https://doi.org/10.15218/ejnm.2021.03 Erbil j. nurs. midwifery, Vol. 4, No. (1), May 2021 Original Article Midwives’ Views and Perceptions of Patient Dignity in Midwifery Services ABSTRACT INTRODUCTION Human dignity has been defined as re- specting human individuality. In this defini- tion, each individual is regarded to be a unique human being *1+. It is highly recom- mended that human dignity must be re- spected in healthcare settings *2+. In the moral codes of midwifery profession, hu- man dignity has been referred to as an ob- ligation and a human right *3+. As a result of human dignity being maintained, a feel- ing of being valued develops in the individ- uals, leading to a rise in trust *4+. As de- fined by the World Health Organization, dignity is the inherent value and worth felt by individuals, and it is strongly linked to freedom of choice, self-worth, recogni- tion, and respect *5+.The essence of mid- wifery is caring which has root in human trait and emotion *6+. The purpose of mid- wifery caring is to support and help wom- en during childbearing; therefore, the na- ture of midwifery caring is different from caring in other health professions *7+.In midwifery, the quality of caring increases highly once dignity and respect are taken into account *8+. In this regard, it is highly significant for midwifery professionals to create effective interpersonal relation- ships with their clients *9+. However, it should be noted that there is much Background and objective: Human dignity which is defined as respect to human individu- ality is a highly recommended necessity to be taken into account in medical settings to de- liver high-quality services and raise the patients’ satisfaction. Due to a lack of well-defined provisions and instructions in midwifery practice in the Kurdistan region of Iraq, human dignity is threatened in this field. The present study was an attempt to figure out the meaning of patient dignity, what threatens patients’ dignity, and how to promote patients dignity in midwifery settings in maternity departments and clinics in Erbil, in the Kurdistan region-Iraq. Method: The present qualitative study was conducted on 10 Kurdish registered midwives who were working delivery room of Maternity Teaching Hospital and Dyke Private Hospital located in Erbil, Iraqi Kurdistan. In-depth semi-structured interviews were conducted with the midwives to collect required data. The interviews were recorded and then transcribed verbatim and analyzed using the six methodological activities proposed by Van Manen, and the themes and subthemes were extracted. Results: Analyzing the transcribed interviews resulted in emergence of one main theme, namely “need for holistic support” which had subthemes, namely “need for medical sup- port”, “need for mental support”, and “need for sympathetic support”. Conclusion: Human dignity of pregnant and childbearing mothers in maternity depart- ments and clinics is relatively low due to lack of sufficient equipment and facilities and in- sufficient number of midwives and maternity staff. Therefore, appropriate measures need to be taken in these regards. Keywords: Human dignity, Midwifery, Maternity wards, Pregnancy, Childbearing women Tiran Jamil Piro; Department of Midwifery , College of Nursing, Hawler Medical University, Erbil, Iraq. (Correspondence: tiran.piro@hmu.edu.krd ) 23 Erbil Journal of Nursing & Midwifery Received: 25/08/2020 Accepted: 14/12/2020 Published: 30/05/2021 mailto:tiran.piro@hmu.edu.krd https://doi.org/10.15218/ejnm.2021.03 Erbil j. nurs. midwifery, Vol. 4, No. (1), May 2021 Original Article controversy on the elements of respectful care in midwifery practice *10+.Childbirth is a scary and painful experience for most women, which can be relieved by pro- moting women’s emotional wellbeing through provision of quality midwifery care during pregnancy and at birth *11+. Despite the significance of midwifery care, research has indicated that many women have de- scribed their encounters with midwives as uncaring *12+, and some women have re- ported that midwives do not usually be- have with dignity and respect *13+. There are other reports by pregnant women showing midwifery care lacking emotional support, sympathy, and compassion. In jus- tification of such behavior, some have re- ferred to issues like administrative over- load and the organization structure *14+. Patient dignity in midwifery settings has been focused on very few studies. Moreo- ver, the effect of midwives’ behavior at workplace on patient dignity has rarely been studied via observation *15, 16+. Ac- cording to the results of the studies carried out in the Kurdistan region of Iraq, mater- nity and midwifery services are negatively affected by professional unaccountability, lack of job description, and limited health resources which in turn have negative im- pact on the patient’s health and dignity *17+.Give the significance of human dignity in delivery of quality maternity services and mothers’ overall wellbeing, and since human dignity is a complex human phe- nomenon