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This was an analytical study that was conducted to determine effective factors on childbirth with an interval of less or more than two years in health clinics of Zahedan in 1997-1998.The samples consisted of 400 women with a childbirth interval of less than two years and 800 women with a childbirth interval of more than two years. The women with the following criteria were surveyed: gestational age at the time of delivery (27 months or more ), no abortion during the interval of two last childbirth and living with their husbands during the investigation period. Moreover, women's demographic data (such as age, education), the quality of their last pregnancies, the role of men in contraception and the contraceptive methods were also analyzed.The results indicated that there was a significant relationship between the follwing variables and establishing an interval of childbirth: maternal delivery age, education, number of male children and the number of the last pregnancy with an interval of childbirth (pRegarding the unwanted pregnancies, the findings revealed that lactation 15.83% and lactation pills 53% were caused childbirth with an interval of less than two years, while, IUD 76.47% caused childbirth with an interval of more than two years and contraceptive injections 46.43% caused an interval of 2-3 years.There was a significant statistically relationship between contraceptive method and childbirth interval (p <0.001 ).The participation of couples in establishing childbirth interval and applying IUD were confident methods in performing a childbirth interval of more than three years.It is recommended that women should be trained enough for the role of lactation as a contraceptive method. They also required training to apply other contraceptive methods coincidental.

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Links between violence, aggression, and mental illness are well documented. Despite this association, our current understanding of the factors for and optimal treatment of aggression remains limited. This lack of knowledge is alarming because nurses, particularly pediatric nurses who treat aggressive children, are frequent targets of patient aggression. Consequently, the aim of this article is to provide information regarding the concept of aggression in child patients, assessment of violent behavior, implementation of interventional treatment and a review of medical, psychological and social strategies which assist in the understanding of aggression and its clinical intervention. However, the etiology of aggression for the most part still remains a mystery.

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Children are the biggest national investment that a society can make. With increased child population so too have their problems increased, amongst which are the increased incidence of street children, which as a result has endangered their health. This research is a descriptive and cross sectional study towards determining the effective factors on the self-concept of street children aged 6-12 years who were referred to the Khajouye Kermani culture house of Tehran in 1380. In this regard, 140 street children between the ages of 6-12 were chosen. The method was a 4-part questionnaire which included personal, family and societal information and questions related to the self- concept of the children. The data was collected by interviews with the children. In accordance with the average and the deviation criteria achieved, the level of self-concept was divided into four groups, extremely negative, negative, positive and extremely positive. The results showed that half of the subjects (50%) had very negative concepts of themselves and only 2.2% of them had a very positive self- concept levels. Therefore the street children had a very low self- concept level. Also as concerns the factors affecting self- concept was also a meaningful relationship between self- concept and some factors such as gender, education, level of income, duration of work, level of happiness within the family, counseling, reaction to the child's mistakes, having necessities for the home, adequate nutrition and clothing, having street friends before work (P<0.05). Therefore street children are at risk as regards their mental and physical development because they suffer from low self- concept levels and require special attention. Because of the vast responsibilities nurses can play an important role to improve of the health of these children.

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Introduction: Evaluation of health care services is an essential step in improving health care quality and without it such an improvement could not be achieved.

Material and Methods: In this descriptive study, parent’s satisfaction of child’s health care in the health and treatment centers affiliated to Tehran University of Medical Sciences was evaluated. Four hundred parents who had attended 25 health and treatment centers were participated in this research. A questionnaire was completed through the interview with parents of 1 to 12 months old children. Analytical and descriptive statistics were used for the analysis of data.

Results: The finding of this study showed that the majority of parents had average levels of satisfaction concerning communication’s skills of health care providers and high levels of satisfaction about availability of these cares. Satisfaction of parents in the section of the vaccination was high and majority of samples had average levels of satisfaction about growth monitoring of children. There was a relationship between infant&aposs age and parent’s satisfaction.

Conclusion: Based on these findings recommendations have been made for future research. The findings of this study can be utilized in public health planning in order to improve the quality of the infant’s health care services.

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Background & Aim: Adverse childbirth experiences as a trauma can evoke fear and post-traumatic stress disorder in some women. This study was conducted to investigate the effect of counseling on post traumatic stress disorder after a traumatic childbirth.

