The Role of Midwife from the Perspective of Midwives, Obstetricians and Women: A Qualitative Study

Introduction

Midwife literally means "with woman". According to the International Confederation of Midwives (1), a midwife as a responsible and professional person provides a wide range of services to women, including care, support and counseling during pregnancy, childbirth and postpartum. A midwife also performs delivers at her own risk and care for newborn. The ICM (2011) introduces midwives as key caregivers of women during childbirth process (1-2).

A midwife is a person who, regularly admitted to a midwifery educational program, duly recognized in the country in which it is located, successfully completed the prescribed course of studies in midwifery and acquired the qualifications to be registered and/or legally licensed to practice midwifery (3). Midwifery is defined as “skilled, knowledgeable and compassionate care for childbearing women, newborn infants and families across the continuum from pre-pregnancy, pregnancy, birth, postpartum and early weeks of life”. The evidence shows us that midwifery plays a “vital” role, and when provided by educated, trained, regulated, and licensed midwives, is associated with improved quality of care and rapid and sustained reductions in maternal and newborn mortality (3).

Midwives in Iran can provide midwifery services in public and private hospitals along with other members of the health care team. They can also provide midwifery services independently in private midwifery clinics. Midwives are able to supervise, care for, educate and advise women and girls during puberty, marriage, fertility and menopause. They also provide services to women during and after pregnancy, conduct vaginal deliveries with their own responsibility, and provide care for infants and children under six years of age. These services include prevention, consultation, family planning, detection of abnormalities in mother, infant and child, medical emergencies, diagnosis and treatment of common genital diseases, screening of gynecological cancers, implementation of emergency midwifery procedures in the absence of obstetrician, and refer clients who require specialized services to medical centers (4).

Various studies in some countries, such as Mexico, have shown that relying solely on the physicians to provide midwifery care may not be as cost-effective for the society as the health system expects (5). Researchers believe that employing health care providers other than physicians can reduce unnecessary referrals (5).  On the other hand, in countries such as Australia, where mothers have a strong desire to receive ongoing midwifery care by midwives, this has led to better and more effective midwife-mother communication (6). Provision of this type of care has also been effective and important for the spouses of pregnant women (7).

The negative attitude of health care policy makers in the Iranian health care system towards the capabilities of midwives has led to a decrease in the authority and job motivation of midwives. This issue has even affected the attitude of midwives towards their job and has caused dissatisfaction among them (8-11), which has reduced their motivation towards their profession, especially in the economic and social context of today’s society, causing a decrease in effective communication between midwife and client (12). This can seriously lead to a decline in the health of women, family and society. In this regard, a study in Nigeria showed that the negative attitude of midwives can also affect women's choice of childbirth (13).

In Iran, the status of midwifery is unclear and the professional position of midwives is not properly defined. Despite midwives’ important role in the provision of healthcare for mothers and child, In Iran, this profession has not only not experienced career development but has also faced many problems in career options.. In Iran's hospitals, despite the fact that vaginal delivery is part of midwives' duties, this responsibility has been taken away from them and given to the obstetricians and gynecologists (14-15).

If the capabilities of midwives are ignored, maternal and neonatal health and subsequently the health of society will face problems; therefore, measures should be taken to understand the current position of the midwifery profession and make it clear to the general public. Therefore, since the views of women and health care providers providing midwifery services regarding the role of midwives in the health of women and society can indicate the real status of midwifery profession in Iranian society, conducting a qualitative study on recognizing the position of midwives in Iranian society may remove communication barriers between midwives and families. Therefore, due to the dearth of study in this field, the present study was conducted to clarify the perceptions and experiences of midwives, obstetricians and women about the role of midwives.

Materials and Methods

This qualitative study was carried out in Shahrekord city in Iran. Data was collected from February 1, 2018, until June 15, 2018. This study conducted using qualitative content analysis approach, which is the subjective interpretation of the content of texts data , which is done through systematic process of coding and identification of themes or patterns (16). Content analysis is based on inductive reasoning and has three conventional, directed and summative approaches. It is a systematic coding and categorizing approach that can be used to explore a large amount of textual data in order to determine communication patterns and trends (17). In this study, the conventional approach was used because the aim was to describe the role of midwives through their communication with women and other professional staff including obstetricians in an less explored context.

