A. Tang

On January 10, a United States federal report revealed that rates of cesarean delivery in Puerto Rico (PR) have soared 12% from 2018 to 2022 for each age group younger than 40 (The Guardian). Now Puerto Rico represents one of the world’s largest c-section rates at more than 50% of infants delivered through surgery. While c-section deliveries are considered safe, the spiking trend arouses concern because PR doctors are increasingly using cesarean surgery as their main and only method (AP News). In some cases, doctors pressure expecting mothers to undergo surgery for medical convenience rather than the mother’s health (The Guardian). This is especially perilous as PR women have the highest rates of premature delivery and infant mortality among Latina sub-groups (NCBI). The reasons behind rising c-section rates are a complex concoction of a “brain drain,” poor economic conditions and systematic healthcare issues.

The “brain drain,” or the emigration of skilled workers from Puerto Rico to the mainland U.S., has impacted the medical industry the hardest. From 2014 to 2020, the workforce of 14,500 physicians decreased to 9,000 (Science Direct). It falls close to warnings from the United Nations that the island will not meet the recommended physicians per capita ratio (Science Direct). Yet, despite the demand for physicians, many do not see staying on the island as worth it. Physicians cite quality of life and lack of pay as problems (Science Direct). A pap smear in PR represents the same cost for materials and time as on the mainland, but physicians are paid only $25 compared to the typical $50 (Science Direct). As rent and rates of violence rise on the island, physicians feel compelled to leave for the mainland U.S. for themselves and their families (Science Direct). This leaves an overworked physician population in a place of about 3.3 million people (Worldometers). As a result, physicians are pressed to schedule c-section deliveries to ensure as many hands-on deck as possible (AP News). Scheduling c-sections often offers more convenience for staff, who are not paid adequately to attend to a woman in labor for 24 hours (The Guardian).

The preference for c-sections stem beyond necessity. Physicians are paid poorly in part due to the wider condition of healthcare in PR. Though the island pays for social security and Medicare, it receives significantly less federal healthcare funding than the states (The Guardian). Physicians are not reimbursed properly, which trickles down to medical students struggling with student loans (Science Direct). Training sites lack positions and the best training in PR comes in the form of expensive private medical schools (Science Direct). Even after schooling, it is at the behest of mainland-based insurance companies to decide whether to hire new physicians (Science Direct). When hired, junior doctors prefer c-section operations because many are not well-trained in forceps or vacuums (AP News). C-sections represent less litigation risk and pleads to be paid with insurance companies.

Like physicians, most mothers in Puerto Rico prefer c-section (AP News). This is out of a desire to avoid pain or to retain a certain body image (AP News). However, PR’s Department of Health determined that more than half of c-section surgeries were not medically necessary (AP News). After surgery, many women are forced to see family physicians, presenting symptoms of postpartum depression and breastfeeding problems (The Guardian). C-section surgeries can discourage a second pregnancy, which factors into Puerto Rico’s declining birth rate (The Guardian). The World Health Organization warns that, as with any other surgery, c-sections in places with limited resources can pose harm (AP News). But the overhaul of economic and healthcare conditions— for better treatment of doctors and patients— remains to be seen.


The Guardian: https://www.theguardian.com/world/2024/jan/16/puerto-rico-cesarean-sections-health-crisis

AP News: https://apnews.com/article/puerto-rico-cesareans-deliveries-births-cdc-117b735b3847d9279fbbfb89e7a55294

Stat News: https://www.statnews.com/2024/02/21/medicare-puerto-rico-disparities-health-reimbursement/

Science Direct: https://www.sciencedirect.com/science/article/pii/S0277953623002459#:~:text=In%20the%20last%20decade%2C%20the,9%2C000%20(Varney%2C%202018).

Worldometers: https://www.worldometers.info/world-population/puerto-rico-population/#:~:text=Puerto%20Rico%202023%20population%20is,(and%20dependencies)%20by%20population.

NCBI: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3642771/

Posted April 2, 2024