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 Table of Contents  
Year : 2019  |  Volume : 6  |  Issue : 4  |  Page : 183-191

Exploring stakeholder's perception about factors affecting on implementation of physiologic birth plan: A qualitative approach

1 Department of Psychiatric Nursing, Psychiatry and Behavioral Sciences Research Center, Addiction Institute, Mazandaran University of Medical Sciences, Sari, Iran
2 Department of Midwifery, Nursing and Midwifery School, Mazandaran University of Medical Sciences, Sari, Iran

Date of Submission07-May-2019
Date of Acceptance13-Jul-2019
Date of Web Publication6-Sep-2019

Correspondence Address:
Miss. Farideh Rezaie-Abhari
Department of Midwifery, Nursing and Midwifery School, Mazandaran University of Medical Sciences, Sari
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JNMS.JNMS_20_19

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Context: Following the increase in cesarean section rate in Iran, the Ministry of Health and Medical Education has planned a program for the promotion of normal birth. The plan named as “physiologic birth” that is equal with “spontaneous labor.”
Aims: This study aims to explain factors affecting the implementation of “physiologic birth plan from stakeholders” view.
Setting and Design: In this qualitative study, purposive samples of 21 health-care stakeholders (2 men and 19 women) were interviewed in 2016. The participants included three obstetricians and gynecologists, six midwives, three managers and experts in charge of the plan at the Mazandaran University of Medical Science, and nine women who gave birth under the physiological delivery (Spontaneous Labor) plan.
Materials and Methods: Face-to-face semi-structured interviews and one focus group discussion were employed to collect the study data.
Statistical Analysis Used: Qualitative content analysis method was used.
Results: From the data analysis, the main theme “integrity of designing and implementation” and five subthemes as the influencing factors, namely, The “inadequate resources,” “ambiguity in tasks and roles,” “attention to psychosocial atmosphere,” “considering of the delivery culture,” and “incomprehensive training and updating the plan,” were extracted.
Conclusion: This research suggests that the success behind implementing a plan in health-care system including the physiological delivery plan depends on the factors that are requiring should be identified and investigated from the designing stage to the implementation stage and after that. Thus, health system policymakers and planners are required to pay attention to diverse above-mentioned aspects in its designing and implementation.

Keywords: Health-care system, Natural childbirth, Qualitative study, Stakeholders

How to cite this article:
Azimi Lolaty H, Rezaie-Abhari F. Exploring stakeholder's perception about factors affecting on implementation of physiologic birth plan: A qualitative approach. J Nurs Midwifery Sci 2019;6:183-91

How to cite this URL:
Azimi Lolaty H, Rezaie-Abhari F. Exploring stakeholder's perception about factors affecting on implementation of physiologic birth plan: A qualitative approach. J Nurs Midwifery Sci [serial online] 2019 [cited 2022 Jan 19];6:183-91. Available from: https://www.jnmsjournal.org/text.asp?2019/6/4/183/266124

  Introduction Top

Following the World Health Organization (WHO) report, Iran has ranked second for the cesarian section (CS) delivery rate worldwide with its CS level as high as 41.9%.[1] Although it was reported to be as high as 70% in some parts of Iran.[2] Short-term maternal complication associated with CS may be include bleeding, increased risk for deep venous thrombosis, injury of urogenital or gastrointestinal organs, and postoperative infection. In the next pregnancies, there are increased risks of severe bleeding following uteroplacental complications.[3] The children's complication associated with CS are adverse respiratory, hypoglycemia, newborn sepsis, confirmed seizures, necrotizing enterocolitis, hypoxic-ischemic encephalopathy, admission to the neonatal intensive care unit, prolonged hospitalization, and death.[4] In addition, hence, Iran ministry of health set priority for a natural birth and introduced physiological method of birth for low-risk pregnant women.[5]

