Medical Protocols and Birth Practices: Breastfeeding in COVID-19 Cuba

The Cuban Ministry of Public Health highly prioritizes maternal-infant health; however, despite universal access to medical care and the support of generous state-mandated parental leave, the rates of early initiation of breastfeeding have fallen over the last decade (UNICEF). As active members of La Leche League (LLL), and cultural anthropologists studying breastfeeding in Cuba, we have observed that highly medicalized birth practices and postpartum care protocols in maternity hospitals and neighborhood clinics createbarriers to the initiation and support of exclusive breastfeeding. Here, we focus on tertiary level care and provide an update on the Ministry of Public Health´s protocols for dealing with possible COVID cases in pregnant and lactating individuals, and the threat these protocols represent for the breastfeeding dyad.

Birth in Cuba takes place exclusively in hospitals, where routine IV fluids, antibiotics, Pitocin inductions, cesareans and the separation of mothers from their newborns immediately after birth are common, despite extensive evidence that these practices are detrimental to the initiation and maintenance of exclusive breastfeeding (UNICEFGarcía Jordá 2010 , Borges Damas et al 2018Marcos 2012de la Cal Sabater 2015). Additionally, birth complications and obstetric violence are important causes of mental health issues that impact breastfeeding and new mothers’ resilience (Olza Fernandez 2010).

Although rooming-in is the norm in Cuban hospitals, mothers in LLL support groups complain that they are not allowed to nurse lying down and that babies must sleep in a bassinet. Patients are required to wear hospital gowns that do not open sufficiently to allow comfortable access to the breast for nursing or for skin to skin contact. When babies require special care in the NICU, breastfeeding becomes even more difficult (García Jordá 2010). NICU parents are only allowed to nurse once every three hours for 20 minutes and are not allowed to nurse at night. Between scheduled nursing times, medical personnel often introduce fortified cow milk, bottles, and pacifiers. These first days are critical for breastfeeding initiation, and separation prevents nursing on demand, which stimulates milk production.

Most women in LLL support groups reported that they did not receive help with latching on and nursing positions in the hospital. Medical staff commonly teach that cracked nipples and pain are normal and that breastfeeding requires sacrifice. As milk comes in, nurses provide painful massages that create further discomfort. This hospital environment creates multiple barriers to establishing successful nursing, and many new mothers leave the hospital ill prepared to continue breastfeeding. Dyads separated in the early days may even return home without having had the opportunity to create a strong bond.

Against this backdrop, how are Cuban moms and babies faring today in the middle of the novel Coronavirus pandemic? Since the crisis began, Cuba´s National Treatment Protocol Against COVID-19 has been based on radical social isolation measures and contact tracing designed to contain the epidemic. Close contacts of suspected cases are quarantined in specially designated health centers. Upon receiving a negative PCR test, patients are sent home where they must self-isolate for an additional 14 days. In early April, international flights and domestic transportation ceased, tourism ground to a halt, and public activities including schools and large stores closed (Beldarraín Chaple, et al 2020).

Pregnant persons with a suspected COVID-19 infection are managed in the same way as the general population (Escambray 2020,Protocolo Nacional MINSAP, 2020). If clinically stable, vaginal birth is the goal, with the hope that they will test negative by the time labor begins. The Protocol calls for measures to be taken to artificially shorten the second stage of labor, “because the patient will be very limited in her pushing by the face mask” (Protocolo Nacional MINSAP, 2020:44). Despite the lack of high quality evidence of vertical transmission, it also calls for early cord clamping, a practice that comes with health risks for mother and baby (Protocolo Nacional MINSAP, 2020:44Pita Rodríguez, et al.WHO 2012WHO 2014).

The Protocol recognizes that there is no significant evidence that the virus can be transmitted through human milk and that both the World Health Organization and the Iberamerican Society for Neonatology (SIBEN) recommend continuing breastfeeding regardless of viral status. Despite these recommendations, the Cuban Protocol calls for separating the dyad, sending the baby to the NICU for observation and suspending breastfeeding until discharge. Only preterm babies are to be given human milk from hospital milk banks. Hand expression is recommended so that re-lactating might be possible later, but the milk is not given to the baby (Protocolo Nacional MINSAP, 2020). The information we report here on the Protocol has not been made officially available to pregnant or lactating parents and is only available to doctors or through MINSAP´s online health library.

