The Viewpoint of Iranian Gynecologists and Midwives on the Expectations of Pregnant Women: A Content Analysis Study.

BACKGROUND: Prenatal care providers play an important role during pregnancy. Because healthcare providers provide comprehensive support to pregnant women, they must pay attention to pregnant women's expectations and efforts to meet their expectations. Understanding of pregnant women's expectations is associated with continuation of care and improving the health of the community. The present study is carried out to investigate the viewpoints of Iranian gynecologists and midwives on the expectations of pregnant women.
MATERIALS AND METHODS: This qualitative study was carried out on 10 prenatal care providers in Shiraz in 2018. Sampling method was purposive. Sampling continued until data saturation. Structured, face to face and in-depth interviews were used for data collection. Implementation and coding of interviews were performed simultaneously with data collection. The data were analyzed using conventional content analysis approach. The Lincoln and Guba criteria were used to increase the trustworthiness of the data.
RESULTS: Two main categories were emerged after analyzing of the data. The main category of "competent prenatal care providers" consisted of three subcategories: professional skills, communication skills, and individual characteristics. Another main category was the "appropriate pregnancy and childbirth centers" that included two subcategories of personnel-facilities and management system.
CONCLUSIONS: According to the results, prenatal care providers have been aware that women during pregnancy period expect to have competent providers. Also, they tend that receive pregnancy care and delivery from appropriate pregnancy and childbirth centers. Copyright:

Introduction

Prenatal care providers play an important role during pregnancy.[1] A competent health care provider can be a reliable supporter of women during pregnancy period and delivery.[2] Providers can provide comprehensive support to pregnant women, they must know and pay attention to pregnant women's expectations.[3] Nowadays, special attention has been paid to the expectations of caregivers in medical matters and the healthcare providers must focus on needs and response to them.[4]

Prenatal care providers for improving health community must be aware of the expectations of pregnant women and try to meet these needs.[5] Midwives and gynecologists as prenatal care providers have a close relationship with pregnant women. Therefore, it is necessary to know the expectations of pregnant women.[6] A careful understanding of the expectations of pregnant women by their providers will help them to make decisions for meeting pregnant women's needs and respond to the logical expectations of pregnant women.[3] Also, if providers understand the expectations of pregnant women and attention to them, they will make decisions based on pregnant women's expectations.[6]

Pregnant women have different expectations. These expectations created based on their different needs. Responding to these expectations by prenatal care providers lead to continuing to receive healthcare that has a significant impact on fetal and maternal health. Also, women who met these demands, have pleasant memories from their pregnancy period and childbirth.[7] On the other side, unmet expectations can lead to undesirable clinical outcomes.[8] Understanding the expectations of pregnant women is very important, because if providers pay attention to the expectations of pregnant women, it motivates them to take more effort to improve their overall competencies.[6]

Finally, it can be cited that understanding and responding to the expectations of pregnant women by prenatal care providers lead to providing more optimal care, which is considered as the ultimate goal of the health system.[3] Previous studies attempted to investigate medical professionals' opinions of pregnant women's expectations.[910] Results of research showed some physicians believed that caregivers had high expectations.[11] Literature review showed that no study has been carried out in Iran on the views of prenatal care providers regarding the expectations of pregnant women.

Considering the expressed importance of understanding the expectations of pregnant women by prenatal care providers, researchers' showed interest in investigating this issue, and no study has been done so far, the authors decided to conduct a study aimed to investigate the expectations of pregnant women from the perspective of gynecologists and midwives to determine whether pregnancy care providers have noted that what expectations pregnant women have from them. It is hoped that the result of this study can be a step toward introducing expectations of pregnant women to prenatal care providers.

Materials and Methods

This qualitative research is part of expanded qualitative research carried out between June and December 2018 in Shiraz—capital of Fars province in the Southwest of Iran—via a conventional content analysis approach. In total 10 prenatal care providers were selected with purposeful sampling and the maximum variation based on their age, education, years of providing prenatal care, and various centers. The inclusion criteria were having at least 3 years of working experience, enough time, and willingness to contribute in the interview. The data were gathered through individual, face to face, in-depth and structured interviews by the main researcher. In present study, interviews continued until the data saturation was reached, which resulted in a total of 10 prenatal care providers participants being interviewed. All interviews were done in a suitable environment based on the participants' preferences.

