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Background Globally, the increased use of cesarean sections has become prevalent in high-income and low and middle-income countries. In Palestine, the rate had risen from 20.3% in 2014 to 25.1% in 2018. The difference is that we have rates as high as 35.8 % in some public hospitals and some as low as 15%. This study aimed to understand better why there is a variation in cesarean rates in public hospitals that use the same protocol. Methods A qualitative approach was used. In-depth interviews with 27 specialists, obstetrics and gynecologists, and midwives in five government hospitals were performed. The hospitals were selected based on the 2017 Annual Health Report reported cesarean section rates. The interview guide was created with the support of specialists and researchers and was piloted. Questions focused mainly on adherence to the obstetric guidelines and barriers to the use, sources of information, training for healthcare providers, the hospital system, and the factors that affect decision making. Results The results indicated that each public hospital at the system level had a different policy on cesarean sections. One specialist decided for a cesarean section at high-rate hospitals, while low-rate hospitals used collective decision-making with empowered midwives. At the professional level, all hospitals urged for the importance of a continuous training program to refresh the medical team knowledge, in-house training of new members joining the hospital, and to discuss cases that are subjective to obstetrician-gynecologists interpretations. Conclusion We recommend strengthening the implementation of support for staff to meet the standards in the national obstetric protocol. Encourage collective decision-making between obstetrician-gynecologists and midwives and use a second opinion. The Robson classification implementation in hospitals will allow medical teams to evaluate delivery management processes and provide a standardized method for reporting and comparison between hospitals, regions, and countries. |
