Original Article

Factors in the Provision of High Quality Midwifery Care: A Qualitative Content Analysis

Introduction

In recent years, health care has undergone significant changes, and the promotion of health care has been the goal of many scholars.¹ In the meantime, improving the quality of midwifery care has become one of the main priorities of the World Health Organization (WHO), due to the fundamental role of quality care in women’s and families’ health.² Changing priorities and shifting the focus from routine care to patient-centered care, and also the transformation of professional knowledge calls for deeper discussion about quality midwifery care.

In today’s competitive healthcare organizations, you can expect to move forward if only the desired care outcomes have been achieved. Experiences have shown that strengthening midwifery care and ensuring quality care can reduce maternal and infant deaths by more than 80%.³ In spite of widespread access to midwifery care in many parts of the world, there are still significant cases of maternal mortality, and this fact can be attributed to the poor quality of care.

Several studies around the world have intended to explore the components of high quality midwifery care.^4-6 While providing high quality maternity care has been considered in Iranian medical system, its components have not been addressed explicitly. For instance, a study in Iran concluded that the quality of maternity care is not desirable and high level of access to midwifery services does not guarantee to the high quality of maternity care and improved outcome.⁷ So, in recent years, more attention has been paid to the quality of midwifery services, particularly in developing and less developed countries, because improvement in the quality of care requires a deep understanding of its determinants.^8-10

In Iran, there is a significant shortage of literature related to the quality of midwifery care. Qualitative studies explore the phenomenon with all its complexities within the relevant context, and emphasize on the dynamic, multidimensional, and individual aspects of human experiences.¹¹Therefore, this qualitative study was conducted to explain the factors that affect the provision of high quality midwifery care, using the experiences of midwives working in maternity hospitals of Qom.

Materials and Methods

This qualitative study is a part of a Ph.D. thesis. Semi-structured and in-depth interviews were conducted with midwives that had been selected by purposeful sampling. The samples in this study included 15 midwives working in 4 maternity hospitals in Qom (2 public hospitals, 2 private hospitals). Inclusion criteria were, being a midwife with experience of working in delivery unit for at least one year, willing to participate in the study, and having the ability to express and share personal experiences.

Semi-structured and in-depth interviews were performed with open ended questions to find out how Iranian midwives describe high quality midwifery care. Interviews were performed between June 2017 and February 2018. Prior to the interviews, time and place of the interviews were agreed upon by the participants. Demographic characteristics of the participants were obtained before the start of interviews. The interviews were performed individually in a quiet place suggested by the participants. At the beginning of each interview, objectives of the study were explained to the participants and a written informed consent was obtained from them, and then the interview was performed and recorded. Each interview lasted for approximately 50-90 minutes.

The content of the interview was typed verbatim within 24 hours. The process of encoding was performed simultaneously with the data collection. Experiences of two participants who were not happy with the recording of their voices were written by hand. During the study process, the researcher provided the participants with her phone number and obtained their phone number in order to stay in touch with them throughout the study and obtain necessary information.

General questions were based on the study objective: “What are the components of high quality midwifery care? What factors affect the quality of midwifery care? Can you talk about high quality midwifery care?”

Probing questions were also used during the interviews if needed, which included: “Can you explain more? What do you mean by that?” Also, an attempt was made not to use words or phrases that could guide the interviewees. In the qualitative studies, number of samples is determined by data analysis and sampling is continued until data saturation is reached.¹²The principle of maximum variation was used during the sampling and an attempt was made to select samples with different characteristics in terms of education level, work experience, place of work, and age. After 15 interviews, data saturation was reached (no new categories emerged and the obtained categories were saturated in terms of features and dimensions).

Qualitative content analysis proposed by Graneheim & Lundman’s was used in this study.¹³ For this purpose, initial classification began from the second interview and by continuation of the interviews, number of codes and primary classes were determined. Then, categories, subcategories and main themes were formed by comparing the classes based on their similarities and differences. Encoding and data analysis were performed by Microsoft Word for Windows 2013 software. None of the interviews was repeated. Encoding was done by ZM, and its structure along with the formation of categories was confirmed by AE and ZKh.

