– 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."

Expand this summary.

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 |||||


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– President Trump made big news Thursday through his power to issue pardons and commute sentences. First, he announced that he would issue a full pardon to conservative firebrand Dinesh D'Souza, who once pleaded guilty to campaign finance violations. Hours later came two higher-profile names: Trump told reporters on Air Force One that he might pardon Martha Stewart and free former Illinois Gov. Rod Blagojevich from prison, reports the AP. Details and developments: D'Souza: "He was treated very unfairly by our government!" Trump tweeted. In 2014, D'Souza received five years' probation and a $30,000 fine after prosecutors say he used "straw donors," reports the Washington Post. That is, prosecutors say he got people to donate money to the GOP New York Sen. Kirsten Gillibrand in 2012 with the understanding that he would reimburse them. His background: The 57-year-old is a best-selling author and filmmaker who was one of President Obama's most vocal critics. He also went after Hillary Clinton frequently. See this trailer for his Hillary's America for a taste. He has a "penchant for trolling and needling liberals," writes Dylan Matthews in a profile at Vox. D'Souza has long maintained that he was prosecuted because of his politics, and he was gloating publicly at the expense of former US attorney Preet Bharara Thursday, notes the New York Post, which collects the related tweets.

Focused crawls are collections of frequently-updated webcrawl data from narrow (as opposed to broad or wide) web crawls, often focused on a single domain or subdomain. ||||| Published on Mar 5, 2016

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 —

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 Through stunning historical recreations and a searching examination of fascism and white supremacy, "Death of a Nation" cuts through progressive big lies to expose hidden history and explosive truths.

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 Want to connect with Dinesh D'Souza online for more hard-hitting analysis of current events in America? Here’s how:

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 Twitter: https://twitter.com/dineshdsouza

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 Email: http://www.dineshdsouza.com/email/ ||||| On May 31, President Donald Trump, one of America’s premiere conservative trolls, decided to pardon Dinesh D’Souza, a conservative writer and documentarian whose penchant for trolling and needling liberals, and embracing conspiracy theories in the process, rivals that of Trump himself.

 If that comparison seems unfair, just watch the trailer for D’Souza’s 2016 film, Hillary’s America:

 It references D'Souza's past conviction for violating campaign finance law (for which Trump is pardoning him), portraying his prosecution as a politically motivated witch hunt, and seeks to tie the current Democratic party to the Ku Klux Klan and slaveowners (Democrats were historically the pro-segregation, pro-slavery party until the parties flipped on race around 1964).

 It features a cameo from Jonah Goldberg, the National Review writer best known for his universally discredited attempt to equate New Deal liberalism with European fascism. It's peppered with over-the-top voiceovers by D'Souza — "What are these Democrats hiding?"; "What if the goal of the Democratic party is to steal the most valuable thing the world has ever produced? What if their plan is to steal America?" — over an ominous, melodramatic score.

 This kind of silliness and purposeful provocation on race is D'Souza's bread and butter. See this tweet from 2015:

 YOU CAN TAKE THE BOY OUT OF THE GHETTO...Watch this vulgar man show his stuff, while America cowers in embarrassment pic.twitter.com/C9yLG4QoOK — Dinesh D'Souza (@DineshDSouza) February 18, 2015

 After people on Twitter pointed out that this is extremely racist, D'Souza replied with the most tepid of quasi-apologies:

 I know Obama wasn't actually raised in a ghetto--I'm using the term metaphorically, to suggest his unpresidential conduct — Dinesh D'Souza (@DineshDSouza) February 18, 2015

 Someone with only a light exposure to D'Souza's oeuvre might be tempted to dismiss this and Hillary's America as ludicrous attention grabs from a fringe criminal, and perhaps they'd be right to do so.

 But D'Souza was for decades a member in good standing of American conservative intellectual life, who served in the Reagan administration; was affiliated with serious, respected conservative think tanks; and was a big player in the campus right's 1980s rise to prominence. In 2007, that suddenly started to change, and his work took on a more conspiratorial, hyperbolic tone, culminating in stuff like the Obama selfie stick tweet.

