Identifying Strategies for Implementing Woman-Centered Care in Iranian Maternity Services: A Modified Delphi Study

Abstract

Background

At the heart of the midwifery profession lies the profoundly valuable philosophy of woman-centered care. Given the high rate of unnecessary interventions and women’s limited access to optimal health services in Iranian maternity care, a locally-developed strategy is essential to promote woman-centered care. The current study aimed to provide strategies to improve and promote woman-centered care in the provision of maternity services.

Methods

This study is part of a mixed-methods research with a sequential explanatory design, conducted in two rounds using a modified Delphi technique. This study was conducted from July to September 2023 in Tabriz, Iran. The strategies were designed by incorporating the results of the quantitative and qualitative phases of the mixed-methods study, along with a literature review and feedback received from the experts. This study involved 13 experts with Ph.D. degrees in Midwifery or Reproductive Health, drawn from the faculty members of various educational and research institutions across different cities in Iran (Tehran, Tabriz, Alborz, Ahvaz, Urmia, Ardabil, and Babol). Consensus was defined as ≥70% agreement on a 5-point Likert scale in the second round.

Results

The strategies included 89 statements, which were divided into seven categories: 1) ethical values, 2) professional competence, 3) occupational and regulatory laws 4) education of women and midwives, 5) labor, pregnancy, and childbirth 6) policy-making and implementation, and 7) social recommendations. All 89 recommendations (100%) achieved the predefined consensus threshold of ≥70%. Based on consensus levels, recommendations were classified into two implementation tiers: Core recommendations (Priority 1) with 100% consensus (n=62) recommended for immediate implementation, and Optional recommendations (Priority 2) with 92.30% to 76.92% consensus (n=27) suitable for phased implementation.

Conclusion

The findings of the current study provided clear principles and standards regarding strategies for improving and promoting woman-centered care in health centers and hospitals by Iranian midwives. These recommendations serve as a self-assessment tool for midwives, a framework for curriculum revision, a roadmap for administrators to optimize staffing, and clear policy directions for budget allocation, midwife-led care models, and reducing out-of-pocket expenses. Future research should evaluate implementation feasibility across diverse settings and include perspectives from all maternity care stakeholders.

Introduction

Undoubtedly, the contribution of women, as the backbone of primary health care systems and the foundation of families, is often unrecognized and undervalued. The official slogan for International Women’s Day on March 8, 2025, is “For All Women and Girls: Rights. Equality. Empowerment”. Additionally, the slogan for the 2025 International Women’s Day campaign is “Accelerate Action”. These two slogans emphasize the urgent and decisive action needed to achieve gender equality and ensure that all women and girls have equal rights, opportunities, and power.¹

Women’s health encompasses

A broad range of physical and mental well-being and goes beyond reproductive health to include the unique conditions of women and the social factors affecting women’s health.²

There is a direct link between women’s health and the need for woman-centered care (WCC). As this approach prioritizes women’s perspectives and addresses the full spectrum of their health needs, from reproductive health to mental and social well-being. By prioritizing the perspectives, needs, and preferences of women, this approach is widely recommended to enhance the quality of maternity services.³

Woman-centered care (WCC) is one of the approaches to improving gender inequalities in the quality of health care and is the basis of the United Nations World Conference on Women report in 1995,⁴ the World Health Organization report in 2009,⁵ and the United Nations report in 2018 titled “Gender Equality in the 2030 Agenda for Sustainable Development”.⁶ In the midwifery profession, there is widespread acceptance of the definition of woman centered care provided by Leap. According to this definition, WCC includes principles such as women’s choice, control, continuous care, and self-determination during the pre-pregnancy, pregnancy, childbirth, and postpartum periods.⁷

Despite the numerous definitions of WCC presented globally, there was no evidence-based definition for WCC until 2024. Finally, according to the evidence-based definition provided by Brady et al, in a WCC approach, women have the right to choice and control in their childbirth experiences. Relationships built on trust and mutual respect empower women and recognize their inherent ability to meet their needs. This is confirmed through collaborative and informed evidence-based decision-making that supports women in navigating complex health systems and ultimately improves health outcomes for both women and infants.⁸

Notably, the evidence-based definition by Brady et al excludes continuity of care as a core feature of WCC, which plays a fundamental role in Leap’s definition, because the midwives participating in their international Delphi study did not consider this feature essential. For Iran, where research confirms the value of continuous midwifery care and medicalized interventions are prevalent, an integrated approach combining Brady’s pragmatic, inter professional framework with Leap’s emphasis on continuity may be most effective for sustainable WCC implementation.^7,8

WCC offers extensive benefits for mothers, newborns, families, and midwives. For mothers, it facilitates physiological labor, enhances self-confidence, and enables freedom of movement during childbirth. For newborns, it strengthens mother-infant bonding, promotes active maternal care, ensures a calm birth, and supports early breastfeeding initiation and continuation. For families, it encourages active participation and enhances feelings of security and control, leading to satisfaction. For midwives, it fosters mutual communication, professional autonomy, and job satisfaction.⁹

In Iran, medicalized interventions are common, including non-consensual episiotomies, excessive vaginal exams, routine oxytocin, and high cesarean rates. These contribute to negative birth experiences in 37% of Iranian women—higher than global averages.¹⁰ Despite growing recognition of WCC, professional tensions between gynecologists and midwives, rigid protocol adherence, and limited midwifery autonomy persist. International recommendations fail to address Iran’s cultural and structural challenges, and no local consensus framework exists.¹¹

Consequently, given the different cultural context in Iranian women’s society, there is insufficient knowledge about how to achieve WCC and its principles in Iranian society. Such knowledge is necessary to inform future intervention planning, policy development, and guidelines that, in turn, promote WCC. Therefore, this study was conducted with the aim of providing strategies to improve and promote WCC in the provision of maternity services among Iranian midwives.

