Sterilization and Birth-Control Practices in a Selected Sample of Puerto Ricans Living in a Manhattan Slum

Sterilization and Birth-Control Practices in a Selected Sample of Puerto Ricans Living in a Manhattan Slum Beatrice Bishop Berle, M.D.

To

A PHYSICIAN accustomed to advise his patients on the spacing of children, either directly or through referral to a planned-parenthood clinic, or to a physician who considers such advice against his religious principles, the request for sterilization from a healthy young woman of 25 in the course of a third uncomplicated pregnancy comes as a shock. The fact that this young woman was born in Puerto Rico and migrated to the continental United States since the birth of her second child only serves to strengthen the doctor's feeling that he does not understand Puerto Ricans. The doctor's refusal to accede to the request may be equally perplexing to the patient-indeed she may be overheard explaining in her native Spanish to other patients in the waiting room that the doctors are very backward in New York, as she would have no trouble getting operated upon in Puerto Rico.

PUERTO RICAN ATTITUDES The basis for the Puerto Rican attitude is the subject of this paper and will be considered from the demographic, clinical, and anthropologic points of view. During the last 50 years, the mortality rate in Puerto Rico has declined from 36.9 per 1000 in 1900 to 9.9 per 1000 in 1950. Live births during the same period have increased from 20.5 to 38.7 per 1000.' This shldy was made possible through a grant from the Foresight Foundation to Mt. Sinai Hospital, New York, and to the Department of Anthropology of Columbia University, New York. The social anthropologist who worked with the author is Elena Padilla, Ph.D. 267

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As a result: 1. The island of Puerto Rico has become one of the most densely populated areas of the world (Fig. 1). 2. Industrialization, migration, and the promotion of means to control human reproduction all form part of the program to deal with the problems of surplus population in Puerto Rico and to raise the standard of living. Indeed, all three factors influence the woman who presents herself to the physician with a request for sterilization. While the woman and her family have migrated in the hopes of obtaining better living conditions in a more highly industrialized society, her reproductive potential has not decreased. The total number of births which occurred in New York City in 1950 to women of child-bearing age, 15 to 44 years, are: Puerto Rican-born women, 135 births per 1000 ·women; total white women, 82 per 1000; total nonwhite women, 100 per 1000.3 The chances are that Puerto Rican women are not unacquainted with

IPUERTO IPUERTO

RICO RICO

I NETHERLANDS BELGIUM JAPAN

1950 ( 737.0) 1940 (556.0) <778.0)

( 716.71 ( 583.0 l

ENGLAND

AND

JAMAICA

(350.0

CEYLON HAITI

0 Fig. 1.

(532.9)

>

I

(300.0)

I

(283.0>

1<122.8>

CHINA

D D

WALES

UNITED STATES ( 50.0) INDIA

(43.61

800 700 600 400 500 POPULATION Population density per square mile of 10 countries in midyear 1950 and of Puerto Rico 1950 and 1940.2 100

200

300

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contraceptive methods, as the subject is frequently discussed in the Puerto Rican press today and has been a public issue for the past 20 years. Birth Control

The Puerto Rican Emergency Relief Administration (PRERA), which was founded in 1933 to deal with the many economic problems of the island, established a number of birth-control clinics. These were closed before the election of 1936, as a result of political pressure brought to bear by the Congress of the United States.• Private funds continued the work for a time. In 1939 a court decision legalized the distribution of birth-control materials for medical reasons. That same year, a bureau was established under the name of Maternal Health in the section of maternal and child hygiene of the Department of ·Health. The bureau of Maternal Health became the Prematernal Health Clinics, and these are defined by the Department of Health, in its annual report of 1946, as: clinics located in the various health stations throughout the island in order to improve the health of women by providing contraceptive material where "clear medical indications" exist.' The report further states that the Department of Health is concerned only with a woman's health and has no interest in the problem of population density. Summarizing the annual reports of the past 10 years, it appears that the prematernal clinics throughout the island admit from 3000 to 4000 new patients a year, and that approximately the same number become nonactive in the course of the year. Women who become pregoant, who stop using birth control, or who cannot be traced are included in the nonactive category. Over the same period, 30,000 to 45,000 dozen condoms, 1000 to 3000 diaphragms, and 1000 to 9000 tubes of vaginal jellies have been distributed annually through the prematernal clinics. 5 Condoms are credited with the greatest number of failures where a record of these is obtainable, but those who are interested in the movement are hopeful that the diaphragm will be more popular and effective now that instruction for its use is being delegated increasingly to female nurses rather than to male doctors. 6 An inquiry to try to determine more exactly the effectiveness of birth-control measures was made in 1953 by Reuben Hill, who interviewed a random sample of individuals ( 2667 females and 304 males) attending prematemal clinics in nine parts of the island. The persons interviewed were all living with a sexual partner and had at least 1 child, the median being 4.2 children per

