Advertisement

Intentions to leave and actual turnover of community midwives in the Netherlands: A mixed method study exploring the reasons why

  • Esther I. Feijen-de Jong
    Correspondence
    Corresponding author at: Midwifery Academy Groningen, Dirk Huizingastraat 3-5, 9713 GL Groningen, The Netherlands.
    Affiliations
    Department of General Practice & Elderly Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands

    Amsterdam University Medical Center, Location VUmc, Department of Midwifery Science, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands

    Midwifery Academy Amsterdam Groningen, Inholland, Groningen, The Netherlands
    Search for articles by this author
  • Nicolette van der Voort-Pauw
    Affiliations
    Midwifery Academy Amsterdam Groningen, Inholland, Groningen, The Netherlands
    Search for articles by this author
  • Esther G. Nieuwschepen-Ensing
    Affiliations
    Martini Hospital Groningen, The Netherlands
    Search for articles by this author
  • Liesbeth Kool
    Affiliations
    Department of General Practice & Elderly Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands

    Amsterdam University Medical Center, Location VUmc, Department of Midwifery Science, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands

    Midwifery Academy Amsterdam Groningen, Inholland, Groningen, The Netherlands
    Search for articles by this author
Open AccessPublished:February 11, 2022DOI:https://doi.org/10.1016/j.wombi.2022.02.004

      Abstract

      Background

      In the Netherlands, the turnover of midwives of relatively young age is high. This is concerning since a lack of midwifery experience can negatively affect the quality of maternity care.

      Aim

      To study the rate and the reasons for intending to leave, and to explore the reasons for leaving midwifery jobs in the Netherlands.

      Methods

      We used a mixed-methods design including a quantitative survey (N = 726) followed by qualitative interviews (N = 17) with community midwives.

      Findings

      Almost one third of the respondents considered leaving the profession. The decision to actually leave the job was the result of a process in which midwives first tried to adapt to their working conditions, followed by feelings of frustration and finally feelings of decreased engagement with the work. The reasons for leaving midwifery practice are an accumulation of job demands, lack of social resources and family responsibilities.

      Discussion

      Compared to international figures, we found a lower rate of midwives who considered leaving the profession. This could be explained by the differences in the organisation of midwifery care and the relatively high job autonomy of midwives in the Netherlands. Nevertheless, changes must be made in terms of decreasing the demands of the job and creating more job resources.

      Conclusion

      Innovations in the organisational structure that focus on continuity of care for pregnant individuals, job satisfaction for midwives and building a sustainable workforce may result in an increase in the retention of midwives. These innovations would ensure that women and their babies receive the best care possible.

      Keywords

      Statement of significance
      Problem or issue
      In the Netherlands, the high turnover of midwives at a young age is concerning since a lack of midwifery experience can negatively affect the quality of maternity care.
      What is already known
      Intentions to leave the midwifery profession is a strong indicator of actually leaving the profession. International figures show high rates of intention to leave among midwives.
      What this paper adds
      One in three community midwives in the Netherlands considered leaving the job as a practising midwife. The reasons for leaving midwifery practice are an accumulation of job demands, lack of social resources and family responsibilities. We have added knowledge concerning the process of intending to leave to actually leaving the midwifery profession. Our findings show that midwives tried to make adjustments in their work and when these attempts failed, commitment to work and to the team decreased and ultimately led to leaving the job.