Methods

Study Design

This study is part of a mixed-methods research with a sequential explanatory design,¹² conducted in two rounds using a modified Delphi technique. The quantitative section of the study was a cross-sectional study that examined the status of WCC and its associated factors among 575 Iranian midwives working in public and private healthcare centers in Tabriz, using the Woman-Centered Care Self-Reporting Tool for Midwives (WCC-MSR) in Iran.¹³ The qualitative section aimed to elucidate the perspectives and experiences of midwives and pregnant/postpartum women regarding WCC and its related factors, involving 15 midwives and 10 women under their care.¹³ While the qualitative study identified key barriers and facilitators from the perspectives of midwives and women, it did not provide practical, consensus-based strategies for implementing WCC across the Iranian maternity system. The current manuscript focuses exclusively on the modified Delphi technique, which was conducted to develop practical strategies for WCC. The present Delphi study extends those findings by generating a list that synthesizes the results of the quantitative study,¹³ the qualitative study,¹⁴ a literature review. Most importantly—the recommendations of reproductive health and midwifery experts from across Iran, resulting in actionable recommendations with consensus levels exceeding 70%. Therefore, this study was conducted with the aim of providing strategies to improve and promote WCC in maternity services from July to September 2023, involving 13 experts (specialists in midwifery and reproductive health) in Tabriz, Iran.

The Delphi method can be defined as a structured technique for effectively moderating a group communication process that allows a group of individuals to address a complex problem as a whole. This is based on the assumption that a group of experts and a multitude of relevant perspectives provide a more valid outcome than a judgment made by a single expert, even if that expert is the best in their field.¹⁵ In the Delphi approach, when a set of structured questions/statements derived from the relevant literature on the topic is used, it is referred to as the modified Delphi technique, which is the approach employed in this study. This technique was chosen because it is a suitable method for topics with limited evidence and documentation regarding maternal care services, such as WCC, for which there are no guidelines for implementation in clinical settings. This Delphi study is reported based on the framework for conducting and reporting Delphi studies (CREDES).¹⁶

Participant Recruitment and Setting

To provide strategies for improving and promoting WCC by midwives, the lead authors (MM and S M-A) first identified specialists to form a steering committee. Participants in this study included 13 experts with Ph.D. degrees in Midwifery or Reproductive Health, comprising 5 members from the field of midwifery and 8 from reproductive health, drawn from the faculty members of various educational and research institutions across different cities in Iran (Tehran, Tabriz, Alborz, Ahvaz, Urmia, Ardabil, and Babol). A purposive sampling strategy was employed to gather the opinions of midwifery and reproductive health specialists from across the country. To ensure diversity, midwives with varying work experiences and academic degrees were selected from different provinces.

The inclusion criteria for experts participating in the Delphi study included: midwives with at least five years of experience, those with a background in clinical services for women, members of educational and research faculty, and those who were knowledgeable about WCC issues. To inform the development of the survey and create a framework for the steering committee discussions, a comprehensive review of existing literature related to supportive strategies for improving WCC was conducted by the researcher (S M-A) in the PubMed, Scopus, and Web of Science databases, as well as the Google Scholar search engine over a two-week period in July 2023. The search employed the following key terms and combinations: “woman-centered care” OR “woman-centred care” OR “patient-centered care” OR “client-centered care” AND “maternity services” OR “midwifery” AND “implementation” OR “strategy” OR “guideline”. This review focused on the definition, concept, and measurement of WCC. We limited the search to studies published in English within the last 10 years. Articles that only contained the abstract of a proposed study without reporting study findings were excluded. A total of 16 articles were thoroughly examined. Finally, based on the findings from the literature review and results from two quantitative and qualitative studies, the corresponding and first author (MM and S M-A) prioritized topics to include in the Delphi surveys and formulated the survey questions.

In the next stage, a formal request was made to specialists to express their willingness to join the panel and participate in the Delphi method. At this stage, the purpose of the topic and the role of the experts, as well as a brief explanation of the activities conducted, were emailed to them. This included a letter detailing the study’s aims, the participation process, the timeline, an introduction to the Delphi survey, a consent form related to the study, and a guide on the concept of WCC. Before participating, panel members were informed about the survey topics and the estimated length of the survey. Each round provided an appropriate time frame (two weeks) for responses, with additional time allocated for reminders and responses one day after the deadline. However, participation was voluntary, and they could withdraw at any time. They were also informed that their individual responses would not be shared with other panel members and that their contributions would be kept confidential. Panel members did not receive any compensation for their time. Additionally, in each round of the survey, the study’s aims were reiterated to the participants before presenting any survey questions, and they were encouraged to contact the research team via Email if they had any questions. After each round, the research team analyzed the results.

