Volume 23, Issue 2 (6-2026)
J Res Dev Nurs Midw 2026, 23(2): 65-72 |
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Ghanbarzadeh M, Moghasemi S, Seyedghasemi N S, Borghei N S, Saboori Rostami T. Midwives’ knowledge and practice of respectful maternity care and related factors in Golestan province, Iran: A cross-sectional study. J Res Dev Nurs Midw 2026; 23 (2) :65-72
URL: http://nmj.goums.ac.ir/article-1-2366-en.html
URL: http://nmj.goums.ac.ir/article-1-2366-en.html
Maryam Ghanbarzadeh1 
, Sedigheh Moghasemi2 , Navisa Sadat Seyedghasemi3 , Narjes Sadat Borghei1 , Tahmineh Saboori Rostami1
, Sedigheh Moghasemi2 , Navisa Sadat Seyedghasemi3 , Narjes Sadat Borghei1 , Tahmineh Saboori Rostami1
1- Counseling, and Reproductive Health Research Center, Golestan University of Medical Sciences, Gorgan, Iran; School of Nursing and Midwifery, Golestan University of Medical Sciences, Gorgan, Iran
2- Counseling, and Reproductive Health Research Center, Golestan University of Medical Sciences, Gorgan, Iran; School of Nursing and Midwifery, Golestan University of Medical Sciences, Gorgan, Iran ,Moghasemi.s@goums.ac.ir
3- Department of Biostatistics and Epidemiology, School of Health, Golestan University of Medical Sciences, Gorgan, Iran
2- Counseling, and Reproductive Health Research Center, Golestan University of Medical Sciences, Gorgan, Iran; School of Nursing and Midwifery, Golestan University of Medical Sciences, Gorgan, Iran ,
3- Department of Biostatistics and Epidemiology, School of Health, Golestan University of Medical Sciences, Gorgan, Iran
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Results
Of the 342 eligible midwives invited, 137 completed the questionnaire, corresponding to a participation rate of 46%. The demographic and occupational characteristics of the midwives are shown in Table 1. The mean age and work experience of the participating midwives were 35.3 and 10.7 years, respectively. On a 10-point scale, the mean job satisfaction score was 6.8, and the mean level of interest in the field was 8.3.
The standardized mean and median scores for midwives' knowledge and practice of RMC are shown in Table 2. Knowledge and practice scores differed significantly across all domains except "providing safe care." Detailed item-level findings are presented in Supplementary Tables B1-B3.
Spearman’s correlation analysis (Table 3) suggests that greater knowledge of emotional support and safe care is generally associated with better practice in the corresponding domains, whereas knowledge of mistreatment prevention has weaker and less consistent associations with practice. Total knowledge scores were moderately and significantly correlated with total practice scores (r = 0.45, P < 0.001).
Table 4 compares total practice and knowledge scores according to demographic and occupational characteristics. The only statistically significant difference was observed between education levels for total practice scores (P = 0.05), with participants holding a Bachelor’s degree reporting higher median practice scores, 95.65(13.04), than those holding a Master’s degree, 84.90 ± 4.84. No significant association was found between education level and total knowledge scores (P = 0.43).
Spearman’s correlation analysis showed that demographic and occupational history characteristics generally had weak associations with both knowledge and practice of respectful maternity care (Table 5). Age and years of work experience were not significantly correlated with any domain, with coefficients ranging from -0.17 to 0.12. Job satisfaction was modestly correlated with practice scores, reaching significance only for total practice (r = 0.18, P = 0.03). Interest in midwifery emerged as the most consistent correlate of practice, showing significant positive associations with mistreatment prevention (r = 0.23, P < 0.001) and total practice (r = 0.19, P = 0.02), as well as an association with safe care practice (r = 0.16, P = 0.05). No demographic or occupational history variable was significantly associated with any knowledge domain (Table 5).
Discussion
In this study, midwives demonstrated good levels of knowledge and practice regarding respectful maternity care. The highest knowledge and practice scores were observed in the domains of "providing emotional support" and "providing safe care." By contrast, the lowest scores in both areas were observed in the domain of "preventing mistreatment."
Consistent with previous studies conducted in other regions of Iran (22,23), our findings highlight midwives’ relative weakness in the domain of “preventing mistreatment.” This domain emphasizes the importance of safeguarding women’s dignity throughout labor and childbirth (21). Notably, unlike the other two domains, knowledge scores in this domain were not significantly associated with practice scores. Therefore, factors beyond knowledge, such as occupational pressures and environmental conditions, may contribute to midwives’ lower performance in this domain.
According to our findings, job satisfaction and interest in midwifery affect both the overall practice score and the practice score in the domain of “preventing mistreatment.” This finding is consistent with the studies by Haqdoost et al. (22) and Hadizadeh et al. (24), both of which indicate a direct relationship between job satisfaction and midwives’ professional performance. In many regions, including Iran, the structure of the healthcare system contributes to stress and burnout among midwives, adversely affecting the quality of obstetric care provided (25,26). Overall, 72.82% of Iranian midwives experience high levels of occupational stress (27). Stress can reduce job satisfaction (28) and consequently diminish the motivation to provide RMC. Thus, although midwives may have adequate knowledge of respectful maternity care, stress and excessive workloads may prevent them from implementing it effectively.
Midwives’ mean knowledge scores were higher than their practice scores in all domains except the provision of safe care. Consistent with these findings, studies involving mothers indicate that many experience various forms of mistreatment and disrespectful care (29,30). Some midwives do not regard violence against women during childbirth as mistreatment but instead view it as a means of ensuring a successful delivery (31).
