Midwifery 40 (2016) 95–101

Contents lists available at ScienceDirect

Midwifery
journal homepage: www.elsevier.com/midw

Midwives' experiences of working conditions, perceptions

of professional role and attitudes towards mothers in Mozambique
Katja Adolphson, MD (Junior Doctor), Pia Axemo, MD, PhD (Consultant),
Ulf Högberg, MD, PhD (Senior Professor)n
Department of Women's and Children's Health, Uppsala University, SE-751 85 Uppsala, Sweden

art ic l e i nf o a b s t r a c t

Article history: Background: low- and middle-income countries still have a long way to go to reach the fifth Millennium
Received 18 November 2015 Development Goal of reducing maternal mortality. Mozambique has accomplished a reduction of ma-
Received in revised form ternal mortality since the 1990s, but still has among the highest in the world. A key strategy in reducing
4 June 2016
maternal mortality is to invest in midwifery.
Accepted 13 June 2016
Aim: the objective was to explore midwives’ perspectives of their working conditions, their professional
role, and perceptions of attitudes towards mothers in a low-resource setting.
Keywords: Setting: midwives in urban, suburban, village and remote areas; working in central, general and rural
Maternal mortality hospitals as well as health centres and health posts were interviewed in Maputo City, Maputo Province
Midwifery
and Gaza Province in Mozambique.
Professional role
Method: the study had a qualitative research design. Nine semi-structured interviews and one follow-up
Empathy
Developing countries interview were conducted and analysed with qualitative content analysis.
Mozambique Results: two main themes were found; commitment/devotion and lack of resources. All informants
described empathic care-giving, with deep engagement with the mothers and highly valued working in
teams. Lack of resources prevented the midwives from providing care and created frustration and feel-
ings of insufficiency.
Conclusions: the midwives perceptions were that they tried to provide empathic, responsive care on
their own within a weak health system which created many difficulties. The great potential the midwives
possess of providing quality care must be valued and nurtured for their competency to be used more
effectively.
& 2016 Elsevier Ltd. All rights reserved.

Introduction retention and deployment of health personnel, and working for

gender equality are also important parts of the process (UN, 2014;
The UN's Fifth Millenium Development Goal was to reduce Say et al., 2014; Requejo et al., 2015).
maternal mortality by three quarters, which, in many countries, Mozambique is one of the world's poorest countries, but has
had not been fulfilled by the proposed target date of the end of reported a rapid decrease in maternal deaths since the 1990s
2015 (UN, 2014). The process of forming the post-2015 agenda and coupled with an increase in the deployment of midwives (Van
the next set of sustainable development goals have now taken Lerberghe et al., 2014). The ratio of maternal mortality decreased
place, and a challenge is to give appropriate attention to sexual from 1300 per 100,000 in 1990 to 480 in 2013; but this is still
and reproductive rights and health (Haslegrave, 2014, https://sus among the higher numbers in the world. This rate might be af-
tainabledevelopment.un.org/?menu ¼1300). Giving women access fected by, although measures are taken to prevent it, by the low
to skilled birth-attendance, facility births, family planning, ma- level of skilled birth attendance and insufficient access to emer-
ternal health care with ante- and postnatal visits access to safe gency obstetric care. Fifty-four per cent of the women who give
abortion are issues of vital interest to these developments. A birth do not have access to a skilled birth attendant, by poorest
functioning system for referral along with a focus on training, quartile 32% and by richest quartile 90%, in 2011 (UNICEF STA-
TISTICS, 2016).
n The majority of maternal deaths occur during the intrapartum
Corresponding author.
E-mail addresses: [email protected] (K. Adolphson), period, making the focus on this particular period a key compo-
[email protected] (P. Axemo), [email protected] (U. Högberg). nent. The best and most cost-efficient strategy for first-level

http://dx.doi.org/10.1016/j.midw.2016.06.012
0266-6138/& 2016 Elsevier Ltd. All rights reserved.
96 K. Adolphson et al. / Midwifery 40 (2016) 95–101

