Painful Dream of Motherhood: A Hermeneutic Phenomenological Study of Married Women with Ectopic Pregnancy in the Islamic Republic of Iran

Ectopic pregnancy (EP) is a significant cause of maternal morbidity and mortality. This study aimed to explore the understanding and experience of women with EP in the Islamic Republic of Iran. This qualitative study carried out through a Heideggerian hermeneutic/interpretative phenomenological approach, using face-to-face semi-structured phenomenological interviews with twenty-five participants referred to a public maternity hospital in Rasht, Iran. Data were collected and analyzed using the seven-step analytical approach of Dickelman et al. (The NLN criteria of appraisal of baccalaureate programs: A critical hermeneutic analysis, NLN Press, 1989; Journal of Nursing Education. 32:245-250, 1993) to phenomenological studies. The results reveal how living in the shadow of Islamic Sharia Law in Iran turns EP into a trauma and creates a different experience and meaning of EP for each woman. In this view, multiple factors, including 'family support' and 'faith in Islamic Sharia,' have determined how married women experience sociocultural and psychological consequences of EP. These findings apply to women with EP in Iran. Given that EP is more than an anomalous pregnancy with socially culturally constructed suffering in the context of the Islamic Republic of Iran. Hence, policymakers and healthcare providers should consider a multidimensional approach to this devastating event in pregnancy and support and empower the women whose dream of motherhood is jeopardized and terminated by the experience of EP.

Nursing in oncology ward with intertwined roles: a focused ethnography

BACKGROUND

Characteristics of nursing care in the oncology ward depend on this ward's specific context. This study aimed to investigate the nursing care in the oncology ward regarding the culture of this ward.

METHODS

This qualitative study was conducted in an oncology ward using a focused ethnographic approach. The whole nursing team of the selected ward (N = 16) participated in the study through purposeful sampling. Three methods of observation, interview, and field documents were used for data collection. Data were analyzed by Spradley's (1980) ethnographic method.

RESULTS

'Nursing in the oncology ward with intertwined roles' emerged as the main theme. This theme included the following subthemes: 'Robin Hood nurse,' 'a secretive nurse,' 'a negligent nurse,' 'a snitching nurse,' 'a complaining nurse,' 'an apathetic senior nurse,' 'a stigmatized training nurse,' 'a brazen-bodied nurse,' 'a compassionate nurse,' 'a moonlighting nurse,' and 'a drug bartender.'

CONCLUSION

This study provided a deep cultural insight into nursing care in the oncology ward, considering the particular culture of this ward and emphasizing the nurses' intertwined roles. These roles are on a spectrum, with positive roles, such as compassion, on one side and negative roles, such as negligence, on the other. The results of this study can be provided to nursing managers; therefore, by being aware of nurses' roles considering the specific subculture of the oncology ward, they can provide psychological interventions to improve the mental health of reluctant and complaining nurses and ethics-based training for secretive, negligent, and snitching nurses to provide quality care to the patient.

Ups and downs of addiction harm reduction in Iran: key insights and implications for harm reduction policy and policing

Drug use is a critical behavioral disorder or a delinquency behavior (in the judiciary system's words) that comes with a burden at multiple levels: individual, community, public, and global. These social structures apply different interventions to reduce this burden in their field. Given the society as a whole, these structures must be harmonious and synergistic to optimize these endeavors in terms of cost-benefit. In practice, however, reducing the burden of addiction is followed by conflicting approaches by different organizations, in terms such as "eradicating drugs," "eliminating drug users," "obliterating addiction," and ultimately, drug use harm reduction. In the harm reduction philosophy, drug use is recognized as an inescapable fact in human societies, and tries to control its personal and public consequences in different dimensions (health, economic, and social). Therefore, this approach includes broad measures such as: changing the pattern of consumption (from high-risk substances to less dangerous substances) through modification of the laws and law enforcement measures, distributing disposable syringes to prevent HIV transmission, providing basic life needs such as shelter for street-based drug users to reduce the social consequences like homelessness, prescribing substitute agonists to reduce the committing crime to obtain the needed drugs, and even the drug court program, which prevents the exacerbation of complications in a person with a chronic and relapsing disorder, due to the imposition of inappropriate sentences (like incarceration in unacceptable conditions). It is contrary to the approaches that aim to reduce the drug supply rate and drug use incidence and prevalence to zero. As a result of the conflict of interests, goals discrepancies, and differences in organizational culture, these approaches may contrast with each other. We see this in the harm reduction between the health system and law enforcement. Different factors affect the harmony or conflict between these two structures. This article addresses the impact of ideology, social conditions, and bureaucratic administration on the relationship between the health system and the police in drug use harm reduction in Iran.

