Abdolalipour et al.

BMC Pregnancy and Childbirth (2024) 24:283 BMC Pregnancy and Childbirth
https://doi.org/10.1186/s12884-024-06449-4

RESEARCH Open Access

Effect of implementation of the WHO

intrapartum care model on maternal
and neonatal outcomes: a randomized control
trial
Somayeh Abdolalipour1, Shamsi Abbasalizadeh2, Sakineh Mohammad-Alizadeh-Charandabi3,
Fatemeh Abbasalizadeh2, Shayesteh Jahanfar4, Fatemeh Raphi5 and Mojgan Mirghafourvand3,6*

Abstract
Background In 2018, the World Health Organization published a set of recommendations for further emphasis on
the quality of intrapartum care to improve the childbirth experience. This study aimed to determine the effects of the
WHO intrapartum care model on the childbirth experience, fear of childbirth, the quality of intrapartum care (primary
outcomes), as well as post-traumatic stress disorder symptoms, postpartum depression, the duration of childbirth
stages, the frequency of vaginal childbirth, Apgar score less than 7, desire for subsequent childbearing, and exclusive
breastfeeding in the 4 to 6 weeks postpartum period (secondary outcomes).
Methods This study was a randomized controlled trial involving 108 pregnant women admitted to the maternity
units of Al-Zahra and Taleghani hospitals in Tabriz-Iran. Participants were allocated to either the intervention group,
which received care according to the ' ‘intrapartum care model, or the control group, which received the’ ‘hospital’s
routine care, using the blocked randomization method. A Partograph chart was drawn for each participant during
pregnancy. A delivery fear scale was completed by all participants both before the beginning of the active phase (pre-
intervention) and during 7 to 8 cm dilation (post-intervention). Participants in both groups were followed up for 4 to 6
weeks after childbirth and were asked to complete questionnaires on childbirth experience, postpartum depression,
and post-traumatic stress disorder symptoms, as well as the pregnancy and childbirth questionnaire and checklists
on the desire to have children again and exclusive breastfeeding. The data were analyzed using independent T and
Mann-Whitney U tests and analysis of covariance ANCOVA with adjustments for the parity variable and the baseline
scores or childbirth fear.
Results The average score for the childbirth experience total was notably higher in the intervention group (Adjusted
Mean Difference (AMD) (95% Confidence Interval (CI)): 7.0 (0.6 to 0.8), p < 0.001). Similarly, the intrapartum care quality
score exhibited a significant increase in the intervention group (AMD (95% CI): 7.0 (4.0 to 10), p < 0.001). Furthermore,
the post-intervention fear of childbirth score demonstrated a substantial decrease in the intervention group (AMD

*Correspondence:
Mojgan Mirghafourvand
[email protected]
Full list of author information is available at the end of the article

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Abdolalipour et al. BMC Pregnancy and Childbirth (2024) 24:283 Page 2 of 15

(95% CI): -16.0 (-22.0 to -10.0), p < 0.001). No statistically significant differences were observed between the two groups
in terms of mean scores for depression, PTSD symptoms, duration of childbirth stages, frequency of vaginal childbirth,
Apgar score less than 7, and exclusive breastfeeding in the 4 to 6 weeks postpartum (p > 0.05).
Conclusion The intrapartum care model endorsed by the World Health Organization (WHO) has demonstrated
effectiveness in enhancing childbirth experiences and increasing maternal satisfaction with the quality of obstetric
care. Additionally, it contributes to the reduction of fear associated with labor and childbirth. Future research
endeavors should explore strategies to prioritize and integrate respectful, high-quality care during labor and childbirth
alongside clinical measures.
Keywords Intrapartum care, Childbirth experience, Fear of childbirth, Quality of care

Background on ' ‘women’s rights during childbirth and optimizing

The majority of the 140 million childbirths happening health and comfort for mothers and their infants [6, 7].
each year around the globe are among women with no In this regard, the WHO recognizes intrapartum care as
initial risk factor for themselves or the newborn [1, 2]. a platform that allows experienced care providers within
Still, childbirth itself is crucial for the survival of both the a well-functioning system to deliver clinical and non-
mother and the infant, as any complication could severely clinical measures that are respectful, individual-specific,
increase the risk of morbidity and mortality. In pursuit mother-centered, and practical, to optimize the mother’s
of the third goal of sustainable development (To ensure and the infant’s birth outcomes. To achieve this goal, the
healthy lives and promote well-being for everyone at all WHO has suggested an intrapartum care model that
ages), global programs have increased their focus on the puts the mother and her infant at the center [7]. The nine
matter to ensure that women and their newborns would components of this model are as follows: 1) Respectful
not only survive a potential birth complication but also labor and childbirth care; 2) Receiving emotional support
reach their full potential for a healthy life [3]. from a companion of choice; 3) Effective communication
Despite the years-long discussions and studies, there with staff; 4) Pain relief strategies; 5) Regular labor moni-
is still no standardized definition of " normal” childbirth. toring, documentation of events, audit, and feedback; 6)
Recent studies have suggested that the benchmark for Oral fluid and food intake; 7) Mobility in labor and birth
normal labor, devised using the results of studies dating position of choice; 8) Pre-established referral plan; 9)
back more than 60 years, may not be suitable for mak- Continuity of care [7].
ing decisions for every woman [4, 5]. In the past two Healthcare specialists responsible for designing local
decades, there has been a considerable surge in the usage and national health protocols and directly providing
of diverse interventions to initiate, accelerate, control, or care for pregnant women and their newborns are the
monitor the physiological process of childbirth, aiming to primary targets for this model; these include midwives,
improve the outcome for both mothers and infants [3]. In nurses, general practitioners, obstetricians, and mother
some regions, women and newborns die due to limited and child health program managers [3]. As outlined in
professional care, while in other regions, they suffer from the intrapartum care recommendations of the WHO,
unnecessary, redundant, or even harmful interventions the experience of the care is as crucial as providing clini-
that stem from medicalized childbirth [6]. This increase cal care in reaching the desired individual-based results
in the medicalization of childbirth processes weakens [8]. However, non-clinical measures during childbirth,
the ' ‘woman’s ability to give birth and negatively affects such as providing emotional support via companionship,
her experience [3]. Most maternal care policies have rec- effective communication, and respectful care—which
ognized that all women and their infants must access may be relatively inexpensive, are not considered priori-
evidence-based, fair, compassionate, and respectful care ties in many healthcare centers [9]. Similarly, obstetric
during childbirth. However, what women experience options that respect women’s values and promote deci-
during labor and childbirth in many settings – both high sion-making in childbirth’s first and second stages are not
and low-income – is not positive and also, there is not constantly provided. These non-clinical aspects of care
universal access to fundamental interventions [7]. during labor and childbirth are crucial parts of the care
In 2018, recommendations of the World Health Orga- experience and should complement any essential clinical
nization (WHO) regarding intrapartum care emphasized intervention to optimize the quality of the care provided
the quality of the care, intending to provide recom- to the woman and her family [3].
mendations regarding intrapartum a favorable experi- The recommendations are based on the idea that by
ence. The span of these recommendations goes beyond using effective measures during labor and childbirth
mortality prevention and includes an attitude based and by avoiding ineffective (and potentially harmful)

