The challenges of delivery in Pre-hospital Emergency Medical Services ambulances in Iran: a qualitative study

doi:10.21203/rs.3.rs-3415847/v1

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Research Article

The challenges of delivery in Pre-hospital Emergency Medical Services ambulances in Iran: a qualitative study

https://doi.org/10.21203/rs.3.rs-3415847/v1

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published 02 Sep, 2024

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Background: Although encountering with unplanned births in the ambulance is uncommon, but the Emergency Medical Service (EMS) providers may face with it before arrival to hospital, that can accompany with problems and challenges for ambulance staff, pregnant women and neonates. This research was done to explain the experiences of EMS providers and pregnant women.

Methods: A qualitative study was conducted, and 28 Emergency Medical Technicians (EMT_s), midwives and pregnant women who had experience of prehospital births in ambulance were interviewed. Data were analyzed with thematic content analysis also MAXQDA/10 software was used for data analysis and code extraction.

Results: The analysis of the interviews revealed two main categories. Factors that cause delivery in ambulance and its challenges. The factors include cultural problems, weak managers and inaccessibility to facilities and the challenges consist of fear and anxiety, native culture and lack of resources.

Conclusions: Several approaches should be taken to reduce birth in ambulances and Pre-hospital Emergency Medical Services (PEMS), including long-term cultural activities with community participation, public education and awareness-raising activities, education and follow-up of pregnant women with simultaneous increase accessibility to health facilities. Also, EMT_s should be educated and trained about delivery in ambulance. Services improvement by providing proper and equipped ambulance as well as support EMT_s against litigation claims are other important activities.

Ambulance

Giving birth

Pre-hospital emergency medical services

Emergency medical technicians

Working as an EMT_s in a PEMS setting means meeting patients in different situations and EMS providers must always prepare themselves to deal with different and challenging issues [1]. One of these situations is encountering a pregnant mother near to delivery so that the EMT_s faces the giving birth before taking the pregnant mother to the health centers with delivery facilities [2, 3]. This situation can be considering as a stressful challenge for an EMT_s because childbirth is a high-risk and infrequency medical condition and the health of the mother and neonate may be at risk [3].

When faced with unplanned birth in ambulance, rapid clinical decision-making is often required and it requires skilled EMS providers in attendance of pregnant women because it may accompanied with risks such as excessive bleeding, retained placenta, shock and the possibility of need for blood transfusion for the mothers and also complications such as hypothermia, hypoxia, twisting of the umbilical cord around the fetal neck and the need for resuscitation for the neonates [4, 5]. Despite this, education and training about care for delivery was not formally included within the EMT_s curriculum and helping to give birth is basically not defined as the duty of EMT_s. Therefore, the EMT_s are not trained to manage women in unplanned birth condition before arrive to hospital or equipped health centers [6].

The staff of PEMS in Iran is known as EMT_s have different levels of education, and in addition to EMT_s, nurses, anesthetic and operating room technicians, who are all man, with associate and bachelor's degree are recruited in this system [7]. The PEMS is based on the Anglo-American model and the general physicians not attend the ambulances, and they are in the dispatch centers as medical director. There are two male EMT_s in each ambulance who provide EMS_s to the patients [8]. When the pregnant mother call the dispatch center to receive service and the mission is announced to the nearest emergency station to the caller, the EMT_s should take a midwife, who works at the health care service center, with them on the mission but sometimes because the midwives are on another mission, they cannot go with the EMS staff, and the mission for pregnant or near delivery women must be done by two male EMT_s. The aim of this study is to describe experience of EMT_s, midwives and pregnant mothers who gave birth in ambulance about delivery in ambulance. Few studies have been done in this regard but delivery in limited space of ambulance and helping to give birth by male EMT_s is a special situation in Iran's cultural condition which needs further study.

Research design

This study was conducted with a qualitative approach to describe experience of EMT_s, midwives and pregnant mothers who gave birth in ambulance about delivery in ambulance and data was collected with semi-structured interviews to reflect specific situation that they have undergone [9, 10]. The data was analyzed using content analysis approach.

