Zahedan University of Medical Sciences

Safe Delivery Posts: A successful initiative to improve equitable reproductive health & childbirth services in outskirts of Zahedan, southeast of Iran

In 2000, Zahedan (capital of Sistan and Baluchestan province, southeast of Iran) had a total of 480,000 Iranian population and was hosting about 100,000 non-Iranian and immigrant population. Nearly 200,000 people lived on the outskirts of the city, with a significantly lower socioeconomic status (in terms of income, literacy rate and general health indicators, etc), as compared with the rest of the population living in the city.

As it has been stipulated in the Iranian PHC Network Development Plan, in the context of rural Iran, Rural Delivery Facilities (RDFs) that are led by midwives have been established to improve access to maternal health services, particularly the skilled birth attendance for women living in remote and rural areas. Zahedan University of Medical Sciences (ZAUMS) has 8 cities with a population of about 1.600,000. A total of 15 Rural Delivery Facilities (RDFs) have been operating in rural areas for many years. The contribution of midwife-led RDFs to the maternal health in Sistan and Balouchetsan, southeast Iran, has been substantial, as more than 8000 deliveries per year takes place in those units.At present, more than 80 percent of health deliveries are in hospitals and about 10 percent are in SDFs. However, less than 10 percent of births are still unsafe and at home. This rate has been declining in recent years.

PO7 Project Provincial Managers (Right to left: Dr. Seyed Mehdi Tabataabei, Mr. Ghadir Najafi Zadeh, Dr. Majid Rahimi, Mr Abbassali Shahriari, Dr. Malek Kiani, Dr. Azizollah Jahantigh)

Over three decades, significant improvements in the availability of and accessibility to public health services, including maternity services have occurred in different parts of country. But some pregnant women, especially those living in outskirts of the cities do not utilize the services provided by maternity units in the hospitals. The main reason for underutilization of services are the cultural barriers and low socio-economic status (low income & literacy rate) of those women. In the year 2000, about 57% of deliveries in the outskirts of Zahedan, mostly located in the northern parts of the city, were unsafe and were done at home by traditional birth attendants. From 1997 to 1999 a case-control study was conducted to investigate the reasons of women not referring to maternity hospital for delivery (1). The hospitals high fees (38%), was the most prevalent reason for not giving birth at hospital (1). Even though the majority of the hospitals in Zahedan were located in the central and southern regions of the city, access to maternity hospital was possible for all residents of the city, but underutilization of the services was a major challenge for safe delivery and maternal health.

In 2001, with the aim of providing equitable access to reproductive health services, especially increasing prenatal care coverage and reducing unsafe childbirth in the suburban areas, as part of a joint project titled " Strengthening delivery of reproductive health (RH) services in five areas of the country, Project No, IRA/00/P07", with the collaboration of the United Nations Population Fund, the ZAUMS Vice Chancellor for Health established two Safe Delivery Posts (SDPs) in two urban health centers (i.e. HazratFateme and Hazrat-i-Vali-e-Asr Health Centers), in the outskirts of Zahedan. Practically, SDPs are similar to RDFs except that they have been established to offer maternity services to the under-privileged women living in an urban setting. The services provided by SDPs are free-of-charge for both Iranian and non-Iranian women. To our best knowledge , Zahedan is the only city in the country that have used the experience form RDFs in rural areas to establish SDPs in suburban areas.

 
To complement the services, there has been a coordination between Emergency Medical Center (EMC), so that in case of a emergency, the mother or infant would be transferred to more specialized centers through the Emergency Department.

In the following cases, midwives stationed in SDPs are required to refer pregnant women to more specialized centers for delivery:
- If the mother has an underlying condition during pregnancy, such as heart disease, diabetes, respiratory illness, etc., which could endanger maternal and infant life at birth.
- If there is a risk for mother and the baby during labor, delivery or after delivery, such as: preeclampsia, eclampsia, arrest of labor, complicated delivery, obstructed labor, fetal distress, bleeding, abnormal presentation, etc.

Another valuable service that is fully implemented in these SDPs is the implementation of the "roomingin" protocol toencourage "exclusive breastfeeding" and the reproductive health counseling that is done within 6 hours of delivery, due to the close relationship between mother and the Midwife.
The activity of these SDPs has grown dramatically over the last 15 years. As of the previous year, between 200 and 220 safe deliveries were performed in these SDPs each month(Figure1). These activities have led to a dramatic improvement in the indices of safe deliveries in these areas. One of significant achievements of SDPs establishment is a significant reduction in home births in the previous deliveries of women attending SDPs form 66% in 2002 to 12.5% in 2016 (Figure 2).

Figure 1- The annual number of safe deliveries taken place in SDPs , 2002-2016

Figure 2- Place of previous delivery of women who delivered in Safe Delivery Posts, 2002-2016

In administrative terms, till the end of 2004 these SDPs were funded by UNFPA with the technical oversight of the Zahedan Health Center. With the end of the United Nations Population Fund"s support, this project continued under the supervision of the Zahedan University of Medical Sciences in order to maintain and sustain the program.
So far, two studies have been carried out by Dr. Zahra Moudi, a PhD in reproductive health and an academic staff at the School of Midwifery and Nursing in ZAUMS, to assess different aspects of the performance of SDPs. Based on her study results, this model of midwifery care that offers the benefits of modern medical care and meets the needs of the local population can reduce the cost of giving birth and ensures equitable access to care among vulnerable women living in suburban areas(2). The results of another study that compared the outcomes of childbirth care in a tertiary teaching hospital and SDPs showed that women who gave birth in SDPs had more opportunities to experience natural physiologic labors with fewer adverse outcomes (3).

With the implementation of the Health Transformation Plan from 2014 in Iran, with the goal of implementing new population policies and promoting normal vaginal deliveries (NVDs), all normal vaginal deliveries in the hospitals for Iranian women are offered free of charge.Unfortunately, due to some constrains, some pregnant women living in suburban areas have no Iranian ID or are non-Iranian nationals and therefore not eligible for receiving free-of-charge NVD services in hospitals. Therefore, it has been stipulated that the activity of these SDPs will continue as in previous years, and in these units free-of-charge child birth a services are carried out.

In 2016, in order to improve SDPs infrastructure, as part of the Health Transformation Plan in ZAUMS new buildings were constructed for both of SDPs. New equipments were also provided by Relief International (RI), an international organization with the capacity and invitation to respond to emergencies inside Iran. RI partners with government agencies and local organizations to support the most vulnerable Afghan refugees. Relief International has been working with Afghan Refugees in Zahedan since 2016, providing basic services such as health care, food security and sanitation and drinking water to 1,500 Afghan households in and around Zahedan city.

 Copyright © 2017 Zahedan University of Medical Sciences. All rights reserved.

Translated by: Mohaddesseh Noura, Midwife at Zahedan University of Medical Sciences, email: mo_noura25@yahoo.com
Edited by : Vice Chancellor for Health, email: zu.healthdeputy@gmail.com

References

1. Salehi M, Ghasemi Pour Z. Reasons for Zahedan"s vomen for not reffering to delivery vard for child delivery. Journal of Reproduction and Infertility 2002;3(9):50-5.

2. Moudi Z, Ghazi Tabatabaie M, Mahdi Tabatabaei S, Vedadhir A. Safe Delivery Posts: an intervention to provide equitable childbirth care services to vulnerable groups in Zahedan, Iran. Midwifery. 2014;30(10):1073-81.

3. Moudi Z, Tabatabaei SM. Birth outcomes in a tertiary teaching hospitals and local outposts: a novel approach to service delivery from Iran. Public Health. 2016;135:114-21.