text: Rio de Janeiro (AFP) - New regulations aimed at rolling back Brazil's obsession with Cesarean sections took effect Monday, with the government hoping it can steer the country from its status as a world leader in C-section births. 
   
   The rules and a campaign called "Childbirth is normal!" address what Health Minister Arthur Chioro has dubbed an "epidemic" of Cesareans, currently accounting for more than half of births in this nation of 200 million. 
   
   About 84 percent of Brazilian mothers on private health care undergo the operation, in which the baby is delivered through a small incision in the mother's abdomen -- often for no other reason than the convenience of being able to choose the date. 
   
   In public hospitals, that figure is approximately 40 percent. 
   
   This still tops the 32 percent rate in the United States and is massively higher than World Health Organisation recommendations of 10 to 15 percent. 
   
   Brazil's new rules require doctors and hospitals to share information with patients, notably the number of Cesareans they have already carried out. 
   
   When they fail to give requested information, the health insurance companies face fines of up to about $8,000. 
   
   Making patients better informed will help diminish the rush for C-sections, health officials say. 
   
   "Childbirth is one of the most important moments in the life of a woman and her family," said Jose Carlos de Souza Abrahao, director of ANS, a specialized health ministry agency. 
   
   "By informing her of the risks that could come with an unnecessary surgical procedure, she will be more sure in her decision regarding the delivery, choosing what's best for her health and for her baby's health." 
   
   - Mothers mean money - 
   
   Mass Cesareans are Brazil's "international shame," pediatrician Luciana Herrero told AFP. 
   
   Ignorance and desire for convenience drive Brazilian mothers-to-be to the operating table, said the author of the just published book "Diario de Bordo do Parto," or "Guide to Childbirth." 
   
   But Herrero echoed many in Brazil, saying that "encouragement" by doctors and hospitals is also to blame. 
   
   Even when fees for a Cesarean and normal birth don't vary, the surgical option is still more profitable for hospitals because it can be scheduled to the minute and has little of the unpredictability -- and possibly long working hours -- of natural labor. 
   
   Rosana Clein, a 37-year-old marketing manager in Rio, wanted to have her son naturally three months ago. At the last minute, due to pain, she had Tom delivered by Cesarean. 
   
   Even well before, though, when she was insisting on keeping things natural, she felt pressured. 
   
   "I tried to find a doctor who was supposed to do a natural birth like this, but in Brazil it's not so easy. They try to convince you the best way is to do a Cesarean. They say you're going to have a lot of pain the natural way," she told AFP. 
   
   "For the doctor, it's really easier to have the Cesarean. You can book it and you have your agenda. It's not a question of saying, 'Go to the hospital now in the middle of the night.'" 
   
   - Changing the culture - 
   
   Cesareans may be convenient but they can also be dangerous for the mother and potentially pose grave future health consequences for the baby, ranging from an increased risk of obesity to chronic illness. 
   
   Herrero applauded government attempts to make women better informed. 
   
   "Knowledge is power," she said. 
   
   "Seven out of 10 Brazilian women begin their pregnancy intending to have a normal delivery, but barely half of them do so. 
   
   "I wonder how many of these women changed their mind during their pregnancy, how many had a real medical reason justifying surgery, and how many were persuaded unnecessarily to have the Cesarean?" 
   
   But the latest government effort is still insufficient. 
   
   "I believe the solution must include other sectors of society and be discussed openly with all involved... so that together we can put births in Brazil onto a new path," said Herrero. 
   
   Clein said that after speaking with many other expectant and new mothers over the last year, she feels change is already happening. 
   
   "There are a lot of women trying now to have the natural way. They're talking a lot about it, that it's good for the baby, just in the same way that they say breastfeeding is good for the baby." ||||| C-Sections Deliver Cachet For Wealthy Brazilian Women 
   
   Enlarge this image toggle caption Felipe Dana/AP Felipe Dana/AP 
   
   The office is immaculate, as you would expect in an upscale neighborhood in Sao Paulo — all sterile, white, modish plastic furniture and green plants. Behind the reception desk are pictures that would look more appropriate in a pop art gallery than a private maternity clinic. 
   
