Pushing in Silence: Modernizing Puerto Rico and the Medicalization of Childbirth 9781477314135

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Pushing in Silence

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Pushing in Silence Moderni z i ng P uerto Rico and th e Medica li z at ion of Ch ildbirth

Isabel M. Córdova

University of Texas Press    Austin

Copyright © 2018 by the University of Texas Press All rights reserved Printed in the United States of America First edition, 2018 Requests for permission to reproduce material from this work should be sent to: Permissions University of Texas Press P.O. Box 7819 Austin, TX 78713-­7819 http://utpress.utexas.edu/index.php/rp-­form ♾ The paper used in this book meets the minimum requirements of ANSI/NISO Z39.48-­1992 (R1997) (Permanence of Paper) Library of Congress Cataloging-­i n-­P ublication Data Names: Córdova, Isabel M., author. Title: Pushing in silence : modernizing Puerto Rico and the medicalization of childbirth / Isabel M. Córdova. Description: First edition. | Austin : University of Texas Press, 2018. | Includes bibliographical references and index. Identifiers: LCCN 2017003511 ISBN 978-­1-­4773-­1363-­3 (cloth : alk. paper) ISBN 978-­1-­4773-­1412-­8 (pbk. : alk. paper) ISBN 978-­1-­4773-­1413-­5 (library e-­book) ISBN 978-­1-­4773-­1414-­2 (non-­library e-­book) Subjects: LCSH: Childbirth—Puerto Rico—History. | Obstetrics—Social aspects—Puerto Rico—History. Classification: LCC RG518.P9 C67 2017 | DDC 618.20097295—dc23 LC record available at https://lccn.loc.gov/2017003511 doi:10.7560/313633

For Diego, with love

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Contents

ix

Map and Tables

xi Acknowledgments 1 Introduction

16 Chapter one. Phase One: Midwife-­Assisted Home Births, 1948–1953 49

Chapter two. Phase Two: Transitioning toward Hospital Births, 1954–1958

84

Chapter three. Phase Three: Physician-­Assisted Hospital Births, 1959–1965

107

Chapter four. Phase Four: Medicalized Births, 1966–1979

138

Chapter five. Phase Five: Novoparteras and a Technocratic, Litigation-­Based Model of Birth, 1980–2000

172

Conclusion and Epilogue

181 Notes 205 Bibliography 223 Index

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Map and Tables

62 Map 2.1. The municipalities of Puerto Rico 30

Table 1.1. Distribution of births by place and provider, Puerto Rico, 1951

58

Table 2.1. Distribution of births by birth attendant and location, Puerto Rico, 1953–1954

59

Table 2.2. Comparison of overall distribution according to birth attendant, 1951 and 1954

60

Table 2.3. Selected demographic statistics, Puerto Rico, 1945–1985

63

Table 2.4. Births by municipalities, birthing place, and birth attendant, Puerto Rico, 1953–1954

64

Table 2.5. Births in Ponce according to location of delivery, Puerto Rico, 1953–1962

87

Table 3.1. Selected demographics, Puerto Rico, between 1945 and 1963

114

Table 4.1. Selected consumption data, Puerto Rico, 1940 and 1964

154

Table 5.1. Selected cesarean rates in the Western world, 1985

154

Table 5.2. Selected cesarean rates in the Western world, 2002

155

Table 5.3. Cesarean rates in Puerto Rico by region and sector

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Acknowledgments

M

ost academic books are the result of a long journey involving many years and many people. Pushing in Silence began its journey well over a decade ago. My debt and gratitude for all the support I have received is enormous, but I will be brief. In its initial iterations María del Carmen Baerga guided my work at the University of Puerto Rico. My father, Félix Córdova Iturregui, read and commented on my earliest project in its entirety. Later, at the University of Michigan, Sueann Caulfield oversaw my research and writing as it evolved into a dissertation. Rebecca Scott, Marty Pernick, Marcia Inhorn, and Alex Minna Stern all influenced my work during those years as well. After my return to Puerto Rico, Lucy Peña helped steer me through the archives at the UPR School of Medicine. Recently, after years of setting this work aside, several colleagues in the Rochester area of upstate New York provided invaluable feedback on portions of the book. These include Anne Macpherson, Jonathan Ablard, Tom Lappas, Molly Ball, Ryan Jones, Aiala Levy, and Pablo Sierra. At Nazareth College, Olivia Staff assisted with formatting, notes, and proofreading. My mother, Carmen Suárez, and my sister, Cristina Córdova, not only were a source of emotional support, but they were on call on more than one occasion when I needed an extra set of eyes at a moment’s notice. Elsie de Jesus shared her insight on a couple of my later chapters. I wish to express my gratitude to the anonymous reviewers and to Kerry Webb, Angelica Lopez-­Torres, and Amanda Frost at the University of Texas Press, as well as Jay Marchand for the indexing. My greatest debt, however, goes to Clare Counihan, who spent long hours poring over my manuscript. Her keen eye and talent were exactly what I needed to move this book forward. My biggest inspiration, constant companion, and teacher, however, has been my son, Diego. This book is but a tiny testament to the ways he shapes my life.

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Pushing in Silence

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Introduction

I

n the middle of the twentieth century, there were more than twice as many midwives (1,500) as registered doctors (729) on the island of Puerto Rico. More than 60 percent of births were assisted by midwives, most of them at home, while doctors attended 25 percent of births, almost exclusively in a hospital setting.1 Twenty years later midwives had disappeared, and the number of physicians had almost tripled. By 1970 almost every baby in Puerto Rico was being delivered in a hospital under the authority of a physician, typically an obstetrician. What explains this shift? What changes in attitude—toward birthing, midwives, and doctors—accompanied it? This book delves into how and why giving birth moved from a home-­ based, family-­oriented process assisted by women and midwives, and accomplished by the mothers, to a medicalized, hospital-­based procedure directed by predominantly male biomedical practitioners, and ultimately, after the 1980s, to a reconfigured technocratic model of childbirth driven by doctors’ fear of malpractice suits and corporate hospital concerns.2 In the process, obstetricians managed to assert and consolidate themselves, while midwives disappeared or recast themselves in response to new demands and possibilities. Part of the dramatic and widespread changes that occurred in Puerto Rico between the late 1940s and early 1970s included shifts in culture and the way birth was practiced. This book focuses on transformations of birthing in Puerto Rico after 1948, the year that the first locally elected governor (the highest position in Puerto Rican government) took office with new programmatic ideas intended to radically transform the social,

political, and economic landscape. The development of some of the belief systems and everyday practices that accompanied this period of rapid industrialization on the island are among my central concerns in the book. It is through these themes that I engage with scholarship that scrutinizes how biomedicine is culturally constructed in different regional and historical contexts. The aggressive industrialization of Puerto Rico from the late 1940s until the 1970s, geared toward raising the standard of living and developing the island, converged unavoidably with shifts in birthing practices. I build upon the existing history of medicine, women, the body, the family, industrialization, and the politics of power, as well as the production of knowledge of contemporary Puerto Rico. The title of the book, Pushing in Silence, refers to these changes. Birthing in the new millennium is often portrayed by the US media as a noisy, dramatic event limited to the pushing stage of labor and delivery. The actual process, though, is longer and, in most cases, much quieter. During most of the birthing process the body is engaged in a tremendous amount of transformational work, but it is less apparent to us, much like the changes in birthing practices in Puerto Rico. The choice of the title reflects the drama of change, yet is an invitation to challenge our notions about birthing and quieter forms of historical change. As the young populist government instituted new political, economic, and ideological structures, its state-­led project to industrialize and modernize Puerto Rico allowed physicians to assert themselves over the more informal forms of apprenticeship and intuitive, community-­based practices such as midwifery. Puerto Ricans largely accepted and legitimated new institutional social and medical services. Customs once practiced in relatively isolated and intimate domestic spaces began occurring outside of the home as Puerto Ricans sought out these experts and services. The government grew, establishing itself as a colonial welfare system looking to uplift and remake itself following an industrial model informed by rational, scientific planning, which ideally included even the most remote sectors of the island. These forces coalesced with the development of medical education, new medical technologies, significant improvements in the overall quality of life on the island, the urbanization of Puerto Rico, and a new faith in science, and moved labor and deliveries into the hospital while redefining childbirth and its practice altogether. World War II America, as a whole, experimented with similar models of modernization. Regardless of which model was adopted—the Soviet model of state-­led, heavy industrialization and social engineering or the US model of industrial capitalism—the pervasive notion was that modernization was synonymous with industrialization and would lead to 2 Introduction

progress. Linking technology to progress is an old notion, prevailing in places like Great Britain since the late eighteenth century before waning in Europe as a consequence of the destruction of World War I but then rebounding in popularity in the United States during the interwar period. Michael Adas, in Machines as the Measure of Men, states that “the long-­ standing assumption that technological innovation was essential to progressive social development came to be viewed in terms of a necessary association between mechanization and modernity.”3 He emphasizes that technology was associated not only with progress and modernity, but in the United States modernization became a new ideology whose main exponents were social scientists.4 The social geographer David Slater, in an article on geopolitics and development theory, adds that these ideas carried over to US foreign aid in Latin America. President Truman’s program, geared toward stabilizing the developing world in hope of warding off communism and revolution, aimed to make the scientific advances and industrial progress of his country available to the developing world.5 These models equating progress with industrialization form part of modernization theory. According to Ronald Inglehart and Wayne Baker, the postwar United States followed a version of modernization theory that viewed underdevelopment as a consequence of internal characteristics: “traditional economies, traditional physiological and cultural traits, and traditional institutions.”6 It followed, then, that if modern values could replace tradition, the people of other countries would follow the path of capitalist development modeled by the United States. My contention is that Puerto Rico’s industrialization project was predicated on these trends and that medicalization of birthing in Puerto Rico was a consequence of a new industrial-­urban lifestyle. By arguing that birthing practices changed as a result of the state-­led industrial project, I propose that there is an irremediable relationship between economics, politics, and culture, and that a change in one produces change in the others. At the same time, while recognizing this synergy, I am not suggesting that any one of these categories exerts a consistent or predictable power over another. I am merely affirming that they serve or undermine one another to varying degrees. Many would disagree. Scholars have long debated whether economics or politics drives culture, whether they are independent of one another, or whether culture drives change in the economic or social structures. Inglehart and Baker clarify that recently two schools of thought have dominated the debate: one emphasizes that culture responds to political and economic forces, and the other sees culture as independent of political or economic influence.7 Sociologists— influenced by cultural theorist Max Weber, postmodernism, and, more 3 Introduction

recently, the cultural turn—have tended to favor the proposition that culture is autonomous from other institutional spheres.8 The medicalization of birth was not imposed unilaterally by those in power. There were campaigns to eliminate home births and eradicate midwives in the United States, but there is no evidence of these sorts of campaigns in Puerto Rico. Access to science, technology, and urban spaces became increasingly possible for women all over the island, including the countryside. As these became available and the middle class grew, mothers-­to-­be, and midwives themselves, let go of traditional modes of living and instead participated in ways they equated with progress and modernity. They moved away from their preindustrial past and into industrial patterns of life that included bringing babies into the world at a hospital, among other things. Rural villages in Puerto Rico, and around the world, were places where “biological, natural, and ritual rhythms, much more than clock time, determined the pace of daily life.”9 The decline of agriculture, the attraction of jobs in manufacturing, and the ensuing reliance on welfare services when the industrial promise of the city fell through restructured that rural rhythm of life. The general population, with varying degrees of constrained choice, gravitated toward what they perceived as efficient progress and standardized development in their everyday lives. Historians Ricardo Salvatore, Carlos Aguirre, and Gilbert Joseph note that “in liberal democratic societies, ruling groups have to fashion ideologies of legitimation that have a modicum of credibility.”10 The promise of industrial progress that the Partido Popular Democrático (PPD) proposed for Puerto Rico was powerful and persuasive to the vast majority of the population, and during the 1950s and 1960s this promise was fulfilled in important ways.

Development and Medicalization The medicalization of birthing is not unique to Puerto Rico but follows a pattern common to regions that have adopted Western biomedical standards along with industrial development strategies. The shift from rural to urban rhythms and the introduction of science and technology as a means to improve lives and solve social ills are models that are familiar to most of us. Complex industrial societies organize themselves through their institutions and laws. Through professionalization of specialized disciplines, experts set and regulate their own practices and protocols. The training 4 Introduction

and specialization of professionals in increasingly subdivided and specialized fields, which commonly accompanies development, led to the rise and consolidation of the obstetrician as a medical expert. Bureaucracy, too, expands and becomes more complicated.11 Once ideals and standards are in place, experts intervene when they are not met. Fixed guidelines determine what is normal and abnormal. Medical knowledge about pregnancy, labor, and delivery also becomes standardized and compartmentalized, including new ideas about what is normal or abnormal. This categorization is an emblematic feature of the medicalization of birth or the implementation of what medical anthropologists such as Robbie Davis-­Floyd describe as the “technocratic model of birth.”12 According to the technocratic model of birth, the successes of medicine “are founded on science, effected by technology, and carried out through large institutions governed by patriarchal ideologies in a profit driven economic context.”13 The basic tenet of the technocratic model of birth, as described by Davis-­Floyd, divorces the laboring body (or woman) from its cultural, social, and emotional context and divides it into separate components to better understand and control it. A distant expert, along with his or her machines and staff, treats the body like a machine. This model assumes that the body is faulty and is best cared for from the outside because it is not able to monitor and care for itself efficiently. In addition, the obstetrician and technology carry the main responsibility for decision making in labor and the outcome of delivery.14 The technocratic model of birth subordinates individual needs to standardized institutional practices and protocols. In general, industrial societies make norms and values universal.15 Along these lines, feminist scholars Carolyn Sargent and Caroline Brettell argue that around the world, medicine has constructed the female body according to an industrial-­capitalist model of production, and has conceptualized reproduction in terms of efficiency and predetermined stages.16 Intuitive and more holistic conceptual approaches toward birth and the body receded under the authority of the medical-­scientific specialist. In the chapters that follow, I elaborate on how technocratic biomedical standards in birthing became generalized and spread throughout Puerto Rican society by the 1970s. Feminist theories of medicine, science, and epistemology all inform my analysis of Puerto Rican birthing.17 The medical divisions of labor, its credentialism, and claims to scientific knowledge—and how these led to the devaluation of women’s skills and previous positions as lay healers—are central to my narrative of the history of birthing in Puerto Rico. Medical anthropologists and sociologists have often addressed the manner in which 5 Introduction

medicine pre­sents itself and is consumed as neutral and rational knowledge. Raymond DeVries, for example, claims that medicine is yet another social product subject to “the influence of structural arrangements and cultural ideas.”18 The assumption that medicine is neutral and rational holds true for most people in Puerto Rico. The emphasis that Western societies have placed on risk (medical, legal, and so on) has been a key element in the consolidation of expert and professional power. Therefore, if midwives would have presented themselves as risk and uncertainty reducers, they would have been able to claim a professional space—but they didn’t.19 This ability to appear to reduce uncertainty explains, in part, the rise of the expert obstetrician in Puerto Rico as well. This book, then, is a study of competing conceptualizations of the childbearing body as either prone to chaos and weakness or imbued with natural powers to give life. Both conceptualizations are problematic in their extremes. The body, in my work, functions within the three areas that feminist scholars such as Nancy Scheper-­Hughes and Margaret Lock have delineated: the individual self, the social body, and the political body.20 The individual bodies under scrutiny here are the pregnant bodies of Puerto Rican women who placed themselves in the hands of experts and institutions that medicalized, standardized, pathologized, stratified, monitored, and controlled the process of labor and delivery as part of the same process affecting the broader social and political bodies in post–­World War II Puerto Rico. Feminist scholars working on reproductive health, including Michelle Murphy, stress the importance of the coupling of progress and technology during the postwar period.21 Authors such as historian Laura Briggs and public health analyst Annette Ramírez de Arellano have linked the PPD’s modernization efforts and the concern with so-­called overpopulation to reproductive practices and policies in Puerto Rico.22 Many local government leaders and doctors in the 1950s and 1960s were Malthusians23 who had participated in long-­ standing efforts to control reproduction on the island. The history of these efforts has generated tremendous controversy, which several scholars have addressed. In Reproducing Empire, Briggs shows that Puerto Rican women served as guinea pigs in clinical trials for hormonal oral contraceptives and have had among the highest rates of sterilization and cesarean sections in the world since the 1970s. Briggs acknowledges the abuses doctors committed against Puerto Rican women who were sterilized without their consent or full understanding, but challenges the notion that most sterilizations were unwanted. Even so, why, in the new millennium, do a third to nearly half of Puerto Rican children come into the world via the scalpel 6 Introduction

and the same proportion of Puerto Rican woman choose to be sterilized? I am interested in expanding Briggs’ work by exploring these questions. Who resorts to sterilization, birthing at home, and using private health care institutions versus public ones has for the past decades varied by class. On occasion I use the terminology Shellee Colen has coined, “stratified reproduction,” when my work speaks to her theoretical framework, in which reproductive technologies and practices play out differently for people of different genders, geographic origins, ethnicities, races, economic classes, and places within the global economy.24 I do not address all of these categories, but I do discuss the importance of class, gender, and geographic place in the history of childbirth practices in Puerto Rico. Class, for instance, plays an important role in the choices and possibilities for mothers and health care practitioners. Davis-­Floyd explains that medicine reflects American core values oriented toward science, high technology, economic profit, and patriarchy. Mainstream society in both the United States and Puerto Rico practices a supervaluation of science, which claims objective, positivist truths that tend to lead to reductionist practices.25 Following this line of thinking, by studying birth, I capture some of Puerto Rico’s core value systems of the second half of the twentieth century. Making birthing practices the point of entry of historical analysis permits us to untangle some of the relationships among culture, everyday practices, politics, the law, and the Puerto Rican industrial model of colonial development.

Context In the decades following World War II, a new faith in science and medicine and the belief that everyone could control their own destiny with the help of professional experts spread through many regions of the world. Many believed that science and medicine, in tandem with foreign aid, would enable so-­called developing countries to eradicate poverty, which might otherwise destabilize them and lead them down the path of communist revolution.26 At the time, Puerto Rico was in the early stages of industrial development and officially searching for a way to resolve its internationally criticized colonial relationship with the United States. Local leaders had fashioned the aggressive process of colonial industrialization after the ideas of prominent liberal leaders such as Franklin Roosevelt and Rexford Tugwell.27 Their ideas were adapted in the 1940s 7 Introduction

by leaders such as Puerto Rico’s first locally elected governor, Luis Muñoz Marín (1948–1964), through the project Manos a la Obra (Operation Bootstrap), which altered all levels of Puerto Rican society.28 The original political platform of Muñoz Marín’s PPD was to industrialize and urbanize the country, thereby generating higher standards of living and opportunities for Puerto Ricans. Supported by a strong majority of the population, the PPD aimed to diversify the economy, attract US investment through explicit incentives such as tax exemptions, create more factory jobs, and provide more social welfare programs. These policies accelerated the process by which Puerto Rico changed from an agriculturally based economy and culture to a techno-­industrial one driven by urban production, and they transformed social structures in just twenty years. By the 1970s, Puerto Rican agriculture had all but disappeared, but manufacturing did not offer sufficient jobs, leaving large sectors of Puerto Ricans unemployed and reliant on welfare services. As life in general changed, so did birthing practices and expectations. The state provided free and affordable health services within a biomedical model of authoritative, paternalistic care, and private hospitals expanded their obstetrical services for those with private insurance or more financial resources. Once medical institutions proved to be viable and affordable spaces for all Puerto Ricans, and families grew accustomed to leaving home to access public services, women were much more apt to birth in those same spaces. Puerto Rico’s post-­1948 government and its liberal-­populist economists believed that the state should not only protect private property but also guarantee the social welfare of its population and intervene in the economy.29 The state thus assumed both the right and the obligation to intervene in family life and cultural practices to ensure family well-­being.30 Initially, PPD efforts to raise the standard of living did improve the quality of life on the island as measured by education, infrastructure, and health standards between 1948 and 1970. These improvements were achieved through a planned economy in conjunction with massive social welfare programs. The Puerto Rican state behaved in a paternalist manner, taking over the traditional responsibilities of the male head of household and provider. The figure of the strong male patriarch had been rattled by urbanization, and many local leaders and intellectuals feared for the stability and progress of the family, the home, and eventually all of society. The absence of men in the home due to migration to the United States in search of jobs, World War II, and later the Korean and Vietnam Wars, the number of single mothers, and the increasing rates of divorce worried many government planners.31 Many women left their domestic spaces and made their 8 Introduction

way through the labyrinths of government bureaucracies in search of services and welfare. Just as in the US South after the 1920s, the government of Puerto Rico sought order in the 1950s and 1960s by monitoring family life and making it accessible to planners and experts with the goal of improving the overall quality of life on the island.32 Domestic life in Puerto Rico, once intimate and often rather secluded, opened up and moved into a mostly urban, public world of institutions and experts. These PPD strategies not only fortified Puerto Rico’s colonial status but also reconfigured the collective everyday consciousness of Puerto Ricans as the island became dependent on the United States for all of its basic needs.33 Operation Bootstrap enhanced US economic dominance by disproportionately favoring its business interests at the cost of local production. The economy diversified but remained under the control of US capital. The ratification of the first Puerto Rican constitution and the Estado Libre Asociado status took Puerto Rico off the United Nations list of existing colonies while leaving it under US jurisdiction with no vote or representation in Congress. Dependency and close ties to the United States also affected the development of medical institutions, social practices, and attitudes on the island. Often, Puerto Ricans would equate progress and science with the United States, and US experts and universities constantly provided direction in the construction of new programs and institutions, such as the School of Tropical Medicine and the UPR School of Medicine. The island’s post­1948 governments disseminated notions of progress and social equality that emphasized the need for technology, standardization, and bureaucratization. Professional expertise became paramount as experts came to hold monopolies of knowledge within discrete fields, leaving little room for autonomy or questioning on the part of clients.34 Relying on the state, viewing institutional standardized protocol as inevitable, and seeking experts and their technologies became commonplace in the collective consciousness of Puerto Ricans. Many scholars, especially those who work in the anthropology and sociology of reproduction, argue that there has been a medicalization of Western societies in general. Scheper-­Hughes and Lock further explain that “social problems are recast as individual pathologies and symptoms.”35 Davis-­Floyd observes that US culture fears the chaotic and uncontrollable.36 In Puerto Rico, the United States has sought to “tame the tropics” to better maintain its control over the island. These aims were reinforced by local groups such as the PPD. These silent forces, controlling and monitoring life on the island, led to changes in attitudes toward birthing and birthing practices. 9 Introduction

Setting: A Time of Rapid Change There are many reasons why Puerto Rico after the 1940s makes for an intriguing setting. This period captures several key, unique experiences for the history of the island. The nation’s current colonial status was legalized and consolidated, and many of the mainstream political actors and parties that exist today came into being. One would be hard-­pressed to find a time and place (mostly between 1950 and 1965) that experienced faster and more widespread changes, including changes in birthing. The dramatic compression of time and space makes the Puerto Rican case unique. Some statistics illustrate the extent and swiftness of these changes. In 1945 there were 42 babies born for every 1,000 inhabitants, infant mortality was 93 per 1,000, and maternal mortality 319 per 100,000.37 In 1967 the birth rate was 27 per 1,000, infant mortality was 33 per 1,000, and maternal mortality 37 per 100,000.38 It is worth pausing for a moment to consider these numbers. These remarkable drops in infant and maternal mortality transpired in just over two decades. The same period also saw a rapid decline in fertility rates, which tends to accompany increases in maternal and infant survival rates. In 1946 only a small fraction—approximately 11 percent—of Puerto Rican households had a refrigerator, over half of households lacked an indoor kitchen, and only about 20 percent had indoor flush toilets.39 Nearly half of the population collected water from wells or rivers.40 By 1960, Puerto Ricans could drink running tap water from any municipality.41 Most families not only had refrigerators but also televisions and toilets by then. Most medical needs in the late 1940s were taken care of within the home by family. In rural areas, over 90 percent of women gave birth at home, and in urban centers 72 percent did.42 In 1967 over 90 percent of all births, rural and urban, occurred in hospitals.43 The overall death rate was 12 per 1,000 inhabitants in 1948; by 1964 it had dropped to 7 per 1,000 inhabitants. Many areas of the developing world experienced similar shifts, but they were almost always confined to particular towns or urban spaces.

Unique Status Puerto Rico holds a unique political, legal, and geographical status that makes it a compelling locus of study. It is economically, legally, and politically bound to the United States as an official territory, yet it shares historical and cultural ties with Latin America and the Caribbean. Its close relationship with the United States provides a revealing comparison with 10 Introduction

other neocolonial and uneven spheres of power in the world. In common with many other countries, Puerto Rico has maintained much of its distinct culture, although its colonial relationship with the United States is more acute. Further intensifying the relationship between the island and the continent is the fact that Puerto Rican migration to the United States skyrocketed in the 1950s—a process that was fostered through a collaboration between the colonial state, the US government, and private industry. Puerto Ricans would provide cheap labor, and US industry would help reduce poverty and population density on the island. During the same decade that the first Puerto Rican medical school opened in 1950,44 migration to New York reached its peak, making emigration to the continental United States a familiar experience for most families and putting them in direct contact with New York City life. Puerto Rico’s medical schools and training have direct ties (curriculum, textbooks, and professors) with the United States, yet, curiously, birthing practices diverged in the two countries. Whereas by 1950 most US births had already moved to the hospital setting, Puerto Rican women were still birthing primarily in the home with midwives up to the 1960s. On the other hand, there were strong movements to provide alternatives to biomedical hegemony in the United States as well as in some Latin American countries. In the 1960s and 1970s, second-­wave feminism in the United States took on many forms and came in direct contact with reproductive practices, health care, and biomedicine. Gender historian Michelle Murphy explains that feminist groups in the United States sought to empower women all over the world to seize control over reproduction and self-­govern their fertility, even if by doing so, they participated in postcolonial practices.45 In Latin America, folkloric, traditional, or alternative medicine coexisted (and continues to do so, to some degree) with mainstream Western biomedicine.46 In important ways, many governments and medical institutions in different parts of the world adapted to less interventionist, less authoritative, and more holistic and humane medical protocols during the late twentieth century.47 They incorporated midwives, tried to reduce the numbers of episiotomies and cesarean sections, and permitted mothers in labor to be accompanied by family and friends. In contrast, authoritative medical procedures in Puerto Rico went virtually uncontested and followed particularly extreme technocratic, interventionist, and hierarchical birthing practices. Episiotomies, cesareans, and restricted access for partners and family members persisted with little resistance. Puerto Rico’s colonial relationship to the United States and relative lack of development led to an exaggerated adoption of US technocratic medical models. 11 Introduction

Understanding this flow of professional training and the manner in which it played out differently in each country has been a focus of postcolonial studies and Latin American and medical history. Scholars of Latin American and Caribbean histories of medicine and public health—such as Marcos Cueto, Julyan Peard, Laura Briggs, and Steven Palmer—have recognized the relationship between empire and public health, but they warn us that we should not assume that medical developments were exclusive to Europe and the United States, or that medicine was merely transplanted to Latin America unilaterally.48 With this in mind, in addressing the relationship between US and Puerto Rican medicine, I focus on local actors within Puerto Rico. In other words, I discuss changes in birthing practices related to the industrial development of post–­World War II Puerto Rico, framed within a colonial experience.

Structure This book is divided into five chapters organized chronologically. Each chapter covers one of the five phases of birthing history during which measurable shifts occurred, upon which I elaborate below. In each chapter I discuss the history of midwives, general medical education and obstetrics, models of birth, birthing laws, birthing practices, general health statistics, variations in general trends, and the overall political, social, and economic context and pace of development. Chapters 1 through 4 include vignettes told by midwives, mothers, and doctors who were involved in the birthing experience during the period covered by that chapter. The stories derive from thirty interviews I completed between 2002 and 2007 in Puerto Rico. These real experiences of individual people who experienced childbirth in some way during each phase of the island’s birthing history enliven a narrative that can occasionally be weighed down with broad-­sweeping statistics and generalizations, losing the human story line. The stories convey experiences that exemplify the characteristics of each particular time frame. In chapter 5, I share my own birthing story. I did not depend on these oral histories to draw conclusions. Rather, they informed my analysis in conjunction with an expansive array of primary sources, including government documents, medical publications, and newspaper and journal articles, among others. The doctors I interviewed attended births from the 1950s until the 1990s. Most of them worked in the metropolitan area, were part of the University of Puerto Rico faculty at some point, and specialized in ob12 Introduction

stetrics and gynecology, but I also interviewed a small group of doctors who worked in rural areas. These were semistructured interviews that usually lasted one to two hours, were recorded in audio, and were later transcribed. In addition, I interviewed mothers who gave birth at home and in hospitals between the 1940s and 1960s. I was able to interview only one midwife who had worked as a comadrona auxiliar (lay midwife) before the 1970s. From what I gathered, most of them were no longer alive. I did, however, interview three midwives who worked after the 1980s doing home births. Most interviewees were selected through a referral system from previous interviews. Others came from my own research, experiences, or conversations with family, friends, and neighbors in Puerto Rico. The names of my informants have been changed, with their permission, to protect their privacy. In addition to my own interviews, I drew from a series of interview notes and transcriptions recorded in the southern region of the island in 2000 by undergraduates studying the history of Puerto Rico at the Interamerican University of Guayama. The students interviewed mothers who had birthed with midwives as well as a few midwives who had worked during the 1950s and 1960s.

Chronological Framework Midwifery progressively disappeared between 1950 and 1970, a period that coincides with aggressive industrialization, but it then resurfaced as the result of the work of five women in the 1980s, coinciding with the decline of the industrial model and the rise of new social movements, among which feminism stands out. I have divided the history of birthing in Puerto Rico into five phases reflecting shifts in practices after 1948. In collecting, organizing, and interpreting my data, I was able to identify patterns and shifts that allowed me to delineate these five distinct phases. I did this with the intention of offering coherence and an analytical framework—not an illusion of tidy human progress. Our human past—and present, for that matter—does not unfold as neatly. Each of the birthing phases is defined by where mothers were giving birth, who attended their deliveries, and what technologies or models of birth predominated. Before 1953, home births under the care of a midwife predominated. In the second phase (1954–1958), the first shifts indicating a tendency toward institutionalization emerged. During this phase, changes occurred at particularly uneven and often rapid rates. Statistics changed notably from one year to the next. 13 Introduction

Also during the second stage, hospital births surpassed those at home by a minute margin, but midwives continued to assist most births. Physicians attended from a fourth to a third of all births in phase 2. The third phase (1959–1965) was the most dramatic for birthing shifts: for the first time the number of hospital, medically assisted births surpassed the number of home or midwife-­assisted births, and the number of midwives guiding births declined significantly. In the fourth stage (1966–1977), hospitals consolidated their power, birthing became medicalized, new technologies appeared, the fetus was perceived as a person independent of the mother, and midwife-­assisted home births disappeared from the public records completely. In the fifth and final phase (1980–1990s), birthing continued to follow a technocratic model, but a handful of midwives began attending home births and publicizing their work. I call these midwives novoparteras because although the terms partera and comadrona were used during all these stages, partera has become more common. Novoparteras pre­sent themselves as related to midwives of the past, but they recast their practices and identities within the conceptual framework of modern industrial values. For example, novoparteras have adopted the tools of modern biomedicine while still preserving their autonomy. Puerto Rico’s technocratic model of birth, hegemonic after the 1980s, required obstericians and obstetric nurses using heavy medical intervention, and depended on medical technolgies. Ironically, as obstericians gained space and power, new threats such as malpractice suits and soaring insurance costs began undermining their practices. Although these general time frames hold true for most of the island, significant geographical differences indicate change was uneven and patchy. Whereas during a given year, especially in the first two stages, it was the rule to give birth at home in some municipalities, in others it was the exception. Given the fact that in Puerto Rico, private and public hospitals have both played a significant role in birthing, I point out that the characters and practices involved in these scenarios also varied in response to class differences. In private hospitals, for example, parturient women had longer hospital stays and delivered with more medical interventions than those in public hospitals. They were also under the direct supervision of doctors, whereas in public hospitals the nurses and midwives continued to play a central role for many years. These microstudies remind us that historical events rarely, if ever, unfold at a consistent and equal pace. I close the book with a brief conclusion that sums up the factors that contributed to the the medicalization of childbirth practices in Puerto Rico between the 1940s and 1990s, and an epilogue suggesting that child14 Introduction

birth practices will likely experience significiant changes in the near future. We are witnessing the number of obstetricians diminish due to the medico-­legal climate, the cost of malpractice insurance, and islandwide economic strains, and this will open up new possibilities for alternative birthing options for women in the coming decades.

15 Introduction

Ch a pter one

Phase One

M i dwife-­Assisted Home Bi rths, 1948 –195 3

Tomasa’s Story In 1952, Tomasa had been married for less than a year and was expecting her first child.1 She was eighteen, living with her in-­laws, and knew she was pregnant when she stopped getting her period. Life in her small house in a rural, coastal town near Canovanas was calm, and Tomasa filled her days tending to her home. She ground and brewed coffee early in the morning, fed the chickens, cooked, cleaned, and tended to laundry. Early one morning she felt lighter than usual and kept particularly busy. Tomasa knew that her baby was due sometime soon, but she could not be sure. She had a comfortable pregnancy and had been able to go about her business as usual for the previous nine months or so. When her mother-­in-­law awoke that morning, she found Tomasa busy scrubbing the kitchen and preparing lunch. The in-­laws joked about her light and happy demeanor. That evening Tomasa felt strange. There was little to do after dark, and instead of lighting a lamp or a candle, she decided to retire for the day. That is when the dolores (pains) began, but she thought little of them and was embarrassed to say anything to her mother-­in-­law. She hated to complain. At ten o’clock she went to the kitchen, got an empty caneca (pint of liquor) bottle, and filled it with hot water to put on her belly. Her pains “heated up” (se calentaron los dolores), and she started to pray and cry, but quietly so as not to draw attention to herself. A few hours later, when her mother-­in-­law came in to see what was happening, she saw that Tomasa had started to leak water (amniotic fluid) and called her husband to go find their son so that he could fetch the local midwife.

Doña Julia walked in at one in the morning.2 She was dressed in white from head to toe. Her hair was covered with a white handkerchief. Tomasa immediately recognized the deep wrinkles of the woman smiling down at her. She had often seen Doña Julia in church and knew that she had assisted many women in the community with their babies. She had spoken on occasion with Doña Julia about her pregnancy, and she had always offered good, practical advice. Everyone knew that Doña Julia was officially registered as a midwife in Canovanas, and she was well liked and respected in the community. Doña Julia set down her black bag (maletín), leaned over and inspected Tomasa’s belly with her hands, and then proceeded to wash her hands carefully. Once Doña Julia had confirmed that Tomasa was well into her labor process by performing a vaginal tactile exam, she stepped out of the room. She asked for hot water, towels, newspapers, and a wooden slate and slipped back into the bedroom. She proceeded to wash Tomasa with boric water and shave her in preparation for the birth. Soon thereafter, Doña Julia pulled out some sheets, covered the mattress in newspapers, laid a rubber sheet that Tomasa had bought over the newspapers, dressed the bed in clean white sheets, and placed a wooden board under the mattress to provide Tomasa with better support when pushing. Tomasa’s contractions seemed to slow down. It was then that Doña Julia sent word to warm up some dark beer with rue (ruda) leaves.3 As the water boiled, Doña Julia joked with Tomasa to put her at ease. She gave the warm drink to Tomasa with the intention of rekindling her contractions and moving the labor process along. Tomasa’s husband said little and did not interfere. He trusted that Tomasa was in good hands. For the next hours, Doña Julia stayed at her bedside rubbing her belly. Whenever she seemed in pain and desperate, Doña Julia prayed. Finally, just before the sun came up, Tomasa gave birth to a healthy baby girl. Doña Julia cut the cord with scissors that she had sterilized. She washed the baby and placed it on Tomasa’s belly to coax out the placenta, and then pressed and rubbed the abdominal area to assist in its delivery. Doña Julia then carefully passed the baby to the mother-­in-­law for the father to see, and returned to clean and dress Tomasa so that she could rest. After a few hours the baby had fed from her mother’s breast and all seemed well. Doña Julia gave the father a paper with all the necessary information needed to register the newborn and said her good-­byes. Tomasa’s husband thanked Doña Julia and paid her ten dollars. For the next nine days Doña Julia stopped by briefly to inquire about the well-­being of the baby and mother. As was customary, the new mother 17 Midwife-Assisted Home Births

would rest for a couple of days and then keep the baby indoors after five in the afternoon for a full month. Tomasa had another eight children at home with Doña Julia in much the same manner.

Introduction and Chapter Overview Tomasa’s story is based on one of the thirty open-­ended, semistructured interviews I completed between 2002 and 2007 with mothers who had given birth during the period covered by this study, and with midwives and doctors who had worked at that time. The preceding story about the birth of Tomasa’s first baby represents how the vast majority of rural and lower-­income women experienced childbirth in Puerto Rico between 1948 and 1953. Until 1953, many midwives were registered with the Puerto Rico Department of Public Health and had received some training from state health services. These midwives were registered as comadronas auxiliares. It was likely Doña Julia was a comadrona auxiliar because of her attire, such as her black bag and head scarf, and her practices, including use of a plastic sheet, razor, and boric acid, and her dissemination of information about the demographic registry to the father. As many scholars have pointed out, 1948 marked a watershed in political and economic history. What few scholars have explored is how these changes translated into transformations of belief systems and cultural practices such as childbirth. This chapter covers the history of childbirth in Puerto Rico between 1948 and 1953, a period when traditional childbirth practices predominated but the seeds for change were planted. After exploring the role of the comadronas auxiliares, the registered midwives at the time, I discuss the role of laws and regulations, professional organizations, educational institutions, and broader socioeconomic changes as essential seeds for change. Finally, I delve into the training and professional organization of physicians through the establishment of the University of Puerto Rico School of Medicine and the efforts of the Asociación Médica de Puerto Rico (AMPR) to influence the process of establishing medical authority. Along with my analysis of the transformations of birthing practices and the social relationships of those directly involved in childbirth, I also uncover the existing common childbirth practices and attitudes, the services available to women during this period, and the type of training available to childbirth practitioners. Between 1948 and 1953, mothers, doctors, and midwives considered childbirth a normal and expected part of everyday family life, with medical intervention rarely needed. It was a female activity that left most men, 18 Pushing in Silence

whether they were fathers or doctors, on the sidelines. Midwives and mothers-­to-­be were the chief knowledge bearers regarding pregnancy, childbirth, and rearing children. Mothers-­to-­be from the more privileged social classes, however, were more likely to deliver their babies in a hospital setting under the care of a physician. Public health, education, and welfare institutions were developing but had not yet entirely claimed pregnancy and childbirth, as they would in later periods discussed in this book. The first four-­year medical school opened in Puerto Rico in 1949, foreshadowing future changes in health and medical practice. Already influencing childbirth practices and midwifery were legal and licensure regulations under limited state supervision. Doctors, who had become well organized under the AMPR at the beginning of the century, sought to move health care out of the home and into biomedical4 institutional spaces while they guarded their autonomy and fought to keep local politics at bay. Before 1953, obstetric technologies were limited to an occasional lab test, some x-­rays, forceps deliveries, rare cesarean sections, some analgesics (Demerol, scopolamine), episiotomies, and blood transfusions where they were available, but a great majority of women birthed in hospitals and homes without experiencing any of the above. During the early 1930s, the Puerto Rico Department of Health initiated an effort at organizing and meeting with midwives to provide some training and collect birth statistics systematically in accordance with local licensing laws and regulations. Midwives were to meet monthly in the town to which they were assigned in what was called the Club de Comadronas (Midwives’ Club). This approach of reaching out to rural communities and providing social services throughout the island was consistent with the New Deal efforts of social relief and government intervention after the 1930s. Therefore, within this context—and understanding that neonatal, maternity, and fertility rates and outcomes were indicators of standard of living—the Department of Health focused attention on the effective collection of statistics and on improving reproduction-­related outcomes, as well as holding health care providers accountable for their services. This meant addressing the existence of midwife-­assisted homebirths. In the eyes of the government, most doctors, and the general public, the service of midwives was valuable because it resulted in better maternal and infant care, and provided a connection with public health efforts. Recognizing the need for midwives, the colonial government began its first move toward intervening in their practices in the 1930s, but in 1948 a new government, with new goals, began putting new regulations and institutions in place. As outlined in the introduction, these winds of change came under the paradigm of state-­led industrialization and moderniza19 Midwife-Assisted Home Births

tion, which eventually would phase out midwives and place childbirth in the hands of physicians. Therefore, between 1948 until 1953, although midwives and home births still predominated, the government and social science experts presented new political, economic, and ideological paths that would facilitate the medicalization of childbirth and the disappearance of midwives. Throughout Latin America, democracy took root on the heels of the increasing participation of broader social sectors—including laborers, peasants, and a growing middle class—under the auspices of state-­led modernization efforts. The expanded participation of society not only brought a majority following to the young Partido Popular Democrático (PPD), but culminated in pulling in previously marginalized and isolated sectors of the island into mainstream practices and conversations. Historians often define this stage in Latin American history as a transition between modernity, often under a populist government, and industrial expansion or state-­led industrialization.5 Puerto Ricans were part of this general shift, embarking on a populist, state-­led industrialization effort after the mid-­1940s. The PPD, using its slogan “Bread, Land, and Liberty” and following the leadership of Luis Muñoz Marín, took on many of the characteristics of other Latin American populist governments. The party had massive, far-­reaching popular support all over the island. In addition to an ambitious effort to industrialize the country, the PPD took up the task of formalizing and updating its colonial relationship with the United States. It did so by approving its first local constitution, under a locally elected government, yet under the constraints of the US government, during a time that was both hostile toward political dissidence and characterized by a Puerto Rican populist-­style leadership. The introduction of welfare, the expansion of public education and public health care, and the dissemination of the ideals of growth and equal opportunities for all were some of the PPD’s goals. Attaining popular consent through the interventionist state became fundamental to legitimating the colonial capitalist project.6 For the first time in Puerto Rican history, the new 1948 government of Luis Muñoz Marín had attained precisely this populist consent, which would serve to unify and transform life on the island in unprecedented ways. Modernization for the government in postwar Puerto Rico entailed dismantling the traditional agrarian culture and substituting modern values and institutions strongly influenced by the social sciences, as expressed through their models and preset standards. Their interest in normative structures grew rapidly. The modernization project, then, entailed the systematic specialization, organization, classification, and scientific 20 Pushing in Silence

study of the economy and social issues. Childbirth practices would also come under the influence of and mimic these trends. While most women delivered at home in the 1940s, women who were from more privileged social classes and were better educated often delivered their babies in hospitals. Some even received prenatal care, although this was rare. Women who birthed in hospitals were not always aware they formed a small minority. Women from more humble backgrounds usually birthed at home under the premise that it was the most normal and perhaps the only choice available to them. Everyone they knew birthed at home. It was almost as if, for pregnant women, there existed two Puerto Ricos, each with no knowledge of the other.7 Between 1948 and 1953, childbirth practices were in great flux. Although one might have been able to foresee a shift toward medicalization, traditional home birthing practices were the norm. As the industrialization of labor and the institutionalization of welfare, education, and health care consolidated rapidly throughout the island, birthing practices followed suit. The first step in that direction was the organization and training of traditional midwives by the Department of Health.

The Comadrona Auxiliar Beginning in the 1930s and continuing into the 1950s, the Puerto Rico Department of Health presented the legislature with several proposals to establish training centers for midwives. Health officials believed that unless they were able to organize midwives’ services, they would not be able to decrease rates of birthing complications and mortality or improve neonatal health and the island’s overall conditions of health.8 At midcentury the Department of Health reported that more than 1,500 auxiliary midwives were working on the island.9 This number represented only those midwives who participated in trainings and registered with their local units every month. The vast majority delivered babies at the mothers’ homes. One can also assume that there were some midwives who worked outside of the state’s radar. In 1949, for example, the Department of Health estimated that there were more than 200 “clandestine” midwives.10 In 1946, with financial backing from the US Children’s Bureau—Child Health Services, the health department’s Bureau of Maternal and Infant Hygiene absorbed maternal and children’s services. They offered services in conjunction with unidades de salud (health units) from seventy-­six urban and eighty-­five rural communities.11 Every health unit provided pre- and postnatal clinics. (They also housed the training sessions, described below, 21 Midwife-Assisted Home Births

that fulfilled the requirements for obtaining auxiliary midwife certification.) Even though the clinics offered pre- and postnatal care, few women sought these follow-­up options. It had not been common practice, and women did not feel the need to see a doctor if they were not ill. Recognizing the low levels of prenatal care and believing that it would improve maternal outcomes, the health department sought to increase prenatal care and to centralize systems for gathering statistics. It is difficult to generalize about why or how midwives entered the practice. Some probably began by observing a doctor in a hospital setting, while others trained by accompanying midwives in their family from a very early age, and yet others fell into midwifery by chance. There are some accounts in the series of interviews carried out by students from the University of Guayama of midwives who were assisting births well before being recruited or pressured by their municipalities through outreach and publicity campaigns to attend the monthly meetings and take the exam to become licensed as comadronas auxiliares.12 Most heeded this call out of fear of not being in compliance with the law or in hope of increasing their prestige as midwives. Others, although in much smaller numbers, chose to forgo acquiring a license and avoided the law. One woman told interviewers in 2000 that she had decided not to attend the meetings. To skirt the law, she would receive a baby at birth and carry it, with the placenta still attached to the umbilical cord, to the closest hospital to have a doctor cut the cord. She never charged for her services. In this way she assumed no legal responsibility for practicing midwifery. Apparently she encountered no resistance from the local hospitals.13 Law 22 of 1931 was the first to refer to comadronas auxiliares and their authorization. This was the law that led to the creation of the Club de Comadronas for the purposes of training and supervising midwives under the Puerto Rico Department of Health. The program had the dual intention of organizing, training, and regulating midwives who were already practicing as well as recruiting future midwives to attend mainly home births. Nine nurse-­midwives supervised the club and met every month with licensed midwives in different locations across the island. Health department personnel instructed the auxiliary midwives about their responsibilities during the monthly meetings of the Midwives’ Club, which were required for certification. They were to follow the aseptic standards of hygiene, use gloves, and refer high-­risk cases to qualified physicians. They were to counsel the pregnant woman and prepare her for both delivery and caring for her new baby. Midwives occasionally registered the newborn or reminded the family to do so, and they were supposed to make postpartum visits. Doña Julia, the midwife in our opening 22 Pushing in Silence

story, fufilled most of these protocols. Furthermore, midwives were expected to take on some aspects of social work for other family members in need of assistance. She kept a personal birthing registry, which she delivered to her health department supervisors every month. Midwives were also supposed to recruit future midwives and report anyone practicing midwifery without the required permits, but I found no evidence of such reports.14 Midwives’ influence varied in each community and in some municipalities the hospital’s presence in births was stronger. Comadronas auxiliares had to pass a written exam in San Juan (the capital) and then attend the monthly meetings with their registers/notebooks, in which they were to write the names of every parent and newborn they serviced. The notebooks were then submitted to and inspected by their municipal supervisor. After confirming regular attendance at club meetings, the Department of Infants and Hygiene would issue an annual certification to every midwife who passed an oral examination. The district supervisor (usually a nurse) and the chief of the Department of Infants and Hygiene signed the certificate. After passing their written exam, the midwives received a button and an insignia and were instructed to buy a uniform and a medical bag from the Department of Infants and Hygiene. The midwife used the insignia, uniform, and bag during every delivery. As mentioned above, the uniform was white from head to toe. Midwives were to wear a cap and cover their mouths with a cloth mask while attending deliveries. In their bags they carried tweezers, scissors, enemas, capsules for cleaning and disinfecting, silver nitrate15 drops, a mask, sheets, a scale, razors, tape measures, alcohol, gauze, a tray and metal or porcelain plates, cotton, clothes, postpartum pills, and soap. In one interview, Tomasa, the mother whose story opens this chapter, recalled the arrival of her midwife: “She came, brought her black bag with her towels and her scissors. She was real clean. She was all registered in Conovanas. She arrived with her cap, like a handkerchief that covered all her hair.”16 Interviewees consistently described midwives as wearing white and carrying their black bags. It seems that these visual markers were noted and stressed by both mothers and midwives. The fact that midwives had uniforms, instruments, and black bags probably provided some prestige and legitimacy. The white uniforms served to visually identify the profession and its corresponding hygiene; the instruments represented power and expertise; and the black bag linked the midwife with the world of medics. Doña Penchi, a midwife I discuss further in chapter 2, would spend an entire day preparing for the monthly comadrona meeting at the health center.17 She took great pride in keeping the contents of her black medical 23 Midwife-Assisted Home Births

bag in prime condition. She washed her sheets and diapers and left them over hot vapors until they glistened. Once they were dry and ironed, Doña Penchi folded the four diapers carefully and placed them in the white linen bags she had sewn. She did the same with the two sets of sheets. Next she placed her scissors and tweezers in metal bowls on the clean floor, covered them in alcohol, and lit a match to them to sterilize them. She laid out her gauze, postpartum pills, silver nitrate drops, rubber sheet, balance, and sublimada capsules and packed everything individually and neatly in her black bag. During her interview she recalled that she would take a final peek inside her bag and breathe in the sterile aroma that was so familiar in her household. Doña Penchi left for her meetings satisfied that her black bag was prepared in case her supervisor selected it to inspect in front of all the other midwives that month. All of the comadronas would sing their anthem to open every meeting. Many years later, Doña Penchi had no trouble reciting it. The anthem is a testament to the dedication of these women and the administrative role of the Department of Health: Our prestige is to fulfill our duties, keep a clean uniform and medical bag too. The midwife wishes to do her job, delivering healthy children and infection-­free mothers. We care for baby’s eyes with all our heart, with silver nitrate drops we end infections. The midwife wishes to do her job, delivering healthy children and infection-­free mothers. We wash our hands well with a brush, soap, and water. . . .

By closely analyzing the language in the narratives of the Guayama interviews, we can learn more about the practice of midwifery.18 The first notable aspect is the fact that although the comadronas described similar situations, their use of language varied significantly.19 There is little indication of a standardized professional vocabulary, supporting the descriptions of midwives as solitary, self-­directed practitioners. The terms that were consistently used referred to the instruments they used and their monthly meetings. The comadronas tended to refer to contractions and the onset of labor as dolores (pains) and cuando le empezaban los dolores (when the pains started). They also spoke commonly of teas and massages, but sometimes varied between using the words sobo (rubdown) and masaje. Besides this, their language referring to their practice varied greatly. Some 24 Pushing in Silence

comadronas spoke of the fetus or baby as nene, others muchachito and bebé— all rather informal ways of referring to small children. They spoke of how they would listen to the mother’s heart and feel the baby. Sometimes they mentioned medical terms such as eclampsia, placenta previa, hemorragia, and vertebras, a sign of medical training. The use of biomedical vocabulary is infrequent though, indicating limited exposure. One Guayama comadrona referred specifically to language and told her interviewer that “nowadays” hospitals and doctors use “sophisticated vocabulary.” By this she was probably referring to the standardized, scientifically codified vocabulary imparted in medical schools. Language was not the only area where minimal systematic medical modeling is evidenced. As discussed earlier, prenatal care was rare. The comadronas auxiliares rarely visited mothers before birthing and did little to prepare them. The mothers-­to-­be followed no special diets and no particular rules. One could speculate that the lack of prenatal care implied the assumption that women were built for birthing, and their bodies, in tandem with the forces of nature or God, were all they needed to manage the process. Very few women made appointments with a local hospital doctor before their due date. Unless a woman felt her baby was in danger or she fell ill, she would rarely travel to a medical facility. Women of more privileged classes, with personal medical contacts, were much more likely to seek regular medical care during their pregnancies. Some women had previous relationships with their midwives, but often the first significant contact would begin with the onset of labor. The women interviewed by the Interamerican University of Guayama students described the practices of the midwives in their birthing experiences as having much in common. Without exception they spoke of massages given by the midwives, who used bare hands over the woman’s abdomen to establish the baby’s position and assist with labor. The crede (a massage done over the belly to aid in the expulsion of the placenta after birth) was also practiced regularly by comadronas. The mothers whom I interviewed invariably spoke of these techniques. For example, Nilsa said that her midwife “brought oil and started to massage the belly . . . and rubbed and rubbed and rubbed with oil” to assist with her labor process.20 Olive oil was typically used for massages, and women described doctors and nurses performing these massages in hospital settings as well. By placing an ear over the mother’s abdomen, a midwife can locate the baby’s heartbeat. Tomasa reported that Doña Julia massaged her abdomen and listened to the baby’s heartbeat this way. Most midwives gave mothers different sorts of teas to assist with the birthing process and contractions. But more than the use of specific herbs, 25 Midwife-Assisted Home Births

midwives and mothers seemed to turn to any sort of warm liquid for the mother to drink with the belief that it would calentar los dolores (heat up the pains) and speed up the labor process. Tomasa recalled that Doña Julia would “heat up some beer with a rue leaf . . . or mint . . . something warm.”21 Vanesa, another mother, said that her midwife would give her coffee, “something to warm me up . . . something warm.”22 According to the Guayama interviews, the interviews I carried out, and official government documentation, it seems that comadronas and families had a basic understanding of sterilization and contamination. Midwives boiled the sheets for an hour to sterilize and have them ready before arriving at the mother’s home. They placed their instruments, such as scissors and tweezers, on plates to soak in alcohol and later lit them on fire or boiled them. It is likely that mothers cleaned diapers by boiling them and that folk knowledge included some forms of asepsis, but most of these practices were taught and stressed during the midwives’ monthly club meetings. Once in the home, the midwife would bathe the mother entirely and carefully clean and shave the area of the vulva in preparation for childbirth. Either the midwife or the mother would prepare a bed with clean sheets. If the bed was too soft, they would place a board under the mattress; if a bed was unavailable, they would make one on the floor. Before receiving the baby, the midwife would wash her hands and arms with an antiseptic capsule or regular soap. Some midwives applied enemas to the mother in preparation for birth.23 Other midwives were instructed by the health department not to use enemas and did not do so.24 Postpartum, the midwife would proceed to check, clean, weigh, and measure the newborn. The Guayama interviewees mentioned that mothers would be cleaned and given a pill that the Department of Health required, but this unknown type of pill was not mentioned in any of my interviews with mothers, midwives, or doctors. The exact nature of this pill is unclear. Some midwives claimed that it prevented postpartum infections, and others that it relieved pain. Comadronas commonly applied silver nitrate to the baby’s eyes, sometimes in the presence of a witness since it was common for the mother to be distracted, tired, or asleep after giving birth, meaning she could not be dependable if called upon to testify in case the midwife was questioned about whether she had applied the drops. It was legally possible for a Department of Health supervisor to stop by the mother’s house after a birth. Though I found no instances of these visits, the concern that it could happen was very present in the Guayama interviews with midwives. The midwife would usually visit the household for several days after the birth to inquire if all was well, and sometimes 26 Pushing in Silence

wash the baby and clean the belly button until the remaining cord fell off. Tomasa reported that Doña Julia performed all of these duties. Though government documents explicitly state that midwives received no salary from the government, a few doctors mentioned during their interviews that midwives were working as salaried employees in municipal hospitals during the 1950s.25 More commonly, their pay depended upon the good will, resources, and disposition of the families they served. After the birth of Tomasa’s first child, her husband paid Doña Julia ten dollars for her services. In the best circumstances they might receive twenty dollars, but for the most part they received between five and fifteen dollars. Payment often depended on what the family could offer at the moment. Frequently, after working long and uncomfortable hours, midwives were left empty-­handed. In sum, the labor of the midwife mirrored that of other workers in the informal sectors; it functioned more as supplemental income than the salary of a head of household or professional. It is unlikely that anyone could have counted on midwifery as her sole source of income. Preindustrial models of labor were not restricted to the work of midwives. The labor of physicians corresponded similarly to preindustrial characteristics during the late 1940s and early 1950s in Puerto Rico. As did most midwives, doctors tended to charge only a few dollars for regular home visits, claimed that they would never turn a patient away due to lack of funds, and many only earned government salaries of a few hundred dollars a month at the time. In some cases, doctors worked for low salaries and even volunteered their time at the medical school.26 Whether birthing was in the hands of doctors or midwives at this stage, and even if birth transpired in a hospital setting, services responded to the rhythm dictated by the birthing mother. Doctors and midwives might resort to massages, teas, or even forceps to help the mother along, but did little to control or alter the speed and progress of the birth process. This corresponds to preindustrial paradigms, meaning that people had assumptions about the role of birth attendants and how birthing itself follows biological rhythms, so they did not strive to control what was seen as pertaining to nature. Distinctions between family, reproduction, leisure, and medical expertise were not rigid. At the same time, signs of standards of care and public health training were apparent in the practices of midwifery and physicians. They sterilized basic tools and materials and were cognizant of the law. Midwives worked alone, and though they seemed to fulfill most of their legal requirements, they did not feel a persistent weight of oversight by the Department of Health. This perception was also true for the 27 Midwife-Assisted Home Births

mothers under their care. I suspect that it was rare for a midwife or mother to receive a visit from a supervisor. When asked if their midwives were supervised, mothers almost always responded negatively, though most were aware that they were licensed. Mothers reported that midwives followed the norms established by the Department of Maternal and Infant Hygiene (capsules, pills, shaving, silver nitrate), but midwives took the liberty of adapting their practices. For example, it seems that few wore gloves and masks. Of the sixty women interviewed by the Guayama students and the twenty mothers and comadronas I interviewed myself, each of whom described multiple birthing experiences, no one recalled a single poorly managed emergency. They reported no deaths or serious complications that resulted in morbidity. Everyone stated that in the event of an emergency, the woman was laid on a hammock or placed in a large chair and carried to the closest hospital. The option of an ambulance was rarely mentioned, though some did say they might be able to borrow a neighbor’s vehicle. Government statistics support claims that morbidity rates were no worse in the domestic setting than in the hospital. Many women had their first few children in the 1940s at home, whereas later children tended to be born in a hospital. Mothers invariably described home births as more human, pleasant, and nicer experiences than those in hospitals. The only unpleasant and problematic events they described were ones that transpired in hospitals. Government documents support the conclusion that their experiences were part of a wider trend. According to government statistics, midwives had better outcomes than doctors in hospitals during the late 1940s and early 1950s. The 1950–1951 “Annual Report of the Sanitary Director to the Governor of Puerto Rico” cites a study that showed of all of the maternal mortalities that year, 47 percent were women under the care of physicians, and 28 percent were attended by auxiliary midwives. A few years earlier, of the total maternal deaths, 73 percent occurred in hospitals.27 If one considers that women were being transferred in case of complications or emergencies, then we can account for the higher mortality rates at hospitals, but it might not fully explain the significant disparities. During the mid-­twentieth century, women often felt better tended to and less alone with midwives. This perception, nonetheless, did not last. Despite recalling their home births as positive experiences, decades later almost all of the interviewees stated that women should give birth in the hospital. Tomasa, for example, described all of her home births as pleasant experiences with no complications and spoke of her midwife in ex28 Pushing in Silence

tremely positive terms. In fact, she explained that “whenever we lost our nerve [during labor], she would tell us, ‘Oh no, you are going to have to go to the hospital.’ . . . And because we didn’t want to go to the hospital, well, we would make an effort.”28 Yet when I asked her what she would recommend to future mothers, she said they should seek medical assistance because “things have gotten so complicated.”29 Tomasa was expressing a sense that life used to be simple but had since been complicated by modern urban lifestyles, and that because of this, the proper place to have a child was in an urbanized space prepared to handle complexities. It was not until hospitals grew and offered better and more specialized services that women began to consider them appropriate spaces for bringing their children into the world. The comadronas of the mid-­twentieth century worked alone and in relative isolation. Each comadrona worked within her own community, with no significant communication with midwives in other communities. No national organization for midwives united them beyond the local monthly government meetings for training and collecting statistics initiated in the 1930s. By then, if not previously, comadronas had begun to practice shared techniques and approaches in delivery. The Department of Health’s Club de Comadronas project had undeniable effects on midwives. The titles themselves are telling. The government conceptualized them as auxiliaries or assistants to doctors under the supervision of the Puerto Rico Department of Health. They met in clubs—not institutes, departments, or associations. We can testify to the department’s effects on the comadronas in certain practices that are described in the interviews under consideration. Among these were using postpartum medication (the mysterious pill) and the silver nitrate eye drops for newborns, shaving, and wearing uniforms, including caps and gloves. Despite the department’s requirements, the level of supervision was limited and barely visible in the actual practice of the comadronas auxiliares. Nevertheless, following common parameters of the process of early modernization, comadronas gradually became subject to more supervision and regulation by institutions that required and collected their statistics. As the twentieth century progressed, more women (especially those with economic resources) looked toward hospitals for delivering their babies. The relationships between autonomy, the law, and the clientele directly affect the practice of midwifery. Because comadronas auxiliares were not professionally organized through a guild, association, or union prepared to defend their professional autonomy, their practice and social standing weakened in the face of the proactive organization on the part of 29 Midwife-Assisted Home Births

Table 1.1. Distribution of births by place and provider, Puerto Rico, 1951 Type of birth attendant

Home births (59%; 46,293)

Public hospital births (31%; 24,581)

Private hospital births (9%; 7,333)

Doctors (19,695 = 25%)

.7% (526)

49% (12,015)

98% (7,154)

Midwives (49,445 = 63%)

99% (45,671)

15% (3,774)

0% (0)

Nurses (9,067 = 12%)

Less than .3% (96)

36% (8,792)

2% (179)

Source: Departamento de Salud, Informe anual de 1951, 113. Note: There were 78,207 total births in Puerto Rico in 1951.

doctors and the rising medical establishment. Comadronas did not adapt their profession to the changing demands of the island’s population and the shifts created by new urban-­industrial demands. Nor did they find ways of promoting midwifery as one of the higher-­paying career options available for women. It was more viable for a woman to study nursing or education than try to make a living as a midwife. Moreover, the practice of midwifery never entered the social imaginary of legitimate modern professions. Some midwives retired because of age, but others did so out of fear of being held accountable for medical complications or because they understood that their services were no longer in demand in the new world of modern medicine. The health department acknowledged the midwife’s service as a legitimate one, even though it desired, in the long run, to move laboring women into institutions under a medical specialist’s supervision.30 The hospital represented the world of modern medicine. Whether a woman accessed the institutional medical spaces to birth varied according to social class and the region where she lived. The practitioners who served in these different spaces also varied. If we look closely at the birth providers in Puerto Rico, we find three kinds whose influence varied depending on the birthing location. Table 1.1 shows the distribution of births in 1951 tended to by midwives (63 percent), doctors (25 percent), and nurses (12 percent) according to where 30 Pushing in Silence

the delivery took place. Midwives assisted 99 percent of home births and 15 percent of public hospital births, but none in private hospitals.31 Nurses played a significant role only in public hospitals, taking charge of at least a third of the deliveries. In municipal hospitals, as opposed to district hospitals, doctors and nurses attended almost the same number of deliveries (just over 8,000 each), while midwives attended 19 percent of deliveries (3,774 of the 20,008).32 Doctors dominated the private institutional spaces, delivering almost all of the babies there. In 1951, however, the number of women who gave birth in private institutions in comparison to public hospitals was low.33 Overall, the midwives, without a doubt, were the primary childbirth providers, even though hospitals and health centers already dotted the Puerto Rican landscape, and most towns counted on a town doctor. The health infrastructure to support institutional, government-­ sponsored medicine existed and was expanding. The groundwork was in place for childbirth practices to change in favor of the hospital. The population on the island was responding to many changes that would reconfigure their daily lives, and all of these changes would alter the sociocultural frameworks of families in favor of medicalized childbirth. Changes were particularly prevelant in the private sector, which served more affluent mothers.

