Midwives‟ expectations from pregnant women regarding their participation in safe delivery: a qualitative study

Background : Pregnant women’s participation in safe delivery is associated with safety assurance and improvement. Safety and care quality improvement in developed countries has so far been based on research and clinical evidence. Nonetheless, stakeholders’ preferences and expectations were not much taken into account. This study aimed to explore midwives’ expectations from pregnant women regarding their participation in safe delivery. Methods : This qualitative study was conducted in 2019 in three public hospitals in Urmia, Iran. Data were collected through 24 in-depth semi-structured interviews with 24 midwives. Sampling was done purposively and continued up to data saturation. Data were analyzed through Graneheim and Lundman’s qualitative content analysis. Results: Midwives’ expectations from pregnant women regarding their participation in safe delivery were grouped into the two main themes of effective communication (with two main categories) and empowerment of pregnant women (with three categories). The five main categories of these two themes were client’s interaction with midwife, confidence in midwife, readiness for delivery, health literacy improvement, and participation in safe behaviors, respectively. Conclusions : Understanding midwives’ expectations regarding pregnant women participation in safe delivery is important to the development of policies for care quality and safety improvement in perinatal care.

variation in terms of age, work experience, and employment and marital status. The first and the second participants were senior in-charge midwives with long clinical experience. Data were collected through semi-structured interviews started with broad questions. The first and the second interviews were almost unstructured and interviewees were just asked to talk about their experiences of care delivery. Pointed questions were also avoided and participants were allowed to freely talk about their experiences. This technique helped us collect more indepth data. From the third interview on, interviews were semi-structured and were guided using questions developed based on the findings of the first and the second interviews. Examples of these questions were, "May you please explain about your experiences of care delivery to pregnant women in your unit?" "What behaviors did you prefer your patients show?" Based on participants' responses to these questions, probing questions were used to delve into their experiences. Examples of these questions were "Can you provide explanations about this?" "What do you mean by this?" "How do you describe your perception of this topic?" "In your opinion, what is the meaning of this experience?" During interviews, participants' facial expressions and non-verbal signals were documented. At the end of each interview, interviewee was asked whether she wanted to add anything more. Finally, her participation was acknowledged and she was informed about the possibility of a follow-up interview. The duration of the interviews ranged from twenty to sixty minutes. All interviews were held in a quiet room in participants' workplace, were recorded using a recorder, and were immediately transcribed. Graneheim and Lundman's conventional content analysis approach [19] was used to analyze the data concurrently with data collection. Initially, each whole interview was considered as the unit of analysis and its transcript was read for several times in order to obtain a general understanding about its main ideas. Words, sentences, and paragraphs which were related to the study aim were considered as meaning units and were condensed, abstracted, and coded. Codes were compared with each other in terms of their conceptual similarities and differences and were categorized into subcategories and categories. Then, subcategories and categories were compared with each other and the latent content of the data was conceptualized as main themes. Lincoln and Guba's criteria [18] were used to ensure trustworthiness of the findings. Credibility and dependability were maintained through member checking and peer checking. In member checking, excerpts from interviews together with their codes were provided to some participants to confirm the congruence between their experiences and the generated codes. In peer checking, the generated codes and categories were provided to peers experienced in qualitative studies to check the accuracy of the data analysis. In case of any disagreement, data analysis was repeated and its findings were presented to peers to confirm the accuracy of the data analysis. This study was approved by the local Ethics Committee of Urmia University of Medical Sciences, Urmia, Iran (IR.UMSU.REC.1397.476).Information about confidential data management and voluntary withdrawal from the study was provided to participants and informed consent was obtained from each of them.

Results
Twenty four midwives participated in the study. They ranged in age from 26 to 49 years and in work experience from 36 months to 28 years. They held bachelor's or master's degree in midwifery. Two participants were senior in-charge midwives and others were staff midwives. Moreover, two participants had the experience of working in private hospitals (Table 1). During data analysis, 550 primary codes were generated, which were reduced through combination to 238 codes. These codes were grouped into twelve subcategories, five main categories, and the two main themes of effective communication and empowerment ( Table 2).

Effective communication
Most participants considered midwife-client effective communication as a factor encouraging client's participation in SD. They noted that clients' interaction with midwives and their confidence in them facilitate effective communication.

