Rules, Responsibility, and Empathy in Maternity Hospitals: A Qualitative Study in Iran

1. Background

Empathy has been known as one of the fundamental principles of medical professions. Empathy is the ability to understand a person's standpoint and their experience of illness, which, through this cognitive resonance, fosters a sense of motivation to assist them. Empathetic doctors and nurses are better equipped to provide optimal care for their patients as they attend to their concerns and worries and administer appropriate treatment. Numerous studies have demonstrated the beneficial effects of empathy on patient outcomes, establishing its crucial role in the delivery of quality health care (1-3).

Differentiating between empathy and sympathy is very important, as they have different clinical outcomes for the patients. Sympathy is the capacity to enter into or join the feelings of another person's feelings. Empathy is defined as the capacity to perceive and understand without joining the feeling of the patient's situation (4). Although sympathy shares feeling, empathy shares understanding. It is important to note, however, that these 2 emotions are not necessarily opposing, but rather, each has its own appropriate use depending on the setting, context, and occasion (5).

Empathy is a difficult and multifaceted construct, and its definition and measurement are difficult. In fact, the medical community has yet to reach a consensus on a singular definition of empathy. Some researchers have emphasized empathy as a cognitive attribute, others as an affective or emotional one, and others have integrated both aspects (6).

Literature reviews demonstrated that cross-cultural differences in social norms, ethnicity, religious beliefs, institutional factors, family-related factors, and gender stereotyping can affect empathetic engagement (4). Some researchers have reported that women show more empathy than men and express a more caring attitude (gender differences) (7). However, some others have mentioned no significant differences between males and females (8, 9).

Childbirth is an important event in a woman's life and often is experienced as an intense, strong, difficult, and unpredictable life experience, which influences almost all her subsequent life events and daily routine. It should be noted that when women are in a specific situation and do not want to speak or they are not able to communicate verbally (eg, at some stages of birth), empathy plays an essential role (10). Midwife empathy has been emphasized as a crucial component of woman-centered midwifery care. High-quality midwifery care has been interwoven with the professional communication of women with their midwives (10, 11).

Providing effective and empathic communication between midwives and mothers increases satisfaction and control over delivery and reduces blood pressure, anxiety, pain, and fear of childbirth. Moreover, this efficient interaction creates a sense of safety, leading to shorter labor times, decreased medical interventions during childbirth, the establishment of mutual trust, enhanced participation and informed decision-making, and, most importantly, improved maternal health outcomes (12, 13). On the other hand, the professional empathic skill of a midwife prevents occupational burnout and boosts job satisfaction and perception of others' feelings (4).

2. Objectives

As many women give birth each year in Iran (14), achieving quality care during labor and childbirth is one of the most challenging aspects of the Fifth Millennium Development Goal (15), and empathy is a fundamental component of woman-centered midwifery care (10), this qualitative study aimed to explore the perspectives of midwifery trainers, students, and maternity hospital personnel in Iran concerning empathy. Specifically, the research sought to understand how these individuals define empathy and how they demonstrate empathy toward women.

3. Methods

This qualitative study was conducted in Iran in September 2022. A total of 41 participants (24 students, 14 personnel, and 3 midwife trainers) were subjected to 2 rounds of semi-structured queries via WhatsApp over the course of 2 phases.

Eligible participants who provided verbal consent were interviewed. The participants were recruited using the purposive sampling method; thus, they were selected according to their roles and functions in the ward. Purposeful sampling was used in terms of selecting information-rich cases for an in-depth study. We chose individuals with high levels of empathy among students, personnel, and midwifery trainers based on our familiarity with these individuals. The relevant personnel were present in the patient-related department.

The first question was, “How do you manage this situation? Imagine a pregnant woman who has a second gravida (experiencing labor pain) and has attended to a midwifery emergency. The patient's vaginal examination revealed 3 cm dilatation and 50% effacement. The attending physician prescribed hospitalization for further observation. However, the patient expressed concern for her 2-year-old child, who was alone at home and requested to be allowed to return home and come back when her pain intensifies. After receiving the answer to the first question, the second question was addressed as “What is your opinion about empathy toward the client?

