Review
HJOG 2026, 25 (1), 23-33| doi: 10.33574/hjog.0612
Paraskevi Giaxi1, Maria Dagla1, Maria Iliadou1, Angeliki Antonakou2, Vikentia Harizopoulou1,
Panagiota Tzela1, Kleanthi Gourounti1
1 Department of Midwifery, University of West Attica, Athens, Greece
2 Department of Midwifery, International Hellenic University, Thessaloniki, Greece
Correspondence: Paraskevi Giaxi, Agiou Spyridonos 28, 12243 Athens, email: parigiaxi@gmail.com
Abstract
Background: Safety is central to midwifery care, although its meaning and context varies significantly across different periods, cultures and geographic contexts. This scoping review explores how safety is conceptualized within midwifery-led care models, with an emphasis on temporal and cross-cultural differences.
Methods: A scoping review was conducted using PubMed, Scopus, Web of Science, and selected organizational sources to identify conceptual and theoretical studies on safety in midwifery-led care.
Results: A total of 10 eligible studies were included and thematically synthesized. Through the synthesis of these studies, the findings reveal a transition from a predominantly biomedical model, focused on avoidance of harm and standardized procedures, to a broader, person-centered perspective. This evolving understanding frames safety as a dynamic, multidimensional concept shaped by emotional, relational, cultural, and socio-political factors, including humanitarian crises and the legacy of colonialism.
Conclusion: Overall, safety in midwifery care emerges through the interplay of clinical, cultural, and contextual dimensions. To enhance maternal and neonatal outcomes, health systems and midwifery education must adopt this expanded, more inclusive understanding of safety and apply it in the design of care models and policy frameworks.
Keywords: Perinatal care, midwifery-led care, person-centered, maternal and neonatal safety, quality, midwifery education
Introduction & Background
The development of cognitive schemas enables individuals to interpret new stimuli based on prior knowledge and experience [1]. These schemas are particularly useful as they allow the simplification of an otherwise extremely complex world [2]. However, sometimes these schemas can prevent individuals from fully perceiving the entirety of the situations they are involved in, leading them to misinterpret new conditions based on prior experiences, when this is not warranted [1,2]. This risk is especially relevant in today’s digitized and multicultural societies [3,4]. This concern stems from the fields of psychology and anthropology but serves to interpret misperceptions and errors observed in many different scientific disciplines, including health sciences [5]. Scientific knowledge tends to be interpreted through Western norms, a result of the significant contribution of Western civilization to the development of science since the Renaissance [6]. However, this may limit science from effectively addressing important issues that extend beyond the Western cultural framework, highlighting the importance of addressing such cultural barriers [7].
In midwifery, overcoming cultural assumptions is critical. Unlike other health professions, midwifery is closely linked to the embodied, emotional, and symbolic experience of childbirth [8]. Midwives often engage with a wide range of cultural practices, expectations, and rituals surrounding birth [9]. What one culture considers “safe” or “normal” may differ significantly from the biomedical model, creating tensions in practice [10]. Thus, midwives must be not only clinically skilled but also culturally responsive and critically reflective of dominant assumptions [11].
Beyond the cultural dimension, it’s equally important to explore the potential evolution of the very concept over time. It would be an oversimplification to consider safety as something unchanging through the ages. As society evolves and technological advances create new possibilities, needs, and challenges, the concept of safety is constantly reshaped [12]. A defining example that prompted a reevaluation of when and how one is considered safe is the COVID-19 pandemic. This global crisis challenged prior assumptions about safety within health systems-and society more broadly-highlighting vulnerability, fragility, and the need to rethink the meaning of this fundamentally important concept [13]. During the pandemic, safety began to be conceptualized differently [13,14]. Therefore, it is difficult to speak of a single, unified definition of safety in a world that evolves rapidly, giving rise to novel and unfamiliar challenges [14].
Midwifery-led care refers to a model in which midwives have the main responsibility to manage the care of pregnant women, a process carried out throughout pregnancy, childbirth, and the postpartum period [15]. Several studies have focused on key issues related to safety in midwifery practice, while many interventions aim to enhance safety for women and their children [16,17]. However, the prerequisite for effective interventions is a clear understanding of what safety actually means in today’s midwifery. Divergent interpretations may lead to distorted representations of what constitutes safety, potentially resulting in policy failures [18]. Although safety is a central concept in midwifery care, little is known about how it is framed across different cultural and historical contexts.
