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

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. 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.