The Concepcion Palacios Maternity Hospital—Venezuela's largest—is quite a contrast with the spick and span intensive care center we visited for our previous report. The place looks a little run down. Some of the corridors and stair wells could do with a good scrub. Many of the light bulbs are broken. But is this hospital collapsing? Are new-born babies dying here unnecessarily? Indeed, has infant or maternal mortality gone up across the country? Are there grounds to argue that Venezuela faces a health emergency and needs the international community to intervene?
Is this hospital collapsing?
Luanys Rivera walks me through the maternal-fetal medicine unit she has been in charge of for the last year. This is where high-risk, expectant mothers and their babies are looked after before, during and after birth. Luanys can't be much more than 30. She talks confidently and frankly about the challenges they face.
Shortages in Venezuela?
Early in June, a group of doctors and other staff from this hospital and two others blocked the road outside. They wanted to protest against the lack of drugs and medical supplies, and to demand an international humanitarian intervention. Luanys sympathizes with their frustration. The hospital has real problems. She says she doesn't want to get into the politics of it. I don't ask, but that is usually a sign that someone is not a convinced Chavista. However, her diagnosis is slightly different.
A Building in Need of Repair
She takes me down the corridor to the far end of the unit. On the way she points to several missing strip lights in the ceiling. The electricity company came yesterday and they're supposed to be bringing replacements. “We'll see.” Her biggest problem is with the state of the building, which dates from the fifties. They've had to close several rooms down here because of leaks. In one of these wards the smell is not good. The restroom is stained from dripping waste water.
Her main problem is the building
“Of the 62 beds in this area, I have 30 out of action.” But these problems are not new. They are a bit worse now, but she's seen similar failures for at least the last five years. She's not sure if it's because the builders didn't do a good job on the original conversion work, or for lack of maintenance. “In spite of these problems, we keep attending patients.” In fact, “the number of births here at Concepción Palacios increased about 20 percent in the first four months of this year, compared with the same period in 2015.”
Earlier, the hospital director, José Luis Odreman, had shown me the figures. They were up to almost 1,000 births in January. “It was the most productive four months the hospital has had in the last 10 years.”
Now they have a new problem. The aircon in the labour wards wasn't working properly and they've had to move everything to a different area with fewer beds while it is replaced. As a result, births were down to just over 700 in May and between 200 and 300 in the first part of June. Dr. Odreman insists this has nothing to do with the shortages in Venezuela. “It's the kind of problem any hospital anywhere could face.”
'No Baby Has Died for Want of a Drug'
Contrary to the narrative promoted by the opposition and much of the media, Luanys feels medicines and medical supplies are less of a problem, at least in the immediate sense. Some things are lacking some of the time. Others almost permanently. But there are usually alternatives. Take the agents they use for blood cultures to identify which bacteria or fungi are causing an infection. They haven't had any for months, so they have to go to outside laboratories. But again, this has been a recurrent problem throughout the eight years she's been here.
“The patient in there has cancer”, Luanys remarks as we walk on. “Would she mind talking to me?” Luanys goes to ask, then beckons me in.
Her fears were misplaced
Felicidad Amaranta looks very drawn. She discovered she had a recurrence of breast cancer when she was already pregnant, with twins. They were delivered, prematurely, by caesarian yesterday. She forces a smile. “I was frightened of coming here, with everything you hear, that there are no medicines or anything. But it hasn't been like that at all. Thank God they've given me everything I need and treated me very well.” She seems much more worried about how she'll manage to find diapers and milk for her two new sons. And about her cancer. The lump is large and painful. Her oncologist has given her two weeks to rest before she restarts her chemotherapy.
In the intensive care ward for critically ill newborns, other mothers tell similar stories.
