I have just returned from another mission to Iran, where I am working on a project to improve the childbirth practices for women and babies for the Ministry of Health and Medical Education. This has been my third trip, funded through the UNFPA, and it is pleasing to see that some improvements are now in place and that efforts are being made to take these further.

The main effort has focused on the establishment of eight centres where normal births can occur. These are located in Tehran (2 centres) and 6 in regional cities around the country, including Mashad, Gorgon and Tabriz. Each has been provided with some basic equipment that would be found in a typical birth centre such as a bath, access to a toilet and shower, floor mats and birth balls, some privacy and more space.

In Iran, obstetricians are totally in charge of childbirth and midwives play a subservient role, acting as obstetric nurses. It was encouraging to have several obstetricians tell me of the great success they are having with physiologic birth in these new centres. It certainly helps that virtually all obstetricians are women in this Muslim country, but also sad that many have chosen caesarean births for themselves, due to the inhuman conditions that prevail in most hospitals.

One of the main goals of this visit was to help set up a program for training childbirth educators in Iran. I feel this aspect of my visit has been less successful than I hoped, for a variety of reasons. It is clear that there is no concept of how a training course should be established and the role of the educator is not clearly defined or even understood. There is a fledgling program in place but this needs to be completely re-vamped so that it reflects adult education principles, incorporates appropriate subject matter and enables educators to develop presentation, communication and counselling skills.

Each of the new centres had set up a program of prenatal education for pregnant women. This is a first – until recently there had been no formal education available for expectant parents. The program that is in place covers the basics of pregnancy and post natal care but is very inadequate when it comes to labour and birth. Women are still not being given any information about the many interventions and medical procedures they will be routinely subjected to in hospital. There are no detailed discussions on shaving, enemas, rupture of membranes, oxytocic drips, forceps, vacuum, episiotomy and caesarean birth. Discussion about the other routines that are carried out, such as no access for a companion, restriction of fluids in labour, hourly vaginal examinations, labouring on the bed, the use of pethidine and nitrous oxide for pain and the routine separation of mother and baby following birth also need to be included.

For many women, giving birth in Iran represents a horrific experience where their human rights are disregarded and they are routinely subjected to humiliating, embarrassing and unnecessary procedure. Many will opt for caesarean birth to avoid these indignities. The Ministry of Health is keen to change this, but it will take a concerted effort on several fronts to improve the birth experiences for women.

I’ve been asked to make a number of recommendations.

First, I have suggested that those hospitals and obstetricians who have embraced normal physiologic birth should be publicised as widely as possible, in recognition of their work and also to alert women that alternatives are now starting to appear.

Secondly, I have recommended that a new course be developed that focuses solely on midwifery. At present the basic nursing course and the subsequent midwifery degrees are too broad, requiring graduates to be competent in areas outside the accepted scope of midwifery such as paediatrics, gynaecology and women’s health. Many of the midwifery courses are taught in part by obstetricians and a standard obstetric text is the basic reference. This is unsatisfactory and has left midwives feeling unable (and unwilling) to take responsibility for the care of women during pregnancy and birth.

The whole area of childbirth education needs a re-think. A clear vision of its purpose, objectives and structure needs to be prepared and a program developed that is separate from mainstream midwifery, preferably administered by a dedicated team of master trainers. I’ll be working with they key personnel within the Ministry of Health on these issues.

Overall, this has been an interesting mission. I was left feeling frustrated by the educator’s workshop I presented, but heartened by my program for the obstetricians. The midwives workshop was mixed – they need a lot of support and encouragement to fully embrace their role as primary health care professionals.

As ever, the Iranians have been generous and gracious hosts. I have been very well cared for (through boundless hospitality) and I feel I have made some very dear friends over the past few years. I hope that I can continue to work with these people as they make further progress in the future.