Methods & Materials: This research was a clinical trial which was conducted at Kamaly hospital in Karaj. Samples (300 women) who had experienced a traumatic childbirth were selected by a convenient sampling method and were randomized into an intervention (n=150) and a control (n=150) group. The intervention group received face-to-face counseling within 72 hours of birth for forty to sixty minutes in a session. The control group just received usual care after childbirth. The data collection tool was questionnaire, which was completed via interview. The measuring variables were demographic characteristic, reproductive history, maternity social support, and post-traumatic stress disorder. Data were analyzed using descriptive statistics and inferential tests (Chi-square, Fisher&aposs exact test, and generalized Fisher&aposs exact test) by SPSS v.13 software.

Results: After 4-6 weeks of follow-up there was no significant difference regarding post-traumatic stress disorder between two groups (P=0.295). At 3-month of follow-up, the intervention group reported less post-traumatic stress disorder comparing with the control group (P=0.001).

Conclusion: A midwife-led counseling plan is effective in reducing post-traumatic stress disorder during a long term.

 

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Background & Aim: Nutrition is a very important factor in toddler age growth. Getting started the first steps of the children with family in this period shows the necessity of paying attention to the correct nutritional behaviors. Therefore this research has been conducted for assessing the effect of nutritional behavior model on the quality of toddler&aposs nutrition and performance of their mothers.

Methods & Materials: This research is a semi-experimental study, in which sixty six children (12-36 months old) were selected from two health care centers in the southern part of Tehran. The subjects were selected using non probability-convenient sampling method. The data gathering tool was 3 questionnaires: 1. Mother and child demographic characteristics 2. Mother&aposs function assessment tool about toddler&aposs behavior during feeding 3. Reminding tool of 24 hours food. The tools were filled in using interviews. Then nutritional behavior model was instructed in a workshop during 2 days, 3 hours a day. After the intervention data were recollected again and were analyzed by descriptive and inferential statistics.

Results: The results showed a significant difference in mother&aposs function about toddlers nutritional behavior during nutrition before and after the intervention (P<0.001). Also a significant difference was seen in the toddlers nutrition pattern before and after the intervention (P<0.05).

Conclusion: Based on the research findings it can be concluded that nutritional behavior model is effective in improving the pattern of toddler&aposs nutrition and in increasing mothers&apos knowledge related to a correct function on toddler&aposs behavior during feeding. Therefore educational plan to mothers on correct nutritional behaviors is suggested in order to improving the quality of toddler&aposs nutrition.

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Background & Aim: Due to the fact that family centered care have a crucial role in pediatric nursing, it seems compatibility of nurses&apos and parents&apos perception about parents&apos needs can lead to deliver higher quality care. The aim of this study was to compare parents&apos and nurses&apos perceptions about needs of hospitalized children&aposs parents.

Methods & Materials: This is a cross-sectional survey. One hundred and fifty parents and 80 nurses were selected using convenient sampling method. Data was gathered using Kristjánsdóttir&aposs "parental needs of hospitalized children" questionnaire. Data were analyzed using descriptive and analytical (Chi-squared & Mann-Whitney U tests) methods.

Results: Research findings showed that there was significant difference between both parents&apos and nurses&apos perceptions about parents&apos needs (P=0.012). Both groups believed that parents&apos needs are met partially in hospitals. There was not meaningful difference between the parents&apos and nurses&apos perceptions concerning meeting parental needs (P=0.666). Based on their perceptions, understanding of parents&apos needs help them to meet their requirements in health care facilities. There was a significant difference between parents&apos and nurses&apos perceptions regarding parents&apos need (P=0.018).

Conclusion: Parents and nurses recognized all of the parents&apos needs to be important there were also deficits in meeting these needs. Therefore, parents&apos cooperation with health care team is necessary to facilitate the recovery of sick children as well as meeting parents&apos needs.

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Background & Aim: Exclusive breast feeding is highly recommended for children under six months and the best time for starting supplementary food is the end of sixth months. Inadequate feeding can lead to malnutrition. Since infants&apos supplementary feeding pattern is influenced highly by the socio-cultural status it is necessary to study the subject in diverse conditions. This study aimed to investigate supplementary feeding pattern in 6-12 months children referred to Ilam clinics in 2002.

Methods & Materials: In this study, 364 mothers with 6-12 months children were selected using convenient sampling method from 10 health care centers. Data were collected using a four-sectioned questionnaire including mothers and their babies demographic characteristics, feeding pattern (frequency, the type of milk), supplementary food (the age of onset and the type of the first supplementary food, the time of starting mixed foods, and the source of information about supplementary food) and mothers&apos performance about feeding with supplementary food. The questionnaire was filled via interview.

