Cesarean section rate in Iran, multidimensional approaches for behavioral change of providers: a qualitative study

<p>Abstract</p> <p>Background</p> <p>The cesarean section rate has been steadily rising from 35% in 2000 to 40% in 2005 in Iran. The objective of this study was to identify barriers of reduce the cesarean section rate in Iran, as perceived by obstetricians and midwives as the main behavioral change target groups.</p> <p>Methods</p> <p>A qualitative study with purposive sampling was designed in which data were collected through in-depth interviews and document analyses. Hospitals were selected on the bases of being public and or private and their response to the ministry's C-section reduction interventions. The hospital director, obstetricians and midwives from each hospital were included in the study. The classification of barriers suggested by Grol and Wensing was used for the thematic analysis.</p> <p>Results</p> <p>After 26 in-depth interviews and document analyses, the barriers were identified as: financial, insurance and judicial problems at the <it>economic and political context </it>level; the type and ownership of hospitals, absence of an on call physician, absence of clear job-descriptions for obstetricians and midwives, too many interventions in the delivery process and shortage of human resources and facilities at the <it>organizational context </it>level; distrust and insufficient collaborations between obstetricians and midwives from macro to micro level at the <it>social context </it>level; attitudes toward complications of C-section, reduced capabilities of obstetricians, midwives and residents at the <it>individual professional </it>level; and finally, at the <it>innovation </it>level, vaginal delivery is time consuming, imposes high stress levels and is unpredictable.</p> <p>Conclusion</p> <p>Changing service providers' behavior is not possible through presentation of scientific evidence alone. A multi-level and multidisciplinary approach using behavior change theories is unavoidable. In future studies, the effect of the barriers should be determined to help policy makers recognize the most effective interventional package.</p

A research agenda to improve incidence and outcomes of assisted vaginal birth

Access to emergency obstetric care, including assisted vaginal birth and caesarean birth, is crucial for improving maternal and childbirth outcomes. However, although the proportion of births by caesarean section has increased during the last few decades, the use of assisted vaginal birth has declined. This is particularly the case in low- and middle-income countries, despite an assisted vaginal birth often being less risky than caesarean birth. We therefore conducted a three-step process to identify a research agenda necessary to increase the use of, or reintroduce, assisted vaginal birth: after conducting an evidence synthesis, which informed a consultation with technical experts who proposed an initial research agenda, we sought and incorporated the views of women's representatives of this agenda. This process has allowed us to identify a comprehensive research agenda, with topics categorized as: (i) the need to understand women's perceptions of assisted vaginal birth, and provide appropriate and reliable information; (ii) the importance of training health-care providers in clinical skills but also in respectful care, effective communication, shared decision-making and informed consent; and (iii) the barriers to and facilitators of implementation and sustainability. From women's feedback, we learned of the urgent need to recognize labour, childbirth and postpartum experiences as inherently physiological and dignified human processes, in which interventions should only be implemented if necessary. The promotion and/or reintroduction of assisted vaginal birth in low-resource settings requires governments, policy-makers and hospital administrators to support skilled health-care providers who can, in turn, respectfully support women in labour and childbirth. [Abstract copyright: (c) 2023 The authors; licensee World Health Organization.

Clarification of Safe Delivery by Iranian Experts Based on Clinical Governance: A Qualitative Study

Objective:To clarify the principles of a safe delivery based on Clinical Governance Criteria, as recommended by the pertinent experts. Materials and methods:The current study was part of a qualitative research conducted by content analysis method in 2013 and purposive sampling, performing 24 in-depth interviews based on semi-structured questions and analyzed using thematic content analysis. The participants in this research included midwives, obstetricians, managers, and hospital doctors. The data were under continuous consideration and comparative analysis in order to achieve data saturation. Results:The main concepts derived from interpretations of the pertinent experts include: Patient & Public involvement; Risk Management; Education; Clinical efficiency; Clinical audit; Personnel & Management. Conclusion:In a safe delivery, there is a vicious cycle of causes the elimination of which is only possible through benchmarking patterns that attend to most aspects of a safe delivery.Changes to services require utilization of appropriate change management strategies

In Depth Analysis of the Leading Causes of Maternal Mortality Due to Cesarean Section in Iran

Objective: Despite the declining trend of maternal mortality (MMR) in Iran between 1990 and 2013, direct causes are still the major reasons for maternal death. One of these direct causes is complications of cesarean section (CS). Since the rate of CS in Iran is quite high (47.9%) and the trend continues to rise, there is an alarming threat of the possibility of increasing MMR in the country as a result of cesarean section complications, especially in repeated cases. In this study, we attempted to determine the indications of CS in reported maternal mortality, with special attention to risk factors predisposing to CS and/or to maternal mortality. Materials and methods: A retrospective study was implemented for the period between March 2009 and March 2012. All nationally reported data regarding maternal death during pregnancy, labor and 42 days after parturition during these 3 years was collected and input to software specially designed for this project. Subsequently, cases of maternal death related to pregnancy termination by cesarean section were selected for analysis. Results: There were 393 cases of maternal death with cesarean section as the termination method. Indications of CS were mostly emergency and repeat and the leading causes of death were postpartum hemorrhage and hypertensive disorders. Most of these deaths occurred in academic hospitals and the most common type of delay was brought about by hospital management, specifically personnel issues. Conclusion: Based on this study, acknowledging CS as a serious health threat endangering every achievement in the maternal health program is the most important policy and efforts should be focused on provision of guidelines for realistic CS indications, standardized CS procedures, and post CS care as well as propagation of training courses in risk management and high risk case-finding protocols

Prevention of pregnancy complications in iran following implementing a national educational program.