From Preindustrial to Industrial Patterns of Everyday Life and Health Prior to 1948, Puerto Rico functioned as a traditional colony, with a US governor appointed by the president of the United States as the highest local figure under the jurisdiction of the US federal government. Luis Muñoz Marín was the second governor of Puerto Rican extraction, but he was the first to be elected by Puerto Ricans. He oversaw the drafting of a constitution in 1951 and established a local government to represent the people of Puerto Rico. Under his leadership the newly elected PPD, with the support of the United States, forged a plan for aggressive industrial development with the hope of positioning Puerto Rico within the Western, developed world. As a result, large portions of the population felt a sense of hope and the possibility for renewal, while others experienced a sense of nationalist loss and were targeted by political repression. Ironically, while many voted to cement Puerto Rico’s relationship with the United States by maintaining its protected status, national pride was 31 Midwife-Assisted Home Births

strong as many returned from the war and others boarded planes for New York City in search of work. Nevertheless, Puerto Rico in the mid- to late forties was primarily a poor, rural country with little industrial development. More than a third of its adult population had not gone through the formal education system.34 The poorer a family, the less education it received. Only a third of the population had a fourth grade education.35 One-­fourth of mothers worked for wages outside of the home, and mothers had an average of six to seven children. Rural families were usually larger than urban ones.36 More than a fourth of children born to low-­income families (grossing less than $500 annually) did not live past their adolescent years.37 Their life expectancy increased as the mother’s education increased. Housing structures and facilities varied. Few homes were built completely with cement. In the 1940s, 10 percent of rural homes were straw bohíos, similar to the pre-­Columbian dwellings of the indigenous population. Almost 60 percent of the population had makeshift kitchens ( fogo­ nes) in open, outdoor areas close to the house.38 Only 1 percent of homes had electric stoves, and 11 percent had refrigerators.39 Despite many years of public health campaigns pushing for construction of latrines, close to 20 percent of homes still lacked these facilities, and a mere 20 percent of houses had a toilet.40 In general, many households did not have access to running, potable water, forcing 40 percent of families to collect water from nearby rivers or wells.41 Remarkably, just over ten years later, Puerto Ricans could drink from any faucet on the island, life expectancy had increased by ten years, and the number of doctors had almost tripled.42 Freeways and cars began crisscrossing the island. By the early 1970s, more than 70 percent of households had toilets, almost every house contained at least one television set, and nearly 95 percent owned a refrigerator. By then, about 90 percent of the population was literate as well.43 Between the 1940s and 1960s, public school attendance doubled and university attendance tripled.44 Maternal mortality rates dropped from 319 per 100,000 deliveries in 1945 to 85 per 100,000 in 1958, and general mortality rates were cut in half for the same time period.45 The main causes of death changed from diarrhea and tropical diseases to cancer, heart ailments, and accidents. All of these changes are typically indicators targeted by proponents of modernization. In this light, it should come as no surprise that if life, and therefore culture, in Puerto Rico was in an impressive state of flux, childbirth practices and paradigms would experience similar transformations. As the new government pushed its development agenda forward, it also expanded, redefined, and sought ways to regulate life on the island. 32 Pushing in Silence

Legal Controls and Regulations of Childbirth Practices The eventual disappearance of midwifery and home births in Puerto Rico, inherent in the transition toward a modern technological and industrial society, was supported by legislative and legal-­medical campaigns. Laws and regulations, as well as educational requirements, moved society in the direction of the tighter, more rational, and more standardized control sought by modernization theorists of the time. These legal requirements favored biomedical institutions and physicians. The country counted on biomedicine to improve the health of a nation that was sickly, underdeveloped, and working below desired levels of productivity. Puerto Rican leaders and industrialists believed medicine would be key in providing the stability needed to make the island competitive with other developed countries.46 The history of birthing regulations demonstrates how legal and cultural interpretations concerning professions and their practices varied during different moments in history. To effectively communicate the relationships between society, culture, and the law, I discuss regulations dating back much earlier than the mid-­twentieth century. By analyzing the history of legal controls over birthing practices, I will demonstrate how attitudes and expectations regarding childbirth changed. Furthermore, childbirth controls and regulations were important in determining which professions and what kinds of practice eventually prevailed. The law in many ways molds cultural practices and attitudes. It can serve as a vehicle of ideological transmission and diffusion. Laws have the power of affecting relationships between lay workers and professionals. Individuals shape or repress their behavior to adhere to, or accommodate to, what is stipulated legally; these adjustments then affect the manner in which different actors or groups, addressed in a particular law, relate to each other, which in turn influences the attitudes of those same people.47 The law reflects worldviews and belief systems, which are historically determined collective and intellectual manifestations.48 Midwives in Puerto Rico had a historical disadvantage in terms of their relation to power. The interactions between medicine and the law provided a network of controls, regulations, and educational standards that structured and organized the professions related to birthing, as well as birth itself, according to biomedical understandings. Through the history of legislative measures related to childbirth, we can trace the changing cultural values and forces that eventually pushed midwives out of the workforce. This legal history is one of biomedical power that managed to 33 Midwife-Assisted Home Births

express and represent the changing face of Puerto Rican industrial society to the detriment of other health-­related professions such as midwifery. There are different options for regulating professional practice. One option might respect the principles and workings of those groups and seek to regulate them intact. For example, Raymond DeVries describes the difference between what he calls “hostile” and “friendly” licensing in his book Regulating Birth: Midwives, Medicine and the Law. Friendly licensing includes individual practitioners in the decision-­making process and is controlled by the members of the profession itself. Hostile licensing, in contrast, places control in the hands of professionals who are external to the group that is being regulated.49 The latter was the case for Puerto Rican midwives. Hostile licensing weakened their profession and practices because it positioned them under the jurisdiction of those foreign to their practices and interests. In Puerto Rico, professionals needed to heed one more level of authority than professionals from most other countries: the imperial metropole. For the sake of a thorough understanding of the history of the legal structures affecting midwives and birthing in Puerto Rico, I will briefly extend beyond the temporal framework of 1948–1953. Before the United States took over the island, the Spanish crown held jurisdiction over Puerto Rico. Responding to the interests of Spanish governing bodies and the belief systems of the more affluent social groups of that time, late eighteenth-­century Spanish laws, specifically the Ordenanzas, established titles for doctors, surgeons, bleeders, and midwives. The state’s main concern was midwives’ practical experience; acceptance of ecclesiastic, moral, and racial hierarchies; and appropriate feminine conduct. An 1804 law required that midwives pass an examination that tested their knowledge and practical skills, and that they prove their status as widows or married women.50 Aspiring midwives had to pre­sent permission from their husbands, proof of baptism and of good standing and behavior (buena vida y costumbres) from their priests, proof of having three years of hands-­on experience under the supervision of a surgeon or certified midwife, and proof of their “pure blood” (limpieza de sangre) status.51 This regulation also stipulated that midwives should refrain from undertaking long trips inappropriate to their sex, for women were to stay close to home to comply with gender norms.52 The language and stipulations of the Ordenanzas opened up the possibility for some women to train as midwives under the supervision of other midwives, and this permitted a certain level of professional autonomy. The Ordenanzas excluded unmarried women of African ancestry, however, thereby inscribing both sexual and racial prejudices. At the same time, the law was not formulated by midwives. Thus, it might be considered—albeit inciden34 Pushing in Silence

tally rather than deliberately—an example of hostile licensing. Nearly a century later (1888), the Ateneo Puertorriqueño, a cultural and intellectual center on the island, founded the Institution of Superior Education, which offered some postsecondary education titles. Among these was that of midwifery.53 This institute examined a group of midwives in 1892 and graduated twelve women who later served as midwives.54 Attitudes toward midwives seemed cordial at minimum, but this would not continue into the following century. Physician-­historian Manuel Quevedo Báez, writing in 1946, explained that at the turn of the century many towns on the island had no access to biomedical services. He points out that the field of obstetrics had been “abandoned to the mercy of women with no instruction” who did not have “the foggiest idea” of what the art of birthing entailed or any knowledge of asepsis or personal hygiene. “Ironically,” Quevedo wrote, he himself was born in the hands of one of these “flamboyant midwives.” Happily, he did not suffer the consequences of what he then called “an atrocity.”55 However, Quevedo confessed that the mothers in these “dark” times who “so easily rendered their children to the world” did not suffer from puerperal infections or complications.56 Quevedo’s admission that the high rates of puerperal fever became more frequent after medical asepsis and antiseptic procedures were more widely practiced did not impact his prejudice and negative attitudes toward midwives. Although he associated midwives, not doctors, with filth and inconsistencies, in fact doctors at the time were lackadaisical with their own practice of asepsis and had alarming track records.57 In contrast to the views of doctors and government officials, Carmen Luisa Justiniano, in her testimonial novel about growing up in rural Puerto Rico in the early twentieth century, characterizes midwives as conscientious and careful. In Con valor y a como dé lugar: Memorias de una jíbara puertorriqueña (With valor by any means necessary: Memories of a Puerto Rican peasant), Justiniano describes the hygiene methods and medicinal knowledge passed on to her by her grandmother just after 1930: The first thing she taught me while attending a laboring woman was the hygiene of the midwife herself, and how the use of gloves, unknown to campesinas, . . . was necessary, real important or [mandated by] law that our clothes were clean and that our hands and arms be immaculately cleaned with soap and water. Fingernails also had to be short and clean. . . . Cutting the umbilical cord was another job that had to be carefully done, to avoid hemorrhaging and infections. . . . The scissor used had to be washed with rum and 35 Midwife-Assisted Home Births

submerged in boiling water, or if not passed through a flame of a lamp or candle. . . . This strip [to tie the cord] should be sterilized well. . . . Also Rosemary leaves would be roasted and a disinfectant powder would be made from it to cure the area that was cut. . . . After the birth the mother should stay in bed for several days, taking into consideration her hygiene and nutrition.58

Measures for social control by those in or associated with power include the registering of specialized guilds, such as the AMPR; educational requirements and the granting of licenses; and the standardization of services and protocols that certain sectors must follow in order to be considered a professional. For the most part, these measures were articulated by those with access to political and social power structures. As expected, professional guilds, recognized by the government, and those having access to the resources needed to lobby and pressure the government were the most successful in influencing and directing laws. Those without these resources or representation, such as midwives, were not able to directly influence the legal decisions by which they had to abide. One of the most organized and powerful groups of the Puerto Rican medical class has been the AMPR, founded in 1902 at the same time that many other professional, labor, and artisan guilds and unions were developing.59 The association established close ties with the government and exercised a political function on the island from the start. At some point before 1946, the association added a legislative committee to their organizational structure.60 This committee became one of the more active groups within the association. There is ample documentation in the reports and talks offered to the local legislative government branches in which the association took part.61 In 1948 it sponsored a radio show pertaining to health problems and organized several conferences for parents and schoolteachers.62 A year later, in addition to its professional bulletin, the public relations committee published and distributed, free of charge, El Heraldo Médico to political leaders, teachers, students, and other professionals.63 The AMPR was affiliated with the American Medical Association and sponsored the construction of buildings and libraries, organized hospitals, drew up and submitted laws, created a space for itself in local newspapers, and acquired air time on radio and television.64 The medical association successfully lobbied for a law that established an examination board in 1903.65 The regulation of midwifery was included under this law, and in 1904 the Board of Medical Examiners certified the first midwife.66 The board amended the law in 1915, adding new requirements (completion of the eighth grade and proof of having practiced in 36 Pushing in Silence

a hospital).67 A decade later (1925), another law required midwives to achieve the status of graduate nurse (which usually required a high school degree) as a prerequisite for taking certification exams.68 All of these laws played a fundamental role in the legal practice of midwifery in Puerto Rico by placing standards of licensure in the hands of doctors, a form of hostile licensing. In 1931 the governor,69 following local senate recommendations and proposals by the medical association, and according to law 22 of 1931, appointed seven doctors to serve on the Board/Tribunal of Medical Examiners for a four-­year term. The tribunal was authorized to grant licenses for the following professions: surgeon, osteopath, intern, and midwife. The licenses cost $25 for doctors and $5 for midwives and interns. Article 20 stated that in order to practice, a prospective midwife must meet the following requirements: be of age; to have good health; to be of good moral conduct and mentally sound; to pre­sent an eighth grade diploma from . . . Porto Rico [sic]. . . pre­sent a license of graduate nurse and a midwife’s diploma obtained after studying theory and practice for not less than a year, and to have assisted, under professional direction, not less than fifty childbirths . . . in one of the hospitals or clinics duly recognized by the Board of Medical Examiners. After the applicants have been accepted, they shall pass a theoretical examination in obstetrics, gynecology, and pediatrics and a practical examination in an obstetric clinic. . . . That such license shall authorize [midwives] to attend only normal childbirths.70

According to this law, the tribunal would have the power to withdraw or cancel a license if a midwife committed “fraud or deceit during the practice of her profession . . . committed a felony, was a confirmed alcoholic . . . or was addicted to the use of narcotics . . . or assisted . . . in . . . a criminal abortion . . . malpractice . . . [or] immoral and dishonorable conduct.”71 These were high professional standards that deviated little from those established for physicians. This law authorized the certification of midwife assistants for the first time, although there was never a significant group of women who actually fulfilled what was stipulated in this law by acting as assistants to midwives. Instead, the more than 1,000 licensed auxiliary or assistant midwives worked as primary birth attendants, usually alone and with no on-­site supervision. Although legally defined as assistants, they were listed in later government reports as officially tending to most of the home 37 Midwife-Assisted Home Births

births in Puerto Rico. Law 22 did not specify the requirements for auxiliary midwives. In this case, the intent of the law was to regulate practitioners, but it never came to fruition. Instead it set the stage for regulation of the auxiliary midwives who did come to play a key role in childbirth. In 1931, the Negociado de Higiene Infantil (Department of Infant Hygiene) began training midwives through courses taught by nurses trained in obstetrics.72 Auxiliary midwives received certification upon the completion of courses and an oral examination. These certifications gave them license to practice as childbirth attendants. In 1935, the Midwives’ Club was active and comadronas did indeed report their deliveries.73 Licenses are the end result of the interaction between medicine and the law.74 Ostensibly, licensing regulates and establishes standards for medical practice to follow, as well as protects citizens from abuse. It establishes limits and accepted procedures. At the same time, it can create monopolies and consolidate professional power, inhibit social change within its own realm of operation, protect disciplines, and defend the interests of those in power or who have access to the power and decision-­making structures.75 Social relations are in part shaped this way. Licensing serves to legitimize or delegitimize professions. In 1947 law 390 further defined the Board of Nurse Examiners and acknowledged the practice of practical and auxiliary midwives.76 This law established that [g]raduate nurses shall be authorized to practice as assistant midwives, and the Department of Health shall issue to them the proper license . . . the Department of Health shall be authorized to issue a license to any practical midwife to practice as assistant midwife, with such preparation and under such regulations as said Department may prescribe . . . in any place where the services of an assistant midwife are needed and there are no graduate nurses who practice as assistant midwives.77

This ambiguous law did not define terms or practices for auxiliary midwives, but it seemed to acknowledge both the need for and the presence of practical midwives, much as the previous 1931 law had done. The term practical midwife seems to refer to those who had been self-­trained and were assisting births in Puerto Rico long before the existence of this law. The passing of this law was probably a response to the scarcity of medical providers on most of the island and the desperation of the state to provide understaffed health care centers with medical personnel. It made more sense to pull providers from the existing local resources and work 38 Pushing in Silence

with them. Nevertheless, this law preserved biomedical professional hierarchies. Practical and auxiliary midwives could only practice where graduate nurse-­midwives were unavailable. It is doubtful that nurses themselves had organized professionally to obtain access to midwifery as they were already attending more than 10 percent of births in Puerto Rico and would have had little reason to dedicate themselves exclusively to midwifery. The potential impact of this law became evident years later. In 1951 the commissioner of health, Juan A. Pons, revised and approved the regulations that were to order the practice of midwives under the authority of the 1931 and 1947 laws. Four years later the Department of Hygiene published a report on the auxiliary midwife program (“Material informativo sobre el programa de comadronas auxiliares”). It opened with tones that resonated with Dr. Quevedo’s opinions concerning turn-­of-­the-­century midwives. The department report described midwives as being “a group of illiterate and ignorant women imprisoned in a world of superstition” and went on to say that classes to take them out of their state of ignorance would be organized.78 This disdain surfaced despite the fact that hundreds of midwives were already receiving government-­led training in local midwives’ clubs. At the same time, the document admitted that midwives had a certain prestige, especially in “marginal communities.”79 The health department saw the midwife’s role as one of support for the pregnant woman and her family. Her job was to advise and help the woman prepare for her birth, pregnancy, and motherhood. The 1955 report also mentioned that “From the public health point of view, the auxiliary midwife is a determinant and effective factor as she has been trained on the health of both the baby and the mother at birth, avoiding possible complications.”80 The report listed the obligations of the auxiliary midwife as including the registration of the newborn, making postpartum visits, doing social work, attending normal births, offering resources according to the family’s needs, turning in their birth registration cards monthly, recruiting other midwives, and aiding in the control of illegal midwives.81 Midwives learned about asepsis and how to refer difficult births to hospitals. This was also the period when an independent school sponsored by the Department of Health was opened for the training of obstetric nurses.82 When the secretary of health, Guillermo Arbona, revised the regulations for auxiliary midwives in 1951 under law 22 of 1931, he changed the minimum age of midwife practice from twenty-­one to eighteen years, and established that a midwife had to obtain her license from the Department of Health Tribunal, be a US citizen, be a moral woman of a good name, complete the training offered through the public health unit, and pass an exam or be a graduate nurse with experience in obstetrics. She had to dem39 Midwife-Assisted Home Births

onstrate intelligence and interest, know how to write appropriately, attend the monthly meetings of the health department, be respectful to her superiors, work in the municipality that she was assigned, and apply a silver nitrate solution to the newborn’s eyes. She was prohibited from treating women with swollen feet or hands (which is common among pregnant woman), those who had previous surgical interventions, or women who had hemorrhaging or a prolapsed umbilical cord. This list of requirements was extensive. It was never specified what a “moral woman of good name” was, but we know that many midwives came from less privileged sectors of society with very different customs and beliefs from those of their professional and administrative superiors. This moral ambiguity presented a problem in the sense that many of the midwives’ methods or lifestyles may have been in conflict with these interests. In fact, well over a hundred midwife certificates would be canceled every year from the late 1940s through early 1950s, but the reasons are unknown.83 Midwives’ obligations were almost all geared toward the support of physicians and the state. In this sense, midwives were expected to fulfill the roles that have traditionally been defined by notions of gender. They gave families emotional support, made referrals to authorized medical and social agencies, and completed registry and reporting paperwork. They were only permitted to exercise their more specialized birth-­related knowledge if it did not fall under medical definitions of a high-­risk pregnancy. In Puerto Rico, midwives have been trained under official medical models since 1931. If midwives could have had access to independent schools where they could have practiced within the realm of their own methods and models, then they could have graduated as direct-­entry midwives84 instead of obstetric nurses or auxiliaries. These midwives could have feasibly established their own examination measures and standards of practice, and ensured the rigor and quality of their practices on their own terms. Later they would have had a say in when and how to pre­sent their own proposals to the appropriate governmental bodies, as the medical profession was doing by the 1950s.

The Push for a Medical School and Denunciation of Folk Healers In the process of making a profession official, educational structures emerged to consolidate the functioning and control of that profession. In the same way that processes toward licensing can be hostile or friendly, educational procedures can also impact a profession in different ways. 40 Pushing in Silence

Midwifery was never recognized as a legitimate profession within the parameters of the new modern-­industrial Puerto Rican society and therefore never had an independent educational structure to support its formation. Doctors, on the other hand, had both educational and professional institutions that served to consolidate, legitimate, and develop their profession. Though doctors and institutionalized medical options were becoming quite visible and seemed to be expanding in the early 1950s, few could have imagined the drastic changes that birthing would undergo in the subsequent decade. Before 1950, anyone who wished to follow a career in medicine had to leave the country for training. The island boasted a major research and training center for tropical diseases, the School of Tropical Medicine, which had been in operation since 1926. Until 1950, however, there was no medical school capable of producing US board-­certified physicians. This all began to change quickly when administrative medical leaders and educators set the wheels in motion for the creation of the medical school, which would change the face of medical practice and services throughout the island. The AMPR held a roundtable discussion during its 1948 convention to discuss the possible establishment of a medical school. They heard statements from the local commissioner of health, the chancellor of the University of Puerto Rico, and several prominent doctors who held administrative positions on the island. Juan Pons, the commissioner of health, presented a strong case for establishing a medical school. He claimed that tuberculosis and diarrheal diseases, the leading causes of death at that time, were social diseases and that, according to him and the World Health Organization, every human had an inalienable right to good health.85 To these claims he added that the United States estimated that there should be a doctor for every 600 to 900 people, yet in 1949 Puerto Rico there were only 696 physicians, or one doctor for every 3,009 people.86 Pons called for an expansion of medical services to reach the middle, working, and indigent classes who had little or no access to adequate medical care. He concluded that Puerto Rico needed to train more good physicians with knowledge of their own local conditions and that this could only be done at home.87 In addition to Pons’ heartfelt plea for a medical school, Dr. Costa Mandry, medical historian and then director of the Ponce Pila Clinic, provided a brief history of previous attempts at establishing medical education in Puerto Rico. He reminded his audience that in 1892, a few years before the United States took over the island, the Ateneo Puertorriqueño began medical instruction in anatomy, obstetrics, physiology, and hygiene. This 41 Midwife-Assisted Home Births

effort ceased during the Cuban-­Spanish-­American War.88 In 1922 a group of Puerto Rican doctors attended a dinner at the Columbia University Club and aroused enough interest among Columbia’s administrators to push a bill through in May 1923 authorizing any large US university to establish a branch medical college in Puerto Rico. After funds were appropriated for a commission to study the topic, Columbia worked with local doctors to establish the School of Tropical Medicine in San Juan. Later, in 1934, another bill to establish a medical school was introduced in the local senate, but the lack of funding deterred the effort.89 In 1943, University of Puerto Rico president Jaime Benítez appointed a group of prominent Puerto Rican doctors to report on the possibilities of establishing a medical school, which resulted in the recommendation to create one within the existing public university system. The following year the Puerto Rican legislature passed a bill allocating $500,000 for a medical school.90 Dr. Costa closed his remarks by making a few dramatic points. He stated that 70 percent of the deceased in Puerto Rico had not seen a doctor for their last illness, and in most areas there were shortages of doctors and specialists, and many vacant positions in the Department of Health in general. According to him, 38 percent of doctors worked in the San Juan area, while there were towns with over 77,000 inhabitants without any doctors.91 It was clear that the number of doctors and access to institutional medicine were inadequate by modern-­ industrial standards, and doctors and government leaders teamed up to find ways to change this, though not everyone agreed on the process. Chancellor Benítez and other influential leaders in medicine stated their opinions about opening a school of medicine at a 1948 meeting of the AMPR. Benítez presented the university’s position, stating that it was in favor of a medical school in Puerto Rico, but that it did not have to be under the auspices of the university.92 Guillermo Arbona, director of the School of Public Health in the School of Tropical Medicine, assured those present that the Puerto Rican public supported the establishment of a medical school, but he also attempted to explain the lukewarm position that the medical association had taken on the subject. Arbona claimed that doctors were afraid politics and lack of funds would hamper efforts to build a medical school. They worried that standards might diminish and competition might increase if local access to medical education were expanded.93 On the other hand, Arbona informed his audience that the existing curriculum and library of medicine at the School of Tropical Medicine would suffice for the first two years of medical study. In addition, Puerto Rico could count on its twenty-­two years of past medical research and the construction of medical sites by the Insular Health Department, 42 Pushing in Silence

as well as many other hospitals, for the training of their medical students. The San Juan City Hospital, for example, had recently been approved by the American Medical Association and would be an appropriate site for clinical training. Puerto Rico also could draw from the 65 (of 852) doctors on the island who had been trained in acceptable medical schools to train future students.94 Arbona believed that all of these factors put Puerto Rico in a good position to establish a qualified medical school. The one dissonant voice at that 1948 meeting was Enrique Kopisch, from the Department of Pathology at the School of Tropical Medicine. His basic premise was that more doctors did not necessarily equate to better health care, and that it would be cheaper to send Puerto Ricans to train in US medical schools. He stressed how common it was for doctors to stay in urban centers and provided the example of Cuba, which boasted an excellent ratio of doctors to people, but 58 percent of the doctors were in Havana, leaving many peasants with no health care. In Kopisch’s opinion, the medical problems in Puerto Rico hinged on poverty and low levels of education, which would not disappear by establishing a medical school or having more doctors. The apprehension surrounding the medical school expressed by Kopisch and the medical association did, in part, become cause for concern at different levels by the 1950s and 1960s. There would be a school of medicine; more doctors; more intervention by the state in medical affairs; a permanent scrambling for money, space, and resources; and constant difficulty with the distribution of medical staff outside of the metropolitan areas. The medical association’s interest in organizing doctors and having a voice in matters of their profession as well as in national campaigns was long-­standing. Most members considered themselves firm believers in the modernization project and were active in influencing a change in attitudes and behaviors of most Puerto Ricans, especially those in rural and poor communities. The AMPR did not limit its interest in education to medical providers: education was also a means to alter the cultural practices of the public. The AMPR, made up of local physicians, had been working closely with existing governmental power structures since the early twentieth century. It began a generalized campaign in the spring of 1948 with the intention of educating the Puerto Rican people about using institutional medical services. These organized physicians feared that the public at large was not accessing modern medical services but instead following traditional practices of home healing and seeking the aid of curanderos (traditional healers). El Mundo published an article quoting local physicians 43 Midwife-Assisted Home Births

who claimed that Puerto Ricans were living in a fog of ignorance by shying away from the science of medicine in favor of curanderos, who were described as swindling, deceiving charlatans. The medical association urged people through radio programs to leave home when they fell ill and seek the aid of physicians and pharmacists.95 Even though there seemed to be no specific mention of midwives in this campaign, biomedical attitudes toward lay healers were clear. Perhaps since most midwives were operating under governmental and medical supervision and licensing, they were not specifically targeted. Either way, the association was committed to redirecting public opinion in favor of institutional medicine. The problem now was to make sure there would be enough local doctors to attend these new clients. The new school of medicine would soon be poised to provide the pathway to satisfy these demands.

The School of Medicine The University of Puerto School of Medicine opened for the academic year of 1949–1950 as an extension of the School of Tropical Medicine, which already offered clinical instruction in venereal diseases, pediatrics, obstetrics, tuberculosis, pathology, epidemiology, tropical dermatology, and tropical deficiency diseases. The school initially worked in consultation with Columbia University. The first-­year curriculum began with courses in first aid, histology, embryology, neuroanatomy, biochemistry and nutrition, physiology, biostatistics, and psychiatry. Classes met Monday through Saturday, and tuition was set at $1,200 a year, much more than most Puerto Ricans could afford.96 As each cohort of students moved through medical training, the curriculum expanded and new faculty were hired. The fourth-­year curriculum was in place by June 1953 with two-­month clinics in internal medicine, surgery, pediatrics, and obstetrics and gynecology, and one-­month clinics devoted to public health, chest diseases, psychiatry, and medical specialties. Students would then complete two months of training outside of the medical school. By this time arrangements had been made with the San Juan Municipal Hospital, San Juan Presbyterian Hospital, the Bayamón District Hospital, and the San Patricio Veterans’ Hospital for clinical instruction. The connections between the UPR School of Medicine and schools in the rest of the world were both significant and surprisingly limited. Links with US schools were solid and continuous. In contrast, there seemed to be a notable disconnect between some of the departments in the UPR 44 Pushing in Silence

School of Medicine and the School of Public Health—one that would become more severe over time. The School of Public Health clearly visualized part of its mission as extending medical training to neighboring countries; Spanish-­speaking students from all of Latin America were welcomed and attended courses there. In fact, one could claim that public health in Puerto Rico had an explicit internationalist focus without losing its local commitment. This international inclination was less pronounced when it came to the training of physicians. Medical professors and students were deeply engaged in two main geographical arenas: Puerto Rico and the United States. At the same time, there was a long-­standing custom of traveling to Mexico and Spain for medical training and returning to Puerto Rico to practice. Though European, Latin American, and Caribbean doctors and administrators made a few visits, almost all interaction at the School of Medicine occurred between Puerto Rico and the United States. As a US territory, Puerto Rico was subject to federal controls, licensing, and educational accreditation. From the early 1950s, as the medical school was taking shape, several University of Puerto Rico medical professors received grants to study methods and organization at US universities such as Columbia, Harvard, Tulane, and the University of Minnesota. Dr. Fuster, whom I interviewed for this project, was a full-­time University of Puerto Rico faculty member, head of the Obstetrics and Gynecology Department, and one of the doctors who received a grant to study in the United States. The medical school would soon shape the minds of young doctors and introduce approaches to best practices of obstetrical care that would differ notably from the older generation of physicians who had been delivering babies on the island.

Attitudes and Patterns of Use among Childbirth Providers and Mothers Conceptual frameworks at midcentury concerning birthing and the need for intervention and monitoring were clearly different from those at the end of the twentieth century.97 Between 1948 and 1953, the number of medical interventions other than Demerol, episiotomies, and forceps was low. Cesarean sections were performed in less than 10 percent of births, and most births were documented as normal and spontaneous.98 At that time, keeping interventions to a minimum was a reflection of a doctor’s success according to government and medical authorities.99 Doctors were all trained to use forceps, however, and many did resort to them. In fact, doctors who practiced and trained during the 1950s and 1960s often criti45 Midwife-Assisted Home Births

cized younger obstetricians for their lack of knowledge about forceps and other childbirth maneuvers, and their unwillingness to use them.100 Doctors could turn to x-­rays, simple lab tests, and stethoscopes for prenatal care and monitoring fetal development. Use of pain management drugs varied greatly. Demerol was probably the most common drug administered for pain, but some doctors reported using Pentothal, scopolamine, and even spinal blocks. Doctors administered analgesics themselves because they could not count on anesthesiologists as there were very few and they dedicated their efforts to major surgery. Most doctors at this time were general practitioners with a broad preparation but without specialization or highly technical training. They practiced family medicine and did not rely on laboratories and medical equipment to make a diagnosis. During their medical education, physicians received some training in obstetrics, and many accumulated plenty of experience with labor and delivery. But rising levels of occupational specialization typically accompany rising levels of industrialization.101 To this we can add that these trends also decrease the value of traditional occupations such as midwifery as it had been practiced in Puerto Rico. In the less developed sectors of the island, however, traditional modes of living held sway. Perceptions about midwives were vague and inconsistent. The health department believed that “particularly in rural zones, slums, and housing projects, the midwife enjoyed a certain social prestige.”102 Few doctors were interested in taking on the burdens of labor and delivery, and most were happy to leave childbirth to midwives. Of the ten doctors interviewed for this project, all reported having trusted the work of the comadronas auxiliares and nurses who were well versed in childbirth practices.103 Women with more money, especially in urban areas, preferred the hospital’s more formal environment and were more comfortable in institutional spaces. At private hospitals, where women from more privileged sectors would birth, there was little space for the midwife. There, the role of science and professional expertise found its niche. Within elite circles, private hospitals represented progress and, therefore, to give birth in them communicated social status. Only those who could pay out-­of-­pocket or had private insurance could afford private services, which not only provided direct medical supervision but also permitted longer stays in private and semiprivate spaces, both unavailable in public facilities. But this social prestige and and access to private hospitals perhaps played into birthing practices in less conscious ways than we might assume. Those without access to that kind of health care did not 46 Pushing in Silence

seem resentful, nor did they strive to access these hospital services for their birthing needs.104 Though it is difficult to make geographical generalizations because of so many exceptions, patterns of use and access also varied between rural and urban spaces, which also tended to reflect class differences. Often, the problem with making regional generalizations is that within particular sectors of the island it was common to find pockets or neighborhoods that contrasted starkly with mainstream classifications. For instance, nestled within an area that might be considered predominantly urban, developed, and upper middle class, there would be small barriadas or neighborhoods resembling very underdeveloped, poverty-­stricken rural sectors. Subsidized urban housing projects also sprang up around the island in areas that did not share their demographics. Furthermore, during the first three phases of birthing history covered in this book, rural Puerto Ricans moved in great numbers to urban centers, carrying, as well as disrupting, their cultural practices and belief systems. In the mid-­1940s, more than 90 percent of rural mothers birthed at home, whereas just over 70 percent of urban mothers did the same. As mentioned above, urban mothers with the highest levels of education and income were the most likely to choose a hospital setting for childbirth. Before 1953, the health department and Puerto Rican law allowed midwives to oversee normal and low‑risk births, almost as an unavoidable measure, until the institutionalization of birthing was complete. In other words, even though it was accepted that these women could handle uncomplicated births, the health department did not consider it ideal.105 The midwife represented vestiges of backwardness not supported by the modern-­industrial project.106 She did not respond to the demands of scientific rigor that the medical expert represented. The hospital—with its cleanliness, orderly image, and access to new, though limited technologies—symbolized the future. According to the paradigm of industrial progress, the midwife was superfluous, but until that progress was attained, midwives continued to provide a useful service, even though they were treated almost as a placeholder.

Conclusions Among the defining characteristics of this phase of the history of birthing in Puerto Rico are the centrality of the midwife and home births, the small number of interventions during pregnancy and delivery, and the 47 Midwife-Assisted Home Births

very early stages of medical-­institutional expansion. By 1948, doctors had already accumulated several decades of experience in professional organizations and self-­representation through groups such the AMPR. Midwives, on the other hand, responded to periodic calls from the Department of Health but had not managed to engage in self-­organized efforts to represent or promote their professional interests. Regulations and licensing requirements also left midwifery at a disadvantage vis-­à-­vis physicians. Childbirth was considered, in the minds of medical practitioners and families, a natural and expected female process that could, in rare cases, produce unexpected and pathological results but that would, by and large, be a successful event. Doctors were trained outside of Puerto Rico and most practiced general medicine, which included obstetrics and gynecology. The women who did not deliver their babies at home would predominantly deliver in public hospitals, many of which were fraught with deficiencies and therefore not usually considered a better option. Doctors at this time were not the exclusive bearers of expert knowledge. Mothers, fathers, midwives, the state, and even doctors considered midwives, as well as mothers, the experts in childbearing. Whether this expertise was learned, achieved through experience or formal education, or born of innate female knowledge, it was deemed valuable enough to hold a space of socially accepted power during childbirth for most laboring women. Midwives were loosely regulated by the state, and although their practices demonstrated a limited, standardized influence from medical and state-­led institutions, they usually practiced alone, using their own discretion. Their contact with mothers was almost exclusively limited to labor, delivery, and immediately postpartum. They were part of the communities they served but did not necessarily form social network systems distinct from others in the community. Childbirth itself was not yet defined as a pathological, high-­risk event in need of strict regulation and standardization, but there were already some classification efforts in place that served to distinguish between normal and abnormal births. Most births were assumed to be normal. The pregnant body was not monitored nor penetrated regularly by any sort of medical provider or complicated technology, whether that be the clinic, physician, or midwife. The female body was considered capable of birth without intervention and was assumed to be able to withstand some hardship, with birth outcomes ultimately in the hands of God or nature. Until 1953, the act of birthing and the practices associated with labor and delivery mirrored preindustrial paradigms associated more with nature and agrarian life. 48 Pushing in Silence

Ch a p ter two

Phase Two

T r ansitioning toward Ho spi tal Bi rths, 1954– 195 8

U

ntil 1953, most births in Puerto Rico occurred in homes with midwives, but from the mid-­1950s onward, the total number of births occurring in hospitals began to surpass those at home. By 1954 it was clear that birthing in Puerto Rico was headed away from the home and into institutionalized spaces. Phase 2 of this process, covering the period between 1954 and 1958, was characterized by regional, unequal patterns of change in hospital births. Although the setting for a slight majority of island births changed, many women still delivered their babies at home, and midwives maintained their position as the primary birth attendants. However, midwives were also aware that there were no new recruits following in their footsteps. In this transitional period, institutions and experts consolidated their knowledge— and power—piece by piece at swift, albeit uneven rates. Even though most Puerto Ricans began to view hospitals as appropriate spaces for childbirth for the first time, they continued to view birth as a natural part of the life cycle that required little to no intervention. Doña Penchi, a midwife who practiced in the late 1950s, was well aware that she was one of a diminishing group of childbirth practitioners and that things were changing in Puerto Rico. When I interviewed her, she revealed that after birthing ten children of her own at home with midwives, she worked as a comadrona auxiliar in the rural town of Corozal. She remembered the first day, in the mid-­1950s, that she had approached Nurse Moreno, the area supervisor of the comadrona auxiliar program. Moreno exclaimed that it was precisely strong women like her who were needed to train as midwives and invited Doña Penchi to their next meeting. Every

month, for more than a year, she attended the meetings with the textbook that the health department had provided, listened to Moreno as she gave her class, and returned home. Once she was ready, she passed a written exam and recited her oath: I solemnly promise before God and in the presence of my colleagues, to guard the life of all mothers and children before, during, and after labor and delivery . . . I will help all mothers, who might need medical services to access them . . . promise . . . to keep all family secrets that may be entrusted to me. . . . I will always have my bag prepared and I will make cleanliness my guide and end. So help me God.

The oath reflects the dedication and pride midwives felt toward their work. It contributed a tone of ritualistic solemnity, and it illustrated the role midwives were to play in connecting mothers to medical care when needed. Doña Penchi received her midwifery diploma and insignia in 1956 and proceeded to buy her bag and white uniform. It was not long after that when her services were first solicited. As discussed in the previous chapter, her license entitled her to receive five dollars from the municipality for every birth registered in her book each month. The families she served would also either pay her another five dollars or give her some other compensation, usually in the form of animals or produce. Doña Penchi was proud of her skills and felt satisfied with helping so many poor mothers bring their children into the world. Because she served God and counted on his presence, she felt confident all would continue well. Even so, as a midwife she made sure to follow the rules and refer to the hospital any mother who presented with severe bleeding or who was in labor with the baby in a transverse or unsafe position to deliver. Her clients in Corozal would see a doctor in the town public health unit for prenatal care, where the staff would instruct them to seek out a midwife for the delivery because the local hospital did not have enough room to tend to all of them. Doña Penchi met some of her clients at the local health units; others knew her from around town, and others sought her out without ever having met her. She usually assisted up to three mothers per month. Doña Penchi’s work as a midwife ended years later after she moved closer to San Juan, where there were no monthly comadrona meetings, and women often traveled to the hospital to give birth. This suited her just fine. She was older and less willing to be interrupted at all hours of the 50 Pushing in Silence

night to attend a birth. None of her children wished to train as midwives, and she said she had been the last midwife to train under the health department’s comadrona auxiliar program in Corozal. Several of her grandchildren, however, would take up medical careers as doctors, nurses, and dentists. According to Doña Penchi, these medical careers seemed better suited to life in Puerto Rico after the 1950s than that of the comadrona. These historical shifts in birthing paralleled those beginning to take form as part of the governmental industrial project. The increasing number of institutionally trained medical practitioners such as obstetricians, nurses, and nurse-­midwives, coupled with the rising accessibility to advances in medicine for a greater proportion of the population, made the prospect of birthing in hospitals more acceptable to mothers. Most hospitals, like the one in Corozal, were not yet able to accommodate them, which is likely the reason so many women still chose to birth at home with comadronas. Most women who did utilize hospital services did so in the public sector, where birthing practices differed from those in private sectors. (I will explain the regional and public-­private discrepancies below.) To explore this second birthing phase in Puerto Rico from 1954 to 1958, the remainder of this chapter is divided into sections that offer context and examples of changes related to birthing practices, including Puerto Rico’s sociopolitical context during the second half of the 1950s; general and regional changes in where and with whom women gave birth; the state of training of comadronas, nurses, nurse-­midwives, and doctors; common medical childbirth interventions and practices; and differences between private and public sector medical practices and patterns of use.

Operation Bootstrap (1954–1958): The Context for Rapid Transition By 1954, Puerto Rican society had moved further away from closed, internally focused family units to outward-­looking groups who believed many family issues could be resolved by external specialists with expert knowledge. Practices such as birthing, for example, once primarily taken care of in the home, unfolded more frequently in public institutional spaces managed by experts. Economically, Puerto Rico was operating less as a predominantly rural, agrarian society and more as an urbanized one based on manufacturing.1 The social structure based on a casa grande (usually a sugar plantation estate), as well as the smaller mountain coffee farms, had been unraveling for some time. As Doña Penchi mentioned, the population had migrated toward urban centers, and the sense of rural intimacy had lost its 51 Transitioning toward Hospital Births

hold over much of the island. The late 1950s was also the peak of outmigration to the United States.2 At the same time, families fixed their hopes on the newly formed state and its Partido Popular Democrático (PPD) projects to alleviate poverty and promote development. Many trusted the party’s leaders to fulfill their promises for a “better Puerto Rico.” The industrialization plan, Operation Bootstrap, was established to raise the standard of living, bring order and social peace, and increase production.3 The story of industrialization, urbanization, and development—or modernization theory—is a familiar one to any twentieth-­century scholar of Latin America. In Puerto Rico, though, social and economic changes occurred faster and covered more geographic and class terrain than in most other countries. Why was it that when the industrial project became a local and federal priority after World War II, it took root in just a couple of decades, whereas similar processes took more than twice as long in Europe and the United States? Several significant and mostly unforeseen obstacles, including natural disasters and the island’s colonial relationship to the United States, stunted a process of industrialization that otherwise might have begun decades earlier, resulting in Puerto Rico’s relatively late and rapid industrialization. Two major hurricanes, San Ciriaco (1899) and San Felipe (1928), destroyed much of the island and its crops. Subsequently, Puerto Rico’s economy became entirely dependent on the United States, with the Foraker and Jones Acts stipulating unfavorable economic conditions: among other things, they mandated converting the peso to the dollar at grossly disadvantaged rates, obligated Puerto Rican businesses to use US ships exclusively for trade, and favored US-­based investments and imports over local ones. The Great Depression further aggravated what was already a dire scenario on the island. The industrialization project was initially successful because it combined a new, local PPD leadership with a majority following from all areas of the island, which included and reached out to the rural sectors, and the postwar imperial initiatives coming from the United States. Puerto Rico’s size and infrastructure also facilitated quick and far-­ reaching changes across class and geographic boundaries. Italian historian Paolo Macry claims that urban living favors political and social structures focused more on bureaucratic and public norms than family norms.4 As had happened in many places around the globe, the Puerto Rican family was no longer the primary unit of production. It had transformed in response to shifting social and economic demands; the restructuring of the labor system, for example, had a direct impact on the family. The diffusion of factory work pushed the family into new cultural systems and modes of living.5 Science historian Michael Adas explains, 52 Pushing in Silence

“New attitudes toward time and work were central elements in the new sensibility that emerged among the European and North American middle classes as a consequence of the rise of capitalist economies.”6 These new sensibilities and changes in lifestyles were intrinsic to industrial-­capital societies. To these local changes, it is important to add the large number of Puerto Ricans emigrating to the continental United States, almost exclusively to New York City, in search of work and a better life. Families and neighborhoods had become less self-­sufficient, and the domestic sphere no longer managed health, nutrition, and employment. Many families started looking outward for their basic needs to the state and public sectors. The great majority of Puerto Ricans were strongly invested in the ideas of progress and modernity, via industrialization, that had been promoted by the PPD. Science and technical experts were cornerstones in these plans for progress. As the social sciences boomed, their experts took on leadership roles. US experts were also attracted to the island. They consulted on ways to collect and interpret data, and they suggested paths toward development. In this general atmosphere of change, there were no significant social forces in place that offered alternatives to the ideas or structures related to science-­based truth claims and biomedical expertise. Ideas related to progress and science did not manifest themselves merely in ideological realms but also with concrete results that everyone could see and experience directly. Health standards and quality of life had been improving all over the island concurrently with the PPD’s implementation of its industrial project. There was a general sense on the island, which even the pro-­ statehood party shared, that Puerto Rico was capable of joining the modern, developed world. The promise of modernity, with its technological experts and the creation of an urban, public service infrastructure, created new possibilities and spaces for childbirth. In Historia económica de Puerto Rico, Rafael de Jesus Toro of the PPD describes modern societies and their characteristics in ways that mirrored ideas espoused by party leaders. He argues that what they all agreed on was that Puerto Rico needed to achieve significant increases in economic production and material well-­being. To create a healthy economy, technology based on scientific knowledge needed to be widespread. Commercial exploitation and paid labor replaced subsistence agriculture, and cities and manufacturing expanded. Education and literacy became universalized, extended families became less common, and the nuclear family began to replace this previous model, among other things.7 Another author and PPD urban planning scholar, Navas, claimed that regardless of differences among individuals, party members believed in economic growth and de53 Transitioning toward Hospital Births

velopment through scientific methods and planning.8 The PPD aimed to distribute material and social wealth to greater sectors of society under a democratic banner representing the free world. These theories spread throughout the Americas. According to Adas, the post–­World War II modernization paradigm “supplanted the beleaguered civilizing mission as the preeminent ideology of Western dominance. American social scientists were the main exponents of the new ideology.”9 Therefore, Cold War politics, especially in places like Puerto Rico, where colonial relationships continued to call democracy into question, prescribed formulas for progress that would not appear authoritarian and that would aim to benefit a majority. Thus, if Puerto Rico was to pro­gress as la gran familia (the great family), the metaphor that Governor Muñoz Marín often employed when referring to the island’s people, local attitudes and individual behavior would also have to change by adapting to modern concepts of democracy, development, and order.10 For progress to occur, Marín needed to secure social harmony.11 The political unrest that characterized the 1950s12 and the vastly uneven levels of development that left impoverished urban pockets threatened the peaceful image needed to attract foreign capital and ensure a democratic society capable of avoiding a communist rebellion. This circular philosophy of modern development is evident in the PPD’s Catecismo del pueblo, which states, “One must give the people all opportunities for good health and education, because a healthy and prepared man is able to produce more for his own welfare and for the social prosperity of all.”13 After World War II, scientific advances affected health care all around the world. Pharmacology made significant strides in providing options for oral contraceptives, antibiotics, and vaccines.14 These advances enhanced the credibility of the medical model in developed countries. Others that aimed to join the list of developed countries, such as Puerto Rico, knew that adopting this medical model would bring them closer to their modernization goals. Even so, biomedicine took longer to become institutionalized in developing countries, which partly explains why in the 1950s, when in the United States nearly all babies were born in hospitals, in Puerto Rico that was not yet the case.15 Medical anthropologist Fraser cautions us to remember that in the United States, what was true for the Anglo population was not the case for African American babies in the South, who were still born at home with midwives.16 Therefore the history of birthing in the United States would be quite different if broken down by region, class, and race. People living in underdeveloped and disadvantaged communities remained under the preindustrial model of birthing, sharing more similarities with Puerto Ricans than middle class and afflu54 Pushing in Silence

ent US mothers. The marriage between race and social class and the ways in which social class causes differences in behaviors is well established in scholarship across disciplines and regions throughout the world. Informal therapists in developing countries or areas, such as midwives, were still in demand where resources were scarce and technocratic medicine had less reach. Long before the 1950s, churches, then municipalities, and later the central government registered births and gathered basic demographic data. However, Operation Bootstrap made vital statistics and demographic studies a cornerstone of bureaucracy, with entire departments dedicated to its service. This sort of measure indicated the attempt to organize, regulate, and manage society, yet another characteristic of the industrial model. Even registered midwives were to carry and use a basic record book for the births they attended. The five dollars that the municipality of Corozal paid Doña Penchi and other comadronas auxiliares for registering births was perhaps as much for their record keeping as their birthing services. Once the midwife registered a baby, the government could identify the place of birth and include the child in their general records of vital statistics. Data collection was part of the search for order and classification, and could support increased production in an advanced capitalist society. Once these responsibilities were in the hands of the government and their structures of supervision, such as the Department of Health, the authority and power of the keeping, gathering, and distribution of information shifted from the local parish to the central state government. Under the auspices of the state, the comadrona auxiliar learned to follow this model through the record-­keeping expectations of the new state. The comadrona served as a temporary instrument of change in the transitional phase toward full institutionalization. Hospitals took on an even greater bureaucratic function as part of this process, generating enormous quantities of statistics and health records. The labor force, at large, underwent significant changes. The female labor force was growing faster than the male labor force.17 With the reduction of agriculture and the deskilling of many areas in manufacturing, many men lost job opportunities in agriculture and were unable to find alternatives. Unemployment became a clear problem as Operation Bootstrap progressed, and more job opportunities arose for women than men, especially in the garment, service, sales, and office occupational sectors.18 More women were taking jobs outside of the home. The formal participation of Puerto Rican women in the labor force fluctuated between 20 and 30 percent throughout the period covered in this study, more than double what it was at the beginning of the century.19 Baker and Inglehart, in their 55 Transitioning toward Hospital Births

article “Modernization, Cultural Change, and the Persistence of Traditional Values,” claim that “Industrialization produces pervasive social and cultural consequences, from rising educational levels to changing gender roles,” and that increased income and participation in the labor force are the factors that most influence and change traditional values.20 Industrialization reorganizes society by changing labor patterns, which then exert a silent pressure that alters not only behavior but cultural values as well. These kinds of social changes related to labor help explain how concepts and expectations related to birthing morphed over time. Moreover, reproduction ranked high as an issue of concern for Puerto Rican industrialists. The fertility of the island’s women, considered excessive by some, worried the Puerto Rican and US governments, as well as social reformers and social scientists. Scholars such as Laura Briggs, Annette Ramírez de Arellano, Iris López, and Alice Colón have identified this period in Puerto Rico as one in which medical intervention around family planning began escalating to new levels with the introduction of the oral contraceptive pill and female sterilization. Intellectuals and government leaders considered overpopulation a threat to Puerto Rican development and democracy, which is one reason why the government promoted mass migration to the United States.21 Malthusian theories weighed heavily on the island, and social problems were often blamed on high fertility levels and high population density. Despite these new efforts and concerns about fertility, only a minority of Puerto Rican women sought contraception before 1958.22 Even so, news that science and medicine could be placed in the hands of women, families, and governments to limit female fertility in the form of devices, pills, and operations spread throughout the island. The potential for medicine and the state to intervene with women’s bodies and affect family size now existed, but women did not immediately embrace it. This hesitancy would change over time, but in the 1950s, Puerto Rican women were not accustomed to having their bodies probed or exposed to new technologies and procedures. During the mid-­1950s the Department of Health initiated a program to reorganize health services by region, thereby coordinating the dispersed health services with those provided through social welfare. This regionalization of health took several years to implement and was not completed until the early 1960s, a period discussed in the following chapter. The plan was to link national health with social welfare. In time, this merger would become a forceful driver of changes in birthing. Each of five district hospitals was to serve as the nucleus for its region. Municipalities also ran services in local medical units. On a municipal level, it was not uncommon to see more than half of local budgets dedicated to medical services. 56 Pushing in Silence

Municipalities spent an average of 32 percent of their budgets on health care.23 It is clear that the government made health care a priority, but if the population wanted to access welfare and health services, they would need to learn how to navigate the space of the clinic and the hospital. Since, for the most part, these were new spaces, it would require a period of adaptation for people to become familiar with and accustomed to these spaces. As a result of Operation Bootstrap, social order became more complex, conforming to capitalist forms of production; labor was more intensley subcategorized, specialized, and monitored. The formation and reliance of the population on experts became paramount to maintaining efficiency and legitimacy in any institutional space. Making these spaces available and acceptable to the broader public would prove essential to transforming life on the island. The medical school, a generator of some of these needed experts, was accredited and funded within its initial years, and Puerto Rico was soon graduating its own local doctors. The demand for doctors by this time was much higher than could be met by the number of graduates. Therefore, for the time being, midwives and nurses needed to step in where there were no doctors available.

Uneven Transitions: Overview of Birthing Among the distinguishing characteristics of the period covered in this chapter (1954–1958) are the uneven patterns of change in hospital birthing unfolding on the island. Following the general move toward institutionalized and industrialized urban spaces, birthing practices, professionals, and settings were all in a staggered transition toward institutional expertise. To stress the messier aspects of historical change, the following section focuses on these uneven patterns of change in birthing choices on a regional level; the uneven process of professionalization for predominantly female medical careers (nurses, nurse-­midwives, and midwives) versus those that were predominantly male (physicians); and some of the differences unfolding between the public and private sphere. The relationship of federal, commonwealth, and municipal governments with childbirth practitioners and the medical school is discussed with the hope of shedding light on how they varied and influenced one another. I also examine the relationship between the social class and training sites of doctors and whether they chose to work in the public or private sector. I conclude this discussion by explaining the state of medical interventions and medical perceptions about childbirth. Between 1954 and 1958, midwives attended a slight majority of births in 57 Transitioning toward Hospital Births

Table 2.1. Distribution of births by attendant and location, Puerto Rico, 1953–1954 At home (48.6% of total births)

In the hospital (51.4% of total births)

Midwives 100%

Midwives 12%

Doctors ———

Doctors 67%

Nurses ———

Nurses 21%

Source: Departamento de Salud, Informe anual de 1953– 54, 81.

