Iranian Maternity Services Set Out a 89-Point Agenda for Woman-Centered Care
A modified Delphi study in Iran has turned a broad clinical ideal into a structured set of actions for maternity services. The work produced 89 strategies for improving woman-centered care across health centers and hospitals, with every recommendation reaching the study’s predefined consensus threshold. For a care model that often depends on local culture, staffing patterns, and institutional priorities, the result is unusually concrete: clinicians and administrators now have a prioritized list rather than a general aspiration.
The study was conducted from July to September 2023 in Tabriz and drew on a mixed-methods research program with a sequential explanatory design. Investigators built the strategy set from quantitative and qualitative findings, a literature review, and expert feedback, then refined the list through two Delphi rounds. Thirteen experts with Ph.D. degrees in Midwifery or Reproductive Health, representing institutions across several Iranian cities, took part in the process. Consensus was defined as at least 70% agreement on a 5-point Likert scale in the second round.
One sentence captures the clinical weight of the exercise: every one of the 89 statements cleared the bar.
Seven Domains Shaping the Care Model
The final recommendations were grouped into seven categories: ethical values, professional competence, occupational and regulatory laws, education of women and midwives, labor, pregnancy, and childbirth, policy-making and implementation, and social recommendations. This spread matters because woman-centered care is not confined to bedside communication. It is shaped by training, law, workflow, staffing, the degree of respect offered during labor, and whether health systems support the time and resources needed to provide individualized maternity care.
The domain structure also reflects a familiar fault line in obstetric practice. A care model may be ethically endorsed but still fail in daily use if midwives lack authority, if institutions reward speed over shared decision-making, or if women enter services with limited information about their options. By placing education, regulation, and policy alongside clinical practice, the strategy set treats maternity care as a systems problem rather than a single-provider issue.
The 89 recommendations were not treated as a flat list. Instead, they were divided into two implementation tiers. Core recommendations, labeled Priority 1, included 62 statements with 100% consensus and were positioned for immediate implementation. Optional recommendations, labeled Priority 2, included 27 statements with consensus ranging from 92.30% to 76.92%, suggesting they are suitable for phased adoption.
Immediate Priorities and Phased Actions
The sharp division between Priority 1 and Priority 2 is clinically useful. Core recommendations can guide near-term changes in maternity units without waiting for major structural reform, while optional items can be staged as resources allow. In practical terms, that could help administrators separate non-negotiable standards from longer-horizon changes tied to budgeting, staffing, or policy revision.
The authors framed these recommendations as more than consensus language. They can function as a self-assessment tool for midwives, a template for curriculum revision, and a roadmap for administrators trying to optimize staffing. The list also reaches beyond professional education into health-system financing, including budget allocation, midwife-led care models, and the reduction of out-of-pocket expenses. Those are not abstract policy targets; they determine whether women can actually access respectful, continuous maternity services when they need them.
A maternity service cannot claim woman-centered care if the system forces women to absorb the cost of fragmented attention.
Why the Strategy Set Matters for Daily Maternity Practice
The strongest clinical value of the study lies in its local specificity. Iranian maternity care has faced high rates of unnecessary interventions and limited access to optimal health services, making a locally developed framework especially relevant. A strategy imported wholesale from another health system may fail if it conflicts with legal structures, cultural expectations, or workforce realities. Here, the recommendations were built from the local context and then tested against expert agreement, which gives the final product greater policy traction inside the system it is meant to change.
The emphasis on ethical values and professional competence suggests that woman-centered care is being defined not only as kindness or communication style, but as a discipline of practice. In obstetrics and midwifery, this includes informed participation, respect for preference, and the capacity to support labor and birth while minimizing unnecessary intervention. When those principles are reinforced by education and regulation, they can shape institutional norms rather than relying on isolated individual behavior.
The results also point to a broader implementation challenge. Reaching consensus among experts is a necessary step, but it does not guarantee uptake in crowded maternity wards, under-resourced clinics, or hospitals where staffing and reimbursement systems reward efficiency over individualized care. The study therefore stops at a critical threshold: it identifies what experts agree should be done, but the next test is whether those recommendations can be embedded in real-world clinical settings without dilution.
What the Delphi Consensus Can and Cannot Prove
A Delphi study is designed to organize expert judgment, not to measure patient outcomes. It can identify what a highly informed panel believes should happen, but it cannot by itself show that the recommended changes reduce intervention rates, improve maternal experience, or alter neonatal outcomes. The 100% consensus on the Priority 1 items does, however, signal unusually strong agreement on what belongs at the center of reform.
For health systems trying to translate values into practice, the article offers a practical architecture. Administrators can use the core recommendations to set standards, educators can use them to revise training, and policy-makers can use them to align financing and staffing with the demands of respectful maternity care. Future research now has a clear assignment: test feasibility across diverse settings and bring in the voices of all maternity care stakeholders, not only experts in midwifery and reproductive health.
The study leaves one concrete question on the table: which of these 89 recommendations can move from expert agreement to routine bedside behavior without losing force in the transition.