Explaining Challenges Experienced and Evaluation of the Working Condition of Midwives: A Mixed-Method Study Protocol

Introduction

According to historical evidence, midwives are key member of the health workforce to help improve the health of the community, especially the mothers and children’s health, and are the backbone of the obstetrics team in providing health care and reproductive health services for women (Pettersson, 2008). Midwifery is one of the most important jobs and plays a significant role in reducing mortality and preventing complications of women and children (Mirmolaei et al., 2005). According to the International Confederation of Midwives, midwives have a professional responsibility that provide support, counseling and care for women (Adatara et al., 2021). They make up a major proportion of healthcare workers worldwide, and more than 80% of women’s health care is provided by them (Hashemi Nejad et al., 2013). The profession of midwifery is one of the occupations that, based on the religious and customary beliefs of Iran, with all the physical and psychological pressures, has been assigned to women, who also have different roles depending on their position (Hashemi Nejad et al., 2013; Molaie et al., 2011). Since the job is considered one of the most important issues of everyone’s life, Job satisfaction or dissatisfaction can not only affect different aspects of life but also affects the efficiency of health care (Manoukian et al., 2007). Health agencies have a special place in society, due to the importance of their role in providing preventive care and treatment, but unpleasant environments and hard work can cause physical and mental disorders and job dissatisfaction in hospital staff (Sharifzadeh et al., 2017). This leads to emotional rupture and indifference and reduces the quality of services provided to the patient (Mirmolaei et al., 2005). Healthcare workers, especially in hospitals, are at high risk to face occupational health hazards (Izadi & Piruznia, 2018). And midwifery, as a high-risk job (Atulomah & Oladepo, 2002), faces many occupational risks and challenges (Atulomah & Oladepo, 2002; Ismaila et al., 2020; Zarrini et al., 2018) and these challenges are one of the major concerns (Atulomah & Oladepo, 2002). Some of them are related to the complex work process of the midwifery profession, which leads to significant pressure on the professional group, and others are related to the difficulty of working and facing occupational risks (Geraghty et al., 2019; Hunter & Warren, 2014). For example, work stress due to heavy workloads and long working hours (Ismaila et al., 2020), the emotional needs of the job, facing women with complex care needs, and working in traditional settings with a shortage of midwives, fear of punishment, lack of support and low appreciation (Gholamzadeh et al., 2011; Ismaila et al., 2020; Park & Kim, 2013), the loss of their social networks due to working away from home, and sometimes facing economic burden, especially when women are unable to pay, mentioned as midwifery job challenges (Hunter & Warren, 2014; Ismaila et al., 2020). Also, the difficulty of midwifery duties from the perspective of midwives working in health centers has a greater role in the occurrence of midwifery errors (Cheraghi et al., 2020). According to researchers, midwifery is an emotional job in which caring for women and their families, despite the social complexities, confronts midwives with anxiety, pain, fear and sadness, which make it difficult for them to work in these challenging situations (Hunter, 2010). And it is not surprising that low morale and job stress are of particular importance in the midwifery staff (Hunter & Warren, 2014). Today, work stress has become a common and costly problem in the workplace (Smith et al., 2009). Because facing many problems leads to increased stress, dissatisfaction, apathy, frustration and job burnout of midwives and reduces their participation in providing desirable care (Hunter & Warren, 2014; Mizuno, 2011; Tibandebage et al., 2016). And studies have declared that stressful working conditions lead to increased absenteeism, lawlessness, and staff turnover (Collins et al., 2010; Tibandebage et al., 2016). According to the reports, midwives face limitations and physical and medical problems during their work, including the risk of nosocomial infections, which in most cases are due to lack of appropriate personal protective equipment (Pettersson, 2008). According to a study have been conducted in Nigeria, hospital staff Mentioned the 4 main predisposing factors for blood-related accidents including lack of access to protective equipment, inappropriate staff behavior, high workload, and high work speed (Ofili et al., 2003). Also, Atwama et al., reported midwives work in high-risk environments compared to other jobs, but receive less support (Atulomah & Oladepo, 2002). Common occupational hazards in the obstetrics and gynecology unit include work-related stress (83.3%), needle injuries (75.6%), skin contact with bloodstains (73%), sleep disorders (42.3%), Skin reactions (37.2%) Attacks have been reported by patients (24.3%) and hepatitis (8.9%), and almost half of staff used diazepam or alcohol to cope with work stress (Orji et al., 2002). Studies were conducted in Iran have shown the dissatisfaction of the working midwives, mostly has been in the dimensions of workplace conditions, job security, salaries, and benefits (Mirmolaei et al., 2005). In some areas, various solutions are implemented to increase the motivation of midwives to provide quality care, such as improving working conditions and continuous monitoring and creating high educational opportunities (Pettersson, 2008). Evaluation of the challenges and risks related to the midwifery job to design appropriate strategies to prevent accidents and burnout, which affect people’s health, and examining the problems of an organizational necessity (Zarrini et al., 2018). Because to achieve the health of organizations, it is necessary to pay attention to the quality of work life of employees, provide a suitable environment that meets personal needs and create a motivating environment to perform tasks, meet their job challenges and improve care. The present study was designed to explain the challenges and risks of midwives’ work environment in Iran in a mixed-method study.