Delivery is a natural process that has to be carried out with the least medical interventions, and such interventions must be involved only in the cases when the mother's or the fetus' lives are in danger.[6] Then, to promote maternal health and lower unnecessary CSs, the ministry of health has begun to hold the physiological childbirth preparation classes and since 2008, it is being executed in several provinces including Mazandaran in the country.[7] In this regard, physiological childbirth is a delivery method starting spontaneously and progressing and in this natural process, without unnecessary interventions.[8] Some of the common reasons for intend to CS instead of vaginal delivery are fear of delivery,[9] the possible harm to the baby [10],[11],[12] and the mother, fear of severe pain during the vaginal delivery.[12],[13]

The physiological delivery facilitating plan has its own strengths and weaknesses so that in a research evaluating physiological delivery plan (2009), it was revealed that this plan requires revision in terms of the implementation environment and field.[5] Associated with physiological delivery plan, some qualitative studies [5],[14],[15] have been performed, though not being sufficient for explaining the factors influencing the optimal implementation of the plan.

Overall, due to lack of a study deeply surveying all the influential factors (inhibiting – facilitating) involved in the physiological delivery plan; as well as regarding this matter that the qualitative studies are appropriate to deeply analyze the factors influencing the outcomes and are the foundation for developing conceptual frameworks for the evaluation and the pathological dimension of the interventional programs.[16] Consequently, the aim of this study was to outline the factors affecting the physiological delivery program from health-care stakeholders' point of view.

  Materials and Methods Top


A qualitative approach and content analysis method of Graneheim and Lundman.[17]

Participations and setting

The participants were 21 (2 men and 19 women) out of the health-care stakeholders. In the research, the stakeholders included: nine mothers after physiological delivery, three obstetricians and gynecologists, six midwives and doula midwife, and three administrators of the physiologic delivery plan in the field of health-care management of Mazandaran University of Medical Science, being purposefully selected and participating in the study.


The data have been collected through deep semi-structured interviews and concurrent with collecting the data, their analysis has been done comparatively using the conventional qualitative content analysis method. The participants have been interviewed individually and also through participating in a focus group session. By prior coordination with the participants, the interview time was scheduled, and the approximate interview duration of 23–90 min and on average, 46 was established. The interview started with a general question designed as the interview guide and included the open-ended and detailed answer. The subjects' answers guided the interview process to achieve the main study goal. The initial main question in this interview was posed based on the participants' status and role in the plan. For example, a participating mother was asked: Regarding this point that you underwent physiological labor, “would you please tell us about your experiences in this respect?” Then, the guiding and probing questions are posed for a deeper understanding of the effective factors, with some questions such as “Can you explain more about this subject based on your experience?” “What does it mean?.” Data gathering continued until data saturation achieved, and no new information discovered in data analysis.

Data analysis

By the participants' agreement, all interviews were recorded on an MP3 player and written down word by word as being listened to several times and typed on word software and analyzed. The data analysis process followed the stages defined by Graneheim and Lundman.[17] Then to generally perceive the interview content, the whole interview text was read several times, and after that, the meaning units written in the text were defined and extracted in the form of condensed meaning unit. Subsequently, these units were explained as codes, categories, subcategories, and finally, as the themes.

In order to increase the data credibility, Lincoln and Goba's criteria [18] were followed. Credibility was achieved by being engaged for more than a year, checking interpretations' accuracy, and conformity with the participants' experiences and modifying the codes not reflecting what the participants stated (member check). After writing down the conducted interviews along with the accompanied codes, the emerging concepts and categories were controlled by two qualitative research experts. For providing the findings' transferability or fittingness, in addition to comparing the findings of the present study with those of other studies and sampling with maximum variety, the obtained findings were presented with seven individuals not participating in the research, confirming the findings' fittingness.

Ethical considerations

At the beginning of the interview, the participants were informed about the study objectives, the methods, and taking care of the sensitive data and their freedom for inclusion or exclusion from the study. The participants' oral and written informed letter of consent and their permission for recording their dialogue was acquired. The time and location of the interview were arranged with the participants according to their willingness for sufficient chance for conversation and participating in the interview. The ethical code is 1293.

  Results Top

In this study, the mean (standard deviation) working history of the health-care practitioners was 20.28 (9.01), and the mean (standard deviation) age of the participating mothers was 26 (1.63), the mothers' educational level was reported as 86% undergraduate and 14% graduate.

