The marginalisation of midwifery in medicalised pregnancy and childbirth: a qualitative study

In many places across the globe, midwives are the first caregivers of pregnant women and parturient (Sandall et al, 2016). Nonetheless, significant differences exist in the organisation of midwifery services, education and roles (Sandall et al, 2016; Enkin et al, 1995), and pregnant women are often faced with different options that render it difficult to identify the best choice (Enkin et al, 1995; Moghasemi et al, 2018). The midwifery model of care and the medical model follow different approaches to pregnancy care provision and childbirth. These approaches can culminate in a complementary outlook that causes favorable midwife–physician interactions. However, important differences exist between the two models, such as differences in philosophy, interactions between provider and pregnant woman, focus in prenatal care, use of childbirth interventions and other facets of care during labor, and the objectives of care (Rooks, 1999; Bryers and Van Teijlingen, 2010).

In the past four decades, the medical model of care came to dominate perinatal care in low-risk pregnancies and childbirth. Pregnancy and childbirth were defined as high-risk incidents. Under these circumstances, women give birth under physicians' order. Childbirth medicine became the dominant form of the knowledge and midwives became part of it (Henley-Einion, 2003). The medical model can be considered as part of a process of gaining control over the nature (Bryers and Van Teijlingen, 2010). Advances in maternity care and significant reduction in maternal mortality and morbidity, as well as changes in the social and cultural construction of risk in pregnancy and childbirth led to domination of the medical model of care (Wagner, 2001; Bryers and Van Teijlingen, 2010; Alder et al, 2009). This phenomenon is called the medicalisation of pregnancy and childbirth.

According to Conrad, ‘medicalization consists of defining a problem in medical terms, using medical language to describe a problem, adopting a medical framework to understand a problem, or using a medical intervention to treat it’ (Conrad, 1992). When pregnancy and childbirth are conceptualised as high-risk parts of life that endanger the health of women and newborns, being cared for by a physician becomes a necessity (Parry, 2006). Under these circumstances, the role of midwives in the process of pregnancy and childbirth is transformed (Smeenk and ten Have, 2003). Moreover, people's perception toward service providers could also change. They do not consider midwives as a first care provider for pregnant and parturient women (Barker, 1998).

The World Health Organization (WHO) estimates that approximately 15% of all women suffer from serious complications during pregnancy, whose long-term issues can be prevented by timely and professional interventions. That is to say those women need not only trained midwives but also medical services. This argument paved the ground to justify the medicalisation of pregnancy (Johanson et al, 2002).

Iran is a developing country that has made significant advances in healthcare and managed to reduce its rate of maternal mortality (United Nations Children's Fund, 2013; Mobarakabadi et al, 2015). For the last 100 years, Iran has made academic midwifery education available, which consists of a Bachelors, and Masters of midwifery and a PhD program in reproductive health (Hakimi, 2019). Midwives that graduate from university with a Bachelor's degree can legally start their work at hospitals, healthcare centers or private offices. In Iran, the definition of midwifery and its job description are consistent with the International Confederation of Midwives' (2011) definition and description, but the approach of presenting midwifery services is different from countries leading in midwifery care (Moghasemi et al, 2018). A study in Iran showed that midwives perform 35% of all childbirths, while physicians have taken over the remaining 65% (Khodakarami and Jannesari, 2009).

One of the features of the medicalisation of prenatal care in developing countries is that it has become medicalised in large cities, while the services have not yet penetrated the rural areas. This disparity reinforces the notion that childbirth out of hospitals and supervised by midwives should only be performed in places where modern medical practice has not yet penetrated (Wagner, 2001). In Iran, caesarean section accounts for 74.3% of all childbirths in Tehran metropolis (Bahadori et al, 2013), but in some underprivileged areas of the country, such as parts of Sistan and Baluchistan Province, mothers still give birth at home under the supervision of uneducated traditional midwives (Tabatabaie et al, 2012).