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Abdolalipour et al. BMC Pregnancy and Childbirth (2024) 24:283 Page 3 of 15

interventions, healthcare providers can support women Inclusion criteria included being before the start of the
in achieving their desired physical, emotional, and mental active phase of childbirth and having a childbirth rank of
outcomes for themselves, their babies, and their family first or second childbirth. The exclusion criteria included
[7]. Efforts for improving respectful maternal care could indications for cesarean section (e.g., non-cephalic pre-
be counted as one of the admirable and supplementary sentation, multiple pregnancies, placenta previa, etc.);
attributes of a healthcare system, and investing in such obstetric conditions such as post-cesarean vaginal child-
fields can have a significant direct impact on the qual- birth, pre-eclampsia; underlying conditions such as
ity of care delivered to mothers [10]. On the other hand, cardiovascular disease and diabetes, etc.; stillbirth or
mothers who have experienced low-quality care may be abnormal fetus; intellectual disability or other mental dis-
hesitant to use healthcare services for future pregnancies orders of the mother; and loss of a close relative in the
and could also discourage potential users by sharing their past three months.
negative experiences [11].
Medical interventions have greatly influenced child- Sample size
birth in Iranian healthcare centers [12]. Furthermore, The determination of the sample size for this study was
most Iranian mothers (75%) report one or more instances conducted utilizing G-power, focusing on the variables
of non-respectful maternal care. More than half of them “fear of childbirth” and “childbirth experience”. Referring
stated that they did not even have the right to move dur- to findings by Shakarami et al. [16] on fear of childbirth,
ing childbirth or choose the most comfortable position with assumed values of M1 = 69.3, M2 = 55.44 (antici-
[13]. Given the growing agreement among general health pating a 20% reduction due to intervention between
specialists that midwifery care has an essential role in the measurement phases), SD2 = SD1 = 8.5, two-sided
providing high-quality service for mothers and infants α = 0.05, and Power = 90%, a sample size of 11 individu-
[14, 15], and also since no study could be found that had als was calculated. Furthermore, drawing from Ghanbari
analyzed all sections of the WHO’s recommended care Homayi et al.‘s [17] outcomes on the childbirth experi-
model, this study was conducted aiming to determine ence variable, assuming M1 = 2.71, M2 = 3.25 (presuming
the effects of implementing this model on the pregnancy a 20% increase due to intervention), SD2 = SD1 = 0.73,
experience, fear of childbirth, and the quality of intra- two-sided α = 0.05, and Power = 95%, a sample size of 49
partum care during labor and childbirth (primary out- participants was determined. Considering a 10% drop-
comes), as well as the duration of childbirth stages, the out rate, the overall sample size calculated for each group
frequency of vaginal childbirth, Apgar scores less than was 54 participants.
7, PTSD (post-traumatic stress disorder) symptoms and
postpartum depression, desire for a subsequent preg- Sampling and randomization
nancy, and exclusive breastfeeding in the 4 to 6 weeks Sampling began with women admitted to the maternity
postpartum period (secondary outcomes). ward using the convenience method after receiving the
code of ethics (Ethics code: IR.TBZMED.REC.1401.093)
Methods and registering at the Iranian Registry of Clinical Tri-
Study design and participants als (Code: IRCT20120718010324N69). After the women
This study was the randomized controlled trial section received a thorough explanation of the goals and meth-
of a thesis (a parallel convergent mixed-methods study) ods of the study, those who were eligible and interested
conducted from June 11, 2022, until June 27, 2023. The signed a consent form before completing the socio-
study population was pregnant women admitted to the demographic and obstetric characteristics question-
Taleghani and Al-Zahra maternity centers. Alzahra Hos- naires. The women were then assigned to the study
pital is a Medical Education and Research Center and groups before entering the active phase of labor. The
also, is one of the gynecological and obstetric referral allocation method was block randomization (stratified
centers in the northwestern region of the country. This based on the number of childbirths, including nullipa-
center has 10 labor and delivery rooms (LDR). Taleghani rous and second childbirth), with block sizes of 4 and 6
Hospital is another Medical Education and Research and an allocation ratio of 1:1. To ensure allocation con-
Center in Tabriz and generally, women with low-risk cealment, the intervention method was placed inside a
conditions are admitted there.This center has eight LDRs. series of consecutively numbered opaque envelopes. Due
Each LDR in these centers is equipped with woman and to the nature of the intervention, blinding the researcher
neonate resuscitation facilities, fetal heart rate monitor- and the participants was impossible. However, to ensure
ing, a warmer, a suction device, a bathroom, and a birth the blinding of the data collectors, the post-labor ques-
ball. Also, pharmacological pain relief methods are per- tionnaires were completed with the researchers’ aid. The
formed at the request of women. data were analyzed by a researcher blinded to the study
groups. Both groups of women were recruited from both

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hospitals. Women in the intervention group received the points were mentioned to the companion, and the
WHO intrapartum care model and those in the control researcher monitored their execution.
group received the routine care of hospitals but in sepa- 3. Effective communication with staff: the WHO
rate LDRs. considers communication effective if:

Intervention and follow-up a. Women and their families are informed of the
The researcher (a midwifery Ph.D. student) provided par- evidence, risks, and benefits attributed to methods,
ticipants in the intervention group with the intrapartum procedures, and utilizing/not utilizing technologies
care model recommended by WHO. With the approval and strategies during obstetric care; (b) Effective,
of the head of the maternity ward, care was provided respectful, and two-sided communication techniques
during labor, childbirth, and postpartum until the par- are employed, and women and their families are
ticipant was transferred to the postpartum ward. In cases respectfully listened to; The women and their
that needed consultation or faced unexpected high risk, families are allowed to take part in the decision-
obstetricians involved in the research (second and fourth making process according to their personal/familial/
authors) were contacted. The intervention included the cultural preferences [3]. The researcher considered
nine components of the WHO-recommended intrapar- All these items while providing care for the
tum care: intervention group.

