The challenges of delivery in pre-hospital emergency medical services ambulances in Iran: a qualitative study

Abstract

Background

Although unplanned deliveries in ambulances are uncommon, Emergency Medical Services (EMS) providers may encounter this situation before reaching the hospital. This research aims to gather insights from Emergency Medical Technicians (EMTs), midwives, and expectant mothers to examine the causes of giving birth in ambulances and the challenges EMTs, pregnant women, and midwives face during delivery.

Methods

A qualitative study was conducted, and 28 EMT_s, midwives, and pregnant women who had experience with pre-hospital births in the ambulance were interviewed. Data were analyzed using thematic content analysis. The MAXQDA/10 software was employed for data analysis and code extraction.

Results

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

Conclusions

Several approaches should be implemented to reduce the number of births in ambulances and Pre-hospital Emergency Medical Services (PEMS). These include long-term community cultural activities, public education, awareness campaigns, education and follow-up for pregnant women, and improved accessibility to health facilities. Additionally, EMT_S need to receive proper education and training for ambulance deliveries. Enhancing ambulance services and supporting EMTs in dealing with litigation claims are also critical.

Introduction

Working as an EMT in a PEMS environment means encountering patients in various scenarios. EMS providers must always be prepared to handle diverse and challenging issues [1]. One of these situations is encountering a pregnant mother near delivery, so the EMTs may have to assist with the birth before reaching the mother to a health center with delivery facilities [2, 3]. This situation can be considered a stressful challenge for EMTs because childbirth is a high-risk and infrequent medical condition, and the health of the mother and neonate may be at risk [3].

Maternal and neonatal mortality ratio is one of the most important indicators of a country’s development [4]. On the other hand, an unplanned birth in the ambulance increases the risk of danger to the lives of the mother due to complications such as excessive bleeding, retained placenta, shock, and the potential need for a blood transfusion for the mother, in addition, there are risks for the neonate such as hypothermia, hypoxia, umbilical cord entanglement around the fetal neck, and the need for neonatal resuscitation [5, 6].

McLelland et al. have shown that maternal and neonatal outcomes after unplanned births before arrival to hospitals are significantly poorer than planned home or hospital births [7]. In this context, Svensson and Fridlund stated that when delivery in an ambulance is unavoidable, EMS providers should be skilled in delivery management and maternal and newborn health care [8].

Despite this, in Iran, education and training about delivering neonates were not formally included in the EMTs’ curriculum, and assisting with childbirth is not defined as part of their duties. Therefore, EMTs are not trained to manage women with unplanned childbirth situations before they arrive at hospitals or equipped health centers [7].

Most EMTs in Iran are hired from emergency medicine graduates with either associate or bachelor’s degrees. However, individuals with bachelor’s degrees in nursing, associate or bachelor’s degrees in operating room technology, and bachelor’s degrees in anesthesiology are also hired due to staff shortages. Regrettably, the categorization of EMS employees into basic, intermediate and paramedic levels has not been implemented in Iran. Despite distinct job descriptions for these three levels, the lack of categorization results in all employees having the same job description. In addition to providing first aid, all employees can administer intravenous fluids and medication in the ambulance, following their diagnosis or consultation with the dispatch physicians under emergency protocols. Employed staffs do not get specific university training in mother and baby care during childbirth. They usually undergo brief, theoretical training. Also, the PEMS conducts in-service training based on identified needs, typically not including mother and baby care during ambulance delivery [9].

