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Arch Iran Med. July 2020;23(7):469-479
Original Article
Health Care and Medical Education to Promote Women’s
Health in Iran; Four Decades Efforts, Challenges and
Recommendations
Shima Tabatabai, PhD1*; Nasser Simforoosh, MD2
1Medical Ethics and Law Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
2Urology and Nephrology Research Center, Department of Urology, Shahid Labbafinejad Medical Center, Shahid Beheshti University of
Medical Sciences, Tehran, Iran
Received: July 26, 2019, Accepted: January 1, 2020, ePublished: July 1, 2020
Abstract
Background: The aim of this paper is to present a synthesis of solutions for post-graduate medical education (PGME) and the
health-care system in addressing challenges in relation to women’s health.
Methods: A critical review was conducted within three themes: women’s health status, women’s preferences for female physicians,
and women in surgery. The study was conducted in two phases that consisted of an analysis of the trends of Iranian women’s
health and women’s participation in PGME since 1979 followed by a thematic analysis to assess the current challenges and their
implications on medical education.
Results: Our analysis revealed important trends and challenges. Since 1979, life expectancy has increased by 29% in Iranian
women, while female adult mortality rate has decreased by 78%, and maternal mortality rate has decreased by 80%. The number
of female medical specialists has increased by 933% , while the number of female subspecialists has increased by 1700%.
According to our review, ten major challenges regarding women’s health were identified: 1) Increase in chronic disease; 2)
Increase in cancer cases; 3) Preference for same-gender physicians in sensitive procedures; 4) Delayed care-seeking due to lack of
female surgeons; 5) Lack of gender-concordance in clinical settings; 6) Underestimating female surgeons’ capabilities; 7) Female
physicians’ work-family conflicts; 8) Male-dominancy in surgical departments; 9) Women’s under-representation in higher rank
positions; and 10) Lack of women in academic leadership.
Conclusion: We identified different solutions to bridge these gaps. Community-based education, Gender- concordant considerations,
and empowering women in surgical departments could help medical education policy makers to address the challenges.
Keywords: Iran, Medical education, Trends, Women doctors, Women’s health
Cite this article as: Tabatabai S, Simforoosh N. Health care and medical education to promote women’s health in Iran; Four
decades efforts, challenges and recommendations. Arch Iran Med. 2020;23(7):469–479. doi: 10.34172/aim.2020.44.
*Corresponding Author: Shima Tabatabai, Post-Doctoral Researcher in Medical Education, Medical Ethics and Law Research Center, Shahid Beheshti University
of Medical Sciences, Tehran, Iran. Tel: +98-21-22405611; Fax: +98-21-22588016; Email: shtabatabai@yahoo.com, shima.tabatabai@sbmu.ac.ir
10.34172/aim.2020.44
doi
ARCHIVES OF
IRANIAN
MEDICINE
Introduction
Women constitute nearly half the population of the world,
but their role in strengthening social structure is way
beyond this figure. Women’s health has an essential role
in family health and social development.1,2 Based on the
religious doctrine, apart from their family roles, women
in Iran enjoy commendable respect in their social roles. So
health authorities need to devote considerable attention to
women’s health and wellbeing.3 Following the revolution of
1979, promoting mother and child health was determined
as one of the most important priorities of Iran’s ministry
of health and medical education (MOHME).3 Over the
last decades, Iran has witnessed remarkable achievements
in the health and medical education systems, resulting in
the increased efficiency of mother and child healthcare.4
Gender is a social determinant of health, and women’s
health issues differ from that of men in many unique
ways.5 Meanwhile, it cannot be ignored that the World
Health Organization (WHO) has categorized women
as vulnerable, due to physiological changes women go
through in their lives including menstruation, pregnancy,
and menopause and their important role as mothers in
the family.1 Women’s health is influenced not just by their
biology but also by economic conditions as well as social
and family responsibilities. Further, discrimination against
women in many countries restricts their access to the
necessities of life, including health care.6 Women’s health
and well-being are monitored by multiple indicators.1
These determinants of health give rise to health needs and
inequalities across regions and populations.7
The factors affecting women’s health are complex. In this
regard, our study focuses on three broad themes applicable
in all contexts including ‘women’s health indicators and
aspects’, ‘women’s preferences for same-gender physicians’,
and ‘women’s participation in PGME and Academic
leadership’. The achievements of the Iranian MOHME
and current worldwide challenges are presented in detail
in the results.
Although there is a growing body of literature
explaining women’s health needs and challenges,1-10 it is
Open
Access
http://www.aimjournal.ir
Arch Iran Med, Volume 23, Issue 7, July 2020
470
Tabatabai and Simforoosh
not clear how the medical education system can play an
effective role to bridge the gaps. In this study, we aimed at
answering this question in order to improve post-graduate
medical education (PGME) and the health-care system
to incorporate national priorities in addressing women’s
health challenges.