The lowest-scoring item in the knowledge section was “Providing accurate information to companions about the progress of labor.” Informed decision-making is essential to the provision of safe and respectful maternity care. Although midwives are eager to provide care that supports informed and participatory decision-making, they encounter several barriers. These include insufficient specific knowledge and training, fear of blame and legal repercussions, structural constraints such as limited time, and a medicalized approach to midwifery care (32).
In the practice section, the lowest-scoring statement was “I do not allow women to have companions in the delivery room.” Notably, approximately two-thirds of midwives did not allow companions in the delivery room. Similarly, in the study by Shakibazadeh et al., the most common form of mistreatment reported from the mothers' perspective was in the domain of "not allowing movement, fluid intake, and having a companion" (29). Although previous research has demonstrated the numerous benefits of having a trusted companion (33), factors that may hinder a companion's presence during labor include limited awareness among staff and mothers of these benefits, insufficient space, concerns about mothers' privacy, and fear of an increased risk of infection (34).
Most midwives reported that they “provide equal care to all women, regardless of their socio-economic status, ethnicity, etc,” with over 99% doing so all or most of the time. This finding is consistent with other studies (29,35). In the study by Shakibazadeh et al. (29), the least frequently reported forms of mistreatment were related to “stigma and discrimination.” Meanwhile, Hajizadeh et al. found that the highest respectful maternity care score was in the domain concerning women (35). By contrast, in a study conducted by Mirzania et al. in Tehran, 53.8% of maternity care providers expressed negative attitudes toward stigma and discrimination, believing that equal services could not feasibly be provided to all women during labor and delivery. That study included midwives, obstetrician-gynecologists, and medical students, whereas the present study focused exclusively on midwives (36). However, implicit bias, which may unconsciously influence staff behavior (37), should also be considered, although it was not examined in the present study.
Midwives’ age was inversely associated with the practice score in the ‘safe care’ domain. This domain emphasizes maintaining confidentiality and privacy, respecting women’s religious beliefs and cultural practices, providing evidence-based care, and ensuring that women are informed about the progress of labor and the care and interventions they receive during childbirth (21). In the study by Moridi et al. in Tehran, age had the strongest effect on midwives’ knowledge of RMC (23). The difference observed in our study may be explained by older midwives’ greater reliance on traditional routines, which may sometimes conflict with RMC standards, whereas younger midwives may have received more recent training and therefore had greater exposure to contemporary RMC concepts.
Several limitations should be acknowledged. First, data were collected using a self-report questionnaire, which may have introduced social desirability and reporting biases. Future studies incorporating direct observation of clinical practice and women's perspectives on the care received would provide a more comprehensive evaluation of respectful maternity care. Second, recruitment was challenging because contact information was unavailable for some eligible midwives. In addition, reliance on telephone invitations may have reduced participation and affected the response rate. Consequently, only 137 of the 342 eligible midwives participated, yielding a participation rate of 40.1%. This relatively low response rate represents another limitation of the study.
Conclusion
The findings of this study indicate that midwives demonstrated good levels of knowledge and practice regarding respectful maternity care. Nevertheless, significant discrepancies between knowledge and practice in the overall score and in the domains of emotional support and mistreatment prevention suggest that knowledge alone is insufficient to ensure consistent implementation in clinical practice. Therefore, interventions extending beyond knowledge enhancement, including supportive organizational strategies and continuous professional development, are recommended to promote the effective implementation of respectful maternity care.
Acknowledgement
This study was conducted as part of a master’s thesis in Midwifery Counseling at the Faculty of Nursing and Midwifery, Golestan University of Medical Sciences, Gorgan, Iran. The authors sincerely thank the Deputy of Research and Technology of Golestan University of Medical Sciences and all midwives who participated in the study for their valuable cooperation and support.
Funding Sources
The present study was financially supported by the Deputy of Research and Technology of Golestan University of Medical Sciences (Research Code: 113208).
Ethical Statement
This study was initiated after permission was obtained from the Ethics Committee of Golestan University of Medical Sciences (Ethics code: IR.GOUMS.REC.1401.601). After sufficient information regarding the study aims and procedures had been provided, written informed consent was obtained from all participants. The study was conducted in accordance with the ethical principles of the Declaration of Helsinki. Participation was entirely voluntary, and participants had the right to decline participation or withdraw at any time without consequences for their work or benefits. The confidentiality of participant information was strictly maintained through data coding and anonymization. All study data were stored securely and were accessible only to authorized research personnel.
Conflicts of Interest
The authors declare no conflict of interest.
Author Contributions
MG, NB, SM, and NSG conceived the study, developed the research plan, and analyzed the collated data. MG collected the data. NB, SM, NSG, and TS participated in implementing the research plan and assisted with data collection. MG and SM prepared the first draft of the manuscript and were responsible for submitting it for publication. All authors supported the study, reviewed and revised the article, and proposed changes. All authors participated in reviewing and revising the manuscript and ultimately approved the current version for publication.
Data Availability Statement
The datasets generated and analyzed during the current study are available from the corresponding author upon reasonable request.
Use of Artificial Intelligence
AI was used only for English-language editing, translation assistance, and manuscript proofreading. No AI tools were used for data analysis, interpretation of findings, or generation of scientific conclusions.
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Introduction
Respectful maternity care (RMC) involves providing care that preserves women's dignity, privacy, and confidentiality, protects women from harm, supports informed decision-making, and provides ongoing support throughout labor and delivery (1). Despite global improvements in maternal and neonatal outcomes, ensuring high-quality care remains essential. Integrating evidence-based practices with personalized and respectful care is critical to achieving the Sustainable Development Goals of reducing maternal and newborn mortality. Approximately 50% of maternal deaths and over 60% of neonatal deaths result from poor-quality care (2).
