Strategies to improve the quality of midwifery care and developing midwife-centered care in Iran: analyzing the attitudes of midwifery experts

Evaluating an internal quality assurance process for achieving national accreditation standards in midwifery education: a study protocol

The World Health Organization and the International Confederation of Midwives emphasize the importance of accreditation to enhance quality in midwifery education. In midwifery education programmes, internal self-assessments are used to meet accreditation criteria. However, research on this topic is scarce. Therefore, this paper describes how we plan to conduct an evaluation of an internal quality assurance process in midwifery education aimed at achieving national accreditation standards in Bangladesh. This study has a longitudinal exploratory design and will be guided by the principles of process evaluation of complex interventions. An internal quality assurance self-assessment intervention will be introduced at 31 private and public education institutions in Bangladesh. To ensure a sustainable implementation, the Plan-Do-Study-Act cycle will be introduced. Data will be collected using self-administered questionnaires and focus group discussions with midwifery faculty and final-semester students. Descriptive statistics and regression models will be performed for the quantitative data, and the qualitative data will be analysed using content analysis. It is anticipated that, without internal quality assurance of midwifery education programmes, accreditation alone is unlikely to enhance quality. We aspire for this research project to illustrate a process that the midwifery institutes can implement themselves for sustainable transformation towards high-quality midwifery education in countries where such internal quality assurance processes have not yet been integrated into the education system.Trial registration: The study was registered retrospectively with the ISRCTN registry on 26 August 2024. The registration number is: ISRCTN14492910.

Factors Affecting the Implementation of Community Perinatal Midwifery Care in Greece, in Relation to the Perspectives, Attitudes, and Expectations of Primary Healthcare Midwives

The implementation of community perinatal midwifery care in Greece, as in many other healthcare settings, is influenced by a variety of factors that interconnect, among others, with the perspectives, attitudes, and expectations of primary healthcare midwives. Understanding these factors is crucial for improving maternal and neonatal standards of care and ensuring that midwives are successfully reinforced in their professional roles. A comprehensive keyword search of the literature was conducted on five databases to identify recent studies: Cumulative Index of Nursing and Allied Health Literature (CINAHL), Medline, PubMed, Scopus, and Google Scholar. The search was restricted to articles published between 2008 and 2024, and search terms and variations of search terms included but were not limited to "community midwives", "community midwifery", "views of", "expectations", "perspectives of community midwives", and "implementation of community midwifery". As opposed to local reality, there seems to be an extensive global variety of literature associated with the views and expectations of midwives regarding their public role in the community. The fruitful implementation of community perinatal midwifery care in Greece depends on the merging of various factors, including the healthcare system's structure, support from the public and governmental policy, cultural attitudes toward birth, and the educational background of midwives. Community midwives' views and expectations play an essential role in how they navigate various challenges and opportunities they face along their daily professional life. To develop the delivery of community-based perinatal care, it is vital to provide a multilayered approach that contains structured policy improvements, increased assistance for midwives, enhanced public education, and interprofessional teamwork.

Exploring care quality in midwifery clinical practice settings in Ghana - a qualitative study

BACKGROUND

High-quality care is a significant factor in reducing maternal and neonatal mortality. There are known barriers affecting midwives' ability to provide quality care in low- and middle-income countries. The presence of qualified and competent midwives, coupled with the elimination of barriers, is essential for enhancing care quality, especially in education program clinical practice settings.

AIM

To explore factors that affect Ghanaian midwifery students' provision of high-quality care while on clinical rotation.

METHOD

Six focus-group discussions were conducted with a total of 36 midwifery students in Accra, Ghana. Data were analyzed using deductive content analysis applying a conceptual framework identifying social, economic and professional factors influencing the provision of high-quality care.

RESULTS

Social factors identified patient resistance to student midwives, class-based discrimination, traditional practices being preferred over evidence-based care, communication barriers, and poor security. Economic factors were unexpected expenses and inadequate compensation. Professional factors were lack of necessary materials, insufficient number of staff, and a theory-practice gap between classroom learning and hands-on experiences.

CONCLUSION

Factors impacting Ghanaian midwifery students' ability to provide high-quality care in clinical settings were summarized, highlighting social, economic, and professional challenges. Key issues include patient resistance, class-based discrimination, inadequate compensation, theory-practice gaps, and lack of materials. The findings emphasize the need for improved support, resources, and quality clinical learning environments. There needs to be investment in infrastructure and prioritization of pedagogy in clinical settings to enhance midwifery education and care quality in Ghana and more broadly in low- and middle-income countries.

