title: Effects of Recruiting Midwives into a Family Physician Program on Women's Awareness and Preference for Mode of Delivery and Caesarean Section Rates in Rural Areas of Kurdistan.
abstract: BACKGROUND
  The accepted rate rate of caesarean section is 15%. It is expected that an increase in the density of midwives in the family physician program lead to a decrease in this indicator. This study aimed to compare the rates of caesarean section and women's awareness and preference for mode of delivery before and after the implementation of the family physician program in health centres with and without an increase in midwives density.
  
  
  METHODS
  In this cross-sectional study, using multistage cluster sampling method a total of 668 mothers with two-month-old children were selected from among all mothers with two-month-old children who were living in rural areas of Kurdistan province. Using the difference-in-differences model and Matchit statistical model, the factors associated with caesarean section rates and women's awareness and preference for mode of delivery were compared in centres with and without an increase in midwives density after the implementation of the family physician program. To compare the changes before and after the program, we used the data collected from the same number of women in 2005 as the baseline.
  
  
  RESULTS
  After adjusting for baseline data collected in 2005, the resutls showed no significant change in caesarean section rates and women's awareness and preference for mode of delivery in the centres with and without an increase in midwives density after the implementation of the family physician program. The Matchit model showed a significant mean increase 14%(0.03-0.25) in women's awareness of the benefits of natural childbirth between 2005 and 2013 in health centres where the density of midwives increased compared with health centres where it did not. The difference-in-differences model showed that the odds ratio of women's preference for caesarean section decreased by 41% among participants who were aware of the benefits of natural childbirth, (OR = 0.59, 95% CI: (0.22-0.85); P>0.001).
  
  
  CONCLUSIONS
  The results of this study showed that an increase in the density of midwives in the family physician program led to an increase in women's awareness of the benefits of natural childbirth. An increase in women's awareness of the benefits of natural childbirth was associated with a decreased preference for caesarean section, however this reduction did not have a significant impact on caesarean section rates; possibly, this finding might be attributed to the complexity of this problem that needs a mixed strategy involving various stockholders.
authors.affiliation: Midwifery and Reproductive Health Department, Faculty of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
authors.forename: Shayesteh
authors.initials: S
authors.lastname: Hajizadeh
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: Midwifery and Reproductive Health Department, Faculty of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
authors.forename: Masoumeh
authors.initials: M
authors.lastname: Simbar
authors.affiliation: Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran.
authors.forename: Farshad
authors.initials: F
authors.lastname: Farzadfar
mesh_terms: D001364:Awareness; D002585:Cesarean Section; D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D007231:Infant, Newborn; D007492:Iran; D008297:Male; D008880:Midwifery; D009313:National Health Programs; D010821:Physicians, Family; D011247:Pregnancy; D012424:Rural Population