Exploring the Role of Midwives in Promoting Childbearing from the Perspective of Couples: A Qualitative Content Analysis

INTRODUCTION

The dramatic decline in global fertility rates represents a major demographic transformation. ¹ In 1970, 22 countries had fertility rates below the replacement level, but this number quadrupled to 79 countries between 2010 and 2015. Between 2015 and 2020, 25 countries recorded fertility rates below 1.5. ² In Iran, the latest figures showed a total fertility rate of 1.7 children in 2019. ³ Projections suggest Iran’s natural growth rate will decrease to almost zero percent in 2045-2050. ⁴

A previous study in Iran indicated that 70% of participants were disinclined towards childbearing. ⁵ This reluctance stems from factors like individualism, pursuit of independence, economic and social pressures, rising marriage age, education levels, gender equality, employment, and women’s increased social engagement. ^{6 , 7}

Attitude towards fertility is a primary determinant of reproductive behavior. ⁸ A positive attitude towards childbearing leads to early childbearing and a larger number of children, while a negative attitude reduces the desire for children. ⁹ As a responsible individual, a midwife can create a positive attitude towards childbearing in couples by providing correct counseling and proper education. ¹⁰

Positive pregnancy and childbirth experiences are a key determinant in the desire for future children. Therefore, greater satisfaction with pregnancy and childbirth care directly fosters a stronger inclination towards subsequent childbearing. ¹¹ Given that mothers’ memories of their childbirth can last for two decades or more, healthcare professionals should be acutely aware of the enduring impact of their care on maternal experiences. ¹²

As frontline healthcare providers, midwives play a crucial role in promoting health and hygiene and are recognized for their impact on the quality of health service delivery and care. ¹³ The importance of leveraging midwifery care to improve fertility services has received international emphasis. ¹⁴

Given Iran’s rapidly declining fertility rate, which presents a significant demographic crisis requiring urgent and effective solutions, midwives play a vital role in providing counseling, support, and care throughout pregnancy, childbirth, and the postpartum period; ¹⁵ since no prior studies, either nationally or internationally, have explored the role of a midwife in childbearing from the couples’ perspective and considering that qualitative research enables an interpretative and contextual exploration of the phenomena in their natural environment, ¹⁶ this study aimed to explore the role of a midwife in childbearing through a qualitative approach based on couples’ viewpoints.

MATERIALS AND METHODS

This qualitative study was done using conventional content analysis. Purposive sampling was performed at the 17th Shahrivar Healthcare Center, West Health Center No. 4, and Razi and Imam Khomeini hospitals in Ahvaz, Khuzestan Province, from July to November 2024. After obtaining permission from Jundishapur University of Medical Sciences and obtaining ethical approval, the first researcher (P.E.) initiated data collection by visiting these centers and hospitals, introducing herself to potential participants, outlining the study objectives, and obtaining written informed consent.

The inclusion criteria were living with a spouse, having no children or at most two children, not being infertile, having no diseases contraindicating pregnancy according to self-report, being able to speak Persian, and being willing to participate. The couple who were unwilling to participate in the study were excluded. Furthermore, couples with three or more children were not included due to their reluctance to have more children or participate in reproductive research, often influenced by economic or other factors. Based on these criteria, the first researcher conducted semi-structured, in-depth interviews with individuals who were capable of providing rich and comprehensive information on the study topic.

Some participants daily referred to healthcare centers and hospitals, while others were identified through healthcare centers and invited by phone for interviews. Interviews were conducted with a couple simultaneously in private, quiet rooms within healthcare centers, used only for special consultations. In hospitals, the interview time and place were chosen by mutual agreement, ensuring a quiet and comfortable environment for the couples. Interviews were conducted with both partners present simultaneously to facilitate a deeper shared understanding and richer expression of their perspectives. Each session lasted approximately 55 to 60 minutes.

In qualitative research, the sample size is guided by data saturation. In this five-month study, the researcher achieved saturation, and no new codes emerged after interviewing 30 individuals (15 couples).

The interview started with questions about the participants’ age, education level, employment status, and the number of children in the family. The interview guide included one general question: “Please describe your experiences with health and treatment services received from midwives, specifically concerning childbearing.” Subsequent probing questions such as “What do you mean by…?” and “Could you please explain further?” were tailored based on the couples’ responses to the question.

