An investigation into the acceptability, adoption, appropriateness, feasibility, and fidelity of implementation strategies for birth companionship in Tehran: a qualitative inquiry on mitigating mistreatment of women during childbirth.

BACKGROUND: A birth companion is a powerful mechanism for preventing mistreatment during childbirth and is a key component of respectful maternity care (RMC). Despite a growing body of evidence supporting the benefits of birth companions in enhancing the quality of care and birth experience, the successful implementation of this practice continues to be a challenge, particularly in developing countries. Our aim was to investigate the acceptability, adoption, appropriateness, feasibility, and fidelity of implementation strategies for birth companions to mitigate the mistreatment of women during childbirth in Tehran. METHODS: This exploratory descriptive qualitative study was conducted between April and August 2023 at Valiasr Hospital in Tehran, Iran. Fifty-two face-to-face in-depth interviews were conducted with a purposive sample of women, birth companions, and maternity healthcare providers. Interviews were audio-recorded, transcribed verbatim, and analyzed using content analysis, with a deductive approach based on the Implementation Outcomes Framework in the MAXQDA 18. RESULTS: Participants found the implemented program to be acceptable and beneficial, however the implementation team noticed that some healthcare providers were initially reluctant to support it and perceived it as an additional burden. However, its adoption has increased over time. Healthcare providers felt that the program was appropriate and feasible, and it improved satisfaction with care and the birth experience. Participants, however, highlighted several issues that need to be addressed. These include the need for training birth companions prior to entering the maternity hospital, informing women about the role of birth companions, assigning a dedicated midwife to provide training, and addressing any physical infrastructure concerns. CONCLUSION: Despite some issues raised by the participants, the acceptability, adoption, appropriateness, feasibility, and fidelity of the implementation strategies for birth companions to mitigate the mistreatment of women during childbirth were well received. Future research should explore the sustainability of this program. The findings of this study can be used to support the implementation of birth companions in countries with comparable circumstances.

Challenges to the implementation of a multi-level intervention to reduce mistreatment of women during childbirth in Iran: a qualitative study using the Consolidated Framework for Implementation Research.

BACKGROUND: Mistreatment during childbirth is a growing concern worldwide, especially in developing countries, such as Iran. In response, we launched a comprehensive implementation research (IR) project to reduce mistreatment during childbirth and enhance positive birth experiences in birth facilities. This study identified the challenges of implementing a multi-level intervention to reduce mistreatment of women during childbirth using the Consolidated Framework for Implementation Research (CFIR). METHODS: An exploratory qualitative study, involving 30 in-depth interviews, was conducted between July 2022 and February 2023. Participants included a purposive sample of key stakeholders at different levels of the health system (macro: Ministry of Health and Medical Education; meso: universities of medical sciences and health services; and micro: hospitals) with sufficient knowledge, direct experience, and/or collaboration in the implementation of the studied interventions. Interviews were transcribed verbatim and coded using directed qualitative content analysis (CFIR constructs) in MAXQDA 18. RESULTS: The identified challenges were: (1) individual level (childbirth preparation classes: e.g., adaptability, design quality and packaging, cosmopolitanism; presence of birth companions: e.g., patient needs and resources, structural characteristics, culture); (2) healthcare provider level (integrating respectful maternity care into in-service training: e.g., relative priority, access to knowledge and information, reflecting and evaluating); (3) hospital level (evaluating the performance of maternity healthcare providers: e.g., executing, external policies and incentives); and (4) national health system level (implementation of pain relief during childbirth guidelines: e.g., networks and communications, patient needs and resources, executing, reflecting and evaluating). CONCLUSIONS: This study provides a clear understanding of the challenges of implementing a multi-level intervention to reduce mistreatment of women during childbirth and highlights potential implications for policy makers and practitioners of maternal health programs. We encourage them to take the lessons learned from this study and revise their current programs and policies regarding the quality of maternity care by focusing on the identified challenges.

