Development and validation of the code of ethics for midwives in Iran

Abstract

Background

Considering ethical issues in midwifery care is essential for improving the quality of health services and the client's satisfaction. This study aimed to develop and validate the code of ethics for Midwives in Iran (ICEM).

Materials and methods

This was a mixed sequential study that was performed in three phases including a qualitative study, a review, and the content validity assessment. The first phase was a qualitative study with a content analysis approach. The data were collected by conducting in-depth semi-structured individual interviews with 14 midwifery and ethics experts. The purposive sampling method was used to recruit the participants and sampling continued until data saturation. The data were analyzed using the conventional content analysis described by Graneheim and Lundman. Lincoln and Guba’s criteria were used to confirm the trustworthiness of the data. Then, a narrative review of the selected national and international codes of ethics for Midwives was performed to complete the items of the ICEM. For validity assessment, the face and content validity of the items of ICEM was assessed by 15 experts to calculate the content validity ratio (CVR) and index (CVI).

Results

Fourteen experts were interviewed in the qualitative phase, and 207 codes were extracted from a content analysis which were categorized into 23 sub-categories and 6 main categories. The extracted codes were considered as the items for ICEM that were completed by a review of the selected national and international code of ethics for Midwives. The content validity and ratio assessment of the items demonstrated an average CVI = 0.92 and CVR = 0.85. Then, the final version of ICEM was developed with 92 items in 6 domains about; 1) "professional Commitments" with 30 items; 2) "providing midwifery services to the client and her companions” with 26 items; 3) “relationship with colleagues" with 11 items; 4) “herself” with 6 items; 5) “education and research” with 8 items; and, 6) “management” with 11 items.

Conclusion

ICEM was prepared with 92 items in six sections that facilitate its use for midwives who are working in the different fields of care, counseling, education, research, and management. In this new version of the ICEM, the items related to recent social-, scientific, and technical improvements were considered for providing ethical midwifery care.

Introduction

Midwifery is a vital profession because midwives are responsible for maternal–fetal/neonatal care in the perinatal period, and their decisions effect maternal and infant health and the wellbeing of family members [1]. Midwives communicate with the mothers and their families during the perinatal period which is a special and critical period of human life [1]. Midwives play a significant role in the health care system by providing care and counseling during the perinatal period [2, 3]. Midwifery is a medical discipline that requires professional ethical considerations in providing care [4]. In Iran with a history of more than one hundred years of academic midwifery education, more than 30,000 midwives with Bachelor's, Master's, and Ph.D. degrees in midwifery are now working as care providers, managers, educators, or researchers in the Iranian public health system [5].

The term ‘ethics’ is a set of social rules, principles, and norms that guide people in a society, and is about right and wrong behaviors, as well as good or bad characters [6], and it involves measuring the conformity of a person's actions to a code of conduct or set of principles [7]. Medical ethics has been defined as "the analytical activity in which the concepts, assumptions, beliefs, attitudes, emotions, reasons, and arguments underlying medico-moral decision-making are examined critically" [8]. Four principles including respect for autonomy, non-maleficence, beneficence, and justice, were identified in the 1970s as guiding concepts of medical ethics [9]. Thereafter, principles such as confidentiality, privacy, consciousness, solidarity, human dignity, pluralism, tolerance, non-discrimination accountability, truth, and fidelity were also suggested by others with different cultural and historical contexts [10,11,12]. Then codes of ethics were developed for different medical professions gradually to help them provide care based on ethical principles [13].

Midwives also need a code of ethics to enable them to provide quality care services [14]. The code of ethics for midwives promotes self-regulation, fosters professional identity, and protects midwives and clients, as well as being used as a tool to measure professional ethical practice [7]. The American College of Nurses and Midwives (ACNM) code of ethics was first published in 1990, and then the code of ethics of the International Confederation of Midwives (ICM) was introduced in 1993. These documents and the Values Statement of the Midwifery Association of North America (MANA) guide the behavior of midwives in their practice, including providing care and counseling to women and their families, labor management, research, and health service management [15].

A code of ethics for midwives can be developed in different countries based on the country's culture and health system [16]. The code of ethics for midwives was developed in Iran in 2015 [17] with 85 items in 6 domains 1) the professional tasks (23 items), 2) providing midwifery services to the client and her companions (27 items), 3) communication with colleagues (11 items), 4) about herself (6 items), 5) in education and counseling (8 items), and 6) About management (10 items) [17]. Also, the midwifery professional practice guideline was developed based on the nursing code of ethics in 6 domains 1) altruism (6 items), 2) Honor and honesty (24 items), 3) Justice (5 items), 4) Respect (11 items), 5) Conscientiousness (19 items), and 6) Excellence (14 items) [18].