Participants

The participants of this study consisted the EMT_s and midwives who had the experience of helping to give birth in ambulance and the women who had given birth in ambulance. The authors contacted EMT_s as well as pregnant mothers who had given birth in the ambulance and invited those who were willing to be interviewed for face-to-face or telephone interviews. In totally 28 persons include 13 EMT_s, 8 midwives and 7 mothers that given birth in ambulance showed interest in participating. All EMT_s had assisted at least one delivery in ambulance (Table 1).

Table 1

Demographic characteristics of the participants
Participant no	Gender	Age (years)	Level of education	Workplace	Operational experience (years)	Gravid*
P1	Male	34	Associates’ degree	EMS^**	6	-
P2	Male	39	Bachelor’s degree	EMS	10	-
P 3	Male	41	Bachelor’s degree	EMS	8	-
P 4	Male	46	Associates’ degree	EMS	15	-
P 5	Male	33	Bachelor’s degree	EMS	3	-
P 6	Male	26	associates’ degree	EMS	1	-
P 7	Male	33	Bachelor’s degree	EMS	7	-
P 8	Male	32	Bachelor’s degree	EMS	2	-
P 9	Male	30	Associates’ degree	EMS	5	-
P 10	Male	27	Associates’ degree	EMS	3	-
P 11	Male	22	Bachelor’s degree	EMS	1	-
P 12	Male	26	Bachelor’s degree	EMS	2	-
P 13	Male	33	Bachelor’s degree	EMS	3	-
P 14	Female	26	Bachelor of midwifery	HCC^***	4	-
P 15	Female	25	Bachelor of midwifery	HCC	2	-
P 16	Female	36	Bachelor of midwifery	HCC	9	-
P 17	Female	43	Bachelor of midwifery	HCC	15	-
P 18	Female	32	Bachelor of midwifery	HCC	8	-
P19	Female	24	Bachelor of midwifery	HCC	7	-
P 20	Female	30	Bachelor of midwifery	HCC	3	-
P 21	Female	37	Bachelor of midwifery	HCC	11	-
P 22	Female		Illiterate	Housewife	-	2
P 23	Female		Elementary education	Housewife	-	3
P 24	Female		Illiterate	Housewife	-	4
P 25	Female		Illiterate	Housewife	-	2
P 26	Female		Elementary education	Housewife	-	2
P 27	Female		Illiterate	Housewife	-	5
P 28	Female		Elementary education	Housewife	-	3
^*Gravid: What was the birth rank of the delivery she gave in the ambulance? ^**EMS: Emergency Medical Services ^***HCC: Health Care Centers

Table 1.

Data collection

Before the interview the participants were received sufficient information about the interview and purpose of the study. They were assured about the confidentiality of the information and told them that their participation in this study was completely voluntary. Also told that their interview would be recorded and they could cancel the interview at any time.

Data were collected through semi-structured interview with 13 EMT_s and 8 midwives with experience of help to delivery in ambulance as well as 7 pregnant women that given birth in ambulance. Interviews were conducted in a separate room at the workplace of EMT_s and midwives. Four pregnant mothers were interviewed at their home and three others by telephone. An Interview guide and open-end questions were used and the interviews lasted from 45 to 75 minutes. The interviews were recorded using a voice recorder and later transcribed completely by authors )Table 2).

Table 2

Interview guide
- Please describe your mission and talk about you’re feeling about childbirth in ambulance. - Do you think you were ready for the childbirth mission? - What made you give birth in ambulance? Couldn't you have come earlier? - Can you explain the pros and cons of giving birth in an ambulance? - Please explain about giving birth by a man or the presence of a man during the birth. - What do you think we should do to improve the results? - Do you think that the current university training and in-service training are enough for such missions? - Is there anything left you want to talk about?

Table 2.

