Delivery is a spontaneous process that needs no intervention (1); however, it is considered a disease due to the process of medicalization. Some factors have been identified to contribute to pregnancy and delivery as a disease, including increasing the rate of cesarean section (C-section)  in Iran (2) and the world (3, 4), prolonged fasting at hospitals, increasing episiotomy and its complications (5, 6), and prolonged hospitalization (3, 4).

Fearing labor pain and feeling of loneliness during pregnancy are the predictors of labor pain and distress that may increase the risk of emergency C-section and rate of elective C-section. However, C-section is not the solution, and fear may remain over the postpartum period leading to considering labor an unpleasant experience (7). Application of new labor methods, such as Mother-Friendly Hospital Initiative, as well as nonpharmacological and supportive interventions, can make labor pleasant for mothers, particularly through improving the mental and emotional aspects of childbirth. It could also result in the reduction of elective C-section through relieving pain and fear (8).

The Mother-Friendly Hospital Initiative was developed in 1990s in order to manage the delivery process, promote maternal and neonatal health, reduce treatment costs resulting from increased labor interventions, and increase breastfeeding. As labor is a natural process, the mother-friendly hospital (MFH) was introduced in 1996 (9). Implementation of MFH plan requires a definition of country-specific standards (10). Therefore, the Ministry of Health and Medical Education has developed the following 10-step principles of MFH in Iran (11):

1) Providing routine care during pregnancy, delivery, and postpartum period based on the Ministry of Health and Medical Education’s protocols and scientific evidence;

2) Providing specialized midwifery services during delivery and establishing the relationship with the higher and lower levels of healthcare and cross-hospital;

3) Providing healthcare and paraclinical services in emergency midwifery and labor, including blood transfusion, specialized tests, and pediatrician involvement in high-risk delivery;

4) Training staff in the methods of painless labor and nonpharmacological pain relief;

5) Training mothers and families about labor preparation courses, emphasizing on awareness and use of respiratory techniques, relaxation, and musculoskeletal exercises;

6) Providing healthcare based on mothers’ religious beliefs and values and respecting mother's privacy;

7) Avoiding routine interventions, including fasting mother, shaving, enema, restricting mother's movement during labor, delivery in lithotomy position, labor induction, intensifying labor contractions, and episiotomy;

8) Performing physiological labor and using pharmacological and nonpharmacological pain relief methods;

9) Presence of trained family member with mother during labor and delivery;

10) Implementation of 10 steps of neonate-friendly hospitals based on the guidelines of the Ministry of Health and Medical Education (11) Currently, population policies have been changed in Iran. Increasing the birth rate is one of the important issues in health policies that can be achieved through promoting normal labor, making labor pleasant, and reducing C-section (12). These are considered the most important issues in the Health Evolution Plan. However, the rate of C-section has not dropped to an acceptable level after the development of the Health Evolution Plan (13). As the establishment of MFHs aims at promoting normal labor and respecting mothers’ rights, it is necessary to assess MFH steps. This study aimed to determine the MFH steps across the hospitals in Qazvin province, Iran.

Materials and Methods

This descriptive cross-sectional study was conducted in nine hospitals in Qazvin province, Iran, in 2017. All public and private hospitals with gynecology unit (i.e., maternity ward) were included in the present study. Data were collected using the standard MFH checklist. Content validity was confirmed by the Ministry of Health and Medical Education. Reliability of the checklist was reported by Tork Zahrani using correlation test (r=0.855) (14).

 The MFH checklist consists of 10 steps and 110 items related to places, equipment, facilities, records, hospital statistical data, as well as interviews with clients and staff. Expected level of MFH was obtained at 80% in all the steps. Ten steps were addressed with the following number of items:

Step 1: 19 items (i.e., providing healthcare before, during, and after labor);

Step 2: 7 items (i.e., access to midwifery services during labor);

Step 3: 11 items (i.e., providing health and paraclinical care in obstetrics and gynecology emergencies);

Step 4: 8 items (i.e., teaching staff about pharmacological and nonpharmacological painless labor),

Step 5: 14 items (i.e., teaching labor preparation to mothers and caregivers);

Step 6: 14 items (i.e., providing services based on religious values and privacy);

Step 7: 12 items (i.e., avoiding routine care);

Step 8: 18 items (i.e., physiologic labor, as well as pharmacological and nonpharmacological pain management);

Step 9: 6 items (i.e., accompanying a trained caregiver with mother during labor);

Step 10: Implementation of 10 steps of neonate-friendly hospitals based on the guidelines of the Ministry of Health and Medical Education (It was determined if the hospital has achieved a neonate-friendly certification, and whether the certification has been shown across the hospital)

In order to assess the above-mentioned steps, the researchers completed the MFH checklist after entering the centers. Completion of the checklist involves the comprehensive assessment of physical space (i.e., the inspection of labor wards, labor preparation classes, as well as obstetrics and gynecology clinics). In addition, 210 interviews were conducted with 90 clients (i.e., 10 clients and their caregivers in different shifts in each hospital), and 30 head staff (i.e., in charge of delivery room, emergency, and postpartum period), and 90 staff of labor wards in different shifts.

To assess the statistical data of the hospitals, 10 random records were evaluated in each hospital controlled by the IMAN^[1] net. This was a part of the protocol for the approval of the MFH certificate. In addition, the score of each step was separately calculated. Each item was scored 0-10, and the total score was within the range of 0-1100. The final score (i.e. the rate of MFH) was considered optimal if it was equal to or greater than 80% of the rate established based on the guidelines of the Ministry of Health and Medical Education. The checklist was completed based on the Mother Health Office guidelines.

The collected data were analyzed using SPSS software (version 24) using descriptive statistics, including mean and standard deviation. Given the sample size, the assumption of normal distribution was not fulfilled; therefore, nonparametric Mann-Whitney U test was employed to compare mean values. This study obtained approval from the Ethics Committee of Qazvin University of Medical Sciences (code: IR.QUMS.REC.1396.253), and the researchers gained permission to attend the hospitals. In addition, the authorities of nine hospitals in Qazvin province received necessary documents and explanations.

Results

Out of nine hospitals, five hospitals were public, and the remaining four hospitals were private. Seven hospitals were at the second level, and the other two hospitals were at the first level and third level. Five hospitals were located in Qazvin, and other four hospitals were across the province.

 Two hospitals obtained accepted scores at all steps. Rates of the 10 steps were reported as 90.79%, 78.88%, 89.39%, 68.47%, 77.72%, 71.5%, 78.14%, 43.34%, 80.66%, and 100% for step 1, step 2, step 3, step 4, step 5, step 6, and step 7, step 8, step 9 and step 10 respectively. Moreover, the rate of step 8 reported as 47.34% was undesirable and less than expected (Table 1).

As shown in Table 1, steps 1, 3, 5, 9, and 10 were above the optimal rate; however, steps 2, 4, 6, 7, and 8 were under the optimal rate.

In terms of hospital type, the results showed that the overall rate of steps was higher in private hospitals, compared to that in public hospitals (80.35 vs 78.56). However, the difference was not statistically significant (P=0.08). Results of the Mann-Whitney U test revealed that the rate of step 6 was significantly higher in private hospitals, compared to that in the public hospitals (P=0.014). Nevertheless, there was no significant difference between the two types of hospitals with regard to other steps (Table 2).

In terms of hospital level, the results showed that the second-level hospitals were reported with the highest rate of MFH scores (second-level: 80.25, third-level: 75.62, and first-level: 74.72) (Table 3).