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Learn more: PMC Disclaimer | PMC Copyright Notice BMJ Open . 2026 Apr 15;16(4):e110853. doi: 10.1136/bmjopen-2025-110853 Search in PMC Search in PubMed View in NLM Catalog Add to search Childbirth experience among different Iranian ethnic groups: a cross-sectional study Somayeh Abdolalipour Somayeh Abdolalipour 1 Department of Midwifery, Faculty of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran (the Islamic Republic of) Find articles by Somayeh Abdolalipour 1 , Nikta Tavananezhad Nikta Tavananezhad 2 Department of Nursing and Midwifery, Sa.C, Islamic Azad University Sanandaj Branch, Sanandaj, Iran (the Islamic Republic of) Find articles by Nikta Tavananezhad 2 , Mina Iravani Mina Iravani 3 Department of Midwifery, Faculty of Nursing and Midwifery, Ahvaz Jondishapour University of Medical Sciences, Ahvaz, Iran (the Islamic Republic of) Find articles by Mina Iravani 3 , Fatemeh Bakouei Fatemeh Bakouei 4 Department of Midwifery, Babol University of Medical Science Faculty of Nursing and Midwifery, Babol, Iran (the Islamic Republic of) Find articles by Fatemeh Bakouei 4 , Fatemeh Janani Fatemeh Janani 5 Department of Midwifery, Faculty of Nursing and Midwifery, Lorestan University of Medical Sciences, Khorramabad, Iran (the Islamic Republic of) Find articles by Fatemeh Janani 5 , Azam Mohammadi Azam Mohammadi 6 Department of Reproductive Health and Midwifery, Nursing and Midwifery Care Research Center, School of Nursing and Midwifery, Iran University of Medical Sciences, Tehran, Iran (the Islamic Republic of) Find articles by Azam Mohammadi 6 , Solmaz Ghanbari-Homaie Solmaz Ghanbari-Homaie 1 Department of Midwifery, Faculty of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran (the Islamic Republic of) Find articles by Solmaz Ghanbari-Homaie 1 , Mojgan Mirghafourvand Mojgan Mirghafourvand 7 Social Determinants of Health Research Center, Department of Midwifery, Faculty of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran (the Islamic Republic of) Find articles by Mojgan Mirghafourvand 7, ✉ Author information Article notes Copyright and License information 1 Department of Midwifery, Faculty of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran (the Islamic Republic of) 2 Department of Nursing and Midwifery, Sa.C, Islamic Azad University Sanandaj Branch, Sanandaj, Iran (the Islamic Republic of) 3 Department of Midwifery, Faculty of Nursing and Midwifery, Ahvaz Jondishapour University of Medical Sciences, Ahvaz, Iran (the Islamic Republic of) 4 Department of Midwifery, Babol University of Medical Science Faculty of Nursing and Midwifery, Babol, Iran (the Islamic Republic of) 5 Department of Midwifery, Faculty of Nursing and Midwifery, Lorestan University of Medical Sciences, Khorramabad, Iran (the Islamic Republic of) 6 Department of Reproductive Health and Midwifery, Nursing and Midwifery Care Research Center, School of Nursing and Midwifery, Iran University of Medical Sciences, Tehran, Iran (the Islamic Republic of) 7 Social Determinants of Health Research Center, Department of Midwifery, Faculty of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran (the Islamic Republic of) Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise. None declared. ✉ Dr Mojgan Mirghafourvand; [email protected] Received 2025 Sep 15; Accepted 2026 Mar 31; Collection date 2026. Copyright © Author(s) (or their employer(s)) 2026. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ Group. This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: https://creativecommons.org/licenses/by-nc/4.0/ . PMC Copyright notice PMCID: PMC13084850 PMID: 41985963 Abstract Abstract Objective Ethnic communities provide an appropriate setting for examining patterns of pregnancy and childbirth. Policy-making aimed at improving maternal health will be rendered ineffective in the absence of knowledge and comprehension of the traditions and beliefs associated with childbirth. The objective of this study was to cross-ethnically compare childbirth experiences. Design This research used a cross-sectional methodology and was conducted in 2023. The sampling in the cities of Tabriz (Azeri), Sanandaj (Kurdish), Babol (Mazani), Khorramabad (Lur), Ahvaz (Arab) and Tehran (Fars) was conducted using the cluster random approach. The data collection instruments included questionnaires of sociodemographic and obstetric characteristics and childbirth experience (Childbirth Experience Questionnaire 2.0). In bivariate analysis, a one-way analysis of variance test was employed. In contrast, a general linear model (GLM) was used in multivariate analysis to adjust for the influence of sociodemographic and obstetric characteristics. The data were analysed using SPSS V.24 software. The p value less than 0.05 was considered significant. Setting Health centres in cities with different ethnic groups all over Iran. Participants For this purpose, 1331 women from six ethnic groups who were referred to health centres were selected 4 to 6 weeks after giving vaginal birth. Results The following are the mean (SD) scores (scoring range: 1–4) for the childbirth experiences of the participating women: Azeri 2.31 (0.32), Kurdish 2.14 (0.31), Fars 2.26 (0.42), Mazani 1.93 (0.38), Lur 2.14 (0.4) and Arab 2.06 (0.18). Results from GLM multivariate analysis showed that while Azeri (B: 0.25; 95% CI 0.16 to 0.35; p<0.001), Kurdish (B: 0.10; 95% CI 0.03 to 0.18; p=0.007) and Fars (B: 0.18; 95% CI 0.03 to 0.27; p=0.014) women had significantly higher mean scores for childbirth experience than Arabs (the reference