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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. Plain English summary: 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. [ABSTRACT FROM AUTHOR]

Background: The "Adequate Childbirth Program" (PPA) is a quality improvement project that aims to reduce the high rates of unnecessary cesarean section in Brazilian private hospitals. This study aimed to analyze labor and childbirth care practices after the first phase of PPA implementation. Method: This study uses a qualitative approach. Eight hospitals were selected. At each hospital, during the period of 5 (five) days, from July to October 2017, the research team conducted face to face interviews with doctors (n = 21) and nurses (n = 28), using semi-structured scripts. For the selection of professionals, the Snowball technique was used. The interviews were transcribed, and the data submitted to Thematic Content Analysis, using the MaxQda software. Results: The three analytical dimensions of the process of change in the care model: (1) Incorporation of care practices: understood as the practices that have been included since PPA implementation; (2) Adaptation of care practices: understood as practices carried out prior to PPA implementation, but which underwent modifications with the implementation of the project; (3) Rejection of care practices: understood as those practices that were abandoned or questioned whether or not they should be carried out by hospital professionals. Conclusions: After the PPA, changes were made in hospitals and in the way, women were treated. Birth planning, prenatal hospital visits led by experts (for expecting mothers and their families), diet during labor, pharmacological analgesia for vaginal delivery, skin-to-skin contact, and breastfeeding in the first hour of life are all included. To better monitor labor and vaginal birth and to reduce CS without a clinical justification, hospitals adjusted their present practices. Finally, the professionals rejected the Kristeller maneuver since research has demonstrated that using it's harmful. Plain English summary: Brazil has high Cesarean Section (CS) rates, with rates far from the ideal recommended by the World Health Organization and a model of care that does not favor women's autonomy and empowerment. In 2015, a quality improvement project, called "Projeto Parto Adequado" (PPA), was implemented in Brazilian private hospitals to reduce unnecessary cesarean section, in addition to encouraging the process of natural and safe childbirth. One of the components of this project was to reorganize the model of care in hospitals to prepare professionals for humanized and safe care. The data were collected in 8 hospitals with interviews with 49 professionals, approximately two years after the beginning of the project in the hospitals. There were changes in the hospital routine and in the care of women after the project. The professionals incorporated practices such as skin-to-skin contact and breastfeeding; diet during labor; non-invasive care technologies, especially to relieve pain during labor; birth plan; pregnancy courses with guided tours in hospitals (for pregnant women and family); and analgesia for vaginal labor. There was adaptation of existing practices in hospitals to reduce CS that had no clinical indication; better monitoring of labor, favoring vaginal delivery. And finally, the professionals rejected the practice that presses the uterine fundus, for not having shown efficacy in recent studies. We can conclude that the hospitals that participated in this study have made an effort to change their obstetric model. However, specific aspects of each hospital, the organization of the health system in Brazil, and the incentive of the local administration influenced the implementation of these changes by professionals in practice. [ABSTRACT FROM AUTHOR]

Background: In Cambodia, stillbirths and their underlying factors have not been systematically studied. This study aimed to assess the proportion and trends in stillbirths between 2017 and 2020 in a large maternity referral hospital in the country and identify their key determinants to inform future prevention efforts. Methods: This was a retrospective cross-sectional analysis with a nested case–control study of women giving birth at the National Maternal and Child Health Centre (NMCHC) in Phnom Penh, 2017–2020. We calculated percentages of singleton births at ≥ 22 weeks' gestation resulting in stillbirth and annual stillbirth rates by timing: intrapartum (fresh) or antepartum (macerated). Multivariable logistic regression was used to explore factors associated with stillbirth, where cases were all women who gave birth to a singleton stillborn baby in the 4-year period. One singleton live birth immediately following each case served as an unmatched control. Multiple imputation was used to handle missing data for gestational age. Results: Between 2017 and 2020, 3.2% of singleton births ended in stillbirth (938/29,742). The stillbirth rate increased from 24.8 per 1000 births in 2017 to 38.1 per 1000 births in 2020, largely due to an increase in intrapartum stillbirth rates which rose from 18.8 to 27.4 per 1000 births in the same period. The case–control study included 938 cases (stillbirth) and 938 controls (livebirths). Factors independently associated with stillbirth were maternal age ≥ 35 years compared to < 20 years (aOR: 1.82, 95%CI: 1.39, 2.38), extreme (aOR: 3.29, 95%CI: 2.37, 4.55) or moderate (aOR: 2.45, 95%CI: 1.74, 3.46) prematurity compared with full term, and small-for-gestational age (SGA) (aOR: 2.32, 1.71, 3.14) compared to average size-for-age. Breech/transverse births had nearly four times greater odds of stillbirth (aOR: 3.84, 95%CI: 2.78, 5.29), while caesarean section reduced the odds by half compared with vaginal birth (aOR: 0.50, 95%CI: 0.39, 0.64). A history of abnormal vaginal discharge increased odds of stillbirth (aOR: 1.42, 95%CI: 1.11, 1.81) as did a history of stillbirth (aOR: 3.08, 95%CI: 1.5, 6.5). Conclusions: Stillbirth prevention in this maternity referral hospital in Cambodia requires strengthening preterm birth detection and management of SGA, intrapartum care, monitoring women with stillbirth history, management of breech births, and further investigation of high-risk referral cases. Plain language summary: In Cambodia, there is very little information published on stillbirths to know precisely how many there are and to understand the underlying reasons they occur so they can be prevented in the future. Our study aimed to quantify the number of stillborn babies and identify some underlying risk factors from one of the largest maternity referral hospitals in Phnom Penh, Cambodia. We examined data from almost 30,000 health facility medical files of women who gave birth between 2017 and 2020 which included 938 stillbirths. We found that about 3.2% of births ended in a stillbirth and that this percentage increased between 2017 and 2020. Women who had preterm babies, or whose babies were small in weight for their gestational age, and babies that were born breech had a higher chance of being stillborn. Women who had abnormal vaginal discharge, which can indicate a possible infection, also had a higher odds of having a stillbirth. We also found that women who had a stillbirth previously had almost three times higher chance of having another stillborn baby. Having a caesarean section reduced the likelihood of having a stillborn baby by about half. These findings suggest that efforts are needed to better identify and manage women with preterm births and monitor fetal growth as well as ensure breech births are managed adequately. [ABSTRACT FROM AUTHOR]