Sampling and interviewing continued until no new information was gained. At this time, the data were considered to be saturated. After the interview sessions, the collected data were transcribed and analyzed using qualitative conventional content analysis. Extracted codes were managed via MAXQDA version 10 software, resulting in the emergence of subcategories and categories. MAXQDA is a software program designed for computer-assisted qualitative and mixed methods data, text, and multimedia analysis. We managed codes and categories using this software program.

To ensure the validity of the data, the interviewer shared her understanding of what the participants said with themselves, and they expressed their opinion to the researcher about the compatibility of the interviewer's understanding with their own experiences. The researcher ensures the verifiability of this research by keeping the documents in all stages of the research. In fact, the researcher takes measures to ensure that the research can be verified by others. They achieve this by keeping all the relevant documents and records throughout all stages of the research process. This includes maintaining proper documentation of methods, data, analysis, and any other relevant information that supports the research findings. By doing so, the researcher allows others to review and validate the research process and results, enhancing the credibility and trustworthiness of the study.

3.1. Declaration of AI-Assisted Technologies in the Writing Process Statement

During the preparation of this work, the authors used the SCISPACE service in order to improve readability and language. After using this tool, the authors reviewed and edited the content as needed and took full responsibility for the content of the publication.

4. Results

With the exception of 1 member of the personnel, all of the 40 participants provided responses to the 2 inquires presented. The length of the interviews varied from 45 to 60 min. The interviews yielded a total of 265 codes, with 121 of these codes focusing on strategies for managing clients, 64 codes relating to the definition of empathy, and 77 codes linked to the factors to be considered in the context of empathy. These codes were subsequently sorted into 3 categories: “Client management is a top priority for every midwife,” “the definition of empathy," and “essential considerations in relation to empathy," each of which had 9 subcategories.

4.1. Category I: Client Management Is a Top Priority for Every Midwife

Client management comprises a set of actions that midwifery personnel should have undertaken to perform their duties effectively. A total of 121 codes were associated with client management. Within the client management category, 3 subcategories were identified, namely, “compliance with the rules,” “respecting the patient's rights,” and “efforts for empathizing.”

4.1.1. Compliance with the Rules

All participants held the belief that adherence to midwifery regulations was imperative. Universally, they endeavored to act as a competent midwife and lawfully manage the mother's welfare. In this regard, they make the right midwifery decision and then match the mother's condition with the decision.

Considering the condition of the patient that was raised in the question and the urgent need of the client to be hospitalized, in the first place, all the participants believed in the justification and hospitalization of the patient. This involved prohibiting the patient from leaving the hospital, providing medical rationale for hospitalization, informing the patient of the risks of departing the hospital in the presence of a companion, persuading the patient, and reminding the mother of her maternal obligations. These were the codes that were cited as a means of convincing and accepting the patient.

4.1.2. Respecting the Patient's Rights

Some of the participants raised concerns regarding the importance of the patient's autonomy and their right to make an independent decision about receiving health care services; sometimes, they are forced to discharge the patient due to her insistence. Some participants explained that if the mother was allowed to leave, they would order her to return quickly and follow up with the patient seriously. They would advise the mother to return promptly and ensure diligent follow-up care for the patient.

In this particular instance, one of the participants asserted that an alert patient who possesses adequate knowledge has the ability to depart and subsequently return to the hospital with their own personal consent. Under these circumstances, it is imperative to relay the potential warning signs to the patient and recommend that they return home, take a warm shower, retrieve their personal effects, entrust their child to a dependable individual, and expeditiously return to the hospital if the pain intervals diminish or if there is any evidence of leakage or bleeding. Additionally, it is obligatory to accurately record the patient's contact information and diligently monitor the progression of their condition.

To prevent subsequent legal problems, some participants preferred to delegate the responsibility of the patient to a higher authority, such as a supervisor or doctor. Following a thorough evaluation of the likelihood of premature labor and confirming that childbirth was not imminent, certain participants would get written consent from the patient and her accompanying individual (if applicable) before releasing her. This approach demonstrated a regard for the patient's autonomy and decision-making abilities while simultaneously minimizing the probability of legal complications.