Analysis was performed with MAXQDA version 20, following the Graneheim and Lundman approach, which involved transcribing each interview soon after data collection, closely reading transcripts to capture general meaning, coding significant units, grouping related codes into larger categories, and interpreting the implicit content to identify the central theme. ¹⁷

In this study, after obtaining the participants’ permission, the first researcher conducted the interviews; then, the interviews were recorded using a digital voice recorder and transcribed verbatim. Two researchers (P.E. and N.J.) then read the transcripts line by line, identified important sentences and phrases, and performed coding. Similar codes were merged, and integration continued until the main theme emerged. Disagreements were resolved by a third author (M.I.). Codes were identified; then, based on their similarities and differences, they were organized into subcategories. Similar subcategories were merged, and the main categories were obtained. Finally, a central theme emerged that reflected the core content of the data.

To enhance the rigor and trustworthiness of the data, we applied four criteria proposed by Lincoln and Guba: credibility, dependability, confirmability, and transferability. ¹⁸ To increase credibility, the researcher maintained prolonged engagement with the data and invited the participants to review and verify the findings against their views. For dependability, the main theme and subcategories of the studywere reviewed and refined by two external auditors. To ensure confirmability, the researcher consciously set aside personal biases on the study topic to maintain objectivity. Transferability was addressed by selecting and interviewing the parents with diverse social, economic, and educational backgrounds to maximize variation, aiming to ensure that the findings would hold meaning in similar contexts elsewhere.

This research was approved by the Ethics Committee of Ahvaz Jundishapur University of Medical Sciences in Iran (code: IR.AJUMS.REC.1403.136). Patients’ participation in this study was entirely voluntary. The purpose of the investigation was clearly explained to patients before their participation. All participants provided written informed consent for recording the interviews and their participation. The participants were guaranteed complete confidentiality, anonymity, and the right to withdraw from the study at any time without any repercussions for their care.

RESULTS

In this study, 15 couples were interviewed. The mean age of men was 33.93±5.14 years, and that of women was 29.73±4.81 years. The demographic characteristics of the participants are listed in Table 1.

The study findings comprised 93 codes which were organized into 11 sub-categories, four main categories, including “Empowering Couples,” “Creating Motivation for Having Children,” “Preparing for Parenthood,” and “Supporting the Overcoming of Childbearing Barriers,” and finally a central theme “The midwife as a key supporter in promoting childbearing”, as shown in Table 2. Below, we elaborate on the sub-categories and categories by providing examples of the participants’ statements.

Empowering Couples

This study suggests that midwives contribute significantly to promoting childbearing by raising awareness among individuals and families and strengthening the couples’ self-efficacy and self-esteem.

1.a. Raising Awareness among Individuals and Families

Raising awareness about childbearing, as with other important issues, empowers individuals to make more informed and thoughtful decisions. A participant said:

“I remember when we had just gotten married, I went to a midwife, and she explained many things to me, such as the appropriate age for marriage and having children, the complications of pregnancy at an older age, and the effects of delaying childbearing. I got pregnant early in our marriage.” (W8)

1.b. Strengthening Couples’ Self-Efficacy and Self-Esteem

In this study, participants mentioned that one way midwives empower couples to have children is by strengthening their self-efficacy and self-esteem. Some participants said:

“When I was a student, I thought I couldn’t raise a child while studying at university simultaneously, but once I referred to the health center to get contraception, the midwife talked to me, and I learned how to manage it.” (W4)

“Balancing a demanding career with motherhood felt impossible, creating a dilemma as I also desired children. However, two consultation sessions with a midwife enabled me to make an informed decision, and I am now thankfully pregnant.” (W13)

“Our income is at a moderate level. We always thought that we wouldn’t be able to afford a child with this income, but when we went to the health center, the midwife talked to us, and we learned how to manage living expenses better; then, our first child was born.” (H7)

2. Creating Motivation for Having Children

The findings of this study suggest that midwives can enhance the couples’ motivation for having children by expressing the benefits of having siblings for the child, childbirth as a catalyst for family stability, and couples’ need for support in old age.