Background: Whether women should be able to decide on mode of birth in healthcare settings has been a topic of debate in the last few decades. In the context of a marked increase in global caesarean section rates, a central dilemma is whether pregnant women should be able to request this procedure without medical indication. Since 2015, Law 25,929 of Humanised Birth is in place in Argentina. This study aims at understanding the power relations between healthcare providers, pregnant women, and labour companions regarding decision-making on mode of birth in this new legal context. To do so, central concepts of power theory are used. Methods: This study uses a qualitative design. Twenty-six semi-structured interviews with healthcare providers were conducted in five maternity wards in different regions of Argentina. Participants were purposively selected using heterogeneity sampling and included obstetrician/gynaecologists (heads of department, specialists working in 24-h shifts, and residents) and midwives where available. Reflexive thematic analysis was used to inductively develop themes and categories. Results: Three themes were developed: (1) Healthcare providers reconceptualize decision-making processes of mode of birth to make women's voices matter; (2) Healthcare providers feel powerless against women's request to choose mode of birth; (3) Healthcare providers struggle to redirect women's decision regarding mode of birth. An overarching theme was built to explain the power relations between healthcare providers, women and labour companions: Healthcare providers' loss of beneficial power in decision-making on mode of birth. Conclusions: Our analysis highlights the complexity of the healthcare provider-woman interaction in a context in which women are, in practice, allowed to choose mode of birth. Even though healthcare providers claim to welcome women being an active part of the decision-making processes, they feel powerless when women make autonomous decisions regarding mode of birth. They perceive themselves to be losing beneficial power in the eyes of patients and consider fruitful communication on risks and benefits of each mode of birth to not always be possible. At the same time, providers perform an increasing number of CSs without medical indication when it is convenient for them, which suggests that paternalistic practices are still in place. Plain Language Summary: In the last few decades, there has been a debate on whether women should be able to choose if they haver a vaginal birth or a caesarean section. This debate has been framed by the fact that an increasing number of caesarean sections are being performed. Since 2015, Argentina has a Law of Humanised Birth. We conducted a study to understand the power relations between healthcare providers, pregnant women and labour companions in decision making on mode of birth in this new legal context. To do so, we used central concepts of power theory. We conducted 26 semi-structured interviews with healthcare providers in five maternity wards of Argentina. The interviewees were obstetrician/gynaecologists (heads of department, specialists working in 24-h shifts, and residents) and midwives where available. We used thematic analysis to build themes from the data. We discovered that healthcare providers perceive themselves to be losing beneficial power in decision-making on mode of birth. Even though they claim to want women to make autonomous decisions, they feel frustrated when this happens. They also perceive it to be more difficult to communicate with patients regarding the risks and benefits of vaginal birth and caesarean section. At the same time, providers carry out an increasing number of CSs without medical indication when it is convenient for them, which suggests that paternalistic practices are still in place. [ABSTRACT FROM AUTHOR]

Background: Brazil's maternity care is highly medicalized, and obstetric interventions in labour and birth are high, mainly in private health system. The Adequate Birth Project (PPA—Projeto Parto Adequado) is quality improvement project designed to reduce unnecessary caesarian section rates in private hospitals in Brazil. This study evaluated the association between the participation of the PPA and the birth experience assessed by the women. Methods: It was carried out in 2017/2018 a hospital-based research with a convenience sample of 12 private hospitals among the 23 participants of the project. In this article, a sub-sample of 2348 mothers of 4878 postpartum women, including only women who desired vaginal birth at the ending of pregnancy was analyzed. Multigroup structural equation modelling was used for data analysis to compare vaginal birth and caesarean section. The latent variable was constructed from four items: participation in decisions, respectful treatment during labour and birth, satisfaction with the care during childbirth, satisfaction with care of the baby. Results: In the vaginal birth group, women who participated in PPA rated the birth experience better than women who did not participate (standardized coefficient: 0.388, p-value: 0.028). On the other hand, this effect was not observed (standardized coefficient: − 0.271, p-value: 0.085) in the caesarean section. Besides, the explicative models for a good birth experience varied to the type of childbirth. Among women with vaginal birth, complication during pregnancy and younger age were associated with a more positive birth experience. In contrast, for women with a caesarean section, access to information and participation in the pregnant group was associated with a better evaluation of the birth experience. Conclusions: The childbirth care model that encourages vaginal delivery and reduces unnecessary caesarean modulates the birth experience according to the type of birth. This study also highlights the importance of perceived control, support, and relationship with the health team shaping women's experience with labour and delivery. These factors may affect policy, practice, and research on childbirth care. [ABSTRACT FROM AUTHOR]