group), women of Mazani ethnicity had significantly lower scores (B: −0.10; 95% CI −0.18 to −0.04; p=0.002). Conclusions Women of different Iranian ethnicities have varying childbirth experiences. Women of Azeri and Fars ethnic groups report higher satisfaction with childbirth than those of others. Mazeni women had the lowest mean scores for having a positive birth experience. To offer compassionate and effective treatment for their patients, healthcare providers must have a deep understanding of cultural diversity. Keywords: Natural Childbirth, Midwifery, Postpartum Women, Pregnancy STRENGTHS AND LIMITATIONS OF THIS STUDY. The study features a substantial sample size and complete representation of Iranian ethnic groups. A random sampling approach was used, enhancing the generalisability of the results. The study did not control for labour pain relief methods, which could influence childbirth experiences. Mothers with infants requiring hospitalisation were not excluded, possibly impacting maternal perceptions and confounding results. Background The childbirth experience is a unique life event involving physiological and mental-psychological processes. It is influenced by various factors such as social, environmental, organisational and political contexts. 1 Women with a positive childbirth experience feel a sense of accomplishment and confidence. A mother’s optimistic perception of her childbirth experience is associated with favourable emotions toward the baby and successful adjustment to her maternal role. 2 Conversely, women who have had a negative childbirth experience recall the event with feelings of pain, anger, fear and grief, or they may not recall it at all, suggesting a phenomenon known as traumatic forgetting. 3 Various aspects influencing the formation of a pleasant childbirth experience encompass monthly income, educational attainment, preparedness for childbirth, personal autonomy, self-confidence, parity, duration of labour, pain intensity throughout labour and delivery, instrumental delivery and the use of epidural anaesthetic. 4 Given that childbirth encompasses both biological and cultural aspects, it is evident that the cultural perception of childbirth varies based on social culture and class. Consequently, culture and ethnicity may also influence women’s level of satisfaction with the childbirth experience. 5 Ethnicity is a multifaceted notion that has evolved over history and is influenced by individual self-identification and societal norms. 6 Iran, a nation known for its cultural diversity, holds second in the Middle East and 28th globally in terms of the ethnic and cultural diversity index. 7 Persian speakers comprise half of Iran’s population; the other half is divided among other ethnic groups, each with a distinct percentage of the country’s population: Azeri, Kurd, Lur, Baluch, Gilak, Mazani, Arab and Turkmen. The primary ethnic groups in Iran comprise Fars, Azeri, Gilak, Mazani, Kurdish, Arab, Lur, Baloch and Turkmen. 8 Anthropological perspectives emphasise that childbirth practices and experiences are socially constructed within cultural and institutional contexts. Davis-Floyd highlighted that maternity care systems, shaped by interpersonal relationships and social institutions, strongly influence women’s childbirth experiences and their ability to have their needs met during labour and childbirth. 9 Ethnic and cultural differences have been shown to affect pregnancy and childbirth experiences globally, particularly in relation to access to care, provider communication and maternal satisfaction. 10 11 Sociocultural beliefs and community norms shape women’s expectations of labour pain, acceptable interventions and desired support during birth, which in turn affect whether women appraise their experience positively or negatively. 12 Process of care factors—such as respectful communication, therapeutic interaction and perceived provider competence—have been shown to be major determinants of maternal satisfaction, and these are often interpreted through the lens of the woman’s cultural expectations. 13 14 Language barriers, differing communication styles and culturally discordant care can undermine shared decision-making and reduce satisfaction among ethnic minority women. 15 Moreover, cultural norms influence social support structures during childbirth, including the role of companions and family involvement, which contribute to women’s emotional well-being and perceived quality of care. 16 These mechanisms provide a theoretical basis for using ethnicity as a key analytic variable in examining variations in childbirth experience. In Iran, existing research has largely focused on childbirth experiences within single ethnic groups using qualitative approaches or has examined heterogeneous populations without ethnic comparisons. Studies among Kurdish women, for example, have highlighted themes of empowerment, social support, life transformation and spiritual meaning associated with childbirth. 17 18 Quantitative research has assessed childbirth experiences among Iranian women and validated the Persian version of the Childbirth Experience Questionnaire (CEQ). 19 20 Beyond Iran, global evidence confirms ethnic disparities in childbirth experiences concerning access to care, cultural competence of providers, communication barriers and maternal satisfaction. 