Labor and childbirth are vulnerable periods for women, and a lack of respectful care may result in lasting negative experiences, including fear of childbirth and a preference for cesarean delivery (3,4). Furthermore, a positive association has been identified between the total RMC score and both aspirations for future fertility and the preferred fertility rate under ideal socioeconomic circumstances (5). In this regard, the World Health Organization emphasizes the importance of strengthening midwifery education to achieve higher-quality care across childbirth, reproductive health, and the overall well-being of women and children (2).
Disrespect during childbirth is a global concern (4), and women who experience such disrespect are more likely to receive low-quality care (5). Many women experience disrespectful maternity care for various reasons (6-10). Some providers consider verbal abuse justified when women do not comply with instructions, particularly during emergencies (11). One study found that only 15% of midwives had sufficient knowledge of RMC principles (12). Factors such as inadequate facilities, high workloads, and limited staff training adversely affect the provision of respectful care (13).
Evidence suggests that RMC reduces the risk of disrespect and abuse by up to two-thirds (14). Essential elements of RMC include informed consent, communication, dignity, privacy, equitable access to care, emotional support, and continuous care provided by competent and motivated professionals (15). Few studies have directly examined midwives’ knowledge and practices regarding RMC (12), and the available findings are mixed. For example, midwives in Bhutan reported awareness of women’s rights but often failed to respect women’s choices in practice (13). In a study conducted in Nepal, maternity care providers held negative attitudes toward certain practices, such as allowing birth companions and supporting women’s preferred birth positions (16). In another study, midwives demonstrated substantial perceived competence alongside self-reported RMC practices (17).
Although studies in different regions of Iran have examined midwives’ knowledge and practice of respectful maternity care, their findings vary across provinces (16,17). Differences in midwifery autonomy, hospital organizational type (Public, private, or semi-private), the presence of OB/GYN residents, and regional resources and cultures may contribute to this variation (12). Building on this evidence, the present study aimed to assess midwives’ knowledge and practice of RMC and examine related factors in the maternity wards of Golestan Province, Iran.
Methods
Study Design and Participants: A cross-sectional study was conducted from February to September 2023 among midwives working in the maternity wards of hospitals across Golestan Province, Iran. The inclusion criteria were an associate degree or higher in midwifery, at least one year of experience in a maternity ward, access to a smartphone, computer, or laptop, and internet access. The exclusion criteria included experiencing a significant adverse event within the previous six months (e.g., severe illness, death of a first-degree relative, or divorce), self-reported mental health disorders (e.g., anxiety or depression), or the use of related medications. We used the STROBE reporting guideline (18) to draft this manuscript and the STROBE reporting checklist (19), included as Supplement Table A, during editing.
Sampling: Initially, a census sampling strategy was adopted, and all eligible midwives working in the selected hospitals were invited to participate. The response rate was 46% ((137)/ (342-50) =137/292=46%) (Figure 1). The adequacy of the number of participants was assessed to determine whether it was sufficient to examine the association between the two primary study variables (Knowledge and practice). Because no previous studies had reported the expected correlation coefficient between these variables, the correlation observed among the first 100 participants (r = 0.50) was used to estimate the minimum required sample size. Assuming a significance level of 0.05 and statistical power of 80%, the minimum required sample size was estimated to be 29 participants. Recruitment continued until all eligible midwives had been approached, and a total of 137 midwives were ultimately included in the study, exceeding the estimated minimum sample size.
.PNG)
Demographic and Occupational Characteristics Form: This form consists of two parts. The first part includes questions on age, educational level, marital status, and mode of delivery among participants who had children. The second part includes questions on the type of university from which the participant obtained a Bachelor’s degree, years of work experience, type of hospital, the presence or absence of obstetric and gynecologic residents in the hospital, employment status, job satisfaction (Measured on a 10-point scale), interest in midwifery (Measured on a 10-point scale), and possession of a 60-hour physiological birth certificate. Because this course familiarizes midwives with the physiological process of labor, the need for psychological and emotional support during labor, and pain-reduction techniques (20), participation in the course was considered potentially relevant to midwives' knowledge and practice of RMC.
MKP-RMC Scale: This 46-item instrument assesses midwives’ knowledge (23 items) and practice (23 items) across three domains: emotional support, safe care, and mistreatment prevention. The emotional support domain includes items related to establishing friendly communication and fostering mothers’ autonomy and comfort. The safe care domain emphasizes confidentiality, privacy, respect for women’s religious beliefs and cultures, the provision of evidence-based care, and the communication of information about the progress of labor, the care received, and interventions during childbirth. The mistreatment prevention domain focuses on maintaining women’s dignity during labor and childbirth and preventing violations of their rights. Knowledge items are scored as 1 (Correct) or 0 (Incorrect/I don’t know), with total scores ranging from 0 to 23. Practice items are rated on a 5-point Likert scale (1-5), yielding total scores between 23 and 115. Reverse scoring was applied to items 21-23 (21). To enable comparisons, scores were standardized to a 0-100 scale using the formula below. The face and content validity and reliability of the instrument were assessed by Moridi et al. (21). Cronbach’s alpha was 0.78 for knowledge and 0.87 for practice.
Respectful maternity care (RMC) involves providing care that preserves women's dignity, privacy, and confidentiality, protects women from harm, supports informed decision-making, and provides ongoing support throughout labor and delivery (1). Despite global improvements in maternal and neonatal outcomes, ensuring high-quality care remains essential. Integrating evidence-based practices with personalized and respectful care is critical to achieving the Sustainable Development Goals of reducing maternal and newborn mortality. Approximately 50% of maternal deaths and over 60% of neonatal deaths result from poor-quality care (2).