Results: Findings showed that the growth curve in 84.8% of babies was in the health road. About 38% of babies were the first child. In 50.9% of samples, supplementary food was started before 6 months of age and in 49.9% of the cases, it was started after 6 month old. Supplementary feeding accompanied with breast feeding in 83.5% of the infants. The most used supplementary food was rice mucilage (40.8% of the babies). The interval between starting one supplementary food and the other one was 3-4 days in 50.2% of the cases. Also 80.8% of samples started feeding in the amount of one spoon and increased it gradually. The majority of mothers (64%) did not add sugar, salt and spices in order to attract their babies. As well, 75.6% of samples used spoon and cup for feeding and 92.9% knew the safe time for keeping cooked food in the refrigerator. The source of information about supplementary feeding in 65.4% of mothers was health care providers and in 5% were books and booklets.

Conclusion: Findings indicated that more than half of mothers began supplementary feeding for their children before 6 months old without pursuing any accepted pattern. It seems that usual educational programs in Ilam were unable to answer all the problems aroused in this issue. Hence, educating mothers using other methods such as visual teaching material is recommended.

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Background & Aim: Nausea and vomiting is one of the major side-effects of chemotherapy. Due to complex nature of its management, both medical and non-medical therapies are recommended. This study aimed to investigate the effect of music therapy on chemotherapy nausea and vomiting in children with malignancy.

Methods & Materials: In this quasi-experimental study, 30 children aged 8-12 who were under chemotherapy were recruited. After getting the current treatments, the children listened to a kind of music for 45 minutes at 6, 9, and 12 hours after the beginning of the chemotherapy. Nausea and vomiting was measured using both numerical and descriptive scales every 8 hours for 24 hours after beginning of the chemotherapy. Data were analyzed using Willcoxon and Mcnemar statistical tests in the SPSS, version 11.5.

Results: The rate of nausea was declined significantly at the 16^th and 24^th hours after music therapy. Assessment of nausea by descriptive scale showed a decline only at 24^th hours after music therapy. The rate of vomiting did not show any significant difference between two stages.

Conclusion: Music therapy could decrease the amount of nausea in children with malignancy under chemotherapy however, it does not any effect on the rate of vomiting.

 

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Background & Objective: Invasive procedures are severe stressors for
in-patient children. The stress result in sleep disorder, reduced concentration, and increased pain. Nowadays, pharmacologic and nonpharmacologic interventions are used to control stress. We aimed to assess the effect of massage on children&aposs anxiety level before intensive procedures.

Methods & Materials: In this clinical trial, 70 children aged 7-11 were recruited from a children hospital. The participants were randomly allocated to the intervention and control groups. The intervention group received massage therapy in the Yeen tang point and palms for five minutes. The control group received the usual care. Anxiety was measured using OSBD-R. Data were analyzed using Mann-Wittny and Willcoxon statistical tests.

Results: The anxiety level was not significantly different between two groups before the intervention (Control group: 3.24±0.48 Intervention group: 3.24±0.56) (P=0.472). Following the massage, the anxiety level decreased significantly in the intervention group (Intervention group: 1.57±0.54 Control group: 3.37±0.46) (P<0.001).

Conclusion: Massage in the Yeen tang point and palms can reduce the anxiety level in hospitalized children prior to invasive procedures. It is recommended to use this massage technique in pediatric wards to reduce anxiety level.

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Background & Aim: Pain is an unpleasant experience related to potential or actual tissue damage. Distraction is an effective technique to control pain. This study aimed to examine the effect of pressing a small soft ball during intravenous catheter insertion on pain related behavioral responses of children.

Methods & Materials: A randomized clinical trial study was conducted in surgical ward of the Qods hospital in Qazvin, Iran in 2010. Sixty children aged 4-6 were selected through a simple randomized sampling method. The children were allocated into two equal intervention and control groups. Data were collected using the FLACC scale. In the intervention group, children were asked to press a soft ball during IV catheter insertion. The researcher marked the FLACC during the procedure. In the control group, no distraction was made during the IV catheter placement. The data were analyzed using descriptive statistics, independent-sample t-test, Chi square at P<0.05.

Results: There was no significant difference between the two groups in terms of demographic variables including gender, birth order, race, age and type of disease. In the intervention group, none of the children experienced severe pain during IV catheter insertion and 63.3% of the children had moderate pain. In the control group, 50.0% of children had moderate pain and 23.3% of them experienced severe pain during IV catheter insertion. There was a significant difference in perceived pain between the children of two groups (P<0.001).