In Iran, obstetricians and gynecologists are responsible for the full management of all childbirths, as well as labor and delivery (TorkZahrani, 2008). Even though many low-risk childbirths are performed by midwives, they have limited authority in the management of low-risk pregnancies and childbirth. It appears that midwives have a unique position in medicalised pregnancy and childbirth in the Iranian society that mandates further investigation. This study was conducted to elaborate the perceptions of perinatal care providers and recipients regarding midwifery services.

Methods

Approach

A qualitative content analysis approach was used to achieve the study objectives. This method enabled the researchers to fully immerse in the data and obtain new approaches to and extensive descriptions of the study phenomenon (Hsieh and Shannon, 2005).

Sampling

The participants were selected from Mashhad, the centre of Khorasan Razavi Province in Iran. A total of 15 midwives working in the delivery rooms of hospitals, private offices and healthcare centers, seven obstetricians and 27 pregnant and postpartum women were selected using purposive sampling with maximum diversity in terms of the demographic data, so as to collect an extensive range of data. Of the candidates selected for the study, one midwife and one obstetrician declined the invitation because of their time constraints.

Data collection

Data were collected through in-depth semi-structured interviews between September 2014 and May 2015. The interviews were held at healthcare centers, the private offices of midwives and obstetricians and, occasionally, participants' homes. The interviews lasted between 35 and 80 minutes. They began with an open-ended question: ‘What views and experiences do you have regarding midwifery care?’. Probing questions were then posed in view of participants' responses, such as: ‘Can you elaborate on that?’. All the interviews were recorded and transcribed verbatim, and analysed simultaneously with the data collection. Data collection continued until no new data were obtained; that is, until data saturation was reached (Macnee and McCabe, 2008).

Ethical considerations

This study was part of a PhD dissertation approved by the Ethics Committee of Mashhad University of Medical Sciences (Ethical Approval Code: 511/2944). All the participants signed informed written consent forms and were assured that they could withdraw from the study at any time. All the interviews were recorded, encoded and transcribed anonymously, to maintain the subjects' confidentiality.

Data analysis

Data analysis began concurrently with data collection. The main theme and categories were extracted using the Graneheim and Lundman (2014) method of qualitative content analysis. The entire interviews were taken as the unit of analysis. All the interviews were reviewed several times, for the researcher to get fully immersed in the data and extract the meaning units. The meaning units were then summarised and encoded in the next step. The codes were categorised into subcategories, and subcategories with similar meanings were placed in one category, and the final theme thus emerged from the meanings lying in the categories and connecting them (Graneheim and Lundman, 2004).

Data were analysed with MAXqda (portable 2007, udo Kuckartz, Berlin, Germany). Two members of the research team examined the interviews to improve their trustworthiness and maintain their credibility. Peer debriefing was used to find the similarities and weaknesses of the analyses. Parts of the interview transcripts along with their relevant codes were handed to the participants to be approved or returned for revision, if necessary (member check). The transferability of the data was improved by asking two non-participating midwives to examine the interviews and codes (Polit and Beck, 2009).

Results

A total of 15 midwives, seven obstetricians and 27 pregnant and postpartum women participated in this study. Tables 1 and 2 show the demographic details of the participants. Midwives are indicated by M, obstetricians by O, pregnant women by P and postpartum women by PP.

The main theme that emerged from the analysis of the data was ‘the marginalisation of midwifery in the context of medicalised pregnancy and delivery’. The governance of medicine over the entire process of pregnancy could have been avoided if midwifery was not marginalised, as the main philosophy of midwifery is providing perinatal care for low-risk pregnancies and natural childbirth. Therefore, if this profession had not been degraded in society, medical supervision over low-risk normal pregnancies would not have become possible. The theme of marginalisation of midwifery explains subthemes including ‘unfavorable social context’ for this profession and ‘the disempowerment of midwifery’ in such context. Figure 1 presents the components of this theme.

