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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.


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Reader Comments (7)

Thanks for the translation Jill!!!! As a Puerto Rican woman...I am sadenned by the abysmal state of obstetrics in the island. More people need to become aware of this and take a stand against this! It basically is the ultimate "colonized" state of being. I mean...we were used as lab rats for the contraception pill, were sterilized in masses after the government approved Law 116 in 1937...and are now being induced and sectioned in masses as well. It's like the collective uterus of the Puerto Rican women has been under siege for so long that few people realize the abhorrence of it all and its implications for future generations of Puertorriqueñas. Thanks for including this in your page.

May 31, 2011 | Unregistered CommenterMónica

I wonder if Dr. Amy will jump in an defend this cesarean rate? It's only 15% higher than the United States, after all.

A Dr. in my town has a 45% cesarean rate, and she is not even a high-risk OB. I can hardly believe that she is allowed to practice in that manner.

May 31, 2011 | Unregistered Commentersara

Is the increasing cesarean delivery rate necessary? Before you answer, take five minutes and watch my video presentation of the same title at https://www.birthrisk.com/Public/BirthriskVideos4.aspx

If we want to reduce the number of cesarean deliveries then we need to get away from the concept of a “cesarean delivery rate” and with all due respect to the World Health Organization (WHO), it is irresponsible to set a target cesarean delivery rate without any knowledge of the physical characteristics of the women who are going to give birth. For example, consider the following paradox: my video shows you the Cesarean Rate History difference between an 18 year old first time mother and a 36 year old first time mother, so if we want to decrease the cesarean delivery rate, all we need to do is encourage teenage pregnancy. (This is only an example of the paradox, please hold your tomatoes)

Women need to get informed and obstetrical care providers need to take the free Birthrisk.com Challenge. If every obstetrical care provider takes the Challenge, we will know who is performing the unnecesareans. As long as we let obstetrical care providers hide behind a “cesarean delivery rate” we will never find the unnecesareans, so stop telling women to ask their obstetrical care provider; “What is your cesarean delivery rate?” and start telling them to ask; “What is your Birthrisk Cesarean Birth Measure?”

I have a question for Dr San Roman. I appreciate your balanced approach, but I wonder on what basis your evaluation distinguishes between 'the physical characteristics of the women' ('patient factors') and the 'labor management strategies' ('provider factors') used to treat these women.

It seems to me that women are treated differently depending on their characteristics, and that this in turn leads to different outcomes.

I was stuck by your hypothetical example because I was 38 when I gave birth. Plus I had a chronic disease (type I diabetes).
And -- of course?! -- I had a c-section.
I am willing to admit that my 'physical characteristics' were, in and of themselves, increasing my chances of having a c-section.
However, they are NOT what LED to my c-section. What led to my c-section was an induction when my body wasn't ready for it. And, along the way, a coerced peridural which stopped labor (after it took 3 days to start it).
I will never know whether these labor management strategies were medically necessary or not. I do know that other care providers would have given me more time before deeming the induction necessary, and would have informed me of the poor chances of success of this induction.

What I am hinting at is that, had I been 18 and not a diabetic, these labor management strategies would not have been imposed on me anywhere. But because I was a 'high risk' patient, they were part of the protocol in the hospital where I gave birth.

Isn't it a bit circular to assign to the 'physical characteristic of the woman' what is not the result of these characteristics themselves but rather of medical decisions BASED on these characteristics?

I am using my case as an example, but I believe the question I am asking concerns a large number of women.

I thank you in advance for giving it some thought.

June 1, 2011 | Unregistered CommenterCato

Cato – Thank you for sharing your personal story. Your story is exactly what my software will bring to light. A Cesarean Rate History would have informed you as to what has happened to similar women who were induced. The fact that you have diabetes did not increase or decrease your inherent risk that labor will end in a cesarean delivery but it was the reason that you were induced and it is the induction that increased your risk. An obstetrical care provider who uses my Cesarean Rate History software will have valuable information that they can share with their patients so as to make a more informed decision of the risks and benefits of induction versus expectant management.

The answers to your questions are not quick and easy. There are several video presentations on my website but take a look at the eight minute general presentation first at https://www.birthrisk.com/Public/BirthriskVideos6.aspx . Please let me know if you have any other questions.

This is disturbing in so many ways and my fear is that unless more systemic changes occur in the process of hospitalized birth in the US we are heading the same way.

for example

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

already appears to be a predominating attitude with c-section rates at 33% and the media obsession with celebrities having c-sections.

At least in the US there is a vocal counter narrative to the medicalizing of birth and the reality of unnecessary cesareans.

June 2, 2011 | Unregistered CommenterAfter C Section

After C Section: I can tell you that there are vocal groups in the island...active groups of women pushing back. There has been no significant support from the government. Thus, not much has changed. We are working hard to get an active ICAN chapter in Puerto Rico, and are working to connect those women with similar organizations in the mainland to increase visibility and support for this issue.

June 4, 2011 | Unregistered CommenterMónica
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