      1. Introduction

      In the Netherlands, the workforce of midwives consists of a relatively low number of experienced midwives, leading to an unbalanced workforce [
      • Kenens R.
      • Van der Velden L.
      • Vis E.
      • Batenburg R.
      Cijfers uit de registratie van verloskundigen, peiling 2018.
      ]. Sixty-one percent of Dutch midwives are under the age of 40, which differs from most other countries [
      • Kenens R.
      • Van der Velden L.
      • Vis E.
      • Batenburg R.
      Cijfers uit de registratie van verloskundigen, peiling 2018.
      ]. For instance, the median age (37 years of age) of the Dutch population of midwives differs from that in the United Kingdom (47 years of age) [
      • Hunter B.
      • Fenwick J.
      • Sidebotham M.
      • Henley J.
      Midwives in the United Kingdom: levels of burnout, depression, anxiety and stress and associated predictors.
      ]. In the United States, 58% of midwives are 40+ years old compared to 38% in the Netherlands. Seventy-two percent of midwives in the Netherlands work in the community, 28% in the hospital [
      • Kenens R.
      • Van der Velden L.
      • Vis E.
      • Batenburg R.
      Cijfers uit de registratie van verloskundigen, peiling 2018.
      ]. A good balance between experienced and less experienced midwives ensures a stable workforce and contributes to good practice [
      • Smith A.
      • Dixon A.L.
      • Page L.A.
      Health-care professionals’ views about safety in maternity services: a qualitative study.
      ]. Experienced midwives can share their accumulated expertise and knowledge to less experienced midwives [
      • Bäck L.
      • Hildingsson I.
      • Sjöqvist C.
      • Karlström A.
      Developing competence and confidence in midwifery-focus groups with Swedish midwives.
      ]. Low ratios of experienced midwives to less experienced midwives could negatively affect the delivery of safe care [
      • Smith A.
      • Dixon A.L.
      • Page L.A.
      Health-care professionals’ views about safety in maternity services: a qualitative study.
      ]. In order to maintain a balanced workforce, and taking into account that almost 90% of pregnant women in the Netherlands start care in midwifery care, it is highly important to gain insights into the number of midwives who intend to leave the midwifery profession, the underlying reasons for this intention to leave and the reasons for the actual turnover of midwives [
      • Leversidge A.
      Why midwives leave-revisited.
      ,
      • Warmelink J.C.
      • Wiegers T.A.
      • de Cock T.P.
      • Spelten E.R.
      • Hutton E.K.
      Career plans of primary care midwives in the Netherlands and their intentions to leave the current job.
      ].
      The intention to leave a profession refers to the probability of staying or leaving the profession. Although the intention to leave a job does not necessarily mean actual turnover, it is one of the most important indicators of leaving a profession [
      • Coomber B.
      • Barriball K.L.
      Impact of job satisfaction components on intent to leave and turnover for hospital-based nurses: a review of the research literature.
      ,
      • Takase M.
      A concept analysis of turnover intention: implications for nursing management.
      ]. Intention to leave is often triggered by negative reactions to organisational factors (e.g. organisational culture or interpersonal relations), work-related employment factors (e.g. workload or financial rewards), employee factors (e.g. demographic factors such as years of experience or the area of work) or external aspects of the job (e.g. family issues and the availability of other compatible jobs) [
      • Takase M.
      A concept analysis of turnover intention: implications for nursing management.
      ]. These negative reactions (or triggers) are often followed by negative psychological responses, such as frustration and withdrawal. Withdrawal has been found to manifest itself as absenteeism, avoidance behaviour and lowered performance [
      • Coomber B.
      • Barriball K.L.
      Impact of job satisfaction components on intent to leave and turnover for hospital-based nurses: a review of the research literature.
      ,
      • Takase M.
      A concept analysis of turnover intention: implications for nursing management.
      ].