Figure 1. Themes, subthemes and categories

Unfavorable social context

The study participants reported that as the medical model of care took over society, an unfavorable social context emerged for professional midwifery practices in normal pregnancy, and that the social status of midwives diminishes in such an environment. Participants also reported that the lack of support from supporting organisations further aggravates the unfavorable status of midwifery in the society. As a result, midwives do not have the opportunity to provide perinatal care using the midwifery model of care.

Social-professional degradation of midwifery

The participants reported that the conditions governing midwifery have deteriorated the profession. The failure to support midwives has facilitated the undermining of this profession, which aims to provide care for normal pregnancies. These conditions paved the way for the increased medical supervision of pregnancy. The lack of an efficient referral system has prevented midwifery care from becoming the first level of referral in normal pregnancies. The failure to provide an accurate job description for physicians and midwives that defines their roles in the provision of care in normal pregnancies has further helped undermine midwifery.

‘They don't want midwives to be the first level of care. Midwives fill out referral forms for any mother who needs referral to higher levels, brief them and refer them to obstetricians, but those mothers never come back. When you contact the mothers, they say that the obstetrician has said that midwives aren't skillful and that they want to be under the supervision of obstetricians’

(M, 9 years work experience)

Although the main role of midwifery is the provision of care in normal pregnancies, participants reported that the Iranian society is not aware of the duties, abilities and skills of midwives. This lack of awareness leads to a lack of trust in and unwillingness to receive midwifery care. It can be argued that the society has forgotten midwifery and its duties.

‘Most of them (midwives) are experimental, I mean, they may not have gained experience through education. Well, this disheartens you and you can't trust them’

(P, 34 years old)

Participants reported that midwives' limited and faded presence in the city has reduced people's access to them and deprived society of midwifery services. Meanwhile, easy access to physicians and medical services prepares mothers for receiving medical pregnancy care.

‘[Midwife offices] are scarce, not as many as obstetricians in the city, not like that. I have seen few [signs] reading ‘Bachelor of Midwifery’. It's like people look at them as consultants’

(P, 26 years old)

There is an unwillingness in society to accept midwifery care, as well as a lack of trust in the profession, which has marginalised midwifery.

‘A colleague of mine was a general physician, and told me our colleague in the other room is a midwife, do you want a visit? I didn't like it and said no. I have a doctor myself’

(P, 30 years old)

For most mothers, midwifery care had been defined as a practice for low socioeconomic classes. The social status they expected of perinatal care could not be met by such care.

‘I think that the middle class goes to midwives more often, because they can't really afford it [medical perinatal care]’

(PP, 34 years old)

The incomplete structure of care provision has limited midwives in providing care from pregnancy to childbirth. Society's tendency toward cesarean section is another reason for the lack of tendency towards midwifery care.

‘Mothers ultimately need someone to take care of their labor and delivery. The midwives of healthcare centers are not allowed to accompany the mother for childbirth. Another issue is that cesarean section has become so popular in our society and since a midwife can't handle cesarean sections, naturally, pregnant women must be under the supervision of a specialist’

(M, 30 years work experience)

The participants reported that the failure of society to pay attention to midwifery care has further contributed to the unfavorable status of midwifery, which has kept perinatal care from flourishing in midwifery offices.

‘Few come for pregnancy care. I know about several midwives who have offices here. I know for a fact that no pregnant woman visits them’

(M, 12 years work experience)

The findings show the unfavorable conditions of midwifery in Iran. They do not illustrate whether the unfavorable conditions of midwifery have caused the increased supervision of medicine over normal pregnancies or if the expansion of medical supervision has weakened midwifery. What can be concluded from the analysis of the data is that the unfavorable conditions of midwifery in the context of medical authority have weakened this discipline and deprived society of its services, which has led to the further medicalisation of pregnancy and childbirth.