intrapartum care isbirths in health centres, dominated by midwives, Method

but with other categories of personnel participating in the team
(Campbell et al., 2006). Midwives play a key role in global strategies The study followed a qualitative research design (Dahlgren
for the provision of maternal health care. Professional midwives have et al., 2004). Semi-structured interviews were chosen as the most
the ability to bring care closer to the woman, both physically and appropriate method to address midwives working experiences
socioculturally (ten Hoope-Bender et al., 2014), and to reduce several and their perceptions of mothers in a low-resource setting. The
risks of complications connected to giving birth that can lead to data were interpreted and discussed using an ethical framework of
mortality or severe morbidity such as severe blood loss and perineal the universal rights of childbearing women, the ICM definition of
trauma (Van Lerberghe et al., 2014). An analysis of 461 reviews of the the midwife, and the ICM code of ethics for midwives (ICM, 2008a,
effectiveness of practice shows that a majority of practices that are 2008b).
effective are in the midwife's repertoir (Renfrew et al., 2014), and
State of the World's Midwifery 2014 states that midwives can provide Settings
almost 90% of essential care for mothers and newborns (UNPFA et al.,
2014). A shift from a health system focused on finding pathologies to Data collection took place in four different types of environ-
one providing skilled care for all is a key strategy, and the midwives ments – urban, suburban, village and remote – in three southern
are integral to this element (Renfrew et al., 2014). The International provinces in Mozambique; in Maputo City, Maputo Province and
Confederation of Midwives (ICM) definition of the midwife and its Gaza Province. Maputo City is the capital of Mozambique having
code of ethics (ICM, 2008a) state, in relation to the midwife's pro- 1.7 million inhabitants mainly living in the urban environment and
fessionality and responsibility, that the midwife is an autonomous almost 90% of births are facility births. Maputo province consists of
provider of care taking responsibility for their own actions and both of urban/periurban and rural environments with hetero-
showing competency within midwifery, working respectfully to- genous living conditions and with, for example, a rate of 80% fa-
gether with midwives and other categories of staff, and who have cility births in the village of Manhica. Gaza Province consists
“responsibilities to themselves as persons of moral worth”. mainly of rural areas, has one of the country's highest poverty
Midwifery is crucial for improvements in the quality of ma- rates, and a facility birthrate of 60% (Table 1).
ternal health care, and comprises more than just one dimension.
There are the aspects of technical competencies and proficiency in Participants
the use of equipment, as well as combining inter-personal skills
with responsiveness, and having knowledge of the organisational Mozambique's equivalents to midwives are called maternal and
structure and its facilities for appropriate referral (ten Hoope- child health nurses, who each have received a different quantity
Bender et al., 2014). and quality of training. The most senior level has four years of
Midwives are important in providing person-centred care with training at university level, and the medium and basic levels have
high quality. The care midwives can provide should fit with the
two and one years, respectively, in health training centres. These
goals to encourage normal reproductive health, avoid over-
categories of personnel are hereafter referred to as midwives.
medicalisation of birth (Campbell et al., 2006), improve health
Midwives in different workplaces were purposively sampled
outcomes and empower women (ten Hoope-Bender et al., 2014).
with the help of midwife coordinators from the local health
However, a growing body of research and empirical information
ministries. In the remote area of Gaza Province, midwives were
reveals evidence of malpractice in delivery service, such as the
recruited with the snowball method.In Maputo Province the
disrespectful treatment and abuse of women who are birthing.
midwives were working in health centres and maternity care
Therefore, several statements have been made from influential
centres in a suburb of Maputo City, and in a rural hospital situated
organisations, such as WHO, FIGO and the White Ribbon Alliance,
in a village 80 km outside the city. In Maputo City the midwives
addressing the importance of improving the interpersonal quality
were working in a general hospital and a central hospital within
of care so as to be more responsive towards the needs and wishes
the city. In Gaza Province the midwives were working in health
of women. A charter regarding respectful maternity care – signed
posts and health centres in a remote area – one of the province's
by WHO, ICM and FIGO, among others – stating the universal
poorest and least populated.
rights of childbearing women and based on conventions and de-
The majority of the midwives were between 20 and 35 years
clarations of human rights was developed in 2011 (FIGO et al.,
old with 1–5 years of working experience. Two informants were
2015). These rights are; the “right to freedom from harm and ill
older (40–55 years) with ten and 40 years of working experience,
treatment, right to information and informed consent and respect
respectively. Most of the midwives had medium-level education
for choices and preferences, right to confidentiality and privacy,
and two had basic level (Table 2).
right to dignity and respect, right to equality and freedom from
discrimination and equitable care, right to timely health care and
the highest attainable level of health as well as right to liberty, Data collection
autonomy, self-determination and freedom from coercion.” This
statement fits well with the ICM philosophy and model of mid- Nine midwives were interviewed. One supplementary inter-
wifery care as well as the ICM international code of ethics for view was also performed with one of the midwives who gave
midwives (ICM, 2008a, 2008b). Midwifery is a groundstone in particularly reflective and open answers. Each interview lasted
process of accomplishing safe births and the challenges for mid- between 40 and 90 minutes. The interviews took place during the
wives are especially demanding in constrained settings. Hence, midwives’ working hours and mainly in private treatment rooms,
there are several further dimensions of their professional perfor-
Table 1
mance that should be placed in focus. The aim of this study was to
Population density, percentage facility birth and time of referral by setting.
explore midwives’ perspectives of their working conditions, their
professional role, and their attitudes towards mothers in a low- Urban Suburban Rural Remote
resource setting. By exploring these perspectives, more knowledge
2
is gained about the needs of midwives to optimise their function Population density per km 5100 2400 82 1–4
Facility births 90% 90% 80% 60%
in their professional role and how to most effectively ensure ful- Time to referral hospital by car o1 h o1 h 1,5 h 7h
filment of the human rights of mothers.
 K. Adolphson et al. / Midwifery 40 (2016) 95–101 97

