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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 most pervasive form of female genital mutilation/cutting--infibulation--involves the almost complete closure of the vaginal orifice by cutting and closing the labia to create a skin seal. A small opening remains for the passage of urine and menstrual blood. This physical closure has to be re-opened--defibulated--later in life. When they marry, a partial opening is made to enable sexual intercourse. The husband commonly uses his penis to create this opening. In some settings, a circumciser or traditional midwife opens the infibulated scar with a knife or razor blade. Later, during childbirth, a further opening is necessary to make room for the child's passage. In Norway, public health services provide surgical defibulation, which is less risky and painful than traditional forms of defibulation. This paper explores the perceptions and experiences of surgical defibulation among migrants in Norway and investigates whether surgical defibulation is an accepted medicalization of a traditional procedure or instead challenges the cultural underpinnings of infibulation. Methods: Data derived from in-depth interviews with 36 women and men of Somali and Sudanese origin and with 30 service providers, as well as participant observations in various settings from 2014-15, were thematically analyzed. Results: The study findings indicate that, despite negative attitudes towards infibulation, its cultural meaning in relation to virility and sexual pleasure constitutes a barrier to the acceptance of medicalized defibulation. Conclusions: As sexual concerns regarding virility and male sexual pleasure constitute a barrier to the uptake of medicalized defibulation, health care providers need to address sexual concerns when discussing treatment for complications in infibulated women. Furthermore, campaigns and counselling against this practice also need to tackle these sexual concerns. [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: It is well acknowledged that Female Genital Mutilation/Cutting (FGM/C/C) leads to medical, psychological and sociocultural sequels. Over 200 million cases of FGM/C exist globally, and in Kenya alone, a total of 12,418,000 (28%) of women have undergone FGM/C, making the practice not only a significant national, but also a global health catastrophe. FGM/C is rooted in patriarchal and traditional cultures as a communal experience signifying a transition from girlhood to womanhood. The conversations surrounding FGM/C have been complicated by the involvement of women themselves in perpetuating the practice. Methods: A qualitative inquiry employing face-to-face, one-on-one, in-depth semi-structured interviews was used in a study that included 30 women living with obstetric fistulas in Kenya. Using the Social Network Framework and a feminist analysis we present stories of Kenyan women who had developed obstetric fistulas following prolonged and obstructed childbirth. Results: Of the 30 participants, three women reported that health care workers informed them that FGM/C was one of the contributing factors to their prolonged and obstructed childbirth. They reported serious obstetric complications including: the development of obstetric fistulas, lowered libido, poor quality of life and maternal and child health outcomes, including death. Fistula and subsequent loss of bodily functionalities such as uncontrollable leakage of body wastes, was reported by the women to result in rejection by spouses, families, friends and communities. Rejection further led to depression, loss of work, increased sense of apathy, lowered self-esteem and image, as well as loss of identity and communal sociocultural cohesion. Conclusion: FGM/C is practised in traditional, patriarchal communities across Africa. Although the practice aims to bind community members and to celebrate a rite of passage; it may lead to harmful health and social consequences. Some women with fistula report their fistula was caused by FGM/C. Concerted efforts which embrace feminist understandings of society, as well as multi-sectoral, multidisciplinary and community development approaches need to be employed to address FGM/C, and to possibly reduce cases of obstetric fistulas in Kenya and beyond. Both government and non-government organisations need to be involved in making legislative, gender sensitive policies that protect women from FGM/C. In addition, the policy makers need to be in the front line to improve the lives of women who endured the consequences of FGM/C. [ABSTRACT FROM AUTHOR]

Background: In Kenya, indirectly caused maternal deaths form a significant portion of all maternal deaths within the health system. Many of these deaths are avoidable and occur during delivery and labor. Poor quality health service has been a recurring concern among women in Kenya, with women reporting interactions with healthcare workers that are often demeaning and abusive. This paper explores the experiences and perceptions of both female patients and healthcare workers regarding mistreatment during childbirth. This study aims to provide recommendations on how dignified care can be made the norm, specifically focusing on a peri-urban setting in Kenya. Methods: The research was accomplished using qualitative research methods with focus group discussions and in depth interviews with women and healthcare workers. The aim was to gain a deeper understanding of the manifestations of mistreatment within the context of a peri-urban setting in Kenya. Results: Female patients reported different forms of mistreatment, such as verbal abuse, physical abuse, neglect, discrimination, abandonment, poor rapport and failure of the health system to uphold professional standards. The healthcare workers described a health system that was weak and fragmented with poor policy support particularly for the new free maternity services policy leading to the mistreatment of women. Conclusion: Newly formed County Governments need to provide resources for a functioning health system to ensure an enabling environment for the provision of high quality maternal health services. This process can include feedback loops with maternity clients to ensure woman-centered services. Policy makers need to strengthen oversight for the implementation of the free maternity services Community health volunteers can be trained to provide this information. Professional associations that govern the standards of quality care for healthcare workers need to address the mistreatment through retraining and norms transformation. [ABSTRACT FROM AUTHOR]