2.a. Expressing the Benefits of Having Siblings for the Child

One of the most effective ways to encourage couples to have children is to explain the potential challenges faced by only children, such as loneliness and social pressure, while highlighting the benefits of having siblings, like companionship and shared support. A participant said:

“I always believed that one child was enough, but when we talked to the midwife in the health center, she told us about the benefits of having siblings and the disadvantages of having only one child, my opinion changed, and that’s what made us decide to have a second child.” (H8)

2.b. Childbirth as a Catalyst for Family Stability

In this study, the participants mentioned that one way midwives motivated couples to have children was contributing to family stability. A participant said:

“Although we had been married for several years, we had no intention of having children until recently, when we felt our lives had become lifeless and monotonous. My husband and I had grown cold towards each other. We went to a midwife, and she told us how much having a child could help warm our relationship and stabilize our life, and we decided to have a child.” (W10)

2.c. Couples’ Need for Support in Old Age

Based on the results of the present study, couples’ need for support in old age increases their motivation to have a child. A participant maintained:

“We were only seeing the present and the current situation. Once, when my wife had a problem and I went with her to the midwife’s office, she told us that at least due to your old age, you should have children. You won’t always be this young and energetic. Her words were like a wake-up call for us, and we decided to have children.” (H12)

3. Preparing for Parenthood

The findings of this study indicate that midwives play a crucial role in childbearing by facilitating the experience of fatherhood and motherhood, facilitating the acceptance of unwanted pregnancy and preventing abortion, and providing high-quality preconception care and high-quality prenatal care.

3.a. Facilitating the Experience of Fatherhood and Motherhood

In this study, the participants mentioned that one of the ways midwives prepare couples for parenthood was facilitating the experience of fatherhood and motherhood. A participant said:

“Honestly, we intended to immigrate and weren’t thinking about having children at all, but once we went to the health center to get contraception, we talked to the midwife, and she told us about the joy of having children, that a child gives meaning to a person’s life, and how sweet the experience of fatherhood and motherhood is. Our opinion changed, and we decided to have a child.” (W2)

3.b. Facilitating the Acceptance of Unwanted Pregnancy and Preventing Abortion

According to this study, by facilitating the acceptance of unwanted pregnancy and preventing abortion, midwives can help to increase fertility. A participant said:

“Honestly, my second pregnancy was unplanned, and I initially wanted an abortion. My other child was very young, I was working, and life felt overwhelming. I sought the midwife’s help to terminate the pregnancy, but after four counseling sessions, she talked me out of it, and now I’m so grateful I continued with it.” (W11)

3.c. Providing High-Quality Preconception Care

The results of this study showed that midwives can prepare couples for parenthood by providing high-quality preconception care. A participant said:

“Because my first pregnancy was so challenging due to diabetes, we decided not to have more children. However, every time we went to the health center, our midwife at the health center offered numerous helpful approaches, including encouraging exercise and assisting me in reaching a healthy weight through diet and activity, which has since managed my diabetes. As a result, we are now considering having another child.” (W6)

3.d. Providing High-Quality Prenatal Care

Receiving high quality care during pregnancy helped the couples to experience a good pregnancy and plan for their next child. A participant maintained:

“We honestly had a truly wonderful experience with our first child. The care we consistently received at the health center was excellent. They patiently answered every question we had and always made it possible for me to be with my wife to hear our baby’s heartbeat. It was such a positive and supportive environment that it has made us eager to have another child.” (H4)

4. Supporting the Overcoming of Childbearing Barriers

The study highlights the crucial role of midwives in addressing barriers to childbearing.

4.a. Changing Negative Attitudes and Correcting Misconceptions

Based on the results of this study, by changing negative attitudes and correcting misconceptions, midwives can increase the couples’ desire to have children. Some participants said:

“I had various hobbies; I went to the gym and had a lot of fun. I thought having a child would prevent me from being able to make time for myself and achieve my goals, but after three sessions of talking and consulting with the midwife, I realized that my perspective was wrong.” (W9)

“Current social trends often equate having many children with being ‘uncool,’ and larger families can face subtle disapproval. This led us to choose single-child status, but a conversation with my wife’s usual midwife prompted a change of heart.” (H3)

4.b. Overcoming the Fear of Pregnancy and Childbirth

The results of this study showed that midwives could help the couples overcome fear of pregnancy and childbirth. Some participants said:

“My fear of childbirth was significant. Although I dearly wanted children, this fear was a major deterrent. Thankfully, through numerous discussions and consultations with the midwife, my fear diminished, and I am now planning a pregnancy.” (W1)

“My concern about weight gain and losing my figure post-childbirth, given its importance to me, made the prospect of pregnancy daunting. However, after discussing this with a midwife, who initially found my concern amusing, but then offered kind and insightful guidance on maintaining fitness during and after pregnancy, I have a child.” (W15)

“I struggle to understand the common narrative of childbirth being frightening and painful. My personal experience, facilitated by a private midwife, my husband’s support, and thorough prenatal education, was remarkably positive. The positive recollections of my pregnancy and delivery would certainly influence a future decision to have another child.” (W4)

“We were constantly plagued by worries about our baby’s well-being, questioning potential health issues. Our anxieties lessened considerably when the midwife we visited detailed fetal health and screening procedures, and now my wife is expecting a child.” (H5)

DISCUSSION

Aiming to elucidate the function of midwives in the promotion of childbearing from the couples’ standpoint, the present study established their pivotal and multifaceted roles in augmenting parental inclination towards procreation. These roles involve the empowering couples, creating motivation for having children, preparing for parenthood, and supporting the overcoming of childbearing barriers.