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couple. The diHerence in fertility between users and nonusers of birth control was not significant.• Sterilization

Inquiry was made of these same individuals as to their knowledge of sterilization. Of the sample, 90.5 per cent knew of the procedure under the name of la operacion, and 1 out of 5 women had been sterilized. The maximum number of sterilizations were done 10 years after marriage. Twentyfive per cent were sterilized after the seventh pregnancy. Those more recently married in the sample were sterilized earlier. 7 • 8 The history of sterilization in Puerto Rico is an interestiog one. Because of overpopulation, poor economic and health conditions, and the high maternal- and infant-mortality rates, the practice of postpartum tubal ligation had been used for quite a number of years in various hospitals in Puerto Rico, including the district government hospitals, before 1940.9 During the early 1940s the Church of the Brethren, Quakers, and Mennonites, in agreement with the Puerto Rican Reconstruction Administration (successor to the Puerto Rican Emergency Relief Administration), established rural projects for medical relief, public health, recreation, education, and social welfare. At the project operated by the Church of the Brethren, 350 postpartum tubal ligations were performed between May, 1943, and September, 1945. Of these women who were thus sterilized, their average age was 30 years and they each had an average of 6.6 children.' Dr. Franklin K. Cassel,' who served with the Brethren Service Commission and who was in charge of the maternal and child-health program in the Castaner Project, reports: "Only postpartum tubal ligations were done where medical indications and the health of the mother and her family made it advisable for such a procedure to be carried out. Indeed, we did a considerable number of these operations because· of the relatively low standard of health and the sizable number of large families. At one time our medical program was under fire by the Catholic authorities who complained to the Insular Department of Health who, in turn, investigated this phase of our work. Mter reviewing our statistics and observing first-hand the situation, the department issued an official report commending our health program and requesting a continuation of this good work." It is difficult to estimate how many women have actually been sterilized

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in Puerto Rico. Table 1 is a summary of records and observations on this point collected from a variety of sources. The Belaval figure was presumably obtained by a questionnaire sent to all hospitals throughout the island, while the official figures published by the Department of Health, which do not vary significantly from year to year, indicate only those sterilizations performed for strictly medical reasons, i.e., previous cesarian sections, uterine prolapse, severe varicose veins. Poverty and multiparity alone do not come under the heading of medical indications. It is also said that the . director of the maternity hospital in Caguas does not permit sterilization on any grounds whatsoever and no ·sterilizations are ever reported for that hospital. The means by which official disapproval may be circumvented are several-Grace (Table 1) reports that the women interviewed at the Army base hospital had been operated on in small private hospitals, and another physician in Puerto Rico reported that a woman who delivered on the maternity ward of a municipal hospital may be transferred to the gynecologic section of that hospital for tubal ligation or to a private hospital where the operation may be performed by a private physician for a minimum fee TABLE 1.