however, staff sometimes interrupted by knocking on the door. interviews were analysed by two of the authors (KA, UH) and the
Semi-structured interviews were used for the data collection rest by one (KA). From the content analysis, conclusions could be
and were conducted by one of the authors (KA) with a translator. drawn about how the midwives experienced their working con-
The collection method enabled the data gathered from one inter- ditions, their role as a midwife and their view of the mothers.
view to be compared to another interview. An interview guide
with structured introduction questions and open-ended questions
was developed. After five interviews, the open-ended questions Findings
were revised, and several questions were replaced with case-
vignettes to stimulate further reflection upon working conditions. Two main themes became evident through the analysis of the
The midwives were asked how they worked with mothers and interviews after the discussion of the categories; “Commitment/
colleagues, about pride in their work, motivational factors and Devotion” and “Lack of Resources” (Table 4). There were cases
perceived obstacles in their work. They were also asked to tell where the lack of resources influenced the commitment/devotion.
about cases they found hard to manage and to make an analysis of Thus the categories overlapped in a few cases, but were sorted into
the underlying reasons for these. One part of the interview, which the Commitment/Devotion category.
has been excluded from this article, was related to a course they
had participated in 2013.
Commitment/devotion
The interviews were conducted with the consent of the Min-
istry of Health of Mozambique, with the Minister of Health's
Scope of practice
written approval. Approval was also sought from all local De-
When asked about their work and the mothers, the midwives
partments of Health in Gaza, Maputo City and Maputo Province,
expressed an empathic attitude towards the mothers and seemed
and a local Midwife Coordinator from each department accom-
to be willing to work hard for them. Due to factors they could not
panied the team to the health facilities. All participants were in-
affect or influence, they were often not able to help the mothers –
formed about the objectives of the study, that the interview would
something that created frustration and feelings of insufficiency.
be recorded but the data reported anonomously, that their parti-
The midwives thus described a devotion to their work and their
cipation was voluntary and that they could withdraw their parti-
mothers, and factors posing a threat towards their commitment.
cipation at any time. The participants gave their verbal consent
All midwives gave a description of their scope of practice,
before taking part in the interview.
ranging from antenatal care to births, post partum visits and
neonatal care. Midwives working in smaller health units had a
Analysis
broader scope of practice and midwives working in remote areas
reported engaging in care outside their own area of expertise. A
The content analysis was made as described by Graneheim and
wide scope of practice was reported and these were perceived as
Lundman by the principal investigator (KA) (Graneheim and
both as an asset in providing job satisfaction, but also as a source
Lundman, 2004). A memo was written summarising the main
of stress as a result of a lack of human resources.
perceptions of the interview and was reviewed by two authors
(UH, PA). The interviews were transcribed in English and every
Team work
interview was read through several times to obtain an overview.
To manage complex and emergency cases, well-functioning
One interview was considered as one unit of analysis. The content
teamwork was imperative. The midwives working in remote areas
of the interviews was divided into meaning units and condensed,
used extended teamwork, for example, using a mobile phone to
labelled with a code, and divided into categories and themes using
the software OpenCode (phmed.umu.se) (Table 3). Six of the 10
Table 4
Main themes and their categories.
Table 2
Description of the midwives interviewed. Education level; medium 2 years, basic Theme Categories included in theme
1 years. Years of working experience.
Commitment/devotion Feelings of having no influence on situation
Setting Urban Suburban Rural Remote Frustration
Scope of practice
Health facility Central hospital Health center Rural Health post Motivation
and health hospital Personal difficulties connected with work
center Teamwork
Number of 2 2 2 3 Pride in work
midwives Working for the mothers
Age of midwives 25–30 26–35 40–55 21–30
Working 2 1–5 7–33 1–1,5
experience Lack of resources Lack of or non-functioning equipment and material
Education level Medium Basic and Basic Medium Lack of human resources
medium Lack of or non-functioning referral pathways