      In relation to the number of midwives who have intentions of leaving the profession, it is known that 66.6% of UK (United Kingdom)-midwives, 42.8% of Australian midwives and 67.3% of Canadian midwives considered leaving the midwifery profession in the last 6 months before completing the questionnaire [
      • Hunter B.
      • Fenwick J.
      • Sidebotham M.
      • Henley J.
      Midwives in the United Kingdom: levels of burnout, depression, anxiety and stress and associated predictors.
      ,
      • Harvie K.
      • Sidebotham M.
      • Fenwick J.
      Australian midwives’ intentions to leave the profession and the reasons why.
      ,
      • Stoll K.
      • Gallagher J.
      A survey of burnout and intentions to leave the profession among western Canadian midwives.
      ]. The most commonly cited reasons for Canadian midwives’ intention to leave were the negative impact of an on-call schedule on personal life, followed by concerns about their mental and physical health [
      • Stoll K.
      • Gallagher J.
      A survey of burnout and intentions to leave the profession among western Canadian midwives.
      ]. Within the UK study, the most common reason for considering leaving the profession were shortages of staff at work, not being satisfied with the quality of care that they can give and being dissatisfied with working conditions and workload [
      • Hunter B.
      • Fenwick J.
      • Sidebotham M.
      • Henley J.
      Midwives in the United Kingdom: levels of burnout, depression, anxiety and stress and associated predictors.
      ]. In addition, within the group of UK midwives who considered leaving the midwifery profession, there were higher levels of burnout, depression, anxiety and stress in comparison to the midwives who did not consider it [
      • Hunter B.
      • Fenwick J.
      • Sidebotham M.
      • Henley J.
      Midwives in the United Kingdom: levels of burnout, depression, anxiety and stress and associated predictors.
      ].
      Turnover is often defined as the voluntary termination of membership to an organisation by an employee of that organisation [
      • Hunter B.
      • Fenwick J.
      • Sidebotham M.
      • Henley J.
      Midwives in the United Kingdom: levels of burnout, depression, anxiety and stress and associated predictors.
      ]. Common reasons for leaving are dissatisfaction due to a lack of time to deliver appropriate care, shortage of staff and a high workload [
      • Harvie K.
      • Sidebotham M.
      • Fenwick J.
      Australian midwives’ intentions to leave the profession and the reasons why.
      ]. Moreover, studies show that midwives feel demoralised, disempowered, and overwhelmed by the medicalisation of birth, as well as a lack of autonomy [
      • Hunter B.
      • Fenwick J.
      • Sidebotham M.
      • Henley J.
      Midwives in the United Kingdom: levels of burnout, depression, anxiety and stress and associated predictors.
      ,
      • Catling C.
      • Rossiter C.
      Midwifery workplace culture in Australia: a national survey of midwives.
      ,
      • Pezaro S.
      • Clyne W.
      • Turner A.
      • Fulton E.A.
      • Gerada C.
      ‘Midwives overboard!’ Inside their hearts are breaking, their makeup may be flaking but their smile still stays on.
      ].
      Despite this research on intentions to leave and the reasons for turnover, little is known regarding the reasons of community midwives in the Netherlands to leave the workforce. This study adds specific new knowledge and insights based on a maternity care system in which midwives work as autonomous medical professionals. This study focuses on elements such as the strong relation between the intention to leave and actual turnover and on the possibility that a midwife’s performance could already be different once they intend to leave.
      The aim of this study is to identify the rate and reasons of intention to leave and to explore the actual reasons for leaving the midwifery profession in the Netherlands. The following research questions will be answered: (1) What is the rate of intention to leave among community midwives? (2) What are the reasons for intending to leave among community midwives and do these reasons differ between newly qualified midwives and experienced midwives? (3) Why do community midwives really leave the profession?