Materials and Methods
This study systematically identified, critically appraised,
thematically analyzed and synthesized studies related
to women’s health challenges and facilitators for
strengthening health and medical education system to
promote women’s health in Iran. To begin organizing the
structure of the literature review, one reviewer performed
a preliminary review and analysis. Since women’s health
priorities and related challenges vary globally, we needed
to identify relationships between the sources we reviewed.
Based on our readings and notes, we looked for the themes
which were the recurring concepts across the literature.
This preliminary analysis was discussed with the other
author and some academic experts from women’s health
department. This thematic review provides an in-depth
examination of principles through evaluation of relevant
objectives. It focuses on a central element which is taken
into consideration from different point of views. Finally,
three broad themes were selected to conduct the critical
review and thematic analysis in two phases. The first
phase was conducted to analyze the existing evidence on
trends and the achievements of different aspects related
to women’s health. The second phase was conducted to
categorize the health and medical educations system
challenges related to women’s health promotion. The
existing empirical and theoretical studies were summarized
to provide more comprehensive recommendations.
Data Collection
The keywords and various combinations of the key terms
included ‘Iranian women’ , ‘women health’, ‘ health
indicators’, ‘epidemiological transition’, ‘challenge’,
‘woman health promotion’, ‘medical education’, ‘gender
gap’, ‘women physicians’, ‘female specialists’, ‘surgeon’,
‘obstacle’, ‘barrier’, ‘gender-based discrimination’,
‘masculine culture’, ‘glass ceiling’, ‘work-life balance’, ‘part-
time’, ‘family’, ‘career’, ‘academic leadership’, ‘satisfaction’,
‘surgical specialty’, ‘surgical departments’ and Boolean
operators ‘AND, OR’ were used to increase the sensitivity
of our search. To be more precise, we excluded the studies
that focused on psychological aspects of women’s health,
and disciplines other than medicine. Also, the reference
lists in the literature were searched manually. Initially,
the electronic databases including MEDLINE, PubMed,
Science Direct, Scopus, and Google Scholar were searched
in March 2019 which was limited to the studies published
after January 1999. To find any possible new publication,
the search was updated in June 2019. The best existing
evidence and data on women’s health in Iran were retrieved
from MOHME national reports, national cancer registry
report, and scientific electronic databases and our previous
national research supported by the academy of medical
sciences on growth of women in PGME.
Inclusion and Exclusion Criteria
Papers published in English were included in the review.
Articles including editorials, commentary, and studies
irrelevant to the research question were excluded. The
duplicate references were removed both automatically and
manually (Figure 1).
Data Analysis
Thematic analysis was used to identify key challenges
from the reviewed articles. With repeated reading of data
extracted from the articles, the text segments that were
related to the study objective were identified. Finally, the
data were coded into a total of ten challenging themes.
Completing the open coding, themes and subthemes were
assigned to them. Then, the literature was qualitatively
synthesized followed by matching of the identified
challenges with their solutions to meet the women’s health
priority.
Both authors participated in critical review and synthesis
of evidence. Through these discussions, more themes
for challenges began to emerge. Any discrepancies were
resolved by consensus, thereby validating the final results.
The percentage change that represents the degree of change
over time and was calculated using the following formula:
Results
Our analysis revealed important current growth trends
and ten challenges. The results are presented in three
selected themes. The sub-sections of each theme begin
with a descriptive summary of the current trends and
achievements and then continue with identified challenges.
Women’s Health Indicators and Different Aspects
Table 1 summarizes the status of selected indicators related
to women’s health and the significant changes in women’s
health over the last decades in IR Iran.
According to the 2016 census results released by the
Statistical Center of Iran, women comprise 49.3% of
the population.9 The Iranian population profile showed
increasing aging and urbanization rate.10,11 Life expectancy
(LE) is known as a distinct index of development. Iranian
women’s LE is on the rise,11,12 while general fertility, mother/
infant mortality rate, female mortality rate, diseases related
to pregnancy/childbirth, and communicable disease
mortality rate are declining (Table 1).13-16
Arch Iran Med, Volume 23, Issue 7, July 2020 471
Medical Education to Promote Women’s Health in Iran
Challenge 1. Increase in Chronic Diseases
The health profile is influenced by the demographic and
epidemiological transition. The prevalence of chronic non-
communicable diseases is increasing globally. The issue of
aging, paired with increasing life expectancy, will bring
about long years of living with co-existing conditions such
as heart disease and hypertension among the elderly.8,17
The urbanization index has increased by 60% since 1976
(Table 1). Urban life has brought about numerous health
problems, especially for women.