1. Respectful labor and childbirth: To apply this part 4. Pain relief strategies: In this study, the researcher
of the intervention, sections of the Sheferaw et al. provided non-pharmacological pain relief techniques
(2016) respectful care questionnaire were used. such as teaching abdominal breathing with correct
The questionnaire’s subdomains indicate that care inhalation and exhalation, thermotherapy, changing
should be friendly, on time, non-discriminative, and the ' ‘mother’s position, and -with her consent-
non-abusive [18]. In delivering respectful care, the massage [20]. In cases requiring pharmacological
questionnaire encompasses measures to prevent pain relief methods, the obstetrician involved in the
physical harm or maltreatment, foster empathy, study approved and monitored the process.
address the mother by name, communicate in a 5. Regular labor monitoring, documentation of events,
language familiar to her, respect her beliefs and audit, and feedback: documentation of labor and
values, adhere to scheduled care delivery, and childbirth events was done by the researcher in
exhibit non-discriminative behavior throughout the addition to the staff. Additionally, the researcher
caregiving process. regularly and closely monitored the provided
2. Receiving emotional support from a companion obstetric care during labor, childbirth, and the first
of choice: With the approval of the head of the two hours after birth, and feedback was given when
maternity ward and the hospital’s supervisor, necessary. Monitoring included periodic fetal heart
women in the intervention group had a companion auscultation using Doppler, controlled uterotonics
of their choice present during labor. In cases (oxytocin or misoprostol) and umbilical cord traction
where the companion could not be present, the to prevent postpartum bleeding, delayed clamping of
researcher performed the decided tasks with the the umbilical cord, regular monitoring of the mother
mother’s approval. As outlined in a previous study regarding vaginal bleeding, uterine tone, and vital
[19], the suggested responsibilities of a companion signs [7] as well as documentation of labor accidents,
encompass supportive actions (remaining nearby, such as using a partograph form.
providing comfort, offering massages, displaying 6. Oral fluid and food intake: The companions received
kindness, offering encouragement and motivation). a list of recommended easily digestible foods and
Additionally, expected behaviors in response to fluids (drinking water, juices, dates, biscuits, and
signs of fatigue, stress, anxiety, crying, screaming, or cakes) to obtain. However, they were allowed to
other indications of the mother feeling overwhelmed consume anything they wished in small and frequent
are highlighted. Other recommendations include meals.
adhering to guidelines (such as wearing standard 7. Mobility in labor and birth position of choice:
attire, refraining from food and tobacco use, avoiding According to a previous study [21], the selected
contact with instruments, and notifying personnel positions for the intervention group in the first stage
when leaving the hospital), as well as recognizing of childbirth included sitting, walking, semi-sitting,
the right to request information from the staff. all-fours, and recumbent on the side (both sides).
Additional emphasis was put on respecting other Each of these positions, along with its benefits, was
women’s privacy. In the present study, all of these instructed to the mother by the researcher. They

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Abdolalipour et al. BMC Pregnancy and Childbirth (2024) 24:283 Page 5 of 15

were asked to start with the position they felt most fundal pressure to accelerate the second stage of child-
comfortable in and remain there for ten minutes birth- are also implemented.
before resting for ten minutes between positions. Throughout and following childbirth, obstetric data,
Additionally, they were instructed to have all five including the active phase duration of labor, durations
positions in mind during 4, 7, and 10-cm dilations. of the second and third stages of childbirth, and Apgar
The mobility guideline was based on a former study scores, were documented. Additionally, checklists evalu-
[22] and advised each woman in the intervention ating the success percentage of interventions were duly
group to walk for an average of one hour during completed. A childbirth fear scale was completed once
labor, divided into smaller but frequent occasions, before the active phase (to record the baseline fear of
by her endurance. If the mother was uncomfortable childbirth) and once in 7 to 8 cm dilation. The researcher
with this protocol, she decided on her mobility and was the childbirth agent for all women in the interven-
position during labor by herself. tion group. Participants in both groups were followed up
8. Pre-established referral plan: Higher-level referrals for 4 to 6 weeks after childbirth and completed the preg-
were unnecessary since the study took place in nancy and childbirth questionnaire (PCQ), childbirth
specialty hospitals. Still, regular assessments during experience, Edinburgh’s postpartum depression scale,
labor, the entire childbirth process, and early and PTSD symptoms scale, as well as the desire for sub-
postpartum were performed for potential cases sequent childbearing and exclusive breastfeeding check-
that required consultation with obstetricians to lists. The interviews were conducted at the women’s
be identified as soon as possible and appropriate preferred locations, mostly at healthcare centers where
decisions to be made without delay. Due to the vital they had their electronic files. One of the interviews took
importance of regular monitoring during labor and place at the clinic of the maternity hospital, where the
childbirth, this section of intervention was provided women had come for postpartum visits and check-ups.
for both groups of intervention and control.
9. Continuity of care: For women in the intervention Study outcomes
group of the present study, continuity of care was in Primary outcomes Childbirth experience, intrapartum-
the form of providing care during labor, childbirth, as care quality, and fear of childbirth.
well as postpartum care (first day) by the researcher
in the maternity ward, and on the tenth and fortieth Secondary outcomes Postpartum depression, PTSD
days in the clinic of the educational-therapeutic symptoms, duration of childbirth active phase, duration
center (in case of attendance) and (if attendance was of childbirth second stage, duration of childbirth third
not possible) by phone. stage, normal vaginal childbirth, Apgar score less than 7,
desire for subsequent childbearing, and exclusive breast-
Women in the control group received routine care from feeding in the 4 to 6 weeks postpartum period.
the maternity ward staff and obstetric residents. This
standard care primarily includes medical approaches Data collection and scales
and attempts to accelerate the process through interven- The socio-demographic characteristic question-
tions such as oxytocin injection. Despite the clear guide- naire This questionnaire included questions about age,
lines on what can be considered respectful care, not all age of spouse, marriage status, duration of the marriage,
women receive this kind of respectful care in these cen- BMI, woman and her spouse’s education and occupation,
ters. Furthermore, the emphasis on medical and clinical housing status, and income status of the family.
care often overshadows the importance of supportive
practices, such as allowing the mother to choose her The obstetric characteristic questionnaire This ques-
position, encouraging walking during labor, facilitating tionnaire included questions regarding gestational age,
a companion of choice, promoting the use of non-phar- number of pregnancies and childbirths, previous abor-
macological pain relief methods, and engaging in joint tions, attending classes during pregnancy, whether the
decision-making. A companion of the ' ‘woman’s choice pregnancy is wanted, type of possible previous childbirth,
is not routinely allowed during childbirth. Additionally, history of difficult labor, spouse support during preg-
continuity of care by a specific care provider is often not nancy, transfer the baby to NICU, skin to skin contact,
possible, as the labor staff, childbirth agent, and postpar- breastfeeding in the labor room, and intention to have
tum staff are usually different. In these maternity centers, cesarean in the next childbirth.
midwives have to work in an overmedicalized environ-
ment, which in addition to taking care of several women, The success rate of the intervention checklist This
severely limits the opportunities for midwifery-led care. checklist was designed to measure how successful each
In some cases, non-recommended measures -such as intervention section was for each ' ‘woman’s labor. The