Before the interview, the objectives of the research were expressed to the participants. Then prenatal care providers were assured that the information collected would be anonymous and confidential and was used only for this study. Interview was started with open-ended questions such as, “What are the expectations of pregnant women from their prenatal care providers according to your experience?”, “What skills do you have that a pregnant women expect?” and “What is the expectation of pregnant women from prenatal care centers?” Following questions were also designed according to responses of participants. The interviews were entirely recorded and the significant notes were taken. A code was assigned to each participant based on the time schedule for entering the interview. The interview lasted between 20 and 50 min. In order to conventional content analysis approach, the data were analyzed immediately after the first interview and continued concurrently with later interviews. The audio files were heard several times and then they were converted into a writing format. The notes were studied line-by-line for several times and the main concepts were named as “Meaningful units”. After compression of meaningful units, they were labeled with codes. Then, codes were considered by two researchers. If there were differences in their opinion, the final codes were determined after reaching consensus. In the next step, the codes with the same concept were placed in a subcategory. Then, the subcategories with the same concept formed the main categories.

The four Lincoln and Guba criteria were used to increase the trustworthiness of the data. These criteria include credibility, dependability, transferability, and confirmability.[12] Prolonged engagement in research and member checks were used to assess the credibility of data. Strategies of coderecode and peer checking were applied for dependability. Transferability was assessed by data saturation and maximum variation sampling, so that prenatal care providers were selected with a wide range of age, education, place of care, and work experience. Then, for confirmability, the findings of the research were confirmed by other researchers who were not involved in this study.

Ethical considerations

The present study is part of the Ph.D. dissertation of the first author in Reproductive Health. It was approved with the code of ethics of IR. SBMU.PHNM.1396.843 in October 9, 2017 from Joint Ethics Committee of Nursing-Midwifery and Pharmacology faculties at the Shahid Beheshti University of Medical Sciences. In order to conduct the study, the researcher explained the objectives of this study and informed written consent was obtained. The time and place of the interview were determined according to the participants' preference.

Results

In this study, 10 prenatal care providers participated (6 midwives, 1 Ph.D. in reproductive health, and 3 gynecologists). A total of 4 participants provided prenatal care in the public sector and 6 in the private sector. There are characteristics of participants in Table 1. After the interviews were analyzed, 39 codes and 5 subcategories were developed. Finally, two main categories of “competent prenatal care providers” and “appropriate pregnancy and childbirth centers” were extracted. Table 2 shows the way of extraction of main categories.

Table 1

Demographic characteristics of the participants

Participants	Job	Age (Years)	Providing of prenatal care (years)
No. 1	Midwife	47	25
No. 2	Midwife	61	34
No. 3	Midwife	36	14
No. 4	Midwife	48	15
No. 5	Midwife	37	15
No. 6	Midwife	48	20
No. 7	Ph.D. in reproductive health	49	25
No. 8	Gynecologist	46	15
No. 9	Gynecologist	38	4
No. 10	Gynecologist	58	26

Table 2

Codes, subcategories and main categories

Codes	Subcategories	Main categories
Having experience, the request for necessary ultrasound, careful examination, providing of intensive care to high-risk pregnant women, healing hands, water birth, essential referral to experienced physicians, continuous prenatal care and childbirth, high scientific information, education to pregnant women, answering to pregnant women’s questions.	Professional skills	Competent prenatal care providers
To talk with pregnant women, to listen to pregnant women, to pay attention to feeling of pregnant women, having intimate behavior, reducing the concerns, attracting the trust of pregnant women, to make an enjoyable childbirth, having contact with pregnant women via the phone or social networks.	Communication skills
Good morals, kind, patient, calm, self-confidence, to give enough time to examine, maintaining privacy of pregnant women, pay attention to pregnant women’s needs, giving the right to choose to pregnant women, responsible, prudence, lack of attention to economic profit.	Individual traits
Expert personnel, good-tempered personnel, attractive design of center, equipped center, short distance.	Personnel and facilities	Appropriate pregnancy and childbirth centers
Allows a companion, short waiting time, having a contract with the insurance companies.	Management system

