Community-based maternity care from the view of Iranian midwives: A phenomenological study.

BACKGROUND: Midwifery cares take place in diverse communities with different ethnics groups. Therefore, midwifery cares could be planned wisely and principally based on women's and their families' changeable demands which focus on social and cultural issues. This qualitative study explored the midwives' experiences of care in the community.
MATERIALS AND METHODS: This qualitative study was conducted by descriptive phenomenological approach. The subjects, selected by purposive sampling, comprised 13 midwives employed in Isfahan, Iran. Semi-structured interviews were audio-taped, transcribed, and simultaneously analyzed through Colaizzi's method.
RESULTS: With descriptive analysis of participants' experiences, three main themes were explored (personal characteristics of the community midwife, social determinants of women's health, and achieving community-based midwifery skills).
CONCLUSIONS: Knowledge of women's social status, gender inequality in health, and existence of social health risk factors for women in their community helps midwives to provide reproductive health care based on clients' needs and demands. Therefore, midwives should enhance the quality of their care through integrating professional skills with a full understanding of the social context.

INTRODUCTION

During the transition to motherhood, women need attention and social and psychological support from midwives. In addition, midwives are expected to support them in adapting to the changes they experience during pregnancy, birth, and motherhood, and monitor them.[1] The social support of the midwives has significant effects on the quality of life of the infants regarding physical and mental aspects.[2] If health care providers do not have enough knowledge about social problems, and the emotional, physical, and social conditions underlying pregnancy, they cannot provide effective care.[3] The midwifery profession is rooted in public health, and it is community oriented in nature.[4] It is in constant communication with the women, and includes elements that represent the profession. One of these elements is understanding the community through its rules and governing customs. In this profession, like other health sciences, knowledge of the social and behavioral sciences is necessary.[5] For example, because sexual behavior and reproduction has both biological and socio-cultural origins, social science researches, through understanding the human factors involved in sexual health, and fertility, and by investigating their effects and results, have an important contribution in improving sexual and reproductive health.[6] Therefore, having a social approach to the treatment of sexually transmitted diseases that has a social component is always emphasized.[7] According to the United Nations Commission on Social Determinants of Health, social factors affecting health have a 50% contribution; in fact, these social factors are the cause of injustice in health care systems and societies.[8] Based on these researches and advanced nursing and midwifery practices, the effects of social factors, and the issues among inhibiting factors and factors forming health behaviors should be considered.[9] Social trends and anticipated needs of the health system showed that there is a growing need for health care professionals who can effectively manage the needs of community health and the society.[10] Economic, social, and demographic changes and facing different challenges compared to the past show the need for medical practitioners to have a community-based vision.[11] They should have the ability to assess the community, recognize the basic needs of the community, plan and design interventions, and implement them in different groups and societies.[12] Sociology provides a framework for the care of pregnant women and their social context. Sociological explanations for perceived inequities, poverty, and deprivation help the midwives in better understanding the content of care, accepting people's lives without judgment, providing qualified health care, and having a better understanding of the society. In addition, they enable them to think more and analyze before accepting the routine.[13] Community midwives have a more positive perception of their role and function in relation to their patients because they are able to practice their gained analysis and apply them.[14] In social midwifery, in addition to the adoption of environmental factors and social factors influencing health and fertility, understanding the impact of these factors on the organization and delivery and utilization of obstetric services by the community are important.[15] Changes in the socioeconomic structure of society, role of women in the workplace, and change in expectations of birth are associated with the new social meaning of pregnancy.[13] Therefore, the search for social meanings of midwifery should be done so that the midwives can analyze their perspectives in practice.[16]

Some developed countries consider the decrease in maternal mortality in recent decades to be a result of the expansion of activities in community-based midwifery. In their study, Hagberg and Ulf identified the reduced maternal mortality in the Netherlands, Norway, and Sweden as a result of serious cooperation between local doctors and midwives.[17] In the study of Prasad and Dasgupta performed in India, Malaysia, Sri Lanka, and Indonesia, the dramatic reduction in maternal deaths was due to applying a midwifery care model. This model that has a universal acceptance is the communication and collaboration between traditional midwives and their home care, with educated midwives, gynecologist support when necessary, and participation of women in care.[4] In Cambodia, the maternal mortality rate was reduced by only modifying the underlying social factors related to health.[18] In Iran, community orientation in medical sciences has been discussed for many years, but community orientation in midwifery needs more consideration due to the importance of maternal and child health. In a survey conducted on all the midwives working in the provinces of Kerman and Shahroud, Iran, in 2010–2011, the awareness of the midwives of Kerman regarding community-based midwifery was at a low level, and for midwives of Shahroud, it was at a moderate level.[1920] In order to further understand the social factors affecting maternal health and enhance the professional knowledge of the midwives in this field, which further improves maternal health and job satisfaction of midwives, this qualitative study was conducted to explore the midwives’ experiences of community-based midwifery in Isfahan, Iran.

