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  • Pushing in Silence: Modernizing Puerto Rico and the Medicalization of Childbirth by Isabel M. Córdova
  • Laura Briggs
Isabel M. Córdova. Pushing in Silence: Modernizing Puerto Rico and the Medicalization of Childbirth. Austin: University of Texas Press, 2018. xiv + 234 pp. $29.95 (978–1–4773–1412–8).

Pushing in Silence came out at a complicated time. With an estimated three thousand deaths from Hurricane María and a highly publicized fight about how to fund Medicaid in Puerto Rico, how do we read a book about how modernization drove women on the island to give birth in hospitals—except as tragedy? It’s possible that the answer is, in part, that it is more important than ever to restore a sense of the island as a complex place with a rich history—as much more than a disaster. This book certainly gives us that.

Córdova’s account begins well before most Puerto Ricans had electricity, and fewer still had babies in hospitals. Across five historical periods, she tells the story of how women on the island went from thinking of a midwife as the unquestioned birth attendant of choice to seeing the hospital as the safest—normal, expected—place to give birth. In the final chapter, she discusses the emergence of a small number of novoparteras—new midwives—who began practicing in recent years in response to hypermedicalization and skyrocketing caesarean rates.

This story, in broad outlines, is familiar from nearly everywhere, but Puerto Rico is a fascinating place to study it because it happened so fast—in 1950, midwives attended the majority of births, most of them at home, but by 1970, virtually all births were in hospitals. In contrast to the mainland United States, there was no physicians’ campaign to eliminate midwifery on the island, and licensing regimes, while not particularly friendly to midwives nor controlled by them, were not terribly harsh.

Rather, what Córdova documents is that over the course of twenty years, barely a generation, people changed their minds about childbirth. She argues that “birthing practices changed as a result of the state-led industrial project” (p. 3). While this may seem like a reach, Córdova does an outstanding job of showing how the political-economic project of development touched everything—including the habits of mind that affected how women sought health care and physicians practiced.

While the book uses traditional statistical and archival tools of social history, tracking changes in medical training and hospital births by municipality, some of the most fascinating parts are her oral histories, which put story and words to this remarkable transition. As one midwife Córdova interviewed, Doña Penchi, explained, by the 1960s, women had new “diseases” as a result of modern society and increased recourse to medications, and thus required the intervention of hospitals to manage these newly modernized bodies (p. 83).

For a brief period, roughly 1950 to 1966, modernization really did deliver on its promises; life expectancy increased and birth rates dropped, setting the stage for seeing childbirth differently. By the middle 1960s and the “lost decade” of the 1970s, the economy stalled, and inflation and unemployment rose sharply. The incomes of half of Puerto Ricans fell below the poverty line. There was an expansion of public assistance and other state projects, including those that demanded [End Page 706] that people make use of medical providers. This shift only accelerated the transition to hospital births. As Córdova writes, “moving within institutional settings and turning to specialized service providers became part of everyday life on the island” (p. 136).

Rates of female sterilization is a key question in Puerto Rican Studies, and Córdova attends to it. She suggests that the widespread adoption of what Robbie Davis Floyd calls a “technocratic” model of birth1 (hospitals/managed labor/cesareans) can tell us about the rapid rise of tubal ligation in Puerto Rico, reaching one-third of women of childbearing age by the early 1970s. Contrary to common belief, surgical sterilization rates are not actually higher in Puerto Rico than on the mainland, but they rose faster and earlier. Córdova argues that while feminists were busy fighting against sterilization...

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