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ratio was calculated by providing a yes (if the intervention seven items are based on the intrapartum care experi-
was made) or a no (if the intervention was not made due ences of women who have recently given birth (Alpha
to the ' ‘mother’s decision or other reasons). In compo- Cronbach = 0.88). Questions are formulated in positive
nents of the intervention that are more subjective (such and negative statements, rated on a five-point Likert
as respectful care, effective communication with staff, scale, from totally agree (1) to totally disagree (5). PCQ
and emotional support from a companion of choice), scores were recoded so that higher points were indicative
the checklist was completed according to the ' ‘mother’s of higher satisfaction levels. The total range for scores is
response, and in other sections by the researcher. The between 25 and 125 [25]. In this study, only the second
implementation rate of effective communication with half of this questionnaire (experiences of women who
the maternity ward staff was 78%; respectful care, emo- have recently given birth regarding intrapartum care) was
tional support from a companion, regular monitoring of used.
labor and documentation of events, and pre-established
referral plan were 100% implementation; continuity of The PTSD symptom scale 1 (PSS_I) This scale has 17
care, mobility in labor and positioning had a success rate questions, and using the Likert scale grades the sever-
of 91.5%, 83% and 87% respectively; oral intake of food ity of signs for each criterion. The subsets of this tool
and fluids was successful on 96% of occasions; and non- include (A) signs of re-experiencing (4 questions), (B)
pharmacological and pharmacological pain relief strat- signs of avoidance (7 questions), and (C) signs of motiva-
egies were implemented on 88.2% and 11.8% of cases, tional responses (6 questions). The total range of scores
respectively. is between 0 and 51 and higher scores were indicative of
The childbirth experience questionnaire (CEQ 2.0): This higher stress levels [26].
questionnaire measures the childbirth experience and
includes 25 statements that cover the following areas: Edinburgh’s postpartum depression scale This scale
own capacity (feeling of control, personal feelings about was designed by Cox et al. in 1987 and has implications
childbirth and labor pain), professional support (infor- for measuring depression during pregnancy and after
mation and midwifery care), perceived safety (feeling childbirth. This tool is comprised of ten questions with
of safe and memories of childbirth), and participation four options each, which in some questions are ordered
(‘ ‘individual’s ability to change position, be mobile and from low to high severity (items 1, 2, and 4) and in some
receive pain relief during labor and childbirth). Twenty- questions from high to low severity (items 3, 5, 6, 7, 8, 9,
two out of the twenty-five statements are multiple-option and 10). In each question, the participant receives a point
questions, and the remaining three are completed using from 0 to 3 based on the severity of the symptom; hence
Visual Analogue Scales (VAS). The validity and reli- the total score will range from 0 to 30. The validity of this
ability of this tool were confirmed in the population of tool was calculated by determining the concurrent corre-
American women. Sentences with negative meanings lation coefficients of ' ‘Edinburgh’s and ' ‘Beck’s depression
(experience of severe pain, fatigue, fear, and unpleasant scales to be 0.78, and its reliability was calculated using
memories) are given negative scores. An average of high Alpha Cronbach and split-half methods to be 0.75 [27].
scores in this tool signals a more positive childbirth expe-
rience [23]. Partogram A Partogram is a simple and valid diagram
and is often considered the best tool for monitoring the
The delivery fear scale (DFS) This scale was designed childbirth process and the health status of the mother
by Wijma et al. and used to measure a ' ‘woman’s fear and her infant. Using this form allows healthcare staff to
of childbirth during labor. DFS is a valid self-evaluation express the details of the childbirth process visually; this
questionnaire with ten response levels per item, ranging includes information about the ' ‘mother’s health, the
from 1 (strongly disagree) to 10 (strongly agree). Higher health status of the infant, recording the process of child-
scores indicate greater fear during labor [24]. birth, as well as managing it. A Partogram is a primary
The pregnancy and childbirth questionnaire (PCQ): This alarm mechanism that could significantly facilitate the
questionnaire is employed to assess mothers’ perspec- decision-making process regarding the on-time referral of
tives on the quality of obstetric and intrapartum care fol- the mother [28]. Information about the duration of child-
lowing childbirth. Designed by Truijens et al. in 2014, it birth, natural vaginal childbirth, the implication of oxyto-
is comprised of 25 items: 18 items are based on the wom- cin, analgesia, amniotomy or episiotomy, and the degree
en’s experiences and perceptions of pregnant women of perineal tear, as well as the Apgar score, was elicited
about the quality of obstetric care, which themselves from this form.
are divided into two subgroups of personal behavior (11
items; Cronbach’s Alpha = 0.87) and educational infor-
mation (7 items; Alpha Cronbach = 0.90). The remaining

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Abdolalipour et al. BMC Pregnancy and Childbirth (2024) 24:283 Page 7 of 15