   The list of services at the clinic in Brazil's largest city is long: fertility treatments, specialized gynecology and, of course, obstetrics. But one thing they rarely do here is preside over a vaginal delivery. 
   
   Dr. Alexandre Sasaoka struggles to remember the last time he assisted at one. We do them, he says, but rarely. 
   
   Enlarge this image toggle caption Felipe Dana/AP Felipe Dana/AP 
   
   And he's not alone. 
   
   Brazil has one of the world's highest rates of cesarean deliveries: Some 80 to 90 percent of women in private hospitals in the country give birth via cesarean section. In some hospitals that number climbs to 99 percent. 
   
   Much Higher Than The U.S. 
   
   That contrasts with 30 percent of women in the United States and 1 in 4 women in Britain. 
   
   And even that is high: The World Health Organization says more than 15 percent of women giving birth by C-section is too many. It cites increased medical costs and neonatal complications as potential problems. 
   
   But Brazil's economic boom of the past decade has dragged some 40 million people into the middle class. The emphasis on status begins at birth — and cesarean deliveries are the Louis Vuitton of the maternity world. 
   
   Women in Brazil want C-sections, says Sasaoka. They like them because they prefer being able to schedule their delivery and better organize their busy lives. 
   
   Sasaoka says he also recommends them. 
   
   He says he doesn't think they are necessarily better, but that a woman needs to consider more than just the medical aspect of birth, such as the impact on her and her family. 
   
   Of course, he says, there are many advantages to a natural birth; C-sections are a major surgery, after all. But he says women ask for C-sections, and they also allow doctors to be better organized. 
   
   For example, he says, doctors don't have to interrupt what they are doing with other patients to assist a natural birth. 
   
   Pressure From Doctors 
   
   
   
   There is a debate in Brazil as to why the rate here is so high. Doctors like Sasaoka say it's due to the demand. 
   
   But new mother Mariana — who doesn't want her last name used for fear of offending her doctor — says often women feel bullied into it. 
   
   She says she wanted to have a vaginal delivery. 
   
   "My doctor said to me he'd have more control in a C-section than in a natural birth," she says. 
   
   He also told her he would also almost certainly have to do an episiotomy — a procedure where the vaginal opening gets cut to allow for delivery. She was terrified. She says her doctor kept telling her that C-sections were better, and that she felt pressure to have one. 
   
   Still, Mariana decided to try to give birth naturally. Then two weeks before her due date, her blood pressure spiked. And her doctor said she needed to have a C-section after all. The next day she was in the operating room. 
   
   To this day she wonders if it was really necessary. She says that's the legacy of all the intervention here. 
   
   "I don't know. I think he was right," she says. "But the problem in Brazil is we lack the trust between doctor and patient." 
   
   Brazil has a two-tiered medical system. The C-section rate in public hospitals is much lower, the result of a government push to reduce medical costs associated with C-sections. 
   
   But in private hospitals, cesarean deliveries are seen as status symbols. 
   
   And that, say natural childbirth advocates, has to change. 
   
   While doulas — or birth coaches — are a regular presence in many maternity wards these days in the U.S., they are still uncommon in Brazil. 
   
   But they are the first port of call for couples looking to have a natural birth. 
   
   Doula Mariana de Mesquita talks to a couple who say they are having trouble finding a doctor who is willing to deliver their baby vaginally. 
   
   She says her profession basically disappeared with the rise of C-sections. And she says one of the most important roles she has these days is education. 
   
   "Most women don't even know how long labor can last, the basics," de Mesquita says. "So I teach them what a normal birth is like, what they can expect." 
   
   Sign Of Liberation Or Submissiveness? 
   
   Brazil essentially copied the North American obstetric model, which is very interventionist, she says. 
   
   De Mesquita adds that doctors do get paid more for C-sections, which is another reason for their prevalence. 
   
   But she also blames women here. 
   
   She says Brazilian women aren't afraid of surgery. There is a lot of plastic surgery, for example. 
   
   "Women put themselves at risk for very little," de Mesquita says. 
   
   She says people in Brazil see C-sections as a sign of women's liberation, but she sees them as "a sign of their submissiveness to a violent medical system." 
   