Table 3
Examples of meaning units, condensation, code, category and theme.

Meaning unit Condensed meaning unit Code Category Theme

Within the difficulties, at the end you become very hopeful be- Hopeful at the end be- Commitment Motivation Commitment/
cause when the morning comes you see many babies deliv- cause you saved many Meaningful work Pride in work Devotion
ered, more than ten, and you say, “Ahhh, if it was not my efforts lives. Working for the
all of these people would not be alive.” mothers
Yes, they (ambulance on call) answer, but sometimes they don’t They answer but do not Sometimes ambulance Lack of or non-func- Lack of resources
respond. They answer, “Yes, I will come,” but they don’t appear. appear. does not appear tioning referral
98 K. Adolphson et al. / Midwifery 40 (2016) 95–101

obtain second opinions. to be supportive. Several talked about the importance of huma-
nised birth care.
“… I’m trying to get in contact with the medical doctor but
sometime it happens that he doesn’t answer the phone. I call “It was very sad, in terms of the mother … We said to the family
all the people … and I can call another physician that I know to that they could come visit any time. We arranged a room where
get some advice.” Midwife in remote area. she could be by herself, so she didn’t have to stay with others
who had babies. Whe sat by her side, counselling her.” Midwife
The midwife who was most content with her working en-
in urban area.
vironment was the one who worked closely together with a col-
league, even during the night. One midwife working in a remote area expressed a preventive
approach, carrying out health education to motivate people to
“We don’t miss much … Here we work two together, and that is
come to the hospital and understand pregnancy complications.
enough to work … At night we are two, we can decide.” Midwife
Her story also contained a sense of frustration over the difficulty of
in urban area.
changing societal attitudes and behaviours.
Pride in work “A 12-year-old we can’t deliver here … And the mothers of the
Factors that empowered the midwives were saving lives, giving girls don’t want them to be transferred, so we have to explain a
hope, helping people and having the sense that their work was lot to the mothers. This forces us to work a lot with these cases
meaningful. Their devotion was strengthened by sharing mothers’ … Always have to talk, talk, talk. We talk about the complica-
joy over their newborn babies and overcoming obstacles together tions … Everybody thinks that a maternity always gives life, but
with women. we talk about death.” Midwife in remote area.
“… after the mother has pushed out she says, “Thank you for
Frustration
supporting us, nurse,” and every time I feel more motivated, I
Working alone under difficult conditions, with a lack of re-
feel more enthusiastic.” Midwife in urban area.
sources and personnel, along with a weak referral system created
Pride in their work was enhanced when the midwives could much frustration.
alleviate labour pain, achieve a sense of calm and trust and resolve
complicated cases. The midwives were prepared to take brave “At night I am alone and there are many difficulties.” Midwife in
decisions. suburb.