The desire for subsequent childbearing checklist This blood pressure, twins) or having their third childbirth or
checklist is a simple yes or no question regarding the more. There was no case of unwillingness to participate
desire to have more children. in the study; therefore, the 108 mothers (54 in the con-
trol and 54 in the intervention groups) who met eligibility
The exclusive breastfeeding checklist This checklist is a criteria were chosen as samples. Two of the participants
simple yes or no question on whether or not the newborn (one in either group) were lost to postpartum follow-up,
received exclusive breastfeeding for the first 4 to 6 weeks as they did not answer phone calls (Fig. 1).
after birth. The mean ± SD, (min–max) of the participants’ ages
were 26.2 ± 7, (16–43) and 26.1 ± 6.5 (16–44) in the inter-
Validity and reliability of the utilized tools vention and control groups, respectively (p = 0.966). The
In this study, the validity of the socio-demographic and percentage of nulliparous was 49.1% in the intervention
obstetric questionnaires was measured through con- and 41.8% in the control group (p = 0.450) and there was
tent and face validity. Psychometrics properties of all no significant difference in terms of birth ranking. There
the tools used in this study, except for PCQ, includ- were no significant differences in terms of other socio-
ing childbirth experience [29], fear of childbirth [30], demographic or obstetric characteristics among partici-
postpartum depression [31], and PTSD symptoms [26] pants of the two groups (p > 0.05). Table 1 shows other
questionnaires, have been tested and confirmed in Iran. socio-demographic attributes of the study groups.
The PCQ’s psychometrics have been tested in another The mean ± SD, (min–max) for the childbirth expe-
study, which was part of this thesis and currently is rience total score was 3.5 ± 0.3, (2.8–4) and 2.8 ± 0.4,
underreview. (1.9–3.5) in the intervention and control groups, respec-
tively, which according to the parity-adjusted ANCOVA
Data analysis test was significantly higher in the intervention group
The collected data in this study were analyzed using SPSS (Adjusted Mean Difference (AMD) (95% CI): 0.7 (0.6 to
version 24. A dual data-entry method was adopted. The 0.8), p < 0.001). Additionally, all subdomains of childbirth
normal distribution of all data, except for PTSD symp- experience were significantly higher in the intervention
toms and duration of childbirth, was confirmed through group compared to the control group (p < 0.001). The
a Kolmogorov–Smirnov test. Descriptive statistics, com- mean ± SD, (min–max) of the intrapartum care quality
prising frequencies (percentage) and mean (SD), were score was 31.8 ± 7.1, (28–125) in the intervention group,
utilized to portray socio-demographic and obstetric char- which is notably higher than the 25.2 ± 7.8, (17–125)
acteristics. For data with abnormal distribution, medians of the control group (AMD (95% CI): 7.0 (4.0 to 10),
(25th and 75th percentile) were employed. To compare p < 0.001). The mean ± SD, (min–max) for the post-inter-
childbirth experience, postpartum depression, and vention fear of childbirth score was 33.5 ± 17.3, (10–76)
quality of obstetric care between the two study groups, for the intervention group and 51.7 ± 19.9, (14–86) for the
an Analysis of covariance (ANCOVA) test with parity control group, which after adjusting for parity and the
adjustment was applied. Additionally, the post-inter- baseline fear of childbirth scores, was significantly lower
vention fear of childbirth variable was assessed between in the intervention group (AMD (95% CI): -16.0 (-22.0
groups using an ANCOVA test with adjustments for par- to -10.0), p < 0.001). Regarding depression, no significant
ity and pre-intervention fear of childbirth. To compare difference could be reported between the two groups
the PTSD symptoms and duration of childbirth stages (AMD (95% CI): 0.9 (-1.0 to 3.0), p = 0.352) (Table 2).
variables between the study groups, a Mann-Whitney U According to the Mann-Whitney U test, there were
test was performed. To compare the frequency of below no significant differences between groups in terms of
7 Apgar scores, vaginal childbirth, desire for subsequent PTSD symptoms (p = 0.166), duration of the active phase
childbearing, and exclusive breastfeeding, a chi-square (p = 0.768), the second stage (p = 0.395), or the third stage
test was performed. Since all questionnaires and check- (p = 0.743) of childbirth (Table 3).
lists were completed by the researcher and co-researcher, The number (percentage) of natural childbirth in the
there was no missing data. Analysis was conducted intervention and control groups was 49 (90.7%) and 50
employing the modified intention-to-treat (ITT) strategy. (92.6%), respectively, and the difference was not signifi-
cant (p = 0.838). Out of the 54 participants in the inter-
Results vention group, there were 49 vaginal childbirths and five
The sampling process began on June 11, 2022, and was cesareans, and the control group had 50 vaginal child-
finished on April 5, 2023. The follow-up process ended births and four cesareans. The indications for cesarean
on May 7, 2023. Initially, 129 mothers who were admitted delivery included one case of bradycardia and, four cases
to the maternity ward were evaluated, 21 of whom were of prolonged first stage in the intervention group, three
removed from the study due to high-risk pregnancy (high cases of bradycardia, and one case of meconium-stained

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Abdolalipour et al. BMC Pregnancy and Childbirth (2024) 24:283 Page 8 of 15

Fig. 1 Flow diagram of the study

amniotic fluid in the control group. There were no infants childbirth, and increase ‘mothers’ satisfaction with the
with a below 7 Apgar score in the intervention group, but quality of intrapartum care, but had no significant statis-
three were born in the control group. Still, this difference tical effect on depression, PTSD symptoms, duration of
was not significant between groups (p = 0.243). Similarly, childbirth stages, type of childbirth, Apgar score, desire
the two study groups were not significantly different in for subsequent childbearing, or exclusive breastfeeding.
terms of desire for subsequent childbearing (p = 0.115) In our study, the mean of the total score for the child-
and exclusive breastfeeding in the 4 to 6 weeks postpar- birth experience, along with all of its subdomains, was
tum period (p = 0.473) (Table 4). significantly higher in the intervention group. In a study
by Demirci et al., ' ‘women’s participation in the provided
Discussion care during labor and receiving support from a compan-
The present study aimed to assess the effects of the ion and the staff was correlated with a positive childbirth
implementation of the WHO-recommended intrapar- experience [32]. Women’s perception of pain during
tum care model on some maternal and neonatal out- childbirth and the control they had over themselves dur-
comes. The results suggested that this intervention could ing labor and childbirth are among other variables
positively affect the childbirth experience, reduce fear of reported to be directly correlated with the childbirth

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Abdolalipour et al. BMC Pregnancy and Childbirth (2024) 24:283 Page 9 of 15

Table 1 Socio-demographic and obstetric characteristics of the study participants

Variable WHO Recommendation Routine Care P-value
(n = 54) (n = 54)
Mean (SD) Mean (SD)
Age (years) 26.2 (7) 26.1 (6.5) 0.966a
Spouse age (year) 31.8 (6.1) 32 (5.5) 0.882a
Marriage age (year) 5.6 (5.2) 6.6 (5) 0.321a
BMI (kg/m2) 24.9 (4.2) 25.4 (4.4) 0.534a
Gestational age (week) 38.6 (1.4) 38.5 (1.6) 0.533a
N (%) N (%)
Marital status
Married 54 (100) 54 (100)
Income 1.000b
Adequate 12 (22.2) 13 (24.1)
Relatively adequate 37 (68.5) 36 (66.7)
Inadequate 5 (9.3) 5 (9.3)
House status 0.124b
Personal house 22 (41) 34 (63)
Rented house 18 (33) 10 (18.5)
Relative house 14 (26) 10 (18.5)
Education 0.209b
Primary/Secondary/ High school 30 (55.6) 34 (63)
Diploma 15 (27.7) 17 (31.4)
Academic 9 (16.7) 3 (5.6)
Spouse education 0.449b
Primary/Secondary/ High school 23 (42.6) 28 (52)
Diploma 20 (37) 17 (31.5)
Academic 11 (20.4) 9 (16.7)
Job 0.205c
Housewife 49 (90.7) 53 (98.1)
Employee 5 (9.3) 1 (1.9)
Spouse job 0.842d
Employee/Worker 21 (38.9) 19 (35.2)
Free job 33 (61.1) 35 (64.8)
Number of pregnancies 0.296b
1 27 (50) 22 (40.7)
2 20 (37) 21 (38.9)
3 and higher 7 (13) 11 (20.4)
Number of childbirths 0.450d
First childbirth 26 (49.1) 23 (41.8)
Second childbirth 27 (50.9) 32 (58.2)
Previous abortions 0.639d
Yes 44 (81.5) 41 (75.9)
No 10 (18.5) 13 (24.1)
Participation in childbirth preparation classes 0.657d
Yes 15 (27.8) 12 (22.2)
No 39 (72.2) 42 (77.8)
Unwanted pregnancy 0.970d
Yes 21 (38.9) 13 (24.1)
No 33 (61.1) 41 (75.9)
Type of previous childbirth 0.137b
No childbirth 30 (55.6) 22 (40.7)
Vaginal 24 (44.4) 31 (57.4)
Cesarean 0 1 (1.9)
History of difficult childbirth 0.236d