CLINICAL TRIAL NUMBER

Not applicable.

Comparison of maternal and neonatal outcomes of midwifery-led care with routine midwifery care: a retrospective cohort study

INTRODUCTION

Globally, the management of low-risk pregnancies by midwives often leads to a more natural childbirth process, which enhances physical and psychological outcomes for mothers and their babies. Midwives implement various models of maternal care in practice. This study investigates and compares maternal and neonatal outcomes associated with midwifery-led care versus routine midwifery care in private hospitals in Iran.

METHODS

This retrospective cohort study was conducted in Iran in 2022. The study population consisted of two groups including 387 women in the Routine Care Group (RCG) and 397 women in the Private Care Group (PCG). Participants were selected through continuous sampling in accordance with the inclusion criteria. The two groups were compared in terms of some maternal and neonatal outcomes. The research data collection tool was a researcher-made checklist with variables adjusted according to the 'Iman' system of the Iran Ministry of Health. Based on this tool, the data were extracted from the mentioned system and analyzed with SPSS software.

FINDINGS

The results indicated no significant difference between the two groups in terms of the type of delivery (p = 0.999), the use of forceps or vacuum (P = 0.5) and transferring the mother to the operating room (OR) or the intensive care unit (ICU) immediately after delivery (P = 0.744). However, there was a statistically significant difference between the two groups in terms of labor pain control (P < 0.001), induction of labor (P < 0.001), and the use of episiotomy (P < 0.001). Regarding neonatal outcomes, there was no statistically significant difference between the two groups in relation to the average infant weight (P = 0.46), Apgar score (P = 0.75), need for resuscitation (P = 0.999), skin-to-skin contact (P = 0.626), initiation of breastfeeding (P = 0.241) and admission to the neonatal intensive care units (NICU) (P = 0.66).

CONCLUSION

Given the positive impact of private care on key maternal outcomes, it is recommended that health policymakers create the conditions necessary for establishing a continuous midwifery care model in both governmental and private hospitals. Besides, more quantitative, qualitative, and especially mixed methods research should be conducted to explore the challenges and facilitators of this model across various settings.

Perceived barriers and opportunities of providing quality family planning services among Palestinian midwives, physicians and nurses in the West Bank: a qualitative study

BACKGROUND

Despite advancements in family planning (FP) services, several barriers persist in the Occupied Palestinian territory (oPt), blocking women's access to suitable, high-quality and equitable FP services. The aim of this study was to understand how healthcare providers perceive their abilities, barriers and opportunities in providing good quality FP services. Furthermore, it seeks to explore knowledge and training regarding FP among healthcare providers engaged in providing FP services.

METHODS

A qualitative study was undertaken from August to September 2022 in seven Primary Health Care (PHC) clinics distributed in three governorates and operating under the Palestinian Ministry of Health (MoH) in the West Bank. Semi-structured, in-depth face-to-face interviews were conducted with 13 health providers (Physicians, midwives and nurses), using an interview guide in Arabic language. Transcripts were subsequently analyzed using the six phases of reflexive thematic analysis.

RESULTS

FP services face various challenges, including shortages in resources such as staff, supplies, infrastructures and FP methods. Midwives possess significant potentials to offer accessible, high-quality, efficient and equitable FP services, yet, their capacities remain underutilized, representing a missed opportunity for a country like Palestine. The study provided a current overview of FP services while illustrating the need for quality FP services and the need for an updated continuous education and training, updated standardized guidelines and protocols and supportive supervision are needed across all levels of healthcare providers. Finally, providers reported a wide range of structural barriers to FP services.

CONCLUSIONS

It is crucial to meticulously address both community-related and health system factors to enhance the fulfillment of FP needs and reduce unintended and closely spaced pregnancies. Policymakers should invest in the development of laws and regulations regarding FP services, promoting a comprehensive and holistic approach to FP services. This includes formulating supportive policies, capacity building of human resources and maintaining security of FP commodities.

The effect of a midwifery continuity of care program on clinical competence of midwifery students and delivery outcomes: a mixed-methods protocol

BACKGROUND

The midwifery continuity of care model is one of the care models that have not been evaluated well in some countries including Iran. We aimed to assess the effect of a program based on this model on the clinical competence of midwifery students and delivery outcomes in Ahvaz, Iran.