21 22 Hence, ethnic groups provide an appropriate framework for examining patterns and tendencies in pregnancy and childbirth. Comprehending the cultural customs and beliefs surrounding childbirth is of utmost importance. Without this understanding and data, efforts to develop policies that enhance maternal health will lack efficiency. Therefore, it is imperative to familiarise oneself with the diverse concepts, traditions and behavioural limitations prevalent in each culture to ensure efficient healthcare provision. 23 Existing research in Iran has primarily examined childbirth experiences either through qualitative studies focusing on individual ethnic groups or through quantitative studies conducted in heterogeneous populations without ethnic stratification. 17 , 20 Consequently, quantitative comparative evidence assessing differences in childbirth experiences across multiple Iranian ethnic groups using a standardised instrument remains lacking. Addressing this gap can inform culturally responsive maternity care policies and interventions aimed at improving maternal satisfaction and equity in childbirth experiences. Identifying group-specific patterns of satisfaction and dissatisfaction may assist clinicians and maternity care providers in anticipating women’s needs, improving culturally sensitive communication and tailoring intrapartum support and care practices. Such evidence can contribute to patient-centred maternity care, enhance the quality of provider–woman interactions and ultimately improve women’s childbirth experiences across diverse populations. Therefore, this study was designed to compare childbirth experiences among six major Iranian ethnic groups using a cross-sectional design and a validated standardised questionnaire. Methods Study design and setting This study employed a descriptive-analytical cross-sectional design and was conducted in six cities located in different geographical regions of Iran: Tabriz (northwest), Sanandaj (west), Babol (north), Khorramabad (west), Ahvaz (southwest) and Tehran (central Iran), each predominantly representing a major Iranian ethnic group (Azeri, Kurdish, Mazani, Lur, Arab and Fars, respectively). Data were collected in public primary healthcare centres affiliated with the Ministry of Health and Medical Education, which routinely provide postnatal care services to women after childbirth. Participants In Iran, postpartum women typically attend these health centres for routine follow-up care, including maternal and neonatal health assessments, vaccination services and family planning counselling. The study was conducted in 2023, during the early postpartum period (4 to 6 weeks after childbirth), a timeframe in which women are commonly engaged with postnatal care services. These health centres serve as the first point of contact for postnatal care after discharge from the hospital across urban populations and operate under standardised national maternal healthcare guidelines. This study considered only women who had given birth to their first or second child vaginally within the past 4 to 6 weeks. The exclusion criteria encompassed pre-existing conditions such as diabetes, cardiovascular disease, mental disability or any other mental disorder affecting the women, as well as the passing away of a family member within the previous 3 months. Sampling In each city, health centres were considered as primary sampling units (clusters). A list of all public health centres providing healthcare was obtained from the local health authorities. From this list, approximately 25% of health centres in each city were selected using simple random sampling. Health centres were not stratified by size or catchment population; however, proportional allocation was applied at the participant level. Specifically, the number of women recruited from each selected centre was determined proportionally based on the number of eligible women registered at that centre during the study period. The chosen women were contacted by telephone and provided the requisite research information. Finally, they were invited to participate in the research and the in-person meeting. The study objectives were thoroughly explained to the mothers during the in-person meeting. The participants then completed questionnaires of socio-demographic and obstetric characteristics, and CEQ2.0. Sample size The sample size was calculated based on the results of the study by Ghanbari-Homayi et al, 24 considering a prevalence of 37% for negative childbirth experience, α=0.05 and d=0.1. The initial sample size was determined to be 89 individuals. Due to the cluster sampling, by applying the design effect equal to two and considering a 20% possible dropout rate, the final sample size was calculated to be 215 individuals for each ethnic group. Data collection tool The data collection instruments used in this study encompassed questionnaires on sociodemographic and obstetric characteristics, as well as the CEQ2.0, and the data were collected through interviews. Sociodemographic characteristics questionnaire This questionnaire consisted of items regarding ethnicity, age, spouse’s age, age at marriage, woman and spouse’s education level, woman and spouse’s occupation, ethnicity, marital status, residency status, spouse support during pregnancy, and household income. Obstetric characteristics questionnaire The questionnaire encompassed items regarding gestational age, number of pregnancies, number of alive children, number of abortions, participation in prenatal classes, wanted or unwanted pregnancy, history of stillbirth, history of infertility and history of difficult childbirth. The questionnaires assessing sociodemographic and obstetric characteristics were evaluated for validity using content and face validity measures. Content validity was evaluated