This study suggests that midwives can empower couples by raising awareness among individuals and families and strengthening the couples’ self-efficacy and self-esteem. In recent years, different factors such as lack of suitable employment, higher educational attainment, elevated expectations, excessive familial strictness, and the appeal of singlehood amidst socio-cultural shifts led to an increase in the age of marriage. ¹⁹ One study demonstrated that, due to delay in marriage, childbearing is postponed. ²⁰ Therefore, it is crucial to implement significant measures in response to these trends and midwives can play a vital role in this context. By providing information to families about marriage and childbearing at appropriate ages, and by educating young people, midwives can promote timely marriage and childbearing.

Based on the results of the present study, education and lack of adequate income are barriers to having children. This is supported by one study, which identified education, employment, and economic status as crucial factors in the inclination towards having only one child. ²¹ However, according to the results of this study, by empowering individuals in managing economic issues and knowing how to manage education and having children simultaneously, can increase the individuals’ self-efficacy and their desire to have children because self-efficacy empowers individuals to surmount challenges and eliminate obstacles to significant life choices, including childbearing, by leveraging their skills and abilities. ²² One study showed that women with higher self-efficacy had a greater tendency toward childbearing, which aligns with the present study. ²³

This study findings suggest that midwives can create couples’ motivation for having children by expressing the benefits of having siblings for the child, childbirth as a catalyst for family stability, and the couples’ need for support in old age.

The regret of not having siblings and subsequently not experiencing being an aunt or uncle is a unique experience that can have detrimental effects on the physical and emotional well-being of children who are only one child. ²⁴ Another study indicated that having only one child might hinder children’s cognitive and social development, ²⁵ as relationships with siblings provide the first and best environment to experience and learn these areas. The midwife can encourage couples to have more children by emphasizing the benefits of having siblings and explaining the disadvantages of having a single child.

From a social psychological perspective, the emotional attachments of men and women to their children strengthen marital relationships and reduce the divorce rates. ²⁶ One study in Russia also showed that having children and many children reduced the likelihood of divorce. ²⁷ Therefore, a midwife can encourage couples to have children by highlighting the benefits of children in strengthening the couple’s relationship and family life.

Furthermore, the couples’ anticipation of their needs in old age serves as another motivator for childbearing. A qualitative study outlined four key expectations of elderly parents from their children: physical care and personal hygiene assistance, social support and respect for their dignity, emotional support and the preservation of their independence and privacy, and financial assistance for basic living expenses. ²⁸ Given that motivation is an intrinsic force driving behavior towards specific goals, ²⁹ midwives can tap into this by reminding couples of their future need for filial support.

The findings of this study indicate that midwives have an important role in childbearing by facilitating the experience of fatherhood and motherhood, facilitating acceptance of unwanted pregnancy and preventing abortion, and providing high-quality pre-conception care and prenatal care.

Motherhood is often considered a woman’s most significant role and a path to personal fulfillment. ³⁰ Likewise, a study highlighted the couple’s aspiration to become parents as a primary driver of their desire to have children. ³¹ In addition, by providing counseling and emphasizing the couple’s sense of fulfillment through having a child, the midwife can encourage individuals toward childbearing.

This study findings highlighted the efficacy of proper counseling in aiding couples with unintended pregnancies to accept the pregnancy and forget abortion. Women experiencing unwanted pregnancies often harbor negative feelings towards their condition and the approaching birth, risking their own and their baby’s mental well-being if the pregnancy continues. Conversely, opting for termination carries the risk of septic abortion and maternal mortality. ³² Considering that counseling and education promote maternal-fetal attachment, ³³ midwives are positioned to play a critical role in this context.

The findings of this study indicate that providing high-quality pre-conception care helps couples to consider childbearing. For example, evidence has shown that high-quality pre-conception care for individuals with diabetes, ensuring normalized blood glucose levels before conception, significantly reduces the occurrence of congenital anomalies, premature births, and spontaneous abortions. ³⁴ Consequently, midwives, as skilled providers of pre-conception care, are instrumental in this domain.