Based on the above, it is essential to examine how safety is conceptualized in midwifery, a gap that this scoping review specifically aims to address. More specifically, this scoping review explores how safety is defined in midwifery-led care by examining two core dimensions: the evolution of the concept over time, and its variation across geographic and cultural contexts.
Material and methods
Study design
This article presents a scoping review that explores how the concept of safety in midwifery-led care has been defined and interpreted over time and across different cultural and geographical contexts. Instead of applying a rigid protocol, the review followed a thematic and interpretive approach aimed at capturing the breadth and diversity of existing conceptualizations.
Literature search
A search was carried out in three independent databases (PubMed, Scopus, and Web of Science) using the following key-words: ‘‘safety’’ AND (‘‘midwife*’’ OR ‘‘midwiv*’’). These key-words were chosen because there were two clearly defined parameters, meaning safety and midwifery. Hence, no other key-words focusing generally on birth or other related parameters were included. Filters were applied to present only records which were reviews or systematic reviews. The search was carried out on May 23, 2025 and led to 1,310 records in Pubmed, 282 in Scopus and 1,230 records in Web of Science. In addition, a snowball search was conducted using Google Search, to find documents published by related organizations. Indeed, such documents are not found in databases like Pubmed, which include peer-reviewed published content. Therefore, it was necessary to use an alternative approach. All the literature search process adhered to the latest version of the PRISMA Statement (version 2020) [19]. The literature search process was performed by the first four authors. Any disagreements were resolved through discussion, with the support of the last author.
Study selection
The criteria of the study selection were as follows: (1) peer reviewed publication or document published by a recognized midwifery or health organization (2) focusing on the concept of safety in midwifery. The papers were excluded if (1) they were published in a language other than English (2) they were original research articles, not literature or systematic review. The decision to exclude original research was not based on a lack of relevance but was methodologically driven: the aim of this scoping review was to explore how safety is conceptually defined in scholarly discourse, rather than how it is operationalized in specific empirical contexts. While this choice may have excluded valuable experiential perspectives (especially those arising from qualitative studies) it allowed for a clearer synthesis of how safety is constructed across diverse cultural, historical, and theoretical frameworks. In case of including original research, which would adopt specific conceptualizations without first examining them, specific potentially biased conceptualizations would disproportionately affect the findings of the present study. To avoid bias and to gain a deep insight of the conceptualizations themselves, including original research was not considered sensible.
Data extraction
The extracted data included: 1) authors 2) type of record 3) differences in the conceptualization over time 4) differences across cultural and geographical contexts. The data were extracted into a table and afterwards they were discussed based on the two main axes of the study, the differences over time and the differences across diverse cultural and geographic contexts.
Results
Included studies and data extraction
At first, record identification from databases took place (N=2,822). After removing the duplicates manually, 1,492 original papers were screened. A total of 1,381 papers were excluded by title, leading to a total of 111 papers, which were full-text accessed. Four were excluded since they were not a peer-reviewed publication, while 100 did not focus on the concept of midwifery-led safety. No papers were excluded for not being in English or being original research, since those studies were excluded at an earlier stage. In the second search process (websites, organizational sources, and citation searching), 12 records were evaluated, excluding 1 since it was not published by a recognized organization and 8 because they did not focus on midwifery-led safety. No records were excluded from language other than English or not being original research. Figure 1 provides an overview of the literature selection process.
Figure 1. Flowchart of the Literature Selection Process (Adapted PRISMA 2020)
The extracted data of the studies included are presented in Table 1. As indicated by the table, there were 10 records, 3 from organizations and 7 peer- reviewed publications. The two studied parameters, variations over time and variations based on the cultural and geographic context, are presented at two related columns.
Differences over time
Historically, safety in midwifery-led care was framed primarily through a biomedical lens, grounded in institutional protocols, technological surveillance, and standardized procedures aimed at minimizing risk. While effective in certain respects, this definition was narrow and often overlooked the emotional, psychological, and relational dimensions of childbirth, now widely acknowledged as central to maternal wellbeing [20]. The American College of Nurse-Midwives also affirms the need to meet evolving standards of care that include these broader dimensions [21].