by a panel of 9 experts comprising professionals with expertise in midwifery, obstetrics, reproductive health and nursing. These experts reviewed each item to ensure that it was simple, clear, relevant and necessary for capturing the intended variables related to socio-demographic and obstetric factors among Iranian women from various ethnic groups. Face validity was assessed by administering the questionnaires to a pilot sample of 20 women representative of the study population, who provided feedback on the clarity, wording and cultural appropriateness of the items. Based on the feedback, necessary modifications were made to enhance understandability and relevance. Childbirth Experience Questionnaire The CEQ was originally developed and validated in Sweden by Dencker et al as a multidimensional, self-administered instrument. This questionnaire assesses the childbirth experience of women and consists of 25 items. The questionnaire encompasses the following domains: ‘own capacity’ (managing personal emotions related to childbirth and labour discomfort), ‘professional support’ (obstetric care and knowledge), ‘perceived safety’ (sense of security and recollections of childbirth), and ‘participation’ (an individual’s capacity to alter position, movement and alleviate pain during labour and childbirth). There are 22 items presented as multiple-choice questions with four alternatives and three items presented as a Visual Analogue Scale. Items associated with adverse experiences (such as intense pain, fatigue, fear and unpleasant memories) are assigned negative scores. The response format was a 4-point Likert scale ranging from 1 (totally agree), 2 (mostly agree), 3 (mostly disagree) to 4 (totally disagree). Achieving high mean scores in this instrument indicates a more favourable childbirth experience. The instrument’s validity and reliability have been confirmed in Swedish women population. Cronbach’s alpha coefficients were acceptable for group analyses (>0.70) in all but the participation domain. 25 Ghanbari-Homayi et al have assessed the validity and reliability of the Persian version of this questionnaire in Iran. The items had a Cronbach’s alpha of 0.93 and a correlation coefficient of 0.97. The content validity index ranged from 0.83 to 1, whereas the content validity ratio was computed between 0.8 and 1. 26 Data analysis The data were analysed using SPSS V.24 software. The sociodemographic and obstetric characteristics were described using descriptive statistics, which included the frequency (percentage) and mean (SD). Normality of continuous variables was evaluated using skewness and kurtosis indices and by visual inspection of histograms, boxplots and normal Q–Q plots. Absolute skewness values <2 and absolute kurtosis (proper) values <7 were regarded as indicating no substantial departure from normality. 27 Based on these criteria, all continuous variables were assumed to be normally distributed. The birth experience among the research groups was compared using a one-way analysis of variance (ANOVA) test in the bivariate analysis and a general linear model (GLM) in the multivariate analysis while controlling for the sociodemographic and obstetric characteristics. Ethnicity was included as the primary independent variable and sociodemographic and obstetric variables that showed a statistically significant association with childbirth experience in univariate analyses (p<0.05) were entered into the multivariate model to control for potential confounding effects. To examine whether the association between ethnicity and childbirth experience varied across sociodemographic and obstetric factors, interaction terms between ethnicity and education level and between ethnicity and parity were tested using GLM. Ethnicity and education were entered as categorical variables. Arab ethnicity and academic education were used as reference categories in the ethnicity×education model. In the ethnicity×parity model, Arab ethnicity and multiparous women (≥2 births) were used as reference categories. Statistical significance was assessed using Type III tests, and regression coefficients (β) with 95% CIs were reported. Patient and public involvement Patients or the public were not involved in the design, or conduct, or reporting, or dissemination plans of our research. Results The sociodemographic and obstetric characteristics This study involved 1331 pregnant women with a mean (SD) age of 29.3 (6.5) years, representing six different ethnic groups: Arab, Kurdish, Fars, Mazani, Lur and Azeri. Approximately 73% of the participants were homemakers, and most (94.7%) were married. A third of the women (30.4%) experienced an unintended pregnancy, and the majority of them (73%) reported receiving minimal or average support from their partners throughout the pregnancy period. Regarding the number of pregnancies, 43.2% of the women were primiparous, while the remainder were multiparous. Table 1 lists further the sociodemographic and obstetric characteristics. The online supplemental table shows sociodemographic and obstetric characteristics by ethnicity. Table 1. Sociodemographic and obstetric characteristics of the study participants (N=1331). Sociodemographic characteristics Obstetric characteristics Variable Number (%) Variable Number (%) Ethnicity Number of pregnancies Azari 250 (18.8) 1 575 (43.2) Kurdish 215 (16.2) 2 575 (43.2) Fars 216 (16.2) 3 and higher 181 (13.6) Mazani 220 (16.5) Number of alive children Lur 215 (16.2) Death of child 285 (21.4) Arab 215 (16.2) 1 596 (44.8) Age (year) 29.3 (6.5) * 2 and more 450 (33.8) Spouse