The study samples included women referred to gynecologist or midwife for reproductive health care (like pre-conception care, pregnancy and postpartum care, women's health care such as cancer screening.). Midwifery service providers such as gynecologists, midwives, obstetric residents, and midwifery students in the fourth semester onwards also entered in the study as participants. Purposeful sampling was used at the beginning of the study and continued until data saturation considering the maximum variation in age, educational degree, years of work experince and employment status. At first, the researcher obtained permission from the University’s Deputy for Research and attended the health centers, hospitals and women's clinics affiliated to Shahrekord University of Medical Sciences and then, identified eligible women and qualified midwives who had consent to participate in the study. After obtaining written consent from the participants, the researcher also explained the study objectives and methods to the samples. Then, a contact number was obtained from the participants in order to coordinate an interview session in a safe and comfortable place.

Inclusion criteria were: a midwifery student in the fourth semester (or higher), a working midwife, a resident of obstetric and gynecology, a gynecologist, or woman receiving midwifery services, living in Shahrekord city, consent to participate in the study and interview, Persian language, having a good expressive power and relatively good physical and mental health. Those who did not want to continue participating in the study were excluded from the study.

The research samples included 4 midwifery students, 6 employed midwives, 1 gynecologist assistant, 1 gynecologist, 1 responsible midwife for the midwives working in the health center, 1 responsible midwife for the midwives in a medical center and 7 women receiving midwifery services.  During the data collection process, 23 interviews were conducted in a semi-structured manner (two participants were re-interviewed for better understanding). Since some of the participants were providers of midwifery services, the interviews were conducted at their workplaces, and for the participants who received midwifery services, interviews were conducted in the hospital, health center, or any place that was more convenient for the participants. Each interview lasted 20-70 minutes. Then, the interview text was carefully transcribed verbatim, and the coding process was performed by repeatedly reviewing the interview text.

Data collection was accomplished through semi- structured face-to-face interview  using interview guide. Interview questions included preliminary, main, probing and concluding questions. The followings are some of the questions used in the interviews:

1- In your opinion, who is a midwife?

2- Please tell me about the areas that midwives could provide services?

Data analysis was performed simultaneously with data collection, using conventional content analysis method and constant comparison of data. According to Graneheim & Landman (2004), the following steps were used to analyze the collected data:

1. Transcribing the interview texts verbatim and reading them frequently to get a general insight.
2. Dividing the text into compressed semantic units.
3. Summarizing compressed semantic units and giving them specific codes.
4. Sorting codes into subcategories and categories based on their similarities and differences.
5. Developing themes as the internal content of the text (18).

Data were analyzed using MAXQDA-2018 software. During the data collection and analysis, any points related to the research data in the researcher's mind were written down by the researcher in a  research  journal and were used to complete the subsequent interviews and carry out data analysis.

According to Guba and Lincoln, examining the scientific validity of qualitative studies includes four criteria: credibility, transferability, dependability, and confirmability (19). The researcher tried to increase the validity of the findings by taking various measures, such as establishing appropriate interaction with the participants during the study, being immersed in the data, selecting samples with maximum variation, and coding the interview texts with the help of research team members. In order to increase the reliability of the data, the researcher used peer check method and also provided a part of the encoded interview texts to a number of participants to get their confirmation. On the other hand, in order to confirmability, a number of interviews with their written texts were randomly selected and sent to a number of researchers familiar with the qualitative method, but were not part of the study, and their comments were considered.

Results

In this study, 80 pregnant women who were candidates for elective C/S were included. Based on the data presented in Table 1, the average age of the participants in the control and intervention Demographic data of the participants is given in Table 1.