Data analysis

Content analysis approach was used as a method for analysis of data related to study. An inductive approach that means that the author avoided using predetermined categories and instead, the authors has searched for similar words and expressions and the same meaning in the typed texts of the participants interview and has formed categories. In the initial analysis stage, the text was read several times to find meaning units that corresponded to the study targets. Then the meaning units were condensed and condensed units were coded [9, 11, 12]. Granheim et al, states that categories can be formed from meaning units so that they can be compared with each other, or they can be compiled into broader categories or subgroups [9]. In this study the codes were compared and categorized in two stages until finally two main categories were obtained and then each category was divided into three sub-category which highlighted the main content of the interviews. Also, for data analysis using MAXQDA/10 software.

Ethical considerations

The present study was approved by Ethical Committee Medical Sciences University of Shahrekord (Ethics code: IR.SKUMS.REC.1400.244). The study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. The participants were given adequate information about the nature of the study and then informed consent was obtained to participate in the study. They had the right to ask questions about the ambiguities and tried to clarify them as much as possible. They were assured that the obtained information will be completely confidential and will be used only for this research, also the findings was published so that none of the participants can be identified. Also, participants had the right to withdraw from the study at any time [13].

Twenty-eight people participate in this study. 13 participants were the EMT_s, 8 persons were the midwives and 7 were the mothers that given birth in ambulance. After the content analysis, the results were 5 divided into 2 general categories of causes leading to giving birth in ambulance and challenges. Then each category was divided into 3 subcategories. The causes of childbirth in ambulance were divided into 3 subcategories of local culture, inaccessibility, and weak managers. Also, the challenges of giving birth in ambulance are divided into three subcategories: fear and anxiety, people's culture, and ambulance and equipment. The categories are described respectively in the continuous text with clarifying quotes from the participants (Fig 1).

Figure. 1

THE CAUSES LEADING TO GIVING BIRTH IN AMBULANCE

Local culture

Culture can be considered a way to live and including ethnicity and race, behavioral response that is acquired over time, beliefs, attitudes, values, customs, norms, taboos, that is accepted by a society of people.[14]

- Illiteracy

All participants in the study pointed to illiteracy. They said that most of the women who live in remote areas and the nomadic women are illiterate, because there are no available schools. Also, culturally, people in remote area do not care about girls' education, and some girls who go to school withdraw after elementary stage and get married at a very young age. Therefore, most of them are illiterate or their literacy is limited to reading and writing that can have a great impact on prenatal care and timely -care-seeking for giving birth. Due to low literacy, pregnant women usually follow the traditions, rituals and older women opinion instead of doing appropriate health actions. One of respondents quoted:

“They are illiterate and do not have enough knowledge about the signs of childbirth. They do not listen to our advice and are more influenced by the advice of elders, especially mothers-in-law”. (P₁₆)

- Obeying the senior women

In the nomadic and rural area, special respect is given to older women such as mothers-in-law or senior women and pregnant women usually consider advises of these persons in the community rather than health center staff. These uneducated and untrained women give recommendations based on their own or others' birth experiences that may cause delays in going to the birthing center and put the women and newborn more at risk.

"My mother-in-law told me that if your back, arms, legs, and abdomen have pain at a same time, you are near to give birth. Now that only your abdomen becomes loose and tight, you are not about to give birth, that’s why I called the 115* late” (P₂₃)

- The heavy activity of pregnant women

The pregnant women in low socio-economic or rural area explained that they were often engaged in heavy physical activity like other non-pregnant women until the last moments of pregnancy, and in many cases labor pains begins while doing physical activity. The activities like farming, grazing sheep’s, milking cows and sheep’s, spinning wool, doing housework and many other heavy works. Activity and movement itself are a factor that can advance childbirth, especially in women with higher gravidity.

"I was milking the sheep when my labor pain started. At first, I didn't think it was labor pain, but when it happened again, I realized it was labor pain." (P₂₅)

Inaccessibility

- Remoteness and difficult geography

As mentioned in the introduction the most of childbirth in ambulance occurs in women living in remote areas, so that sometimes it takes 6 to 8 hours from the time of calling PEMS and ambulance arrives at their bedside to return and reach the first equipped birthing center. Also, the PEMS is called when there is not much time left until giving birth, therefore the long distance can be a factor for childbirth in ambulance.