HIV, migration, gender, and drug addiction: A qualitative study of intersectional stigma towards Afghan immigrants in Iran

HIV-related stigma has been identified as a major barrier to the diagnosis, prevention, and treatment of HIV among immigrants. The intersection of HIV with other forms of stigma can lead to greater inequality in health outcomes and access to health services. This study aimed to improve the understanding of HIV stigma towards Afghan immigrants in Iran through an intersectional perspective. The data were collected using 25 semi-structured interviews with the following three groups: Afghan immigrants who were diagnosed with or at risk of HIV infection due to injection drug addiction or having multiple sexual partners (n = 8), HIV service providers (n = 8), and policymakers/managers/experts (n = 9). Thematic analysis was used for data analysis. The participants described different manifestations of stigma (internalized, anticipated, perceived, experienced stigma, and discrimination) associated with HIV and interlocked with other aspects of stigma, including migration, gender, and drug addiction. According to the results, the intersection of different layers of stigma should be taken into account while designing and implementing HIV prevention and treatment programmes. It was also recommended to conduct the necessary interventions such as comprehensive HIV education, social support, as well as peer and outreach services to reduce stigma and discrimination based on the immigrants' needs as well as cultural and social values.

A life-saving endeavor: The meanings and strategies of coping in patients with ectopic pregnancy in Iran

Aim of this study was to explore the experienced coping strategies by patients with an ectopic pregnancy in order to ameliorate the quality of treatment. This is a qualitative study based on a phenomenological tradition in which data were collected through semi-structured and in-depth phenomenological interviews with twenty-five married women, experienced ectopic pregnancy. Data were analyzed through an interpretative phenomenological analysis. “Life-saving endeavor” was the main theme that emerged from the participants’ experiences. It refers to a set of strategies used by women to cope with Ectopic Pregnancy. Life-saving endeavor consists of four subthemes, that is ‘submission to destiny’, ‘the blue sky after the storm’, ‘karma; the world’s supervisor’ and ‘setting foot on earth’. The results of this study reveal that women with ectopic pregnancy have implemented various strategies to cope with this complication of pregnancy, based on their life worldviews and beliefs. However, only those women who had a realistic angle to the disease were able to adapt to life again. As a result, accurate identification of these strategies and real comprehension of their life experiences by medical care providers, and applying positive experiences including a realistic attitude promotion to the other patients are recommended.

Aspects Influencing Access to HIV/AIDS Services among Afghan Immigrants in Iran: A Qualitative Study

BACKGROUND

A successful response to the risk of human immunodefficiency virus (HIV) infection among immigrants requires improved access to HIV prevention, diagnosis, and treatment services. However, most immigrants face significant challenges in accessing HIV/AIDS services. The aim of this study was to explore the aspects influencing access to HIV/AIDS services among Afghan immigrants in Iran.

METHODS

This was a qualitative study using conventional content analysis that was conducted from June 2018 to April 2020 in Tehran, Iran. Purposeful sampling method was performed. We conducted 25 semi-structured interviews with three groups of stakeholders including Afghan immigrants infected with or at risk of HIV (n=8), service providers (n=8), and policymakers/managers/experts (n=9). Inductive qualitative content analysis was applied according to the Granheim and Lundman method. Data were analyzed using Open Code software version 4.03.