Without direct access to the Protocol, it was only by reading between the lines of recent press reports and stories on social media that we were able to confirm that COVID-19 positive mothers and their infants were being separated. On May 4, we learned through Facebook about the case of Cristhofer, in the province of Ciego de Avila. When we saw the post, it had already been shared 324 times, and it was later picked up by state media outlet CubaDebate. Just days after his birth, Cristhofer and his mother Orleisdys were quarantined because one of her close contacts was a confirmed case. Under quarantine, Orleisdys continued to breastfeed, until test results confirmed that she was positive. Even though he had been exposed to the virus, Cristhofer was negative, a testament to the immunity offered by breast milk. Rather than protecting the breastfeeding relationship, the health ministry enforced the Protocol. Orleisdys was sent to a treatment center 170 km away in Camagüey. Although completely healthy, the baby spent fourteen days in the NICU separated from her and the rest of the family, who were under observation in a local isolation center. Rather than being fed with his own mother’s milk or human milk from a local milk bank, Cristhofer was fed fortified cow milk.

In the second case, published in Cubadebate on May 10, we learned about the experience of Lady, a twenty-year-old  (asymptomatic, but suspected to have COVID-19) who went into labor on Mother´s Day at an isolation hospital in Matanzas province. Her labor ended in a Cesarean, and providers isolated the newborn in the NICU to prevent contact with his mother until the results of her test came back negative.

As both cases show, healthcare providers’ medical management of mothers and newborns followed the Protocol, ignoring the protective effect of early breastfeeding initiation on infant mortality and morbidity and the need for postpartum parent-child bonding. These practices are tone deaf to the existing international recommendations on breastfeeding in times of COVID-19 which highlight the importance of human milk for human babies during the pandemic (Stuebe 2020WHO 2020SIBEN 2020SafelyFed Canada 2020).

To better understand the concerns of Cuban nursing mothers during the Coronavirus pandemic, we carried out an online survey answered by 78 nursing mothers from May 22 to 23, 2020. Respondents were 81% first time mothers and 80% residents of Havana. Almost half of the mothers (47.4%) stated that they lacked information about the medical management of COVID-19 cases in lactating mother-baby pairs. Over half (52.6%) were anxious about being separated from their child. A significant number (42.3%) worried about breastfeeding being disrupted, and 43.6% felt that their baby would be exposed to greater risk without breastfeeding. None of the 78 responded affirmatively to the statement “I understand that separation is the best option for me and my baby.” This is, however, the option that the Cuban Protocol offers providers and parents.

The majority of mothers considered that breastfeeding had given them the strength to face the everyday stresses of pandemic life, and that knowing that they were protecting their baby by providing them with increased immunity gave them peace of mind. With the rest of the family at home with them, they enjoyed more support from their partners and spent more quality time with their babies with fewer distractions. Many commented that breastfeeding during the pandemic helped them reaffirm their bond with their baby.

As we have described, the disconnect between medical protocols and evidence-based practices creates significant barriers to the initiation and support of support of exclusive breastfeeding in Cuba. The COVID-19 protocols for handling suspected and confirmed cases are rigid and fail to take into account either mothers´ concerns, best practices or international recommendations that women’s choices and rights to sexual and reproductive health care should be respected regardless of COVID-19 status. Even despite these difficulties,  Cuban mothers are finding ways to connect to motherhood and enjoy breastfeeding even in times of COVID-19.

Micelys Torres Sánchez is the leader of La Leche League Cuba. You can connect via Facebook “Liga de la Leche en Cuba” and watch a video made by LLL mothers in Cuba about their experience of nursing through the Pandemic.

Hope Bastian is an Assistant Professor at the University of Havana, Deputy Director of Academic and Student Affairs at the Consortium for Advanced Studies Abroad in Havana, and the author of the book Everyday Adjustments in Havana: Economic Reforms, mobility and emerging inequalities .

Micelys and Hope are cultural anthropologists and nursing mothers.