From the data analysis, the main theme “integrity of designing and implementation” and five subthemes as the influencing factors, namely, the “inadequate resources,” “ambiguity in tasks and roles,” “attention to psychosocial atmosphere,” “considering of the delivery culture,” “incomprehensive training and updating the plan,” were extract [Table 1]. Some of the statements presented by the participants about the emerged subthemes are as the following:
Table 1: Final codes, categories, subthemes, and main theme about factors affecting on implementation of the physiologic birth plan

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Inadequate resources

The adequacy of implementation context with its organizational and meta-organizational dimensions verifies that to implement a plan successfully, it is required to pay special attention to the implementation background and context. This category has described the effect of adequacy or lack of adequacy of the implementation context in designing and implementing the plan, which plays an important and key role in the plan's success. The statements of all participants unanimously are somehow indicative of the plan implementation context not being prepared.

An authority considered instability and lack of a united and integrated policy in the relevant organizations and their plurality despite efforts behind conformity in the plan implementation, as the factors hampering the success of a plan:

“Changing policies and lack of a single policy in the service providing departments, the multiplicity of decision-making in the country and the various policies existing for the provision of health services will pave the ground for this plan not to succeed.”

On the one hand, the plan's financial dimension's credit deficit and ambiguity, manpower and unpredicted physical space such as labor delivery room and the congestion existing in the maternity environments have been of other inhibiting factors in the plan implementation. In this respect, for instance, one of the participants stated:

“Health package wants to develop and improve the delivery blocks. However, well, the credit is not so much to let you make general and major changes.”

In this regard, another participant talked to the obstetrician this way: “I am alone and I cannot deal with everything, so the human resource isn't sufficient. Indeed, we have 2 residents for so many patients in the educational hospital, we cannot really get to them, and we get worn out.”

Ambiguity in tasks and roles

The ambiguity of the tasks and roles are another factor that undermined the integrity of designing and implementation of the plan [Table 1].

In this regard, one of the participating midwives said:

“The problem we see now is that most midwives are ignored, I have been in healthcare at least for 15 years and I used to deliver babies with closed eyes but it's a long time I am just watching.”

Another participant stated: “The midwives' office is devoid of clients, why has midwives' activity got dull? Why? They don't even earn enough for paying their office rent. Why our midwives have reached this point?”

Attention to psychosocial atmosphere

In this subtheme, a range of common feelings, pleasant and unpleasant feelings and also their induced psychosocial challenges are revealed, which are experienced by all stakeholders in various manners.

The most significant pleasant experiences in this regard have been those of mothers in physiological delivery, described this way: “That moment was very weird for me and I always want and like to experience childbirth stage again.”

The praise and encouragement by others has been a psychosocial consequence called an enjoyable experience by a participating mother: Physiological delivery that was sweet for me, then all loaded me messages as “well done”! Stating as, “We couldn't believe you did it, not all girls today can go through it.”

Paying attention to the mother's psychological needs and making efforts to resolve them is the case required to be considered in the plan. In this regard, a participating mother talked of a doula midwife attending there and her role in making her peaceful: “You know ma'am, (naming a doula midwife) supported me through her words, it was relaxing.”

The manner of caring behaviors during childbirth can have important effects on the mother. In this regard, a participant said: “That woman who came to take blood sample was very affable, she approached and all of the time told me it was close and raised my spirit.”

Understanding and observing the mental challenges of the mother is one of the significant psychosocial aspects. A mother described her mental states as it follows: “Under the conditions you are in pain, then you feel maybe you're on the verge of death and not to get to see your infant, these constantly cross your mind, you think what if I don't see my infant. What if I die? You are always thinking about these.”

The desire for independence in life is a desirable psychosocial feature needed to be considered. About this, a participating mother stated: “I saw in physiological labor, you immediately got to stand on your feet, you could hug your infant, you got to run your chores. I couldn't accept to undergo CS and have another person running my errands.”