      2. Participants, ethics and methods

      2.1 Design

      To answer our research question, we used a mixed method sequential explanatory design: quantitative data was enriched with in-depth information to gain broad knowledge. The study consists of two parts:
      • 1
        A quantitative survey study of a sample of practising community midwives in the Netherlands to identify the rate and reason for the intention to leave.
      • 2
        A qualitative study consisting of in-depth interviews with community midwives who left the midwifery profession.
      We used the results of part 1 to provide input for part 2.

      2.2 Theoretical framework

      We used the adjusted Job Demands and Resources model created by Hoonakker et al. [
      • Hoonakker P.
      • Carayon P.
      • Korunka C.
      Using the job-demands-resources model to predict turnover in the information technology workforce–general effects and gender differences.
      ] (Fig. 1) as theoretical framework. The decision to use the JD-R model as a theoretical framework is mainly related to its heuristic nature, as it has the potential to identify the demands and resources for a specific professional group, in this case midwives [
      • Schaufeli W.B.
      • Taris T.W.
      A critical review of the job demands-resources model: implications for improving work and health.
      ]. Within this model, the wellbeing of a professional is dependent on two concepts: job demands and job resources. Job demands are the physical, psychological, social, and organisational characteristics of a job. Job resources are the resources that help to achieve work goals or reduce the demands of the job, including receiving feedback, having task control, or having social support. Wellbeing itself is a combination of work engagement and exhaustion/burnout [
      • Hoonakker P.
      • Carayon P.
      • Korunka C.
      Using the job-demands-resources model to predict turnover in the information technology workforce–general effects and gender differences.
      ,
      • Schaufeli W.B.
      • Taris T.W.
      A critical review of the job demands-resources model: implications for improving work and health.
      ,
      • Bakker A.B.
      • Demerouti E.
      The job demands-resources model: state of the art.
      ]. Exhaustion/burnout can ultimately lead to withdrawal behaviour, intending to leave and, ultimately, to actual turnover, which is the focus of this study [
      • Hoonakker P.
      • Carayon P.
      • Korunka C.
      Using the job-demands-resources model to predict turnover in the information technology workforce–general effects and gender differences.
      ].
      Fig. 1
      Fig. 1The adjusted Job Demands and Resources model, including the possible outcomes of exhaustion and work engagement [
      • Hoonakker P.
      • Carayon P.
      • Korunka C.
      Using the job-demands-resources model to predict turnover in the information technology workforce–general effects and gender differences.
      ].

      2.3 PART 1: survey study

      In part 1, we conducted a cross-sectional study. We used three questions that were part of the ‘Dutch national wellbeing of midwives study’ [
      • Kool L.
      • Feijen-de Jong E.I.
      • Mastenbroek N.J.J.M.
      • Jaarsma A.D.C.
      Midwives’ Occupational Wellbeing and Its Determinants. A Cross-sectional Study Among Newly Qualified and Experienced Dutch Midwives.
      ], measuring the wellbeing of midwives in the Netherlands. The ‘Dutch national wellbeing of midwives study’ was conducted in 2019. This cross-sectional study was carried out among practising midwives in the Netherlands using a questionnaire that was constructed using validated scales [
      • Kool L.
      • Feijen-de Jong E.I.
      • Mastenbroek N.J.J.M.
      • Jaarsma A.D.C.
      Midwives’ Occupational Wellbeing and Its Determinants. A Cross-sectional Study Among Newly Qualified and Experienced Dutch Midwives.
      ]. The validated scales used were the Dutch versions of: (1) the Maslach Burnout Inventory, the UBOS-C (Utrecht Burnout Scale-clients) for professionals working with clients in social professions or health car [
      • Schaufeli W.B.
      • van Dierendonck D.
      UBOS. Utrechtse Burnout Schaal. Handleiding.
      ], the UWES (Utrecht Work Engagement Scale) [
      • Schaufeli W.B.
      • Bakker A.B.
      The Utrecht Work Engagement Scale (UWES). Test Manual.
      ], the QEEW 2.0 (Questionnaire on the Experience and Evaluation of Work) [
      • van Veldhoven M.
      • Meijman T.F.
      • Broersen J.
      • Fortuin R.J.
      Handleiding vragenlijst beleving en beoordeling van de arbeid (VBBA)(Manual Questionnaire Perception and Evaluation of the Work Situtation).
      ], the Psychological Capital Questionnaire (PCQ) [
      • Luthans F.
      • Avolio B.J.
      • Avey J.B.
      • Norman S.M.
      Positive psychological capital: measurement and relationship with performance and satisfaction.
      ], and the General Self-Efficacy Scale (GSE) [

      B. Teeuw, R. Schwarzer, M. Jerusalem. Dutch general self-efficacy scale. Retrieved November. 1994;22:2010.

      ]. Dependent variables in this study were burnout symptoms and work engagement. Independent variables were sociodemographic characteristics, task demands, resources at work, and personal resources.

