Pushing in Silence: Modernizing Puerto Rico and the Medicalization of Childbirth by Isabel M. Córdoba (review)

Isabel M. Córdoba examines the change in birthing practices in Puerto Rico from home deliveries assisted by midwives to hospital births attended by obstetricians. The consolidation of the medical field of obstetrics/gynecology and the declining use of traditional midwives occurred in virtually all Latin American countries during the first half of the twentieth century. However, according to Córdoba, there are several aspects of Puerto Rico’s experience that make it different and important.

First of all, as such changes go, it happened very quickly. In 1948, nearly all babies were born at home, and mothers relied on midwives. By 1970, virtually all women gave birth in hospitals under the supervision of obstetricians, usually male. Córdoba also argues that in Puerto Rico, unlike elsewhere in Latin America, the transition to hospital deliveries was accomplished without a major campaign by doctors to consolidate their position in the obstetric field. Midwives had no professional or corporate group to defend their positions and gradually fewer and fewer women were attracted to the field. Mothers preferred doctor-attended births, midwives’ pay was very low, and midwives became gradually less acknowledged in their communities.

Key to understanding the rapid medicalization of birth practices in Puerto Rico is the modernization process known as Operation Bootstrap (Manos a la Obra), promoted by the US government and largely enacted by the island government under Governor Luis Muñoz Marín, beginning in the 1950s. Operation Bootstrap aimed to industrialize Puerto Rico rapidly by giving tax incentives to potential investors. It was designed to make Puerto Rico a showplace of US colonialism, and, by the 1960s, a Caribbean capitalist alternative to socialist Cuba. Under the program, health services, education, and communications were improved, the population became more urban, and more women worked outside their homes. According to Córdoba, the population in general welcomed these advances and along with them the increased expertise and specialization of the medical field that was facilitated by the establishment of the medical school at the University of Puerto Rico in 1950. With the decline of the Bootstrap development project in the late 1960s, more welfare measures were put into place to help an increasingly disadvantaged population, and this encouraged reliance on government services, including institutional medical care.

As Córdoba tells it, first middle-class, well-educated women and then women in general began to feel safer giving birth in a hospital setting that seemed hygienic and technologically advanced, and where emergencies could be dealt with immediately. The introduction of fetal heart monitors, Cesarean sections, drugs to reduce pain during labor, and other advances may have reassured mothers and helped doctors to deal with complications. However, these procedures and techniques also “medicalized” childbirth, and according to Córdoba actually set up an opposition between mother and fetus in which the mother was actually seen as an obstacle to a “normal” birth process. Also, as women expected more and more from their obstetricians, they became more likely to blame them if there were emergencies or problems during labor and delivery. Consequently, prices for medical malpractice insurance increased, and doctors often performed C-sections, feeling that they had greater control using this surgical procedure than in a natural but prolonged labor, perhaps complicated by the position of the baby. By 2002, Puerto Rico had one of the highest rates of Cesarean sections in the world, and the cost of malpractice insurance for obstetricians had skyrocketed.

The book ends with an epilogue that describes the recent situation in Puerto Rico. Fewer medical students are attracted to gynecology and obstetrics because of the risk and high cost of insurance. With doctors shying away from the field, there has been a call for the training of nurse midwives who may help reduce the wait—sometimes of months—women are experiencing to see doctors for prenatal care. A...