MATERIALS AND METHODS

This study was a qualitative study with a phenomenological approach. The aim of this qualitative study was to explore the experiences of community-based midwives of midwifery services. Participants in this study were 13 midwives working in Isfahan with an average working experience of 23 years. The participants were selected using purposive sampling. Inclusion criteria included history of working for over a year. First, the purpose of the study was explained and verbal consent to participate in the study was obtained, and then consent was gained to record the interviews. Ethical standards such as anonymity, confidentiality of the information, right to withdraw from the study at any time, and obtaining permission from the university were respected. Data collection method was conducting semi-structured individual interviews. The research started with personal questions on topics such as age and working history. Then, it was linked to the interview question: “Please express your experience of midwifery care.” The next question was based on the participants’ responses. For recording the data, the interview was taped and notes were taken during the interview. Then, the entire interview was transcribed; all the subsequent steps were handwritten. The sampling was stopped when the data were repeated and data saturation was observed. The interview venue was determined by the participants and the duration of the interview was between 45 and 120 min.

To ensure the reliability of the data in this study, the original data were referred to original reference for many times, and the categories were frequently examined to ensure that the results showed the real content of the data. For verification, the researcher maintained documentation in all phases of the research. Moreover, for transferability, the results were given to two experienced midwives, who did not participate in the research, and their experiences were compared with the present results (external verification). Meanwhile, using a sampling technique with maximum variation helped toward the appropriateness or transmissibility of the data in this research. To assess the reliability, the opinions of a supervisor and a professor of qualitative research were used. Parts of the interview were sent to them and then the codes and their analyses were compared with those of the researcher.

The researchers chose Colaizzi's method for data analysis. Data collection and analysis were performed simultaneously. First, the participants’ descriptions were read for meaning, and then the relevant statements were extracted, and the meanings of words were written. The researcher tried to get insight of the data by repeated listening to the interview, transcribing the audio recordings, repeated reading of the notes, and recalling the experiences and observations. Then, the data were coded, and with each interview, data were reviewed and if ambiguity existed, the researcher would question the participants again. In the next stage, the data with similar codes were clustered. Finally, the meanings of the units or themes were extracted. In the last stage, the results were presented as a comprehensive description without ambiguity of the phenomenon being studied.

RESULTS

The participants of the study were 13 experienced midwives working in Isfahan with 10–40 years of experience and a mean age of 47 years [Table 1]. According to the research aim, explaining midwives’ experiences of community midwifery services, and analysis of data, 3 main themes and 10 sub-themes emerged. The main themes included characteristics of community-based midwives, women's health and social risks, and achieving community-based midwifery skills.

Table 1

Participants’ characteristics

Theme 1: Characteristics of community-based midwives

Individual characteristics of midwives; family environment; society with its cultural, political, economic, and social characteristics; experiences that were gained during years of interacting with patients; their thoughts about social issues; and their perspective toward society have led the midwives to achieve a community-based vision.

Adherence to scientific and professional principles

Participant number 7 considered adherence to scientific principles of professional midwifery and providing complete services as a necessity for midwifery:

“I have always tried to take good care of and look after my patients, I would inform the patient about her condition, I would perform the best practice for her in terms of scientific principles, I fully understand the importance of patient education.”

Gender sensitivity in providing services

Midwives, while being informed of the existing inequalities between women and men in the society, along with providing gender- sensitive reproductive health services, are trying to use every opportunity to reduce gender discrimination and violence against women and restore their reproductive rights. Nevertheless, they still experience challenges. Participant number 13 sees the situation with a social perspective and stated as follows:

“There are many times that patients come to me and explain about their family problems that affect their health (like violence and poor hygiene), and they want me to talk with their husbands, I try to talk with the husband in a way that informs him and also prevents the women's situation from being damaged in the family. My experience has proved that this method can help to protect the rights of women. I know that it is my duty to be informed of the status and position of women in society.”