Labor and childbirth are vulnerable periods for women, and a lack of respectful care may result in lasting negative experiences, including fear of childbirth and a preference for cesarean delivery (3,4). Furthermore, a positive association has been identified between the total RMC score and both aspirations for future fertility and the preferred fertility rate under ideal socioeconomic circumstances (5). In this regard, the World Health Organization emphasizes the importance of strengthening midwifery education to achieve higher-quality care across childbirth, reproductive health, and the overall well-being of women and children (2).
Disrespect during childbirth is a global concern (4), and women who experience such disrespect are more likely to receive low-quality care (5). Many women experience disrespectful maternity care for various reasons (6-10). Some providers consider verbal abuse justified when women do not comply with instructions, particularly during emergencies (11). One study found that only 15% of midwives had sufficient knowledge of RMC principles (12). Factors such as inadequate facilities, high workloads, and limited staff training adversely affect the provision of respectful care (13).
Evidence suggests that RMC reduces the risk of disrespect and abuse by up to two-thirds (14). Essential elements of RMC include informed consent, communication, dignity, privacy, equitable access to care, emotional support, and continuous care provided by competent and motivated professionals (15). Few studies have directly examined midwives’ knowledge and practices regarding RMC (12), and the available findings are mixed. For example, midwives in Bhutan reported awareness of women’s rights but often failed to respect women’s choices in practice (13). In a study conducted in Nepal, maternity care providers held negative attitudes toward certain practices, such as allowing birth companions and supporting women’s preferred birth positions (16). In another study, midwives demonstrated substantial perceived competence alongside self-reported RMC practices (17).
Although studies in different regions of Iran have examined midwives’ knowledge and practice of respectful maternity care, their findings vary across provinces (16,17). Differences in midwifery autonomy, hospital organizational type (Public, private, or semi-private), the presence of OB/GYN residents, and regional resources and cultures may contribute to this variation (12). Building on this evidence, the present study aimed to assess midwives’ knowledge and practice of RMC and examine related factors in the maternity wards of Golestan Province, Iran.
Methods
Study Design and Participants: A cross-sectional study was conducted from February to September 2023 among midwives working in the maternity wards of hospitals across Golestan Province, Iran. The inclusion criteria were an associate degree or higher in midwifery, at least one year of experience in a maternity ward, access to a smartphone, computer, or laptop, and internet access. The exclusion criteria included experiencing a significant adverse event within the previous six months (e.g., severe illness, death of a first-degree relative, or divorce), self-reported mental health disorders (e.g., anxiety or depression), or the use of related medications. We used the STROBE reporting guideline (18) to draft this manuscript and the STROBE reporting checklist (19), included as Supplement Table A, during editing.
Sampling: Initially, a census sampling strategy was adopted, and all eligible midwives working in the selected hospitals were invited to participate. The response rate was 46% ((137)/ (342-50) =137/292=46%) (Figure 1). The adequacy of the number of participants was assessed to determine whether it was sufficient to examine the association between the two primary study variables (Knowledge and practice). Because no previous studies had reported the expected correlation coefficient between these variables, the correlation observed among the first 100 participants (r = 0.50) was used to estimate the minimum required sample size. Assuming a significance level of 0.05 and statistical power of 80%, the minimum required sample size was estimated to be 29 participants. Recruitment continued until all eligible midwives had been approached, and a total of 137 midwives were ultimately included in the study, exceeding the estimated minimum sample size.
Demographic and Occupational Characteristics Form: This form consists of two parts. The first part includes questions on age, educational level, marital status, and mode of delivery among participants who had children. The second part includes questions on the type of university from which the participant obtained a Bachelor’s degree, years of work experience, type of hospital, the presence or absence of obstetric and gynecologic residents in the hospital, employment status, job satisfaction (Measured on a 10-point scale), interest in midwifery (Measured on a 10-point scale), and possession of a 60-hour physiological birth certificate. Because this course familiarizes midwives with the physiological process of labor, the need for psychological and emotional support during labor, and pain-reduction techniques (20), participation in the course was considered potentially relevant to midwives' knowledge and practice of RMC.
MKP-RMC Scale: This 46-item instrument assesses midwives’ knowledge (23 items) and practice (23 items) across three domains: emotional support, safe care, and mistreatment prevention. The emotional support domain includes items related to establishing friendly communication and fostering mothers’ autonomy and comfort. The safe care domain emphasizes confidentiality, privacy, respect for women’s religious beliefs and cultures, the provision of evidence-based care, and the communication of information about the progress of labor, the care received, and interventions during childbirth. The mistreatment prevention domain focuses on maintaining women’s dignity during labor and childbirth and preventing violations of their rights. Knowledge items are scored as 1 (Correct) or 0 (Incorrect/I don’t know), with total scores ranging from 0 to 23. Practice items are rated on a 5-point Likert scale (1-5), yielding total scores between 23 and 115. Reverse scoring was applied to items 21-23 (21). To enable comparisons, scores were standardized to a 0-100 scale using the formula below. The face and content validity and reliability of the instrument were assessed by Moridi et al. (21). Cronbach’s alpha was 0.78 for knowledge and 0.87 for practice.
Data collection
Following approval by the Research Ethics Committee, the contact information of eligible midwives was obtained from the university's Vice Chancellor for Treatment. The principal investigator (M.G.) contacted potential participants by telephone to explain the study objectives, assess eligibility, and obtain oral informed consent. Eligible midwives were subsequently sent a link to the online questionnaire. An electronic informed consent form appeared on the first page of the questionnaire, and participation proceeded only after consent was provided. Nonrespondents received up to three follow-up reminders. Individuals who did not respond after these attempts were excluded from the study. The data collection process is shown in the study flowchart (Figure 1).