Challenge 2. Increase in Cancers
According to the WHO report in 2010, 72% of deaths in
Iran are due to non-communicable disease, and 12% were
caused by cancers.18 Cancer is growing at an alarming rate
and is a major threat to the health system. As reported
by the WHO, the percentage of cancer patients is on the
rise. Cancer is a major problem in Europe and generally
causes more than 20% of deaths in women.19 As stated in
recent studies, cancer is the third cause of death in Iran,
after cardiovascular diseases and road accidents. As the
country’s elderly population increases, cancer will become
epidemic.20 This is also the case around the globe, as the
number of cancer patients has almost doubled annually by
2020.18 The national cancer registry reported breast cancer
as the most prevalent cancer in Iranian women. Ovary
cancer was the most prevalent, and cervical cancer was the
least prevalent one in the reproductive system.21
Women’s Preferences for Female Specialists and Surgeons
In our literature review, a considerable number of studies
investigated the patients’ preferences for their physicians’
gender.23-27 We identified that most of women prefer
female surgeons for sensitive procedures.25-36 Women’s
preferences for same-gender specialists are highly sensitive
and have numerous foundations such as culture, religion,
past experiences, and physicians’ practice style that can
affect a person’s comfort level.22,24-27
In 1985, the Iranian MOHME decided that only
female physicians were admitted to the Ob-Gyn specialty
education due to female patients’ demand and right for
same-gender Ob-Gyns.3,23 Over the last decades, the
number of female residents entering all specialist fields and
therefore, the number of female specialists have increased
Records identified through
database searching
(n =184)
Screening
Included
Eligibility
Identification
Records after dup licates removed
(n = 57)
Abstract screened for
eligibility
(n = 221)
Did not meet full inclusion criteria
Ineligible articles
(n = 166)
Full-text articles retrieved
for quality assessment
(n = 55)
Full-text articles excluded
after quality assessment
(n = 6)
Studies included in
qualitative synthesis
(n = 49)
In the Preliminary review
3 themes (t
he concepts recur across the literature
) were selected.
Theme 1) Women’s health
indicators and Challenges
Theme 2) Preferences for
same gender physicians
Theme 3) Women in surgica l
departments and leadership
Records after dup licates
removed
(n = 119)
Records identified through
database searching
(n = 92)
Records identified through
database searching
(n = 235)
Records after dup licates removed
(n = 146 )
Removed irrelevan t one
(n =101)
Figure 1. Flow of Information through the Different Phases of the Review.
Arch Iran Med, Volume 23, Issue 7, July 2020
472
Tabatabai and Simforoosh
in Iran. Figure 2 shows that the women’s numbers in
Ob-Gyn specialty have increased much more than other
specialties.
Challenge 3. Increasing Demand for Female Physicians
and Surgeons in ‘Sensitive’ Medical Visits and the Supply
There is an increasing preference for female physicians
concerning their practice style. Female surgeons respond
to the socialization demand of their female patients with
their care, warmth, patience, and empathy.24 Increasingly,
male medical students report being refused by female
patients, particularly in obstetrics and gynecology, which
impacts recruitment into the discipline.26 A study to
assess the gender preferences of women regarding their
choice of a breast surgeon showed that about a third of
women prefer a female breast surgeon for their breast
examination.25 Embarrassment during the examination
was the major reason for same-gender preference.26
Urologic problems are among other highly sensitive issues
for women regarding the physician’s gender.27,28 A study in
2017 showed that more than half the female participants
had a preference for same-gender urologists.29 Pregnant
Muslim women usually seek female obstetricians for
prenatal care and prefer to have a female doctor present
at delivery.30 Another study showed that 90.6% of women
do not select male Ob-Gyns.31 Studies which investigated
patients’ physician gender preference in the emergency
department (ED) settings have shown that in the ‘routine’
Table 1. Status of Selected Indicators Related to Women’s Health in Iran
Time Duration V1 (%) V2 (%) Percentage Changes
Population profile with focus on women’s population of Iran
Iranian Women’s population91976–2017 (48.62 %) (49.33%) 1.46%
Female <15 years 1976–2018 42% (23.04%) -45.14%
Female 15–59 1976–2018 54% (68.49%) 26.83 %
Female ≥60 1976–2018 4% (8.42%) 110.5 %
General fertility 1979–2018 6.2 2.01 -67.58 %
Urbanization index9,10 1976–2017 46.7% 74.39% 59.5%
Women health indicator11,12
Life expectancy
LE at birth 1980–2016 59.7 76.9 28.81 %
LE at 60 1985–2016 15 20 33.33 %
Maternal health13,14
Maternal mortality per 100 000 live births 1990–2015 123 25 -79.7%
Communicable disease mortality rate 1990–2016 21.2% 8% -62.26%
Share of diseases related to childbirth 2003–2011 7% 6.6% -5.71%
Women health risk factor per 100 000 population
Obesity percent 2016 32.2%
Smoking percent 2016 0.7%
Non-communicable diseases13-17 (Cardiovascular disease and cancers are the main current etiologies for death and disability in Iran)
Elderly women suffering from heart disease 2014 25%
Hypertension in aged women 2014 46 %
Female mortality rate
