Challenges to the implementation of a multi-level intervention to reduce mistreatment of women during childbirth in Iran: a qualitative study using the consolidated framework for implementation research

Abstract

Abstract 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 experience in the birth facilities. In this study, 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). Methods: An exploratory qualitative study involving thirty in-depth and semi-structured interviews was conducted between July 2022 and February 2023. Participants include a purposive sample of key informants 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 companion: 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., external policies and incentives, executing); and (4) National health system level (implementation of painless childbirth guidelines: e.g., networks and communications, knowledge and beliefs about the intervention, executing, reflecting and evaluating). Conclusions: This study shows 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 in the implementation of their current programs and policies regarding the quality of maternity care by focusing on identified challenges.