Data trustworthiness was confirmed by the criteria of creditability, dependability, transformability, confirm ability and authenticity.

To ensure the credibility, the interviews’ transcripts were reviewed and returned to the participants to confirm their validity. Peer review was another method used to ensure the reliability of the data. For this purpose, the interview texts, as well as extracted codes and categories were presented to some people who were experts in qualitative study and their comments were applied in the process of encoding. Long term engagement with the phenomenon and constant review (over 9 months) of the data were other measures taken to ensure the credibility of the findings.

To ensure the dependability of the findings, the researcher presented the data analysis process to other qualitative researchers to find out whether they come to the same conclusion and extract the same categories. At the end, the codes and categories that needed some correction were viewed and amended.

To ensure the transformability of the findings, the researcher tried to comply with the principle of maximum variation in sampling, and the findings were compared with the results of other studies. Confirm ability evaluates the objectivity of the study.¹⁴ In the present study, to ensure the confirmability, the researchers had to show that their perception is not biased. Therefore, they tried to describe the study processes clearly.

Participants were ensured that participation in the study is voluntarily and they can withdraw from the study at any time with any reason. Additionally, the participants were ensured that their identity will remain confidential throughout the study. The reason from recoding of the interviews was explained to the participants and if any of them objected, her interview was not recorded and written notes were taken instead. A written informed consent was obtained from each of the participants and the principle of confidentiality was preserved throughout the data collection, data analysis, and publication of the findings.

Results

A total of 15 midwives with the mean age of 33.5 years and mean work experience of 12.9 years were selected to participate in this study. The findings of content analysis revealed two main themes, including “individual factors” and “professional-organizational factors” (Table 1).

Theme 1: Individual Factors

Majority of the participants in this study stated that individual factors play an important role in ensuring and the delivery of high quality midwifery care. This theme consisted of five subthemes, including personal efficiency, staffs’ psychological status, value-centeredness, cultural-educational issues, and professional attachment.

Personal efficiency

Participants referred to the importance of manpower as the focus of quality care provision, and emphasized on the knowledge-centeredness, expertise-centeredness and experience as the bases of quality care.

“Personnel should be able to provide care. We cannot expect someone who does not have enough knowledge on how to treat the client to deliver a high quality care” (P.4, 37 yr., W.E. 15).

Another participant stated: “I know many midwives who when they are faced on an issue that know very little about, they go and gather as much scientific information about the issue as they can. They also try to get help from more experienced colleagues. These people recognize the importance of knowledge” (P.9, 26 yr., W.E. 3).

Staffs’ Psychological Status

The participants in this study referred to some of the individual factors, such as mental health and stress, as factors that could be associated with quality midwifery care.

“I’m a stressed person. I have a lot of problems in my life, with stress being the root cause of them. I cannot keep my calm... Our mental disturbance can really disrupt our professional performance” (P.7, 41 yr., W.E. 17).

“Poor working conditions and work-related stress in combination with emotional disturbance can lead to medication error and threaten optimal performance” (P.2, 39 yr., W.E. 16).

Value-Centeredness

We noticed that, the midwives’ adherence to values has a strong role in promoting and ensuring quality of midwifery care. Participants stated that preserving values by midwifery personnel is key to achieving professional goals and increasing client satisfaction.

“Everyone in our profession must have the “helping” spirit, which is a must-have requirement for any midwife. Otherwise, she can never have a professional behavior in stressful conditions” (P.3, 28 yr., W.E. 5).

Cultural-Educational Issues

Participants in this study acknowledged that professional care is dependent on several factors, one of the most important of which is the staffs’ culture. Referring to the fact that ethical beliefs are influenced by family environment and applying these beliefs in society can affect various aspects of care, they considered these factors to be very important.

“Basically, we cannot ignore family education and the environment in which we live. The performance of people in any environment emanates from these factors, and manifests itself in the professional environment” (P.2, 39 yr., W.E. 16).

