Evaluating Midwives Communication Skills from the Perspective of Parturient Women Attending to Hospitals for Delivery

Document Type: Original Research Article

Authors

1 MSc of Midwifery, Faculty of Nursing and Midwifery, Ghaen School of Nursing and Midwifery, Birjand University of Medical Sciences, Birjand, Iran

2 Assistant professor, Department of midwifery, Faculty of nursing and midwifery, Mashhad University of Medical Science, Mashhad, Iran

3 Assistant Professor, Department of Clinical Psychology, Faculty of Educational Sciences, Ferdowsi University of Mashhad, Mashhad, Iran

4 Professor, Health Sciences Research Center, Departement of Biostatistics and Epidemiology, School of Health , Mashhad University of Medical Sciences, Mashhad, Iran

Abstract

Background & aim: Communication is a fundamental human need. Medical students and healthcare professionals must be attuned to the needs of patients using effective communication skills. With regards to medical training, currently the focus is on theoretical matters and communication skills are taken for granted. This problem has caused miscommunication with patients referred to teaching hospitals. We conducted this study to assess communication skills of midwives from the perspective of parturient women.
Methods: In this descriptive study, we evaluated 50 midwives working in maternity wards of Ghaem, Imam Reza, Omolbanin, and Hasheminejad hospitals in Mashhad, Iran. Three parturient women were selected per one midwife in a maternity ward. The parturient women participating in this study were in labor, delivery, admission or postpartum stages and completed the Interpersonal Communication Skills inventory by interview. To analyze the data, descriptive statistics, t-test, ANOVA, and Pearson product-moment correlation were performed, using SPSS 16.
Results: The mean scores of communication behaviors of midwives with parturient in delivery, admission, and postpartum stages were 92.61±10.81, 93.31±10.59, and 94.19±8.26, respectively. Between the previous delivery of parturient, with communication behavior of midwives in the stage of admiss­ion or post-partum (P=0.015) and satisfaction of pregnancy with communication behavior of midwife in labor stage (P<0.04), there was satisfactory significant.
Conclusion: From the perspective of parturient women, the midwives’ communication was average. Today, the midwives’ communication skills are of optimal importance in health system development plan. Thus, implementing training programs on communication skills while utilizing modern methods and emphasizing on specific educational needs of midwives, as well as continuing to monitor their communication behaviors are recommended.

Keywords


Introduction


Communication is of paramount importance, to the extent that some scholars claim that individual problems, disorders, and advancements root in their communication. Effective communication is a combination of several fields including art, education, anthropology, and behavioral skills (1).

The quality of care should improve for women for delivery, and enhancement of midwives’ communication skills is of key importance to promote health of expecting mothers (2). Among healthcare providers, midwives are expected to communicate with a diverse group of individuals, indicating the significance of this profession. Midwives provide counseling and training for not only pregnant women, but also for their entire family. They are also responsible for maintaining and enhancing the health of mothers and their infants and providing information for the patients. Experienced midwives should have effective communication with mothers and their families in order to achieve the aforementioned goals (3).

Studies performed in maternity wards showed that appropriate communication could be the main determining factor for satisfaction of mothers with the provided care (4). An effective relationship between midwives and mothers can result in enhanced satisfaction, lowered blood pressure, anxiety, and pain, increased sense of security, mutual trust, and interaction, making an informed decision, reduced fear of vaginal birth, enhanced sense of assurance, better control of the delivery process, and more importantly, improved health (5).

 However, over the past decades, reports demonstrated that communication in the field of healthcare is defective (6). Miscommunication is one of the most common causes of complications in patients. Complications in medical practices, along with inherent performance limitations accentuate the importance of standard communicative tools for clinical personnel (6).

Results of studies conducted to evaluate the performance of healthcare providers during delivery demonstrated that patient complications are related to factors such as human resources, as well as communicative and leadership factors. Hence, organizational commitment, executive leadership, secure environment, and high-commu-nication quality during delivery are essential (7, 8).