Puerto Rico, as was true in 1953–1954, a transitional year between phases 1 and 2 of the island’s history of childbirth (table 2.1). The health department continued to count on midwives’ services; it not only acknowledged their importance but thought there would always exist a need, no matter how small, for midwives to supplement the work of physicians. Nevertheless, a declining number of women were training to be midwives, and there were significantly fewer meetings and training sessions. Doña Penchi witnessed this decline herself: she was one of the last midwives trained in her municipality, and after she moved to San Juan, she was unable to find a place to attend the monthly meetings. Despite the health department’s proclaimed intention to maintain the program, Doña Penchi and other midwives eventually stopped working due to the lack of infrastructure and government support for their home-­based services. As shown in table 2.2, the hospital setting was changing as well. Doctors were delivering more babies, and nurses appreciably fewer. In 1954 the number of hospital babies delivered by nurses had fallen 15 percent from 1951, whereas the percentage of babies delivered by midwives fell only 3 percent. The decrease in reliance on nurses is intriguing, but I cannot begin to speculate why this was the case. Overall, midwives delivered over half of all babies born in 1954, followed by physicians, who delivered about a third. Table 2.2 shows the general changes that occurred between 1951 and 1954 in terms of what type of childbirth practitioner attended the delivery. In just three years doctors increased the number of babies they 58 Pushing in Silence

delivered by almost 10 percent, and midwives reduced their numbers by about the same. These rapid changes are characteristic of the industrial period in Puerto Rico overall. As health statistics improved, fertility rates declined, a common feature of industrialization worldwide. While the discourse of a population “explosion,” which both government and civic leaders in the United Status and Puerto Rico blamed on poverty and underdevelopment, framed the 1950s and 1960s, the truth was that health and the general standard of living improved and fertility declined.24 In 1956 the rate of births for every 1,000 inhabitants was 34.8, and it continued dropping, reaching 15.3 per 1,000 inhabitants in 1999.25 The rate of maternal mortality that same year was 112.6 for every 100,000 live births and continued dropping until the 1970s.26 Fetal deaths followed a similar pattern (table 2.3). Maternal and neonatal survival rates improved along with general health. Birth-­related statistics improved as childbirth moved into a hospital setting. While this correlation seems to suggest that medicalized birthing was safer, the data reveal the relationship was more complex. Birthing outcomes had begun improving even during the years when home births and midwife-­attended births outnumbered those in hospitals under the care of doctors. The most radical improvements in Puerto Rico’s general standard of living occurred between the early 1940s and early 1970s. Infectious diseases diminished, diets and sanitary conditions improved, education became more widespread, and salaries increased. The use of hospitals and the general medicalization of society increased toward the end of this period. Therefore, institutionalized biomedicine was not the primary or singular force behind improvements in health and quality of life, but rather a product of, and contributor to, the rapid changes spurred by industrialization. Table 2.2. Comparison of overall distribution according to birth attendant, 1951 and 1954

1951 1954

Doctors %

Midwives %

Nurses %

25 34

63 55

12 11

Source: Departamento de Salud, Informe anual de 1953–54, 81.

59 Transitioning toward Hospital Births

Table 2.3. Selected demographic statistics, Puerto Rico, 1945–1985

Year

General mortality rates (per 1,000)

Infant mortality rates (per 1,000)

Maternal mortality rates (per 100,000)

Birthrate (per 1,000)

1945 1948 1953 1958 1963 1967 1976 1985

14.1 12.2  8.2  7.0  7.0  6.4  6.6  7.1

93.4 78.5 63.3 53.7 44.8 32.7 20.2 14.9

319.0 291.8 183.5  85.4  54.3  36.7  12.3  12.6

42.2 40.8 35.1 33.1 31.1 26.9 24.1 19.4

Source: Oficina de Planificación, Informe anual de estadísticas vitales de 1985 (1987), 13a. Note: The years 1948–1958 cover the first two phases of Puerto Rico’s birthing history, when midwives were the primary birth attendants, and are discussed in chapters 1 and 2.

The hospital was not always an attractive option for the general population. Health centers (centros de salud) were often small and offered little more to assist women with their deliveries than they could find in their homes.27 In Puerto Rico during the 1950s, conditions at the different medical sites varied widely. Many clinics and hospital sites had not changed radically over the previous decades. The law that regulated and licensed hospitals on the island came into effect in 1950 (during the first phase of the history of birthing), but by the end of the decade only 14 percent of the hospitals had managed to obtain a license. The other hospitals operated under provisional licenses, which required yearly renewals.28 Many sites were in a deplorable state, with little or no medicine or equipment, decaying buildings, mosquitoes and bugs, minimal record keeping, and dirty and broken-­down facilities such as bathrooms and plumbing.29 Given these conditions, it should come as little surprise that home births with midwives would seem a sensible, preferred option for many families bringing new babies into the world. In many ways, despite the notable advances in health and the push toward modernizing services, change came swiftly but not at equal rates for all.

60 Pushing in Silence

Uneven Transitions: Overview of Birthing Practices by Region The fact that just over half of all births in Puerto Rico between 1954 and 1958 occurred in hospitals, yet with midwives assisting most deliveries, glosses over some significant disparities that persisted during that period. These differences gradually disappeared by the 1970s. According to the health department’s annual report for 1953–54, thirty-­two of the island municipalities’ midwives assisted more than double the number of births attended to in hospitals.30 Even though, in general terms, more women in urban areas used the hospital to give birth than in rural areas, this was not always the case. Also striking is the fact that municipalities where hospital births were twice that of those performed at home were both urban and rural.31 In other words, I cannot responsibly conclude that during the 1950s, women in urban Puerto Rican spaces left their homes at higher rates to deliver their babies in hospitals than those in rural spaces. In Caguas and Guaynabo, for example, the number of home deliveries was almost equal to the number of hospital births (table 2.4).32 There is little geographic or demographic consistency among the municipalities with a high number of midwife-­assisted births: Guayama, a rural, coastal area in the south; San Juan and Ponce, which have the two largest cities; and San Sebastián, a rural, mountain region in the center of the island.33 Even though in cities such as Mayagüez, Caguas (not fully urban at the time), and San Juan more women gave birth at hospitals, the number of births under the care of midwives remained high. In San Juan, for example, out of a total of 5,356 births, 2,118 were tended to by midwives. In Yauco and in Utuado, both rural mountain regions, most births took place at home with midwives.34 The municipality of Ponce deserves special attention. The presence of midwives there during this period was impressive even though it included a major urban area with good hospitals (see tables 2.4 and 2.5). In 1954 there were 1,664 hospital births and 3,056 home births; all but 15 of those home births were attended by midwives.35 Ponce also had high rates of death and birth-­related complications in and out of hospitals. Despite the fact that at the beginning of the 1950s, ponceñas, for the most part, did not give birth at hospitals, this changed abruptly, in just a few years. Ponce followed the path of many rural towns, especially others in the south (such as Salinas, Santa Isabel, and Guayama), where midwives maintained their importance longer than in other urban centers. In contrast, Ponce possessed renowned medical facilities. While women in Ponce persisted longer than other urban women in using midwives to help deliver 61 Transitioning toward Hospital Births

Map 2.1. The municipalities of Puerto Rico 1. Aguadilla 2. Aguada 3. Rincón 4. Añasco 5. Mayagüez 6. Hormigueros 7. Cabo Rojo 8. Isabela 9. Moca 10. San Sebastián 11. Las Marías 12. Maricao 13. San Germán 14. Sabana Grande 15. Lajas 16. Guánica 17. Quebradillas 18. Camuy 19. Lares 20. Adjuntas 21. Yauco 22. Guayanilla 23. Hatillo 24. Utuado 25. Peñuelas 26. Arecibo

27. Jayuya 28. Ponce 29. Barceloneta 30. Florid 31. Ciales 32. Orocovis 33. Villalba 34. Juana Días 35. Manatí 36. Vega Baja 37. Morovis 38. Coamo 39. Santa Isabel 40. Vega Alta 41. Corozal 42. Barranquitas 43. Aibonito 44. Salinas 45. Dorado 46. Toa Alta 47. Naranjito 48. Comerío 49. Cidra 50. Cayey 51. Guayama 52. Toa Baja

53. Bayamón 54. Aguas Buenas 55. Arroyo 56. Cataño 57. Guaynabo 58. San Juan 59. Caguas 60. Patillas 61. Trujillo Alto 62. Gurabo 63. San Lorenzo 64. Carolina 65. Juncos 66. Yabucoa 67. Maunabo 68. Loiza 69. Canóvanas 70. Las Piedras 71. Río Grande 72. Nagüabo 73. Humacao 74. Luquillo 75. Fajardo 76. Ceiba 77. Vieques 78. Culebra

Table 2.4. Births by municipalities, birthing place, and birth attendant, Puerto Rico, 1953–1954

Municipality Río Piedras Fajardo Utuado Ceiba Dorado Vieques Trujillo Alto Bayamón San Juan Naguabo Río Grande Mayagüez Guaynabo Caguas Ponce Cayey Yabucoa San Sebastián San Lorenzo Guayama Moca Orocovis Vega Baja Vega Alta Yauco

Total births

Born in hospital

Born outside hospital

Assisted by doctor

Assisted by nurse

Assisted by midwife

Assisted by others

5,513 469 1,461 195 371 212 424 2,025 7,567 575 383 2,617 871 2,147 4,720 1,461 1,119 1,257

4,722 (86%) 396 (84%) 357 (84%) 158 (81%) 301 (81%) 167 (79%) 332 (78%) 1,473 (73%) 5,356 (71%) 406 (71%) 260 (68%) 1,673 (64%) 464 (53%) 1,041 (48%) 1,664 (35%) 498 (34%) 367 (33%) 309 (25%)

791 73 1,104 37 70 45 92 552 2,211 169 123 944 407 1,106 3,056 968 752 948

65  1  4  1  3  3  6  8 76 —  1 30  1  4  4  4  5 34

39  7 14 —  4  4 — 12  1  3  2  1  2  7 10  5 13  3

687 65 1,083 35 63 38 86 532 2,118 162 119 912 403 1,095 3,041 950 722 891

— —  3  1 — — — — 16  4  1  1  1 —  1  4 12 20

1,107 1,219 767 892 1,021 522 1,350

248 (22%) 264 (22%) 157 (21%) 151 (17%) 178 (17%) 83 (16%) 134 (10%)

859 955 610 741 843 439 1,216

 2  1 11  7 10  1  8

 7 112 — — — —  1

850 842 592 732 833 438 1,207

— —  7  2 — — —

Source: Departamento de Salud, Informe anual de 1953–54, 203–204. Note: These selected municipalities are ranked from highest hospital birth rates to lowest. All but the hospital births took place at home.

Table 2.5. Births in Ponce according to location of delivery, Puerto Rico, 1953–1962 Year 1953–1954 1954–1955 1956–1957 1959–1960 1961–1962

At hospital %

At home %

35 45 47 69 75

65 55 53 31 25

Source: Departamento de Salud, Informe anual de 1954–55, 204. Note: In 1954, 29 percent of births in San Juan were at home and 71 percent at hospitals; in Mayagüez, 36 percent were at home and 64 percent at hospitals.

their babies, they also demonstrated a pronounced veer toward the hospital during the same period as the rest of the country. Still, the southern area was the last to abandon home births with midwives. Surely, Ponce deserves further study beyond the scope of this investigation, but I will venture to propose a few theories about its unique patterns. The southern area has a different social and cultural structure than the rest of the island. The sugar cane economy maintained its influence until after the 1950s. According to scholars of this area—such as Isar Godreau, Sidney Mintz, and Richard Ferguson—the artisan, handicraft, and local traditions had a strong cultural influence.36 Communities were less inclined to adapt or dismantle their traditions. Ponce was a conservative zone with numerous community pockets that were isolated from one another. Birthing practices and customs might not have been easily accepted or incorporated into the hospital setting. The hospital probably discredited or disregarded the knowledge and rituals of the midwife and family. Though Ponce was an urban area, it probably preserved preindustrial cultural traits and modes of living for a bit longer than areas such as San Juan. Despite this resistance, however, it would not be long until most Ponce women chose to birth at the hospital. The 1950s proved to be a time where old paradigms were particularly challeged. The aim of Operation Bootstrap leaders and the tone most Puerto Ricans assumed was to accept change as positive, though it admittedly also triggered concerns about the potential unraveling of moral and social order that commonly accompanies change. All of this faltered a bit 64 Pushing in Silence

in the 1950s, when many war veterans returned, and many farm workers migrated to the United States in search of jobs, which were locally scarce. Those who returned brought back new ideas influenced by the United States (where births occurred in hospitals). At the same time, a new professional class began to develop (mainly in education and in health) that was willing to accept the new industrialization tendencies and whose members refused to return to the cane fields and to what they saw as outdated customs. Communities throughout the island were slowly becoming more urban and relying more on professional services. Medicine followed these tendencies, with doctors assuming the role of expert health care providers.

Modernizing Training for Birthing Professionals People place their trust in and seek help from those they consider knowledgeable. After midcentury, knowledge in Puerto Rico became the domain of professionally (institutionally) trained experts who specialized in a particular field. Experts could monitor, control, and take care of whatever was deemed culturally valuable. As families got smaller, moved to cities, and became more nuclear, Puerto Ricans placed more value on children and moved their care into the hands of experts. The wisdom of mothers and grandmothers concerning child rearing, nutrition, and labor no longer sufficed. Instead, obstetricians, educators, psychologists, and pediatricians began to have the upper hand. After the mid-­1950s the practice of midwifery had lost some sociocultural legitimacy while biomedical providers had gained it. There was a growing attitude that female and informal knowledge was no longer as relevant. This trend is typical of societies that move from agriculturally based models to industrial ones. Often, professions gain power and social legitimacy when what they do becomes related to concepts of risk. DeVries argues that by associating childbirth with risk and by identifying, naming, and classifying diseases, doctors easily gained prestige and power by presenting themselves as able to manage these situations.37 By legal mandate and through educational workshops, midwives were either coerced or convinced into deferring complicated or difficult births to medical instututions and doctors. They, in turn, would inform their clients to do the same, situating themselves in a subservient rank within a new professional and social order. Medical support staff needed to update and complement new medi65 Transitioning toward Hospital Births

cal standards and physicians, but it would not be easy because the overwhelming health care demands weighed nurses down. Gender expectations undercut efforts to professionalize nursing, and resistance to new professions such as nursing/midwifery hindered recasting them within biomedicine. For these and many other reasons, the formation of the different personnel related to birthing varied greatly.

Comadronas Auxiliares In the 1950s, the secretary of health, Juan Pons, declared that “[t]hrough the improvement of the training of auxiliary midwives we shall be better prepared to reduce maternal and infant mortality rates. The nurse midwife training program already established will be, perhaps, our best method to accomplish our objectives.”38 He recognized that midwives were an essential part of their plan to improve maternal and infant mortality and morbidity rates, but he also mentioned another group of medical personnel: nurse-­midwives. He alluded to the gap being filled by auxiliary midwives in more remote areas and hinted at the need to create a new sort of midwife, one equipped to operate as hospital support staff. Dr. Pons explained that 46 percent of the total deliveries were home deliveries . . . a fact that has to be considered of great value, since our statistics depend entirely upon [the midwives’] performance. . . . They contributed also with 4,861 deliveries in municipal hospitals which constituted 6.3 percent of all deliveries. That is, in total they performed 52.3 per cent of the 77,160 births for this fiscal year.39

Ironically, the Department of Health declared the first midwives’ week in 1953 in recognition of their labor, just as the numbers of midwives began to decline notably.40 Regardless of the fact that midwives continued to attend the majority of births, by 1953 the numbers of comadronas auxiliares had decreased to 1,100, 400 fewer than the reported number of 1,500 in 1950, and continued to decline thereafter.41 As Doña Penchi mentioned, the number of apprentices also diminished, dropping to half of what it had been in 1955–1956 (181 apprentices).42 While midwives were still in demand and the health department regarded them as key players in maternal health, fewer and fewer women were registering to serve as midwives. Those who did never organized, actively recruited, or advocated for their permanence in the 66 Pushing in Silence

system. Doña Penchi, for example, never tried to convince her children or neighbors to train to be midwives, even though some of them went into other medical professions such as nursing. In her interview, Doña Penchi stated that the other auxiliary midwives in Corozal spoke little with her, and they did not interact beyond the monthly meetings. It is quite possible that the dearth of midwives and physicians overall, but especially in hospitals, obligated many nurses to temporarily assist with hospital deliveries.

Nurses During the second half of the 1950s nurses served as birth attendants. On occasion they would deliver babies, and other times they would assist in the delivery, yet few nurses entered their profession with the intent to specialize in childbirth. The role of nurses in the history of childbirth is significant in that they delivered up to 20 percent of the babies born in hospitals during this period (see tables 2.1 and 2.2). They did not, however, appear to have played a noticeable role in home births. When they were not in charge of hospital deliveries, they served as support for doctors and filled problematic gaps in the system, rarely receiving adequate training, pay, and institutional support. The level of professional organization among nurses compared to that of doctors was significantly lower, but certainly more than midwives. Nursing education and work conditions varied greatly from those of physicians. Gender roles and medical hierarchies can account for many of these differences. In the 1950s, nurses were women and the vast majority of physicians were men. Interestingly, this had not always been true: in 1899, half of the nurses in Puerto Rico were male.43 The scarcity of nurses and meager training had haunted Puerto Rican medicine for years. There had been a higher demand for nurses than nurses available to work, and very few had any significant formal medical training. Salaries for nurses were lower than for hospital administrative staff, rarely surpassing $180 a month in the late 1950s. During this time, more than 60 percent of the nursing staff were auxiliary personnel, most of whom had no formal training but were listed as nursing staff in hospital records.44 Graduate nurses—especially those with post–­high school degrees, who made up the smallest group of all nurses—were a very mobile group, like much of Puerto Rico’s population during the 1950s. Most graduate nurses either migrated to the United States or always considered it a pos67 Transitioning toward Hospital Births

sibility. Like doctors, even if the women who studied nursing were from small towns, as most were, they coveted nursing positions in the San Juan metropolitan area. In June 1958, the Puerto Rican legislature passed resolution 99 authorizing and funding a two-­year study on the conditions and use of medical services on the island. The goal was to end up with recommendations for a long-­range plan for improving services. Accordingly, the Puerto Rico Department of Health, the UPR School of Public Health and Medical Administration, and Columbia University organized a diverse research team and undertook an ambitious study conducted each summer from 1958 through 1960.45 The project’s report was telling. It found that nurses were drawn into the profession by the desire to serve others and religious motives. These motivations seem similar to those reported by midwives. Many were attracted to the scientific nature of the profession.46 The one factor that motivated most to go into nursing was having a friend in the same field.47 Most nurses worked for the government and found that government service provided more advantages than private service, such as retirement, vacation, and job security.48 It is possible, as in the case of Doña Penchi’s daughters, that women who might have in previous decades been inclined to take up midwifery were now more likely to venture into nursing. Women were making choices about their futures without realizing they were reshaping the landscape of medical and maternal services. These are the kinds of silent forces behind the historical changes to which this book’s title, Pushing in Silence, refers. There were many places where Puerto Ricans could obtain training in nursing, and the curriculum did not vary greatly. A central factor undermining the preparation of nurses was that most of the training sites were medical institutions instead of educational institutions. The immense demand for nurses dictated much of the training, requiring students to carry out most of their training in clinical settings, where they worked twenty to forty hours a week, leaving little time and energy for study. Thus, the training was driven by clinical demand instead of an established curriculum, and learning was compromised in order to fill hospital needs. To further exacerbate the situation, more than half of nursing instructors in Puerto Rico in the late 1950s had failed to fulfill the basic requirements needed to teach in higher education, and many had not even completed their own basic degrees.49 With this kind of scenario in nursing education, it should have been no surprise to see a growing number of students failing their board exams. After 1954, exam scores dropped significantly every year until the close of the decade.50 The nursing programs that were growing at rapid rates were those of enfermería práctica (practical nurs68 Pushing in Silence

ing) under the control of vocational schools of the Department of Public Education.51 These situations did nothing to enhance the reputation of nursing. Like most female professions, nursing was driven by practical need and experience, and was subservient to higher male positions of authority and supervision. Women, deemed natural caretakers by most Puerto Ricans, fulfilled the immediate demands of medical institutions to the detriment of a rigorous education. Just as midwives were relegated to practical training and used by the public medical system to treat uncomplicated pregnancies that doctors and hospitals were unable to attend, most nurses were also trapped by the practical needs and demands of the health system. Their salaries and training were often rudimentary and ranked very low. Yet nurses worked in institutional settings, whereas midwives worked primarily in private homes while reporting to public institutions. Nurse-­midwives were a possible model of professional care bridging midwifery and nursing, and the government did promote a nurse-­midwife program in Puerto Rico, but then had trouble launching and maintaining it due to resistance from nurses and doctors.

Nurse-­M idwives During the early 1950s, in the midst of the previously mentioned regionalization of the health system, a respected public health administrator, John Grant, consulting for the Rockefeller Foundation, decided to recruit women to oversee and lead a project for nurse-­midwives on the island.52 Grant had been assisting with the restructuring of Puerto Rico’s public health system. Locally, Dr. Pons and later Dr. Arbona, as secretaries of health, supported this effort. Through mutual friends and family members, Grant was introduced to a young, ambitious Puerto Rican woman interested in a career in medicine, Miriam Castro de Castañeda. She was recruited to train in the United States, and her story, captured in one of my interviews, is an exceptional yet important one to share. Castro de Castañeda, always an excellent student, had in 1948 (the first year of the period covered in this book) received the devastating news that she had not been accepted into the Women’s Medical College in Virginia.53 As an alternative, a nursing professor coaxed her to apply to an innovative graduate nursing program at Yale University as a stepping stone to medical school. Dr. Grant became aware of Castro when she was engaged in her graduate studies and went to meet with her in Connecticut. When he asked 69 Transitioning toward Hospital Births

about her plans, she informed him of her desire to study medicine. Instead of encouraging her, he told her that Puerto Rico did not need more doctors and proceeded to narrate a story on the poor health outcomes of mothers and babies, and how Puerto Rico was in the midst of a regionalization program focused on preventative medicine. He spoke to her about hemorrhaging mothers dying alone in childbirth and how nurse-­ midwives were the solution to these problems.54 Grant followed up on their conversation with several phone calls, finally convincing Castro to accept a scholarship to study nurse-­midwifery at the Maternity Center in New York (where most patients were Puerto Rican), while also earning a degree in public health/nurse-­midwifery from Johns Hopkins University. First, she earned her master’s in public health and nursing from Yale. During her later studies she was able to return to Puerto Rico to conduct research in 1958 as a consultant with the medical school. Eventually she moved back to the island to lead a long campaign to keep the nurse-­ midwife program alive.55 In the meantime, by 1953, the health department had established a training center for obstetric nurses under the Negociado de Salud Materno-­ Infantil (Bureau for Maternal and Child Health), located in the public health unit of Las Monjas in Hato Rey. Four other nurses with college degrees went to the Maternity Center in New York to train for six months in obsteric nursing so they could return to staff the nurse-­midwife program.56 This was orginally an independent program in midwifery to prepare nurses to attend women in any setting, including the home; however, the four nurses were never able to steer their practice toward home-­based care, as they had planned, once they returned to Puerto Rico and were working for the Department of Health.57 Therefore, the intent of this initiative never came to fruition, and home birth within a contemporary framework was never an option. To participate in the nurse-­midwife program, one needed to be a “graduate” nurse, meaning one with at least a high school degree. The training consisted of a one-­year internship in maternity services, including assisting a minimum of fifty births. The nurse-­midwives also had to pass the exam given by the medical examination board. Only four or five nurse-­midwife licenses were issued annually by this means, hardly enough to meet the growing demand.58 Because the nurse-­midwife program was not affiliated with a medical school or training center but was instead administered by the health department, it ran into problems immediately. By 1958, Castro, along with obstetricians and doctors Eduardo Arandes, Iván Peregrina, and Guillermo Arbona, proposed creating a school for nurse-­midwives within the UPR 70 Pushing in Silence

School of Medicine.59 (The university’s School of Nursing had rejected Castro’s proposal of training nurse-­midwives at that time.60) A few years later the program was transferred to the medical school. The situation of nurses, nurse-­midwives, and comadronas auxiliares was precarious between 1954 and 1959. In contrast, the medical school was graduating more doctors and growing rapidly. Therefore, affiliation with the School of Medicine seemed like a strategic move toward stabilizing the nurse-­midwife program and would be pursued at a later date.

The School of Medicine In 1956, the School of Medicine released a four-­year progress report in which Dean Hinman wrote that “undergraduate medical instruction has been average; postgraduate medical instruction has been nil; public health graduate instruction has been at an amazing rate [sic]; certain phases of the research program have expanded at an astonishing rate. Service to the public has been gratifying.”61 Financial support for the school grew significantly, despite the persistent clamor over lack of resources. Dean Hinman reported that local government funding had increased from $835,000 in 1952 to $940,000 in 1955, and that funds from other sources had increased from $11,900 to $430,780 during that same period. Research publications also boomed, from thirty-­seven to ninety-­three during that four-­year period.62 By 1958, the basic budget, as well as the teaching and research grant budgets, had each neared the $1,000,000 mark.63 The massive increase after 1954 was primarily due to funds from the National Institute of Health allocated by the US Congress.64 By the academic year 1953–1954, the medical school had been admitted as an affiliated member of the Association of Medical Colleges and approved as a four-­year medical school by the US Council on Medical Education and Hospitals. In June 1954, the school’s first group of forty-­five doctors in medicine graduated. That same year, five seniors received two-­month clerkships at Columbia University.65 Of the graduating class, twenty-­two interned in the United States and twenty-­three in Puerto Rico.66 In 1955, the school was planning to admit fifty-­two students per year. Of the total student body, 121 received some sort of scholarship funding. Two-­thirds of the students had received government assistance, obligating them to repay the scholarship by working for the government upon completion of their degrees. In the late 1950s, over a third of the younger generation of doctors had had at least part of their medical education financed by scholarships.67 This financial assistance opened the doors 71 Transitioning toward Hospital Births

of the medical school to those from less affluent sectors of Puerto Rican society. Medical students covered topics related to obstetrics and gynecology in all four of their years of schooling. Students studied embryology the first year, obstetrics the second, and obstetrics and gynecology in rotating clerkships during the third and fourth years. Starting in 1957, seniors were required to do a formal presentation of twenty to thirty minutes to fellow students and staff during their obstetrics and gynecology clerkship. Obstetrics had become a specialized subject and an important part of the curriculum. Beginning in the early 1950s, the School of Medicine was involved with several research projects in the area of reproduction. The Department of Obstetrics was in charge of overseeing a research project on the metabolism of progesterone in 1954. Other research funds for the School of Medicine included a $16,000 grant from the US Department of Health to study uterine cancer. The Worcester Foundation awarded $10,000 for research on reproduction after a campus visit by its director, Dr. Pincus, developer of the birth control pill. This put the School of Medicine at the forefront of developing the birth control pill, which was introduced experimentally on the island before it became available in the United States. The history of US birth control is directly linked to the oral contraceptive research done in Puerto Rico and the contributions of Dr. Pincus.68 University of Puerto Rico doctors also initiated important local research projects. During the late 1950s, the Department of Obstetrics and Gynecology undertook one long-­term study of multiple pregnancies and another on cesarean sections done in the San Juan City Hospital over the previous ten years.69 The ability of the School of Medicine to establish itself as a reputable research facility was due, in part, to affiliations with foundations such as Worcester and Rockefeller. At the same time, the experimental introduction of birth control and research on cesarean sections changed the relationship between medicine and the female body. In addition to research funding, the UPR Department of Obstetrics and Gynecology counted on visits from prominent US doctors who would give lectures, visit patients with students, and interact with staff and students. The connection between the United States and Puerto Rico was a strong one. During the school’s first decade, the Department of Obstetrics and Gynecology received visits from physicians from Harvard, Cornell, Columbia, and George Washington, as well as Cook County, Jefferson, and Buffalo. During the 1957–1958 academic year, the School of Medicine also had visitors from the West Indies Medical College. In this case, the visit was for observation because a medical school had recently been 72 Pushing in Silence

founded in Jamaica and the University of Puerto Rico was considered a possible model for similar efforts in the region. Through these interactions the medical school established a sound relationship with neighboring countries, the United States, and the local population. These relationships served to propel the authority of Puerto Rican medicine forward internationally and legitimate its place at home. The leadership of the faculty within the local community also strengthened the school’s reputation. Physicians who taught in the Department of Obstetrics and Gynecology during the 1950s played important roles in island associations and organizations that held social prestige and political clout but offered no remuneration. Dr. Gil, chief of obstetrics and gynecology at the San Juan City Hospital in 1957, was also president of the Toastmasters Club and a fellow of the American College of Obstetricians and Gynecologists (ACOG). He gave many talks at schools and nonmedical gatherings to argue against family planning. He considered any type of birth control, including the rhythm method, to be morally and socially harmful. Dr. Pelegrina, who would later head the department, was the president of the obstetrics and gynecology section of the Asociación Médica de Puerto Rico (AMPR) and an ACOG fellow the same year. Dr. Díaz Carrazo was president of the Santurce Exchange Club, and Dr. García was on the Commission of Legislation and Public Relations of the medical association and served as president of the Commission of Health and Welfare of the San Juan Lion’s Club.70 This type of community participation might not have yielded salaries, but it kept doctors well connected, made them good candidates for promotion, and garnered social prestige. The influence of the medical community in the broader social body of the island was tangible. Notwithstanding the rise in medical authority and social prestige, the teaching staff at the medical school earned meager salaries, had few resources, lacked teaching space, and worked long hours. As often happens, practice had not caught up with emerging ideological frameworks. The obstetrics department did not have enough resources, even after a significant budget increase, to offer more than a couple full-­time appointments to teaching staff during its first decade of existence.71 This meant that professors had to dedicate much of their time to private medical practice if they wanted to live comfortably. The School of Medicine was doing well and growing quickly, yet had room to grow and improve. The fact that it had an understaffed department was a sign that medicine was becoming increasingly specialized, which would eventually provide more options for patients. The San Juan City Hospital approved a three-­year residency program 73 Transitioning toward Hospital Births

in obstetrics and gynecology in 1952.72 Slowly, by this second phase in birthing history, from 1954 to 1958, more medically trained birthing specialists began offering their services on the island. Articles on obstetrics and gynecology by both local and mainland doctors began appearing in the medical association’s bulletin. Topics included anemia during pregnancy, inductions, use of x-­rays in prenatal care, major gynecological surgery, pain relief during labor, and practices associated with brain damage in newborns. The sub-­specialization of labor is a common characteristic of societies in more advanced industrial stages. Accordingly, the specialization of obstetrics was developing in tandem with an increased demand for trained biomedical birthing experts in hospital settings.

Medical Intervention During Childbirth In the initial stage of obstetric specialization, medical interventions during labor and delivery did not vary greatly from those discussed in chapter 1. Episiotomies continued to be common, and cesarean sections continued to be rare. On the other hand, sterilizations and hysterectomies were on the rise. Removing women’s uteruses to relieve symptoms related to vaginal relaxation and prolapsed uteruses had become the most common major gynecological surgery in Puerto Rico. Twice as many hysterectomies were performed in Puerto Rico than in most parts of the United States. Obstetric professor David Holmes from the University of Puerto Rico attributed this fact to the high multiparity rates of Puerto Rican women. He also lamented that there had been no new techniques or procedures available to obstetricians and gynecologists in the last fifty years.73 The high number of hysterectomies might be an early sign of the higher rates of obstetric interventions in Puerto Rico than in the United States. The increase in obstetric interventions on the island is notable because, though they were also central to the history of birthing in the 1950s, by the 1970s they would distinguish and characterize Puerto Rican birthing practices. As far as inducing labor, another intervention that would later be widely practiced, doctors suggested that it should be done only for women with a mature cervix ready to birth, whose fetus has engaged into the pelvis in preparation for birth, and only if the baby or woman is in some kind of danger. Induction was usually practiced by either manually breaking water or by administering Pitocin (oxytocin).74 Warm enemas were also suggested to induce labor. Even though Pitocin was used with some regularity, it was still in experimental stages.75 It is not uncommon for medical 74 Pushing in Silence

procedures, instruments, and drugs to be used before they are fully tested and given approval. Medical indications for induction and cesarean sections included preeclampsia, problems with diabetes or Rh negativity, and cephalopelvic disproportion. Absolute and relative contraindications included prematurity, fetal distress, high station of the fetus’s head, previous incision in the uterus, increased tension in the uterus, abnormal bleeding, parity greater than five, and a mother over age thirty-­five.76 During inductions, doctors suggested using analgesics such as Demerol, morphine, atropine, and scopolamine.77 These doctors did acknowledge in writings published in Puerto Rico that inductions and the medications accompanying them could cause depressed respiration in the infant, tears in the cervix, ruptures of the uterus, smothering of the fetus, and increased uterine bleeding.78 It is crucial to elucidate common practices and perceptions about appropriate medical interventions of the period in order to trace changes over time. The AMPR published an article from a chief US Navy obstetrician in 1956 promoting twilight sleep deliveries using scopolamine. It would be administered (with or without other drugs) during labor, rendering a woman unconscious during her labor and delivery process so that she has no memory of it. I have found no evidence that this procedure ever became commonplace in Puerto Rico beyond a few private practitioners, including Dr. Castillo, whom I interviewed during my research. He practiced in the San Juan area at the Ashford Presbyterian Hospital and would resort to concoctions of Demerol and scopolamine during deliveries, often at the patient’s request. Castillo had been trained at Harvard, was a specialist at Boston’s Brigham Women’s Hospital, and also served mothers from affluent backgrounds in private institutions.79 In the United States the twilight sleep method of pain and anxiety relief had been practiced for decades. According to a 1956 article in the AMPR bulletin, there had been “an increasing demand for painless labor from the pregnant woman” in the United States.80 Even though Puerto Rican medicine was associated in many ways with US medicine, and was undoubtedly influenced by it, medicine on the island typically maintained elements of distinctive practices. Medical historians such as Wolf and Leavitt contend that for decades, women in the United States had a particular fear of pain during birth and either deferred to their doctors’ recommendations for pain relief or demanded it themselves. Wolf argues that the problem, up until the 1960s, was that male doctors had very little understanding of the actual pain and sensations experienced during childbirth, leading them to administer pain relief medications rather arbitrarily.81 Furthermore, the need (or perceived 75 Transitioning toward Hospital Births

need) for pain relief justified specialized medical intervention and gave obstetricians a respected space in the medical world. US women were willing to cede their power of negotiation to specialists, and most ended up very grateful for having been spared the excruciating pain of the pushing stage of labor. Similar patterns of behavior involving cesarean sections and inductions in Puerto Rico followed in subsequent decades. The women in Wolf ’s studies had come to believe they would not be able to tolerate the pushing stage of labor, when the baby is finally expelled. Though Leavitt makes a similar argument, she claims that doctors had been administering scopolamine, as well as ether and chloroform, since the mid-­1800s.82 It seems, though, that Puerto Rican women in the 1950s did not experience the same level of fear and anxiety as their US counterparts. This dynamic is an important example of how medical practice and perception speak to one another and redefine each other in ways that are not always responding to the scientific, objective, or disinterested research that we often assume supports medical practice. The interplay between perception and the increased acceptance of medical intervention will be important in future chapters. Though every birthing experience is different, almost all women who have experienced labor and delivery without medication describe the pushing stage as the least painful but perhaps the most intense.83 Because it is the stage during which women bear down, work hard, and make the most noise, US doctors assumed that was when women needed their help the most. Most women would probably agree that what is usually the most painful and trying stage of labor is during transition, when completing the final centimeters of dilation, right before the pushing stage. It is easy for women to believe that because labor has gotten harder and more painful up to that point, it could only get worse. The prospect of expelling a seven-­pound baby out of what is usually a rather small, intimate, and delicate orifice leads some to assume that the most horrifying part of labor would be the pushing stage. This was precisely when obstetricians in the United States tended to medicate mothers into oblivion, extract the baby with forceps, and later hand it over to a supposedly untraumatized, grateful mother.84 Debates among Puerto Rican obstetricians about appropriate or accepted interventions during pregnancy and childbirth were ongoing. Many physicians hung on to the idea that fewer interventions were better, but some had resorted to more extreme interventions, such as twilight sleep. There was also a new trend toward performing hysterectomies to alleviate certain gynecological complaints. There was little communication among specialists. Dr. Riftkinson, a University of Puerto Rico profes76 Pushing in Silence

sor and neurologist, warned about routine obstetrical practices that could be damaging to newborns in a 1957 article in the AMPR bulletin. He was concerned about how little medical students knew about the importance of blood and oxygen flow to infants during labor and delivery, and he criticized common practices such as clamping the cord immediately after labor, inducing labor days or even a week before full term, using narcotics and anesthesia during labor, and performing unnecessary cesarean sections. Neurologists knew all of these procedures had detrimental effects on newborn brains and, in some cases, even led to twice the normal rate of neonatal deaths.85 Most doctors used anesthesia sparingly for pain relief during childbirth in Puerto Rico at this time. Dr. Castillo claimed that because there was only one anesthesiologist in San Juan in the mid-­1950s, he would be called only for cesarean sections.86 On the one hand, Puerto Ricans and Americans took for granted that all medical practice in the twentieth century was inherently predicated on proven scientific research and up to date with the latest discoveries across disciplines, despite the fact this was not always so. Secondly, the apprehension that some physicians felt about intervening excessively with childbirth pointed to a continued trust in a woman’s ability to give birth. Medicine did not adopt aggressive, authoritative, interventionist styles in obstetrics until later, when assumptions about risk and the ability of the human body changed. For the time being, however, reliance on and accessibility of interventionist technologies were limited. Of the women who gave birth between 1954 and 1958, none of the those I interviewed or spoke to informally described their experiences as terrifying or excruciating. Almost everyone mentioned labor pains, but I saw and heard little evidence of the fear of birthing described by scholars of US birthing practices. This lack of fear might help explain why Puerto Rican doctors intervened less during childbirth than US doctors. Fear and tension have been linked to more complications and pain in childbirth. If Puerto Rican mothers were less anxious about the birth process, they might actually have experienced less pain. I assume that fear and pain were not motivating Puerto Rican women to deliver in the hospital, even though they had for many US women in earlier decades. These different perceptions of pain and fear suggest that childbirth was viewed differently in Puerto Rican culture than in the United States, and that emotional responses, coupled with access to resources, shaped behavior and relations of power. For example, privileged US women both feared the pain of birth and had the means to escape it, thereby ceding control and power to the obstetrician, who could keep them from experiencing that pain and fear. 77 Transitioning toward Hospital Births

Public versus Private: Varying Patterns of Medical Usage and Services The second phase of birthing history in Puerto Rico included an overall shift toward hospital births, but at an uneven rate. Though the move toward the hospital setting suggests an increased reliance on physicians and obstetrics, midwives still attended most births. However, just like the regional differences discussed earlier, discernible differences in birthing practices and patterns arose between public and private medical institutions. Because the structure of medical services in Puerto Rico was so different from that of the United States, and birthing practices varied between the public and private sectors, it is worth elaborating on some of the specific characteristics of the Puerto Rican public and private medical sectors. Several official, independent systems provided medical services in Puerto Rico simultaneously: the ELA (state) Department of Health, the municipal governments, and the Fondo del Seguro del Estado. Together they provided close to two-­thirds of all hospital services at very low or no cost to the public. Private hospitals provided the remaining one-­third of services. The US government also delivered a small percentage of services to veterans and their families. The local government occasionally contracted private services, which meant that 90 percent of all hospital costs were covered by the government.87 Medical services were provided through five district hospitals, thirty-­three hospital units in the health centers, six tuberculosis hospitals, a psychiatric hospital, and a hospital for leprosy. As part of the 1958–1960 study mentioned earlier, in the summer of 1959 the Department of Health, working with Columbia University, gathered information on 500 physicians who had received their degrees after 1940.88 The study included almost all of the physicians with more recent degrees practicing at the time. Half of them worked for the government, and half were in private practice. Each physician participated in an interview of one to two hours concerning their practice, training, attitudes, and the future of their medical practice. The results of this Puerto Rican investigation eventually became a topic of discussion among public health workers and intellectuals in the United States.89 The premises of the following paragraphs are largely drawn from this study. Despite the apparent interest of municipalities in improving and providing health services, studies revealed a widespread concern among both doctors and patients about the current state of affairs in municipal health centers. Municipal hospitals and health centers reported treating a higher number of patients than they were equipped to handle. They had inade78 Pushing in Silence

quate physical structures and space, and were low on supplies, equipment, and staff. Allocation of resources was inconsistent, staff were underpaid, and municipal employees were not protected by the state personnel law. The state paid professional staff, such as doctors, who often rotated for periods of time into rural municipalities because it was very difficult for them to attract quality technicians, doctors, nurses, and other medical staff. In fact, staff often dispatched medication without proper prescriptions.90 But what doctors and the public considered the gravest of all the problems faced by municipal health centers was the split in authority between the health department, or “modern medical professional advances,” and local mayors.91 Doctors described deep tensions and continuous conflicts with local politicians. Elinson, in his book The Physician’s Dilemma, writes, “Many physicians believe[d] there [was] too much political interference with the practice of medicine in Puerto Rico,”92 referring specifically to the seventy or so mayors on the island who used local resources as they wished. Some doctors reported that mayors were distributing medicine and using ambulances as part of political campaigns, and personnel were at the mercy of political shifts and personal preferences. Doctors reported the friction with mayors was one of the main reasons for leaving the public sector. Such was the state of affairs between doctors and mayors in the late 1950s that the governor appointed the secretary of health to head a committee to look into mayor-­physician relationships, among other things.93 Toward the end of the 1950s, 58 percent of all medical visits in Puerto Rico were to governmental dispensaries; 35 percent were to private medical offices; and 7 percent were home visits from doctors.94 Those patients visiting private offices and receiving medical visits came from the higher income brackets. On the other hand, almost all who had sought medical services in the previous three months incurred out-­of-­pocket medical expenses, most for medication.95 Few people had medical insurance at this time; 82 percent of families interviewed had no health insurance at all. Blue Cross and the Teachers Association Health Plan were the most common among the few who did have insurance.96 The government covered nearly 90 percent of expenses whether they were incurred in district, federal, private, or nonprofit hospitals. Seventy percent of hospitalized patients stayed in large common rooms, and 20 percent in semiprivate rooms. Only 11 percent enjoyed private quarters. The average cost per patient per day in the general and district hospitals was slightly over seven dollars, a third of what was being spent in the United States.97 Most health centers around the island were operating at only about half of capacity, raising costs per patient.98 One reason for the low occupancy was duplication of services. For example, government clin79 Transitioning toward Hospital Births

ics were often within a few miles of each other, and municipal and Fondo del Seguro (similar to worker’s compensation) medical institutions were located in the same geographical area. Surgery and obstetrics were the most common reasons for hospitalizations, accounting for close to 20 percent. Interestingly, most of those admitted for surgery and obstetrics came from higher-­income groups; the remaining hospitalizations had higher rates among those from lower-­ income groups.99 We know that the higher the level of education and income, the smaller the family size during this time. If more middle- and upper-­class women were admitted to hospitals for obstetric care yet having fewer babies than lower-­class women, it is probable that class was playing a role in women’s decisions about where to have their babies. Postpartum stays also varied between private and public hospitals. Private hospitals lodged 60 percent of new mothers between eight and ten days, whereas in public hospitals the same percentage of mothers stayed for approximately five days. Private hospitals kept 2 percent of their maternity patients for only five days.100 The long stays in private hospitals were likely a luxury afforded to more affluent mothers as a form of support during the initial days of postpartum so that they could get rest and extra care, something public hospitals could not afford to do. Class and regional differences played out in other significant ways in terms of services accessed and opinions about public services. Two-­thirds of those interviewed in urban areas reported that government institutions were as good as or better than private ones, but rural residents were divided almost evenly on the same issue. This was probably because the top research and medical government institutions were in metropolitan areas.101 Social class influenced the type of medical providers sought by patients as well. Spiritists had long been a health care alternative in Puerto Rico. Combining science and religion with mediumship, they worked with spirits to heal and assist those who sought out their help. In the late 1950s, close to a third of those from the lower income brackets had consulted spiritists for their health care needs, compared to just 5 percent from the highest bracket. Patients in rural areas were more likely to visit a spiritist than a pharmacist.102 In general, most people sought medical help locally, but more than a third were hospitalized outside their zone of residence.103 This move away from the home and local community was a major contributor to the institutionalization and medicalization of childbirth. A marked cleavage between private and public practices and practitioners existed, with wealthier patients much more likely to access private medical services. There were also class differences between doctors serving government agencies and those in private practice. In Puerto Rico 80 Pushing in Silence

at the time, most doctors working under full-­time government contracts also had some type of private practice, and most of those in private practice also carried some sort of government workload. According to Elinson, at the time, “Government service [was] more attractive to physicians from middle class families and private practice to physicians from wealthy families.”104 Curiously, the small minority of physicians who came from poor families were also more likely to be in private practice. Two-­thirds of young physicians reported coming from upper middle-­class or wealthy families.105 The likelihood of physicians working within the government system also depended on the location of their educational training and internships. Most Puerto Rican doctors trained in the 1940s and 1950s received their undergraduate education elsewhere, primarily in the continental United States. On the other hand, most Puerto Rican doctors interned in Puerto Rico, with only one-­fourth completing their internships in the United States. Those who did intern in the United States were the least likely to work in the public sector, perhaps because US medicine has been predominantly private overall. The physicians most likely to serve the public system interned in countries outside the US system altogether.106 The reasons doctors were attracted to either private or public practice also varied. In general, though, doctors in private practice cited the advantages of higher salaries (in the long run), more independence, better working conditions, closer relationships with patients, a greater sense of security, and more public, social, and medical prestige. Still, government service did have a few advantages. Despite salaries being half that of private practice, government service offered better pay in the initial years of practice, provided opportunities to be of service to the community and to do interesting work and research; made for a better home life; and provided paid vacations and retirement benefits.107 Nevertheless, private practice felt more secure to Puerto Rican physicians, whereas in the United States, government employment offered a greater sense of security to doctors.108 These differences in use and employment between the public and private medical sectors are important because in later periods, childbirth practices between the two sectors would begin to diverge notably.

Conclusions By 1958, more than 1,400 doctors and just over 1,000 auxiliary midwives were practicing in Puerto Rico. The number of doctors had doubled, but the number of midwives had dropped by 400 since the beginning of the 81 Transitioning toward Hospital Births

decade. Moreover, only a handful of midwives entered training to begin or continue their practice. The medical school, in contrast, had been fully accredited, had graduated its first few cohorts of physicians, and was obtaining more funding. Women in medicine, including nurses and nurse-­ midwives, struggled to assert themselves professionally. Although the Department of Health had come to recognize the labor of midwives, gave them credit for improved maternal health statistics, and on paper planned to strengthen the midwifery program, in practice it did little to keep the comadrona auxiliar program alive. The department’s promotion of the training of nurse-­midwives also met with little success. In the mid- to late 1950s, more babies were born with the help of midwives than of doctors and nurses, but for the first time in Puerto Rican history, the number of babies born in a hospital setting surpassed that of home births. This trend toward hospital births was true throughout the island, but not in each municipality or microgeographical area. In some municipalities, most women were birthing at home, and in others the majority were birthing in hospitals. Despite these apparent discrepancies in birthing trends, what was consistent was that few women were interested in taking over the jobs of the now older midwives. Midwifery seemed doomed to extinction. Most physicians were general practitioners, but the specialty of obstetrics showed a modest growth in numbers, interest, and training opportunities. Most doctors worked in the public sector, where the majority of hospital births took place. Doctors from wealthy backgrounds, as well as those trained in the United States, preferred working in the private sector, where their patients were from more privileged backgrounds. Operating within the accepted norms of the time, most doctors were hesitant to intervene during labor and delivery, even though many did perform episiotomies because they believed that it aided women and because it was easier for them to suture than a spontaneous tear. Very few women tore spontaneously, and only a low percentage of mothers had significant complications during delivery. Mothers, doctors, nurses, and midwives were confident about the female body’s ability to give birth, and most assumed it would go well if left to run its course and the mother had had a good pregnancy. Some doctors may have worried about hemorrhaging, cephalopelvic disproportions, anemia, and diabetes to some degree, but most would not expect these problems to occur often. Doctors with cesarean rates over 5 percent were sometimes described as “butchers” by their colleagues.109 To them, obstetric interventions were usually surgical ones (requiring knives), and doctors who treated 82 Pushing in Silence

childbirth as a surgical procedure were criticized for treating women as butchers do a slab of meat. Several mothers and midwives I interviewed suggested that women in the 1950s had fewer complications and no problems birthing at home because women were healthier and took less medication. Doña Penchi explained that women began birthing in hospitals because of all the new diseases that did not exist when she was delivering babies as a midwife.110 She conceived of these “diseases” as unidentified products of modern society, but she seemed to allude more to a belief that home births were not compatible with progress. Tomasa, one of Doña Penchi’s clients, claimed that “today things get more complicated every day and we are not like before. So many medicines and stuff that make the baby crossvert [sic], invert this and that. . . . I have catalogued it as it being because of the many things people take to avoid children.”111 These comments express the changing ideas these women had about childbirth from 1954 to 1958. To them, childbirth had been a simple, natural process, but it had changed, gotten complicated, and now needed to occur in a hospital setting. The perceptions of these two women reveal how concepts about maternity and childbirth changed over time, not the actual biological changes that mothers experienced. This kind of social recasting of childbirth would move it definitively to a medicalized setting.

83 Transitioning toward Hospital Births

Ch a pter th ree

Phase Three

Ph ysician-­Assisted Hospital Births, 195 9 –1965

T

he previous chapter covered the second phase of birthing in Puerto Rico, from 1954 to 1958, when more than half of all births occurred in a hospital setting for the first time, but midwives were still the primary birthing attendants. By 1959 that was no longer true, and from 1959 to 1965, the place of birth and who attended the birth changed more dramatically than in any other period. During this third phase, birthing took a decisive step into the realm of institutionalized medicine, and physicians claimed primary authority for the first time. Although most births on the island after 1959 took place in the hospital, a few municipalities kept auxiliary midwives busy in the domestic setting to care for the women who resisted hospitals due to distance, economic constraints, or preference. Private and district hospitals ceded little room to midwives and nurses, but municipal hospitals, in addition to turning to doctors, often placed the responsibility of delivering babies on nurses and some midwives. Government efforts to consolidate and standardize health services bore fruit. More doctors specialized, and obstetrics slowly gained momentum, though general practitioners were the ones who assisted most mothers as they brought their babies into the world. In a society whose cultural practices leaned ever more on scientific and institutional expertise, industrialization programs, together with medicine and public health efforts, transformed medical practices and socioprofessional relations. Puerto Ricans relied increasingly on formally trained experts and less on popular wisdom, trusted technology more than ever, and accepted standardized methods in health and human development, even if they failed to account for differences. The expanding popular acceptance

of biomedical models of care reflected a cultural shift that would pave the way to move births away from the home, into the hospital, and into the hands of obstetricians. Standardization and widespread bureaucracy at the state level were characteristic of industrialization in Puerto Rico, just as in most industrial societies.1 In 2005 I interviewed a woman I will refer to as Ingrid. Her experiences exemplify the predominant changes in birthing practices on the island after 1959. She had her first of eight children in 1953 (during the first phase of birthing, discussed in a previous chapter), at home with a midwife in a rural town in the southeast of Puerto Rico.2 When she had her third and fourth children at home, she experienced postpartum complications that eventually drew her to the hospital during phase three of the island’s history of childbirth (covered in this chapter). Her youngest children were delivered in the hospital with medical staff, but not without Ingrid first approaching her midwife. She was aware that some women were already giving birth in the hospital, but she had turned to a trusted comadrona auxiliar to tend to her, just as all her friends and family had done. Ingrid recalled that when she felt her first contractions late in her first pregnancy, her husband called for the comadrona. She arrived with her white clothes and black bag, and she stayed by Ingrid’s side for three days, giving her teas, rubbing her belly, and looking after her until after the delivery of her first baby girl. Normally, after the first couple of months without menstruating and suspecting she might be pregnant, Ingrid would go to the government clinic to begin prenatal care. There, the nurses tested her urine to verify the pregnancy, gave her vitamins, weighed her, measured her belly, took her blood pressure, and gave her any pertinent advice. For x-­rays or more elaborate tests and procedures, Ingrid traveled for two hours to the Humacao hospital. The nurses were well aware that most of the women they saw at the clinic were still choosing to birth at home, but things were changing swiftly, and many women who had birthed their first few children at home later sought out the hospital for subsequent births. Ingrid ended up in the hospital shortly after her midwife delivered her fourth child at home. All went well in the delivery, but afterward the placenta was not expelled, and the midwife began to worry. Instead of trying to pull it out, the midwife decided to cut the umbilical cord and prepare the mother and baby for transport to the hospital. Concerned that she could be held accountable for potential complications in the home, the midwife accompanied Ingrid to the hospital. Once there, the midwife informed the hospital staff of the situation and left Ingrid and the baby in their care. The doctor manually pulled the placenta out of Ingrid’s uterus. 85 Physician-Assisted Hospital Births

Luckily for all, there were no other postpartum complications, but that would change after the birth of her next child. In 1960, three days after having her fifth child at home with no apparent difficulties, Ingrid began hemorrhaging. Her first thought was that she had failed to properly take care of herself, but she had several children to look after. Her husband had come home from the sugar mill for a few days, as was his custom, to be present for the birth of their child. When he realized that Ingrid was bleeding, he ran to seek help. Her mother and a neighbor, who had been giving Ingrid a hand for the last few days, prepared a hammock and tied it to a long stick to transport her down the road. She was then taken in a neighbor’s car to the closest hospital, given a blood transfusion, and sent to a larger hospital in Humacao, where she remained a few more days. Ingrid was lucky to avoid the danger of postpartum hemorrhaging, a common cause of maternal deaths in the 1950s and 1960s. Her doctor warned her that it was no longer safe for her to have babies at home. Ingrid had her sixth child in the local hospital a couple of years later. She felt safer in the hospital, close to nurses and medical equipment. The doctor and nurses did not diverge much from what the midwife had done at home during the first two stages of labor other than connect her to an IV. She was not given an episiotomy or medicated into twilight sleep, and her doctor did not use forceps. Things got complicated, though, during her third stage of labor, after delivery of the baby. The baby was out and well, but once again Ingrid did not seem to be expelling the placenta. The doctor decided to pull it out himself, completing the final stage of childbirth. Ingrid’s next two children came into the world in much the same way. When Ingrid took her newborns to follow-­up appointments at the public health unit, the nurses usually informed her of family planning options. Yet like almost all women she knew, Ingrid did little to avoid getting pregnant. Multiple pregnancies were the norm in her town: one of her neighbors gave birth twenty-­two times. Ingrid was aware that she had access to birth control and did pick up a pack of pills following one of her medical visits, but only took them for about a month. She became pregnant ten times and had eight children, most of them about two years apart. Perhaps this spacing occurred because she breastfed for the first year or so, or perhaps it was just the way her body worked, but it was not due to the use of birth control. In this chapter I explain why women moved to clinical settings to give birth, and argue that the introduction of experts and authoritative knowledge regarding childbirth emerged as a consequence of the industrial 86 Pushing in Silence

project and the changes in lifestyles and attitudes it instigated. The way Puerto Ricans conceptualized birthing and its appropriate setting changed in ways that affected practices. The government restructured the public health care system to concentrate all welfare services around the hospital while providing more attractive options for mothers who could afford them. Under this model, the hospital became a point of access for state welfare services. Yet, despite the fact that by 1965 the great majority of women were delivering in hospitals, access to and use of prenatal services and public clinics continued to vary by class, and women in some regions proved more reluctant to seek hospital care than others. During this phase of the island’s birthing history, the education of nurse-­midwives solidified within the medical school, but auxiliary midwives’ training drifted into the shadows. To further explore the characteristics of this birthing phase and changes regarding childbirth, this chapter addresses the following topics: the cultural paradigm and lifestyle shifts related to birthing; the attempt to centralize public services through regional hospitals; the state of nursing, midwifery, and physician education; and finally, regional and public/private variations in patterns of hospital use.

Dismantling Old Paradigms Between the 1940s and late 1950s, Puerto Ricans’ standard of living improved and, with it, their expectations for better health care (table 3.1). General mortality declined, and the death of young children, once commonplace, especially in larger families, became rare. Early death no longer Table 3.1. Selected demographics, Puerto Rico, between 1945 and 1963

1945 1953 1958 1963

General mortality rate (per 1,000)

Infant mortality rate (per 1,000)

Maternal mortality rate (per 100,000)

Birthrate (per 1,000)

14.1  8.2  7.0  7.0

93.4 63.3 53.7 44.8

319.0 183.5  85.4  54.3

42.2 35.1 33.1 31.1

Source: Oficina de Planificación, Informe anual de estadísticas vitales de 1985 (1987), 13a.