Apart from long distance to health centers, difficult geography is another issue. Most of the villages do not have a proper access road and the access roads passes through the hills and mountains. The roads are in very poor condition and in raining season especially in winters, it becomes very difficult and sometimes impossible to pass by ambulance because of muddy pathway. In some areas, the EMT_s have to walk for at least half an hour to reach pregnant women. Sometimes donkeys and mules are used to bring pregnant women to the ambulance (Fig. 2).

"After we drove the ambulance for three hours, we had to walk the rest of the way and we walked for about 45 minutes to reach the pregnant mother's residence." (P₃)

We left the emergency station at 10:00 PM and delivered the mother and her neonate to the hospital at 5:00 AM. We walked on a part of the road where the ambulance could not go, and we carried the pregnant mother with a donkey to the ambulance." (P₇)

Figure. 2

- Poverty

Some pregnant mothers do not need to be sent to the hospital as an emergency, but due to the advice of midwives, it is better for them to settle near equipped birthing centers for a few days. But due to poverty, they refuse to do so. Even some of them do not have the ability to pay for transportation to health centers. Therefore, they prefer to wait until the last moment and then Call 115 and be transferred to the hospital by ambulance.

"The problem we had was that she was a high-risk pregnant mother, but she didn't need to be sent as an emergency patient at the moment. But whenever we told her to go to a gynecologist, she said I don't have money and I can't go." (P₁₄)

Weak managers

- Inefficiency of the health system

Inadequate health care centers make it difficult for people living in remote areas to access these centers. Also, it is not cost-effective for the government to establish health center in remote areas. Another problem that causes an increase in giving birth in the ambulance and was mentioned by five of the midwives who participated in the interview is poor management, weak education and irregular prenatal services by midwives working in health centers. The weakness of health service managers causes irresponsibility of some midwives and improper care during pregnancy for women living in remote areas.

“If midwives in health centers have enough responsibility, there will be less childbirth in the ambulance. Midwives should force pregnant mothers, specially the high risks, to leave remote and difficult geographic areas and go to cities with birthing centers with the first sings of giving birth, but sometimes they don't care about their duty. Because their supervision is not strict enough" (P₁₇)

- Inadequate resource

Taking action such as providing a residential places near equipped health centers by health officials and encouraging high-risk or near giving birth women to settling in these places for a few days, causes such women to be specially monitored and evaluated by midwives during this time, and immediately transferred to equipped center in case of labor pains. But this is not possible for all centers due to inadequate resource or inefficiency of managers, also shortage of professional EMT_s in remote areas is another common problem. Due to facilities deprivation, professional EMT_s are not satisfied to serve in such areas.

"Nobody is willing to work here, we have no facilities here. Whoever works here must be away from her family for a long time. Especially there is always shortage of midwives and nurses. For this reason, the care of pregnant women in deprived areas is not done properly." (P₁₉)

THE CHALLENGE OF GIVING BIRTH IN AMBULANCE

Fear and Anxiety

The most common emotion pointed to by the study participants was fear and anxiety. The reasons for this are divided into three subcategories, which are explained below.

- Lack of confidence to manage delivery

Giving birth in ambulance is an uncommon but significant clinical event that may encountered by emergency medical staff. Most of them have no experience in this field. This is a high-risk situation that may have outcomes for both mother and her neonate. The life of the mother and baby may be endangered during childbirth and the EMT_s may not be able to take the necessary measures to save their lives. Limited clinical experience and education cause to lack of confidence to manage this situation properly and this causes fear and anxiety. They constantly ask themselves if they can keep the mother and the baby healthy and bring them to the hospital or not?

"It was 2 or 3 o'clock in the morning and the mother became dystocia during childbirth in the ambulance. It was really terrible. The mother was agitated, her relative was screaming, and I was just praying that nothing would happen. I think I lost ten years of my life because of fear and stress that night." (P₁₈)

Giving birth in ambulance is not considered in educational curriculum, because taking delivery is not defined as part of the EMS duties. Also, in training courses while working, usually, no importance is given to childbirth in ambulance. Poor academic performance and lack of training creates lack of confidence and cause fear, stress and anxiety.