Mortality rate, adult (per 1000 females aged 15–60) 1977–2015 279.23 62.01 -77.79 %
Cardiac ischemia mortality per 100 000 population 2014 24.69%
Mortality from CVD, cancer, diabetes or CRD between ages 30 and 70 (%) 2000–2015 23% 15% -34.78 %
Cancer cases registered20,21
Percentage of cases in women Time Duration V1(%) V2 (%) % Changes
2003–2009 (43.8%) (45.42%) 3.7 %
Percentage of common cancers in women21
Breast
2005–2009
23.16% 28.25% 21.98 %
Ovary 2.98% 4.02% 34. 9%
Corpus Uteri 2.45% 2.79% 13.88%
Cervix 1.86% 2.17% 16.67%
Other type of cancers in women
Colorectal
2003–2009
7.53% 8.5% 12.88%
Gastric cancer 6.92% 6.95% 0.43%
Blood system cancers 4.02% 4% -0.5 %
Bladder 2.86% 2.44% -14.69%
Lymphatic system cancers 2.65% 2.68% 1.13%
V1, 1st Value; V2, 2nd Value; LE, Life Expectancy; CVD, Cardio-Vascular Disease; CRD, chronic respiratory disease.
Arch Iran Med, Volume 23, Issue 7, July 2020 473
Medical Education to Promote Women’s Health in Iran
visits and ‘sensitive’ medical visits, there is a propensity
for same-sex physician preference. There is a considerable
preference for the presence of a female physician in the
ED to handle gastrointestinal diseases, clinical assessment,
non-life-threatening cases, and physical examination for
female patients.32
Challenge 4. Delays in Care Seeking Due to a Perceived
Lack of Female Clinicians
We identified that many Asian women and many devout
Muslim women delayed care seeking due to a perceived
lack of female clinicians and may have very advanced
disease by the time they seek medical help. Delayed care
seeking is associated with adverse health outcomes.25,33,34
Challenge 5. Lack of a Comprehensive Approach to Fulfill
the Need for Gender-concordant Health Care Provider
Model Based on Islamic Principles in Health and Medical
Education System
Lack of gender-concordant providers can be a barrier to
timely care. Studies show that American Muslims not
only request for the physician but also care providers
of the same gender because of their Islamic values and
concerns about preserving modesty.35,36 Some women
refused male providers even in emergencies and refused
male anesthesiologists when female physicians were not
available.33-35
Women’s Participation in Postgraduate Medical Education
and Higher Rank Academic Positions
There has been a remarkable increase in female specialists
and subspecialists since 1979 (Table 2). Women doctors
now account for over 50% of total residents. Most women
entered non-surgical subspecialty fields (Table 3). Our
results showed that ob-gyn, geriatrics, pediatrics, and
dermatology are the specialties with the highest percentage
of Iranian female physicians (Table 3).
Between 1979 to 2015, the total number of Iranian
medical specialists increased by 332%, while the greatest
increase pertained to women with 933% (Table 2). The
total number of active specialists increased by 332%,
while the number of active women specialists increased
by more than 1000% (Table 2). The number of women
subspecialists increased from 57 in 1979 to1025 in 2015,
showing a 1700% increase (compared with 528% increase
for both women and men). Our results revealed that
although the men’s numbers have increased during these
years, the women’s increase has been greater (Table 2).
The majority of women doctors are attracted to general
care fields, while a smaller proportion of women enter
surgical specialties and subspecialties. Also, the percentage
of women interested in pediatric subspecialties continues
to grow (Table 3). Today, one of the 65 medical science
universities in Iran (1.5%) is managed by a woman
chancellor and about 35% of recruited faculties were
women in 2017.37
Challenge 6. Underestimating Female Surgeons’ Capabilities
due to their Physiology
Historically, a ‘masculine’ or patriarchal culture was
formed in medicine formed as a result of the dominance
of biologically male doctors. Now, the term “masculine’
is not restricted to the literal description of biological sex
–essentialism– but is cultural.38 An argument was that
surgeons must protect themselves by distancing themselves
from carrying their patients’ suffering and they must have
stronger emotional repression mechanism, while the
female physician cannot handle so much suffering. Studies
emphasized that female doctors perceived continuous
discrimination based on the patriarchal culture persisting
with the male dominancy in medicine and experienced
negative comments about their gender.24-38
Challenge 7. Obstacles (Work–family Conflict) Which
Affect Female Doctors’ Preference in Choosing Surgical
Fields
Worldwide, female physicians have different preferences
for specialty selection and working patterns compared
to men. These differences will affect how the physician
workforce evolves in the next ten to twenty years.39 Women
perceived obstacles to career success in surgery such as
difficulties in balancing family and professional life.40,41
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pathology(women)
Radiology(women)
ophthalmology(women)
orthopedy(women)
E.N.T(women)
Psychiatry(women)
cardiology(women)
Derm..(women)
Urology(women)
nfectious disease(women)
neorology( Woman)
Physical medicine(women)
Radiotrapy(women)
Forensic Medicine
Social medicine(women)
NuCear.M(women)
occupationalwomen
sports med
AeroSpace
neurosurgery(women)
General surgery(women)
Figure 2. Growth Trends of Female Specialists in All Specialty Fields in Iran Since 1979.