Considering the facilitating role of the spouses and the doula midwifes in mother's decision for the physiological delivery has been expressed in various forms:

A mother said: “My hubby said, Whatever you think, you can if you have the ability. I am agreeing: then the mother continued” I also heard normal labor is much better. Then he backed me. And the other said “One thing helping me more to decide about physiological delivery was the doula midwife.”

Healthcare personnel's sense of satisfaction with implementing the plan is another critical psychosocial aspect in this regard. A participant described this feeling in the best way: “I was relishing this sense so much that after years I just perceived the meaning of midwifery.”

The possibility of the obstetrician, gynecologist, and midwife being exposed to unwanted events and stresses of conducting normal delivery and its subsequent legal issues are of the important psychosocial issues, which intervenes as a significant barrier to the plan implementation and has been stated by a participant: “Some obstetrician, gynecologist and midwife don't like labor induced stress and the legal issues have got really too many. Then they don't allow labor phase to pass spontaneously, because they don't want to get stressed so they intervene by CS.”

One of the psychosocial aspects is the managers' attitude and belief in implementing this plan. A participant expressed so in this respect: “If we change the attitude of the head of the hospital, that person can help us in this direction to make the physiological delivery plan proceed well.”

Considering of the delivery culture

In the current research, this subtheme points out the dominant labor culture and non-caring behaviors that somehow can lead to utilizing unnecessary interventions in the labor. A participant said: “The mentality and negative mindset of the society toward girls and woman at the gestation age is that normal labor is accompanied with high pain and that the infant may get mentally retarded.”

Noncaring behaviors surrounding normal delivery is of the cases stated as an unfavorable culture among those inclined to natural delivery and a barrier for taking measures for physiological delivery: “I had heard too much about those laboring naturally in the hospitals, as they are mistreated and it preoccupied my mind, but when I came to the class, I found out it isn't due for such things to happen.”

The physiological delivery experience was a pleasant sense encouraging these mothers to participate in the formation of a right culture. In this respect, a participant said: “After that, for whoever I described, they said they'd like to go through such labor again.”

One of the cases as an important and influential factor fostering a culture in the field of physiological delivery is the common belief at various dominant levels of health-care system and considered as an inhibiting factor. A participant stated: “They (the obstetrician, gynecologist and midwife) themselves haven't come to this belief that physiological delivery has to dominate CS.”

Incomprehensive training and updating the plan

This subtheme mentions two significant dimensions in a plan included: The role of basic training, continuous and comprehensive training and the use of research results for updating the plan.

A participant stressed the significance of basic training's role and stated: “A resident or physician who graduates have to be trained in the training course of physiological or natural delivery, as well as according with “patient-oriented view on the pregnant women” they can't work and (their mind) is inclined toward CS and such procedures.”

Applying the studies derived results in designing the programs, utilizing the study extracted results at all levels and an evidence-based approach for the officials, the obstetricians, gynecologists and midwives and mothers, and moreover, using research-based standard tools and methods like partograph, refer to the plan research adequacy dimensions and lacking it is taken as research gap. Regarding this, a participant expressed: In the meetings, the specialists, the head of department and faculty member attended without studying and said, “The pelvis of the mothers in the city… (name of a city) isn't suitable for natural delivery. It can be defended if studied. We suffer from research gaps in this respect that has to be bridged.”

“Integrity of Designing and Implementation” as the main theme, confirms the presence and or absence of the factors influencing the plan's outcome from the time of designing a plan until achieving its goals. Furthermore, in the case of its presence or adequacy, the plan will be implemented properly, and otherwise, the plan will go on with unfavorable problems, and complications and or its continuation will be prevented.