“Each person has been taught the stuff that can be seen in his/her work environment. Therefore, we see more desirable performance in people who have a higher family culture” (P.9, 26 yr., W.E. 3).

Professional Attachment

The participants introduced professional attachment as one of the key aspects of quality care. They stated that professional attachment creates a meaningful and profound feeling in people, causing them to provide quality care.

“One of our colleagues really loves her job in such way that, we see how she stays beside her patient with positive feeling. She is professional, principled, and kind and stays with the mother until her infant is born. This is why we always see the best care provided by her” (P.6, 35 yr., W.E. 11).

“It is very important to be interested in the profession. Sometimes a person comes to work with disinterest and a need or a habit, not an interest. If you are not interested, you don’t try to improve yourself. I think the interested and motivated people try to improve themselves” (P.2, 39 yr., W.E. 16).

Theme 2: Professional-Organizational factors

The midwives who participated in this study pointed to a number of professional-organizational factors that are in place to ensure optimum midwifery care. This theme consisted of 6 subthemes, including professional characteristics, patient characteristics, personal-professional welfare, and professional empowerment system, value-centered culture of the organization, and organizational monitoring and evaluation.

Professional Characteristics

Participants in this study referred to various professional factors that affect the quality of care. They pointed to the high workload, occupational background, and numerous responsibilities as important factors that undermine the relationship between a midwife and a mother, lead to fatigue and burnout of the midwife and ultimately, negatively affect different aspects of quality care.

“The numerous responsibilities and consecutive working shifts, long working hours, lack of appropriate equipment, and the high fatigue affect us so much that we sometimes behave badly with patients.” (P.9, 26 yr., W.E. 3).

“Our work is heavy. There are lots of legal and moral responsibilities. These responsibilities and the distrust of some physicians and mothers towards midwives cause job burnout. I’m just thinking about the end of my shift... Often, these professional issues have a negative impact on my performance.” (P.15, 30 yr., W.E. 4).

Patient Characteristics

The participants in this study referred to the patient characteristics, such as culture, socio-economic status, level of education, and awareness about their rights in the provision of professional and quality care, as factors that affect quality of care. Below are some of these experiences:

“Sometimes, if we analyze a bad behavior and unethical care of a midwife, we see that the client herself has caused this behavior. Non-cooperation, inappropriate behaviors with midwife, being rude to the midwife, using a tense tone of voice, and others are some of these behaviors. Well, no matter how good and considerate a midwife is, she may not be able to behave properly all the time” (P.10, 49yr., W.E. 28).

“What I found in the work was that the patient’s awareness of her rights has a profound effect on the behavior of others. When the patient is unaware of her own rights, when she thinks that everything else that others do is okay, it can lead to decrease in work commitment and ethical and professional behavior” (P.9, 26 yr., W.E. 3).

Individual-Professional Welfare

According to the participants in this study, another individual factor influencing the formation of professional commitment is individual welfare. They referred to the level of income, quality of professional life, and professional satisfaction as factors that affect the provision of quality care.

“In my opinion, the quality of life of the midwives can play an important role in their practice and performance. When you constantly deal with professional challenges, it degrades your quality of life and this affects the quality of care you provide” (P.12, 44 yr., W.E. 20).

“I’m not happy with my job. It’s true that these things shouldn’t have a negative effect on my work, but if feel a kind of compulsion in my work that affects my performance” (P.10, 49 yr., W.E. 28).

Professional Empowerment System

Many participants in this study referred to the professional empowerment system as one of the main prerequisites for understanding the dimensions and the importance of high quality midwifery care, adding that, development of training programs and professional standards along with providing role models can be a powerful tool in ensuring the quality of care.

“We must have in-service training programs so that we can always improve ourselves... I think, there are lots of scientific and ethical standards that we must follow” (P.3, 28 yr., W.E. 5).

“I think it’s good for the authorities to come up with a set of ethical standards, and constantly remind them to staff. These standards certainly have an effect on people’s behavior... We can see their effect over time” (P.7, 41yr., W.E. 17).