Preliminary data analysis led to the creation of 401 codes. The researcher then carried out repeated review of the codes, merged similar codes and deleted unrelated items, and finally using content analysis method, three main categories emerged from the data, including 1) "uncertain identity" including five subcategories of midwife as a maternity care provider, a gynecologist assistant, a healthcare team member, an undecided healthcare professional, a professional with overlapped duties 2) "community-based educator" including three subcategories of women and mothers health promoters, community’s fertility promoters, patient respondents, as well as 3) "compassionate and empowered supporter," including three subcategories of women’s constant companion, underpaid supporter and unsupported advocate (Table 2).

Category 1: Uncertain identity

The lack of a clear identity for the midwifery profession in Iran was one of the most frequently mentioned concepts by participants. Hence, the category of uncertain identity was formed, including five subcategories of midwife as a maternity care provider, a gynecologist assistant, a healthcare team member, an undecided health professional, a professional with overlapped duties.

1-1: Midwife as maternity care provider

According to the instructions of the Iranian Ministry of Health, the midwifery education system is such that a person trained in this profession, i.e. taking care of pregnant women and mothers, can fully master and provide services. Therefore, a midwife is specialized in her profession and can provide midwifery services independently.

Regarding the general description of midwifery job, a participant, who was also a member of the midwifery faculty, said:

A woman who graduates from Iranian universities with a bachelor's degree in midwifery is able to do a variety of tasks, including childbirth, pregnancy and family planning, infant care, etc. In puberty and menopause that have their own special care, a midwife can deliver a wide range of services (Midwifery faculty member).

Another participant stated in this regard:

In fact, a midwife is a person who helps mothers in all kinds of ways during pregnancy until childbirth, the whole delivery process, especially when it is physiological delivery, after delivery, and postpartum for a few weeks to a few months. ..It means that a woman is in relation with her own midwife throughout her life, especially during fertility age and even menopause, so I can say that a midwife has a wide range of duties and responsibilities (Midwifery student no 3).

In Iran, a midwife can set up an office after obtaining a bachelor's degree in midwifery and work in her office privately and independently, so one of the midwifery students mentioned this as one of the benefits of midwifery profession and said:

Midwifery is somewhat more independent than other fields of medical sciences. For example, a midwife can set up her own office when she gets bachelor's or master's degree, and even when she gets her doctorate she can set up a clinic (Midwifery student no 1).

some participants explained the scope of midwife's duties based on her workplace :

If a midwife works in an office, clinic or other medical center, she can do some of the tasks such as preventing and treating gynecological diseases, sexually transmitted and infectious diseases, and family planning. A midwife can play a major role in diagnosing gynecological diseases (Midwifery student no 3).

Midwives can prescribe and interpret women's health screening tests, but they are not able to treat very severe and resistant infections or gynecological cancers. It is the responsibility of gynecologists (woman no 7).

A midwife can easily provide some health care to patient in the health centers, and pregnant women are first visited by a midwife. A midwife knows when to send a pregnant woman to screening test, what a pregnant woman should eat and what supplements she needs. A midwife also knows what education should be given to a pregnant woman.  Physician also sees the pregnant woman, but periodically, and it is the midwife who mostly deals with the pregnant woman. In fact, it is the midwife who writes the health records of pregnant women (Resident of Obstetrics and Gynecology).

Regarding midwives who work as accompanying midwives, this participant said:

Some accompanying midwives are trained to perform good maneuvers, which have been medically proven to be effective in the delivery process and labor pain (Resident of Obstetrics and Gynecology).

1-2: A gynecologist assistant

One of the terms frequently mentioned in the statements of participants was the working situation of midwives in the referral and university hospitals in large cities. The participants acknowledged that the midwives working in these places have an assistant role for gynecologist. In this regard, one of the midwives said:

Midwives who work in centers where gynecologists and residents of Obstetrics work are practically just like an assistant. This is while midwives learn a wide range of skills in their 4-years education, including physiological delivery and distinguishing between normal and abnormal deliveries. However, we actually see that midwives in referral centers only provide practice record, do nursing procedures and get non stress test. In fact, the midwives are not allowed to do their role in the process of natural  labor and childbirth and work only as gynecological assistants (Midwifery faculty member).