RESULTS

Aspects influencing access to HIV/AIDS health services were categorized into 3 themes (that were extracted from 9 categories): 1. Cultural aspects (cultural similarities and differences, values and beliefs); 2. Psychosocial aspects (social support, stigma and discrimination); and 3. Service delivery related aspects (awareness, health services coverage and integrity, health services financing, accessibility, and continuity of care).

CONCLUSION

The findings suggest that efforts to improve Afghan immigrants' access to HIV/AIDS health services in Iran need to consider the cultural aspects, increasing HIV awareness, providing support, reducing stigma and discrimination, and improving health services coverage, integrity, financing, and continuity of accessible services.

"Applying Intersectionality in designing and implementing health interventions: a scoping review"

BACKGROUND

Given the potential of intersectionality to identify the causes of inequalities, there is a growing tendency toward applying it in the field of health. Nevertheless, the extent of the application of intersectionality in designing and implementing health interventions is unclear. Therefore, this study aimed to determine the extent to which previous studies have applied intersectionality and its principles in designing and implementing health interventions.

METHODS

The title and abstract of the articles which were published in different databases e.g. PubMed, Web of Science, Proquest, Embase, Scopus, Cochrane, and PsychInfo were screened. Those articles that met the screening criteria were reviewed in full text. The data about the application of principles of intersectionality, according to the stages heuristic model (problem identification, design & implementation, and evaluation), were extracted through a 38-item researcher-made checklist.

RESULTS

Initially, 2677 articles were found through reviewing the target databases. After removing the duplicated ones and screening the titles and abstracts of 1601 studies, 107 articles were selected to be reviewed in detail and 4 articles could meet the criteria. The most frequently considered intersectionality principles were "intersecting categories" and "power", particularly at the stages of 'problem identification' as well as 'design & implementation'. The results showed that "multilevel analysis" principle received less attention; most of the studies conducted the interventions at the micro level and did not aim at bringing about change at structural levels. There was a lack of clarity regarding the attention to some of the main items of principles such as "reflexivity" as well as "social justice and equity". These principles might have been implemented in the selected articles; however, the authors have not explicitly discussed them in their studies.

CONCLUSIONS

Given the small number of included studies, there is still insufficient evidence within empirical studies to show the implication of intersectionality in designing and conducting health interventions. To operationalize the intersectionality, there is a need to address the principles at various stages of health policies and interventions. To this end, designing and availability of user-friendly tools may help researchers and health policymakers appropriately apply the intersectionality.

Developing and Validating Food Choice Determinants Questionnaire: An Instrument for Exploring Food Choice Determinants in Iran

Background:

This study was carried out to design and validate a questionnaire to measure the majority of factors influencing food choices among adults in Iran.

Methods:

A sequential exploratory mixed-method approach was applied to develop the initial item pool of the Food Choice Determinants Questionnaire (FCDQ) starting with a qualitative study to explore the food choice dimensions and its components. Designing the initial questionnaire using these dimensions and the 36-item Food Choice Questionnaire (FCQ) was then performed. The face, content, and construct validity were also assessed. The construct validity of the questionnaire was assessed using the exploratory factor analysis (EFA). Cronbach's alpha was applied for each main theme to examine the internal consistency.

Results:

After content and face validity process, a 60-item FCDQ was developed with total items' content validity index (CVI) of 0.69 indicating a reasonable level. The Cronbach's alpha coefficients for each of the six constructs in the scale have shown satisfactory internal consistency.

Conclusions:

This instrument is valid and reliable to measure food choice determinants in adults and could be applied to design interventions aiming to better food choice.