Survey Rounds and Sampling Method

The Delphi method relies on the researcher assessing the scope of the issue and the available resources to determine the appropriate size of the panel. Additionally, it emphasizes that the researcher should consider the panel size based on the skills and knowledge of the specialists in the field, the diversity of representation, experience, and work in the construct being studied.¹⁷ There are no specific recommendations for the number of rounds required in a Delphi study, as the number of Delphi rounds is determined individually and according to the opinions of the specialists. The CREDES framework for conducting and reporting Delphi studies indicates that the number of rounds in a Delphi survey can range from 1 to 5, with most studies utilizing two or three rounds in their review.¹⁸ Considering that the Delphi study is an iterative process and based on similar Delphi studies conducted in midwifery, all of which completed two survey rounds, it was anticipated that this study would also require two survey rounds. Ultimately, after receiving feedback from the specialists and the research team, it was agreed that the understanding of the concept of WCC could be achieved in a total of two survey rounds.¹⁹ Similar to other Delphi studies, we did not determine the sample size based on achieving statistical power; rather, our goal was to recruit a diverse group of participants who would represent various specialists relevant to this field. Scientific resources suggest that a panel consisting of 8 to 10 specialists is sufficient to generate a wide range of opinions, and some studies have exceeded this limit.²⁰ Some believe that increasing the number of participants leads to greater reliability of the data; however, there is little empirical evidence regarding the impact of the number of specialists on the reliability of consensus. Therefore, the expertise of individuals is more important than their quantity. Ultimately, a total of 13 specialists in midwifery and reproductive health participated in the Delphi stages.

First Round of Delphi

The first round of the Delphi study began with sending an invitation to the expert panel via email. In the first phase, texts related to the development of questions were extracted based on previous studies and the results of the quantitative and qualitative sections of the mixed-methods study. The findings from the literature review and the results of the quantitative and qualitative sections provided a foundation for developing key areas of WCC. Each faculty member was asked to provide a list of judgments, predictions, or opinions regarding the identified issues or topics. At this stage, three open-ended questions were posed, and specialists were requested to submit their written responses to these questions. The questions were clear and unambiguous, and since the intensity of the program’s implications was related to the use of relevant verbs and adverbs, clear verbs were employed. Each participant was asked to provide their revised recommendations and additional comments regarding the questionnaire. The questions were as follows:

• 1)In your opinion, what characteristics define WCC?
• 2)What factors do you think can facilitate the provision of WCC?
• 3)What factors do you believe could act as barriers and obstacles to providing WCC?

Responses were collected, coded, and categorized. Duplicate responses were removed, and some answers with similar meanings were combined. Qualitative analysis of the open-ended responses was conducted using the analytical framework of Gill and Heath,²¹ which includes the processes of transcription, familiarization, coding, and analysis. The entered data were read, re-read, and coded, with similar sentences merged and converted into final codes. Key words and phrases were reviewed, combined, and summarized in general sentences to capture the intended meanings in the responses. During the qualitative analysis, two researchers (S M-A and MM) independently analyzed, coded, and interpreted the data, collaborating to resolve any disagreements and reach a consensus on the content.

Second Round of Delphi

After receiving the data from the first phase and incorporating new suggestions, the second round continued with the revision of the statements. The first author (S M-A) created the initial list and categorized the items based on five themes identified through thematic analysis in the study by Schobinger et al (2024). The corresponding author (MM) independently reviewed the list for clarity and to ensure that no items from the quantitative and qualitative study results and expert opinions were overlooked. Ultimately, a list of 89 items was included in this survey. At this stage, the revised items were sent to the panel members via email. Given the possibility of experts withdrawing in this round as well, efforts were made to emphasize the importance of the second round to all panel members.

Therefore, all panel members completed the second round within the specified timeframe. At this round, panel members were asked to indicate their level of agreement with the extracted statements using a 5-point Likert scale (strongly agree, agree, disagree, strongly disagree, and not applicable) regarding their importance in WCC and feasibility/cost-effectiveness. For each question, the option “not applicable” was included, and panel members were asked to select this option if they felt a question was outside their experience or area of expertise.

At this stage, the statements were reviewed based on the level of agreement. The status of agreement or disagreement among the panel members was clarified, and in this round, experts were given the opportunity to express any new ideas, interpretations, as well as to add or remove other items, and to explain the strengths or weaknesses of various statements. Globally, there are no uniform guidelines regarding what is considered consensus in a Delphi study.²² Different studies employ various approaches that best suit their needs. Three consensus criteria have been used by different studies, including the percentage level of agreement, mean scores, and interquartile ranges.²² We used the percentage level of agreement. Additionally, the Delphi method does not require participants to reach a fully agreed-upon outcome; assessing the presence or absence of agreement in a specific area is practical. Therefore, the terms “agreement” or “consensus” can be defined in each round and between rounds. Given that the topic of WCC was considered important but not life-threatening, a minimum prior agreement level of 70% was deemed acceptable.²³ For consensus calculation, responses of “strongly agree” and “agree” were combined as agreement, while “disagree” and “strongly disagree” were combined as disagreement. Responses of “not applicable” were excluded from the denominator, as these indicated that the item was outside the expert’s area of expertise. The consensus percentage was therefore calculated as: (number of “strongly agree” + “agree” responses) / (total responses – “not applicable” responses) × 100. Globally, there are no uniform guidelines regarding what is considered consensus in a Delphi study; we used the percentage level of agreement with a minimum prior agreement level of 70% deemed acceptable.²³

Ethical Consideration

This study was approved by the Ethics Committee of Tabriz University of Medical Sciences (approval code: IR.TBZMED.REC.1401.051; approval date: 6, April 2022), complied with the principles of the Helsinki Declaration, and involved full disclosure of study objectives and procedures to participants, who were assured of voluntary participation, the right to withdraw at any stage without consequences, and complete confidentiality of their identity and information throughout the research process.