Even one of the women receiving midwifery services believed that midwives could only diagnose the disease and refer patients to physician. In this regard she stated:

I think midwife cannot prescribe medicine for women. Well, physicians are more specialized. The midwife can only refer women to physician(Woman no 2).

Another participant that she is a gynecologists had a similar opinion and said:

I view a midwife as my companion and helper. I am a specialist who is not able to deliver care alone. The best person who can help me with pregnancy and childbirth is a midwife (Gynecologists).

1-3: A healthcare team member

Some participants identified midwives as members of a specialized team that provides health services. In this regard,  one of the participant who had a positive view of midwives' activities in the community said:

A midwife is a specialized nurse. She is one category higher than a nurse. In addition to nursing measures such as resuscitation, medication administration, venipuncture, dressings, injections and so on, a midwife knows about midwifery care, such as NST, vaginal examination, examination of patient contractions and diagnosis of emergencies (Gynecologists).

1-4: An Undecided healthcare professional

It is not a secret for almost all people, whether they are midwives or care receiver of midwifery services that midwives have a good professional knowledge, but the issue that was repeatedly raised in the interviews was the current uncertainty of midwives' position in the health system. In the past, due to the shortage of gynecologists, midwives were trained extensively throughout the country to provide midwifery services with full authority, but now midwives are almost isolated in large and well-equipped cities. In this regard, one of the midwifery students participating in this study said:

A midwife in Iran is a responsible person who has a stressful job, but at the same time her position in health system is not clear. Currently, midwives are between physicians and nurses. Sometimes they are called nurse or doctor, while they are midwive. This disappoint me, because we are not physician and we do not like to be called physician. This is a shame. (Midwifery studend no 2).

Another participant who was in charge of midwives working in a health center, in response to the question: "What is the current position of midwives in Iran?” stated:

They have no position. I really do not know the position of midwife at the national, ministerial or social levels. It has no place anywhere (Head of Midwifes in Health Centers no 2).

1-5: A professional with overlapped duties

The patients' referral system has not been properly implemented in Iran; on the other hand, most of the midwives’ duties can be performed by gynecologists. This has caused a serious and disturbing overlapping between the job description of midwives and gynecologists. One of the midwifery student participating in this study said in this regard:

Compared to a midwife, a gynecologist can perform all the tasks that a midwife has been trained to do. Midwives are dominated by gynecologists, so if you ask a mother to choose between a midwife and a gynecologist to manage her gynecological problem or help her in childbirth, she often prefers a gynecologist (Midwifery student no 3).

She also believed that in order to improve the professional status of midwives and acknowledge their true status, it is better to prevent the interference of gynecologists in the first-level of midwifery services:

If there was a difference between the duties of a midwife and a specialist and also a clear job description for both, none of them could interfere in other’s duties. This could improve the status of midwives. For example, physiological delivery under supervision of obstetricians is the responsibility of midwives. In this way, a midwife knows her job and no one interferes in her work, but now they do not allow the midwife to do the work she has been trained to do. (Midwifery student no 3).

In general, some women are satisfied with receiving health services from a midwife, but others prefer to receive these services from a person with a higher level of education. These women do not consider the quality of services provided and the degree and specialist title of service provider is more important for them. In fact, one of the issues that have undermined the true status of midwifery profession in Iran is the non-implementation of referral system. Also, interference between the job description of midwives and gynecologists in Iran is another issue that has affected midwives’ status in this country.

Category 2: Community-based educator

Since midwives are at the primary level of healthcare providers in the country's health system, it can be said that midwives are one of the closest providers of health services to women and families. What we learned from the participants' conversations led to the formation of a category "community-based educator" including three subcategories of women and mothers health promoters, community’s fertility promoters, patient respondents.