Solving moral problems in their profession

While providing care to clients, midwives were repeatedly exposed to ethically difficult circumstances. Thus, they began to solve these problems with their skills and the knowledge of social and cultural status of their community. Participant 2 stated her own experiences in dealing with midwifery problems in the social aspect, and with her understanding of the social situation of women, she found a good solution. She seemed satisfied with her solution. She knew that this solution was due to her understanding of women's social status.

“I had a case that a girl got pregnant before being married, and she wanted abortion. I talked with them for several sessions and convinced them to get married. They have a good life now, I am happy that I prevented abortion and its complications for the mother, and I am at peace with my conscience that I helped them form a family.”

Care based on religious beliefs

Community-based midwives should know that in order to be successful in providing care in the Iranian society, they must be aware that religion and religious values are the variables that affect the lifestyle and health of the people. Furthermore, they should be aware of these beliefs in order to help clients improve their health. Participant 6 talked about her initiative action in using the religious beliefs of the people to solve problems:

“A pregnant woman came to me and complained about her husband's violence, I talked with the husband and gave him a booklet that I had made with notes from the Holy Prophet, Imam Ali, and other Imams’ statements about violence prohibition and its harmful effects on the health of the family. Later I realized that this action was effective, the religious teachings helped the patient avoid the health risks of being beaten for herself and the child.”

Theme 2: Women's health and social risks

The midwifery practice is influenced by the characteristics and principles governing the public. Since this profession is associated with birth, couples, and reproducing generations, it is a purely social profession. In providing health services to communities, the midwives are in direct contact with the social problems that affect the reproductive health of the clients. Therefore, the midwives should be familiar with the principles of sociology and how the midwives should serve within the community.

Damages caused by poverty to the health of mother and child

From the perspective of community-based midwives, poverty and social inequality of the society are the most important problems that affect the health of both mother and baby, including premature birth, low birth weight, and infant mortality. In addition, a midwife should be familiar with the community support networks in the society in order to advise her client. Participant 10 stated thus:

“I had a patient with the history of the death of two infants, shortly after birth, due to financial problems and poverty she had delivered at home. For her third pregnancy I asked her to be hospitalized but she could not afford the cost so the third child was born at home and died, I went to see her for postpartum care, she had tears in her eyes and was staring at a point.”

Social beliefs in conflict with the health and status of women

Different social groups have different beliefs and values that affect the health and status of women. Community midwives must be aware of the beliefs and status of women in order to make appropriate decisions to keep women out of harm inflicted by the society.

“A newly wed bride was brought to me for checkup. I asked the man to take her to the coroner, but he did not accept and told me that he believed me. When I examined her, I found that she was not a virgin, and the problem went back to many years ago when she was 12 years old and weaved carpets at her master's house, the master's son had raped her. I did not know how to judge. Knowledge about the status of women in society, the future of this woman, and concerns about the disintegration of the family made me deny the truth about her and I did not tell the husband.”

Damage to women's health caused by laws of the society

The midwives expressed their concern and frustration for women's health regarding the adherence to certain rules. In their view, the existence of some rules and having the same approach to some social issues threatens women's health. This included abortion prohibition that caused women with unwanted pregnancies and illegitimate relationships to have unsafe and illegal abortions. Moreover, this method can result in serious health injuries and even death. Most participants considered this issue as an important concern in their profession:

“I had a patient whose husband had passed away and now she was pregnant from an illegitimate relation. She wanted me to help her, but there was nothing that I could do. I was certain that she would have an unsafe abortion and her life was in danger. The law had tied my hands, and there was no support and legal system that I could refer her to. I just explained to her about the risks of septic abortion. Later, she came to me with severe bleeding and fever.”

Theme 3: Achieving community-based midwifery skills

Today, more than ever, there is a need for midwifery to become community-based. This is due to the changes that have occurred, in recent decades, in science and human communities and, consequently, have affected moral and social values. Analysis of the midwives’ statements showed that there are several social damages caused by gender discrimination which threaten the reproductive health of women. Moreover, the health needs of women in social and cultural contexts should be extracted, and services appropriate to their needs should be designed. These services should be given to women who do not have access to them. Thus, obstetric services should be fully community-oriented and midwives should gain many skills in this way.

