Cesarean Sections and the Medicalization of Birth in Gran Asunción, Paraguay Open Access
Goldenberg, Tamar Shoshana (2011)
Abstract
Background: The World Health Organization recommends that
cesarean section rates
not exceed 15%; however in 2008, 46% of births in Gran
Asunción occurred by cesarean
section. The increased use of cesareans in resource-poor settings
is associated with
increased maternal and neonatal morbidity and mortality and high
health care costs.
Objective: To understand why there is a high cesarean
section rate in Gran Asunción,
Paraguay and to provide recommendations on how to reduce cesarean
section use.
Methods: A qualitative needs assessment was performed between
May and August 2009.
Data collection included thirty in-depth individual interviews,
twenty with recently
postpartum women who had vaginal or cesarean births and ten with
obstetric
gynecologists who worked at public hospitals in Gran Asunción.
A systematic analysis
of verbatim transcripts identified major themes, comparing and
contrasting patterns
within and between interviews.
Results: The high utilization of cesarean sections in Gran
Asunción results from a birth
culture that poorly prepares women for vaginal birth, medicalizes
the birth process, and
promotes the idea among both women and doctors that natural birth
is risky. The use of
medical interventions during vaginal birth, including artificial
oxytocin, artificial
membrane rupture, and episiotomies are common and overused. In
addition, women lack
social support during labor and birth. Vaginal births are often
portrayed as a negative
experience; many women consequently fear having a vaginal birth and
prefer having a
cesarean section. Both doctors and women noted that women sometimes
"beg" for
cesarean sections on arriving at public hospitals. Some doctors
also prefer cesarean
sections, especially when a woman is asking for one, because they
are perceived as more
convenient, controllable, and ultimately, less risky in terms of
accusations of malpractice.
This complex interplay of doctor and maternal preference for
cesareans contribute to the
use of cesarean sections without medical indications.
Discussion: Intervention strategies to educate women
during pregnancy, increase
continuity of care, improve hospital infrastructure, allow for
social support during labor,
and decrease the use of negative birth practices could reduce the
cesarean section rate in
Gran Asunción by shifting the birth paradigm to a more
humanized model of birth.
Table of Contents
Table of Contents
Chapter 1: Introduction 1
Introduction and rationale 1
Purpose statement and research questions 3
Significance statement 4
Definition of terms 4
Chapter 2: Literature Review 6
Patterns of cesarean sections in Latin America 6
Patterns of cesarean sections in Paraguay 6
Health impact of cesarean sections without medical indication
8
Economic impact of cesarean sections 11
Maternal preference vs. doctor preference 13
The impact of medical technology 16
Evidence-based research to reduce cesarean sections 17
Chapter 3: Methods 21
Study location 22
Study population 24
Recruitment 26
Ethical considerations 27
In-depth individual interviews with postpartum women 27
In-depth individual interviews with obstetric gynecologists
28
Participant observations and key informant interviews 29
Data analysis 30
Limitations 31
Chapter 4: Results 34
Secondary Data Analysis of CEPEP ENDSSR 2008 34
General demographics 34
Prenatal care demographics 34
Birth demographics 35
Variation in cesarean section use 36
Qualitative Data Analysis 37
In-Depth Individual Interviews with Obstetric Gynecologists
38
General perceptions about cesarean use 38
Doctors' beliefs about the importance of preparation for birth
39
The medicalization of prenatal care 43
Barriers that prevent educating women during prenatal care 45
Class differences 46
Time spent with the woman 47
The social network as a source of information 48
Preparing women for vaginal birth vs. cesarean sections 49
The use of medical technology during vaginal birth 50
Doctors' perceptions of social support and the doctor's role during
labor 53
Doctors' perceptions of accompaniment during labor 54
The doctor's role during labor and birth 54
Doctors' descriptions of maternal preference for cesarean sections
55
The role of the private sector 56
When women beg for cesarean sections 57
Doctors' perceptions of cesarean sections 58
Doctors' perceptions of risks and complications 60
Doctors' recommendations 62
In-Depth Individual Interviews with Postpartum Women
63
Women's accounts of experiences of prenatal care 64
Women's experiences with medical technology 68
Feeling "tirada" vs. experiencing continuous care: Social support
during labor 69
Talking to other women: The impact of the social network 74
Women's fears of vaginal birth and cesarean sections 76
Women's recommendations 81
Chapter 5: Discussion 82
Birth culture: Fear and the medicalization of birth 82
Interventions to reduce the cesarean section rate 86
Childbirth education 87
Continuity of care 90
Reducing the use of unnecessary medical interventions and practices
92
Accompaniment during labor 94
Consequences for unnecessary surgery 97
The private sector 98
Additional research 98
Government advocacy 99
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