Women's empowerment is an issue of concern at the global level, which was given special attention in the Millennium Development Goals (1). Women's empowerment is also the fifth goal of the Sustainable Development Goals, which seeks to eliminate discrimination and violence against women, recognize and value domestic work without wages and provide universal access to reproductive and sexual health rights and services. It also encourages using technology in order to provide information and empower women, ensuring the effective presence of women in managerial, political and economic levels, and creating transformation to ensure equality in women's access to rights and economic resources (2). Considering the main role of women in family health, it is justified to pay attention to empowering women and the factors affecting it in different societies (3).
Empowerment is a complex concept and refers to the development and evolution of people's skills, which leads to the improvement of individuals, family, as well as social potential and growth (4). According to the definition of the World Health Organization, empowerment is a personal and social process in which people understand their role and responsibility for their health and participate in achieving and maintaining their health by using the knowledge and skills provided by health service providers (5). From another point of view, empowerment is a set of psychological characteristics, the most important of which is having the opportunity and possibility to make decisions (6), which increases self-confidence, self-efficacy, and the level of control over life (7). It can be said that empowerment is a concept with different interpretations and meanings, which is formed, in a social context; hence, the level of achieving women's empowerment is considered one of the indicators of the societies' progress (8). Health service providers, especially midwives, can play an important role in empowering women (9). The woman-midwife relationship is a vital vessel for providing care and trust, and empowering women (10).
Around the world, about two million midwives are providing health services, especially services related to sexual and reproductive health and rights (11). According to the United Nations Population Fund, midwives can prevent up to two-thirds of maternal and neonatal deaths. They can also meet up to 87% of all reproductive and sexual health needs in communities (12). Midwives are the primary providers of a wide range of services including pregnancy, labor, delivery and postpartum care, family planning services, and screening for diseases such as breast and cervical cancers. In addition, midwives can empower women by correctly evaluating and improving women's sexual health and providing sexual health services such as appropriate sexual counseling. They also play a prominent role in defending women and girls and asserting their rights and needs, especially in areas deprived of facilities and in areas where fertility has been heavily medicalized (11-14). Midwives work alongside women and, by taking into account the cultural and social contexts of their society; they support women's rights to make decisions about the care provided and empower women to express issues that affect their health and that of their families (15).
Despite international efforts towards empowerment, women and girls around the world are still exposed to the harms caused by gender inequality and the neglect of their rights (2). Empowering women is still considered a necessity. On the other hand, midwives can be very helpful in women’s empowerment due to the close and vital midwife-woman relationship and the scope of services provided by midwives to women. For this purpose, it is necessary to properly understand the role of midwives in empowering women.
To the best of our knowledge, no study has reviewed the role of midwives in empowering women. As aforementioned, midwives can have a significant impact on empowering women, so this review was conducted to identify the role of midwives in empowering women based on the available evidence.
Materials and Methods
This narrative review was conducted based on the six steps of the Scale for Assessment of Narrative Review Articles (SANRA) including 1. Justification of the article's importance, 2. Statement of aims 3. Description of the literature search, 4. Referencing, 5. Scientific reasoning and, 6. Appropriate presentation of the data (16).
In order to access articles on the role of midwives in women's empowerment, databases including Web of Science, Scopus, PubMed, PsycInfo, and Cochrane library were searched by two authors, independently, without a time limit up to September 1st, 2022 using keywords of female empowerment, empowerment, empowerment of women, midwife, and midwifery. Also, Persian databases of IranMedex, SID, and Magiran were searched with Persian keywords. References of included articles were also searched manually.
The inclusion criteria were full articles in English and Farsi languages, focused on the role of midwives in empowering women. Case reports, letters to the editor and short communications were excluded from the review cycle.
775 articles were found by the initial search. After removing duplicated articles, 287 titles and abstracts were assessed for inclusion criteria. 38 articles met the inclusion criteria, of which nine articles were removed based on exclusion criteria. 29 articles were included in this study. The study selection process based on the PRISMA flowchart 2020 (17) is shown in Figure 1.