Arch Iran Med, Volume 23, Issue 7, July 2020
474
Tabatabai and Simforoosh
Female surgeons reported difficulties in balancing between
family responsibilities (childcare duties, homecare duties),
and excessive workload and on-call commitment.41 Studies
revealed that female surgeons were satisfied with their
choice of profession, but they were less satisfied with their
work-life. Other studies described that excessive workload,
the on-call duties, full-time commitments, work-related
stress, frustration, and worry were often cited as the
negative aspects of surgery and the reasons why female
surgeons rated their level of job satisfaction to be moderate
or dissatisfied.40-42
Challenge 8. Obstacles (Health and Medical Education
System Barriers) Contributing to Male Dominancy in
Surgical Departments
Studies showed that female academic surgeons experience
challenges that are perceived to differ from their male
colleagues. Historically specialties like urologic, orthopedic
and plastic surgery have been male-dominated fields and
lack of female colleagues and bias against women pursuing
career in some surgical fields are other obstacles.38,42
Female surgeons perceived discrimination by the male
power structure in surgery and felt excluded from the male
dominant culture. Most of them are unsatisfied with their
career advancement, unequal promotion, unequal pay and
income, as well as lack of female mentors and research
funding.43
Challenge 9. Mismatch between the Brilliant Women’s
Achievements in Postgraduate Medical Education and
their Future Career
We identified a mismatch between the current achievements
of women in medical specialty/subspecialty training and
their future participation in top-level decision-making
positions. International evidence indicates persistent
under-utilization of women’s expertise in leadership
Table 2. Iranian Women’s Percentage Increase in Postgraduate Medical Education (Compared with Percentage Increase for Both Women and Men)
Gender 1979–1980
No. (% )
2014–2015
No. (% ) Percentage Changes Increase
(For the Numbers)
Admitted in specialty
residency
Women admitted 61(20%) 1721(59%) +195% 2721.31%
Total (women and men) 304(100%) 2916 (100%) 859.21%
Reregistered specialists Women specialists 1988 (13%) 20550 (31%) +146% 933.7%
Total 15410 (100%) 66590 (100%) 332.1%
Active specialists+
residents
Women 1550 (12%) 17950 (38%) 1058.06%
Total 12410 (100%) 46650 (100%) 276%
1985 2015
Admitted in
subspecialty programs
Women admitted in subspecialty 2 (8%) 94 (35%) +337.5% 6400%
Total 25 (100%) 330 (100%) 1220%
Subspecialists supply Women subspecialists 57 (8%) 1025 (22%) +175% 1698%
Total 748 (100%) 4700 (100%) 528.34%
Table 3. Specialties with Highest and Lowest Percentage of Women Doctors in 2014-2015
Highest Percentage of Women Lowest Percentage of Women
Obstetrician-Gynecologist 80% General surgeon 10%
Geriatric medicine specialist 50% Emergency medicine Sp. 10%
Community medicine Sp. 47% Sports medicine Sp. 10%
Dermatologist 40% Urologist 7%
Pathologist 40% Neurosurgeon 5%
Pediatrics 36% Orthopedic surgeon 4%
Infectious disease specialist 31% Aerospace medicine 0%
Radiologist 31%
Occupational medicine Sp. 30%
Subspecialties with highest and lowest percentage of women doctors
Highest percentage of women Lowest percentage of women
Child psychiatrist 65% Vascular surgeon 0%
Pediatric gastroenterologist 51% Thoracic surgeon 2%
Pediatric endocrinologist 50% Plastic surgeon 2%
Pediatric pulmonologist 50% Pediatric surgeon 2%
Neonatal-prenatal medicine 44% Cardiovascular surgeon 2%
Pediatric nephrologists 40%
Arch Iran Med, Volume 23, Issue 7, July 2020 475
Medical Education to Promote Women’s Health in Iran
and higher rank positions in medical academia. Women
reported feeling career advancement opportunities were
not equally available to them as to their male peers.44,45
Challenge 10. Lack of a Comprehensive Approach in
Preparing Female Medical Students and Residents for their
Future Leadership Role in Health and Medical Education
Systems
Women under-representation in academic leadership
and top-level positions is a challenge worldwide.45 This
phenomenon is called the ‘glass ceiling’, restricting
female specialists and surgeons from promotion beyond
a certain level.46 Women reported insufficient mentoring
for their future leadership roles and insufficient access to
professional networks as the constraints against reaching
top-level positions.46-48
Discussion
To the best of our knowledge, this is the first comprehensive
study to review the Iranian Health system achievements
and current challenges in order to provide an integrative
description of how we can promote health care and
medical educations in meeting women’s health priorities.