“It was a child of only 14 years. That had been made pregnant In their descriptions of severe cases the midwives expressed
by her teacher. I knew how the girl felt, because she was cap- feelings of inadequacy and a wish to help but not being able to.
able of telling me everything … It was a beautiful birth, I was “We can see but we can do nothing to solve the problem.”
there talking with her about motherhood. And it was the first Midwife in suburb.
vacuum extraction I did in my life … I managed to save the
child, in reality it was two children there. Because for a 14-year- One midwife was thinking about changing occupations due to
old it's hard to give birth … It's a birth I am very proud of, really the difficult circumstances in her health centre.
proud.” Midwife in village
“The mother and her company were crying, and I didn’t know “If I wasn't a midwife I could find another job and be happy.”
what to do, if I should transfer. But I said no, I said we had to Midwife in suburb.
continue … I had power that I can solve this problem. I am able When something severe had happened, the informants de-
to solve this problem.” Midwife in remote area. scribed stress and sorrow afterwards, showed signs of adopting
Some expressed that they had the determination to become a guilt and sometimes blame. Although, at the same time, most also
midwife since childhood and several described the professional- stated that they knew they had done their best.
ism they achieved during midwifery training. They conveyed a “… and I can keep thinking why and why did I didn’t do
keen devotion while working alone with the little resources something at least to save the baby. But this, in that case, I did
available, continuing with steadfast commitment after the loss of a my level best.” Midwife in urban area.
fetus to be able to support women in similar situations. In severe
cases they were action-oriented and alert, doing everything pos- Factors that decreased motivation, such as the need for a higher
sible within their spectrum of action. salary, lack of possibility of promotions and further career oppor-
tunities, were raised by one midwife.
“But you always have to do things. Always keep doing some-
thing. But you don’t have a team, for example, in the peripheral “I can’t put them [her children] to continue studying further
areas you are alone.” Midwife in rural area education because of the wage which is too low.” Midwife in
“Here we have all types of situations. We have to be ready to do rural area.
everything.” Midwife in suburb.
Lack of resources
Empathy was perceived as the backbone of their service and
they often identified with the mothers.
Lack of or non-functioning equipment and material
“I feel all the difficulties women feel … In this moment of All informants reported extensive lack of equipment and ma-
screaming I can put myself in everything that is happening. terial, human resources and lack of or non-functioning referral.
Practically, really, it's like it was myself.” Midwife in village. Much equipment and material was non-functioning or missing
and delivery of equipment often took an unacceptably long time.
Working for the mothers In some remote health facilities, such a basic thing as access to
The midwives tried to secure responsiveness in their care running water or a well was missing, and the mothers had to bring
through showing empathy and adjusting the care to the women's their own water to the birth. Several midwives reported a lack of
needs. Many felt the mothers’ grief at the loss of a infant and tried resources as the main obstacle in their work.
 K. Adolphson et al. / Midwifery 40 (2016) 95–101 99

“The main obstacle that I have is the one I mentioned before. I “If it's a family that has a car I talk to the family, put her in the
would like to work in a health centre which has all conditions.” car, go with them and find the ambulance on the way.” Midwife
Midwife in suburb. in remote area.

