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Metrics details. Cesarean section CS is one of the most common surgical procedures in the world. In developed and developing countries, CS has grown significantly over the past decades.
This study was conducted with the aim of reviewing the results of published studies on the impact of the HTP on CS in Iran. Twelve studies were selected. Seven studies reported statistically significant results, showing a positive impact of the implementation of the HTP on CS reduction. Increasing access to maternity services and community-based education through mass media could help changing the attitudes of Iranian mothers towards CS.
Health is a valuable global capital, and, hence, health policy- and decision-makers are working to improve it, ensuring the delivery of better health provisions, a fair and just access to healthcare facilities and implementing effective policies [ 1 ].
Most countries are developing, evaluating and re-programming health policies, and, therefore, health system reforms can be considered as a continuous improvement cycle to achieve better health levels [ 2 ]. In its report, the World Health Organization WHO has stated that public organisms and organizations should promote health and well-being, meeting with the expectations of the users, guaranteeing access to services and protecting against increasing health costs [ 3 ].
Iran, one of the Eastern Mediterranean Regional Office EMRO countries, has suffered from various health problems due to economic-financial issues, causing people to be dissatisfied with the services of various sectors of the healthcare system. The HTP, which has sought to financially protect people against healthcare costs, has significantly improved the quality of health services and has increased their access.
It has been implemented in public hospitals nationwide since May 5, [ 4 ]. One of the indicators of proper healthcare provisions is the rate of cesarean section CS. CS is one of the most common surgical procedures worldwide. In developed and developing countries, CS has grown significantly over the past decades [ 5 , 6 ]. This high, unacceptable figure can be seen as a warning, which should foster the implementation of adequate policies to reduce CS in Iran.
Unnecessary CS can have adverse consequences on health both for the mother and the infant. A WHO study showed that maternal mortality was higher for CS than for vaginal delivery [ 9 ], also indicating that there is a very strong relationship between CS and infant mortality [ 10 ]. Furthermore, unnecessary CS imposes financial costs both for households and the entire healthcare system [ 5 ]. Health policy- and decision-makers in Iran in the past have proposed several plans to reduce CS rate [ 11 ].
Lack of proper knowledge of the complications of CS, fear of pain, psychological stress, and shortened delivery time are the major factors contributing to the choice of having CS [ 12 , 13 ]. A comprehensive package for the promotion of vaginal delivery aimed at promoting maternal and infant health in public hospitals was included in the HTP.
In order to encourage mothers to undergo normal vaginal delivery, this was offered in public state hospitals free of charge. Encouraging public agencies and service providers to deliver methods for reducing labor pain, including pharmacological and non-pharmacological methods, was also implemented by the plan. In addition, to support the culture of pregnancy and childbirth, the provision of maternity-ready classes for pregnant mothers and the empowerment of service providers were among the other measures taken for the promotion of vaginal delivery.
To investigate the effect of the HTP on CS after its implementation, different studies have been carried out. Pooling these investigations together can help assessing the overall effect of the HTP on CS rate, as well as improving decision making for developing and providing more suitable and effective programs. Therefore, this study was conducted with the aim of systematically reviewing the results of published studies on the impact of the HTP on CS in Iran.
The search strategy was developed by consulting an expert librarian. The reference list of each eligible article was also reviewed for potentially relevant studies. Any disagreements were resolved through discussion. Studies investigating the effect of the HTP on CS in the form of cross-sectional, cohort, time-series studies written in English or Persian were included.
Those studies whose results were not clear, or designed as letters to editor, editorials, case-reports, case-series, commentaries or conference abstracts were excluded. The surname of the first author, the year of publication, the location of the study, the study design, the number of participants, and the most important findings of the included studies were independently extracted by 2 authors.
Any discrepancy was solved through discussion. In the initial search, studies were found. Then, 42 duplicate studies were deleted. After reviewing the title, 68 studies were excluded. In the next step, the abstract of the studies was assessed and, finally, 12 studies meeting with the previously stated inclusion criteria were selected [ 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 ], as shown in Fig.
Studies were conducted between and In most studies, the HTP was implemented in public hospitals, whereas in 3 and 2 studies in private and health ministry hospitals, respectively. According to the study design, 4 and 6 investigations were cross-sectional and descriptive-analytic studies, 1 was a time series analysis and 1 a quasi-experimental investigation.
Seven studies reported statistically significant results. More in detail, bias due to confounding was low for all studies, whilst bias in selection of participants was generally low but moderate for 2 studies. Bias in measurement of interventions was moderate for 3 studies, as well as bias due to departures from intended intervention.
Bias due to missing data was moderate for 4 studies. Bias in measurement of outcomes was moderate for 5 studies, whereas bias in selection of reported results resulted moderate for 6 studies. To the best of our knowledge, this study is the first systematic review of the impact of the implementation of the HTP on the CS rate in Iran. In a study published in , the temporal trend of CS between and has been studied.
CS had a worrying upward trend in most countries of the world. Therefore, policy- and decision-makers should take effective health policies and strategies to reduce this trend [ 29 ]. Health policy-makers in Iran should be aware that CS is a surgical operation that has its own complications and may have long-term effects and serious consequences for future pregnancies in women [ 30 , 31 ].