METHODS

This sequential embedded mixed-methods study will include a quantitative and a qualitative phase. In the first stage, based on the Iranian midwifery curriculum and review of seminal midwifery texts, a questionnaire will be developed to assess midwifery students' clinical competence. Then, in the second stage, the quantitative phase (randomized clinical trial) will be conducted to see the effect of continuity of care provided by students on maternal and neonatal outcomes. In the third stage, a qualitative study (conventional content analysis) will be carried out to investigate the students' and mothers' perception of continuity of care. Finally, the results of the quantitative and qualitative phases will be integrated.

DISCUSSION

According to the nature of the study, the findings of this research can be effectively used in providing conventional midwifery services in public centers and in midwifery education.

TRIAL REGISTRATION

This study was approved by the Ethics Committee of Ahvaz Jundishapur University of Medical Sciences (IR.AJUMS.REC.1401.460). Also, the study protocol was registered in the Iranian Registry for Randomized Controlled Trials (IRCT20221227056938N1).

Ethical Climate in the Delivery Wards of Educational Hospitals in Southeast Iran

Ethical climate is one of the important factors in the working climate of the hospital. Considering the difference in the Ethical climate in different departments of the hospital and the importance of the ethical climate in the delivery ward, this study aimed to assess the characteristics of hospital ethical climate in delivery ward of educational hospitals in southeast Iran. This descriptive and multi-center study was conducted from 2020 to 2021 in educational hospitals in southeast Iran. Two hundred forty midwives working in delivery wards, midwifery instructors, and midwifery students were included in the study by census method. Data collection tools included a demographic information form, Olson's Hospital Ethical Climate Survey, completed using the self-report method. The mean ethical climate in the midwifery group (3.82 ± 0.63 out of 5) was higher than in the instructors' and students' groups. The lowest mean score obtained from the ethical climate questionnaire of participants was associated with the inability to use their experiences in the delivery ward. The lowest mean of ethical climate from the midwives' point of view is the Physicians' dimension and the patient's dimension from the instructors' point of view. The highest mean score belonged to the ethical climate of the supervisors. According to the results of the present study, it is suggested to implement protective laws to support the higher independence of midwives to improve the ethical climates by using their experiences in the delivery department.

Assessing midwifery services in Iran via the balanced scorecard framework

This study investigates the impact of intra-organizational information, midwife job satisfaction and performance assessment on the quality of midwife services. The questions are empirically tested with survey data obtained from 276 midwives, specialist doctors and nurses, and mothers who recently gave birth in a cross-section of Iranian public healthcare organizations. The results from a structural equation model suggest that an improved performance assessment system leads to higher quality midwife services. In addition, the results indicate that midwife job satisfaction and intra-organizational information increases the quality of midwife services, both directly and indirectly, through the mediating effect of a performance assessment system. Our study contributes to the growing research exploring the interface between accounting and health issues by recognizing the importance of a performance assessment system of midwifery services via the balanced scorecard framework for understanding the quality of midwife services.

Evaluation of the Impact of Management Changes on Midwives' Attitudes: A Questionnaire-Based Comparative Study in a a Women's and Children's Hospital in China: A Questionnaire-Based Study

BACKGROUND Change management has become an important tool for hospitals to continuously improve themselves in a competitive market. This questionnaire-based study aimed to compare the attitudes of 78 midwives before and after management changes in work schedules and performance-related pay between March and October 2022 at a women's and children's hospital in China. MATERIAL AND METHODS The survey utilizing a job involvement scale and a self-designed questionnaire was distributed through WeChat group chat for all midwives of the hospital. The hospital has 87 midwives. A total of 78 midwives participated in the questionnaire survey. RESULTS The midwives' score ranges of work initiative, work attitude, work value, work recognition, and work enthusiasm and focus before change management were 21-39, 19-37, 23-29, 12-18, and 12-20, respectively, but that after change management they were 22-39, 19-37, 23-30, 13-18, and 14-23, respectively. After change management, both of the P values for work attitude and work enthusiasm and focus were less than 0.05, 80.23% of the midwives were willing to work across the 2 campuses, and all surveyed midwives agreed on unified accounting of performance pay under the condition of working across the 2 campuses. Their views changed from "maintaining the status quo: taking the initiative - passive resistance" to "questioning" to "openness to change: acceptance". CONCLUSIONS The change management implemented within our department is feasible and the clinical risk is controllable. More attention was paid to the midwives' perceptions and humanized management was applied during change management, leading to a success of change.

