Puerto Rico's 48 Percent Cesarean Rate

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By Jill Arnold


An English translation of Arys L. Rodríguez Andino article, Cesáreas más de la cuenta, which appeared on May 9, 2011 on PrimeraHora.com.

Puerto Rico’s unfortunate first place ranking in rate of cesarean births at 48% can be attributed not to the doctors who perform them, but to a health care system that is designed in a way that makes cesarean birth the easier option.

OB-GYN Ramon Perez, who advocates for humanized and out-of-hospital birth, believes that the way in which the system functions makes a cesarean delivery easier than a vaginal delivery.

“We have to work in volume. So, how would you set up your work day if you need 20 births or more to survive? You would have to live at the hospital. You would have to sacrifice your personal life,” explained the doctor, who did deliveries “by volume” for two years.

Precisely because he “had no life,” he changed the way in which he works and now attends only four births per month.


How did he change?

I began to integrate midwifery techniques and began attending out of hospital births.


Why is he alone in this?

Because I am a black sheep and we understand that societal violence begins at the moment of birth and we do not wish to contribute to social violence—that the beginning of life should be as humane and minimally violent as possible.

This violence against women is something that no sector acknowledges, claims Dr. Ana Parrilla, associate professor of the Graduate School of Public Health’s Maternal and Infant program.

I am saddened by the indifference with which Puerto Rico handles the issue, she stated.

According to [Parrilla], the dramatic increase in cesarean sections in the country began at the beginning of the 1990’s, when vaginal birth after cesareans ceased and when the public health system was privatized.

“Before, you would use the public system for birth and, if the doctor finished their shift, they went home and another one started theirs. Now, with private doctors, they want to have better control of their time,” she explained.

Although it is often thought that obstetricians earn more for a cesarean than for a vaginal birth, Parrilla states that this is not the case. “They don’t make more, but they spent fewer hours. A cesarean takes an hour. It’s control of your time and you can do other things like golf or whatever you want,” she said.

Although she has nothing against doctors wanting to have time to enjoy life, [Parrilla] believes it is unethical to perform repeat cesareans or inductions that will end in cesareans to adjust births to accommodate the schedule of the obstetrician.

“This is immoral because if you accept payment for [birth], you have to be available to do it well. It would be better for you to fight with insurers to get them to pay you fairly,” she said.

While it is certain that the cesarean saves lives and has its place, the rate of 48% is far above the 15% recommended by the World Health Organization. “We are doing three times the amount needed. Forty-eight percent is a travesty,” she insisted.

The cesarean has become so normalized that some do not perceive it as a major surgery.

 “People believe that the cesarean is no big deal— something common— and when a pregnant woman is told she needs a cesarean, they are happy and congratulate her,” stated Pérez.

That is one of the reasons why pregnant women ask for a cesarean. “Many ask for it at the moment of birth, after they’ve been given Pitocin. They have them medicated and in pain. This is torture. What they are committing is an act of violence,” said Parrilla, explaining why a pregnant woman would end up asking for a cesarean especially if labor was induced.

“They are inducing too often; it is believed that 60 percent [are induced] but there are hospitals which do it more. In Puerto Rico, babies are born Monday, Tuesday and Wednesday between 8 o’clock and 5 o’clock,” said Parrilla. “Labor should not be induced without medical indication and it is impossible that 60% of women have a medical need,” she stated.

This forced process increases the chance of complications. “It’s forcing a process for which the body is not ready. The odds of a complication are higher and the chance for success is lower. Pregnancy and birth are a healthy condition, not an illness, and you are in charge of your health,” said the obstetrician, who believes that the system deprives women of the chance to make decisions about their birth and makes it so the doctor needs to make decisions for her,” he added.

Dr. Parrilla laments that a woman has to fight during her birth for the recognition of her right to give birth in the way that she chooses.

“This strikes me as tragic, that you would have to be a warrior during birth.” She deplores that a natural act would need to be turned over to a surgeon.

According to Parrilla, the government has done nothing to try to reduce the rate of cesareans, nor has it required hospitals to report the percentage of babies born by this method.

“It has not done anything. It has dug the hole, but they don’t want to get their hands dirty. If there is no political reason to make changes, it won’t be done,” she explained, adding that in first world countries, midwives attend births.