While a few women have been employed in the country’s capital in recent years, most pre-hospital emergency workers are men [9], and two male EMTs in each ambulance provide emergency medical care to patients on each mission [10]. In some areas, when there are a lot of missions involving pregnant women, EMTs may need to bring a midwife from health centers based on local guidelines. However, in many cases, childbirth happens without a midwife present in the ambulance and is instead managed by two male technicians. This is often because the midwife is on another mission or there are no local guidelines mandating the midwife’s presence [9, 10]. Giving birth in the ambulance with the assistance of male technicians causes significant shame and embarrassment for Muslim women, particularly those residing in remote rural and nomadic areas [11]. Several studies have investigated the challenges of childbirth before reaching medical centers. However, this particular study focuses on specific aspects. These include the challenges faced by emergency technicians who do not have sufficient training for such situations, the cultural challenges of delivering in ambulances for pregnant women in the unique cultural context of Iran, especially in the presence or with the assistance of male technicians, and the challenges of giving birth in limited ambulance space during long journeys before reaching medical facilities. This study aims to gather insights from EMTs, midwives, and expectant mothers to examine the causes of giving birth in ambulances and the challenges EMTs, pregnant women, and midwives face during delivery.

Method

Research design

This study used a qualitative approach to investigate the causes of giving birth in ambulances and the experiences of EMTs, midwives, and pregnant mothers who delivered babies in ambulances. The researchers gathered data through semi-structured interviews to gain insight into their situations [12, 13]. Following this, the data was analyzed using a content analysis approach.

Participants

The participants of this study consisted of the 28 EMT_s and midwives who had experience helping to give birth in the ambulance and the women who had given birth in the 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 total, 28 people showed interest in participating, including 13 EMTs, 8 midwives, and seven mothers who gave birth in the ambulance. All EMTs had assisted in at least one delivery in the ambulance (Table 1).

Table 1 Demographic characteristics of the participants

Data collection

Before the interview, the participants received detailed information about the interview and the study’s objectives. They were assured about the confidentiality of the information and informed that their participation in the study was entirely voluntary. In addition, they were told that their interview would be recorded and that they could cancel it at any time. The data for this study was collected through semi-structured interviews. Thirteen EMTs, eight midwives with experience in ambulance deliveries, and seven pregnant women who delivered in the ambulance were interviewed. Due to the long distances to the workplaces of some study participants and for their convenience, the interviews were conducted in separate rooms at the workplaces of EMTs and midwives. Four pregnant women were interviewed in their homes, and three were interviewed by telephone. All interviews were conducted during the morning work shift to better reach the participants from May 2023 to June 2023. An interview guide with open-ended questions was used, and the interviews lasted 45 to 75 min. All interviews were recorded using a voice recorder and later transcribed by the authors (Table 2).

Table 2 Interview guide

Because many of the women who gave birth in the ambulance resided in remote areas, it was challenging to interview them. Additionally, many of these women were illiterate or had limited education, making it difficult for the interviewer to rely solely on open-ended questions. As a result, the interviewer had to ask more direct questions about the study’s objectives, potentially leading to unintended information bias [13].

Data analysis

The content analysis approach was used to analyze data related to the study. An inductive approach means that the author avoided using predetermined categories; instead, the authors searched for similar words and expressions and the same meaning in the typed texts of the participant’s interview and formed categories. In the initial analysis stage, the text was read several times to find meaning units corresponding to the study targets. Then, the meaning units were condensed, and condensed units were coded [12, 14, 15]. Granheim et al. state that categories can be formed from meaning units to be compared or compiled into broader categories or subgroups [12]. 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-categories, which highlighted the main content of the interviews. Also, for data analysis using MAXQDA/10 software.

Ethical considerations

The present study was approved by the Ethical Committee Medical Sciences University of Shahrekord (Ethics code: IR.SKUMS.REC.1400.244). The participants were given adequate information about the nature of the study, and informed consent has been obtained from the participants, their parents and legally authorized representatives in this 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 would be completely confidential and used only for this research. Also, the findings were published so that none of the participants could be identified. Also, participants had the right to withdraw from the study at any time [16].

Results

Twenty-eight people participated in this study. 13 participants were EMTs, 8 were midwives, and 7 were mothers who gave birth in ambulances. After the content analysis, the results were divided into two general categories of causes leading to giving birth in an ambulance and challenges. Then, each category was divided into three subcategories. The causes of childbirth in ambulances were split into 3 subcategories: local culture, inaccessibility, and weak managers. Also, the challenges of giving birth in ambulances are divided into three subcategories: fear and anxiety, people’s culture, and ambulance and equipment. The continuous text describes the categories with clarifying participant quotes (Fig. 1).

