San José, Costa Rica, since 1956
Mother's Day

Giving birth through Costa Rica's public health care system

In honor of Mother’s Day and in hopes of providing useful information to moms and families, The Tico Times is proud to share the first-person accounts of two of our writers who recently gave birth in Costa Rica. Here, Managing Editor Jill Replogle describes her experience navigating the Caja as a new arrival to the country.

When I first heard the term “obstetric violence,” I was a few weeks into my new job as managing editor at The Tico Times, a few more weeks into my new life in Costa Rica and six months pregnant. I was browsing stories in La Nación online and came across one about a woman who had given birth in the bathroom at the Women’s Hospital in San José. The Ombudsman’s Office called it “obstetric violence.”

The story mentioned another case: that of a woman at the same hospital who said she was forced to expose herself in her incomplete hospital gown to male personnel who didn’t have anything to do with gynecological care.

I later Googled the term and found this definition from the women’s rights group May28.org:

Obstetric violence is a specific type of violation of women’s rights, including the rights to equality, freedom from discrimination, information, integrity, health, and reproductive autonomy. It occurs both in public and private medical practice during health care related to pregnancy, childbirth, and post-partum and is a multi-factorial context of institutional and gender violence.

At the time, my husband had been pushing for me to have our baby at a public hospital. After all, he said, he had broken his arm on his first trip to Costa Rica 15 years ago, spent several days at Hospital Calderón Guardia (or maybe San Juan de Dios, he can’t remember) and received great treatment. Best of all, he said, it was free.

Now, a hefty chunk of my monthly paycheck was going toward my government health insurance, whether I chose to use it or not.

Still, I was pushing for something a little more…romantic.

My first child was born at a Kaiser hospital in the United States. For the second, I was thinking home birth, with a loving midwife, perhaps a hot tub. I even found a midwives group in Costa Rica that offered just that for a price that was cheap by U.S. standards.

Still, my husband reminded me, it was going to cost a lot more than free.

I had a few months to decide, so I filed away the obstetric violence stories in the back of my head and got signed up for prenatal care at my local EBAIS clinic. Everything had been fine with my pregnancy thus far, so prenatal visits seemed like a good way to test the waters of Costa Rica’s public health system.

Basic care

EBAIS, Equipos Básicos de Atención Integral, are the primary-care clinics that make up the base of Costa Rica’s public health care system, or Caja. The EBAIS I was assigned to is run by the Universidad Iberoamericana under contract with the Caja.

On my first visit, I was told by the nurse that he and the doctor I was assigned to would see me through my entire pregnancy, including postnatal care. With the exception of one prenatal visit, this has been true. And this is great if you like your caregivers – not so great if you don’t.

I’m lukewarm about my assigned EBAIS nurse and doctor. I’ve become buds with the nurse, and he seems completely proficient at what he does, which is basically take height and weight, fill out forms and give shots. My doctor also seems perfectly proficient at what she does, but she’s not exactly warm and attentive.

My biggest beef: during my pregnancy, she never once asked me if I had any questions — about anything. This was so different from my visits to the Kaiser nurse-widwife who oversaw my first pregnancy.

Luckily, since this was my second child and everything seemed fine, I didn’t have a lot of questions.

But I did have a few: Which hospital should I go to when the time came? When should I go? What should I bring? It’s not that my doctor wouldn’t answer questions, it’s just that I had to take the initiative to fit them into our short visits.

A friend pointed out later that the answers to most pregnancy-related questions for new Costa Rican moms-to-be probably come from their experienced mothers, aunts and sisters. But that doesn’t necessarily mean they’re giving good advice. Plus, there are surely Costa Rican women who don’t have strong support systems. What about the confused, pregnant 19-year-old who’s estranged from her family?

Nevertheless, as it got closer to delivery time, I was warming to the idea of having my baby at Calderón Guardia, my assigned hospital. Yes, I had heard some horror stories, but most of the Costa Rican women I talked to had good things to say about their births in public hospitals.

Inspection

I went to check out Calderón Guardia’s maternity digs one day, hoping to make a final decision. A friendly nurse answered my questions about the delivery process and let me peek in on the ward. She even told me they had birthing balls for women who requested them. I was impressed.