2-1: Women and mothers’ health Promoter

Since midwifery graduates gain comprehensive and complete information about the health of women, mothers, and children during their university education, and also as they are not as busy as gynecologists, they can easily transfer this information to individuals and promote the health of women and the whole society. One of the midwives participating in this study said:

Women, even if they have a doctorate degree in other fields, are unaware of issues related to their own health or that of their child. This is while the midwife knows these issues well and can easily provide correct information to people in the community (Midwife no 1).

Regarding the importance of midwifery training, another participant said:

A midwife knows how to teach breastfeed, changing nappies, giving bath, hugging babies and burping a newborn to mothers in childbirth preparation classes,. A nurse does not have the information that a midwife has about childbirth and infant care, so a midwife can teach and help mothers in these areas (Midwife no 2).

2-2: Community’s fertility Promoter

Another role of midwives is promoting community’s fertility. Since midwives have a closer relationship with mothers and women in the community, they can play a more prominent role in educating families and improving the reproductive health of individuals.

 Moreover, the development of midwifery activity in the community could cause a significant increase in the number of vaginal deliveries and a sharp reduction in voluntary cesarean sections without medical indication, which in turn improve women's reproductive health and reduce infertility problems in the community. In this regard, an experienced midwife working in a maternity hospital said:

If a midwife performs a virginal delivery, it will affect the statistics of virginal delivery and mothers will leave the maternity ward with pleasant memories. As a midwife, I see that some gynecologists want the mother to give birth safely and have less attention to emotional relationship between mother and birth attendant. I have repeatedly told physicians that giving birth mother is an active, not passive process. Indeed, she has to give birth herself, without us forcing her to do so. (Midwife no 2).

2-3: Patient respondent

Midwives during their education are trained to fully manage the delivery process. They know that childbirth is a gradual process and requires patience. That is why most midwives are very patient. In response to the researcher's question: "What comes to your mind when you hear the word midwife?” one of the participants said:

I think a midwife is someone that I can easily ask any question about me and my child. Midwives know better how to treat patients with respect, most midwives treat patients with respect and feel responsible for the patient's treatment. (Woman no 4)…p m

Category 3: Compassionate and empowered supporter

Women, due to various physiological and pathological reasons, require the effective presence of a knowledgeable and patient health supporter at different stages of their lives. Among all health service providers, midwives are the ones who have both sufficient knowledge and sufficient time to provide the necessary support to women and their families. Therefore, according to what the participants said, the category “compassionate and empowered supporter," including three subcategories of women’s constant companion, underpaid supporter and unsupported advocate was formed.

3-1: Women’s constant companion

Despite all the unfavorable conditions mentioned, midwives in Iran are still passionately providing health services to pregnant women all across the country. They are happy to provide high quality services to pregnant women and mothers. One midwifery student said in this regard:

A midwife is a person who loves and adores a pregnant woman. She strives to reduce the mother's pain and discomfort, whether it is physical or psychological.  She also tries to solve the personal problem of pregnant women. In fact, midwife is a supporter of the mother and her child, and a supporter of life in general, who supports women physically and psychologically (Midwifery student no 1).

In this regard, one of the midwives in charge of a midwifery health center stated:

A midwife is a constant companion of pregnant women, someone who can support women during pregnancy, childbirth and postnatal and accompany them after childbirth. In fact, she is a constant companion of pregnant women. Companion refers to someone who provides support physically and psychologically, is able to communicate with the mother, and also someone that the mother can trust (Head of Midwifes in Health Centers no 1).

3-2: Underpaid supporters

In Iran, some health care disciplines, such as nursing are considered as manual labor and have higher salaries, but despite the high demand for midwives, they, especially those working in maternity hospitals, are not subjected to the manual labor law, which allows higher pay and earlier retirement. Regarding the midwives' low income, one of the midwives working in the hospital said:

Well, everyone works for money. If you work hard but earn less, it is clear that you feel pressure, especially when your work is hard (Midwife no 1).

This is while midwives and gynecologists have completely different incomes to do the same thing:

One of my relatives went to a midwife and a gynecologist for her problem, but received exactly the same treatment. However, the visit fee was extremely different (Midwife no 2).