Recent studies in Iran showed an increasing expectation of improved quality of maternity services through respectful care [19], and midwives’ need for ethical knowledge to manage different situations and provide safe and proper legal and ethical maternity care [20]. Besides, Iranian midwives’ responsibilities changed after the implementation of the "Health Sector Evolution Plan" in 2015 in Iran, and midwives were introduced as a member of the “Health Care Team” and the “Family Health Care Provider” so there was some changes in the midwives’ responsibilities [21, 22]. Additionally, following the decreasing fertility rate in recent decades in Iran, promoting childbearing was announced as a critical policy, and improving the quality of maternal services was emphasized as an important strategy [23]. Also, the COVID-19 pandemic created some concerns about providing midwifery care with ethical considerations [24]. Moreover, the World Health Organization emphasized considering ethical issues in providing quality maternity care for making a positive childbirth experience [25]. Therefore, regarding several changes in midwifery responsibilities because of the increasing women's expectations about the quality of maternity services, evolution in health care system in Iran, and the related fertility and population policies, updating the midwifery ethical code seems to be necessary. Besides, the ethical code needs to be updated, evaluated, and validated periodically because of changing women's needs and the social situation [15]. Then, midwives can improve midwifery care services by providing morally and respectful services and increasing the client's satisfaction. Therefore, this study aimed to develop and validate the code of ethics for Midwives in Iran (ICEM).

Methods

This was a mixed sequential study that was performed in three phases [26] including (1) a qualitative study to develop the first set of the items for ICEM, (2) a review of the selected national and international code of ethics for Midwives to complete the items of ICEM, and then 3) validation of the items (Fig. 1).

Fig. 1

Procedure of the study to design and validate the code of ethics for midwives in Iran ICEM

Phase 1) The qualitative study

The first phase was a qualitative study with a content analysis approach to generate the first set of items.

The design and the setting

The qualitative study aimed to explain the essential ethical considerations in different aspects of midwifery practice including midwifery care, counseling, service management, education, and research. This study was conducted in different departments that midwives provide services, including care, education and research departments in the private or public sectors in Tehran-Iran. The participants were individually interviewed in their workplaces in hospitals, health centers, or universities.

The participants

The participants in the qualitative part of the study were midwives who were involved in providing perinatal care services in the private and public sectors or the managers, the university faculty members of the midwifery departments, the researchers in the midwifery field, and the medical or nursing/midwifery ethics experts. They had at least two years of work experience. The participants were selected through purposive sampling from May to August 2022. Maximum variation was considered in selecting the participant's experience in care, education, research, management, and duration of work experience. The participants were individually interviewed in their offices after explaining the objectives and the process of the study and then obtaining written informed consent. Subjects’ willingness to withdraw from the study was the only exclusion criteria.

Data collection

The data were collected using in-depth semi-structured individual interviews with open-ended questions. The interviews began with open-ended questions such as "What is the concept of midwifery ethics" and "How midwifery ethics could be considered in midwifery services". The interviews continued to clarify the dimensions and characteristics of the subject with probing questions such as "How?", “What do you mean by that?" and “Please elaborate on this point” (Supplement 1).

Trustworthiness

Four criteria of credibility, confirmability, dependability, and transferability by Lincoln and Guba were used to ensure trustworthiness [27]. To increase credibility, the researcher devoted enough time to data collection. In addition, the diversity of participants by selecting midwives who worked as providers, educators, researchers, and managers as well as using different methods of data collection such as individual interviews and field notes were considered. The members, the peers, and the experts' checks of data were also used to assess the trustworthiness of the data [27].

Data analysis

Data were analyzed using a conventional content analysis based on the criteria proposed by Graneheim and Lundman [28]. The recorded interviews were transcribed and then reviewed by the researcher several times to achieve an accurate understanding of the contents. The text was divided into meaning units, meaning units were condensed while preserving the meaning and labeled with codes. Similar codes were then categorized. The extracted codes were considered as the items of ICEM.

