With growing rural populations and more people eligible for Medicaid, the US is experiencing an increased lack of access to obstetric care in many rural areas. From 2004 through 2014 more than half (54%) of all U.S. rural counties either did not have or lost local obstetric services (Hung, Henning-Smith, Casey, & Kozhimanni, 2017). Currently, many states across the US have more than 65% of counties that do not provide any obstetrical services, regardless of ability to pay via insurance, private pay, or Medicaid (Moran, 2017). These statistics emphasize the urgent need to develop sustainable methods to increase access to affordable, effective care for the twenty-eight million women of reproductive age living in rural America.
United States statistics are alarming, yet low-income and emerging economy countries seem to be making greater gains in maternal-child care when compared to the US. For example, in the US the rate of mother-to-child HIV transmission is 1.2 per 100,000 (Centers for Disease Control and Prevention [CDC], 2017a), and the incidence of congenital syphilis cases is the highest it has been since 1997 (CDC, 2017b). Although the HIV transmission rate seems low, six Caribbean islands were validated by the WHO as having totally eliminated mother-to-child transmission of both HIV and syphilis. Anguilla, Antigua and Barbuda, Bermuda, Cayman Islands, Montserrat, and St. Kitts and Nevis now join Cuba (the first country to accomplish elimination), Thailand, and Belarus (UNAIDS, 2017) as having achieved dual elimination. Armenia has eliminated mother-to-child transmission of HIV, and the Republic of Moldova has eliminated mother-to-child transmission of syphilis (WHO, 2016).
Eliminating those sexually transmitted infections isn’t the only thing Cuba has done well. The Cuban healthcare system is an excellent example of how a developing country implements policies and manages limited resources to positively affect maternal and infant mortality. Since 1960, Cuba has reduced infant mortality more than eight-fold from 37.5 to 4.5 (Keck & Reed, 2012). This reduction directly attributed to Hogares Maternosor Maternity Homes, which are maternity hospitals that address key social determinants of health such as nutrition, education, counseling, and recreational activities along with standard prenatal care.
The success of Hogares Maternos is due to equal parts of social and medical care. Proper prenatal and antenatal care is available and accessible for all women in Cuba through a community based maternity home system (Gorry, 2011). Cuba has recognized and addressed how issues of lack of prenatal care reduce opportunities for pregnancy-related and childcare education, as well as childbirth preparation. Lack of attention to these factors leads to lower birth weight, increased rates of infant mortality, and fewer well-bay and well-child checkups. Poor antenatal care may also be a barrier to prevention of and diagnosis of maternal disorders and diseases (Mbuagbaw et al., 2015). All this care is provided from a government that spends far less of its GDP on healthcare than the US (WHO, 2018).
Rural U.S. states are worlds apart from Cuba politically, socially, and economically, yet these states face similar challenges regarding access to care and lack of technological resources for maternal and child health in rural areas. Complete adoption of a Cuba like system is neither realistic nor advisable in the US; however, there are lessons from Cuba’s successes that could be applied to rural areas in the US. For example, Alabama faces significant challenges in rural health care, and given the general failure in the US to address social determinants of health which underlie the health disparities in this country, maternity homes may contain applicable ideas from elsewhere in the world. Other less resource rich countries have successfully addressed lack of access to care and are able to promote positive, healthy social connections and well-being for pregnant women and their babies.
There are cultural and resource challenges to implementing Cuban methods of prenatal care in the US. Continued collaboration with Cuban colleagues can guide effective, equitable, and efficient care for rural U.S. women and their infants, and we should further explore methods and policies that would results in solutions which may alleviate poor maternal and child health outcomes in the rural US. Examining other successful models within and outside the US is an important key to such solutions. The US can learn and implement effective Cuban methods to increase prenatal and obstetric services by considering adaptation of Cuban methods to U.S. culture and policy. The Cuban model, which focuses on social determinants of health should be further explored as the existing U.S. obstetrical approach is not working. Specifically, how could Hogares Maternos be adopted and adapted within the US in rural states like Alabama by leverage existing infrastructure.