The main category of the “competent prenatal care providers”

According to interviews, prenatal care providers expressed that pregnant women expect to have competent midwives or gynecologists with professional skills, communication skills, and individual characteristics. This category has 3 subcategories and 31 codes.

A.1 The subcategory of “professional skills”

According to the perspective of the participants, pregnant women expected to have the providers with professional skills. This subcategory included 11 codes as follow: having experience, the request for necessary ultrasound, careful examination, providing of intensive care to high-risk pregnant women, healing hands, water birth, essential referral to experienced physicians, continuous prenatal care and childbirth, high scientific information, education to pregnant women, answering to pregnant women's questions.

Participant No. 6 said about having experience of providers: ”Pregnant women select an experienced gynecologist or midwife”.

Participant No. 7 cited about requesting for necessary ultrasound ”Pregnant women expect to not to be requested for unnecessary ultrasound.

Participant No. 5 cited the careful examination of provider: ”Pregnant women say that a provider should be careful”.

Participant No. 4 described providing of intensive care to high-risk pregnant women: ”A high-risk pregnant woman expects that her physician provides intensive care like emergency cesarean section”.

Participant No. 10 explained the provider's healing hands: ”pregnant women want their physician to be a miracle worker”.

Participant No. 1 stated some pregnant women intend to deliver in water: ”Pregnant women select me, because I do the water birth”.

Participant No. 2 said about referring a pregnant woman: ”a pregnant woman expects to be referred to an experienced physician if it is essential”.

Participant No. 10 stated continuous prenatal care and childbirth or presence of her prenatal care provider at all stages of delivery: ”Pregnant woman wants to have delivery with her prenatal care provider and even in labor and delivery rooms, stay with them all the time”.

Participant No.5 in the case of provider's high scientific information said: ”A pregnant woman expects her provider has a high scientific level”.

Participant No.1 stated about education to pregnant women by the provider: ”Pregnant women like to learn to solve their own problems”.

Participant No. 8 explained provider's answering to questions of pregnant women: ”A woman tends to have a provider who answers to all her questions”.

B.1 The subcategory of “communication skills”

Pregnant women expect their midwife or gynecologist to be able to make communication with them. This subcategory has eight codes as follow: to talk with pregnant women, to listen to pregnant women, to pay attention to the feeling of pregnant women, having intimate behavior, reducing the concerns, attracting the trust of pregnant women, to make an enjoyable childbirth, having contact with pregnant women via the phone or social networks.

Participant No. 10 stated about talking of the provider with pregnant women: ”The patients prefer the gynecologists those who talk to them for example they ask: How is your baby?”.

Participant No. 9 explained about listening of the provider to pregnant women: ”Pregnant women expect that we listen to them very careful”.

Participant No. 10 cited about to pay attention to the feeling of pregnant women: “Pregnant women expect to pay attention to their feeling”.

Participant No. 2 described intimate behavior of the provider: ”Pregnant women would like to behave them intimately as we behave with our sister”.

Participant No. 1 stated expecting pregnant women from their provider to reduce their anxiety: ”Most pregnant women tell me when we refer you, all our worries disappear”.

Participant No. 2 stated attracting the trust of pregnant women: ”The pregnant woman wants her provider to be able to keep her trustworthy”.

Participant No. 3 said to make an enjoyable childbirth: “I give childbirth in a place where pregnant women are decorated based on their own favorite till the delivery be pleasant for them”.

Some providers explained about tending of pregnant women for contact with their provider by the phone or mobile app. Participant No. 5 stated: ”One of my pregnant women requested to talk to me more through the phone” andparticipant No. 3 said: ”Pregnant women like that we be available to them via WhatsApp, Instagram or Telegram.”