   That's nonsense, says 29-year-old Pamela Bassy. She works at a store in an upscale mall, and she's expecting a son in a few months. 
   
   With a cesarean, she says, she can take full advantage of her maternity leave, working right up to the day before she gives birth. 
   
   "My family and my husband wanted me to have a vaginal birth," she adds. "But in the end, it's my choice." ||||| Image copyright Getty Images Image caption The caesarean rate in Brazil is more than 50% 
   
   New rules have come into force in Brazil aimed at reducing the country's high number of caesarean births. 
   
   Eighty-five per cent of all births in Brazilian private hospitals are caesareans and in public hospitals the figure is 45%. 
   
   The new rules oblige doctors to inform women about the risks and ask them to sign a consent form before performing a caesarean. 
   
   Doctors will also have to justify why a caesarean was necessary. 
   
   They will have to fill in a complete record of how the labour and birth developed and explain their actions. 
   
   Each pregnant woman will now be assigned medical notes which record the history of her pregnancy, which she can take with her if she changes doctors. 
   
   The new rules are designed to reduce unnecessary surgical procedures, and ensure pregnant women are aware of the risks associated with caesareans. 
   
   However, experts say that a scarcity of maternity beds and wards equipped to deal with natural births means that for many women in Brazil, caesarean birth is seen as the best option. 
   
   "The best way to guarantee yourself a bed in a good hospital is to book a caesarean," Pedro Octavio de Britto Pereira, an obstetrician and professor at the Federal University of Rio de Janeiro, said in an interview with BBC Brasil last year. 
   
   'Uncivilised and primitive' 
   
   Women who want to give birth naturally in a private hospital have reported finding all the beds are reserved for scheduled deliveries. 
   
   There have been numerous reports of women going into labour without a caesarean scheduled and being forced to travel from hospital to hospital in search of a bed. 
   
   Researchers say many women also see caesareans as more civilised and modern, and natural birth as primitive, ugly and inconvenient. 
   
   In Brazil's body-conscious culture, where there is little information given about childbirth, there is also huge concern that natural birth can make women sexually unattractive. 
   
   Many doctors prefer caesareans too, as they can plan the time of a birth, and feel more protected from litigation. 
   
   Gynaecologist Renato Sa told BBC Brasil: "Doctors are responsible for what happens and in a situation of risk they chose a caesarean, because if there is a death or complication they will be asked why they didn't do this. Doctors are afraid of natural childbirth." ||||| Identifying barriers and facilitators towards implementing guidelines to reduce caesarean section rates in Quebec 
   
   Nils Chaillet a, Eric Dubé b, Marylène Dugas a, Diane Francoeur c, Johanne Dubé d, Sonia Gagnon e, Lucie Poitras f, Alexandre Dumont a 
   
   Background 
   
   The World Health Organization recommends that the caesarean section rate should not be higher than 10% to 15%.1 The caesarean delivery rate in Canada increased steadily from 17.5% of deliveries in 1994–1995 to 23.7% in 2002–2003.2,3 Moreover, caesarean delivery was associated with high maternal and neonatal complication rates and increased health-care costs.4–9 
   
   According to the Society of Obstetricians and Gynaecologists of Canada (SOGC), vaginal delivery represents the safest route for the fetus and newborn in the first and subsequent pregnancies.10 SOGC clinical practices guidelines contribute to the promotion of evidence-based practice and represent an appropriate means for reducing caesarean section rates in Canada. The challenge lies in implementing these guidelines.11–15 Each clinical environment presents organizational, professional, maternal and cultural particularities. The identification of specific barriers and facilitators represents a new approach for identifying the determinants of guidelines use by health professionals.7,15–18 
   
   This study’s premise is that strategies to implement guidelines and reduce caesarean section rates should take into account physicians’ perceptions in order to identify different forces and variables influencing their behaviour. Consequently, we carried out an exploratory study to investigate obstetricians’ perceptions of SOGC guidelines, and to identify barriers to, facilitators of and obstetricians’ solutions for their implementation. 
   