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Abdolalipour et al. BMC Pregnancy and Childbirth (2024) 24:283 Page 10 of 15

Table 1 (continued)
Variable WHO Recommendation Routine Care P-value
(n = 54) (n = 54)
Mean (SD) Mean (SD)
Yes 9 (37.5) 7 (21.2)
No 15 (62.5) 26 (78.8)
History of infertility 0.359d
Yes 5 (9.3) 9 (16.7)
No 49 (90.7) 45 (83.3)
Spouse support 0.518b
Low 34 (63) 38 (70.4)
Moderate 11 (20.3) 9 (16.6)
Much 9 (16.7) 7 (13)
Transfer baby to NICU 0.805d
Yes 9 (79.6) 11 (20.4)
No 45 (83.3) 43 (16.7)
Skin-by-skin contact 0.436d*
Yes 42 (85.7) 39 (78)
No 7 (14.3) 11 (22)
Breastfeeding in the labor room 0.470d*
Yes 40 (81.6) 37 (74)
No 9 (18.4) 13 (26)
Intention to have cesarean in the next childbirth < 0.001d**
Yes 5 (17.9) 16 (76.2)
No 23 (82.1) 5 (23.8)
a
Independent t-test; b Chi-square for trend; cFisher’s exact test; dChi-square
*
Analyses were done for 49 women in the intervention and 50 women in the control group, **Analysis was done for 53 women in each group

experience [33]. The perceived professional support sub- women by providing them with the necessary informa-
domain received a significantly higher mean score in the tion regarding childbirth saw success in spreading posi-
intervention group compared to the control group. Previ- tive maternity experience. Continuing care by a specific
ous studies show that support from a midwife is one of midwife improves the ' ‘woman’s childbirth experience
the notable factors in this regard, where the actual care through different factors, for example, by providing self-
is far better than ' ‘women’s expectations. Such support management of pain, the ability to face the challenge of
severely depends on the midwife’s and the woman’s rela- childbirth, control over the process, as well as limiting
tionship and is shown to be the most important factor stressful examinations and interventions [38].
of intrapartum care [34, 35]. Women in the interven- In this study, the quality of intrapartum care as pre-
tion group scored higher in the participation subdomain cepted by women was significantly higher in the inter-
as well. Previous studies show that a feeling of personal vention group than in the control group. Similarly, a
influence on the surrounding environment and partici- study by Fumagalli et al. showed a correlation between
pation in the childbirth process is crucial for a woman interventions during childbirth and a reduction in the
to have a positive childbirth experience [34, 36]. Per- care quality as perceived by the mother. Oxytocin induc-
ceived safety was another subdomain where women in tion, epidural analgesia, and instrumental childbirth
the intervention group scored higher than those in the were associated with low satisfaction, while multiparity
control group. Situations that the mother considers safe, correlated to higher intrapartum care quality satisfac-
familiar, and supportive will boost oxytocin secretion tion [39]. Conversely, higher mobility during labor and
and the parasympathetic nervous system. This facilitates exclusive care by the provider increased ‘mothers’ satis-
both the childbirth process and the positive oxytocin- faction by improving maternal outcomes [40]. Previous
related central actions, consequently boosting positive studies also show the role of the maternity center and the
experiences and emotions [37]. Women in the interven- type of care provided in this regard. Sophisticated hos-
tion group scored higher than those in the control group pital equipment, qualified personnel, and a clean hospi-
for the personal capacity subdomain. According to a tal environment are commonly reported factors affecting
review study by Taheri et al., trials that aimed to prevent mothers’ satisfaction [41, 42]. However, improvements
unnecessary obstetric interventions through continu- to the infrastructure and mothers’ health service cover-
ous care from a specific midwife and empowerment of age do not guarantee high-quality service on their own;

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Abdolalipour et al. BMC Pregnancy and Childbirth (2024) 24:283 Page 11 of 15

Table 2 Comparison of childbirth experience and its sub- Table 4 Comparison of type of childbirth, Apgar less than 7,
domains, intra-partum care quality, fear of childbirth, and intention to further childbearing and exclusive breastfeeding 4–6
postpartum depression between the study groups weeks postpartum
Variable Inter- Control MD P-value Variable WHO Routine P-valuea
ven- (n = 53) (95%CI) Recommendation Care
tion (n = 53) (n = 53)
(n = 53) N (%) N (%)
Mean Mean Type of childbirth 0.838*
(SD) (SD)
Vaginal 49 (90.7) 50 (92.6)
CEQ*Total (Score range: 1 3.5 (0.3) 2.8 (0.4) 0.7 (0.6 < 0.001a
Cesarean section 5 (9.3) 4 (7.4)
to 4) to 0.8)
Apgar score less 0.243*
CEQ-Participation 3.7 (0.4) 2.8 (0.6) 0.9 (0.7 < 0.001a
than 7
to 1.1)
Yes 0 3 (5.6)
CEQ-Perceived Safety 3.4 (0.4) 2.9 (0.5) 0.6 (0.4 < 0.001a
to 0.8) No 54 (100) 51 (94.4)
CEQ-Own Capacity 3(0.5) 2.4 (0.6) 0.6 (0.4 < 0.001a Intention to further childbearing 0.115
to 0.9) Yes 27 (50.9) 18 (34)
CEQ-ProfessionalSupport 3.9 (0.2) 3.1 (0.5) 0.8 (0.6 < 0.001a No 26 (49.1) 35 (66)
to 0.9) Breastfeeding in 4 to 6 weeks postpartum 0.473
Intrapartum care quality 31.8 25.2 7.0 (4.0 < 0.001a Yes 44 (83) 40 (75.5)
(Score range: 25 to 12) (7.1) (7.8) to 10.0) No 9 (17) 13 (24.5)
Fear of childbirth (pre- 39.5 42.8 -2.8 (-9.2 0.377b** a
Chi-square
intervention) (Score range: (16.2) (17.0) to 3.5) *
Analysis was done for 54 women in each group
10 to 100)
Fear of childbirth (post- 33.5 51.7 -16.0 < 0.001c***
intervention) (Score range: (17.3) (19.9) (-22.0 to instead, to encourage childbirth in healthcare facilities
10 to 100) -10.0) and improve the ' ‘mother’s health outcome, the benefi-
Postpartum depression 11.5 10.5 0.9 (-1.0 0.352a ciaries should modify the healthcare system to be more
(Score range: 0 to 30) (4.9) (5.0) to 3.0) humane, respectful, fair, and responsive to mother’s con-
a
ANCOVA adjusted for parity; bIndependent t-test; c ANCOVA adjusted for parity cerns [11].
and pre-intervention fear of childbirth
*
childbirth experience questionnaire, **Analysis was done for 54 women in each
After the intervention in the present study, the fear of
group; *** Analysis was done for 49 women in the intervention and 50 women childbirth score showed a more significant reduction in
in the control group the intervention group than in the control group. The
study by Isbir et al. shows that continuous supporting
Table 3 Comparison of duration of labor stages and PTSD* care during childbirth can effectively reduce the fear of
symptoms between the study groups childbirth during the active and transitional phases of
Variable Intervention Control (n = 53) P-valuea delivery. Two factors can explain this effect: first, con-
(n = 53)
stant accompaniment eliminates the sense of loneliness
Mean Median Mean Median
and fear of childbirth caused by inadequate support from
(SD) (Per 25 (SD) (Per 25
to 75) to 75) healthcare specialists. Second, participants who had a
The active phase of 201.2 180 208.4 180 0.768b higher level of precepted support during childbirth and
labor (114.1) (120 to (117.8) (120 to employed methods that boosted relaxation during the
240) 240) active and transitional phases of childbirth had a more
The second stage of 28.1 30 (20 31.6 30 (15 0.395b positive attitude toward the supportive intrapartum care
labor (14.8) to 30) (18.0) to 40) they received, which could have consequently reduced
The third stage of 8.4 7.5 (5 to 7.6 5 (5 to 0.743b their fear of childbirth [43]. Furthermore, mother-ori-
labor (6.8) 10) (3.2) 10)
ented childbirth environments that provide a sense of
PTSD*symptoms 7.8 8 (2 to 6.4 4 (0 to 0.166
(Score range: 0 to 51) (7.5) 10) (6.8) 9)
freedom and safety can effectively reduce fear [44]. In
a
Mann-Whitney U Stoll et al.‘s study, women intending to undergo a cesar-
b
Analyses were done for 49 women in the intervention and 50 women in the ean section reported fear of childbirth stemming from
control group concerns about pain, the potential impact on their sex-
*
Post-Traumatic Stress Disorder ual attractiveness, and potential harm to themselves or
the baby. Conversely, those intending to have natural
childbirth expressed fears related to medical interven-
tions during the process. Furthermore, women who
received remarkably satisfactory care from midwives had
a noticeably lower fear of childbirth score than those who

