Women's Views on Mode of Birth in Public Hospitals in Argentina: Inputs From a Formative Research to Optimize the Use of Caesarean Section

Background : This paper reports on women's perspectives on the birth mode in five public maternity hospitals in Argentina. The study is a formative research study component aimed at tailoring interventions to reduce unnecessary caesarean section (CS) use. Methods : Participants were postpartum women aged ≥15 years old in five hospitals in the provinces of Salta, Corrientes, Tucuman, Santa Fe and Buenos Aires City. Hospitals completed an institutional survey indicating the availability of obstetric services. The fieldwork was carried out from November 2018 to June 2019. Trained interviewers gathered data on obstetric history, companionship, mode of delivery preferences, and general opinion on vaginal and caesarean section births through semi-structured interviews. The interviews were coded and analysed with standard quantitative methods. Results : The five hospitals had

in two, 67% (p<0001). CS preference was associated with giving birth in those two hospitals and the numbers of miscarriages adjusting by maternal age and previous pregnancies. The reasons for preferring a VB included faster recovery, feeling ready, and considering it more natural. Most women chose CS as the best mode of birth to avoid birth pain. CS disadvantages included post-procedure pain, dependence on others to take care of her or the baby afterwards, and prolonged time in the hospital. Six out of ten women would have liked to be asked by their providers about the MOB of choice.
Conclusions: Women giving birth in public maternity hospitals of Argentina preferred a vaginal delivery to a caesarean section. There is an ongoing need to improve access to pain management during labour and vaginal birth and include women's opinions along the decision-making process for selecting the mode of childbirth. Hospitals with a lower preference for VB will require additional efforts to understand women's needs and values.

Background
During the past century, childbirth changed from being a natural and domestic experience to a medical and professional act. Progress in medical interventions and technology in childbirth led to improvements in women and children's life and health. The introduction of safe 5 caesarean section (CS) was a critical development of that process, and, today, CS is at the centre of emergency obstetric care. However, its overuse in low-risk pregnancies is problematic, since the procedure increases the risk of short-term and long-term comorbidities (1)(2)(3). The Latin American region has rapidly adopted CS, reporting the most significant increase in CS rates during 1990-2014 (4). Studies based on Latin-American data suggested 10 that the private healthcare sector drives CS use (5)(6)(7)(8). However, in Argentina, public hospitals increased surgical births by 22% in 2010-2017 (9,10), exceeding the global CS rate growth (4).
A decade ago, a cross sectional study in Buenos Aires City indicated that, in overall, 92% of women preferred vaginal birth (VB) over CS with no differences between private and public 15 facilities (11), a rate similar to Nordic countries in Europe and other developed countries (12,13). It is uncertain if women preferences have since then evolved and if we can attribute the increasing trend in public hospitals to a shift in mode of birth (MOB) preferences in the public sector. There are also uncertainties about how the contextual factors related to the limited access to obstetric care services -like pain management or antenatal education-in the 20 public sector in Argentina may influence decision-making.
We conducted a formative research study in public hospitals in Argentina which included women, healthcare professionals and hospital administrators to understand the contributing factors related to the increase of CS rates in Argentina and the barriers and facilitators for the implementation of interventions aiming at optimizing its use (14). This research aims to 25 contribute to the tailoring of interventions and to inform the development of protocols and guidelines in Argentina. This paper presents the findings of semi-structured interviews (SSI) to gain understanding on women's preferences and their views and opinions on the MOB.

