Nívea Díaz Torres was afraid of becoming a mother in 2016. She was 28 and tried to do everything right during her pregnancy to ensure the healthiest delivery of her baby.
But despite her desire for a vaginal birth, Díaz Torres felt forced by her gynecologist to have a caesarean section.
C-section deliveries have skyrocketed in Puerto Rico, with more than half of babies (50.5%) being born via surgery in 2022, according to data released last week by the US Centers for Disease Control and Prevention. This percentage far exceeds the percentage for the US mainland, which is around 32%.
Healthcare providers use a caesarean section – the delivery of a child through an incision in the abdomen – when they believe it is a safer option for the mother, the baby or both, and in some cases, lifesaving. But doctors in Puerto Rico are increasingly turning to the surgical procedure as their main tool, health experts on the island say.
Díaz Torres’ gynecologist in Bayamón, an urban community outside the capital San Juan, advised her to deliver her son through induced labor, in which labor is stimulated by the introduction of hormones. The expectant mother, then 39 weeks pregnant, trusted the doctor and scheduled her hospital visit for the following week.
What should have been one of the milestones in her life turned into a nightmare. Díaz Torres’ body did not respond to the drugs intended to speed up labor. She was tired. She felt that the medical staff at the hospital were insensitive to her pain and did not answer her questions.
After the induced labor failed, the midwife proceeded with a caesarean section.
“It was an unnecessary C-section,” said Díaz Torres, now 35 years old. “That was the last thing I wanted. They scared me and told me something was wrong with my baby. The reality was that I didn’t respond to the induced labor because I wasn’t ready to give birth yet. My body was in fight-or-flight mode.”
Health experts say Díaz Torres’ experience is becoming increasingly common. “What we see are not emergency caesarean sections. They are not performed to save the life of the mother or the child, according to guidelines,” said Ana Parrilla-Rodríguez, a physician and professor of maternal and child health at the University of Puerto Rico’s graduate school of public health. “Often, cesarean sections are performed for the convenience of the doctor.”
Parrilla Rodríguez said it is common for doctors to schedule C-sections at times convenient for medical staff, such as during the day and before holidays.
The CDC report shows that Bayamón saw a 12% increase in C-sections from 2018 to 2022, from 57.1% of all births to 63.9%.
The problem goes far beyond the rising number of caesarean sections. Puerto Rico is facing a serious health crisis marked by a significant exodus of doctors, exacerbated by severe budget cuts and austerity measures amid a massive national debt.
More than 40% of Puerto Rico’s 3.2 million residents live below the poverty line, compared to a 19% for Mississippi, which has always been one of the poorest states in the US. The economic conditions on the island influence the healthcare system at every level.
Midwives are the only licensed professionals who can legally deliver a baby in Puerto Rico, leaving out birth nurses and certified nurse-midwives as alternatives. And midwives on the island are hard to find, as many flee to the US for better wages and living conditions.
Despite being a U.S. territory and paying Social Security and Medicare taxes, Puerto Rico specifically receives less federal health care funding than all fifty states. The fixed allocation – unlike the states, which receive open-ended funding – comes with a spending ceiling that can remain well below expenditures.
Puerto Rico’s Department of Health did not respond to multiple requests for comment.
As a result, doctors may use cesarean sections as a way to address staff shortages. “A big factor is the economic landscape,” Parrilla Rodríguez said. “The reimbursement rate for vaginal deliveries and C-sections is not enough for physicians to justify staying in the office for 24 hours while a woman is in labor.”
Total healthcare funding in Puerto Rico averages approx $4,290 per capita per yearcompared to $12,218 per capita nationally, impacting health care at every stage of life in the largest overseas territory under the sovereign control of the United States.
Parrilla Rodríguez said C-sections often discourage mothers from having a second child, which could play a role in Puerto Rico’s declining birth rate. The island registered 17,772 deliveries in 2023the lowest number since record-keeping began in 1888, before the U.S. invaded Puerto Rico, according to preliminary Demographic Register data.
Puerto Rico’s capped healthcare financing system exposes its shortcomings most acutely during economic recessions or natural disasters such as Hurricane María in 2017, which struck just months after the island declared bankruptcy.
The Category 4 hurricane was the strongest storm to hit Puerto Rico in nearly a century; a Harvard study estimated the death toll at 4,645.
The chaotic medical situation after María, combined with power outages, prompted countless doctors to leave the island to look for jobs elsewhere. Lawmakers estimated that three months after the disaster Ten doctors left the island every day.
Even before the hurricane, health experts were sounding the alarm bells. For example, Parrilla Rodríguez published one study in 2008, highlighting Puerto Rico’s troubling cesarean section rate, which at the time was approximately 48%.
The impact is felt most brutally by Puerto Ricans outside the metropolitan area. Vieque, an island 16 kilometers from the main island, still does not have a functioning hospital after Hurricane María destroyed its only medical center. About 8,000 people live in the municipality, more than half of whom live in poverty.
Expectant mothers must cross via ferry to the main island for medical care. But the nearest delivery room, located in Fajardo on the east coast, closed in 2022. That facility was housed in the beleaguered Hima San Pablo Hospital, which declared bankruptcy in August. In San Juan, about an hour away, the San Jorge Children’s Hospital declared bankruptcy in 2022.
Lorimar Ortiz Ortiz, a general practitioner in the southern municipality of Ponce, said the effects of high C-section rates trickle down to her practice when mothers come to her with postpartum depression and breastfeeding problems.
“We’re talking about women who didn’t get the birth and breastfeeding they wanted. That’s two strikes,” Ortiz Ortiz said. “The reality fell short of expectations and brought risks for anxiety and depression.”