age (year) 33.7 (6.3) * Previous abortions Marital status Yes 410 (30.8) Married 1261 (94.7) No 921 (69.2) Unmarried 70 (5.3) History of stillbirth Income Yes 75 (5.6) Adequate 183 (13.7) No 1256 (94.4) Relatively adequate 1002 (75.3) Participation in childbirth preparation classes Inadequate 146 (11) Yes 408 (30.7) House status No 770 (57.9) Personal house 761 (57.2) Type of participation Rented house 570 (42.8) Regular 217 (16.3) Education Irregular 358 (26.9) Illiterate/primary school 103 (7.7) Unwanted pregnancy Secondary school 256 (19.2) Yes 404 (30.4) High school 139 (10.4) No 925 (69.5) Diploma 386 (29) History of difficult childbirth Academic 447 (33.6) Yes 71 (5.3) Spouse education No 1260 (94.7) Illiterate/primary school 243 (18.3) History of infertility Secondary school 200 (15) Yes 53 (4) High school 165 (12.4) No 1078 (81) Diploma 358 (26.9) Spouse support during pregnancy Academic 364 (27.3) Very low/low 481 (36.1) Job Moderate 491 (36.9) Housewife 973 (73.1) High 261 (19.6) Employee 356 (26.7) Very high 96 (7.2) Spouse job Unemployed 116 (8.7) Employee 320 (24) Worker 429 (32.2) Free job 462 (34.7) Open in a new tab * Mean (SD). Childbirth experience The mean score (SD) for childbirth experience among the women who took part in the study was as follows: 2.31 (0.32) for Azeri, 2.14 (0.31) for Kurdish, 2.26 (0.42) for Fars, 1.93 (0.38) for Mazani, 2.14 (0.4) for Lurs, and 2.06 (0.18) for Arab ethnic groups (score range: 1 to 4). The findings of one-way ANOVA indicated statistically significant differences in the childbirth experience scores among the ethnic groups under investigation. The subdomain of ‘own capacity’ exhibited the greatest mean scores among the childbirth experience subdomains in the Azeri (2.36) and Fars (2.47) groups. The subdomain of ‘participation’ received the lowest scores among the Mazani (1.68). In contrast, the subdomain of ‘professional support’ received the lowest scores among the Lur (1.98), Mazani (1.84) and Arab (1.84), as shown in table 2 . Table 2. Comparison of childbirth experience between the Iranian ethnic groups. Variables Ethnicities (n=1331) P value * Azeri Mean (SD) Kurdish Mean (SD) Fars Mean (SD) Mazani Mean (SD) Lur Mean (SD) Arab Mean (SD) Total score of CEQ.2 † 2.31 (0.32) 2.14 (0.31) 2.26 (0.42) 1.93 (0.38) 2.14 (0.40) 2.06 (0.18) <0.001 Subscales of CEQ.2 Own capacity 2.36 (0.39) 2.18 (0.46) 2.47 (0.37) 2.03 (0.36) 2.23 (0.45) 2.34 (0.21) <0.001 Perceived safety 2.31 (0.43) 2.42 (0.51) 2.12 (0.55) 2.08 (0.46) 2.23 (0.52) 2.02 (0.23) <0.001 Participation 2.28 (0.48) 1.99 (0.51) 2.35 (0.80) 1.68 (0.60) 2.09 (0.64) 1.96 (0.29) <0.001 Professional support 2.26 (0.42) 1.93 (0.43) 2.08 (0.53) 1.84 (0.60) 1.98 (0.44) 1.84 (0.27) <0.001 Open in a new tab * One-way ANOVA. † CEQ.2: (rang score:1–). ANOVA, analysis of variance; CEQ2, Childbirth Experience Questionnaire version 2.0. The results of the multivariate analysis, which used the GLM and adjusted for sociodemographic and obstetric variables, showed that the mean score for childbirth experience was significantly higher in the Azeri (B: 0.25; 95% CI 0.16 to 0.35; p<0.001), Kurdish (B: 0.10; 95% CI 0.03 to 0.18; p=0.007) and Fars (B: 0.18; 95% CI 0.03 to 0.27; p=0.014) groups compared with the Arabs (the reference group). Conversely, the mean score was significantly lower in the Mazani (B: −0.10; 95% CI −0.18 to −0.04; p=0.002) than in the Arab ethnic group. However, there was no statistically significant difference between the Lur (B: 0.06; 95% CI −0.01 to 0.13; p=0.097) and Arab groups ( table 3 ). Table 3. Comparison of childbirth experience between the Iranian ethnic groups based on the adjusted general linear model (GLM). Ethnicity Childbirth experience B (95% CI) P value * Azeri 0.25 (0.16 to 0.35) <0.001 Kurdish 0.10 (0.03 to 0.18) 0.007 Fars 0.18 (0.03 to 0.27) 0.014 Mazani −0.10 (−0.18 to −0.04) 0.002 Lur 0.06 (−0.01 to 0.13) 0.097 Arab Reference Other Ethnicity (Azeri)*Education (secondary school) 0.32 (0.13 to 0.52) 0.001 Ethnicity (Azeri)*Education (diploma) 0.25 (0.06 to 0.44) 0.010 Ethnicity (Azeri)*Education (academic) 0.23 (0.04 to 0.42) 0.017 Ethnicity (Fars)*Education (high school) 0.33 (0.10 to 0.55) 0.004 Ethnicity (Fars)*Education (diploma) 0.23 (0.03 to 0.42) 0.022 Ethnicity (Mazani)*Education (secondary school) −0.24 (-0.46 to −0.02) 0.032 Ethnicity (Arab)*Education (academic) Reference R 2 =0.139 Adjusted R 2 =0124 Ethnicity (Azeri)*Parity (1) 0.32 (0.23 to 0.42) 0.001 Ethnicity (Azeri)*Parity (2 and higher) 0.21 (0.13 to 0.29) 0.001 Ethnicity (Kurd)*Parity (1) 0.10 (0.005 to 0.20) 0.040 Ethnicity (Fars)*Parity (1) 0.25 (0.16 to 0.34) 0.001 Ethnicity (Fars)*Parity (2 and higher) 0.15 (0.06 to 0.24) 0.002 Ethnicity (Mazani)*Parity (1) −0.09 (-0.19 to −0.002) 0.046 Ethnicity (Mazani)*Parity (2 and higher) −0.015 (-0.24 to −0.06) 0.001 Ethnicity (Lur)*Parity (1) 0.11 (0.006 to 0.20) 0.034 Ethnicity (Arab)*Parity (2 and higher) Reference R 2 =0.124 Adjusted R 2 =0.117 Open in a new tab * GLM adjusted for age, spouse age, income, history of abortion, unwanted pregnancy, history of difficult childbirth, spouse support during pregnancy and number of pregnancies. Significant interaction effects were observed between ethnicity and both education and parity. Using Arab women with academic education and Arab multiparous women as reference groups, Azeri and Fars women generally demonstrated higher CEQ scores across several education and parity levels, whereas Mazani women showed lower CEQ scores in specific subgroups ( table 3 ). Discussion This study was done to compare the childbirth experiences of women belonging to various Iranian ethnic groups. The current study found that the Mazani ethnic group had the lowest mean score for childbirth experience, while the Azeri and Fars ethnic groups had the highest mean score. There were significant statistical differences in the mean score of childbirth experience among various Iranian ethnic groups. However, this difference remained inconsistent after the multivariate test between the Lur and Arab ethnic groups. Pregnancy and childbirth are inherently social phenomena; thus, they seem to have different meanings to different women. Pregnant women’s cultural background might shape their attitudes toward pregnancy and childbirth. Pregnant women’s attitudes toward pregnancy and the concept of parenting are influenced by societal norms and cultural beliefs. 