The full text of 29 included studies was reviewed and data were extracted by two authors working together. In cases of disagreement between the two researchers, two senior and experienced researchers would review the articles and made the final decision. Extracted data including the first author's name, year of publication, country of origin, and empowerment area were tabulated (Table 1). In regards to heterogeneity in the included studies, quantitative synthesis was avoided, and findings and conclusions were formed based on a qualitative synthesis.
During the process of this study, ethical considerations related to conducting a review study including the accuracy in the evaluation process, participation of all authors in the review process, clarifying the role of authors and sources of financial support of the study, avoiding bias in selection, exclusion or interpretation of the results obtained from the evaluated articles, correct citation of articles and avoiding plagiarism, as well as refraining from creating data (18) were considered.
775 articles were found by the initial search. After removing 488 duplicated articles, 287 titles and abstracts were assessed for inclusion criteria. 249 records did not meet inclusion criteria and 38 articles met the inclusion criteria, of which nine articles (six conference abstract, two short communications and one editorial) were removed based on the exclusion criteria. 29 articles were included in this study, of which 14 (48%) articles were published during the past five years. Articles were from various countries, with different cultural and socio-economic backgrounds (Table 1).
Nine articles were from Europe (19-27), six from the Middle East (14, 28-32), four from East and South Asia (33-36), four from Oceania (37-40), two from Africa (2, 41), and four articles from North and Central America (42-54).
Two main categories "reproductive and sexual health" and "gender-based discrimination and violence" were identified as areas in which midwives can play their role in empowering women (Table 2).
Empowerment of reproductive and sexual health
This category includes all the care and services that midwives provide to empower women during pregnancy, childbirth, postpartum, breastfeeding, and family planning. Undoubtedly, teaching and counseling women about pregnancy, labor, childbirth,breastfeeding, and family planning are one of the main roles of midwives (10, 22, 28-30, 33, 38, 40, 45-46).
To access all mothers, midwives should effectively use technology in the expanding field of sexual and reproductive health services (31,33).
Midwives should inform women about their rights in health centers and existing laws to protect mothers and children (10, 24, 27-28, 3031, 38). They should strengthen mothers' self-confidence and self-efficacy by establishing effective and positive communication with women and their family members (21, 22, 24, 30, 33, 34) and involve women and mothers in all stages of care during labor and delivery, in other words, midwives should provide woman-centered care (21, 38, 40, 42, 43). Midwives strengthen women's self-confidence by constant presence and responding to women's' psycho-emotional needs by creating an effective woman-midwife relationship through encouragement, empathy, guidance, and support in all stages of pregnancy, childbirth, postpartum, breastfeeding and family planning (22, 24, 27, 28, 40, 42, 45, 47).
The World Health Organization (2018) has also emphasized on improving the quality of interactions between women and midwives by different approaches including; maintaining respect and dignity of women, providing essential information and emotional support, observing ethical principles, attention to feelings, respecting women's choices and preferences, promoting autonomy, respecting women's privacy, eliminating abuse, discrimination, and neglect, providing a safe and continuous care, protecting confidentiality and obtaining women's consent before performing any procedures (48, 49). Studies also point to the importance of providing team services and continuum of care (30, 34, 40).
In terms of postpartum care and breastfeeding, the World Health Organization (2022) recommends that all mothers during the first 24 hours after delivery, in addition to receiving health services, receive adequate training and counseling on how to care for the baby, importance of early and exclusive breastfeeding and solutions for common problems in breastfeeding (50). Midwives play a vital role in maintaining and promoting breastfeeding through teaching and reminding mothers of the importance of breastfeeding, supporting the continuation of breastfeeding, and helping mothers to improve breastfeeding practices (9).
In the field of sexual health care and services, midwives help women express their sexual problems by creating a safe and initiative environment by asking questions about sexual issues and providing counseling, leading to the removal of taboos and the sense of shame and concern related to talking about sexual needs among women, especially young women (14,19). Midwives can also help increase women's ability of self-care, performing safe sex and reducing the risk of sexually transmitted diseases by providing information and consultation, especially among the women with high-risk, such as substance abusers (32). Family planning services are also a part of midwifery care and all women should receive high-quality counseling about family planning (51). Midwives significantly play an active role in changing attitudes and improving women's knowledge in their decision to have children or use family planning services (51). Midwives can also help empower women in sexual health through sexual education (52).