   Methods 
   
   We used a qualitative study design to explore and describe obstetricians’ perceptions in three Montreal hospitals (one primary-level, one secondary-level and one tertiary-level),19 with annual deliveries ≥ 1000, caesarean section rates ≥ 20%, and where 75% of obstetricians agreed to participate. Data was obtained from two focus group sessions, with obstetricians from each of the three hospitals, dealing with induction of labour at term and fetal health surveillance in labour guidelines, and operative vaginal birth and vaginal birth after previous caesarean birth guidelines. For secondary-level and tertiary-level hospitals, with more than 10 clinicians, focus groups were divided into two sessions; thus there were four focus groups in each hospital. All obstetricians were approached to participate in the study. 
   
   Data sources and collection 
   
   A focus group gathers people from similar backgrounds or experiences to discuss a specific topic of interest.19 Focus groups conducted at each unit were scheduled at the convenience of participants. Semi-structured interviews were conducted with clinicians who were not able to take part in the focus groups. The focus groups and personal interviews lasted approximately 90 minutes. A moderator, also referred to as an interviewer, conducted each focus group in the presence of an observer, but only the moderator conducted the semi-structured interviews. The moderator was in control of the session and was responsible for the direction taken by the focus group. The main tasks of the observer were to take notes, including non-verbal observations, to record and observe the session. All focus groups and interviews were audio-taped and transcribed verbatim. The interviewer and observer reconstructed detailed notes of each interview immediately after the session. An interview guide was used for all focus groups and interviews (Annex 1, available at http://www.who.int/bulletin/volumes/85/10/06-039289/en/index.html). 
   
   Focus groups and interviews about SOGC guidelines were structured in the following manner: respondents were asked to describe their perceptions about the adoption of recommendations, barriers and challenges encountered when following the recommendations, and factors and interventions they believed important for facilitating and supporting use of the recommendations. 
   
   Guidelines recommendations 
   
   This study focused on four SOGC evidence-based guidelines (available at: http://www.sogc.org) for improving best practice in obstetric care:20–24 induction of labour at term, fetal health surveillance in labour, guidelines for operative vaginal birth and guidelines for vaginal birth after previous caesarean birth (Annex 1). 
   
   Data analysis 
   
   Analysis of transcripts was planned according to Graham 2004.18 The tapes were transcribed, and their accuracy was verified. Analysing the data from one hospital at a time, two researchers (NC, ED) jointly coded and categorized ideas into broader themes through consensus until all the transcripts were reviewed. To ensure study rigor and reduce limitations, we used the logbook method in A manual for the use of focus groups to help analyse transcripts;19 this consists of a table used to record answers on selected topics. Focus groups and semi-directed interviews were separately analysed. Once all transcripts were analysed, results were reviewed to describe findings that apply to the study as a whole. As hypotheses were generated, we sought confirmation by returning to the transcripts to find evidence to refute or support these. One obstetrician (AD) on the research team reviewed the analysis to ensure the accuracy of our interpretations and critical analysis during the entire process. 
   
   Findings 
   
   Ten focus groups divided into two sessions (Annex 1) and six semi-structured interviews were conducted in the three hospitals. On the 33 available obstetricians, 27 (80%) agreed to participate, ensuring that the sample is highly representative (Table 1). 
   
   Interviewed obstetricians noted that the clinical practice guidelines were generally easy to understand and that they preserve obstetricians’ discretion to judge appropriate treatment. Moreover, the guidelines are perceived as evidence-based and as a legal reference. However, obstetricians identified specific barriers to and facilitating factors for implementing the guidelines’ recommendations in practice (Tables 2 and 3). Obstetricians also said the focus group sessions acted as strong facilitating factors, and that these should constitute the first step for improving the use of recommendations in practice. 
   
   Induction of labour at term 
   
   Obstetricians said the augmentation of induction of labour before 41 complete gestation weeks, mainly explained by the increase in maternal requests and the unavailability of induction during the weekend, is an important barrier to change. Induction at term, especially with unfavourable cervix (i.e. Bishop Score < 6),="" may="" increase="" the="" risk="" of="" failure="" to="" progress="" and="" the="" need="" for="" a="" caesarean="">20 
   
   According to obstetricians, the augmentation of maternal request for induction at term was explained by maternal insecurity or logistic factors (end of maternity leave) because of insufficient information about the delay between estimated and real birth dates. Consequently, providing the latest expected birth date to women instead of the mean expected birth date has been perceived as a potential facilitator to reduce induction on maternal request. Moreover, obstetricians said that when they were planning an induction, explanations about the method to be used, side-effects, risks of caesarean section and possible complications were insufficiently discussed with the woman. 
   
