Table 1 Barriers of reducing C-Section rate in Iran; Categories, Themes and subthemes

Economic and Political Context

   • Economic Issues

Lower tariff for vaginal delivery compared to C-section

The low share of midwife from vaginal delivery tariff

Fee for service payment methods

The role and responsibilities of insurance companies

   • Legal issues

Multiple centers for dealing with medical errors

No respect for the physicians in the court

Incapability to judge based on the existing condition and available facilities

Lack of criteria for selecting technicians in the legal system, low knowledge and skill among the technicians,

The absence of practical guidelines for judges

Ignoring the stem of the problem

Inability to produce evidence-based and scientific proofs due to technological problems

Simplicity of filing a complaint by families

The absence of any support for midwives

The high price of blood money

Individual Professional

Physicians' good perception about cesarean section complications

Physician's declining skills of managing vaginal delivery

The Teaching residents system

Midwives' declining skills of managing vaginal delivery

The teaching midwives system

Lack of ethics in suggesting cesarean section without indication by providers

Organizational context

Hospital Management Methods (Autonomous Hospitals)

Hospital type (public, private, teaching or referral)

Lack of on call physicians

Lack of physicians and midwives' job descriptions

Lack of human resources specialized in obstetrics

Lack of human resources specialized in midwifery

Additional Interventions

Unsuitable attitude toward mothers in the labor Room lack of acceptable facilities of the labor Room

Lack of suitable pregnancy care provision

Social context

Lack of cooperation at associative levels between midwives and specialists

Distrust between midwives and specialists in hospitals

Innovation (vaginal delivery)

Time consuming

High stress levels

Being unpredictable