Conclusion: Distraction is an effective, non-expensive, and easy-to-access technique to control and reduce pain in children during IV catheter placement. This study showed that distraction through pressing a soft ball was effective in reducing the behavioral responses of pain in children who underwent IV catheter placement.

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  Background & Aim: Children with cerebral palsy need permanent care and attention in various stages of growth and development. The parents experience problems in taking care of these children and making them independent. This study was conducted to explore these experiences.

  Methods & Materials : This qualitative study was conducted in 2011-2012 using content analysis. Purposeful sampling was used to recruit 19 parents of children with cerebral palsy referred to rehabilitation centers in Tehran. The data were gathered using in-depth and semi-structured interviews and were analyzed inductively.

  Results: Data analysis results revealed three original categories including "life with hardness" ، "being in ambiguity" ، and "need to be supported" ، and several subcategories including "physical strain" ، "psycho-emotional strain" ، financial burden" ، "restriction in social activities" "facing with anonymous" ، "lack of having an advisor" ، "need to get help from professionals and specialists" ، "need to have emotional- spiritual support" ، and "need to have help in caring the child".

  Conclusion : Parents in permanent care of children with cerebral palsy face with new and various situations consistently and experience difficulty and bewilderment because of insufficient family and social support. Further studies are needed to explore the support process of caregiver parents of these children.

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  Background & Aim : Childhood cancer discloses family, and mother in particular, to a number of challenges. It consumes a lot of time, energy, and money of parents to fulfill their caring responsibilities. In some cases and along with increase of caring pressure, mental health of parents deteriorates. The vesting consequences of such events may alter the process of children caring and their quality of life (QoL). The purpose of this study was to examine the relationship between mother’s general health status with the QoL of the child diagnosed with cancer.

  Methods & Materials : In this descriptive cross-sectional study, 124 mothers of children diagnosed with cancer and aged 6-14 years old, referred to Imam Reza and Amir Hospitals in Shiraz during a four month period (from early November to late February) were selected to the study. Data were gathered using the following instruments: 1) the questionnaire of factors related to QoL in children 2) mother's general health status form 3) TNO_AZL Children Quality of Life (TACQOL) and 4) Ped QL Cancer Module. Data were collected through interviewing with mothers and reviewing the medical records of the hospitals. Data were analyzed using the Kruskal–Wallis, Spearman correlation coefficient, Mann-whiteny test and logistic regression in the SPSS-19.

  Results: : A few number of mothers (7.3%) reported good general health status and a large number described their general health status as moderate (55.6%) and poor (37.1%). The mean of health related QoL score and the specific QoL score for children were 78.45±10.05 and 65.51±17.54, respectively. According to the multi-factorial logistic regression, demographic and social factors such as child’s age and treatment-related factors including the period of radiotherapy, along with the duration of disease were more correlated with health and specific QoL scores in children, compared to the mothers’ general health status score.

  Conclusion : Results from this study suggested that emotional support is as important as financial empowerment. The QoL in these patients and their families may improve by identifying the families who are at risk of mental problems.

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  Background & Aim: Cancer is the most common childhood chronic medical illnesses that can affect quality of life of the children and their families. The aim of this study was to determine the effect of coping skills training on quality of life among parents of children with leukemia.

  Methods & Materials: This non-randomized clinical trial was conducted from March to June 2013. Ninety eight parents of children with leukemia who were referred to two selected hospitals affiliated to Tehran University of Medical Sciences were enrolled to study using convenience sampling method. The participants were allocated to two experimental (n=48) and control (n=50) groups. Data were collected through two questionnaires including demographic characteristics of the parents and children, and the Persian version of the Caregivers Quality Of Life index Cancer. Coping skills training including social communication skills was performed through small group discussion (5-8 members) in four 2-hours sessions for the experimental group. The questionnaires were completed four weeks after the intervention by the parents. Data were analyzed using the independent t-test, paired t-test, Fisher's exact test and Chi-squared test in the SPSS-16. 

  Results: The results showed significant increase in the overall quality of life after the intervention (P<0.001). The quality of life of parents in the experimental group was improved significantly in comparison with the control group (P=0.045). Mental/emotional burden (P<0.001) and lifestyle disruption (P<0.001) decreased significantly after the intervention.

  Conclusion: The coping skills training affected the quality of life among parents of children with leukemia . Effective educational interventions may help to increase the quality of life of parents who have children with Leukemia.