Ethics approval and consent to participate

The study was approved by the ethics committee of Shahid Beheshti University of Medical Sciences, with the code “IR.SBMU.RETECH.REC.1401.113”. Before conducting the interviews, the researcher briefed the participants on the objectives and ensured the confidentiality of the information and the voluntary type of participation. All the interviews were conducted in a private and quiet room. Written informed consent was obtained from all participants.

Phase 2) The review of the code of ethics

In this phase of the study, a review of the selected national and international code of ethics for Midwives was performed to complete the first set of the extracted items from the qualitative phase of the study. A literature search was performed in PubMed (including Medline), Web of Science, Scopus, Embase, Science Direct, and Cochrane databases as well as in the Google search platform. MeSH and keywords including ethics, code of ethics, midwifery, Midwife, and midwives were used to find documents related to the purpose of the study. No restrictions were placed on language or publication date (until May 2023).

Phase 3) Validation of the ICEM

For the face qualitative validity assessment, 5 midwives were asked to assess the difficulty, irrelevancy, and ambiguity of the extracted items of ICEM. In the qualitative content validity assessment, 15 midwives who work as care providers, educators, researchers, and managers were asked to judge the grammar, choice of vocabulary, and placement of the items. The content validity of the items was assessed by the 15 experts in midwifery and ethics including 2 midwives working as the maternity service provider, 2 maternity service managers, 11 university faculty members, and researchers of midwifery and medical ethics. To assess the content validity ratio (CVR), the experts signified their opinions by assigning each item scores of 1 to 3, which correspond to “not essential,” “useful but not essential,” and “essential,” respectively. The scores were then calculated using the following formula: CVR = (Ne – N/2)/(N/2), where Ne is the number of experts indicating an item as “essential” and N is the total number of experts. The accepted value was determined based on Lawshe’s table and the number of experts. According to this table for 15 experts, a CVR of more than 0.49 for the item is acceptable [29]. Content Validity Index (CVI) was calculated based on Waltz and Bausell’s criteria to ensure the appropriateness of the items for measuring the content. The experts scored the relevancy of the items using the four-point Likert scale (scores 1 to 4, respectively). The CVI score of each statement was computed as the number of experts giving a rating of 3 or 4 to each item, divided by the total number of experts. Based on this index, items with a CVI higher than 0.79, between 0.70 and 0.79, and lower than 0.70 were considered suitable, needing modification, and unacceptable, respectively [30] (Fig. 1).

Results

The findings are presented in three phases including Phase 1 the qualitative study to develop the primary items for ICEM, and then Phase 2 for completing the items of ICEM by a review of the international code of ethics for midwives, provided by the valid related organizations and other countries, and then in phase 3 the results of the validity assessment.

Phase1: The qualitative study

Every individual interview lasted 45–60 min, and all the interviews were tape-recorded. In addition to interviews, field notes were used for data collection. Although data saturation was achieved with 12 interviews, two additional interviews were conducted for greater certainty.

The participants in the qualitative phase of the study were 14 experts, including 6 midwives who were working in the private and public sectors; 2 midwives who were maternity service managers, 4 faculty members of the university at the department of midwifery or midwifery-related research centers, and 2 experts in medical ethics (Table 1).

Table 1 The characteristics of participants in the qualitative phase of the study to develop midwifery code of ethics in Iran

The findings in the qualitative phase showed the 207 codes in 23 sub-categories and 6 categories including ethical consideration about 1) the clients, 2) the clients’ companions, 3) herself, 4) the colleagues, 5) the environment, and 6) the procedures. Figure 2 shows a schematic view of the concept of ethics for midwives.

Fig. 2

The concept and a schematic view of the concept of ethics for midwives

The midwifery ethical considerations about the clients

This category showed 84 codes in 11 subcategories including greeting, privacy, confidentiality, empathy, creating a scene of security, providing respectful and non-bias care, the right to choose, attention to the wishes and needs of clients, reducing the stress, providing quality care and providing the information (Table 2).

Table 2 The codes and the subcategories of the category "The midwifery ethical considerations about the clients"

Greeting

Most of the participants pointed to the greeting as an important ethical point in using the identification card and welcoming, making verbal and friendly communication, and introducing the structure and processes as the client's rights. A participant said:

“We also have to go to other doctor's offices or hospitals. I like to be welcomed by the person in charge and ask about my pain” (BSc., Maternal health provider, public hospital).