and can be studied well through individuals’ lived experiences, the present study was carried out to investigate the meaning of patient dignity, how patients’ dignity is threatened, and how patients’ dignity is promoted in midwifery settings. The present qualitative phenomenological study was carried out by using Van Manen’s hermeneutic phenomenological method *18+. from December 2019 to Feb- ruary 2020 to achieve a deep understand- ing of human dignity of mothers according to midwives working in maternity depart- ments and delivery rooms of Erbil, Iraqi Kurdistan. Phenomenological researchers seek to ask how persons experience their lived world. Max van Manen’s Hermeneu- tic phenomenological approach is especial- ly relevant to nursing research as it pro- vides a way to understand how the per- sons experience their world. This approach also provides six steps of data analysis which encourages the nursing researchers to craft the texts in order to develop the structure of meaning of the texts or themes. Then, the researchers would be able to understand the meaning of the ex- perience of the participants as they lived in it and the knowledge would provide ser- vices or strategies to help them more effectively. The study sample consisted of 10 Kurdish registered midwives who were working delivery room of Maternity Teach- ing Hospital and Dyke Private Hospital lo- cated in Erbil, Iraqi Kurdistan. This number of participants based on data saturation because the goal of qualitative research is achieving data saturation or redundancy. Saturation occurs when adding more par- ticipants to the study does not result in obtaining additional perspectives or infor- mation. They were selected from among registered midwives by using purposive sampling based on some inclusion criteria: work experience of more than 1 year, speaking and understanding Kurdish, and willingness to participate in the study. Semi-structured in-depth interviews are employed in order to collect required data in phenomenological studies *19+; there- fore, the midwives in the present study were interviewed face-to-face. For this purpose and to elicit required information about the interviewees’ lived experiences regarding human dignity of mothers, they 24 Erbil Journal of Nursing & Midwifery METHODS https://doi.org/10.15218/ejnm.2021.03 Erbil j. nurs. midwifery, Vol. 4, No. (1), May 2021 Original Article which were recorded at the interviewees’ permission and then transcribed verbatim and translated into English for analysis *after obtaining permission from the inter- viewee+. Each interview lasted between 30 and 60 minutes that was continued until data saturation occurred. Transferability, conformability, dependa- bility, and credibility which are Lincoln and Guba’s four-criterion gold standard were used to make sure about the rigor of the study *20+. Also, member- and peer- checking techniques proposed by Devadas (2016) *21+ were employed to make sure about the credibility of the findings, which was also ensured through the researcher’s prolonged engagement with the data and referral to maternity departments and clin- ics in Erbil to communicate with the partic- ipants effectively and elicit reliable data from them. Required approval on the research proto- col was obtained from the ethics Com- mittee of Hawler Medical University/ College of Nursing. Moreover, the partici- pants were provided with a thorough ex- planation about the study’s aims, method of data collection, their information confi- dentiality, and their right to withdraw from the study at any phase. In addition, in- formed participation consent was obtained from the participants. The midwives also permitted the researcher to record the in- terviews. Furthermore, each midwife was given a unique code (Midwife 1= M1- Mid- wife 2, =M2, etc.) in order to keep the col- lected data anonymous. were asked open-ended questions, such as “What do you think about aspects of hu- man dignity according to your experience of working here?” To elicit more detailed information, exploratory questions like how and what questions were used. Kurd- ish was the language of the interviews The transcripts of the interviews were ana- lyzed following the six methodologicalac- tivities proposed by Van Manen *18+ (See Table 1). 25 Erbil Journal of Nursing & Midwifery Data analysis Table 1: Van Manen’s six methodological activities *18+ Van Manen’s Methodi- cal Activities The Researchers’ Activities Approaching the nature of lived experience Pregnancy and childbirth are among the most significant events in every woman’s life. Without appropriate mater- nity and medical care and also psychological support from maternity team, human dignity of mothers can be negatively affected. Investigating experi- ence as it is lived Selecting midwives with suffi- cient experience. Thinking about the major themes as the characteristics of the phenomenon Utilizing thematic analysis Using the art of writing and rewriting to de- scribe the phenomenon through Creating a phenomenological text through writing and