Bridging the Gap Between Ethical Theory and Practice in Medicine: A Constructivist Grounded Theory Study

Physicians try hard to alleviate mental and physical ailments of their patients. Thus, they are heavily burdened by observing ethics and staying well-informed while improving health of their patients. A major ethical concern or dilemma in medication is that some physicians know their behavior is unethical, yet act against their moral compass. This study develops models of theory-practice gap, offering optimal solutions for the gap. These solutions would enhance self-motivation or remove external obstacles to stimulate ethical practices in medicine. The Constructivist Grounded Theory Methodology is applied here where the participants and the main researcher mutually interacted with each other. Data collection was performed through qualitative methods including observation and semi-structured interviews with 21 physicians and medical students. Initial and focused coding was done, from which principal concepts were later extracted. MAXQDA software was used for analyzing data. Analysis of twelve major concepts in the study resulted in two factors and solution groups, from which four general notions influencing the ethical theory and practice gap in medicine were extracted: (1) providing effective education to change attitude and behavior; (2) considering motivational and emotional factors; (3) reconstructing regulations and processes to facilitate ethical practice; (4) conducting comprehensive and systematic studies. The existing medical educational system needs to be reconsidered to add to individual internal motivation, including optimizing persuasion strategies, maximizing participation of students, adhering to virtuous ethical theories, and fostering emotions. Additionally, regulations and processes can be reconstructed to remove practical obstacles and promote ethical practice with insignificant damages to individual self-motivation.

Interpersonal Communication among Critical Care Nurses: an Ethnographic Study

Introduction: Interpersonal communication in critical care units is one of the most important factors due to complicated and critical conditions of patients. Nurses’ confrontation with ethical distresses and conflict resolution techniques are often influenced by the culture governing these units. This study aimed to explore interpersonal communication culture among critical care nurses.

Methods: A focused ethnographic approach was used to conduct study in Iran. The research method was based on the research evolutionary cycle model recommended by Spradley (1980). Data were collected over six months through purposeful sampling and semi structured interviews (n=18) and participation observation (n=43). The data were obtained over six months of observation and interview with participants. Data analysis was done by Spradley method and was interpreted to discover the meaning units from the obtained themes. MAXQDA10 was used to manage data.

Results: Five major domains of observations and high-level consensus were extracted in this study, including grouping, work-life interaction, professionalism, organizational atmosphere and experience.

Conclusion: Development of interpersonal communication culture is influenced by various factors. Besides, the working models and nurses’ use of workspace are indispensable components of effective communication at workplace. The findings of this study can be helpful in determining appropriate strategies and practices to resolve communication problems among nurses by specifying challenges, thereby leading to proper communication among nurses, promoting this communication and finally providing high quality and more effective care.

Related Factors to Paternal Adaptation: A Cross-sectional Study for First-time Fathers

Background:

Becoming a father challenges men's ability and many men describe fathering as a negative and frustrating experience. This study was designed to determine related factors to paternal adaptation in first-time fathers.

Materials and Methods:

This cross-sectional study was conducted in healthcare centers in Qom and environs, Iran, from July to September 2015. Participants were 572 first-time fathers. Healthcare centers were selected by lottery and sampling was carried out continuously. Data were collected by demographic form and Paternal Adaptation Questionnaire; Spearman's correlation coefficient, Mann–Whitney and Kruskal–Wallis test, and multiple linear regression model were used. p < 0.05 was considered as significant level.

Results:

Participants were first-time fathers with a mean (SD) age of 29.89 (4.45) years. The results indicated that planning for parenting is the most predictive factor in the ability to perform the paternal roles and responsibilities (β = 2.67, p < 0.001); marital satisfaction is the most predictive factor with regard to perceiving parental development (β = 3.09, p = 0.001) and stabilization in paternal position (β = 4.66, p < 0.001). Father's self-employment was the only predictive factor relating to challenges and worries (β = −1.19, p < 0.001) and marital satisfaction was the most predictive factor for paternal adaptation (β = 14.68, p < 0.01).