The recovery rooms, on the other hand, looked a little bleak — no big bouquets of flowers and “It’s a boy!” balloons. And there were eight beds to a room.

Still, it seemed all right. Plus, our bank account was in a waning phase, making the home birth option seem increasingly expensive.

Also, I’m a journalist who’s mostly lived in a country, the U.S., with a heavily-debated health care system based on private practice (I’m not going to get into Obamacare here). I figured I should have a full universal health care experience and, maybe, share what I learned with others.

Nothing like subjecting your unborn child to experiential journalism.

D-Day

My ID band from Calderón Guardia.

Jill Replogle/The Tico Times

Part of my plan for making my birth experience at least vaguely romantic was to limit the institutional part of the birth as much as possible. So when I started feeling contractions at 2 a.m., I kept my cool and went back to sleep. I labored all the next day at home, keeping track of the length and spacing of my contractions per guidelines I found on the Internet (remember, the doctor had told me nothing about when to head to the hospital).

Finally, around 5 p.m., I decided it was time to hit the road.

When my husband and I got to the emergency entrance at Calderón Guardia, an orderly immediately took me in and guided me to a sort of cul-de-sac at the end of a corridor with a few benches surrounded by basic examination rooms. My husband had to stay behind, I thought to do paperwork.

In the pre-maternity area, a male nurse took me into one of the examination rooms, told me to strip (while he half turned his back), put on a gown and get on the examination table. He left the door open.

Privacy is clearly much less a concern here than in a U.S. medical setting. I had already figured this out from my prenatal visits to EBAIS, but here, it was even more clear. No paper sheet over my bottom half; No leaving the room while the patient undresses.

I didn’t care. Modesty and childbirth don’t really jive. But I now see his demeanor as a sign of his general attitude toward women in labor. The nurse’s subsequent probing was one of the more painful examinations I’ve ever had. When I groaned loudly, clearly in pain, he smirked and said, “What, that hurts?”

This, I thought, was obstetric violence. And I had barely gotten through the door.

When the exam was over (quickly, thank God), the nurse told me to sit down on one of the benches and wait. So I waited, and waited. As my contractions got closer and closer together, I wondered with increasing angst why they hadn’t yet sent my husband back. After what seemed like forever (but was probably only about 15 minutes), I asked and someone went to retrieve him from the lobby.

Finally, one of the orderlies took us, along with two other laboring women and their partners, up to the maternity ward. The whole group had to wait for me several times as I doubled over with contractions in the hallway and on the elevator. By the time we got to the delivery wing, I was ready to push.

I asked to go to the bathroom, and mistakenly said something about feeling the urge to push in the same breath. “No, no,” a nurse said in a panicky voice, “don’t push!”

I don’t know for sure, but I imagine something like this is what happened to the woman who had her child in a bathroom at the Women’s Hospital. Now, all maternity staff seemed to be on alert.

I managed to pee without dropping a newborn in the toilet, but afterwards, they wheeled me straight into the delivery room.

Push!

“Feet in the stirrups,” one of the nurses said as they transferred me onto the birthing bed.

“Do I have to?” I asked.

“No,” the obstetric nurse in charge said, stepping in. Then she addressed the rest of the medical team and reminded them gently that patients can give birth in whatever position they want. I immediately felt better. I could tell that this woman had been schooled in the new way of treating women during birth — with respect for their choices and confidence in their ability to get the job done without unnecessary interference.

She was great. She encouraged me, coached me when I needed it and kept me informed on how things were going. Less than an hour and a half after I got to the hospital, Emilio was born.

My husband cut the umbilical cord and a nurse handed me the baby almost immediately — another sign of good maternity practices. But I had to give him up after less than a minute while they commenced cleaning and checking him.

Still, the obstetric nurse explained what they were going to do to the baby and had my husband oversee everything while I got stitched up.

Recovery

When I had gone earlier to check out one of the post-maternity recovery rooms at Calderón Guardia — the ones with the eight beds — I had only seen three or four of the available beds actually occupied. So I figured, when it came my turn, maybe I’d be so lucky.

Nope: all eight beds were full in my room.