One individual said that in the event that a patient does not agree to remain in the hospital and insists on leaving, they would allow the patient to depart only after coordinating with the doctor and informing the supervisor. Another participant mentioned that if the patient continues to insist on leaving despite an explanation of the risks involved, they will permit the patient to go with the personal consent of their spouse, emphasizing the potential danger signs and informing the supervisor. Additionally, the participant would obtain a triage number and routinely check on the patient's condition every hour.

4.1.3. Efforts for Empathizing

With the exception of 2 participants, all others demonstrated a willingness to empathize with the patient. The actions taken to demonstrate empathy included allowing the child to remain with the mother, sending a companion or the father to the child, reaching out to the mother's acquaintances, assisting the mother in making informed decisions, providing the option of video calls, using ambulance services to transport the mother to the child, clarifying the situation to both mother and child, identifying the core issue and attempting to address it, seeking the assistance of the hospital's social worker, and delegating someone to attend to the child. All of these recommendations proved to be beneficial.

One of the participants articulated that in the event of a lack of conviction or trustworthy caregiver for the child, in light of the duration and interval of uterine contractions, past birth history, and distance to the mother's residence, a decision would be made. It is possible that the child may remain with their mother during labor.

4.2. Category II: The Meaning of Empathy

The analysis of the participants' definitions of empathy was placed in the category of the meaning of empathy. Three subcategories (ie, “helping in any possible way," “understanding the clients’ world," and “creating a feeling of assurance in clients") formed the meaning of the empathy category.

4.2.1. Helping in Any Possible Way

The codes of helping the client in accepting the problem, hearing the solution from the client's language, giving suggestions and solutions, and looking for a solution formed the “helping in any possible way" subcategory.

One of the participants offered a definition of empathy, stating that:

It involves the ability to comprehend an individual's circumstances without feeling neglected or unsupported and, when viable, to provide fitting guidance and recommendations. It is crucial to note that empathy should not be conflated with sympathy, as the latter does not require experiencing the emotions of another in order to exhibit kindness and empathy.

4.2.2. Understanding the Client's World

The codes of understanding the client's circumstances and condition, comprehending the client's physical and mental state, putting themselves in the client's shoes, looking from the client's point of view, and adopting their perspective formed the subcategory of “understanding the client's circumstances and condition."

One of the participants mentioned, “Empathy means understanding the conditions and problems of the client; for example, in the scenario presented, the child was left unaccompanied at home with no one to attend to their needs. Merely disregarding this situation and focusing solely on the mother's hospitalization would not constitute an empathetic response. Rather, empathizing with the mother's concerns and devising a solution for the welfare of her child exemplifies a manifestation of empathy". Furthermore, another participant contributed to the discussion by defining empathy as the ability to place oneself in the position of the other individual without adhering to one's own perspective.

4.2.3. Creating a Feeling of Assurance in Clients

The codes of reducing the client's concerns, managing the client's stress, alleviating the client's fear, giving a feeling of calmness, establishing trust, and mental and psychological support formed the subcategory of “creating a feeling of assurance in the client."

In this regard, one of the participants said, “Empathy is defined as the act of mitigating the stress and tension experienced by the mother, with the intention of enhancing the efficiency of the delivery process. Moreover, it fosters a sense of safety and security within the mother toward us.”

4.3. Category III: Essentials in Empathy

In part of the interviews, the participants pointed out issues that should be taken into account in empathizing. These cases were classified in the category of “essentials in empathy." “Not harming clients," “not harming oneself," and “utilizing effective communication skills" formed this category.

4.3.1. Compliance with Professionalism

The codes of “conveying a sense of empathy," “prioritizing the health of the patient," “considering justice in behavior," “regarding honor and honesty," “not judging the patient," and “not making dependent the patient on specific health provider" formed the subcategory of “compliance with the professionalism."

One of the participants said, “We should not judge the patient. Some even go beyond judgment and blame the patient."

Another participant said: “Some of my colleagues lie to patients about their past experiences; of course, we shouldn't lie; for example, we should not tell her that I was like this during my labor. We should give all good and enough information to patients with simple examples and simulations. But lying is not so right."