87 Physician-Assisted Hospital Births

formed part of the expected course of life. Many citizens increasingly felt entitled to food, jobs, education, medicine, expert opinions, scientific advances, and an overall improved quality of life. Public welfare projects geared toward defending those who were vulnerable, including babies and people living in poverty, were augmented. Because women could access these services only through and in institutional spaces, it followed that mothers would be more willing to use institutional services such as hospitals than in the past. By the 1960s, most Puerto Ricans would look to experts and scientific institutions to resolve issues pertaining to health and risk. Accordingly, mothers like Ingrid moved to hospital settings where experts, science, and regulations would protect them and their babies from possible risks. To refuse the options available to them made little sense. Even though Ingrid had been taken to the hospital after the birth of her fifth child, at the insistence of her midwife, she birthed at home for her next delivery. It was not until the midwife, doctors, and her own experience with complications convinced her that she was better off birthing in the hospital that she finally decided to deliver her last children there. She admitted that she eventually felt safer in the medical setting. It is likely that the change of setting in this case saved her life, as she probably would not have survived hemorrhaging at home without medical intervention. The concept of risk itself moved swiftly up the sociocultural ranks and became an important consideration in significant life events. People felt they had more choices and control, and could strive for a better quality of life; they could weigh risk and take the time to consider it seriously. There was a new collective agreement that sustained the claim that individuals could plan, control, and work toward a goal successfully. Life, it seemed, could be studied and predicted, and risk could be managed. Social theorist and renowned sociologist Ulrich Beck, in his book Risk Society: Towards a New Modernity, writes that risk “may be defined as a way of dealing with hazards and insecurities induced and introduced by modernization itself. . . . [I]n contrast to earlier epochs the risk society is characterized essentially by a lack: the impossibility of an external attribution of hazards.”3 The advanced industrial society (“reflexive modernity”) that Beck refers to is more advanced than that of 1965 Puerto Rico (corresponding more with the later phases of birthing history described in this book), but the early signs of a high-­tech risk society were evident by the 1960s. Operation Bootstrap’s industrialization most likely falls into Beck’s concept of “simple modernity,” but whether simple or reflexive, modernity’s social structures seek control over nature, the socialization of scientific knowl88 Pushing in Silence

edge, the further division of labor, the preparation of experts, and the assurance of greater predictability. These changing values and tendencies—adapted by mothers, doctors, and midwives—served to regulate their behaviors, eliminating the need to threaten them legally into using the available tools of modernity. They seamlessly moved away from what they now deemed “folkloric,” domestic, and backward approaches to health and reproductive matters.4 Indeed, as the previous chapter and Ingrid’s story indicate, it was often the auxiliary midwife who convinced mothers to access government health services instead of continuing to assist births with them at home. By the 1960s, authoritative knowledge regarding birth had become the domain of institutionalized medicine, a dominant model that Puerto Ricans would follow. Before the 1960s, however, expert and authoritative knowledge of birthing practices had not resided primarily in medicine or its institutions. Gertrude Fraser, in her history of African American midwifery in the southern United States, affirms that the tendency toward authoritative knowledge and universal processes formed part of the ideological foundations of capitalism and industrial societies at large.5 Although hospitals and medical specialists had yet to fully occupy the medical landscape, they were gaining traction quickly. In his article “Morelli, Freud and Sherlock Holmes: Clues and Scientific Method,” European historian Carlo Ginzburg discusses the difference between what modern societies classify as “low knowledge” and “high knowledge.” In an industrial society, he argues, popular or folkloric knowledge loses its footing, and scientific knowledge takes the throne. Low knowledge, as represented by auxiliary midwives’ practices, is acquired through informal means, based on quotidian experiences, and usually transmitted orally. It is widely accessible and does not count on rigorous methods to exclude nonspecialists from its practice. High knowledge, on the other hand, is associated with power.6 If a group manages to define and limit access to knowledge, as Puerto Rican doctors and obstetricians did, it can better ensure its power within its field of expertise. Furthermore, if academic institutions (such as the UPR School of Medicine) and the government (licensing agencies and the Department of Health) join forces to support this endeavor, they have a successful formula for exclusion and power. This type of power, supported by cultural hegemony, did not require physicians to mount a campaign against midwifery to monopolize the practice of labor and delivery. In Puerto Rico, this process empowered obstetricians and excluded comadronas, who had become obsolete by the mid-­1960s. 89 Physician-Assisted Hospital Births

The government, doctors, and women themselves increasingly conceptualized the bodies of women in Puerto Rico within a capitalist context of rapid industrialization and development. Female bodies, in this context, needed to be controlled and to behave in expected ways. Within the framework of modernization theory, reproduction required planning and constraint within preestablished norms. Responsibility for health and circumstances resided more in the individual than in the hands of God or nature. Just as labor and family structures morphed to suit urban and factory-­ style modes of living, so too did birthing and the medical establishment. As obstetricians increasingly took charge of maternity wards, the medical establishment reconceptualized reproductive processes in terms of efficiency and organizational function.7 Feminist anthropologist Emily Martin, in her influential book The Woman in the Body: A Cultural Analysis of Reproduction, specifies that industrialized medicine conceptualized the uterus “as a machine that produces the baby and the woman as laborer who produces the baby.”8 The obstetrician manages the birth and determines if the pace of labor warrants intervention. The baby is the product. In fact, Martin explains, in this model the baby and mother are often in conflict rather than being an integral unit.9 It would not take long for medicine in Puerto Rico to adopt this theory of baby versus mother. The definition of a normal birth changed ultimately to included time limitations. Whereas before 1960 women could be in labor for several days and still fall on the normal spectrum, by the mid- and late 1960s labor and delivery were expected to transpire within more constrained temporal parameters. Several doctors I interviewed spoke of these new birthing parameters and definitions. Dr. Mulero, for example, explained that before the mid-­1960s, most births were normal, which simply meant one that was progressing.10 Dr. Onís said that eventually normal births were medically defined as those that completed within twenty-­four hours because the longer the birth, the less oxygen the baby was getting.11 In contrast, Ingrid’s fourth birth at home, described above, lasted three days with the comadrona at her side. This model of birth was not sustainable within the framework of obstetric medicine in Puerto Rico by 1965. Modern medical practice presented itself as a science with access to efficient technology. Public health institutions underwent a process of reorganization and accreditation, and Puerto Rican medicine in the 1960s produced local, trained professionals who operated within licensed institutions and followed particular protocols and procedures. More doctors specialized and reached different areas of the island. In 1956 (the end of the previous phase of this birthing history), there were only 56 obstetri­cians 90 Pushing in Silence

registered to practice in Puerto Rico; by 1971 (during the next phase of birthing history) 160 were registered.12 Dr. Tomás, from a rural southwestern town, described the early 1960s as a medical turning point in his area. After 1960 a new hospital opened in his town, and specialists began arriving to serve the local population.13 Another rural doctor from the northwestern area of the island described a similar situation. He too referred to 1962 as when the new health centers began operations. In his interview, Dr. Villamil recalled that once patients saw the new facilities, which were better staffed and equipped than the old health units, they were inclined to use them.14 Previously, women had avoided using the older local hospital: “The hospital had a bad reputation . . . it was a little room there eight by eight, a hallway of six by eight [feet] . . . and a small room in front to give stitches, nothing else. It had another room on this side where the nurse was to give shots and the like.”15 By the 1960s, new hospitals, clinics, and doctors offered both the illusion and the delivery of preplanned standards of care and medical technologies. Modern biomedicine follows many standardized protocols and seeks to constrain irregularities. Each disease has stages of development, and the medical field establishes what it considers adequate responses to restore health. Average and normal patterns are determined by means of data collection and observation, which require particular professional responses.16 Labor and delivery lasting three days, like Ingrid’s, did not fall within the twenty-­four-­hour limit referred to by Dr. Onís. The lengthy time frame alone would classify her labor as abnormal. Physician and philosopher Georges Canguilhem explains that “From the moment that the etiology and pathology of an anomaly are known, the anomaly becomes a pathology.”17 The irony is that in the biological sciences (including physiology) few processes or subjects align with the ideal or average.18 This lack of consistency is often the case with pregnant and laboring women. According to feminist scholars Carolyn Sargent and Caroline Brettell, once the cause, origin, and behavior of an event or situation that does not respond in an average or predictable manner are identified, it becomes pathological and therefore something that must be normalized.19 Pathos refers to suffering or a sense of impotence, sentiments contrary to the maintenance of life.20 It would be the task of the physician to normalize the patient’s pathos. Childbirth often deviates from averages and standards, thus as women and doctors began to frame their expectations within these norms, it became more likely for labor and delivery to look less normal and in need of specialized attention. Standardization, yet another characteristic of industrial societies, is a classification process that determines how one should proceed and what 91 Physician-Assisted Hospital Births

to expect in any given situation. Standardization methods determine what is normal and establish an ideal by means of generalizations to be followed by all involved in that process. Jürgen Habermas argues that norms and values become more generalized and formalized as a society evolves.21 Laws and regulations codify values, and broader sectors of society accept them as their own. Consequently, most members of the society spend much time and energy trying to meet these standards. Those who labor in specialized areas (e.g., education, medicine, law) must ensure that practitioners observe their particular guidelines and standards. By the 1960s, Puerto Rican medicine was closely following the new procedures. At the same time, even though many physicians continued to view childbirth as a natural phenomenon, medical discourse began referring to labor and delivery as potentially pathological and high-­risk. Some physicians took a particularly extremist stance. For example, Dr. Onís, who trained in the mid-­1950s and was board certified in the United States by the late 1950s, described all first births as abnormal and all first-­time deliveries as high-­risk by definition.22 By the 1960s, as pregnancy, labor, and delivery became more universally standardized processes within the medical community, doctors responded accordingly to set standards and expectations for the medical community through their writing and based on their own experiences. Hospitals established predetermined protocols and requirements within existing scientific, legal, social, and economic boundaries. All of these standardized procedures provided clients, in this case pregnant and birthing women, more universal or at least uniform parameters in which to set their own expectations. As medicine became more organized, centralized, and institutionalized, the Department of Health also moved to centralize its services around the regional hospitals, which were continuing to expand.

Operación Regionalización: Centralizing Health and Welfare within the Hospital Setting During the 1960s, the Department of Health underwent structural changes. As described in the previous chapter, the government finally implemented the reforms of Operation Regionalization extensively.23 The plan centralized the health, welfare, and data collection systems around the regional hospitals.24 92 Pushing in Silence

Dr. Guillermo Arbona, the secretary of health, held this position from 1957 to 1966, the period in which birthing moved to the hospital setting and the regionalization plan unfolded. The health care system underwent marked structural alterations under his direction. After growing up in a remote, rural town on the interior western side of the island, Arbona studied medicine at the University of St. Louis. He returned to Puerto Rico in 1934.25 Though Arbona was a supporter of the PPD social programs, he tried to remain at the margins of party politics. An important leader in public health, he believed in community health, family planning, and socialized medicine. Arbona represented Puerto Rico regularly at the World Health Organization and its meetings. During the 1960s, he collided with the Medical Association of Puerto Rico when he pushed for the further socialization of medicine on the island.26 The medical association was very outspoken about its opposition to socialized medicine and was not always supportive of Arbona’s initiatives. Dr. Arbona submitted his executive plans for Puerto Rican public health to the US Public Health Service between 1959 and 1961, stating his intention to decentralize services into regions while integrating welfare and public health services under one roof.27 He argued that in light of rapid social change, the health care system needed to expand its services: In the face of the radically new life circumstances which many Puerto Ricans now face as a result of the rapid cultural and socioeconomic developments of recent years, it is becoming necessary for the Department of Health to assume a progressively wider span of responsibilities. Health in Puerto Rico can no longer constitute merely the absence of disease, nor can well being automatically be assumed if the more overt manifestations of personal need or social disorganization are not immediately apparent. The Department of Health must utilize to the fullest extent all the possibilities it now possesses for helping the clients it serves on a multidimensional basis.28

Arbona understood that proper health care could only be obtained within a model of socioeconomic progress and an improved quality of life. The regionalization plan divided Puerto Rico into five health regions. Each region coordinated health care with social welfare and public services through a regional hospital. Smaller public health units (such as the municipal health centers, the municipal hospitals, and the public health units of the fifty-­four health districts), the district hospitals, and the Uni93 Physician-Assisted Hospital Births

versity Hospital of Río Piedras fed into the regional hospital. In this first of several attempts at restructuring the health care system, the focus was on direct patient care institutions.29 The proliferation of health centers and hospitals, public health restructuring, and the success of the medical school in graduating many more doctors expanded the options for health care for the majority of Puerto Ricans who could not afford the costs of the private sector. Puerto Rican daily newspapers such as El Mundo reported on these efforts in 1964 and 1965.30 Often these programs were funded by the federal Hill-­Burton Act (Hospital Survey and Construction Act) and organized according to the plans of the Puerto Rico Department of Health.31 The growth of an institutional, medical infrastructure that could provide affordable access to experts and technologies offered an attractive new option for the people on the island. In the metropolitan area hospitals and the clinical spaces affiliated with the University of Puerto Rico, demand outpaced availability of facilities and resources.

The School of Medicine The UPR School of Medicine, established only in the previous decade, took root and showed remarkable signs of expansion by the first half of the 1960s along with institutionalized medicine in general. Within a decade the Puerto Rican government and its medical leadership had created a medical school along with an extensive public health infrastructure that laid the foundation to institutionalize health care and make it accessible islandwide. The 1960s proved to be a time when plans for more academic and scientific rigor and expansion in higher education within the clinical sciences would come to fruition. By the close of the 1950s, the Superior Educational Council had voted to establish a Graduate School of Arts and Sciences. In this spirit, the School of Medicine added graduate education to their curriculum.32 The 1958 annual report from the UPR School of Medicine and School of Tropical Medicine opened with the dean stating that the “school of medicine is physically bursting at its seams.” The dean declared that they were in need of a new medical science building and required more attractive salary scales to maintain and recruit personnel.33 The medical school had grown beyond its physical and monetary capacity and needed to look into expanding. Annual reports authored by the School of Medicine staff help to locate its efforts, successes, and limitations within the context of broader industrial expansion occurring in the 1960s. The 1960 report describes 94 Pushing in Silence

the school’s expansion as a “product of recent growth of Puerto Rico.”34 Antonio Medina, in a 1965 publication by the School of Public Health’s Maternal and Child Health Program, described Puerto Rico as a “country passing through a rapid transitional process . . . forced to deviate from the classical patterns” and with urgent needs to come up with quick medical responses.35 Puerto Rican medical education and the medical community envisioned themselves as inseparable components of development. In general, the School of Medicine did not experience any sudden or unexpected changes during the early 1960s. Clinical medicine was heavily influenced by the United States while remaining locally grounded and motivated, but other areas, such as public health, persevered “and [stood] ready to assume a larger role in medical education in Latin America.”36 Funding continued to increase, though it could not keep up with the rise in medical costs and demand. Facilities were limited, and the Department of Obstetrics and Gynecology struggled with alterations of space and shifts in location during this period. The school counted on well-­ prepared physicians among their faculty and welcomed a few women to their ranks, but salaries could not compete with the lure of private practice. The curriculum and student body remained relatively stable in comparison to earlier years.37 One notable change in the medical school was a temporary transfer of some departments. When the obstetrics and gynecology unit of the San Juan City Hospital was closed for repairs, it was transferred to Bayamón, where faculty reported they were “faced with a new type of medical practice—practice geared to the needs of a region made up of several widely scattered communities.”38 The medical school continued to be affiliated with the San Juan City Hospital, but the Bayamón District Hospital became the main clinical teaching hospital. The Puerto Rico Department of Health turned over its 300 Bayamón beds to the university, but further difficulties arose. In January 1960, the obstetrics and gynecology department of the UPR School of Medicine became the first to officially carry out all of its academic activities within that hospital.39 Medical students in their senior year were required to attend a minimum of twenty deliveries, but the Bayamón hospital did not have a high enough maternity volume for this requirement. Therefore, the San Juan City Hospital worked in conjunction with Bayamón for this purpose, despite the fact it was under construction.40 The School of Medicine continued to confront shortages of resources and space. At the close of the 1950s, the Rockefeller Foundation had awarded a grant of $400,000 to improve teaching and research in the hospital.41 Regardless of the significant increase in funds in all areas, com95 Physician-Assisted Hospital Births

plaints persisted about the obstacles to recruiting and retaining qualified teaching staff. The university faced challenges in sustaining sufficient full-­ time positions and offering competitive salaries.42 Several years later, the 1964 Obstetrics and Gynecology Annual Report identified a serious lack of space, deterioration of facilities, lack of ability to offer tenure to faculty “men,” and an overwhelming workload placed on hospital staff. Faculty worked for low salaries and were expected to take on teaching, administrative, clinical, and research duties simultaneously.43 In 1964 a significant sum of money coming from the federal government had a noticeable impact on maternity care in San Juan. Public law 88 assigned more than $800,000 from the Children’s Bureau to improve maternity services in northeast Puerto Rico (including the San Juan area).44 This event altered the maternity services offered through the obstetrics and gynecology clinics run by the UPR School of Medicine. By the following year, the local maternal and infant care program began operating under this initiative. Clinic visits increased by 500 percent, and hospital deliveries by 10 percent.45 Most obstetrics and gynecology research and articles by University of Puerto Rico staff addressed cancer, anemia, and contraception.46 During the 1960s, contraception and population control remained on the agenda. Dr. Gregory Pincus, well known as the developer of oral birth control pills and also director of the US-­based Worcester Foundation of Experimental Biology, was a visiting lecturer in the UPR School of Medicine, and the University of Puerto Rico’s Dr. Celso Ramón García, who directed most reproduction-­related research projects, became assistant directors of the Rockefeller Foundation’s Reproductive Center, further reinforcing the relationship between continental and island medical communities and strengthening research interests in reproduction.47 Medical interest in female reproduction, ironically, was a male-­dominated field. Although women obstetricians occasionally served on the faculty, their numbers were few, but obstetricians such as Dr. Ana Casals Scott gradually showed up on faculty payrolls.48 The 1961–1963 bulletin listed Dr. María Berio as the only woman of the nineteen professors and instructors of obstetrics and gynecology.49 A few years later, there were no women listed as instructors.50 In 1964, the University of Puerto Rico’s Dr. Adeline Pendleton Satterthwaite stepped into an important position as a liaison with Planned Parenthood.51 In the mid-­1960s, Dr. Gloria Vega received a dual appointment as associate professor in obstetrics/gynecology and internal medicine, and Dr. Satterthwaite served as an international consultant.52 Throughout the 1960s, obstetrics was dominated by men who specialized in female reproduction, contrasting sharply with the coma96 Pushing in Silence

dronas auxiliaries of the 1950s who were exclusively women working with laboring mothers. One of the ways physicians secured their social relevancy was by ascertaining connections with other local and international communities. University of Puerto Rico medical faculty maintained their engagement with both local organizations and the medical communities of the Americas. During the early 1960s there was a constant flow of visiting professors in obstetrics and gynecology from the United States as well as a few from Latin American nations, including Chile, Argentina, and Uruguay.53 University teaching staff held on to their leadership roles in the Medical Association of Puerto Rico, and their obstetrics and gynecology section attended American College of Obstetricians and Gynecologists meetings and conferences and visited other important medical schools in the United States.54 Medical students moved regularly between Puerto Rico and the United States. Senior students completed their internships in both places, and graduates worked in both private and public institutions in the United States and Puerto Rico, although ratios would vary from year to year. For example, in 1962, twelve seniors completed their internships in the United States, while ten did so in Puerto Rico. In 1964, twenty-­nine seniors remained on the island for their internships, and only ten went to the United States.55 During these same years, about 17 percent of graduates served in the armed forces, and between 15 and 19 percent worked in private settings. Most graduates worked for the public sector.56 The educational curriculum and training for general physicians in the area of obstetrics and gynecology did not undergo any significant reforms during the 1960s. Students studied embryology during their first year in medical school and had an hour and fifteen minutes a week on obstetrics during their second trimester of the second year, which increased to three hours a week during the third trimester. Medical students rotated in specialty clerkships during their last two years of study. Obstetrics and gynecology was one of the areas on which students spent the most hours.57 It became apparent by the 1960s that although some women continued birthing at home and the institutional infrastructure and medical training multiplied, the demand for obstetricians and hospital beds in areas such as San Juan outstripped what was available. There were more women seeking hospital beds than institutional medicine could provide. This demand furthered the medicalization of birthing and signified that the mothers themselves were behind many of the changes in birthing. Mothers pushed for changes by gravitating toward and demanding medicalized services. 97 Physician-Assisted Hospital Births

Nurse-­M idwives and Obstetric Nurses Institutional medicine expanded and the population consumed it more than ever. The professionalization of physicians deepened, and medical specializations grew. Despite the growth of medical facilities, the professionalization of physicians, and the increased demand for professional nurses, nurses-­midwives during this phase of Puerto Rico’s birthing history still struggled to achieve recognition and social status as medical professionals. Their efforts to position themselves depended on advocacy from key health officials and, more important, key concessions in positioning nurse-­midwives within the medical hierarchy. The nurse-­midwives’ training center moved to the obstetrics and gynecology department of the UPR School of Medicine but remained under the administration of the Department of Health with funding from the federal government’s secretary of maternal and child health.58 Director Castro pushed for this move as a way to root the program and guarantee its survival. Training lasted twenty-­eight weeks and covered complete maternal care from prenatal to postpartum. Previously, it lasted twice as long. The shorter time span allowed for a greater number of graduates per year, although the number never rose above nineteen.59 Establishing a critical mass of nurse-­midwives was fundamental to increasing their visibility and the likelihood of persisting in a climate where obstetrics controlled the momentum. There were a few key players behind the transfer of the nurse-­midwife program to the School of Medicine. As described in the previous chapter, Miriam Castro de Castañeda, the new director of the nurse-­midwife program, united with prominent obstetricians from the School of Medicine as well as Puerto Rico’s secretary of health to transfer the program to the School of Medicine with an annual budget of $30,000 in 1960.60 Castro was privy to the changing face of medicine and its power dynamics on the island. She was a relentless advocate for nurse-­midwives because she believed they could improve maternal outcomes, but her intent was not to challenge obstetricians or have nurse-­midwives substitute for them. Castro knew her mandate to develop a program for nurse-­midwives would be tenuous since she had already witnessed physicians’ resistance to them. It was a new program and seemed out of place to some in the medical establishment. Castro was aware there were not enough doctors to tend to all of the parturients, but neither were they willing to comfortably open up their professional space to new, alternate providers. She also understood that for the program to be successful in the cultural landscape of the 1960s, it was indispensable for nurse-­midwives to be part of the biomedi98 Pushing in Silence

cal model of care. She had to act cautiously and diplomatically to ensure medical acceptance. In Castro’s words, since this “was a new program . . . in the Medical School . . . we could not go looking for independent practice. We had to be very smart. I have learned this.”61 She redesigned the curriculum to gain acceptance and support from the School of Medicine. Though the program could have been geared toward independent practice, she reformulated the role of the nurse-­midwife to function under direct medical supervision. During a trip to Baltimore, Castro visited a well-­known obstetrician with whom she had worked during her graduate studies in the United States and asked him if he could pre­sent a lecture to Puerto Rican doctors and medical students about the importance of nurse-­midwives. He agreed. The talk was a success and very well attended. This collaboration cleared the path for the nurse-­midwife training program in its new 1960 medical school setting.62 The first cohort of nurse-­midwives graduated in 1961, and the school remained stable for the following decade, thanks in part to Castro’s lobbying of Puerto Rican legislators. Castro petitioned for the support of physician and legislator Pablo Morales Otero in her effort to revise the existing law concerning midwives to include nurse-­midwives.63 Her efforts resulted in the passage of law 97 in 1961. It specified minor changes to midwifery, such as adding the words “obstetric nurses” alongside “midwives” and henceforth opening a legal space for new, institutionally trained medical practitioners to assist in labor and delivery. Unlike comadronas auxiliares, obstetric nurses were to work exclusively in hospital settings under the direct supervision of doctors. Therefore, while the law recognized obstetric nursing as a legitimate profession, it restricted the practice. According to Castro, comadrones auxiliares were no longer practicing or being trained. Referring to childbirth in the 1960s, she claimed, “We were in another era. We were now preparing obstetric nurses.”64 Though it was clear that times were changing, Castro’s belief that midwives were no longer delivering babies on the island was inaccurate. The number of comadronas was in decline, but they were still in service.

Folklore and Auxiliary Midwives (Comadronas Auxiliares) As the nurse-­midwife program tried to grow roots in the School of Medicine and change its model from an independent practice to one of medical support, the independent comadrona auxiliares continued to decline 99 Physician-Assisted Hospital Births

in number. During the first half of the 1960s, the Department of Health granted licenses to auxiliary midwives. By 1963, official government records listed only 900 midwives compared to almost twice that number in 1950.65 The number of meetings and training sessions for midwives also went down, from 800 to 330 a year by 1960.66 This number increased again to 789 in 1962, but the meetings were never mentioned again in subsequent health reports.67 The future of auxiliary midwives seemed quite uncertain, and there was no indication that new recruits would expand their ranks. Some midwives explained that they abandoned midwifery due to the level of sacrifice it entailed and the low pay. Doña Antonia, an auxiliary midwife from the southern part of the island, claimed that they “retired on their own accord because it was a lot of work and there wasn’t much money.”68 Others mentioned that they felt intimidated by the medical world and simply succumbed to the social shifts toward hospitals and technology. Doña Rosa also worked as a midwife in the southern region before midcentury. Her personal doctor told her that she needed to retire because of a heart ailment. He filled out her retirement papers and she abandoned her work.69 A few mothers spoke of how the midwives got older and no longer wanted to deliver babies, and how they insisted that mothers go to the local health centers to be seen by doctors and nurses.70 By the early 1960s, comadronas were helping to nudge mothers toward institutional settings. It was also likely that women were valuing their services as part of a market economy and were therefore less willing to work without steady wages, making midwifery less appealing. Midwifery was born from popular knowledge, and—though it might be tempting to see this as innate and therefore unchangeable in contemporary culture—we should not assume that it could not evolve alongside its sociopolitical environment. It did so in other countries such as Sweden and the Netherlands with tremendous success. In Puerto Rico, however, midwifery was labeled as folklore in a period when there was great pressure to leave the past behind. Gramsci, for example, described folklore as a philosophy of common sense.71 But common sense retained little cultural value in the 1960 medical landscape of Puerto Rico.

Regions Between 1959 and 1965 the great majority of births transpired in the hospital setting (over 80 percent), a dramatic rise from the preceding period. Yet, as in the previous decade, these global statistics provide an incomplete 100 Pushing in Silence

picture. Two extremes coexisted in Puerto Rico in the early 1960s, and chapter 2 demonstrates that shifts were geographically defined by presenting data from each municipality to show that mothers moved toward hospital births first in the northeast and last in the southern region. As early as 1960, over 75 percent of babies in the northeastern municipalities—­ Fajardo, Vieques, Río Piedras, San Juan, Bayamón, and Dorado—were born in hospitals, while in other parts of the country only 25 percent of women delivered in hospitals. The twelve municipalities that make up this latter group signal the limitations of the industrial project.72 They were areas where institutional births had not taken hold. A mixture of eight interior, northern, and southern municipalities reported that less than 5 percent of women would leave home to give birth.73 Overall, around a third of the municipalities (twenty-eight) were seeing more home births.74 Most hospital births occurred under the care of physicians, but there were some exceptions. These exceptions challenge the assumption that equates hospital births with obstetric-­attended births. In fifteen municipal hospitals, including Arecibo, Arroyo, Caguas, and Lares, the number of nurses and midwives who assisted births was equal to or greater than the number of doctors who did. Notable cases included the municipal hospital of Aguas Buenas, which reported 187 midwife-­assisted deliveries compared to 10 by doctors.75 Several municipal hospitals (in Ciales, Guaníca, Gurabo, Juncos, Loíza, and Manatí) reported that most of their births were midwife-­assisted.76 Once again, the case of Ponce was the most extreme. The municipal hospital there reported 1,231 of their deliveries were done by midwives, 150 by doctors, and 13 by nurses. Carolina was also an interesting case; there the numbers of nurse-­, midwife-­, and doctor-­ assisted births were fairly balanced. District and private hospitals, as we have seen previously, reported extremely low numbers of deliveries by any providers other than physicians. These numbers might have been because district hospitals had more doctors and specialists on hand, even though they too were government-­run. In 1961, fourteen municipalities reported more babies born outside of the hospital setting than in hospitals. In just a year, more than a dozen municipalities experienced more hospital-­assisted births than home births, yet another example of the rapid birthing transitions occurring in Puerto Rico. In Ponce, most women chose the hospital as the preferred setting to give birth, but 1,612 births did occur at home, and many births in the municipal hospital were attended by midwives.77 Some midwives moved into the institutional setting and were trained and licensed by the Department of Public Health, but they eventually disappeared as an option for parturients in the hospital setting in the early 101 Physician-Assisted Hospital Births

1960s, even in normal births. The only midwives who managed to find a small space in this new birthing order were the nurse-­midwives in their roles as physician assistants. In the absence of campaigns or legislation to explicitly eliminate midwives, viable explanations for the phasing out of midwives are hard to find. I argue that the cultural paradigms favoring the institutionalized biomedicine inherent in the urban-­industrial state-­led project, accepted almost universally in Puerto Rico, caused midwifery and home births to lose saliency. Birthing practices at this time varied not only by region but also by class, as they had in earlier periods. These forms of stratified reproduction were crucial to defining differentiated practices that would reinforce both class and regional differences as birthing moved toward a hegemonic medical model.

Use of Services and Prenatal Care The class divide in maternity care, and health care in general, persisted during the 1960s. Who sought prenatal care and where they went for care varied by class and education level. According to an exhaustive study done in 1965–1966, one-­sixth of pregnant women that year never received any form of prenatal care.78 Almost three-­fourths of expectant mothers who received no care had less than a sixth-­grade education. This is significant considering that merely 1 percent of women who had attended college went without prenatal care.79 Most teenagers visited public facilities for their prenatal care.80 What was true for women across the board was that the more pregnancies a woman had, the less likely she was to seek prenatal care, even though almost all women felt they should be cared for by a physician.81 As discussed in the previous chapters, the social class of mothers determined whether they would access care in the private or public sectors. Close to twice as many expectant mothers went to government clinics for their prenatal care than to private facilities.82 Women utilizing private clinics for their prenatal care in 1965 were overwhelmingly professional, from urban areas, and had a high level of education.83 Some factory workers also frequented private clinics. Over 40 percent of the women who used private services were employed at the onset of pregnancy, but those employed as domestic and factory workers were most likely to use government clinics for their prenatal care. Reasons for not seeking prenatal care were wide-­ranging. Interestingly, lack of information and certainly the cost (free care was available) were 102 Pushing in Silence

not explanations for not receiving prenatal care.84 Accessibility and cost of transportation were the major obstacles. These same reasons would explain why women in rural areas might have had a harder time accessing birthing services than those in the cities. In most rural areas the levels of education were lower for similar reasons. Having no one to look after their other children and having to wait for long hours in a medical office were additional factors keeping women out of medical facilities. Also, half of all women claimed to feel embarrassed when a male physician performed vaginal exams, though it is not clear whether this prevented women from seeking prenatal care.85 Despite campaigns by the government and medical association to inform the community about prenatal care and public health, the main source of information about prenatal care and medical services for women in the 1960s was family and friends. Only 10 percent mentioned professionals and just 3 percent mentioned the mass media as sources of information and forces behind their move toward seeking prenatal care.86 Though most pregnant women were receiving prenatal care by the mid-­1960s, a striking change from earlier periods, few received what the medical community and government institutions considered adequate care. Overall, women were seeking out medical care more often, which led them to increased prenatal care. Review of medical records revealed some surprising statistics. One of every five women who received prenatal care was never seen by a physician of any kind. Despite the fact that Puerto Rico had a long history of parasite infection and high levels of anemia, hemoglobin determination was not part of prenatal care in 29 percent of cases, nor were stool exams done in 57 percent of the cases studied. Polio and tetanus shots were rare, and less than 60 percent of expectant mothers were actually tested to determine their Rh factor. Medical protocol at the time considered all of these procedures part of prenatal best practices. A quarter of all pregnant women ceased their prenatal care between their sixth and eighth month of gestation.87 None of the women attending public facilities in 1965 made the recommended number of prenatal visits.88 Thus, while women were accessing prenatal care in greater numbers, in many cases the care was subpar for the medical standards of the time. Many government and public health leaders had pushed for the consolidation of medical and social services and moved them under one roof to promote better and more balanced care. If we recall the goals of Secretary Arbona in restructuring the public health system, we know that his intent was to raise the standard of living for patients by providing access to welfare services for those afflicted by poverty. Despite this intent, staff from public medical institutions referred only handfuls of expec103 Physician-Assisted Hospital Births

tant mothers for social or nutritional services, even though almost every woman had a prescription for dietary supplements and doctors were well aware of the widespread nutritional deficiencies on the island. Medical staff did refer half of the women for welfare services, however. Staff considered their clientele who fell within state levels of poverty entitled to food stamps and the minimal welfare support available for poor families.89 It took some time to close the gap between the possibility and intent of services and practice. Medical and public health faculty and researchers at the University of Puerto Rico believed that there was a correlation between prenatal care and maternal-­fetal outcomes. This correlation was not apparent in previous decades to comadronas auxiliares, and they did not practice prenatal care. The university researchers and faculty noted that Puerto Rican women in New York, regardless of their rates of poverty and difficulties assimilating, experienced, on average, better birth outcomes than women on the island. They claimed that women who did not receive prenatal care suffered higher rates of neonatal mortality, premature birth, and still birth. The high number of teenagers with no prenatal care showed the poorest outcomes of all groups.90 The neonatal mortality rate in Puerto Rico was 28 in 1,000 births compared to 18 in 1,000 for Puerto Ricans in New York, but mortality increased to 48 in 1,000 for women who had not received prenatal care.91 These outcomes certainly supported the concerns expressed by the medical community about the importance of prenatal care. Outcomes and use of services varied by class and between the island and the United States as much as birthing patterns diverged among the different regions on the island itself. Nevertheless, over time, regional differences, at least with regard to the location where mothers chose to deliver their babies, diminished as more babies were born in hospitals with doctors.

Conclusions By 1960 women had taken a decisive step toward institutional birthing and away from home births. They placed the delivery of their infants in the hands of physicians and demonstrated confidence in the medical system. They might have been comfortable at home and perhaps trusted their midwives, but by the early 1960s there were nurses and doctors who claimed access to knowledge and instruments of science and progress that could assist them. The health department insisted that women should see doctors for prenatal care and that trained midwives should refer any of their 104 Pushing in Silence

clients with complications. The regionalization project organized health and welfare services around the hospital, and women became familiar with these centers. They went for medical visits, free milk, dental appointments for their children, and other public assistance programs. Historian Kathleen Canning summarizes feminist scholars’ claims about the perception of the female body in industrial societies. She writes that as the government and its social institutions became more organized and complex, women’s pregnant bodies began to represent “an uncontrollable, unpredictable threat to a regular, systematic mode of social organization.”92 Puerto Rico’s modernization project was no exception. Most Puerto Ricans, whether they were doctors, mothers, nurses, or midwives, no longer felt comfortable to simply let nature take its course and accept whatever outcome God, nature, or destiny planned. Experts and institutions were available and were legally and culturally sanctioned to reduce risk and increase predictability. They could intervene with nature and destiny to some extent. They had access to higher knowledge, operated within licensed institutions, and were allied with science and technology. People, including pregnant women and their families, began to leave their domestic settings in search of these experts due to a newfound trust in “expert systems.”93 Class played an important role in maternal services. Who would get episiotomies and who would birth with midwives at home depended greatly on the mother’s background. Women with higher levels of education, factory jobs, or professional positions tended to seek better prenatal care, to use private clinics, and to receive episiotomies and pain medication more often than those from more marginal sectors of society. Doctors assumed rural, lower-­class women were less healthy yet needed less help in childbirth. Most women received some sort of prenatal care, but for many who used the public health care system, this care was poor. Since 1959, the very definition of normal childbirth had changed. Since the 1940s public health leaders had trained midwives to refer complicated or high-­risk births to doctors and to follow basic standardized procedures such as wearing a uniform, attending monthly meetings, sterilizing sheets and scissors, and even using silver nitrate drops for newborns’ eyes. Their transition to a scientific regime was incomplete, however. For example, they did not follow rigid time frames to distinguish normal from abnormal deliveries. By 1960, biomedicine had emerged as an almost exclusive option for the care of parturients. Most physicians practiced general medicine, but medical specialties were gaining momentum, and several cohorts of obstetricians had recently completed local residencies. Obstetrics began distinguishing normal from abnormal births and shortened the accept105 Physician-Assisted Hospital Births

able time frame in which a delivery should take place. Up until the 1960s, everyone, including the medical community, considered most births normal and found little need to intervene. In time, obstetricians would consider a greater proportion of births to be abnormal and pathological, setting the stage for medicalized, technocratic births. For a birth to be considered normal medically, women needed to deliver quickly and under close medical supervision. They needed to be helped with episiotomies and forceps so as to not overexert themselves or put their babies in danger. Doctors preferred to cut and later suture because, according to them, it was easier to sew a calculated cut in the perineum than to risk a spontaneous tear, even though such tears are rare and were never reported as a problem for midwives or even doctors who did not perform episiotomies. Medical institutions grew and expanded. The UPR School of Medicine could barely keep up with the demand for services. The government sought out a new, state-­of-­the-­art medical spaces to expand and coordinate services, but for the time being, students and faculty made do with what was available. The country still needed more doctors in many rural towns, and nurses were in tremendous demand. The school for nurse-­ midwives found a new home in the medical school and graduated several hundred trained nurses who specialized in childbirth to assist doctors over the following decade. Auxiliary midwives were disappearing. It was a new era for childbirth.

106 Pushing in Silence

Ch a p ter four

Phase Four

M edicaliz ed Births, 1966–1979

I

n 1966 a small group of women from the health department in the southern region of Puerto Rico called the public’s attention to what they claimed was an important and overlooked issue. Asunción María Velázquez, an obstetric nurse and midwife supervisor, clarified: I am referring to the group of midwives who for years and years has been working with the poor and humble people of Puerto Rico, a cooperative group who has fulfilled its duty without . . . limits . . . as public servants. And today these midwives are interested in knowing to which group they belong, because after so many years of hard labor, they are now forgotten. Most of them today are elderly women who need to obtain the benefits of their sacrifices, nevertheless they receive nothing and no one can say how to help them.1

Auxiliary midwives were not entitled to pensions, social security, sick days, or health insurance, which might have motivated many women to move toward the formal government labor force. But those who did went into other areas: many became public school teachers, nurses, and government office workers. As women stepped into the service and professional workforce, the role of the auxiliary midwife faded quickly and did not last through the next decade. During the second half of the 1960s, birthing in Puerto Rico began its final significant phase of transformation of the twentieth century. Mid-

wives disappeared, the hospital as an institution consolidated its power, and birth became medicalized. Unlike childbirth during phase three of this birthing history, by the late 1960s it was fully medicalized everywhere on the island. In the early 1960s there were still home births in some regions, and general practice doctors assisting low-­technology births still predominated in most hospital settings. Medicalized hospital births became hegemonic in Puerto Rico after 1966.2 Specialists and technologies took over, and by the 1970s fear of lawsuits was plaguing the medical profession. Doctors often made decisions fueled by fear of legal reprisals, and they struggled with social pressures generated by the rising costs of their practices and malpractice insurance. In 1971 there were fewer than 100 auxiliary midwives registered with the Department of Health.3 A year later merely 500 home births transpired throughout the entire island.4 By the late 1970s, midwives and evidence of their practice had vanished from government reports altogether. In the late 1960s strong social and cultural forces coalesced, giving birthing a final push toward medicalization. In this chapter I argue that changes in social structures within the family and the workforce, operating within a context of a growing economic crisis and access to new technologies, transformed childbirth practices. The economic crisis of the 1970s led to a significant expansion in federal welfare programs and pushed a greater number of women than ever before out of the home in search of jobs and food stamps. Puerto Rico grew predominantly urban with an expanding lower-­middle class. People learned to seek out and accept expert advice, scientific truth claims and universalisms, and technology in their day-­to-­day lives. Families sought out institutionally sanctioned experts and became active consumers of biomedicine as well as material culture. New considerations regarding risk management, clinical pathology, and fetal personhood also played meaningful roles in birthing in unprecedented ways. In contrast with the previous phases of birthing history, by the 1970s there were few to no exceptions regarding the medicalization of birth on the island. Ideas about medical knowledge and intervention, birth, and science shifted substantively during the last half of the twentieth century. Institutional biomedical control over birthing became hegemonic. The predominance of biomedicine occurred in particular social, cultural, economic, and ideological settings that either facilitated or promoted biomedical acceptance. Dr. García, a Puerto Rican physician who obtained medical training during the 1960s in Puerto Rico and the United States, later decided to break with conventions of mainstream Puerto Rican obstetrics and dedi108 Pushing in Silence

cate his career to maternity in public health. This decision stemmed from his conflicts with the turn that obstetrics took toward authoritarian medicalized practices after the 1960s. His story illustrates some of the tensions in obstetrics during the 1970s. Though Dr. García’s story is an anomaly, it is emblematic of how difficult it was to carve out space for alternative birthing practices in obstetrics during the 1970s, after auxiliary midwives had disappeared and physicians were the only option. José García graduated from Georgetown University in 1963 with a degree in premedicine and then returned home to begin his studies at the UPR School of Medicine.5 He graduated in 1967 and went to Baltimore to complete his medical internship. Thanks to his medical career, Dr. García escaped the horrors of the Vietnam War. Drawn to maternal medicine, he accepted a residency in obstetrics and gynecology at the university hospital in the newly formed and growing medical center, where he was trained to use prophylactic forceps and to administer Demerol and Vistaril to laboring women once they reached five centimeters of dilation. These medical procedures had become standard practice whether women needed them or not. They were in place to prevent possible complications or discomfort. As Dr. García was completing his residency in the early 1970s, the use of the electronic fetal monitor was becoming routine for most deliveries at the university hospital. Episiotomies continued to be part of standard care, as they had in previous years. All of these interventions informed the newly medicalized birthing practices throughout Puerto Rico. I will discuss their importance further below. Upon completing his specialization in 1973 and returning to Puerto Rico, Dr. García worked for a few years in prenatal clinics that were run by the maternal and infant care program. Most of his clinical work was done in Cataño, a subregion of the San Juan metropolitan area. Once he had passed the second part of his obstetrics board certification in 1975, he began a short stint as a professor at the University of Puerto Rico School of Medicine. Somehow, even with his demanding schedule, Dr. García managed to finish a master’s degree in public health with a concentration in maternal and infant health by 1976. Like most doctors on the island, García went into private practice. In 1977 he teamed up with a couple of other specialists to build a large and steady clientele and ran a successful practice in Santurce, an urban area in the San Juan region. All three obstetricians kept abreast of the latest currents and debates and agreed to challenge many of the practices that predominated in Puerto Rican obstetrics at the time. For example, they allowed fathers to accompany the mothers through labor and delivery. A few years before the American College of Obstetricians and Gynecologists 109 Medicalized Births

released their statement in support of vaginal birth after a cesarean, Dr. García and others in his practice were performing such deliveries. García and his colleagues also began questioning the efficacy of the electronic fetal monitor after seeing the first studies coming out of the United States that cast doubt over its success rates, and they stopped using it in normal deliveries. Unable to maintain the intensity of both a faculty position and his private practice, Dr. García left his faculty position after less than ten years. He said he would often be overcome with feelings of guilt for succumbing to private practice and leaving his public health commitments behind. He would reflect on his principles and beliefs, and recall the scholarships he received during his public health training. In the mid-­1980s, Dr. García decided to take a radical and uncommon step in his profession. He left his successful private practice and ventured back to the university. This time, he did not approach the medical school but rather the School of Public Health, which by 1970 had parted ways with the School of Medicine. The divorce of public health and medicine created plenty of tension for García as a doctor working in public health. Many doctors at the medical school interpreted his commitment to public health and his critical views of medicine as betrayal. His initial job in the School of Public Health was to organize and coordinate public health courses for medical students, who consistently asked García what he was doing there after staring in disbelief at all of the medical diplomas on his wall. They had assumed he was employed in public health due to his lack of qualifications and achievements. Dr. García moved on to a prestigious career in the school’s program for mothers and infants, where he faced ongoing controversy because of his opposition to obstetric standards such as routine interventions and authoritarian behavior toward patients. Eventually, with relations between the School of Public Health and the School of Medicine souring, even the courses García had once organized between the two disappeared, severing their final connection. As a result, there has been a detrimental lack of communication between those who work in public health and medicine in Puerto Rico since the 1970s. As described in previous chapters, leaders trained in public health and welfare, many of whom occupied prominent positions in the Department of Health, organized and pushed for programs such as the preparation of home-­based midwives. What explains the decline of the influence of public health in medicine? How and why did midwives become solely attendants in a hospital setting as support staff? The final traces of recorded regional differences in where and under whose supervision women delivered their babies occurred in the late 110 Pushing in Silence

1960s; by the late 1970s, home births were unheard of throughout the island. If we compare all five health regions using data from 1967–1968, we can still find some geographical differences. The northeast, San Juan, and UPR’s School of Medicine saw the fewest home births in 1967, while the southern health region (Ponce) claimed almost half of all home births.6 The northeast region was the only area where women used private hospitals more than public hospitals to give birth. In fact, just over half of all private hospital births were in the northeast, even though only 28 percent of all island births occurred in a private setting.7 In 1967, the southern region reported that 88 percent of their births took place in hospitals, and the northeast region reported 98 percent (the highest in Puerto Rico).8 Three years later, the southern region reported that over 95 percent of babies there were born in the hospital setting, and by 1971 every region was reporting a minimum of 96 percent of their births as hospital deliveries.9 Public hospitals continued to be used at least twice as often as private hospitals by parturient women in Puerto Rico. Although changes in birthing practices did not happen at perfectly even rates and in neat patterns throughout the island, it is possible to make a blanket statement that by the 1970s, women in Puerto Rico were having their babies in the hospital under the care of an obstetric team. This change was swift: it took less than twenty years for birth to become almost universally medicalized and for midwifery to disappear. The 1967 Bureau of Maternal and Child Health annual report noted that the numbers of auxiliary midwives were dropping yearly and that registries needed updating, but it also stated that midwives should not disappear because there would always be home births, and medical staff could never oversee all the pregnant women in Puerto Rico.10 According to the report, the northern region (Arecibo) especially needed comadronas auxiliares because women in some remote rural areas were still turning to clandestine midwives.11 The health department did not envision medical practice ever being able to cover all of the births on the island and projected a need to maintain some midwifery services. This perspective is surprising considering the health department’s efforts to make the hospital the point of access for almost all public service care, and the momentum that obstetrics and medicine had gained. At the same time the health department might have merely had a hard time believing there would ever be enough medical practitioners available to attend every birth on the island. As described in the previous chapter, the practice of midwifery was never persecuted in Puerto Rico like it had been earlier in the United States. Instead, midwives’ space and acceptance diminished as modern discourse, technology, and institutions squeezed out the informal local alter111 Medicalized Births

natives. Women, including midwives themselves, assumed the discourse of modernity and little by little abandoned so-­called folkloric practices. Midwives were not organized and had no professional representation or any forum in the formal structures of power; their voices were silent in the social restructuring of Puerto Rico. Island doctors did not perceive midwives as rivals or competition. No major debates concerning midwives appeared in medical literature, newspaper articles, or government campaigns. None of the doctors I interviewed for this project mentioned taking any action against midwives, nor did they express any resentment toward them. As an example, we can look at the 1964 report from the president of the medical association. In this address, there is a section entitled “Quackery” in which Dr. Carlos Bertrán expresses concern about “the grave consequences that result from the practice of healers (santiguadores), spiritists, chiropractors and other charlatans.” He goes on to affirm that “the theories and practices of scientific medicine are the correct ones.”12 Midwives were not mentioned in the list of undesirable health practitioners or quacks. In sum, I found no evidence of large-­scale tension or struggles between midwives and doctors.

Factors Leading to the Medicalization of Childbirth The general context of the public management of social tensions and ills provided fertile ground for the medicalization of birth in Puerto Rico. The economic crisis and the political activism born in response to it highlighted the stagnation of the industrialization project by 1970. Recognizing this crisis, the US government increased funds for social relief and welfare with the hope of alleviating the social crisis. The expansion of social relief programs occasioned further dependency on the state. More than half of the general population fell below the poverty line and depended on government welfare programs, which permitted the monitoring and control of family life more than ever.13 Modernization and urbanization had brought on what many considered to be new social evils—abortion, crime, drug use, and record unemployment rates—and what many considered a general breakdown of moral values and work ethic. Puerto Rican society, overall, took a turn toward pathologizing its social behavior in order to manage it. The welfare state envisioned the family as a unit capable of either uplifting the quality of life in Puerto Rico or contributing to its deterioration. Social services encouraged families who did not have the means to rear 112 Pushing in Silence

their children according to middle-­class standards to control their fertility rates. Reproduction was at the center of many discussions concerning civil rights, poverty reduction, feminism, and overpopulation. After 1973, as a result of the Roe v. Wade Supreme Court decision, abortion went from being a crime to a contested right. By the late 1960s most Puerto Rican women had attempted, one way or another, to control their reproduction. Nearly half of all Puerto Rican women were sterilized (most voluntarily) during their reproductive years, and many incorporated birth control into their lives for the first time. Many women felt they needed to plan their families to secure a better future for themselves and their children.14 They sought medical and scientific expertise to engage in family planning and opened up their bodies to science to escape biological impositions. It was not only social science that could study the social body and offer analysis and solutions to problems; the hard sciences and complex technology could also make concrete and significant social contributions. Medicine too followed the path of heavy technology and further specialization, thereby reorganizing professional and patient relationships. Machines helped the medical gaze to penetrate the human body, and a new patient emerged: the (previously inaccessible) fetus. Doctors came into tension with patients as they gained access to social prestige through new technologies, finding they had to justify their practices and decisions more than ever. Medicine became defensive, expensive, specialized, and technology-­driven as new options for women became available. When I refer to social structures and social aspects, I include the organization of systems of labor, interprofessional relationships, and family structures. Labor had divided into specialties, reshuffling hierarchies, practices, and professional relations. Only professionals with licenses working within accredited institutions could practice medicine, for example. Ideologies and belief systems changed too.15 Social institutions such as the family reformulated their roles, structures, and practices during this time. For example, women were better educated and worked outside of the home more often, families became smaller, and most basic needs were met outside of the home and in urban settings. Private and public institutions systematically regulated, tracked, analyzed, and standardized social structures according to preset protocols and guidelines. For instance, the Department of Education set standards according to so-­called normal stages of child development, and home economics became a profession aimed at supporting scientific motherhood and domesticity. Obstetrics divided pregnancy and labor into stages and standards to regulate it and intervened whenever it fell outside of those parameters. Science and technology became bearers of truth and masters of solutions. 113 Medicalized Births

Table 4.1. Selected consumption data, Puerto Rico, 1940 and 1964

Consumption of quarts of milk (per capita) Number of motor vehicles Percentage of homes with electricity Students receiving public vocational training

1940

1964

65 27,000 29% 1,929

212 281,402 81% 127,590

Source: Progreso económico social (pamphlet; year and author unknown), 1–7.

The medical establishment was firmly on its feet by the late 1960s and had no reason to feel threatened by midwifery. Obstetricians had gained full control of childbirth, had greater demand than they could meet, and had no reason to believe this would change. The evolution of the UPR School of Medicine (see chapter 3) contributed to the sense of security that doctors felt about their position in Puerto Rican society. In fact, in the late 1970s two more medical schools began training doctors on the island: the Central Caribbean University in Cayey (1976) and the San Juan Baptist School of Medicine (1978). Medical education expanded and underwent further administrative subdivisions in response to medical practice and demands. As obstetricians and their access to technology secured their place of authority in Puerto Rican childbirth practices, the industrialization model wavered. Operation Bootstrap, which had once offered Puerto Ricans the promise of a higher standard of living and a path toward joining the developed world, ran its course. Until the early 1960s the lives of most Puerto Ricans changed remarkably, making the industrialization project appear successful indeed. (For evidence of this success, see table 4.1.)

Crisis, Social Monitoring, and Consumption Following a period of improvement in the standard of living, Puerto Rico confronted a crisis after the fall of the populist-­industrial project in the late 1960s. The stagnation of the local industrialization project and the crisis of world capitalism in the 1970s led to reform of the welfare state as it assumed a leadership role with the hope of providing some direction and stability to a deteriorated system.16 Poor families sought to make their lives more tolerable by seeking public assistance, which allowed the wel114 Pushing in Silence

fare state to monitor, study, and penetrate their homes, Public hospitals, public housing, unemployment benefits, food stamps, and the Women, Infant and Children Support Program (WIC) expanded and kept many families afloat. Though perhaps not apparent at first glance, this expansion of welfare in Puerto Rico influenced birthing practices. Midwives—who once worked largely within communal and domestic spaces and were more accepted in rural, poorer, and more marginal sectors—engaged very little with mass media, culture, and consumption. In previous decades, birthing was a private ritual taken care of within the confines of the family unit. The state did not intervene, and women did not seek government aid to satisfy the basic needs of their families. Moreover, the population had not previously been involved in the consumption of organized biomedicine. However, the expansion of welfare services obligated families to spend a significant amount of time in government offices and pulled them into the network of institutionalized and monitored services where experts would deliver, regulate, and condition their educational, dental, and health services, their food, and even their purchasing power. Once in these spaces family members would learn about and be channeled into mainstream institutions and consumption patterns. Most Puerto Ricans had remained in a relatively marginal role in mass capitalist consumption until after the 1960s. This general move toward the state and institutional spaces of expertise opened up the pregnant bodies of women to obstetric intervention.

Specialization and Medicalization After midcentury in Puerto Rico, popular trust in matters of health and human development resided in the hands of professionally (institutionally) trained experts who specialized in a particular field of knowledge. People in postindustrial societies trust and seek help from those they consider knowledgeable or who have access to what they need or see as socially advantageous; experts can monitor and take care of those subjects deemed culturally valuable. In Puerto Rico, the general population had begun to place things of value in the hands of the proper authorities. The value of children changed as families got smaller, moved to cities, and became more nuclear. Once women had fewer children, their rearing became more guarded. Grandmothers’ and mothers’ wisdom concerning child rearing, nutrition, and even when to push during labor diminished 115 Medicalized Births

in value. Hence, expertise concerning pregnancy, childbirth, and child rearing was left to institutionally trained experts. Public institutions insisted on specialists, and licensing codes also required expertise. In the same vein, medicine and public health relied on and demanded specialized experts. By the late 1960s, over a third of the island’s population was living in the northeast region, which included San Juan.17 It was a particularly young population. Dr. Juan Hernández Cibes, who worked in the northeast region and reported on maternal and infant care, claimed that there was a new philosophy in public health that insisted on professional specialization. These specialists were to work in multidisciplinary teams in order to be most effective.18 By 1967 the university hospital’s maternity unit was counting on specialized nurses, new equipment for fetal monitoring, and the first full-­time anesthesiologist assigned exclusively to obstetrics.19 The hospital also had improved its handling of records but continued to battle with inadequate space for the increased demand.20 Obstetricians, educators, psychologists, social workers, and pediatricians held the upper hand in knowledge about family dynamics and child development. In childbirth, the general practitioner gave way to the obstetrician. Cesarean sections, forceps, induced labor, episiotomies, and fetal monitoring became standard birthing practices. Obstetricians used these procedures with little consideration of the risks and costs and without previous clinical research, yet patients and doctors consumed and applied them with the assumption that they were scientifically sound and efficient. Experts sanctioned by the state, medical institutions, and the prevailing culture of the time put these and other practices in place and came to control them. Once a woman was in the medical domain of the hospital, she had little say about birthing interventions or procedures. Her entire birthing experience was structured to facilitate the work of the medical expert in the way that he (and now sometimes she) saw fit. It was now the doctor who delivered the baby. And the doctor was bound by norms imposed by the medico-­legal, political, and cultural milieu in which he moved. None of this had been the case twenty years earlier in Puerto Rico. After the mid-­1960s, there were more articles in local medical journals that debated the role, position, and evolution of medicine than in the previous ten years. Doctors publicly referred to medicine as a science and either stopped referring to it as an art—as they had been for decades—or called it both an art and a science. Doctors claimed that medicine was an “applied science” that oscillated between the biological sciences and observable, systematized clinical research.21 This is not to say that doctors intended to separate themselves from their religious beliefs. Relating medi116 Pushing in Silence

cine to science did not strip medicine of its connection to God in the eyes of many doctors. In addition, there was considerable worry across many social sectors about the rising cost of medicine and the relationship between medicine, society, and government. In a 1967 inaugural speech given to the medical association, the elected president, Izquierdo Mora, repeatedly referenced God as he spoke of the many transformations in Puerto Rico, both positive and problematic, over the past years. According to him, Puerto Rico was changing into an urban society with a decent infrastructure and higher salaries. People were living longer and suffering less from tropical diseases (but more from degenerative diseases). According to Mora, the “medicine we practice now is a lot more scientific.”22 He explained that already close to half of the population had medical insurance.23 All of the these issues formed part of a rhetoric of modernity as assumed evolutionary progress. But on a more alarmist note, he pointed to the rising costs of medicine and the increases in drug and alcohol addiction, criminal abortions, and delinquency as the unfortunate side effects of progress. In his address, Mora added that about 150 doctors were acquiring new licenses every year, that medicine had splintered into twenty specialties and subspecialties, and that it was undergoing transformations. The rise of medical specialties redefined the possibilities and parameters of birthing practices.

The School of Medicine: Subspecialties In 1966, UPR was reorganized into three separate campuses, one of which was the Medical Sciences Campus, housing the medical school. Each campus had its own administration to oversee the activities of its schools, programs, and departments. This was representative of the compartmentalization and specialization of professions and education in general. The Medical Sciences Campus continued to flourish. In 1967, the first PhD was awarded.24 The Department of Obstetrics and Gynecology and the maternal and infant care program were now under the administration of the Medical Sciences Campus. The medical school increased its enrollment after 1966. At this time, plans to build an innovative and ambitious medical center—where all the newest forms of medicine, science, and services could interact within one space—were underway. The medical center would contain all of the medical educational facilities as well as several hospital and specialty services. The Department of Obstetrics and Gynecology experienced changes 117 Medicalized Births

beyond the administrative restructuring that affected the entire medical school. The volume of deliveries increased exponentially, making the department one of the school’s busiest and largest units. In the mid-­1960s, the university hospital staff was already admitting more pregnant women than it could treat. Between 1964 (two years before this phase of the island’s birthing history) and 1966, the number of hospital deliveries increased by over 1,000 and continued to follow similar patterns in the following years.25 By the 1970s, half of all hospital admissions were in obstetrics and gynecology.26 In the mid-­1970s reports from the department turned bitter when referring to the repeated requests for physical expansion and improvement of facilities, which campus administrators had ignored.27 The move from the home to the hospital and from the countryside to the city had happened so quickly that the urban medical infrastructure struggled to keep stride. At the same time, the new technologies and equipment available to obstetricians increased expenditures and stressed the medical school budget. Perinatal medicine began to occupy a considerable space in obstetrics, appearing almost overnight as a new subspecialty. The hospital purchased equipment and machines that allowed obstetricians to analyze and manage the unborn fetus. Technologies such as fetal ultrasound (sonograms), neonatal care units, and fetal surgery, all available by the 1970s, allowed doctors to take on the care of the fetus in ways that were not previously available.28 Reproduction scholar Rayna Rapp explains that sonograms and fetal monitors allow medical experts to “bypass pregnant women’s self-­ reports in favor of a ‘window’ on the developing fetus.”29 The combination of available technologies to see the fetal image and assign it a clinical status of its own and the recasting of childbirth as a medical event riddled with danger served to stress the mother’s separateness from her fetus as making her either a possible adversary or a protector of her developing baby.30 Feminists and medical anthropologists such as Rapp, Laury Oaks, Anne Oakley, and Robbie Davis-­Floyd have thoroughly studied and documented these dynamics. The relationship between the fetus and the mother also changed as mothers had access to the baby’s heartbeats and images. Through these technologies, the fetus was no longer an abstract future possibility of a child that became more real as the pregnant woman began to feel its movements and see her belly grow, but a miniature person whose presence could be medically detected long before the female body could. The fetus thus became an autonomous actor and a new patient by the 1970s. 118 Pushing in Silence

The fetus acquired a new form of personhood, beyond the moral, imagined, or religious dimensions it had previously garnered only through the mother.31 This new fetal personhood undoubtedly added fuel to the anti-­ abortion movement in the 1970s. Even though Puerto Rican medical organizations had taken anti-­abortion positions for decades, the campaigns on the island were not as radical or active as they were in the United States during the 1970s, and doctors practiced abortions regularly throughout the island. Abortion was illegal in Puerto Rico before 1973 except to preserve the life or health of the mother. “Preserving the health of the mother” allowed for some legal flexibility, and there is plenty of evidence indicating that abortions were carried out in both medical settings and clandestine spaces. Nevertheless, doctors in Puerto Rico made a substantial amount of noise concerning what they labeled “criminal abortions.” The Medical Association of Puerto Rico, with the help of the daily newspaper El Mundo, mounted a campaign in the early 1960s against what they understood was a growing plague of elective abortions. They were concerned about the health risks to women, but they were even more concerned about the moral implications. After the revolution in Cuba, women from the United States stopped traveling there for weekend visits to terminate unwanted pregnancies, as was once widely practiced. Doctors in Puerto Rico claimed women seeking abortions were now flying to Puerto Rico instead.32 Outraged that the island was seen as a haven for what many decried as immoral and illegal, the medical association mobilized many of its resources to convince the government of Puerto Rico to take action against those who performed elective abortions. This campaign, of course, lost impetus after the Roe v. Wade decision in 1973. By 1974 the Department of Obstetrics listed abortion among its problems to confront as there were not enough medical personnel elsewhere to fulfill the demand, now increased, for abortions. Due to this demand and the fact that they had too much work and too little space, coupled with the fact that the issue caused tension among staff, the department recommended a separate facility be built to handle elective abortions.33 At the same time, a tremendous amount of time and energy were going into research and discussion concerning population control and family planning. Doctors in many arenas addressed abortion and contraception as methods of family planning, bridging the laboratory and mass media. Puerto Rican women, and sometimes those from the continental United States, pressured Puerto Rican obstetricians and gynecologists to respond to their family planning requests. The state, on the other hand, pressured 119 Medicalized Births

physicians to respond to political and economic plans. By the late 1960s medical specialists were in a position to respond to both requests, thereby increasing their power while boosting possibilities for contention. Puerto Rican obstetricians had recently added perinatal medicine to their repertoire of expertise. They spearheaded new research projects in the medical school involving amniotic testing and fetal health or information.34 In 1967 the Department of Obstetrics and Gynecology acquired the equipment necessary to open a perinatal unit.35 The unit enabled doctors to monitor amniotic blood pressure, maternal blood pressure, respiration, and heart rates, and collect data on fetal heart rates, movement, pH levels in the blood, carbon dioxide, and lactate levels of mothers and babies. Doctors were confident that they were equipped to practice more scientifically sound obstetrics. Acquisition of this perinatal equipment indicated that Puerto Rican obstetrics had moved into the medicalized, heavily managed care of childbirth that entailed clinical management of fetal and maternal pathologies. In 1967, University of Puerto Rico obstetricians organized a special postgraduate symposium, “The Diagnosis of Intrauterine Fetal Disorders,” which included distinguished specialists from Columbia University, the University of Uruguay, the University of Berlin, the University of Milan, London University, and many others.36 The symposium situated Puerto Rican obstetrics in the company of perinatal leaders in the Western world. Many of the medical school’s research projects also centered on contraception and were funded by US pharmaceutical companies or the Population Council from the mainland.37 Puerto Rican obstetricians presented themselves as experts in population control and family planning, which they had been practicing and researching for over a decade. Among other problems in 1966, the obstetrics department reported the challenge of issuing an official statement on family planning. Ironically, despite having been directly involved in population control efforts, neither the Department of Health nor the Department of Obstetrics had ever issued an official position statement or directive. In 1966, the Department of Obstetrics stated that overpopulation was “one of the most serious problems facing the Puerto Rican community.”38 In 1968, following the death of Dr. Pincus, head of the Worcester Foundation for Experimental Biology and a key figure in the development of the oral birth control pill, supervision of foundation projects migrated to the Department of Obstetrics. The Ford Foundation took over the funding of research already in progress.39 Research mostly focused on the potential dangers and side effects of contraception,40 even though, initially, doctors and scientists in the United States denied the potential dangers of the pill.41 120 Pushing in Silence

A great deal of funding and intellectual exchange occurred between the United States and Puerto Rico. And as it had before, Puerto Rico often served as a bridge between United States and the so-­called developing world. Doctors and specialists from around the world and the United States continued to visit: the UPR School of Medicine received visiting professors from Brazil, Uruguay, “Africa” [sic], Taiwan, Peru, Malaysia, Trinidad, the Dominican Republic, Berlin, Chile, and the United States in the late 1960s alone.42 In the context of the Cold War, Puerto Rico served as an anti-­communist showcase connecting Latin America and the United States and as a contrast to Cuba. Puerto Rican medical experts influenced and led efforts in the United States. University of Puerto Rico professors traveled all over the United States to pre­sent work and meet with colleagues. Director of obstetrics and gynecology Ivan Pelegrina initiated an exchange with the University of Michigan and Wayne State University that would later lead him to take a leave from the university to study public health, with an emphasis in community obstetrics, in Ann Arbor.43 In 1974, Pelegrina resigned his position as head of the UPR obstetrics department to direct a clinic at the University of Michigan.44 These transatlantic connections made Puerto Rican doctors leaders in medicine, not merely receivers of knowledge and funding from the North. Puerto Rican doctors were poised to monopolize positions of authority in all matters related to female reproduction, and obstetrics was no exception. Accompanying this rise in authority, though, was a darker side of progress that would plague obstetricians for the remainder of the century and into the new millennium.

