Comparing the professional role and tasks approved in curriculum with the ongoing role and tasks of midwives employed in Tabriz health care units

Introduction To prevent health problems and promote public health and treatment, having capable and skilled personnel with sufficient knowledge and skills providing the best services is necessary. The lack of relevancy between academic courses and professional needs in the workplace is a critical issue in nursing and midwifery education.1,2 The United Nations’ World’s Midwifery Report notes that, although a number of countries promised and are showing developments in training skilled midwives, the desired standards have not yet been met.3 Midwifery skills and education in developing countries is defined based on the International Confederation of Midwives (ICM). As defined by the ICM, “a midwife is a responsible and accountable individual who provides women with support, care and advice necessary during pregnancy and childbirth and the postpartum period, leads delivery on her own responsibility, and cares for newborns and infants.” The care includes preventive measures, promotion of normal vaginal delivery, diagnosis of problems in both mother and child, access to medical care, and other appropriate help as well as participation in emergency measures.4 Defined roles and tasks in the curriculum for midwifery include diagnosis, care, treatment, training, counseling, and prevention. A skilled midwife is an essential link in all the care processes and has an important role in reducing


Introduction
To prevent health problems and promote public health and treatment, having capable and skilled personnel with sufficient knowledge and skills providing the best services is necessary.The lack of relevancy between academic courses and professional needs in the workplace is a critical issue in nursing and midwifery education. 1,2he United Nations' World's Midwifery Report notes that, although a number of countries promised and are showing developments in training skilled midwives, the desired standards have not yet been met. 3Midwifery skills and education in developing countries is defined based on the International Confederation of Midwives (ICM).
As defined by the ICM, "a midwife is a responsible and accountable individual who provides women with support, care and advice necessary during pregnancy and childbirth and the postpartum period, leads delivery on her own responsibility, and cares for newborns and infants." The care includes preventive measures, promotion of normal vaginal delivery, diagnosis of problems in both mother and child, access to medical care, and other appropriate help as well as participation in emergency measures. 4efined roles and tasks in the curriculum for midwifery include diagnosis, care, treatment, training, counseling, and prevention.][5][6] In order to train a midwifery expert to fulfill the abovementioned roles appropriately, it is necessary that midwifery students experience high quality education that fits the health needs and social conditions of the country. 7,8iven that health care is provided by midwives at the Tabriz University of Medical Sciences as an integrated service, and covers the whole population, including pregnant women and neonates, children, adolescents, young, middle-aged, and elderly men and women, workers in these health units have to acquire the needed skills and abilities to perform multiple roles and tasks required by the population in need of care.This is emphasized in the educational change and innovation package, as provided, and is localized and value-based. 9This problem is most often seen in education courses affiliated with the medical sciences.Sereshti et al 10 surveyed the educational needs of midwifery graduates from the viewpoints of employed midwives and officials charged with oversight.The results showed that educational needs of midwives were not consistent with what officials expected.In the study, midwives had stated the educational requirements in their performance area that was not enough attention paid to them in their curriculum.Toulabi and Alhani 11 compared curriculum objectives with professional needs from the viewpoints of three years nursing and midwifery graduates, and the results showed a decreasing trend.Revision of the nursing and midwifery education system to improve the ability of graduates in patient care, more application of theoretical courses, getting training in professional efficiency were suggested.In a qualitative study, Amiresmaili et al 12 attempted to identify problems in general physician education and concluded that lack of comprehensiveness of courses and topics and a mismatch between designated educational goals and the real needs of society as well as an emphasis on theory to the detriment of practice in educational centers were among the most important challenges.In their study in Indonesia, Henness et al 13 reported the influence of midwives' educational needs in all tasks to determine and prioritize educational and training needs of midwives and a new curriculum to meet these needs.The results of a study of a training program in Jordan on the design and content of the midwifery curriculum and the ability of the curriculum to train skilled midwives to maximum capability in standard tasks to take care of low risk pregnant mothers showed that more attention has been paid to treatment and intervention in the curriculum rather than to roles;thus, expected international definitions of midwives and changes in the curriculum have been recommended. 14In their study on the family physician curriculum, Ahmadi et al 15 also concluded that the curriculum for family physicians and Medical Education courses had to be revised.A literature review showed that research in this field was conducted more educational need assessment and satisfaction survey and was not a comprehensive study that to Comparison the professional role and tasks curriculum-based with the current role and tasks of midwives in Tabriz Medical Sciences University.Therefore, the study was carried out with the aim to compare the professional role and task approved in curriculum with the ongoing role and task of midwives working in the health care units.

Design, setting and participants
This cross-sectional study was carried out in urban and rural health centers of Tabriz, Iran, in 2015.All midwives working in rural and urban health care units of Tabriz health centers were recruited via census (n = 225).Inclusion criteria were: holding a Bachelor of Science (BS) degree in midwifery, having a defined duty in a family health unit, at least 6 months of on the job experience in the health care unit, and employment in one of the approved posts for midwives, including midwife in charge, family health expert, midwife, and health team midwife.