Fig. 1

The challenge of delivery in ambulance

The causes leading to giving birth in ambulance

Local culture

Culture can be considered a way to live, including ethnicity and race, the behavioral response that is acquired over time, beliefs, attitudes, values, customs, norms, and taboos that are accepted by a society of people [17].

Illiteracy

All participants in the study highlighted the issue of illiteracy among women. They noted that many women in remote and nomadic areas are unable to read or write due to the lack of accessible schools. Additionally, there is a cultural disregard for girls’ education in these regions, leading to early marriage and high dropout rates for girls after elementary school. As a result, many women have limited literacy skills, impacting their ability to seek proper prenatal care and timely medical attention during childbirth. Due to their low literacy levels, pregnant women often rely on traditional practices, rituals, and the advice of older women instead of taking appropriate health actions. One of the 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 nomadic and rural areas, special respect is given to older women, such as mothers-in-law or senior women, and pregnant women usually consider the advice of these persons in the community rather than health center staff. These uneducated and untrained women provide recommendations based on their own or others’ birth experiences, which may lead to delays in accessing the birthing center and increase the risks for women and newborns.

“My mother-in-law told me that if your back, arms, legs, and abdomen have pain at the same time, you are near to giving 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

Pregnant women in low socio-economic or rural areas have reported that they often engage in heavy physical activity, similar to non-pregnant women, right up until the end of their pregnancies. In many cases, labor pains begin while they are doing physical activity such as farming, tending to sheep, milking cows and sheep, spinning wool, doing housework, and other physically demanding tasks. It has been observed that physical activity and movement can potentially help in advancing childbirth, especially in women who have had multiple pregnancies.

“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

It was noted that most ambulance births occur in women living in remote areas. As a result, it can take 6 to 8 h from calling PEMS for the ambulance to arrive and transport the expectant mother to the nearest equipped birthing center. This delay is often due to the long distance that the ambulance has to cover, especially when the call is made with little time left until the birth.

Apart from the long distances to health centers, difficult geography is another issue. Most villages do not have proper access roads, and the existing roads pass through hills and mountains. The roads are in very poor condition, and in the rainy season, especially in winter, it becomes very difficult and sometimes impossible to pass by ambulance due to the muddy pathways. In some areas, EMTs must walk for at least half an hour to reach pregnant women. Sometimes, donkeys and mules are used to transport pregnant women to the ambulance. (Fig. 2)

Fig. 2

Remoteness and difficult geography (Chaharmahal and Bakhtiari province, Iran)

“After driving the ambulance for three hours, we had to walk the rest of the way. It took us about 45 minutes to reach the pregnant mother’s residence.”(P₃).

We departed from the emergency station at 10:00 PM and transported the mother and her newborn to the hospital by 5:00 AM. We traversed a section of the road that was inaccessible to the ambulance, so we used a donkey to carry the pregnant mother to the ambulance.“(P₇).

Poverty

Some pregnant women may not need an emergency visit to the hospital, depending on their medical condition, but according to the advice of the midwives, it is recommended to stay near the birthing centers for a few days. However, due to poverty, some refuse to do so. Some cannot even afford to pay for car rentals to transport them to medical centers. As a result, they prefer to wait until the last moment and then call 115 to be taken to the hospital by ambulance because of the free pre-hospital emergency ambulance.

“We encountered a situation where a pregnant woman was high risk, but it wasn’t necessary for her to be treated as an emergency case at that time. However, every time we advised her to see a gynecologist, she would respond that she didn’t have the money to go.“(P₁₄).