Defensive Medicine and Patient-­Doctor Tensions Social and scientific progress came at a cost. The biomedical-­technological consolidation of medicine generated its own social tensions. Paradoxically, scientific medicine became hegemonic as it simultaneously lost moral standing in the public eye. Doctors repeatedly alluded to this. They seemed nostalgic for a (perceived) past in which they were accorded more public reverence and were attributed priestlike altruism. Medical literature in the United States also re­cords a breakdown in doctor-­patient rapport. The reliance on biomedical experts and the belief that science was equipped to cure almost any ailment came with a distrust in individual experts who could abuse their place of power and authority. Some articles and statements that originally appeared in the United States 121 Medicalized Births

were reprinted in medical journals in Puerto Rico, demonstrating a common concern. An article by Charles Price in the Ohio Medical Journal, for example, was reprinted in Puerto Rico in 1971.45 The article focused on malpractice, an issue that would haunt medicine for years to come. Malpractice loomed over medical practice and worked its way slowly into medical decisions after the 1960s. In explaining why malpractice claims were soaring, Price listed a breakdown in traditional patient-­physician rapport as a fundamental factor. Patients and doctors had changed their attitudes, in Price’s analysis. His explanations included doctors’ lacking time, patients feeling rushed, publicity leading patients to expect too much, and finally, high salaries leading to public resentment.46 As a consequence of these rifts, patients would be more likely to feel disconnect from or frustrated with their doctors, whom they might accuse of negligence and then seek legal redress. Dr. Ramírez and the other doctors I interviewed all expressed consternation about how malpractice law and the insurance industry had overtaken medicine. Ramírez graduated from medical school in Philadelphia in 1956 and returned to Puerto Rico in the late 1960s to specialize in obstetrics and gynecology. He spent most of his life as an obstetrician in private practice tending to middle-­class women who birthed in the Auxilio Mutuo Hospital in Río Piedras. (I will refer to Dr. Ramírez several times later in this chapter.) Dr. Ramírez explained that the Medical Association of Puerto Rico sought to pass a law requiring all doctors to have malpractice insurance. At the time only about a third of physicians were covered. In 1966 this law passed, requiring physicians to buy insurance to practice legally in Puerto Rico. Originally, the medical association hoped that mandatory coverage would lower insurance costs and protect its members. Ramírez and the other doctors interviewed classified this effort as a fatal error that exacerbated the precarious legal climate in which doctors worked.47 Most obstetricians had either a personal lawsuit story that haunted them or one from a close colleague. Ramírez explained that one of the factors that drove him out of private practice was a lawsuit filed against him by his own niece. He decided then that in that kind of medico-­legal climate the practice of medicine was no longer worth it.48 The medical profession was on the defensive by the late 1960s. Physicians persistently referred to three main concerns: high medical costs, libre selección (the ability of patients with no primary care physician to have direct access to specialists), and social deterioration, especially among young people. Their position and power in society was stronger than ever, but physicians were rendered vulnerable by a growing tension between 122 Pushing in Silence

rising medical costs and access to medical care. Doctors insisted publicly on their desire to serve the population and claimed that their motivations were not self-­interest and wealth. In 1971, the incoming medical association president addressed these issues. Dr. Fernando Cabrera listed medical costs, libre selección, and juvenile delinquency as major concerns that the medical profession needed to address.49 He pointed out that “the generational gap has never been so abysmal.”50 Cabrera then moved into a heartfelt narrative, declaring that “our profession has been accused of lacking social conscience and of unscrupulously seeking profit. . . . Our country counts on a medical profession who in its majority serves disinterestedly and above all protects the health of its people.”51 Responding to criticism of high salaries and calling into question some of the choices physicians made regarding the rising costs of medicine and the demand for more doctors, Dr. Annette Ramírez de Arellano, from the UPR School of Public Health, wrote in 1976 that medicine did not follow the laws of the free market.52 She argued that increasing the number of doctors would not solve the geographic and economic distribution problems facing Puerto Rico, as many argued. Ramírez de Arellano complained that licensing laws blocked free and open access to the health service market.53 Doctors chose the services they provided, as well as the frequency and hours of services, and established their honorariums within a wide margin.54 In addition to her economic analysis, Dr. Ramírez de Arellano made another important point about the general medicalization of society. What once were considered moral, legal, or social issues (such as alcoholism, addiction, crime, marital problems, and population control) that should be addressed through the church or welfare and legal systems had become medicalized social issues.55 What she described was the pathologizing and medicalization of society. Once a society subscribes to the notion that the social fabric is rife with ills, it is more likely to seek out specialists to combat them, but it follows that it will blame those specialists if the ills are not ameliorated. This increased reliance on medical expertise, then, also leads to increased finger pointing when the medical profession does not respond satisfactorily. For their 1976 annual conference, the Medical Association of Puerto Rico invited Edward Reinhard, a Missouri doctor and professor, to address their members. In his talk, “Medicine and the Crisis of Confidence,” Reinhard began by mentioning that medicine had gone from witchcraft to science in the last hundred years and was now in its golden age, yet physicians were not regarded with respect.56 According to Dr. Reinhard, 123 Medicalized Births

the medical profession itself was to blame for that lack of respect. He presented the audience with examples to help them understand a patient’s perspective and made a compelling case for increasing compassion. Reinhard claimed that the factors that influenced what patients thought about the medical profession included the depersonalization and fragmentation of medical care, the skyrocketing cost of medical treatment, doubts about the competence of large segments of the medical profession, and the role of the news media and drug advertising in creating false ideas and expectations as to what can reasonably be achieved.57

He warned, though, that these were not the real problems “that have led to the crisis in confidence.” Rather, the problem was “the way in which [medical professionals] have reacted to them.”58 According to Reinhard, physicians had “a great tendency to develop a God Complex,” but arrogance was “a luxury physicians [could] no longer afford.”59 He felt that physicians should walk with their patients “through the valley of the shadow of death” if need be.60 A couple of years earlier, a third-­year medical student from New York University who visited the island for three weeks wrote a letter to the editor of the medical association’s bulletin remarking on the attitudes of local physicians toward patients and how they compared to attitudes in the United States. Jeffrey Lessing’s take on the doctor-­patient relationship was slightly different than Price’s. Lessing understood that relationships with patients in the United States were improving. (This opinion might be because he was new in the medical field, likely from a different generation than other established and practicing doctors who were publishing at the time, and had no point of reference from the past.) He claimed that US patients were becoming active participants in their health care and doctor-­patient relationships and placed it in a positive light. Lessing wrote that despite the excellent quality of medical care afforded the patients in the Mayagüez Medical Center, I am disappointed to find that the changing relationship between doctor and patient found in the United States is for the most part absent here. Several examples may clarify this point: All too often a doctor entered the room of a patient, said no more than a curt hello, performed an examination, and left. There was no attempt at conversation, nothing was done to 124 Pushing in Silence

alleviate the patient’s anxieties. . . . The Puerto Rican patient at the present time seems to be less medically sophisticated, less demanding of the health care delivery system. However, the lack of demand for better communications is no reason not to provide it.61

Although one might be inclined to interpret his comments as the product of imperial superiority, I would argue that Lessing might in fact have had an important point to make. Doctors picked up on patient complaints and astutely identified what effects direct access to specialists had on patient-­ doctor relationships. As families moved away from their communities and began demanding (and being required by public regulations) to access subspecialized experts, they also moved away from personalized and holistic care practices. In time patients, including women in labor, came to expect treatment from specialists who would spend a little time with them and demonstrate their ability to access and manage the latest technologies. Patients simultaneously admired and resented this increased specialization and reliance on technologies. Public health and alternative health movements had made their mark on US medicine, but those movements were much weaker in Puerto Rico. The difference in health options can perhaps explain to some degree why US women were perhaps more likely than Puerto Ricans to demand an active role in their health care and why US doctors took a slightly less authoritative role. Furthermore, because of historical reproductive conditions and abuses, women’s movements in Puerto Rico focused on domestic violence, abortion, and HIV during the last decades of the twentieth century and mostly overlooked quality of care and birthing alternatives.62

Science, Technology, and Ideology Few would disagree that life in Puerto Rico changed dramatically between the 1940s and 1970s. The role and composition of the state itself changed. So did the role of the expert and the relationship between science, technology, knowledge, and power. Perhaps the most difficult topic to address is changing ideology. It has been difficult, historically, to measure, quantify, and ground trends and flows in the social imaginary and mentalities of a people. Even so, I wish to take on that challenge in explaining cultural practices related to birthing. Historians can capture ideological shifts through actions. Without significant transmutations in the collective consciousness, Puerto Ricans would not have changed their birthing practices 125 Medicalized Births

and lifestyles as they did. Simply put, Puerto Ricans began accepting many new practices and truth systems and discarding previous ones. Louis Althusser, in his book Ideología y aparatos ideológicos de estado, clarifies the relationship between ideology and practice. He explains that every conscious person who believes freely in their ideas usually acts upon them. Ideas exist in their acts, and acts form a part of rituals and practices that are henceforth inscribed within the material existence of an ideological apparatus.63 There is no practice free from ideology.64 Institutional, medicalized birth would not have prevailed were it not for the complicated ideological forces sustaining it. Since there does not seem to have been an open battle against or in favor of midwives, it is logical to assume that it was the industrial, economic, cultural, and ideological changes unfolding in Puerto Rico that drove midwifery into virtual extinction. Medicalized birth became hegemonic as opposed to being imposed unilaterally by explicit force. Science and technology had taken root in the popular conscience by the late 1960s and 1970s. The sense that technology was infallible, free from human subjectivity, and a fundamental agent for progress permeated contemporary culture. As I explained in the introduction, technology is not an organized, self-­contained institution that operates on its own, but it does promote and facilitate other institutional operations and structures that situate it in a place of privilege. Of course, the notion that technology would shoulder the general evolution and improvement of human societies was not new. It dates back to the industrial revolution,65 which first unfolded in Europe but later found more fertile ground in the United States. It very slowly found its way to Puerto Rico, where it did not become culturally universal until after the 1950s. Two hundred years separate the first developments and implementations of the steam engine in Europe from the emergence of Puerto Rico’s Operation Bootstrap and biotechnical medicine. Dr. Quevedo Báez, a renowned Puerto Rican doctor and historian, offered an example in a 1949 publication of how science and progress were one and the same, rendering all else deficient. He described the world of the midwife as dark and foreign, but more important, as harking back to a time before the era of modern science, which guaranteed better births, thus imposing its scientific jurisdiction . . . because science, in no way can be responsible for irregularities, which could compromise scientific truth. . . . The pure practice of the art of birthing followed, with all of its of rigor, and . . . practical triumphs of obstetrics.66 126 Pushing in Silence

Technology and science were among the main motors driving the modern, industrialized world. Technology was a way out of underdevelopment, a liberating force. By the 1950s, science and technology would lessen the workload of housewives with washing machines and stoves, save the life of a premature baby with incubators, give women options for controlling fertility, provide fast freeways and transportation to health centers, and even offer better job opportunities. Gender and techno-­science scholar Michelle Murphy explains that government investment in family planning, social welfare as a right of citizenship, and the “enjoinment of individuals to be economically rational actors open to technical modification” were all characteristic of the biopolitical terrain during the second half of the twentieth century in the United States.67 Machines and technological instruments became more obtrusive and began to play a key role in Puerto Rican obstetrics after the mid-­1960s. The electronic fetal monitor, the sonogram, anesthesia, and cesarean sections exploded onto to the scene and after the 1970s became part and parcel of the experience of pregnancy and childbirth. In fact, I would argue that women came to accept and expect technological, medical intervention in reproduction. By the 1970s, women of childbearing age resorted both actively and passively to contraception, abortions, sterilizations, fetal monitors, sonograms, epidurals, cesarean sections, and eventually fertility treatments. That is to say, medical technology became a central and active part of most women’s lives by the 1970s, in sharp contrast to what their mothers had experienced. This was also true of Puerto Rican women who had migrated to New York City after the 1950s.68 The role of the fetal monitor in obstetric care illustrates the interplay between technology, medical practice, and culture. The electronic fetal monitor (EFM) was developed in the 1950s but not commercially available until the late 1960s. It then spread swiftly throughout the Americas and Western Europe during the 1970s.69 Dr. García, who specialized as an obstetrician in Puerto Rico during the early 1970s, recalled that “the use of the monitor at the start of the 1970s was practically automatic as soon as we had access to it, because at first we did not have it.”70 The EFM is usually connected to the mother during delivery to detect and re­cord fetal heart rate and uterine contractions, and also captures fetal movement and maternal blood flow. It is a data gathering and processing device. Initially obstetricians conceived of the EFM as a technology to be employed only during high-­risk labors, but they soon applied it to the management of normal deliveries. Obstetricians hoped that it would alert them to fetal distress and lack of oxygen, which could lead to neonatal death, cere127 Medicalized Births

bral palsy, and retardation. The machine was accepted widely in obstetric wards in the Western world long before it was evaluated or used in clinical trials. A couple of decades later, after extensive studies, there was virtually no evidence to support the link between use of an EFM and improvement in neonatal outcomes in normal births. There was, however, considerable evidence linking the EFM to increases in the number of unnecessary interventions that led to further complications and morbidity rates.71 Even more interesting was the ideological shift toward trusting machines more than humans—or at least agreeing that technology and its machines increased human infallibility—that redefined human relationships and transformed cultural practices. According to medical scholars, the EFM had several concrete effects on medical practice during labor and delivery in the United States, parts of Europe, and Puerto Rico; for example, cesarean rates increased significantly.72 This is partly because the EFM can often make the fetal heart rate seem altered or irregular, alarming medical staff and parents even when the fetus is actually healthy and stable. EFMs also allowed for (or justified) the reduction of nursing staff in many hospitals because it could supposedly monitor the progress of labor in the absence of medical personnel. Intermittent auscultation73 ceased to be part of the standard of care for laboring women after the introduction of EFM, and by the 1980s general medical staff in the United States were trained to use the EFM, but few were trained to perform auscultations.74 Altering the dynamic between the patient and medical staff, the EFM reduced the direct contact between patient and staff. Margarete Sandelowski, in her book Devices and Desires: Gender Technology and American Nursing, describes a very similar process for US nurses in the 1960s who had less direct contact with patients and instead gathered information about them when they “monitored monitors.”75 The reliance on machines moved US nurses away from intuitive, observation-­based care.76 The EFM changed the relationship between mother and fetus, doctor and fetus, medical practice and law, and medical staff and nature or biology. The EFM presented itself as a means to trace nature and “reveal part of nature’s code,” making it permanently available for interpretation.77 It separated fetal health from maternal health and allowed experts to intervene in the name of the fetus. For the first time, fetal health and maternal health could be pitted against each other. Fetus and mother were not only two individuals, each under the care and management of medicine, but now appeared to be competing over scarce resources. In some cases, the mother’s laboring body seemed to be acting to the fetus’s detriment and 128 Pushing in Silence

depriving it of oxygen. These impressions contrasted sharply with those that had predominated in the 1940s, in which the mother was seen as a nurturing life source capable of great achievements and sacrifice for her child. In this way, the application of technology in childbirth served to reconceptualize the birthing body. Labor and delivery under electronic monitoring involved a disembodied, recorded set of physiological data interpreted by, or at least available to, anyone engaged in the birthing process. It gave access to the conditions of the fetus in vitro and opened them up for mathematical interpretation and evaluation throughout labor and delivery, and long after. Ken Bassett, in an article in Social Science and Medicine, elaborated that “EFM recordings bypassed the constraints of any human consciousness and opened up obstetrical events to repeated interpretations spread over time and space.”78 It allowed the assessments and actions of medical staff to be reevaluated by experts who were not present. In contrast, childbirth without the EFM allowed the mother to retain “awareness of and responsibility for her own condition” and confined decision making to the nurse or doctor directly in charge of the case and following its developments.79 The EFM facilitated reducing fetal health to the heart rate, which could not accurately stand in for overall fetal health. The use of EFM also had a dialectic relationship with laws and litigation within a society more vested every day in the standardization of clinical care and the management of risk.80 The EFM contributed to defensive medical strategies, a result of the perceived threat of public scrutiny and legal action. It pressured physicians to order medically unnecessary tests and procedures, which spoke more to their own protection and legal pressures and less to medical savvy. Bassett and his colleagues explain: Medicine influences law by developing clinical practices seen as culturally related to patient injury; and associated documentary practices which offer the means to reconstruct relevant clinical events. Law is entirely dependent on these medical developments. But law, in turn, influences medicine through both its litigation process and judgments at trial, affecting both the behavior of individual physicians and medical standards.81

Mainstream Western medicine came to focus on care, which identified, categorized, and treated diseases. Bassett claims that it stresses pathologies, or the scientific approach to abnormalities caused by disease.82 The EFM collects data in a way that treats childbirth as a pathology in need of medical management that was accountable to litigation. Technologi129 Medicalized Births

cally mediated images of bodily processes fed into the move toward defensive medicine and high costs. The introduction of an array of new technologies resulted in important ideological and practical paradigm shifts in medicine. The continued and prolonged use of technologies such as EFM, despite convincing evidence arguing against its routine use, has been sustained by the newly emerging faith in the ability of technology to resolve clinical pathologies. Ironically, although this faith depended on a cultural tendency to favor technology and science, the EFM was not subject to scientific, clinical validation. The lack of scientific validation of technologies is a common irony, and medical scholars and scientists are well aware that the United States and Puerto Rico did not establish effective methods to evaluate and analyze the use and applications of new medical technologies that emerged after the 1960s.83 Medical historians and doctors in Puerto Rico agree that the cult of high technology in medicine came to life in the 1970s. Dr. García pointed out that the rupture between medicine and public health coincided with the encroachment of high technology in medicine.84 The two University of Puerto Rico schools have not joined forces since then. Despite their physical proximity, they have grown quite distant and communicate very little. Puerto Rican public health dedicated its efforts to community-­based work and prevention. The School of Public Health did a lot of research on links between health, medicine, and social behavior or outcomes. The School of Medicine focused on cures and the clinical sciences. Dr. García claimed that there was a general disregard for and devaluation of public health in Puerto Rico; both the government and medical practitioners underplayed the possible contributions of public health to medical practice after the 1960s. By placing birthing within the realm of medicine (obstetrics) and moving it from public health, where it had been decades earlier, birthing practices and practitioners followed the road of subspecialized medicalization.

Standardization, Efficiency, Disease, and Reproduction Government leaders based the industrialization project on ideas of rationalizing society and making it more efficient and productive. This led to standardizing procedures and often eliminated the possibility of treating individual events as unique and distinct. One prevailing doctrine was that one cannot know what one cannot measure or quantify.85 It became essen130 Pushing in Silence

tial to identify what was “normal” and “average” in the effort to establish laws and to proceed with exactitude.86 Equally important, standardization and the setting of protocols established a standard of care that would be provided to all patients, offering equity. While this had a democratizing effect, pitfalls were inherent. Health and human development, just as any other phenomena to be addressed along these lines, required order, classification, and organization into normative and normal stages. If the norm was not attained, experts intervened to support proximity to that norm. However, human development and biology do not manifest themselves as identically progressive experiences unaffected by individual conditions, contexts, and interpretations. Bureaucratization and standardization have the effect, in part at least, of erasing individual differences and placing established standards above individual demands. Privileging standards over individuality could produce results that undermine the predetermined goals. In birthing, the rights of mothers could be threatened by doctors overlooking their individual needs, decision-­making processes, or personal beliefs. Furthermore, as Murphy states, “doctors, as agents within these systems were themselves increasingly subject to standardized protocols, reducing professional authority . . . and circumscribing the scope for judgment.”87 Nonetheless, this systematic ordering became an accepted part of daily life and culture between 1966 and 1979. No disease follows identical patterns and stages, nor does it always respond in the same manner to drugs and treatments. Few physiological systems respond and react identically, just as children do not learn at the same pace.88 Women do not have identical pregnancies and deliveries. Dr. Ramírez exclaimed in an interview that “the only thing predictable about [laboring] women is that they are always unpredictable.”89 What is incongruent, though perhaps useful, is that we have come to establish, accept, depend on, and fully operate under standardized norms even though they do not reflect the complexities of what they represent and thereby lose precision. These attempts at establishing patterns and norms provide some comfort and predictability, and often raise standards and parity of services to a certain extent, but they also alienate the people involved, whether in a factory, a maternity ward delivery room, or a classroom. Midwifery and earlier general medical practice had little interest in establishing this type of rigid standardization, and practitioners were more open to individual differences. Each birthing experience was mostly left to follow its own course, whatever the outcome. This view of childbirth was not an acceptable fit in the contemporary rubric of institutionalized medicine and post-­ 1960s Puerto Rican cultural patterns. Like most daily activities and living patterns in an industrial society, 131 Medicalized Births

female reproduction was organized in terms of efficiency and function. It needed to operate within hospitals, medical protocol, and contemporary time constraints. Instead of conceptualizing pregnancy, labor, and menopause as part of life, medicine and the general culture began to see them as pathological disorders that posed dangers to women and, at times, society at large. Conceptualizing female reproductive cycles in this way increased the likelihood of women placing their health in the hands of experts in control of scientific, specialized knowledge who could reduce uncertainty and normalize their deficient and problematic bodies. When pregnancy becomes a pathology that poses risks, societies dominated by beliefs in scientific, industrial progress legitimate the expert. Who could justify risking something as valuable as a newborn by distancing childbirth from experts and their technocratic options? The processes related to this era of technology, science, and industrialization rest on an acceptance of universal truths or tendencies. Gertrude Jacinta Fraser’s African American Midwifery in the South calls our attention to this dynamic. She draws on Immanuel Wallerstein’s writings in Historical Capitalism (1983) to define the ideology of universalism, which has been a keystone of capitalist ideology. It is a set of beliefs claiming that what is knowable and meaningful can be generalized, and that science can eliminate the subjective by identifying and describing these truths about our physical and social world.90 The ideology of neutrality, a claim of positivist science, closes the door to criticism and assigns exclusive power to science (and those who have access to scientific knowledge) and its universal truths. This ideology becomes an instrument of social control, albeit often with good intentions. The likelihood of eliminating individual difference is related directly to the emotional distance of the observer. The natural sciences have sacrificed the individual case study in favor of a rigorous mathematic standard of generalizations.91 The logic is that by stripping away subjectivity, experts are better poised to treat problems, or patients in this case, in a just and responsible manner. Feminist techno-­science scholar Michelle Murphy adds that the access to technologies and its instruments assumed an aspiration to bypass subjectivity. This “mechanical objectivity” became an infrastructure that experts could use to make interpretations and develop theoretical explanations, and was celebrated by the 1970s as a new epistemic value.92 The midwife of the first half of the twentieth century did not have access to technology and did not adhere to this logic. It was the obstetrician who could follow the parameters just described and who had access to the infrastructure of mechanical objectivity. The hegemony of the medical expert fed from these socially ac132 Pushing in Silence

cepted universals as it discredited popular wisdom and trivialized the intuition or knowledge of the pregnant or laboring mother. The midwife did the reverse. According to anthropologists Joseph Comelles and Angel Martínez Hernáez, medical pathology established models of disease through inductive reasoning, while popular medicine described them as mosaics of cases without arriving at a particular synthesis.93 The comadrona gained knowledge and training through her own experience as well that of other women and other midwives. They were self-­educated and saw each woman as different yet capable of handling her own birthing process, which was arduous, relatively unquestioned, and innate to women. Loss or death was also interpreted by the comadrona as part of the natural or spiritual world, where humans had limited agency. They did not see much need to intervene with the pregnant and laboring body, and nonphysiological aspects of birthing and life were also included in the process. The irrational or incompletely understood was not necessarily negative, nor was it distrusted. I would add that it seems many physicians (generalists) early in the century had a similar approach to birthing.

The Role of Women Changing sociocultural and economic patterns affected the definitions, expectations, and interpretations of childbirth. These same changes affected the role of women and the structure of their families, pointing to another contributing factor in the medicalization of labor and delivery. Academic and government leaders targeted women for different reasons with the hope of prompting Puerto Rican women, at home or in the workplace, to let go of backward, folkloric beliefs and practices, and to adopt scientific, rational behavior as taught by experts.94 Women were to stop believing “in old lies and absurd superstitions” regarding pregnancy and childrearing.95 Women were to seek out experts “familiar with the scientific truth” such as nurses and social workers.96 Government and public service agencies mounted long-­term, multifaceted campaigns to reeducate women and draw them into government-­run institutions. The Division for Community Education (DIVEDCO) distributed pamphlets, movies, and posters and went door-­to-­door all over the island with this kind of information and propaganda.97 In Puerto Rico after the 1930s, women began working more often outside of the domestic sphere. Midwifery was once one of the few jobs available to women outside of agriculture and not directly related to housework such as washing and sewing clothes. Although it was not well paid 133 Medicalized Births

and required plenty of personal sacrifice, midwifery held social prestige and was a way of generating extra income. At the same time, it provided women with an intellectual outlet and a way of developing knowledge and skills. By 1970, employment and educational opportunities for women were different. With industrialization came employment opportunities in manufacturing, education, nursing, sales, and clerical work.98 Urban working-­class and professional women had access to health care and education and lived lifestyles very different from those of earlier generations. The degree of acceptance of the technocratic model of birth and medical interventions in health care varied by race and class. Robbie Davis-­ Floyd, in her article “The Technocratic Body and the Organic Body: Hegemony and Heresy in Women’s Birth Choices,” brings to our attention a few studies which demonstrate that working-­class women had more of a tendency to resist medicalization, and white women accepted technocratic models of birth more readily than women of color. This manifestation of stratified reproduction resulted in women from higher echelons perceiving technology and efficiency as integral to their world and thereby their reproductive health. They demanded and had access to the best of modern technology in their health care.99 Despite the economic crisis in Puerto Rico, there were more middle-­class women and women with higher levels of education giving birth after the mid-­1960s than in the mid-­1950s. It would follow, then, that more women would seek technocratic services where experts would interpret the pregnant body. In previous chapters I presented evidence along these lines, where differences in maternity care were apparent between private and public sector users. Stratified reproduction played out on many levels. Notions of class, race, and gender had complex roles in birthing. These notions joined forces with those related to modernity, science and techno-­medicine, expertise, and standardization. For instance, tolerance of pain is closely associated with race and hard to separate from social class. Race and class are closely related in Puerto Rico. Doctors conceptualized “refined,” whiter women as weaker, intolerant of pain, and more susceptible to illness than women with darker skin.100 In fact, this image predominated in many parts of the world. Gender norms and elite ideals held that whiter and wealthier women needed to be protected from the agonies of birthing. These color-­ coded, racist notions of pain tolerance date back to the creation of the Atlantic world and slavery. The demands of women also had an effect on interventionist strategies in relation to the female body. The link between the demands that women placed on medical science and the acceptance of medicalized births is relevant to my earlier claims. Women’s struggle to obtain access to safe abor134 Pushing in Silence

tions and contraceptives to liberate them from their biological destinies also attracted them to the world of medical interventions. Many women wanted to have fewer children and ensure that the ones they did have ran fewer risks.101 They did not want to leave their reproduction to chance, despite pregnancy and birthing being uncertain by nature. Fetal monitoring, cesareans, and sonograms gave women, not just doctors, a sense of control and reduced uncertainty. Efficiency required avoiding difficulties and pain, not doing more work than necessary, following predetermined routines, reducing risks, incorporating expert scientific knowledge and technological advances, and saving time. Brevity was valuable, and monitoring a necessity. Twentieth-­century women’s movements in Puerto Rico did not focus on birthing and maternal health. There were, however, some breastfeeding projects and campaigns directed toward maternity rights in the workplace at the very end of the century. Puerto Rico did not follow the example of the United States and Europe, where women’s groups mobilized to improve the care of mothers and babies in the hope of offering more alternatives.102 Mothers in Puerto Rico said very little about their births at a public level. This silence merits further study. The medicalization of birth altered women’s self-­ conception. Jo Murphy-­Lawless, a scholar on reproduction, reminds us that notions about the female body are inscribed within the cultural discourses circulating at any one given time. Obstetric interventions affect how women visualize themselves. Medicine and obstetrics treat the female body as fragile and incapable of supporting and managing its own labor and delivery.103 Murphy-­Lawless reasons that “our experiences are constructed by obstetrics . . . [and] the obstetric viewpoint becomes part of our experience. And the real dilemma for us is how that process is made to appear ordinary and normal.”104 Here we see the ideological frameworks of science, government, medicine, the law, and gender interacting and reinforcing each other. Women who were subsumed in the culture of progress and science, which once served to free them from biological determinism, eventually believed that they were not only incapable of withstanding labor and delivery, but also that they could pose a threat to the life of their baby during that process. The body of the parturient came to be seen as defective, dangerous to her and her child, intolerant to pain and hard work, and unpredictable—and therefore in need of monitoring, control, and medical intervention. It was the belief in these deficiencies that led women to demand pharmacological and technical interventions. Feminist scholars have for decades argued that experience creates knowledge, and knowledge shapes experience. Pregnant and laboring women were a prod135 Medicalized Births

uct of the ideological formation of industrialization and came to rely on the institutionalized birthing system of the modern world.

Conclusions The years between 1966 and 1979 were pivotal for the history of childbirth in Puerto Rico for a variety of reasons. The mass appeal and success of the PPD and its industrialization projects crumbled. Even so, the experience of political participation and a newfound sense of entitlement to a better quality of life within the neocolonial framework had permeated even the most remote sectors of the island. The general population was now accustomed to leaving home, traveling to a clinic or hospital, and waiting in long lines for many types of public assistance or to gain access to the required bureaucracy of the state. With half of Puerto Ricans living below the poverty line, dependence on public assistance intensified. Moving within institutional settings and turning to specialized service providers became part of everyday life on the island. It followed that pregnancy, labor, and delivery would also come to be seen as a natural part of this institutional world. To this institutional matrix, one must add the powerful aggregate of scientific advances. The mid-­1960s and 1970s were replete with new technologies that allowed direct entry into the human body. The public had access to heart and kidney transplants, prenatal diagnosis of Down syndrome, neonatal intensive care, legalized abortions, oral contraception, and the ability to listen to and track fetal heart beats, as well as watch in vitro images by sonogram. If we refer back to the history of birthing, we can see that specialized medicine is relatively recent in Puerto Rico and proliferated as midwives disappeared. Specialization led to more aggressive medical practices, and doctors’ and patients’ perceptions of higher risk demanded expertise. At midcentury only select physicians had adopted specialist discourses and identities, and they rarely referred to technological interventions as a sign of good medicine in birthing. By the late 1960s this was no longer the case. Doctors began to specialize and to aggressively manage pregnancy, labor, and delivery because it was considered, more often than not, a pathological process. Along these lines, more experts were in demand to cover the different medical subfields (for example, anesthesia and perinatal medicine), and a centralized system of data collection and record keeping emerged. Specialists, technologies, and institutional areas developed in response to these demands—and with these developments came new anxieties. 136 Pushing in Silence

The UPR Department of Obstetrics was heavily invested in new technological developments and moved swiftly to advance a subspecialty in perinatal medicine. Obstetrics entered the realm of technology and specialties as it confronted a new facet of defensive medicine. Puerto Rican doctors on the whole became defensive about their intentions and practice, and a disruption in the rapport between their profession and their clientele emerged. Childbirth no longer centered exclusively on the mother. Medicine and its machines had unveiled the once elusive patient inside her: the fetus. Obstetrics became deeply engaged in the construction of the fetal personhood. This occurred mostly separate from the mother in a context of technological obstetric management aimed at reducing clinical pathologies. Obstetrics defined the fetus as fragile, at risk, in need of defense, and sometimes the victim of the mother’s own physiology. Clinical pathology dominated the medical scene in larger hospitals and medical education. Between 1966 and 1979 childbirth became medicalized in Puerto Rico. By the end of this period, women in Puerto Rico had stopped using midwives and had turned to doctors and medical specialists to deliver their babies. Birth was no longer a private, domestic event involving just the mother and her midwife or family doctor. It had become an institutional procedure, actively managed by experts with claims to scientific knowledge and technology that could be called upon to control, monitor, predict, and appear to reduce risk. Motherhood was no longer to be trusted and left to instinct, nor was it built into womanhood. Women and their bodies required assistance, and bringing babies into the world demanded expert and institutional support.

137 Medicalized Births

Ch a pter fiv e

Phase Five

Novoparteras and a Techno cratic, Li t ig ation-­Based Model of Birth, 19 8 0– 2 0 0 0

B

y 1980 one could safely make several assumptions about the experience of childbirth in Puerto Rico: a specialized medical team would care for the parturient and newborn in a hospital setting; this medical team would connect the mother to machines, make some kind of surgical incision on her body, and prescribe medication during labor and delivery; the newborn would later sleep and be fed in a hospital nursery. These were all routine standards of practice after the 1980s. This final phase of Puerto Rico’s birthing history was not merely medicalized (moved exclusively to a medical setting), but operated under a new model of care. Medical anthropologists such as Robbie Davis-­ Floyd describe this model of birth practiced in Puerto Rico during the last two decades of the twentieth century as technocratic. As discussed in the introduction, I borrow Davis-­Floyd’s definition of technocratic birth as one that results from a technocratic society’s core values. It conceives of the mother’s body as a defective machine, and it assumes the inherent superiority of technologies used to correct and counteract deficiencies and improve their performance.1 As practiced in Puerto Rico during the last two decades of the twentieth century, this technocratic childbirth was also interventionist, surgically inclined, and shaped by a new litigation-­based climate. In a technocratic model of birth, the body of a laboring woman stands to improve and become more efficient and able to tolerate childbirth under the care of scientifically trained medical staff, their technologies, and their drugs.2 This model treats the body as a machine. It is a phase in the history of childbirth replete with ironies. As childbirth became less

of a potential hazard to mother and baby, obstetrics defined it as innately hazardous and risky. However, increased interventions designed to reduce risk and hazard introduced new threats. Sociologist Jo Murphy-­Lawless argues that obstetrics generates ways of knowing about pregnancy, labor, and delivery that influence culture and eventually become inscribed in the ways most women view the process.3 Obstetrics and childbirth practices create meaning and influence the relationship a woman has with her own body and the process of birthing. Natalie Fixmer-­Oraiz, in writing about the introduction of emergency contraception in the lives of women, interrogates the ways in which reproductive technologies “negotiate and shape cultural and political communities” and alter the ways women experience their bodies and maternity.4 By the 1980s, obstetrics was informing everyday understandings about childbirth and the childbearing body. Several factors combined to enable the ascendency of a medical-­ technocratic model of childbirth: the unpredictable nature of childbirth, its presumed unbearable pain, the availability of pain medication and new technologies, and the requests of families to control their reproduction. But doing so had several noteworthy consequences. By placing the delivery of their babies in the hands of obstetric teams and high-­tech hospitals, mothers partially relieved themselves of the inconveniences of childbirth and its outcomes, transferring them into the hands of medical teams. As a result, obstetrics became more authoritative and interventionist, but patients also increasingly blamed doctors for deficient outcomes, thereby leading obstetrics in a litigation-­based direction. Fewer babies were birthed vaginally, and more were delivered surgically than ever before, while the fear of lawsuits and the astronomical costs of malpractice insurance simultaneously crushed obstetricians. As is often the case, reduced options and the rise of hegemonic practices spurred alternate responses at the margins. The rise of litigation-­ based, technocratic birth models motivated a small minority of women to seek alternative models. This fifth phase of Puerto Rican birthing practices witnessed a minor rebirth of home-­based birthing alternatives guided by certified midwives. I call the midwives attending births on the island after the 1980s novoparteras (new-­midwives) to distinguish them from the comadronas (midwives) who had disappeared as birth attendants by the 1970s. The number of women choosing home births showed an almost imperceptible rise in Puerto Rico and in the United States. I was one of those women who sought out a home birth under the care of a midwife in the 1990s. My story is not an unusual one for home births, 139 Litigation-Based Model of Birth

and in many ways it illustrates a common profile and experience of women who chose to avoid the technocratic model. The population served by these novoparteras had changed significantly from that of the 1950s–1970s. Women delivering their babies at home during the 1960s tended to come from less privileged backgrounds and had less formal schooling than those delivering in hospitals. They were not making a conscious effort to seek health care alternatives and more control in their lives, whereas the women choosing home births by the 1980s represented the middle-­ class and highly educated women seeking a central role in their birthing experiences. I was almost thirty years old and had been married for several years to a general practice physician trained in Ecuador with a master’s degree in public health from Cuba. Having earned a degree in international studies from Macalester College in Minnesota, I was teaching in the Puerto Rican public school system. I planned my pregnancy carefully, aiming to give birth at the end of the school year to avoid missing classes and to be home with my baby for a few months before returning to work. I moved to Puerto Rico a couple of years after graduating from college. Seven years later, I still had not found a gynecologist I felt comfortable with. A few whom I consulted asked me what was wrong since I had not yet had children. Most seemed bothered that I asked questions, knew a bit about my own body and health, and requested information. I came away from these visits feeling disrespected and disillusioned. I had never pursued radical alternative health care options, but I was skeptical of institutional medicine. Some of my skepticism had been nurtured by my mother, a registered nurse and nurse-­midwife (though she never practiced midwifery and worked in a community clinic instead). Before I started teaching in Puerto Rico, I worked with the Native American and Latino communities in Minnesota as an HIV-­AIDS case manager and was committed to health issues and advocacy. This work expanded my appreciation of the value of traditional medicine. My husband, too, believed in incorporating alternative medicine in his practice and frequently came home to share horror stories about what he witnessed in the hospitals where he was completing his residency. When I realized in 1996 that I was pregnant, I started to search for options for my prenatal care and delivery. I read a lot about pregnancy, labor, and delivery, and I talked to many mothers about their experiences. I made several decisions about things that were important to me, including breast-­feeding, having family present during my delivery, and avoiding a so-­called preventive episiotomy. My husband, Luis, researched the 140 Pushing in Silence

topic and found overwhelming medical evidence against routine episiotomies. He took this evidence to his friends and colleagues to explore their reactions and opinions, and he searched far and wide for an obstetrician who would agree not to perform a routine episiotomy, to no avail. I soon realized that I would have very little, if any, say regarding my own labor and delivery in a hospital setting. I would not be allowed to eat, drink, or move about during labor; I would not be able to have my mother and partner present; and I would have to fight to keep my baby in the room and breast-­feed at will. It was 1996, and virtually no women nursed their babies in Puerto Rico. At some point, my mother mentioned the possibility of a home birth. I had never heard of anyone who had birthed at home. I began researching and reading about the home birth option, and the more I read, the more I liked the idea. I made phone calls and talked to women involved with alternative health and women’s issues and discovered that there were women who had birthed at home with midwives in Puerto Rico over the previous decade. After a few more phone calls I finally got in touch with a local midwife and arranged to meet her at my house. After meeting Debbie, a Puerto Rican woman licensed as a midwife in the United States, I had no doubt that a home birth would be the best option for me. Luis also agreed to the home birth option. Debbie met with me for over an hour, made me feel comfortable, answered my questions, and set up a prenatal plan that covered diet, exercise, keeping me comfortable, and seeing an obstetrician. She even referred me to a few obstetricians who might be open to providing parallel care for me. I did not feel comfortable lying about my birth plan to my doctor, so I chose a doctor about forty minutes away with whom I could share my decision to birth at home. This middle-­aged Puerto Rican obstetrician agreed to monitor my prenatal care, order my lab tests (Debbie was not legally authorized to do so), and take me as a patient if I needed to be transported to the hospital at any point during my labor. He did not know Debbie in person but had worked with her clients before and had come to respect her practice. I met with Debbie once a month at my home. We discussed my diet, reviewed my lab tests, and talked about how I had been feeling and what I might do to feel more comfortable. She asked questions about my health and kept track of my weight, blood pressure, pulse, water retention, and belly size. Sometimes she performed a vaginal tactile exam to check for any irregularities or infections. She put me in contact with other mothers and midwives and provided information about a range of topics related 141 Litigation-Based Model of Birth

to pregnancy. She also helped me find a place to take prenatal classes, although she let me know that she did not believe women needed to learn or practice breathing and control skills for labor and delivery. My pregnancy seemed healthy, and I did not run into any complications. I continued working until a week before my due date. My mother was staying at my home by then in preparation for the birth, and my midwife was on call. About five days after my due date, I woke up at night to use the restroom. My water broke as I was returning to bed. I woke up my mother and husband to tell them. I could feel mild contractions, but they did not bother me. I called my midwife, who after a brief conversation told me to try to go back to sleep and have a good breakfast after waking up, and that she would be over later during the day unless I felt things had progressed enough for her to change her plans. I did just that. When I woke up again, I felt mild contractions but continued my morning routine. At lunch time I had some spaghetti and then I covered the bed in plastic and new sheets and made sure I was well-­stocked with popsicles and Gatorade, as Debbie had suggested. Later in the afternoon, I took a long walk in my neighborhood. From time to time I needed to stop walking to breathe through a contraction. My contractions were getting stronger and closer together, but their spacing was irregular. I kept in touch with Debbie over the phone, and she came over in the evening, shortly after my walk. In the late evening, after my labor had gotten more intense, I decided to retire to my bedroom. The baby was facing backward (posterior), and I was feeling pain in my lower back. Debbie, my mother, Luis, and a friend stayed with me. Every hour, Debbie took my vital signs and listened to the fetal heartbeats with a fetoscope (similar to a stethoscope). She also performed a few vaginal checks to follow my dilation progress. I was effacing and dilating at the same time. We sat on my bed watching a ballet on television. I concentrated all my efforts on breathing through my contractions, which were coming every three to ten minutes. Debbie and Luis gave me hard massages on my lower back to relieve some of the back pain and pressure during my contractions. I had been in labor for a long time by then, and I was getting worn out. When I entered transition, the most intense yet shortest stage of labor during the final centimeters of dilation, I was vomiting with every contraction and my body was shaking. Debbie told us that I needed liquids and was losing strength. Debbie considered applying an IV to hydrate me. My mother gave me Gatorade and had me take some bites from a popsicle instead. Exhausted, I informed everyone that I wanted to go to the hospital and have a cesarean. They all looked at each other in disbelief, and 142 Pushing in Silence

both Debbie and my husband explained that I was already fully dilated and effaced, that all my vital signs and the baby’s vital signs were fine, and that even in a hospital I would probably not get a cesarean at this point. There was no doubt that had I been in a hospital, they would have ordered a cesarean by then. My water had broken at the onset of labor, and I was taking too long to deliver by medical standards. Both of these would be reason enough to either use Pitocin, a synthetic hormone used to stimulate contractions and labor, or order a cesarean. Most of my birthing process fell outside of normative medical parameters: my contractions were never a perfect five minutes apart, I had dilated and effaced simultaneously, and my baby was facing backward (posterior). When I finally stopped vomiting and was ready to push, my muscles were worn out, and I could barely hold myself up. I did not feel any sensation to push. Everyone decided I should try to walk to restimulate my labor. Debbie and Luis supported me on either side and helped me walk a bit. It did nothing. Then Debbie suggested I squat, sit on the toilet, and go on all fours. Still, I felt nothing. Somehow, I gathered some strength, stood up, and held on to the bathroom wall with Luis crouched down on the floor under me. By then I was making noise with every pushing sensation I felt. My contractions had turned the baby, and he was in the ideal birthing position (anterior). My father, his wife, my grandmother, and several aunts and uncles were all downstairs early in the morning of May 23 praying for me and waiting anxiously. They could hear my grunts as I pushed. They were worried for us, knowing it had been a long labor. None of them had birthed at home and probably wondered why I chose to do so. My baby was finally crowning, and Debbie let me know. She looked up at me and for the first time spoke in a serious tone and instructed me to muster my strength and push. I felt scared for the first time and gathered what I had left in me to push with all my might. I pushed too hard and too quickly for my own good, but Diego was out in one single push. Luis received him and after the cord stopped pulsing, cut it. I was in labor for thirty-­one hours. I sat on the floor and realized there was blood all over the bathroom. I am unsure of the exact order of things after that moment. Debbie had me get in the empty bathtub and told me I was hemorrhaging and that she would have to give me an injection of Pitocin to stop the bleeding. She injected my thigh, and all was well. Later, I sat on the bathroom floor, looked at Diego in my arms, saw that he was whole, had wide open eyes, and was big and beautiful. My mother was busy cleaning the bathroom as other members of my family started streaming in to look quietly at me and 143 Litigation-Based Model of Birth

my baby. Everyone left soon after, and the new father took baby Diego to the other room, where he was cleaned and dressed. Debbie then turned to me and said I still had to expel the placenta. When she saw my face of disbelief, she said, “I do not normally do this, but I will give it a tug.” She did, it came out, and she took it. Debbie lifted the placenta and inspected it carefully to make sure it was complete and that nothing was left inside. Luis took the placenta and buried it by a small lemon tree that we planned to give Diego when he was older. Before I knew it, I was in my pajamas and resting in my bed. Debbie weighed and measured Diego, checked his reflexes, and assigned him an Apgar score of nine, which she later changed to a perfect ten.5 Diego was eight and a half pounds and looked extremely healthy. Debbie helped me breast-­feed him, and all seemed well. Debbie said she needed to check my pelvic floor and that she was afraid I had some rupturing. I had ruptured vessels in my eyes and face (petequia) when I pushed Diego out, and Debbie knew that my perineum had been intact right before the delivery, but she suspected that there had been some rupturing in that final push. She had only had one other mother tear during a delivery, a professional ballerina. I had danced ballet for eight years and had planned to become a professional when I was young. Ballet dancers tend to develop very thick and hard pelvic floors. Debbie had Luis examine me along with her. I had third degree tears and several hematomas. Debbie recommended suturing, but I could not stand the thought of it and complained. I knew that most minor tears repaired themselves, but Debbie explained that these were not minor. I also knew that my husband was particularly good at stitches, so I asked if he could do it and agreed to three stitches. Debbie sprayed some local anesthetic and disinfectant, and Luis took the three stitches as I quietly ­hummed to myself. The truth is that I did not even feel them. I was finally left to rest. Debbie stopped by the next day to check on me and Diego and asked us how the breast-­feeding was going, if I had gotten rest and eaten, and if I felt okay. She stopped by the following week as well, and called me regularly for a couple months after birthing. I continued to talk to her from time to time, and in 2000, when I was doing my master’s research on the history of midwifery at the University of Puerto Rico, Debbie was the one who gave me the documents produced by the novoparteras and who referred me to other practicing midwives for my interviews. While my own story does not represent a typical Puerto Rican birthing experience of the 1990s, it does illustrate how birthing had changed 144 Pushing in Silence

since the 1940s. Midwives and general practitioners in the 1940s would consider the length of my labor, for instance, as acceptable, whereas by the 1980s the slow progress would be considered deficient. By and large, the novoparteras wished to offer an alternative to the technocratic model while selectively accessing biomedical knowledge and tools. Their training was, on many levels, institutionalized, and the demand that existed for their services emanated from a place of relative social privilege. This final chapter addresses three issues that are fundamental to the final phase of the history of birthing in Puerto Rico in the twentieth century: the legal climate that enveloped obstetrics, the explosion of surgical births, and a minor resurgence of home births and modern midwifery as a new alternative for women in Puerto Rico in the 1980s. In the first section, I address the legal climate around obstetric practice because of the influence it exerted on the field. During my archival research, as well as in my interviews, I was impressed by doctors’ persistent fear of malpractice suits. Given the sharp rise in insurance premiums and the high-­profile lawsuits publicized in the media, it is not surprising that the threatening legal climate in which obstetricians work influences their practice. Second, I examine the process by which cesarean section rates in Puerto Rico became among the highest in the world.6 This phenomenon, I argue, emerged from the same process of the medicalization of birth that resulted in the elimination of midwifery. The third section introduces the novoparteras and their practice.

Civil Rights, Obstetrics, and the Medico-­Legal Climate In the 1940s the Partido Popular Democrático (PPD) launched a campaign to bring the population of the entire island into its plans for social equality and development, plans that Puerto Rico’s other major parties—the Partido Nuevo Progresista (New Progressive Party), which was pro-­statehood and more conservative, as well as the third most influential party of the time, the Partido Independentista Puertorriqueño (Independence Party), which participated in more progressive grassroots efforts—later adopted and continued. All political leaders after the 1950s were conscious of the fact that Puerto Ricans came to expect access to basic needs—education, food, housing, employment, and health care—as civil rights. This was true regardless of where people’s allegiances were on the political spectrum. And even though Puerto Ricans participated in enormously diverse politi145 Litigation-Based Model of Birth

cal organizations around the island, as well as in places like New York and Chicago, no powerful or broad new health movements influenced health care in Puerto Rico after the 1970s as they did in the United States.7 By the 1980s activist and nonprofit organizations made efforts to address specific health-­related issues, but their impact on general health reform and patient rights was limited. Very few voices in Puerto Rico called for the demedicalization of critical life events such as birthing, for example. Critics who focused on controversial issues such as the overwhelming numbers of sterilized Puerto Rican women were mostly based in the United States, while in Puerto Rico an ever-­increasing number of women sought out this permanent surgical solution to family planning, despite the history of abuse Puerto Rican women had endured in early experimentation efforts with the contraceptive pill, Emko cream, the IUD, Depo Provera, and coerced sterilizations.8 Grassroots activism around women’s issues increased during the 1980s and 1990s, and some organizations—Grupo Pro Derechos Reproductivos (1990s), Taller Salud (1979), Asociación Puertorriqueña Pro-­Familia (1950s), and El Frente Socialista (1990s), among others—addressed issues of domestic violence, abortion rights, family planning, sex education, maternity leave, and fertility control.9 There were also efforts to expand and formalize health food options and different forms of natural medicine, but all of these remained marginal alternatives to biomedicine. Many women took prenatal classes influenced by the Bradley Method or Lamaze, and some obstetricians began allowing husband-­coaches and using breathing techniques in their delivery rooms. Everyone, from insular and federal government representatives to radical feminists, were so focused on family planning—often for different reasons—that they had little need or energy to include birthing rights on their agendas. The consequences of the civil rights movement and pressure from all the different health rights movements in the United States reached Puerto Rico in the form of new laws and protocols incorporating patient rights. Perhaps most important, by the 1980s courts were more inclined to “view the doctor-­patient relationship as a partnership in decision making rather than a doctor’s monopoly.10 Patients had the right to informed consent, to see their medical records, and to have equal access to care.11 This expansion of rights often played out with patients realizing that they could appeal to the justice system in reprisal for negligent or harmful medical care. Patients did not gain a sense of entitlement or equal footing once they were under the actual care of the physician or in a hospital setting. However, doctors knew that they were vulnerable to litigation, leading them to practice defensive medicine. But defensive medicine did not mean 146 Pushing in Silence

better medicine. Medical practice conformed to local standards of practice (which now included cesareans), was not always supported by research, and constantly weighed risks in accordance with many different, powerful conflicting interests. Health care by 1980 was managed by a complicated set of corporate interests. Medical administrator Ivan Colón published an article in the Medical Association of Puerto Rico’s journal in 1987 on the modern concept of medical risk management. He explained that modern medicine involved a dependency on biomedical technology and complex administrative processes that regulate medical practice.12 According to Colón, risk management was the relationship between insurance and quality control.13 The motors that drove technocratic medicine and created a demand for risk management included an array of paradoxical elements: medical technologies, which usually increase the complexity and risks of medical practice14 and inflate costs while becoming a necessity for documentation and diagnostic purposes; cost control, which limits interventions doctors and hospitals could perform; quality of patient care, which requires more guarantees as patients become more frustrated and demanding; and the stipulations of regulatory agencies such as Medicare, the Department of Health, and the Joint Commission.15 Risk management needed to juggle all of these issues, and administrators such as Colón were aware that medical practices needed to operate within all of these parameters and avoid breaching preestablished protocol.16 The autonomy of the individual physician as well as the patient was constrained within this context, which is ironic since many of the reasons for these constraints stemmed from seeking professional autonomy and patient rights. In his influential book The Social Transformation of American Medicine, medical historian Paul Starr explains how the factors described by Colón had a snowball effect on one another, transforming medical practice into the complex web of technocratic medicine it has become today. He explains: The dynamics of the [corporate medical] system in everyday life are simple to follow. Patients want the best medical services available. Providers know the more services they give and the more complex the services are, the more they earn and the more they are likely to please their clients. Besides, physicians are trained to practice medicine at the highest level of technical quality without regard to cost. . . . No limits were placed on the number or variety of medical specialties, while specialists received higher insurance reimbursements than general practitioners. Almost every conceiv147 Litigation-Based Model of Birth

able encouragement was given to hospitals to grow. Most insurance covered hospital care; doctors’ services, if given in hospitals, were more likely to be covered and paid at a higher rate.17

Starr’s description of the turn toward high cost, exaggerated medical interventions, and hospitalizations in the United States after the 1960s also provides us with some insight into how Puerto Rican childbirth practices were subject to similar dynamics. Once the government and insurance companies began covering maternal medical bills, they would be in a position to dictate and shape the landscape of childbirth practices, favoring institutionalized biomedicine and interventions. The Puerto Rico Department of Health confirmed the same dynamics in the medical system in their 1980 report on health facility statistics. The department reported that health services were facing a proliferation of insurance companies, subsidized by the public and private sectors, and a tendency to increase the number of services and specialized referrals given to each patient per symptom. The report also stated that hospitals charged insurance companies for incurred expenses, often excessively.18 By the mid-­1980s, hospital admissions for obstetrics and gynecology accounted for just over 27 percent of all admissions, second only to internal medicine (29 percent).19 The corporatization of medicine and technocratic models of birth that facilitate the overuse of medical interventions also contributed to excessive cesarean operations. The inertia of contemporary institutional medicine juxtaposed with efforts to protect patient rights produced stresses that generated legal animosities. Obstetricians were among the most sued of all medical specialists, and the number of lawsuits escalated through the 1990s. However, many misconceptions fueled the state of fear in which obstetricians lived and inflated the actual threat of a lawsuit. The exorbitant premiums of required malpractice insurance acutely affected obstetricians, who were under the impression that the high premiums were a direct correlation to the number of settlements and payments that insurance companies had had to give plaintiffs and lawyers. Obstetricians felt they had been victimized and had suffered disproportionately and unjustly in a culture that favored patient rights and powerful lawyers. In fact, many viewed insurance companies as victims of the overuse of the legal system. This legal climate, and the steep cost of insurance premiums, emerged in my interviews as one of the main reasons obstetricians abandoned their practices and why others chose not to continue in the field. Puerto Rican lawyer José Velázquez challenges these ideas in his book Crisis de impericia médica. He claims that there was no such malpractice 148 Pushing in Silence

crisis in Puerto Rico and that very few cases made it to court unjustly. In 2000, for cases that did pro­gress and were found in the plaintiff ’s favor, insurance companies paid an average of $27,750 to the plaintiff, whereas in the United States it was $125,000.20 Velázquez argues that the high cost of malpractice insurance premiums or the lack of available coverage was not due to the number of lawsuits or the money paid in legal settlements. Rather, according to Velázquez, the first crisis in medical malpractice coverage, which occurred in the United States in the early 1970s, was a result of the low returns and losses that insurance companies faced on their investments due to the crisis in the stock market and low interest rates.21 A similar dynamic played out in Puerto Rico but never reached crisis proportions, despite the media frenzy and reactions it provoked within the medical community on the island. Velázquez makes a good argument that this crisis, and the three that followed, were imported from the United States and manipulated by medical leadership, insurance companies, and the media. During the 1970s economic crisis, many insurance companies providing medical malpractice coverage to hospitals and doctors either ceased providing services or raised their premiums significantly in the United States.22 In Puerto Rico, the first insurance companies dedicated exclusively to medical malpractice came to life.23 Velázquez claims that after the publicity generated in the United States and in Puerto Rico about the crisis in malpractice insurance, the rise in premiums, and the exaggerated compensation payments to patient-­victims who take legal action, the Puerto Rican public became more prone to sue for malpractice. A litigation consciousness was born in the late 1970s in Puerto Rico. The beginning of the breakdown of doctor-­patient relationships in the 1960s and 1970s was due in large part to urbanization and professional specialization; medical care moved out of the domestic sphere, and the doctor was no longer a member of the local community and connected to the family. This deterioration of doctor-­patient relationships accompanied the medicalization of childbirth. While postindustrial culture imbued doctors with a newfound scientific authority, which the state sanctioned, it also identified doctors as strangers and part of the corporate, institutionalized world. Once patients learned that the hand that healed was also capable of harm, and that patients could demand compensation for any wrongdoing, litigation increased. By generating public concern over malpractice, doctors unknowingly rendered themselves more vulnerable to claims.24 Just as obstetrics was gaining universal control over birthing practices, patient-­doctor relationships were rapidly deteriorating. As a result of the financial crisis of US insurance companies in the late 149 Litigation-Based Model of Birth

1970s, the medical community in both the United States and Puerto Rico paid a great deal of attention to legal actions taken against them. In 1982, the Medical Association of Puerto Rico publication, The Bulletin, began including a new section titled “Medicolegal Decisions” in which they posted summaries of recent court cases related to malpractice cases from all over the United States. Of note, there are no cases from Puerto Rico listed in this section from 1982 to 2000—an absence that coincides with Velázquez’s point about the importation of the US legal crisis to Puerto Rico. Even the US Army played on the legal fears and oppressive costs of malpractice insurance plaguing doctors in a full-­page ad in the medical association bulletin.25 The headline boldly states, “Dr. Collins isn’t paying his medical malpractice premium this year.” The ad goes on to explain that the army would do the worrying for any physician in order for them to dedicate their time and energy to the practice of medicine instead of paperwork and medical suits. Army doctors could count on a good benefit package, with the government covering their malpractice insurance. The military capitalized on heightened medico-­legal worries as a recruiting strategy. The Puerto Rican government passed a series of medico-­legal reforms in the 1980s in response to a second perceived crisis in the area of medical malpractice coverage and lawsuits. Several laws set limits to the amount of compensation awarded to victims of malpractice in government institutions and required all hospitals and doctors to provide annual proof of insurance coverage or a personal fund of $300,000 per individual physician.26 High-­risk specializations such as obstetrics and neurosurgery required more substantive policies. During the early 1980s few insurance companies offered malpractice coverage in Puerto Rico, and almost all were US companies. In 1986, in response to the call for help and the growing concerns of doctors, the government created Simed, a medical insurance union that provided policies to practitioners and included all the authorized companies operating in Puerto Rico. Doctors were not the only practitioners affected by their relationship to the law. As discussed in previous chapters, the history of legislation pertaining to birth attendants provides insight into the state position regarding the appropriate care and standards required during childbirth. The history of birthing took a new direction in the 1980s.