Client's interaction with midwife
Most participants noted that question and answer between midwives and their clients result in their interaction.
When a mother receives labor induction, she asks what the administered solution is, why it is administered, and whether there is any ampoule in the solution. Thereby, her midwife explains for her the process of induction and thereby, the client is involved in care (P7).
Most participants highlighted that the provision of incomplete history data by clients may endanger their safety and interfere with diagnosis and treatment. Clients' expression of their individual and health-related needs and midwives' attempt to fulfill those needs can ensure client safety. Many times, we had mothers who got out of bed in the recovery ward without informing their healthcare providers. The results of such unsafe practice were hypotension or fall. If a mother expresses her needs (for example for water or toilet), we can help her and thereby, protect her against negative events (P5).
Participants considered pregnant women's disrespectful behaviors, such as shouting aloud, verbal aggression, and angry outburst as barriers to midwife-client interaction.

Confidence in midwife
According to the participants, pregnant women's confidence in midwives is one of the bases of effective communication and has significant effects on their obedience to healthcare providers. Most participants believed that women's confidence in midwives' knowledge and abilities strengthens their relationships, while their lack of confidence in midwives damages their relationships and breaks the chain of care. After delivery, you suddenly see that the parturient has three business cards of different physicians, denoting that she has no confidence in midwives (P8

Empowerment of women
The second main theme of the study was empowerment of women. Participants expected pregnant women to participate in prenatal classes, receive education and counseling, improve their knowledge and abilities, and actively participate in SD.

Readiness for delivery
Almost all participants noted that participation in physiologic delivery classes and adequate physical and mental readiness are necessary for pregnant women's participation in SD. According to our participants, mental readiness for delivery reduces pregnant women's fear and anxiety and helps them have a safe and less complicated delivery.

Most women have fear over delivery. Fear has adverse effects on both mother and fetus and increases the need for medical interventions (P11).
Some participants believed that physical and mental readiness are related to each other so that physical readiness results in mental readiness and promotes pregnant women's participation in health-related behaviors.
Our experience shows that women who use breathing techniques experience lower anxiety and stress, show greater readiness for normal delivery, and are more interested in postnatal breastfeeding (P4).

Health literacy improvement
Given the accessibility of midwifery counselors, our participants expected pregnant women to receive prenatal counseling and acquire reliable information about pregnancy and delivery from midwifery counselors. In fact, they believed that pregnant women should plan for participation in SD through participation in prenatal counseling classes.
Pre-pregnancy health is associated with a healthy and low-risk pregnancy and delivery (P17).
Moreover, our participants expected that in case of any problem, pregnant women should receive counseling from midwifery counselors. A woman with a history of preterm delivery who comes to receive education and counseling will have better pregnancy outcome (P22).

Participation in safe behaviors
According to the study participants, pregnant women's participation in infection control behaviors and their safety-related feedback to healthcare providers about their problems are among the methods for participation in SD. Participants expected women to participate in infection control behaviors such as hand washing during the course of their hospital stay.

During their stay in maternity unit, women can prevent infection transmission through washing their hands and adhering to hygiene regulation (P1).
Our participants also expected pregnant women to report medication side effects or any other warning symptoms during their hospital stay.

