title: Development of strategies to reduce cesarean delivery rates in iran 2012-2014: a mixed methods study.
abstract: BACKGROUND
  With the change in population policy from birth control toward encouraging birth and population growth in Iran, repeated cesarean deliveries as a main reason of cesarean section are associated with more potential adverse consequences. The aim of this research was to explore effective strategies to reduce cesarean delivery rates in Iran.
  
  
  METHODS
  A mixed methodological study was designed and implemented. First, using a qualitative approach, concepts and influencing factors of increased cesarean delivery were explored. Based on the findings of this phase of the study, a questionnaire including the proposed strategies to reduce cesarean delivery was developed. Then in a quantitative phase, the questionnaire was assessed by key informants from across the country and evaluated to obtain more effective strategies to reduce cesarean delivery. Ten participants in the qualitative study included policy makers from the Ministry of Health, obstetricians, midwives and anthropologists. In the next step, 141 participants from private and public hospitals, insurance experts, Academic Associations of Midwifery, and policy makers in Maternity Health Affairs of Ministry of Health were invited to assess and provide feedback on the strategies that work to reduce cesarean deliveries.
  
  
  RESULTS
  Qualitative data analysis showed four concept related to increased cesarean delivery rates including; "standardization", "education", "amending regulations", and "performance supervision". Effective strategies extracted from qualitative data were rated by participants then, using ACCEPT derived from A as attainability, C as costing, C as complication, E as effectiveness, P as popularity, and T as timing table 19 strategies were detected as priorities.
  
  
  CONCLUSIONS
  Although developing effective strategies to reduce cesarean delivery rates is complex process because of the multi-factorial nature of increased cesarean deliveries, in this study we have achieved strategies that in the context of Iran could work.
authors.affiliation: Social Determinants of Health Research Center, Alborz University of Medical Sciences, Karaj, Iran.
authors.forename: Razieh
authors.initials: R
authors.lastname: Lotfi
authors.affiliation: Reproductive Endocrinology Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
authors.forename: Fahimeh Ramezani
authors.initials: FR
authors.lastname: Tehrani
authors.affiliation: Reproductive Endocrinology Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
authors.forename: Marzieh Rostami
authors.initials: MR
authors.lastname: Dovom
authors.affiliation: Maternal Office, Ministry of Health and Medical Education, Tehran, Iran.
authors.forename: Farahnaz
authors.initials: F
authors.lastname: Torkestani
authors.affiliation: Maternal Office, Ministry of Health and Medical Education, Tehran, Iran.
authors.forename: Mehrandokht
authors.initials: M
authors.lastname: Abedini
authors.affiliation: World Health Organization, Tehran, Iran.
authors.forename: Sima
authors.initials: S
authors.lastname: Sajedinejad
keywords: Cesarean delivery; Iran; mixed methods