150 Pushing in Silence

Laws Related to Birth Attendants The final change before the new millennium related to legislation directly affecting midwives was law 112 of 1980 (amending law 22 of 1931, which regulated midwifery and birth attendant licenses). The most noteworthy change related to midwives was that the word midwife had disappeared and the power of professional associations had expanded, thereby assuming that the only people attending births were doctors in hospitals. Legal documents, including the Department of Health’s annual reports, no longer mentioned home births and midwives. With this law, midwifery became deregulated, paradoxically opening the way for greater independence, all the while pushing them into anonymity. The midwife was not recognized legally, but neither was she specifically marked as illegal. According to this law, however, midwives were required to have a license to assist a delivery. Ironically, despite the intent of the law, because there was no means of actually acquiring a license to practice in Puerto Rico, midwives would only have the option to assist a delivery illegally. As far as the law and the Department of Health were concerned, midwives no longer played a part in Puerto Rican society. One group that was able to react to the deregulation of midwives within the new legal and cultural parameters was the Nursing Association. In 1985 the Board of Nursing Examiners authorized a register for obstetric nurses under the 1965 law 121 that regulated nursing. Nurse-­midwives did graduate during the 1980s and 1990s in Puerto Rico, but they found it very difficult to find work as midwives within the biomedical system. Powerful medical institutions could have feasibly trained midwives to fulfill new technical and scientific expectations, yet this did not occur. Instead, midwives could only achieve a legitimate status by placing themselves within officially recognized biomedical power structures. Legal recognition, however, alters practice. Despite the allocation of status, visibility, and privileges, professionals are less inclined to contradict imposed standards and might self-­censor their behavior to avoid penalties and maintain their license, making innovation or change difficult. In the case of midwives, and especially novoparteras (about whom I elaborate below), this could have serious implications since their practices did not necessarily follow dominant medical patterns. Midwives and obstetricians often had differing understandings of what the birthing process is and how it should be handled. Some nurse-­midwives joined obstetrical teams, thus giving up their independence and putting themselves under authoritative, interventionist, and predominantly male medical supervision. Nurse-­midwives situated 151 Litigation-Based Model of Birth

themselves in inferior roles in a context where all supervision and decision making were done by people outside of their profession. One could even argue that in this scenario they no longer acted as midwives, but rather as nurses. The law thus suppressed midwifery as an independent practice and redefined it within the medical domain. Midwives did not participate in these procedures of supervision and legal decision making concerning their practice. The penal code of 1974–2004 describes the requirements for obstetric nurses to obtain a license.27 Obstetric nurses had to be of legal age and in good mental and physical health, have good moral standing, and have a diploma from a recognized high school; they were also required to attend twenty-­five normal births under medical supervision in a recognized clinic and pass a written exam. Surprisingly, in section 1191, “midwives” (not obstetric nurses) are briefly mentioned in a regulation that required them to register with the local district, which then submitted the registration to the secretary of health. The text refers only to this process of registration and nothing else. In the 1980s, one of the few new Puerto Rican novoparteras attempted to follow this registration procedure.28 She wrote a personal letter to the secretary of health inquiring about the midwife registry and the auxiliary midwife exam, which she knew had fallen into disuse. She had met Secretary Izquierdo Mora when she attended his mother as a paramedic during an emergency. She later contacted him, inquiring about the law. Izquierdo Mora responded and promised to look into it. She sent a second letter but never received an answer.29 Midwifery fell into legal limbo after the 1980s. The Puerto Rican history of birthing regulations and licensing exposes the links between the law, culture, and social power structures. These areas affect one another constantly in ever-­changing, reciprocal ways. Because midwives had no legal standing in Puerto Rico, medical practitioners and institutions protected themselves by excluding them. While some physicians on the island would have been open to collaborating with midwives, their malpractice insurance and licensing regulations did not permit it. Midwifery’s lack of legal standing generated hostility between midwives and other medical practitioners. The same schisms developed between any sort of alternative medicine and institutional, mainstream practice. The possibilities of sharing knowledge and experiences were severely limited. Patients were forced to choose between obstetricians and midwives. Pregnant women had to choose either to work with a midwife who had no access to existing medical structures or health insurance and was practicing in the margins of the law, or with an obstetrician who was legally regulated and therefore restricted and bound to accepted protocols. 152 Pushing in Silence

All of the novoparteras working in the 1990s said there were a few obstetricians they identified as allies and who agreed to attend pregnant women hoping to birth at home with a midwife. Some expecting mothers were able to make longer trips to visit these obstetricians while they were under the care of midwives and develop a birth plan with both attendants, as I did. Other women who planned home births chose not to disclose their plans to their obstetricians. Doctors who might otherwise have attended a home birth could not do so for the same reasons they could not work with midwives. The legal and administrative context in which birthing practices developed after 1980 placed birthing in a tense relationship with doctors, insurance companies, and technology. New options, medical insurance coverage, more hospitals, and access to the latest technologies did not always work to benefit the health of the mother and infant. In other words, despite the rising costs and availability of options, the post-­1980s technocratic model of birth did not necessarily provide the results that were expected. Analyzing the rise in cesarean section deliveries allows us to explore the contentions that arose in the 1980s.

Cesarean Sections After the 1970s, birthing in Puerto Rico had become fully medicalized. It later followed a technocratic model, and deliveries by cesarean section skyrocketed; in some hospitals, they became as common as vaginal deliveries. In 1989 a new category was included on Puerto Rican birth certificates to track birthing methods. Since then Puerto Rican birth certificates have included a section indicating whether the birth was surgical. Half of all 1989 births in private hospitals were by cesarean section.30 Since the 1980s, Puerto Rico has maintained its rank among the countries with the highest rates of cesarean deliveries. The United States has ranked among the top five, but always behind Puerto Rico.31 The US and Puerto Rican cesarean rates were similar in the 1980s, but while US rates remained relatively steady, they doubled in Puerto Rico over the next two decades. The high rates were, in part, a product of doctors in Puerto Rico being much less likely than US doctors to allow women with a previous cesarean to deliver vaginally.32 The rates of cesareans increased with the age and level of education of the mother, as they often do in other areas of the world. This global trend ties surgical deliveries to social class. The public health sector was still serving the majority of pregnant women in Puerto Rico, just as it had in previous years. Yet by the early 153 Litigation-Based Model of Birth

Table 5.1. Selected cesarean rates in the Western world, 1985 Brazil Puerto Rico United States Uruguay

32% 29% 23% 17%

England Spain Czechoslovakia Netherlands

10% 10%  7%  7%

Source: Turner, “Cesarean Section Rates, Reason for Operations Vary Between Countries,” Family Planning Perspectives 22, no. 6 (Nov.–­Dec. 1990): 281.

Table 5.2. Selected cesarean rates in the Western world, 2002 Puerto Rico Mexico Italy Brazil United States

45% 39% 36% 37% 26%

England Netherlands Honduras Haiti

22% 10%  8%  2%

Sources: Bertrán et al., “Rates of Caesarean Section: Analysis of Global, Regional and National Estimates,” Paediatric Perinatal Epidemiology 21 (2007): 98–113. Data for England and the Netherlands from S. N. Mukherjee, “Rising Cesarean Section Rate,” Journal of Obstetrics Gynecology of India 56, no. 4 (July–­Aug. 2006): 298.

1990s, a third of the Puerto Ricans had some sort of private health insurance, almost always through employers. Despite this increased access to private medical care, 62 percent of mothers delivered their children in government hospitals, and 38 percent delivered in private hospitals.33 The differences in obstetric practices and definitions in these two sectors are worth mentioning. Private hospitals and hospitals serving women from higher social classes performed cesarean sections more frequently. At the same time, women from higher social classes received better prenatal care and had better health outcomes than women from less privileged social sectors. Yet obstetricians from private hospitals in 1991 reported many more complications and risk factors during their deliveries. As an example, cephalopelvic disproportions were reported at 12 percent in private hospital deliveries compared to 2 percent in public hospitals.34 Private hospitals performed 154 Pushing in Silence

cesareans in 27 to 73 percent of their deliveries.35 During the same year, in the public University District Hospital—one of Puerto Rico’s leading medical institutions, where the most complicated cases from across the island were referred—the cesarean rate was 27 percent.36 Further clues that sociocultural factors and not solely medical need motivated surgical births are in the varying statistics from the various regions and public and private sectors. Table 5.3 details some of these disparities. During the same year and in the same region, cesarean rates were up to twice as high in private hospitals as in public hospitals. These differences are not always consistent, and there are regions where the differences are less dramatic. Moreover, cesarean rates vary greatly from hospital to hospital. Despite the inconsistencies and variations between hospitals, general trends point to increases in surgical interventions. According to medical standards of the time, cesarean sections should be performed whenever the well-­being of the mother or baby is threatened. If doctors followed these standards in Puerto Rico, it means they Table 5.3. Cesarean rates in Puerto Rico by region and sector C-­sections per 1,000 live births, 1980

C-­sections per 1,000 live births, 1984

Public Private Difference

Public Private Difference

North

152 307 102%

132 338 156%

Northeast

268 416  55%

East

219 293  34%

Region

C-­sections per 1,000 live births, 1980

C-­sections per 1,000 live births, 1984

Public Private Difference

Public Private Difference

West

138 325 136%

227 426  88%

224 512 130%

South

112 190  70%

165 354 115%

211 378  80%

Metropolitan

212 395  86%

229 502 119%

Region

Source: Departamento de Salud: for 1980, Health Facilities Statistics, 1981–83, 64; for 1984, Health Facilities Statistics, 1984–85, 82.

155 Litigation-Based Model of Birth

found between one-­fourth and half of all deliveries to be abnormal or problematic. Doctors therefore considered the physiology of almost half of all laboring mothers dangerous to themselves or their babies. How does this affect contemporary definitions of motherhood and the female body? What does it mean that nearly half of all mothers in Puerto Rico came to believe that they were unable to rely on their capacity to deliver their babies safely? It is not likely that birth was more dangerous for babies in the 1980s and 1990s than during the previous thirty years. Was the high incidence of cesareans related to improved rates of maternal and infant mortality and morbidity? If so, how would we explain that countries such as the Netherlands and Czech Republic, ranked among the best for infant and maternal mortality and morbidity rates, are also ranked as having among the lowest cesarean section rates? Why were the midwives working in Puerto Rico in the 1980s and 1990s able to deliver at least 95 percent of their clients’ babies without cesareans, medications, or episiotomies, and without provoking lawsuits or poor neonatal and maternal outcomes? There are no easy answers to these questions, but it would be no stretch of the imagination to accept that among the array of factors that might form part of the discussion is that changes in birthing practices related to cesareans did not merely rely on objective scientific evidence, but included shifts in the sociopolitical and cultural environment. In 1950 a pregnant woman could assume that she would birth vaginally, but by the 1990s, women knew their babies had a good chance of being removed from their wombs surgically. In 1950, medical standards classified doctors with rates of cesarean deliveries higher than 10 percent as incompetent, and in the early 1960s, cesareans constituted just over 5 percent of all deliveries on the island. They increased to 27 percent by 1980, around 33 percent by 1990, and over 40 percent by 1996.37 In the 1950s cesarean sections were surgical, life-­saving procedures—not precautionary or preventative procedures. They were performed only as a last resort, when the mother’s life—and in rarer cases, the newborn’s—was in danger. As discussed in previous chapters, doctors had previously strived to maintain low cesarean rates because of the negative impact a high rate could have on their medical practice. In the 1990s, birth by cesarean was cast in a new light by doctors and patients. Most people associated cesareans with good obstetric practice, and doctors knew they could protect them from possible lawsuits while leaving the recent mother feeling grateful and reassured that she had been served by a highly qualified specialist. Dr. Ramírez, who had practiced medicine since the 1950s, offered his explanation for the rise in cesarean section deliveries over the course of 156 Pushing in Silence

his career as an obstetrician. Ramírez graduated from a medical school in Philadelphia in 1956 and returned in the late 1960s to specialize in obstetrics and gynecology. In the interim, he spent several years in Germany with the military in maternity services. After years of practice in Puerto Rico, he dedicated much of his time to educating and training future obstetricians. Ramírez did not allow partners to enter the delivery room; held rather conservative positions regarding women, labor and delivery; and was probably the first and only doctor to administer epidurals to his own patients in 1969 without the help of an anesthesiologist.38 He performed episiotomies in 98 percent of his deliveries.39 I include these details to establish that he was a proponent of medicalized births and did not favor alternative birthing practices, even in the new millennium, when I interviewed him. During his time in Germany, the cesarean rate was 3 percent, whereas in his practice in 2005 in the San Juan Municipal Hospital, it was 30 percent.40 Ramírez explained that “a single baby born with damages [condiciones] . . . costs millions” and doctors’ fear of lawsuits had driven up the cesarean rates.41 He insisted that many doctors resorted to cesareans as a preemptive strategy to avoid potential malpractice suits. Doctors chose to perform cesareans because they did not want to be liable if anything went wrong during a delivery or with the child’s future development. According to this line of thought, a cesarean was evidence that the medical team did all it could for the mother and child.42 Dr. Carmona, another obstetrician I interviewed during my research, elaborated on the rise in the number of cesareans. All doctors mentioned this increase as one of the changes birthing underwent over the final decades of the twentieth century. Carmona said that obstetricians had ceased resorting to intrauterine maneuvers and no longer delivered babies that were not in the ideal vertex presentation.43 He went on to say that doctors were no longer trained to deliver a breech baby, nor did they know how to assist when an infant’s shoulder was delaying a delivery, for example. Furthermore, doctors refused to perform less invasive manual maneuvers because they feared if anything went wrong, they would be accused of malpractice.44 Carmona and other obstetricians acted on the premise that problems in the course of a vaginal delivery would be considered the doctor’s fault, whereas a cesarean delivery would free a doctor of responsibility.45 Another reason cited for the increase in cesareans was the substitution of cesareans for forceps deliveries. Despite the evidence against this practice, which resulted in the elimination by the 1980s of forceps training in obstetric curriculum both in Puerto Rico and the United States, the obstetricians I interviewed were not critical of forceps use, though they were 157 Litigation-Based Model of Birth

aware of this shift. Many implied that if doctors could resort more often to forceps deliveries, they would not have to perform so many cesarean operations. This perplexing argument, I suggest, emerged in response to current concerns about the high cesarean rates while ignoring previous medical research and controversies because they are no longer part of current conversations and concerns. To be clear, delivery by forceps has its own set of problems and is by no means unproblematic. The trend toward specialization and increasing reliance on new technologies and expert assistants also contributed to the rise in cesarean sections. Dr. Mulero, for example, spoke of a marked improvement in medical facilities and access to a variety of specialists making for safer options, in addition to the fact that these surgeries were becoming more accessible and familiar.46 Despite the overall recognition that cesareans carry a higher risk of complications and increase recovery time, doctors were comfortable and familiar with the procedure, which only in rare cases threatens the mother’s life. If we add the fact that the specialized medical-­industrial complex also supported and paid for operative procedures carried out in hospital settings by experts, it makes for a convincing component of the explanation for the rise in cesareans. Also, cesareans are more predictable, efficient, and convenient than spontaneous labor, complementing the postindustrial expectations of expediency and greater efficiency. Modern Western medicine classifies vaginal deliveries as the normal, preferred, and safest form of birthing yet routinely moves away from that ideal by identifying childbirth as pathological. According to Dr. Ramírez, cesarean rates at the San Juan Municipal Hospital during the early 2000s were only 12 percent for first-­time mothers, but 30 percent when mothers with a previous cesarean are included. A similar tendency was seen all over the island and was due to fears surrounding women having vaginal births after cesareans. Every doctor I spoke to in Puerto Rico, whether in formal interviews or informally, expressed a strong fear and quick reaction to vaginal birth after cesarean (VBAC), with the exception of those doctors (and midwives) such as Dr. García (see chapter 4) who did not adhere to local medical conventions. Women around the world have VBACs successfully, including in the United States, where the rate is higher than in Puerto Rico. A couple of very rare yet dramatic cases in which mothers with previous cesareans ruptured their uteruses during labor were cited by some doctors in Puerto Rico as the reason they are not willing for their patients to have a VBAC. So in Puerto Rico, with rare exceptions, the saying “once a cesarean, always a cesarean” held true. Most women are aware that a cesarean involves surgery and carries some risk, but they also know 158 Pushing in Silence

that there are risks attached to pregnancy, labor, and delivery overall. With the advent of blood transfusions, improved anesthesia, and antibiotics, many of the more common and fatal risks associated with cesarean operations were greatly reduced. What many doctors were aware of, but very few women knew, however, are the complications accompanying cesareans—risks that rise significantly after a second and third cesarean. Obstetricians in Puerto Rico and the United States have claimed that more than one cesarean delivery is high risk, and multiple cesarean deliveries entail so much risk that they recommend avoiding further pregnancies altogether. Therefore, according to medical guidelines, the decision to perform a cesarean carries with it the weight of the concurrent decision to avoid future children or put the mother’s well-­being at considerable risk.47 Many health organizations have issued statements of concern over the rising rates of surgical births since the 1980s. The World Health Organization (WHO) has urged countries to maintain cesarean rates below 15 percent, and the American College of Obstetricians and Gynecologists recommends no more than 15 percent for first-­time mothers.48 Often, international health organizations have promoted midwifery as a solution to high health costs, poor birth outcomes, and high cesarean rates. This recommendation would probably come as a surprise to many in Puerto Rico. These groups establish guidelines and offer suggestions that influence hospital staff, nurses, and obstetricians around the globe. In 1985, for example, the WHO held several important conferences in Brazil and California to establish appropriate birthing technologies and analyze and criticize the routine use of medical interventions such as episiotomies, cesarean sections, electronic fetal monitoring, shaving, enemas, induction, rupturing membranes, and using analgesics and anesthesia.49 These international pressures and concerns impacted the United States. Recognizing room for improvement and wanting to respond to international trends and concerns, in health objectives outlined for 1990 the US Department of Health included the goals of reducing neonatal and maternal mortality and lowering the rate of newborns with low birth weights.50 The few midwives doing home births in Puerto Rico after the 1980s had significantly higher breast-­feeding rates; lower cesarean, maternal, and infant mortality rates; and fewer underweight babies than the national averages. In fact, they surpassed the goals set by the US Department of Health for 2010. According to a study completed in 1999 by Debbie Díaz and Merixa Cabrera of UPR’s School of Public Health, the percentage of underweight babies born under the care of midwives was 1.7 (compared to 10 percent born in hospitals), cesarean sections never surpassed 4 per159 Litigation-Based Model of Birth

cent, 98 percent of mothers breast-­fed their infants (compared to less than 10 percent of mothers who delivered in hospitals), and 89 percent of their clients delivered successfully at home as planned without compromising the well-­being of the mother or child.51

Novoparteras (New-­M idwives) The late 1970s and 1980s were periods of reformulation and transformation. Midwifery practices died out to be born again under a new guise. These were not the auxiliary midwives52 from the 1950s who could not defend or adapt their practices during the overwhelming changes of colonial industrialization. The very small group of midwives of the postindustrial period came imbued with new knowledge and the intention to sustain their principles and autonomy. They were the bridge between the ancient legacy of midwives and the demands of modernity. I refer to this post-­1977 group of midwives as novoparteras and those who were part of the initial group of government-­licensed midwives between the 1930s and 1970s as comadronas auxiliares. I use two distinct terms for several reasons. The terms parteras, comadronas, and matronas have been used interchangeably in Puerto Rico and can lead to confusion. Even so, periodic preferences and titles carry determined meanings in particular historical moments that I try to maintain. It also serves us better to distinguish between the midwives who worked from 1946–1977 and those who began working after the 1980s. Though they are akin to the comadronas auxiliares, the novoparteras are clearly distinct in that they saw themselves as part of a broader movement, sought each other out, and incorporated biomedical practices. The post-­1980 midwives refer to themselves in their documentation and international presentations as Grupo de Parteras Puertorriqueñas (Group of Puerto Rican Midwives). Partera is the Spanish word for “midwife,” stemming from parto, meaning “birth.” This term is used more frequently today. Comadrona, meaning “with the mother,” is another name for “midwife” in Spanish. Although this term is still used regularly, it tends to refer to the group of midwives practicing before the 1970s. The Department of Health referred to licensed midwives as comadronas auxiliares through the 1970s. The novoparteras met formally for the first time in 1997 to put together what they titled “Special Documents of the Midwives of Puerto Rico”53 to define their profession and establish their statutes of practice, among other things. The group adopted a definition for midwife (partera) in ac160 Pushing in Silence

cordance with the International Confederation of Matrons (ICM) and the Federation of Gynecology and Obstetrics (FGO) and adopted by the WHO. It reads as follows: A matron is someone who, after being regularly admitted to an educational midwifery program, duly recognized in the country in which it pertains, has completed successfully the required courses and acquired the competence required of her in order to be authorized to practice as a midwife. She should be able to offer supervision, care and advice to women during their pregnancy, birth and postpartum stages: to direct births under her own responsibility and bestow care to newborns and/or the nursing child. This care includes preventive measures, the detection of abnormal conditions of the mother or child, attaining medical assistance and the performance of emergency medical care in the absence of medical assistance. She has an important task of advising and educating in areas of health, not only for the women, but also within the family and the community. The work should include prenatal education and preparation for maternity and extends to areas of gynecology, family planning and infant care. It may be practiced in a hospital, private practice, health center, at home or in any other service.54

Novoparteras are also required to have a high school diploma and a license in cardiopulmonary resuscitation (CPR) for adults and infants, and they must complete midwifery courses and university-­level classes in anatomy, physiology, microbiology, embryology, pathology, genetics, psychology, and botany. Additional recommendations included attending 20 births supervised by certified midwives and 10 births outside of a hospital setting; conducting 75 prenatal exams (20 of which should be intakes prior to prenatal care), 20 newborn exams, and 40 postpartum exams; and following up with continued education after certification. The novopartera documents include a brief section on the history of midwifery from biblical times, a definition of the profession, statutes for practice, the health criteria they require of their patients, their declaration of values for infant and maternal care, their vision of the maternal cycle and health in general, and finally their professional requirements. The documents reflect profound knowledge of international standards and public health issues and their concern with securing autonomy and respect for their profession. This intellectual effort to organize and document their practice set them apart from the comadrona auxiliares of earlier 161 Litigation-Based Model of Birth

periods. The novoparteras were organized, informed about all aspects of midwifery, and determined to remain an alternative to mainstream maternal health institutions. They were willing to confront the challenges of the modern industrial world and formed ties with other midwives on a local as well as international level. Their educational standards were high, and they were trained in several health-­related fields. Their “values [we]re born from the respect toward life, scientific knowledge and the necessary empirical understandings to manage the gestation, puerperal and birthing processes of the human being.”55 Unlike previous Puerto Rican midwives, the novoparteras sought a niche within the worldwide midwifery network. These contacts and international affiliations afforded them strength in providing support and validation beyond Puerto Rico. One of these groups was the International Confederation of Midwives (ICM), founded in Belgium in 1919. The WHO and the United Nations Children’s Emergency Fund (UNICEF) both recognize the ICM, and the WHO ratified the definition of midwifery that the ICM drafted together with the International Federation of Gynecology and Obstetrics (1972).56 This was the same definition that the novoparteras of Puerto Rico adopted. In 1982 the Midwife Alliance of North America (MANA) emerged.57 This organization connected midwives from the United States, Canada, and Mexico, and included Puerto Rico due to its status as a US territory. MANA is a member of the ICM.58 Several of the novoparteras are US certified professional midwives (CPM) and members of MANA.

Novoparteras and Their Clients In 1978 there were two women who began attending home births: one worked in the area around Rincón (the western side of the island) and the other in Luquillo (the eastern side).59 The Rincón midwife was from the United States; the Luquillo midwife was Puerto Rican. Another woman, born and raised in San Juan, studied midwifery in the United States around 1980–1982. Between 1983 and 2002 she attended more than 400 successful births.60 A fourth woman, after meeting with the other two still in Puerto Rico, began attending prenatal exams in 1986 with the second midwife in Luquillo and in 1991 studied midwifery in Texas.61 She too returned to Puerto Rico to work as a midwife. Later, a midwife from the United States came to the island to work for two years (around 1997–1999).62 In 1998, a final midwife joined the group.63 The latter two midwives are not specifically included in this study because they started their practice after I had 162 Pushing in Silence

completed my research. Each of these novoparteras had formal training in several health-­related fields. Although these five women attended an insignificant percentage of births in Puerto Rico compared to obstetricians, they had a disproportionate impact in the local media. They were on television64 and were covered several times a year in the press.65 They offered an alternative for pregnant women, represented Puerto Rico in international forums, published articles in midwifery publications,66 and helped to coordinate the Latin American and Caribbean Network for the Humanization of Childbirth (RELACAHUPAN).67 In the study from UPR’s School of Public Health, Debbie Díaz and Merixa Cabrera drew from a randomized sample of fifty-­three mothers who birthed at home with the novoparteras. All of them were asked the same questions regarding the services that they had received from novoparteras.68 Their ages at the time of their home births ranged from twenty-­ five to thirty-­nine. Most were married and had no particular religious affiliation. Sixty percent of the women had obtained a college degree, and 30 percent had done some form of graduate studies. Twenty percent of these women were from the United States, and 68 percent were Puerto Rican. The clients’ incomes varied from $1,000 to $2,000 a month for 43 percent of the mothers, and over $2,000 a month for 42 percent, making for a predominantly middle-­class clientele.69 Every mother interviewed classified the novoparteras’ services as excellent or very good and reported that they would have their next baby in the same fashion. Though the novoparteras did not have much of an effect on obstetrics, the success of their practice challenged many of the premises of mainstream obstetrics. They challenged the assumption that the only safe and proper place to deliver a baby was in the hospital with episiotomies, electronic fetal monitors, IVs, and epidurals. At the same time, they insisted that home births were not for everyone. Because they knew their impact and numbers were low, the novoparteras looked to reinforce their ideas in likeminded transnational movements. Novoparteras responded to international tendencies and represented Puerto Rico at international forums. They also promoted their practice in the local media to such an extent that many people in Puerto Rico had heard of them, and when I mentioned them to obstetricians in the new millennium, they were less likely to react with a condemning comment, as they often did in the 1990s. Most readers are probably somewhat familiar with the practice of obstetrics and have been in a hospital setting and able to imagine many of the experiences I describe about hospital births. By contrast, few people are familiar with practices of novoparteras. The subsequent pages provide 163 Litigation-Based Model of Birth

a closer look into these practices and also the lives of the few novoparteras practicing in Puerto Rico during this time period.

Ruth: The Bridge Between the Past and the Present Ruth, a mother of six, was born in Santurce, Puerto Rico, in 1938. Her father was a quincallero (street vendor) and her mother a seamstress. Ruth’s postsecondary education was originally in secretarial skills. She was accepted to the University of Puerto Rico to study biology but, because of personal reasons, never attended class. She did train with the first group of naturopathic physicians on the island.70 Naturopathic medicine treats health conditions through the body’s inherent ability to heal, and naturopathic physicians aid the healing process by incorporating a variety of alternative methods based on the patient’s individual needs, including nutrition, herbal medicine, and homeopathic remedies, among others. They also consider diet, lifestyle, work, and personal history. According to Ruth, naturopathy was an extension of her upbringing.71 Although not formally trained, her mother had practiced it. While living for a brief period in California as a young adult, Ruth trained as a home health aide, similar to a home nurse. She later studied kinesiology and trained in reflexology, natural childbirth methods, acupuncture, and CPR. She studied these different techniques throughout her life in Puerto Rico, Pennsylvania, and California. In addition to practicing naturopathy, she began offering midwife services after 1978. In contrast to the other novoparteras, Ruth had no formal training in midwifery. In Ruth’s words: “I am a midwife simply because life led me without me realizing it. . . . I love it.”72 She attended her first birth unexpectedly. In the late 1970s, while she was working in a health food store on the east coast of Puerto Rico, a couple came in to solicit her help in the birth of their first child. They were determined not to go to the hospital and decided to solicit Ruth’s assistance because she had six children of her own and was trained in natural medicine. At that time Ruth had never witnessed a birth. Yet when she realized that the couple would otherwise birth alone, she agreed to assist them. Ruth thought that if anything happened, she could at least send for help. Even so, she insisted that they first visit an old midwife from the area who had retired from practice. The former midwife gave them instructions, which Ruth used when she received that first baby. Within a year a second mother, a psychologist, came looking for her services. Ruth explained that she was not a midwife but finally agreed to 164 Pushing in Silence

study together with the expectant mother to prepare for the birth. They consulted with doctors, read many books, and took CPR courses. Over time, Ruth continued consulting with other older midwives and educating herself about pregnancy and labor. From then on, mothers continued to seek her help. Ruth interpreted her role as a midwife as being “an instrument of God.”73 She was conscious of the fact that she was bridging the past and the present. She believed her career as a midwife had evolved from experience, demand, and divine gifts. She attended over 230 pregnancies and deliveries and had the most impressive statistics of the novoparteras in 2000, when I interviewed her. Of the 230 deliveries, 228 gave birth with her. She explained during her interview that she had never turned a woman down for any reason, including complications or risks. She added that she even managed to control diabetes in the few women who displayed the symptoms. All women and babies under her care concluded their pregnancies and postpartum in optimal health. She transported two women to the hospital in stable condition.74 One of the transports resulted in a cesarean section, an indication that cesareans had a vital role to play even in Ruth’s mind. She never needed to use stitches because her clients never experienced noticeable perineal tears. Ruth never had to confront medical complications in any of the 230 births she assisted. Mothers received scrupulous prenatal care with Ruth. Some saw a gynecologist as well. Ruth visited the pregnant women at home every month. She reviewed their diets, emotional health, hours of sleep, hours of watching television, and exercises in a detailed manner. Toward the end of gestation, she increased her visits to every two weeks. She monitored the mother’s diet, water consumption, and exercises, taught about proper nutrition, and, if necessary, provided instruction for cooking alternatives and recipes. On occasion, Ruth performed pelvic exams and checked for infections or irregularities. For the actual birth, Ruth took her herbs, teas, natural antibiotics, a thermometer, stethoscope, fetoscope, clamps, Pitocin, scissors, and gloves. She checked the mother’s and the baby’s vital signs regularly. Ruth provided birthing mothers with perineal massages with olive oil, and when it came time to push the baby out, she manually protected and supported the perineum. She never left the mother alone. Generally, Ruth worked by herself but on occasion one of her family members accompanied her. She, in turn, occasionally accompanied other midwives and might also invite a midwife to her births. The father, who was usually present during labor and delivery, cut the umbilical cord unless he declined. Anyone the mother wished to have present could be there, but Ruth did ask for 165 Litigation-Based Model of Birth

silence during the contractions. Ruth taught the mother breathing techniques during the prenatal care phase to control pain. She also used reflexology and acupressure for pain management. During postpartum, Ruth inspected the baby and the mother carefully. She weighed and measured the newborn, took its vital signs several times, and made sure that everything was in order. Before leaving, Ruth applied Golden Seal, a natural disinfectant and antimicrobial herb with several medicinal uses, to the baby’s eyes. Over the following days, Ruth visited the family several times and kept progress notes. Before she began meeting with the other novoparteras, Ruth would leave payment for her services to the family’s discretion. This changed when the Group of Puerto Rican Midwives decided to standardize costs so that clients would not be swayed by economic factors when making birthing choices. The novoparteras did not want such matters to affect their relations with clients.75 Ruth described her “mothers” (clients) as marvelous and particularly intelligent. She claimed that they were brave and adamant about birthing at home. They were willing to adapt their lives to achieve better health and bring their babies to the world in the best possible manner. They did not want outside intervention and trusted Ruth. Her clients came from all religions, beliefs, and nationalities.76

Rita: Naturalist and Emergency Medical Technician Rita was born in 1955 in Old San Juan, where she grew up. She is the daughter of an enlisted military man/postal worker and a housewife. Rita studied to be a secretary and accountant in a vocational school but later enrolled in the Interamerican University in the late 1970s. She majored in psychology and anthropology. Later she completed courses in premedicine and natural medicine in Puerto Rico, and on occasion in Oregon, in the early 1980s. Rita then went to New Mexico to study at Santa Fe Midwifery and Healing Arts. During her time there, midwifery and natural medicine split into separate schools to become accredited. Rita obtained her certification in midwifery but needed to find a place to fulfill her practice requirements before she could be licensed. Instead, she returned to Puerto Rico to study emergency medicine at UPR’s Medical Sciences Campus. For the next ten years, between working as a paramedic and teaching, she put her emergency medical technician (EMT) license to good use. Not satisfied with her training, she went back to the United States to study midwifery at the Maternity Center La Luz in El 166 Pushing in Silence

Paso, Texas. This time she was able to gain clinical practice in the birthing center and trained there for fourteen months. Concerned about not having enough practical experience and too much theoretical preparation, Rita decided to join a Mexican obstetrician, Dr. Matalarita, whom she met at the clinic, and his Cuban wife in a mobile medical unit that traveled through northern Mexico providing ambulatory services to women. Upon returning to Puerto Rico, Rita needed to find a steady job but was unsure about how to begin working as a midwife, so she worked and taught emergency medicine with the Department of Health. Eventually she made contacts with La Leche League and began attending births after 1983. It was then that Rita came into contact with Ruth. By this time Rita was married and chose to move to the United States one more time so her husband could pursue graduate studies. She returned to Puerto Rico when he was offered a job in the tropical rainforest of El Yunque after the 1989 devastation of Hurricane Hugo. She has lived and worked as a midwife in Puerto Rico since. Rita had attended more than 400 births by 2002 and had transported only 2 percent of her clients to hospitals. These transports mostly resulted in cesarean sections. Of the total births, she recalled two emergencies where women were transported to the hospital and delivered their babies without further complications. She resorted four or five times to the episiotomy. Rita reported no maternal or fetal deaths among her clients. Rita required an initial interview with women who sought her services to make sure they were clear about what a home birth entails. They discussed what their expectations were and determined whether they would work well together. No one was accepted as a client until the first lab results were obtained indicating normal levels of sugar and hemoglobin. She then completed a medical and personal history. Rita did not take clients with uncontrolled high blood pressure, nor did she do premature deliveries. Over the course of the pregnancy, she monitored the gestational development and developed a birthing plan with the mother. She never attempted to persuade a mother to birth at home. This decision came from the mother. Rita was very clear and insistent about this. The woman had to be willing to learn, to be open and honest, and to enter into an intimate relationship with her midwife. Rita preferred beginning prenatal care in the very early stage of pregnancy. If during the pregnancy a health condition developed that could put the mother or baby at risk, the mother was dropped as a home birth client. Rita would take four bags with her the day of the actual birth. She had equipment for medical emergencies, oxygen, Pitocin, and herbs and homeopathic plants. Rita assisted the mother with massages and suggested 167 Litigation-Based Model of Birth

positions for the different stages of labor and circumstances that could arise. Rita was very comfortable with the use of herbs and alternative medicine. The atmosphere and place of the birth were up to the mother. She varied and adapted her strategies in accordance with each woman. After the birth, Rita stayed with the family for four or five hours. Before leaving, she made sure that breast-­feeding was established, the mother was bathed and had used the bathroom, had the necessary assistance she required, and that she was properly fed. Though the costs of Rita’s services were predetermined, she said she received payment from only a third of her clients. It was clear to her that she could not make a living this way. Like other novoparteras, Rita did not possess business acumen, nor did she have the mechanisms to follow up on debts owed for her services. For midwifery to be a realistic or attractive professional alternative, the practice would have to be restructured, midwives would have to work in teams, and prices would have to increase. If health insurance in Puerto Rico would cover birthing expenses with midwives, as it does in other countries, midwifery could be a feasible career alternative. The auxiliary midwives of previous years had confronted these same limitations in their ability to make a living from their practice. Rita’s clientele exceeded average levels of education. They also had an inclination toward alternative medicine and liberal ideals. They were almost without exception women “who [felt] affectionate toward everything having to do with the family.”77 They were mothers who wanted a lot of control over their bodies and birthing experiences.

Debbie: Organizer and Unifying Force Debbie was born in 1964 and raised between Hato Rey, Isla Verde, and the United States. Her father worked in casinos his entire life and was an athlete. Her mother was a secretary. Debbie received her high school diploma through a program similar to the GED option in the United States. She studied at both the University of the Sacred Heart and the Interamerican University, receiving a BA in history. Before completing her degree, she began reading about midwifery. After graduating in 1990, Debbie decided to go to Texas to train as a midwife in the clinic Maternidad La Luz. At that time it was led and staffed completely by direct-­entry midwives.78 Located in El Paso, the clinic’s clients were mostly Mexican or of Mexican descent. The school is state-­certified to train midwives. The curriculum at the time included 168 Pushing in Silence

neonatal resuscitation, physiology, pathology, breast-­feeding, pharmacy, herbs, homeopathy, and emergency procedures. Students were required to attend births for seven months on a daily basis. After returning to Puerto Rico, Debbie earned thirty more credits in natural science and successfully completed a course for paramedics. In 1997 she began graduate studies at UPR’s Medical Science Campus, where she completed a master’s degree. A decade earlier, when Debbie had learned that her neighbor had delivered her baby at home under Ruth’s care, she immediately sought contact with Ruth. In 1986, Debbie initiated conversations with her and began accompanying her to prenatal appointments. However, Debbie relates her roots in midwifery to her grandmother, who was a healer and espiritista.79 One of the values among the novoparteras is the recognition of the ancestral roots of their profession. Debbie explained: “I feel as if a thick silver [umbilical] cord connects me to the midwives from before.”80 Coming from a matrifocal family of strong, educated feminists who supported each other always, Debbie felt that midwifery was a way of adding to and participating in the physiological and intuitive power of women. To her, midwifery was a way of working in an atmosphere of profound respect for and in collaboration with other women. After ten years of work as a midwife and more than a hundred deliveries, 89 percent of her mothers had delivered full-­term at home. Most of those she transported were first-­time mothers. She had one case in which the fetal heartbeat was erratic enough that she decided to transfer the mother to a hospital. She never had a complication or emergency situation that was not handled adequately. She did not practice episiotomies, and though she was prepared to suture (she had done so three times), put in an IV, and use oxygen or Pitocin, she rarely had to resort to any of these measures. According to Debbie, “a midwife is an expert in keeping health balanced.”81 Novoparteras believe in collaborating with other professionals, and she made all the necessary referrals. During pregnancy, the mother typically visited a gynecologist and completed a battery of tests that allow risks to be identified or ruled out. Debbie informed her clients that if she detected a complication at any time during the pregnancy, delivery, or postpartum, she would refer them to a hospital or place them under a physician’s care. In the prenatal stages the midwife did what she could to prevent or correct anomalies such as preeclampsia. She almost always succeeded and continued care as planned, but in the cases that she was unable to maintain or restore health, the client would not remain under her care. Debbie visited the mother’s home once 169 Litigation-Based Model of Birth

a month until the thirtieth or thirty-­second week of gestation, when visits increased to every two weeks. In the thirty-­sixth week, Debbie saw the mother on a weekly basis and went on alert. During prenatal visits Debbie addressed the physical and emotional status of the mother, answered questions, and took the mother’s blood pressure, temperature, and pulse. The most basic element in the care of the mother and fetus was to follow a proper diet. Debbie measured the fetus, listened to heartbeats of both mother and child, and checked for symptoms of preeclampsia, urine infections, and toxemia. Visits lasted at least forty-­five minutes. For the delivery, the mother was responsible for providing impermeable bed pads, cotton, rubbing alcohol, hydrogen peroxide, baby hats, clean sheets, and Gatorade to stay hydrated. Debbie stayed with the mother for the duration of the labor. She took vital signs regularly during the contractions with her fetoscope and stethoscope. If Debbie needed to, she would use her herbs and tinctures and also biomedical drugs, such as Pitocin, which can be used for slow contractions or, as in my case, stop hemorrhaging. To intervene with the savvy of the woman’s body was not prudent, in Debbie’s opinion. Although she believed that there were women who did not listen to their body signals and sometimes panicked, thus requiring more intervention than others, for the most part women knew instinctively what to do. Without instructing the birthing mothers, Debbie found that they found the best movements and positions to work through their needs on their own. Normally Debbie found that she did not have to suggest what would be best or most comfortable. She emphasized that “The best mothers that birth are those who are in tune to the signals that their body gives.”82 The father who wished to could receive the baby. The protocols that determined when someone should be transported were discussed clearly and established ahead of time between the family and the midwife. For the postpartum period, Debbie first verified that the entire placenta had been expelled. She observed the health of the woman and newborn, checked bleeding, ruptures, heart rates, and so on. She inspected the baby from head to toe. She checked the height and weight, the intestines, heart, lungs, and testicles, among other things. During the first hour following the delivery, the mother would breast-­feed to stimulate involution of the uterus, reduce bleeding, and bond with the newborn. This postpartum care took four to six hours. Follow-­up visits were made the following day and on the fifth, twelfth, and thirtieth days after delivery. Debbie described her clientele as women interested in alternative medicine who were open to exploring new approaches to health. They were educated and demanding. Most were concerned with being well bal170 Pushing in Silence

anced emotionally and physically and followed good diets. Debbie said women approached her at different stages of their pregnancy, though most frequently during their sixth month. She felt her relationships with clients were very close. Mothers choose their midwife, but midwives also choose their clients, according to Debbie. She explained the relationship between the mother-­to-­be and her midwife as an intimate process in which they interact and connect on an emotional level. The novoparteras worked independent of the biomedical world, the intensifying litigation-­based culture, and even one another, but they sought to collaborate and draw strength, justification, and protection from one another and the recent advances in medicine. They envisioned their practice as an extension of the comadronas of Puerto Rico’s past, but one that they had actively shaped and designed.

Conclusions By the 1980s improvement in childbirth outcome statistics had peaked. New and powerful players who represented corporate interests, such as insurance companies, as well as hospital and government administration and management constrained medical practice and the autonomy of physicians. Risk management strategies attempted to straddle patient rights and corporate interests, which often played out in detrimental ways for both mothers and obstetricians. Doctors began incorporating defensive practices out of fear of facing malpractice litigation instead of acting solely according to their best medical judgment. As a result, cesarean rates in Puerto Rico were among the highest in the world, becoming nearly as common as vaginal deliveries in some hospitals by the 1990s. Though there were few grassroots efforts to curtail the technocratic approaches to birth or offer birthing alternatives, and even though mainstream culture and legislation had eliminated the options of home births and midwifery, five midwives kept the profession alive in Puerto Rico. These midwives attended the home births of over a thousand women during the 1980s and 1990s, but they remained a marginal option. The legacy of this handful of midwives, however, far surpassed their numbers and the number of their clients.

171 Litigation-Based Model of Birth

Conclusion and Epilogue

T

he first decade of the new millennium was riddled with controversy and new directions in terms of childbirth practices and practitioners. The Puerto Rican press questioned the very survival of obstetric practice on the island, and the government-­sanctioned public health initiative to incorporate and extend the services of nurse-­midwives had begun. There was good reason to suspect that the next twenty years would witness another important shift in birthing practices. Future changes were likely to be characterized by extremes and reflect growing social disparities. Before discussing some of the more recent controversies surrounding childbirth practices, it is worth reviewing some key factors in the history of birthing that brought us to the new millennium of technocratic childbirth. The history of birthing in Puerto Rico from 1948 to the 1970s was marked by extremes as well. Within two decades, birthing ceased to be a predominantly domestic, mother-­centered event with little intervention, and midwives as the most common attendants. At midcentury, most women in Puerto Rico lived relatively isolated lives in rural areas, had little education, and had limited access to resources, although this varied according to class. Rural and less privileged women almost all birthed at home, behind closed doors, in the presence of their midwives. At that time most people in Puerto Rico assumed that women were built to birth successfully and merely needed some guidance and support in the process of labor and delivery. By the 1970s, midwives had disappeared, and more than 98 percent of women in Puerto Rico birthed in hospitals with doctors. After the 1980s births were monitored, and almost all women experi-

enced childbirth with pain medication and episiotomies, and were connected to electronic fetal monitors and IVs. Shortly thereafter, between a fourth to a half of all women had their babies by cesarean operations, surrounded by medical health care specialists moving about the maternity ward. Childbirth was redefined by the medical establishment within preset parameters, and it became the responsibility of medicine to intervene with any behavior that fell outside of these parameters. Along the same lines, women’s birthing bodies were defined by obstetrics and later understood by the women themselves as insufficient or too defective to birth without medical intervention and assistance. I have argued that these extreme changes in birthing practices were a result of rapid, sweeping changes in Puerto Rico on economic, political, social, and ultimately cultural levels. There is no evidence pointing toward a concerted effort by any one government agency or private group aimed at campaigning against or in defense of midwifery, as there had been in the United States or in England. No powerful institution invested any major time or resources into convincing Puerto Rican women to leave their homes and bring their babies into the world in the hospital setting. Instead, as families ventured out of their more isolated, home-­based daily lives to access basic needs; became active in public, urbanized spaces; and bought into a system based on colonial state planning led by scientifically trained experts and organized by bureaucratic institutions, they adapted their birthing practices. So too did the practitioners who served them. The history of birthing in Puerto Rico after the mid-­twentieth century evolved toward a technocratic model of birth. Biomedical authoritative knowledge moved into the hands of obstetricians, relied on technology, was distributed through large institutions, treated the female body as inherently defective, and stressed standardized practice over individual differences. Later a corporate-­legal framework further transformed and constrained birthing practices. These changes were facilitated by many factors, which were built into a complex system—transforming and reinventing itself under the colonial projects of state-­led industrialization—and occasionally pushed or inhibited by particular individuals or interest groups. The existence of a local, federally accredited four-­year medical school after 1950 influenced health care practice on the island. It provided Puerto Rican doctors with more opportunities to pro­ject themselves as legitimate researchers and contributors to medical production and international medical networks. More people could aspire to studying medicine since they no longer had to leave the island to get a degree. Though the UPR School of Medicine always struggled to acquire sufficient funding, space, and resources, by the 173 Conclusion

1960s it was growing at an astounding rate and became a component of Centro Médico, a state-­of-­the-­art hospital and medical complex. The School of Medicine was as much a product as a catalyst of the rise of bioinstitutional medicine. The Medical Association of Puerto Rico preceded the school by several decades and had always been active in propelling the medical profession forward. The leaders of the medical association tended to be traditionally minded men who were resistant to change. As one might expect, this conservative tendency permeated the medical school. At the same time, because of the dire economic conditions and the lack of adequate infrastructure, doctors did not manage to influence common households until the second half of the twentieth century. Through organizations like the medical association, however, physicians were able to pro­ject a professional front and defend their best interests. One of the ways the association secured its power was by building partnerships and lobbying within the state legislature. Members managed to communicate their interests and pre­sent themselves as the few legitimate experts in matters of health and medical practice. These interests and the sociopolitical tendencies of the time were reflected in the laws and licensing controls related to medical practitioners and birth attendants. Because of this, legal regulation favored biomedicine and physicians, and recognized them as the only qualified childbirth supervisors and ultimate figures of authority, thereby pushing childbirth into the realm of the medical world. However, despite the fact that we may fall prey to our own cultural assumptions, we should remember that pregnancy, labor, and delivery need not be considered a medical hazard. At the same time, there are certainly dangers that a mother and child may face in exceptional circumstances, and proper medical intervention can make all the difference. Even so, by medicalizing birth, or moving birth into the hands of specialized, hospital-­based physicians, pregnancy became routinely associated with danger, risk, or disease as a pathological physiological state in need of monitoring and intervention to maintain or correct it. The idea of making Puerto Rico a place of greater production and efficiency (one of the premises behind Operation Bootstrap, the state-­ led industrialization project initiated by the Partido Popular Democrático leadership in the 1940s) also played its role in redefining childbirth practices. Social science experts, supervised mostly by those educated in the United States, carried out studies all over the island in an attempt to better understand poverty and a variety of social issues. These experts disseminated the belief that by collecting data and making observations, one 174 Conclusion

could identify a problem and propose rational ways to improve or resolve it. Science and technology were their allies. Physicians began operating under similar paradigms. They classified childbirth into stages, set parameters for how the stages were to pro­ gress, and intervened with any pregnant or laboring body that deviated from preestablished behaviors. In this way the medical and lay community eventually came to believe not only that women should not be left to nature to deliver their babies, but also that their bodies were potentially dangerous to their babies, and more often than not faulty. Complex modern societies set standards and regulate services, usually with the intention of democratizing and raising levels of consistency and consumer guarantees. They seek to save time, produce more with less effort, and reduce risks. It should come as no surprise then, that birthing and obstetric practice moved in the same direction. Ironically, in opposition to the initial intention of measures of standardization, individual differences were overlooked, and innovations or alternatives that might improve services were stunted. The Puerto Rico Department of Health, which was the principal health care provider on the island from 1948 until the 1990s, promoted reforms with the intention of improving health and social services. The regionalization plan of the 1950s and 1960s centralized all health and welfare services around the island’s major regional hospitals. The goal was to improve the coordination of public services and assistance for families. The hospital became the center of information and services, further emphasizing its power as a point of encounter for service providers, professionals, bureaucrats, administrators, and consumers. Women and families gravitated toward the hospital to take care of their needs. The hospital became a familiar place of possibility where the government would coordinate and distribute welfare services. The expansion of the welfare state was a determining factor in the medicalization of birthing in Puerto Rico. After the 1960s, once the industrial project seemed to run out of steam, Puerto Rico’s colonial government began taking on an ever-­growing paternalistic role and expanding its welfare services in an attempt to appease people living under a stagnant economy and a government that could no longer deliver on its promises. By the 1970s most people lived in urban areas, and unemployment had reached a record level of almost 25 percent. More than half of the population fell below the Puerto Rican poverty level, which was lower than the federal level. Many people had become regular consumers of public services, and they expected to have their basic educational, health, housing, and nutritional needs met. 175 Conclusion

Family life in Puerto Rico was turned inside out. It went from a predominantly closed, private, rural space where most basic needs would be met within the home, to an urban, public, consumer-­oriented space in which families were dependent on the state. Those who had the financial means were consumers of health services in the privatized sphere. They also sent their children to private schools, had private health insurance, and could pay mortgages. Childbirth practices evolved within these dynamics. As people moved into public spaces of consumption and the institutional world of specialists and standardized norms, they also began to see the hospital as the acceptable place for birthing and for acquiring various resources offered by the state. Hospitals and larger institutional spaces allowed consumers and providers to access expensive forms of technologies that transformed the doctor-­patient relationship along with childbirth practices. Access to blood transfusions and anesthesiologists made cesareans safer—and doctors more likely to rely on them. Electronic fetal monitors and sonograms in the 1970s presented the fetus as a being independent from the mother and generated false alarms about fetal distress, instigating heightened emergency measures and further interventions. These new machines also helped to separate the mother’s and fetus’s well-­being and coincided with medical theories that described the mother’s physiology as potentially dangerous and violent toward the innocent fetus. Medical technologies used to monitor and diagnose in accurate and objective ways are not infallible. Many, like the fetal monitor, can be misleading, yet are incorporated into medical practice with little previous research and rarely questioned. They serve to distance providers from patients and to compartmentalize health and the body. Instead of a practitioner observing, touching, and talking to the woman in labor, a team of experts waits in separate stations and reacts to the sounds and ink markings coming from a machine to tell them whether to call an obstetrician. The use of machines to track, re­cord, diagnose, and monitor; the urbanization and democratization of society; the institutionalization and medicalization of health; and new concepts of risk management all coalesced after the 1970s and, in the context of an economic recession, spurred a climate of litigation. This tense atmosphere, in which doctors and hospitals became fearful of lawsuits, put physicians on the defensive and altered medical practice. One of the major consequences of defensive medicine has been the rise of cesarean sections. These surgeries made patients feel they had obtained the best medical care possible, and, oddly enough, left doctors believing that they would be less vulnerable to lawsuits. Cesareans can save lives and also reduce morbidity, but they are not safer than vaginal 176 Conclusion

deliveries for most first-­time mothers; nevertheless, by the 1990s a quarter to half of all women in Puerto Rico were birthing by cesarean operations. In contrast to the hypermedicalization of childbirth in Puerto Rico, I documented a very small form of resistance beginning in the 1980s represented by the novoparteras and their clients, who chose to deliver their babies at home. Home births can be viewed as a counterhegemonic force opposing the technocratic model of birth, but because there were so few, it is difficult to argue that they altered mainstream birthing practices in Puerto Rico. The novoparteras were women trained in both naturalist and biomedical settings who, for the most part, were certified to be midwives in the United States but did not have legal authorization to attend births in Puerto Rico. They carved out a small space for themselves and managed to offer home birth as an alternative to more than a thousand women in Puerto Rico by the new millennium. Midwives went from being one of the only birth attendant choices in the early twentieth century to disappearing altogether, and yet in the 1980s a small group of women turned to midwives and home births once again. In the new millennium, with the enormous rates of cesareans attracting international criticism, and obstetricians feeling the pressures of malpractice premiums and lawsuits, birthing might veer sharply away from obstetrics, and women might once again call on nurses and midwives to be by their sides. Institutional obstetrics is big business and dominates maternal care, yet local doctors and the American College of Obstetricians and Gynecologists (ACOG) argue that it is in crisis due to malpractice insurance premium costs and the threat of lawsuits, which have deterred new students from specializing in obstetrics and have led current obstetricians to abandon their practices.1 The reaction to this alleged crisis within Puerto Rican obstetrics shook the island at the onset of the new millennium, but for the first time in island’s history, the victims of malpractice responded, sending new tremors throughout the island and breaking down previous alliances among physicians, legislators, and the press. In April 2001, medical malpractice insurance premiums rose by 60 percent for private doctors and 85 percent for hospitals after being approved by the New Progressive Party under previous leadership. This set off a chain of events around the island, capturing the attention of many different groups, including the popular press.2 The College of Physicians and Surgeons of Puerto Rico, which had recently imposed mandatory membership, focused its energy on strategies to combat this increase, claiming that it was a surprise. In the meantime, several articles were published in El Nuevo Día, a 177 Conclusion

daily newspaper with the widest distribution in Puerto Rico, covering the government’s insufficient data collection regarding malpractice suits. The newspaper published articles about several cases of medical malpractice as well.3 Concern with malpractice was not limited to Puerto Rico. In the United States, the Joint Commission on Accreditation of Hospitals warned the medical community in early December 2001 about the alarming increase in medical errors transpiring in the operating rooms.4 In 2002, the same journalist who had investigated malpractice issues the previous year for El Nuevo Día published an article about the possible exodus of obstetricians and gynecologists because of the onerous costs of malpractice premiums. Doctors were quoted as claiming that specialists were leaving the island to work in the United States.5 What they failed to report was that premiums, litigation compensations, and the frequency of malpractice claims were more than twice as high in the United States as in Puerto Rico. Simed, the island’s only medical insurance provider, explained its situation and rationale to the College of Physicians, the government, and the local press, saying that the increased premiums had resulted from the company’s deficit. Simed admitted, however, that this deficit was generated in large part by only 3 percent of its clients. In other words, there were doctors on the island who had been found guilty of medical malpractice, and many on more than one occasion.6 The Medical Examiners Tribunal never called these doctors for questioning, and they never faced any sort of admonishment from medical authorities. To make matters worse, the list of doctors guilty of malpractice was not released to the public. In truth, a small number of doctors was costing the insurance company a lot of money and driving premiums up for everyone. Patients had no way of knowing which doctors had clean records and which did not. In a press conference following this report, the Tribunal of Medical Examiners admitted that they had never suspended privileges for any doctor to practice medicine because of malpractice, even though they had a legal responsibility to do so. They claimed that they lacked the resources to fulfill this duty.7 In the end, the governor, Sila Calderón, recommended that the members of the tribunal step down. When they resisted, she stripped them of their posts in December 2002.8 Between 2001 and 2002, doctors in both the United States and Puerto Rico mobilized forces to lobby and introduce legislative reforms to restrict malpractice litigation and payments and control legal fees. Physicians did not stop there. They also held press conferences, generated a public campaign that presented images of doctors leaving the island or closing their practices because of the insurance crisis, and threatened to 178 Conclusion

withhold services if the situation did not improve.9 Obstetricians and gynecologists were one of the most active groups involved in these campaigns and, along with surgeons and orthopedists, paid among the highest premiums, ranging anywhere from $8,000 to $35,000 a year. The Puerto Rican branch of ACOG voiced their outrage on August 16, 2002, in their own press conference.10 This group announced that forty obstetricians in the Ponce area had decided not to renew their insurance after the premium increases and were forced to abandon thousands of pregnant women who needed their services. Several newspaper articles circulated, stemming from the same calls of alarm from Ponce.11 Weeks later the campaign continued, and the press circulated descriptions of overflowing delivery rooms due to the diminishing number of obstetricians.12 The chaos generated around malpractice and the efforts of medical organizations paid off when Puerto Rican congressional representative Rafael García Colón presented two bills to cap malpractice compensation payments and limit patients’ rights to sue doctors for malpractice.13 This generated heated debate in the Puerto Rican legislature, where many different opinions were heard, but where doctors seemed to be dominating with their point of view, at least until September 11, when a new force arrived on the scene. The newly created Association of Medical Malpractice Victims made their first public appearance on the steps of the capitol during one of the many legislative hearings on medical malpractice reforms. There, the association’s representatives informed the press that they would pre­sent their case during public hearings and appeal to the conscience of the governor and legislators. The news made it into every major newspaper on the island.14 Victims of medical malpractice took the stand and moved almost everyone with their stories of horror, hardships, and deep loss due to the negligence of some members of the medical community. This proved to be a turning point, and many legislators, as well as the public at large, realized that they needed better information. The testimonies of members of the Association of Victims of Medical Malpractice were so effective that García Colón withdrew the proposed legislation that had spurred this particular series of debates.15 In desperation, obstetricians escalated their previous threats. This time, San Juan obstetricians in both public and private hospitals informed the press that they would no longer attend new patients. In late November the island woke up to a front page spread in the newspaper El Vocero that described Puerto Rican obstetrics as a profession in crisis but, more importantly, proclaimed that pregnant women would have to wait four months to see a doctor and that prenatal care was in danger altogether.16 This re179 Conclusion

port referred specifically to the university hospital in Río Piedras, affiliated with the UPR School of Medicine. A month earlier a similar situation had occurred in the Auxilio Mutuo Hospital, a prestigious private institution also in the San Juan metro area.17 The decision of obstetricians to mobilize and carry out a boycott or work stoppage was unprecedented. Their threat to limit obstetric services was successful in pressuring the legislature to hold an extraordinary session on December 2, 2002. This time, interest groups representing all sides of the debate presented their cases.18 The new proposals submitted by obstetricians, however, died on the legislative floor, and the Christmas holidays brought on the New Year with these issues unresolved. While doing my research interviews in late 2005, it was clear that these issues regarding medical malpractice lingered like a dark cloud over the lives of obstetricians. Without exception, they expressed tremendous frustration and described their situation as one of great injustice, citing cases in which the lives of innocent doctors and their families had been forever ruined by an unjustified lawsuit. They explained that doctors entering the profession could no longer afford their own practices and were experiencing economic hardship. They were convinced that for the first time in almost a century, the number of obstetricians and medical residents was in decline. “The brightest students are not dedicating themselves to maternity and gynecology . . . out of fear of litigation. Students are terrified nowadays,” declared Dr. Castillo.19 According to Dr. Cordero, an active local leader of ACOG, in recent years barely 65 percent of residency positions in the United States had been filled by US citizens, whereas in previous decades almost all had been. The remaining 35 percent of residencies were filled by foreigners, with sixty left unclaimed in the 2005.20 In 2007, as obstetrics seemed to be in decline, the Puerto Rico Department of Health announced a new initiative to send nurse-­midwives to more remote areas of the island where women had less access to obstetricians.21 These nurse-­midwives were to provide prenatal care and even attend uncomplicated births if need be. This initiative did not become widespread or offer substantive alternatives to medical obstetrics. Ten years into the new millennium there were many reasons to believe that childbirth in Puerto Rico, as well as in the United States, was reaching a new crossroads.