Evidence suggests that mistreatment during childbirth is a growing concern worldwide, especially in developing countries, such as Iran. In this qualitative study, through 30 in-depth interviews with key stakeholders at different levels of the health system (macro: Ministry of Health and Medical Education; meso: universities of medical sciences and health services; and micro: hospitals), we identified the challenges of implementing a multi-level intervention to reduce mistreatment of women during childbirth using the Consolidated Framework for Implementation Research (CFIR). The data were analyzed using directed content analysis and a deductive approach in MAXQDA 18 software. The identified challenges were: (1) individual level (childbirth preparation classes: e.g., adaptability; presence of birth companions: e.g., patient needs and resources); (2) healthcare provider level (integrating respectful maternity care into in-service training: e.g., relative priority); (3) hospital level (evaluating the performance of maternity healthcare providers: e.g., executing, external policies and incentives); and (4) national health system level (implementation of pain relief childbirth guidelines: e.g., networks and communications). This study provides a clear understanding of the challenges of implementing a multi-level intervention to reduce mistreatment of women during childbirth; and highlights potential implications for policy makers and practitioners of maternal health programs.

Mistreatment of women during childbirth and its influencing factors in public maternity hospitals in Tehran, Iran: a multi-stakeholder qualitative study.

BACKGROUND: Mistreatment during labour and childbirth is a common experience for many women around the world. This study aimed to explore the manifestations of mistreatment and its influencing factors in public maternity hospitals in Tehran. METHODS: A formative qualitative study was conducted using a phenomenological approach in five public hospitals between October 2021 and May 2022. Sixty in-depth face-to-face interviews were conducted with a purposive sample of women, maternity healthcare providers, and managers. Data were analyzed with content analysis using MAXQDA 18. RESULTS: Mistreatment of women during labour and childbirth was manifested in four form: (1) physical abuse (fundal pressure); (2) verbal abuse (judgmental comments, harsh and rude language, and threats of poor outcomes); (3) failure to meet professional standards of care (painful vaginal exams, neglect and abandonment, and refusal to provide pain relief); and (4) poor rapport between women and providers (lack of supportive care and denial of mobility). Four themes were also identified as influencing factors: (1) individual-level factors (e.g., providers' perception about women's limited knowledge on childbirth process), (2) healthcare provider-level factors (e.g., provider stress and stressful working conditions); (3) hospital-level factors (e.g., staff shortages); and (4) national health system-level factors (e.g., lack of access to pain management during labour and childbirth). CONCLUSIONS: Our study showed that women experienced various forms of mistreatment during labour and childbirth. There were also multiple level drivers for mistreatment at individual, healthcare provider, hospital and health system levels. Addressing these factors requires urgent multifaceted interventions.

Mistreatment during labour and childbirth is a common experience for many women around the world. A picture of the nature and types of mistreatment; and especially its influencing factors has not yet been identified in Iran. A qualitative approach to explore manifestations of mistreatment during labour and childbirth while learning about the factors that influence them was used for this study. It obtained this information thanks to semi-structured interviews with women, maternity healthcare providers, and managers between October 2021 and May 2022. Our findings showed that women experienced various forms of mistreatment during labour and childbirth. At individual level, e.g., providers' perception about women's limited knowledge on childbirth process was an influencing factor for mistreatment. At healthcare provider level, a highlighted factor was provider stress and stressful working conditions. At hospital level, e.g., staff shortages played a main role; and at national health system level, participants believed that lack of access to pain management during labour and childbirth was an influencing factor for mistreatment. These findings can provide a good platform for designing and implementing intervention programs to reduce disrespectful maternity care. It can also be used as a guide for managers and policymakers to improve the quality of services provided to women.

Challenges for implementation of inter-sectoral efforts to improve outbreak response using consolidated framework for implementation research; Iran's COVID-19 experience.