Background: Institutional delivery care-seeking behavior is considered a crucial step in preventing maternal and child death. However, the barriers and facilitators related to institutional delivery care-seeking behavior in the study area were not studied very in-depth. Hence, the current study aimed to explore barriers and enablers of institutional delivery care-seeking behavior in Northwest Ethiopia. Methods: A descriptive phenomenological qualitative inquiry was used. The data was collected by using a piloted interview guide. We collected data using in-depth interviews among women and men; and key informant interviews from the Female health development army and health extension workers in November and December 2019. Framework analysis was utilized for the analysis of the data. Results: This study found out the potential factors which hinder and facilitate institutional delivery. The barriers to institutional delivery included the belief that pregnancy and childbirth are normal and business of women's, women's preference of home delivery with traditional attendants, family influence, fear of bad behavior of health care workers, and lack of resources. The facilitators were free maternal services (ambulance services and maternity services), having the experience of safe childbirth at health facilities, and women's health development army linkage with health extension workers. Conclusion: This study provides evidence that low-risk perception of home delivery, socio-cultural influences, service provision modalities, and financial factors were the determinants of institutional delivery service use. Therefore, a stage-matched intervention shall be designed to improve the uptake of institutional delivery service use. Plain language summary: Institutional delivery plays a critical role in the prevention of maternal death and improves newborn health. Although most of maternal health services were free of charge in Ethiopia, institutional delivery is low in the rural Central Gondar zone of Wogera and East Dembiya districts. Low institutional delivery was the major contributors to high maternal deaths in Ethiopia. This low utilization of institutional delivery in the study area could also affect the health status of the newborn. This study was conducted to explore the community perceptions of the socio-cultural and health service factors influencing institutional delivery. Overall, 30 interviews (18 In-depth and 12 Key-informants) were conducted in the selected rural kebeles of Wogera and East Dembiya districts to collect data from women and their husbands for in-depth interview; and key informant interviews from the female health development army and health extension workers. The facilitators of institutional delivery categorized into three themes; namely, free maternal services (ambulance services and maternity services), having the experience of safe childbirth at health facilities, and women's health development army linkage with health extension workers. The socio-cultural factors impeding institutional delivery categorized into five themes; namely, the belief that pregnancy and childbirth are normal and business of women's, women's preference of home delivery with traditional attendants, family influence, fear of bad behavior of health care workers, and lack of resources. Conducting a stage-matched intervention shall be designed to improve the uptake of institutional delivery service use in Wogera and East dembiya districts. [ABSTRACT FROM AUTHOR]

Background: Iran has one of the highest national caesarean section rates worldwide. Few studies explored in-depth the health-facility and health-system level factors that affect women's choices on mode of delivery in Iran. The aim of this study was to explore the health-facility and health-system level factors affecting women's preferences on mode of delivery in Tehran. Methods: We conducted a qualitative study using in-depth face-to-face interviews with women between October 2017 and May 2018. Study participants were sampled purposively from a range of health service settings to include women of varying experiences regarding childbirth. Eligibility criteria were Persian-speaking, women with or without childbirth experiences. All interviews were audio-recorded and lasted 30–45 min. After verbatim transcription of the interviews, we created a preliminary thematic framework to analyze the data. A combined inductive (themes emerging from the data) and deductive (key concepts across existing frameworks) approach was used during data analysis. Results: In total, 26 in-depth interviews were conducted. Five central themes influencing women's preferences on mode of delivery emerged from the analysis: (1) health system conditions (important differences between the quality of care provided at private and public hospitals; staff shortages, skills, competency, motivation and also accessibility to staff during the longer time required for a vaginal delivery; policies and protocols on vaginal birth after cesarean, pain relief for vaginal birth, and having companion during labor; (2) standards of care in facilities (physical condition in facilities; physical examinations and procedures; continuous and organized care; ethics); (3) interaction between women and providers (communicating in a supportive manner with women and communication women's partners/families); (4) preserving women's dignity (delivering high quality and respectful care); (5) provision of information (education about pregnancy and childbirth including environment in facility, labor processes/procedures, and the risks and benefits of both vaginal delivery and caesarean section). Conclusions: Our study suggests, there are barriers to increasing demand for and satisfaction with vaginal birth, such as women's perceived sub-optimal quality of care during labor and birth, understaffed facilities that lack standard protocols and have limited physical space, and lack of privacy and dignity. The multifactorial nature of the increase of unnecessary Cesarean section calls for multicomponent interventions to revert this trend. These interventions need to address the health-systems' and health-facilities' deficiencies behind women's preference for Cesarean section. [ABSTRACT FROM AUTHOR]