Promotion of vaginal delivery and reduction of CS are the main priorities of the MoHME [ 11 ], which aims at ensuring a high quality maternal care.
The present review showed that CS exhibited a decreasing trend after the implementation of the HTP, also because vaginal delivery was offered free of charge. Paying attention to financial issues in health system reform is, indeed, very important, and, on the other hand, the cost of CS directly impacts on the cost of health care [ 32 ]. Increasing the offer of CS would increase direct payments and out-of-pocket OOP expenditure, dramatically weakening the sustainability of the healthcare system.
In a study by Moradi and collaborators, assessing the effectiveness of the package for the promotion of vaginal delivery, midwives and physicians said that free-of-charge offer represented a major incentive for choosing natural delivery, besides the reduced maternity services tariffs [ 33 ]. On the other hand, doctors and providers of maternity services have less legal responsibilities in performing normal labor compared to CS [ 34 , 35 ]. In a study, for instance, mothers have expressed concerns and pain of normal labor, including fear of rupture, deformation and relaxation of the genitalia [ 36 ].
Furthermore, the findings of the present study showed that, after the implementation of the HTP, the rate of CS increased in some private hospitals. This is consistent with the literature and studies performed in other countries. Also, another study in Uruguay showed that, due to increased payments to doctors in the private sector, CS rate was twice as high as in the public sector [ 38 ], due to financial incentives for physicians and reimbursement of costs by insurers [ 39 , 40 , 41 ].
In many cases, insurance covers the cost of CS in the private sector, which makes mothers not worried about the costs. In a meta-analysis, the results showed that mothers with private insurance had a greater tendency for choosing CS in the private sector [ 42 ].
Overall, a positive impact of the implementation of the HTP on CS reduction was shown in the existing scholarly literature. Extensive efforts should be made to properly implement health policies, and, in this regard, support should be granted to all stakeholders and groups that can contribute to the effective implementation. If the process of implementation of a policy is accompanied by a slowdown and encounters problems, negotiation, training and various strategies should be taken as proper measures and interventions [ 43 ].
Health policy- and decision-makers have implemented a package for promoting natural delivery and reducing CS rate. To further explore the effect of this policy, more studies are needed in all Iranian provinces in public and, especially, private hospitals. To achieve the goal of reducing CS, all individuals and groups should be involved.
Encouraging physicians to perform vaginal delivery through reforming the payment mechanisms, and increasing access to maternity services and community-based education through mass media could help changing the attitude of Iranian mothers towards CS. This study has some limitations that should be properly mentioned: there is a dearth of studies aimed at evaluating the effectiveness of this policy on the reduction of CS in many Iranian provinces, especially the provinces with the highest rates of CS.
Also, there is a need of qualitative studies on the tendency of mothers to choose CS rather than normal delivery, as well as investigations related to the opinions of physicians and midwives after the implementation of the HTP.
Most studies merely collected information from public hospitals and less from private hospitals. Another shortcoming of the present review is the publication bias, due to the fact that gray literature was not searched. Milbank Q. Frenk J. The global health system: strengthening national health systems as the next step for global progress. PLoS Med. World Health Organization.
The world health report —Health systems: improving performance. Accessed 24 Apr Health sector evolution plan in Iran; equity and sustainability concerns. Int J Health Policy Manag. Prevalence and determinants of caesarean section in private and public health facilities in underserved South Asian communities: cross-sectional analysis of data from Bangladesh, India and Nepal.
BMJ Open. Prevalence of and risk factors associated with cesarean section in Lebanon—a retrospective study based on a sample of 29, women. Women Birth. Appropriate technology for birth. Google Scholar. Prevalence and causes of cesarean section in Iran: systematic review and meta-analysis.
Iran J Public Health. Caesarean section without medical indications is associated with an increased risk of adverse short-term maternal outcomes: the — WHO Global Survey on Maternal and Perinatal Health.
BMC Med. Caesarian delivery and neonatal mortality rates in 46 low- and middle-income countries: a propensity score matching and meta-analysis of demographic health survey data. Int J Epidemiol. Caesarean section in Iran. Cesarean preference rate and factors associated with it among pregnant women with previous vaginal delivery in Neyshabur, Iran.
FGAC: coming in from OAS4081
You can install the Toolkit during the installation of the application server, or you can do it any time after you installed the application server using the Oracle Application Server administration forms. The schemas where you load the packages have changed between versions 3. Users execute the objects in the common schema with their own privileges, rather than with the privileges of the common schema. If you are upgrading from 3.
Objective: Cesarean section CS is one of the most common surgical procedures in the world. In developed and developing countries, CS has grown significantly over the past decades. This study was conducted with the aim of reviewing the results of published studies on the impact of the HTP on CS in Iran. Twelve studies were selected. Seven studies reported statistically significant results, showing a positive impact of the implementation of the HTP on CS reduction.
Any input would be appreciated. The fine grained access control code is running in a different "space" then your code. It does not have access to your package states and such. You need to set the username in a context before using the FGAC. The application context is the way to get the state to the FGAC routines. Thats my security policy and a function to set up the application context and the create context. Now I can implement the package body.