Value-Centered Culture of the Organization

According to the participants in this study, the value-centered culture of the organization refers to the commitment, support and purposefulness of managers, authorities, and organizations that are very important in professional performance. Value-centeredness is considered as one of the pillars of professional midwifery care. It also emphasizes on the value-based culture of the organization.

“The performance of authorities and their commitment is a model for us. It affects our behavior significantly. When we do not get support from the organization, it may indirectly influence our behavior in the workplace and with patients” (P.4, 37 yr., W.E. 15).

“The environment of the organization is really important. When no one is paying attention to what we want, I can’t work as well as I should. Since they have no commitment, they can’t expect commitment from us” (P.7, 41 yr., W.E. 17).

Organizational Monitoring and Evaluation

From the viewpoint of the participants in this study, the principled assessment of performance and motivating the workforce will increase the level of professionalism, job satisfaction and ultimately, the effectiveness and quality of midwife’s performance.

“The organization must monitor and supervise the performance of its personnel; an objective supervision... When there is no monitoring or principled supervision, the punishment and encouragement is useless... That’s why our motivation for the principled performance decreases” (P.7, 41 yr., W.E. 17).

Discussion

Increasing advances in medical science and technology as well as socio-economic status of people, along with increasing knowledge and awareness have led to significant development in the provision of services, and midwifery services are no exception.¹⁵ Although improving the outcomes of maternal health depends on improving the quality of midwifery care, efforts to improve the quality of midwifery care are not effective without knowing related factors. The findings of this study point to the individual and organizational-professional factors as the main factors that affect the quality of midwifery care.

Individual Factors

Based on the findings of this study, individual factors are among the important factors that affect the quality of midwifery care. The first subclass of individual factors extracted from the data was personal efficacy. Participants referred to the theoretical knowledge and professional skills as the most important bases of quality care, and highlighted the importance of scientific reasoning along with the skill-centeredness as the foundation of quality performance. Based on the literature review, provision of services using expert knowledge,^16-19 professional standards,^20,21 and practical skills,^16,17,21,22 which represent the competence of individual in the cognitive and communicative fields, are among the most important requirements for quality care. Studies show that professional and individual experiences are effective factors in professional attitudes that are reflected in professional performance of the individual.²³ The results of this study showed that professional excellence, which results from professional attachment, can be one of the effective factors that ensure quality care. In this regard, researchers have stated that one’s identity and attachment to his profession is among the characteristics that are expected from each member of the profession in order to ensure the quality of care.^16,24-26 Studies show that the balance between personal and professional life, personality traits, quality of life, stress and depression^24,27are among individual factors that affect the provision of quality care.

Professional-Organizational Factors

The role of professional- organizational factors in ensuring quality care was highlighted by many of the participants in this study. They believed that one of the effective factors in the formation of quality care is professional empowerment. In this regard, the result of a study showed that, the weakness of midwifery education system and lack of sufficient professional rules and regulations are among the most important factors that prevent midwives from delivery optimal professional performance.²⁸ On the one hand, according to the results of studies, the organizational monitoring and evaluation that are manifested in punishment and reward systems can play an effective role in the principled and professional performance of midwives.^23,29 Participants in this study also highlighted the role of individual welfare in providing quality care, which is in line with the results of other researchers.^30-32 In this regard, Filby et al in a study described the salary as one of the important issues in the quality of care, because by affecting the motivation, self-esteem and satisfaction of people, it can influence the midwives’ professional performance.²⁸

The participants referred to some of the features of midwifery profession that can make a midwife unable to provide high quality care. This topic has been discussed by many scholars.^28,33,34 Researchers have stated that stressful conditions could prevent a midwife from providing high quality care. In the literature, numerous responsibilities and high workload, which were also mentioned by many of the participants in this study, are among the factors that affect the quality of care. Researchers have pointed to work stress and long shifts as factors that lead to excessive fatigue. By referring to the disturbance in circadian rhythms caused by sleep deprivation, the researchers have also highlighted the role of professional characteristics in quality care.^29,33 They have argued that fatigue and professional pressure can make people mentally vulnerable and prevent them from providing committed care.^28,29 From the researchers’ point of view, higher work pressure is associated with a higher mortality rate, as well as patients and personnel’s dissatisfaction,^29,30 which impair the provision of quality care.³¹Referring to professional challenges and interpersonal conflicts, Bedwell describes them as the inhibitors of scientific and principled care.³⁴

