Maternal and Child Health Journal

, Volume 18, Issue 10, pp 2382–2392 | Cite as

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

  • Mercedes Colomar
  • Maria Luisa Cafferata
  • Alicia Aleman
  • Graciela Castellano
  • Ezequiel Garcia Elorrio
  • Fernando Althabe
  • Susheela Engelbrecht


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.


Qualitative research Health personnel Mode of delivery Cesarean section 



Nicaraguan Social Security Institute


Ministry of Health/Ministerio de Salud




Program for Appropriate Technology in Health


United States Agency for International Development



This study was made possible by the generous support of the American people through the United States Agency for International Development (USAID), under the terms of the Leader with Associates Cooperative Agreement GHS-A-00-08-00002-00. The contents are the responsibility of the Maternal and Child Health Integrated Program (MCHIP) and do not necessarily reflect the views of USAID or the United States government. The intervention was implemented by the Ministry of Health of Nicaragua (MINSA) with technical support from USAID’s flagship maternal, neonatal and child health program (MCHIP), PATH/Seattle and Managua, the Institute for Clinical Effectiveness and Health Policy (IECS), and the Montevideo Clinical and Epidemiological Research Unit (UNICEM). We thank Yann Lacayo, Henry Espinoza and Margarita Quintanilla from PATH/Nicaragua for their help in the organization of the focus groups and in-depth interviews.

Conflict of interest

The authors declare that they have no competing interests.