   Medico-legal concerns also encouraged induction for convenience and the rise of induction of labour before 41 complete gestation weeks. Indeed, a general proactive approach was seen by obstetricians as a means to reduce potential risk of lawsuits. The unavailability of induction during the weekend has also been perceived as an important barrier to change, increasing the risk of induction failure because women may be induced two days before the expected date. This may lead to an interruption of labour, then to a caesarean section. The adoption of a departmental policy in hospital B promoting the standardization of induction at term positively influenced the use of recommendations. Staff meetings, formal protocols for induction at term and standardized information to women contributed to enhance the adoption of the recommendations and to reduce induction at maternal request. 
   
   Fetal health surveillance in labour 
   
   Obstetricians noted a slow uptake of intermittent auscultation in the delivery unit. There is some evidence that the use of continuous electronic fetal monitoring may lead to increased false positives for fetal hypoxemia and to resulting caesarean sections.21,22 
   
   Human resources and organizational factors have been seen as the main barriers to performing intermittent auscultation, as a one-to-one nurse–patient ratio is uncommon in the three hospitals. Moreover, obstetricians noted that the use of continuous electronic fetal monitoring and the presence of a unit’s central monitoring system may permit a nurse to attend to several women simultaneously. However, it could have negative effects on the progress of labour because of the lack of psychological support to the mother.28 Another identified barrier was that some anaesthesiologists prefer the use of continuous electronic fetal monitoring when women receive an epidural. Obstetricians also noted that unavailability of equipment was an important barrier to accurately diagnosing fetal hypoxemia. The absence of a pH meter at hospital B was identified as a practical impediment to an optimal use of recommendations because obstetricians cannot use fetal scalp blood sampling to investigate non-reassuring patterns of the electronic fetal monitoring. Moreover, when a pH meter was available, the use of fetal scalp blood sampling might be limited because of technical limitations, including the skill level of operators, anatomical difficulties associated with the procedure and associated pain experienced by the woman. 
   
   Fear of lawsuits was also suggested as a factor that limits the use of intermittent auscultation. Obstetricians described continuous electronic fetal monitoring as reassuring because this method is based on objective criteria, and an electronic fetal monitoring paper strip represents a strong evidence of good practice in case of lawsuits. Obstetricians also noted that continuous electronic fetal monitoring helps to supervise students and residents in the delivery unit. However, some obstetricians thought that medico-legal concerns may also encourage the use of intermittent auscultation because interpretation of the strip is difficult and variable. For them, the use of intermittent auscultation as described in the guidelines represents the best practice and the optimal way to avoid the charges of malpractice. 
   
   Obstetricians commented that the growing number of less experienced junior nurses, especially during the night, has also slowed the adoption of the recommendations because they seem more comfortable using continuous electronic fetal monitoring. In contrast, senior nurses seem more comfortable with the use of intermittent auscultation, because of their experience, and this may influence their colleagues to adopt the recommendations. Equally, obstetricians stated that senior obstetricians may have stronger influence than junior obstetricians in promoting the adoption of intermittent auscultation. Finally, obstetricians noted that strong nursing and obstetric leadership is an important facilitator for encouraging the adoption of guidelines. 
   
   Moreover, maternal preference to have continuous electronic fetal monitoring has been perceived as a potential barrier to the adoption of recommendations. Obstetricians thought that the women may be reassured by continuous electronic fetal monitoring, especially when they receive weak labour support. 
   
   Operative vaginal birth 
   
   Obstetricians noted a weak adoption of operative vaginal birth recommendations, especially for breech presentation and the use of forceps. 
   
   Conclusions of the term breech trial of Hannah et al.25 stating that planned caesarean sections are seen as a means to reduce potential risks of morbidity and lawsuits also affected adoption of the recommendations. Obstetricians indicated that they await more evidence about maternal and neonatal morbidity before fully adopting the guidelines. Not having a blended payment method also has been perceived as an economic incentive to recommend caesarean sections, because they are easier to schedule than vaginal deliveries and generate additional income. 
   