 At the same time, D'Souza's work has become more popular, and arguably even more influential. And throughout, he's expressed same attitude toward race displayed in that tweet. And now, with Trump as president, D’Souza is finally being welcomed back into the conservative mainstream, as a pioneer of the kind of politics our president has brought to the national stage.

 Here's a basic primer on who D'Souza is, and how he got to this point.

 1) Who is Dinesh D'Souza?

 Dinesh D'Souza is an American conservative writer and commentator. He briefly worked in the Reagan White House on domestic policy issues from 1987 to 1988; has served as a fellow at the American Enterprise Institute (AEI) and the Hoover Institution; and was president of The King's College, a small evangelical school in Manhattan, from 2010 to 2012.

 But D'Souza is probably best known for his writing. He's written 16 books, many of them best-sellers, most of which either critique liberal attitudes on race and gender (Illiberal Education, The End of Racism), defend the concept of America against perceived enemies (What's So Great About America, America: Imagine a World Without Her), or defend orthodox Christian theology (What's So Great About Christianity, Life After Death: The Evidence).

 He's also taken a turn into documentary filmmaking in recent years. His 2012 film 2016: Obama's America is the fourth-best-performing documentary at the box office ever, and the second-best-performing political documentary after Fahrenheit 9/11. He followed it up with America: Imagine the World Without Her, based on the book of the same name, which was released in 2014.

 2) How did D'Souza's career start?

 D'Souza first came to prominence as a student at Dartmouth (he graduated in 1983), where he was one of the first editors of the Dartmouth Review, a still-extant conservative campus publication. During his time there, the Review:

 The last of those incidents prompted then-classmate and future Treasury Secretary Timothy Geithner to go up to D'Souza at a coffee shop and ask him "how it felt to be such a dick," an event Geithner recounted in his memoir Stress Test and in an interview with Vox:

 After graduating from Dartmouth, D'Souza moved to Princeton, New Jersey, to edit a small magazine called Prospect, which targeted Princeton students and was overseen by a conservative alumni group, Concerned Alumni for Princeton, that counted future Supreme Court justice Samuel Alito among its members. D'Souza's most infamous article at Prospect concerned a freshman whose mother had stopped paying tuition upon discovering her daughter was having sex with a fellow student. D'Souza was outraged that Princeton offered the student financial aid after her mother stopped supporting her. Students reacted poorly to the violation of their classmate's privacy, organizing a petition condemning D'Souza.

 From Prospect, D'Souza moved to the magazine Policy Review, then affiliated with the Heritage Foundation, and from there to the Reagan administration. He opted to go to AEI rather than join the George H. W. Bush administration, and started writing his most successful books there before leaving for the Hoover Institution in 2001, where he remained until 2007.

 3) What does D'Souza believe?

 Probably the best way to interrogate D'Souza's beliefs is by going through what his major books argued.

 Illiberal Education (1991) is a fairly standard-issue critique of what D'Souza deems "political correctness" on college campuses, focusing in particular on affirmative action policies in both student admissions and faculty hiring, and on what D'Souza saw as an abandonment of the traditional Western canon through the inclusion of more modern female, non-white, and non-heterosexual writers. The book got a largely respectful reception, with Tom Wolfe, Robert Bork, and most strikingly Morton Halperin (then the ACLU's DC director and a fairly down-the-line liberal) providing blurbs. Nancy Dye, then an English professor at Vassar, was less positive, writing in the New York Times, "Mr. D'Souza has constructed his argument by cobbling together anecdotal accounts of campus incidents."

 The End of Racism (1995) was considerably more incendiary. Here are a few lines from the book:

 The book got a respectful hearing in some corners; historian George Frederickson called it the "most thorough, intelligent, and well-informed presentation of the case against liberal race policies that has yet appeared" in the New York Review of Books. By contrast, philosopher Richard Rorty wrote a takedown for the New York Times, consisting largely of direct quotations from the book, and concluding, "Conceivably somebody could make a case for the claim that white Americans are now entitled to relax, go color-blind, and let the African-Americans rebuild their culture on their own. Mr. D'Souza has not even begun to make it." Economist Glenn Loury and community activist/Paul Ryan mentor Robert Woodson, who are both black, resigned their posts at AEI in protest of the book.