Result

Characteristics of the Expert Panel

A total of 15 Midwifery or reproductive health specialists were invited, with 13 experts participating in both rounds of the Delphi survey, resulting in a notable expert response rate of 86.7% (13/15) for each survey round. All participants had clinical experience in Iranian hospitals and medical education. The specialist composition included reproductive health (n=7), midwifery (n=4), and PhDs in reproductive health by research (n=2). Among these 13 midwifery and reproductive health specialists, their ages ranged from 36 to 58 years (mean=48.3 years). Their clinical experience ranged from 3 to 35 years, and their academic experience ranged from 3 to 26 years. Additionally, all participating specialists held doctoral degrees and were faculty members at medical universities across Iran (100%, 13/13) (Table 1).

Table 1.

Characteristics of Experts in the Delphi Technique (n=13)

Participant	Sex	Degree	Academic Rank	Clinical Experience (Years)	Academic Experience (Years)	Institution Type	Area of Specialty
1	Female	PhD	Assistant professor	7	7	University of Medical Sciences	Midwifery
2	Female	PhD	Associate professor	20	22	University of Medical Sciences	Reproductive health
3	Female	PhD	Instructor	5	20	University of Medical Sciences	Midwifery
4	Female	PhD	Assistant professor	35	9	University of Medical Sciences	Reproductive health
5	Female	PhD	Associate professor	8	24	Research center	Reproductive health
6	Female	PhD	Assistant professor	17	17	University of Medical Sciences	Reproductive health
7	Female	PhD	Assistant professor	3	11	University of Medical Sciences	Reproductive health
8	Female	PhD	Assistant professor	6	16	University of Medical Sciences	Reproductive health
9	Female	PhD	Assistant professor	12	11	University of Medical Sciences	Midwifery
10	Female	PhD	Assistant professor	16	3	University of Medical Sciences	Midwifery
11	Female	PhD	Assistant professor	5	26	University of Medical Sciences	Reproductive health
12	Female	PhD	Associate professor	5	24	University of Medical Sciences	Reproductive health
13	Female	PhD	Assistant professor	7	6	University of Medical Sciences	Midwifery

Two Rounds of Delphi Survey

In the first round, experts’ opinions on the characteristics, facilitators, and barriers of WCC were collected. After coding and categorizing all 13 experts’ responses, 137 recommendations were initially identified. These were consolidated into 56 unique recommendations by merging duplicates and removing items with identical or similar concepts. For example, “respecting women’s dignity” and “maintaining women’s autonomy” were merged into “respecting women’s dignity and right to choose” (Item 1). Items that were conceptually distinct—such as “privacy,” “confidentiality,” and “respect”—were retained as separate items because they represent different dimensions of ethical care recognized in the literature and by the expert panel. Similarly, “continuous care” (temporal aspect) and “midwife-led care” (service delivery model) were retained as distinct strategies. Subsequently, 33 additional recommendations from literature reviews and the study’s quantitative and qualitative findings were added, resulting in 89 final recommendations. Examples of literature-derived items included “implementing midwife-led continuity of care models” and “designing online systems for delivering WCC,” while items derived from the qualitative phase included “avoiding instilling feelings of inferiority in clients with addiction, AIDS, and hepatitis” and “refraining from curiosity about women’s personal matters.” No recommendations were removed in the second round, as all 89 items achieved ≥70% consensus, with 76 items (85.4%) exceeding 90% agreement.

The highest-ranked recommendations—achieving 100% consensus—included: ensuring adequate staffing levels, providing continuous midwifery care, educating women about their rights, implementing midwife-led care models, reducing out-of-pocket expenses, allocating sufficient budgets, preparing birth plans, and revising midwifery curricula. Areas with relatively lower agreement (84.61% and 76.92%) included routine interventions during labor, reducing reliance on technology, modifying inflexible protocols, and media portrayals of pregnancy. These items, while still achieving consensus, reflected more diverse expert opinions and may require further discussion before implementation.

The 89 final recommendations were categorized into seven groups: 1) ethical values in woman-centered care (n=16), 2) professional competence in woman-centered care (n=20), 3) occupational and regulatory guidelines for woman-centered care (n=4), 4) education for women and midwives on woman-centered care (n=16), 5) labor, pregnancy, and childbirth in woman-centered care (n=11), 6) policy and implementation strategies for woman-centered care (n=20), and 7) social aspects of woman-centered care (n=2) (Table 2).

Table 2.

Core Recommendations for Improving of Woman-Centered Care in the Iran

Domain	Core Recommendation (Highest-Priority Recommendations)*
Ethical Values	Respecting women’s dignity and right to choose Comprehensive care (physical, psychological, cultural, social) Allocating time to listen to mothers’ needs Addressing race, poverty, violence Employing skilled midwives committed to ethical principles Midwives having skills to persuade clients Avoiding inhumane/unethical behaviors
Professional Competence	Placing women at the center of care Establishing supportive environment for informed decision-making Active participation of women in their care Professional support from healthcare staff Continuous care from pregnancy to postpartum Appropriate interpersonal and team relationships Increasing family member participation (especially spouses) Considering women’s previous experiences Adhering to physiological approach Introducing self and explaining duties to women
Occupational Regulations	Adequate staffing levels Eliminating duplicate documentation Enhancing midwives’ job satisfaction
Education	Educating women about their rights Educating mothers about reasonable expectations Providing information in simple language Providing essential education about childbirth In-service training programs Enhancing clinical knowledge of providers Enhancing psychological knowledge of providers Utilizing evidence-based information Shifting educational approaches to WCC models Fostering positive attitudes in midwives Designing WCC models adapted to resources
Policy Implementation	Reviewing midwifery curricula Reforming negative managerial attitudes Expanding range of services (home-based care) Encouraging establishment of WCC centers Considering macro-level health policies Designing online systems for WCC Allocating sufficient budget Continuous quality assessment Incorporating WCC into national protocols Preparing birth plans with women Implementing midwife-led care models Addressing conflicts of interest Reducing out-of-pocket expenses

Notes: The complete list of all 89 recommendations, including consensus type, consensus percentages, recommendation ranking and optional recommendations, is presented in Table S1. *100% Consensus.