Weak managers

Inefficiency of the health system

Insufficient healthcare facilities in remote areas make it challenging for people to access essential services. The government finds it cost-prohibitive to establish health centers in these areas. Additionally, inadequate education, poor management, and irregular prenatal services provided by midwives in these health centers have contributed to a rise in ambulance births. Mismanagement by health service managers has caused some midwives to deliver improper care to pregnant women in remote areas.

“If midwives in health centers have enough responsibility, the ambulance will have less childbirth. Midwives should encourage pregnant mothers, especially those at high risk, to leave remote and geographically challenging areas and go to cities with birthing centers at the first signs of giving birth. However, sometimes they neglect their duty because their supervision is not strict enough.“(P₁₇).

Inadequate resource

Health officials can take actions such as providing residential places near well-equipped health centers and encouraging high-risk or pregnant women to stay there for a few days. This will allow these women to be specially monitored and evaluated by midwives. In case of labor pains, they can be immediately transferred to an equipped center. However, not all centers have the resources or efficient management to support this. Another common issue is the shortage of professional midwives in remote areas, as they are not satisfied to serve in such areas due to a lack of facilities.

“Nobody is willing to work here because we lack facilities. Those who do work here must be away from their families for a long time. There is always a shortage of midwives and nurses, which means that pregnant women in deprived areas are not receiving proper care.“(P₁₉).

The challenge of giving birth in ambulance

Fear and anxiety

The study participants most commonly cited fear and anxiety as their primary emotions. The reasons for this can be divided into three subcategories, which are explained below:

Lack of confidence to manage delivery

The unexpected event of giving birth in an ambulance can be a significant and uncommon occurrence for emergency medical staff. Many of them lack experience in this area, making it a high-risk situation for both the mother and the baby. The limited clinical experience and education among EMTs can lead to a lack of confidence in managing this situation properly, causing fear and anxiety. As a result, EMTs may question their ability to keep the mother and baby healthy and safely transport them to the hospital.

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

The process of giving birth in the ambulance is not included in the educational curriculum, as it is not considered a part of EMTs’ duties; training courses typically do not priorities childbirth in ambulance scenarios. Which can lead to poor academic performance, lack of confidence, and feelings of fear, stress, and anxiety among EMS providers.

“During our time at university, we received no training at all. They didn’t even let us practice with mannequins. They only gave us a brief theoretical explanation. We are only relying on the experiences of others.“(P₁).

Fear of litigation

Childbirth is a high-risk medical condition. Even when the pregnant mother is in the hospital with gynecologists, experienced midwives, and all necessary equipment and medicines at her bedside, there is still a possibility of endangering the health of the mother and the baby. None of these resources may be available in the ambulance. Additionally, the space in the ambulance is insufficient to give the mother a proper position, perform necessary maneuvers, and use a sterile set. Despite these challenges, a patient’s relative may be present in the ambulance and monitor the staff’s behaviour and performance. If there are any health problems for the mother or the baby, the patient’s family may seek legal action and involve the EMTs in legal challenges and litigation. Also, the hospital staff, when taking the mother and baby from the EMT_s, did not consider that before the hospital, the EMTs faced at least two hours over difficult geographical roads and the limitations of giving birth in an 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. However, the hospital staff complained 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 afraid 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 embarrassment over giving birth in an ambulance were common among four women who participated in this study. Most of the women, especially those living in rural, nomadic, and remote areas, dislike being naked in the presence of midwives. Having a male attendant on their bed during childbirth is very annoying and embarrassing for them. Many of them ask male EMTs to leave the ambulance during delivery. The presence of male EMTs in the ambulance during childbirth creates a sense of loss of social prestige for male relatives, leading to challenges and conflicts 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. EMTs, especially those with less experience, also experience a lot of shame when they attend to women giving birth.

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

“In some cases of dystocia, I needed someone’s help, at least to infuse intravenous fluids for the mother. However, male EMTs were prevented from entering by the men who were present, such as the husband, father, or brother of the pregnant woman. There was even conflict at times, with the relatives questioning why a man should be present during the delivery.”(P₁₇).