 The Virtue of Prosperity (2000), released in the midst of the dot-com boom, is a celebration of the new wave of capitalism, and in particular the fact that going into business and making money is "seen as cool." He is even enthusiastic about biological enhancements to human life, musing that perhaps "the history of our species can be written with the epitaph that we tried out humanity, found it wanting, and opted for something better." The book, understandably, caused much less of a stir than The End of Racism had, but as Slate's Tim Noah noted at the time, it's notable for containing a critique of the very idea of equality of opportunity. It's unfair, D'Souza argues, for the state to deny his daughter the edge he's attempted to give her through sending her to great schools, offering her ballet and chess lessons, and so on:

 Now, to enforce equal opportunity, the government could do one of two things: it could try to pull my daughter down, or it could work to raise other people's children up. The first is clearly destructive and immoral, but the second is also unfair. The government is obliged to treat all citizens equally. Why should it work to undo the benefits that my wife and I have labored so hard to provide? Why should it offer more to children whose parents have not taken the trouble?

 What's So Great About America and Letters to a Young Conservative followed, but D'Souza's next major book was 2007's The Enemy at Home.

 4) What was The Enemy at Home and why was it so controversial?

 The Enemy at Home: The Cultural Left and Its Responsibility for 9/11 argues exactly what its name implies. "In faulting the cultural left, I am not making the absurd accusation that this group blew up the World Trade Center and the Pentagon," he writes. "I am saying that the cultural left and its allies in Congress, the media, Hollywood, the nonprofit sector, and the universities are the primary cause of the volcano of anger toward America that is erupting from the Islamic world. The Muslims who carried out the 9/11 attacks were the product of this visceral rage."

 He provides an actual list of the people he's blaming at the end of the book, breaking them up into the Congressional Left (Ted Kennedy, Hillary Clinton, Barbara Mikulski); the Intellectual Left (Eric Hobsbawm, Cornel West, Tony Judt); the Hollywood Left (Barbra Streisand, Harry Belafonte, Jane Fonda); the Activist Left (Michael Moore, George Soros, Mumia Abu-Jamal); the Foreign Policy Left (Gore Vidal, Seymour Hersh, Jimmy Carter); and the Cultural Left (Al Franken, Salman Rushdie, Ellen Willis). What's the Matter with Kansas? author Thomas Frank has the distinction of appearing twice, as a member of both the Intellectual and Cultural Left.

 The Enemy at Home was rejected by much of the conservative movement, not least because of the implication that D'Souza agrees with some Islamist critiques of Western culture. For instance, D'Souza writes, "the political right and the Islamic fundamentalists are on the same wavelength on social issues," and, "Yes I would rather go to a baseball game or have a drink with Michael Moore than with the grand mufti of Egypt. But when it comes to core beliefs, I'd have to confess that I'm closer to the dignified fellow in the long robe and prayer beads than to the slovenly fellow with the baseball cap."

 National Review hosted a symposium on the book that was overwhelmingly negative. Roger Kimball, who had issued a glowing review of Illiberal Education, wrote, "The problem with The Enemy at Home is … well, everything." Military historian Victor Davis Hanson wrote, "It is the singular achievement of D’Souza that his bizarre writ has for a moment earned universal condemnation from those who can agree on little else." Liberals, of course, joined in the critique. "Ordinarily … I would never equate hard-right views on [social issues] … with the rantings of an Islamist terrorist," Noah wrote. "I do so now only because D'Souza has written an entire book encouraging me to do just that."

 By the end of the year, D'Souza had left the Hoover Institution, a development that Newsweek's David Sessions, in a profile of D'Souza, suggests was hardly accidental.

