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Childbirth in Costa Rica

Costa Rica boasts the second lowest maternal and infant mortality rates in Latin America, and a government-sponsored health care system –the Caja Costarricense Seguro Social (C.C.S.S.)—which guarantees access to perinatal health care for all pregnant women and infants.   Nearly all births  are attended in the public hospitals by either obstetric nurses or physicians, and traditional midwives have practically become obsolete, except in the most rural and isolated parts of the country, due to strict regulations that limit their practice.  Trained community health assistants make postpartum home visits to all registered mothers at 22 days, and free infant vaccination programs are universally provided.  Over the past 10 years, many of the country’s hospitals have gained “Baby-Friendly” status, which, along with a guaranteed 3-month paid maternity leave, has supported Costa Rica’s 95% breastfeeding rate. 

While these figures may represent great accomplishments in Costa Rica’s maternal/child health care services, they do not describe the quality of care that childbearing women receive in this country.  Step inside a C.C.S.S. clinic, and you will generally find the noisy communal maternity wards overcrowded with pregnant and postpartum women dressed in pale orange institutional gowns, confined to their assigned beds, left to labor without any support or companionship, denied food and drink for hours, and exposed to filthy, blood-contaminated bathrooms.  

The limited medical staff try to manage the ward as if it were a factory, mechanically attending to the “patients,” imposing a series of routine interventions, as outlined in the outdated C.C.S.S. protocols (enema, IV fluids, artificial rupture of membranes, pitocin augmentation, prolonged electronic fetal monitoring and hourly internal vaginal exams)—without informing the woman about such interventions or asking for her consent.  They do not offer any comfort measures or pharmacologic pain relief, but typically patronize or reprimand women who express any anguish in labor, or warn them that they must control themselves “or else the baby will suffer.”  

The birth then takes place in a separate chamber, where further risky routines are carried out, including placing the women in dorsal- lithotomy position with stirrups, coached sustained pushing and breath-holding, forceful manual fundal pressure (Cristellar), episiotomy, premature cutting of the umbilical cord,  cord traction, and aggressive manual exploration of the uterus.  (The WHO classifies all the above mentioned practices as ineffective or harmful.)        

 Evaluation of maternity care in Costa Rica does not include important indicators of quality of care, such as intervention rates and ---most importantly—women’s subjective evaluation of the care they experienced.  One private study of the largest urban public maternity ward in Costa Rica revealed that, of the 6012 births attended last year (2006) in this hospital, 6002 received obstetric intervention.  This hospital had a 58%  induction/augmentation rate (compared to the recommended <10%),  a 45% episiotomy rate (recommended <5%), and a 26%  cesarean rate (recommended 10-15%), typical of all the country’s maternity wards.* 

Ask Costa Rican women the details about their birth experience, and you will hear all the stories of malpractice, near-deaths, intimidation and mistreatment. Sadly, for many Costa Rican women, childbirth is experienced as traumatic, excessively painful, humiliating, inhumane and even abusive.   As a result, many women silently suffer ongoing pain and complications from unnecessary episiotomies and cesareans, debilitating postpartum depression, post-traumatic stress disorder, and damage to their self-esteem, body image and sexuality.  However, this is never discussed in public.