Discussion

This study aimed to develop strategies for improving and promoting WCC from the perspective of midwifery and reproductive health specialists in Iran. The Delphi technique was selected as it provides a flexible approach for gathering expert opinions about WCC concepts, while allowing participants to reconsider their views based on others’ input - an element of reflection not typically available in single interviews or focus group studies.¹⁸ This study employed the Delphi technique to collect expert opinions for developing strategies to improve and promote WCC, ultimately yielding 89 recommendations across seven domains: ethical values, professional competencies, occupational regulations, education for women and midwives, labor/pregnancy/childbirth practices, policy implementation, and social considerations in WCC.

The first category comprised ethical recommendations. The panel agreed on fundamental principles: respecting women’s dignity, ensuring choice, establishing safety, guaranteeing access, providing attentive care with eye contact, and listening to mothers’ needs. A scoping review (2024) in Iran revealed that disrespectful care during childbirth remains a significant concern, predominantly manifesting as verbal and physical abuse alongside violations of maternal privacy. Physical mistreatment frequently involves fundal pressure, painful vaginal examinations, and other practices that contradict international birth standards and WHO guidelines. Privacy violations—including the absence of delivery curtains, the presence of unnecessary personnel during labor, and breaches of patient confidentiality—further contribute to maternal distress and discomfort. Despite ongoing efforts to promote respectful maternity care, these disrespectful behaviors persist, highlighting the critical need to address barriers such as insufficient provider knowledge, poor communication skills, staff shortages, and inadequate infrastructure.²⁴ A cross-sectional study by Yadollahi et al examined the relationship between Iranian women’s perception of their birth team’s compliance with medical ethics and their perception of labor pain. Adherence to ethical principles—particularly respecting privacy, maintaining friendly interactions, and providing fetal health assurance—significantly reduced women’s perception of pain.²⁵ This empirical evidence underscores that attention to ethical issues in Iran is not merely a theoretical concern but directly influences women’s physiological and psychological childbirth experiences.

According to midwives’ perspectives, WCC represents a hierarchical framework with three distinct levels. The foundational level consists of personal beliefs, ethics, and values (whether innate or acquired), which form the essential basis for WCC.²⁶ The second tier represents midwives’ interpersonal interactions with women and their engagement with partners, family members, community stakeholders, and other healthcare professionals involved in women’s care.²⁷ The third tier encompasses the outcomes achieved through WCC, including positive maternal and neonatal health outcomes, enhanced personal satisfaction and empowerment for women, as well as professional fulfillment for midwives and personal growth for women under their care.²⁸

Research evidence demonstrates that the characteristics of a midwife are an effective factor in providing WCC. The close relationship that a midwife establishes with a woman during childbirth makes the midwife the guardian of one of the most important events in a woman’s life.²⁹ Instead of rushing through this important life event, a skilled midwife patiently observes and waits, touches with sensitivity, listens attentively, and shows her understanding and concern for the woman and her family. In line with the results of the present study, an international Delphi study conducted by Brady et al’s aimed at exploring the concept of WCC, with a panel of 59 midwives representing 22 countries. The expert midwives stated that WCC is respectful care that recognizes all aspects of a woman’s life, including her newborn, family, and other significant individuals in her life.³⁰ The Delphi study by Filler et al involving 42 experts (21 women and 21 specialists) on patient-centered care for women similarly revealed that enhancing patient-provider relationships through establishing friendly, respectful, and comfortable interactions emerged as one of the key identified domains.³¹

The second category identified in this study comprised recommendations concerning professional competence in WCC. The expert panel reached consensus on two critical components: maintaining up-to-date, evidence-based knowledge during care provision, and employing skilled, competent midwives committed to scientific principles when delivering care to women. These findings align with the International Confederation of Midwives (ICM) framework, which primarily aims to enhance global midwifery through education based on international standards, while emphasizing the necessity of foundational clinical competencies for delivering evidence-based, standardized, and high-quality maternity services to women and families.³² A comparative analysis of Iran’s midwifery curriculum found that 79.5% of knowledge and 71.6% of skills met ICM standards. However, 24 of 315 essential competencies were inadequate, suggesting students may not be fully prepared for clinical practice.³³ A focus group study by Lohmann et al, examining 20 German midwives’ perspectives on women’s preferences for maternity care similarly identified midwives’ professional attributes as a key thematic category, with professional competence in care provision emerging as a distinct subcategory.³⁴

The study by Mashayekh-Amiri et al found Iranian midwives with less than 5 years of experience had significantly lower WCC scores compared to more experienced colleagues (>5 years),¹³ while Baluwa et al’s systematic review identified clinical competence components for midwifery students including: (a) competency attributes (knowledge, skills, professional performance), (b) prerequisites (motivation, role models, learning environment, personal characteristics), and (c) outcomes (confidence, client safety, care quality),³⁵ collectively demonstrating the critical role of both experience and structured competency development in delivering WCC.