 BONUS QUESTION - Can I get a music break?

 Sort of? There's no obvious musical accompaniment to D'Souza's career, but this is better, I promise. D'Souza appeared in an infomercial for his friend Bruce Schooley's invention, the Fliptree: a pre-lit, multi-component artificial Christmas tree designed to be easy to move and store. It's delightful:

 Thanks to Elon Green for the pointer.

 5) What is D'Souza's view of Barack Obama?

 Not positive! D'Souza has a distinctive grand unifying theory of Obama, expressed in a 2010 Forbes feature; his books The Roots of Obama's Rage, America: Imagine a World Without Her, and Obama's America: Unmaking the American Dream; and his two documentaries. He rejects the frequent conservative attack that Obama is a European-style (or perhaps Alinskyan) socialist at heart, arguing instead that Obama is best understood through the lens of anticolonialism, in particular Kenya's struggle against British imperialism.

 Obama was taught by his father, D'Souza argues, to view the US as an imperialist actor trampling upon states both through outright war (as in Vietnam or Iraq) and through economic exploitation, a natural successor to the more formal role that the British Empire played in much of Africa, the Middle East, and South Asia. "From a very young age and through his formative years, Obama learned to see America as a force for global domination and destruction," D'Souza writes. "He came to view America’s military as an instrument of neocolonial occupation. He adopted his father’s position that capitalism and free markets are code words for economic plunder."

 Everything Obama does can be understood in light of these fundamental commitments, D'Souza believes: "Why support oil drilling off the coast of Brazil but not in America? Obama believes that the West uses a disproportionate share of the world’s energy resources, so he wants neocolonial America to have less and the former colonized countries to have more … Obama supports the Ground Zero mosque because to him 9/11 is the event that unleashed the American bogey and pushed us into Iraq and Afghanistan. He views some of the Muslims who are fighting against America abroad as resisters of U.S. imperialism."

 As was the case with The Enemy at Home, many conservatives rejected D'Souza's theory as preposterous, noting that there are plenty of other, much more plausible explanations for why the Democratic president has pursued policies roughly in line with the Democratic platform, and that Obama's memoir made it very clear that he, far from wanting to emulate his father's politics, was deeply disappointed in him.

 In a particularly pointed piece, The Weekly Standard's Andrew Ferguson identified "misstatements of fact, leaps in logic, and pointlessly elaborate argumentation" throughout the book. "There is, indeed, a name for the beliefs that motivate President Obama, but it’s not anticolonialism; it’s not even socialism. It’s liberalism!" he writes. "Nearly everything that Obama has done as president, including the policies that D’Souza cites as proof of his inherited anticolonial ideology, would have been as eagerly pursued by President John Edwards or President John Kerry."

 For liberals, meanwhile, "Kenyan anticolonialist" became something of a punchline. Matt Steinglass at the Economist decided to turn the tables on D'Souza and concocted a byzantine explanation for D'Souza's conservatism, based upon his family's caste, Catholicism, and position within the Portuguese Indian territory of Goa, that is just as unnecessary as D'Souza's explanation for Obama's liberalism. James Mann at the New Republic added, for good measure, "anti-colonialism is itself not exactly alien to American traditions; our country was founded on it."

 But some important conservatives took D'Souza seriously. In 2010, Newt Gingrich called his argument "the most profound insight I have read in the past six years about Barack Obama," adding, "Only if you understand Kenyan, anticolonial behavior can you piece together [Obama’s actions]. That is the most accurate, predictive model for his behavior."

 6) What are these D'Souza scandals from a few years back?

 There are two D'Souza scandals, more or less. The first came and went in 2012, when World Magazine — a prominent evangelical publication — reported that D'Souza had been spotted at a conference with a woman who wasn't his wife. He repeatedly introduced her as his fiancée, despite the fact that he was still married, and checked into a nearby hotel with her. Court records show that he only even filed for divorce the day that World called him for comment. D'Souza wound up resigning his role as president of King's College. The scandal was complicated by the fact that World's editor-in-chief, Marvin Olasky, had left his role as King's provost upon D'Souza's appointment as president, and the reporter writing the story, Warren Cole Smith, had been a consultant to the school before being let go by D'Souza.