.PNG) Figure 1. Flowchart depicting the study sampling process |
Results
Of the 342 eligible midwives invited, 137 completed the questionnaire, corresponding to a participation rate of 46%. The demographic and occupational characteristics of the midwives are shown in Table 1. The mean age and work experience of the participating midwives were 35.3 and 10.7 years, respectively. On a 10-point scale, the mean job satisfaction score was 6.8, and the mean level of interest in the field was 8.3.
The standardized mean and median scores for midwives' knowledge and practice of RMC are shown in Table 2. Knowledge and practice scores differed significantly across all domains except "providing safe care." Detailed item-level findings are presented in Supplementary Tables B1-B3.
Spearman’s correlation analysis (Table 3) suggests that greater knowledge of emotional support and safe care is generally associated with better practice in the corresponding domains, whereas knowledge of mistreatment prevention has weaker and less consistent associations with practice. Total knowledge scores were moderately and significantly correlated with total practice scores (r = 0.45, P < 0.001).
Table 4 compares total practice and knowledge scores according to demographic and occupational characteristics. The only statistically significant difference was observed between education levels for total practice scores (P = 0.05), with participants holding a Bachelor’s degree reporting higher median practice scores, 95.65(13.04), than those holding a Master’s degree, 84.90 ± 4.84. No significant association was found between education level and total knowledge scores (P = 0.43).
Spearman’s correlation analysis showed that demographic and occupational history characteristics generally had weak associations with both knowledge and practice of respectful maternity care (Table 5). Age and years of work experience were not significantly correlated with any domain, with coefficients ranging from -0.17 to 0.12. Job satisfaction was modestly correlated with practice scores, reaching significance only for total practice (r = 0.18, P = 0.03). Interest in midwifery emerged as the most consistent correlate of practice, showing significant positive associations with mistreatment prevention (r = 0.23, P < 0.001) and total practice (r = 0.19, P = 0.02), as well as an association with safe care practice (r = 0.16, P = 0.05). No demographic or occupational history variable was significantly associated with any knowledge domain (Table 5).
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Table 1. Description of demographic and occupational characteristics
.PNG) SD: Standard Deviation, OB/GYN: Obstetrics and Gynecologic, Private: Islamic Azad Universities Table 2. Comparison of the standardized mean score of knowledge and practice of respectful maternity care among midwives .PNG) * Wilcoxon Signed-Rank Test Table 3. Correlation analysis of knowledge and practice scores by domains .PNG) *Spearman's Correlation, CC: Correlation Coefficient, Significance level: p < 0.01 |
In the generalized linear regression model adjusted for demographic and occupational variables, education level was the only factor significantly associated with knowledge (Table 6). Midwives with a bachelor's degree had significantly lower knowledge scores than those with a master's degree (B = -67.60, 95% CI: -132.82 to -2.39, P = 0.04). None of the other variables showed a statistically significant association with knowledge (P > 0.05).
After adjustment for demographic, educational, and occupational variables, the knowledge score was positively associated with practice (B = 246.73, 95% CI: 152.94-340.52, P < 0.001). No other variables were independently associated with practice (P > 0.05). No associations were observed for job satisfaction or interest in midwifery after adjustment for potential confounders (Table 7).
After adjustment for demographic, educational, and occupational variables, the knowledge score was positively associated with practice (B = 246.73, 95% CI: 152.94-340.52, P < 0.001). No other variables were independently associated with practice (P > 0.05). No associations were observed for job satisfaction or interest in midwifery after adjustment for potential confounders (Table 7).
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Table 4. Comparison of mean total practice and total knowledge scores according to demographic and career history variables
.PNG) *Mann-Whitney U test used for binary variables; Kruskal-Wallis test used for variables with more than two categories. Bolded p-values indicate statistical significance (p ≤ 0.05). OB/GYN: Obstetrics and Gynecologic Private: Islamic Azad Universities Table 5. Correlation analysis results for the relationship between background variables and knowledge and practice in respectful maternity care .PNG) *Spearman's Correlation CC: Correlation Coefficient Significance level: p < 0.01 |
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Table 6. Generalized linear regression analysis of factors associated with respectful maternity care knowledge
.PNG) Result of the comparison between fitted model and the intercept-only model Likelihood Ratio Chi-Square=13.10; p-value=0.729 Table 7. Generalized linear regression analysis of factors associated with respectful maternity care practice .PNG) Result of the comparison between fitted model and the intercept-only model Likelihood Ratio Chi-Square=40.77; p-value=0.002 |
Discussion
In this study, midwives demonstrated good levels of knowledge and practice regarding respectful maternity care. The highest knowledge and practice scores were observed in the domains of "providing emotional support" and "providing safe care." By contrast, the lowest scores in both areas were observed in the domain of "preventing mistreatment."
Consistent with previous studies conducted in other regions of Iran (22,23), our findings highlight midwives’ relative weakness in the domain of “preventing mistreatment.” This domain emphasizes the importance of safeguarding women’s dignity throughout labor and childbirth (21). Notably, unlike the other two domains, knowledge scores in this domain were not significantly associated with practice scores. Therefore, factors beyond knowledge, such as occupational pressures and environmental conditions, may contribute to midwives’ lower performance in this domain.
According to our findings, job satisfaction and interest in midwifery affect both the overall practice score and the practice score in the domain of “preventing mistreatment.” This finding is consistent with the studies by Haqdoost et al. (22) and Hadizadeh et al. (24), both of which indicate a direct relationship between job satisfaction and midwives’ professional performance. In many regions, including Iran, the structure of the healthcare system contributes to stress and burnout among midwives, adversely affecting the quality of obstetric care provided (25,26). Overall, 72.82% of Iranian midwives experience high levels of occupational stress (27). Stress can reduce job satisfaction (28) and consequently diminish the motivation to provide RMC. Thus, although midwives may have adequate knowledge of respectful maternity care, stress and excessive workloads may prevent them from implementing it effectively.