180 Conclusion

Notes

Introduction 1. Arbona, Borrador para un discurso, 113. 2. I am borrowing Davis-­Floyd’s terminology and definition of a “technocratic model of birth,” which I briefly explain further into the introduction. Davis-­ Floyd, Birth as an American Rite of Passage. 3. Adas, Machines as the Measure of Men, 410. 4. Ibid., 411, 416. 5. Slater, “Geopolitical Imagination and the Enframing of Development Theory,” 421. 6. Inglehart and Baker, “Modernization, Cultural Change, and the Persistence of Traditional Values,” 20. 7. Ibid., 20. 8. Gartman, “Bourdieu’s Theory of Cultural Change,” 255. 9. Adas, Machines as the Measure of Men, 208. 10. Salvatore et al., Crime and Punishment in Latin America, x. 11. Althusser, Ideología y aparatos ideológicos; Gramsci, La política y el estado moderno. 12. Davis-­Floyd, Birth as an American Rite of Passage; Davis-­Floyd and Sargent, “Social Production of Authoritative Knowledge in Pregnancy and Childbirth,” 111–120. 13. Davis-­Floyd, “Technocratic, Humanistic and Holistic Paradigms of Childbirth,” S5. 14. Ibid., S5–­S10.

15. Habermas, Teoría de la acción comunicativa, 253–254; Fraser, African American Midwifery, 167. 16. Sargent and Brettell, introduction to Gender and Health, 2. 17. Riska and Weger, Gender, Work and Medicine. Corporization, a term derived from corporation, is very similar to the process of institutionalization and professionalization that I hope to explain. See Apple, Perfect Motherhood; Davis-­Floyd and Sargent, Childbirth and Authoritative Knowledge; Gordon, Moral Property of Women; Martin, Woman in the Body; Roberts, Killing the Black Body; Canning, “Body as a Method?”; Rose, “Hand, Brain and Heart,” 73–90. 18. DeVries, “A Cross-­national View of the Status of Midwives,” 131. 19. Ibid., 143. 20. Scheper-­Hughes and Lock, “Mindful Body,” 7. 21. Murphy, Seizing the Means of Reproduction, 18. 22. Briggs, Reproducing Empire, 35, 68, 144; Ramírez de Arellano, Colonialism, Catholicism and Contraception. 23. Malthusian theory proposes that poverty and underdevelopment are a result of overpopulation in relation to available resources. If fertility rates decline, access to resources increases and poverty diminishes. Therefore, Malthusianists view population control as essential. 24. Colen, “Like a Mother to Them,” 78. 25. Davis-­Floyd and St. John, From Doctor to Healer, 15. 26. Roberts, Killing the Black Body, 259. 27. Rexford Tugwell, a University of Columbia professor and economist who served as one of President Roosevelt’s New Deal advisors, was appointed governor of Puerto Rico in 1942. He played a critical role in working with the local PPD (who held a majority in the legislature already) on plans for economic and in­dustrial development and urbanization in response to Puerto Rico’s economic crisis. 28. For more on these ideas, which were common in the postwar era, see Navas, Cambio y desarrollo en Puerto Rico; Rosario, “Detrás de la Vitrina.” 29. For more information on the process of industrialization, see Dietz, Historia económica de Puerto Rico, 200–339; Ferguson, “Class Transformations in Puerto Rico,” chap. 5. 30. Puerto Rico had its first locally elected governor in 1948 and ratified its first constitution in 1952. Its current government and Free Associated status were constituted at that time. 31. Córdova, “Setting Them Straight,” 30, 38. 32. Fraser, African American Midwifery, 49, 53. 33. Ferguson, “Class Transformations in Puerto Rico,” 317. See also Picó, Historia general de Puerto Rico, 257–290. 34. For more on how this plays out in medical training and birth practices in the United States, see Jordan, Birth in Four Cultures; and Davis-­Floyd and St. John, From Doctor to Healer.

182 Notes to Pages 5–9

35. Scheper-­Hughes and Lock, “Mindful Body,” 10. For works on the medicalization of society, see Foucault, Historia de la sexualidad and Birth of the Clinic; Martin, Woman in the Body; and Rodríguez, Civilizing Argentina. 36. Davis-­Floyd and St. John, From Doctor to Healer, 4–5. 37. Department of Public Planning of Puerto Rico, Informe de estadísticas vitales de 1985, 13. 38. Ibid. 39. Roberts and Stefani, Patterns of Living in Puerto Rican Families, 64, 56, 115. 40. Ibid., 138. 41. Arbona, Borrador para un discurso. 42. Roberts and Stefani, Patterns of Living in Puerto Rican Families, 118. 43. Departamento de Salud, Informe anual de 1967–1968, 122. 44. There had been a School of Tropical Medicine in Puerto Rico since the beginning of the century. 45. Murphy, Seizing the Means of Reproduction, 5. 46. For examples and discussion concerning the coexistence of medical belief systems in Latin America, see Cueto, Entre médicos y curanderos; Palmer, From Popular Medicine to Medical Populism; Sowell, Tale of Healer Miguel Perdomo Neira. 47. US Department of Health and Human Services, Office of Disease Prevention and Health Promotion, Developing Objectives for Healthy People 2010, 133–136. Also see publications from the World Health Organization conference concerning birthing that took place in Brazil in 1985; and Díaz and Cabrera Mont, “El servicio de las parteras,” 33. 48. See Cueto, Salud, cultura y sociedad en América Latina; Palmer, From Popular Medicine to Medical Populism; and Peard, Race, Place, and Medicine.

Chapter one 1. This story is adapted from the author’s interview with Tomasa in October 2005. 2. I have elected to use the modes of naming that were utilized at the time and by my interviewees. I am aware of the implicit sexism of resorting to first names for women or those in professions labeled as primarily female, and last names for those in professions seen as more important and male. I would point out, though, that the term doña is a social marker of respect. (Even though doña is not capitalized in Spanish, I have capitalized it in this book because the narrative is in English.) Doña Julia was of a similar social class and community, Tomasa demonstrated deference to her midwife by employing this title. Her age, experience, and expertise in birthing merited this distinction. In addition, my interviewees did not typically reveal the last names of midwives or the first names of doctors. I would like to point out that I have made an effort to capture the terms and tone of the interviewees and have tried to avoid adding my own.

183 Notes to Pages 9–17

3. The scientific name for rue is Ruta chalepensis. 4. Biomedicine is the treatment of illness in accordance with the formal and institutional knowledge of biology and other sciences. 5. Chasteen, Born in Blood and Fire, chap. 8; Larrain, Identity in Modern Latin America, 22–23. 6. Larrain, Identity in Modern Latin America, 114. 7. During my interviews with mothers who had given birth during this period, almost all of them explained that they had done it the same way all other women they knew had done. Those women from more privileged and professional classes explained that they knew no one their age who had birthed at home and doubted there were even many midwife-­attended home births at midcentury. 8. Departamento del Salud, Informe anual de 1952–53, 214. 9. Departamento del Salud, Informe anual de 1949–50, 73. 10. Ibid., 80. 11. Roberts and Stefani, Patterns of Living, 241–242. 12. The Guayama interviews are a set of sixty interviews that were generously made available to me by Professor Arturo Bird of the Interamerican University of Guayama. The interviews were carried out and documented by a group of undergraduate students for a project about Puerto Rican midwives during their 2000– 2001 course HCHG–1010, Historia de Puerto Rico: Procesos Históricos, offered by Professor Bird. Most of these interviews were with women who had birthed at home on several occasions with a midwife between 1938 and 1960. The college students directly interviewed three midwives. Since I was not able to obtain individual permission from each student, I will not cite or mention real names from these sources and will refer to them mostly as a whole. Most sources refer to women from the area or vicinity of Guayama on the southeastern coast of the island. Throughout the book I refer to these as the Guayama interviews. 13. Guayama interviews. 14. Departamento de Salud, Material informativo sobre el programa de comadronas auxiliares. 15. Silver nitrate is a solution still used today to prevent possible venereal infections from being transmitted to the baby’s eyes during birth. 16. Author interview with Tomasa, 3. “Ella vino, traía su maletín con sus toallas y su tijeras. Ella era bien limpiecita. Ella estaba bien registrada en Canovanas. Llegaba de blanco con su gorra, como un pañuelo que le tapaba todo el pelo.” 17. Author interview with Doña Penchi, July 24, 2007. 18. It is important to note that almost all the Guayama interviews of auxiliary midwives were done by students who were not familiar with the topic, had no previous experience with birthing and its terminologies, and made many errors in the transcriptions. Most of the women interviewed were rather elderly, were reflecting about experiences from many years back, and had been exposed to several decades of new cultural terminology. All of these factors played into their interviews and may well have altered or affected their accuracy.

184 Notes to Pages 17–24

19. I use the term comadronas when I am specifically referring to those midwives who were registered with the health department before 1970. 20. Author interview with Nilsa, October 22, 2005, minute 17. 21. Author interview with Tomasa, 5. 22. Author interview with Vanesa, November 26, 2005, 12. 23. The author’s 2005 interviews with mothers Tomasa, Carmenchi, Nilsa, Vanesa, Victoria, Patricia, and Ingrid contain further details and descriptions of their preparation and deliveries. 24. Author interview with Doña Penchi, July 24, 2007. 25. Author interview with Dr. Villamil, October 17, 2005, 16. 26. Salaries and payment methods are described in the author’s 2005 interviews with Dr. Villamil (8), Dr. Castillo (5), and Dr. Tomás (9). 27. Departamento de Salud, Informe anual del director de sanidad al honorable gobernador de Puerto Rico de 1947–48, 67. 28. Author interview with Tomasa: “. . . si nos poníamos cobardes ella nos decía: ‘no pues tienes que ir pa’l hospital, porque esto no se puede quedar así.’ Y como no queríamos ir pa’l hospital, pues poníamos de la parte de nosotros” (6). 29. Author interview with Tomasa, 13. 30. Departamento de Salud, Material informativo sobre el programa de comadronas auxiliaries, 1. 31. Departamento de Salud, Informe anual de 1951, 113. 32. Ibid. 33. Ibid. Of the 78,000 births in 1951, only 7,300 ocurred in private hospitals. 34. Roberts and Stefani, Patterns of Living, 17. This study included 1,044 extensive interviews with families representing different social and geographical sectors throughout the island; it was done in 1946 for the development of the home economics curriculum of the University of Puerto Rico. 35. Ibid. 36. Ibid., 23. 37. Ibid., 26. 38. Ibid. 56. 39. Ibid., 57, 64. 40. Ibid., 115. 41. Ibid., 138. 42. Arbona, Borrador para un discurso. 43. Dietz, Historia económica, 327. 44. Ferguson, “Class Transformations in Puerto Rico,” 400. 45. Departamento de Salud, Informe anual de estadisticas vitales de 1985 (1987), 13. 46. According to Gramsci, one of the most important functions of the modern state is to “elevate the great mass of the population to a particular cultural and moral level that corresponds to the developmental need of the productive forces and thus the interests of the dominant classes,” which in this case also included the United States (Política y el estado moderno, 174, my translation). Judicial and

185 Notes to Pages 24–33

educational institutions are among the primary vehicles. Althusser points out that “in more complex societies a division of labor occurs along with a division of the ideological apparatus and power is disseminated and specialized” (Ideología y aparatos ideológicos del estado, 36–37, my translation). 47. For further discussion of the relationship between medicine, law, and culture, see DeVries, Regulating Birth, 13–14; and Foucault, Discipline and Punishment. For a general overview concerning critical legal theory and the relationship between law and change, refer to Gordon, “Critical Legal Histories,” 57–125. 48. Portelli, Gramsci y el bloque histórico, 18. 49. DeVries, Regulating Birth, 29. 50. Law III, title XII of book VIII, chap. 16 of the 1804 Ordenanzas (Orders), in Arana-­Soto, Historia de la medicina puertorriqueña, 617. 51. Arana-­Soto, Historia de la medicina puertorriqueña, 618. Everyone was registered at birth, usually in local churches, according to racial status. These categories were subjective in many ways. They often depended on favors or personal judgments of the registering official. Originally limpieza de sangre referred to a person’s relationship to Catholicism. In Puerto Rico and other Spanish colonies it became equated to whiteness or Spanish descent, but there was never a guarantee or possibility of any racial purity. 52. Ibid. 53. Pérez and Rivera, Enfermería en Puerto Rico, 169. The Ateneo Puertorriqueño was a cultural institution for the promotion of the arts and sciences under government auspices. 54. Ibid. 55. I am using quotation marks here when using direct translations from the same selections of Quevedo’s writings as above. Quevedo Báez, Historia de la medicina, 264–265. 56. Ibid., 264–265. 57. Arney, Power and the Profession of Obstetrics, 44; Díaz Ortíz and Cabrera Mont, “El servicio de las parteras,” 74. 58. Justiniano, Con valor y a como dé lugar, 284–285. 59. García, Historia sin coartada, 67–96; Asociación Médica de Puerto Rico, Memorias, 1902–1989. 60. Asociación Médica de Puerto Rico, Annual Report . . . 1946, mentions communications with government representatives in the highest positions (4–5) and reports on the legislative committee (16). 61. See, for example, Asociación Médica de Puerto Rico, Medical Association of Puerto Rico Report to the House of Representatives of 1947 and 1953. 62. Asociación Médica, Annual Report, 1948, 4. 63. Asociación Médica, Annual Report 1947, 4. 64. Asociación Médica, Memorias 1902–1989; see also the annual reports of the AMPR under “public relations.” 65. Leyes de Puerto Rico Anotadas (annotated laws) (LEPRA), law 3 of 1903. 66. Pérez and Rivera, Enfermería en Puerto Rico, 172. 186 Notes to Pages 33–36

67. Ibid. Physicians convinced lawmakers to pass law 73 in 1923 changing the name of the board to the Tribunal of Medical Examiners. In 1931, law 22 was created to regulate medical practice, repealing the 1923 law on the Tribunal of Medical Examiners. 68. Ibid., 173. 69. This is the highest Puerto Rican political office due to the colonial political structure under US jurisdiction. 70. Law 22 of 1931, 221. 71. Ibid., 225. 72. Departamento de Salud, Material informativo. 73. Díaz and Cabrera, “El servicio de las parteras,” 70. 74. DeVries, Regulating Birth, 15. 75. Ibid., 4–7. 76. In 1947, law 390 was approved to amend the second paragraph of section 9 in law 77, creating the Board of Nurse Examiners of 1930, which was amended in 1937. 77. Law 390 of 1947, LEPRA, 751. The term graduate nurse refers to nurses with specialized four-­year university training and those with specialized high school or vocational training. 78. Departamento de Salud, Material Informativo, 1. 79. Ibid., 1 (in section titled “La labor de la comadrona . . . comunidad”). 80. Ibid., 2–3. 81. Ibid. 82. Pérez and Rivera, Enfermería en Puerto Rico, 175. 83. Departamento de Salud, Annual Report of 1947 (107 permits canceled), 213; Annual Report of 1951–52 (168 permits canceled), 106; Annual Report of 1952–53 (200 permits canceled), 93. The 1949–1950 annual report lists 1,547 registered auxiliary midwives and 380 taking courses to qualify for a permit (73). 84. Direct-­entry midwives were educated by other midwives through hands-­on observation and assistance without having taken any formal nursing instruction. 85. Pons, “Why a Medical School for Puerto Rico,” 6–7. 86. Ibid. 87. Ibid., 11. 88. Costa Mandry, “Endeavors to Establish a Medical School in Puerto Rico,” 14. 89. Ibid. 90. Ibid., 15. 91. Benítez, “Position of the University of Puerto Rico,” 26. 92. Ibid. Benítez indicated that two medical schools would be excessive and referred to the retired Dr. Lambert, who directed medical research for the Rockefeller Foundation, as a resource for the creation of this future medical school. 93. Arbona, “Present Facilities,” 20. 94. Ibid., 19. I would like to point out the discrepancy in the reported total number of physicians in this conference among those presenting. I believe this 187 Notes to Pages 37–43

is an indication of the lack of institutionalization of universal criteria as well as methodology of data collection, representative of the time. 95. See articles from El Mundo in the newspaper archives of the Puerto Rican Collection of UPR’s Medical Sciences Campus. “Doctor Astor denuncia los daños causados por los curanderos,” El Mundo, May 11, 1948. 96. University of Puerto Rico, Bulletin of the University of Puerto Rico School of Medicine, Announcements for the Academic Year 1950–51, Río Piedras, Puerto Rico, January 1951, 19. 97. During the 1990s, interventions such as the use of sedation, analgesics, anesthesia, uterotonics (to stimulate contractions), cesarean sections, and episiotomies (a cut in the pelvic floor during delivery) were all routine hospital procedures. 98. Departmamento de Salud, Informe anual de 1947–48, 210, 285, 287, 292; Informe anual de 1949–50, 1951–52, 109. 99. Among the few articles published on the topic in the Boletín de la Asociación Médica de Puerto Rico during this time, two provide clues as to what would have been considered acceptable medical intervention in childbirth. Frank Walsh (“Analgesia and Anestesia in Obsterics,” 294–298) concluded that sedation and anesthesia can cause fetal complications and are harmful for premature deliveries. Simpson et al. (“Routine Extraperitomeal Approach for Cesarean Section,” 490–494) mention that a cesarean rate of 5 percent would be the acceptable limit. Additional information can be found in the author’s interviews with Dr. Castillo, 20; Dr. Ramírez, minute 30; Dr. Onís; and Dr. Mulero, 24. 100. Author’s 2005 interviews with Dr. Castillo (20, 28); Dr. Onís, Dr. Villamil (24), Dr. Cordero, and Dr. Tomás (13). 101. Baker and Inglehart, “Modernization, Cultural Change and the Persistence of Traditional Values,” 21. 102. Departamento de Salud, Material informativo, 2. 103. Author’s 2005 interviews with Dr. Asencio (16), Dr. Castaner (12), Dr. Vicenty (16, 18), Dr. Torres (19) and Dr. Comas. 104. During my interviews with doctors and mothers, I would always ask about patient demographics and why certain services were used instead of others that were available at the time. All of the mothers seemed satisfied with what had been available at the time, and no one expressed a desire to access childbirth services outside of what they had used. 105. Departamento de Salud, Material informativo. 106. Ibid., 1.

Chapter two 1. Dietz, Historia económica de Puerto Rico. 258. 2. Most migration was promoted by the local government and supported by the United States in hopes of providing an escape from unemployment, overpopulation, and underdevelopment. 188 Notes to Pages 44–52

3. González Díaz, Partido Popular Democrático, 59–97. 4. Macry, Sociedad contemporánea, 93. 5. Ibid., 111. 6. Adas, Machines as the Measure of Men, 251. 7. de Jesus Toro, Historia económica de Puerto Rico, 158–160. 8. Navas, Dialéctica del desarrollo nacional, 114–115. Navas analyzes precisely the same industrialization period of the 1950s and 1960s, including changes that unfolded within the PPD leadership. His model of development and modernity is similar to the one presented by de Jesus. He received his PhD from the University of California, Berkeley, in 1972 and later went on to teach in and direct the UPR School of Urban Planning. 9. Adas, Machines as the Measure of Men, 411. 10. The discourse of la gran familia harks back to the latter nineteenth-­century hacendado class and their aspiriations to separate from Spain and push for a unified, harmonious society that overlooked any class, racial, or national differences. For further information, see Gelpí, Literatura y paternalismo en Puerto Rico, 99. 11. González, Partido Popular Democrático, 61. 12. The 1930s and 1950s witnessed significant clashes and confrontations between the Puerto Rican Nationalist Party, other pro-­independence organizations, and both local and US government forces. These clashes resulted in repressive laws, imprisonment of political activists, armed attacks against the US Congress, and even massacres during political protests. For more information see Acosta, La mordaza. 13. PPD, Catecismo del pueblo, 10. 14. Rigau, Historia, 362–363. Contraceptives (1950s), vaccines (1949), and antibiotics started to be used widely in Puerto Rico after World War II. 15. Leavitt, Brought to Bed, 171. In 1950, 88 percent of US babies were born in hospitals. 16. Fraser, African American Midwifery, 37. 17. Safa, “Female Employment,” 89. 18. Rivera, “Development of Capitalism in Puerto Rico,” 42. 19. Picó, “History of Women’s Struggle for Equality,” 47. 20. Baker and Inglehart, “Modernization, Cultural Change and the Persistence of Traditional Values,” 20, 34. 21. See Briggs, Reproducing Empire, chap. 4. 22. Ibid., 122. 23. Columbia University School of Public Health and Administrative Medicine and the Puerto Rico Department of Health, Asistencia médico-­hospitalaria en Puerto Rico, 17. In the mid-­1950s there was a public health unit in all municipalities (total of 76) except Culebra, as well as 114 rural subunits. The 76 public health units were grouped for administrative purposes into 33 sanitary districts. There were 13 urban subunits in the larger cities and 21 health centers operated with hospital units, which rendered services only to the indigent. The Maternal and Child Health Bureau was in charge of all maternal care services, including the midwifery 189 Notes to Pages 52–57

program. Departamento de Salud, Puerto Rico Public Health Plan Submitted to the U.S. Public Health Service U.S. Children’s Bureau, 1955–56, 1956–57, 2. 24. For further discussion on overpopulation discourses, see Briggs, Reproducing Empire, chap. 4. 25. Departamento de Salud de Puerto Rico, Oficina de Planificación, “Evaluación e informes,” Informe anual de estadísticas vitales de 1985, 13a. 26. Ibid. In 1960 the rate of maternal mortality dropped from 89 to 50 for every 100,000 live births but later went up again until 1966. 27. Author interview with Dr. Mulero, October 13, 2005. 28. Columbia University School of Public Health and Administrative Medicine and the Puerto Rican Department of Health, Asistencia médico-­hospitalaria, 27. 29. Ibid., 93–103. 30. Departamento de Salud, Informe anual de 1953–54, 203. 31. Municipalities where hospital births were twice that of home births were Bayamón, Ceiba, Dorado, Fajardo, Naguabo, Río Grande, Río Piedras, San Juan, Trujillo Alto, and Vieques, representing both rural and urban areas. 32. Departamento de Salud, Informe anual de 1953–54, 203. 33. There was also a high number of midwife-­assisted births in Yauco, Mayagüez, Caguas, Utuado, and Vega Baja. 34. Departamento de Salud, Informe anual de 1953–54, 203. 35. Ibid. 36. Ferguson, “Class Transformations”; Godreau, “Missing the Mix”; Mintz, Worker in the Cane. 37. DeVries, “Cross-­National View of the Status of Midwives,” 143. 38. Departamento de Salud and Juan Pons, Puerto Rico Public Health Plan Submitted to the U.S. Public Health Service U.S. Children’s Bureau, 1955–56, 1956–57, 1. 39. Ibid., 17. 40. Departamento de Salud, Informe anual de 1953–54, 76. 41. Ibid., 80. The 1949–1950 Department of Health annual report lists 1,547 auxiliary midwives and 380 in training (73). 42. Departamento de Salud, Informe anual de 1955–56, 43. 43. Picó, “History of Women’s Struggle for Equality,” 51. 44. Columbia University School of Public Health and Puerto Rico Department of Health, Asistencia médico-­hospitalaria, 38–39. 45. Ibid., 4. This extensive study also surveyed 2,951 families from all areas of the island, with just over half being from rural zones. Half of the families were from a low income bracket with limited education, and 12 percent were from a high income bracket and had more education. 46. Ibid., 41. 47. Ibid., 44. 48. Ibid., 43. 49. Ibid., 46–47. 50. Ibid., 47. The information here is from 1954–1958. 190 Notes to Pages 59–68

51. Ibid., 50. 52. Author interview with Miriam Castro de Castañeda, September 27, 2005, 3. 53. Ibid., 1–2. 54. Ibid., 3. 55. Ibid., 4. 56. Departamento de Salud, Puerto Rico Public Health Plan . . . 1955–56, 1956–57, 20; author interview with Miriam Castro de Castañeda, 9. 57. Author interview with Miriam Castro de Castañeda, 10. 58. Pons, Informe del ELA a la XIV Conferencia Sanitaria Panamericana (1954), 18. 59. Author interview with Miriam Castro de Castañeda, 11. 60. Ibid. 61. UPR School of Medicine and School of Tropical Medicine, Four Year Progress Report, 17. 62. Ibid. 63. UPR School of Medicine and School of Tropical Medicine, Educational Development and Program Objective (September 1958), Annex 1. 64. Ibid., Annexes 1–2. 65. Clerkships provided hands-­on clinical training to medical students before they earned their degrees. 66. In 1952, 127 of the 141 medical students lived in student dormitories. 67. Elinson, “Physician’s Dilemma in Puerto Rico,” 16. Presented at an American Public Health Association meeting November 13, 1961. 68. UPR School of Medicine, Annual Report 1954–55, 28–29. 69. UPR School of Medicine, Annual Report 1957–58, 143. 70. Ibid., 96, 116. 71. UPR School of Medicine and School of Tropical Medicine, Educational Development and Program Objective (September 1958), Annex 1. 72. Chafey, “Review of Major Gynecological Surgery,” 451. 73. Ibid., 451–457. 74. Rodríguez Olmo, “Inducción del parto,” 65–69. 75. Finn, “Induction and Stimulation of Labor,” 361. 76. Ibid. 77. Ibid., 368. 78. Ibid., 368, 369. 79. Author interview with Dr. Castillo, September 8, 2005. 80. Quinquilla, “Thorazine in Obstetric Analgesia,” 239. 81. Wolf, “ ‘Mighty Glad to Gasp the Gas,’ ” 367. 82. Leavitt, Brought to Bed, 118, 121, 140. 83. Wolf briefly summarizes pain studies in “ ‘Mighty Glad to Gasp the Gas,’ ” 367–368. 84. Ibid. 85. Rifkinson, “Obstetrical Practices and Brain Damage,” 37–40. 86. Author interview with Dr. Castillo, September 8, 2005. 87. Columbia School of Public Health et al., Asistencia médico-­hospitalaria, 13–15. 191 Notes to Pages 69–78

88. Ibid. 89. Elinson, “Physician’s Dilemma,” 14–20. 90. Columbia School of Public Health et al., Asistencia médico-­hospitalaria, 18–19. 91. Ibid., 19; Elinson, “Physician’s Dilemma,” 19. 92. Elinson, “Physician’s Dilemma,” 19. 93. Ibid., 19. 94. Columbia University School of Public Health et al., Asistencia médico-­ hospitalaria, 5. 95. Ibid. 96. Ibid., 11. 97. Ibid., 53. 98. Ibid., 62. 99. Ibid., 8. 100. Departamento de Salud, Informe anual de 1947–48, 379. 101. Columbia University School of Public Health et al., Asistencia médico-­ hospitalaria, 8. 102. Ibid., 12. 103. Ibid., 13. 104. Elinson, “Physician’s Dilemma,” 17. 105. Ibid. 106. Ibid., 18. 107. Ibid., 15. 108. Ibid. 109. Author interview with Dr. Castillo, September 8, 2005, 20. 110. Author interview with Doña Penchi, final section. 111. Author interview with Tomasa, 13.

Chapter three 1. For an analysis of this phenomenon in general, see Althusser, Ideología y aparatos ideológicos de estado; and Gramsci, La política y el estado moderno. 2. This summary is adapted from the author’s interview with Ingrid, December 27, 2005. 3. Beck, Risk Society, 21. 4. See Foucault’s discussion of the micro-­physics of power and the technology of power in Discipline and Punishment, 25–27. 5. Fraser, African American Midwifery, 167. 6. Ginzburg, “Morelli, Freud and Sherlock Holmes,” 5–10. 7. Refer to Martin, Woman in the Body, xxiv, chap. 4, and her introduction to Gender and Health, 2. 8. Martin, Woman in the Body, 63. 9. Ibid., 64. 10. Author interview with Dr. Mulero, October 13, 2005, 20. 192 Notes to Pages 78–90

11. Soon thereafter, however, he went on to clarify that most complications due to lack of oxygen happened before labor and delivery. Author interview with Dr. Onís, September 6, 2005. 12. Costa Mandry, “Statistics about Physicians in Puerto Rico,” 16; and Apuntes para la historia de la medicina en Puerto Rico, 25. 13. Author interview with Dr. Tomás, December 15, 2005, 21. 14. Author interview with Dr. Villamil, 16. 15. Ibid., 14–15. 16. For a discussion on the connections between the rise of the industrialized nation-­state and standardized, scientific administrative experts, see Nowotny et al., Rethinking Science, esp. 218–219. 17. Author’s translation of Canguilhem, Lo normal y lo patológico, 103. 18. Ibid., 98. 19. Sargent and Brettell, introduction to Gender and Health, 6. 20. Canguilhem, Lo normal y lo patológico, 103. 21. Habermas, Teoría de la acción comunicativa, 54–55. 22. Author interview with Dr. Onís. 23. The secretary of health called for initial studies regarding this plan in 1954, but it was not until 1959 that he presented them to the government. Berríos Colón, “Análisis de la estructura del departamento de salud,” 22–25. 24. Ibid., 24. 25. “Up by the Bootstraps,” Time, October 29, 1965. 26. “Puerto Rican MDs Fear Socialism.” 27. Arbona, Puerto Rico Health Plan, 1959–60–1960–61, 1. 28. Ibid., 2. 29. Arbona, Un borrador para el discurso del gobernador, 22–29. 30. The following were published in El Mundo: García, “Inauguran abril 18 Centro Médico Dr. Enrique Koppisch,” April 9, 1964; “Inauguran hoy Centro Médico en San Sebastián,” October 9, 1964; Pont, “Expanden Hospital,” October 12, 1965; and Pellicier, “Inauguran Hospital Menonita,” October 19, 1965. 31. President Truman approved the Hospital Survey and Construction Act, also called the Hill-­Burton Act, in 1946 to improve health care in the United States through the improvement and construction of hospitals. This act was in force until 1975. Starr, Social Transformation of American Medicine, 283, 348. Puerto Rico was allocated $6.5 million in 1962 from the federal government to build hospitals under the Hill-­Burton Act. 32. UPR School of Medicine and School of Tropical Medicine, Annual Report 1958, 17. 33. Ibid., i. 34. UPR School Medicine and School of Tropical Medicine, Annual Report 1960, 1. 35. Medina, Teaching of Maternal and Child Health, foreword. 36. UPR School Medicine and School of Tropical Medicine, Annual Report 1958, i. 193 Notes to Pages 90–95

37. UPR School Medicine and School of Tropical Medicine, Annual Report 1960–1963. 38. UPR School of Medicine and Tropical Medicine, Annual Report 1959, 69. 39. UPR School of Medicine and Tropical Medicine, Annual Report 1960, 63. 40. Ibid. 41. UPR School of Medicine and Tropical Medicine, Annual Report 1959, 2. For information on Rockefeller Foundation funding for Latin American medicine see Cueto, “Rockefeller Foundation’s Medical Policy and Scientific Research in Latin America,” 229–254. 42. UPR School of Medicine and Tropical Medicine, Annual Report 1959, 70–71. 43. UPR School of Medicine and Tropical Medicine, Annual Report 1964, 83. 44. Ibid., 76. 45. UPR School of Medicine and Tropical Medicine, Annual Report 1965, 73. 46. UPR School of Medicine and Tropical Medicine, Annual Report 1962, 55; Annual Report 1963, 74–75; Annual Report 1964, 81–82. 47. UPR School of Medicine and Tropical Medicine, Annual Report 1960, 65. Five years later (during the next historical phase of birthing), UPR received two additional grants from the Population Council to participate in an international study on the effectiveness of the family planning program based in the San Juan City Hospital and the effectiveness of contraceptive drugs and intrauterine devices. UPR School of Medicine and Tropical Medicine, Annual Report 1965, 77. In January 1958, Dr. Fuster, chair of the school’s obstetrics and gynecology department, died, passing the torch to Dr. Ivan Pelegrina. UPR School of Medicine and Tropical Medicine, Annual Report 1958, 66. 48. Ibid., 80. 49. UPR School of Medicine and Tropical Medicine, Bulletin of the School of Medicine—School of Tropical Medicine: Announcements for the Academic Years 1961– 62, 1962–63, 85. 50. UPR School of Medicine and Tropical Medicine, Bulletin of the School of Medicine—School of Tropical Medicine: Announcements for the Academic Years 1963– 64, 1964–65. 51. UPR School of Medicine and Tropical Medicine, Annual Report 1964, 82–83. 52. Dr. Satterthwaite consulted for the South Korean government to evaluate its family planning program, and she was present at the International Family Planning Conference in Geneva, Switzerland. UPR School of Medicine and Tropical Medicine, Annual Report 1965, 74, 76. 53. UPR School of Medicine and Tropical Medicine, Annual Report 1962, 54; Annual Report 1963, 74; Annual Report 1964, 76. 54. UPR School of Medicine and Tropical Medicine, Annual Report 1959, 2; Annual Report 1958, 93. 55. Annual Report 1963, 8–9. 56. Ibid. 57. UPR School of Medicine and Tropical Medicine, Bulletin of the University of Puerto Rico School of Medicine 1965–66, 1966–67, 52. 194 Notes to Pages 95–97

58. Departamento de Salud, Informe anual del de 1960–61, 38. 59. Castro de Castañeda, in her unpublished essay “Nurse Midwifery in Puerto Rico,” claims that between 1954 and 1960, seventeen nurse-­midwives graduated from this program in Puerto Rico. 60. Author interview with Miriam, 13. 61. Ibid., 14–15. 62. Ibid., 15. 63. Ibid., 16. 64. Ibid. 65. Departamento de Salud, Informe anual de 1962–63, 7. 66. Departamento de Salud, Informe anual de 1960–61, 40. 67. Departamento de Salud, Informe anual de 1961–62, 25. 68. Ayabarreno, “Cuestionario sobre partos por comadrona Antonia,” 4. 69. Ibid, 2. 70. Author interviews with Tomasa, 6 and Vanesa, 3. 71. Portelli, Gramsci, 22. 72. Departamento de Salud, Informe anual de 1959–60, 182. 73. Culebra, Guayanilla, Peñuelas, Hatillo, Vega Alta, Luquillo, Morovis, and Quebradillas reported less than 5 percent of hospital births, and Adjuntas, Ceiba, Cidra, and Orocovis also reported a great majority of home births. Departamento de Salud, Informe anual de 1959–60, 182. 74. In a handful of areas nurses tended to a significant number of women at home as well. Isabela, on the northwestern coast (189 of 629 total births at home), reported many nurse-­supervised home births, and Juana Díaz on the midsouthern coast (531 of 930 total births at home) reported 172 of home births under the care of nurses. Departamento de Salud, Informe Anual de 1959–60, 182. 75. Ibid. The municipal hospital of Arecibo reported 1,279 of their deliveries were assisted by nurses and 21 by doctors; Arroyo reported 2,501 by nurses, one midwife-­led birth, and 14 doctor-­assisted births. In the municipal hospital of Caguas and Lares, nurses oversaw most of their deliveries, and Juana Díaz reported the following births: 306 by nurses, 100 by midwives, and 16 by doctors. 76. Ibid., 182. 77. In Aguada, Jayuya, Luquillo, Morovis, San Sebastián, and Vega Alta, three-­ fourths of all deliveries still occurred at home. Aguas Buenas, Barceloneta, Cayey, Cidra, Juana Díaz, Maunabo, Orocovis, and Patillas reported more home births than hospital births in 1961–1962. Departamento de Salud, Informe anual de 1961– 62, 122–124. 78. Medina, “Utilization of Prenatal Services in Puerto Rico,” 1. A total of 7,486 women who had birthed between the summers of 1965 and 1966 were interviewed at home under a US Children’s Bureau Grant (no. 400) by the UPR School of Public Health. Interviews were supported with birth certificates and the government health records of 80 percent of those served in public facilities; 200 interviews were later cross-checked. (See pp. v, 8, 12.) 79. UPR Medical Sciences Campus, Utilization of Prenatal Services 16, 19. 195 Notes to Pages 98–102

80. Ibid., 2. 81. Ibid. 82. Ibid., 1. In 1951 about 9 percent of women gave birth in private clinics. Departamento de Salud, Informe anual de 1951, 113. 83. UPR Medical Sciences Campus, Utilization of Prenatal Services, 1, 22. 84. Ibid., 2. 85. Ibid., 3–4. 86. Ibid. 87. All of the information in this paragraph before the note number is from UPR Medical Sciences Campus, Utilization of Prenatal Services, 4–5. 88. Ibid., 6. 89. Ibid., 5. 90. Ibid., 7 91. Ibid., 6, 33. 92. Canning, “The Body as a Method?”, 505. 93. Giddens defines expert systems as “systems of technical accomplishment or professional expertise that organize large areas of the material and social environments in which we live today.” Giddens, Consequences of Modernity, 27.

Chapter four 1. Irizarry, “Piden orientación comadronas se quejan gobierno ELA las tiene abandonadas,” El Mundo, March 10, 1966, 37. 2. Alternative birthing methods such as the parto sin dolor (Lamaze and Bradley Method inspired) were available during this period, but they were conceptualized within a medical-­scientific hospital setting. 3. Departamento de Salud, Informe anual de 1970–71, 37. 4. Departamento de Salud, Informe anual de 1971–72, 46. 5. This story is based on the author’s interview with Dr. García, September 13, 2005. 6. Vilar Isern, Informe anual de la División de Salud de Madres, 12. 7. Ibid. 8. Departamento de Salud, Informe anual de 1967–68, 122. 9. Departamento de Salud, Informe anual de 1970–71, 37; Informe anual de 1971– 72, 46. 10. Vilar Isern, Informe anual de la División de Salud de Madres, 11. 11. Ibid., 54. 12. Author’s translation of Bertrán, “Informe del presidente.” 13. Hernández-­Angueira, Mujeres puertorriqueñas, 42–43. For information on the economic crisis of the 1970s, see Sotomayor, Poverty and Income Inequality in Puerto Rico, 1970–1990, 62–64; also see p. 23 for further statistics on poverty and comparisons with the United States. 14. According to a study done by the School of Public Health, by 1968 almost 196 Notes to Pages 102–113

75 percent of married women had used some form of birth control and 60 percent were using birth control at the time of the interview. See Hernández-­Angueira, Mujeres puertorriqueñas, 61. 15. I am using a Marxist definition of ideology as a system of ideas and representations that come to dominate the human spirit and/or particular social groups (Althusser, Ideología y aparatos ideológicos, 47). Gramsci summarizes ideology as a system of cultural values (see Portelli, Gramsci y el bloque histórico, 10), and Althusser (ibid., 52) points out that ideology is a representation of the relationship between an individual’s imaginary existence and his or her existing real life conditions. 16. Hernández-­Angueira, Mujeres puertorriqueñas, 6. 17. Hernández Cibes, Statistical Comparison, 2. 18. Ibid., 8. 19. Ibid., 9–11. 20. Ibid., 9, 12. 21. Torres Pineda, “¿Hacia una medicina más científica?”, 561. 22. Izquierda Mora, “La época de oro de la medicina,” 86. 23. Ibid., 87. 24. This degree was in medical zoology. UPR, School of Medicine Annual Report 1967, 1. 25. UPR, School of Medicine Annual Report 1966, 138. 26. UPR, School of Medicine Annual Report 1974–75, 187. 27. UPR, School of Medicine Annual Report 1974–75, 174–175, 187–189 28. Oaks, Smoking and Pregnancy, 3. 29. Rapp, Testing Women, 29. 30. Oaks, Smoking and Pregnancy, 140. 31. For more discussion on visual images of the fetus and personhood, see Rapp, Testing Women, 121; Oakley, Captured Womb, chaps. 7–8. 32. Ortiz, “Ven médicos locales envueltos denuncian raquet internacional abortos.” 33. UPR, School of Medicine Annual Report 1974–75, 194. 34. UPR, School of Medicine Annual Report 1967, 119–120. 35. Ibid., 109. 36. UPR, School of Medicine Annual Report 1968 and 1969, 117; Adamson, Diagnosis and Treatment of Fetal Disorders. 37. The Population Council is an international nonprofit organization established by John Rockefeller in 1952 and dedicated to reproduction and family planning. 38. UPR, School of Medicine Annual Report 1966, 137. 39. UPR, School of Medicine Annual Report 1968 and 1969, 123. 40. See UPR, School of Medicine Annual Report 1969–1970, 98–100. 41. Rojas Daporta, “Descubridor píldora contraceptiva.” 42. UPR, School of Medicine Annual Report 1966, 132; Annual Report 1967, 116, 113; Annual Report 1968–69, 123. 197 Notes to Pages 113–121

43. UPR, School of Medicine Annual Report 1966, 133, 135; Annual Report 1967, 112. 44. UPR, School of Medicine Annual Report 1974–75, 183. 45. Price, “Malpractice Insurance,” 31–33. 46. Ibid., 32. 47. Author interview with Dr. Ramírez, October 3, 2005, 26. 48. Ibid., 39. 49. Cabrera, “En busca de quijotes médicos,” 327. 50. Ibid., 328. 51. Ibid. 52. Ramírez de Arellano, “El mercado de los servicios médicos,” 167–170. 53. Ibid., 168. 54. Ibid., 167–168. 55. Ibid., 170. 56. Reinhard, “Medicine and the Crisis in Confidence,” 111. 57. Ibid.,116. 58. Ibid. 59. Ibid. 60. Ibid, 117. 61. Lessing, “Carta al editor.” 62. Briggs, Reproducing Empire; Ramírez de Arellano, Catholicism, Contraception; Roberts, Killing the Black Body; Acosta Belén, Puerto Rican Woman; Azize, La mujer en Puerto Rico; Matos Rodríguez and Delgado, Puerto Rican Women’s History. 63. Althusser, Ideología, 60. 64. Ibid., 63. 65. Roe Smith and Marx, introduction to Historia y determinismo tecnológico, 14. 66. Quevedo Báez, Historia de la medicina, 264–265. 67. Murphy, Seizing the Means of Reproduction, 19. 68. Lopez, Matters of Choice, 38. 69. Shy et al., “Evaluating a New Technology,” 182; Bassett, “Anthropology, Clinical Pathology and the Electronic Fetal Monitor,” 283. 70. Author interviews with Dr. García (30) and Dr. Ramírez (20). 71. Martin, “Electronic Fetal Monitoring,” 136; Bassett, “Anthropology, Clinical Pathology,” 285. The EFM has proven useful during inductions and augmentations, when doctors artificially accelerate contractions, which increases risks such as rupturing the uterus or distressing the fetus (commonly, fetal hypoxia). The EFM is useful in these cases because it is tremendously sensitive; it often gives false positives, but it is rarely misread if all is well. If the EFM shows no sign of distress to the fetus, then medical staff can rest easy that the augmentation is not significantly cutting off oxygen flow to the fetus. 72. See, for example, Bassett et al., “Defensive Medicine during Obstetrical Care,” 530. The relationship between the EFM and increased cesarean rates seemed to decline in teaching hospitals after the early 1980s (Shy et al., “Evaluating a New Technology,” 186). 73. Auscultation is listening to the sounds made by the internal organs of the 198 Notes to Pages 121–128

body for diagnostic purposes. For example, nurses and doctors auscultate the lungs and heart of a patient with a stethoscope placed on the patient’s chest. 74. Shy et al., “Evaluating a New Technology,” 187; Lent, “Medical Legal Risks,” 807–837. 75. Sandelowski, Devices and Desires, 122. 76. Ibid. 77. Bassett, “Anthropology, Clinical Pathology,” 286. 78. Ibid. 79. Ibid., 287. 80. Martin, “Electronic Fetal Monitoring”; Lent, “Medical Legal Risks,” 807–837. 81. Bassett et al., “Defensive Medicine,” 524. 82. Bassett, “Anthropology, Clinical Pathology,” 281. 83. Shy, “Evaluating a New Technology,” 187. 84. Author interview with Dr. García, 2. 85. Murphy-­Lawless, Reading Birth and Death, 161. 86. Ibid., 162. 87. Murphy, Seizing the Means of Reproduction, 52. 88. Canguilhem, Lo normal y lo patológico, 133–116. 89. Author interview with Dr. Ramírez, 19. 90. Fraser, African American Midwifery, 167. 91. Ginzburg, “Morelli, Freud and Sherlock Holmes,” 17. 92. Murphy, Seizing the Means of Reproduction, 70. 93. Comelles and Martínez Hernáez, Enfermedad, cultura y sociedad, 1. 94. Ibid., 18. See also DIVEDCO, Nuestros hijos, 16, 24, 27. 95. DIVEDCO, Nuestros hijos, 27. 96. Ibid., 28. 97. For further information about DIVEDCO goals and campaigns directed at women see Flores Ramos, “Mujer, familia y prostitución,” 57–79. 98. Rivera, “Development of Capitalism”; Colón et al., “Trayectoria de la participación laboral de las mujeres en Puerto Rico”; del Alba Acevedo, “Género.” 99. Davis-­Floyd, “The Technocratic Body,” 126–128. 100. For a discussion concerning the racial characteristics of female slaves in the Caribbean see Beckles, “Sex and Gender”; Pernick, Calculus of Suffering; and Ferguson, Class Transformations (504 fn) describing the birthing pains of rich and poor woman in Puerto Rico. 101. Referring to a study published by Vázquez Calzada, Laura Briggs (Reproducing Empire, 122) explains that in 1939, 34 percent of women in Puerto Rico used birth control compared to 74 percent in 1968. 102. For information on US women’s health care activism see Starr, Social Transformation, 391–393; Morgen, Into Our Own Hands, 5, 11, 27; Kline, Bodies of Knowledge, chap. 1. 103. Murphy-­Lawless, Reading Birth and Death, 44. 104. Ibid., 32. 199 Notes to Pages 128–135

Chapter five 1. Davis-­Floyd, Birth as an American Rite of Passage, 92. 2. Davis-­Floyd and St. John, From Doctor to Healer, 4–5. 3. Murphy-­Lawless, Reading Birth and Death, 33, 44. 4. Fixmer-­Oraiz, “No Exception Postprevention,” 30. 5. An Apgar score is an evaluation of a newborn’s heart rate, breathing effort, muscle tone, color, and response to stimulation. 6. Vázquez Calzada and Centro de Investigaciones Demográficas, El matrimonio legal, 16. 7. For information on 1970s US women’s health care activism, see Starr, Social Transformation, 391–393; and Morgen, Into Our Own Hands. 8. Colón-­Warren and Alegría Ortega, “Shattering the Illusion of Development,” 105, 109–110. 9. Ibid., 108. 10. Starr, Social Transformation, 389. 11. Ibid. 12. Colón, “La práctica de la medicina moderna,” 423. 13. Ibid., 424. 14. As medical interventions increase, the subset of possible reactions, errors, and reactions increases as well. Many medical interventions set off a chain reaction of physiological responses, each requiring monitoring techniques to offset side effects. For example, the drug Pitocin stimulates a slow labor but can artificially increase contractions, thereby increasing pain and the possibilities of a ruptured uterus. Pain medication for the intense contractions might induce nausea. Also medical staff will be more attentive to the electronic fetal monitor and be more prone to alert the obstetrician to any possible signs of fetal distress. The level of tension in general increases, adversely affecting labor and leading to use of an ever-­expanding menu of medical technologies. 15. Colón, “La práctica de la medicina moderna,” 423. 16. Ibid., 424. 17. Starr, Social Transformation, 386–387. 18. Departamento de Salud, Statistics on Health Facilities, 1980, 11. 19. Departamento de Salud, Annual Report on Health Facilities Statistics, 1985– 1986, 59. 20. Velázquez estimates that only one of every twenty people who are victims of malpractice in Puerto Rico decide to take legal action and 65 percent of those receive compensation, but less than 2 percent actually make it through the judicial system, where decisions are divided 50/50 in favor of doctors or patients (70). Velázquez, Crisis de impericia médica, 24, 70, 156. 21. Ibid., 23–25. 22. Ibid., 24. 23. Ibid., 35. 24. Ibid., 39. 200 Notes to Pages 138–149

25. Boletín de la Asociación Médica de Puerto Rico 75, no. 4 (April 1983). 26. Velázquez, Crisis de impericia médica, 47–52. 27. See the discussion in chapter 3 about the Medical Board of Examiners (section 49 of the current penal code). The penal code I refer to was in place from 1974 to 2004. 28. Author interview with Rita, Río Grande, February 19, 2002, 26. 29. Ibid. 30. Instituto JTPA del Caribe, Puerto Rico, 29. The trend of higher rates of cesareans in private hospitals is significant and worldwide. In Brazil, cesareans reached 70 percent by 2002. See Mukherjee, “Rising Cesarean Section Rate,” 298. 31. Turner, “Cesarean Section Rates,” 281. 32. In 1989, repeat c-­sections in the US were 28 percent of all pregnancies, and in Puerto Rico, 42 percent. Vázquez Calzada, El matrimonio legal, 4. 33. Ibid., 13. 34. Ibid., 14. 35. Ibid. 36. Ibid., 15. 37. Vázquez Calzada, El matrimonio legal, 2, 4; and Centers for Disease Control and Prevention, “Rates of Cesarean Delivery,” 1369–1371. 38. Author interview with Dr. Ramírez. 39. Ibid., 23. 40. Ibid., 10. 41. Ibid., 10–13. 42. Ibid. 43. Author interview with Dr. Carmona, September 27, 2005, 20. 44. Ibid., 22. 45. Ibid., 21. 46. Author interview with Dr. Mulero, 25. 47. Hager et al., “Complications of Cesarean Deliveries,” 428–434. 48. Moore, “Reducing the Rate of Cesarean Birth,” 41–42. 49. Díaz and Cabrera, “El servicio de las parteras,” 33. 50. The United States concluded that it wished to reduce neonatal mortality to 6.5 for every 1,000 births (in Puerto Rico it was 15 per 1,000 in 1980) and reduce maternal mortality rates from 9.6 per 100,000 in 1978 (in Puerto Rico it was around 10 per 100,000 in 1980) to 5 per every 100,000 births. The United States wished to lower the low birth weight rates from 7 percent in 1978 to below 5 percent. Rigau, “La salud durante el embarazo,” 246–247. The number of low birth weight babies born in Puerto Rico is particularly high, floating at about 10 percent during the 1980s and 1990s. In 1994, Puerto Rico had an infant mortality rate of 11.5 of every 1,000 live births, maternal mortality was at 8 per 100,000, and only 4 percent of new mothers breast-­fed their babies. Díaz and Cabrera, “El servicio de las parteras,” 96. 51. Ibid., 95. 52. Midwives who were officially recognized and licensed before the 1970s 201 Notes to Pages 150–160

were identified as auxiliary midwives. See chapter 1 for their legal history and explanation. 53. These documents were revised in 1998. 54. Parteras de Puerto Rico, “La ciencia de partear,” my translation. 55. Parteras de Puerto Rico, “Declaración de valores.” 56. Díaz and Cabrera, “El servicio de las parteras,” 23. 57. Ibid., 48. 58. Ibid., 29. 59. Author interview with Ruth, June 18, 2000. 60. Author interview with Rita. 61. Author interview with Debbie, December 6, 2001. 62. Follow-­up telephone interview with Debbie, March 26, 2002. 63. Ibid. 64. Author interview with Ruth, 44. A couple more women entered the practice of midwifery after the 1990s. 65. Vincens, “La comadrona,” 46–47; Figueroa, “El oficio divino de las parteras,” 58–59; Heydrich Blanco, “Al natural . . . ,” 60; Vélez Sepúlveda, “Parteras del nuevo siglo,” 82; “Parto en el hogar”; Valle Hernández, “La guía natural hacia la luz,” 28–29; Sanjurjo Meléndez, “El control del alumbramiento” and “El derecho de dar a luz en la casa.” 66. Díaz, “Part of a Distant Past,” 17–18. 67. See web page http://www.relacahupan.org. 68. Díaz and Cabrera, “El servicio de las parteras,” 105. 69. Ibid., 108–122. 70. Ruth was a colleague of Carmen Martínez, Ivan Martínez, Mariano Otero, and Rubén Marchand, all recognized and distinguished naturopathic doctors. 71. Author interview with Ruth, 7. 72. Ibid., 25. 73. Ibid., 25. 74. These women were taken to the hospital because of what Ruth explained were fears and insecurities that arose during long labors. 75. Costs for services in 1996 were as follows: $300 for prenatal care, $300 for the birth (if transported, this charge is eliminated) and $100 for postpartum care. 76. Ruth passed away in 2011 but left an indelible stamp on the history of midwifery on the island. 77. Author interview with Rita, 54. 78. Direct-­entry midwifes train exclusively with midwives without going through medical institutions. 79. Espiritistas communicate and work with the spirit world, a long-­standing tradition among women in Puerto Rico. 80. Author interview with Debbie, 10. 81. Ibid., 16. 82. Ibid., 33.

202 Notes to Pages 160–170

conclusion and epilogue 1. In 2003, ACOG designated thirteen states as having a crisis (DC, FL, GA, MS, NV, NJ, NY, OH, OR, PA, TX, VA, and WA) and six others as having a crisis brewing (AL, CT, IL, KY, MO, and UT). ACOG Response to GAO Report on Liability Crisis, September 25, 2003. 2. Velázquez, Crisis de impericia médica, 74. 3. Sosa Pascual, “Posible un pleito por paciente cambiado,” 26; “Rullán confirma la falta de datos sobre impericia,” 26; and “Entre las primeras causas de muertes,” 24. See also Díaz Román, “Investigarán aumento en la prima por impericia médica.” 4. Velázquez, Crisis de impericia médica, 77; Tanner, “Toman medidas para evitar errors.” 5. Sosa Pascual, “Previsible un éxodo de ginecólogos,” 10. 6. Velázquez, Crisis de impericia médica, 80. 7. Sosa Pascual, “Se lavan las manos”; see also Velázquez, Crisis de impericia médica, 85. 8. Velázquez, Crisis de impericia médica, 108. 9. Ibid., 81–86. 10. “Ginecólogos alzan voz de protesta.” 11. Fernández Colón, “El sur quedará sin servicios “; Caquías Cruz, “ Protestan con bisturí en manos.” 12. Parés Arroyo, “Desbordadas las salas de parto públicas,” 4. 13. Velázquez, Crisis de impericia médica, 87–93. 14. Gómez, “Víctimas de impericia se dejan sentir”; Medina, “Reclamos en Capitolio por impericia médica”; Roldán Soto, “Protesta contra el limite a la compensación por impericia,” 28; Alvarado Vega, “Plaintiffs Protest Effort to Limit Malpractice Lawsuits,” 37. 15. Pacheco, “Autor de medida sobre impericia médica dice que retirará el proyecto.” 16. Rosario, “Regrese en cuatro meses,” 3. 17. Roldán Soto, “Obstetras del Auxilio Mutio le dicen adios a los partos,” 16. 18. Velázquez, Crisis de impericia médica, 110. 19. Author interview with Dr. Castillo, 45. 20. Author interview with Dr. Cordero. 21. Fernández, “A parir en las casas.”