 The second, much more significant scandal involves payments he made to his mistress (who he has since broken up with) and her husband, as well as another couple, to reimburse them for donations made to Wendy Long, the longshot Republican nominee running against Kristen Gillibrand for US Senate in New York in 2012. Long was a Dartmouth classmate of D'Souza's and also wrote for the Review. It's illegal to reimburse for donations, since it effectively allows you to give in excess of contribution limits. In this case, D'Souza funneled $20,000 in money through four friends to Long, far above the $5,000 individual contribution limit (and that's not even counting the $5,000 he gave her himself). D'Souza was caught, and indicted.

 D'Souza pled guilty to one count of making illegal contributions in the names of others, but has claimed throughout that he is being selectively prosecuted by the Obama administration for his political beliefs. Prosecutors, led by prominent US Attorney for the Southern District of New York Preet Bharara, pushed for D'Souza to be sentenced to 10-16 months in federal prison. Judge Richard Berman spared him jail time, sentencing him to eight months in a community confinement center, five years probation, and a $30,000 fine. But Berman categorically rejected the idea that D'Souza was a victim of selective prosecution: "That’s nonsense. Spin is what that is."

 D'Souza served his sentence at a community confinement center in San Diego. He told Fox News' Megyn Kelly during that time that he would check into the center between 7 and 9 pm every night and sleep there, but was otherwise free to do what he likes with his days in general. He was required to stay in the San Diego area for the duration of the sentence, and his media interviews were subject to review by his probation officer.

 His was released from community confinement on May 31, 2015:

 HE'S BAAAACK: After eight months of overnight captivity, I am done with my confinement as of 4 am this morning! pic.twitter.com/rcd3ufyqxw — Dinesh D'Souza (@DineshDSouza) May 31, 2015

 7) How is D'Souza still so popular, if even many conservatives reject him now?

 If D'Souza is no longer accepted by most conservative intellectuals, then he's more than made up for it by making inroads into more conspiracy-oriented conservative circles. His theory of Obama has been embraced by Glenn Beck; InfoWars' Alex Jones brought D'Souza on his show to lament his political persecution by the Obama administration. "Viewed through the lens of the intelligentsia and the media elite, D'Souza has suffered a tragicomic fall from grace, undone by some combination of conspiratorial thinking, pseudo-academic posturing, and hubris," Simon van Zuylen-Wood wrote in a 2013 profile for National Journal. "But in a separate, larger universe, the onetime rising star is ascendant once again."

 That’s even truer now, with Trump leading the conservative movement.

 Zuylen-Wood notes that this new era in D'Souza's career has been rather profitable, with both of his documentaries earning tens of millions of dollars, and he's been able to generate sales by targeting enemies perceived to be trying to sabotage him. "D'Souza has mastered the art of turning perceived slights into commercial gain," Zuylen-Wood writes. "When Costco pulled America the book a few months ago, citing poor sales, D'Souza claimed that he was being targeted for political reasons. (Costco's CEO is an Obama fundraiser.) An AM radio scandal was born. Costco backed down, restocked the title, and D'Souza's books were suddenly more popular than ever."

 Some of D'Souza's bigger provocations, like the selfie tweet or this one:

 Obama forcefully asserts his position on Beheading pic.twitter.com/QbVbvE582d — Dinesh D'Souza (@DineshDSouza) August 29, 2014

 … play directly to this new audience. So did his sympathetic position on Donald Trump in the primaries:

 I'm not endorsing anyone, but I do relish the frustration & befuddlement of the GOP establishment as Trump wins one more time — Dinesh D'Souza (@DineshDSouza) February 24, 2016

 For his part, D'Souza told Zuylen-Wood that he didn't think his approach changed any from when he was an AEI or Hoover fellow: "What you should do, Simon, is go back and read Illiberal Education and its tone, and then read the America book and its tone. I don't think there's a fundamental difference in my approach then and now … Illiberal Education has been baptized into a sort of pathbreaking, sort of sober, responsible book. It was a bomb when I dropped it in 1991!"

