Commentary: Childbirth Education in Iran

Abstract

With regard to childbirth, the role of every health-care system is to improve maternity care as well as the birth experience of women and their family members. Despite many efforts to improve maternity care in the Islamic Republic of Iran, the nation's childbirth care still faces a tremendous amount of unnecessary intervention and, consequently, a high rate of cesarean births. This article describes the strengths and weaknesses of Iran's maternity-care system and childbirth education in light of evidence-based practice.

Birth is not anything new in human life, but modern changes have, in a way, created something very new out of this natural process. As an important part of maternity care, childbirth education attempts to address these changes in order to decrease negative consequences and achieve the goals of contributing to the ongoing physical and emotional health of the mother and her baby and to help families have the best possible childbearing experience (Nichols & Humenick, 2000).

Many factors affect the process of childbirth education. Three main factors are the health-care provider, the health-care environment, and the mother and her family. For successful education to occur during the childbearing year, these factors must be considered carefully and evenly. Lack of preparation in any of these areas may lead to inappropriate results afterward. For instance, if a mother is prepared for normal birth during childbirth education class but the health-care environment and the health-care providers are not ready and able to provide for the woman's needs, the goals of childbirth education will not be met. The aim of this article is to describe childbirth education in Iran.

BIRTH PRACTICES IN IRAN

Iran is located in southwestern Asia and has a population of almost 69 million people, making it the second most populated country in the Middle East. Iran's economy is also the second largest in the region. The health status of Iranians has improved over the last two decades. Iran has been able to extend public health preventive services through the establishment of an extensive primary health-care network. As a result, child and maternal mortality rates have fallen significantly, and life expectancy at birth has risen remarkably.

Almost all of the population in Iran is Muslim. As Zaid (2000) notes, “Islam honors and cherishes the women who give birth” (para. 1). Some religions view childbirth and labor pain as the necessary punishment for women, but Islam believes that childbirth is a sign of the Lord's “creation and majesty” (para. 40). Zaid (2000) also notes:

Pregnancy is a natural condition ordained by Allah. … The philosophy behind the “natural pregnancy and childbirth” movement is that trusting your body's instincts will allow you to proceed with minimal fear and pain, and will create the best situation for you and your unborn child. (para. 1)

In examining childbirth education in Iran, health-care providers are the first factor to consider. Every year in Iran, over 1,170,000 women give birth (Akbary, 2005). Typically, pregnant Iranian women receive their care from physicians or midwives during pregnancy and birth. It is well accepted that there are two different views of pregnancy and birth: the midwifery model, which views pregnancy and birth as a natural processes, and the medical model, which views pregnancy as high-risk and birth as inherently dangerous, requiring technological interventions (Enkin et al., 2000; Harper, 2005). In the midwifery model, midwives embrace a noninterventionist approach to childbearing, allowing nature to take its course during labor and birth. However, when it comes to practical matters, this approach can be very difficult. For instance, in Iran, the premier midwifery preceptor handbook and training manual is Williams Obstetrics (Cunningham et al., 2005), which is used for teaching both midwives and doctors. Therefore, it is not unusual for midwives in Iran to believe in limiting the duration of stages of labor, clamping the cord immediately after the birth and applying gentle traction on the cord, removing the placenta immediately, and separating the mother and baby for at least 1 hour after birth. These procedures do not reflect the traditional midwifery model of care.

In the Iranian system, midwifery education takes at least 4 years of study in a medical university without any previous nursing qualification (direct entry). During recent decades, there have been many efforts to improve education in midwifery. Despite these efforts, midwives in Iran do not learn the midwifery model of care. How can midwives be expected to have a positive attitude toward physiological childbirth and not believe that birth is a medical event when they rarely, if ever, see birth that is not technologically managed? In this situation, Iranian midwives do not have the opportunity to develop a sense of trust in the effectiveness of the normal, natural process of birth. Iranian midwives work in hospitals under the supervision of obstetricians and, in their practice, serve as assistants to the obstetricians. The accepted assumption that physicians should control the care of childbearing women is a significant factor in undermining midwifery and normal birth.

As one of the world's leading experts on childbirth education, Andrea Robertson has written many books and articles in this field. After a 3-day workshop held in Iran in April 2006, Robertson wrote about birth in Iran in her diary. She concluded that physicians are all-powerful, completely dictating the management of every birth and seemingly oblivious to evidence on care, midwifery skills, the mother's wishes, or anything else that might impact their practice (Robertson, 2006).

IRANIAN HEALTH-CARE ENVIRONMENT

The second factor to consider in the care of childbearing women in Iran is the health-care environment. The birth environment has profound effects on how labor progresses and on how women remember their birth experience (Lamaze International, 2007). The place of birth should provide a distraction-free, comfortable, supportive, and reassuring environment for mothers and their families. Women need to remain confident, have the freedom to respond to their contractions in any way that works for them, and have continuous emotional and physical support throughout labor (Lothian, 2002).