Midwives’ clinical competence, as a key determinant of quality and effectiveness in maternity care services leading to improved outcomes for women, achieves optimal clinical results for both mother and child when combined with evidence-based practice.³⁶ Today, evidence-based practice has become an essential component of healthcare systems and regulations due to increasing demands for both high-quality and cost-effective care. In this context, findings from Dahlen et al’s study comparing WCC with other international maternity care approaches in Australia recommended that midwifery care should integrate the best available evidence with complementary guidelines, while prioritizing women’s preferences and choices over organizational or provider interests.³⁷ The study by Taye et al examining evidence-based practice implementation in clinical decision-making among midwives in Ethiopian public hospitals found that approximately half of midwives effectively applied evidence-based practice. Level of hospital, participation in continuing professional development programs, internet access at hospitals, and attendance at conferences or seminars within the past 12 months all significantly improving overall evidence-based practice implementation among midwives.³⁸

The expert panel in our study reached consensus on the necessity of specialized midwives providing continuous care throughout the prenatal, intrapartum, and postnatal periods. While Brady et al’s Delphi study challenged this notion, with participating midwifery specialists asserting that although WCC is optimally delivered through continuity of care models, it remains non-mandatory and can be effectively provided by any qualified healthcare professional.³⁰

The third category identified in this study comprised recommendations regarding occupational and regulatory guidelines for WCC. The expert panel emphasized several critical factors: maintaining adequate staffing levels per shift, implementing standardized one-to-one care systems, eliminating redundant documentation processes, and prioritizing midwives’ job satisfaction. Ensuring appropriate staffing in labor units with standardized systems emerged as a key priority, as this directly impacts the quality of care for women and their newborns.

The panel warned that midwifery shortages lead to detrimental consequences including: reduced parental education and postpartum care provision, increased delegation of tasks to auxiliary birth attendants, recruitment of foreign-trained midwives, closure of birthing centers, disruption of continuity of care teams, and in critical situations, temporary shutdown of labor units for new admissions.³⁹ The study by Turner et al examining the association between midwifery staffing levels and adverse events across 106,904 maternal admissions over 46 months demonstrated an 11% increase in reported harm incidents during periods when midwifery staff numbers fell below average levels.⁴⁰

Consequently, policymakers must develop solutions to address staff shortages and excessive workloads that lead to midwife burnout. First, the consensus on adequate staffing (Item 38, 100%) and standardized one-to-one care systems (Item 37, 92.30%) underscores the urgent need for a national midwife-to-mother ratio standard and targeted budget allocation for recruiting and retaining midwives in labor wards. Policymakers should consider reducing reliance on temporary and rotational staff in favor of permanent positions with competitive compensation and benefits. Second, the recommendation to eliminate duplicate documentation (Item 39, 100%) points to the necessity of designing and implementing an integrated electronic health recording system at the national level—a reform that would reduce administrative burdens and allow midwives to dedicate more time to direct patient care.

High-quality documentation is equally crucial for improving patient care standards and providing legal evidence of care delivery, though the documentation process can prove challenging for practicing midwives. In this regard, Bailey et al’s study of documentation practices among London-based midwives found that midwives performed best on initial note taking and partogram documentation at the start of their shifts, with fatigue potentially contributing to poorer documentation quality during mid-shift and end-shift periods.⁴¹

Understanding job satisfaction factors is critical for creating supportive work environments. A 2025 qualitative study by Pérez-Castejón et al examining job satisfaction among midwives in high-intervention delivery rooms, through interviews with 25 midwives and resident nurses, identified key influencing domains: maternal satisfaction, professional competencies, multidisciplinary teamwork, working conditions, and degree of labor interventions. Impactful working conditions included shift patterns, extended work hours, excessive administrative duties, and inadequate compensation. Prolonged shifts - particularly 12 or 24-hour rotations - were perceived as physically and emotionally exhausting due to the demanding nature of intrapartum care.⁴²

Comparative studies indicate that midwives working in delivery rooms report significantly lower job quality and satisfaction along with higher occupational stress compared to those in community health centers,⁴³ likely due to exposure to unpredictable emergencies, excessive noise, rotating shifts, extended hours, inadequate compensation relative to responsibilities, and heavy workload pressures - all negatively impacting their quality of work life, while Mashayekh-Amiri et al’s study of Iranian midwives found improved job performance scores correlated with higher job satisfaction when controlling for psychosocial workplace factors.⁴⁴

The fourth category identified in this study comprised recommendations regarding labor, delivery, and postpartum care in woman-centered approaches, as emphasized by the expert panel. In this context, results from a longitudinal study following over 900 women for five years postpartum demonstrated that when medical interventions during delivery were minimized, participants were significantly more likely to report positive long-term birth experiences.⁴⁵ The Delphi study by Goetz-Fu et al, conducted through three rounds with obstetric specialists and their patients in France, identified five key categories for developing a shared medical decision-making tool: pain management during labor, medication administration before/during delivery, delivery room events, neonatal primary care, and perineal protection.⁴⁶ Contemporary evidence-based studies confirm that routine interventions in low-risk deliveries fail to enhance safety for mothers or newborns, while certain medical interventions may disrupt natural labor progression, potentially causing unintended complications and maternal dissatisfaction.⁴⁷

The study by Volkert et al examining the impact of obstetric interventions on birth experiences revealed that women who underwent fundal pressure, assisted vaginal delivery (AVD), or unplanned cesarean sections rated their birth experiences significantly more negatively compared to those who delivered without interventions.⁴⁸ While physiological birth—occurring spontaneously without intervention—represents a natural and inherently complex process that should be respected and facilitated whenever clinically appropriate, it is equally important to recognize that certain medical interventions remain essential and life-saving in specific clinical circumstances. The Delphi panel’s recommendations on avoiding routine interventions (eg, routine episiotomy, continuous electronic fetal monitoring without clinical indication, routine intra venous lines) reflect the growing evidence that indiscriminate use of interventions in low-risk pregnancies does not improve outcomes and may cause harm. However, these recommendations should not be misinterpreted as opposing all interventions. Therefore, the panel’s recommendations advocate for a risk-appropriate approach: supporting physiological processes in low-risk pregnancies while ensuring timely and appropriate interventions when complications arise. This balanced perspective aligns with the fundamental principle of “first, do no harm” —which applies equally to unnecessary interventions and to the failure to intervene when medically indicated.⁴⁷

