BABY Natalia entered this world witha birth about as gentle as can be. Her motherwas prepared with prenatal classes,exercises and quality medical care. Thebaby’s father and grandmother were presentand actively supported the mother duringlabor and delivery.After considering several options, thebaby’s mother chose a natural childbirthmethod that uses a tub of warm water toprovide relaxation for the mother and agentle transition for the baby. The water’sbuoyancy and warmth (90-100 degrees F)help with dilation and greatly reduce tearing.Though the water-birth method isavailable at Clínica Católica in Guadalupe,a suburb northeast of San José, the parents-to-be wanted to have the baby in a settingmore like home.However, having the baby in their ownhome was not recommended because theylive more than an hour from a hospital. Theproblem of distance was solved when afriend made space available in her home,just a short distance from the hospital theyplanned to use in case of emergency. Aportable birthing tub was installed in thehome, ready for when labor began.NATALIA’S parents live on a farmtwo hours from San José. For nearly twoyears, they have been enlarging andimproving their old farmhouse, buildingstructures for their livestock and settlinginto a life very different from their formerone in the United States.“When my friends heard I was pregnant,they thought I was going to give birthin a barn,” said the baby’s mother. “Theywere amazed at the technology availablehere when they saw 3-D ultrasound picturesof the baby. Maternity health care inCosta Rica is as good as or better than inthe United States, and the hospitals hereare as modern and well equipped.“For each prenatal visit, my obstetricianspent at least halfan hour with us beforethe exam and answeredall our questions,”she continued.“My friends in theUnited States see theirdoctors for no morethan five minutes perprenatal visit.”Natalia’s grandmother,who lives inthe United States, wasvery excited to hearher daughter waspregnant. After her initial euphoria, shestarted to wonder what health care is likein Costa Rica, and whether her daughterwould be able to find a qualified, English-speakingdoctor.She found the doctors here are welleducated and progressive, and have up-to-dateequipment. “I’ve been veryimpressed, very happy,” she said before thebirth. “I’m just a little worried; it’s a motherthing. I want everything to be okay. Youdon’t want to see your child in pain.”IN her column, “Report from theCampo,” Tico Times reporter Mitzi Starkdescribed childbirth in rural Costa Rica asit was for much of the 20th century (TT,Jan. 16, 2004). Until a few decades ago,rural women usually gave birth at homewithout professional help. As transportationimproved, they started having babiesin hospitals. Even then, improved transportationsometimes meant a journey of afew hours over bumpy roads via car, horsebackor motorcycle while in labor. Today,reported Stark, approximately 95% ofbirths in Costa Rica take place in hospitals.Improved access to health care, a vaccinationprogram and improved sanitationhave contributed to Costa Rica’s lowinfant-mortality rate (the daily La Naciónreported a rate of 9.29 per 1,000 live birthsfor the first half of 2004).However, the “medicalization” ofchildbirth has resulted in an increased rateof Cesarean sections. According to Dr.Adam Paer, the obstetrician who cared forNatalia’s mother, the World HealthOrganization states that a C-section rate ofover 10-15% is not justified in any country.He said that the rate in the United States iscurrently approximately 25%, which iscomparable to the rate in Costa Rica’s publichospitals.What Paer and others regard as a problemis that the C-section rate at CostaRica’s private hospitals is much higher. Heestimates the private hospital rate to befrom 50 to 70%, depending on the hospitaland the physician. He says that the patternof increase here is similar to that in theUnited States in the 1970s, when the Csectionrate “skyrocketed.”WHEN asked whythe C-section rate is sohigh at the nation’sprivate hospitals, Paerexplained that advancesin technologyand the view that pregnancyand childbirthare medical problems,rather than naturalevents in a healthywoman, lead to greateruse of medical intervention.He believesthat one intervention leads to another, andthat inducing labor, continuous fetal monitoringand C-sections should be reservedfor when they are really needed.Other considerations, such as time andconvenience, may also play a role, Paersaid. A C-section can be scheduled inadvance and usually takes half an hour. Aspontaneous vaginal birth takes longer andmay come at an inconvenient time.“The way we are born affects us for therest of our lives,” he says. “We terrorizeour patients with fears of complications.”Paer would like to see changes in attitudesby women and their doctors – namely,that women be better informed abouttheir options and the consequences ofinterventions, and that each pregnantwoman initially be seen as healthy and ableto have a normal delivery.Paer attends home births in addition tothose in public and private hospitals. InCosta Rica, any licensed physician canpractice at any hospital. The patient canchoose which hospital to use.MARIE Tyndall, a Canadian nursewho trained as a midwife in England,teaches prenatal classes for parents-to-bein Costa Rica, provides information onnatural childbirth and breast-feeding, and accompanies women during birth. Whenwomen contact her, she explains thehealth-care system and encourages them totalk with their doctors about procedures.“My aim is to help (women) understandand gain confidence in their ability togive birth and to assert their authority overwhat happens,” Tyndall said. “For somewomen it’s hard to say, ‘No,’ and expresswhat they want.”Many of Tyndall’s clients choose togive birth in a public hospital or use a publichospital as a backup to home birth. Thenurse said in Costa Rica the woman has theright to have a person of her choice withher during birth, can refuse certain procedures(such as a routine episiotomy) andcan give birth in whatever position shefinds most comfortable. However, in publichospitals women are not informed ofthese rights. And, because of the largenumber of patients being cared for and thelack of space and privacy, they meet resistanceif they try to assert their rights.NATALIA is home with her familynow. Her parents are happy with the decisionsthey made for her birth and the professionalcare they received. Grandmotheris pleased her daughter was able to have anatural childbirth, and that it went so well.She expects to visit often and to eventuallylive near Natalia and family.The baby’s father was radiant with joyas he said, “I think our daughter is going tohave a great life in Costa Rica.”Doctor’s Advice for Having a Baby in Costa RicaAdam Paer Singer, MDEducated at the University of Costa Rica, Paer is fluent in English and specializes in obstetricsand gynecology. He is a member of the Costa Rican Medical Association and several otherprofessional associations, including associate membership in the American College ofObstetricians and Gynecologists. A specialist in ob-gyn ultrasound techniques producing3-D and 4-D images, Paer delivers babies through natural and traditional childbirth.He has offices at CIMA Hospital and Mediplaza in Escazú.Before becoming pregnant:1. See your physician for a medical exam and medical history.2. Health problems such as diabetes or high blood pressure need to be broughtunder control.3. Start taking a folic acid supplement before becoming pregnant to reduce the riskof neural tube defects (spina bifida).During pregnancy:4. Obtain prenatal care as soon as you are pregnant.5. Develop a good relationship with your doctor, and know what your rights are.6. Decide where to have the baby and make the necessary arrangements. If the birthis to be at home, a hospital should be no more than one hour away.For the birth:7. If you plan to have your baby in a hospital, consider the distance and road conditions.Some women plan to leave for the hospital as soon as labor begins; othersarrange to stay somewhere near the hospital as their due date approaches.8. All hospitals in the Central Valley are well equipped, and a woman can go to anyemergency room and get high-quality care. At public hospitals, because of the highvolume of patients, care is not as personalized as in private hospitals.