Background: Disrespectful and abusive treatment during childbirth is a violation of women's right to dignified, respectful healthcare throughout pregnancy and childbirth. Although reports point out that marginalized groups in society such as single mothers are particularly vulnerable to abusive and disrespectful care, there is a lack of in-depth research exploring single mothers' encounters at the maternal healthcare facilities, especially in Tunisia. In Tunisia, single mothers are particularly vulnerable due to their social stigmatization and socio-economic marginalization. This study examines the self-perceptions and childbirth experiences of single mothers at the public healthcare facilities in Tunisia. Methods: This study follows a qualitative design. Eleven single mothers were interviewed in regard to their experiences with maternal healthcare services and their perceptions of the attitudes of the health workers towards them. The interviews also addressed the barriers faced by the participants in accessing adequate maternal healthcare services, and their self-perceptions as single mothers. The data were analyzed using an inductive thematic approach guided by the feminist intersectional approach. Emergent codes were grouped into three final themes. Results: Three themes emerged during the data analysis: 1) Experiencing disrespect and abuse, 2) Perceptions of regret and shame attributed to being a single mother, and 3) The triad of vulnerability: stigma, social challenges, and health system challenges. The study highlights that the childbirth experiences of single mothers are shaped by intersectional factors that go beyond the health system. Gender plays a major role in constructing these experiences while intersecting with other social structures. The participants had experienced disrespectful and discriminatory practices and even violence when they sought maternal healthcare services at the public healthcare facilities in Tunisia. Those experiences reflect not only the poor quality of maternal health services but also how health system practices translate the stigma culturally associated with single motherhood in this setting. Social stigma did not only affect how single mothers were treated during the childbirth, but also how they perceived themselves and how they perceived their care. Conclusion: Ensuring women's right to dignified, respectful healthcare during childbirth requires tackling the underlying causes of social inequalities leading to women's marginalization and discrimination. [ABSTRACT FROM AUTHOR]

Background: Malawi has a high perinatal mortality rate of 40 deaths per 1,000 births. To promote neonatal health, the Government of Malawi has identified essential health care packages for improving maternal and neonatal health in health care facilities. However, regardless of the availability of health services, women's perceptions of the care is important as it influences whether the women will or will not use the services. In Malawi 95% of pregnant women receive antenatal care from skilled attendants, but the number is reduced to 71% deliveries being conducted by skilled attendants. The objective of this study was to describe women's perceptions on perinatal care among the women delivered at a district hospital. Methods: A descriptive study design with qualitative data collection and analysis methods. Data were collected through face-to-face in-depth interviews using semi-structured interview guides collecting information on women's perceptions on perinatal care. A total of 14 in depth interviews were conducted with women delivering at Chiradzulu District Hospital from February to March 2011. The women were asked how they perceived the care they received from health workers during antepartum, intrapartum and postpartum. They were also asked about the information they received during provision of care. Data were manually analyzed using thematic analysis. Results: Two themes from the study were good care and unsatisfactory care. Subthemes under good care were: respect, confidentiality, privacy and normal delivery. Providers' attitude, delay in providing care, inadequate care, and unavailability of delivery attendants were subthemes under unsatisfactory care. Conclusions: Although the results show that women wanted to be well received at health facilities, respected, treated with kindness, dignity and not shouted at, they were not critical of the care they received. The women did not know the quality of care to expect because they were not well informed. The women were not critical of the care they received because they were not aware of the standard of care. Instead they had low expectations. Health workers have a responsibility to inform women and their families about the care that women should expect. There is also a need for standardization of the antenatal information that is provided. [ABSTRACT FROM AUTHOR]

Background: Health workers in many low-income countries are not adequately trained to deliver pregnant women safely. In response to this, the Safe Delivery App (SDA) has been developed, which provides animated clinical instruction videos in basic emergency obstetric and neonatal care. The SDA aims to improve knowledge and skills of health workers located in the periphery of the health system in order to improve quality of care and potentially save the lives of mothers and newborns. The objective of this qualitative study was to explore the users' experiences with using the SDA and in which ways the SDA influences their work situation and their perceived ability to conduct safe deliveries. Methods: Eleven focus group discussions and four individual interviews were conducted with a total of 56 midwives, nurses and health extension workers from five districts in West Wollega Zone, Oromiya region of Ethiopia. The data further include observations and informal conversations. All interviews were recorded, transcribed verbatim, checked for corrections and analysed using systematic text condensation. Results: The findings indicate that health workers perceive the SDA as a useful tool, which helps them memorize and update knowledge and skills, and improves their confidence. User patterns follow the relevancy of the tool to the health workers' work situation - those who conduct many deliveries have more often used the app in emergency situations, whereas those who conduct few deliveries more often use it to improve their knowledge and to provide health education to pregnant women. Thus, the SDA is used in varying ways depending on internal and external factors such as own competencies, availability of equipment and frequency of births attended. Health workers experienced that community members showed more recognition and trust in their abilities and ascribed this to their increased confidence in assisting in deliveries. The increased recognition from communities may also be associated to a medical technology. Conclusion: The health workers perceive the SDA as having improved their ability to manage complications during childbirth and have gained increased recognition and trust from the communities. [ABSTRACT FROM AUTHOR]