  Discussion Top

Exploring health-care stakeholders' perception about the physiological delivery plan implementation by content analysis method has yielded a main theme and five subthemes. The discussion induced sub-themes have been presented in the following:

Inadequate resources

This study has revealed that the plan has been suffering from inadequate resources in the implementation context. Regarding this, a study evaluating the maternity facilitation plan in the selected hospitals in Isfahan suggested that this plan requires reviewing in terms of the implementation setting and context.[5]

About the importance of the implementation context in promoting natural delivery, the information resources emphasized the necessity behind providing some arrangements for the promotion of normal delivery.[19]

Ambiguity in tasks and roles

The clarity of the job description tasks is of other categories extracted from this research. Ambiguity in the roles and its due challenges signify the requirement behind the clarity of tasks, especially for the midwives, whether the employed midwives or the doula midwives, in this study. Although in our study, some midwifes stressed on ambiguity in tasks and roles, the authorities stressed the midwives' critical role in preserving the physiological delivery and highlighting its place in the health-care centers.[19]

Attention to psychosocial atmosphere

Interviewing the participating mothers, plenty of gratifying experiences has been reported in the present study. Regarding this, analyzing the primiparous women's anxiety and satisfaction in the two physiological and routine delivery methods displayed the anxiety level at various hours in the physiological group as being meaningfully lower than that of the control group (P = 0.001) and over 28% of the physiological group mothers were satisfied with the labor process, the scores' difference was significant in these two methods (P < 0.000). In the above study, it has been concluded that the widespread use of the physiological delivery method will result in the promotion of the mothers' health quality indicators.[20] Another study suggested that in the physiological delivery, the women meaningfully showed higher satisfaction, lower fatigue, and more energy compared with those experiencing routine labor (P < 0.001).[21]

In addition, in this research, some of the participants were dissatisfied with the family or spouse's attendance and preferred the attendance of a doula midwife to that of their family. In this respect, Kennel assumes that the family and relative's support is not always a delightful experience, this probably can be due to the cultural differences and the attendant's performance.[22]

The current research showed some of the participating mothers were annoyed by the personnel's noncaring behaviors and reported it as very undesirable. About noncaring behaviors and its effects on the mother in a qualitative study done in Australia in 2015, regarding the impact of nonsupportive environment on the personnel's behavior and its effects on the mother quoted by the midwives indicated that a nonsupportive environment can be a potential threat to natural delivery. Hence, a nonsupportive environment can threaten and intimidate the mother. The same study revealed that the factors such as a supporting environment, the midwife's attitude and interest in performing physiological delivery are some of the facilitating factors in the personnel's performance.[23] In addition, the study denoted that motivation and interest in career, unity and integrity among the obstetricians, gynecologists, and midwives have been mentioned as some of the facilitating factors in the plan implementation.

In this study, the requirement of relaxation in the childbirth process has been reported by the participating mothers. In this respect, the study on the effect of using a communication and care continuation model in providing maternal comfort showed that the tranquility experience has been associated with the maternity satisfaction with the care continuation and appropriate relationship.[24] It is important to pay attention to the psychological, informational, social and relational demands and expectations, the mothers' dignity, safety, and medical requirements by the health-care personnel, especially by the midwives to provide high-quality care.[25]

Considering the delivery culture

This subtheme points to the effects of dominate delivery culture and noncaring behaviors on the plan implementation.

The studies also suggested that the existing attitudes and culture in the childbirth field have influenced the mothers' decision for choosing delivery type. A review on the causes behind the cesarean section indicated a negative attitude toward normal delivery and positive attitude toward cesarean section and medical reasons have been of the most prevalent causes for decision for choosing delivery type.[26] About the importance behind the role of culture, a study showed the big difference in the rate of cesarean section from region to region was due to the cultural differences,[27] ignorance, beliefs, behaviors, and inappropriate attitudes [28] and also cultural misconceptions have been stated as the significant factors for selecting delivery type.[29]

Comparing health-care personnel's attitude and pregnant women's view about the two methods known as cesarean section and normal delivery implied that the health-care personnel's attitude toward natural delivery was more positive compared to that of the pregnant women.[30] Another research also suggested that paying attention to various factors influencing labor style and the patients fearing labor pain and making labor experience pleasant and fostering the culture are especially critical.[31]