Ideal midwifery care is essential to gaining communicative skills, preparation practice, and professional development. Optimal commu-nication facilitates the interaction between midwife and patient (9). Parturient women mainly expect midwives to communicate, answer their questions, and have the self-confidence to reassure patients (10).

Given these factors, it could be concluded that communication is paramount to midwifery care. Despite the intense need for effective communication with patients under special conditions of delivery, awareness, attitudes, and skills of healthcare providers, specifically midwives, are not up to par (10).

Delivery is one of the most important events in a woman’s life, in which mental and physical stress is unavoidable. This event is recognized with deep mental, social, and emotional aspects that remain in the mother’s consciousness forever; therefore, unpleasant events during delivery can have a negative long-term mental effect (11, 12).

During parturition, mothers need attention, understanding, empathy, guidance, and support in addition to clinical care (13). However, nowadays dependence on technology in obstetric care has led to ignoring humanitarian aspects of care provision.

Compassion and reassurance leaves mothers with a pleasant and positive experience (14). Accordingly, midwives should have empathy, be attentive, respect other’s beliefs, and provide a comfortable environment, assuring that the patient can proceed with trust and confidence (15, 16).

Relevant studies show that a pivotal factor for a positive delivery experience is comprehensive support of midwives. On the other hand, weak communication skills could potentially have deleterious effects on physical, mental, social, and economical aspects of healthcare (17).

Studies performed in maternal wards over the past years have proved that the majority of midwives experience burnout, the main reason for which might be the anxiety of interpersonal relationships with patients. One way to overcome burnout in midwives is providing training on appropriate and effective communication with parturient women under varying conditions of delivery (18).

Gagnon (1996) found that supportive actions only consume 6% of midwives’ time in a working shift (13). Enkin (1999) once referred to the effect of technology on taking communicative and supportive measures in maternity wards by mentioning that increased use of technology does not explain the lack of supportive actions (1).

A study conducted by Taghizade et al. (2006) showed that the rates of verbal and nonverbal communicative behaviors used by midwives were 68% and 54%, respectively, indicating an unfavorable level. On the other hand, patient satisfaction rates with verbal and nonverbal communication behaviors of midwives were 50% and 48.4%, respectively, demonstrating an indirect correlation with the level of midwives communicative skills (18).

Vafayi quoted from Bowends and Enderson explaining the five environmental stress factors that lead to mental issues in mothers during delivery. These factors are communicative problems between midwives and their patients due to cultural and language differences, physical position, activity restrictions, regulations of the hospital, and loneliness (14).

Results obtained by Park et al. (2005) reflected that burnout in medical personnel can adversely affect the quality and quantity of communication (15). Moreover, in a study conducted by Vafayi (2012), job difficulties and lack of incentives were other important barriers reported by the majority of midwives. Consequently, the majority of communicative barriers between midwives and parturient women could be overcome through improving communicative skills and modifying midwives’ attitudes towards their patients (14). Although the main focus in disease treatment is on developments in medicine and critical care innovation, improvement of non-technological skills is largely ignored. Appropriate commu-nicative skills help with disease recovery, returning to the normal psychological state, and promoting family satisfaction.

Therefore, communication is one of the most fundamental skills that should not be ignored. Appropriate communicative skills can be regarded as one of the best preventive measures against malpractice (18). Given the importance of communication, problems of communication with parturient women, and the large number of patients referring to university hospitals to receive different medical treatments, we aimed to carry out this study to evaluate midwives’ communicative behaviors from the perspective of their patients.

 

Materials and Methods

In this descriptive survey, 50 midwives working in maternity wards of Ghaem, Imam Reza, Omolbanin, and Hasheminejad hospitals of Mashhad, Iran, were randomly selected. The inclusion criteria for the midwives were having at least one year of clinical working experience in maternity wards, working in various shifts, giving informed consent, and not having the experience of participating in training programs or workshops related to communicative skills for at least six months prior to the study. Furthermore, the inclusion criteria for parturient women were being over 18 years old and speaking fluent Farsi.

