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Clinical Audits: A pratical strategy for reducing cesarean section rates in a general hospital in Tehran, Iran
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
2012 (English)In: The Journal of Reproductive MedicineArticle in journal (Refereed) Published
Place, publisher, year, edition, pages
Keyword [en]
cesarean section, clinical audit, Iran
National Category
Obstetrics, Gynecology and Reproductive Medicine
URN: urn:nbn:se:uu:diva-307484OAI: oai:DiVA.org:uu-307484DiVA: diva2:1047081
Available from: 2016-11-16 Created: 2016-11-16 Last updated: 2016-11-23
In thesis
1. Beyond ‘Cesarean Overuse’: Hospital-Based Audits of Obstetric Care and Maternal Near Miss in Tehran, Iran
Open this publication in new window or tab >>Beyond ‘Cesarean Overuse’: Hospital-Based Audits of Obstetric Care and Maternal Near Miss in Tehran, Iran
2016 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

With one in two women delivering surgically, Iran has one of the highest rates of cesarean section (CS) worldwide. CS overuse in low-risk pregnancies potentially exposes women to Maternal Near-Miss (MNM) morbidity with minimal health benefits. This thesis studied obstetric care quality and MNM at hospitals with high rates of CS in Tehran, Iran.

In Study I, we investigated whether audits of CS indications and feedback influenced CS rates at a general hospital. Subsequent to the audit, a 27% reduction in the risk of primary CS was found.

In Study II, characteristics of MNM were investigated at university hospitals between 2012 and 2014. During a 26-month period, 82 MNM cases were identified using the WHO MNM approach. Severe postpartum hemorrhage (35%), severe preeclampsia (32%), and placenta previa including abnormally invasive placenta (10%) were the main three causes of MNM. Iran has a huge influx of migrants from Afghanistan. Women with antepartum CS and those who lacked health insurance, almost all Afghans, had increased risk of MNM.

In Study III, audits examined whether MNM care quality differed between 54 Iranians and 22 Afghans and whether near-miss events were preventable. A majority of MNM cases (62%) arrived at hospital in a moribund state and obstetric care was more suboptimal for Afghans than Iranians (adjusted odds ratio 5.1, 95% confidence interval 1.2–22.6). Moreover, MNM was commonly (71%) potentially preventable and professionals with suboptimal practice were involved in 85% of preventable cases.

In Study IV, a qualitative interview study was conducted to explore care experiences of Afghan MNM survivors. Discrimination, insufficient medical attention, and ineffective counseling were the main experiences. To a lesser extent, poverty and low education were perceived as contributing factors to delays in accessing care.

This thesis emphasizes the importance of high-quality care for preventing undesirable maternal outcomes. The audit method along with interviews was useful to determine quality and equity gaps in care provision. Policymakers and professionals should consider these gaps when structuring programs to reduce adverse maternal outcomes.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2016. 95 p.
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1280
Caesarean section, maternal near miss, clinical audit, care quality, care experience, Afghan migrants, Iran
National Category
Health Care Service and Management, Health Policy and Services and Health Economy Obstetrics, Gynecology and Reproductive Medicine Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Medical Science
urn:nbn:se:uu:diva-308081 (URN)978-91-554-9757-6 (ISBN)
Public defence
2017-01-18, Rosénsalen, Kvinnokliniken, Ing 95-96, Akademiska Sjukhuset, Uppsala, 13:00 (English)
Available from: 2016-12-22 Created: 2016-11-23 Last updated: 2016-12-28

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Mohammadi, Soheila
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