4.3.2. Not Harming Oneself

The codes of “not sympathizing," “not sharing our personal experiences with patients," “not expecting from client to reciprocate," and “believing in empathy" formed “not harming oneself" subcategories.

One of the participants said, “The midwife is cognizant of the fact that she is obligated to approach this term with utmost emotional investment and be capable of effectively communicating her compassion through an empathetic disposition.”

Another participant said, “Empathy and sympathy possess distinct characteristics. We are not supposed to hurt ourselves and suffer from that person's emotions to be a good person."

4.3.3. Utilizing Effective Communication Skills

The codes of respecting patients, talking to patients, active listening, finding a way to communicate, and reducing the cultural gaps formed the subcategory of “utilizing effective communication skills."

One of the participants said: “In my opinion, the parturient does not experience cultural or emotional distance from the midwife. Communication in the parturient's native language is essential in establishing a rapport, and sharing common experiences can be advantageous. Specifically, the midwife should disclose details about her own childbirth or pregnancy, including the pain and difficulties she encountered, as this can foster a sense of closeness." Ultimately, the parturient should perceive the midwife as a fellow woman who may encounter similar challenges rather than an individual who is foreign or incapable of relating. This understanding can be pivotal in optimizing the relationship between the midwife and the parturient, particularly in terms of building trust and ensuring successful outcomes.

One of the participants who had no experience of vaginal delivery pointed out “the positive role of experience simulation" and said, “Sometimes, I make false assertions regarding my physical condition during parturition and give her some practical knowledge using uncomplicated instances and imitations of myself and my colleagues."

According to some participants, empathizing with the patient sometimes faces obstacles. The participants in this research mentioned “the lack of sufficient facilities" and “the habit of judging people" as 2 obstacles to empathy.

One of the participants said, “In Iranian maternity hospitals, the capacity for empathetic engagement is limited, and the presence of a social worker to provide comfort to the mother would be beneficial. However, in actuality, the opportunity for empathizing appears to be scarce.

5. Discussion

In this research, 265 codes were extracted from the participants' answers to 2 questions, which were classified into 3 categories: “client management is a top priority for every midwife,” “the meaning of empathy," and “essentials in empathy” (Table 1).

5.1. Client Management is a Top Priority for Every Midwife

5.1.1. Compliance with the Rules

Due to the global rise in malpractice claims, which has been a source of considerable stress for healthcare professionals (16), it is common for midwives, like other healthcare practitioners, to prioritize client management and adherence to rules over professional conduct and empathy. In their research, Samadi and Shahvari pointed out that the concern of anesthesiologists about forensic medicine is one of the reasons for their lack of professional behavior (17).

5.1.2. Respecting the Patient's Rights

Despite the fundamental importance of respecting, protecting, and fulfilling human rights (18), sometimes, respecting the patient's right to choose proper treatment is a challenge for the health care staff. Accepting or rejecting proposed treatments after being aware of the possible complications caused is one of the patients' rights, which the participants correctly pointed out. However, it is a fact that when declining treatment poses a grave and imminent threat to the well-being of another individual (namely, the fetus), the conditions of the risk should be respectfully explained, and the patient's discharge should be avoided. It is recommended that the rules of professional conduct be fully retrained so that staff and students can make the right decisions in difficult situations.

5.1.3. Efforts for Empathizing

The participants held the belief that to establish empathetic understanding, the midwife must demonstrate a discerning comprehension of the mother's situation and exhibit an unwavering commitment to providing assistance in alleviating any related concerns. Given that an empathetic understanding of common suffering (physical, emotional, and financial) allows for a strengthened relationship (5), it is clear that employing midwives who have experience of normal childbirth in the delivery department can help. The role of similarity of experience between midwives and clients (19, 20) facilitates empathy in the maternity ward. Also, sharing similar experiences or feelings with the client, which is called self-disclosure, is usually helpful in the context of the delivery room. In a research, it was emphasized that self‐disclosure had a significant effect on empathy (21). Self‐disclosure is associated with trust and intimacy in therapeutic relationships and has a strong impact on health care outcomes.