C.1 The subcategory of “individual characteristics”

According to the participants' expressions, the pregnant women expect that their providers have favorable individual characteristics. This subcategory has 12 codes as follow: good morals, kind, patient, calm, self-confidence, to give enough time to examine, maintaining privacy of pregnant women, pay attention to pregnant women's needs, giving the right to choose to pregnant women, responsible, prudence, and lack of attention to economic profit.

Participant No.1 cited about good morals of providers: ”The most important characteristic of a provider is having good morals to be able to communicate with a pregnant woman”.

Participants No. 2 and 10 stated to be kind of providers: “The most important characteristic of a provider according to the viewpoints of pregnant women is that we be very kind with them”.

Participant No. 8 described about being patient of providers: ”A pregnant woman prefers to have a very patient provider”.

Participant No. 7 stated that pregnant women like their providers to be calm: “The most important feature of a provider according to the perspective of pregnant women is that we stay calm”.

Participant No. 2 said about having the self-confident: ”Pregnant women expect which their provider to have self-confident in their job”.

Participant No. 9 cited: ”Pregnant women expect that we spend enough time for their examination”.

Pregnant women tended to maintain their privacy during delivery. Participant No. 5 stated that ”A woman wants that the provider maintains her privacy when she gives childbirth” andparticipant No. 4 said: ”pregnant women would love to maintain their privacy in hospital”.

Participant No. 8 stated about expectation of pay attention to pregnant women's needs: ”A woman likes to have someone that pay attention to her demands as much as possible”.

Participant No. 1 descried about giving the right to choose to pregnant women: ”Every pregnant woman likes to be able to choose her doula or childbirth center”.

Pregnant women liked to have a responsible provider. Participant No. 7 stated: ”It is very important for pregnant women to have a responsible provider”.

Participant No. 8 said thatpregnant women expect to have a prudence provider “The pregnant women prefer to have a very prudence provider in all aspects”.

Participant No. 7 stated about ignoring the providers to economic profit: ”Women say that some providers only consider economical aspects, they do not have a passion for their work at all”.

2. The main category of the “appropriate pregnancy and childbirth centers”

According to interviews, pregnant women expect their midwives and gynecologists to provide prenatal care and childbirth in appropriate centers. One of the characteristics of these centers is suitable personnel and facilities for prenatal care and childbirth. In addition, these centers must have a desirable management system. This main category has eight codes. Table 2 shows the way of extraction of this main category.

A.2 The subcategory “personnel and facilities”

Participants stated that pregnant women expect their provider provide pregnancy and delivery services at the centers with suitable personnel and facilities. This subcategory has five codes as follow: expert personnel, good-tempered personnel, attractive design of center, equipped center, and short distance.

Participant No. 6 stated that pregnant women expect personnel of centers should be expert: ”Pregnant women before going the delivery room always ask us that hospital's personnel are expert?”.

Participant No. 2 about good-tempered personnel said: ”pregnant women pay attention to the good mood and behavior of personnel when they visit a childbirth center during pregnancy”.

Attractive design of pregnancy and childbirth centers was stated by participant No. 2: ”Pregnant women pay attention to the hospitals' environment and the delivery room, especially luxuries are very important for young generation”.

Participant No. 4 said that pregnant women choose well-equipped hospitals for their childbirth: ”Some pregnant women tend to admit in well-equipped hospitals for their childbirth”.

Participants No. 7 explained about choosing of centers with short distance: ”Some pregnant women like the hospital near their home”.

B.2 The subcategory of “management system”

Participants expressed that pregnant women expect their pregnancy and childbirth centers to have to be a desirable management system. This subcategory includes three codes as follow: allowing to have a companion, short waiting time, having a contract with the insurance companies.

Participant No. 5 said about pregnant women's expectation to allow a companion: ”A pregnant woman wants to be accompanied by her husband or mother in childbirth center”.

Expectation of short waiting time for receiving of prenatal care was stated by participant No. 7: “pregnant women expect to be visited by their provider at a appointed hour with a maximum of half an hour to an hour of delay”.

