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Improving maternal care in Cuba
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Undiscovered. Of all pregnancies registered with diabetes in Cuba in 2008,
87% were gestational, i.e. in women not previously known to have diabetes.
With the extension of maternal services for women with diabetes to all of Cuba’s provinces, the risk usually connected with diabetes during pregnancy has been reduced to almost nil.
With a maternal mortality rate of 45 per 100,000 births in 2005, Cuba was already doing well in terms of maternal health compared to an average of 148 in the countries of the Americas. But a team of doctors from the National Endocrinology Institute insisted that major improvements were still to be made. They already had the human resources with well-trained health personnel, but they needed equipment to implement and extend the services and care to all pregnant women with diabetes. Since 2007, the World Diabetes Foundation has supported a project in Cuba aimed at strengthening the quality of care for diabetes and pregnancy in all provinces of the country.
Bárbara and Claudia
Bárbara Serrano Prieto, now 44 and her five-year-old daughter are living proof of the improvement of services for pregnant women with diabetes. Bárbara had her first pregnancy when she was 29 years old. She developed gestational diabetes during pregnancy and lost the baby at 24 weeks of gestation. She was quickly diagnosed with type 2 diabetes and was treated with diet and tablets. Two years later, she got pregnant again without knowing the harm that diabetes could cause to the foetus. “In the beginning my diabetes was not properly controlled and I had to use an increasing dosis of insulin until finally a congenital malformation was discovered. For this reason I had a micro caesarean in the 26th week of pregnancy and had a stillborn baby,” she says. At the time, Bárbara did not receive specialised preconceptional attention but was attended under general obstetrics services.
“Previously, where I live there was no available information about the risks that diabetes could cause to a foetus. I was informed by the doctors at the service centre for diabetes and pregnancy to attend consultation for reproductive risk and preconceptional control to plan a new pregnancy. It took me a little over a year to reach a good metabolic control. When my HbA1C level was below 7% the doctors told me it was safe to become pregnant and I had an uncomplicated pregnancy while taking my insulin. The result was Claudia, a beautiful baby born at 3,5 kilos,” says Bárbara, the proud mother of a healthy girl.
Risk for mother and child
There are two types of diabetes during pregnancy to be aware of. One is among women who know they have diabetes before the pregnancy. This is called pre-gestational diabetes. The other type occurs in women who did not have diabetes before the pregnancy and who will only experience it during pregnancy. This is called gestational diabetes. Women in the latter group, however, have an elevated risk of developing type 2 diabetes later in life.
In either case, the cocktail of diabetes and pregnancy cause problems for the mother as well as for the baby. Director of Cuba’s National Programme for integrated care in pregnancy with diabetes, Professor Antonio Marquez Guillén who has worked with reproductive health and diabetes for decades explains: “In Cuba we do not distinguish so much between pre-gestational and gestational diabetes in terms of attention. The point is that both groups need to be followed closely to make sure they control their glucose level in order to avoid the complications connected with diabetes in pregnancy.”
“Women with pre-gestational diabetes run great health risks for themselves and their offspring if they are not treated properly before and during pregnancy. Maternal mortality in women with diabetes is still elevated in many countries. Perinatal mortality among offspring born by women with diabetes is high all over the world and exceeds the values for the general population. Another risk is that of congenital malformations which cause approximately 30% of the perinatal deaths,” says Prof. Guillén.
The main problem for women with gestational diabetes is the big baby syndrome (fetal macrosomia). Babies born with a birth weight of 4 to 4.5 kg not only cause obstetric traumas for the mother; perinatal morbidity and malformations are also seen more often than in the general population. Moreover, both mother and child have an elevated tendency to develop diabetes later in life.
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Access. Throughout Cuba women now have access to 17 specialised service
centres for diabetes and pregnancy.
Services for all
The total number of pregnancies in Cuba in 2008 was 123,197. The 2,229 women with gestational and pre-gestational diabetes attended in the diabetes and pregnancy services centres corresponds to 1.8% of the total number of pregnancies in the country. “There is no doubt that there is a sub-registry for gestational diabetes in Cuba,” says Dr. Jacinto Lang Prieto, Clinical Manager of the diabetes and pregnancy service centre. “A study in the city of Havana showed a 4.8% prevalence compared to international studies of 5-10%. One of the objectives of this programme is to actively find these patients who are not yet diagnosed but who affect perinatal morbidity and mortality.”
In Cuba today, all women in child bearing age have access to 17 provincial service centres for diabetes and pregnancy (five are in the city of Havana). For women with pre-gestational diabetes, the care initiates before pregnancy at one of 126 municipal consultations set up for reproductive risk in diabetes. In these consultations the women undergo integrated examinations and based on their clinical data and risk of complications, they are advised or not to become pregnant. Once their HbA1c level is below 7% and their average glucose level is below 5 mmol/L - like Bárbara’s - they are given a go-ahead for pregnancy, and as soon as they are pregnant they are referred to the provincial service centre for pregnancy and diabetes.
At the diabetes and pregnancy service centre, trained personnel ensure that the women have the proper screenings and are controlled adequately. With the support from the World Diabetes Foundation, the necessary clinical equipment has been provided in the already existing facilities, and the provision of computers has facilitated the establishment of a national network and systematic record keeping for use in statistics. Furthermore, the project has been provided with essential medicines, equipment and reagents for clinical use in obstetrics and neonatology.
For women with gestational diabetes, diet is an essential part of keeping good glucose control and a majority of them need not take any medication. For women with low or normal weight, 73% achieve good control through diet alone while 44% of obese women obtain control through diet.
Of 2,229 pregnancies with diabetes registered in Cuba in 2008, 283 (13%) occurred among women with diabetes (pre-gestational) while 1,946 (87%) occurred among women not previously know to have diabetes (gestational). “Broadly speaking, for every woman with diabetes who became pregnant in Cuba in 2008, another nine women not previously known to have diabetes developed gestational diabetes,” says Prof. Guillén. This is a strong argument for the necessity of screening for gestational diabetes and not only focus on the women who have diabetes.
Controlled pregnancy is key
As we heard, Bárbara Serrano lost two babies due to uncontrolled diabetes but managed to have a healthy pregnancy and a healthy baby girl the third time when controlling her blood glucose level. A study among 1,038 pre-gestational women in the years 2003 to 2006 shows that significant improvements can be achieved by detecting and controlling the diabetes during pregnancy. Among the cases of pre-gestational pregnancies the occurrence of congenital malformations and of perinatal deaths was significantly reduced among the women who controlled their diabetes. Congenital malformations occurred in 9,1% of pregnancies in the uncontrolled group, while only in 0.9% in the controlled group. Perinatal death occurred in 6,2% of the pregnancies in the uncontrolled group and only in 0,7% among women who were strictly controlled.
“This is a clear indication to us that strict control of pregnant women with diabetes can reduce the risks for both mother and child significantly. With the establishment of service centres for diabetes and pregnancy in all provinces of the country we have now ensured extra attention to all women with diabetes in childbearing age,” says Prof. Guillén. “The challenge ahead of us remains to detect the cases of gestational diabetes.”
Bárbara Serrano for one is happy that the service reached her and encourages all women to make use of it: “I recommend all women with diabetes who want to have children to plan their pregnancy and reach a good metabolic control before the pregnancy in order to avoid congenital malformations and to finalise pregnancy in a healthy and happy way,” she says.
Read more about the project
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