  

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  Background & Aim: Women who experience anxiety during labor are more vulnerable to physical and mental illnesses. Emotional support by a knowledgeable individual can improve physical and even mental conditions. This study aimed to determine the effect of presence of a Doula in delivery unit on parturient women’s anxiety .

  Methods & Materials: This is an experimental study using a randomized interrupted time series with a control group. Using convenience sampling, 64 parturient women with research inclusion criteria were randomly assigned to the control or intervention groups. The parturient women in the intervention group benefited from presence of a Doula and her support. The control group received the usual care without presence of the Doula. Data were collected using the Spielberger state-trait anxiety inventory and a checklist. The results were analyzed using parametric and non-parametric statistical tests in the Stata-11 . 

  Results: The age, education, family income, location of residency, the trait and state anxiety did not have any differences between the two groups at the baseline. After the intervention, the state anxiety was reduced significantly in the intervention group compared with the control group at the time of leaving the labor room, delivery room and recovery room (P<0.001) .

  Conclusion: According to the present research findings, Doula can significantly reduce the anxiety level and its complications among parturient women during childbearing .

  

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  Background & Aim: The &beta-Thalassemia major is a chronic disease that needs a regular blood transfusion. The blood transfusion is a complex process with high probability of human errors during the process which results in serious adverse events in patients. Nurses should deliver care based on the best available evidence or best practice. The aim of this study was to develop an evidence-based clinical guideline of blood transfusion in children with thalassemia .

  Methods & Materials: This study was conducted during 16 months from 2013 to 2014 based on three-step process of guideline adaptation including set up, adaptation and finalization. During these steps, topic and aims of the study were clearly identified. Then health questions were designed based on the PIPOH method. After conducting systematic searches, quality of the retrieved clinical guidelines was evaluated using the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument and a committee consisting of experts and policy-makers in nursing field. After external review, expert panel meetings and consensus between members, the final version of the guideline was developed . 

  Results: The criteria of clinical practice regarding stages of blood transfusion were determined based on the evidence, cultural and health conditions and were presented in twelve sections.

  Conclusion: This clinical practice guideline developed based on evidence can guide blood transfusion process in clinical practice.

  

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Background & Aim: Given the importance of mothers’ health and considering that developmental delay in children affects their mothers’ mental health this study aimed to compare stress and perceived social support in mothers of 6-18 month old children with and without developmental delay.

Methods & Materials: This cross-sectional, analytical study was performed on 610 mothers and their 6-18 month-old infants in health centers affiliated to Shahid Beheshti University of Medical Sciences. The participants were selected through the multi-stage random sampling. To collect data, the following questionnaires were used: obstetric and demographic characteristics, socio-economic status, infants’ characteristics, the Cohen perceived stress scale, perceived social support, and Ages and Stages questionnaire to determine the children’s development status. The data were analyzed by SPSS v.19 software and using descriptive statistics, Pearson correlation, chi-square, independent t-test and Man-Whitney statistical tests.

Results: The mean age of infants were 10.68±4.5 months. Independent t-test revealed a significant difference between mothers’ perceived stress (P=0.004) and social support (P=0.01) in the two groups. In addition, a relationship was observed between the mother’s social support and stress (P<0.04).

Conclusion: The results showed that mothers of children with developmental delays have more stress and lower perceived social support than mothers of normal children. Therefore, it is recommended to perform developmental screening for further examination and the reduction of mothers’ stress, as well as to provide appropriate social support.

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Background & Aim: Maternal request for caesarean section due to fear of normal vaginal delivery (NVD) is one of the main reasons for the high rate of caesarean section. This study aimed to compare the fear of NVD and type of delivery between two groups of pregnant women attended childbirth preparation classes (CPC) and women received routine prenatal care (RPC).

Methods & Materials: In this prospective cohort study, 202 Primigravid women attended healthcare centers for prenatal care services in the East of Guilan were selected using convenient sampling in 2013-2014. Fear of NVD was assessed using a childbirth attitude questionnaire at two stages (before attending CPC or receiving RPC, then at the third trimester of pregnancy). Both groups were followed up to the delivery time. Data were analyzed using inferential and descriptive statistics (Chi square, paired t-test, ANOVA, t-test) through SPSS v.16. P<0.05 was considered as significant.

Results: There was no significant difference (P=0.23) in the mean score of fear of NVD between two groups before attending CPC (35.59±8.78) and receiving RPC (37.08±9.08). The comparison of the mean score of fear of NVD between two groups at the third trimester of pregnancy showed a significant reduction (P<0.001) in the first group (32.30±8.31) than in the second group (37.29±9.55). A significant difference was also observed between two groups in the rate of NVD (P=0.002).