In some cases, the midwives identified the lack of equipment or Delays of referral were in some cases judged as being the cause
material as a cause or potential cause of adverse outcomes. In most of adverse outcomes.
health centres, essential medicines were available at the time of
the visit. However, one midwife reported that magnesium sul- “Then we have to transfer. And the mother … and the baby
phate had been unavailable since the month before the interview. sometimes passed away on the way.” Midwife in remote area.
Intravenous antibiotics were missing or were not part of the
standard equipment in the remote areas.
Discussion
“If something like eclampsia occurs when I don’t have magne-
sium sulphate, there is not much I can do.” Midwife in remote The two themes found in the analysis of the interviews were
area. commitment/devotion and lack of resources. The midwives of
Mozambique are working under harsh conditions with an extreme
Lack of human resources lack of resources, ranging from referral pathways to lack of water.
All informants except one stated that a lack of human resources They were engaged in a wide scope of practice, also outside their
was a problem for them. Several had a very high workload and own competence area. All informants described empathic care-
there was no limit to the number of mothers they might have to giving and pride in their work, with deep engagement with the
treat per day. In the remote areas, the midwives were on call mothers and insight in being responsive towards the needs of the
around the clock. mothers. Frustration and feelings of insufficiency were caused by
not being able to fully help the mothers. Despite many factors that
“Overload of work. For example, if a delivering mother comes at
20.00 in the night and the birth is not very easy, I have to keep could lead to low motivation and despair, the midwives’ answers
her company all night and then I have to do my work during gave the impression that they were alert and ready to battle these
daytime and never have time to rest.” Midwife in remote area hardships.
When interpreted through the universal rights of childbearing
“The big problem is that I'm here alone … in the end of the day I
women (White Ribbon Alliance for Safe Motherhood, 2011), the
become very tired.” Midwife in urban area.
midwives intention seemed to be to provide care free from harm
In all health centres, except the central hospital, the midwives and with respect for the mother while giving her autonomy. The
worked alone during the night. Doctors or a senior midwife were midwives in remote areas tried to respect the right to information
only present in the health facility during the day. In the remote and informed consent, facing hindrances when not being under-
areas they worked alone during the daytime, too, or in the com- stood and not managing to establish trust in the community. The
pany of a health worker (agente de medicina general). Many of the right to timely health care and the highest level of attainable
health centres in the more populous areas seemed to be in urgent health could not be respected due to preventing factors – lack of
need of access to doctors or senior midwives during the night, referral pathways, human resources and material and equipment –
which, according to some midwives, could decrease the need for in the weak health system, which was a source of frustration
referral. among the midwives.
The woman- and newborn-centred aspects of quality of care
“I am alone most of the nighttime. Then I have to attend ten are not given much attention among policy-makers and is an area
cases alone. Even if the servant is there she cannot help me to
that needs much further attention (Van Lerberghe et al., 2014).
deliver babies because she doesn't know.” Midwife in suburb.
This important aspect of care seems to have been realised by the
interviewees, as many of them were already providing this kind of
Lack of or non-functioning referral
care despite the weak health system. A systematic review of 229
Informants in all settings except the urban area reported ex-
qualitative studies, investigating what women themselves want,
tensive problems with referral, with transfer of emergency cases
shows results just in line with the responsive care the midwives
being delayed. The midwives depended on a functioning transfer
tried to provide; that information and education is important and
system, as they had limited resources to help a woman who was
that care needs to be provided in a respectful way by empathic
experiencing serious complications.
health personnel (Renfrew et al., 2014). Other studies have found
“I have no amenities to solve because here we have no condi- that local opinion and experience of the health facility and bad
tion for surgeries. Then the mother's bleeding and then I can’t reputation for interpersonal relations are strong influences on
solve the problem, I have to wait for the ambulance.” Midwife in choice of birth facility (ten Hoope-Bender et al., 2014). Mozambi-
suburb. que is taking the first steps towards implementing these quality
aspects of care and has a great potential in its midwives. Many of
Some told of having to convince the drivers of the ambulances the informants had devised different solutions to providing quality
to handle cases as emergencies, indicating that cooperation at care in order to satisfy the mothers. If these midwives are given
referral was not always flawless. the right support in this process, they have the potential to ac-
“It depends on the driver. They are two, one is more flexible. celerate the development of the health system.
One is not. After the ambulance picks the mother I try to push Regarding the midwife's professional role and responsibility
him to treat it as an emergency.” Midwife in remote area. (ICM, 2008a, 2008b), the participants’ answers indicate that the
midwife in Mozambique has an independent and widespread
In the remote areas there were also reports of ambulances not professional role and they take responsibility for their actions and
coming and the doctor in the referral hospital responsible for the mothers, being engaged and alert. Showing respect toward
sending an ambulance did not always answer the call. The mid- themselves constitutes a greater challenge, however, because they
wives came up with flexible solutions to overcome such trans- are working in a low-resource system that prevents them from
portation obstacles. providing the care their moral code obliges them to.
100 K. Adolphson et al. / Midwifery 40 (2016) 95–101