Woman-centered care and associated factors among midwives working in urban health centers and public and private hospitals in Tabriz, Iran: a cross-sectional study

BACKGROUND

Woman-centered care (WCC) is the cornerstone of the midwifery profession. However, no study has been conducted on WCC provided by Iranian midwives and its associated factors. Thus, this study aimed to determine WCC and factors associated with midwives' WCC for midwives working in urban health centers and public and private hospitals in Tabriz, Iran.

METHODS

This cross-sectional study was the first part (i.e., the quantitative phase) of a sequential explanatory mixed-method study conducted on 575 midwives working in urban health centers and public and private hospitals in Tabriz-Iran from November 2022 to January 2023. The required data was collected by distributing a socio-demographic and job characteristics questionnaire and woman-centered care scale-midwife self-report (WCCS-MSR). To determine the factors associated with WCC, an independent t-test or one-way analysis of variance (ANOVA) was used in bivariate analysis, and a general linear model (GLM) was employed in multivariate analysis to control possible confounding variables.

RESULTS

The statistical population consisted of 575 midwives, with a response rate of 88.2%. According to the GLM, the total mean WCCS-MSR score of single [β (95% CI) 23.02 (7.94 to 38.10)] and married [β (95% CI) 21.28 (6.83 to 35.72)] midwives was significantly higher than that of divorced midwives after adjusting their demographic and job characteristics. Also, the total mean WCCS-MSR score of midwives with sufficient income was significantly higher than those with insufficient income [β (95% CI) 8.94 (0.12 to 17.77). In addition, the total mean WCCS-MSR score of midwives with < 5 years of work experience [β (95% CI) - 7.87 (- 14.79 to - 0.94)], and midwives with official-experimental employment status [β (95% CI) - 17.99 (- 30.95 to - 5.02)], was significantly lower than those with more than 5 years of work experience and contractual employment status.

CONCLUSIONS

The findings indicate that marital status, level of income, years of practice, and employment status were significantly related to WCC provided by midwives. Focusing only on the midwifery community is insufficient to ensure the improved quality of WCC. However, arrangements should be made at three levels, including policy-makers, managers, and health care provider (midwives).

Woman-Centered Care: Standardized Outcomes Measure

Background and Objectives: Patient- or woman-centered care, prioritizing women's perspectives, needs, and preferences, is a widely recommended approach to enhance the quality of maternity care services. It aligns with the broader principles of patient-centered care, emphasizing the importance of a collaborative and respectful relationship between healthcare providers and women. This study evaluates low-risk pregnancies managed by midwives and obstetrician-gynecologists in Lithuania using patient-reported outcome measures and patient-reported experience measures. Materials and Methods: A prospective cohort study was conducted between September 2022 and April 2023. Data were collected through patient-reported questionnaires. Results: A total of 153 pregnant women who had singleton, low-risk pregnancies participated in the study, of whom 24.8% had their pregnancies supervised by a midwife, and 75.2% of the participants had their pregnancies supervised by an obstetrician-gynecologist. The study found no statistically significant differences in assessed patient-reported outcome measures and patient-reported experience measures between both models of care. Conclusions: Adopting patient-centered approaches enables healthcare systems to understand and address women's specific needs and preferences, fostering high-quality and woman-centered care. This research adds to the growing evidence supporting midwife-led care and emphasizes the importance of personalized, woman-centered approaches in maternity care, ultimately enhancing maternal health outcomes and promoting positive experiences for low-risk pregnant women. The quality of care provided by midwives remains uncompromised and equivalently proficient compared to the care provided by collaborative teams.

Experiences of health providers regarding implementation of the physiologic birth program in Iran: A qualitative content analysis

INTRODUCTION

The rate of cesarean section is on the rise in both developed and developing countries, and Iran is no exception. According to the WHO, physiologic labor is one of the main strategies for reducing cesarean section and improving the health of mothers and newborns. The aim of this qualitative study was to explain the experiences of health providers regarding implementation of the physiologic birth program in Iran.