  1. 1.
    International Cesarean Awareness Network (ICAN). White papers: Cesarean fact sheet. International Cesarean Awareness Network, 2002.Google Scholar
  2. 2.
    Villar, J., Valladares, E., Wojdyla, D., Zavaleta, N., Carroli, G., Velazco, A., et al. (2006). Caesarean delivery rates, pregnancy outcomes: The WHO global survey on maternal and perinatal health in Latin America. Lancet, 367(9525), 1819–1829.PubMedCrossRefGoogle Scholar
  3. 3.
    Faúndes, A., & Cecatti, J. G. (1993). Which policy for caesarean sections in Brazil? An analysis of trends and consequences. Health Policy Plan, 8, 33–42.CrossRefGoogle Scholar
  4. 4.
    Barros, F. C., Vaughan, J. P., Victora, C. G., & Huttly, S. R. A. (1991). Epidemic of Caesarean sections in Brazil. Lancet, 338, 167–169.PubMedCrossRefGoogle Scholar
  5. 5.
    Murray, S. F., & Pradenas, F. S. (1986). Cesarean birth trends in Chile to 1994. Birth, 1997(24), 258–263.Google Scholar
  6. 6.
    Notzon, F. C., Cnattingius, S., Bergsjö, P., Cole, S., Taffel, S., Irgens, L., et al. (1994). Cesarean section delivery in the 1980s: International comparison by indication. American Journal of Obstetrics and Gynecology, 170, 495–504.PubMedCrossRefGoogle Scholar
  7. 7.
    Ballacci, F., Medda, E., Pinnelli, A., & Spinelli, A. (1996). Cesarean delivery in Italy: An European record. Epidemiologia e Prevenzione, 20, 105–106.PubMedGoogle Scholar
  8. 8.
    Stjernholm, Y. V., Petersson, K., & Eneroth, E. (2010). Changed indications for cesarean sections. Acta Obstetricia et Gynecologica Scandinavica, 89, 49–53.PubMedCrossRefGoogle Scholar
  9. 9.
    Betrán, A. P., Merialdi, M., Lauer, J. A., Bing-Shun, W., Thomas, J., Van Look, P., et al. (2007). Rates of cesarean section: Analysis of global, regional and national estimates. Paediatric and Perinatal Epidemiology, 21, 98–113.PubMedCrossRefGoogle Scholar
  10. 10.
    Belizán, J. M., Althabe, F., Barros, F. C., & Alexander, S. (1999). Rates and implications of caesarean section in Latin America: Ecological study. BMJ, 319, 1397–1400.PubMedCentralPubMedCrossRefGoogle Scholar
  11. 11.
    World Health Organization (WHO). Country cooperation strategy at a glance, 2006. Accessed 23 Dec 2013.
  12. 12.
    United Nations Population Fund (UNFPA). The State of the world midwifery report, 2011. Accessed 23 Dec 2013.
  13. 13.
    World Health Organization. Department of Reproductive Health and Research. Rising cesarean deliveries in Latin America: how best to monitor rates and risks. Geneva, Switzerland, 2009. Accessed 2 May 2013.
  14. 14.
    National Development Information Institute. Encuesta Nicaragüense de demografía y salud 2006/07: INIDE Informe final [Nicaraguan demographic and health survey 2006/07: Final INIDE report]. Managua, Nicaragua, 2008. Accessed 2 May 2013.
  15. 15.
    World Health Organization. (1985). Appropriate technology for birth. Lancet, 326(8452), 436–437.CrossRefGoogle Scholar
  16. 16.
    Ministerio de Salud. Normativa 042—Norma de Humanización del Parto Institucional. Managua: MINSA, 2010 Mayo.Google Scholar
  17. 17.
    Dirección general de Servicios de Salud. Normativa 011—Normas y protocolos para la atención prenatal, parto y recién nacido y puerperio de bajo riesgo. Managua, MINSA, Agosto—2008.Google Scholar
  18. 18.
    Robson, M. S., Scudamore, I. W., & Walsh, S. M. (1996). Using the medical audit cycle to reduce cesarean section rates. American Journal of Obstetrics and Gynecology, 174(1), 199–205.PubMedCrossRefGoogle Scholar
  19. 19.
    Main, E. K. (1999). Reducing cesarean birth rates with data-driven quality improvement activities. Pediatrics, 103, 374–383.PubMedGoogle Scholar
  20. 20.
    Chaillet, N., Dube, E., Dugas, M., Francoeur, D., Dube, J., Gagnon, S., et al. (2007). Identifying barriers and facilitators towards implementing guidelines to reduce cesarean section rates in Quebec. Bulletin of the World Health Organization, 85(10), 791–797.PubMedCentralPubMedCrossRefGoogle Scholar
  21. 21.
    Chaillet, N., & Dumont, A. (2007). Evidence-based strategies for reducing cesarean rates: A meta analysis. Birth, 34(1), 53–64.PubMedCrossRefGoogle Scholar
  22. 22.
    Althabe, F., Belizán, J. M., Villar, J., Alexander, S., Bergel, E., Ramos, S., et al. (2004). Mandatory second opinion to reduce rates of unnecessary cesarean sections in Latin America: A cluster randomized controlled trial. Lancet, 363, 1934–1940.PubMedCrossRefGoogle Scholar
  23. 23.
    Chaillet, N., Dubé, E., Dugas, M., Francoeur, D., Dubé, J., Gagnon, S., et al. (2007). Identifying barriers and facilitators towards implementing guidelines to reduce caesarean section rates in Quebec. Bulletin of the World Health Organization, 85(10), 791–797.PubMedCentralPubMedCrossRefGoogle Scholar
  24. 24.
    National Institute of Health. Health and Research. Accessed 23 Dec 2013.
  25. 25.
    Muiser, J., Sáenz, M., & Bermúdez, J. L. (2011). Sistema de Salud de Nicaragua. Salud Pública de México, 53(Suppl 2), S233–S242.PubMedGoogle Scholar
  26. 26.
    Pan American Health Organization. Country health profile, Nicaragua. From Health in the Americas, 2007. (Vol. II). Accessed 20 Feb 2013.
  27. 27.
    Declercq, E. R., Sakala, C., Corry, M. P., Applebaum, S., Herrlich, A. (2013). Listening to mothers III: Pregnancy and birth. New York: Childbirth Connection, May 2013.
  28. 28.
    McCourt, C., Weaver, J., Statham, H., Beake, S., Gamble, J., Creedy, D. K. (2007). Elective cesarean section and decision making: A critical review of the literature. Birth, 34, 65–79.
  29. 29.
    Tully, K. P., & Ball, H. L. (2013). Misrecognition of need: Women’s experiences of and explanations for undergoing cesarean delivery. Social Science and Medicine, 85, 103.PubMedCentralPubMedCrossRefGoogle Scholar
  30. 30.
    Liu, N. H., Mazzoni, A., Zamberlin, N., Colomar, M., Chang, O. H., Arnaud, L., et al. (2013). Preferences for mode of delivery in nulliparous Argentinean women: A qualitative study. Reproductive Health, 10(1), 2.PubMedCentralPubMedCrossRefGoogle Scholar
  31. 31.
    Kornelsen, J., Hutton, E., & Munro, S. (2010). Influences on decision making among primiparous women choosing elective caesarean section in the absence of medical indications: Findings from a qualitative investigation. Journal of Obstetrics and Gynaecology Canada, 32(10), 962–969.PubMedGoogle Scholar
  32. 32.
    Sakala, C., Yang, Y. T., & Corry, M. P. (2013). Maternity care and liability: Pressing problems, substantive solutions. Women’s Health Issues, 23, e7–e13.PubMedCrossRefGoogle Scholar
  33. 33.
    Kessler, D. P., Summerton, N., & Graham, J. R. (2006). Effects of the medical liability system in Australia, the UK, and the USA. Lancet, 368, 240–246.PubMedCrossRefGoogle Scholar
  34. 34.
    Sánchez-González, J. M., Tena-Tamayo, C., Campos-Castolo, E. M., Hernández-Gamboa, L. E., & Rivera-Cisneros, A. E. (2005). Defensive medicine in Mexico: An exploratory descriptive survey [SP]. Cirugia y Cirujanos, 73, 199–206.PubMedGoogle Scholar
  35. 35.
    Chassin, M. R., Halvin, R. W., & National Roundtable on Health Care Quality. (1998). The urgent need to improve health care quality. Institute of Medicine National Roundtable on Health Care Quality. JAMA, 280, 1000–1005.PubMedCrossRefGoogle Scholar
  36. 36.
    Yazdizadeh, B., Nedjat, S., Mohammad, K., Rashidian, A., Changizi, N., & Majdzadeh, R. (2011). Cesarean section rate in Iran, multidimensional approaches for behavioral change of providers: A qualitative study. BMC Health Serv Res., 5(11), 159.CrossRefGoogle Scholar
  37. 37.
    Kamal, P., Dixon-Woods, M., Kurinczuk, J. J., Oppenheimer, C., Squire, P., & Waugh, J. (2005). Factors influencing repeat caesarean section: Qualitative exploratory study of obstetricians’ and midwives’ accounts. BJOG, 112(8), 1054–1060.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Mercedes Colomar
    • 1
  • Maria Luisa Cafferata
    • 1
  • Alicia Aleman
    • 1
  • Graciela Castellano
    • 2
  • Ezequiel Garcia Elorrio
    • 3
  • Fernando Althabe
    • 3
  • Susheela Engelbrecht
    • 4
  1. 1.Montevideo Clinical and Epidemiological Research UnitUNICEMMontevideoUruguay
  2. 2.Department of Preventive Medicine and HygieneUniversity of the RepublicMontevideoUruguay
  3. 3.Institute for Clinical Effectiveness and Health PolicyBuenos AiresArgentina
  4. 4.PATHSeattleUSA

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