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

Reproduction in twentieth century Puerto Rico is a common research topic for many social scientists and humanists, yet historian Isabel M. Córdova illustrates how much remains to be done on this issue in her new monograph, Pushing in Silence. Whereas other works largely attend to Puerto Rican women's attempts to limit their fertility during the second half of the twentieth century (such as participation in clinical trials of contraceptives or skyrocketing sterilization rates), Córdova instead focuses on how and where Puerto Rican women gave birth from 1948 until the new millennium. What Córdova finds is a radical shift. Birth moved from a "predominantly domestic, mother-centered event with little intervention, and mid-wives as the most common attendants" (p.172) in 1948 to a medicalized event understood through a lens of risk, monitored by physicians in hospitals, and a complete absence of midwives (comadronas) by 1979. By 2000, a new, small contingent of midwives (differentiated as novoparteras) had arisen to assist elite Puerto Rican women to practically contest technocratic, medicalized birthing practices. How to account for these changes, then, is Córdova's aim. She finds that the "medicalization of birthing in Puerto Rico was a consequence of a new industrial-urban lifestyle" (p.3) ethic that accompanied economic, political, social, and cultural changes in Puerto Rico.

Pushing in Silence unfolds chronologically, which facilitates the illustration of the step-wise and uneven nature of birthing practice changes in Puerto Rico. The book acquaints non-experts to the macro-level changes that underpin Puerto Rican women's reproductive decisions, and enables Córdova to delve into her rich source base and a host of historical actors. Each chapter opens with Córdova telling the story of a midwife she interviewed, then moves on to narrate Puerto Rican society and medical institutions, descriptions of the professionals who oversaw birth, and differences in birthing practices across class and region during each epoch.

Chapter one acts as the baseline. Between 1948 and 1953, Puerto Rican women across the island birthed at home under the tutelage of a comadrona with little expectation of intervention or need for a physician. Contemporaneously, Puerto Rico elected its first governor, Luis Mñnoz Marín of the populist party, and an ethic of modernization, industrialization, and progress led by experts began to emerge. A minor, but noteworthy change to birth, occurred by 1958: a slight majority of births occurred in hospitals, yet the majority of women were attended to by comadronas and nurses, not physicians. The move to the hospital and ascension of physician-led birth was complete by 1965 (detailed in chapter three), but it was not until 1965-1979 that birth was medicalized in Puerto Rico, according to Córdova. The medicalization of birth, accounted for in chapter four, weaves together macro- and micro-level change in Puerto Rico. In the 1970s, it was not generalists, but obstetricians, that attended to Puerto Rican women in hospitals across the island; regional diverse practices were relatively absent and comadronas were completely absent by this period. Obstetricians, equipped with the knowledge and practical skills of medical machinery acquired in schools like the University of Puerto Rico's School of Medicine, were tasked with mitigating risk for the mother and a new patient, the fetus. Though the hospital rooms filled with specialized physicians and technology attested to Puerto Rico's hoped-for progress, physicians in general felt they had lost some of their social prestige and trust of the laboring mother. In the final epoch, 1980-2000, physicians' perception of this lack of trust furthered their reliance on invasive techniques like caesarian sections, electronic fetal monitors, and episiotomies, also accompanied by a spike in the fear of litigation by mothers. Denoted by Córdova as a period of hegemonic, technocratic-medicalized birthing practices, a marginal challenge did...