3-3: Unsupported advocate

This loving supporter works in the Iranian health system without job security or any support from the government. One of the midwives said in this regard:

Now, the midwives' support is very low. They took away some of the powers that midwives used to have. Insurance companies do not sign contracts with midwives. You see, when a midwife prescribes an ultrasound for the patient in her office, the insurance companies do not cover the cost of ultrasound. In fact, the midwife's prescription is not accepted. So, the patient prefers to go to a specialist next time, so that, she can use the insurance to cover the costs. Such problems drive midwives out of the system (Midwife no 1).

Discussion

In the present study, three main categories were extracted from the data analysis, including "uncertain identity", "community-based educator", and "compassionate and empowered supporter".  The category of "uncertain identity" included five subcategories of midwifery care provider, gynecologist assistant, health team member, undecided professional, and overlap in duties. The category of "community-based educator" included three subcategories of women and mothers health promoters, community’s fertility promoters, and patient respondents, and the category of "compassionate and empowered supporter," included three subcategories of female constant companion, underpaid supporter and unsupported supporter.

Most of the participants in the current study did not consider an independent professional identity for the midwives. The impossibility of performing duties according to the job description has caused both providers and recipients of midwifery services to consider unknown identity for midwives. Hansson et al. in their study (2022) showed similar results. The factors such as meaningfulness, adversely high demands, lack of influence and recognition at work, high role conflict and burnout compared to Swedish benchmarks were expressed as the effective factors on midwives' job satisfaction (20). The review by Borrelli’s  (2014) has shown that the characteristics of a good midwife include theoretical knowledge, professional competencies, personal competencies, communication skills and moral values. What the women on labor consider values for midwife include support, choice, controlled emotions, and right information. The meaning of a good midwife may change due to various factors involved in midwifery care, and there is no agreement on what makes a good midwife. In addition, what women consider as values for a good midwife is not clear (21). The findings of study by Borrellishowed that participants did not provide a clear definition of a good midwife. Similarly, the findings of the present study also did not provide an independent identity for midwives from the perspective of service providers and recipients.

Professional identity is defined as the perception of self-professionalism, which is based on attitudes, beliefs, feelings, values, motivations and experiences. Having a positive professional identity, in addition to increasing self-confidence, creating sense of belonging to the profession and establishing interpersonal communication, is the most important factor in creating job satisfaction and the best predictor of job retention. People who have insufficient professional identity and low job satisfaction are more likely to leave the profession. In addition, if professional identity is not realized, the profession itself as well as its legitimacy, independence and public trust will be endangered (22). The evidence shows that in case of lack of professional independence, people will suffer burnout and job satisfaction will also decrease (23). Therefore, policymakers and midwifery officials in Iran should strive to promote the professional and independent identity of midwives. It seems necessary to review the job description of midwives in order to prevent any interference with other professions.

One of the main categories derived in the present study was community-based educator. The participants introduced midwife as a women and mothers health promoters, fertility of community promoters, and patient respondents. Dahlberg et al. (2016) in their study also pointed out the importance of maintaining midwives’ relationship with mothers, especially in the first days of childbirth. They also stated that when a postpartum mother communicates with a midwife referring to her home for visit, she experiences predictability, availability, and self-confidence. Women tend to talk to midwives much easier about their childbirth experience, their role as a mother in the first few days of childbirth and their breastfeeding process. The continuous communication models for midwifery care should be improved, especially to consider the emotional aspects of postpartum period (24).

A qualitative study by Haldors Duttier and Carles Dutther (2011) in Iceland led to the development of an evolutionary theory based on the empowerment of women of childbearing age (25). The professional midwifery care is seen as the main focus of midwifery. A professional midwife who is professionally qualified should always prioritize the safety of women and children and should have professional wisdom and know how to use it. A professional midwife with interpersonal competence has the capacity to create effective communication and positive relationship with women and families. A professional midwife develops herself both individually and professionally, which are two essential prerequisites for true professionalism (25). ICM also believes that midwives respect women and their ability to give birth and promote the health of women and babies (2).