Midwives should identify destructive and harmful social norms in the field of reproductive and sexual health and try to deal with these beliefs using culturally sensitive approaches (36, 41). In addition, midwifes can empower adolescent girls by providing sexual and reproductive health services to them using youth-friendly approaches (12). Another important role of a midwife is to recognize and pay special attention to vulnerable women and mothers, such as those living in remote areas, mothers with low socio-economic status, or mothers suffering from substance abuse (2, 36, 45). In this regard, midwives can play an effective role by using community-oriented approaches, effective presence in society, facilitating relationships and changing the attitudes of community leaders, and mobilizing people in the field of pregnancy/birth care (2, 36).
Empowerment against gender-based discrimination and violence
This category includes all actions, which midwives can take in order to combat gender-based violence and discrimination; these actions include dealing with domestic violence and any harmful practices caused by wrong cultural beliefs, such as female genital mutilation, mandatory virginity examination, or hymen reconstruction.
In this regard, midwives should use both cultural-sensitive and gender-sensitive approaches (19-20, 25) to encourage women to achieve independence, individuality, and ownership of their bodies and express their thoughts and needs (19, 20). Midwives can protect women against violence by increasing women's awareness and knowledge about the physical and psychological complications and consequences of gender-based violence and the existing rights and protective laws that can support women (2, 12, 19, 25). By providing a safe and trustful environment, midwives can create conditions in which women can disclose violence and discrimination more easily, and receive appropriate support, and care (53). Midwives should always carry out routine and explicit screening of all pregnant women for exposure to domestic violence and provide care and support for victims of domestic violence as a principle in routine pregnancy care (12, 23, 39, 44). In addition, midwives help empower women by identifying and preventing the medicalization of gender-based violence and discrimination in the healthcare system, such as performing female genital mutilation or mandatory virginity examination (2, 19, 20).
The current review shows synthesis of evidence regarding the role of midwives in empowering women in the two fields of reproductive and sexual health and combating gender-based discrimination and violence.
According to the findings of the present study, the role of midwives in empowering women is very important during pregnancy, childbirth, postpartum, breastfeeding, and family planning. The findings of various studies have also pointed out the importance of the role of midwives in pregnancy, childbirth, and postpartum care as one of the main areas of empowerment (54-57). Another finding of the present study was emphasizing the role of midwives in empowering women using women-centered approaches (38) (42). Numerous studies have shown the impact and importance of empowering women through creating a suitable and professional relationship between midwives and pregnant women by sharing information and experiences to improve the labor and delivery process along with creating a safe and enjoyable experience such as facilitating a better mother-infant bonding experience (54, 58-65).
One of the ways to empower women is to transfer "power" to pregnant women by facilitating informed decision-making in medical matters during labor and delivery, including the mode of delivery, and delivery environment, by creating an atmosphere in accordance with mothers' decisions and encouraging men to participate and accompany their wives in childbirth (54, 66-68). Midwives play a role in empowering women in the postpartum period by providing information and involving family members and spouses in caring for women and newborns, all of which emphasize the role of midwifery in empowering women (54, 69-71). This approach to women empowerment results from practicing modern midwifery, which is the combination of evidence-based care in midwifery science and its relationship with positive and constructivist approaches.
The findings of the present study emphasize the importance of supporting breastfeeding women by midwives in order to empower women. Consistent with these findings, the results of a systematic review showed that midwives value the education and support of breastfeeding as an important part of their role (72). However, midwives face many barriers, such as lack of time to implement evidence-based breastfeeding guidelines, which can negatively affect breastfeeding support (72, 73). The results of the systematic review and meta-analysis conducted by Schmied et al. (2011) showed that women are not always satisfied with the breastfeeding support received from midwives in the first weeks after childbirth. Dissatisfaction with the support is more observed in the hospital than in the primary health care setting; because midwives perform fragmented care for women in the postpartum period, which can lead to early cessation of breastfeeding (74). The results of a systematic review by McFadden et al. (2017) showed that midwives' support for breastfeeding women affects the duration of exclusive breastfeeding and also the quality and quantity of breastfeeding (75).