We selected three major themes contributing to women’s
health priorities in the health care and medical education
system. Then, we analyzed four decades of achievements
in the postgraduate medical education system in Iran
for each of the three themes. The results are summarized
in Tables 1-3 and Figure 2. Our analysis revealed that
women’s health indicators and women’s participation in
PGME have improved remarkably over the last 40 years.
We identified ten major challenges for the selected themes
regarding women’s health needs (Table 4).
Strengthening the Health-care and Medical Education
Systems to Promote Women’s Health
Women empowerment in medical education, especially
in specialty/subspecialty training, has a direct impact on
women’s health and community wellness. The health
and medical education system authorities have to execute
several interventions for current challenges. We propose
ten recommendations and related implications for the
health and medical education system to incorporate
women’s health priorities in Iran (Table 5).
In our first theme, we found many evidences and
studies which had gathered data on women’s health
indicators in Iran.3,7-13 While analyzing these features, we
found that other reviews consistently stated that women’s
health profile is influenced by the demographic and
epidemiological transition, lifestyle changes, urban life,
unhealthy food, stress, work pressure and lack of physical
activity, use of alcohol and smoking, air pollution, and
carcinogenic particles.14-21
The study of emerging trends and community needs
(aging population health needs, preventive medicine,
chronic disease, and need for disability management)
allows health and medical education policymakers to
make better decisions concerning future health issues
of the country and reforming medical education and
specialty/subspecialty training curriculum. Concerning
the determinant of women’s health, the most relevant
interventions in the medical education system to meet
women’s health priorities were found to be community-
based medical education and alignment of medical
curriculum with national health needs.49 Community-
based medical education is where national health priorities
are addressed. Furthermore, inclusion of gender issues
in medical curricula50 would prepare female specialists
to work in partnership with female patients in self-care,
providing sensitive cares, managing chronic diseases,
and controlling the cause and consequences of prevalent
cancers among Iranian women.
In our second theme, we found many articles which had
gathered data from the perspective of patients or specialists,
and used qualitative or quantitative methods to present
detailed information about the patients’ preference for
Table 4. Qualitative Synthesis for the Challenges in Health and Medical Education System, to Incorporate Women’s Health Needs and Demands
Theme Trends Challenges
Women’s health
indicators
Demographic and epidemiological
transition
1. Increase in chronic diseases among Iranian women population.
2. Increase in cancer cases among Iranian women.
Women preferences for
female physicians &
care providers
Increasing demand for female
physicians and care providers
based on
• Religious and culture
• Past experiences and practice
patterns
3. Increasing demand of female patients for female physicians in ‘sensitive’
medical visits.
4. Delays in care seeking due to a perceived lack of female clinicians.
5. Lack of comprehensive approach to fulfill the need for gender-concordant
health care provider model based on Islamic principles in health and medical
education system.
Women’s physician
participation in PGME
& academic leadership
• “Masculine” culture of
medical surgery
• Patriarchal culture of
leadership
• Glass ceiling at top-level
academic positions
6. Attitude of underestimating female surgeons’ capabilities due to their
physiology.
7. Work–family conflict which affect choosing specialty and subspecialty fields.
8. Male dominancy in surgical departments.
9. Mismatch between the brilliant women's achievements in postgraduate
medical education and their future career.
10. Lack of a comprehensive approach in preparing women for their future
academic leadership roles in medical sciences universities.
Arch Iran Med, Volume 23, Issue 7, July 2020
476
Tabatabai and Simforoosh
same-gender physicians. International studies confirmed
increasing women’s preferences for female physicians,
surgeons and care providers in different countries.24-30
Because of the perceived lack of female physicians,
many women decide to delay care. Also, lack of gender-
concordant providers could be a barrier to timely care.35
A study reported delays in care-seeking among American
Muslim women because of the preference for female care
providers due to their religious belief.25,35 Considering the
population diversity, the health system needs to be sensitive
to cultural differences, values, religious, and also societal
norms.32-34,36 Therefore, providing patient-centered care
for female patients requires considering religious beliefs,
cultural issues, individual preferences, and concerns about
preserving modesty, particularly for sensitive examinations.
