This study aimed to provide strategies for improving the quality of midwifery care and developing midwife-centered care in Iran. The finalized strategies were categorized in eight areas including education, human force, encouragement and support systems, cares and duties of midwives, facilities and equipment, policy making, monitoring and intersectional/ interdisciplinary activities.
As far as strategies for improving midwifery services are concerned, WHO has introduced a nine-paragraph toolbox/directory in 2010, with each paragraph dealing with a certain aspect of improving the role of midwifery in caring for mothers and babies. The first section presents an overview of the position and the general role of midwifery in improving pregnancy, delivery, and post-delivery care and teamwork of midwives with other gynecologists. In the second section, the rules and regulations about the improvement of midwifery care in each country are emphasized. In the third section, adjustment, implementation, and monitoring of the midwifery care standards are discussed. The fourth section addresses the skills and abilities of midwives. The fifth section deals with training and educating midwives and the quality of these trainings.
The sixth section is concerned with midwifery instructors and academic staff who have to play a fundamental role in empowering midwives in addition to their own abilities. In the seventh section, the guiding and directing of midwives discussed, stating that in the case of appropriate guiding and directing of midwives, they can provide high quality care. The eighth section devoted to the continuous discussion of training and empowering midwives after employment and while performing their duties. In the last section (Sect. 9), creating and developing skills in midwives is discussed, emphasizing the skills that can empower midwives to improve the care of mothers and babies (21).
Another comprehensive report has been issued by the Involvement and Participation Association (IPA) and the Royal College of Midwives in the UK with respect to strategies for improving midwife-based cares and the role of midwives. The most important strategies provided in the report includes supporting the midwifery leaders at all organizations levels, performing team works and creating the atmosphere of learning from each other, integrating the midwifery cares with society’s plans and conditions, and designing and presenting available cares based on the individual conditions of the people (22). Our findings are similar to the strategies mentioned by the WHO, IPA, and the Royal College of midwives in England. Thus, it seems that the strategies presented in this study have high reliability and validity to be used in plans and decisions by managers and policymakers.
Enhancement of the quality of midwifery education was among the most important issues emphasized by most of the participants regarding the development and improvement of midwife-based care. During recent years, some studies conducted in Iran have shown that midwifery education is faced with many problems because the midwifery student is not allowed to gain experience herself in educational hospitals. Therefore, midwifery students are sometimes unable to learn properly, because of the involvement of gynecologists in their training. However, when midwifery students receive training in non-university hospitals and are trained by midwifery academic staff, this training is much more effective.
In fact, in spite of the lack of welfare facilities for non- medical students in Iran’s universities, still midwifery education has an acceptable level (23–24). The quality of midwifery education has a deep influence on the presentation of clinical midwifery skills. The graduated midwives should have obtained the minimum clinical and professional skills to perform midwifery duties in order to provide and improve the care for mothers and babies and ultimately enhance the health of the community (25).
To improve their quality, educational plans must be evaluated at certain junctures. One of the fundamental strategies to identify the quality of education is assessing the implemented plan as well as its evaluation based on the acceptable standards that are the significant stimulus for improving and elevating education quality and expanding equal opportunities for research and development of education among all students in Iranian universities. Educational assessment involves measuring the performance of learners and comparing the results obtained from the predefined educational purposes in order to make a decision on whether and how much the educational activities and learning endeavors of the students have led to the desired results (26).
Training midwives and increasing their awareness, were mentioned repeatedly by the participants throughout discussion in this study.
In a joint project with the Institution of Health Equality (IHE), the National Health Service (NHS) of England published a joint report to investigate the strategies of influencing the health system and health inequalities in 2018. In this report, some strategies are explained by the staff and policymakers of the health system that can reduce the inequalities. These recommendations are presented in order for the health system to focus on the social factors influencing the health and in order to decrease health inequality and they include certain measures that can be considered by the health section staff as a part of their work activity.
The first and one of the most important parts of these strategies are training the people and empowering them. In this report, it has been strongly emphasized on the pieces of trainings provided by midwives and educational plans for women and their husbands during pregnancy, post-partum consultation about baby care and lactation, training parents about the early years of the children’s life, consultation for early detection of postpartum blues, and providing other relevant and professional pieces of trainings (27).
According to the definition of midwifery, the important duty of the midwife is counselling and health training for not only pregnant women and families but for the whole society as well. Moreover, it has been pointed out that the work of midwives should include education on the pregnancy period, and preparation of parents for accepting their parental duties, and it must be extended to family planning and caring of children and some cases of women’s gynecological conditions (28). According to the “Midwifery 2020” programme, published by nursing organizations of four countries of England, Northern Ireland, Wales, and Scotland, one of the necessities and fundamental strategies for effectiveness of the midwifery services is empowering midwives to be capable of communicating with people and also the advisory role of the midwife. In this report, the authors maintain that due to the wider relationship of midwives with the people and considering the wide range of services that midwives are able to provide from pre-marriage issues to raising children, they are required to have a wide range of capabilities; and this needs providing comprehensive training for the midwives (29).
The most important strategies recommended by the participants in the present study in terms of human resources were mostly related to employment and increase of midwifery human resources. In this respect, the head of the midwifery association pointed out that according to the law approved by the Ministry of Health, there must be twelve midwives for every 1000 live births in hospitals, but at the present time, only 8–9 midwives are available for every 1000 live births in Iranian hospitals. It is worth mentioning that of the 8000 employed midwives, 2700 are provisionally employed, and after two years, most of them become unemployed (30). As far as the employment of midwives is concerned, the need for midwifery care and services is on the rise and more midwives should be employed, considering the implementation of the urban family doctor plan in Iran and the fact that vaginal delivery is free of charge in governmental hospitals.