The change observed over time does not simply add different components, widening the concept. In fact, it is the change of an approach incorporating holistic and humanistic perspectives, based on the belief that women value relational continuity, autonomy, and respectful care, perceiving them as dimensions of their safety [20]. Hence, it is a remarkable shift, emphasizing trust, on shared decision-making and on multidimensional support, a paradigm shift that aims to improved outcomes and greater satisfaction [22]. In general, the modern conceptualization indicates that safety is not just harm avoidance [20], but requires analyzing and encountering a wide range of parameters related to the wider system [23], leading to a sense of shared responsibility [24].
The COVID-19 pandemic further accelerated this conceptual shift. It revealed the limitations of traditional safety models, which struggled to respond to widespread emotional distress, isolation, and breakdowns in communication [25]. During this time, many women experienced care as unsafe, not due to lack of clinical competence, but due to disrespectful interactions and unmet emotional needs [26]. Hence, the concept could be treated as dynamic and context-sensitive, adapting to societal changes and emerging crises.
Differences across geographic and cultural contexts
The concept of safety is treated differently across geographical and cultural contexts. In Australia, for example, safety for First Nations women is closely tied to the legacy of colonization and the need for culturally safe, trauma-informed care [27]. In India, safety is increasingly defined through community engagement and culturally relevant models, rather than simply adopting Western biomedical approaches [28]. These examples illustrate that while the principles of dignity, autonomy, and justice are widely valued, their meanings and implementation differ across healthcare settings [29].
These differences are not purely cultural. Geographic factors also shape how safety is implemented. In Brazil, for instance, high cesarean rates have prompted a call for midwifery-led alternatives to support physiological birth. In contrast, rural areas in India or China may lean toward over-medicalization, not as a cultural preference, but as a response to limited access to multidisciplinary, continuity of care. In conflict-affected areas like Gaza, basic health system functioning is often compromised, and safety becomes synonymous with the ability to meet even minimal care standards [25].
Thus, safety is not a fixed concept, but rather a locally constructed, culturally mediated, and historically influenced phenomenon. Understanding these nuances is essential for designing responsive, respectful midwifery-led care that addresses diverse populations.
Discussion
Overview of the findings
This scoping review explored how safety is conceptualized within midwifery-led care, focusing on both its evolution over time and its variation across cultural settings. The findings suggest that the meaning of safety has expanded beyond its traditional biomedical foundation to encompass psychological, emotional, and relational dimensions. While clinical safety remains essential, it is now increasingly understood that mental health, autonomy, and respectful treatment are equally critical components of safe maternity care.
For instance, the experience of trauma following medically safe interventions, such as cesarean sections, underscores this shift. Estimates indicate that approximately 10.7% of women develop post-traumatic stress disorder after cesarean delivery [30], revealing that clinical safety does not always translate into a sense of overall safety for women.
The variation between cultural contexts highlights the inability to establish a single, universal definition of safety in midwifery-led care. This scoping review supports the constructivist view of the concept of safety, according to which health professionals, women, and societies as a whole shape perceptions of what constitutes safety based on their cultural norms, as well as the needs arising from their health systems, demographic characteristics, and socioeconomic contexts. This finding aligns with the constructivist perspective, which holds that the evaluation of objective conditions is filtered through the lens of cultural context, significantly influencing the perception of safety [31]. In any case, it seems that in situations of complete collapse of health infrastructure, such as in Gaza, a form of adaptive prioritization emerges, focusing on needs strictly related to the medical dimension [25]. This leads to a narrowing of the broader conceptualization of safety, limiting the influence of cultural context.
Theoretical explanations
Examining the above findings within a common framework, it appears that the shift in the conceptualization of safety is a result of the advancement of health systems and, more broadly, of human civilization. Thus, in cases where there is violence, disorganization, or turmoil, the focus returns to basic medical needs, overlooking the broader dimensions of safety [25]. The two dimensions examined above are therefore inextricably linked, even suggesting that the progress made over time in the conceptualization of safety is a result of broader socioeconomic development. This study thus concludes with a human-centered conceptualization of safety, as also supported by the theory of Maslow [32]. According to this approach, once basic needs are met, particularly the biomedically associated dimension of safety, which could be placed at the fourth level, individuals evolve and pursue goals and needs at higher levels, such as social connection and acceptance at the third level, and respect from others at the second level. Emphasis on cultural dimensions is therefore placed after the fulfillment of basic health and safety needs.