The lack of organisational support for midwifery

Analysis of the data showed that lack of support was a major problem for the midwifery community, which has marginalised midwifery. The media's failure to support the presence of midwives has kept society from learning about the existence and functions of midwifery.

‘It would have been possible to highlight the role of midwives. I mean, such that midwives were known as a good care provider. In this society, the TV and radio or the news media could show that midwives provide excellent care’

(M, 25 years work experience)

The lack of legal support for midwives was another major problem for midwives.

‘The law almost doesn't support midwives at all. I mean, if there's a little problem, the midwife will be questioned’

(M, 25 years work experience)

The lack of support for midwives at management levels has also created a lot of concern for midwives.

‘I don't think we have a reasonable position in the ministry [of health] either. We aren't supported well. If I want to do something, I'm sure no one will support me whether it goes well or not. So I can't implement my ideas’

(M, 25 years work experience)

The lack of support for midwives in the workplace also causes discouragement and concern for midwives.

‘There was a mother, who had lung cancer, she was really ill. When she died, a meeting was held and we were questioned like hell’

(M, 7 years work experience)

The lack of support for midwifery services from insurance companies causes distrust in midwives' skills and dexterity in society, and leads to the incomplete provision of care in normal pregnancies. This scenario has led to the referral of mothers to physicians for receiving services that midwives are not able to provide because of the lack of insurance coverage. This outcome in turn intensifies society's unwillingness to use midwifery care and disrupts midwives' independence in providing maternal care in normal pregnancies. This issue affects the provision of midwifery care in the private sector and deprives the society of midwifery services.

‘Naturally, when I can't order an ultrasound because insurance doesn't cover it, I've got to refer her to a physician, and well, and then she'll obviously prefer to just go to the doctor’

(M, 30 years experience)

Data analysis showed that midwifery, the profession responsible for a major part of perinatal care and natural childbirth, was not supported and was instead isolated from the society. This issue might have created a turning point for expanding the territory of medicine in normal pregnancies and natural childbirth.

The disempowerment of midwifery in interdisciplinary relations

The conditions governing the medicalised environment for midwifery care have facilitated the disempowerment of midwifery. The lack of support and the violation of professional rights pave the ground for fear of being accused of professional negligence, which has decreased the professional self-efficacy of midwives.

Fear of being accused in legal claims

Lack of support has created an environment for midwives where they feel helpless and at risk. The risk of accusation causes them to avoid such risk.

‘We are not supported much until something happens, then they go through the patient's file immediately and say, well, she was 16 weeks along, why did you send her for the ultrasound at week 14? Which might be irrelevant altogether?’

(M, 20 years work experience)

Working in an environment where one is at risk of being accused is associated with many difficulties, such that some people end up feeling helpless.

‘There's pressure from obstetricians on the one hand and from pediatricians on the other. You are simultaneously responsible for the lives of two people. Things happen that the obstetricians, pediatricians and anesthesiologists even cannot diagnose, yet if something happens, they say why didn't you do this or that!’

(M, 7 years work experience)

Under these conditions, even when the midwife has done nothing that could be classed as negligence, she will suffer from psychological tension when facing the unfavorable consequences of the incident.

‘About 1.5 years ago, there was a problem for which I was not responsible, but I had a hard time those days. The doctor had made a wrong diagnosis, but its pain remained for me to suffer through’

(M, 7 years work experience)

‘One mother died in our hospital a few weeks ago. Although our residents took care of her, I think maybe the midwives gave her medicine that led to her death’

(O, 29 years work experience)

The unfavorable environment created for midwifery formed a fear of being accused among midwives and resulted in reactions that encouraged the mothers to seek medical supervision for their normal pregnancies.

The violation of professional midwifery rights

The relationships governing midwifery and other disciplines in this area of expertise also contribute to its disempowerment. The cycle that began with the violation of professional midwifery rights ultimately leads to professional disappointment. Midwives consider the authority of medicine over their profession to be a factor contributing to disempowerment and marginalisation. It can be argued that the territory of medicine has expanded so that it has now reached the decision-making levels of midwifery.