Privacy

All the midwives participating in the study considered privacy as one of the most important ethical considerations in the midwifery profession:

"Our patients should be completely sure about their privacy. Women should be taken care of in a situation where their privacy is completely protected in terms of covering and sound." (Ph.D., the University Professor, and medical ethics researcher, university).

Confidentiality

All participants mentioned the necessity of confidentiality as a critical consideration, especially regarding the information obtained from the client during counseling and care.

"There are some problems where the patient has a problem but says that my family doesn't know. For example, a patient with epilepsy said My mother-in-law doesn't know, I don't want her to be told about it."(BSc., care provider, private clinic).

Some of the participants mentioned the importance of protecting women's information transfer through the internet.

"The midwife should care about the online transfer of women’s information with the name of the client, such as sending the information through the application, e-mail, fax, and social media) and consider the legal aspects for sending the information.” (MSc., Maternity service manager, Public hospital).

Empathy

The majority of participants pointed out the necessity of creating a sense of empathy with the client, especially during labor and delivery, and expressed its value as half the treatment:

"I always put myself in the place of the client, I treat women the way I want to be treated." (BSc., care provider, Public hospital)

Security

Most of the participants mentioned security as an essential right of the women in the midwifery services:

"An intimate and respectful relationship with them is necessary. We should spend time and talk to the woman and her companions in a way that they feel what we are doing for her is something that is the best for her " (BSc., care provider, Public hospital).

Respectful and non-biased care

Respecting and not being biased care were emphasized by the participants:

" In the midwifery practice, since women's problems are not like other medical problems such as foot pain, I believe that we should talk to the clients politely and considering their culture and literacy so that they understand and accept things well” (a midwife, researcher, a university research center).

Decision-making

The majority of the participants stated that the client has the right to choose or reject a treatment during the physiologic process of labor and childbirth:

"Unfortunately, the women don’t have the right to choose, they can't tell an opinion in our system. While they have the right to choose, for example, their position in the labor process” (BSc., care provider, Public hospital).

Considering the wishes and needs of clients

Paying attention to the client's wishes and needs was emphasized by the majority of the participants:

"The major problem is how much the client considers it the right to express her needs, and how much the care provider considers meeting the client's needs as the right " (Ph.D., the University Professor, and medical ethics researcher, University).

“Respond to the physical, psychological, spiritual, emotional, cultural and social needs of the clients who are seeking midwifery care and also educate all clients self-care" (Ph.D., a reproductive health researcher and university professor, University”.

"The midwife should consider the special needs of vulnerable clients such as high-risk mothers and infants, women with chronic diseases, or AIDS, or with alcohol and drug addiction, victims of violence, homeless, prisoners, refugees, and immigrants and the elderly in providing midwifery services" (MSc, a midwifery service manager, Public hospital).

“They should provide midwifery services in exceptional circumstances, such as disasters (eg. earthquake and flood) or in an epidemic or pandemic of diseases like Covid-19 pandemic.” (Ph.D., Midwifery/RH researcher, University).

Reduce the stress

Many participants stated that women should be aware of the labor process and the related care and services beforehand.

“I teach her in advance. For example, what position to be in, or take a deep breath to reduce her anxiety and stress?” (BSc., care provider, private hospital).

Providing quality care

All participants highlighted the importance of providing quality care, without any discrimination, and based on social justice to benefit the clients and prevent harm.

" The practice should result in the patient's wellness and goodness. Besides, the next principle is avoiding harm to the patient. Whatever we do, may have some complications. The next principle is social justice, which refers to the fact that care should be provided to all people, regardless of their race, gender, religion, and so on, and it should be only based on the client’s needs (Ph.D., a university professor, and medical ethics researcher, university).

"Midwives should play an effective role in promoting the health of women, family, and society" (Ph.D., a university professor and researcher in midwifery, university).

Providing information

All the participants mentioned the necessity of providing information as a client's right. The information should be provided properly and based on the client's needs to help them in making informed decisions.

"First, when they come, I give some information to the client and her companion about the normal procedures of her labor and delivery and the care procedures. For clients who may not go through the normal delivery procedure, and need a cesarean section, I provide the related necessary information to both the patient and her family."(BSc., care provider, a private hospital).

The ethical consideration in the relationship between midwives and the client’s companions

This category includes 15 codes in 2 subcategories including the importance of giving information to the clients and involving them in the maternal care process (Table 3).

