Cesarean delivery in Iran: a population-based analysis using the Robson classification system

Psychometric properties of the experiences of maternity care scale among Iranian women

BACKGROUND

Assessing women's perceptions of the care they receive is crucial for evaluating the quality of maternity care. Women's perceptions are influenced by the care received during pregnancy, labour and birth, and the postpartum period, each of which with unique conditions, expectations, and requirements. In England, three Experience of Maternity Care (EMC) scales - Pregnancy, Labour and Birth, and Postnatal - have been developed to assess women's experiences from pregnancy through the postpartum period. This study aimed to validate these scales within the Iranian context.

METHODS

A methodological cross-sectional study was conducted from December 2022 to August 2023 at selected health centers in Tabriz, Iran. A panel of 16 experts assessed the qualitative and quantitative content validity of the scales and 10 women assessed the face validity. A total of 540 eligible women, 1-6 months postpartum, participated in the study, with data from 216 women being used for exploratory factor analysis (EFA) and 324 women for confirmatory factor analysis (CFA) and other analyses. The Childbirth Experience Questionnaire-2 was employed to assess the convergent validity of the Labour and Birth Scale, whereas women's age was used to assess the divergent validity of the scales. Test-retest reliability and internal consistency were also examined.

RESULTS

All items obtained an impact score above 1.5, with Content Validity Ratio and Content Validity Index exceeding 0.8. EFA demonstrated an excellent fit with the data (all Kaiser-Meyer-Olkin measures > 0.80, and all Bartlett's p < 0.001). The Pregnancy Scale exhibited a five-factor structure, the Labour and Birth Scale a two-factor structure, and the Postnatal Scale a three-factor structure, explaining 66%, 57%, and 62% of the cumulative variance, respectively, for each scale. CFA indicated an acceptable fit with RMSEA ≤ 0.08, CFI ≥ 0.92, and NNFI ≥ 0.90. A significant correlation was observed between the Labour and Birth scale and the Childbirth Experience Questionnaire-2 (r = 0.82, P < 0.001). No significant correlation was found between the scales and women's age. All three scales demonstrated good internal consistency (all Cronbach's alpha values > 0.9) and test-retest reliability (all interclass correlation coefficient values > 0.8).

CONCLUSIONS

The Persian versions of all three EMC scales exhibit robust psychometric properties for evaluating maternity care experiences among urban Iranian women. These scales can be utilized to assess the quality of current care, investigate the impact of different care models in various studies, and contribute to maternal health promotion programs and policies.

Optimizing caesarean section use and feasibility of implementing the Robson classification system: Perspectives of healthcare providers and policymakers

Introduction and Objective

In recent decades, caesarean section rates have increased dramatically worldwide and the reasons for this trend are not fully understood. This continuing trend has raised public health concerns regarding higher maternal and perinatal risks, high costs, healthcare efficiency, and inequality of services. The current study aimed to explore the perspectives and insights of healthcare providers and policymakers in the Israeli health system regarding the factors that drive caesarean section rates and the readiness and feasibility of implementing the Robson Ten Group Classification System for the first time.

Methods

Semi-structured interviews were conducted (n = 12) with purposefully selected healthcare providers and policymakers in Israel. Data was analysed inductively using a thematic analysis approach.

Results

The findings reflected the "changing landscape" in childbirth practices and attitudes that contributes to the rising caesarean section rate, including childbirth at older ages, birth planning, and a transition toward a more collaborative decision-making approach to childbirth. The participants emphasized the lack of a standardized classification or consistent data monitoring of caesarean section in the Israeli health system. Additionally, enablers to implement the Robson Ten Group Classification System in Israel (ease of use, data collection and recording, and the allocation of resources and personnel), as well as barriers (concerns over workload, limited resources, budget implications, and technological complexity), were found.

Conclusions

This study revealed the multifaceted factors shaping caesarean section rates within Israel and underscored the perceived need for evidence-based monitoring and informed decision-making in healthcare practices. Our findings support the conclusion that empirical evidence and clear data are crucial for effective caesarean section use and are currently lacking in Israeli hospitals. Thus, it is recommended to adopt a globally standardized, accepted, and effective tool-the Robson Ten Group Classification System-to accommodate the "changing landscape" in alignment with evolving medical and societal dynamics, which consequently will assist in optimizing caesarean section use.

