Evaluation of the World Health Organization intrapartum care model implementation: a parallel convergent mixed study

Abstract

Abstract Introduction: In 2018, World Health Organization’s recommendations regarding intrapartum care emphasized the quality of the care, with the intent of providing a positive experience. The span of these recommendations goes beyond mortality prevention and includes an attitude based on women’s rights during childbirth and optimizing health and comfort for mothers and their infants. The aim of this study is to examine the impact of implementing this care model in two stages: quantitative (controlled randomized clinical trial) and qualitative (content analysis) on childbirth experience, quality of care during labor and childbirth, fear of childbirth (primary outcomes), and some maternal and neonatal outcomes. Methods: The present study uses a mixed method with a parallel convergence approach, including both qualitative and quantitative phases. The quantitative phase of the study was a randomized controlled clinical trial conducted on 108 hospitalized pregnant women for the first or second childbirth in the maternity departments of Al-Zahra and Taleghani hospitals in Tabriz city. Participants were randomly assigned to two groups, the intervention group (54 women receiving care based on the World Health Organization's model of intrapartum care) and the control group (54 women receiving routine hospital care). Partograph charts were completed during labor for the participants. The Fear of Childbirth Questionnaire was completed before the start of the active phase (before the intervention) and after the intervention at 7-8 cm dilation. The participants in both groups were followed up 4-6 weeks after childbirth, and the childbirth experience questionnaire, postpartum depression questionnaire, perceived stress questionnaire, quality of care during childbirth questionnaire, desire for future childbearing checklist, and exclusive breastfeeding were completed. Independent t-tests, Mann-Whitney U test, and ANCOVA with parity variable adjustment and baseline score were used for data analysis regarding fear of childbirth. In the qualitative phase, the experiences of childbirth were explored through the implementation of a childbirth care model. Information was collected through individual in-depth interviews using the purposive sampling method, and analysis was conducted using thematic content analysis. Results: There was no significant difference between the two groups in terms of demographic and midwifery characteristics, and also basic fear of childbirth (P<0.05). Analysis for the type of childbirth and newborn below 7 Apgar score variables on 54 people in both groups, for the variables of fear of childbirth and quality of care during childbirth on 49 people in the intervention group and 50 people in the control group (5 people in the intervention group and 4 people in The control group gave birth by cesarean), and for other variables, 53 people in both groups (dropout of one person in each group due to non-response to the call in the follow-up 4-6 weeks after delivery) were performed. The mean of the childbirth experience total score was significantly higher in the intervention group (AMD (95%CI): 7.0 (0.6 to 0.8), P<0.001). The mean of the intrapartum care quality score was significantly higher in the intervention group (AMD (95% CI): 7.0 (4.0 to 10), P<0.001). Additionally, the mean for the post-intervention fear of childbirth score was significantly lower in the intervention group (AMD (95% CI): -16.0 (-22.0 to -10.0), P<0.001). No significant difference was observed between the two groups regarding mean scores of depression (P=0.352), PTSD symptoms (P=0.166), duration of active phase of childbirth (P=0.768), second phase (P=0.395), third phase (P=0.743), the frequency of vaginal childbirth (P=0.838), below 7 Apgar score (P=0.243), desire for subsequent childbearing (P=0.115) and exclusive breastfeeding 4-6 weeks postpartum (P=0.473). The analysis of the related qualitative data of women’s experiences led to the development of five main categories including pain relief, peace of mind, capacity building, positive attitude, and unmet needs. Conclusion: The implementation of the World Health Organization's model of care during childbirth has been effective in improving childbirth experiences, satisfaction with the quality of care, and reducing fear of childbirth in labor and delivery. To understand how respectful and quality care during labor and childbirth can be prioritized, and how non-recommended practices such as routine episiotomy or fundal pressure can be eliminated from clinical settings, further studies are needed. Additionally, obtaining the perspectives of caregivers and midwives on the implementation of this care model can be influential in identifying challenges and barriers to its implementation, towards improving women's unsatisfactory childbirth experiences.