The exclusion criteria were preference for caesarean section, familiarity with the personnel, and previous history of hospital admission due to the other reasons than pregnancy. For the purpose of sampling, teaching hospitals of Mashhad University of Medical Sciences (4 hospitals) and the number of midwives working in maternity wards of each hospital (n=130 midwives) were listed. Out of all the midwives, 53 cases met the inclusion criteria.

The sample size was determined for midwives based on a similar study, in which patient satisfaction with communicative skills of midwives was assessed using the following formula (6).

 

After obtaining approval of the Ethics Committee of the university and permission from educational supervisors of the three selected hospitals, three parturient women were selected per each midwife. The patients in delivery, admission, or postpartum stages filled out the Interpersonal Communication Skills inventory through interview with the author after transferring the parturient to the postpartum unit during the first 12 hours.

To analyze the data, descriptive statistics, t-test, ANOVA, and Pearson product-moment correlation were performed using SPSS 16. Evaluation of midwives’ communicative behaviors from admission to post-partum stages was not done separately. Considering the relative stability of physical and mental conditions of mothers in the postpartum stage compared to the labor and delivery stages, the two stages were evaluated together. Before completing the inventory, written informed consent was obtained from the subjects (midwives and patients) and the study process was explained to them.

Out of the 53 midwives who consented to participate in the study, one case withdrew from the study and one midwife was excluded due to planned vacation during the study.

Interpersonal Communication Skills invent-tory is a researcher-made questionnaire, which was designed using Calgary Cambridge Guide and Standard Interpersonal Communication Skill Inventory, and through studying the latest references, relevant articles, while having consultations with supervisors and advisors. Content and face validity of the scale was established. Cronbach’s alpha reliability of the inventory was calculated to be 0.85. The inventory contains 40 items regarding different situations of midwife communication with parturient women in maternity wards. Items are rated using a 5-point scale including the ability to receive and understand verbal and nonverbal messages, regulation of emotions by parturient, active listening skills, midwife’s attitude toward the communication process, and communication confidence. The minimum and maximum possible scores obtained from the inventory were 0 and 160, respectively.

The scores were categorized in three communicative behavior groups including weak (0-53), moderate (54-106), and good (107-160). The collected data was entered into SPSS, version 16. To analyze the data, descriptive statistics, t-test, one-way ANOVA, and Pearson product-moment correlation were used.

 

Results

The mean age of the midwives was 39.21±9.58 years, and their mean working experience was 16.12±8.61 years (range of 1-29 years). In total, 15 midwives (30%) were employed in Ghaem Hospital, 11 (22%) in Imam Reza Hospital, 11 (22%) in Omolbanin Hospital, and 13 (26%) in Shahid Hashemi Nejad Hospital. The majority of the midwives (97.9%) had Master’s degree; 41 (83.0%) were married, 31 (61.7%) were moderately satisfied with the workplace, 26 (52.2%) were moderately satisfied with their job, 26 (51.39%) were officially employed, 35 (70.2%) had experienced natural vaginal delivery, and 20 (39.4%) had experienced natural delivery twice. Statistical tests showed the correlation between some individual characteristics of midwives and their communicative behaviors (Table 1).

Mean age of the parturients was 25.40±5.53 years (age range: 15-42 years). Furthermore, 48 (32%) parturients had secondary school degree, 130 (87%) were housewives, 82 (55%) experienced delivering, 85 (57%) experienced natural delivery, 82 (55%) were satisfied with their current pregnancy, and 90 (60%) women were satisfied with life.