Mothers' Perceptions About Childbirth Preparation Classes: A Qualitative Study

Background

Childbirth preparation classes are designed for better adaptation of couples to physiological and psychological changes related to pregnancy and childbirth. Therefore, we aimed to explore the mothers' perceptions about childbirth preparation classes.

Methods

A qualitative study was conducted using the conventional qualitative content analysis method from May to August 2022. Eighteen women who had given birth in the last six months in one of the hospitals in Tehran and at least 20 days had passed since their delivery were included in the study; also, five husbands, two midwives, and two obstetricians were interviewed. The participants were purposefully selected according to the inclusion criteria. Sampling continued until data saturation. Data were collected through individual, in-depth, and semi-structured interviews and analyzed by the MAXQDA version 10 software.

Results

Mothers' age ranged from 17 to 37 years. 128 primary codes, 7 sub-sub themes, 3 sub-themes, and one theme were extracted. The sub-themes included satisfaction from the choice (perception forming for better choices, common consent), making the wait pleasant (dignity-oriented professional care, adaptation to change, feeling of empowerment), and good termination (free and conscious choice for birth mode, self-control during delivery process). Finally, a theme called "making motherhood pleasant" was extracted.

Conclusion

Making motherhood pleasant can be a meaningful achievement of childbirth preparation classes. Paying more attention to improving the quality of these classes can help improve family health. Therefore, policymakers should implement strategies to facilitate women's access to these classes.

Post-cesarean Delivery Analgesia Using Spinal Anesthesia: Ropivacaine-Fentanyl vs. Ropivacaine-Sufentanil

Background

To improve the quality of intraoperative and postoperative analgesia during spinal anesthesia, intrathecal opioids are used as adjuvant drugs in combination with local anesthetics.

Objectives

This study aimed to compare the intrathecal injection of ropivacaine-fentanyl with ropivacaine-sufentanil in terms of the duration of analgesia after cesarean section (CS).

Methods

This randomized, double-blind clinical trial study was conducted on women referred to Imam Khomeini Hospital of Ahvaz City for elective CS in 2021. A total of 51 patients were randomly divided into 2 groups. The first group (n = 25) received ropivacaine (17.5 mg) + fentanyl (25 μg), while the second group (n = 26) received ropivacaine (17.5 mg) + sufentanil (2.5 μg) for spinal anesthesia. Eventually, several parameters were investigated, including the duration of sensory and motor block, duration of analgesia (based on the Visual Analog Scale (VAS)), hemodynamic parameters, and possible complications.

Results

The duration of surgery (P = 0.059) and the duration of motor block (P = 0.962) were not significantly different between the 2 groups. The mean duration of analgesia (from the time of entering recovery to reaching VAS = 3) was 203.12 ± 72.93 and 207.46 ± 69.59 minutes in the fentanyl and sufentanil groups, respectively (P = 0.658). Systolic and diastolic blood pressure (SBP/DBP) drops in minute 5 were observed more frequently in the sufentanil group than in the fentanyl group (P = 0.027 and P = 0.002, respectively). At the other time points, however, no significant difference was observed between the 2 groups in terms of hemodynamic variables (P > 0.05). Finally, the frequency of pruritus was higher in the sufentanil group than in the fentanyl group (26.9% vs. 4.0%; P = 0.024).

Conclusions

Adding fentanyl or sufentanil to intrathecal ropivacaine provides a similar duration of analgesia. However, fentanyl was associated with better hemodynamic stability and a lower incidence of pruritus.

Women's experiences with implementation of the physiologic birth program in Iran: a qualitative content analysis study

Introduction

Increased rate of caesarean section (CS) without medical indication is a global concern. According to the guidelines of the World Health Organization (WHO), the physiologic birth program is one of the strategies for reducing the rate of unnecessary caesarean sections. The aim of this study is to explain women's experiences with the implementation of the physiologic birth program in Iran.

Materials and methods

This study is a part of a mixed-method study involving 15 targeted semi-structured interviews individually conducted with women attending physiologic birth classes between January 2022 and June 2022. Interviews continued until data saturation was achieved. Data were analyzed using conventional content analysis approach based on the criteria proposed by Graneheim and Lundman, using MAXQDA10 software.