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Abdolalipour et al. BMC Pregnancy and Childbirth (2024) 24:283 Page 12 of 15

received care from obstetricians [45]. These findings, the duration of the first stage [54], breathing techniques
along with the results of the present study, show that care and relaxation shortened the first and second stages [55],
providers have a critical role in moderating the fear of and the upright position effectively reduced the dura-
childbirth. tion of the second stage of labor [56]. Perhaps the lack
In this study, the study groups showed no difference of a significant difference in the duration of labor stages
in terms of postpartum depression and PTSD symptoms in this study could be attributed to ' ‘oxytocin’s use -to
scores. Generally, psychiatric and social interventions strengthen contractions and accelerate labor- in 78%
considerably reduce the number of women suffering from of cases in the control group, as opposed to 44% in the
postpartum depression. Promising interventions include intervention group.
regular and professional at-home examinations, phone In the present study, there was no significant differ-
support, and interpersonal psychotherapy [46]. Addi- ence regarding vaginal and cesarean childbirth frequency
tionally, in a 2018 study by Capik et al., satisfaction with between the study groups. Few studies have succeeded
the healthcare staff ’s attitude during childbirth, receiv- in reducing cesarean rates [57]. A study conducted in
ing support, and a positive childbirth experience were 32 hospitals in the Canadian city of Quebec managed
negative predictors, and experience of postpartum dif- to yield lower cesarean rates by making interventions
ficulties by the mother were positive predictors of post- such as auditing the indications for cesarean and pro-
traumatic stress [47]. Still, this disorder is more common viding feedback and advice for healthcare specialists;
among women with previous psychiatric disorders [48]. however, the effect size was small (adjusted absolute
Anyhow, it could be said that aside from the childbirth risk difference = 1.8%) [58]. A study aiming to analyze
experience, numerous other factors can cause PTSD and the correlation between modified intrapartum care and
depression symptoms. A history of depression is one of cesarean rates, which was conducted in 39 hospitals in
the important risk factors for postpartum depression Connecticut and Massachusetts, showed that the pres-
in women [49]. Other recognized risk factors include a ence of a trained midwife alongside the mother at all
high-stress lifestyle, lack of social support, domestic vio- times, as well as employing less interventionist manage-
lence, and marital dissatisfaction. Cultural characteristics ment approaches (such as limiting the use of IV lines and
of the family also affect the mother’s mental health sta- allowing food consumption during childbirth) were sig-
tus after childbirth. Various cultures have different fam- nificantly associated with lower cesarean rates [57]. Our
ily structures, and the value attributed to women during ‘study’s lack of a significant difference regarding vaginal
pregnancy and after childbirth differs from one culture delivery rates is probably related to the inadequate sam-
to another [50]. Additionally, studies have shown that ple size for analyzing this objective.
postpartum depression is one of the important predictors In this study, no statistically significant difference was
of post-traumatic stress, and results in this regard sug- observed in terms of the inclination for future childbear-
gest that crucial factors other than childbirth experience ing between the groups. In a study by Zeng et al., a lower
and the attitude of staff affect stress [51, 52]. Due to the desire level for subsequent pregnancies had a significant
correlation between a history of psychiatric disorders in connection with a greater fear of childbirth [59]. High
women and mental health disorders such as postpartum levels of fear of childbirth are associated with negative
depression andPTSD, future studies should analyze the childbirth experiences, and fear of future pregnancies,
effects of such variables by assessing the ' ‘mother’s base- which probably result in lower desire levels for child-
line mental health status. bearing in women [60]. Since, in this study, the desire
Not only is there clinical importance to shortening the for subsequent childbearing was significantly stronger
duration of childbirth, but it is also shown to increase in nulliparous women compared to multiparous women,
satisfaction and allow mothers and their infants to the lack of significance in this variable between the two
receive fewer interventions during childbirth, which itself groups of this study could be attributed to multiparous
positively affects the outcomes of childbirth [43]. In our women already having enough children and lack the will
study, the duration of childbirth stages had no significant to have more.
difference between the two groups. However, the results In this study, there was no significant difference
of Dwiarini et al.‘s study showed that perinatal instruc- between groups regarding exclusive breastfeeding
tions, walking during the first stage, the childbirth sta- between 4 and 6 weeks after birth. Starting breastfeeding
tus, the infant’s weight, fear of childbirth, and childbirth during the first hour after birth is reportedly one of the
self-efficacy were the factors affecting the duration of factors for successful breastfeeding in the long term [61].
the active phase and second stage of childbirth. Higher However, primiparity, emotional distress during preg-
levels of self-efficacy and less fear were predictors of nancy, and cesarean delivery are recognized as indepen-
the shorter active phase and second stages of childbirth dent factors for exclusive breastfeeding for less than two
[53]. Moreover, back massage was effective in reducing months [62]. Perhaps the lack of a significant difference