BACKGROUND: The recurrence of emerging infectious diseases reminds us that rapid response to related outbreaks require coordinated inter-sectoral/ organizational and trans-disciplinary approaches. This study examined the challenges for implementation of inter-sectoral efforts to improve COVID-19 pandemic response in Iran using the consolidated framework for implementation research (CFIR). METHODS: We conducted a qualitative content analysis of in-depth interviews between March 2020 and February 2021 in Tehran, Iran. Participants included health professionals and experts involved in the prevention, treatment and control of COVID-19 pandemic from different levels of the health system (macro: Ministry of Health and Iranian National Institute of Health Research; meso: universities of medical sciences and health services; and micro: hospitals), selected using purposive sampling. Recorded interviews were transcribed verbatim and coded using a deductive approach (CFIR constructs). RESULTS: In total, 12 interviews with the participants were conducted; and eight themes emerged as the most important challenges for implementation of inter-sectoral efforts to improve outbreak response in COVID-19. These challenges include lack of proper intervention sources, complexity, poor networking with external organizations, cultural issues, inadequate availability of resources, inadequate access to knowledge and information about inter-sectoral collaboration implementation, and planning issues for it. CONCLUSIONS: Implementing inter-sectoral efforts to improve outbreak response require addressing several implementation challenges. There should be effective leadership and command system, prioritizing the problem, having proper intra-sector collaboration, adequate supervisory, strong social capital, managers and officials' positive beliefs and organizational culture towards inter-sectoral collaboration, sufficient knowledge and information about the implementation, and providing proper programs to implement inter-sectoral collaboration. These findings recall the need to develop and in particular, implement a specific infra-structure through a well-designed program at the government level to strengthen this approach.

Health literacy and quality of life among Iranian pregnant women: The mediating role of health locus of control.

Background: Main health challenge of the 21st century is improving quality of life (QoL). This study aimed to investigate the mediating role of health locus of control (HLC) between health literacy and QoL among Iranian pregnant women. Methods: In this cross sectional survey, 400 pregnant women referred to the community health centers of Gonabad, Iran, and completed the demographic, health literacy, QoL, and multidimensional HLC questionnaires during 2015-2016. Descriptive statistics and structural equation modeling were conducted using SPSS 22.0 version and AMOS 24.0 software. Results: The findings showed that health literacy has a significant positive effect on the physical (ß= 0.54, p< 0.001) and mental (ß= 0.57, p< 0.001) health. Also, it has a significant positive effect on internal subscale (ß= 0.42, p< 0.001) and a significant negative effect on the chance (ß= -0.51, p< 0.001) and powerful others (ß= -0.33, p< 0.001) subscale of HLC. From HLC subscales, internal HLC had a significant positive effect on physical (ß= 0.26, p< 0.001) and mental (ß= 0.12, p= 0.010) health, while the effects of chance and powerful others on QoL dimensions were not significant. The findings indicated that internal HLC is a partial mediator between health literacy and physical dimension of QoL. Conclusion: The results indicate that health literacy can be considered as an effective factor in HLC orientations and can improve QoL. This reflects the need for more attention on health literacy and the recognition of the type of HLC beliefs, especially the internal belief in health promotion programs for pregnant women.

Validity and Reliability of Form C of the Multidimensional Health Locus of Control Scale in Pregnant Women.

BACKGROUND: The health locus of control (HLC) can indirectly determine the health status. The current study aimed to assess the validity and reliability of Form C of the Multidimensional Health Locus of Control (MHLC-C) scale in pregnant women. METHODS: 554 pregnant women participated in this cross-sectional study conducted in 2017; they referred to community health centers affiliated with Mashhad and Gonabad Medical Sciences Universities. Multi-stage random sampling was done. In this study, first, the questionnaire was translated into Farsi; then, face validity and construct validity were done through exploratory factor analysis, and concurrent criterion validity was also examined. Moreover, the reliability was assessed through internal consistency and stability methods. RESULTS: The results of the exploratory factor analysis showed that the MHLC-C scale consisted of four subscales, i.e. Chance, Internal, Other People, and Doctors, which accounted for 51.18% of variance. The results of the reliability analysis showed an acceptable internal consistency for the scale (Cronbach's alpha coefficient for subscales from 0.62 to 0.90). Also, the test-retest results showed good stability for all subscales other than Doctors (P<0.05). The concurrent validity of Forms B and C of MHLC scale showed a positive and significant correlation between subscales. CONCLUSION: The results of this study showed that the MHLC-C scale had acceptable validity and reliability in pregnant women and is suggested as an applicable criterion for assessing individuals control beliefs with any medical or health-related condition in Iran.