Results

Analysis of the findings of the study led to the emergence of 2 themes, 4 categories, and 10 subcategories. The first theme was the positive experiences of the women ("satisfaction with pregnancy" and "making the childbirth process pleasant"), and the second theme was their negative experiences with physiologic birth ("challenges and limitation of physiologic birth program" and "lack of high-quality obstetric services in the public health system").

Conclusion

The results of this study showed that childbirth preparation classes reduced women's fear and stress and enhanced their positive attitude toward vaginal delivery by preparing them for childbirth. Also, effective communication with midwives and their support along with efficient implementation of physiologic birth techniques led to successful pain management and satisfaction with the birth process. Policymakers should implement strategies to remove limitations and make this program accessible to all women.

Robson classification of caesarean births: implications for reducing caesarean section rate in a private tertiary hospital in Nigeria

BACKGROUND

Caesarean section (CS) is a potentially lifesaving obstetric procedure. However, there are concerns about the rising CS rate in many countries of the world including Nigeria. The Ten-Group Robson classification system is presently recommended as an effective monitoring tool for comparing CS rates and identifying target groups for intervention aimed at reducing the rates. The aim of this study was to evaluate the cesarean section rate and the groups with the highest risk of CS at the obstetric unit of Babcock University Teaching Hospital (BUTH), using the Robson classification system.

METHODS

A cross-sectional study involving 447 women who gave birth at the obstetric unit of BUTH between August 2020 and February 2022. Relevant information was retrieved from the delivery records of the study participants. Data were analyzed using the IBM-SPSS Statistics for Windows version 23.0 (IBM Corp., Armonk, NY, USA).

RESULTS

The overall CS rate was 51.2%. Multiparous women with previous CS, single, cephalic, term (group 5); nulliparous women, single cephalic, term, with induced labour or pre-labour CS (group 2); women with preterm single cephalic, term (group 10); and single cephalic term multiparous women in spontaneous labour (group 3) were the largest contributors to CS rate accounting for 34.5%, 14.0%, 12.6%, and 10.0% respectively. The commonest indication for CS was previous CS (87; 38.0%), followed by poor progress in labour (24; 10.5%).

CONCLUSIONS

The CS rate in BUTH is high and Robson groups 5, 2 10 and 3 were the major contributors to this high rate. Interventions directed at reducing the first CS by improving management of spontaneous and induced labours; and strengthening clinical practice around encouraging vaginal birth after CS will have the most significant effect on reducing CS rate.

The trend of normal vaginal delivery and cesarean sections before and after implementing the health system transformation plan based on ICD-10 in the northeast of Iran: A cross-sectional study

Background and Aims

Concerning the growing rate of cesarean sections (CSs) worldwide, encouraging normal vaginal deliveries (NVDs) and mitigating CS rates is a necessity. This study investigated the status of delivery in hospitals affiliated with the Mashhad University of Medical Sciences (MUMS) before and after implementing health system transformation plan (HSTP).

Methods

A cross-sectional study was conducted in 2017 in the obstetrics and gynecology ward in four MUMS teaching hospitals. Data were extracted from hospital information systems (HISs) based on the International Classification of Diseases (ICD-10) and analyzed in SPSS VE10 software.

Results

The results revealed a significant difference between the rate of NVDs and CSs before and after HSTP, such that implementing this plan in MUMS hospitals has raised the rate of NVDs by 4%. Except for the age groups of less than 15 and 36-40 years, the difference between NVD and CS was significant in different age groups before and after HSTP. The rate of NVD significantly increased within 2 months after implementing HSTP. Furthermore, the difference in the rate of previous CS before and after implementing HSTP was significant (p < 0.001).

Conclusion

The results of this study show the positive impact of the implementation of the HSTP on CS reduction and NVD increase in the studied hospitals. Since the studied hospitals were teaching and concerning the different costs of NVD and CS between the public and private hospitals, it is recommended to study all hospitals with the obstetrics and gynecology ward to precisely assess the success of HSTP in encouraging NVD.

Does Obesity Influence Women's Decision Making about the Mode of Delivery?