Objectives

The objectives of each phase are as follows:

Methods/Design

Sampling Method

The research participants will be selected through purposive sampling among midwifes who work in hospital or health care centers. After the process of obtaining permission to conduct research from the officials of “Tabriz” and “Ilam” universities, the study will begin. Inclusion criteria including: working in hospitals and health centers, having at least 1 year of work experience, Absence of any illness or mental disorder. The withdrawal and non-attendance of the participants were considered as the exclusion criteria.

Data Collection

Qualitative data will be collected using in-depth and semi-structured interviews, containing open questions. Before conducting the interviews, the research team reviews the questions, and the ways to obtain valid data and focus on research questions. The interviewer will pilot the interview on a subset of participants, and used this information to further refine the guide with respect to culturally sensitive and appropriate questions. The interview will begin with a key question, “What are your experiences and feelings about midwifery?”, “What are the problems with your job at work?”, “What do you think about the various occupational hazards of midwifery?”, What do you think are the difficulties in midwifery?”, “What do you think are the factors that cause problems and occupational hazards?”, and “What do you think are the factors that prevent job problems and risks?” to explore the depth of their experience. During the interview, as far as possible, the Note field will be used and non-verbal data such as tone of voice and behaviors were recorded, too. The sampling will continue until data are saturated. All interviews will be carried out in a quiet room and without someone other than the interviewees.

Data Analysis

Data analysis process will be performed simultaneously with data collection using MAXQDA software version 10. The qualitative data will be analyzed using qualitative content analysis based on the Graneheim and Lundman method (Graneheim & Lundman, 2004). We chose content analysis because this method enables researchers to sift through large volumes of data with relative ease in a systematic fashion (Graneheim & Lundman, 2004; Harwood & Garry, 2003). In this approach, the data will be analyzed through frequent text reading to obtain a full understanding of it. Then, the texts will be read word by word to extract the codes. First, the objective words that contain the key concepts will be specified. The researcher continued digging the text by taking notes from the initial analysis until the major codes will be extracted. In this process, the code labels reflecting more than one key thought will be directly extracted and specified. Then, the codes will be categorized based on their difference and/or relationships. The codes will be categorized into themes and main categories. Subcategories will be extracted based on differences and similarities.

The interviewer will try to establish a friendly relationship with the participants to validate the results. To increase the validity of the data, the interviews will submit to the participants after transcription in order to affirm their statements. If necessary, additional statements will add to the data. Authors will review data several times and revise word-by-word, and the significant sentences and concepts in each line or paragraph will specify and a code will assign to every sentence. The transcriptions will submit to colleagues along with the extracted codes and categories, and their viewpoints were used regularly. Also, external viewpoints will use to increase the reliability.

