Rates of Cesarean Delivery Among Puerto Rican Women

Puerto Rico and the U.S. Mainland, 1992-2002

Morbidity and Mortality Weekly Report. 2006;55(3):68-71. 

In This Article

Editorial Note

In Puerto Rico, annual rates of total and primary cesarean delivery were stable during 1992-1996 before increasing sharply from 1996 to 2002. Nearly half of all live births in Puerto Rico in 2002 were by cesarean delivery. Rates of cesarean delivery and primary cesarean delivery were 72% and 85% higher, respectively, among Puerto Rican women in Puerto Rico than on the U.S. mainland. From 1992 to 2002, the greatest increases in rates of cesarean delivery in Puerto Rico were among the youngest and least educated women; however, the highest rates remained among women aged ≥40 years and those with the highest levels of education.

During 2002, the rate of cesarean delivery among women at low risk for a cesarean delivery giving birth for the first time in Puerto Rico was 44.8%, nearly three times the Healthy People 2010 target of 15% for women at low risk for a cesarean delivery and nearly double the 22.6% rate for Puerto Rican women at low risk for a cesarean delivery who delivered on the U.S. mainland. The cesarean rate (22%) for first births to all women at low risk for a cesarean delivery who delivered in the United States was similar to that for Puerto Rican women. Cesarean deliveries put women at greater risk for maternal morbidity[1,2] and can lengthen hospital stays and make rehospitalization more likely.[2,3] During 2002, among women delivering in Puerto Rico with a previous cesarean delivery, approximately 96% had a repeat cesarean delivery. Whether VBAC or repeat cesarean delivery poses greater risk for a mother and infant is unresolved.[7] According to the American College of Obstetricians and Gynecologists, most women with one previous cesarean delivery are candidates for VBAC. However, individual risk factors need to be considered; therefore, the ultimate decision regarding mode of delivery should rest with the patient and her provider.[8] Measures to reduce the cesarean delivery rate in Puerto Rico should focus on lowering the rate of primary cesarean deliveries, especially among women at low risk for a cesarean delivery.[9]

The findings in this report are subject to at least three limitations. First, because Hispanic ethnicity of the mother is not recorded on birth certificates in Puerto Rico, a small number of live births in Puerto Rico included in the analysis might have been to women who were born in Puerto Rico or on the U.S. mainland but were not of Puerto Rican origin. Second, certain information that might influence differences in rates of cesarean delivery and VBAC (e.g., reason for cesarean delivery, type of hospital, or type of insurance coverage) is not currently collected on birth certificates. Finally, no distinction could be made between cesarean deliveries that were elective and those resulting from medical indications or conducted as emergency procedures.

Why cesarean delivery rates in Puerto Rico are higher and increasing at a faster rate than those among Puerto Rican women delivering on the U.S. mainland is not known. High rates of cesarean delivery also have been reported among women delivering in certain Latin American countries, with rates highest in private hospitals.[10] The higher rates in Puerto Rico might be associated with differences in maternal characteristics, attitudes toward cesarean delivery, obstetric practices, or health insurance coverage. Further research is needed to examine these factors and their potential association with rates of cesarean delivery and VBAC among Puerto Rican women.


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