Summary of Records and Observations on the Number of Women Sterilized in Puerto Rico

Source

Proportion sterilized

Sample

Hatt 11

6000 representative households, islandwide

6.6% of all ever married 8.3% upper-income group 2.7% lower-income group 11.3% marital unions between

Belaval (quoted by

All women delivered in hos-

17.8 to 19.3%

1930-1939 Stycos 10 and Sutter 14 )

pitals during calendar

year 1949 Stycos 8

Random sample of 2667 females interviewed in prematernal clinics

Puerto Rico Department Mayaguez-1225 deliv.

of Health 1952-1953 Grace 15

Rio Piedras-3154 deliv. Caguas-999 deliv.

38% of those with more than

6 children 20% of total number

18 sterilizations ( 1.5%) 119 sterilizations (3.80%) 0 sterilizations

U.S. Army base hospital (spot 20% check 60 successive medical admissions of young Puerto Rican Army wives)

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of $60. In neither of these cases will a record of Ia operacion appear in a form which permits counting. According to Stycos10 the reasons for the popularity of sterilization, apart from its effectiveness, are in the cultural pattern of the people. La operacion is something which may be spoken of without offending female modesty whereas the use of any form of mechanical means involves communication and discussion of sexual matters between spouses, and this type of com. munication he found is ahnost nonexistent.

Induced Abortions It is even more difficult to determine the extent to which induced abortions are practiced in Puerto Rico. Hatt11 and Cofresi12 state that abortions are not a problem, meaning by this that they are not frequently practiced, but both of these workers used a structured questionnaire and did not probe. Padilla, the social anthropologist associated with the current study, found that both rural and urban lower-class women in Puerto Rico frequently attempt to abort themselves by the oral ingestions of medications, herbs, purgatives, or patent medicines. Women also inserted sondas into the vagina or hired a midwife to insert them. This involves packing the vagina with Kotex in order to "choke" the fetus. A midwife known to practice abortion is subject to losing her license and to other penalties as well. Padilla further suggests that since induced abortions are frowned upon by society· and sterilization is not, the latter becomes a desirable means to control the size of the family. How far the pattern of ineffective use of mechanical means of contraception and the preference for sterilization carries over to Puerto Ricans living in the continental United States is a question of interest to physicians and social workers. The following report which forms part of an extensive study of health conditions and practices among lower-class Puerto Rican slum dwellers in Manhattan brings some evidence to bear on this question. METHOD

Observations on the Puerto Rican population living in a designated health area in the upper East Side of Manhattan were carried out by a team of physicians and social anthropologists. The medical team kept office hours on an average of 2 afternoons a week for 3 years in a three-room apartment,

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giving outpatient service to individuals living in the neighborhood and making a number of home calls, thus developing contact with many families both in their homes and in the medical office. The anthropologists were present in the area for 2 years and studied its people by means of participantobserver interviews on the street, at school, and in the home, and through the administration of questionnaires containing a number of unstructured questions. A group of 80 Puerto Rican families were selected for more intensive study by both the medical and anthropologic teams. The fertility records of the women in these households was investigated. Their attitudes on the subject of optimal family size, the use of contraceptives, and sterilization as a means of family limitation were recorded both by physicians and anthropologists. In the course of the 3-year observation by the physician many of these women became pregnant and were referred for appropriate prenatal care. The physician remained in touch with them and was able to follow their course.

FINDINGS There were 86 women in this group who had been exposed to pregnancy. Eight were young women born in New York of Puerto Rican parents. Three had never had any children and the mates of these 3 gave a history of gonorrhea. Seventy-five were born in Puerto Rico and had migrated to Manhattan, some as long as 30 years ago, others as recently as 2 years ago; their age ranged from 20 to 67. In the group of 75 are included 6 widowed grandmothers living with their adult children. Fertility of Native Puerto Ricans The fertility record of the 75 native Puerto Rican women, as obtained through our medical histories and checked with hospital records, is shown in Table 2. The actual number of children exceeded the ideal family size as expressed to anthropologists in interviews. Three was most frequently mentioned as the optimum number of children desired by native Puerto Ricans, the actual mean was 4.5 and 18 women had borne 6 children or more. At the time of writing these women had 289 live children, a survival rate of 87.3 per cent through the years. More than half the children who died were victims of malnutrition, or infectious or enteric diseases in Puerto Rico in early infancy, and 3 died in a fire during the first year of migration. As in Puerto Rico, men expressed pride in keeping their women pregnant.