"We were not trained at all during our studies at the university. They didn't even let us train with mannequins. They told us a brief theoretical issue. Here we are just using the experiences of others." (P₁)

- Fear of litigation

Childbirth is a high-risk medical condition and even when the pregnant mother is in the hospital and gynecologists, experienced midwives as well as required equipment and medicines are present at her bedside, there is a possibility of endangering the health of the mother and the baby. None of the mentioned resources may be available in the ambulance, also the space is not enough to give the mother a proper position, perform the necessary maneuvers and use a sterile set. Despite all these problems, a patient's relative is also present in the ambulance and monitors the staff's behavior and performance, and in case of any problems for the health of the mother or the baby, there is a possibility that the patient's family refer to judicial authorities and involves the EMT_s in legal challenges and litigation.

Also, the hospital staff, when taking the mother and baby from the EMT_s, do not consider that before the hospital the EMT_s faced at least two hours over difficult geographical roads and the limitations of giving birth in ambulance. They report the health problems of the mother and the baby as the shortcomings and negligence of the EMT_s and record them in the patient's file. These may become giving birth- related litigation against EMT_s and PEMS later. Therefore, there is always the concern and fear of getting involved in litigations.

“We brought the mother from the top of the mountain; she gave birth on the way. We were on the road for 6 hours. Not the normal road, but the dirt and hard geographical pathway, the fact that we brought the mother and the baby healthy to the hospital and handed them over was a masterpiece in itself. But the hospital staff were complaining that the baby or the mother was not managed properly. They didn’t consider the conditions of the ambulance, the road and the equipment, and they checked the smallest things, often we were fear of getting involved in litigations after delivering the mother and baby to the hospital." (P₉)

Native culture

- Feeling ashamed and embarrassed

Feelings of shame and embarrassed over delivery in ambulance were a common sense of four women who giving birth in ambulance and participated in this study. Most of the women, especially those who living in rural, nomadic and remote areas, even dislike to being naked in the presence of midwives, so having a male attendant on their bed during childbirth is very annoying and embarrassing for them. Many of them ask male EMT_s to leave the ambulance during delivery. For the male relatives, the presence of a male EMT_s in the ambulance during childbirth creates a sense of destruction of social prestige, as a result sometimes this leads to challenges and conflict with the patient's relatives. They usually don’t accept the presence of a man at the bedside, unless they feel that the mother’s life and the baby are in danger. EMT_s, especially those with less experience, also experience a lot of shame when they come to the bedside of women in giving birth.

“One of the pregnant woman’s relatives told me that I don't want you to stay at the bedside. She did not allow me to stay in the ambulance and help the delivery. After giving birth, we went and saw that the umbilical cord was tied with a thread.” (P₁₀)

"In some cases, in Dystocia, I needed someone to help me.at least to infuse intravenous fluids for the mother, but the men who were present, the husband, the father or the brother of the pregnant woman, prevented male EMT_s to come in. Sometimes there was even a conflict because the relatives said why a man should be present during the delivery.” (P₁₇)

Lack of facilities

- Non-standard ambulances) low quality ambulances)

The Ambulances using in PEMS have limited space and were not designed to giving birth. The bed in the ambulance is a simple bed that designed for transfer of all patients and does not have the ability to maneuver in difficult births. The space around the bed is also very limited. In addition to the pregnant mother, a relative and at least one EMT_s are present in the rear cabin of the ambulance, and this makes the space more limited. There is not even a place to open the sterile set and it causes the un-sterility of the procedure in many cases. It is impossible to use warmers and incubators, and the EMT_s or midwives have to warm the babies by hugging them.