Several dimensions of job satisfaction were expressed by the the perspectives of midwives working in an urbanenvironment,
Mozambican midwives. A survey in Senegal and Mali to develop a but their answers regarding working conditions, teamwork and
tool to measure satisfaction among health professionals in Sub- resources were consistent with earlier interviews.
saharan Africa identified eight dimensions influencing job sa-
tisfaction. These are continuing education, salary and benefits,
management style, work environment, tasks, workload, moral Conclusions
satisfaction, and job stability (Faye et al., 2013). Another study
shows that woman interaction and engaging in teamwork with The midwives provided empathic, responsive care on their
colleagues are also important, and several studies show that low own, without much support from the system. Lack of equipment,
salary can affect motivation and thus performance (Rowe et al., material and personnel and a defective referral system created
2005; Jarosova et al., 2015; Warmelink et al., 2015). In a study from frustration and kept them from providing care. By exploring these
rural Tanzania, an important factor for job satisfaction was tools perspectives, more knowledge is gained about the needs of mid-
and infrastructure to provide care, supporting the results of this
wives to optimise their function in their professional role and how
study that lack of resources and a functioning referral system
to most effectively ensure the human rights of mothers. The great
creates frustration and feelings of insufficiency and thus present
potential that the midwives possess of providing quality care
risks that affect the midwives’ job satisfaction (Mbaruku et al.,
needs to be valued and nurtured for their competency to be used
2014). Experiences from other countries show that investments in
more efficiently.
quality of care, such as coordination of referral systems from
peripheral units to hospitals and technical improvement, come
late in the process of improving maternal health care, and in many
countries these changes are not yet being implemented (Van Conflict of interest
Lerberghe et al., 2014).
An important finding is that very few participants described We have no conflict of interest according to the JJS guidelines.
having thoughts of changing work, even though all described an
exhausting lack of human resources. Deficiency of human re-
sources has been found to be a source of job dissatisfaction and Funding
often results in high staff turnover (Gerein et al., 2006); however,
this was not apparent in this study and could perhaps be due to The Swedish International Development Cooperation Agency
several informants having relatively less work experience or the (Sida) provided the stipend Minor Field Field Studies and Uppsala
encouraging factors of the job exceeding the discouraging ones. In Medical School funded the study.
the long run, not being able to provide the care that is thought
necessary due to lack of equipment, medication, personnel and a
functioning referral system should have an effect on the midwives’ Authors' contributions
motivation and might add to demoralisation and attrition (Gerein
et al., 2006; Gabel, 2013). All authors read and approved the final manuscript. KA had
primary responsibility for acquisition, analysis, and interpretation
Strengths and limitations of the data and writing the manuscript. UH and PA participated in
the study design and analysis, and in interpreting the study re-
The method matched the objective of the study well, there was sults, and revised the manuscript.
a great variation in terms of participants and contexts.The content
analysis took place with two authors involved in six interviews
and one author analysing three, which mirrors the credibility of Acknowledgements
the study.A limitation of the study is that it only takes in the
midwives’ perspectives of their care providing and does not bal-
AMREF Health Africa and Samo Manhica, coordinator of AMREF
ance the findings with the perspectives of the mothers. The study
Mozambique, facilitated the study.
results should be transferable to other environments with similar
resource conditions and could contribute when prioritising re-
sources in low-income settings. Transparent presentation of
method and description of context also contribute to transfer- Appendix A. Example of the interview questions
ability of the study (Graneheim and Lundman, 2004). Reflexivity
was achieved through making adjustments to the interview guide  Tell me about your current working situation.
in response to the participants’ circumstances, although this could  What do you think are the largest obstacles preventing you
affect the dependability of the study, as the method of data col- from performing your work in the best way possible?
lection was therefore not entirely consistent. The researchers were  Could you tell me about a case with fatal or nearfatal outcome?
aware that the research environment and the participants’ per- Why do you think this happened?
ceptions of the interviewer could affect the answers. In this case,
the strengths were that the interviewer came from outside the
context but was within the same age as the women, creating an Vignette Case 1
open interview environment. Potential weaknesses were that the
interviewer had less knowledge of the cultural context, language You are working during daytime in the maternity. You are de-
barriers, the risk of misinterpretation by the translator and at livering a woman of 22 years, it is her first child. It is after the
times distraction from other personnel. At the start of several of delivery of the baby, but before the placenta has arrived.
the interviews, the desirability effect was evident but ceased as the  Tell me how you would work with this patient in the
interview progressed. The number of interviews was not fixed maternity?
beforehand, and interviews were conducted until theoretical sa-  What can you do there to help her?
turation was achieved. The last interviews only contributed with  What in your working place makes it harder to help her?.
 K. Adolphson et al. / Midwifery 40 (2016) 95–101 101