‘We usually see that the heads are doctors, the head of the ministry of health is a doctor, and the head of the Medical Organization is a doctor. Midwives aren't independent. That's why they simply put midwives aside, because they are an obstacle for the doctors’

(M, 19 years work experience)

In addition to managerial levels, midwives believed that their job has been encroached by doctors.

‘Obstetricians have unfortunately taken over midwives' jobs. They are doing midwifery tasks. Maybe it's because they are making a lot of money through it’

(M, 19 years work experience)

In fields where midwives still offer services, the contradictions between medical and midwifery care were reported by the participants to be a significant concern.

‘Nowadays women take different kinds of vitamins. Well, when we tell them that they can supply their need for vitamins through food, this is a contradiction. They don't know whether to believe me or the doctor’

(M, 11 years work experience)

In addition to the fact that some management-level jobs in midwifery were occupied by doctors, others were given to nurses. Meanwhile, in Iran, midwifery is a profession that is independent of nursing. The differences in the professional field and specialty of the two groups create challenges for midwives.

‘It's good to have a midwife in the nursing management system. But there's none. Some problems occur in the delivery room and nurses might not be familiar with them. In fact, some of the problems and tensions in the workplace occur because we don't have a midwife supervisor’

(M, 30 years work experience)

Low professional self-efficacies in midwifery

The unfavorable conditions governing midwifery have led to reduced self-confidence and poor self-efficacy in midwives. This issue has led to the delegation of authority to physicians and dependence on physicians.

‘Because we have no support and there's no one to support us, we limit our work to a fixed framework in order to avoid problems. The limited stuff we do is also imbued with worry’

(M, 30 years work experience)

The lack of trust in oneself for providing independent services frequently results in midwives referring their patients to physicians and welcome their patients' simultaneous medical care-seeking for normal pregnancies, as this practice helps them disclaim responsibility. This action will not be overlooked by service recipients and is a reason for their distrust in and unwillingness to use midwifery services.

‘I tell many of the mothers who come here to also have a doctor visit them regularly, so that if there's a problem, I'm no longer responsible’

(M, 12 years work experience)

The unfavorable market of this profession reduces interest in and motivation for working in the field of midwifery. The lack of a clear future with the unfavorable conditions of midwifery disappoints working midwives and means they are willing to quit the field, as well as discouraging students from entering this profession.

‘My sister was accepted for a midwifery education. She went to a hospital and talked to an obstetrician, who said to her that people don't go to midwives as long as there are specialists. She changed her major when she heard this’

(M, 19 years work experience)

Professionals who were once responsible for providing care in normal pregnancies and natural childbirth are faced with many problems in the medicalised environment, which has marginalised their role and delegated their authority to physicians. The result of this process has been the medicalisation of normal pregnancies and natural childbirth.

Discussion

Midwifery was investigated in terms of medicalised pregnancy and childbirth, using a qualitative approach for explaining the perceptions of midwives, obstetricians, and pregnant/postpartum mothers. The analysis of the data revealed the marginalisation of midwifery in the context of medicalised pregnancy and childbirth.

The social and professional degradation of midwifery occurred in the context of medicalised pregnancy and childbirth, with the help of components such as the impossibility of providing comprehensive midwifery care during pregnancy and childbirth, the limitations for continuing care from pregnancy to childbirth, the unawareness of the society about the scientific and professional abilities of midwifery and, finally, the lack of tendency to and trust in midwifery. Analysis of the data showed that midwives are scarcely present in cities, which is caused by the limited interest of those who live in the city in midwifery care. This issue has reduced access to midwifery services. Meanwhile, access to physicians has increased in cities, which shows that people's conception of pregnancy and childbirth has changed. When people consider pregnancy and childbirth high-risk phenomena, the provision of care by physicians becomes necessary (Parry, 2006). Under these circumstances, the role of midwives in perinatal care fades (Smeenk and ten Have, 2003) and they become marginalised.

