Mode of Childbirth in Low-Risk Pregnancies: Nicaraguan Physicians’ Viewpoints

Abstract

To explore attitudes of physicians attending births in the public and private sectors and at the managerial level toward cesarean birth in Nicaragua. A qualitative study was conducted consisting of four focus groups with 17 physicians and nine in-depth interviews with decision-makers. Although study participants listed many advantages of vaginal birth and disadvantages of cesarean birth, they perceived that the increase in the cesarean birth rate in Nicaragua has resulted in a reduction in perinatal morbidity and mortality. They ascribed high cesarean birth rates to a web of interrelated provider, patient, and health system factors. They identified five actions that would facilitate a reduction in the number of unnecessary cesarean operations: establishing standards and protocols; preparing women and their families for labor and childbirth; incorporating cesarean birth rate monitoring and audit systems into quality assurance activities at the facility level; strengthening the movement to humanize birth; and promoting community-based interventions to educate women and families about the benefits of vaginal birth. Study participants believe that by performing cesarean operations they are providing the best quality of care feasible within their context. They do not perceive problems with their current practice. The identified causes of unnecessary cesarean operations in Nicaragua are multifactorial, so it appears that a multi-layered strategy is needed to safely reduce cesarean birth rates. The recent Nicaraguan Ministry of Health guidance to promote parto humanizado ("humanization of childbirth") could serve as the basis for a collaborative effort among health care professionals, government, and consumer advocates to reduce the number of unnecessary cesarean births in Nicaragua.

Non-clinical interventions to reduce unnecessary caesarean section targeted at organisations, facilities and systems: Systematic review of qualitative studies

“…The studies investigated stakeholder views of different types of midwife staffing models [36,50,52–54]; financial strategies [28,29,43–44,48,58–60]; and organisational culture [27,40,42,46,47,49,51,55–57,61,62]. We also included two studies of social (doula) support during labour [39,41], with the decision for inclusion made by consensus, because of their positive effect on caesarean section rate reduction in the associated Cochrane review of effectiveness studies.…”

“…availability of equipment, theatre access) as powerful mediators of barriers or facilitators to reducing unnecessary caesarean section. [28,36,39,40–42,46,47,49,51,55–58,61,62] In high-income countries where “quick win” changes had been made to labour and delivery rooms to encourage normal labour and birth, the priority an organisation gave to maintaining them was fundamental to their effectiveness in reducing caesarean section rates. [56,61] This included changes to in-room facilities for labour and guaranteed access to operating theatres when necessary.…”

“…In middle-income countries inadequate facilities (lighting, bathrooms, air-conditioning and shared delivery areas), or the actual conversion of delivery rooms into operating theatres, were reported as important barriers. [42,47,55,57] The need to consider the birth environment as comprising of material facilities, but also material relations between humans and systems was evident within and between studies, and across resource settings.…”

“…[27,36,42–44,46,47,55] This could simply be a consequence of different financing structures, clinical policies, and the working environment. However, it could also be due to the power of the predominant philosophy of pregnancy and childbirth, based on perceptions of the purpose of the particular kind of unit.…”

“…[28,43,46,47,52–55,57–60] . This was partly due to the powerful impact of non-clinical factors, such as management processes, rules, regulations, and conflicting strategies.…”