rewriting Maintaining a strong and oriented relation to the phenomenon Discussing the themes about phenomena Balancing the research context by considering the parts and the whole Moving between transcripts and themes TRUSTWORTHINESS ETHICAL CONSIDERATION https://doi.org/10.15218/ejnm.2021.03 Erbil j. nurs. midwifery, Vol. 4, No. (1), May 2021 Original Article According to study result the selected mid- wives’ age ranged from 25 to 56 years, and their work experience from 1 to 37 years. With regard to their education level, most of them were graduates of midwifery insti- tutes (n=5), some studied midwifery school (n=4), and one of them graduated from university and had bachelor’s in midwifery. Analyzing the interview scripts led to the emergence of one main theme which was labeled as “need for holistic support”, and it consisted of three subthemes, namely “need for medical support”, “need for mental support”, and “need for sympa- thetic support”. The midwives’ lived experiences regarding the aspects of human dignity and its status in the studied maternity departments and clinics were interpreted as pregnant women and mothers’ need for holistic sup- port. The midwives believed that mothers’ human dignity can be raised and main- tained if they are provided with compre- hensive support which gives them the feel- ing that they are well-valued. In this re- gard, Midwife 4 said: “Human dignity can be achieved in many ways. As far as preg- nant women are concerned, I guess if they are given sufficient support and help, their human dignity will be ensured. In our ma- ternity department, we pay close attention to mothers’ needs and try to meet them. Due to some shortages; however, we may fail to provide full support and meet every single need of the mothers.” Comprehen- sive support was also mentioned by Mid- wife 7 who stated: “Being pregnant espe- cially for those with their first experience can be quite worrying and apprehensive. However, if comprehensive support is pro- vided, mothers can feel better, which also raises their human dignity by giving them a sense of being valued. Unfortunately, due to various issues, such as huge workload in maternity departments and lack of suffi- cient maternity staff, comprehensive sup- port and help are sometimes difficult to provide. ”First subtheme: Need for medical support One of the most frequent types of support mentioned by almost all of the midwives was medical support. They stat- ed that what mothers expect from them more than anything else is medical help and support. They linked medical support and human dignity by referring to the sense of value that mothers have after re- ceiving a good deal of medical support. In this regard, Midwife 2 said: “I’ve been working as a midwife for more than 15 years, and I know what makes mothers satisfied. They’d like to be provided with good medical care. I guess provision of good medical care also raises the level of human dignity among mothers.” 26 Erbil Journal of Nursing & Midwifery RESULTS Table 2: Below shows the participants’ demographic characteristics. Demographic characteristics n(%) Sex Female 10(100.0) Male 0(0.0) Age (years) 25-30 2(20.0) 31-40 3(30.0) 41-50 3(30.0) 51-60 2(20.0) Place of resi- dence Urban 10(100.0) Rural 0(0.0) Level of educa- tion Midwife- 4(40.0) Institute 5(50.0) Bachelor 1(10.0) Work experi- ence (years) 1-10 2(20.0) 11-20 3(30.0) 21-30 3(30.0) 31-40 2(20.0) Main theme: Need for holistic support https://doi.org/10.15218/ejnm.2021.03 Erbil j. nurs. midwifery, Vol. 4, No. (1), May 2021 Original Article of human dignity.” In addition, Midwife 10 stated: “Respecting mothers along with sympathizing with them can give them the feeling that they are valued. Although I don’t have enough time to spend with mothers and sympathize with them, I treat them with full respect and show my sym- pathy in my behavior. I know it may not be sufficient, but I guess it does the trick and raise the level of their human dignity.” Third subtheme: Need for mental support Pregnancy can threaten women’s mental health if they are not provided with suffi- cient mental support. This is particularly true about those with their very first expe- rience. Therefore, one of the human re- sponsibilities of maternity team and mid- wives is to help mothers and pregnant women psychologically. In this regard, Midwife 3 said: “Due to the special cultural structure of Kurdish families, pregnant women in some families do not normally receive appropriate psychological support from their families particularly from their husbands. Therefore, once they refer to us, they are usually in a poor mental state, so in addition to maternity services, we need to prepare them mentally to become a mother. Because in primary health care centers they took just medical support without emotional support or advices. However, again due to the culture in the region, which encourages people to have many children, delivery rooms and mater- nal wards are always crowded, and mid- wives do not usually have sufficient time to spend with mothers and