 D'Souza has a point. He's been provoking people for provocation's sake since he published an interview with a Klan member accompanied by a doctored photo of a black classmate being lynched. Sometimes he'll even admit that's what he's doing:

 .@Mediaite I love it when my tweets score a direct hit, measured by the intensity of shrieking on the left — Dinesh D'Souza (@DineshDSouza) October 6, 2014

 Correction: This post originally referred to World Magazine's editor-in-chief as "Martin Olasky." His first name is Marvin. ||||| Recently pardoned conservative filmmaker Dinesh D’Souza wasted no time before mocking the man who put him away following his full pardon by President Trump on Thursday.

 “KARMA IS A BITCH DEPT: @PreetBharara wanted to destroy a fellow Indian American to advance his career. Then he got fired & I got pardoned,” D’Souza tweeted at Bharara, former United States attorney for the Southern District of New York.

 Bharara indicted D’Souza in 2014 for using “straw donors” to funnel $20,000 to Wendy Long’s 2012 US Senate campaign in New York. D’Souza pleaded guilty and was sentenced to eight months in a halfway house and five years’ probation, along with a $30,000 fine.

 Trump fired Bharara, appointed by President Barack Obama, after he refused to resign last year.

 The former prosecutor tweeted earlier Thursday that he stands by the conviction.

 “The President has the right to pardon but the facts are these: D’Souza intentionally broke the law, voluntarily pled guilty, apologized for his conduct & the judge found no unfairness. The career prosecutors and agents did their job. Period,” he tweeted. ||||| FILE - In this May 20, 2014 file photo, conservative scholar and filmmaker Dinesh D'Souza, left, accompanied by his lawyer Benjamin Brafman leaves federal court, in New York. President Donald Trump says... (Associated Press)

 FILE - In this May 20, 2014 file photo, conservative scholar and filmmaker Dinesh D'Souza, left, accompanied by his lawyer Benjamin Brafman leaves federal court, in New York. President Donald Trump says he will pardon conservative commentator Dinesh D'Souza who pleaded guilty to campaign finance fraud.... (Associated Press)

 FILE - In this May 20, 2014 file photo, conservative scholar and filmmaker Dinesh D'Souza, left, accompanied by his lawyer Benjamin Brafman leaves federal court, in New York. President Donald Trump says he will pardon conservative commentator Dinesh D'Souza who pleaded guilty to campaign finance fraud.... (Associated Press) FILE - In this May 20, 2014 file photo, conservative scholar and filmmaker Dinesh D'Souza, left, accompanied by his lawyer Benjamin Brafman leaves federal court, in New York. President Donald Trump says... (Associated Press)

 WASHINGTON (AP) — The Latest on President Donald Trump's consideration of pardons and sentence commutations (all times local):

 12:05 p.m.

 President Donald Trump says he is considering commuting the sentence of ex-Illinois Gov. Rod Blagojevich and pardoning Martha Stewart.

 The comments came aboard Air Force One on Thursday after he announced on Twitter that he planned to pardon conservative commentator Dinesh D'Souza.

 Trump tells reporters that Blagojevich said something dumb but that "lots of politicians" do and thinks his sentence is excessive.

 The Democratic former governor began serving his 14-year prison sentence on corruption convictions in 2012. His scheduled release date is 2024. Blagojevich was also a contestant on Trump's "Celebrity Apprentice" reality television show in 2010.

 Stewart was convicted in 2004 of obstructing justice and lying to the government about why she unloaded stock just before the price plummeted.

 Trump says she "used to be one of my biggest fans."

 ___

 10:10 a.m.

 President Donald Trump says he will pardon conservative commentator Dinesh D'Souza, who pleaded guilty to campaign finance fraud.