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TABLE 2.

Fertility Record of Seventy-five Puerto Rican Women

Age Twenty-one-Sixty-seven No.

Para Gravida Spont. abortion Induced abortion Fetal deaths Twinpreg. Children now alive (1955)

331 371 30 5 7 5 289

For instance, in one family where the woman had borne 12 children, all of them problems to society, the patient told the doctor that she did not need to bother with contraceptives as her husband was impotent. One year later, both parents were extremely proud of their thirteenth child and explained to the physician that indeed the father was once more potent. Also, on visiting the home the physicians observed much attention lavished on the infant until he became ambulatory. Visitors and siblings played with and picked up the new baby as if he were a doll, and the baby brought to the clinic was always dressed in new clothes when older children might be inadequately clad. Five induced abortions were admitted in the group of 75 Puerto Rican migrants. One was induced 15 years after migration in a woman who had borne 7 children and whose husband was unemployed at the time. This abortion appears to have ended her reproductive career. The number of admitted induced abortions is probably far below the actual figure, as women know that induced abortions are illegal in the United States, and the physician working in the area, not wishing to appear in an equivocal light, made it very clear that she was on the side of the law. The majority of women born in Puerto Rico were not always articulate and specific in their discussion of birth-control methods. The 18 women who had been sterilized and the 15 who acknowledged no current sexual partner were not concerned with the subject, and these make up half the group. Of the remainder, not quite half claimed that they did nothing to prevent conception. Distaste for the diaphragm and fear that it may cause infection or cancer was expressed in many comments to physicians and anthropologists alike. A woman, ·age 34, 18 years in the United States, Gravida IV, Para IV, expressed herself as follows: "I went to the clinic and

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they gave me half a pear. My husband was disgusted. 'Throw out that boat,'" he said. This woman obtained a tubal ligation in Mt. Sinai Hospital at the end of her fourth pregnancy on the grounds of severe varicose veins both in the vulva and in the legs. On the whole, Norform suppositories and jellies were preferred on the grounds that the husband was less aware of their use. Those men who used condoms expressed satisfaction that the control lay in their hands, but widespread unwillingness to the use of condoms in marriage was expressed in the same terms as it is in Puerto Rico and in other countries. In the questionnaire administered by anthropologists to migrants of both sexes la operacion was mentioned unanimously as the preferred and "only sure way" to limit families. This opinion was expressed by individuals regardless of its possible application in their own particular case. A response like the following indicates that the attitude toward sterilization described as characteristic for Puerto Ricans living on the island" persists after migration: A couple with 3 children were lamenting with the anthropologic field worker that in New York one cannot get an operation even with 6 children or one may have to pay $300 to a private physician. The wife added that were she to become pregnant again she would return to Puerto Rico where her mother would obtain a letter from the mayor of her home town securing a free bed in the municipal hospital. - In fact, 20 women in this group of 75 native. Puerto Ricans had been surgically sterilized-this includes 3· hysterectomies, 16 tubal ligations, and 1 instance of diseased tube removal (Table 3). Four women left New York during their last pregnancy and returned to Puerto Rico for the express purpose of having la operacion performed after delivery. Two were in their early thirties and 2 in their early twenties. One had 4 children and the others 3 children each. All 4 had been in New York more than 4 years and 1 had migrated 13 years previously at the age of 10. On questioning, they expressed satisfaction that the question of future pregnancies was settled once and for all. Another young couple who had successfully moved out of the slum area to better quarters only 2 years after migration, where the husband was a skilled mechanic steadily employed at $80 a week, and where the woman had an excellent health history and 6 uncomplicated deliveries, paid $250 to have i tubal ligation performed in a private hospital in New York City.

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TABLE 3.

Twenty Sterilizations in Seventy-five Native Puerto Rican Females

Para

Stated

Live Child.

Place

No.

Age

l.