According to the participants’ statements in the current study, midwives are compassionate and capable supporters. The results of the study by Torki et al. (2024) showed that most of the women participating in the study considered midwifery support to be useful and effective throughout all stages of pregnancy, labor, and delivery(26). In a qualitative study by Brown et al. (2009) in Canada, participants identified four key roles for midwives and delivery nurses, including supporter, educator, patient companion, and continuous provider of care (27), which is consistent with the findings of the present study. Byrom and Downe (2008) also conducted a phenomenological study to discover the characteristics of a good leader and midwife, and their results also emphasized on the supportive role of midwives. The participants' experiences and statements about good midwives and leaders as well as poor midwives and leaders led to the emergence of two main categories; "skill competence" and "emotional intelligence". The category of skill competence was related to aspects of midwife’s knowledge, skills and competence and the category of emotional intelligence was related to specific characteristics of midwife's personality. Their study showed that the ability to function consciously, safely and competently is considered a basic need for both clinical midwives and midwifery leaders. Another factor contributed to the development of a good midwife or midwifery leader was the enhancement of emotional capacity (28).

Licorice and Seebold (2008) also conducted a grounded theory study in Australia to investigate the students' experience of competence acquisition and the role of midwifery instructor. Their findings revealed the supportive role of midwives. They showed that students generally recognize the midwifery instructors as helpful or non-helpful. They concluded that a positive relationship between the midwifery instructor and student is a key factor in the success of student's education, and instructors with supportive personality increase the level of students’ learning (29). According to the findings of the mentioned studies and the emphasis on the supportive role of midwives, midwifery officials and policy makers should make policies to highlight this characteristic of midwives and improve their communication skills in various dimensions to promote the professional identity of midwives.

The use of qualitative method for this research was both the source of its strength and weakness. Its strength was the ability to hear people's opinions in different situations. But since the findings of qualitative studies cannot be generalized, it is considered a weakness. Therefore, it is suggested to conduct quantitative studies on a larger and diverse populationsusing the basic findings obtained in this study.

Conclusion

As evidenced by the results of the present study, despite the clear position of the midwifery profession in improving the health and fertility level of society, this position is currently facing problems and has lost its main and key nature in maintaining and improving women’s and family health. The existence of some restrictions to provide midwifery services for midwives, underestimation of midwifery services by health officials and doctors, mostly women's negative view of midwives' ability to provide midwifery services are among the issues that can be effective in the deterioration of midwifery status in the society. Therefore, paying more attention to the midwifery identity as an independent profession and its revival and the revival of the professional authority of midwives is a necessity of the health system. The efficient and capable midwives could be effective in maintaining and promoting the health of the society at a lower cost compared to obstetricians.

Declarations

Acknowledgements

This study is the result of a project (Grant no. 904) approved and financially supported by Deputy of Research, Shahrekord University of Medical Sciences, Sharekord, Iran. We would like to thank the officials of university for their help as well as all the esteemed colleagues, gynecologists, obstetric residents, midwifery tutors, midwifery students and women who shared their experiences with us in this study.

Conflicts of interest

The authors declared no conflicts of interest.

Ethical considerations

Participants were all informed of the objectives and process of the study. Informed consent was obtained from the participants to participate in the research. The participants were assured of the confidentiality of their information. They were informed that their participation is voluntary and that they could withdraw from the study at any time. It was also explained that the data would be used for scientific purposes without using the names of the participants. The Declaration of Helsinki was also observed. 

Code of Ethics

Ethical approval was obtained from the Ethics Committee of Shahrekord University of Medical Sciences, sharekord, Iran (ethics code: IR.SKUMS.REC.1397.107).

Funding

Shahrekord University of Medical Sciences was responsible for the financial support of this project.

Authors’ contributions

ZT and MS planned the study, analyzed the data, interpreted the results and prepared the manuscript. ZT preformed manuscript for submission and was responsible for submitting and its followings up. All authors have read and approved the final version of the manuscript and agreed to be accountable for all aspects of the work.