provide mental support fully for labor. That is why I sug- gest hospitals that they employ a psycholo- gist to assist maternity wards and delivery rooms in this regard.” In the same regard, Midwife 9 said: “Being pregnant and be- coming a mother can be an overwhelming experience. That is why such women need to be supported psychologically. Midwives can provide mental support; however, our 27 Erbil Journal of Nursing & Midwifery Despite the significance of medical care and support, the midwives revealed the fact that their departments were not well- equipped and facilitated, as a result, they sometimes fail to provide sufficient medi- cal care. In this regard, Midwife 5 said: “Our department is undermanned. Also, it is not well-equipped. So, it is quite com- mon that mothers may not receive full medical care, which I’m quite sure has a negative effect on their personality and human dignity.” Similarly, Midwife 8 stat- ed: “Maternity wards are usually crowded, and the facilities and equipment are not enough to respond to every single moth- er’s need for medical support fully. In addi- tion to equipment, we need more mid- wives and maternity staff to provide better maternity services and medical care which will raise our clients’ human dignity.” Second subtheme: Need for sympathetic support Another important aspect of sup- port mentioned by most of the midwives was the mothers’ need for sympathetic support. They referred to this kind of sup- port as the most important factor in en- hancing mothers’ human dignity and self- value. In this regard, Midwife 1 related: “In addition to maternity care, one thing they need is sympathetic help. This is even more important for those women who are experiencing their first pregnancy. I usually listen to them and try to give them sympa- thetic support, too. However, given the crowdedness of department and shortage of time, sometimes I’m just able to give them maternity care and advice.” Moreover, Midwife 6 said: “There are just two midwives in our super-crowded deliv- ery room, so we hardly have enough time to spend with the mothers. I know they need something more than maternity and medical care. We need to spend time with them and listen to their concerns and feel- ings. They sure need our sympathetic sup- port which is helpful for their feeling https://doi.org/10.15218/ejnm.2021.03 Erbil j. nurs. midwifery, Vol. 4, No. (1), May 2021 Original Article number one concern is delivering materni- ty services, so I guess psychological support needs to be provided by someone who specializes in psychology specialty in labor or giving midwives the opportunity to sup- port and advise women before pregnancy until birth not just in labor.” During pregnancy and at birth, mothers need to be treated with dignity and re- spect. Such dignity should be associated with appropriate maternity care provided by midwives and maternity staff *22+. As a stressful job, midwifery can lead to quick job burnout which in turn can cause low levels of job satisfaction among midwives. Job dissatisfaction can cause midwives to behave in a way that their clients feel they do not receive services and are not valued or respected fully *23, 24+. As shown by the results of the present study, some issues in maternity wards like high workload and lack of sufficient well-trained maternity staff cause midwives to fail to provide full support to pregnant women and mothers, which can have negative impacts on the level of mothers’ human dignity. Research has indicated that promotion of partner involvement, facilitation of new social con- tacts, pedagogical creativity, emotional confirmation, and a listening and holistic approach by midwives are highly appreciat- ed and welcomed by pregnant women dur- ing pregnancy and at childbirth *25+. More- over, it has been proved that it is highly helpful to provide women with antenatal sessions where they have the chance to have contact and get familiar with the mid- wives and maternity team. During such ses- sions, it is also vitally helpful to prepare pregnant women with explanations and feedback on their progress during their pregnancy and labor. The success of such sessions and feedback is highly dependent on the midwives’ competence and previous training *26+.That is why research has high- lighted the need for more competent mid- wives, pre- and in-service training courses, improvement of working conditions, men- tal preparation of pregnant women, and appropriate health policies to deliver re- spectful maternity services and promote human dignity *27+. Since there is not suffi- cient evidence-based practice in maternity care, a feeling of pressure is experienced by women while trying to receive such care *28+.Successful childbirth requires management of the process by a well- experienced midwife. This process consists of various specialized interventions which should be carried out by enough number of midwives and maternity nurses. In addi- tion to the maternity team, collaboration from the childbearing woman is required, which can be obtained once her