This research is a qualitative study to develop strategies, approved by the Ethics Committee of Tarbiat Modares University, Tehran, Iran (IR. MODARES. Rec 1397.267) and study will be conducted in the fields of health and treatment of the Ministry of Health and the selected Iranian national universities. The selected universities in this study include three type I universities (Shiraz, Isfahan, Tehran), one type II university (Zahedan), and two type III universities (Alborz, Shahrekord). Tehran University of Medical Sciences was randomly selected from three Tehran Universities of Medical Sciences (Shahid Beheshti, Tehran and Iran). It was selected because we need to have one of the capital's medical sciences universities in the research process. Alborz University of Medical Sciences is selected because of the immense cultural diversity in this province that is due to the over-migration. Accordingly, different implementation of the maternal mortality surveillance system is more possible than other provinces. Shiraz University of Medical Sciences is considered for being a pioneer in the development and implementation of some maternal health related programs (Accreditation Programs). Isfahan University of Medical Sciences is selected because maternal mortality rate in this university shows a decreasing trend during the last three years. Zahedan University of Medical Sciences is selected among the other medical sciences universities of the country because of the high maternal mortality rate of this university. Finally, Shahrekord University of Medical Sciences is selected among other medical sciences universities of the country because of the low maternal mortality rate of this university. At all stages of the study, informed written and oral consent will be obtained of all participants. This research will be conducted in two phases. In the first phase, the processes of maternal mortality surveillance system are analyzed qualitatively and through using a directed approach. In fact, using this analysis, the experiences of the surveillance system actors about the challenges of this system will be discovered and, after being completed, the codes base on the available categories, subcategories and final or main categories will be identified. In order to conduct the second phase of the research, a panel of experts is set up with the aim of considering the best strategies for the improvement of the Iranian maternal mortality surveillance system by considering the above analysis. In order to formulate these strategies, several meetings will be organized with the participation of the Ministry's maternal health actors, stakeholders, and researchers of the study. In these sessions, the assessment of the internal and external environments in relation to the implementation of the Iranian maternal mortality surveillance system will be done by considering the obtained analysis, then, balancing these points, the strategies will be formulated.
First phase: qualitative study (Explaining the actors' experiences)
The first phase of the study is designed to answer this question that “How are the actor's experiences for Iranian maternal mortality surveillance system?” This study will be conducted using a qualitative content analysis method.
Sampling Method
Purposive sampling method will be used in this research, whereby the actors, through active participation in the research, will help the researcher in better understanding of the problem. Sampling will continue until data saturation is reached and the categories are repeated.
Participants: The research participants are the maternal health actors in the Ministry of Health and Medical Education and the selected universities of the country. Maternal health actors in the Ministry of Health and Medical Education: In the area of health, these actors include the head of the Maternal Health Department, the expert in maternal health and the head of family, population and school’s health department. In the field of treatment, they include the head of the midwifery department, the expert of mothers in the midwifery department, the head of the treatment and evaluation department, the head of hospitals affairs, the head of the clinical excellence department, deputy of treatment and director of treatment.
Maternal health actors in the selected universities: In the field of the Health Deputy, these actors include the head of the maternal health department, the expert in maternal health and the head of family, population and school’s health department. In the field of the treatment deputy, these include the head of the midwifery department, the expert of mothers in the midwifery department, the head of the treatment and evaluation department, the head of hospitals affairs, the head of the clinical excellence department, deputy of treatment and director of treatment .In the field of educational deputy, they include educational assistant, the gynecologist member of the mothers' mortality and morbidity committee, the head of gynecology department and the head of midwifery department of medical as well as nursing and midwifery schools and the heads of these faculties. In the referral hospitals they include the hospital head, the hospital manager, maternity officer, the head of mortality and morbidity committees, matrons and educational supervisors.