This situation is clearly not entirely functional or beneficial for women and their children. International organizations, such as the WHO [20], emphasize how cultural identity and women’s preferences can be respected even in crisis conditions. Therefore, even if the effort to meet higher-level needs follows the satisfaction of more basic ones, this situation cannot be considered functional, but rather distorted and problematic. After all, taking into account the cultural factors involved in midwifery-led care is essential to reducing disparities and improving outcomes for culturally oppressed groups [33].
Policy implications
On a practical level, there is a high need to expand the definition of safety in midwifery care beyond the traditional biomedical model. The recent report of the WHO [20] will probably be a critical turning point towards this direction. For that reason, it is imperative to use wider definitions in midwifery education and continuing professional development programs. In countries like Australia, related efforts have already taken place [34]. Yet, it is essential to expand this trend to other countries and regions, integrating this conceptualization of safety in all curriculums.
In general, policymakers must treat the one-size-fits-all model as insufficient. Therefore, they must adapt policies to improve safety across diverse geographic, cultural, and socioeconomic conditions, as indicated by the different conceptualizations of safety in places like Australia, India, and Gaza [25, 27, 28]. For example, in countries with a colonial past or systemic inequities, such as First Nations communities, it is essential to adopt a culturally safe and trauma-informed approach [27]. Hence, a significant effort must be made to form participatory and community-engagement models, not only to improve safety but also to use midwifery care to tackle oppression and systemic racism on both health and broader societal levels.
Policymakers must also focus on future resilience. In cases of crisis, such as during the COVID-19 pandemic, widespread recognition arose regarding structural weaknesses and the fragility of health systems [26]. In the post-pandemic world, special emphasis must be placed on pandemic preparedness, which applies to healthcare in general [35], as well as to midwife-led care [36]. Therefore, it is imperative to make a shift, based on the broader conceptualization of safety, to enhance preparedness for future crises.
Limitations & suggestions for future studies
This study has certain limitations that must be reported. The exclusion of original research may have led to the omission of some papers that did, in fact, focus on aspects of safety conceptualization. In addition, the studies had to be published in English, potentially resulting in the exclusion of relevant perspectives from non-English-speaking regions where midwifery is practiced differently. Furthermore, even though organizations like the WHO [20] have expanded the concept of safety, there may still be bias toward dominant frameworks, thereby excluding the perspectives of oppressed communities.
Based on all the above, future studies must emphasize the incorporation of midwives’ points of view across different places and cultures, in order to evaluate their perspectives on differences in conceptualization. In addition, it is important to examine the perspectives of women regarding safety. Finally, it would be worth investigating how future crises, beyond pandemics, such as climate change, could highlight the need for further expansion of the concept of safety.
Conclusions
Safety has a central role in midwifery-led care. Over time, a shift has taken place in the conceptualization of midwifery-led safety, which is no longer viewed solely through a biomedical lens. Instead, safety reflects a wider, person-centered concept, shaped not only by physical, but also by emotional, cultural, psychological and social dimensions. Yet, this change does not necessarily occur at a practical level, and there might be resistance to shifting from a biomedical conceptualization to a broader biopsychosocial conceptualization. Safety is an evolving concept, recently emphasizing autonomy, dignity and cultural sensitivity, which is of most importance in diverse societies, especially in those with history of oppression, as well as in times of crisis (such as, the COVID-19 pandemic and the humanitarian crisis in Gaza). Hence, safety is not a “one size fits all” concept. Instead, safety is dynamic and differs significantly across societies, historical periods, social circumstances and cultural contexts. This difference in the conceptualization of safety indicates that developing and delivering midwifery-led care might be more complex than considered, since a wide range of safety-related needs has to be taken into consideration. To improve safety outcomes, midwifery education and health policy have to focus on the redefinition of safety as multidimensional and adaptive, recognizing not only its biomedical, but also its changing psychological, social and cultural dimensions. This is a crucial step toward a paradigm shift in healthcare, although such transformation may encounter substantial resistance and underlying tensions. In conclusion, it is essential to use a context- sensitive approach regarding midwifery-led safety, highlighting the need for careful evaluation and context-specific interventions.
Disclosure of conflicts of interest
The authors report no conflicts of interest.
Funding
No funding.
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