Lack of facilities

Non-standard ambulances) low quality ambulances)

The ambulances used in PEMS have limited space and were not designed for giving birth. An ambulance bed is a simple bed designed to move all patients and cannot be changed shape or manoeuvred under challenging births. The space around the bed in the rear cabin of the ambulance is very limited. Along with the pregnant mother, a relative, and at least one EMT are also present, making the space even more limited. There is not even enough space to open the sterile set, which often leads to the procedure being unsterile. Additionally, it is not possible to use warmers and incubators, so the EMTs or midwives have to warm the babies by hugging them. Many interview participants highlighted the lack of security measures for both the mother and the baby when ambulances navigate winding and rough roads. The ambulances are often in poor condition, and travelling on dirt roads leads to dust filling the rear cabin, creating an unclean environment. Additionally, ambulances are sometimes used to transfer pregnant women after transporting traffic accident victims, resulting in a dirty and bloody rear cabin. Due to limited resources, it is impossible to purchase ambulances with more space in the rear cabin; ambulances with a larger space in the rear cabin cannot pass through rough and difficult geographical roads.

“The space inside the ambulance was very limited. The bed was not suitable for childbirth, so 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 there was even a slight dystocia, we couldn’t give the women a special position.”(P₁₄).

“The ambulance, used for transporting road accident patients, was filthy with dried blood, creating an unsanitary environment that made us feel sick.“(P₂₆).

Inadequate equipment and medicines

Special drugs and equipment are necessary to maintain the health of the mother and baby during and after delivery. However, ten participants in the study mentioned the lack of drugs and equipment in the ambulance. For example, the absence of Syntocinon, a drug that plays a major role in childbirth by increasing uterine contractions and is also used to stop bleeding after delivery, was noted. They also mentioned that some drugs, such as Syntocinon, should be kept in the refrigerator, but sometimes there was not even a simple cooler in the ambulance. Therefore, driving long distances in the summer could cause the drugs to deteriorate.

“Syntocinon should be kept in the refrigerator. During hot seasons, when we had to travel long distances to reach pregnant women, the medicine was kept outside the refrigerator for extended periods. Sometimes, there wasn’t 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 stand. Many times, we did not have enough sterile sets to give birth.”(P₁₁).

Discussion

After analyzing the data, two general categories were formed, including the factors that cause delivery in ambulances and the challenges of delivery in ambulances. Three themes were formed in each category: local culture, inaccessibility, weak managers in the first category, fear and anxiety, native culture, and lack of resources in the second.

The study results indicated that local culture significantly influences pregnant women who delay seeking timely care at hospitals or equipped health centers for delivery. In rural, nomadic, and remote areas, it is common for girls to marry at a young age. In this culture, the education of girls is not prioritised as much as their early marriage, leading to many being illiterate or having limited literacy skills. This lack of education may be the primary reason for the delay in seeking skilled care at equipped centers. Sarker’s et al. qualitative study highlighted the impact of women’s illiteracy on home delivery, emphasizing that illiteracy is a significant factor causing women to avoid seeking delivery care at hospitals or equipped centers [18]. Other studies have also shown that illiterate women or those with low levels of education may be unaware of the risks associated with childbirth, leading them to prefer delivering at home [19, 20].

In rural and native areas, there is a harmful practice of obeying senior women such as mothers-in-law. These women, who are often illiterate and untrained, give advice based on their own or others’ experiences of childbirth. This can lead to delayed timely care-seeking and put the pregnant mother and baby at greater risk. In some cases, pregnant women in rural areas give birth with the assistance of mothers-in-law or other senior women, leading to delays in seeking care from equipped health centers. This delay may be due to the belief that nothing will happen if they don’t seek timely medical assistance and that they can give birth at home without complications. Sychareun et al. demonstrated in a study that sometimes women and their husbands preferred to give birth at a hospital or health center but were advised by seniors, especially the mother and mother-in-law, to give birth at home based on their own childbirth experiences [21].