Table 3 Codes, sub-categories, and categories of the ethical considerations in the midwife's relationship with companions, with herself, and with colleagues extracted from the qualitative phase of the study

Importance of giving information to the clients

The majority of the participants emphasized the importance of giving information to the clients about the care procedure, the client's problems, the progress, and the importance of their involvement.

“The necessary information should be given to the companion so that she/he can take care of the mother whenever it is necessary" (Ph.D., midwifery/RH researcher, a university).

Involving the companion in the maternal care process

All participants highlighted the need for family involvement in the care procedure and decision-making.

"Involving at least one of the companions solves many problems because they feel that a relative is also taking care of her."(MSc., midwifery service manager, a private hospital).

Ethical considerations regarding the midwife's relating to herself

This category includes 35 codes in 3 sub-categories including paying attention to retraining, respecting the rights, and self-monitoring and evaluation (Table 3).

Retraining

Retraining was mentioned as one of the most important ethical considerations about midwives themselves.

"We have been working twenty years ago. Although we have had many retraining workshops during these years on various issues, we need more. For example, we need to be trained about midwifery ethics". (BSc, care provider, a public hospital).

Respecting the rights

Some participants mentioned the violation of midwives' rights in the delivery room.

"When we are in the delivery room, after helping to a normal vaginal delivery or even giving an episiotomy and its repairing, and reporting the procedure in a blue sheet, the doctor would come and sign. All the trouble was for us, then, there was no name of us, and the wage for birthright is for the doctor. We do not defend our right at all.” (BSc., care provider, a public hospital).

Self-monitoring and evaluation

Many participants mentioned the importance of self-monitoring and evaluation in the midwifery profession.

"Midwife must evaluate herself to practice, for the patient's safety and safety of ourselves, both." (MSc., midwifery service manager, a private hospital)

Ethical consideration in a midwife’s relationship with the colleagues

The category includes 27 codes in 3 sub-categories including cooperation with other midwives, supporting colleagues, and respecting and reporting to the manager (Table 3).

Cooperation with other midwives

All participants stated that cooperation between midwives is a critical issue.

"Our colleagues should have a good and friendly cooperation for providing care and all should accept responsibility for their actions" (MSc., a maternity service manager, public hospital).

Supporting the colleagues

The majority of participants said that midwives should support their colleagues through respectful communication, teamwork, patience, and flexibility.

“They should avoid criticizing the colleague in front of the patient or her companion, and respect each other in the maternity services"(Ph.D., medical ethics researcher, university).

Respecting and reporting to the manager

All participants stressed the respectful and responsive relationship of midwives with the managers.

“One should be very respectful in dealing with the supervisor, and provide a complete report of the report her/him about patients". (BSc., midwifery care provider, a public hospital).

Ethical considerations in providing care and management procedures

The category includes 26 codes in 2 sub-categories including care procedures and administrative and management procedures (Table 4).

Table 4 Codes, sub-categories, and categories of the ethical considerations in providing midwifery Care procedures and with the work environment, extracted from the qualitative phase of the study

Care procedures

All participants mentioned the midwifery ethical considerations in the care procedures such as; safety compliance, making medical devices secure and sterile, preventing transmission of infectious diseases, paying attention to needle penetration and use of disposable needles, ensuring that the mother is properly covered during childbirth, using sterile equipment, using of physiologic birth processes, spiritual perspective in care providing, providing the necessary care and avoiding unnecessary invasive procedures, greeting and guiding about the care process, being honest in writing the record, providing correct and complete recording, avoiding to record unnecessary sensitive private information.

" If we have a system that has a defined and reasonable waiting time, we can make an appropriate appointment time. It is also very important for patients to make a follow-up appointment "(MSc., maternity service manager, a private hospital).

Administrative and management procedures

The participants also stated that ethical considerations are necessary for the administrative and management procedures and mentioned items such as; promoting the knowledge and practice of midwifery through research and development of midwifery care standards; reducing patient waiting time, providing follow-up services, monitoring for compliance with ethical regulations, taking an ethics exam for midwifery students’ acceptance, choosing students who communicate respectfully and sincerely, monitoring prevention tips when visiting clients with infectious diseases, monitoring the separation of sterile and non-sterile equipment, providing timely services, providing services with modern technology, supervising on care provision according to perinatal care standards, supervising on the structure of perinatal care procedures including physical environment and facilities.