Research environment
The health deputy of the Ministry of Health and Medical Education, as well as the health and treatment deputy of the selected national universities (Alborz, Tehran, Isfahan, Zahedan, Shahrekord and Shiraz Universities of Medical Sciences) construct the research environment.
Inclusion and exclusion criteria
Inclusion criteria consists of having at least two years of working experience in the position of maternal health expert and being an active member of the university's mortality and morbidity committees. For the hospital authorities, one year of experience in the relevant position is sufficient. The exclusion criteria will be the unwillingness of the participants at any phase of the research to continue their collaboration.
Data collection method
Data collection in this phase will be done through in-depth semi-structured interviews, field notes and observations. Interviews will be conducted with the maternal health actors at the Ministry Health and Medical Education and the selected universities, and field notes are based on their nonverbal behavior. In the interviews, the processes of implementing the Iranian maternal mortality surveillance system (Collecting maternal death data, Maternal death review, Intervention design and Execution of interventions) will be examined to determine its distance from the standards; moreover, the challenges and defects of implementing such a system will be evaluated. Observation is also done by the random participation of the researcher in one or more death committees of the selected universities in order to record how the maternal mortality surveillance system is implemented.
Data analysis method
Directed content analysis will be used for data analysis and interpretation. All 3 stages of preparation (convert interview to text), organize (the emergence of new categories by forming an unconstrained matrix) and reporting, will be considered [11].
Accuracy and reliability of the data
To assure the trustworthiness of the findings, the four criteria of credibility, dependability, confirmability, and transferability will be employed.
Phase II: Strategies design
The second phase of the study is designed to answer this question that "what strategies are effective for Iranian maternal mortality surveillance system?" In order to conduct the second phase, sessions will be held considering the mentioned analysis and using focus group discussion method to find the best strategies for improving the Iranian Maternal Mortality Surveillance System.
Participants
The research population in this phase includes the head of the midwifery and reproductive health board, the head of women's board, the head and expert of the Department of Maternal Health in the Ministry, the head of the Department of Midwifery, one faculty member of the Obstetrics and Gynecology Department, one faculty member of the Midwifery Department, stakeholders out of the health system (representative of the Medical Council, representative of the Forensic Medicine Organization, representative of the Broadcasting Organization, representative of the Welfare Organization, and representatives of the Provincial Government, Governor and Municipality).
Research environment
The sessions for the development of strategies will be held at the Ministry of Health and Medical Education.
Inclusion and exclusion criteria
Inclusion criterion is that the participants are required to have at least 2 years of relevant work experience. The exclusion criteria will be the unwillingness of the participants at any stage of the study sessions to continue their collaboration.
Data collection method
Data collection process in this phase is performed through focused group discussion, so that the views, judgments, and attitudes of the visiting professionals about the strategies used for the improvement of the surveillance system are considered in several sessions. It should be noted that before the sessions, the results of the first part of the research as well as the comparisons of maternal mortality surveillance systems in the world, are prepared as a protocol and are given to the stakeholders of the research by the researcher. The first session will be held with the participation of the representatives of the Health Ministry, the head of the department of the Midwifery of the Health Ministry, and the head of the department of Maternal Health at the Health Ministry. After presenting the general issues of the national system of maternal mortality surveillance and its significance in the field of health, the results of the interviews about the analysis of this system will be discussed. Given the mission of the Ministry in improving the national system of maternal mortality surveillance to reduce maternal deaths, and based on the obtained analysis, the context is provided for determining and selecting a number of stakeholders in order for the sessions to be held purposefully. In the next sessions, with the presence of the aforementioned members and selected stakeholders, the internal (strengths and weaknesses) and external (opportunities and threats) factors of the maternal mortality surveillance system will be assessed.
Data analysis
Data analysis is performed in other sessions through creating a strategic balance between the strengths, weaknesses, opportunities, and threats (SWOT). The formulation of the strategies is done through this balance. The matrix tables (decision matrix, prioritization and selection matrix, and final matrix) are then drawn to consider the most important strategies.