Some participants correctly mentioned the code of “finding a way to communicate,” as Kerasidou and Horn believed that mutuality and relatedness are fundamental for the development of empathy (22). The emphasis should be placed on the necessity of participatory communication, in which the midwife discusses possible changes in the course of the pregnancy with the woman (23). However, the act of intentionally providing false information regarding previous experiences, which was mentioned by some of the participants as a means of communication, ultimately diminishes the patient's trust and intimacy in therapeutic relationships (21).

5.2. The Meaning of Empathy

Participants had different interpretations of the concept of empathy. In Costa-Drolon et al.’s research, the majority of participants believed they should be able to imagine and try to understand someone else’s feelings and experiences and, without losing objectivity, see the world through that person’s eyes (6). This view is categorized as “understanding the client's worldwide" in our research. “Helping in any possible way" and “creating a feeling of assurance in clients" were 2 other views in our research. Our participants mostly meant perceptive empathy, the ability to directly perceive the experiences of others (24).

"Creating a feeling of assurance in the client" is a valuable ability, as researchers believe that empathetic professionals perceive their needs as they feel safe to express the thoughts and problems that concern them (25). Moreover, empathy helps to manage the situation. It can be inferred that an increase in the level of clinical competence and verbal communication skills among health care providers can lead to a decrease in the anxiety levels of their clients (26).

Since a significant mean difference was found between the empathy tendencies of the students who chose the profession willingly and unintentionally (27), it is necessary to recruit employees who are interested in the profession and have a higher empathy vigor.

In the present study, the act of touching the client's hands was not reported by any of the participants. However, it was observed that the experience of pain in the client was significantly attenuated during the touch condition (28).

5.3. Essentials in Empathy

5.3.1. Compliance with Professionalism

Empathy is part of professional conduct (6), and in this research, the participants correctly pointed out the adherence to the principles of professional behavior in the empathizing process. In this way, some of the participants pointed to “not harming oneself.” Like other aspects of professionalism, people should not ignore their physical and mental health. In this case, we need to provide greater assistance and support to health care providers in engaging in self-compassion and self-care; this can be achieved through ongoing training, education, and acquisition of proficient skills (29).

“Utilizing effective communication skills" is another code that should be noted in our study. In a study, it was shown that the rate of using verbal communication skills by midwives is 62%, and the rate of women's satisfaction with it is 50%; in addition, the rate of using non-verbal communication skills by midwives is 56%, and the rate of women's satisfaction with it is 48.4%; it was at an undesirable level (30).

As Waite says, “The broad lesson is to display empathy when understanding the immediate emotional state of another person. Even then, choose your words cautiously. Often, active listening is most appropriate. Not everyone seeks or welcomes advice. Some simply need to vent and know they are heard” (5). Instruction on communication skills should be considered in midwifery curricula.

Some participants reportedly observed that their ability to empathize was affected by contexts. Another researcher recognized that context plays a significant role in influencing empathy (6). Kerasidou and Horn believe empathy exercised by the individual health care professional alone is not enough to ensure empathetic care overall. The health care system as a whole needs to embrace empathy as one of its principles and make it the basis on which it operates (31).

In Moudatsou et al.’s study, some of the factors that negatively influence the development of empathy are the lack of adequate time, the focus on therapy within the existing academic culture, the high number of patients that professionals have to manage, and the lack of education in empathy (25). In an unprofessional environment, professional practice can hardly take place (32). Providing the context to have professional behavior (including empathy) is a matter that should be taken into consideration by the authorities. However, deficiencies are never a valid reason to ignore empathy.

One of the strengths of this study is the inclusion of interviews with various individuals, including trainers, students, and midwifery personnel. We employed various perspectives and views; however, it is important to note that participants often aimed to present themselves in a positive light and may have been hesitant to openly criticize their own performance.

As participants answered 2 rounds of semi-structured questions in WhatsApp in only 2 stages, some answers were short, and it can be questioned whether they were long enough to reveal the meaning of empathy. It is recommended that the field of obstacles to empathy be further explored in future studies. Also, these findings can be used in staff training.