Discussion
This study aimed to explore midwives' expectations from pregnant women regarding their participation in SD. Findings revealed effective communication and empowerment of women as the two main themes of the study. Similarly, a former study showed that patient participation is effective in establishing effective nurse-patient communication [20]. Another study showed that effective communication between midwives and pregnant women can enhance satisfaction, give senses of security and mutual confidence, facilitate informed decision making, improve control over delivery, reduce blood pressure, fear over normal vaginal delivery, pain, and anxiety, and most importantly, improve health status [21]. Study findings showed question and answer between midwives and clients about health status, labor progression, and fetal health as an example of effective communication. This is in line with the findings of a former study [14]. Midwives answering clients' questions and providing them with information enable both of them to actively participate in clinical decision making, provide mutual support to each other, and prevent patient safety hazards [22]. A study showed that patients who actively ask questions from their healthcare providers more actively participate in clinical decision making, feel greater control over their health, and show closer adherence to treatment regimens [23]. Midwives in the present study expected their clients to provide detailed history about their health status because they believed that a complete history helps physicians and midwives make right decisions. A complete history helps physicians reach accurate diagnosis and prescribe effective treatments even in the absence of physical examination data and laboratory findings [24]. However, a study in Iran found that cultural barriers may prevent patients from providing detailed data to their physicians, particularly about issues which contradict their beliefs [25]. Of course, care services in Iran are currently provided without careful attention to patients' participation in clinical decision making, adequately informing them about treatment options, and their active participation in clinical decision making [26]. Similarly, a study reported that despite the significance of communication and participation for quality midwifery care delivery, they are neither adequately valued nor considered as important aspects of the process of childbirth [27]. Findings showed that in midwife-client interactions, repeated disrespectful behaviors may result in discomfort for midwives and negatively affect care quality. A study reported that 21% of healthcare providers confirmed the relationship of disruptive behaviors with patient death and more than 50% of them believed that disruptive behaviors are associated with negative clinical outcomes such as impaired patient safety, medical errors, negative events, low care quality, and low patient satisfaction [28]. Disrespectful behaviors at workplace, particularly verbal violence, are a significant problem in midwifery settings [29]. A study in Iran showed that 57.7% of midwives in hospitals, healthcare centers, and private offices had experienced verbal violence committed in 60% of cases by patients' companions [30]. Workplace violence has inverse relationship with mental health [31], quality of work life [32], job satisfaction [33], and professional performance [34] and has direct relationship with stress and job burnout [35]. Therefore, researchers, managers, policy makers, midwives, and other authorities need to develop and take creative measures in order to prevent disrespectful behaviors towards midwives and protect and support them against these behaviors.
Our findings also indicated that clients' confidence in midwives is necessary for their participation in SD. Confidence is the cornerstone of effective midwife-client communication which can encourage clients to obey midwives' orders. Similarly, a study reported that besides technical skills, healthcare providers need their clients' confidence for the delivery of quality services [36]. Confidence affects attitudes and behaviors and is considered as a prerequisite for participation in health-seeking behaviors, information provision to healthcare providers, and treatment adherence [37]. Of course, confidence in healthcare providers may result in clients' blind obedience to them even if the services recommended by healthcare providers are unnecessary or produce insignificant effects [38]. Another expectation of midwives from pregnant women regarding their participation in SD was to get adequately ready for delivery through attending physiologic delivery classes. A study reported that participation in prenatal classes was effective in significantly reducing pregnant women's delivery-related stress and increasing the rate of normal vaginal delivery among primiparous women [39]. A systematic review also showed that participation in prenatal classes empowers pregnant women for delivery [40]. Moreover, participation in these classes enhances women's self-efficacy for delivery and reduces midwives' occupational stress [41]. Therefore, pregnant women should be encouraged to attend these classes to develop their abilities and readiness for delivery. Our participants also expected pregnant women to develop their health literacy. A former study in Iran reported that most pregnant women had limited health literacy [42]. Our participants believed that seeking and receiving counseling from physicians or midwives during the pre-pregnancy and prenatal periods can develop women's health literacy. In line with this finding, a study in Iran reported the significant positive effects of counseling on anxiety during pregnancy [43]. Apparently, pregnant women are constantly concerned with fetal health and delivery [44]. Such concerns are associated with the increased risk of cesarean section, postpartum depression, and neonatal complications such as low birth weight [45]. Therefore, pregnant women can be recommended to receive professional counseling and education from physicians or midwives, though a study reported that counseling had no significant effects on anxiety [46]. Such contradictory results may be due to the differences in the context and the counseling interventions sued in different studies. We also found that midwives expected pregnant women to participate in safe behaviors such as hand washing. A study reported that perinatal self-care promotion programs (on self-care activities such as healthy nutrition and regular physical activity) are effective in empowering pregnant women for self-care, reducing pregnancy complications, and promoting safe pregnancy [47]. Our participants expected women to provide them with feedback about medication side effects and high-risk conditions during labor and delivery. In line with this finding, a former study reported that patients can participate in healthcare delivery through participating in clinical decision making and infection control interventions, detecting and reporting medication side effects, and performing self-care activities [48].
To the best of our knowledge, this was the first study into the expectations of midwives from pregnant women regarding their participation in SD. Among the study limitations was the reluctance of some participants to share their experiences and feelings. Of course, we attempted to gain their confidence through providing them with adequate explanations about the study and the use of its findings for quality improvement.

Conclusions
Midwives have different expectations from pregnant women regarding their participation in SD. Most of these expectations aim at ensuring safety and improving pregnancy and delivery outcomes. Expectations identified in the present study can be used in healthcare policy making in order to improve the quality of healthcare services, enhance client satisfaction, and ensure client satisfaction in perinatal care. Prenatal and perinatal care should include interventions for developing pregnant women's health literacy, promoting their participation in prenatal classes, and improving midwives' communication skills.

Availability of data and materials
The data analysed during the current study are available from the first author on reasonable request.