Changing the conceptualisation of normal pregnancy and natural childbirth does not occur by itself. The lack of support from national radio and TV, insurance companies and the legal authorities, the lack of an efficient referral system, and the lack of a correct job description and definitions for the different levels of referral have all contributed to the disempowerment of midwifery in the society. Shaw (2013) also believes that the medicalisation of women's health disrupts the traditional acclaim and knowledge of midwives (Shaw, 2013). Goodman (2007) conducted a qualitative study in the USA and concluded that organisations have successfully changed the type of maternal care and reduced the popularity of midwifery services. Goodman (2007) concluded that economic power and authority have created a cover for people to autonomously decide to reduce access to midwifery services through their power, organisational authority and autonomy. People in power are able to do such things without being held accountable for what they do in society (Goodman, 2007).

Pregnancy and childbirth can pose serious risks (Group, 2010), and one of the main objectives of perinatal care is to reduce the risk of mortality as a result of pregnancy and childbirth complications (Cunningham et al, 2014). While medical procedures are useful for ill mothers and children in response to the pathological problems of pregnancy and childbirth, their use when the mother and child are healthy predispose them to unnecessary risks (Christiaens et al, 2013).

These interventions can change the social structure of reproduction and maternal care. The advocates of this trend usually justify the increasing use of interventions by the argument of ‘safer childbirth or ‘more options for women’. Although these interventions can empower some women, they can reduce the ‘authority’ of others and increase the authority of medical professionals in pregnancy and childbirth, which increase general healthcare expenses (Maureen, 2005).

This scenario wastes human and economic resources (Lariccia and Pinnelli, 2009). Conrad et al (2010) estimated the costs of 12 medicalised conditions in the USA as 77.1 billion dollars based on 2005 data (Conrad et al, 2010). Goodman et al (2007) showed that if midwives are demarginalised, and pregnancy and childbirth are demedicalised, 20 billion dollars of savings can be expected over ten years in the USA (Goodman, 2007). Routine and unnecessary interventions lead to wasted resources in developed countries, even though they do not cause a tragedy. Meanwhile, in developing countries, the same issues create a tragedy by wasting limited resources. When developing countries also adapt themselves to non-evidence-based, specialised childbirth procedures that are popular in Western countries, they cause the death of women in their countries because of gynecological cancers and other reasons, as they turn the management of the limited resources available into a crisis (Wagner, 2001).

Although many interventions have been used in the process of pregnancy and childbirth, the fixed rate of maternal and fetal mortality since 1982 is considered a horrendous phenomenon. Analysts attribute this constancy or, in some cases, increase in mortality to the role of caesarean sections (Cunningham et al, 2014). Currently, maternal mortality as a result of pregnancy and childbirth complications is an important indicator of development in society and its reduction has always been one of the most important commitments in all countries (United Nations, 2011). Therefore, any care intervention that increases the maternal mortality rate is considered an indicator of poor health quality (Poverty, 2015).

Conclusions

The present study is one of the few that has attempted to explore the perceptions and experiences of perinatal care providers and recipients in relation to midwifery in Iranian society, with a qualitative in-depth approach. The study showed that, with the medicalisation of pregnancy and childbirth, midwifery has become marginalised and midwives do not have a favorable status. The continuation of this trend can fully remove midwifery from normal pregnancy care and natural childbirth, which could impose heavy expenses on the healthcare sector. Based on the analysis of the data, the complications of this marginalised status for society were discussed. This study presented only an extensive description of the current state of affairs. Future research can consider approaches that place midwives in the center of maternal care in low-risk pregnancy and childbirth.

Key points

• Midwifery has degraded both socially and professionally in the Iranian society in the context of medicalized pregnancy and childbirth,
• Midwifery is at risk of being totally excluded from low-risk pregnancy care and childbirth.