28 For instance, the Kurdish community, which in this study was one of the ethnic groups with a comparatively higher childbirth experience score, views pregnancy and childbirth as good life events, particularly when parents intend to begin a new family. During pregnancy, women experience heightened intimacy, protection and kindness from their spouses and family members. 17 The attitude of pregnant women in the Kurdish community is influenced by their upbringing, their attitudes regarding gender roles, the significance attributed to pregnancy, and the societal expectations placed on pregnant women. 18 The Mazani ethnicity had the lowest score for childbirth experience in this study, which aligns with findings from previous research. 19 20 Women in Mazandaran province in Iran have the highest rate of caesarean delivery, which stands at 70%. It has been observed that bad experiences of natural childbirth may contribute to the inclination towards caesarean delivery in these women. 29 30 Furthermore, Mazandaran has experienced a significant decline in fertility rates in recent years, with a rate of 1.2. This means that, on average, Mazandaran couples have approximately one child. 31 Furthermore, the low score of childbirth experience is an additional influential factor that affects the likelihood of married couples having children again, alongside other factors such as attitudes towards gender roles, social acceptance and marital satisfaction. 32 In light of the data regarding the fertility and childbirth rates among Mazani women, as well as the absence of research on the factors contributing to unsatisfactory childbirth experiences, it is imperative to undertake qualitative studies to gain insight into the perspectives of Mazani women regarding their childbirth experiences. The current study found that the mean childbirth experience score among the Arab and Lur ethnicities, which are classified as ethnic minorities in Iran, was significantly lower compared with the larger Fars and Azeri ethnicities. Although all participants in this study resided in urban areas, differences in healthcare infrastructure, resource availability and socioeconomic conditions across cities may contribute to variations in childbirth experiences among ethnic groups. Urban settings in Iran are heterogeneous, and disparities may exist even within non-rural populations. 33 In the major urban areas of Iran, there is typically more availability of diverse facilities and a larger likelihood of engaging in cross-cultural exchanges with individuals from various ethnic and cultural backgrounds. 34 The absence of cultural and language knowledge has been recognised as a hindrance to obtaining maternal health services. Women in minorities may experience discrimination and cultural insensitivity from care providers. Furthermore, women belonging to ethnic minority groups may encounter the cumulative consequences of racial prejudice. 23 35 A qualitative study conducted by Ahmed et al identified two main barriers to seeking community support, including insufficient competency in the dominant language and a shortage of primary care practitioners who are culturally competent. 36 Women residing in large metropolitan areas with high levels of financial stability tend to prioritise their rights in decision-making and active involvement during childbirth. By contrast, women residing in smaller cities and belonging to minority groups may anticipate a reduced level of personal autonomy and involvement in their childbirth experience. These variations may be related to disparities in cultural norms of delivery, or they may stem from the lack of authority among women belonging to ethnic minorities to exercise autonomy over their own choices. 37 Consistent with previous research, women of Arab and Mazani ethnic groups in our study obtained the lowest scores in the ‘participation’ sub-domain during this investigation. Fear of childbirth and severe labour pain influences women’s perceptions of the childbirth experience. 6 Heydarpour et al discovered a notable disparity among the Fars, Azeri and Kurdish ethnic groups in their comprehension of the intensity of pain, fear and anxiety that can occur during childbirth. 38 The degree to which individuals perceive pain is consistent with the sensitivity of cerebral cortex cells and is unique; however, responses to pain vary and are influenced by various social, cultural, psychological and educational factors. 39 The variation in pain responses among different groups can be attributed to several factors, including the distinct physical environments of Iranian childbirth hospitals, the quality of training received before and during childbirth, and the cultural and religious backgrounds of the various ethnic groups. 