Sample Size and Sampling Method

After controlling the sample size for research purposes, the maximum sample size was calculated. So that the 95% confidence interval, 90% statistical power was considered. According to the study of Abdolmaleki et al. (Abdolmaleki et al., 2020) considering the acceptable error of 5% around the mean (m = 48.86) and the standard deviation of 14.59 for the job satisfaction scale, the required sample size is 137 people and according to the study of Komeili-Sani et al. (Komeili-Sani et al., 2015), Taking into account the acceptable error of 5% around the mean (m = 183.08), and the standard deviation of 54.07 for the job stress scale, 135 people were calculated. Also, according to the report of Hadizadeh et al. (Hadizadeh et al., 2015), the sample size of 54 people was calculated for the quality of work life scale around the mean (m = 65.23), and the standard deviation was 12.16. In addition, regarding the workload of nurses reported by Malekpour et al. (Malekpour, 2014), considering the acceptable error of 6% around the average score of physical need (m = 55.83) and the standard deviation of 22.16, the sample size of 168 people was calculated. Considering the maximum sample size based on occupational hazards and considering the design effect and 10% of sample loss, the final sample size of 290 people was calculated for each city.

n = ( Z 1 − α 2 ) 2 × s 2 d 2

After the approval of the ethics committee and obtaining permission from the officials of hospitals and health centers, sampling will be done in several stages in the target cities and the sample size will be calculated by considering hospitals and health centers in layers and according to the number. Participants who work in these centers will be considered. Teaching hospitals and a non-teaching (private) hospital will be selected from each city. To select health centers in each city, first the clusters are identified and from each cluster, one or two health centers will be randomly selected using Randomizer software. Centers will continue until the calculated sample volume is reached.

Discussion

Midwifery is a high-risk occupation in which the risks are higher than those in other professions (Turkmani et al., 2013). In spite of the important role of midwives in maternal health care, they experience numerous challenges in the workplace which affect their ability to do the responsibilities and prevent the midwives from providing sufficient midwifery care (Filby et al., 2016; Geraghty et al., 2019; Homer, 2006). A systematic review on midwifery care in low and middle-income countries declares that barriers for providing sufficient midwifery care are created by social, economic and professional factors (Filby et al., 2016). The outcomes of these barriers are feelings of fatigue and moral distress, which in turn affects the quality of the care provide (Bremnes et al., 2018; Filby et al., 2016). A study from Tanzania identified three main barriers to providing quality care with midwifes; poor-working conditions, lack of status and perceived lack of knowledge (Bremnes et al., 2018). In the another study in Ghana, researchers explored and described five challenges experienced by midwives who provide maternal healthcare to childbearing women and newborns, including Lack of logistics, Inadequate infrastructure like lack of beds and physical space, Shortage of midwifery personnel, Lack of motivation, and Limited in-service training (Adatara et al., 2021). Midwives and removing the barriers they face are regarded as key for improving child and maternal health (Filby et al., 2016).

We aimed to explore and highlight the challenges the midwives face in their practice, and to investigate which measures the midwives find necessary to implement to improve them condition. This may provide actions to be taken informed by the midwives’ firsthand experience of the situation. Seeing their own suggestions being taken into account may lead to increased motivation, thereby improving the midwives’ working conditions, which in turn could better maternal and child health in our country.

The mixed-method approach supports the combination of opinions, approaches, and different methods if they are helpful for understanding concepts. The strategy proposed by this study may be helpful in weariness of health professionals and policy makers should be aware of challenging, problems and occupational hazard in midwifery working setting. So, it is hoped that the strategy proposed in the current study could lead to improvements in midwife’s satisfaction and health care services.