The expert panel reached consensus on educational recommendations for WCC, emphasizing the need to provide information using clear, simple language adapted to each woman’s literacy level while avoiding medical jargon, as evidence shows that women’s understanding of pregnancy processes, staff roles, and newborn care significantly impacts their birth experience,⁴⁹ with transparent information delivery serving as the essential foundation for informed decision-making that enhances both their participation in care choices and sense of control, ultimately improving childbirth outcomes.⁵⁰

In this regard, the results of the study by Creedy et al regarding the knowledge and skills of midwives for assessing and promoting the health literacy of mothers indicated that midwives need training on assessing and enhancing mothers’ health literacy to ensure that women understand the information conveyed.⁵¹ The results of the study by Vogels-Broeke et al indicate that pregnant women primarily obtain information from midwives (91.5%), family or friends (79.3%), websites (77.9%), and apps (61%). Additionally, when providing information to clients, healthcare providers should consider the clients’ informational needs, the quality of the information provided, barriers to receiving information, and the clarity and comprehensibility of the information.⁵²

The findings of a qualitative study by Javanmardi et al in Iran, exploring the challenges of accessing health information during pregnancy from the perspectives of women, midwives, and gynecologists, revealed several challenges. These included inadequate interaction between pregnant women and healthcare providers, stress and anxiety about facing problems, common pregnancy-related complaints, busy lifestyles and lack of time, difficulties in accessing various information sources, and the inability to distinguish correct from incorrect information.⁵³

Another category extracted from the experts’ panel perspective was policy recommendations and executive regulations for WCC. The panel reached a consensus on key policy and legal issues in WCC, including home birth implementation, continuity of midwife-led care, and reducing out-of-pocket expenses for women.

While home birth and midwife-led care are compelling, their implementation faces substantial challenges. Home births remain largely prohibited despite electronic certification provisions, with traditional practices marginalized. Registration barriers—including lack of identity documents and unregistered marriages—create administrative obstacles, especially in underserved regions. Limited infrastructure and absent referral pathways further constrain feasibility. Regarding midwife-led continuity of care, while evidence from Iran demonstrates positive effects on normal vaginal delivery rates and exclusive breastfeeding, several systemic barriers impede implementation. Health providers have identified key obstacles including: lack of continuous midwifery care in the healthcare system, absence of free accompanying midwives, lack of integrated healthcare and hospital service provision, insufficient implementation of physiologic birth programs, and professional autonomy limitations for midwives. The regulatory environment further complicates implementation: midwives’ medical autonomy is increasingly limited, home births are prohibited, and high cesarean rates—driven by healthcare privatization and economic interests of gynecologists—undermine midwifery-led models. Additionally, structural challenges in midwifery workforce management, including inadequate staffing levels, lack of midwifery supervisors, and insufficient supportive policies, must be addressed. From a policy readiness perspective, implementation requires: legal and regulatory reform to clarify midwives’ scope of practice and professional autonomy, establishing integrated health information systems to support continuity of care, addressing workforce shortages and creating new midwifery positions, insurance coverage and financial support for midwifery services, and creating separate low- and high-risk wards in maternity hospitals to facilitate physiological birth while maintaining safety for complicated cases. Without addressing these interconnected regulatory, infrastructural, and workforce barriers, the successful translation of these recommendations into sustainable practice remains uncertain.

The results of a clinical trial by Mohaghegh et al on the impact of birth plans integrated into childbirth preparation classes on maternal and neonatal outcomes among Iranian women showed that the rates of natural childbirth, satisfaction with the delivery process, and early initiation of breastfeeding were significantly higher in women with birth plans compared to those without.⁵⁴

Additionally, the findings of a systematic review by Ahmadpour et al on the effect of birth plans on delivery outcomes indicated that the average childbirth experience score and frequency of vaginal delivery were significantly higher in the birth plan group compared to the control group.⁵⁵ The results of the realist review by Simmelink et al on understanding how and under what conditions midwife-led continuity of care (MLCC) can be implemented revealed that the identified mechanisms could be grouped around challenges at the macro level, leadership issues, role ambiguity and conflict, as well as personal and professional boundaries. Despite strong evidence supporting MLCC, the diverse interests of stakeholders and power dynamics hinder its implementation. Midwife-led continuity of care (MLCC) leads to better maternal and perinatal outcomes, higher satisfaction among women, and increased job satisfaction among midwives compared to other models of care.⁵⁶

The qualitative study by Johansson et al on postpartum midwifery care at home identified three main themes: 1) mothers receiving postpartum home care from midwives did not feel “purposeless”; 2) professionally authoritative midwives guided the transition into motherhood; and 3) the home became a safe and secure environment for new mothers.⁵⁷ The results of the study by Alizadeh-Dibazari et al on birth preparedness and its facilitating and inhibiting factors from the perspective of pregnant and postpartum women in Iran revealed that maternal health during pregnancy, having a prenatal care plan, improved health literacy, and developing a birth plan were identified as critical elements for effective birth preparedness.⁵⁸