Introduction: The ratio of cesarean deliveries (CDs) has been increasing worldwide, with a growing problem of cesarean delivery on maternal request (CDMR) and an alarmingly increasing rate of CD in the private sector. There are numerous factors influencing women’s preferences for the mode of delivery and their opinion about shared decision making (SDM). Material and method: The study was designed as an online survey, filled in by 1040 women. The questionnaire included questions about women’s preferences for the mode of delivery, their opinions about CDMR and the process of decision making regarding the mode of delivery. Results: There were no statistically significant differences found between women with a BMI ≤ 25 kg/m2 and >25 kg/m2, nor with a BMI ≤ 30 kg/m2 and >30 kg/m2, on the subject of the preferred method of delivery, and the opinion regarding SDM and CDMR without medical indications. More than 85% of women in all groups, who preferred CD as the mode of delivery, wanted to have CDMR. Conclusion: We have not found obesity and overweight to be a factor influencing women’s preferred mode of delivery, their opinion about SDM and their preference for CDMR without medical indications. However, the sample size of women with morbid obesity with a BMI ≥ 35 kg/m2 was too small for the results to be considered significant in this group, and it will therefore be subject to further studies.

The incidence of congenital anomalies in newborns before and during the Covid-19 pandemic

Background

Pregnant women are one of the most vulnerable groups in the Covid-19 pandemic. Due to the lack of knowledge about fetal and perinatal complications following Covid-19 infection, the association of Covid-19 pandemic and congenital anomalies in babies conceived and born during this pandemic is unclear. Current study aimed to investigate the association between the Covid-19 pandemic and congenital birth anomalies in Iran. The population of newborns whose embryonic period coincided with the Covid-19 crises were compared with a similar group born during the pre-Covid-19 period.

Methods

This is a retrospective comparative analysis of congenital birth anomalies in Iran; desired data was extracted from national birth registry database. All registered congenital anomalies in hospital births were compared between two time periods: During Covid-19 (1st November 2020- 28th February 2021) and Before Covid-19 (1st November 2019-29th February 2020). Incidence of congenital anomalies at birth were compared and analyzed between these two time periods.

Results

The incidence of congenital birth anomalies are significantly increased during Covid-19 pandemic compared with before Covid-19 (P value < 0.00001). The number of all types of anomalies has increased in the current pandemic, but the congenital anomalies of the central nervous system (P value = 0.04) and Genitourinary (P value = 0.03) have a larger contribution than before.

Conclusion

Covid-19 pandemic are associated with congenital anomalies at birth. There are several factors in the Covid-19 pandemic which can affect fetal development in the first trimester of pregnancy. Possible reasons include vertical transmission of Covid-19 infection; maternal fever, stress and anxiety; insufficient preconception and prenatal care; neglect of fetal screening; and poverty imposed by this pandemic.

Challenges facing clinical midwifery education in Iran

BACKGROUND

Delivering high-quality midwifery services requires a professional, educated and competent workforce. The challenges of clinical training and education for midwives in Iran have prevented midwifery students from fully gaining the clinical competency required of midwifery graduates.

METHODS

This qualitative study was conducted to identify and explain the challenges of clinical training for midwives in Iran and to determine their underlying factors within the sociocultural and educational context of this country. Data were collected from a purposive sample in a western province of Iran, which included clinical midwives working in public and private maternity units, midwifery instructors working at educational institutes, and midwifery students. After receiving an ethics approval for the project and informed consent from the participants, data were collected through focus group interviews held with midwifery students (n = 9) and semi-structured interviews held with midwifery instructors (n = 6) and clinical midwives (n = 7). Data were then analyzed using the framework proposed by Graneheim and Lundman using MAXQDA-10.

FINDINGS

The analysis of the data led to two themes: "Discriminatory approach in the health system" and "Professional nature of midwifery". The noted discrimination was caused by the insecure position of midwives in the health system, inequalities related to education and training opportunities, and the demotivation of midwives. The professional nature of midwifery discussed the community in transition, functional paradoxes and high-risk labor.

CONCLUSION

The findings revealed numerous challenges facing clinical midwifery education and training in the study setting, which may in part be explained by the sociocultural context of maternity services in Iran. The learning opportunities provided to midwifery students should be improved by making significant revisions to the structure of clinical settings where students are placed. Tackling discrimination against a profession and its students is essential, and it is equally important to value the contributions of midwifery students and midwives to their practice and their efforts to ensure safe maternity care for women and newborns. The quality of the clinical learning environment must therefore be improved for this group, and the active participation of competent and autonomous midwifery instructors in this environment can have a facilitatory role.