Measures and data collection
Data was collected using a researcher-designed questionnaire.The questionnaire was designed to address specialized training courses, main topics and roles and tasks contained in the national midwifery curriculum approved in 2012.The first part asked for demographic information of the study participants (12 questions), the second part included questions related to the use of any of the main topics' specialized courses with current performance (136 main topics), and the third part included questions related to the relevancy regarding of professional roles and tasks contained in the curriculum compared with their current performance of the midwives who were being surveyed.Roles related to diagnosis (11 tasks), education (7 tasks), consulting (6 tasks) and prevention (4 tasks) that were completed by employed midwives as a self-assessment.Data included demographic information such as their age, education place, employment status, and professional work experience.Questionnaire statements were scored from 1 to 5 based on a 5-point Likert scale (where very high = 5, high = 4 medium = 3, low = 2, and very low = 1).The overall average for each scale and subscale were computed.The possible range of scores was 1-5.Validity of questionnaire was confirmed by ten experts of midwifery and medical education, and Cronbach α (α > 0.9) was used to assess its reliability.

Statistical Analyses
Data were presented using mean (SD) and number (%) for numeric and categorical variables.All data were analyzed by SPSS 17 (SPSS Inc, IL, Chicago, USA).

Results
Of 225 employees entered study, 195 (86.6%) completed the questionnaire in the second half of 2015.The average age of respondents was 38.56 ± 7.34;the minimum and maximum were 23 and 50 years, respectively.The average job experience of respondents' was 12.13 ± 7.26 years.In terms of approved posts, 37% were working as a midwife in charge, 40.7% as a midwife, 19.5% as a health team midwife and 2.8% as a family health expert.Table 1 shows demographic information of population under study.

Main topics of specialized courses
Table 2 showed mean relevancy of specialized courses main topics in the curriculum with their current performance.In examining the relevancy of main topics of specialized courses for midwives with their current performance, the highest relevancy was found in the specialized course of normal pregnancy training, with an average of 4.21±0.73and the main topic of familiarity with training and counseling of pregnant women related to pregnancy was observed with an average of 4.30 ± 0.75.General and specific pathology had an average of 2.22 ± 0.91 and the topic of familiarity with degeneration and cell death, and studying and observing microscopic details of tissues and abnormal organs in the body, sampling methods and abnormal tissue staining had the lowest relevancy, with an average of 2.00 ± 1.01.The courses with the highest relevancy to midwives' current activity were: normal pregnancy internship, pregnancy and delivery 1, principles of maternal and child nutrition, newborns, newborns internship, mother and child health and fertility 4, and gynecological internship, maternal and child health internship, pregnancy and delivery 3 (see Table 2).The topics related to the courses of general and specific pathology, biostatistics, general psychology, women and family, specialized English, principles of epidemiology and disease control, management of principles and its application in midwifery, psychiatric principles in midwifery, physiopathology and surgery, and internal medicine internship had the lowest relevancy.Table 3 demonstrated mean relevancy of professional roles and tasks in the curriculum with the ongoing roles and tasks of midwife.

Professional roles and tasks
In diagnosis, care-intervention role: As seen in Table 3, tasks related to pregnancy care under normal circumstances and referral of cases had the highest mean (3.78 ± 1.94) and effectively communicating with patients had the lowest relevancy (3.35 ± 1.07).In the education role: training to identify risk factors in pregnancy and training tips related to contraceptives had the highest mean (4.17 ± 0.81) and training clients and companions in the field of self-care and referrals to care had the lowest relevancy (3.64 ± 0.95).
In the consulting role: consulting at the postpartum period had the lowest (3.11 ± 0.81) and consulting on family planning had the highest relevancy with current tasks (4.13 ± 0.78).In the prevention role: planning and implementation of prenatal care to clients was the highest (3.94 ± 0.92) and participation in research projects had the lowest relevancy (3.36 ± 1.25).In general, the diagnosis, care and interventional role had an average of (3.60±0.82), the educational role had an average of (3.98 0.78±), consulting had an average of (3.95 ± 0.78) and prevention had an average of (3.77 ± 0.8), which are all consistent with the professional roles and tasks in the curriculum for midwives and current tasks.