21

2

3

1

2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.

21 23 23 25 25 27 27 28 29 30 30 30

3 3 3 6 4 3 6 6 3 7 5 8

3 3 3 10 4 3 6 13 2 7 5

3 3 2

6

4 3 6 6 2 7 5 6

14. 15.

31 31

4 8

4 7

4 7

16. 17. 18.

33 33 34

5 3 8

5 3 8

5 3 5

19.

48

10

6

2

multiple sections Varicose veins MSH P.R. Enough child. Hysterectomy, MSH cystocele, rectocele, secondary menorrhagia P.R. Hysterectomy,

4

prolapse Hysterectomy,

Gravida

6

reason

Contracted pelvis; P.R. multiple sections Enough child. P.R. Enough child. P.R. Enough child. P.R. Varicose veins M.H.•

Migration

Premigration

6 yrs. postmigration 13 yrs. postmigration Premigration 7 yrs. postmigration Premigration

Enough child.

P.R.

Convulsions

Enough child. Multiparity

Vol. H.• 25 yrs. postmigration Pr.H.b 2 yrs. postmigration MSH' 4 yrs. posbnigration

?P.I.D.

P.R.

Premigration

Multiparity Enough child. Multiparity-

MSH

7 yrs. postmigration

P.R.

Premigration

MSH

5 yrs. postmigration

placenta previa

20.

54

8

8

Enough child. Multiparity and

P.R.

4 yrs. postmigration

M.H.

4 yrs. postmigration

MSH

5 yrs. postmigration 6 yrs. postmigration 6 yrs. postmigration

Premigration

2 yrs. postmigration

cystocele, rectocele a

M.H.-municipal hospital, New York City.

bPr. H.-private hospital, New York City. o MSH-Mt. Sinai Hospital, New York City.

a Vol. H.-voluntary hospital, New York City.

Religion Contraception and sterilization were practiced regardless of whether the individuals called themselves Catholics or Protestants, and this concords with the experience of other investigators."• 12 One woman, who attended a Catholic church regularly, on inquiry by the physician as to possible preg·

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nancy slapped her relaxed abdomen joyfully exclanning, "thank God that's all over." She was Para VII, Gravida VII, and her tubes had been tied 2 years previous at _Mt. Sinai Hospital on the grounds of multiparity. The only women in this group who refused sterilization where it was offered on the grounds of multiparity were 2 devout Pentecostalists. One woman, Para XVII, Gravida XIV, had given birth to 3 sets of twins, and in her fortieth year had a premature separation of the placenta and delivered a premature infant. Her husband refused to sign an authorization for tubal ligation in spite of urgmg on the part of physicians. He remained firm on the ground of the Old Testament: "that mankind must multiply and populate the earth." A previous child for whom he had been unable to provide was taken over by another couple; members of his religious group. The second woman (Para VII) was steadfast in the conviction that she must bear as many children as God intended. This point of view prevailing at times among nonCatholic groups has been observed on the island of · Puerto Rico. 13 Premature Sterilization

A different aspect of the sterilization problem is illustrated by the woman whose tubes have been prematurely ligated and who wishes to become pregnant. Four cases of this type have been seen at the Mt. Sinai Hospital in the past year. Two were young women who had never been pregnant and who reported that their tubes had been ligated when they were 18 years of age on the. insistence of their husbands who did not want children. Now 5 years later these women were divorced and their remarriage depended on the possibility of their becoming pregnant. Bilateral tuboplasty was performed on 1 patient with resulting patency of tubes as tested by insufHation postoperatively. On reexamination 4 months later, the tubes were no longer patent. In the case of the second patient, an ovarian cyst was found at operation and both tubes had been surgically removed at the time of the first laparotomy, suggesting that they may have been diseased, thus casting s~me doubt on the patient's account of the reason for surgery. The other 2 patients, both in their early twenties, had. borne 2 and .4 children, respectively, and now wished more children. A multiple myomectomy and bilateral salpingoplasty was performed on 1 patient, with no resulting pregnancy although one tube was patent by. insrifllation. Six

