Caesarean birth in public maternities in Argentina: a formative research study on the views of obstetricians, midwives and trainees

Abstract

ObjectivesTo explore obstetricians’, midwives’ and trainees’ perceptions of caesarean section (CS) determinants in the context of public obstetric care services provision in Argentina. Our hypothesis is that known determinants of CS use may differ in settings with limited access to essential obstetric services.SettingWe conducted a formative research study in 19 public maternity hospitals in Argentina. An institutional survey assessed the availability of essential obstetric services. Subsequently, we conducted online surveys and semistructured interviews to assess the opinions of providers on known CS determinants.ResultsObstetric services showed an adequate provision of emergency obstetric care but limited services to support women during birth. Midwives, with some exceptions, are not involved during labour. We received 680 surveys from obstetricians, residents and midwives (response rate of 63%) and interviewed 26 key informants. Six out of 10 providers (411, 61%) indicated that the use of CS is associated with the complexities of our caseload. Limited pain management access was deemed a potential contributing factor for CS in adolescents and first-time mothers. Providers have conflicting views on the adequacy of training to deal with complex or prolonged labour. Obstetricians with more than 10 years of clinical experience indicated that fear of litigation was also associated with CS. Overall, there is consensus on the need to implement interventions to reduce unnecessary CS.ConclusionsPublic maternity hospitals in Argentina have made significant improvements in the provision of emergency services. The environment of service provision does not seem to facilitate the physiological process of vaginal birth. Providers acknowledged some of these challenges.

Behavioural factors associated with fear of litigation as a driver for the increased use of caesarean sections: a scoping review

“…The legal environment and how it influences maternity care were the focus of 24 studies 13 14 21 22 33–38 41 43 46 47 49 50 52 54 62 63 76–79. While laws, legal norms and procedures differ by context, we identified common themes across different studies.…”

“…Ten studies explored FoL’s impact on MoB decision making beyond providers’ self-report. The proxy measures used to explore FoL included changes to malpractice insurance premiums,38 39 41–43 previous experience with litigation19 22 44 45 and changes to liability laws 22 46…”

“…Seven studies explicitly discussed providers’ beliefs around the relative safety of CS 37 41 51 54 60–62. The inclination to perform CS to avoid litigation risk can be motivated by providers’ belief that CS is a safer option than VB, and that CS guarantees the best outcome for mother and child 63.…”

Women's mode of birth preferences and preparedness of hospitals to support vaginal birth in the public health sector in Argentina

“…The public obstetric services included in this study from five Argentinean regions reported an average caesarean delivery rate of 39% which was considered overuse of the procedure by the healthcare providers at the hospitals. 19 Despite the disproportionately high rates of caesarean birth, most postpartum women interviewed in these services indicated a preference for vaginal birth, citing faster recovery time, increased postpartum autonomy and ability to care for one's child, and a preference for a natural delivery as primary motives. Women interviewed as part of past studies on MOB preference in Latin America indicated similar preferences and motives for vaginal birth.…”

“…11,15 Furthermore, although research has highlighted factors specific to the public sector that may contribute to caesarean birth overuse such as a disconnect between information from prenatal care to delivery, 16 there is no clear evidence that women's preferences diverge while receiving care in the public versus private health sector. 17 As part of a larger formative research project conducted by a multidisciplinary, international research partnership, 18,19 this study aimed to describe women's MOB preferences and identify the factors associated with those preferences in public hospitals in Argentina. Study findings will be used to inform the design and implementation of women-centred interventions for reducing unnecessary caesarean birth in the Latin American region.…”