"The midwifery service managers always should seek for the ways to promote the knowledge and practice of midwifery through research and development of midwifery care standards" (Ph.D., midwifery and reproductive health researcher and professor, University).

"Of course, our manager tries to provide a fair shift schedule with no discrimination but it is sometimes out of her control, she couldn't do it well” (BSc., maternal care provider, a public hospital).

Ethical considerations in the midwifery work environment

This category included 20 codes in 2 subcategories including the environment and the facilities and equipment. All participants stressed the importance of providing an appropriate work environment as well as proper equipment and facilities as the ethical consideration for providing midwifery services (Table 4).

Midwifery work environment

Most participants talk about the features of a proper work environment such as providing services in an environment with sufficient light, a thermally balanced environment, a neat and clean physical space, a delightful environment, with proper ventilation and sound, sufficient space, equipment and facilities, convenient and accessible place to provide care, with adequate safety, providing care in a proper place to keep the client's privacy, attempting to make the client feel at home, with proper arrangement of the rooms and appropriate setting of the clinic for easy access.

“It should have proper ventilation, there should not be too much noise so that you can concentrate on your work, there should be enough light, the right temperature” (a midwife, care provider, private hospital).

"The number of personnel should be enough, the space should be equipped, and the medical equipment should be excellent so that we can provide quality services.” (MSc., maternity service manager, a public hospital).

Table 4 shows the ethical considerations related to the care procedures and the work environment which were extracted from the interviews in the qualitative phase of the study.

Phase 2: A review of the international midwifery code of ethics

The code of ethics provided by eight valid midwifery organizations and institutions was reviewed and summarized in Table 5.

Table 5 Summary of a review of the code of ethics presented in the selected organizations and countries

The concept of ethics for midwives is considering ethics in providing the client's care, in interactions with companions, about herself, the environment, and processes. About the clients, these considerations are providing care with empathy, keeping privacy and confidentiality, as well as paying attention to the right to choose, dignity, desires, and needs, reducing stress, and providing respectful and safe quality care without any discrimination. About the companions, the considerations are giving the relevant information and permitting them to participate in the care. Cooperation, coordination, respect, and proper reporting are also necessary for colleagues. Paying attention to retraining, self-evaluation, and awareness about midwifery rights should also be considered about herself. Committed behavior regarding the maintenance and improvement of the physical environment, equipment, facilities and paying attention to the standards in care and management is necessary (Fig. 2).

Development of the midwifery code of ethics in Iran

After extracting the items from the qualitative phase and completing the items after reviewing the international midwifery code of ethics, the items were assessed in terms of the content validity index (CVI) and ratio (CVR) by 15 experts including 2 midwives working as the maternity service provider, 2 maternity service manager, 11 university faculty members and researchers in midwifery. Then, the items were revised and edited by the research team.

Finally, the ICEM was developed by 92 items in 6 sections including:

1) "Professional Commitments" with 30 codes; 2) "Providing midwifery services to the patient and her companions” with 26 items; 3) “relationship with colleagues" with 11 items; 4) “herself” with 6 items; 5) “education and research” with 8 items; and, 6) “management” with 11 items. The content validity index and ratio assessment by 15 experts demonstrated an average (CVI = 0.92, CVR = 0.85).

The classification in the six sections was considered to facilitate its use by midwives who are working in the different fields of care, counseling, education, research, and management. These items are listed in Table 6.

Table 6 The final version of the Code of Ethics for midwives in Iran ICEM

Discussion

Considering that all countries have specific regulations and job descriptions in the midwifery service delivery systems, which are based on the cultural, economic, and social conditions of that country [39], the development of a specific code of ethics for every country and even each profession is necessary. Therefore, this study used an innovative approach to develop a valid midwifery code of ethics for the first time in Iran. The items were generated from the content analysis of the interviews with the midwifery and ethics experts who were familiar with providing midwifery services as well as the cultural and social condition, and then the items were completed by reviewing the code of ethics of valid sources in the world and finally, the validity of the content was measured and confirmed by the experts.

Midwives in Iran with bachelor's and master's degrees provide counseling and care services during the perinatal period within the framework of defined tasks in health centers, hospitals, and private offices to women with normal pregnancies. Midwifery graduates with Ph.D. degrees are also employed for teaching and research activities at universities and research centers as well as management jobs. Since Iran has a population with different ethnicities, including Persians, Turk, Kord, Turkmen, Arabs, Gilaks, Lor, Mazan, Baluch, etc., with different religions and cultures, the familiarity of midwives with different customs and beliefs and providing respectful care services and responding to their special needs are essential. In addition, since midwifery services are effective on the life of two humans including the mother, and the fetus or infant providing quality respectful services while considering ethical issues is critical [40].