Decision-making skills for social problems

Community-based midwives should have the ability to make decisions for the specific social conditions. This requires sufficient knowledge of community needs, and legal and supportive networks. Midwives, over time, reach a maturity in their career and are able to provide their experiences to community health planners. Participant 3 stated as follows:

“Sometimes the patient has a problem that goes back to social problems, and if it is not solved it could cause serious damage. I tried to find solutions for my client's social problems, and it did not damage the norm of society and religion, and yet it did not harm the patient's health.”

Participant number 7 talked about the maturity that she reached in her profession during time:

“At the beginning of my career when a patient referred to me with a social problem like husband's violence, I used to shout at him and tell him that he had no right to do such a thing. But now I have gained maturity through time and try to view the matters from the community perspective and try to help the patient and help them avoid being damaged.”

Professional knowledge and skills associated with social culture

If the midwives want their services to match with the needs of women in society, they must have a complete understanding of their community and learn the ways to influence public opinion and change their behaviors. In other words, midwives should be able to provide and design their services based on specialized knowledge of their profession and their social and cultural context. Participant 13 stated thus:

“I was examining a patient and realized that she had fetal macrosomia, and told the patient that she had to have cesarean. The patient referred to me later really ill and pale. She told me that she got scared of going to a hospital, since she had to have cesarean, so she delivered the baby at home. At that point I realized that although the midwifery science suggested cesarean because of the fetal condition, I had to consider the patient's culture that did not approve cesarean, and explained the situation to her.”

Communication skills regarding patients with social damage

Effective communication with the mothers in professional midwifery not only is an expression of respect for the dignity and rights of clients but also an important factor in understanding their problems that need to be solved with regard to cultural and ethical sensitivities of the society. The community-based midwives should be able to communicate with the women who have experienced social damage in the same way as addicted women, prisoners, and women with high-risk behaviors, in order to provide health services, because these women rarely refer for care and often leave the services incomplete. Hence, midwives must screen and identify these women with their professional and communication skills and provide them with necessary health services. They must also have communication with other relevant organizations in the field and refer patients to them.

“I had a patient with two children. She referred to me for checkup and she was really concerned about dangerous female diseases, and asked about STD. I felt that I should have a better relation with her and have more information about her. So she told me that her husband was sentenced to life imprisonment and they had been divorced, and she had been a concubine to make a living, and now she had concerns about her health. I talked to her about the prevention of unwanted pregnancy and sexually transmitted diseases, and introduced her to social welfare for financial assistance.”

DISCUSSION

The main role of midwives in advancing women's health is based on their participation with respect and dignity, and by defending their rights, considering the cultural sensitivities, and is focused on promoting health and preventing disease.[21] Most of these roles demonstrate the community-based role of midwives. Community midwives, in carrying out their mission, should have complete understanding of the society and take steps with regards to the health care delivery system. They should identify the obstacles that reduce the benefits of the services for women. Furthermore, consistent with the changes of the society, they should have a holistic view of women's health and be aware of the risks that threaten the mental, physical, and spiritual health of the mothers.[8] They should be proficient in effective communication techniques and counseling, have knowledge of social and behavioral sciences, and identify the social and emotional problems related to perinatal health which can lead to adverse consequences for the mother, baby, and family.[51922] In the present study, the participants named the following as characteristics of community-based midwives: Application of rational experiences, initiative in dealing with social problems, professional courage and critical thinking, feminist perspectives, and understanding the position of women in society. In the study by Keramat et al. on community-based midwives, communication skills, critical thinking, initiative, improving management skills, leadership, and counseling were named.[19] Communication skills, critical thinking, and initiative were consistent with the results of this study. Midwives’ experiences about vulnerability of women and problems related to reproductive health, understanding economic problems, and reduction of the social and legal support had made the participants of the study to have a feminist point of view. Therefore, the midwives had found that despite their scientific and professional mission, they had heavier social responsibilities. Hanna,[23] Surtees,[24] and Davies[25] emphasized the social role of midwives, in addition to their scientific activities as part of the feminist program.