Conclusions:

It appears that the father's occupation, planning for becoming a parent, and marital satisfaction are the most predictive factors for paternal adaptation and its domains, thus by planning appropriate interventions aimed at developing the ability of fathers in these aspects, especially marital satisfaction, it is possible to facilitate men's adaptation to paternal role.

Setting research priorities to achieve long-term health targets in Iran

Background

In 2015, it was estimated that the burden of disease in Iran comprised of 19 million disability-adjusted life years (DALYs), 74% of which were due to non-communicable diseases (NCDs). The observed leading causes of death were cardiovascular diseases (41.9%), neoplasms (14.9%), and road traffic injuries (7.4%). Even so, the health research investment in Iran continues to remain limited. This study aims to identify national health research priorities in Iran for the next five years to assist the efficient use of resources towards achieving the long-term health targets.

Methods

Adapting the Child Health and Nutrition Research Initiative (CHNRI) method, this study engaged 48 prominent Iranian academic leaders in the areas related to Iran’s long-term health targets, a group of research funders and policy makers, and 68 stakeholders from the wider society. 128 proposed research questions were scored independently using a set of five criteria: feasibility, impact on health, impact on economy, capacity building, and equity.

Findings

The top-10 priorities were focused on the research questions relating to: health insurance system reforms to improve equity; integration of NCDs prevention strategy into primary health care; cost-effective population-level interventions for NCDs and road traffic injury prevention; tailoring medical qualifications; epidemiological assessment of NCDs by geographic areas; equality in the distribution of health resources and services; current and future common health problems in Iran’s elderly and strategies to reduce their economic burden; the status of antibiotic resistance in Iran and strategies to promote rational use of antibiotics; the health impacts of water crisis; and research to replace the physician-centered health system with a team-based one.

Conclusions

These findings highlight consensus amongst various prominent Iranian researchers and stakeholders over the research priorities that require investment to generate information and knowledge relevant to the national health targets and policies. The exercise should assist in addressing the knowledge gaps to support both the National General Health Policies by 2025 and the health targets of the United Nations’ Sustainable Development Goals by 2030.

Parents' concerns regarding the growth characteristics of their adolescents: a qualitative inquiry in Iran

In recent times, parents have become increasingly concerned, both subjectively and objectively, about their adolescents' body height/weight growth. Parent-adolescent interactions about this issue and the potential socio-psychological consequences of such interactions should be considered as an important influencing factor on the future of adolescents' sexual and reproductive health. To achieve a greater understanding of such concerns, it is necessary to further elucidate parents' experiences on this topic, so as to expand the existing literature. This study aimed to explain the perceptions of parents' concerns regarding their adolescents' growth characteristics in the socio-cultural context of Iran as a transitional society. This paper is part of a larger qualitative study designed using the Constructivist Grounded Theory Methodology (CGTM). We conducted open-ended intensive interviews with eleven parents individually and recruited them through purposeful and theoretical sampling from a teaching hospital, community, and a primary school in Tehran with theoretical sampling variation in terms of teenagers' age, sex, and birth order, place of residence, parents' occupation and education, and the self-reported socio-economic status. Using the analytical procedures of the CGTM, we performed analyses. In the findings, the concept of 'living with constant sense of uncertainty' emerged from the subcategories including 'feeling existing and potential concern about expected minimum and maximum bio-positions of growth,' 'feeling potential concern about biological health consequences,' 'feeling potential concern about the emergence of early/late maturity signs,' 'feeling potential concern about adolescent's emotional threat,' 'feeling concerned about future employment, education, marriage, and fertility,' and 'feeling potential concern about the society's view'. These findings suggest that parents are living with a constant sense of uncertainty about their teens' growth characteristics throughout the transition from adolescence. All stakeholders including parents, health-care practitioners and policymakers, and anthropologists/sociologists should be focus on such concerns, in order to manage them and their possible socio-psychological burdens.