The current study results demonstrated that midwives could increase the couples’ willingness to have children by delivering high-quality care to pregnant women and their spouses. Another study found that unpleasant experiences of previous pregnancy and childbirth were significant reasons for the couples’ reluctance to have a second child, ³⁵ which is consistent with this study.

The study showed the crucial role of midwives in supporting the overcoming of barriers to childbearing by changing negative attitudes, correcting misconceptions, and overcoming the fear of pregnancy and childbirth.

Unfortunately, nowadays, most parents have a negative attitude toward childbearing for various reasons. Many sociologists now identify this attitudinal shift as the primary cause of declining fertility in recent decades. ³⁶ Research has established that a more positive attitude towards children within families and society, emphasizing their value, increases the desire for childbearing. ³⁷ Thus, strategies to reshape societal attitudes and address this barrier to childbearing are essential, and midwives can play a crucial role through targeted education.

Misconceptions about childbearing persist among some couples. Prioritizing personal fulfillment through goals, plans, and hobbies is increasingly common, particularly among educated women. Additionally, certain couples deem smaller families essential for their comfort and well-being, perceiving numerous children as disruptive to their peace. ³⁸ Consequently, midwives can play a pivotal role in promoting childbearing by offering targeted counseling and accurate education to reshape existing beliefs.

A significant barrier to childbearing identified in this study was the fear of pregnancy and childbirth, compounded by concerns about physical changes like loss of fitness. Reinforcing this, another study cited anxiety about weight gain and perceived unattractiveness during pregnancy as deterrents to having children, ³⁵ aligning with the present findings and underscoring the critical need for maternal education.

Prenatal classes provide a suitable opportunity for midwives to identify and address the sources of individuals’ fear by making childbirth a positive experience and creating good memories of labor for couples, so they are encouraged to have more children. A positive childbirth experience, characterized by maternal satisfaction and reassurance, positively influences future childbearing intentions. ³⁹

Continuous midwifery care provided by midwifery students during labor has been reported to result in a more positive childbirth experience compared to routine ward care. ⁴⁰ Furthermore, respectful behavior from the healthcare staff has been identified as the most critical factor in maternal satisfaction with the birth experience. ¹² Consequently, midwives can significantly enhance the childbirth experience by employing various methods, including pharmacological and non-pharmacological pain management, and by facilitating the presence of a companion during labor.

Based on the couples’ experiences, midwives act as key advocates of promoting healthy childbearing by empowering parents, reducing barriers, strengthening motivation, and creating readiness for parenthood. Therefore, considering the effective and community-oriented role of midwives in encouraging families to have children, it is recommended that policymakers should pay more attention to the position of midwives when enacting laws and programs related to childbearing and the youth of the population.

A major strength of this study is the first to explain the role of midwives in childbearing from the couples’ perspective. Also, in this study, interviews were conducted simultaneously with couples, allowing them to share a deeper and more mutual understanding of their views with the researcher.

This study has some limitations. As the first study of its kind, there is no directly comparable research available for discussion. Moreover, midwives and health policymakers were not interviewed about the role of midwives in childbearing.

CONCLUSION

Given the vital role of midwives in encouraging childbearing and supporting families, it is recommended that policymakers should recognize and strengthen the position of midwives when formulating childbearing policies and programs.

Future research should explore the role of midwives in promoting childbearing from the perspectives of midwives themselves and policymakers using qualitative approaches, followed by quantitative studies to assess the impact of these efforts.

Acknowledgment

This article is extracted from the Ph.D. thesis of Parvin Esfandiarinezhad. The authors wish to thank all couples who participated in the study for their valuable time and willingness to share their experiences. The study received financial support from Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.

Authors’ Contribution

PE and MI were responsible for the conceptualization and design of this study. The data collection was conducted by PE. The data analysis and interpretation were carried out by PE, NJ, and MI. PE and MI drafted the initial manuscript. All authors critically reviewed, revised the manuscript, and approved the final version for publication. All authors take responsibility for the integrity of the data and the accuracy of the data analysis. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.

Funding Source

This study was supported by Ahvaz Jundishapur University of Medical Sciences (Grant number: RHPRC-0307)

Conflict of Interest

None declared.

Declaration on the use of AI

No Artificial Intelligence (AI) tools were used in the data collection, analysis, or preparation of this manuscript.

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