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The Paradox of Medicalization in the Dominican Republic: High Rates of Cesarean Section, Ethnic Inequity and Maternal/Neonatal Mortality in a Context of Low Public Expenditure (2020–2024)

This study reveals that in the Dominican Republic, high cesarean section rates coexist with low public health spending and poor maternal outcomes, while Haitian women face significantly lower access to these interventions compared to Dominican women, highlighting a paradox of overmedicalization driven by ethnic inequity and structural underinvestment.

Original authors: Elena Gonzalez-Rodriguez, Raul Castaneda-Vozmediano, Ruth Gil-Prieto

Published 2026-07-06

📖 5 min read🧠 Deep dive

CC BY 4.0

Original authors: Elena Gonzalez-Rodriguez, Raul Castaneda-Vozmediano, Ruth Gil-Prieto

Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). ✨ This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer

The Big Picture: A Medical "Overdose" That Isn't Helping

Imagine the healthcare system in the Dominican Republic as a giant kitchen. The goal of this kitchen is to feed everyone (provide safe births) well. However, the chefs (doctors and hospitals) have decided that the only way to serve a meal is by frying it in a deep fryer (performing a Cesarean section), even when the ingredients could have been perfectly cooked in a simple oven (a natural vaginal birth).

This study, covering the years 2020 to 2024, looked at over 460,000 births in public hospitals. It found that the Dominican Republic is "frying" its babies at a rate of 46.3%. The World Health Organization (WHO) says the ideal rate is between 10% and 15%. The Dominican rate is more than three times higher than what is considered necessary.

The Great Divide: Two Different Menus for Two Groups

The most shocking part of this study is that the "menu" changes depending on who you are.

Dominican women are served the "fryer" (C-section) about 53% of the time.
Haitian women (who are often neighbors and share the same hospitals) are served the "fryer" only 31% of the time.

The Analogy: Imagine two people walking into the same restaurant. One person is told, "You must have the deep-fried special, it's the best!" The other person is told, "You can just have the grilled option." The study found that being Haitian makes you significantly less likely to get the surgery, even after adjusting for age and where they live. This suggests that nationality acts like a hidden filter in the system, deciding who gets the medical intervention and who doesn't, regardless of whether they actually need it.

The "Broken Thermostat" of Hospitals

The study looked at 214 different hospitals, and the results were like a broken thermostat in a building. Some rooms were freezing, while others were on fire.

The Extremes: Some hospitals were doing C-sections for 100% of their patients. Two specific hospitals (Dr. Román B. Brache and Dr. Rafael J. Mañón) had rates of 100%.
The Pattern: These "over-frying" hospitals were clustered in specific regions (National District, Northeast, and Southern Cibao).
The Problem: It's not that these hospitals are better; it's that they are operating without a clear rulebook. The study found that the variation between hospitals was so huge that it couldn't be explained by how sick the mothers were. It was about how the hospital ran its business.

The Paradox: More Surgery, More Danger

Here is the confusing part, or the "Paradox":

Usually, we think: More money spent on health = Better results.
But in this case, the study found: More C-sections + Low Public Spending = High Death Rates.

The Money: The Dominican Republic spends very little on public health (only about 3.3% of its total money).
The Result: Despite having a high number of surgeries (which are expensive and risky), the country has a very high rate of mothers and babies dying.
The Comparison: When the researchers compared the Dominican Republic to countries like Spain or Canada, they saw that spending more money on health does lower death rates. But in the DR, just doing more surgeries didn't lower the death rate. It's like trying to fix a leaky roof by buying more hammers instead of fixing the shingles. The tool (the surgery) isn't the solution; the quality of care is missing.

Why is this happening?

The paper suggests that the high number of surgeries isn't because the mothers are sicker. Instead, it's driven by:

Bias: Doctors might treat Dominican women differently than Haitian women due to language barriers (Spanish vs. Creole) or unconscious prejudices.
Habits: Hospitals have gotten used to doing surgeries and haven't been checked on enough.
Lack of Midwives: The study notes that midwives (nurses who specialize in natural birth) are crucial for keeping C-section rates down, but their role seems underutilized.

The Bottom Line

The study concludes that the Dominican Republic is stuck in a loop where it performs too many surgeries, spends too little money on the quality of care, and sees too many deaths.

The proposed fix isn't just to buy more equipment. The authors suggest:

Checking the "Thermostats": Auditing the hospitals that are doing 100% surgeries to see why.
Fairness: Making sure Haitian and Dominican women get the same advice and care.
Listening to Midwives: Letting more midwives guide women toward natural births when it's safe.
Better Rules: Enforcing the existing rules (like the Robson Index, a tool to check if surgeries are necessary) so they actually work.

In short: The system is "over-medicalizing" birth for some, "under-protecting" others, and failing to save lives, all while spending very little money. The solution requires changing the culture of the hospitals, not just the math.