The strenuous activities performed by pregnant women, such as farming and animal husbandry in rural and nomadic areas, may lead to earlier delivery times. This can result in delays in seeking timely medical care and giving birth in the ambulance. Goffinet’s and Cooke study indicated that although employed women with normal activity have a lower risk of preterm birth, working more than 42 h a week and standing for more than 6 h a day can increase the risk of preterm labor [22].

The main problem is the lack of access to delivery services because of poverty, limited transportation, long distances, challenging geography, and poor roads, especially during the rainy season. Many people living in remote areas cannot afford transportation to nearby cities to receive necessary pregnancy care, medical tests, medications, or hospitalization. As a result, they opt to give birth at home or delay seeking help until the last minute and then call for transfer by PEMS. Damaceno et al. showed that women are more likely to give birth outside well-equipped delivery centers due to socioeconomic conditions and geographical distance. They found a significant correlation between the travel time to health-equipped centers and the incidence of out-of-hospital childbirth [23]. Hirose also mentioned that an increased distance from hospitals and other childbirth facilities leads to longer departure delays. Additionally, poverty causes delays in the decision to move to the hospital when delivery symptoms are apparent [11].

Contrary to the findings of this study, Loughney et al. believed that living near a hospital may increase the risk of delivery before arrival. He says: Some women who live near the hospital may mistakenly think they can reach the delivery suite quickly and therefore postpone going to the hospital until the last minute and cause delivery before arriving [24].

Another reason for the increased number of births in ambulances can be the incompetency of health managers. Establishing health centers in remote areas may not be cost-effective, and the government’s economic situation does not allow for setting up such centers. The lack of facilities and necessary support in remote areas also causes a shortage of professional staff, as they are not satisfied to serve in such areas. In addition, the irresponsibility of midwives, irregular services during pregnancy for women settling in remote areas, poor management, weak education, and inadequate equipment can endanger the health of the mother and baby and also increase childbirth in ambulances. In another study by Khatri et al. the lack of facilities and resources and the unavailability of midwives were the barriers for pregnant women to use equipped centers for childbirth. Khatri et al. mentioned the midwife shortage and the lack of expected support from existing midwives as barriers to providing permanent services [25].

The EMTs experienced a great deal of fear and anxiety while helping the mothers give birth in the ambulance. This was due to the possibility of endangering the health of the mother or the baby, as well as the unknown and unexpected nature of the event. They had not been properly educated and trained for such deliveries and, as a result, lacked the confidence to handle the situation, which contributed to their feelings of fear and anxiety. The results of Persson et al. study showed that confidence in one’s ability creates a feeling of security. In this study, she states that to be safe and secure, the nurses who work in ambulances must be educated about delivery in ambulances [2]. Also, Norden et al. emphasized that staff should receive practical and theoretical training, such as dealing with birth before arrival at the hospital [26]. Persson et al. argued that the knowledge of EMTs about the risk of complications, such as massive bleeding of the mother, asphyxia of the newborn, stillbirth, and prematurity of the neonate, causes concern, nervousness, and anxiety [2].

An additional source of fear and anxiety identified in this study was the concern about becoming entangled in legal disputes and litigation due to the possibility of receiving complaints from patients, their relatives, or hospital staff against EMS providers. When a patient is transported by ambulance, a relative is usually present. This means that the behaviour and performance of the medical personnel are being observed. If an unfortunate and unexpected event occurs for the mother or the baby, there is a possibility that the patient’s family will turn to legal authorities and involve the ambulance staff in legal conflicts and litigation. Also, when the mother and her baby are admitted, the hospital staff records all of the problems in the patient files as shortcomings and negligence of the EMTs; therefore, there is the probability of getting involved in litigation later. The research conducted by Afshari et al. revealed that EMS staff could face legal prosecution for their practices. The study emphasized that the possibility of litigation and the need to attend legal proceedings are highly stressful for EMS providers [27]. Colwell et al. identified legal prosecution as a significant source of stress for EMTs. They reported that complaints against EMS were primarily from patients, healthcare providers, and patients’ relatives. Reasons for these complaints included lack of skills, transfer-related problems, and lost personal belongings [28]. Dobbie and Cooke mentioned that the family of an obstetric case claimed that the lack of equipment to manage the preterm baby in the ambulance led to the development of cerebral palsy and blindness [29].