Centersof under insurance contract were one another pregnant women's expectations. Participant No. 4 said that: “The pregnant woman tends to be admitted to the hospital that accepts her health insurance card” and participant No. 5 cited: ”The cost is very important for pregnant women; they select hospital which accept their supplemental health insurance card”.

Discussion

The present study is the first research in Iran that has explained the expectations of pregnant women from the viewpoint of their providers. After the data were analyzed, two main categories were extracted. First main category was “competent prenatal care providers” that included professional skills, communication skills, and individual characteristics of providers. Professional skills' subcategory represents clinical skills and sufficient knowledge of providers. The results of this study showed that the caregivers prefer to choose an experienced and careful provider. Clinical examinations are of utmost importance to diagnose early complications, necessary interventions, and control fetus and mother's health, while carelessness in examination can be associated with medical errors.[13] In present study, providers talked about pregnant women's expectation, such as referral of pregnant women to other expert physicians, providing of high-quality care, education, and answering to pregnant women's questions. These results were consistent with other researches.[1415161718] In this study, continuous prenatal and childbirth care was one another of the expectations of pregnant women such as previous studies.[1920] The communication skills of prenatal care provider were another subcategory of the competent prenatal care providers. It included verbal communication skill, emotional communication skill as well as achieving the satisfaction of pregnant women. Some studies showed similar result.[21222324] In this subcategory, access of pregnant women to providers via social networks or phone was one of the explained expectations in this study. This expectation can be considered as an enabling factor for pregnant women in this era of time.[252627] Subcategory of individual characteristics included good moral of providers, respect to pregnant women, professional ethics, and identified as another competency of prenatal care providers. In previous studies, results were similar to finding of the present study.[212627] Expectation of honoring pregnant women was one of the expressed issues in a study.[28] Also, Belgian pregnant women intended that the providers maintain their privacy.[29]

The second main category was “Appropriate pregnancy and childbirth centers”. It included personnel and facilities and management system. The subcategory of personnel and facilities indicated proficient personnel and favorable facilities of these centers which is consistent with the findings of Tuschy et al.[30] In subcategory of management system, having companions, short waiting time, and suitable cost of care were expressed as expectations of pregnant women by their providers that was such as other researches.[3132] Expectation of the presence of a trusted person next to pregnant women was similar with African pregnant women's expectation.[33] According to the patients' rights charter in Iran, health centers must respect to the time of the clients.[25] Our participants stated that pregnant women tended to spend a shorter time to receive prenatal care. This was similar to results of a quantitative study.[29]

Owing to the fact that prenatal care providers play a key role in providing prenatal care, and because pregnant women expect their providers to act professionally and have communication skills and good individual characteristics; therefore, the importance of improving their competencies is clear. In addition, participants cited pregnant women expect their midwives and gynecologists provide prenatal and childbirth in appropriate centers that providers should keep this in mind as well.

It is hoped that providers effort to meet the expectations till women have an enjoyable memory from their pregnancy and childbirth. Also, the policy makers and planners in Iran should pay attention to the expectations of pregnant women in their plans to achieve client-centered care that is one of the most important goals of health system. The authors of this study recommend that a qualitative study is investigated based on expectations of pregnant women from prenatal care providers on pregnant women's perspective. Also, they suggest the views of prenatal care providers are compared with opinions of pregnant women in other study. Improving awareness of prenatal care providers about pregnant women's expectations is the other suggestion. Also, the extracted expectations could be used to design a questionnaire for assessing competencies of prenatal care providers. Unwillingness of some participants to attend the interview is one of the limitations of this qualitative study.

Conclusion

According to the results, prenatal care providers have been aware of the fact that women during their pregnancy expect to have a competent provider. Also, pregnant women expect their midwives and gynecologists to provide prenatal care and childbirth in appropriate centers.

Financial support and sponsorship

Shahid Beheshti University of Medical Sciences, Tehran, Iran

Conflicts of interest

Nothing to declare.