Lack of security restraint for mother or baby is another problem and Most of the participants in the interview pointed to the feeling of insecurity for the mother and the baby when the ambulance passes through the winding and rough roads. The ambulances are also worn out and when passing through dirt roads, dust fills the rear cabin and pollutes the space. Sometimes, after transferring patients of traffic accident, ambulances transfer the pregnant women, and this causes the rear cabin to be dirty and bloody. Due to limited resources, it is not possible to purchase ambulances with more space in the rear cabin, in addition, the ambulances with a larger space in the rear cabin unable to pass through rough and difficult geographical roads.

“The space inside the ambulance was very limited. Its bed was very bad. Because it was not designed for childbirth. There was no place to open the sterile delivery set. We had to open the set under the patient's feet or on the relative’s chair. If even a slight dystocia was occurred, we could not give the women a special position.” (P₁₄)

"The ambulance was used to transport patients of road accidents and it was not washed. It was full of blood. We felt sick, it was not a clean environment at all." (P₂₆)

- Inadequate equipment and medicines

Special drugs and equipment are needed to maintain the health of the mother and baby during and after delivery. But ten of the participants in the study mentioned the lack of drugs and equipment in the ambulance. For example, lack of Syntocinon that plays a major role in childbirth by increasing uterus contractions and also used to stop bleeding after delivery. They also mentioned that some drugs, such as Syntocinon, should be kept in the refrigerator, but sometimes there was not even a simple cold box in the ambulance, therefore long distances driving in the summer could cause the drugs deterioration.

"Syntocinon should be kept in the refrigerator. Especially in the hot seasons, when we had to travel a long distance to reach the pregnant women, the medicines were kept outside the refrigerator for a long time. Sometimes there was not even a cold box in the ambulance." (P₃)

"The ambulances were not equipped; I remember when the ambulance didn't even have an intravenous fluid’s stand. Many times, we did not have enough sterile sets for giving birth” (P₁₁)

The aim of this study was to describe the experiences of EMT_s that faced with giving birth in ambulance before hand over pregnant women to equipped health centers. After analyzing the data, two general categories were formed at first, including the factors that cause delivery in ambulance and the challenges of delivery in ambulance. Three themes were formed in each of these categories: Local culture, inaccessibility and weak managers in first category and fear and anxiety, native culture and lack of resources in the second.

The results showed that local culture has significant influence on pregnant women delayed to timely using hospital or equipped health centers for delivery. In rural, nomadic and remote areas, it is accepted that the girls should marry at a young age. In this culture, the education of girls is not as important as their early marriage. Therefore, they are usually illiterate or only know reading and writing. This is may be the main reasons for the delay in timely use of skilled cares in equipped centers. Sarker, in his qualitative study, emphasized the effect of women's illiteracy on home delivery. He mentioned that illiteracy is an important factor that cause women to not seeking delivery care from hospitals or equipped centers [15]. The other studies also showed that illiterate women or women with low level education are unaware from giving birth complications and this contribute to preferring delivery at home [16, 17].

Obeying senior women such as mother-in-law is the other detrimental behavior that accepted in rural and native areas. These women, who are often illiterate and untrained, give advices based on their own or other’s past experience of childbirth, that cause delayed timely care-seeking and put the pregnant mother and baby more at risk. Often in rural area there are the women who gave birth with the assist of mother in low or other senior women and this cause the pregnant women to delay in seeking care from equipped health centers, maybe they think that nothing will happen if they don’t refer timely and they can give birth at home without any complication. Sychareun et al, in his study demonstrated this, the sometimes the woman and her husband preferred to give birth at a hospital or health centers, but the seniors, specially the mother and mother-in-law, advised them to give birth at home because of their own past experience of childbirth [18].

It seems that the heavy activity of pregnant women such as farming and animal husbandry, which is a part of the customs of rural and nomadic areas, cause the delivery time to advance. This may cause neglect to go to health centers for delivery on time and giving birth in ambulance. Goffinet mentioned in his study although those women who are employed and have normal activity have a lower risk of preterm birth but working more than 42 hours a week and standing more than 6 hours a day can increase the risk of preterm labor [19].