Opposite-sex relationship questionnaire for female adolescents: development and psychometric evaluation

Aim The goal of the present study is to adopt state-of-the-art techniques and standards to develop and evaluate a measure, called the opposite-sex relationship questionnaire for female adolescents (OSRQFA), to assess the reasons why adolescent girls would or would not develop, a relationship with an adolescent boy. Methods A mixed-method, sequential, exploratory design was adopted. In the qualitative phase, an in-depth interview approach was used to identify the properties and dimensions to be included in the OSRQFA. In the quantitative phase, the psychometric properties of the OSRQFA were evaluated according to face, content and construct validity. Reliability and stability were assessed with Cronbach's α and test-retest analysis, respectively. Results A preliminary questionnaire including 86 items which emerged from the qualitative phase of the study was designed. Based on the impact scores for face validity and the cutoff points for the content validity ratio (CVR) and content validity index (CVI), the preliminary questionnaire was reduced to 57 items. The Kaiser criteria (eigenvalues >1) and scree plot tests demonstrated that 21 items forming six factors, which were labeled 'innate predilection', 'abstinence', 'peer pressure', 'fear of the relationship consequences', 'family atmosphere' and 'risk taking', that accounted for an estimated 66.19% of variance provided an optimal fit with the data. These scales had acceptable levels of internal consistency (α = 0.822) and stability (r = 0.871, p < 0.001). Conclusion The OSRQFA with 21 items and 6 factors demonstrated suitable validity and reliability in a sample of Iranian female adolescents. The OSRQFA's has good psychometric properties, and can be used by other researchers in future studies.

Psychometric properties of the Persian version of Social Adaptation Self-evaluation Scale in community-dwelling older adults

INTRODUCTION

The Social Adaptation Self-evaluation Scale (SASS) is used to measure social function and social motivation in depressed patients. There is little attention to social function in the treatment of depression. The aim of this study was to assess the validity and reliability of the Persian version of SASS (P-SASS) for older adults.

PARTICIPANTS AND METHODS

This is a cross-sectional and methodological study. The participants were 550 community-dwelling older adults living in Tehran who were selected randomly from the primary health care centers. To assess the psychometric properties of SASS, we first did translation and cross-cultural adjustment on SASS and then used P-SASS and the Geriatric Depression Scale (GDS) for gathering data. A number of analyses, including Pearson's correlation, exploratory factor analysis, and Cronbach's α, and receiver operating characteristic curve were used to manage the data with the IBM SPSS Statistics V.22.

RESULTS

The mean age of the participants was 66.09±6.67 years, and 58.9% of them were male. The Cronbach's α was 0.97. The test-retest reliability correlation coefficient was 0.78. Principal component analysis showed that P-SASS consists of two components. P-SASS score showed a significant negative correlation with GDS (r=-0.91, P<0.01), which suggests good convergent validity. The P-SASS cutoff point was 28 (sensitivity: 0.97 and specificity: 0.94).

CONCLUSION

P-SASS has good reliability and validity for older adults. So, it can be considered as an appropriate tool to evaluate the social function and social motivation of older persons with and without depression.

Paternal adaptation in first-time fathers: a phenomenological study

OBJECTIVE

This study aimed to explore men's experiences of paternal adaptation during their first year of transition to parenthood.

BACKGROUND

Stepping into fatherhood is one of the most important events that may occur in a man's life and can lead to fundamental changes in their identity and lifestyle. However, to our knowledge, no studies have been conducted on men's experiences of paternal adaptation in an Iranian context.

METHODS

In this phenomenological study, 15 Iranian men who had the experience of parenting for the first time were recruited using the purposeful sampling method. In-depth semi-structured interviews guided by a questionnaire were used to collect data. The data were analysed using interpretative phenomenological analysis.