Objective:To determine the impact of a national intervention program on some pregnancy complications in Iran. Materials and methods: this multicenter study was conducted in governmental sector in 14 provinces in Iran between 2003 and 2005. Intervention included education of all maternal health care providers including gynecologists, general physicians, and midwifes in the governmental sector. Time interval between the pre- (of 3,978 and 3,958 pregnancies) and post- (3,958 pregnancies) measurements were 18 months. Self reported data on pregnancy complications were registered. Interviews were conducted by trained personnel. Participants were interviewed when admitted for delivery or at the time attending for vaccination of their 2 month infants. Results:The following pregnancy complications were reduced significantly as compared to before intervention: 1) bleeding or spotting, 2) urinary tract complications, 3) blurred vision and severe headache, 4) premature labor pain, 5) anemia, 6) severe vomiting, 7) inappropriate weight gain, 8) endometritis, 9) urinary incontinence, 10) breast abscess or mastitis, 11) wound infection, and 12) bleeding was significantly reduced after intervention, compared to before intervention. Premature rupture of membrane showed a significant increase. These complications did not show a significant change: 1) hypertension, 2) fever and chills, 3) convulsion, shock, and loss of consciousness, and 4) obstetric fistula. Conclusion:National programs may be proved to be largely effective by decreasing some of the pregnancy complications in developing countries

Maternal Mortality Ratio and Causes of Death in IRI Between 2009 and 2012

Objective: The Maternal Mortality Ratio is an important health indicator. We presented the distribution and causes of maternal mortality in Islamic Republic of Iran. Materials and methods: After provision of an electronic Registry system for date entry, a descriptive-retrospective data collection had been performed for all maternal Deaths in March 2009- March 2012. All maternal deaths and their demographic characteristic were identified by using medical registries, death certificates, and relevant codes according to International Classification of Diseases (ICD-9) during pregnancy, labor, and 42 days after parturition. Results: During 3 years, there were 5094317 deliveries and 941 maternal deaths (MMR of 18.5 per 1000000 live births). We had access to pertained data of 896 cases (95.2%) for review in our study. Of 896 reported deaths, 549 were classified as direct, 302 as indirect and 45 as unknown. Hemorrhage was the most common cause of maternal mortality, followed by Preeclampsia, Eclampsia and sepsis. Among all indirect causes, cardio -vascular diseases were responsible for 10% of maternal deaths, followed by thromboembolism, HTN and renal diseases. Conclusion: Although maternal mortality ratio in IRI could be comparable with the developed countries but its pattern is following developing countries and with this study we had provided reliable data for other prospective studies

Inequality in Maternal Mortality in Iran: An Ecologic Study

Background : Maternal mortality (MM) is an avoidable death and there is national, international and political commitment to reduce it. The objective of this study is to examine the relation of MM to socioeconomic factors and its inequality in Iran′s provinces at an ecologic level. Methods : The overall MM from each province was considered for 3 years from 2004 to 2006. The five independent variables whose relations were studied included the literacy rate among men and women in each province, mean annual household income per capita, Gini coefficients in each province, and Human Development Index (HDI). The correlation of Maternal Mortality Ratio (MMR) to the above five variables was evaluated through Pearson′s correlation coefficient (simple and weighted for each province′s population) and linear regression-by considering MMR as the dependent variable and the Gini coefficient, HDI, and difference in literacy rate among men and women as the independent variables. Results: The mean MMR in the years 2004-2006 was 24.7 in 100,000 live births. The correlation coefficients between MMR and literacy rate among women, literacy rate among men, the mean annual household income per capita, Gini coefficient and HDI were 0.82, 0.90, −0.61, 0.52 and −0.77, respectively. Based on multivariate regression, MMR was significantly associated with HDI (standardized B=−0.93) and difference in literacy rate among men and women (standardized B=−0.47). However, MMR was not significantly associated with the Gini coefficient. Conclusion: This study shows the association between socioeconomic variables and their inequalities with MMR in Iran′s provinces at an ecologic level. In addition to the other direct interventions performed to reduce MM, it seems essential to especially focus on more distal factors influencing MMR

Impact of maternal psoriasis on adverse maternal and neonatal outcomes: a systematic review and meta-analysis

Abstract Background There is a dearth of robust evidence regarding the correlation between psoriasis with maternal and neonatal outcomes, making it challenging to establish definitive recommendations for the management of these patients. This systematic review and meta-analysis aimed to review the evidence with regard to the impact of maternal psoriasis on maternal and neonatal outcomes. Methods Following the PRISMA guideline, a systematic search of English articles using PubMed, Embase, Scopus, ScienceDirect, Web of Science, Google Scholar, and the Cochrane Library was conducted. The search was performed from inception to 22nd of May 2022. Result A significant association was observed between psoriasis and maternal outcomes, including cesarean delivery [OR = 1.25 (95% CI: 1.13–1.30, p-value = 0.001)], (pre)eclampsia [OR = 1.29 (95% CI: 1.15–1.44, p-value = 0.0001)], gestational diabetes [Odds Ratio (OR) = 1.23 (95% Confidence Intervals (CI): 1.15–1.30, p-value = 0.001)], gestational hypertension [OR = 1.31 (95% CI: 1.18–1.45, p-value = 0.001)] and preterm birth [OR = 1.22 (95% CI: 1.10–1.35, p-value = 0.001)]. Also, there was a significant association between psoriasis and neonatal outcomes, including small for gestational age [OR = 1.07 (95% CI: 1.02–1.11, p-value = 0.053)], low birth weight [OR = 1.19 (95% CI: 1.02–1.38, p-value = 0.001)] and stillbirth [OR = 1.27 (95% CI: 1.04–1.55, p-value = 0.023)]. Conclusion Maternal psoriasis could negatively impact maternal and neonatal outcomes. Our results strengthen the importance of close monitoring of the mothers’ psoriasis status before and during pregnancy