Discussion
Results showed that specialized courses topics in the curriculum related to current job performance from the perspective of midwives employed Tabriz health units were moderate at 19.85% of the cases and high in 80.15% of the cases, which was somewhat consistent with Shirjang et al 8 on the relevancy of the topics presented for working public health experts.They reported the relevancy rate in basic, main and specialized courses at a moderate level.The number of those who passed theoretical courses and internships can also affect the relevancy rate and should be examined in future studies.In reviewing the opinions of midwifery and nursing staff in governmental hospitals in relation to the clinical application of specialized courses, Mujahid et al 16 showed that pregnancy and delivery, maternal and child nutrition, and radiology and ultrasound courses were the most widely used, while less used ones were internal medicine, surgery, rachianesthesia, and anesthesia and applied laboratory tests, which was in line with the findings of the current study.Results of the study carried out by Mirmoghtadaee and Karamalian 2 in Isfahan showed that the newborn internship was most widely applied in training course, and radiology and ultrasound were the least applied ones from the employed midwives' point of view, which was inconsistent with the results of this study.In our study, employed midwives believed the use of internship courses was more useful than theoretical ones, which is consistent with the opinion of graduates in Khorramabad and Qazvin's studies. 1,11In a qualitative study done by Kohan et al 17 on the attitudes of students and graduates of reproductive health in terms of specialized training courses, relevancy of the curriculum with the field mission and reformation of the specialized courses, presentation were among the results.Shirjang et al 8 studied the employees of public health and found that the general content of courses did not align accurately with the requirements of their job.In this study, using viewpoints of midwives at the health units of Tabriz on the consistency of their role and tasks included in the curriculum with their current role and tasks, useful information can be provided for educational planners.Based on the views of employed midwives, the task of effective and professional with clients, colleagues and officials in terms of the diagnosis and care intervention had the lowest relevancy, which seems to be due to inadequate education in the curriculum, the diversity of tasks and a plurality of clients.
Proper communication with patients can lead to getting enough information, accurate diagnosis and appropriate treatment. 18,19In the study of Mirhaghjou et al 18  In the education role, the duty of training clients and caregivers in terms of self-care and referrals for care had the least relevancy with current tasks, while this responsibility is associated with midwives' job descriptions based on the ministerial training package for the population of midwives.The low relevancy is due to insufficient information of staff in the field of self-care education.In the health care system, due to the broad spectrum of the target population referred to midwives, In a study conducted by Jacob et al on the analysis of midwives and nurses' tasks, 72% of participants stated that they were trained on postpartum care at the university. 22Given the important role of the midwife in identifying problems and preventing complications and mortality, examining the causes of low relevancy in future studies seems necessary.
In the prevention role, the lowest relevancy was in participation in research projects from the staff viewpoints, which may be due to the lack of necessary skills in this regard.In a similar study done by Shirjang et al 8 on the relevancy of public health courses, the staff reported that it is necessary that more applied research be presented.Using colleagues' potential for cooperation in research programs is essential for the country's health system.Therefore, authorities and policy makers should take into consideration the necessity of participation by employed midwives and colleagues' motivation to willingly take part in research.
On the other hand, the least expected duty in the curriculum was considered to be in the prevention role.It should be noted that prevention is a top priority of the health system with regard to the burden of noncommunicable diseases such as cardiovascular disease and cancers in third world countries and considering effective risk factors in the emergence of the diseases such as hypertension, diabetes, and hepatitis;thus, the need for transparency and more attention to theoretical and practical training in the prevention area is clear.One of the limitations of this study is that relevancy was reviewed from the viewpoints of experts via survey.It is recommended that extensive studies on the relevancy of the roles and tasks of midwives in the curriculum with their current tasks be done multilaterally through viewpoints of experts, students, and scientific and technical experts and the graduates of the field to provide more credible and reliable results to guide educational reform.Considering the population of this study, the results are generalizable to Tabriz health center and units.

Conclusion
The results of this study on the relevancy of specialized courses topics with current tasks of midwives working in health care units showed that the average use of midwives was moderate on only one fourth of the training courses provided;thus, it must be revised.The recommendations for reforms include updating the curriculum as well as the content of these courses and/or designing practical activities and internships for more specialized courses.To increase the relevancy of professional tasks and roles with the current tasks, the use of the employed midwives' comments on the revision of the midwifery curriculum and the provision of appropriate educational topics while studying for better preparation for doing assigned tasks are suggested as appropriate considerations for improvement.

Table 1 .
Demographic information of population under study

Table 2 .
Mean relevancy of specialized courses main topics in the curriculum with the current performance of midwife (Possible rang of scale:1-5) Nutrition education various periods of pregnancy, breastfeeding, childhood and preventing malnutrition in mothers and newborns 4.16±0.78History, ethics, laws and rights in midwifery 3.29±0.88Familiar with midwifery in world and Iran and the history of midwifery development in recent centuries 2.97±1.06Familiar with moral and ethical standards and their application in personal and professional life 3.22±1.05Familiar with midwifery rules and regulations in Iran and the world and the relevant legal organizations

Table 2 .
ContinuedComparing the professional role and tasks of midwives

Table 2 .
ContinuedThe application of scientific findings in providing services to sick and vulnerable pregnant women and providing medical aid when

Table 2 .
ContinuedQuality management and improvement in the maternal and child health and reproductive 5

Table 3 .
21an relevancy of professional roles and tasks in the curriculum with the ongoing roles and tasks of midwife Mirzakhani et al21evaluated the clinical skills of midwifery graduates and reported that, on average, 90% of graduates have learned diagnosis and counseling in postpartum problems in their curriculum.