Another topic mentioned by most of the participants in the present study was related to the encouragement and motivating of the midwives. The payment of midwives was among the most important issues mentioned by the participants. They believed that without good payments for the midwifery services, they would not have sufficient motivation and inclination to provide high- quality services. Previous studies also mentioned the significance and place of the appropriate payment for midwives in providing appropriate services by this group of health care providers (31–32). The performance-based payment was another topic that most of the participants mentioned in this study. They believed that; most the midwives are not satisfied with their salary in hospitals and health care networks.
In this study, the head of midwifery scientific association stated that, more than 450,000 normal deliveries were attended by the midwives last year, but only 15 percent of the delivery tariff was paid to them. She also added, “the delivery tariff deserves to be fairly distributed, yet not only do we observe that no increase has been considered in the payments of midwives, but also their predefined rights have been ignored”. Almost all fees are paid to on-call obstetricians, not to the midwives who care for mothers from the first stage of labor to the end. Since workplace discrimination and injustice disappoint the staff and reduce their motivation. Accurate and fair systems should be designed and implemented. Because midwifery is a very sensible practice, payment is more sensitive and significant, too.
In this study, many strategies mentioned by the participants were related to the equipment and facilities of hospitals and maternity wards. The results of the previous studies in this field in Iran also indicated that physical space and facilities of the maternity wards in hospitals are not very satisfying because all women, whether with high or low risk pregnancies, receive the same medical oriented care model offered by obstetricians, exposing them to unnecessary intervention and bringing about possibility of cesarean Sect. (33–34). Sanitation and provision of an appropriate environment for normal delivery can be influential in the satisfaction of mothers and consequently in the delivery pattern. Therefore, alleviating shortages related to the physical space and facilities of the delivery wards of paramount importance, and it is expected that this achieved through implementing the health developmental plan (36).
Determining the appropriate position of midwife in the family doctor system and referral system was among the significant discussions repeatedly mentioned by the participants in the present study and this issue was categorized in the area of the policymaking strategies. Several studies have been conducted in Iran on the assessment of the performance of family doctor and referral system (37). The results of most of these studies indicate many weaknesses and problems in the implementation of the family doctor plan and the referral system.
In the present study, one of the strategies mentioned by the participants in line with the development of midwife-based care was the presence of midwives and their bold and predefined role in the family doctor team. In this regard, some of the participants were of the opinion that midwives should have a bold and executive role from the pre-marriage stages until the raising of the children and this role even continue to the middle age.
In the study of Lotfi et al conducted with the aim of presenting strategies to reduce the cesarean rate in Iran, the revisiting the roles of midwives and determining proper ones for them were emphasized. Moreover, researchers put emphasis on the visiting of pregnant women and referring them by the midwives in the first line of care (37).
In the present study, most of the participants pointed out that the obstetricians (gynecologists) often tend to perform cesarean and do not pay attention to cesarean indications. They believed that according to the gynecologists’ opinion, normal delivery is very time consuming while cesarean section takes them only one hour to perform, so the strategies the participants proposed included imposing strict and efficient punishment and monitoring system to control the performance of the gynecologists in hospitals. Faraji et al (38), found that in 70% of cases, gynecologist played the main role in the high cesarean section rate. Moreover, Signorelli et al. (53) in Italy also found that the gynecologists played a fundamental role in choosing the mode of delivery. Another study by Menacker et al. (39), attributed the increase in the cesarean rate among women with no indication for cesarean was the tendencies and the judgment of doctors. Perhaps the high tariffs of cesarean surgery compared with the normal delivery subconsciously motivate the doctors for performing more cesarean operations. In this regard, implementation of the plan of actualization of hospital services tariffs in Iran can be significantly influential.
Moreover, the development of self-control and monitoring tools and methods in this field could be useful.
As far as interdisciplinary teamwork was concerned, the improvement of the collaboration between midwives and gynecologists was a topic that frequently mentioned by the participants. In the study of Heatly & Kruske, the interdisciplinary collaboration in maternal care has been defined as “a reflective and dynamic process that involves the mother and baby cares professionals in several professions and with the participation of the same mother to generate high quality care. It shares the accountability and responsibility in terms of appropriate levels of the involvement of a professional with the mother during the total period of childbirth. All involved institutions use the observance, understanding, and development of an approach for their performance that uses the knowledge and different professions as the mother needs (40). In the study of Lotfi et al, interdisciplinary collaboration is emphasized to have a role in the reduction of cesarean rate (37). The American College of Gynecology and Midwifery has also specified some objectives in relation to the safety of patients. One of these objectives is the commitment to the culture of patient safety through daily practical teamwork, communications, collaboration, and strong leadership about the service providers (40). The effective collaboration among the professional groups has increasingly been the focus of attention as the fundamental element in safety and good quality of health care. This is especially significant in the context of maternal care, where women have the experience of delivery (41).
According to the results of some recent studies, the most important obstacles of teamwork are as follows: lack of a clear definition for individual’s duties, weak management, inconsistent communication, the presence of a hierarchical relationship in wards, insufficient skill and knowledge, and inappropriate division of responsibilities (42–43). In order to reduce the adverse effects arising from interdisciplinary conflicts on the quality and safety of providing health services, especially the sensitive and emergency services like delivery cares, planning and implementing effective interventions in this field must be prioritized (44).
The main limitation of the current study is the nonparticipation of high-ranked authorities and policymakers of the Ministry of Health and Medical Education.