The other issue is inaccessibility to delivery services due to poverty, limited transportation, long distances, difficult geography and bad condition of the roads especially in rainy seasons. Most of the people living in remote area are poor and cannot pay for transportation, settling in nearby cities to follow up their pregnancy condition, medical tests, medicines or hospitalization. Therefore, they prefer to give birth at home, or wait until the last moment and then call PEMS for transfer. Damaceno et al, in their research that socio-economic condition and geographical distance predispose women to give birth outside the health equipped delivery center. He mentioned that there is a strong relationship between the time of travel to the equipped health centers and the occurrence of child birth outside the hospital [20]. Hirose also stated that the increase of distance from hospital and other child birth facilities increase the departure delay and when the symptom of delivery were clear, poverty cause to delay in decision to move to hospital [21].

Loughney et al, believes that living near to the hospital may increases the risk of giving birth before arrival at hospital. He says that some women who live adjacent the hospital may incorrectly believe that the delivery suite could be accessed in a short period of time, and therefore postpone the hospital attending until the last moment and this causes birth before arrival [22].

Another reason for the increase delivery in ambulance can be incompetency of health managers. The establishment of health centers in remote area may not be cost-effective and the government's economic situation not allow to set up such centers. Facilities deprivation and lack of necessary support in remote area, also cause shortage of professional staff. They are not satisfied to serve in such areas.in addition irresponsibility of midwives, irregular services during pregnancy to women settling in remote area, poor management, weak education and inadequate equipment can endanger the health of mother and baby and also increase child birth in ambulance. In another stud by Khatri et al, Lack of facilities and resources and the unavailability of midwives are the barriers for pregnant women to use equipped centers for childbirth. He mentioned midwife’s shortage and the lack of expected support from existing midwives as other barriers to providing permanent services [23].

The most sense experienced by the EMT_s during delivery in the ambulance was the feeling of fear and anxiety due to possibility of endangering the health of the mother or the baby and unknown, unfortunate and unexpected events. Giving birth in ambulance is an uncommon but significant clinical event and most of the EMT_s have no any experience in this regard. They have not educated and trained about delivery in ambulance and don't have self-reliance to manage this event and for these reasons they feel fear and anxiety. The results of Persson et al, study showed that confidence in one’s ability creates security feeling, and the experienced nurses expressed confidence. The same as this study, she states that in order to be safe and feel secure, the nurses who work in ambulance must be educated about delivery in ambulance [2]. Also, Norden in this regard emphasized that education of the staff that faced with uncommon events should be more practical and theoretical training such as birth before arrival to the hospital [24]. Persson et al, argued that the knowledge of EMT_s about the risk of complication such as massive bleeding of mother, asphyxia of new born, stillborn and prematurity of neonate cause to concern, nervousness and anxiety [2].

Another source of fear and anxiety found in this study was the fear of getting involved in legal conflict and litigation, because the probability of complaint against the EMS providers by the patient, patient’s relatives, or hospital staff. Usually, one of the patient's relatives is present in the ambulance with her and observes the staff's behavior and performance. If an unfortunate and unexpected event occur for the mother or the baby, there is a possibility that the patient's family refer to judicial authorities and involves the ambulance staff in legal conflicts and litigation. The hospital staff also when admission of the mother and her baby, record all of the problems in patient file’s as shortcomings and negligence of the EMT_s, therefore there is probability of getting involved in litigation later. In the research conducted by Afshari et al, it was found that that EMS staff may be legally prosecuted for their practice. He emphasized that the possibility of litigation and the necessity to attend juridical settings are highly stressful for EMS providers [25]. Colwell et al, mentioned legal prosecution as a major source of stress in EMT_s and reported that the Sources of complaint against EMS respectively included patient, health care providers and patient’s relatives. He stated lack of skills, transfer-related problems and lost personal belongings as reasons of complaint [26]. Dobbie mentioned that the family of an obstetric case claimed that the lack of equipment to manage the preterm baby in ambulance cause to developed cerebral palsy and blindness [27].