37 Additionally, while women experiencing labour pains are permitted to express their discomfort in some cultures, they are expected to maintain silence in others. 40 Several studies have identified variations among women from diverse ethnic backgrounds in terms of their childbirth experiences and attitudes and the treatment they receive. 1 41 42 In their study, Henderson et al discovered that women belonging to ethnic minority groups reported less satisfactory experiences with maternity care compared with women from other groups. 21 For instance, the research indicates that women belonging to ethnic minorities exhibited a higher likelihood of experiencing feelings of insecurity regarding their ability to successfully undergo natural childbirth. Additionally, they displayed increased levels of fear and embarrassment about vaginal examinations and the childbirth process. 42 Women belonging to minority ethnic groups typically exhibit heightened concerns regarding labour and childbirth, particularly concerning enduring pain and suffering, as well as requiring medical interventions during childbirth. Furthermore, these women are more likely to express concerns regarding privacy and communication difficulties when interacting with healthcare providers during childbirth. 21 42 This highlights the importance of addressing various service-related challenges that may arise due to ethnicity, culture and religion. The sensitive cultural issues of embarrassment and shame surrounding pregnancy and childbirth should be taken into account when providing obstetric and medical care. 42 The study by Reddy et al investigated the variations in prenatal interventions across different Asian ethnicities. The researchers explored potential factors, such as social deprivation, limited healthcare access, communication difficulties and underlying medical conditions that could explain the observed differences among these ethnic groups. 22 Several studies have consistently demonstrated that women belonging to minority ethnic groups receive a lower number of prenatal tests compared with women from other ethnic groups. In addition, they receive a reduced number of prenatal ultrasound scans, participate in fewer prenatal education classes, experience a higher rate of hospitalisation during pregnancy and have less autonomy in selecting their birth location. 43 , 45 Several factors that contribute to favourable or bad experiences in pregnant women are associated with the performance of caregivers. 46 The ethnicity and race of patients can also affect physicians’ diagnoses, treatment decisions and attitudes towards patients. The explicit and implicit biases held by physicians against patients of specific ethnic or racial groups might result in inequities in healthcare. Furthermore, the ethnicity of healthcare personnel and physicians can influence the consultation, treatment and ultimate result. The ethnic background of health workers, along with other characteristics, has the potential to result in bias and judgement. 34 The results align with our findings, indicating that women belonging to the Arab, Lur and Mazani ethnic minorities obtained lower scores in the ‘professional support’ sub-domain. By demonstrating appreciation for ethnic traditions and beliefs, maternal healthcare practitioners can enhance their ability to deliver culturally tailored care to women and their families, enhancing maternity and newborn health outcomes. 47 Facilitating safe and effective care necessitates health providers taking steps to encourage modifications in cultural behaviours. 48 Scientific evidence also supports the existence of significant pelvic morphological variation among human populations, which can influence labour mechanics and childbirth outcomes. 49 Studies show that pelvic shape and birth canal dimensions vary across ethnic groups, reflecting genetic, evolutionary and environmental adaptations. For example, populations in colder climates generally tend to have wider pelvic canals, which may facilitate childbirth, whereas those in other regions may show different pelvic morphologies that could impact labour difficulties. 50 Regarding the Iranian context, research indicates that women in northern Iran (Mazandaran province) experience notably high caesarean section rates and more difficult births, which could be related to anatomical factors such as less favourable pelvic shapes for vaginal delivery. 29 30 Such pelvic characteristics might contribute to a higher incidence of cephalopelvic disproportion, which affects labour progression and increases the likelihood of operative delivery. 51 However, it is important to emphasise that the present study did not assess anatomical characteristics directly. Therefore, any interpretation regarding biological variation should be considered hypothetical. Future interdisciplinary research incorporating anthropometric, imaging and obstetric outcome data would be necessary to clarify whether biological-anatomical factors contribute to observed ethnic differences in childbirth experiences. The interaction between ethnicity and education suggests that educational attainment does not equally influence childbirth experiences across ethnic groups. While higher education appeared to strengthen positive experiences among Azeri and Fars women, Mazani women with secondary education demonstrated lower CEQ scores. This may indicate that educational resources translate into improved communication or empowerment differently across ethnic contexts. Similarly, parity modified the association between ethnicity and childbirth