Technical Summary: The Paradox of Medicalization in the Dominican Republic (2020–2024)

Problem Statement
The Dominican Republic faces a critical public health paradox characterized by extremely high rates of cesarean sections (CS) coexisting with low public health expenditure and poor maternal/neonatal outcomes. While the global average CS rate is approximately 21%, and the World Health Organization (WHO) recommends an optimal threshold of 10–15%, the Dominican Republic consistently exceeds 50%. This overmedicalization is compounded by severe ethnic inequities: within the same public health network, Dominican women undergo CS at significantly higher rates than Haitian women. Despite the implementation of the "Protocol of action for the reduction in unnecessary cesarean sections" in 2020 (incorporating the Robson Index), persistent disparities suggest that non-clinical, structural determinants—specifically maternal nationality—drive obstetric practices more than clinical necessity.

Methodology
The study employed a retrospective analytical observational design utilizing secondary data from the Dominican Ministry of Public Health.

Data Source: Aggregated and anonymized birth registration data from 214 public hospitals covering the period January 1, 2020, to December 31, 2024.
Sample: 462,092 deliveries were analyzed after excluding 33,015 cases (6.7%) due to multiple births, out-of-hospital births, or missing data.
Statistical Approach:
- Descriptive Analysis: Calculation of absolute and relative frequencies for CS rates by nationality, age, region, and year.
- Association Testing: Chi-square tests and Cramer's V index were used to assess the strength of association between nationality and intervention type. Univariate risk indices (Relative Risk, Odds Ratio, Attributable Risk Percentage) were calculated.
- Multivariate Modeling: Mixed-effects logistic regression models were developed to estimate the probability of CS, adjusting for confounders (maternal age, year of delivery) and treating health region as a random effect. Model selection utilized Akaike (AIC) and Bayesian (BIC) Information Criteria.
- International Correlation: Spearman correlations ( $\rho$ ) were computed to assess relationships between national CS rates and macroeconomic/health indicators (GDP, public health expenditure, mortality rates) across eight countries.
Software: Analyses were conducted using R (version 4.3.1) with the lme4 package.

Key Results

Overall Rates and Trends: The overall CS rate was 46.3% (95% CI: 46.2–46.8%), significantly exceeding WHO recommendations. The rate increased annually, with an Odds Ratio (OR) of 1.26 for 2024 compared to 2020.
Ethnic Disparities: A stark disparity exists based on nationality. Dominican women had a CS rate of 53.4%, compared to 31.7% for Haitian women.
- Unadjusted Risk: Dominican women had a 1.68 times higher risk (RR) of CS than Haitian women.
- Adjusted Risk: After controlling for age, year, and region, Haitian nationality remained strongly associated with a lower probability of CS (Adjusted OR = 0.38; p < 0.001). Conversely, Dominican women were 2.47 times more likely to undergo a CS (95% CI: 2.434–2.498).
- Attributable Risk: Approximately 40.58% of CS cases among Dominican women were attributable to the difference in nationality compared to Haitian women.
Institutional Variability: Extreme heterogeneity was observed across hospitals. 42 out of 214 public hospitals (19.6%) exceeded a 50% CS rate, with some centers reaching 100% (e.g., Dr. Román B. Brache Hospital and Dr. Rafael J. Mañón Hospital). These high-rate centers were concentrated in Health Regions 0, III, and VIII.
Macroeconomic Correlations:
- CS rates showed no significant correlation with GDP per capita ( $\rho = -0.095$ ) or public health expenditure ( $\rho = -0.024$ ).
- Conversely, public health spending was significantly and negatively correlated with maternal mortality ( $\rho = -0.762$ ) and neonatal mortality ( $\rho = -0.857$ ).
- Despite high prenatal coverage (92.6%), the Dominican Republic exhibited the highest maternal mortality rate (139.7 per 100,000 live births) among the analyzed countries, 35 times higher than Spain.

Key Contributions

Quantification of Structural Bias: The study provides robust statistical evidence that maternal nationality acts as a powerful non-clinical determinant of obstetric care in the Dominican Republic, revealing a system where clinical interventions are mediated by institutional biases rather than medical need.
Identification of the "Medicalization Paradox": The paper documents a unique scenario where high intervention rates (overmedicalization) coexist with low public investment and poor health outcomes, challenging the assumption that higher medicalization equates to better care.
Granular Institutional Analysis: By identifying specific hospitals with extreme CS rates (up to 100%), the study highlights the lack of uniform clinical governance and the need for targeted audits.
Policy-Relevant Data: The analysis isolates the failure of the 2020 National Protocol (Robson Index) to curb rising rates or address ethnic disparities, suggesting that guidelines alone are insufficient without accountability mechanisms.

Significance and Claims
The authors assert that the findings reveal a critical dimension of health equity: inequity is manifested not only as a lack of access but as an unequal distribution of medical risks and benefits based on nationality. The study claims that the current overmedicalization does not guarantee quality of care, as evidenced by the high maternal mortality rates despite high coverage.

The paper concludes that addressing this paradox requires a transformation beyond clinical protocols. It posits that urgent priorities include:

Strengthening Clinical Governance: Implementing systematic Robson Index evaluations and monitoring hospitals with extreme rates.
Intercultural Equity: Addressing language barriers (Creole vs. Spanish) and implicit biases through linguistic mediators and bias training.
Resource Reallocation: Shifting focus from mere coverage expansion to improving critical care capacity and quality.
Empowering Midwives: Leveraging the role of midwives to promote physiological delivery and informed decision-making.

The study emphasizes that without a comprehensive transformation of medical training, culture, and clinical regulation, the cycle of overmedicalization and poor maternal outcomes will persist.