203 Notes to Pages 177–180

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Port, Andrew. “History from Below: The History of Everyday Life, and Microhistory.” In the International Encyclopedia of the Social and Behavioral Sciences, Vol. 11, 108–113. 2nd ed. Amsterdam: Elsevier, 2015. Radkau, Verena. “Los médicos (se) crean una imagen: Mujeres y médicos en la prensa médica mexicana del siglo XIX.” In Género, familia y mentalidades en América Latina, edited by Pilar Gonzalbo Aizpura. Río Piedras: Editorial Universidad de Puerto Rico, 1997. Rivera, Marcia. “The Development of Capitalism in Puerto Rico and the Incorporation of Women into the Labor Force.” In The Puerto Rican Woman: Perspectives on Culture, History, and Society, edited by Edna Acosta-­Belén. New York: Praeger, 1986. Safa, Helen. “Female Employment and the Social Reproduction of the Puerto Rican Working Class.” In The Puerto Rican Woman: Perspectives on Culture, History, and Society, edited by Edna Acosta-­Belén. New York: Praeger, 1986. Scott, Joan. “El género: Una categoría útil para el análisis histórico.” In El género: La construcción cultural de la diferencia sexual, edited by Marta Lamas. Mexico City: Programa de Estudios del Género, UNAM, 1997.

Edited Books Abram, Ruth J., ed. “Send Us a Lady Physician”: Women Doctors in America, 1835– 1920. New York: W. W. Norton, 1985. Acosta-­Belén, Edna, ed. The Puerto Rican Woman: Perspectives on Culture, History, and Society. 2nd ed. New York: Praeger, 1986. Adamson, Karlis, ed. Diagnosis and Treatment of Fetal Disorders: Proceedings of the International Symposium on Diagnosis and Treatment of Disorders Affecting the Intrauterine Patient. New York: Springer-­Verlag, 1968. Azize, Yamila, ed. La mujer en Puerto Rico: Ensayos de investigación. Río Piedras: Ediciones Huracán, 1987. Cancel, Mario, ed. Historia y género: Vidas y relatos de mujeres en el Caribe. Asociación Puertorriqueña de Historiadores. San Juan: Posdata, 1997. Cueto, Marcos, ed. Missionaries of Science: The Rockefeller Foundation and Latin America. Bloomington: Indiana University Press, 1994. ———, ed. Salud, sociedad y cultura en América Latina: Nuevas perspectivas históricas. Lima: Instituto de Estudios Peruanos, 1996. Figueroa Peréa, Juan Guillermo, ed. La condición de la mujer en el espacio de la salud. Mexico City: El Colegio de México, 1998. Ginsburg, Faye D., and Rayna Rapp, eds. Conceiving the New World Order: The Global Politics of Reproduction. Berkeley: University of California Press, 1995. Hayden, Sara, and Lynn O’Brien, eds. Contemplating Maternity in an Era of Choice: Explorations into Discourses of Reproduction. Lanham, MD: Lexington Books, 2010. Marland, Hilary, ed. The Art of Midwifery: Early Modern Midwives in Europe. The 212 Bibliography

Wellcome Institute Series in the History of Medicine. London and New York: Routledge, 1993. Marland, Hilary, and Anne Marie Rafferty, eds. Midwives, Society, and Childbirth: Debates and Controversies in the Modern Period. Studies in the Social History of Medicine. London and New York: Routledge, 1997. Matos Rodríguez, Félix V., and Linda C. Delgado, eds. Puerto Rican Women’s History: New Perspectives on Latin America and the Caribbean. Armonk, NY: M. E. Sharpe, 1998. Roe Smith, Merritt, and Leo Marx, eds. Historia y determinismo tecnológico. Madrid: Alianza Editorial, 1996. Sargent, Carolyn, and Caroline Brettell, eds. Gender and Health: An International Perspective. Englewood Cliffs, NJ: Prentice Hall, 1996. Shepherd, Verene, ed. Women in Caribbean History. Princeton, NJ: Markus Weiner, 1999. Shepherd, Verene, Bridget Brereton, and Barbara Bailey, eds. Engendering History: Caribbean Women in Historical Perspective. New York: St. Martin’s Press, 1995.

Journal Articles Allende de Rivera, C. “Women Health and Public Policy: Practices and Strategies in Puerto Rico.” Puerto Rican Health and Science Journal 9, no. 1 (1990): 105–110. Araujo de Caravalho, Islene. “Midwives of the Sertao.” International Midwife (1995): 11–12. Arbona, Guillermo. “Present Facilities [for a Medical School in Puerto Rico].” Boletín de la Asociación Médica de Puerto Rico 41, no. 1 (1949): 18–20. Asociación Médica de Puerto Rico. “News Release: ACCOG Response to GAO Report on Liability Crisis” (1992). Reprinted in American College’s Obstetrics and Gynecology (2003). ———. “Puerto Rican MDs Fear Socialism” (1946). Boletín de la Asociación Médica de Puerto Rico (1946). Reprinted in American Medical Association News 6, no. 2 (1963). Baker, Wayne, and Ronald Inglehart. “Modernization, Cultural Change, and the Persistence of Traditional Values.” American Sociological Review 65, no. 1 (2000): 19–51. Barceló Miller, María. “Estrenando togas: La profesionalización de la mujer en Puerto Rico, 1900–1930.” Revista del Instituto de Cultura Puertorriqueña 99 (1990): 14–16. Barranco Lagunas, Isabel. “Partera empírica.” Fem, no. 64 (1988): 18–20. Bassett, Ken. “Anthropology, Clinical Pathology and the Electronic Fetal Monitor: Lessons from the Heart.” Social Science and Medicine 42, no. 2 (1996): 283. Bassett, Ken, Nitya Yiyer, and Arminee Kazanjian. “Defensive Medicine During Obstetrical Care: A By-­Product of the Technological Age.” Social Science and Medicine 51 (2000): 530. 213 Bibliography

Benítez, Jaime. “The Position of the University of Puerto Rico.” Boletín de la Asociación Médica de Puerto Rico 41, no. 1 (1949): 25. Bertrán, A. P. “Informe del presidente.” Boletín de la Asociación Médica de Puerto Rico 56, no. 12 (1964): 124–125. Bertrán, Ana P., M. Merialdi, W. Bing-­shun, J. Lauer, J. Thomas, M. Wagner, and P. Van look. “Rates of Caesarean Section: Analysis of Global, Regional and National Estimates.” Pedriatric Perinatal Epidemiology 21 (2007): 98–113. Bradshaw, York, “Urbanization and Underdevelopment: A Global Study of Modernization, Urban Bias, and Economic Dependency.” American Sociological Review 52, no. 2 (1987): 224–239. Briggs, Jill. “As Fool-­Proof as Possible: Overpopulation, Colonial Demography and the Jamaica Birth Control League,” Global South 4, no. 2 (2010): 157–177. Cabrera, Fernando. “En busca de quijotes médicos.” Boletín de la Asociación Médica de Puerto Rico 63, no. 12 (1971): 327. Canning, Kathleen. “The Body as a Method? Reflections on the Place of the Body in Gender History.” History 11, no. 3 (1999). Carrillo, Ana María. “Parteras y ginecólogos: El hombre dijo, háganse las salas de parto.” Fem, no. 64 (1988): 10–18. Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report 55, no. 3 (2006): 68–71. ———. “Rates of Cesarean Delivery among Puerto Rican Women—Puerto Rico and the U.S. Mainland 1992–2202.” JAMA 295, no. 12 (2006): 1369–1371. Chafey, David Holmes, “Review of Major Gynecological Surgery.” Boletín de la Asociación Médica de Puerto Rico 48, no. 11 (November 1956). Chester, Martin. “Electronic Fetal Monitoring: A Brief Summary of Its Development, Problems and Prospects.” European Journal of Obstetrics and Gynecology and Reproductive Biology 78 (1998): 136. Colón, Ivan. “La práctica de la medicina moderna y el concepto de administración de riesgos.” Boletín de la Asociación Médica de Puerto Rico 79, no. 10 (1987): 423–425. Colón-­Warren, Alice, and Idsa Alegría Ortega. “Shattering the Illusion of Development: The Changing Status of Women and Challenge for the Feminist Movement in Puerto Rico.” Feminist Review 59 (1998): 101–117. Córdova, Isabel. “Setting Them Straight: Social Services, Youth, Sexuality, and Modernization in Postwar (WWII) Puerto Rico.” Centro Journal 19, no. 1 (Spring 2007): 26–49. Correa, Alejandra. “De nodrizas y parteras.” Todo es Historia 30, no. 355 (1997): 76–92. Costa Mandry, O. “Endeavors to Establish a Medical School in Puerto Rico.” Boletín de la Asociación Médica de Puerto Rico 41, no. 1 (1949): 14–17. Coxon, Kirstie, Jane Sandall, and Naomi J. Fulop. “To What Extent Are Women Free to Choose Where to Give Birth? How Discourses of Risk, Blame and Responsibility Influence Birth Place Decisions.” Health, Risk and Society (2013). DOI:10.1080/13698575.2013.859231. 214 Bibliography

Cueto, Marcos. “The Rockefeller Foundation’s Medical Policy and Scientific Research in Latin America: The Case of Physiology.” Social Studies of Science 20, no. 2 (1990): 229–254. Davis-­Floyd, Robbie. “The Technocratic, Humanistic and Holistic Paradigms of Childbirth.” International Journal of Gynecology and Obstetrics 75, no. 1 (2001): S5–­S23. Davis-­Floyd, Robbie, and Carolyn Sargent. “The Social Production of Authoritative Knowledge in Pregnancy and Childbirth.” Medical Anthropology Quarterly (n.s.) 10, no. 2 (1996): 111–120. Deschamps Chapeaux, Pedro. “El negro en la economía del siglo XIX: Las comadronas o parteras.” Revista de la Biblioteca Nacional José Martí 12, no. 3 (1970): 49–62. Diamond, Irene, and Lee Quinby. “American Feminism in the Age of the Body.” Signs 10, no. 1 (1984): 119–125. Díaz Ortiz, Debbie A. “Part of a Distant Past: Tracing the History of Midwifery in Puerto Rico.” International Midwife (1995): 17–18. Dye, Nancy Schrom. “History of Childbirth in America.” Signs 6, no. 1 (1980): 97–108. Edmunds, Judy. “Conspiracy of Silence.” Midwifery Today (1998): 11. Elinson, Jack. “The Physician’s Dilemma in Puerto Rico.” Journal of Health and Human Behavior 3, no. 1 (1962): 14–20. Finn, William. “Induction and Stimulation of Labor.” Boletín de la Asociación Médica de Puerto Rico 48, no. 9 (1956): 360–371. Floyd, Robbie Davis, and Carolyn Sargent. “The Social Production of Authoritative Knowledge in Pregnancy and Childbirth.” Medical Anthropology Quarterly 10, no. 2 (1996): 111–120. Gartman, David. “Bourdieu’s Theory of Cultural Change: Explication, Application, Critique.” Sociological Theory 20, no. 2 (2002): 255–277. Ginzburg, Carlo, “Morelli, Freud and Sherlock Holmes: Clues and Scientific Method.” History Workshop Journal 9 (1980): 5–36. Gordon, Robert. “Critical Legal Histories.” Stanford Law Review 36.1/2 (January 1984): 57–125. Hager, Renate M. E., Anne K. Daltveit, Dag Hofoss, Stein T. Nilsen, Toril Kolaas, Pal Oian, and Tore Henriksen. “Complications of Cesarean Deliveries: Rates and Risk Factors.” American Journal of Obstetrics and Gynecology 190, no. 2 (February 2004): 428–434. Hahn, Robert. “Divisions of Labor: Obstetrician, Woman, and Society in Williams Obstetrics, 1903–1985.” Medical Anthropology Quarterly 1, no. 3 (1987): 256–282. Hays, Bethany. “Authority and Authoritative Knowledge in American Birth.” Medical Anthropology Quarterly 10, no. 2 (1996): 291–294. Hindle, Christine. “International Credentialing of Midwifes.” International Midwife (1995): 9–10. Hiriart, Berta. “Parteras y salud reproductiva.” Fem 19, no. 143 (1995): 18–19. 215 Bibliography

Holmes Chaffey, David. “Review of Major Gynecological Surgery.” Boletín de la Asociación Médica de Puerto Rico 48, no. 11 (1956): 451–457. Inclán Perea, María Isabel. “La partera: Figura obsoleta.” Fem, no. 64 (1988): 14–15. Isaac, Joel. “The Human Sciences in Cold War America.” Historical Journal 50, no. 3 (2007): 725–746. Izquierda Mora, Luis. “La época de oro de la medicina.” Boletín de la Asociación Médica de Puerto Rico 59, no. 2 (1967). Katz Rothman, Barbara. “The Daughters of Time on the Path to Midwifery.” Midwifery Today (2000): 8 pp. Lent, M. “The Medical Legal Risks of the Electronic Fetal Monitor.” Stanford Law Review 51, no. 4 (1999): 807–837. Lessing, Jeffery. “Carta al editor.” Boletín de la Asociación Médica de Puerto Rico 65, no. 8 (1973): 200. Marsden, Wagner. “The Politics of Birth.” Midwifery Today (1998): 53. Martin, Chester. “Electronic Fetal Monitoring: A Brief Summary of Its Development, Problems and Prospects.” European Journal of Obstetrics and Gynecology and Reproductive Biology 78 (1998): 133–140. Martin, Emily. “The Egg and the Sperm: How Science Has Constructed a Romance Based on Stereotypical Male-­Female Roles.” Signs 16, no. 3 (1991): 485–501. Moore, Mary Lou. “Reducing the Rate of Cesarean Birth.” Journal of Perinatal Education 11, no. 2 (2002): 41–43. Mukherjee, S. N. “Rising Cesarean Section Rate.” Journal of Obstetrics Gynecology of India 56, no. 4 (2006): 298–300. Parvin, Niknafs, and John Sibbad. “Mama: The Iranian Midwife.” Midwifery Today (1998): 50. Pernick, Martin. “Eugenics and Public Health in America History.” American Journal of Public Health 87 (1997): 1767–1772. Pons, Juan. “Why a Medical School for Puerto Rico.” Boletín de la Asociación Médica de Puerto Rico 41, no. 1 (1949): 6–13. Price, Charles. “Malpractice Insurance—Past, Present and the Uncertain Future.” Boletín de la Asociación Médica de Puerto Rico 63, no. 2 (1971): 31–33. Quinquilla, Rafael. “Thorazine in Obstetric Analgesia.” Boletín de la Asociación Médica de Puerto Rico 48, no. 6 (1956). Ramírez de Arellano, Annette. “El mercado de los servicios médicos.” Boletín de la Asociación Médica de Puerto Rico 68, no. 7 (1976): 167–170. ———. “Pink Collar Medicine: Implications of the Feminization of the Profession.” Puerto Rican Health and Science Journal (1990): 21–40. Reinhard, Edward. “Medicine and the Crisis in Confidence.” Boletín de la Asociación Médica de Puerto Rico 68, no. 5 (1976): 111. Rifkinson, Nathan. “Obstetrical Practices and Brain Damage of the Newborn.” Boletín de la Asociación Médica de Puerto Rico 49, no. 1 (1957): 37–40. Rigau-­Pérez, José. “La salud durante el embarazo y el primer año de vida en Puerto

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Rico: Progreso los objetivos nacionales de salud para 1990.” Boletín de la Asociación Médica de Puerto Rico 78, no. 6 (June 1986): 246–247. ———.”Historia de la medicina: La salud en Puerto Rico en el siglo XX.” Puerto Rico Health and Sciences Journal (2000): 357–368. Rodríguez Olmo, J. “Inducción del parto.” Boletín de la Asociación Médica de Puerto Rico 47, no. 2 (1955): 65–69. Rose, Hilary. “Hand, Brain, and Heart: A Feminist Epistemology for the Natural Sciences.” Signs 9, no. 1 (1983): 73–90. Sargent, Carolyn, and Grace Bascope. “Ways of Knowing About Birth in Three Cultures.” Medical Anthropology Quarterly 10, no. 2 (1996): 213–236. Scheper-­Hughes, Nancy, and Margaret M. Lock. “The Mindful Body: A Prolegomenon to Future Work in Medical Anthropology.” Medical Anthropology Quarterly 1, no. 1 (1987): 6–41. Schrom Dye, Nancy. “History of Childbirth in America.” Signs 6, no. 1 (1980): 97–108. Shy, K., E. B. Larson, and D. A. Luthy. “Evaluating a New Technology: The Effectiveness of the Electronic Fetal Heart Rate Monitor.” Annual Review of Public Health 8 (1987): 165–190. Simpson, J. W., E. A. Zimmerman, and H. M. Jesurun. “Routine Extraperitoneal Approach for Cesarean Section.” Boletín de la Asociación Médica de Puerto Rico 42, no. 8 (1950): 490–494. Slater, David. “The Geopolitical Imagination and the Enframing of Development Theory.” Transactions of the Institute of British Geographers 18, no. 4 (1993): 419–437. Southern, Joel. “On Trial: Women Healers.” Midwifery Today (1998): 35. Stallings, Therese, and Mansfield Marge. “A Working Relationship.” International Midwife (1995): 15–16. Theriot, Nancy. “Women’s Voices in Nineteenth-­Century Medical Discourse: A Step toward Deconstructing Science.” Signs 19, no. 1 (1993): 1–31. Toepke, Marion. “Midwives, Doctors and Power.” Midwifery Today (1998): 9. Torres Pineda, Ramón. “¿Hacia una medicina más científica?”. Boletín de la Asociación Médica de Puerto Rico 58, no. 11 (1966): 561. Trueba, Guadalupe. “Birth in Pre-­Hispanic Mexico.” Midwifery Today (1997): 45–47. ———. “Women’s Reproductive Health: A Global Perspective.” Midwifery Today (1998): 43. Turner, R. “Cesarean Section Rates, Reason for Operations Vary between Countries.” Family Planning Perspectives 22, no. 6 (1990): 281–282. Walsh, Frank. “Analgesia and anestesia in obsterics.” Boletín de la Asociación Médica de Puerto Rico 42 (1950): 294–298. Warren, Adam. “Between the Foreign and the Local: French Midwifery, Traditional Practitioners, and Vernacular Medical Knowledge About Childbirth in Lima, Peru.” História, Ciências, Saúde-­Manguinhos 22, no. 1 (2015): 179–200. Wolf, Jacqueline H. “ ‘Mighty Glad to Gasp in the Gas’: Perceptions of Pain and 217 Bibliography

the Traditional Timing of Obstetric Anesthesia.” Health: An Interdisciplinary Journal for the Social Study of Health, Illness and Medicine, no. 6 (2002): 365–387.

Newspaper Articles Alvarado Vega, José. “Plaintiffs Protest Effort to Limit Malpractice Lawsuits.” San Juan Star, September 12, 2002, 37. Caquías Cruz, Sandra. “Protestan con bisturí en manos.” El Nuevo Día, August 17, 2002. del Valle Hernández, Sara. “La guía natural hacia la luz.” El Nuevo Dia, July 6, 2007. Díaz Román, Miguel. “Investigarán aumento en la prima por impericia médica.” El Nuevo Día, September 11, 2001. “Doctor Astor denuncia los daños causados por los curanderos.” El Mundo, May 11, 1948. Fernandez [Colón], José. “A parir en las casas.” El Nuevo Día, October 16, 2007. ———. “El sur quedará sin servicios ginecológos y de cirujanos.” El Nuevo Día, August 16, 2002. Figueroa, Janirah. “El oficio divino de las parteras.” El Vocero, May 8, 2000, 58–59. García, Carmen. “Inauguran abril 18 Centro Médico Dr. Enrique Koppisch.” El Mundo, April 9, 1964. “Ginecólogos alzan voz de protesta.” Primera Hora, August 17, 2002. Gómez, Antonio. “Víctimas de impericia se dejan sentir.” Primera Hora, September 12, 2002. Heydrich Blanco, Teresita. “Al natural . . .” El Nuevo Día, May 6, 2002. “Inauguran hoy centro médico en San Sebastián.” El Mundo, October 9, 1964. Irizarry, Samuel. “Piden orientación comadronas se quejan gobierno ELA las tiene abandonadas.” El Mundo, March 10, 1966, 37. Medina, Jorge Luis. “Reclamos en capitolio por impericia médica.” El Vocero, September 12, 2002, 23. Mitila Lora, Ana. “Nosotras aguantando y los hombres . . .” Memorias del Siglo del Listín Digital. Mullen, Karen. “Midwives’ Crusade Labor Intensive.” Chicago Tribune, April 2, 2001. Ortiz, Bienvenido. “Ven médicos locales envueltos denuncian raquet internacional abortos.” El Mundo, May 2, 1963. Pacheco, Istra. “Autor de medida sobre impericia médica dice que retirará el proyecto.” El Nuevo Día, September 17, 2002. Parés Arroyo, Marga. “Desbordadas las salas de parto públicas.” El Nuevo Día, September 4, 2002. “Parto en el hogar.” El Nuevo Día, September 2, 2007. Pellicier, Miguel Angel, “Inauguran Hospital Menonita.” El Mundo, October 19, 1965.

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Rojas Daporta, Malén. “Descubridor píldora contraceptiva asegura es infalible; no causa cáncer.” El Mundo, November 30, 1959. Roldán Soto, Camile. “Protesta contra el límite a la compensación por impericia.” El Nuevo Día, September 12, 2002, 28. ———. “Obstetras del Auxilio Mutuo le dicen adiós a los partos.” October 15, 2002, 16. Rosario, Ivonne. “Regrese en cuatro meses.” El Vocero, November 29, 2002, 3. Sanjurjo Meléndez, Libni. “El control del alumbramiento.” Primera Hora, October 22, 2007. ———. “El derecho de dar a luz en la casa.” Primera Hora, October 22, 2007. Sosa Pascual, Omaya. “Entre las primeras causas de muertes.” El Nuevo Día, July 15, 2001, 24. ———. “Posible un pleito por paciente cambiado.” El Nuevo Día, April 12, 2001, 26. ———. “Previsible un éxodo de ginecólogos.” El Nuevo Día, May 2002, 22, 24. ———. “Rullán confirma la falta de datos sobre impericia.” El Nuevo Día, July 15, 2001, 26. ———. “Se lavan las manos el organismo rector de los médicos.” El Nuevo Día, September 24, 2002. Tanner, Lindsey. “Toman medidas para evitar errores.” El Vocero, December 7, 2001, 46. “Up by the Bootstraps.” Time, Friday, October 29, 1965. Valdivia, Yadira. “Aumentan los nacimientos por cesárea.” El Nuevo Día, February 7, 2000. Vda Pont, Julia. “Expanden hospital.” El Mundo, October 12, 1965. Vincens, Marilyn. “La comadrona, una especie que no está extinta.” El Nuevo Dia, September 9, 1996, 46–47.

Conference Papers Güémez Pineda, Miguel. “Imagen social de la partera indígena yucateca a través de la historia.” LASA, Miami, 2000. Pons, Juan. “Informe del ELA a la XIV Conferencia Sanitaria Panamericana.”1954. Rude, Anna. “The Midwife Problem in the United States.” 74th annual session of the American Medical Association. San Francisco, 1923.

Theses Colón, Nayda Berríos. “Análisis de la estructura organizacional del Departamento de Salud: La necesidad de un nuevo modelo de servicio.” Universidad de Puerto Rico de La Escuela Graduada de Administración Pública, 1990.

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Díaz Ortíz, Debbie Ann, and Merixa Cabrera Mont. “El servicio de las parteras en Puerto Rico: Historia de la profesión y análisis del servicio a través del nivel de satisfacción de las madres atendidas durante la gestación, alumbramiento y puerperio en las décadas del 1980–1990.” Universidad de Puerto Rico Recinto de Ciencias Médicas, 1999. Ducret Ramu, Carmen Rita. “La comadrona puertorriqueña: Colaboradora en el proceso de parir.” Universidad Interamericana de Puerto Rico, 1989. Ferguson, Richard Brian. “Class Transformations in Puerto Rico.” Columbia University, 1988. Flores Ramos, José Enrique. “Mujer, familia y prostitución: La construcción del género bajo la hegemonía del Partido Popular Democrático.” University of Puerto Rico, 2002. Godreau, Isar Pilar. “Missing the Mix: San Antón and the Racial Dynamics of ‘Nationalism’ in Puerto Rico.” University of California, Santa Cruz, 1999. Trujillo-­Pagán, Nicole E. “Health Beyond Prescription: A Post-­Colonial History of Puerto Rican Medicine at the Turn of the Twentieth Century.” University of Michigan, 2003.

Laws (Leyes de Puerto Rico) No. 73, 1923. No. 15, 1924. No. 22, 1931. No. 2 of 1931 amended, 1969. No. 390, 1947. No. 97, 1961. Código penal, 1974–2004. No. 112, 1980. No. 2944, Proyecto de la Cámara, 1999.

Interviews All interviews by author except as noted. Ana, December 1, 2005. Antonia. Interview by L. Ayabarreno using “Cuestionario sobre partos,” 2001. Astor, September 12, 2005. Carmenchi, November 29, 2005. Dr. Carmona, September 27, 2005. Dr. Castillo, September 8, 2005. Castro de Castañeda, Miriam, September 27, 2005. Dr. Cordero, August 10, 2005. Debbie, December 6, 2005. 220 Bibliography

Edna, August 18, 2005. Dr. García, September 13, 2005. Ingrid, December 27, 2005. María, December 5, 2005. Dr. Mulero, October 13, 2005. Nilsa, October 22, 2005. Dr. Onís, September 6, 2005. Patricia, December 23, 2005. Penchi, July 24, 2007. Dr. Pérez, September 12, 2005. Dr. Ramírez, October 3, 2005. Rita, February 19, 2005. Rosa, interview by Y. Lago, 2001. Ruth, June 18, 2005. Tomás, December 15, 2005. Tomasa, October 19, 2005. Vanesa, November 26, 2005. Victoria, September 16, 2005. Dr. Villamil, October 2005, 17.

Government Documents Asociación Médica de Puerto Rico. “Informe anual de la Asociación Médica de Puerto Rico,” 1946–1975. Archive, Santurce. ———. “Medical Association of Puerto Rico Report to the House of Representatives of 1947 and 1953.” ———. Memorias, 1902–1989. Columbia University School of Public Health and Administrative Medicine and the Puerto Rican Department of Health. “La asistencia médico-­hospitalaria en Puerto Rico: Resumen y recomendaciones del informe rendido al honorable gobernador y la legislatura del Estado Libre Asociado.” 1960. Departamento de Salud de Puerto Rico. “Informe anual de estadísticas vitales de 1985.” Oficina de Planificación, 1987. ———. “Material informativo sobre el programa de comadronas auxiliares de 1955.” Santurce. ———. “Reglamento para comadronas auxiliares.” 1961. Asociación Médica de Puerto Rico. “Informe anual del departamento de salud de San Juan,” 1946–1992. División de Educación a la Comunidad. “Nuestros hijos.” 1966. Hernández Cibes, Juan. Statistical Comparison of the First Five Years Functioning MIC Project No. 505. Departamento de Salud (Northeast Region), 1968. Medina, Antonio, MD. “The Utilization of Prenatal Services in Puerto Rico,” 1965–1966. UPR Medical Sciences Campus, School of Medicine, Depart221 Bibliography

ment of Preventative Medicine and Public Health, Maternal and Child Health Section. Partido Popular Democrático. Catecismo del pueblo. 1944. “Puerto Rico: Los recursos humanos en cifras.” Edited by Job Training Partnership Act del Carib, 29. N.d. University of Puerto Rico, Bulletin of the University of Puerto Rico School of Medicine, Announcements for the Academic Year 1950–51. Río Piedras, January 1951. University of Puerto Rico School of Medicine and Tropical Medicine. “Educational Development and Program Objective.” 1958. ———. “Four Year Progress Report.” 1956. ———. “University of Puerto Rico School of Medicine Annual Report 1950–1985.” US Department of Health and Human Services. “Developing Objectives for Healthy People 2010.” Office of Disease Prevention and Health Promotion, 1996. Vilar Isern, Rafael. Informe anual de la División de Salud de Madres y Ninos Lisiados del Departamento de Salud de Puerto Rico, 1967–68.

Unpublished Work Castro de Castañeda, Miriam. “Nurse Midwifery in Puerto Rico.” International Confederation of Midwives. “International Code of Ethics for Midwives.” Vancouver, 1993. Parteras de Puerto Rico. “La ciencia de partear: Documentos especiales de las parteras de Puerto Rico.” 1997.

Websites Jacobson, Kate. “A Short History of Midwifery in America.” http://www.frognet .net/~midwife/campaign.html. Jasanada, Alicia. “Partos más seguros, pero menos humanos.” http://www.ciencia .vanguardia.es/ciencia/portada/p531.html.

222 Bibliography

Index

Page numbers in italic indicate material in figures or tables. abortion: access to safe, 134–135; activism regarding, 146; and fetal personhood, 119; illegal, 37, 117, 119; post–Roe v. Wade, 113, 127, 136; Puerto Rico as destination for, 119 ACOG (American College of Obstetricians and Gynecologists), 73, 97, 109, 159, 177, 179–180, 203n1 Adas, Michael, 3, 52–54 African American midwifery, 54, 89 African American Midwifery in the South (Fraser), 132 African ancestry, Puerto Ricans of, 34 Aguirre, Carlos, 4 Althusser, Louis, 126, 197n15 AMPR (Asociación Médica de Puerto Rico), 19, 36, 41–43, 48, 73, 75, 77 anesthesia and analgesia during childbirth, 159; arbitrary administration of, 75; epidural, 127; sedation, 188n97, 188n99; spinal block, 46; standards in 1950s and 1960s, 45–46, 75–77; twilight sleep, 75–76, 86

“Annual Report of the Sanitary Director to the Governor of Puerto Rico,” 28 anomaly as pathology, 91 anthem of comadronas auxiliares, 24 antibiotics, 54, 159, 165, 189n14 Apgar score, 144, 200n5 appliances in homes, 32 Arandes, Eduardo, 70 Arbona, Guillermo, 39, 42, 69–71, 93 Arellano, Annette Ramírez de, 6 asepsis practices, 22–23, 26, 28–29, 35–36, 39, 165 Asociación Médica de Puerto Rico (AMPR), 19, 36, 41–43, 48, 73, 75, 77 Asociación Puertorriqueña Pro-Familia, 146 Association of Medical Malpractice Victims, 179 Ateneo Puertorriqueño, 35, 41, 186n53 atropine, 75 auscultation, 128, 198–199n73 author’s pregnancy and birthing experience, 139–144

auxiliary midwives. See comadronas auxiliares babies as products, 90 Báez, Quevedo, 126 Baker, Wayne, 3, 55–56 Bassett, Ken, 129 Bayamón hospital, 95 Beck, Ulrich, 88 Benítez, Jaime, 42 Berio, María, 96 Bertrán, Carlos, 112 bioinstitutional medicine, 174 birth attendant licenses, 151 birth control pills. See oral contraception birthing board, 17, 26 birthing practice trends: in 1940s–1970s, 125–130; in 1950s, 30, 65 birth process, views of: driven by women themselves, 97, 173; as nonmedical event, 18–19, 48, 49; as pathology, 129–130, 133, 174; perceptions of risk, 65 births assisted by comadronas auxiliares, 16–18, 23, 25–29, 83, 131, 183n2 births assisted by novoparteras, 139–144. See also novoparteras births assisted by nurses, 31, 58–59 (58, 59), 84 births at home: author’s pregnancy and birthing experience, 139–144; compared to hospital births, 28, 49, 64, 82; in contemporary Puerto Rico, 177; decreasing post-WWII, 8, 10; legal problems with (1990s), 153; nurses not attending, 67; rise in, 139 births in hospitals: compared to home births, 28, 49, 64, 82; late 1950s, 78– 81; mother and child in competition, 128–129, 135; physician-assisted (1959–1965), 84–87; by privileged classes in 1940s, 21; public comfort with, 176; role of nurses in, 31, 58, 59; 224 Index

survival rates, 59, 59; transitioning to, in 1950s, 49, 51, 58, 60, 77, 82; use of fetal monitors, 109–110, 116, 118, 127–130, 176. See also defensive medicine; hospitals Board of Medical Examiners, 36–37 Board of Nurse Examiners, 38 Board of Nursing Examiners, 151 body as a machine, 5. See also female body Bradley Method, 146 breastfeeding, 135, 159 breech babies, 157 Brettell, Caroline, 5, 91 Briggs, Laura, 6, 12, 56 Bulletin, The (Medical Association of Puerto Rico), 150 Bureau of Maternal and Child Health report, 111 Cabrera, Fernando, 123 Cabrera Mont, Merixa, 159, 163 Calderón, Sila, 178 Canguilhem, Georges, 91 Carmona, Dr., 157 Carrazo, Díaz, 73 casa grande social structure, 51 Casals Scott, Ana, 96 Castillo, Dr., 75, 77, 180 Castro de Castañeda, Miriam, 69–71, 98 Central Caribbean University (Cayey), 114 Centro Médico, 174 cephalopelvic disproportion, 75, 154 certified professional midwives (CPM), 162. See also novoparteras cesarean section(s): by 1990s, 171; to avoid malpractice lawsuits, 157, 176; becoming standard practice, 116, 127, 143; doctors’ views on, 82–83; effects of on newborns, 77; EFMs and, 128; increase in by country, 154, 156; overuse of, 148, 153, 156; rates of (1948–

1953), 45; rates of (1960s–70s), 6, 11, 74; reasons for choosing, 76, 176; by region and sector in Puerto Rico, 155; risks of multiple, 159; sociocultural factors in, 154–155; vaginal birth after, 110, 158; views of over time, 156–157 children: decreasing mortality of, 87–88 (87); more valued in smaller families, 115–116; standards for development, 113. See also family planning chloroform, 76 chronology of midwifery, 13–15 Cibes, Dr. Juan Hernández, 116 Club de Comadronas (Midwives’ Club), 22, 29 Colen, Shellee, 7 College of Physicians and Surgeons of Puerto Rico, 177 Colón, Alice, 56 Colón, Ivan, 147 Colón, Rafael García, 179 colonialism in Puerto Rico, 7–12; and adoption of birthing practices, 173; colonial government, 8, 19–20, 31, 175, 187n69; and democracy, 54; Estado Libre Asociado status, 9–10; exaggerated adoption of US models, 11; and industrialization, 7, 52, 160, 173; and migration to US, 11; Puerto Rico’s territorial status, 10; and race, 186n51; welfare system under, 2. See also postcolonial practices Columbia University, 42 comadronas auxiliares, 160; anthem of, 24; associated with folklore, 99–100, 112; citizenship requirement for, 39; decrease in numbers of, 22, 66–67, 81–82, 99; Department of Hygiene on, 39; Doña Penchi’s training as, 49–50; gone by 1970s, 89, 100, 108, 110–111, 139; isolation of, 29; lack of professional organization for, 29–30; Law 22 (1931) training, 22–23; losing sociocultural legitimacy, 65; mean225 Index

ing of “midwife assistants,” 37–38; no pensions or benefits for, 107; oath of office, 50; reasons for end of, 100; revised regulations (1951), 39; transitioning toward institutionalization, 55; uniforms and supplies, 23–24, 29, 50; vocabulary of, 24–25; written exam for, 23, 50. See also births assisted by comadronas auxiliares Comelles, Joseph, 133 communism, fears of, 54 constitutional government, 20 contraception: IUD, 146; rhythm method, 73. See also oral contraception; sterilization Con valor y a como dé lugar/With valor by any means necessary (Justiniano), 35–36 cord. See umbilical cord Cordero, Dr., 180 corporization, 148, 182n17 Costa Mandry, Oscar, 41–42 cost of medical care, 122–123 CPM (certified professional midwives), 162. See also novoparteras credentialism, 5 Crisis de impericia médica (Velázquez), 148–149 Cuba, 43, 119, 121 Cueto, Marcos, 12 culture, relationship of, to economics/ politics, 3–4 curanderos (traditional healers), 43–44 Czech Republic, 156 Davis-Floyd, Robbie, 5, 7, 9, 118, 134, 138 death/mortality: between 1945 and 1963, 87, 87; fetal rates of, 59, 167; maternal rates of, 28, 32, 59; as natural, 87–88, 133; of neonates, 77, 127; Ponce rates of, 61; from postpartum hemorrhaging, 86; post-WWII trends in, 10, 59, 60

Debbie: as midwife for author, 141–144, 168–171; training and experience, 168–171 defensive medicine, 121–125; decisionmaking taken from mother, 129; problems with, 146–147; putting mother and child into competition, 128–129, 135; treating birth as pathology, 129–130; treating mother as dangerous, defective, 135, 138, 156 de Jesus Toro, Rafael, 53 demand outstripping supply: of medical school graduates, 57; in records handling, 116 Demerol, 45, 75, 109 democracy in Latin America, 20. See also PPD (Partido Popular Democrático) demographic data collection, 55 Department of Health (PR): and Bayamón hospital, 95; centralizing health and welfare, 92–94; Department of Infants and Hygiene, 23; Department of Maternal and Infant Hygiene, 28; establishing Club de Comadronas (Midwives’ Club), 19, 22, 24, 160; goals of, 159; lack of support for midwives, 82, 100, 108; malpractice concerns, 147–148; midwives disappearing from reports, 151; nursemidwives initiatives, 98, 180; practical versus auxiliary midwives, 38; recognition of midwives, 66; regionalization of health, 56, 175; school for obstetric nurses, 39, 70; study on provision, use of medical services, 68, 78; supervision by, 26–27, 39–40, 55, 110, 151; training of midwives, 19, 48; unknown pill required by, 26, 29. See also UPR School of Medicine Department of Health (US), 72, 159 Depo Provera, 146 developing world: Puerto Rico as bridge to, 121; uneven progress in, 10, 54–55; US plans to stabilize, 3, 7 226 Index

Devices and Desires (Sandelowski), 128 DeVries, Raymond, 6, 34, 65 diabetes, 75, 82, 165 diarrheal diseases, 32, 41 Díaz, Debbie, 159, 163 Díaz, Juana, 195n74, 195n75 DIVEDCO (Division for Community Education), 133 divorce rates, 8 doctors. See physicians dolores (pains) of labor, 24 Doña Antonia, 100 Doña Julia, 17–18, 22–23, 25 Doña Penchi, 23–24, 49–51, 55, 58, 66–68, 83 Doña Rosa, 100 Down syndrome, 136 duplication of services, 79–80 EFM (electronic fetal monitors): becoming standard practice, 109, 116, 127–128; development and availability of, 127; drawing attention from mother, 118, 128, 176; evidence on effects of, 110, 128; situations where useful, 198n71; treating childbirth as pathology, 129–130, 133 Elinson, Jack, 79, 81 Emko cream, 146 employment: increasing unemployment, 112, 115, 175; male and female, 55, 134; public and private, 81 enemas, 26, 74, 159 epidurals, 127 episiotomies: becoming standard, 116, 140–141, 157, 188n97; and class, 105; critics of, 11, 159, 163; novoparteras and, 163, 167, 169; reasons given for use, 82, 106 Estado Libre Asociado status, 9 ether, 76 experts and authoritative knowledge, 86, 88

family-focused society, 51–52; Puerto Rico as la gran familia, 54; shift from extended to nuclear family, 53; shift to urban, public society, 176 family planning, 86, 113; activism around, 146; and class, 80; desire for, 119, 135; experts, pro and con, 73, 93, 120; and family size, 56, 65; government investment in, 127; medical methods for, 56, 113, 146; natural spacing, 86; and overpopulation concerns, 6, 56. See also abortion; contraception fathers, involvement of in birth, 109, 143–144, 146, 165, 170 female body: industrial-capitalist view of, 5, 72, 105, 118, 134–135, 156, 173; mother’s body as dangerous, defective, 135, 138, 156; preindustrial view of, 48, 82 feminists: on anomaly as pathology, 91; on the bodies of women, 6; on experience and knowledge, 135; on fetus as autonomous actor, 118; on “mechanical objectivity,” 132; not focused on birthing rights, 146; on reproductive/fertility rights, 11; theories of, regarding medicine and epistemology, 5 Ferguson, Richard, 64 fertility rates, 10, 19, 56, 59, 113, 182n23 fertility treatments, 127 fetal monitors. See EFM (electronic fetal monitors) fetus as person and patient, 113, 118, 119, 137 FGO (Federation of Gynecology and Obstetrics), 161 Fixmer-Oraiz, Natalie, 139 Fondo del Seguro, 80 Foraker Act (US), 52 forceps, use of: in 1950s and 1960s, 45– 46; confusion over cesareans and, 157–158; lack of research on, 116; mis227 Index

judging need for, 76, 106, 109; prior to mid-1950s, 19, 27, 45 Ford Foundation, 120 Fraser, Gertrude Jacinta, 54, 89, 132 free market, medicine not a, 123 Frente Socialista, El, 146 Fuster, Dr., 45, 194n47 García, Celso Ramón, 96 García, Dr. José, 73, 108–110, 127, 130, 158 generation gap and juvenile delinquency, 123 Giddens, Anthony, 196n93 Gil, Dr., 73 Ginzburg, Carlo, 89 “God Complex” among physicians, 124 Godreau, Isar, 64 graduate nurses, 67–68 Gramsci, Antonio, 100, 185n46, 197n15 Grant, John, 69–70 Great Depression, 52 Group of Puerto Rican Midwives, 166 Grupo Pro Derechos Reproductivos, 146 Guayama, 61 Guayama interviews, 13, 184n12, 184n18, 184nn22–28 Habermas, Jürgen, 92 health services: linking to social welfare, 56; provided for free by state, 8; regionalization of, 56 hemorrhaging, postpartum, 35, 40, 70, 86, 88, 143, 170 Heraldo Médico, El (AMPR), 36 herbal remedies, 17, 25–26, 164–170 “high knowledge,” 89 Hill-Burton Act (US), 94, 193n31 Hinman, Dean, 71 Historia económica de Puerto Rico (de Jesus Toro), 53

Historical Capitalism (Wallerstein), 132 Holmes, David, 74 home births. See births at home hospitals: decaying conditions in, 60; as point of access for services, 87; recordkeeping in, 55; regional differences in, 61–65 (58, 62, 63, 64), 111. See also births in hospitals Hospital Survey and Construction Act (US), 94, 193n31 housing structures, 32 Humacao hospital, 85 hurricanes, 52 husband-coaches, 146 hysterectomies, 74, 76 ICM (International Confederation of Matrons), 161–162 Ideología y aparatos ideológicos de estado (Althusser), 126 ideological shifts in views of science and technology, 125–130 incubators, 127 induction of labor, 74–77, 116, 159 industrialization in Puerto Rico, 2–3; attempting to standardize birth, 130– 131; and legitimacy of midwifery, 41; as PPD platform, 8, 52–53; role of authoritative knowledge in, 86; social/ cultural consequences of, 56, 64–65; stagnation in, 114–115 industrial revolution, 126 Inglehart, Ronald, 3, 55–56 Ingrid, 85–86, 88–91 institutionalization, 13, 21, 47, 55, 80, 176–177 Institution of Superior Education, 35 insurance: health, 79, 122; malpractice, 147–148; and US financial crisis (1970s), 149–150 Interamerican University of Guayama interviews, 13, 184n12, 184n18, 184nn22–28 228 Index

International Federation of Gynecology and Obstetrics, 162 intervention during childbirth, 74–77 intrauterine fetal disorders, 120 intrauterine maneuvers, 157 Isabela, 195n74 IUD, 146 Jones Act (US), 52 Joseph, Gilbert, 4 Justiniano, Carmen Luisa, 35–36 knowledge: authoritative, 86; as domain of professionals, 65; “low” versus “high,” 89 Kopisch, Enrique, 43 labor: length of, 27, 90, 143–145; pain during, 76–77; stages of, 2, 76, 91, 113 la gran familia (the great family), Puerto Rico as, 54 Lamaze, 146 language of midwifes, 24–25 Law 97 (1961), 99 Leavitt, Judith Walzer, 75–76 legal liability concerns, 122, 139, 145, 148–150, 177–180. See also defensive medicine Lessing, Jeffrey, 124–125 liberal-populist economics, 8 libre selección (direct access to specialists), 122–123 licensing: and costs of medicine, 123; hostile versus friendly, 34; as interaction between medicine, law, 38, 113; of midwives, 37, 39–40, 50 life expectancy, mother’s education and, 32. See also death/mortality Lock, Margaret, 6, 9 López, Iris, 56

low birth weights, 159, 201n50 “low knowledge,” 89 Luis (author’s husband), 140–144 Machines as the Measure of Men (Adas), 3 machines in obstetrics, 127–128 Macry, Paolo, 52 malpractice concerns, 122, 139, 145, 148– 150, 177–180. See also defensive medicine Malthusianism, 6, 182n23 MANA (Midwife Alliance of North America), 162 Manos a la Obra, 8–9, 51–57, 64, 88, 114, 126, 174 Martin, Emily, 90 Martínez Hernáez, Angel, 133 massage, 24–25 Matalarita, Dr., 167 Maternal and Child Health Program, 95, 189–190n23 maternal deaths, 28, 32. See also death/ mortality Maternidad La Luz (El Paso), 168 Mayagüez, 61, 124–125 mayors in conflict with doctors, 79 “mechanical objectivity,” 132 Medical Association of Puerto Rico, 93, 97, 119, 122, 123, 147, 150, 174 medicalization of childbirth: between 1966 and 1979 in Puerto Rico, 137; affecting doctor-patient relationships, 149; demand from mothers for, 97; differences in race and class regarding, 134; factors leading to, 112–114, 125–130; and industrialization development, 4; resistance to, 177; specialization and, 115–117; technology and, 120. See also defensive medicine medicalization of society, 123 medical school. See UPR School of Medicine 229 Index

medical students, 97 medical training, 41 medication during birth, 74–76 medicine: as “applied science,” 116; rise of specialization in, 136 “Medicine and the Crisis of Confidence” (Reinhard), 123–124 Medina, Antonio, 95 men: absence of in family, 8; involvement of fathers in birth, 109, 143–144, 146, 165, 170 Midwife Alliance of North America (MANA), 162 midwives: Department of Health recognition of, 66; deregulation of, 151; difficulties bringing in new recruits, 49, 58, 66, 82, 126; doctors’ views on, 46–47; in Europe, 100; as knowledge bearers, 19, 48; lack of self-­ organization among, 48; legal and licensure regulations for, 19, 38–40, 151; loss of legal status (1980s), 151– 152; loss of sociocultural legitimacy, 65; pay for, 27; as self-educated, 133; self presentation by, 6; training of, 69–71, 82, 98; transfer to School of Medicine, 98–99; in United States, 111. See also comadronas auxiliares; nurse-midwives Midwives’ Club, 38 migration to United States, 11, 65 Mintz, Sidney, 64 modernization: and AMPR, 43; theory of, 2–3, 52, 90; and transition to industrialization, 20–21 “Modernization, Cultural Change, and the Persistence of Traditional Values” (Baker and Inglehart), 55–56 Mora, Izquierdo, 117 Morales Otero, Pablo, 99 “Morelli, Freud and Sherlock Holmes” (Ginzburg), 89 Moreno, Nurse, 49–50 morphine, 75

mothers/grandmothers: medical views of, 128–129, 135, 137; mother as dangerous, defective, 135, 138, 156; wisdom of, 65, 116, 133 Mulero, Dr., 90, 158 Mundo, El, 119 municipal health centers/hospitals, 27, 31, 66, 78–80, 84, 93, 101 Muñoz Marín, Luis, 8, 20, 31, 54 Murphy, Michelle, 6, 11, 127, 132 Murphy-Lawless, Jo, 135, 139 Navas, Gerardo, 53–54, 189n8 Negociado de Higiene Infantíl (Department of Infant Hygiene), 38 neocolonialism, 11, 136 neonatal deaths, 77 neonatal intensive care, 136 Netherlands, 156 New Progressive Party, 177 Nilsa, 25 normal versus abnormal births, 48, 90 norms and values, development of, 92 novoparteras (new-midwives), 14, 177; after 1980s, 139, 153; approach of, 145; client profiles, 163; Debbie, 168–171; defined, 139, 160–161; initial organization of, 160–163; international affiliations of, 162; postpartum care by, 170; and prenatal care, 161, 162, 165– 167, 169–170; problem of nonpaying clients, 168; registration procedure for, 152; Rita, 166–168; Ruth, 164–166, 167, 169; standardizing of costs, 166; television coverage of, 163 Nuevo Día, El, 177–178 nurse-midwives: in 2000s, 172; comadronas filling in for, 39; establishing program for, 66–71, 87; first graduate cohort (1961), 99; lack of support for, 82; move to UPR School of Medicine, 98–99; providing care in

230 Index

remote areas, 180; recent initiatives, 180; supervising comadronas, 22; as support staff and assistants, 66, 102, 106, 151 nurses: demand outstripping supply, 67–68; enfermería práctica (practical nursing), 67–68; gender expectations regarding, 66, 67, 69; nurses delivering babies, 31, 58–59 (58, 59), 84, 152; resolution 99 study on, 68–69; training of, 68–69. See also nurse-midwives Oakley, Anne, 118 Oaks, Laury, 118 obstetricians/obstetrics, 82; obstetric nurses, 152; redefining “normal” birth, 90; replacing midwives, 1, 126; shortage of due to insurance costs, 148, 179–180; using technocratic model, 138–139 oils for massage, 25 Onís, Dr., 90–92, 193n11 Operation Bootstrap (Manos a la Obra), 8–9, 51–57, 64, 88, 114, 126, 174 Operation Regionalization reforms, 92– 94 oral contraception: availability of, 54, 56, 86, 136; dangers and side effects of, 120; desire for, 135; rates of use in Puerto Rico, 6, 56, 196–197n14; research on, in Puerto Rico, 6, 72, 96, 120, 146. See also family planning; Pincus, Gregory Ordenanzas, 34 organ transplants, 136 outmigration to United States, 11, 52, 56, 65 outward-focused society, 51 overpopulation concerns, 6, 56 oxytocin (Pitocin), 74, 143, 167, 169–170, 200n14

pain: of birth, 74–76, 139; race and class differences in tolerance, 134 Palmer, Steven, 12 parteras (midwives), 160–161. See also novoparteras Partido Independentista Puerto Rico (Independence Party), 145 Partido Nuevo Progresista (New Progressive Party), 145 Partido Popular Democrático (PPD). See PPD paternalism in Puerto Rico, 8 pathology, childbirth as, 129–130, 133 patient-doctor tensions, 121–125, 149; patient rights laws, 146 payment for midwives, 27 Peard, Julyan, 12 Pelegrina, Ivan, 121 pelvic floor rupture, 144 Pentothal, 46 Peregrina, Iván, 70 perinatal medicine, 118 perineal tears, 165 petequia (ruptured vessels), 144 pharmacology advances, 54 phases of birthing history, 13–14 physicians: assisted births in hospitals (1959–1965), 84–87; conflicts with mayors, 79; delivering babies, 58–59 (58, 59); God complex among, 124; losing moral standing with public, 121–125, 149; numbers of, per patient, 41; obstetricians, 82, 96; in preindustrial times, 27, 31; in public versus private practice, 80–81; religious beliefs of, 116–117; social class of, 81 Physician’s Dilemma, The (Elinson), 79 pill, the. See oral contraception pills administered by comadronas, 26, 28–29 Pincus, Gregory, 72, 96, 120 Pitocin (oxytocin), 74, 143, 167, 169–170, 200n14

231 Index

placental retention, 85–86, 144 Ponce, 61–64 (64), 101, 111 Ponce Pila Clinic, 41 Pons, Juan A., 39, 41, 66, 69 positivist science and neutrality, 132 postcolonial practices, 11–12, 160 postpartum hemorrhaging, 35, 40, 70, 86, 88, 143, 170 postpartum/postnatal care, 22, 26, 28–29, 80, 170, 202n75 poverty level in Puerto Rico, 175 PPD (Partido Popular Democrático): colonial industrialization model of, 7–9; leadership of, 189n8; Operation Bootstrap, 8–9, 51–57, 64, 88, 114, 126, 174; promising industrial progress and modernization, 4, 6, 8, 20, 31, 145; raising standard of living, 8; relationship of with United States, 9, 20, 31; social equality goals, 145; waning support for, 136 practical midwives, 38–39 preeclampsia, 75, 169–170 preindustrial paradigms of birth, 27, 31, 48, 54, 64 prenatal care: in 1940s, 21, 22, 25; in 1950s, 85; in 1960s and 1970s, 103, 136; in 1980s and 1990s, 146, 154; in 2000s, 180; author’s experience of, 140, 141–142; and malpractice insurance, 179; and maternal-fetal outcomes, 104; novoparteras and, 161, 162, 165–167, 169–170; nurse-midwife training in, 98; in public health clinics, 50, 85, 87; reasons for not seeking, 102–103; and social class, 105; use of x-rays in, 74 Price, Charles, 122 private versus public medical sectors, 78–81, 95, 110, 130, 176 professionalization, 4, 29–30, 57, 65–66, 98, 182n17 progress and modernity: associated with

United States, 9; Puerto Rican investment in, 53; technology as, 3 prolapsed uterus, 74 public assistance, 88, 105, 115, 136 public health clinics, 50, 79–80, 85, 87 public health units, 21, 50, 70, 86, 91, 93, 189n23 public versus private medical sectors, 78–81, 95, 110, 130, 176 puerperal fever, 35 Puerto Rico Department of Public Health, 18 Puertorriqueño, Ateneo, 35 Quevedo Báez, Manuel, 6, 39 race: African American midwifery, 54, 89; midwives required to be “pure blood,” 34; “refined” (white) women as weak, pain-intolerant, 134; registration by, 186n51 Ramírez, Dr., 122, 131, 156–158 Ramírez de Arellano, Annette, 6, 56, 123 Rapp, Rayna, 118 “reflexive modernity,” 88 regionalization of health services: birthing practices, 100–102; Ponce municipality example, 61–64 (62, 63, 64); purpose of, 56–57, 175 registration of newborns, 22, 55 Regulating Birth (DeVries), 34 Reinhard, Edward, 123–124 Reproducing Empire (Briggs), 6 Rh negativity, 75 rhythm method, 73 Riftkinson, Dr., 76–77 risk: associating childbirth with, 65, 92; as manageable, 88, 147 Risk Society (Beck), 88 Rockefeller Foundation, 95–96 Roe v. Wade, 113, 119

232 Index

Roosevelt, Franklin, 7 rural regions: importance of midwives in, 61; quality of government institutions in, 80; rhythm of life in, 4; use of spiritists, 80 Salinas, 61 Salvatore, Ricardo, 4 San Ciriaco hurricane, 52 Sandelowski, Margarete, 128 San Felipe hurricane, 52 San Juan Baptist School of Medicine, 114 San Juan City/Municipal Hospital, 43, 72–74, 95, 157–158 San Sebastián, 61 Santa Isabel, 61 Sargent, Carolyn, 5, 91 Satterthwaite, Adeline Pendleton, 96 Scheper-Hughes, Nancy, 6, 9 scholarship on sociology of medicine, 5–6 School of Public Health, 45, 68, 95, 110, 123, 130, 159, 163 School of Tropical Medicine, UPR, 9, 44, 94 science, supervaluation of, 7 scientific motherhood, 113 scopolamine, 46, 75–76 sedation. See anesthesia and analgesia during childbirth shaving vulva for childbirth, 17, 26, 28, 29, 159 silver nitrate, 26, 28–29, 40, 184n15 Simed insurance provider, 178 “simple modernity,” 88 single mothers, 8 Slater, David, 3 Social Transformation of American Medicine, The (Starr), 147–148 social wealth, promises of, 54 social welfare programs, 8, 54, 56–57, 93, 115, 127

sonograms (ultrasound), 118, 127, 136 Soviet industrialization, 2 spacing of births, 86. See also family planning Spanish Ordenanzas and midwives, 34 “Special Documents of the Midwives of Puerto Rico,” 160 specialization in medicine, 124–125 spinal blocks, 46 spiritists, 80 stages of birth, 2, 5, 76, 91, 113, 175 standardization process, 91–92, 175 standard of living, 2, 8, 52, 59, 87–92 (87), 103, 114 Starr, Paul, 147–148 sterilization: coerced, 146; rates of in Puerto Rico, 6–7, 56, 74, 113 stratified reproduction, 7, 134 “superstitions,” traditional beliefs as, 133 Taller Salud, 146 “Technocratic Body and the Organic Body, The” (Davis-Floyd), 134 technocratic model of birth, 172–173; adoption of, 11, 139; and biotechnology, 121–127; consequences of, 147– 148, 153; and corporization, 147–148; defined, 5, 138, 181n2; degree of acceptance of, 134; dissenters from, 139–140, 171, 177; factors leading toward, 132, 139, 147; novoparteras as alternative to, 145 terminology/vocabulary of midwifery, 24–25 Tomás, Dr., 91 Tomasa’s birthing process, 16–18, 23, 25– 29, 83, 183n2 toxemia, 170 Tribunal of Medical Examiners, 178 tropical diseases, 117 Truman, Harry, 3 trust in machines over people, 128

233 Index

tuberculosis, 41 Tugwell, Rexford, 7, 182n27 twilight sleep, 75–76, 86 ultrasound (sonograms), 118 umbilical cord: clamping of, 77; cleaning belly button around, 27; Debbie on metaphorical connection, 169; father cutting, 143, 165; prolapsed, 40; with retained placenta, 85; sterilization of cutting implement, 17, 35–36; un­licensed midwife having doctor cut, 22 UNICEF (United Nations Children’s Emergency Fund), 162 unidades de salud (health units), 21, 50, 70, 86, 91, 93, 189n23 United States: birthing differences by region, class, race, 54–55; concerns about high fertility rates, 56; Department of Health, 72, 159; experts from, in Puerto Rico, 53; increasing social relief funds (1970s), 112–113; media portrayal of birthing, 2; need to “tame the tropics,” 9; overreliance on monitors, 128; Puerto Rico as bridge to world from, 121; Puerto Rico’s status vis-à-vis, 9–10, 34; visiting professors from, 97 universalism in capitalist ideology, 132 UPR School of Medicine: demand outstripping graduates, 57; Department of Obstetrics and Gynecology (UPR), 72–73, 95, 97, 117–118, 120, 137; funding and financial assistance for, 71–72, 95–96, 173; growth of, 94, 174; internships, 97; lobbying for, 41–43; Medical Sciences Campus, 117; opening of, 44; partnership with Department of Health, 89; proposal for nurse-midwives program, 70–71; research on reproduction, 72; and

School of Public Health, 45, 110, 159; subspecialties within, 117–121; and United States, 9, 11. See also Department of Health (PR) urbanization, 51, 65, 175 Utuado, 61 vaccines, 54 vaginal births: after cesarean, 110, 158; decrease in, 139 vaginal relaxation, 74 Vanesa’s birthing process, 26 Vega, Gloria, 96 Velázquez, Asunción María, 107 Velázquez, José, 148–150, 200n20 views of doctors on birth risks. See defensive medicine Villamil, Dr., 91 Vistaril, 109 vocabulary of midwives, 24–25 Vocero, El, 179 Wallerstein, Immanuel, 132 warmth to heat up labor process, 26 war veterans, 65, 78

234 Index

Weber, Max, 3 welfare programs, 8, 54, 56–57, 93, 115, 127 WHO (World Health Organization), 159, 161–162 With valor by any means necessary/Con valor y a como dé lugar (Justiniano), 35–36 Wolf, Jacqueline, 75–76 Woman in the Body, The (Martin), 90 Worcester Foundation for Experimental Biology, 120 working-class women resisting medicalization, 134 World Health Organization, 41 World War I era views of progress, 3 World War II era: home births decreasing after, 8, 10; mortality rate trends following, 10, 59, 60; views of science after, 7, 54 x-rays, 74, 46 Yauco, 61