Midwives’ mean knowledge scores were higher than their practice scores in all domains except the provision of safe care. Consistent with these findings, studies involving mothers indicate that many experience various forms of mistreatment and disrespectful care (29,30). Some midwives do not regard violence against women during childbirth as mistreatment but instead view it as a means of ensuring a successful delivery (31).
The lowest-scoring item in the knowledge section was “Providing accurate information to companions about the progress of labor.” Informed decision-making is essential to the provision of safe and respectful maternity care. Although midwives are eager to provide care that supports informed and participatory decision-making, they encounter several barriers. These include insufficient specific knowledge and training, fear of blame and legal repercussions, structural constraints such as limited time, and a medicalized approach to midwifery care (32).
In the practice section, the lowest-scoring statement was “I do not allow women to have companions in the delivery room.” Notably, approximately two-thirds of midwives did not allow companions in the delivery room. Similarly, in the study by Shakibazadeh et al., the most common form of mistreatment reported from the mothers' perspective was in the domain of "not allowing movement, fluid intake, and having a companion" (29). Although previous research has demonstrated the numerous benefits of having a trusted companion (33), factors that may hinder a companion's presence during labor include limited awareness among staff and mothers of these benefits, insufficient space, concerns about mothers' privacy, and fear of an increased risk of infection (34).
Most midwives reported that they “provide equal care to all women, regardless of their socio-economic status, ethnicity, etc,” with over 99% doing so all or most of the time. This finding is consistent with other studies (29,35). In the study by Shakibazadeh et al. (29), the least frequently reported forms of mistreatment were related to “stigma and discrimination.” Meanwhile, Hajizadeh et al. found that the highest respectful maternity care score was in the domain concerning women (35). By contrast, in a study conducted by Mirzania et al. in Tehran, 53.8% of maternity care providers expressed negative attitudes toward stigma and discrimination, believing that equal services could not feasibly be provided to all women during labor and delivery. That study included midwives, obstetrician-gynecologists, and medical students, whereas the present study focused exclusively on midwives (36). However, implicit bias, which may unconsciously influence staff behavior (37), should also be considered, although it was not examined in the present study.
Midwives’ age was inversely associated with the practice score in the ‘safe care’ domain. This domain emphasizes maintaining confidentiality and privacy, respecting women’s religious beliefs and cultural practices, providing evidence-based care, and ensuring that women are informed about the progress of labor and the care and interventions they receive during childbirth (21). In the study by Moridi et al. in Tehran, age had the strongest effect on midwives’ knowledge of RMC (23). The difference observed in our study may be explained by older midwives’ greater reliance on traditional routines, which may sometimes conflict with RMC standards, whereas younger midwives may have received more recent training and therefore had greater exposure to contemporary RMC concepts.
Several limitations should be acknowledged. First, data were collected using a self-report questionnaire, which may have introduced social desirability and reporting biases. Future studies incorporating direct observation of clinical practice and women's perspectives on the care received would provide a more comprehensive evaluation of respectful maternity care. Second, recruitment was challenging because contact information was unavailable for some eligible midwives. In addition, reliance on telephone invitations may have reduced participation and affected the response rate. Consequently, only 137 of the 342 eligible midwives participated, yielding a participation rate of 40.1%. This relatively low response rate represents another limitation of the study.
Conclusion
The findings of this study indicate that midwives demonstrated good levels of knowledge and practice regarding respectful maternity care. Nevertheless, significant discrepancies between knowledge and practice in the overall score and in the domains of emotional support and mistreatment prevention suggest that knowledge alone is insufficient to ensure consistent implementation in clinical practice. Therefore, interventions extending beyond knowledge enhancement, including supportive organizational strategies and continuous professional development, are recommended to promote the effective implementation of respectful maternity care.
Acknowledgement
This study was conducted as part of a master’s thesis in Midwifery Counseling at the Faculty of Nursing and Midwifery, Golestan University of Medical Sciences, Gorgan, Iran. The authors sincerely thank the Deputy of Research and Technology of Golestan University of Medical Sciences and all midwives who participated in the study for their valuable cooperation and support.
Funding Sources
The present study was financially supported by the Deputy of Research and Technology of Golestan University of Medical Sciences (Research Code: 113208).
Ethical Statement
This study was initiated after permission was obtained from the Ethics Committee of Golestan University of Medical Sciences (Ethics code: IR.GOUMS.REC.1401.601). After sufficient information regarding the study aims and procedures had been provided, written informed consent was obtained from all participants. The study was conducted in accordance with the ethical principles of the Declaration of Helsinki. Participation was entirely voluntary, and participants had the right to decline participation or withdraw at any time without consequences for their work or benefits. The confidentiality of participant information was strictly maintained through data coding and anonymization. All study data were stored securely and were accessible only to authorized research personnel.
Conflicts of Interest
The authors declare no conflict of interest.
Author Contributions
MG, NB, SM, and NSG conceived the study, developed the research plan, and analyzed the collated data. MG collected the data. NB, SM, NSG, and TS participated in implementing the research plan and assisted with data collection. MG and SM prepared the first draft of the manuscript and were responsible for submitting it for publication. All authors supported the study, reviewed and revised the article, and proposed changes. All authors participated in reviewing and revising the manuscript and ultimately approved the current version for publication.
Data Availability Statement
The datasets generated and analyzed during the current study are available from the corresponding author upon reasonable request.
Use of Artificial Intelligence
AI was used only for English-language editing, translation assistance, and manuscript proofreading. No AI tools were used for data analysis, interpretation of findings, or generation of scientific conclusions.