In this regard, the present study exhibited that fearing and negative attitude toward natural labor originates from the common culture based on the individual's previous experiences and other people's experiences. In other side, the mother who delivered by spontaneous labor presented positive attitude to their delivery, a study also revealed, respectively, 21.5% and 78.5% of the women had a negative and positive attitude toward natural childbirth.[32] Some researches showed the sources of forming mothers, attitude and selecting of their delivery method. The study showed that the women's knowledge has resulted more from others' experiences that may not be scientifically correct.[27] Another study also denoted that the majority of the mothers are influenced first by the physicians, and next by the health staff, spouse, mother, and friends in their decision to select the delivery type. Moreover, the motivation for obedience also follows the same order.[33] These results indicate the significance of the role of the physicians and kith and kin in promoting natural delivery. In addition, the importance of fostering delivery culture has been repeatedly emphasized in the studies.[6]

About the effect of the physiological delivery training courses in this study, the mothers, particularly, stressed the effect of the training courses on increasing knowledge and changing attitudes toward labor. Despite other studies being compatible with the present research,[34],[35] some of the studies have not revealed the role of the training courses influencing attitude's change.[36],[37] This difference in the results can probably come from the training content, the opportunity of more interaction with the instructors and other mothers and transferring experiences, creating the opportunity to learn from others' experiences using novel methods, such as childbirth tours.

Incomprehensive training and updating the plan

The role of basic training, continuous training from designing thorough implementation and also using evidence in various stages of a plan is of the most important findings from this theme.

In this research, “patient-oriented view on the pregnant women” has been mentioned as a dilemma and barrier in training natural or physiological delivery to medical students. In this respect, a phenomenological study indicated that to outline the factors influencing the midwives' experiences in performing natural labor in the women with lower risk of pregnancy, suggested that the concept “the risk of adverse culture” refers to the performance in an environment where the dominant attitude toward gestation is considered as the condition potentially accompanied with the problems and implications.[23] In other words, the theme “the risk of adverse culture” corresponds to “patient-oriented view on the pregnant women” in the education of the medical students in this study.

Thus, accordingly, providing unnecessary medical interventions in labor is justifiable due to this attitude. To expand this attitude during these years has led to altering the natural labor service provision standards and restricting natural labor to medical, pharmaceutical, and surgical interventions such as other hospital practices. This labor style not only has affected the service provision system but also has changed the educational system for doing natural labor.[1]

In the present study, the haste in hospitalization has been attributed to lack of training, which itself has been annoying the pregnant mother. Regarding this, a qualitative study found out that “the pressure of time,” approves this fact that the women hospitalized sooner received the interventions such as artificial rupture of membrane and Sentosinone injection more.[23]

The role of studies in this plan fields has been emphasized in this research by the some of the participants. In accordance with this study, some researchers stressed on the requirement of conducting some studies with accurate methodology.[38]

In this research, the theme “updating the plan” has concentrated on utilizing evidence-based and the WHO recommended methods. Moreover, the role of partograph has been pointed out. In this respect, analyzing the effects of drawing partograph during labor, the studies revealed that applying it leads to boosting the quality of the cares, dominating the labor progression process, and also it is useful in care audit.[38] On the other hand, another research indicated that using partograph in full-term women did not have any role in CS increase or decrease.[39]

One of the limitations in this study was the psychological condition and lack of sufficient time of the some participants which might affect the interview process, in this case, has tried to control a friendly atmosphere and to consider their conditions for the interview time, especially for the managers.

  Conclusion Top

The study main theme was the “integrity of designing and implementation.” This study also revealed some factors which influence the plan's outcome from the time designing until achieving the plan goals. In other words, the plan getting placed in two spectra, i.e., success and failure depend on these factors' adequacy or lack of adequacy such as allocation resources, clarity of tasks and roles, psychosocial atmosphere, delivery culture, comprehensive training, and updating the plan.

Authors' contribution

All authors contributed to this research.

Financial support and sponsorship

This study financially was supported by Research Deputy of Mazandaran University of Medical Sciences, Mazandaran Iran.


The present study holding the code 1293 has been done through the support by the Deputy of Research of Mazandaran University of Medical Sciences. Hereby, we sincerely appreciate the honored research vice-president of the university, the respected authorities of the university, and the participants helping us in this study.

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