In order to analyze the correlation between individual characteristics and communicative behaviors of midwives t-test, One-way ANOVA, and Pearson product-moment correlation were

 

 

Table 1. Comparison of the mean score of midwives’ communication skills based on demographic characteristics

Stage

Variable

Midwife communicative behavior

Statistical test

P-value

 

SD±mean

 

 

Labor

Midwife satisfaction with previous delivery or deliveries

Yes

101.78±7.54

t=4.32

P=0.023

 

No

92.09±11.87

 

Delivery

Experience of vaginal delivery

Yes

101.21±5.59

T=-2.89

P=0.037

 

No

94.00±11.17

 

Marital status

Single

20.43±1234

ANOVA=3.78

P=0.033

 

Married

6.93±11.42

 

Divorced

21.44±3.31

 

Job satisfaction

Very low

10.28±9.74

ANOVA=4.83

P=0.031

 

Low

6.18±9.74

 

Moderate

9.87±13.71

 

High

5.86±10.84

 

Postpartum

Type of midwife's previous delivery

Natural

102.57±7.31

t=1.38

P=0.05

 

Caesarean section

93.13±9.75

 

                 

 

Table 2. Comparison between pregnant women’s characteristics and midwives communicative behaviors from the parturient women’s perspective

Variable

Midwives’ communicative behavior

P-value

Test

SD±mean

Age

22-34

96.10±12.60

0.98

Mann-Whitney Fisher's exact test

34-46

106.61±6.68

46-58

99.63±10.18

22-34

106.10±6.60

Educational level

Illiterate

90.36±9.78

0.21

Secondary

93.39±6.08

Diploma and post diploma

94.49±8.68

BA and higher

93.54±9.56

Job

Housewife

92.09±11.87

0.45

Fisher's exact test

Employee

107.91±13.10

Self-employed

95.65±6.94

other

92.54±9.45

Living place

rural

103.58±9.55

0.80

Chi-square test

urban

98.69±9.55

Number of deliveries

1

94.00±11.17

0.10

Mann-Whitney

2

103.17±12.43

3

98.17±7.85

4

104.00±7.19

Delivery experience

Yes

92.09±11.87

0.73

Chi-Square test

No

101.78±7.54

 

 

Previous delivery satisfaction

Yes

93.13±9.75

0.38

Fisher's exact test

No

101.33±5.43

Current pregnancy satisfaction

Yes

101.54±10.19

0.29

Fisher's exact test

No

100.87±5.08

Life satisfaction

Yes

94.00±11.17

0.39

Fisher's exact test

No

100.67±8.21

 

 

 

used. Among the individual characteristics, the type of previous delivery was significantly correlated with communicative behaviors of midwives in the postpartum and admission stages (P=0.015), and satisfaction from pregnancy was significantly associated with the midwives’ communicative behaviors in the labor stage (P=0.040; Table 2).

There was a correlation between midwives’ communicative behaviors and the number of previous deliveries of the midwife in the labor (P=0.036, r=0.80), delivery (P=0.028, r=0.87), and postpartum stages (P=0.05, r=0.61). Statistical tests showed a significant corre-lation between other characteristics of midwives (delivery satisfaction, previous delivery experience, marital status, job satisfaction, and previous delivery type) and their communicative behaviors with patients (Table 1).

The score of midwives’ communicative behaviors during the postpartum stage was higher than the other two other stages followed by the delivery and labor stages; nevertheless, ANOVA test showed no significant correlation (Table 3).

The majority of the parturients evaluated midwives’ communicative behaviors at a moderate level, and statistical tests did not show any significant differences (Table 4).