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Abdolalipour et al. BMC Pregnancy and Childbirth (2024) 24:283 Page 13 of 15

between the two groups could be explained by the fact women’s satisfaction with perceived intrapartum care
that skin-to-skin contact between the mother and her quality. The priority is to promote a responsive health-
newborn, breastfeeding in the first hours after birth, and care system for mothers that provides humane, respect-
breastfeeding instructions and consultations are part of ful, and fair care. Despite the clear guidelines on what can
the routine care in both of the centers where this study be considered respectful care and effective communica-
took place and are provided to all mothers and infants tion with staff, not all women receive this kind of care.
with no clinical complication. Additionally, providing this kind of care may have a lower
priority compared to clinical care. Further studies should
Strengths and limitations be conducted on how to put respectful and high-quality
This is the first study to analyze the effects of all parts care during labor and childbirth on the list of priorities
of the WHO’s intrapartum care model on maternal and alongside clinical measures. Furthermore, studies should
neonatal outcomes. The study’s settings were two of the focus on finding ways to remove non-recommended
largest hospitals in Tabriz, with healthcare consumers measures such as routine induction or fundal hand pres-
with the most diverse socioeconomic profiles. This could sure from clinical settings.
cause the results to be highly generalizable. Addition-
Abbreviations
ally, using the same data collection method (interview) WHO World Health Organization
for both groups and low dropout rates in the follow-up CEQ 2.0 Childbirth Experience Questionnaire 2.0
phase (1.8%) are other strengths of this study. One of DFS Delivery Fear Scale
PCQ Pregnancy and Childbirth Questionnaire
the limitations of this study was that blinding the par- PTSD Post-Traumatic Stress Disorder
ticipants and the researcher was not possible due to the EPDS Edinburgh Postnatal Depression Scale
nature of the intervention. However, data collection after VAS Visual Analog Scale
PSS-I Post-Traumatic Stress Disorder Scale 1
childbirth was done by a co-researcher unaware of group SD Standard deviation
allocations. Furthermore, in a handful of cases, care in K-S Kolmogorov–Smirnov
the intervention group was affected by the routine care NICU Neonatal Intensive Care Unit
ANCOVA Analysis of Covariance
provided by hospital staff; for example, the specialist’s AMD Adjusted Mean Difference
decision to begin induction due to prolonged childbirth
or the decision to perform an amniotomy. The tool used Acknowledgements
We should thank the Vice-Chancellor for Research of Taleghani Hospital,
to analyze care quality was another one of the study’s lim- Alzahra Hospital, and Tabriz University of Medical Sciences and all the women
itations, as it only analyzed the provided care and not the for their participation in this research project.
equipment and facilities of the center. Additionally, data
Author contributions
was only collected from women who gave birth in these All of the authors contributed to the conception, design of the study
two centers without any complications, and therefore the and revised the manuscript. SA drafted the manuscript under the direct
results are not generalizable to women with complicated supervision of MM (Corresponding author). MM (Corresponding author)
conducted the statistical analysis. All authors read and approved the final
childbirth. The Apgar scores of neonates in the interven- manuscript.
tion and control groups were not assessed by the same
person, which could be regarded as a limitation for the Funding
Tabriz University of Medical Sciences provided funding but it had no role in
correct analysis of this variable. Therefore, whether neo- the design and conduct of the study and decision to this manuscript writing
natal complications differ between these groups should and submission.
be further evaluated. Data regarding childbirth and the
Data availability
postpartum period was gathered after childbirth via The datasets generated and/or analyzed during the current study are not
phone interviews rather than in-person, which is another publicly available due to limitations of ethical approval involving the patient
limitation of this study. Another potential limitation data and anonymity but are available from the corresponding author at
reasonable request.
could be the lack of a direct question regarding intent to
breastfeed, as we assumed that nearly all women plan to
Declarations
breastfeed their baby exclusively. Finally, the intent for
subsequent childbearing was assessed by a single ques- Ethics approval and consent to participate
tion. In future studies, the desire for subsequent pregnan- This study has been approved by the ethics committee of Tabriz University
of Medical Sciences (ethics code: IR.TBZMED.REC.1401.093, approval date:
cies can be assessed by a scale or other, more standard 2022-04-20). Informed written consent was obtained from all participants. All
tools before comparing the results. methods were carried out following relevant guidelines and regulations. Also,
the permission has been obtained for all established questionnaires used in
this study.
Conclusion
Implementation of the WHO intrapartum care model is Consent for publication
effective in reducing the fear of childbirth during labor, Not applicable.
improving childbirth experiences, and also improving

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Abdolalipour et al. BMC Pregnancy and Childbirth (2024) 24:283 Page 14 of 15

Competing interests 17. Ghanbari-Homayi S, Fardiazar Z, Meedya S, Charandabi SMA, Asghari-

The authors declare no competing interests. Jafarabadi M, Mohammadi S, et al. Predictors of traumatic birth experience
among a group of Iranian primipara women: a cross sectional study. BMC
Author details Pregnancy Childbirth. 2019;19:182.
1
Department of Midwifery, Faculty of Nursing and Midwifery, Tabriz 18. Sheferaw ED, Mengesha TZ, Wase SB. Development of a tool to measure '
University of Medical Sciences, Tabriz, IR, Iran ‘women’s perception of respectful maternity care in public health facilities.
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Women’s Reproductive Health Research Center, Tabriz University of BMC Pregnancy Childbirth. 2016;16:1–8.
Medical Sciences, Tabriz, Iran 19. Bruggemann OM, Parpinelli MA, Osis MJ, Cecatti JG, Neto AS. Support to
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Social Determinants of Health Research Center, Tabriz University of woman by a companion of her choice during childbirth: a randomized
Medical Sciences, Tabriz, IR, Iran controlled trial. Reprod Health. 2007;4(1):1–7.
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Tufts School of Medicine, Department of Public Health and Community 20. Mascarenhas VH, Lima TR, Silva FM, Negreiros FD, Santos JD, Moura MÁ,
Medicine, Boston, USA Gouveia MT, Jorge HM. Scientific evidence on non-pharmacological methods
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Master of Midwifery, Clinical Research Development Unit, Taleghani for relief of labor pain. Acta Paulista De Enfermagem 2019 July 29;32:350–7.
Hospital, Tabriz University of Medical Sciences, Tabriz, IR, Iran 21. Ali SA, Ahmed HM. Effect of change in position and back massage on pain
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Social Determinants of Health Research Center, Department of perception during first stage of labor. Pain Manag Nurs. 2018;19(3):288–94.
Midwifery, Faculty of Nursing and Midwifery, Tabriz University of Medical 22. Prabhakar D, George LS, Karkada S. Effectiveness of ambulation during first
Sciences, Tabriz, Iran stage of labour, on the outcome of labour among primigravid women in
selected hospitals of Palakkad District, Kerala. Int J Nurs Educ Scholarsh.
Received: 22 July 2023 / Accepted: 26 March 2024 2015;7(1):1–6.
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