Type of study: Original Article |
Subject:
Midwifery
References
1. World Health Organization. Intrapartum care for a positive childbirth experience [Internet]. 2018. 212 p. Available from: https://iris.who.int/server/api/core/bitstreams/ba043cf7-cba4-484d-bf7e-ec79c4102d54/content. [View at Publisher]
2. World Health Organization. Strengthening Quality Midwifery Education for Universal Health Coverage 2030: Framework for action. [Internet]. Geneva: World Health Organization. 2019. 4-92 p. Available from: http://www.midwife.org.tw/upfiles/newsfiles/9789241515849-eng.pdf [View at Publisher] [Google Scholar]
3. Youseflu S, Moradi M, Toghyani Z, Saadatmand F, Gharib M, Haghighat-Dana Z, et al. Influential Factors of Respectful Maternity Care and Its Relationship with Women's Future Fertility Decisions. Iran J Nurs Midwifery Res. 2025;30(3):384-90. [View at Publisher] [DOI] [PMID] [Google Scholar]
4. Miller S, Lalonde A. The global epidemic of abuse and disrespect during childbirth: History, evidence, interventions, and FIGO's mother-baby friendly birthing facilities initiative. Int J Gynecol Obstet. 2015;131:S49-52. Available from: https://pubmed.ncbi.nlm.nih.gov/26433506/ [View at Publisher] [DOI] [PMID] [Google Scholar]
5. Bohren MA, Hunter EC, Munthe-Kaas HM, Souza JP, Vogel JP, Gülmezoglu AM. Facilitators and barriers to facility-based delivery in low- and middle-income countries: A qualitative evidence synthesis. Reprod Health. 2014;11(1):71. [View at Publisher] [DOI] [PMID] [Google Scholar]
6. Bohren MA, Mehrtash H, Fawole B, Maung TM, Balde MD, Maya E, et al. How women are treated during facility-based childbirth in four countries: a cross-sectional study with labour observations and community-based surveys. Lancet. 2019;394(10210):1750-63. [View at Publisher] [DOI] [PMID] [Google Scholar]
7. Hajizadeh K, Vaezi M, Meedya S, Mohammad Alizadeh Charandabi S, Mirghafourvand M. Prevalence and predictors of perceived disrespectful maternity care in postpartum Iranian women: A cross-sectional study. BMC Pregnancy Childbirth. 2020;20(1):463. [View at Publisher] [DOI] [PMID] [Google Scholar]
8. Hajizadeh K, Vaezi M, Meedya S, Mohammad Alizadeh Charandabi S, Mirghafourvand M. Respectful maternity care and its related factors in maternal units of public and private hospitals in Tabriz: A sequential explanatory mixed method study protocol. Reprod Health. 2020;17(1):9. [View at Publisher] [DOI] [PMID] [Google Scholar]
9. Yosef A, Kebede A, Worku N. Respectful maternity care and associated factors among women who attended delivery services in referral hospitals in Northwest Amhara, Ethiopia: A cross-sectional study. J Multidiscip Healthc. 2020;13:1965-73. [View at Publisher] [DOI] [PMID] [Google Scholar]
10. Kaphle S, Vaughan G, Subedi M. Respectful Maternity Care in South Asia: What Does the Evidence Say? Experiences of Care and Neglect, Associated Vulnerabilities and Social Complexities. Int J Womens Health. 2022:14:847-79. [View at Publisher] [DOI] [PMID] [Google Scholar]
11. Balde MD, Bangoura A, Diallo BA, Sall O, Balde H, Niakate AS, et al. A qualitative study of women's and health providers' attitudes and acceptability of mistreatment during childbirth in health facilities in Guinea. Reprod Health. 2017;14(1):4. [View at Publisher] [DOI] [PMID] [Google Scholar]
12. Venkatesan L, Kaur P. Respectful Maternity Care: Knowledge, Attitude and Practice of health care workers and maternal perception about respectful maternity care (RMC) - A Scoping Review Latha. J Compr Nurs Res Care. 2022;7(2). [View at Publisher] [DOI] [Google Scholar]
13. Deki S, Choden J. Assess Knowledge, Attitude and Practices of Respectful Maternity Care among nurse midwives in Referral Hospitals of Bhutan. Bhutan Heal J. 2018;4(1):1-7. [View at Publisher] [DOI] [Google Scholar]
14. Kujawski SA, Freedman LP, Ramsey K, Mbaruku G, Mbuyita S, Moyo W, et al. Community and health system intervention to reduce disrespect and abuse during childbirth in Tanga Region, Tanzania: A comparative before-and-after study. PLoS Med. 2017;14(7):e1002341. [View at Publisher] [DOI] [PMID] [Google Scholar]
15. Shakibazadeh E, Namadian M, Bohren MA, Vogel JP, Rashidian A, Nogueira Pileggi V, et al. Respectful care during childbirth in health facilities globally: a qualitative evidence synthesis. BJOG. 2018;125(8):932-42. [View at Publisher] [DOI] [PMID] [Google Scholar]
16. Ghimire NP, Dahal P, Joshi SK, Swahnberg K. Effectiveness of Forum Play to promote respectful maternity care: A pilot intervention investigating self-reported perception and behaviour among care providers in urban Nepal. PLoS One. 2026;21(6):e0349437. [View at Publisher] [DOI] [PMID] [Google Scholar]
17. Jose SM, Subrahmanyam N. Perceived Competencies and Self-Reported Practices on Respectful Maternity Care ( RMC ) During Childbirth Among Midwives in Health Facilities . A Descriptive Cross-Sectional Study from Kerala. Public Health. 2026;11(1). [View at Publisher] [Google Scholar]