The sense of shame and embarrassed is another challenge that all pregnant women experienced during delivery in the presence of male EMT_s. Women, especially who are living in villages and remote areas, are extremely ashamed to be naked in front of unfamiliar men. Inexperienced EMT_s also experienced the same feeling. The sense that decreased with increasing experience of EMT_s, but did not disappear. Sychareun in this regard had similar finding. He stated that most of the pregnant women felt shy when a male was present in the health facility during delivery [18]. Sarker et al, also showed similar finding to this study. The results showed the people believed if their women gave birth out of the home and in presence of a male physician, their social status and prestige will diminish. He described that women in remote and rural area liked to give birth at home because they didn’t like their genitalia to be exposed to men [15].

In this study, based on participant’s opinions, the limited space, being dilapidated, improper beds for delivery, inappropriate ventilation in warm and cold seasons, dust entering the rear cabin and polluting the environment, being dirty and bloody due to transporting different patients, unavailability of equipment and required drugs is mentioned as another challenge of delivery in ambulance. Suserud et al, about the ambulance space shows that the limited space of the ambulance and the fact that the ambulance moves at a high speed and the safety belt cannot be fastened causes imbalance and disturbance in handling critical situations [28]. Bohström et al, emphasized on lack of equipment and limited space in ambulance and said that these factors may cause stress in ambulance staff [3].

Limitation

The main limitation of this study was the inaccessibility to women who gave birth in ambulance. Because all the women who gave birth in ambulance and their name were registered in the PEMS were living in remote areas. Their phone number was not registered in the system and the registered phone numbers belonged to their husbands. With the collaboration of the midwives working in health centers tried to communicate with them, but most of them were not satisfied to participate in interview. With a lot of effort, only seven people agreed to be interviewed, among them four were illiterate and three had low literacy. Face -to-face and telephone interviews conducted with them, but they could not communicate well and the interviews were not satisfactory.

This study shows that a wide range of factors such as cultural issues, illiteracy, poverty, remoteness and difficult geography roads, unavailability of health facilities and inefficiency of health system can cause delivery in ambulance before arrival to the hospitals. In order to reduce the number of deliveries in the ambulance and decrease the health risk of the mother and the baby, participation and cooperation of the government and community is essential. Correcting cultural wrongs and change local culture requires long-term planning and all stockholder’s participation. Attempt to increase the level of literacy as well as educate all women regarding prenatal care can be helpful. The health authorities should also try to increase the access of people, especially in remote areas, to prenatal care in any possible way.

Regarding the challenges of giving birth in ambulance, it seems that the health system and EMS providers are not prepared for these missions. Because giving births in ambulances are potentially high-risk events both for mothers and babies, education and training of EMT_s in colleges should be followed more seriously and since the EMT_s rarely faced with delivery in ambulance, continuous training programs and continuous quality improvement should be done. providing ambulances with equipment, facilities and medicines needed for childbirth, continuous training, supporting EMS providers against litigation claims and planning for the presence of a midwife in all missions related to pregnant women makes the personnel feel safe and will reduce their fear and anxiety.

EMS: Emergency Medical Services

EMT_s: Emergency Medical Technicians

PEMS: Pre-hospital Emergency Medical Services

Acknowledgement

This study is related to a research design which was ratified and financial Support by
the research and technology deputy of the Medical Sciences University of Shahrekord (Grant No. 5966). I hereby express my deep gratitude toward the respectable Deputy of Researches and Technology of Shahrekord University of Medical Sciences, and all participants that assisted us in this research work, without whom the study could not be possible.

Author’ contributions

All authors have read and approved the manuscript. Study design: RAS, MH; data collection and analysis: RAS; manuscript preparation: RAS, MH.

Funding

The project was financially supported by Shahrekord University of Medical Sciences, Shahrekord, Iran (Grant No. 5966).

Data Availability

The datasets generated in the current study are available from the corresponding author upon reasonable request.

Ethics approval and consent to participate

Consent for publication

Informed consent for publication has been obtained from the participants in this study.

Competing interests

The authors declare no competing interests.

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No competing interests reported.

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The challenges of delivery in Pre-hospital Emergency Medical Services ambulances in Iran: a qualitative study

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