You manage to release the placenta with controlled traction Midwives, ICM. Available at: 〈http://www.internationalmidwives.org/assets/
and give fundal massage and oxytocine. In spite of this, she is uploads/documents/CoreDocuments/CD2008_001%20V2014%20ENG%
20International%20Code%20of%20Ethics%20for%20Midwives.pdf〉 (accessed
bleeding a lot. After a while she starts looking very pale and 23.06.15.).
affected. International Confederation of Midwives, 2008b. Philosophy and Model of Mid-
 How do you work with your colleagues in such a situation? wifery Care, ICM. Available at: 〈http://www.internationalmidwives.org/assets/
 Have you had a similar case? Tell me! uploads/documents/CoreDocuments/CD2005_001%20V2014%20ENG%
 How did you feel and think in the situation? 20Philosophy%20and%20model%20of%20midwifery%20care.pdf〉 (accessed
23.06.15.).
 How did you feel and think afterwards? International Federation of Gynecology and Obstetrics; International Confederation
of Midwives; White Ribbon Alliance; International Pediatric Association; World
Health Organization, 2015. Mother–baby friendly birthing facilities. Interna-
You are doing all you can, but the mother keeps bleeding and
tional Journal of Gynaecology and Obstetrics 128, 95–99.
you realise you will have to transfer her. Jarosova, D., Gurkova, E., Palese, A., Godeas, G., Ziakova, K., Song, M.S., Lee, J., Cor-
 How does referral work in your maternity? deiro, J., Chan, S.W., Babiarczyk, B., Fras, M., Nedvedova, D., 2015. Job satisfac-
 How is the cooperation at referencia? tion and leaving intentions of midwives: analysis of a multinational cross-
sectional survey. Journal of Nursing Management.
Mbaruku, G.M., Larson, E., Kimweri, A., Kruk, M.E., 2014. What elements of the work
Imagine that when you think about the case afterwards, you environment are most responsible for health worker dissatisfaction in rural
realise that there were some things that were missing and some primary care clinics in Tanzania? Human Resources for Health 12, 38.
Renfrew, M.J., McFadden, A., Bastos, M.H., Campbell, J., Channon, A.A., Cheung, N.F.,
mistakes were made.
Silva, D.R., Downe, S., Kennedy, H.P., Malata, A., McCormick, F., Wick, L., De-
 How do you handle this? clercq, E., 2014. Midwifery and quality care: findings from a new evidence-
 What do you usually do when such things happen in your informed framework for maternal and newborn care. Lancet 384, 1129–1145.
working place? Requejo, J.H., Bryce, J., Barros, A.J., Berman, P., Bhutta, Z., Chopra, M., Daelmans, B.,
de Francisco, A., Lawn, J., Maliqi, B., Mason, E., Newby, H., Presern, C., Starrs, A.,
Victora, C.G., 2015. Countdown to 2015 and beyond: fulfilling the health agenda
for women and children. Lancet 385, 466–476.
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