In Iran, more than 95% of births take place in the hospital (Akbary, 2005). In recent decades, continuous support during labor in Iranian hospitals has become the exception rather than the routine. Also, due to Iranian religious and cultural values, which view birth as “women's events” (Zaid, 2000, para. 18), men do not attend labor and birth as a father or a doctor, except under certain conditions. Usually, mothers arrive alone in the labor ward and stay with several other mothers in the same room during labor. Midwives or other health-care providers are the women's only source of support in labor and birth; however, they are often busy with many other tasks and with mothers who need care. In such an environment, support for the mother is most often not available.

In Iran, more than 95% of births take place in the hospital. In recent decades, continuous support during labor in Iranian hospitals has become the exception rather than the routine.

In Iran, mothers are usually confined to bed and do not have the freedom to walk, move, and find comfortable laboring positions. Also, based on Iranian hospital regulations, applying intravenous lines and restricting oral intake are mandatory rules in almost all hospital settings. Supine is the most common birth position used in hospitals, and episiotomy for a first birth is a routine procedure.

If a woman in Iran has had a previous cesarean, all her future births must be cesarean births. There are no birth centers in Iran, and home birth has been forgotten during the last 20 years, except in faraway regions. Due to the lack of a referral system, home birth is currently illegal in Iran. Obstetricians routinely end every pregnancy on the due date (estimated date of birth) rather than allow labor to begin on its own. Thus, it is not a surprise that, in Iran, the cesarean-section rate is almost 40% in public sections and more than 90% in some private hospitals (Alavian, 2007). Fortunately, continuous electronic fetal monitoring and epidurals are rarely available, but some hospitals are beginning to use electronic fetal monitoring and offer epidurals in order to be considered “prestigious.”

THE BIRTH EXPERIENCE IN IRAN

Mothers and their families are the final factor examined in this overview of Iran's maternity-care system. Pregnancy and birth are special events for every woman, and the woman's memory of the experience will last the rest of her life. Women's assessment of their childbirth experience is influenced by both physical and psychosocial factors, highlighting the importance of a comprehensive approach to care in labor and birth (Waldenstrom, Borg, Olsson, Skold, & Wall, 1996). The basis for maternity care should be influenced by women's long-term experiences of childbirth, which can be achieved by supporting women's participation and promoting factors that help women receive an empowering and strength-giving experience of childbirth (Lundgren, 2005). In general, severe fear of labor pain and lack of childbirth education characterize Iranian women's experience of pregnancy and birth. As a result, many Iranian women plan a cesarean birth.

Despite every woman's access to perinatal care in Iran, almost no type of childbirth education program exists in Iran's perinatal-care system. Although health-care professionals in many parts of the world recommend that pregnant women and their partners attend structured antenatal education programs for childbirth and/or parenthood, Iranian pregnant women receive brief information about pregnancy during their 5- to 10-minute routine prenatal visits or in the hospital, and they may receive an additional two or three 15- to 20-minute sessions of extra “classes.” Unprepared mothers often experience excessive fear and anxiety during labor and birth. Fear of childbirth, in combination with counseling, may increase the rate of elective cesarean birth, whereas fear without treatment may have a negative impact on the subsequent experience of childbirth (Ryding, B. Wijma, K. Wijma, & Rydhstrom, 1998).

Despite every woman's access to perinatal care in Iran, almost no type of childbirth education program exists in Iran's perinatal-care system.

It is interesting to note that, despite inadequate preparations, most Iranian women breastfeed their baby for more than 1 year. In Iran, breastfeeding is the societal “norm” because of religious and cultural practices associated with childbearing and childrearing. Among the many reasons for successful breastfeeding practices in Iran, the most important one is the regulation derived from Islam that encourages women to breastfeed their babies. According to Islam, the baby's father should provide emotional and economic care for the mother during this time. Another reason for successful breastfeeding rates in Iran may be rooming-in of baby and mother during the time they are in the hospital, as opposed to having them in separate rooms during the time immediately after birth.

Despite inadequate preparations, most Iranian women breastfeed their baby for more than 1 year. Breastfeeding is the societal “norm” because of religious and cultural practices associated with childbearing and childrearing.

CONCLUSION

As in many other parts of the world, Iran's childbirth climate makes it nearly impossible to strictly utilize evidence-based care practices. Because of the way most women give birth in Iran (in a health-care system and hospital settings with numerous interventions), a comprehensive childbirth education program is greatly needed. Also, as health-care providers, Iranian midwives need to learn more about normal birth and evidence-based care, and to gain confidence in their ability to facilitate normal birth. In addition, the Iranian health administration needs to take more responsibility for establishing childbirth education programs and supporting evidence-based maternity care practices.

AUTHOR'S NOTE AND ACKNOWLEDGMENTS

In light of ongoing efforts to improve childbirth education opportunities in Iran, my future plans include a follow-up report describing the progress and outcomes of these efforts.

I am grateful to Judith A. Lothian for her valuable guidance and editorial assistance. This article would not have materialized without her. Also, I extend special thanks to the members of the Lamaze International Board of Directors for their efforts to help improve attention and care for mothers and babies around the world.