      2.3.1 Study population

      Midwives in the Netherlands who work in community care were included. In Box 1 we have provided background information regarding the way community midwives work in the Netherlands. Midwives working only in an hospital, or education or research were excluded.
      Background information regarding the way community midwives work in the Netherlands.
      Midwifery in the Netherlands
      The professional education of midwives in the Netherlands consists of a four-year direct entry Bachelor of Science programme and gives access to registration in the so-called BIG-register of individual health care professionals of the Health Ministry, allowing license to practice [].
      According to the regulations of the Ministry of Education, the educational program entails 240 European Credits Transfer System (ECTS) on which 100 ECTS spend on placements (60 ECTS in community care settings). One ECTS stands for 25−30 h workload [

      Besluit opleidingseisen en deskundigheidsgebied verloskundige 2008. [Cited 2022 Jan 21] Available from: https://wetten.overheid.nl/BWBR0024254/2014-09-01.

      ].
      According to the national figures, 72% of the midwives work in a community-based setting, and 28% of the midwives work in a hospital-based setting [
      • Kenens R.
      • Van der Velden L.
      • Vis E.
      • Batenburg R.
      Cijfers uit de registratie van verloskundigen, peiling 2018.
      ]. A large proportion of midwives in the community work in independent practices, either as owners or as locums. Only a minority (4%) are employed at an independent practice [
      • Kenens R.
      • Van der Velden L.
      • Vis E.
      • Batenburg R.
      Cijfers uit de registratie van verloskundigen, peiling 2018.
      ]. Each midwifery practice offers 24/7 care. The default independent practice is set at 105 full care units. This means that a midwife takes care of the prenatal, natal and postnatal care of approximately 107 women annually [

      Beleidsregel verloskunde - BR/REG-20108. [Cited 2022 Jan 21]. Available from: https://puc.overheid.nl/nza/doc/PUC_642212_22/1/.

      ]. Community midwives are self-employed, which means they can decide how many clients to take on and how much time to spend with each client. This also means that the number of working hours is not restricted, as is the number of days off. Practice assistants can help the midwife with administrative and organizational tasks.
      Community midwives take care of women experiencing normal pregnancies and births and in postpartum periods. Women are referred to a hospital if risks of adverse foetal or maternal outcomes are high or if complications arise during pregnancy or childbirth. In the hospital, obstetricians, nurses and hospital midwives take over care [

      Midwifery in the Netherlands. [Cited 2022 Jan 21]. KNOV. Available from: https://www.europeanmidwives.com/upload/filemanager/content-galleries/members-map/knov.pdf.

      ].
      Every midwife in the Netherlands needs to renew her BIG-registration every five years []. The most important requirement for on-going registration is a minimum number of hours spent working as a midwife. Next to the BIG-register, 80% of midwives are registered in the quality register from the Royal Dutch Organisation of Midwives. A registered midwife has to show in a minimum of 200 h continuous education/training [

      Midwifery in the Netherlands. [Cited 2022 Jan 21]. KNOV. Available from: https://www.europeanmidwives.com/upload/filemanager/content-galleries/members-map/knov.pdf.

      ].
      Currently, there is a move towards closer collaboration between the different professional groups in ‘integrated care maternity care’. The finance system may change from separate payments for community and hospital-based maternity care to bundled payments for maternity care collaborations in which community midwifery care practices, maternity care organisations, ultrasound centres and hospitals participate. They will then be funded through the collaborative in which they work. This is a potential threat to the self-employed status of community midwives.