METHODS

This study is a part of a mixed-methods study, in which 22 health providers were interviewed from January 2022 to June 2022. Data analysis was performed using Graneheim and Lundman's conventional content analysis approach and using MAXQDA10 software.

RESULTS

Two main categories and nine subcategories emerged from the results of this study. The main categories included "the obstacles to the implementation of the physiologic birth program" and "strategies for improving implementation of the program". The subcategories of the first category included: lack of continuous midwifery care in the healthcare system, lack of free accompanying midwives, lack of integrated healthcare and hospitals in service provision, low quality of childbirth preparation and implementation of physiologic birth classes, and lack of requirements for the implementation of physiologic birth in the maternity ward. The second category included the following subcategories: Supervising the implementation of childbirth preparation classes and physiologic childbirth, support of midwives by insurance companies, holding training courses on physiologic birth, and evaluation of program implementation.

CONCLUSIONS

The experiences of the health providers with the physiologic birth program revealed that policymakers should provide the ground for the implementation of this type of labor by removing the obstacles and providing the particular operational strategies needed in Iran. Important measures that can contribute to the implementation of the physiologic labor program in Iran include the following: Setting the stage for physiologic birth in the healthcare system, creating low- and high-risk wards in maternity hospitals, providing professional autonomy for midwifery, training childbirth providers on physiologic birth, monitoring the quality of program implementation, and providing insurance support for midwifery services.

Women's experiences with implementation of the physiologic birth program in Iran: a qualitative content analysis study

Introduction

Increased rate of caesarean section (CS) without medical indication is a global concern. According to the guidelines of the World Health Organization (WHO), the physiologic birth program is one of the strategies for reducing the rate of unnecessary caesarean sections. The aim of this study is to explain women's experiences with the implementation of the physiologic birth program in Iran.

Materials and methods

This study is a part of a mixed-method study involving 15 targeted semi-structured interviews individually conducted with women attending physiologic birth classes between January 2022 and June 2022. Interviews continued until data saturation was achieved. Data were analyzed using conventional content analysis approach based on the criteria proposed by Graneheim and Lundman, using MAXQDA10 software.

Results

Analysis of the findings of the study led to the emergence of 2 themes, 4 categories, and 10 subcategories. The first theme was the positive experiences of the women ("satisfaction with pregnancy" and "making the childbirth process pleasant"), and the second theme was their negative experiences with physiologic birth ("challenges and limitation of physiologic birth program" and "lack of high-quality obstetric services in the public health system").

Conclusion

The results of this study showed that childbirth preparation classes reduced women's fear and stress and enhanced their positive attitude toward vaginal delivery by preparing them for childbirth. Also, effective communication with midwives and their support along with efficient implementation of physiologic birth techniques led to successful pain management and satisfaction with the birth process. Policymakers should implement strategies to remove limitations and make this program accessible to all women.

Midwives' Perception Regarding Conditions Influencing the Implementation of the Natural Childbirth Promotion Program in Iran: A Qualitative Study

Background

In Iran, the Natural Childbirth Promotion Program (NCPP) has been implemented as a component of the Health Transformation Plan (HTP) since 2014 and as an attempt to encourage natural childbirth practices and reduce cesarean section rates. The purpose of this qualitative study was to explore the perceptions of midwives about conditions influencing the implementation of NCPP.

Methods

In this qualitative study, data were collected through 21 in-depth semi-structured individual interviews with expert midwives who were selected using purposive sampling mainly from one medical university in Eastern Iran from October 2019 to February 2020. Based on the framework method as a thematic analysis approach, the data were analyzed manually. To enhance the rigor of the study, we followed Lincoln and Guba's criteria.

Results

Data analysis yielded 546 open codes. After the codes were reviewed and similar codes were removed, there remained 195 codes. Further analysis led to extraction of 81 sub-sub themes, 19 sub-themes, and eight main themes. These themes included: Responsive staff; Characteristics of the parturient; Recognition of midwifery role; Teamwork; The birthing environment; Effective management; Institutional and social context; and Social education.

Conclusion

Based on the perceptions of the studied midwives, the success of the NCPP is guaranteed by a set of conditions identified in this study. In practice, these conditions are complementary and interrelated, and they cover a wide range of staff and parturient characteristics to the social context. It seems that effective implementation of the NCPP also calls for the accountability of all stakeholders, from policymakers to maternity care providers.