The results of the qualitative study by RM et al. (2019) showed that midwives often feel a conflict between what the mother wants and what is useful for breastfeeding. Despite respecting the mother's choices and limitations, they are worried about mothers not continuing breastfeeding, so they put a special emphasis on informing mothers about the consequences of decisions related to breastfeeding (73). In general, midwives play an important role in increasing mothers' self-confidence and inducing a sense of empowerment in breastfeeding, an important part of which is related to motivating mothers to breastfeed; of course, a midwife's personal experience of breastfeeding also has a significant impact on her supportive role (72,73). Considering the differences in the approaches to breastfeeding support by midwives, as well as the expectations of breastfeeding mothers, it is important that midwives adjust their support to the mother's needs (72).
Another priority for midwives is empowering women in the field of family planning (76). The findings of this study showed that midwives considered access to family planning services as a human right and an essential factor in maintaining and promoting reproductive health for women. Midwives should always strive to promote the right to informed choice and maintain a neutral attitude during family planning counseling. One of the reasons for the failure of midwives in empowering women in family planning is that women consider family planning as less important and they do not pay attention to this need due to cultural poverty and unfavorable social conditions (77). Other reasons for the failure of empowering women in family planning include decentralized public health infrastructure (78), lack of comprehensive family planning training by midwives (79-82), and differences in moral and political views on family planning among midwives (76). Social, cultural, and religious factors are important challenges in society (80, 83-84). According to the midwives' point of view, superstitious and incorrect beliefs, the role of influential members of society in strengthening these beliefs, and men's views on contraceptive methods are obstacles that cannot be easily eliminated with education, but fundamental changes are necessary (76).
Regarding discrimination and sexual violence, the findings of the present study showed that empowering women against violence is part of the protective and active role of midwives. Protecting women, empathizing with them, and being sensitive to their needs and demands in cases of violence against women are part of the midwife's role to empower women (85), due to the profound effects of violence against women on public health and well-being, there is a need to strengthen this role of midwives in health systems (86). The midwife's interest to be active in the fight against gender-based violence can lead to their self-efficacy and improvement in skills needed to empower women against gender violence (87).
From the midwives' point of view, training in the field of preventing violence against women increases their sense of responsibility and reduces perceived barriers to respond to violence against women, and as a result, it can help to improve women's empowerment against violence. However, evidence suggests that training alone does not lead to lasting changes in midwives' performance. Although some midwives received training in the field of domestic and sexual violence, some of them cited reasons such as lack of time, preference to preserve the client's privacy in counseling, and the existence of complex and undefined organizational issues as the reason not to participate in empowering women against gender violence. In addition, approaches to interact with these obstacles in promoting women's empowerment are not fully understood. For example, despite emphasizing the central role of midwives in identifying and managing domestic violence during pregnancy and the necessity of screening pregnant women (88, 89), some midwives are reluctant to do so, because these midwives consider domestic violence as a private issue and have a negative attitude towards it (53).
Regarding combating violence against women, investments such as training women and access and improvement of support services for women exposed to violence must be provided (86, 90-93). A critical factor in addition to training midwives in the field of gender-based violence is to understand how they manage and participate in broader processes including creating social changes at the local or national levels for empowering women (86). In general, it can be said that midwives can play these roles only when they change their own knowledge, awareness, and attitude toward violence against women (2, 23, 44). Because the midwives' lack of knowledge, skills, and self-confidence regarding exposure, management, and care for victims of domestic violence is one of the reasons for them not recognizing and taking effective action in this field (23, 44, 94).
Although the findings of this study indicate the importance of the active role of midwives in the fight against female genital mutilation, according to midwives, major gaps in knowledge and skills in providing services and care regarding female genital mutilation are the main reasons for the failure to control and prevent it (95-97). The professional role and responsibilities of midwives in combating FGM are unclear in many areas, and midwives are largely unaware of the legal issues regarding it. The results of a study using the survey method showed that more than half of the midwives did not know that practicing FGM was an illegal act (98).
In contrast, the results of another study showed that although the majority of midwives knew that FGM was illegal, they were unable to provide details of the law prohibiting it (99).