experience. Azeri and Fars women showed consistently higher CEQ scores across parity levels, whereas Mazani women demonstrated lower scores, particularly among multiparous women. This may suggest that repeated exposure to the maternity care system does not mitigate disparities for certain ethnic groups. These findings highlight that culturally competent maternity care should consider not only ethnicity alone but also how ethnicity interacts with educational attainment and reproductive history. Strengths and limitations of the study This study has strengths and limitations. Among the strengths, the relatively large sample size enhances the statistical power and reliability of the findings. Additionally, the inclusion of diverse ethnic populations improves the representativeness of the sample, and the use of random sampling strengthens the generalisability of results. Furthermore, the application of validated and reliable questionnaires appropriate for the Iranian population supports the internal validity of the study. However, there are also limitations. The cross-sectional design limits the ability to establish causal relationships, and no specific age restrictions were imposed, which may have introduced variability within the sample. The study included only women residing in urban areas, which means that the findings may not be generalisable to rural populations. Moreover, the use of labour pain relief methods (both pharmacological and non-pharmacological) was not controlled for, which may have influenced childbirth experience scores. Mothers whose infants required hospitalisation were not excluded, and neonatal complications may have affected maternal perceptions of childbirth. Lastly, the study did not explore the underlying mechanisms of ethnic differences; qualitative or longitudinal approaches are needed for a deeper understanding. Implication of results Healthcare providers may use the study’s findings to better understand and respect women’s cultural and ethnic diversity. Health practitioners need to prioritise the needs of ethnic populations when providing maternity services rather than placing undue pressure on women and their families to conform to prevailing culture. 1 The findings of this study highlight the need for culturally sensitive maternity care in ethnically diverse settings. Integrating cultural competence training, respectful care practices and language-adapted antenatal education may improve women’s participation and professional support, particularly among minority groups. Strengthening maternity services in underserved regions and ensuring equitable access to quality care are also essential. Identifying ethnic groups at higher risk of negative childbirth experiences may enable targeted supportive interventions. Conclusions Women from different Iranian ethnic groups have varied childbirth experiences. Compared with women from other ethnicities, Azeri and Fars women report more positive childbirth experiences. However, Mazani women showed the lowest scores for their childbirth experiences. To provide culturally competent, practical and sensitive care to individuals, healthcare providers must have an in-depth understanding of cultural variety. The ability to use sensitive knowledge about local and ethnic values in counselling and care and an assessment of cultural reflection on the pregnancy and childbirth process are essential skills for healthcare providers who want to provide high-quality maternity care. Furthermore, qualitative studies are needed to explore the underlying reasons for lower childbirth experience scores observed in certain ethnic groups, particularly to better understand sociocultural, structural and care-related contributing factors. Supplementary material online supplemental file 1 bmjopen-16-4-s001.docx (25.7KB, docx) DOI: 10.1136/bmjopen-2025-110853 Acknowledgements We acknowledge the Clinical Research Development Unit of Taleghani Hospital, Tabriz University of Medical Sciences, Tabriz, Iran, for scientific support. Footnotes Funding: Tabriz University of Medical Sciences provided funding (grant number: 69831) but it had no role in the design and conduct of the study and decision to this manuscript writing and submission. Prepublication history and additional supplemental material for this paper are available online. To view these files, please visit the journal online ( https://doi.org/10.1136/bmjopen-2025-110853 ). Provenance and peer review: Not commissioned; externally peer reviewed. Patient consent for publication: Not applicable. Ethics approval: This study has been approved by the ethics committee of Tabriz University of Medical Sciences (ethics code: IR.TBZMED.REC.1401.215, approval date: 2022-06-01. 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World Health Organization Information for researchers concerning informed decision making: what is an informed consent form? 2013. https://cdn.who.int/media/docs/default-source/documents/ethics/informed-decision-making.pdf?sfvrsn=8b3cf04f_0 Available. BMJ Open. 2026 Apr 15. Review Process File Copyright and License information PMC Copyright notice bmjopen-2025-110853.reviewer_comments.pdf (384.9KB, pdf) Open in a new tab Associated Data This section collects any data citations, data availability statements, or supplementary materials included in this article. Supplementary Materials online supplemental file 1 bmjopen-16-4-s001.docx (25.7KB, docx) DOI: 10.1136/bmjopen-2025-110853 Data Availability Statement Data are available on reasonable request. 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