While identifying the main challenges, we found that
other studies had consistently stated that respecting
women’s preference for same-gender specialists was critical
for women’s health outcome.3,5,29-38 A cancer registry report
showed a slight increase among women, calling for more
attention to women’s health in the country. Early detection
of cancer is the key to controlling the disease, reducing
mortality rate and improving the quality of life for patients
and their families. Unlike screening which is administered
in a healthy society, early detection, under the supervision
of medical specialists/subspecialist, is for those who are at
risk or feel sick.51 Many women who delay care-seeking to
a perceived lack of female clinicians are at risk.25,34 The best
strategies are to establish infrastructures, train more female
medical specialists, and employ qualified care providers
from both genders to perform sensitive procedures for
the same-gender patients. Hospitals are responsible for
considering patients’ religious and spiritual beliefs as part
of their rights and should provide care by same-gender
care providers, especially for Muslim female patients.33
Establishing women’s general educational hospitals
compatible with the requirements for integrated women’s
health care services across multiple medical disciplines is
an important practical solution for gender-concordant
providers in Iran.
Iran’s MOHME has long been concerned with the
women-specific health issues concerning the cultural
and social role of women in families and society.
Iranian women, like most Asian and Muslim women,
prefer female physicians, especially in sensitive medical
procedures. Since1985, only women have entered the Ob-
Gyn specialty training programs and women’s numbers in
Ob-Gyn specialty have increased much more than other
specialties in Iran (Figure 1). Over the last 40 years, Iran
has made remarkable progress in women’s presence in
postgraduate medical education. Our analysis revealed
that although the men’s numbers have increased during
these years, the increase has been greater for women (Table
2). Worldwide, ob-gyn, dermatology, and pediatrics
have become specialties with the highest percentage of
women.3,42-44 According to our study, pediatric related
subspecialties have become the most attractive to female
specialists, while surgical fields are less attractive (Table 3).
In the Islamic Republic of Iran in 2009, the first woman
assigned to a position of Ministry was a gynecologist
professor who became the Minister of Health and Medical
Education. Despite some exceptional examples of the
presence of some competent women in top positions in
Iran’s MOHME, evidence indicates persisting gender
inequality in management positions and gender imbalance
in top academic hierarchies.
Many studies have argued that the reason is an
attitude of underestimating women in an academic
higher rank leadership position. However, other studies
have emphasized the institutional obstacles such as
Table 5. Recommendations Proposed to Promote Iranian Women’s Health and to Meet Women’s Challenges as Patients and as Physicians
Theme Recommendations & Implications for PGMED
Women’s health
aspects
1. Community based medicine: Need for changing curriculum focused on community needs (chronic disease and disability
management, prevention and self-care to control health risk factors).
2. Flexible curriculum for training gender issues: Need for preparing female physicians specifically for women’s community health
demands through flexible curriculum.
Female patients'
preferences for
female Physicians
& care-provider
3. To train more female physicians who are prepared to go into surgical specialties and subspecialty career paths less attractive to
women.
4. Respectfully responding to a female patient’s request for a female provider considering the patient’s values, sensitivity, and
preferences.
5. Taking a comprehensive approach to fulfill the need for gender-concordant care provider model based on Islamic principles in
Iran’s health and medical education system.
Need to be sensitive to religious and cultural issues and concerns about preserving modesty, particularly for personal
examinations.
6. Need for establishing women’s general educational hospitals compatible with the requirements for integrated women health care
services and gender-concordant providers demand in Iran.
Women’s
empowerment
in PGME and
Academic
leadership
7. Increasing flexibility in training and work pattern for female physicians and providing institutional support for creating family-
friendly working conditions.
8. Changing the male-dominated culture of surgical departments in medical education system.
9. Supporting career advancement of competent female specialists and subspecialists.
10. Preparing female medical students and residents for their future leadership roles in medical education systems by offering proper
training programs.
Arch Iran Med, Volume 23, Issue 7, July 2020 477
Medical Education to Promote Women’s Health in Iran
gender inequality, the male-dominant culture in surgery
departments, and the unfriendly work structure.52-54
Certain structural supports including flexibility in training
and working shifts, female-friendly environment, lower on-
call duties, and part-time working practice arrangements to
fit family responsibilities, and providing adequate facilities
for childcare are recommended to attract more female
physicians to surgical fields and retain female surgeons.55-56
Studies confirm that providing flexible and supportive
work conditions for female surgeons would enable a more
satisfactory balance between work and family.54-56
Attitudes and traditions related to the masculine
nature of surgery and the culture of male dominance in
surgical departments are perceived obstacles to career
success for women.57 Attempting deeper changes in this
culture will allow progress, and attract and retain the best
surgeons regardless of gender. The number of women in
tenured faculty positions in surgery departments remains
limited.58,59 The greater presence of female surgeons as
faculty members and mentors in surgical departments
would motivate the female physicians entering surgical
specialties.60,61 Increasing female faculty members and
role models in surgical departments, and developing
rich networks among female surgeons would produce
meaningful change in the currently male-dominated
culture in which male surgeons feel superior to female
surgeons.