RESULTS

The data analysis resulted in the development of 26 themes, 8 subordinate themes and 3 superordinate themes. The superordinate themes included 'steps toward adaptation', 'obstacles to the path of adaptation' and 'stabilisation in the paternal position'.

CONCLUSION

Perceived self-efficacy and satisfaction in fatherhood means an adaptation to the paternal role. Factors influencing paternal adaptation can be classified into the domains of 'facilitating factors' and 'inhibiting factors'.

Factors that promote and impede other-sex friendships: a qualitative study of Iranian adolescent girls

AIM

The aim of this study was to identify factors that promote and impede other-sex (OS) friendships in adolescent girls.

METHODS

A qualitative study conducted with 20 adolescent girls recruited in public places in Tehran, Iran. Information was collected through semi-structured interviews and coded via the conventional qualitative content analysis approach.

RESULTS

Four factors were identified that appeared to promote entry into OS friendships. These factors include (a) a poor understanding of perceived risks, (b) weak religious beliefs, (c) processes of identity formation, and (d) low self-esteem. In addition, six factors appeared to impede entry into these friendships: (a) self-confidence, (b) prioritizing education, (c) maintaining particular entertainment preferences, (d) awareness of prior unpleasant experiences with boys, (e) having strong religious convictions, and (f) shaming from significant others.

CONCLUSION

These findings provide unique insights into the factors that stem from different levels of social complexity, which affect participation in a fundamental form of human experience.

Male Iranian adolescent's reasons for having an other-gender friend

AIM

The aim of this study was to identify the primary reasons why male Iranian adolescents enter into other-gender friendships.

METHODS

A qualitative study was conducted with a sample of 21 male adolescents recruited in public places in Tehran, Iran. Information about each boy's experiences with other-gender friends was collected via semi-structured interviews whose contents were analyzed with a conventional qualitative content analysis approach.

RESULTS

Five reasons were identified for engaging in other-gender friendships: (a) for the purpose of entertainment, (b) financial benefits, (c) increased popularity with peers, (d) sensation seeking and (e) sexual experiences.

CONCLUSION

This study revealed that adolescent males do not follow appropriate goals for communicating with the other-gender. In many cases, these goals could endanger their own health and the health of their other-gender friends. Future researchers must focus on identifying and understanding the factors that influence an adolescent to enter into an other-gender friendship.

Maternal mortality: a cross-sectional study in global health

BACKGROUND

Although most of maternal deaths are preventable, maternal mortality reduction programs have not been completely successful. As targeting individuals alone does not seem to be an effective strategy to reduce maternal mortality (Millennium Development Goal 5), the present study sought to reveal the role of many distant macrostructural factors affecting maternal mortality at the global level.

METHODS

After preparing a global dataset, 439 indicators were selected from nearly 1800 indicators based on their relevance and the application of proper inclusion and exclusion criteria. Then Pearson correlation coefficients were computed to assess the relationship between these indicators and maternal mortality. Only indicators with statistically significant correlation more than 0.2, and missing values less than 20% were maintained. Due to the high multicollinearity among the remaining indicators, after missing values analysis and imputation, factor analysis was performed with principal component analysis as the method of extraction. Ten factors were finally extracted and entered into a multiple regression analysis.

RESULTS

The findings of this study not only consolidated the results of earlier studies about maternal mortality, but also added new evidence. Education (std. B = -0.442), private sector and trade (std. B = -0.316), and governance (std. B = -0.280) were found to be the most important macrostructural factors associated with maternal mortality. Employment and labor structure, economic policy and debt, agriculture and food production, private sector infrastructure investment, and health finance were also some other critical factors. These distal factors explained about 65% of the variability in maternal mortality between different countries.

