Background: The World Health Organization recommends that cesarean section rates not exceed 15%; however in 2008, 46% of births in Gran Asunción occurred by cesarean section. The increased use of cesareans in resource-poor settings is associated with increased maternal and neonatal morbidity and mortality and high health care costs. Objective: To understand why there is a high cesarean section rate in Gran Asunción, Paraguay and to provide recommendations on how to reduce cesarean section use. Methods: A qualitative needs assessment was performed between May and August 2009. Data collection included thirty in-depth individual interviews, twenty with recently postpartum women who had vaginal or cesarean births and ten with obstetric gynecologists who worked at public hospitals in Gran Asunción. A systematic analysis of verbatim transcripts identified major themes, comparing and contrasting patterns within and between interviews. Results: The high utilization of cesarean sections in Gran Asunción results from a birth culture that poorly prepares women for vaginal birth, medicalizes the birth process, and promotes the idea among both women and doctors that natural birth is risky. The use of medical interventions during vaginal birth, including artificial oxytocin, artificial membrane rupture, and episiotomies are common and overused. In addition, women lack social support during labor and birth. Vaginal births are often portrayed as a negative experience; many women consequently fear having a vaginal birth and prefer having a cesarean section. Both doctors and women noted that women sometimes "beg" for cesarean sections on arriving at public hospitals. Some doctors also prefer cesarean sections, especially when a woman is asking for one, because they are perceived as more convenient, controllable, and ultimately, less risky in terms of accusations of malpractice. This complex interplay of doctor and maternal preference for cesareans contribute to the use of cesarean sections without medical indications. Discussion: Intervention strategies to educate women during pregnancy, increase continuity of care, improve hospital infrastructure, allow for social support during labor, and decrease the use of negative birth practices could reduce the cesarean section rate in Gran Asunción by shifting the birth paradigm to a more humanized model of birth.