Although some efforts have been made to increase the
recruitment of women as faculty members in medical
universities in the last decade, about 65% of recruited
faculties were men in 2017. Women still have lower
tenure and promotion rates in Iran.37 Ensuring equal
recruitment opportunity based on merit and not open to
bias, providing appropriate development opportunities
for women to advance their careers, an equal promotion
pathway, equal income, and equal research funding
are the main solutions to address the obstacles faced by
female physician and faculty members in recruitment and
promotion.42,45 The health and medical education systems
need to pay significant attention to facilitators for career
advancement for female specialists and subspecialists.
Provision of career advancement seminars for women to
receive top ranks at all levels of hierarchy, gender-sensitive
appointment and promotion criteria are recommended to
support competent female specialists and subspecialists.
Increasing the number of female mentors and role models
will change the male-dominated attitudes in some surgical
departments.
Establishing a comprehensive structure for preparing
female medical students and residents for their future
leadership roles would contribute to expanding the
number of female leaders in surgical specialties in
medical education systems. Female doctors are still not
moving into leadership roles.61 To be selected as a senior
manager, it is necessary to have related qualifications
and experiences. Networking as a key to women’s career
success enables female medical students and residents in
male-dominated specialties to share their knowledge and
expertise.49 Female mentors motivate female residents
and support them with appropriate information. The
diverse experience of women across different managerial
levels can prepare them for their future senior educational
leadership roles. Legislations could be put in place to
ensure the inclusion of women in senior academic roles.
It is recommended that medical education institutes
should offer proper training programs for gender-sensitive
clinical and educational leadership such as mentoring
programs, training workshops to prepare women for their
future educational leadership roles. Universities should
encourage female physicians to compete with their male
colleagues to reach the top academic ranks and managerial
levels. These changes could guarantee a cultural shift to
empower women in top positions in the postgraduate
medical education system.
Women’s health needs vary globally, and it is beyond
the scope of this paper to address the extent to which
medical education has met all nationally defined needs.
Considering the broad topic, we used a pragmatic
approach for our literature review in three themes.
In conclusion, this article is solution-focused and allows
health and medical education authorities to adopt policies
to enhance women’s health in the country. Over the last
decades, great advancement has been made in the health
and medical education system to improve health status for
Iranian women. To continue this trend, the health care
and medical education system will have to be aligned with
women’s aging population health needs, changing patterns
of diseases, and increasing demand for same-gender
physicians.
Our research highlights the need for gender-concordant
physicians in sensitive cares for Iranian women. As Iran’s
health care and medical education systems continue to
plan for providing effective health care for Iranian women,
it is vital that authorities pay significant attention to
their strong preferences for same-gender care providers
and develop a policy on how to provide optimal care for
women.
We recommend that MOHME develops cooperative
health-care and educational strategies to effectively bridge
the gaps between women’s health priorities and PGME.
Over the last four decades, Iran’s medical education
system has undergone major reforms, shifting from
male-dominant medical universities to a system where all
talented applications can enter undergraduate and PGME,
without influence from gender bias. Continuing this trend
and increasing the number of under-represented women in
surgical departments will require attention to recruitment
and mentorship. Furthermore, women empowerment
in higher surgical academic ranks has a direct impact on
women’s health and community wellness. Medical sciences
Arch Iran Med, Volume 23, Issue 7, July 2020
478
Tabatabai and Simforoosh
universities need to open doors to women to take top-level
positions by improving gender-equity in the promotion
process, especially in the appointment of professors.
Taking a comprehensive approach to fulfill women’s
health needs and develop a futuristic curriculum that will
adequately prepare female physicians and surgeons to
address women’s health demands would be an important
task of medical education policymakers in Iran.
Authors’ Contribution
ST managed the overall design of the study, wrote the draft and
analysed the data. ST and NS conceptualised this study, completed
the manuscript and inspected the quality of data.
Conflict of Interest Disclosures
None declared.
Ethical Statement
All the ethical issues related to critical review and thematic synthesis
of evidences were observed.
Acknowledgements
This article is extracted from a comprehensive national research
supported by the Academy of Medical Sciences of Iran, and Dr.
Shima Tabatabai’s postdoctoral research in Medical Education
supervised by Professor Dr. Nasser Simforoosh at Shahid Beheshti
University of Medical Sciences.
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