"At the moment we have the drugs we need"
Through two holes in an incubator, Yeslyn Rojas usually spends the day holding her son, Julio Cesar, who was born prematurely, at 27 weeks. But she can't now because the water has just gone and she can't wash her hands. “He needs to start with a mixture of my milk and a special oil to help him put on weight. They don't have that here.” It's been quite a search, but with help from her family she managed to find the oil outside. “But here they've given him all the antibiotics and other things he needs.” The head of this area, Rosalinda Prieto, tells me they have had problems with water, with saline solutions and with this or that drug, particularly anti-mycotics to fight fungal infections, which are very common in premature babies. “Sometimes relatives have had to buy the medicines outside the hospital.” Yet they have always found a solution and for the last month or so they have not suffered shortages of any essential drugs. “I can honestly say that in the three years I have been here no baby has died for lack of a medicine they needed.”
Infant Mortality Is Creeping Back Up
Luanys says there has been an increase in infant mortality rates in Venezuela in recent years. “Perhaps not a big one, but an increase.” She thinks the causes are to be found earlier in the process, not inside the hospital itself. For example, the shortage of medicines is clearly more acute in Venezuela's pharmacies—drugs for chronic conditions like high blood pressure, for example—than in the hospitals. “For example, there's been no Betalol in Venezuela for five years.” They were promised another favourite, Hidralazine, which is particularly useful during pregnancy. “It appeared for a while, then the entire stock was sent to the CDIs.” Those are the community clinics which are part of the Barrio Adentro programme run in cooperation with Cuba. “If a mother-to-be doesn't get blood pressure treatment when she needs it, early in her pregnancy, then her condition will gradually get more complicated. And it may end well or it may end badly.”
The grave shortage of contraceptives could be another factor. “Many of our births now result from last year's dearth of contraceptives”, says Luanys. “Unwanted pregnancies are always likely to be of higher risk.” They may be detected later, they may get less support, the mother may be very young.
The shortage of beds could also be a factor, whether here or at other hospitals, especially in the provinces, where supplies are more of a problem. For over half a century, almost 100 percent of childbirths in Venezuela have taken place in hospitals, with a doctor in attendance. If it's a complicated or high-risk pregnancy, the hospital will want to make sure it has all the possible technical resources available before it admits the mother. If it doesn't, it will refer her to another one that does. This has produced a phenomenon known in the trade as ruleteo, meaning something like “run-around”. Pregnant women in need of urgent attention are passed from one hospital to another, often from one city to another, until they find one that will take them. The longer this takes, the higher the risk. If the number of beds is reduced, the problem gets worse.
The increase in maternal mortality seems to have been sharper. Luanys can only speak from experience, “about my small world here.” In 2011 and 2012, she recalls, two or three mothers died during or after childbirth here at Concepción Palacios. “In 2013 there were about six deaths. In 2014 and 2015, it increased again to almost double that.”
Luanys' impressions point in the same direction as the national figures. According to these, in the early years of the Bolivarian revolution, especially from 2003 when the new social programmes kicked in, infant mortality fell sharply. Since 2007 it has edged back up, with some fluctuations. However, last year it was still around half the level of the 1990s. Maternal mortality also fell in those same years, but in a less sustained way. It too has increased since 2007.
If you look more carefully at these numbers, they begin to suggest some very different problems with Venezuela's approach to obstetrics. There is a growing movement in Venezuela to challenge this “medicated” approach and promote natural childbirth, and we'll look at both these issues in our next report on Venezuela's health system.
Concepción Palacios prides itself on keeping up with the latest trends in obstetrics. For the most part, this means the latest equipment and medication. The paradigm of doctors bringing almost all Venezuelan babies into the world in a hospital operating theatre has hardly been questioned here. But at the other end of Luanys Rivera's maternal-fetal unit, there is a small chink in this wall. They have a pilot program using kangaroo mother care, KMC, for premature babies.
Kangaroo mother care
Instead of keeping these fragile newborns in incubators for weeks, as soon as possible they are strapped to the mother, or the father, whose body warmth helps them grow stronger.
With this program, Luanys says, “we have much improved the survival rate of our premature babies”. The director, Dr. Odreman, puts in the context of the difficulties Venezuela is facing. “The challenge for us now is to keep going, but also to reinvent ourselves.”