18. Von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: Guidelines for Reporting Observational Studies. Ann Intern Med. 2007;147(8):573-7. [View at Publisher] [DOI] [PMID] [Google Scholar]
19. Von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP, et al. The STROBE reporting checklist. In: Harwood J, Albury C, de Beyer J, Schlüssel M, Collins G, editors. The EQUATOR network reporting guideline platform [Internet]. The UK EQUATOR Centre; 2025. Available from: https:/resources.equator-network.org/reporting-guidelines/strobe/strobe-checklist.docx [View at Publisher]
20. Irmidwifery.com. Dore-ye amoozesh-e gheir-hozoori dar Ordibehesht 1402 [Online training course in Ordibehesht 1402] [Internet]. 2023 [cited 2025 Jun 17]. Available from: https://irmidwifery.com/dore-ordibehesh-1402/ [View at Publisher]
21. Moridi M, Pazandeh F, Hajian S, Potrata B. Development and psychometric properties of midwives' knowledge and practice scale on respectful maternity care (MKP-RMC). PLoS One. 2020;15(11):e0241219. [View at Publisher] [DOI] [PMID] [Google Scholar]
22. Haghdoost S, Abdi F, Amirian A. Iranian midwives' awareness and performance of respectful maternity care during labor and childbirth. Eur J Midwifery. 2021:5:59. [View at Publisher] [DOI] [PMID] [Google Scholar]
23. Moridi M, Pazandeh F, Potrata B. Midwives' knowledge and practice of Respectful Maternity Care: a survey from Iran. BMC Pregnancy Childbirth. 2022;22(1)):752. [View at Publisher] [DOI] [PMID] [Google Scholar]
24. Hadizadeh Talasaz Z, Nourani Saadoldin S, Taghi Shakeri M. The Relationship between Job Satisfaction and Job Performance among Midwives Working in Healthcare Centers of Mashhad, Iran. J Midwifery Reprod Health. 2014;2(3):157-64. [View at Publisher] [DOI] [Google Scholar]
25. Bohren MA, Vogel JP, Tunçalp Ö, Fawole B, Titiloye MA, Olutayo AO, et al. Mistreatment of women during childbirth in Abuja , Nigeria : a qualitative study on perceptions and experiences of women and healthcare providers. Reprod Health. 2017;14(1):9 [View at Publisher] [DOI] [PMID] [Google Scholar]
26. Shimoda K, Leshabari S, Horiuchi S. Self-reported disrespect and abuse by nurses and midwives during childbirth in Tanzania: A cross-sectional study. BMC Pregnancy Childbirth. 2020;20(1):584. [View at Publisher] [DOI] [PMID] [Google Scholar]
27. Martínez-Galiano JM, Rodríguez-Almagro J, Rubio-Álvarez A, Ortiz-Esquinas I, Ballesta-Castillejos A, Hernández-Martínez A. Obstetric Violence from a Midwife Perspective. Int J Environ Res Public Health. 2023;20(6):4930 [View at Publisher] [DOI] [PMID] [Google Scholar]
28. Ghazali Vardanjani M, Montazeri S, Jahanbani Veshare E, Ghanbari S. Investigating the relationship between organizational health and burnout and job stress among midwives working in hospitals in 2020. J Educ Health Promot. 2024;13:77. [View at Publisher] [DOI] [PMID] [Google Scholar]
29. Shakibazadeh E, Taherkhani F, Yekaninejad MS, Shojaeizadeh D, Tajvar M. Prevalence of disrespectful maternity care in hospitals affiliated with TUMS and its associated factors. HAYAT. 2021;27(3):262-77. [View at Publisher] [Google Scholar]
30. Mirzania M, Shakibazadeh E, Bohren MA, Hantoushzadeh S, Babaey F, Khajavi A, et al. Mistreatment of women during childbirth and its influencing factors in public maternity hospitals in Tehran, Iran: a multi-stakeholder qualitative study. Reprod Health. 2023;20(1):1-26. [View at Publisher] [DOI] [PMID] [Google Scholar]
31. Yalley AA. "We Beat Them to Help Them Push": Midwives' Perceptions on Obstetric Violence in the Ashante and Western Regions of Ghana. Women. 2022;3(1):22-40. [View at Publisher] [DOI] [Google Scholar]
32. Kloester J, Willey S, Hall H, Brand G. Midwives' experiences of facilitating informed decision-making - a narrative literature review. Midwifery. 2022:109:103322. [View at Publisher] [DOI] [PMID] [Google Scholar]
33. Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth. Cochrane Database Syst Rev. 2012:10:CD003766. [View at Publisher] [DOI] [PMID] [Google Scholar]
34. Bohren MA, Berger BO, Munthe-Kaas H, Tunçalp Ö. Perceptions and experiences of labour companionship: A qualitative evidence synthesis. Cochrane Database Syst Rev. 2019;3(3):CD012449. [View at Publisher] [DOI] [PMID] [Google Scholar]
35. Hajizadeh K, Vaezi M, Meedya S, Mohammad Alizadeh Charandabi S, Mirghafourvand M. Respectful maternity care and its relationship with childbirth experience in Iranian women: A prospective cohort study. BMC Pregnancy Childbirth. 2020;20(1):468. [View at Publisher] [DOI] [PMID] [Google Scholar]
36. Mirzania M, Shakibazadeh E, Bohren MA, Babaey F, Hantoushzadeh S, Khajavi A. Knowledge, attitude and practice of healthcare providers on mistreatment during labour and childbirth: a cross-sectional study in Tehran, Iran, 2021. 2022;1-20. [View at Publisher] [DOI] [Google Scholar]
37. Hall WJ, Chapman MV, Lee KM, Merino YM, Thomas TW, Payne BK, et al. Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: A systematic review. Am J Public Health. 2015;105(12):e60-76. [View at Publisher] [DOI] [PMID] [Google Scholar]
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