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months postoperatively, on the recommendation of the department of psychiatry, a successful tuboplasty was performed on the woman who had borne 4 children and she was successfully delivered of her fifth child. When seen at home, this woman reported that her first husband did not support her and their 4 children, and that he ran around with other women and was a drunkard. She did not wish to bear any more children by him and her tubes had been tied in a municipal hospital 4 years ago in Puerto Rico following the delivery of her fourth child. The couple separated and she came to New York with her 4 children, where she has been receiving help from the Department of Welfare. Complaints of dysmenorrhea and constant lower quadrant pain, as well as the desire to bear a child by a man who wished to marry her and support her if he could have a child of his own, brought her to the hospital. Now she is quite sure that she does not wish to have a third laparotomy and that she will use "birth control" following this delivery. Fertility Comparison

In comparing the fertility record of the 8 women born in New York of Puerto Rican parents with that of their mothers and that of their 12 contemporaries, native Puerto Rican women under the age of 30, certain differences are apparent. The native New Yorkers have an average of 3 children and a median of 2.5, while their Puerto Rican contemporaries average 4.5 children per family and a median of 3.5. The mothers of the 8 women born in New York had an average of 6.7 children and a median of 6.5. The mothers did not practice birth control nor were they sterilized. Five of the 12 young women born in Puerto Rico have been sterilized, 3 in New York for multiparity plus medical indications and 2 in Puerto Rico because they wished no more children. The 8 native New Yorkers are using some form of mechanical contraception. Two are using a diaphragm with apparent TABLE 4.

Fertility Record of Women of Puerto Rican Parents, Their Mothers, and Young Native Puerto Rican Women Para

Daughters. age 20 ( 8) Mothers (7)

Gravida

Spont. abortion

Induced abortion Stillbirths Sttrriliud

18 47

24 48

0 0

6

0 0

0 0

53

62

6

3

8

5

NativeP; R.,

under 30 ( 12)

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success and satisfaction. Where contraceptive measures have failed or were not used initially, these women admit to having induced abortions and feel that 1 or 2 children at the most is enough. The 1 exception among this small_ group of 8 is a woman of 20 who has borne 5 children in 5 years, in spite of repeated instructions by competent physicians on the use of the diaphragm. She is married to a recent Puerto Rican migrant and they now live in a rural area in a joint household with her parents, under conditions not unlike those prevailing in a Puerto Rican rural community. In regard to sterilization, these women are aware that la operacion is not available on the same terms in New York as it is in Puerto Rico. Nevertheless 1 woman with 2 children who admits to 3 induced abortions and who is determined to have no more, told one of the physicians recently that she was considering going to a private physician in New York for a tubal ligation. Discussion Surgical sterilization as a means of limiting family size appears to be a well-established pattern among Puerto Rican women (Table 2), the opponents of this method notwithstanding. The possible abuses of this procedure are well illustrated by the 4 cases of premature tubal ligation described. What constitutes premature ligation from the Puerto Rican point of view requires definition. The Puerto Rican family pattern in the lower classes appears to involve successive conjugal unions and a woman who has been deserted or who has separated from her first mate stands a better chance of obtaining support for herself as well as for the children of her first union if she can bear a child to the second man. In the group of 75 native Puerto Rican women under discussion, 1 out of 3 household units, not necessarily unharmonious on this account, consisted of children of more than 1 father. Also, the 4 women who requested a tuboplasty did so because their future depended on being able to bear a child. Indeed, postpartum tubal ligation is not only a problem from the patient's point of view but poses a serious question of ·ethics for physicians and hospitals. On religious grounds, a physician may refuse to consider the matter at all and pass it on to a colleague. This colleague, where an indisputable medical indication for surgical sterilization exists, finds himself on familiar ground. But the "grand multipara," as Eastman defined her, is considered by many hospitals a social and not a medical problem. Both physician and