 

 

Table 3. The mean score of midwives’ communicative behaviors from the perspective of patients in labor, delivery, and postpartum stages

Variable

Labor

Delivery

Postpartum

Total

 

 

N

SD±mean

N

SD±mean

N

SD±mean

N

SD±mean

ANOVA

Midwife communicative behavior

50

92.61±10.81

50

93.31±10.59

50

94.19±8.26

50

93.36±9.88

P=0.54

                         

Table 4. Frequency distribution of communicative behaviors

Variable

Midwife communicative behavior from patients’ perspective

Weak

Moderate

Good

N

%

N

%

N

%

Labor

14

15.1

66

73.6

10

11.3

Delivery

10

11.4

73

81.1

7

7.5

Postpartum

10

11.2

71

79.4

9

9.4

Total

11

12.56

70

78.03

9

9.4

Statistical test P=0.34

 

 

 

Discussion

This study was conducted to evaluate communicative behaviors of midwives’ working at Mashhad teaching hospitals in 2014. In this study, there was a significant correlation between some individual characteristics of midwives, such as experience of natural vaginal delivery, satisfaction with previous deliveries, marital status, job satisfaction, and age, with the score of communicative behavior. This was inconsistent with findings of Barati and Taghizadeh regarding marital status (15, 18-22).

Findings of Barati (2011) showed that communicative skills level of medical students was not acceptable. There was a significant difference among them in terms of mean score of communicative skills based on gender, marital status, educational level, and field. Married students of midwifery, paramedical students, and those holding a PhD degree had higher level of communicative skills than others (15). However, in terms of age and work experience, results of this study are not consistent with findings of Taghizadeh, as well as Hooker and Kurtz (11-13). The significant association of age and work experience with midwives’ communicative behavior can be due to the differences in the study population and setting. In those studies, midwives employed in health centers were the sample, while in the present study, midwives employed in maternity wards were selected.

There was no significant correlation between personal variables of patients such as job, number of prior deliveries, previous delivery satisfaction, and current pregnancy satisfaction, and midwives’ communicative behaviors. Alidoosti et al. (18) conducted a study on women’s satisfaction with the postpartum stage and maternity equipment. In that study, no significant correlation was noted between demographic variables of patients and their satisfaction with midwifery services. This finding was inconsistent with our results in terms of educational level. The results obtained from the current study are inconsistent with findings of Ma'soomi et al. (2016). In that study, there was no significant correlation between the educational level and satisfaction of pregnant women referred to the maternity ward of Imam Reza Hospital in Hamadan, Iran (22). However, in the study by Ma'soomi, there was a significant correlation between number of previous pregnancies and satisfaction in patients. Therefore, higher number of previous pregnancies led to an increase in satisfaction with midwifery services. This finding is not consistent with our obtained results (22).

The mean score of midwives’ communicative behavior from the perspective of patients was 92.61±10.81, 94.19±8.26, and 93.31±10.59 in the labor, delivery, and postpartum stages, indicating a moderate level. This finding was consistent with findings of Alidoosti et al. In that study, mean score of mothers' satisfaction by midwives’ services, including behavior during labor, skill and experience during delivery, emotional support to reduce anxiety, and availability during emergencies, was 55.8±5.10, which was moderate (18). In the study of Navabi and Asri (2002), nursing students’ communication performance with patients was moderate (9).

Kurtz believes that although experience can positively affect communication skills, it should not be the only way to acquire this skill (11).

In the study of Taghizadeh, the level of pregnant women’s satisfaction with midwives’ performance in the labor stage in terms of emotional and moral support along with providing them information was significantly lower than in the delivery and postpartum stages. Stressful and painful labor and the need for more support in this stage could potentially be the reason for midwives’ lower score of communicative skills (19).

In study by Khodakarami, 74% of women participated in the study reported adequate levels of emotional, physical, structural, and information support of midwives during the labor and delivery stages. Furthermore, they had considerable satisfaction with the quality of labor and delivery care, which is not congruent with the findings of the present study (20).

In the study by Taghizadeh, 2.5% of women were satisfied with midwives’ communicative behavior and reported a positive attitude toward midwives on admission. The study was conducted on midwives employed in health centers, whereas the present study was conducted on midwives employed in maternity wards (12).