The finding of the qualitative phase of the study defined midwifery ethics as "considering ethical issues in providing care for the client, in interactions with her companions, about midwife herself, and about the environment and procedure of the services”. Regarding the wide range of midwifery tasks in providing services to the client, many items were included in the category "considering ethical issues in providing care for the client”. The items of this dimension generally refer to the client's rights, empathy, keeping privacy and confidentiality, as well as paying attention to their autonomy, dignity, desires, and needs, reducing stress, and providing respectful and safe quality care without any discrimination. In recent years, the promotion of providing care based on professional ethics and dignity has attracted the attention of countries and international organizations, and respectful maternity care is considered an essential concept for ensuring the rights and safety of women during labor [35]. The important ethical issues about clients are commonly mentioned; avoiding harm and maltreatment, having the right to get information, having the right to informed consent or refuse, respect for the patient's choices and preferences, privacy and confidentiality of information, considering the clients’ dignity and providing timely and quality care without any discrimination [16]. Considering ethical issues and providing respectful maternal care through polite and supportive communication between the woman and the midwife increases the client's self-confidence and provides a basis for respecting the client's rights [41].

The midwifery ethical items about the relationship between midwives and the client's companions showed two main categories including giving the relevant information and permitting them to participate in the care procedures. Clients' companions are mostly the family who are concerned about the client's health and try to get information about the client’s condition [42]. Family-centered midwifery care is a critical model in midwifery and maternal care [43, 44]. In this model of care, it is important to make proper communication with clients and their families, understand their concerns, and answer their questions [45]. Besides, understanding their needs is effective in the communication process causes mutual trust, and improves respectful and ethical care procedures [41].

The midwifery ethical items about colleagues showed the importance of considering respect, protection, proper reporting, and cooperation with other midwives and the team members. Cooperation in team working is an effective interpersonal skill that facilitates achievement the of goals, and quality care cannot be achieved when the care providers act alone [46]. Effective communication between colleagues improves health outcomes as they can share their experiences for providing quality care service [44].

Attention to the rights of midwives as well as training retraining and self-monitoring were mentioned as the most important ethical considerations about the midwife herself. Midwives have a key role in improving maternal-fetal and neonatal health as well as women's sexual reproductive health. Therefore, midwives’ continuous education is necessary to improve maternal and women’s health and the quality of care [47]. Education is a basic element for increasing professional midwives, improving professional and evidence-based practices under international standards, and guaranteeing high-quality services [1]. Developing standards such as the code of ethics for midwives and other health personnel, with cultural consideration can also help the health providers self-monitoring their practice [48] and then improve the quality of care [49].

The ethical considerations about the work environment including the physical environment as well as the facilities and equipment were also stated as an important aspect of the ICEM. No doubt providing quality care with ethical considerations requires an appropriate environment with adequate and efficient equipment and facilities that lead to clients’ satisfaction [50]. However, providing the necessary environment and facilities requires support at the management level.

Considering ethical issues in the care processes as well as management and administrative processes were mentioned as the main aspects of providing midwifery care services. Providing quality care procedures needs appropriate facilities and equipment that in turn needs financial support which is a prerequisite for providing ethical and standard respectful care and maintaining the dignity of the client [51]. The care procedures must be developed based on the community needs and the structure of the health system of every country, and a universal package cannot be used for all countries because some elements such as resources, management, and capacity of the health system are effective in this process [52].

After extracting the items from the qualitative phase of the study, the items were completed with a review of the code of ethics for midwives of the International Midwifery Confederation ICM, American College of Nursing and Midwifery ACNM, UK Nursing and Midwifery Council UKNMC, The British Columbia College of Nurses and Midwives BCCNM, Nursing and Midwifery Board Australia NMBA, New Zealand College of Midwives NZCM, the national code of ethics in Turkey, and Nursing and Midwifery Board of Irland [31,32,33,34,35,36,37,38]. The finding showed that all the above-mentioned codes of ethics as well as the ICEM are developed based on the four principles of medical ethics including respect for autonomy, non-maleficence, beneficence, and justice. In addition, all the documents have similar items but with different specifications and details. It seems ICEM is more similar to the UK Nursing and Midwifery Council which has 95 items and similar details. Besides our findings the review highlighted some items related to recent social-, scientific, and technical improvements such as; 1) responding to the client’s needs in exceptional conditions like disasters and epidemic or pandemic diseases; 2) The social role of midwives in promoting sexual-reproductive health in the community and self-care and the use of media; 3) confidentiality and privacy of client's information while transferring information through internet and, 4) considering all physical, psychological, and social health needs of the clients.