Conclusion: Results confirm the importance of CPC in decreasing fear of NVD and increasing the rate of NVD in primigravid women attended these classes. Therefore, women’s attendance at CPC is recommended to be encouraged.

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Background & Aim: Mother-Child bonding is an emotional aspect of relationship between mother and baby that affects children's psychological development. This study was performed to determine the predictors of mother-child bonding.

Methods & Materials: This cross-sectional study was performed on 270 mothers 8 to 10 weeks postpartum referred to eighteen health centers of Tabriz, 2014-2015. Data were collected using the obstetric and socio-demographic characteristics questionnaire, the Postpartum Bonding Questionnaire, the Edinburgh Postnatal Depression Scale and the Spielberger State-Trait Anxiety Inventory. The statistical tests including Pearson correlation, Independent t, one-way ANOVA and multivariate linear regression were used for data analysis through SPSS v.21. The significance level was considered as P<0.05.

Results: The mean (SD) of mother-child bonding score was 46.2±8.4, with achievable scores range from 0 to 125. 85.2% of mothers had a mother-child bonding disorder. The most frequent disorder pertained to the dimension of impaired mother-child bonding and the least frequent disorder was anxiety about child care. Variables of depression, state anxiety and unwanted pregnancy were among the predictors of mother-child bonding.

Conclusion: The study shows that anxiety, depression, and unwanted pregnancy are the determinants affecting mother-child bonding. Thus, the screening of mothers for the early identification and treatment of anxiety and depression, and also the reduction of unwanted pregnancy rate using purposeful family planning counseling can improve the mother-child bonding, resulting in improved children's growth and development.

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Background & Aim: Cesarean rate has had a rising trend in Iran during the last two decades. Natural childbirth promotion plan has been implemented in the form of health sector evolution plan (HSEP) in order to increase natural childbirth. Present study aimed to evaluate the effect of health sector evolution plan on cesarean rate and the average costs paid by mothers hospitalized in Kurdistan province.

Methods & Materials: This descriptive study was conducted as longitudinal and retrospective study. Cesarean rate in all hospitals of Kurdistan province was assessed in 2013 and one year after the implementation of HSEP. Furthermore, data related to the percentage of out of pocket expenditures by pregnant mothers in one of the hospitals of Kurdistan University of Medical Sciences, which was randomly selected, was also studied. Data were analyzed using SPSS v.20.

Results: There was a 14.02% reduction in the rate of cesarean in Kurdistan province one year after the implementation of HSEP compared to its basal rate in 2013 (P<0.001). The average out of pocket expenditures was 16.05% before the implementation of HSEP. This rate was reduced to 4.30% and 2.5% respectively after the implementation of first and third phases of HSEP.

Conclusion: Natural childbirth promotion plan has reached its predetermined goal, which was a 10% decrease in cesarean rate one year after the implementation of HSEP compared to its rate in 2013. In addition, there was a significant reduction in the percentage of out of pocket expenditures.

Background & Aim: Cesarean rate has had a rising trend in Iran during the last two decades. Natural childbirth promotion plan has been implemented in the form of health sector evolution plan (HSEP) in order to increase natural childbirth. Present study aimed to evaluate the effect of health sector evolution plan on cesarean rate and the average costs paid by mothers hospitalized in Kurdistan province.

Methods & Materials: This descriptive study was conducted as longitudinal and retrospective study. Cesarean rate in all hospitals of Kurdistan province was assessed in 2013 and one year after the implementation of HSEP. Furthermore, data related to the percentage of out of pocket expenditures by pregnant mothers in one of the hospitals of Kurdistan University of Medical Sciences, which was randomly selected, was also studied. Data were analyzed using SPSS v.20.

Results: There was a 14.02% reduction in the rate of cesarean in Kurdistan province one year after the implementation of HSEP compared to its basal rate in 2013 (P<0.001). The average out of pocket expenditures was 16.05% before the implementation of HSEP. This rate was reduced to 4.30% and 2.5% respectively after the implementation of first and third phases of HSEP.

Conclusion: Natural childbirth promotion plan has reached its predetermined goal, which was a 10% decrease in cesarean rate one year after the implementation of HSEP compared to its rate in 2013. In addition, there was a significant reduction in the percentage of out of pocket expenditures by mothers.