In another study conducted by Katebi (2015) to determine the level of communicative skills of midwives, their communicative skills did not correlate with age, marital status, work experience, interest in job, life satisfaction, and experience (16). In the study of Taghizadeh et al., no significant correlation was observed between the majority of the midwives individual characteristics and the level of their communication skills. The findings of that study were inconsistent with those of the present study in this regard (12).

In Barati study (2012), the findings were not consistent with ours in terms of the effect of marital status on the level of communicative skills, this discrepancy might be due to the fact that more than 90% of the students participated in that study were single. Conversely, in the present study, more than 90% of midwives were married (15).

Despite selecting our subjects from all teaching hospitals affiliated to Mashhad University of Medical Sciences, the limitation of this was its small sample size. Different physical and psychological conditions of midwives while being evaluated could be another limitation in this study that was could not be controlled. The strength of this study was evaluating communicative behaviors of midwives in all stages of birth (admission, labor, delivery, and postpartum), which is a comprehensive evalu-ation of midwives’ communicative skills under different working and mental conditions.

 

Conclusion

The midwives’ communicative skills were in a moderate level and a significant correlation was observed between the mean score of communicative behavior and experience, satisfaction, marital status, job satisfaction, and age in the studied midwives. In this regard, married midwives with experience of natural delivery and high job satisfaction showed favorable communicative behavior behaviors. Comparison of the present results with those of previous studies on communicative performance of other medical personnel (general practitioners, specialists, surgeons, and nurses) shows that defective communicative behavior is not simply limited to midwives.

 As communication plays an important role in midwifery services, low communication skills of midwives can lead to dissatisfaction with the care provided. Thus, further studies should be conducted designing training programs for midwives on communication skills before entering the maternity wards and providing medical care. They should practice such behaviors and skills during their training with instructors. Furthermore, in-service training courses should be used to inform the midwives of the modern educational techniques and methods.

 

Acknowledgements

The present study derived from an MSc thesis project (code: 922887) approved on October 2014 by the Research Council of Mashhad University of Medical Sciences. The authors would like to thank Mashhad University of Medical Sciences for their financial support. They also extend their gratitude to educational supervisors as well as the administrators of educational hospitals at Ghaem, Imam Reza, Shahid Hashemi Nejad, and Omolbanin. They also express appreciation to all the research and development departments that were involved with this study.

 

Conflicts of interest

None declared.

  1. Hauck Y, Lewis L, Kuliukas L, Butt J, Wood J. Graduate midwives' perception of their preparation and support in using evidence to advocate for women's choice: a Western Australian study. Nurse Education in Practice. 2016; 16(11):305–311.
  2. Takács L, Seidlerová JM, Šulová L, Hoskovcová SH. Social psychological predictors of satisfaction with intrapartum and postpartum care–what matters to women in Czech maternity hospitals? Open Medicine. 2015; 10(4):119-127.
  3. Rostami H, Golchin M, Mirzaei A. Evaluation of communication skills of nurses from hospitalized patients' perspective. Journal of Urmia Nursing & Midwifery Faculty. 2012; 10(1):135-143 (Persian).
  4. Vaghee S, Yavari M. The effect of communication skills training on the quality of nursing care of patients. Evidence Based Care. 2013; 2(4):37-46 (Persian).
  5. Pourfarzad Z, Vanaki Z, Memarian R. Effect of situational leadership in clinical education on communication competency of nursing students. Journal of Hayat. 2009; 15(2):47-59 (Persian).
  6. Sehati F, Najarzadeh M. Impact of continuing midwifery care during labor on length of delivery. Nursing and Midwifery Journal of Tabriz. 2008; 15(7):13-18 (Persian).

2.     Lyndon A, Johnson MC, Bingham D, Napolitano PG, Joseph G, Maxfield DG, et al. Transforming communication and safety culture in intrapartum care: a multi-organization blueprint. Journal of Obstetric, Gynecologic & Neonatal Nursing. 2015; 44(3):341-349.