   Obstetricians also noted that the use of mid forceps may not be compatible with their philosophy because of their personal experiences or convictions. Another identified barrier to using forceps was the loss of skills or unwillingness to offer instrumental vaginal birth. Indeed, some resident obstetricians and junior obstetricians may experience stress at the prospect of using mid forceps or manual rotations because of their lack of experience and their concerns about legal consequences. However, the possibility of referring a patient to a more experienced colleague has been identified as a potential facilitator to improve the use of these recommendations. 
   
   Maternal refusal to attempt an external cephalic version was also seen as a potential barrier to reduce caesarean section rate for breech presentation. Obstetricians said explanations about the risks and benefits of external cephalic version versus a planned caesarean section were insufficiently discussed with women. 
   
   Vaginal birth after caesarean 
   
   The need of complex infrastructures necessary to offer a safe vaginal birth after previous caesarean birth was perceived as an important barrier to change. Obstetricians noted that the recommendations cannot be adopted everywhere, especially when many hospitals do not have an available anaesthetist on call around the clock. Moreover, the guideline recommends that “a trial of labour should be offered to a woman with one previous transverse low-segment caesarean section”.24 The use of conditional verb tense in the guideline has been identified as a potential barrier to adopting the recommendations, refusing any sort of obligation. 
   
   Fear of lawsuits and concerns about the legal consequences of uterine rupture have been perceived as important barriers to adopting the recommendations because obstetricians are more sensitive to maternal and fetal health during trial of labour, and privilege the faster decision of caesarean section. Obstetricians commented that they wanted more evidence about the benefits of a trial of labour compared to a planned caesarean section, and that they need an accurate method for predicting uterine rupture to fully adopt the recommendations. 
   
   Obstetricians also said that informing the women about the risks and benefits of trial of labour versus planned caesarean section is time-consuming, and may have a low effect on the final decision, particularly when the women request a repeat caesarean section. Women who had undergone a previous caesarean section without complication may ask for a new caesarean section, and reject the offer of trial of labour. Fear of uterine rupture and newborn morbidity, fear of childbirth, fear of emergency caesarean section or pain during labour, and potential request for additional surgery were perceived as factors contributing to maternal rejection of a trial of labour. 
   
   However, the possibility of requesting a second opinion was suggested to be a strong facilitator for encouraging women to attempt a trial of labour (adopted in hospital A) by providing personalized explanations about risks and benefits, and creating a supportive climate for influencing women to choose the safest mode of delivery. However, obstetricians at hospital C suggested that a second opinion should only be obtained between a family practitioner and an obstetrician because of the difficulties in identifying the medico-legal responsibilities between two obstetricians. Moreover, the difficulty in providing a second opinion for women who have already decided to have a planned caesarean section has also been seen as a potential barrier to influencing women’s choices. 
   
   Implementation interventions 
   
   In each hospital, obstetricians seek to improve quality of care. However, medical culture and local environment can modify the nature of the improvement adopted by health professionals.16,26 Obstetricians suggested several strategies for improving the use of guidelines and enhancing their practice. In each hospital, health professionals’ education was identified as an important factor in improvement. Obstetricians suggested that educational workshops focusing on the recommendations in practice would make the guidelines more acceptable and useful to health professionals. In addition, promoting women’s education about the risks and benefits of vaginal delivery compared to caesarean section, with informational materials available in waiting rooms, was perceived as an efficient strategy for sensitizing women and enhancing communication between health professionals and women. Finally, peer review activity (audit and feedback) championed by opinion leaders has been identified as the most important contributor to improve the use of recommendations. Obstetricians recognized that guidelines represent national or international evidence; this sensitized them to change their own practices. However, obstetricians also said that they need more local evidence to effectively change their practices, because they wanted to validate the transferability of the guidelines in their own practices. The local evidence generated by the audit and feedback process, representing a systematic review of local care against explicit criteria,15 was perceived as a strong key factor to assess the transferability and the adoption of the recommendations. Moreover, the identification of opinion leaders, defined as change agents who have significant social influence,27 was seen as a strong facilitator to support the guidelines and to improve the acceptance of the audit and feedback process. Equally, it has been suggested that involving key members of the hospital administration in the feedback activities of the audit process could facilitate potential institutional changes at the level of the hospital. 
   
