During the past century, childbirth went from being a domestic, familiar and community matter to a professional medical act. Changes in how child delivery is perceived and in the use of interventions and new technologies resulted in significant health improvements and, at the same time, took the experience of childbirth out of the family setting and into hospital facilities . One of the interventions that resulted from the improvements introduced by the change in the child delivery care model was cesarean section. Since then, it has become a fundamental life-saving strategy for women and newborns, and it is also one of the emergency OB strategies that the World Health Organization (WHO) considers essential .
Cesarean section is a surgery that is used to solve or prevent certain complications that occur during pregnancy or childbirth and to reduce health risks for women and newborns. However, like any surgical procedure, cesarean section presents some risks and its use implies greater costs for health systems [3, 4, 5]. The inappropriate use of this intervention is a cause of concern given the fact that, as in highly vulnerable social contexts some women do not have access to a cesarean section and in others it is unnecessarily used, it increases inequalities in the access to and use of health interventions in the population.
Though cesarean section rates higher than 15–20% have not shown to have a positive impact on perinatal results [6, 7], the sustained increase in cesarean section rates above those values is a global issue . It is estimated that there was a 3.7% increase in the global average rate of cesarean section use during 2000–2015 and several countries have reported 40–50% cesarean section rates in their populations . Despite the fact that cesarean section has specific clinical indications, there is usually no homogeneous criteria in the use of this intervention and the previously mentioned increase would be the result of a greater use of cesarean section without any clinical indication, mainly in high and middle income countries . Financial incentives, availability of resources in the institutions, health services beliefs and skills, organizational culture aspects, women's characteristics and preferences, among other factors, affect OB practice and may determine the use of cesarean section [8, 9, 10, 11, 12].
Evidence has shown that when isolated interventions are used to address the situations and processes that lead to an increase in the use of cesarean section in clinical practice, the results obtained as to a reduction in its use are less effective . Furthermore, multiple component interventions that include all the stakeholders involved (women, health workers and health systems) have shown to present a higher probability of reducing the incidence of unnecessary cesarean sections [13, 14, 15]. However, the implementation of this kind of interventions is very challenging given the diversity in health care organization, health services practices, the many barriers that must be overcome in order to introduce and sustain the changes promoted by these interventions and also because these interventions demand a change in individual behaviors and affect the organizational culture of services and institutions [16, 13]. This is why the WHO recommends that, before implementing any intervention, a formative research be carried out to identify and define why there is an increase in rates in a specific environment, why this is locally relevant, which the determining factors are for this phenomenon and what women and health professionals think within the framework of certain cultural rules pertaining to the specific contexts .
Both South America and the Caribbean are regions with some of the highest cesarean section rates in the world, and both show a sharp acceleration in their increase . Argentina is no stranger to this situation: the national average rate in public health subsector institutions increased by 23% between 2010 and 2017, to reach 34.7% ranging between 28.4% and 57.7% in 2017 . This heterogeneous increase would indicate that the use of cesarean section might be affected by reasons that are not necessarily clinical. In addition, according to a previous research, women in Argentina prefer vaginal delivery ,which demands a better understanding of the role of women’s preferences as well as the dynamics of the decision-making process in maternal and infant health, and, more specifically, of the organizational cultures in which decisions as regards performing a cesarean section are made. It is also necessary to understand the relationship that health professionals and services have with women in the hospital obstetric care setting. In this context, formative research has great potential.
Formative research has shown to be key in the design, development and execution of health interventions as it makes it possible to identify the characteristics of the stakeholders involved and to adjust the interventions to the peculiarities of the socio-cultural and institutional contexts [18, 19]. This type of research informs about the stakeholders’ beliefs, values, attitudes, knowledge and behavior in relation to a particular problem and its context. Formative research also provides evidence as to why some interventions are effective and others are not, it makes it possible to understand which factors in the health care process contribute to making an intervention implementation satisfactory, and it identifies the culturally appropriate interventions to be tested .
The purpose of our formative research is to collect information from hospitals, health professionals and women as regards the conditions, use, preferences, and potential barriers and facilitators to inform the design and the implementation of non-clinical interventions aimed at optimizing the use of cesarean section in public maternity hospitals in Argentina. This article describes the design, research methodology, and profile of study samples and it is part of a series of publications.