      2.3.2 Recruitment

      Recruitment of respondents took place between December 2018 and March 2019. The recruitment process consisted of two steps: in step one, a random sample of practising midwives (1301 of the total population of 3221 midwives in the Netherlands) registered in the database of the Netherlands Institute for Health Services Research (NIVEL) was used. This sample was supplemented with all Newly Qualified Midwives (< 3 years after graduation) that were available in the database. Midwives in the database had given permission to receive invitations to participate in research. A total of 60 letters were returned to sender, resulting in a NIVEL sample of N = 1241. Participant consent was obtained at the start of the questionnaire; participants could decide to stop filling in the questionnaire without explanation. Participant anonymity was assured as no name or other identifying data were collected.
      In step two, the Royal Dutch Organisation of Midwives – in which 84% of midwives are a member – sent an email with information about the survey to all members. A link and QR code leading to the survey was attached. The first question was about giving informed consent.

      2.3.3 Survey

      The questions used from the survey of the ‘Dutch national wellbeing of midwives study’ are presented in Fig. 2. Furthermore, demographic characteristics and workplace characteristics were collected. The intention to leave was measured using three questions ((1) Have you considered leaving the profession of midwifery in the past six months? [Yes/No], (2) What are the reasons you are considering leaving the profession? [nine predefined answers], and (3) Describe in your own words why you consider leaving the profession [see Fig. 2]).
      Fig. 2
      Fig. 2Included questions regarding Dutch midwives’ wellbeing, a national study [
      • Kool L.
      • Feijen-de Jong E.I.
      • Mastenbroek N.J.J.M.
      • Jaarsma A.D.C.
      Midwives’ Occupational Wellbeing and Its Determinants. A Cross-sectional Study Among Newly Qualified and Experienced Dutch Midwives.
      ].

      2.3.4 Analysis

      Descriptions of background and workplace variables were calculated and summarised. Next, we performed a descriptive analysis regarding the intention to leave using SPSS version 25.0. Also, we performed chi-square tests to compare the intentions and reasons to potentially leave between Newly Qualified Midwives and Experienced Midwives. The level of significance was set at p < .05. Thereafter, we analysed the open-ended question in the survey. We read and reread the comments of respondents and initially coded the fragments independently from each other, then created categories. Next, we organised the categories into themes [
      • Green J.
      • Thorogood N.
      Qualitative Methods for Health Research.
      ]. These themes were then ordered using the applied Job Demand and Resources model [
      • Schaufeli W.B.
      Applying the job demands-resources model.
      ]. ATLAS.ti version 8.4 supported the qualitative analysis.

      2.4 PART 2: interview study

      In part two, we performed 20 in-depth interviews with midwives across the Netherlands. We had to exclude three interviews from these 20 interviews because these midwives worked exclusively in hospital-based care. The included interviews lasted 45 min on average, three were conducted on-site, and 14 online.

      2.4.1 Recruitment

      Participants were recruited through Facebook pages for midwives, through the website of the Royal Dutch Organisation of Midwives, through snowball sampling, and through the researchers' networks. Potential participants were able to send an email to receive additional information about the study. They were invited for an interview after they agreed to participate. Eligible participants were community midwives who had stopped working in the midwifery profession within the past five years. We assumed that they would remember clearly what it was like to quit their jobs.

      2.4.2 Data collection

      Data collection took place in March 2021 and April 2021. Prior to the interviews, a topic list was developed by two researchers. The topics were derived from the document analysis of the open-ended survey questions, a literature study, and the JD-R model. This topic list was tested twice on midwives who were not included in the target population. As a result, the order of topics was adjusted. The interviews were conducted by two researchers, respectively a researcher and a master student/midwife. All interviews were discussed by the entire research team, which allowed us to reflect on the possible influence that the researchers had on the interview process. Depending on the participant's preference, the interview could take place online or on-site. Online interviews were held via digital platforms (Microsoft Teams or Zoom). After 15 interviews, we did not derive new information. However, we decided to carry on with the five interviews which were already planned. All interviews were recorded (by audio and video) and notes were taken. After approximately three interviews, the findings were discussed among the researchers and the topic list was then adjusted slightly. After each interview, a summary was written. All interviews were conducted in Dutch and transcribed verbatim. The transcripts and summaries were member-checked by each participant. No adjustments were needed.