In the World Health Organization’s agenda, out-of-pocket (OOP) payments are considered a critical issue due to their negative consequences for individuals, families, and society. Global evidence indicates that OOP expenditures for healthcare in low- and middle-income countries (LMICs) are relatively higher compared to high-income countries. In most high-income countries, healthcare costs are largely covered by insurance programs, whereas middle- and low-income countries rely heavily on OOP payments.⁵⁹ The results of the study by Gamberini et al on strategies to improve pregnancy care in resource-limited settings revealed that financial barriers were also highlighted as significant obstacles that women and their families must consider. Direct out-of-pocket payments, informal payments, and overall poverty and inequality have a substantial impact on maternal and child health.⁶⁰

The final identified category was the social implications of WCC, as agreed upon by the expert panel. During the prenatal period, women undergo a critical phase of physical transformation, typically gaining an average of 20–50 pounds (approximately 9–23 kg) or more within a relatively short timeframe.⁶¹ Given that women today engage extensively with social media – with 78% of American women using at least one social networking site – the study by Rosenbaum et al examined the relationship between social media use and pregnancy-related body image. The findings revealed that passive use (eg, viewing others’ content rather than creating original posts) and increased time spent on Facebook were independently associated with less positive body image.⁶²

Advertising serves as a powerful force in shaping social norms and individual perceptions, with the potential to psychologically influence how people view themselves and others. This is particularly true for women, who have long been targeted by advertisements promoting narrow and often unrealistic standards of beauty, femininity, and gender roles. In this context, the results of a systematic review by Dai et al on the impact of advertising on women’s self-concept reveal those traditional advertisements—which frequently feature idealized and stereotypical portrayals of femininity—remain associated with negative psychological outcomes. These include increased body dissatisfaction and self-objectification.⁶³

Strengths and Limitation

Based on our comprehensive review, this study represents the first Delphi study in Iran to develop strategies for improving and promoting WCC from the perspective of midwifery and reproductive health specialists nationwide. The high agreement level exceeding 70% allowed for clear differentiation of the developed WCC statements and served as a key quality indicator for Delphi study reporting. Maintaining expert anonymity during the Delphi process promoted honesty, reduced the risk of halo effect, and prevented dominance by prominent group members, representing another strength of this study. The panel included specialists with diverse expertise (midwifery and reproductive health), varying years of experience, and representation from different provinces (ensuring geographical and ethnic diversity).

Several limitations should be acknowledged. First, despite efforts to ensure national representation by recruiting experts from seven cities across Iran, the Delphi panel was limited to 13 midwifery and reproductive health specialists, which may have introduced selection bias. The absence of obstetricians, health administrators and policymakers means that the recommendations may not fully capture the perspectives of all relevant stakeholders, potentially limiting the comprehensiveness and practical feasibility of the proposed strategies. This is a particularly important limitation because the successful implementation of WCC requires collaboration across multiple professional groups and stakeholders; midwives alone cannot drive this transformation without the engagement of obstetricians, nurses, hospital administrators, and policymakers.

While methodological guidelines confirm that panels of 8–10 experts are sufficient for meaningful results, the relatively small size may affect the generalizability of findings. Second, the panel’s professional homogeneity—all members were female midwifery and reproductive health academics—may have introduced professional homogeneity bias. This may have narrowed the range of perspectives and potentially overlooked inter-professional dynamics or systemic challenges beyond midwifery practice. Third, social desirability bias cannot be ruled out, as participants may have expressed agreement with statements aligned with the desirable ideal of WCC, potentially inflating consensus levels and overlooking practical implementation difficulties in real-world settings. Fourth, the expert panel consisted solely of Iranian specialists; therefore, this study reflects only the perspective of Iranian experts, and expanding the panel to include specialists from diverse countries would provide more comprehensive international perspectives. Fifth, Delphi studies inherently rely on expert opinion, which is generally considered a weaker basis for evaluating healthcare interventions compared to empirical evidence. However, as noted in the methods section, this Delphi study forms part of a larger mixed-methods study, with its results being interpreted alongside quantitative and qualitative findings, thereby enhancing the overall quality and robustness of the evidence.

Conclusion

Given that implementing WCC principles offers significant benefits for mothers, newborns, families, healthcare systems, and society at large—yet faces numerous barriers that often lead to its neglect—the practical strategies proposed in this study can serve as crucial steps for midwives and educators to promote WCC in hospitals and health centers. Based on the highest levels of expert consensus and practical feasibility, the top priority recommendations for immediate implementation include ensuring adequate staffing levels in maternity units and implementing midwife-led continuity of care models. Additional priorities are reducing out-of-pocket expenses for women, allocating sufficient budgets for WCC services, preparing birth plans in collaboration with women, and revising midwifery curricula to shift educational approaches toward WCC models. These recommendations may also form a valuable foundation for developing clinical guidelines and protocols across healthcare facilities. Future research should evaluate the feasibility and effectiveness of implementing these recommendations across diverse Iranian healthcare settings (public hospitals, private centers, and rural facilities), assess their impact on maternal and neonatal outcomes and women’s satisfaction, and conduct cost-effectiveness analyses. Furthermore, future studies should incorporate perspectives from obstetricians, healthcare administrators, and policymakers alongside those of midwives and reproductive health specialists, as these stakeholders play vital roles in shaping maternity care services.

Funding Statement

This Study is funded by Tabriz University of Medical Sciences (grant number: 69298). The funding source had no role in the design and conduct of the study, and decision to this manuscript writing and submission.

Data Sharing Statement

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Ethical Statement

The current study was approved by the Ethics Committee of Tabriz University of Medical Sciences [Ethic code: IR.TBZMED.REC.1401.051]. Written Informed consent to participate in the study was obtained from all the participants before enrolment.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.