The results of two other studies reported that midwives' uncertainty about how to interact with women from cultures where FGM is accepted as a tradition; is a barrier to providing quality care to these women (97) and removing this barrier requires comprehensive and more specialized training. However, the results of a study showed that FGM is not included in the midwifery curriculum (100). Another solution to increase the awareness of midwives about FGM is to share existing laws, policies, and guidelines through existing networks in the health and legal systems in a collaborative and continuous manner. There are also challenges related to the collection and recording of data on women who have been circumcised, which is necessary for midwives to change the policies of recording this information, increase the awareness of service providers, and improve and upgrade databases (101-102).
Empowering women in the sexual field is another aspect of women's empowerment, and despite the important role of midwives in assessing sexual health and providing counseling to women in this field (103), the approaches to benefit from midwives in empowering women in sexual health have not yet been identified and realized (13, 104). Paying attention to women's sexuality in healthcare programs is one of the key elements of promoting and improving sexual health. Availability, appropriateness, and affordability of sexual health care are imperative. Despite more attention to sexual health in recent years, attention to other health priorities still leads to the neglect of empowerment in the sexual health field. Some midwives believe that sexual health is not as important as other medical problems (103, 105-106). Some midwives think that women do not want to initiate discussions about sexual issues and that sexual health assessment is not a priority for women (13). If midwives encourage women to express their sexual concerns, they will make women feel comfortable in expressing their sexual issues (107, 108). Despite the high prevalence of sexual problems, there is a reluctance from midwives to provide sexual health care. The World Health Organization confirms that sexual health information and promotion is an integral part of health care services to be provided by midwives. Therefore, they should develop their competence and overcome the obstacles, which prevent them from playing an active and effective role in sexual health care (13, 106).
It should be noted that there are some challenges and obstacles in the midwives' path to empower women, among which we can mention the lack of knowledge, skills, motivation, and sufficient self-confidence due to the disproportionate educational content provided in the academic education course (109). Many midwives work in unsafe, remote, isolated, and resource-limited healthcare settings where they have to overcome daily challenges (110). In addition to the high burden of responsibility and heavy workload, midwives are faced with low income, little or no work leave, and a lack of financial or non-financial incentives, such as housing allowance, commuting, access to continuous education, or professional development opportunities (109, 113). Another problem is the lack of access to the results of evidence-based interventions to improve the knowledge and skills of midwives in the field of empowerment (114). Therefore, it is necessary for governments and organizations to take steps towards empowering women, and create strategies to ensure greater empowerment, better support, and more importantly, to maintain the midwifery profession dynamic in the long term. In addition, it seems necessary to create and strengthen the midwifery associations as a basic infrastructure for the proper functioning of the midwifery profession in order to empower women.
This research has determined the areas and roles in which midwives can actively empower women. Midwives and more comprehensively the healthcare system, knowing these areas and roles, can improve the performance of midwives and provide approaches to remove obstacles in empowering women by midwives. One of the strengths of this research is that, based on our knowledge, it is the first study that reviewed the role of midwives in empowering women, using geographically dispersed studies. The limitation of the present study is language limitations in searching for sources and the failure to evaluate the quality of the articles included in the study due to the diversity of the methodology. Researchers can improve midwives' role in empowering women by identifying the factors and conditions affecting their performance, as well as designing and implementing appropriate interventions and programs.
Based on the findings of the present study, it can be concluded that although midwives play an effective role in providing reproductive and sexual health and combating discrimination and gender-based violence in order to empower women, they still face many challenges in each of the mentioned areas of women's empowerment. Two sub-areas of female genital mutilation and domestic violence have the most challenges compared to other sub-areas of women's empowerment. Lack of knowledge, lack of clear laws and regulations, and lack of legal protection for midwives are among the professional challenges faced by midwives. Therefore, it is necessary for governments, societies, and international organizations to pay attention to the role of midwives and the importance of identifying and solving the challenges they face in empowering women.
We are grateful for the support of Student Research Committee, Mashhad University of Medical Sciences, Mashhad, Iran as well as all the authors whose published works were reviewed in this research.
Conflicts of interest
Authors declared no conflicts of interest.
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