human dignity and respect are well attended to in an appropriate environment *29, 30+. In the present study, the midwives referred to issues like overcrowded maternity wards, lack of sufficient equipment and facilities, and lack enough maternity staff. Mentioning these issues, they stated that full medical support and high-quality ma- ternity services cannot be provided, which can have a negative effect on mothers’ hu- man dignity and the sense of being valued. In line with this finding, Hall et al. pointed out that the pregnant and childbearing women’s independence and dignity can be threatened by the lack of reasonable equipment in midwifery departments and clinics. As a result of such issues in mater- nity wards, they noticed the explicit state- ment by women expressing their feeling of being ignored or deprivation from personal choices, and ultimately their human dignity being threatened *31+. Similar issues were referred to by the women in the study car- ried out by Baranowska et al. who noticed pregnant and childbearing women com- plaining about maternity care as a result of 28 Erbil Journal of Nursing & Midwifery DISCUSSION https://doi.org/10.15218/ejnm.2021.03 Erbil j. nurs. midwifery, Vol. 4, No. (1), May 2021 Original Article dignity. However, midwives in this study stated that they did not have enough time to spend with mothers and give them mental help and support, and they sug- gested that hospitals should employ psy- chologists for this purpose. Similar to this finding, research has shown that women are highly vulnerable during pregnancy be- cause they usually lose their normal physi- cal abilities and undergo some psychologi- cal and social pressures, anxiety, depres- sion, and feeling of uncertainty in life *36- 38+. The human dignity of this group has not received sufficient attention in the Kur- distan region of Iraq, because very few rel- evant provisions and instructions are avail- able *39+. Limitation of the present study was just rejection to participate in the study from some midwives because of their individual reasons. It should be stated that some midwives were not willing to take part in the study and discuss their ex- periences, which could be related to their low trust of the researcher and also their limited time. The themes that emerged in the present study revealed that the status of human dignity among pregnant and childbearing women in the Kurdistan region of Iraq is not satisfactory due to a lack of sufficient equipment and facilities, barely enough number of well-trained maternity staff and midwives, and crowdedness of the mater- nity departments. There is no actual or potential conflict of interest in relation to this study. *1+ Ebrahimi H, Torabizadeh C, Mohammadi E, Valizadeh S. Patients' perception of dignity in Iranian healthcare settings: A qualitative content analysis. Journal of Medical Ethics. 2012; 38:723-8. poor communication with and ignorance of their viewpoint by the maternity team *32+.Research has proved the human dig- nity of mothers rises through constructive communication with the maternity staff. This type of communication is character- ized by sympathetic relationships, the staff’s willingness and readiness to an- swer questions posed by mothers, and the allocation of sufficient time to discuss the mothers’ concerns *33+. In this regard, caseload care has been proposed to be a successful model in which a single mid- wife or small group of midwives are as- signed to take care of pregnant or childbearing women *34+. In the present study, midwives stated that they do not have enough time to spend with mothers and provide them with sympathetic sup- port because there is a high workload on them; however, some of them try to com- pensate that gap by respecting mothers and show their sympathy in their behav- ior. In a similar study carried out by Hall et al., some participants also revealed that the maternity staff did not spend enough time to meet their needs, and no extra support was provided for women with a kind of disability *31+. Similarly, Kozhimannil et al. reported women’s complaints about the insufficient time spent by the maternity staff with them which increases their concerns and stress. They also complained about their failure to understand the medical terminology used by the maternity staff *35+. It shows that pregnant and childbearing women need more friendly and passionate rela- tionships and communication within the maternity departments. The psychological stress of pregnant and childbearing wom- en was emphasized by the midwives in the present study, and as they stated, this situation can be relieved by providing mothers with psychological and mental support, which in turn raises their human 29 Erbil Journal of Nursing & Midwifery CONCLUSION CONFLICT OF INTEREST REFERENCES https://doi.org/10.15218/ejnm.2021.03 Erbil j. nurs. midwifery, Vol. 4, No. (1), May 2021 Original Article Reproductive Health. 2018; 15. 10.1186/ s12978-017-0447-6. *14+ Mathibe JM, Masitenyane SS. 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