   Transferability of the findings 
   
   The findings of this study may not be transferable to all hospital settings. However, the inclusion of hospitals offering different levels of care, representing around 10% of the births in Quebec province, should increase the validity of the findings. Moreover, a qualitative study in Ontario also explored barriers and facilitators influencing the use of intermittent auscultation among nurses identified findings similar to those obtained in this study.28 In addition, a systematic review to maintain high-quality performance of health workers in low- and middle-income countries suggested that audit with feedback in a multifaceted intervention was effective in improving the use of recommendations.29 Likewise, qualitative methods for describing contextual factors and barriers to change have also been identified as a key factor in low- and middle-income countries adopting guidelines. The results of these studies are consistent with those presented in this paper and support the validity of this methodology and the transferability of the findings in Canada and in low- and middle-income countries. 
   
   Study limitations 
   
   The nature of the focus group increases the possibility that the respondents may have been influenced by a member with a high social influence. To limit this bias, all focus group sessions were validated considering non-verbal observations, and no major influence was identified. Data was also jointly coded and classified by categories by two researchers to limit potential bias and inappropriate interpretation of transcripts. Moreover, throughout the analytical process the findings were discussed with the research team, including obstetricians, to improve the critical analysis and to ensure the accuracy of the interpretations. Finally, obstetricians said women’s motivations are an important factor in effectively adopting the recommendations. However, a qualitative study should be conducted with women to ensure the validity of this finding. 
   
   Conclusion 
   
   Identified barriers to and facilitators for the implementation of the SOGC guidelines can be classified into four categories: 1) the hospital level, including management and hospital policies; 2) the departmental level, including local policies, leadership, organizational factors, economic incentives and availability of equipment and staff; 3) the health professionals’ motivations and attitudes, including medico-legal concerns, skill levels, acceptance of guidelines and strategies used to implement recommendations; and 4) women’s motivations, including the nature of medical explanations provided, and the management of maternal request for medical interventions. 
   
   Implementing the use of recommendations is a complex process influenced by multiple factors. Identifying the potential barriers to and facilitators for the adoption of recommendations is an important approach for guiding the development of efficient strategies to improve local acceptance of guidelines. The findings of this study suggest that the implementation of guidelines may be improved if local health professionals’ perceptions are considered in order to make recommendations more acceptable and useful. Our findings also support the assumption that obstetricians seek to implement best practices but that they require evidence, tools and support to assess their practices and enhance their performance. In addition, peer review activities championed by opinion leaders have been recommended by obstetricians for improving the use of the guidelines in their practices. ■ 
   
   Ethical approval 
   
   This study was approved by the ethics committees of the three hospitals. 
   
   References 
   
   Affiliations
target: – In 2013, 32.7% of all babies delivered in America were born by cesarean section. If that sounds high, well, check out Brazil's stats. The BBC reports that at private hospitals, 85% of women deliver by cesarean; in public hospitals, it's about half that (45%). In 2013 NPR reported the figure for some private hospitals is 99%; one doctor NPR spoke with could hardly recall the last time he handled a vaginal delivery. The World Health Organization recommends a 10% to 15% rate. In an effort to get closer to that figure, Brazil is now making it a little more, well, laborious to have a cesarean. New rules were introduced yesterday, reports AFP, and going forward, there's more paperwork. After women are told about the risks (now required), they'll have to sign a consent form; a doctor will have to fill out a form that asks for the justification of the procedure. But forms may not solve what some women say is the real issue: a lack of beds. Those who want to deliver in a private hospital report that the beds are often completely preassigned to women who've booked a cesarean, forcing them to, in some instances, go to hospital after hospital while in labor. AFP reports doctors play a role, too, with some saying doctors encourage women to take the scheduled route, which helps quash middle-of-the-night working hours. As one pediatrician puts it, mass cesareans are the country's "international shame."