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hospital deny responsibility for her until the time when she may come to the hospital in her eighth pregnancy in 8 years with a placenta previa. II this emergency does not arise, her children may be patients in the pediatric clinic for malnutrition, and the family with 8 children, although the father may be an honest, hard-working man, is obliged to apply for aid from the Department of Welfare. Thus, physicians may not altogether escape the social consequences of medical practice and are obliged to enlarge their concept of preventive medicine in order to develop a policy which meets the needs of an overfertile population. Such a policy has been worked out by the Department of Obstetrics of Mt. Sinai Hospital, where 80 per cent of the ward patients are Puerto Ricans. Any woman, with the birth of a sixth living child, may have a postpartum tubal ligation upon her request and that of her husband. This criterion for sterilization on the grounds of multiparity applies to ward and private patients alike, irrespective of the woman's age. In the case of a woman between the ages of 30 and 35, 5 living children are required and in the case of a woman over 35, 4 living children, before a request for sterilization on the grounds of multiparity alone is granted. It may be argued that Puerto Rican women should learn to use mechaoical means of contraception effectively. So far they have not. Cultural patterns to which failure is attributed have been discussed at length by Stycos10 and our observations made on the Puerto Ricans living in a slum area in New York support his view. The small group of second-generation Puerto Rican women discussed are more efficient for the most part, but these are women born and educated in New York City, whose manner of living and thinking differs from that of their parents. In order to teach contraceptive methods to native Puerto Rican women and their mates, a vast number of Spanish-speaking workers familiar with Puerto Rican customs would be required, and judging from the experience in the prematernal clinics on the island, it is not certain that even this would be effective. · SUMMARY AND CONCLUSIONS 1. The Puerto Rican experience in birth control and sterilization has been discussed. 2. The consequences of indiscriminate and premature tubal ligation have been illustrated in 4 cases. 3. The continuation of the pattern of preferring sterilization to birth con·

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trol in a group of Puerto Rican migrants to a Manhattan slum area has been demonstrated. 4. The possibly greater prevalence of induced abortions and the more effective use of contraceptive measures among a group of women born in New York City of Puerto Rican parents has been observed. 5. The necessity for the development by responsible institutions of criteria for sterilization on the grounds of multiparity has been suggested. 142 East 19 Street New York, N.Y. REFERENCES 1.

2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

fuco DEPART}.::[ENT OF HEALTH, BUREAU OF MATERNAL INFANT-HYGIENE Maternal Infant and Chudlwod Mortality in Puerto Rico. March, 1955. WoYTINSKY, W. S., and WoYTINSKY, E. S. World Population Trends and Outlook. New York, Twentieth Century Fund, 1953. JAFFE, A. J. Demographic and Labor Force Clwracteristics of the New York City Puerto Rican Popuwtion in Puerto Rican Popuwtion of New York City. New York, Bureau of Applied Social Research, Columbia. HANSON, E. P. Transformation, The Story of Modern Puerto Rico. New York, Simon & Schuster, 1955. PuERTO Rico DEPARTMENT oF HEALTH Annual Report. 1942-1953. RicE, W. San Juan, Puerto Rico. Personal communication. STYcos, J. M. Female sterilization in Puerto Rico. Eugenics Quart. 1:3, 1954. Srrcos, J. M. The pattern of birth control in Puerto Rico. Eugenics Quart. 1: 176, 1954. CASSEL, F. L. Personal communication. STYcos, J. M. Family and Fertility in Puerto Rico. New York, Columbia, 1955. HATI', P. K. Background of Human Fertility in Puerto Rico, Princeton, N. J., Princeton, 1952. CoFRESI, E. Realidad Poblacional de· Puerto Rico. Caracas, Venezuela, San Juan Imprenta, 1951. STYcos, J. M., BACK, K., and HILL, R. Contraception and Catholicism in Puerto Rico. Milbank Mem. Fund Quart. 84:150. SUTI'ER, J. Le mouvement dans Ia monde in faveur de la limitation des families. Popuwtion 10:277, 1955. GRAcE, W. J., Major, U.S. Army Medical Corps Personal communication. PuERTO