 Trump tweeted Thursday: "Will be giving a Full Pardon to Dinesh D'Souza today. He was treated very unfairly by our government!"

 In 2014, D'Souza was sentenced to five years of probation after he pleaded guilty to violating federal election law by making illegal contributions to a U.S. Senate campaign in the names of others. |||||


Summarize this article:

A “maniac” carjacker has been caught live on television leading police on high-speed chase through the streets of Los Angeles, carjacking a vehicle at gunpoint and crashing at least six times.

 The spree during Monday’s evening rush hour only stopped when the suspect failed to steal a third car that sped away and was shot in the road by police. He is under arrest in hospital.

 It started shortly after 5pm local time in downtown LA, when police tried to pull over the man because he was driving a car listed as stolen.

 But he drove away, starting the chase that would continue through the city and its suburbs, the LA Times reported.

 Footage captured by a helicopter and broadcast on live television showed the car speeding at around 60mph up a three-lane motorway, crashing several times at junctions before veering over pavements and into oncoming traffic on the wrong side of the road.

 The car skidded and started spinning, hitting several other vehicles before coming to a stop in the middle of the road.

 The driver is seen jumping out of the crushed and smoking car before trying to carjack another vehicle, which sped away from him, and pulling what appeared to be a gun on the driver in the car behind it.

 The suspected carjacker fleeing a crashed car

 The footage shows onlookers at the side of the road running away as a woman is thrown out of the car and the gunman speeds off down a side street.

 The woman, later identified as 22-year-old Elizabeth Yarahuan, told KABC-TV Channel 7: “He just came up to me and pointed the gun at me and told me to get out of my car. I was just scared he was going to hurt me.”

 At least eight LAPD cars and helicopters tracked the suspect as the chase continued on several motorways until heavy traffic in Montebello stopped the suspect’s escape.

 Stuck between stationary cars, cameras captured him jumping out of his vehicle and attempting to hijack two more.

 Police attempt to stop the driver as he speeds off again

 But as the second driver resisted and drove away, police running after the suspect on shot him as he fled down the road. He was handcuffed on the ground and taken to hospital in an ambulance.

 Last night, the suspect was alive in hospital being treated for “multiple” gunshot wounds.

 “This individual acted with a complete disregard for other people's lives,” Los Angeles Police Department Commander Andy Smith told the LA Times.

 “He callously put innocent people's lives in danger, even after the police backed off the pursuit and tracked with the helicopter. Thank God no one was killed by this maniac.” ||||| MONTEBELLO, Calif. (AP) — A gunman driving a suspected stolen car led police on a wild chase on roads and freeways east of Los Angeles, smashing into other cars and veering through oncoming traffic before he stole a second car at gunpoint and ran down a crowded street before Los Angeles police opened fire, wounded him and finally arrested him.

 Officers shot the man as he ran on a roadway and appeared to be trying to steal yet another car before he was handcuffed and taken to a hospital in an ambulance, police spokeswoman Rosario Herrera said.

 Police did not release the name or condition of the man, but said he was still alive several hours after the Monday night shooting and is between 20 and 30 years old.

 The woman whose car was stolen at gunpoint on live TV was not hurt but was deeply shaken afterward.

 "He just came up to me and pointed the gun at me and told me to get out of my car," Elizabeth Yarahuan, 22, told KABC-TV as she tried to fight back tears. "I unbuckled myself and I opened the door and ran out. It was horrible. I don't wish that on nobody."

 The chase began about 5 p.m. with officers answering a report of a possible stolen car east of downtown, police said.

 The Toyota sped through South Gate and other cities southeast of Los Angeles. The car zoomed through traffic, sometimes going the wrong way, and struck cars at least four times before it was finally unable to continue.

 The man, wearing a white T-shirt, jumped out and tried to steal another car. As television news helicopters hovered overhead, he pulled what appeared to be a gun, stole Yarahuan's car and took off.

 That car raced along Interstate 710 and state Route 60 with at least eight patrol cars in pursuit.

 The car finally veered onto an offramp and onto a Montebello street, where it became wedged between two other vehicles in traffic.