CONCLUSION

Decreasing maternal mortality requires dealing with various factors other than individual determinants including political will, reallocation of national resources (especially health resources) in the governmental sector, education, attention to the expansion of the private sector trade and improving spectrums of governance. In other words, sustainable reduction in maternal mortality (as a development indicator) will depend on long-term planning for multi-faceted development. Moreover, trade, debt, political stability, and strength of legal rights can be affected by elements outside the borders of countries and global determinants. These findings are believed to be beneficial for sustainable development in Post-2015 Development Agenda.

Safe Delivery Posts: an intervention to provide equitable childbirth care services to vulnerable groups in Zahedan, Iran

BACKGROUND

Recently, there has been a shift towards alternative childbirth services to increase access to skilled care during childbirth.

OBJECTIVE

This study aims to assess the past 10 years of experience of the first Safe Delivery Posts (SDPs) established in Zahedan, Iran to determine the number of deliveries and the intrapartum transfer rates, and to examine the reasons why women choose to give birth at a Safe Delivery Post and not in one of the four large hospitals in Zahedan.

DESIGN

A mixed-methods research strategy was used for this study. In the quantitative phase, an analysis was performed on the existing data that are routinely collected in the health-care sector. In the qualitative phase, a grounded theory approach was used to collect and analyse narrative data from in-depth interviews with women who had given birth to their children at the Safe Delivery Posts.

SETTING

Women were selected from two Safe Delivery Posts in Zahedan city in southeast Iran.

PARTICIPANTS

Nineteen mothers who had given birth in the Safe Delivery Posts were interviewed.

FINDINGS

During the 10-year period, 22,753 low-risk women gave birth in the Safe Delivery Posts, according to the records. Of all the women who were admitted to the Safe Delivery Posts, on average 2.1% were transferred to the hospital during labour or the postpartum period. Three key categories emerged from the analysis: barriers to hospital use, opposition to home birth and finally, reasons for choosing the childbirth care provided by the SDPs.

KEY CONCLUSION AND IMPLICATIONS FOR PRACTICE

Implementing a model of midwifery care that offers the benefits of modern medical care and meets the needs of the local population is feasible and sustainable. This model of care reduces the cost of giving birth and ensures equitable access to care among vulnerable groups in Zahedan.

Home birth and barriers to referring women with obstetric complications to hospitals: a mixed-methods study in Zahedan, southeastern Iran

Background

One factor that contributes to high maternal mortality in developing countries is the delayed use of Emergency Obstetric-Care (EmOC) facilities. The objective of this study was to determine the factors that hinder midwives and parturient women from using hospitals when complications occur during home birth in Sistan and Baluchestan province, Iran, where 23% of all deliveries take place in non- hospital settings.

Methods

In the study and data management, a mixed-methods approach was used. In the quantitative phase, we compared the existing health-sector data with World Health Organization (WHO) standards for the availability and use of EmOC services. The qualitative phase included collection and analysis of interviews with midwives and traditional birth attendants and twenty-one in-depth interviews with mothers. The data collected in this phase were managed according to the principles of qualitative data analysis.

Results

The findings demonstrate that three distinct factors lead to indecisiveness and delay in the use of EmOC by the midwives and mothers studied. Socio-cultural and familial reasons compel some women to choose to give birth at home and to hesitate seeking professional emergency care for delivery complications. Apprehension about being insulted by physicians, the necessity of protecting their professional integrity in front of patients and an inability to persuade their patients lead to an over-insistence by midwives on completing deliveries at the mothers' homes and a reluctance to refer their patients to hospitals. The low quality and expense of EmOC and the mothers' lack of health insurance also contribute to delays in referral.

Conclusions

Women who choose to give birth at home accept the risk that complications may arise. Training midwives and persuading mothers and significant others who make decisions about the value of referring women to hospitals at the onset of life-threatening complications are central factors to increasing the use of available hospitals. The hospitals must be safe, comfortable and attractive environments for parturition and should give appropriate consideration to the ethical and cultural concerns of the women. Appropriate management of financial and insurance-related issues can help midwives and mothers make a rational decision when complications arise.