Methods
Semi-structured interviews 30 The detailed methodology of the formative research study carried out in maternity hospitals of Argentina has been published elsewhere (14). In brief, 19 hospitals purposely selected participated and collected data on the availability of services and resources in the facilities and health providers' views on CS determinants. In addition, five hospitals identified as Hospitals A, B, C, D and E were selected among the initial 19 for a more in-depth assessment 35 of health care professionals' views and opinions regarding CS determinants and interventions.
Additionally, as part of the data collected in this subgroup of hospitals, women's views and opinions about MOB and their reasons were explored (Additional file 1) The adopted strategy for recruitment during this formative research was selecting one woman out of four who had a vaginal or CS delivery every day of the week during three consecutive 40 months or until 130 consecutive cases in each hospital were included (whichever criterion was met first). The SSI was applied by a professional trained for this task (social worker, psychologist, or nurse) who was not a member of the OB/GYN service to prevent any bias and to preserve confidentiality. The fieldwork started in November 2018 and finished in June 2019, with hospitals entering the study at different months. Continuous variables were expressed as mean ± standard deviation (SD) or median (range), and categorical variables as frequencies. Chi-square test was used for study group comparisons.
The preference of MOB was assessed using univariate and multivariate analyses. A logistic regression model explored the association between MOB preferences and maternal obstetric 65 history (parity, history of miscarriage), maternal age, hospital, and delivery mode of index birth. The delivery hospital was included as a dummy variable with Hospital C as the reference and VB as the reference for delivery mode (OR=1.00) (17). Odds ratio (OR) with 95% confidence interval (CI) for binary outcomes and weighted mean difference (WMD) for continuous outcomes were estimated. All statistical tests of hypotheses were two-sided, and

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The characteristics of the hospitals from which women were recruited are described in Table   1   Regardless of their own preferences and/or experience, women were also asked about their general opinions on the advantages and disadvantages of both vaginal and caesarean section deliveries (

Discussion
In the context of a steady increase in CS rates in Argentina, this study explored women's birth Despite these barriers, women in this sample preferred VB over CS. In three hospitals, nine out of ten women favoured VB over a CS. This finding is similar to the only study available addressing birth preferences in Argentina conducted a decade ago and also to women's preferences in European countries (11-13). Women's preference for a VB in the two other 180 hospitals was 20% lower, which is closer to postpartum preferences in China (19) or Italy (20) but higher than Brazil (13).
Women's age or previous pregnancies did not explain these differences. However, favouring CS was associated with giving birth in the two hospitals with higher preference for CS adjusting for age, previous CS, and pregnancy type on the index pregnancy. 185 The difference in MOB preferences across hospitals is challenging to interpret. In this study, women accounted for their preference for vaginal deliveries describing a feeling of being prepared and ready; they also value the possibility of a fast recovery and breastfeed.
The negatives attributes of VB ,as expected, focused on pain during birth. 200 The positive account for CS preference was the possibility of analgesia. Women's reports on pain during and after birth were consistent and repetitive across all participants regardless of their age, MOB, and previous pregnancies. It is also a frequent narrative of women across countries and regions irrespective of their MOB preference (12,(19)(20)(21)(22) . Four of the five participating hospitals had no epidural access by request, hot shower, massages, relaxation, or 205 hypnosis, resulting in sub-optimal pain management during labour. This lack of pain management options is consistent with 'pain' as the recurrent reason women prefer a CS across the world (19,24). A qualitative study by Wang (21) also discusses how limited access to pain relief is a potential determinant of surgical birth. Given these consistent findings, policymakers, managers, and healthcare teams need to be aware and address pain 210 management during and after birth as an essential component of obstetric care, which means that institutions need adequate resources.
When asked about the consequences of both CS and VB, most women focused exclusively on short-term effects. Women in this sector usually do not have additional support to look after their new-borns and themselves after a surgery. We did not explore the support provided by 215 the obstetric services to women that just have a CS. It is also possible that women lack of awareness of long-term risks. Our finding on women's emphasis on immediate consequences is consistent with previous studies in other countries that show that longer-term effects are under-reported (22,25,26).
In line with studies in other settings, the significant finding of our study is that six out of ten 220 women would have wanted to be asked about birth preference (27)(28)(29)

Conclusions
This study reinforces the evidence that women prefer CS over VB even in contexts in which the provision of services do not include a holistic approach to pain management during birth, comprehensive antenatal education and −in some cases− companionship. Women indicated they want to be asked about their birth preference calling for services to incorporate women 240 into the decision-making process during the antenatal period.

Ethics approval and consent to participate
The research study has ethical approval from the Independent Ethical Committee of the Centro

Consent for publication
Not applicable

Availability of data and materials
The data is stored on CEDES' server, encrypted. CEDES is the guardian of the dataset. Data is anonymised. Our data collection forms did not include any variable that could reveal the identity of the participants. The datasets generated and/or analysed during the current study are not publicly available due requests from the participating hospitals but are available from the corresponding author on reasonable demand.