3.     Bashour HN, Kanaan M, Kharouf MH, Abdulsalam AA, Tabaa MA, Cheikha SA. The effect of training doctors in communication skills on women’s satisfaction with doctor–woman relationship during labor and delivery: a stepped wedge cluster randomized trial in Damascus. BMJ Open. 2013; 3(8):e002674.

4.     Bashiri K. Quality of labor support during labor. Journal of Patient Safety & Quality Improvement. 2014; 2(1):58-64.

10. Yaghmaei F, Haruoni MD, Mottaghi B. Measurement of “behavior” or “intention to behaviours” in MS these of Factulty of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences. Journal of Shahid Beheshti School of Nursing & Midwifery. 2009; 19(65):44-48 (Persian).

11. Maars B. Effective communication skills for helpful jobs (Consultant, worker, psychologic, psychiatrist, lawers, management…). Trans: Saffarinia M, Davoodi P, Hasanzadeh P. Tehran: Argman; 2010 (Persian).

12. Taghizadeh ZI, Razaiepour A, Mehran AB, Alimardani Z. Usage of communication skills by midwives and it s relation to client satisfaction. Journal of Hayat. 2007; 12(4):47-55 (Persian).

13. Baker DP, Salas E, King H, Battles J, Barach P. The role of teamwork in professional education of physicians:current status and assessment recommendation. The Joint Commission Journal of Quality and Patient Safety. 2005; 31(4):185-202.

14. Vafaei Z, Javadnoori M, Najar N, Latifi SM. Barriers of effective communication between midwives and parturient women in hospitals of Khuzestan Province, Iran, 2012. The Iranian Journal of Obstetrics, Gynecology and Infertility. 2013; 15(40):10-5 (Persian).

15. Barati M, Moeini B, Samavati A, Salehi O. Assessment of communication skills level among medical college students: verbal, listening, and feedback skills. Journal of Urmia Nursing and Midwifery Faculty. 2012; 10(2):10-20 (Persian).

16. Kadivzadeh T, Katebi MS, Sepehri Shamloo Z, Essmaily H. Assessment of midwives’ communication skills at the maternity wards of teaching hospitals in Mashhad in 2014. Journal of Midwifery and Reproductive Health. 2015; 3(3):394-400 (Persian).

17. Attarha M, Keshavarz Z, Bakhtiari M, Jamilian M. The outcome of midwife-mother relationship in delivery room: a qualitative content analysis. Health. 2016; 8(4):336.

18. Alidosti M, Tahmasebi M, Raeisi M. Evaluating the women’s satisfaction of Hajar hospital services after the delivery. Journal of Clinical Nursing and Midwifery. 2013; 2(1):1-8 (Persian).

19. Naghizadeh S, Sehhati Shafaei F, Barzanje Atri S, Ebrahimi H, Ebrahimpour M. Assessment and comparison of mother’s satisfaction of maternal care givers during hospitalization in teaching and non-teaching hospitals of Tabriz city. The Iranian Journal of Obstetrics, Gynecology and Infertility. 2013; 15(38):24-31.

20. Khodakarami N, Jan Nesari S. Evaluating mothers’ awareness about pregnant women’s rights. Iranian Journal of Medical Ethics and History of Medicine. 2009; 2(1):51-58 (Persian).

21. Bayrami R, Pezeshki MZ, Ebrahimi M. A study of the influence of implementing patients’ rights workshop for midwives on the women’s view point about parturient rights respect. Journal of Urmia Nursing and Midwifery Faculty. 2007; 5(3):93-101.

22. Masoumi SZ, Niazi Z, Bakht R, Roshanaii G. The effect of education of pregnant women's bill of rights to midwives, on satisfaction of the women referred to labor unit of Imam Reza hospital. Scientific Journal of Hamadan Nursing and Midwifery Faculty. 2016; 24(1):58-67 (Persian).