Pregnant women often feel shame and embarrassment when male EMTs are present during delivery. This is especially true for women in rural and remote areas who may feel uncomfortable being naked in front of male EMTs. Even inexperienced EMTs may feel the same way. While the discomfort lessens with more experience, it doesn’t completely disappear. Sychareun et al. found that most pregnant women felt shy when a male was present during delivery at the health facility [21]. Sarker et al. also found similar results to this study. The results indicated that people believed that if their women gave birth outside of the home and in the presence of a male physician, their social status and prestige would diminish. They described that women in remote and rural areas preferred to give birth at home because they did not want their genitalia to be exposed to men [18].

Based on participant feedback, the challenges of giving birth care in ambulances include limited space, dilapidated and inadequate delivery beds, poor ventilation in both warm and cold seasons, dust entering the rear cabin and contaminating the environment, and cleanliness issues due to transporting multiple patients. Additionally, there are concerns about the unavailability of necessary equipment and medications. Regarding the space of the ambulance, Colwell et al. stated that the limited space of the ambulance, its movement at high speed, and the lack of wearing the seat belt due to medical care cause imbalance and disruption in dealing with critical situations [28]. Suserud et al. pointed out that insufficient equipment and limited space in ambulances may lead to stress among ambulance staff [30].

Limitation

The main limitation of this study was the lack of access to women giving birth in the ambulances. This was because few women who had given birth in the ambulance in nearby cities and were more accessible did not agree to be interviewed, and the phone numbers registered in the system from women living in distant areas belonged to their husbands. Therefore, it was difficult to communicate with them. Despite trying to communicate with them through cooperation with midwives in health centers, most women were unwilling to participate in the interview. After much effort, only seven people agreed to be interviewed, four of whom were illiterate, and three had low literacy. Face-to-face interviews were conducted with 4 people at their homes, and telephone interviews with 3 people, but the interviews were not satisfactory due to low literacy.

Conclusion

This study demonstrates that factors such as cultural issues, illiteracy, poverty, remote and challenging geography, lack of accessible health facilities and inefficiencies in the healthcare system can lead to deliveries occurring in ambulances before reaching hospitals. To reduce the incidence of ambulance deliveries and minimize health risks for both the mother and the baby, the involvement and collaboration of the government and community are crucial. Addressing cultural misconceptions and transforming local practices require long-term planning and stakeholder participation. Improving literacy and educating women about prenatal care can be beneficial. Health authorities should also focus on enhancing access to prenatal care, particularly in remote areas.

The challenges of giving birth in ambulances highlight the unpreparedness of the health system and PEMS providers for such situations. Since giving birth in ambulances poses potential high-risk events for both mothers and babies, must incorporate training workshops on caring for mothers during labor into the curriculum of all disciplines that may be employed in PEMS. These workshops should cover natural births and complicated births. These include breech, prolapsed umbilical cord, shoulder dystocia, and maternal bleeding. Training on newborn cardiopulmonary resuscitation after birth should also be included. These workshops should be run by experienced midwives and gynecologists. They should include watching real videos and practicing on mannequins. To enhance the skills in providing care for mothers and babies during delivery in ambulances, the PEMS should periodically conduct these workshops as part of in-service training. Additionally, providing ambulances with the necessary equipment, facilities, and medicines for childbirth and continuous training and support for EMS providers against litigation claims is essential. Furthermore, planning for the presence of a midwife in all missions related to pregnant women can help alleviate personnel fears and anxiety.