 The man jumped out and pulled open a door on a stopped SUV as police chased him. He tried to stop another car that took off before pursuing officers took him down.

 No officers were hurt, but there was no immediate word on whether any other motorists were hurt.

 Driver Martha Duron said she was fine after her car was sideswiped, but it could easily have been different.

 "If he would've hit me hard, in the front, I would've been gone," she told KCAL-TV. "He was going so fast." ||||| In the land of high-speed chases, it was a menacing ride.

 An armed man careened down traffic-clogged freeways during Monday's evening commute, bobbing and weaving across southeast Los Angeles County, often against traffic.

 He collided with at least six vehicles and forced a 22-year-old woman out of her car at gunpoint, police said.

 The chase came to a halt only after as many as three officers fired bullets into him on live television, arresting him as he lay on the pavement in Montebello.

 "This individual acted with a complete disregard for other people's lives," Los Angeles Police Department Cmdr. Andy Smith told The Times.

 "He callously put innocent people's lives in danger, even after the police backed off the pursuit and tracked with the helicopter. Thank God no one was killed by this maniac."

 As of 10 p.m., the man -- who had not yet been identified -- was alive in the hospital with multiple gunshot wounds. His exact condition was unknown, Sgt. Frank Preciado said.

 The pursuit began about 5:15 p.m. near the intersection of East 1st and Soto streets east of downtown Los Angeles on reports of a stolen vehicle.

 Officers in the Hollenbeck Division called for backup before attempting to pull over the man; the vehicle's license plates were listed as stolen.

 The driver failed to stop, spawning a high-speed chase that wound through southeast Los Angeles County and neighboring cities.

 About 5:30 p.m., the man crashed his car near Imperial Highway, then pulled out what appeared to be a gun and stole a car driven by a woman, later identified as 22-year-old Elizabeth Yarahuan.

 "He just came up to me and pointed the gun at me and told me to get out of my car," Yarahuan told KABC-TV Channel 7. "I was just scared he was going to hurt me."

 The pursuit continued onto the westbound 105 Freeway before the driver darted onto the northbound 710 Freeway.

 At least eight LAPD patrol cars trailed the suspect as helicopters tracked his movements.

 The man continued onto the eastbound 60 Freeway, but as he exited the freeway in Montebello, the vehicle he apparently carjacked was hemmed in by heavy traffic.

 After exiting the car, he was pursued on foot by about a dozen officers. After he brandished a gun and tried to carjack a second car, as many as three officers opened fire at him, Preciado said.

 It's unclear how many bullets struck the suspect. A throng of officers surrounded him as he was arrested near Via Campo and Garfield Avenue.

 A semiautomatic firearm was recovered at the scene.

 For breaking news in California, follow @MattHjourno and @LACrimes.

  |||||

– A suspect was shot several times and arrested last night after a car chase that was wild even by Los Angeles standards. Police say that after the armed man they describe as a "maniac" was spotted driving a suspected stolen car east of downtown, he sped through traffic, sometimes on the wrong side of the road, and hit at least four other cars as he was pursued through southeast Los Angeles County, the AP reports. With the chase being broadcast live on TV, the suspect crashed the first vehicle and carjacked another before speeding off. After becoming trapped in traffic, cameras captured the man fleeing on foot and attempting to hijack two more vehicles before he was shot by officers pursuing him, reports the Independent. "This individual acted with a complete disregard for other people's lives," a police spokesman tells the Los Angeles Times. "He callously put innocent people's lives in danger, even after the police backed off the pursuit and tracked with the helicopter. Thank God no one was killed by this maniac." Another police spokesman says the suspect is in the hospital with multiple gunshot wounds. The 22-year-old woman who was carjacked says she's thankful her children weren't in the car. "He just came up to me and pointed the gun at me and told me to get out [of] my car. I unbuckled ... and opened the door and ran out," she tells CBS 2. "It was horrible." Police say that if the suspect survives, he'll be charged with multiple felonies.