As it is mentioned above, “responding to the client’s needs in exceptional conditions like disasters and epidemic or pandemic diseases”, was an important added item to the IMEC. In such a condition, insufficient access to medical and health care services and food, and an increase in STIs usually occur [52, 53]. Some people may experience the loss of a fetus, infant, spouse, or other relatives [54]. Therefore, on-time care and treatment are critical in disasters [55], and midwives need to provide care in crisis such as the necessary special maternal care that was shown recently during the COVID-19 pandemic condition [56, 57].

One other added important code was “The social role of midwives to promote sexual-reproductive health in the community and self-care and the use of media”. The presence of midwives in social networks causes them to be seen and popularized in society [58]. Midwives can play a social role and use social media to provide evidence-based information for promoting sexual-reproductive health behaviors in the community, family, and especially among women. This is ethically a main responsibility of midwives [59].

Since midwives have access to the most private information of people, confidentiality in the recent techniques for internet transfer of the information is so important. Although information transfer through the Internet makes easy and quick access to the client's information in the health system, monitoring the confidentiality of the information is critical [59].

For the first time, we used a mixed sequential study to develop the ICEM, in three phases including a qualitative study, a review of the codes of ethics for midwives in the world, and then a qualitative and quantitative assessment of content validity of the items. Fifteen experienced and skilled experts reviewed the content of the items and presented their opinions for the necessary improvement, and the necessary corrections were performed. Then the experts scored the essentiality and relevancy of the items. The calculated average CVI and CVR were calculated and confirmed by an average of 0.92 and 0.85, respectively. This version of ICEM has 92 items compared to the previous version which had 85 items. It contained 7 further items in terms of keeping confidential in transferring the client's information via the Internet; responding to the client's needs in special circumstances such as epidemics and disasters, and responding to the needs of different vulnerable clients; paying attention to all aspects of clients’ health, have the responsibility in playing social roles in promoting maternal and women's health and also self-care in the community.

Based on the opinion of the experts for making the ICEM easier for use by different groups of midwives working in clinical, educational, research, and management, the ICEM was developed in 6 domains including; "professional commitments", "providing midwifery services to the woman and her companions", "relationship with colleagues", "herself", "education and research" and "management". To do this, the categories of “client and the client accompanies” in the qualitative phase were integrated to form the "the woman and her companions" section in ICEM. Also the categories of “procedures and environment” were merged and formed the “management” section of ICEM. The items related to the common responsibilities of all midwives merged in the "professional commitment" section. The items related to education and research were also merged in the "education and research" section to be used for midwifery educators and researchers.

Finally, it should be noted that to our knowledge this was the first time that a mixed sequential method was used for developing a professional code of ethics. Although, Kangasniemi and colleagues developed an ethic guideline for nurses’ collegiality using the 4-step Delphi method [60]. Therefore, using this method as an innovation could be considered as the strength of the study.

We refer to “her” or “herself” throughout the items of ICEM because all midwives are female in Iran. As the ethical code could be used internationally, we recommend to use with gender-neutral pronouns. The AGREE-HS (Appraisal of Guidelines Research and Evaluation Health Systems) is a newly developed tool designed to evaluate the quality of health systems guidance (HSG) documents and provides a blueprint for HSG document development and reporting [61].

Conclusion

We used a scientific process to prepare a valid ICEM. The classification in the six sections including "professional Commitments”, "providing midwifery services to the woman and her companions", "relationship with colleagues", "herself", "education and research" and "management" were considered to facilitate its use by midwives who are working in the different fields of care, counseling, education, research, and management. In this new version of the ICEM, the items related to recent social-, scientific, and technical improvements such as responding to the client's needs in exceptional conditions like disasters and epidemic or pandemic diseases; the social role of midwives in promoting sexual-reproductive health in the community and the use of media; confidentiality of client’s information while transferring information through the internet were also considered.