Puerto Rican women have the worst birth outcomes among all Hispanic groups because of systematic societal and economic conditions that have plagued the island for years.
That was the main message of a paper called “Social Justice Is Overdue for Puerto Rican Mothers,” published by Cynthia Lebron, assistant professor at the University of Miami School of Nursing and Health Studies, and four of her colleagues.
The paper was published in the American Journal of Public Health Latino Health supplement, the first time the journal has devoted a section to Hispanic health.
Others who participated in the study were José G. Pérez-Ramos of the University of Rochester School of Medicine and Dentistry; Nancy R. Cardona-Cordero of the Universidad de Puerto Rico; Vanessa Morales, a doctoral student at the University of Miami Miller School of Medicine; and Samantha Rivera-Joseph of Drexel University.
In the United States, Black women have the highest maternal mortality rate, with 49.5 deaths per 100,000 live births in 2022. This is nearly three times higher than the rate for white women, which was 19.0 deaths per 100,000 live births.
In most health reports, Latinas are portrayed as “good birthers,” meaning that they fare well in giving birth notwithstanding their societal conditions. However, when data was studied closely, an alarming fact stood out, said Lebron. Puerto Rican women on the island had alarmingly poor birth outcomes.
Puerto Rican women’s birth outcome included a high number of preterm deliveries and increased numbers in infant mortality. Perhaps the most alarming data is that the rate of cesarean sections is 50.5 percent. To put that into context in the U.S., Utah has a 23 percent C-section rate, and Mississippi has 38.5 percent.
“This paper is a call to action,” said Lebron. “Puerto Rican women are having smaller babies, they are having a higher mortality rate, and we need to pay attention. These are U.S. citizens who are receiving subpar health care.”
Hudson Santos, dean of the School of Nursing and Health Studies, said he was incredibly proud of Lebron’s participation on the groundbreaking issue of the American Journal of Public Health.
“In particular, her scholarly examination of the reproductive health crisis in Puerto Rico exemplifies our school’s ongoing work to end disparities on a number of critical fronts, maternal and child health chief among them,” he said. “Dr. Lebron's unwavering commitment to excellence in Latino/Hispanic health is matched by her vision and dedication."
A host of factors affect health care on the island, said Lebron. One main problem is the lack of sufficient obstetricians for the number of patients on the island, said Lebron. This may affect the high incidence of C-sections, an operation that can be life-saving yet also be risky and have side effects.
“Puerto Rico is really limited for resources, and there is a physician shortage, and they try to adjust to meet the need,” said Lebron. One other contributing factor is the disbursement of Medicare and Medicaid funds. With more than 65 percent of the population reliant on Medicare and Medicaid, the island faces severe funding caps, resulting in a shortage of essential maternal and child health services, according to the report.
“The island is given a block amount of money for these services,” said Lebron. “Once the money is gone, it is gone.”
The low funding for health services has encouraged doctors to leave the practice on the island and move elsewhere, said Lebron.
Health care is also gravely affected by the lack of infrastructure and the impact of natural disasters that have affected the island in the past decades. Puerto Rico has been the victim of major hurricanes, earthquakes, and epidemics that have contributed to the scarcity of essential services, said Lebron. A Zika outbreak and the coronavirus pandemic also took a toll on the country.
The island has also had a troubled history with reproductive rights. In the 1930s and 1940s, the U.S. government founded family planning clinics. Doctors there offered women the option to be sterilized, in many cases right after the woman had given birth.
“This resulted in Puerto Rico having the highest sterilization rate in any country in the world,” Lebron said. The clinics also dispensed birth control pills with high levels of hormones and tested the effectiveness of the pills on Puerto Rican patients before approving them for use by the general U.S. population, said Lebron.
The paper offered suggestions on how conditions on the island could improve for maternal health care. These included providing telemedicine consults, where patients could have access to doctors outside their area.
Also, it encouraged the use of “promotoras,” health advisers or doulas, to monitor the expectant mother’s progress and provide care and advice.
“It will take education and legislation to improve conditions,” said Lebron. “But the whole point of public health is not only to live longer but to live longer and healthier.”