Most of the problems and difficulties of the community midwives raised in this study were rooted in social issues. Nevertheless, the participating midwives, despite being fully aware of the issue, were not unaware of the importance of their role. In the study by Graser, the role of the midwife was mentioned as challenging that required many skills. It was also said that if the midwife wanted to deliver care with quality, they should have knowledge about coping and adapting to the risk of medical, emotional, social, political, cultural, economic, and environmental factors that endanger the health of women.[26] A variety of logical methods should be used in order to make decisions based on clinical, economic, cultural, political, and individual situations.[27] One of the emerging themes of this research was to understand the social inequality of accessing health care. In their study, Thompson and Thompson noted the challenges that midwives have regarding insufficient resources to care for women and their infants.[28] Burroway believes that children's health is more dependent on the context of inequalities of the social, political, and economic community, and not on the people who relatively increase the risks or the people who care for them.[29] One of the contradictions that the midwives had in this study was the differences in their value systems with the social beliefs and rules. In this study, the midwives were suffering from internal contradictions and moral dichotomy in accomplishing their social mission. In the study by Thompson and Thompson, these internal contradictions were noted, and they stated that since midwives are an integral member of the society in which they live in, sometimes they face challenges during their performances, which badly affects their personal beliefs.[28] Gender discrimination was another experience of the participating midwives. According to the Commission on Social Determinants of Health, the majority of preventable deaths and disabilities that women experience are related to gender discrimination. In addition, these damages can only be prevented with a considerable transformation in various aspects of the economic and social structure. Eliminating gender discrimination in accessing resources is one of the important steps in achieving equity in health. The remaining of these social discriminations will show their effects on women's health.[30] Gender discrimination in the community has different aspects. However, Choudhury et al. performed interventions in their study to reduce gender discrimination and concluded that this is a complex social issue. They showed that it has deep cultural roots and the women's status in the community was much lower than men. In order to improve the women's health status, in addition to health interventions, there is a need for changes in values and attitudes.[31] Participating midwives, while expressing some of their acquired abilities and skills in dealing with problems, expressed incapacity and helplessness in solving social problems associated with their profession. At a conference in October 2011 in Rio de Janeiro, which was held on decisive social health, it was stated that governments, politicians, and leaders of health are responsible for the provision of public health, and this matter shows the necessity and importance of intervention on the factors and social determinants of health. In addition, interventions can be performed in any country with any social context, in a way that it would promote health and reduce health inequalities.[32] Unwanted pregnancies, illegitimate pregnancies, and abortion requests were common problems of the participating midwives in this study. This had affected their thoughts and performances, and caused severe internal conflicts for them. Jones believed that there are conflicts in many areas of midwifery and the midwives’ personal perspectives affect their care, and this issue is reflected most in termination of pregnancy.[33] Having a holistic vision is one of the skills that health care providers need to achieve. In this study, participants had expressed that they had gained the community-based vision that is required for their practice over time. Currently, in academic health care programs, this serious problem is discussed. In order to enhance students’ information in the field of public health and prevent environmental, economic, and socio-cultural factors affecting health, university training programs have been established. These programs can improve students’ experiences in dealing with the real world, understanding the health needs of the community, and improving behaviors contributing to the society's health.[34] Participating midwives claimed that they had gained maturity in their professional community over time. Melinda Cook pointed out that a kind of mature professional community in which awareness of the social conditions that cause problems for pregnant women is considered essential in providing effective care.[3]

The ability to adapt to approved ethical and scientific standards with the social and cultural context was another skill that the participating midwives considered necessary for community-based midwifery. Hresanova mentioned culture as an extremely important determinant of the mother's care, and stated that it has a direct effect on the health of mothers and babies.[35] The World Health Organization emphasized primary prevention and participation in social programs as one way of bringing theory to practice in education programs and providing services.[6]

The participating midwives considered the art of verbal and nonverbal communication skills as essential in achieving a community-based midwifery. Having good communication skills and effective communication with clients is one of the good midwifery criteria.[1921] The necessity of supporting midwives in the development of their communication skills and the need to incorporate communication skills in their curriculum in order to further understand women and their concerns have been emphasized.[36] Communication skills are of significant importance for health caregivers in order to consult with women, who have conflicts about abortion and family planning due to their cultural and religious views.[37] Morténius et al. talked about the importance of strategic communication in health care workers as a means of facilitating communication between them and their clients in order to clarify the cause of diseases.[38] The art of effective and meaningful communication with women is one of the strategies that promote the health of mothers and children.[39]

CONCLUSION

Since the role of social determinants of health on the promotion and recovery of health of women and children is undeniable, the community midwife must meet certain qualifications and have a holistic vision of society and health.