I barely noticed that first night. After that, it was actually kind of fun sharing the first hours of motherhood with a group of women at the exact same stage. We swapped birth stories and tips for getting the milk flowing.

Besides, I remember having so many interruptions from nurses and others after I gave birth to my daughter in the U.S. that this really didn’t seem much different.

The nurses here were attentive, and it turned out to be comforting to have them in the room around the clock. When my newborn started choking on phlegm, a nurse rushed to my bed, snatched the baby and swept him away. She came back a few seconds later with a calmly-breathing Emilio and one of those snot sucking bulbs that she instructed me how to use if it happened again.

There were some inconveniences — like no toilet paper most of the time in the recovery room’s shared bathroom. I borrowed from my more prepared Costa Rican roommates.

The food was fine. Or, as one of my roommates said: the food was free, ergo it was excellent.

In the end, my hospital stay was barely over 24 hours — a success in my book. Would I recommend it to a friend? It depends on the friend.

If the idea of sharing your child’s first day(s) of life with a group of strangers — and other crying babies — sounds awful, maybe a public hospital in Costa Rica is not for you. If you’re dreaming of a water birth with candles and soft music, you’ll need to look elsewhere.

If you want to join the ranks of the majority of Costa Rican women who have given birth — most of them safely — through the country’s proudly-defended (and often critiqued) public health care system, then go for it.

Three months after I left Calderón Guardia with a tiny new member of the family, he’s happy, healthy and hungry. He keeps me smiling and gives me the strength to handle chronic sleep deprivation and an aching back. In the end, that’s all that matters.

See also: West Side (Birth) Story – Isla arrives at CIMA

Contact Jill Replogle at jillrep@ticotimes.net

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JohnFF

My kids were born 40-50 years ago in the NYC metropolitan area. One was born on the hospital bed as it was being wheeled down the hall to the delivery room. (The attending had taken a too long coffee break, against our advice.) The recovery rooms for three of four had, as I remember, ten or twelve beds. For the youngest, we had a semi-private room. (We had private insurance by then.) The concern exhibited by staff ranged from empathetic to who-cares. My point in telling this is to say that we should expect medical care here in Costa Rica of about the same quality as it was half a century ago in the U.S., except at private hospitals.

If we don’t get our questions anticipated, ask! And if care was inadequate, let them know, politely! The bureaucratic culture here is to not explain processes, whether in medical care or legal affairs. On the other hand, ask for directions, and the answer can take ten minutes and still be inaccurate.

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Etxeberia

Our experience on having a baby at the HCG is nearly identical. We had our oldest son at the Clinica Catolica Hospital and our daughter through the Public System, which is not free. It feels free, but it’s not. We’ve been all paying for it out of our paychecks every month for the past 20 years in my case, but I digress.

The head obstetric nurse that lead the delivery was beyond fantastic. Doctors address her the way a foot soldier address a captain, talk about empowering women. My wife had given me explicit instructions on how she wanted to deliver our baby so I could enforce them when she was in labor. They were followed with -some- questions asked (and a couple of waivers singed).

My wife is a journalist as well, and her impulse was to research extensively on the CCSS recommended practices, obstetric rights and violence and in her particular case, the pros and cons of the use of Oxytocin in the drip to speed up labor. She decided to op-out on oxy. They were not too amused by her decision, but it was -tolerated- reluctantly.

Jill, how was your experience with the drip, did they tell you anything about it? They told us it was only a drip to keep her hydrated but when we refused the use of Oxy, they just inserted a catheter, just in case, with no saline solution or anything.

All in all the experience was mostly positive at the Calderon Guardia, sans a grumpy nurse in the post delivery maternity ward. The personnel in the delivery rooms was great. The main difference I could point out is post delivery. Once the baby is born, partners are showed to the door and allowed only during ridiculusly short visiting hour (it is one hour, 1, uno). They need to renovate those wards, they are worn down. On the private hospital, HCC in our case, partners are welcome to stay in the room and visitors are managed by the patients.

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Jill Replogle

Ah, I had forgotten about the drip. A couple of assistants tried to put one in me, “just to keep you hydrated,” they said. I balked and the obstetric nurse told them to back off, that I didn’t need it and that my natural oxytocin would do me just fine.

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