests allowing them to be accompanied, eating or drinking during labor, not separating babies from mothers right after birth, not applying techniques that artificially speed up natural processes, limiting vaginal touches to once every four hours, and performing episiotomies only if strictly necessary.

These recommendations not only respect women’s rights but also yield positive results from a medical standpoint. Multiple studies have shown that the more comfortable and accompanied pregnant women feel, the greater the probability that their vaginal delivery will be successful and, in turn, aggressive techniques will be required to a lesser extent.

However, questionnaires and interviews with professionals in Cuba show that these recommendations are blatantly disregarded in the country.

Not caring nor humane

Many women described giving birth in an environment that lacked empathy, warmth, or humane treatment. Others directly reported being mistreated, coerced, and verbally abused. Minsap professionals deprived them of the experience they wanted to have when their children came into the world. This contributed to the birth becoming a source of trauma.

Many interviewees stated that they experienced psychological sequelae after their birth. In 30% of deliveries, women were afraid of getting pregnant again or reported having repetitive images of particular moments when giving birth. In one of every four deliveries, women experienced mood swings, difficulty sleeping, or fear of confronting the health care system.

In addition, in 14% of childbirths, women stated they suffered from postpartum depression.

“You will rarely see (these sequelae) reflected as a diagnosis in the medical records,” explains one of the professionals. “These patients are seldom referred to mental health services for treatment, which ends up affecting the physical health and quality of life of the patients and their families,” they added.

The verbal or psychological violence, the lack of empathy, or the feeling of neglect described by the women in the questionnaires have deep causes related to the misogynistic culture and the Hegemonic Medical Model. The verticality of the Cuban health system only aggravates this context, according to the consulted physicians.

Several professionals admitted that they end up passing on the pressures and shortcomings they experience to the women they are treating. This issue can be expected to intensify as the country’s medical services have deteriorated due to a lack of personnel and resources.

Currently, medical personnel in Cuba earn between 190 and 320 USD per month, at the official exchange rate. To survive, some of them accept gifts or cash from patients and usually reserve the best care and the few materials available for their treatments.

“Obstetrics and gynecology are among the specialties that most rely on this informal exchange. If you don’t have your doctor and you ‘don’t go through the gutter’, as they say, you’re screwed,” a recently graduated doctor said from her own experience becoming a mother.

Despite the profusion of healthcare professionals in the country, interviewees described increasingly intense work schedules and shifts due to staff shortages. After shifts of three or four consecutive days on call, it is common for PAMI staff to have to work in health centers or make home visits.

At the same time, the demands to meet statistical targets show no signs of slowing down. “We have to produce results at the same level as countries that have services with all the proper conditions,” in the words of a specialist quoted in Lareisy Borges Damas’ thesis. Borges Damas is a doctor in nursing who has researched models of humanized childbirth.

Several professionals claimed to have lost motivation working with this framework, which negatively affects the quality of the care they provide.

As a gynecology and obstetrics resident from Holguín said, “Nobody wants to work here, so they let this violence happen as long as it doesn’t affect the statistics. There can be ill-treatment as long as the pregnant woman and the baby do not die. That’s more or less how it works.”

Read more from Cuba here on Havana Times