The present study had several limitations that need to be mentioned. The results of this study are limited to the factors that affect the quality of midwifery care in Iranian culture. Therefore, further studies are needed before generalizing the findings of this study. Although this study investigated the experiences of Iranian midwives, the limited number of participants in this study, which is one of the characteristics of all qualitative studies, is another weakness of this study. In addition, this study has only been conducted from the perspective of midwives, which can bias the results in favor of midwives.

This study examined the quality of midwifery care from the perspectives of Iranian midwives. The result of this study showed that high quality care is not formed by itself and many factors are involved in its formation. How to increase and promote quality of care is a topic that still needs deeper investigation. Therefore, future studies are recommended to examine the factors that affect quality of care in different populations.

Conclusion

The quality of midwifery care was investigated in this study from the perspectives of Iranian midwives. Midwives’ viewpoints indicated that provision of high quality midwifery care requires a broad range of prerequisites. This clearly points to the areas that need to be prioritized in order to improve the quality of midwifery care. Global strategies to reduce prenatal mortality and morbidity are focused on the quality of care, and this is not achieved by the investment of governments in midwifery and women’s education, but recognizing the factors that affect quality care. Taking these factors into account in policy making and planning is one of the most important issues that need to be considered. The results of this study can help managers and policymakers of midwifery care in Iran to take necessary actions. Changing midwives’ attitudes towards care, improving their skills, enhancing patient education, making efforts to ensure safe delivery of care are among measures that can be taken to improve quality of midwifery care.

Acknowledgments

This article is part of a Ph.D. thesis on reproductive health at Tehran University of Medical Sciences. The authors would like to thank the Vice Chancellor for Research of Tehran University of Medical Sciences who supported this research. The authors would also like to thank all of the participants who shared their information with the researchers.

Authors’ Contribution

Conceptualization: Zohreh Khakbazan, Abbas Ebadi, Mehrnaz Geranmyeh, Zohre Momenimovahed.

Data curation: Zohreh Khakbazan, Abbas Ebadi, Zohre Momenimovahed.

Formal Analysis: Zohreh Khakbazan, Abbas Ebadi, Mehrnaz Geranmyeh, Zohre Momenimovahed.

Funding acquisition: Zohreh Khakbazan.

Investigation: Zohreh Khakbazan, Abbas Ebadi, Mehrnaz Geranmyeh, Zohre Momenimovahed.

Methodology: Zohreh Khakbazan, Abbas Ebadi, Mehrnaz Geranmyeh.

Project administration: Zohreh Khakbazan, Abbas Ebadi.

Resources: Zohreh Khakbazan, Abbas Ebadi, Mehrnaz Geranmyeh, Zohre Momenimovahed.

Software: Zohreh Khakbazan, Zohre Momenimovahed.

Supervision: Zohreh Khakbazan, Abbas Ebadi, Mehrnaz Geranmyeh.

Validation: Zohreh Khakbazan, Abbas Ebadi, Mehrnaz Geranmyeh, Zohre Momenimovahed.

Visualization: Zohreh Khakbazan, Abbas Ebadi, Mehrnaz Geranmyeh, Zohre Momenimovahed.

Writing – original draft: Zohre Momenimovahed.

Writing – review & editing: Zohreh Khakbazan, Abbas Ebadi, Mehrnaz Geranmyeh.

COI-statement

None.

Data Accessibility

The findings of this study will be available upon request from the corresponding author.

Ethical Approval

This study was approved by the Ethics Committee of Tehran Medical University with the number: IR.TUMS.FNM.REC.1396.3234.

Funding

This work was supported by Tehran University of Medical Sciences (grant number: 9321151003).

Research Highlights

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