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Pushing in Silence

Pushing in Silence
Modernizing Puerto Rico and the Medicalization of Childbirth

This history of evolving birthing practices in Puerto Rico reveals how dramatic transformations in childbirth resulted from broader economic, political, and cultural shifts toward a model of industrial nationhood.

January 2018
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248 pages | 6 x 9 | 1 b&w map |

As Puerto Rico rapidly industrialized from the late 1940s until the 1970s, the social, political, and economic landscape changed profoundly. In the realm of heath care, the development of medical education, new medical technologies, and a new faith in science radically redefined childbirth and its practice. What had traditionally been a home-based, family-oriented process, assisted by women and midwives and “accomplished” by mothers, became a medicalized, hospital-based procedure, “accomplished” and directed by biomedical, predominantly male, practitioners, and, ultimately reconfigured, after the 1980s, into a technocratic model of childbirth, driven by doctors’ fears of malpractice suits and hospitals’ corporate concerns.

Pushing in Silence charts the medicalization of childbirth in Puerto Rico and demonstrates how biomedicine is culturally constructed within regional and historical contexts. Prior to 1950, registered midwives on the island outnumbered registered doctors by two to one, and they attended well over half of all deliveries. Isabel M. Córdova traces how, over the next quarter-century, midwifery almost completely disappeared as state programs led by scientifically trained experts and organized by bureaucratic institutions restructured and formalized birthing practices. Only after cesarean rates skyrocketed in the 1980s and 1990s did midwifery make a modest return through the practices of five newly trained midwives. This history, which mirrors similar patterns in the United States and elsewhere, adds an important new chapter to the development of medicine and technology in Latin America.


National Women's Studies Association 2018 Gloria E. Anzaldúa Book Prize

  • Map and Tables
  • Acknowledgments
  • Introduction
  • Chapter 1. Phase One: Midwife-Assisted Home Births, 1948–1953
  • Chapter 2. Phase Two: Transitioning toward Hospital Births, 1954–1958
  • Chapter 3. Phase Three: Physician-Assisted Hospital Births, 1959–1965
  • Chapter 4. Phase Four: Medicalized Births, 1966–1979
  • Chapter 5. Phase Five: Novoparteras and a Technocratic, Litigation-Based Model of Birth, 1980–2000
  • Conclusion and Epilogue


Rochester, New York

Córdova is an associate professor in the Department of History and Political Science at Nazareth College.


“A thoughtful analysis of birthing practices in Puerto Rico, written from a historical, multifaceted perspective.”

“It’s more important than ever to restore a sense of [Puerto Rico] as a complex place with a rich history—as much more than a disaster. This book certainly gives us that.”
Bulletin of the History of Medicine

Pushing in Silence eloquently narrates the complex experience of birth in Puerto Rico over the course of the second-half of the twentieth century to illustrate how medicalized birth arose due to a cultural value change rather than a vis-á-vis state imposition. ”
Journal of the History of Medicine and Allied Sciences

“Whereas traditional historical accounts have focused on the purely economic and political forces at lay in the institutional development of biomedicine in Puerto Rico, Córdova astutely illustrates the inherent intersectionality in these dynamics. She works to explore the entangled relationship of class, gender, race, politics and power that imbue childbirth and medicine more broadly.”
Social History of Medicine

“Córdoba’s writing is clear, her story is compelling, and she makes excellent use of historical documents and the interviews that she conducted with midwives, mothers, and doctors...This book is important reading for those interested in medical history, recent Puerto Rican history, and gender studies, as well as for medical professionals.”
The Americas

“Engaging…[Córdova] carefully links the medicalization of pregnancy, labor, and delivery on the island to changing economic and industrial policies; to a growing bureaucratic emphasis on standardization and efficiency; and to the professionalization of medical doctors, particularly obstetricians, between 1948 and the early 2000s.”
American Historical Review

“Meticulously researched and engagingly written…[Córdova] provides novel insights on the forces that have so dramatically reshaped the experience of childbirth in Puerto Rico...Pushing in Silence is an excellent contribution not only to the history of Puerto Rico but to the history of gender, medicine, and modernization more broadly.”
Hispanic American Historical Review

“The ethnographic element of Córdova's research methods gives her writing greater sensitivity to the stratified nature of reproduction and, specifically, highlights that the ways women give birth vary based on class, gender and geographic space. As a result, Pushing in Silence reveals overall trends and local nuances.”
Journal of Latin American Studies

“A very detailed and enlightening read…Pushing in Silence contributes to the understanding of the history of medicine and of birthing in the Americas. It provides a poignant look at the effects of development policies on the lived experiences of birth and will surely encourage further research.”
Journal of Latin American and Caribbean Anthropology

“Excellent...Pushing in Silence is a thorough, carefully documented, multilayered history.”
New West Indian Guide

“A brilliantly written, accessible, and comprehensive analysis of the multifaceted social, cultural, and historical conditions that led to the medicalization of birthing in Puerto Rico, which enabled doctors to replace midwives. This history has not been written before. The research is original and unique and is a contribution to the fields of sociology, anthropology, history, and biomedicine.”
Iris O. Lopez, City College of New York, author of Matters of Choice: Puerto Rican Women’s Struggle for Reproductive Freedom


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3M Cloud Library/bibliotheca