      2.4.3 Analysis

      We analysed the transcripts of the interviews by moving from inductive coding to a framework analysis. This included the following steps: (1) We developed a coding scheme; (2) The open codes were placed into categories by two researchers; (3) The applied JDR model by Schaufeli et al. [
      • Schaufeli W.B.
      Applying the job demands-resources model.
      ] was used to order the developed categories. We then conducted a second analysis using a narrative analysis. In each transcript, we looked for the turning points that led to the decision to leave work as a practicing midwife. These turning points were collected in a separate document per participant so that we could properly examine whether there was a potential accumulation of reasons for the participant [
      • Green J.
      • Thorogood N.
      Qualitative Methods for Health Research.
      ]. MaXQDA, version 2020.4 was used to analyse this data.

      3. Results

      In the results, we show the background characteristics of the respondents (survey study) and the participants (interview study). In Table 2, the quantitative findings from the survey related to the rate of midwives with intentions to leave and which reasons they had for consideration to leave are shown. Next, the qualitative findings from the analyses of the open-ended questions of the survey and of the interviews with community midwives are described and presented in Fig. 3. Finally, the outcomes of the narrative analyses are shown.

      3.1 Background characteristics of survey respondents and interview participants

      In part 1, a total of 1078 surveys were completed. We had to exclude 183 surveys because they had multiple missing variables [
      • Kool L.
      • Feijen-de Jong E.I.
      • Mastenbroek N.J.J.M.
      • Jaarsma A.D.C.
      Midwives’ Occupational Wellbeing and Its Determinants. A Cross-sectional Study Among Newly Qualified and Experienced Dutch Midwives.
      ]. We also excluded 169 hospital-based midwives. Our final sample consisted of 726 respondents. In part two, we performed 20 in-depth interviews with midwives across the Netherlands. We had to exclude three interviews because the midwives had worked exclusively in hospital-based care. In Table 1, the background characteristics for both the respondents (in part 1) and the participants (in part 2) are presented. In the text below, the word ‘respondent’ refers to midwives who completed the survey, the word ‘participant’ refers to the midwives who were interviewed.
      Table 1Descriptives of background characteristics and workplace characteristics of survey respondents (N = 726) and interview participants (N = 17).
      Background characteristicsSurvey respondentsInterview participantsCommunity midwives in the Netherlands
      Ref. = Reference categoryN = 726 (%)N = 17 (%)N = 2429 (%)
      Kenens et al. [1].
      Age
      ≤29203 (28.0)1 (5.9)694 (28.6)
      30–39 (ref.)241 (33.2)5 (29.4)833 (34.3)
      40–49146 (20.1)2 (11.8)476 (19.9)
      50–59101 (13.9)5 (29.4)313 (12.9)
      ≥6035 (4.8)4 (23.5)114 (4.7)
      Marital status
      Married/cohabiting with children (ref.)608 (83.7)14 (82.4)
      Alone/separated71 (9.8)3 (17.6)
      Living with own parents47 (6.5)
      Children
      No (ref.)313 (43.1)3 (17.6)
      Yes413 (56.9)13 (76.5)
      Missing1 (5.9)
      Workplace characteristics
      Workplace
      Community care (ref.)712 (98.1)14 (82.4)2429
      Combination of community and hospital care14 (1.9)3 (17.6)Unknown
      Type of employment
      Employed (ref.)65 (9.0)5 (29.4)278 (12.6)
      Owner of a midwifery care practice466 (64.2)7 (41.2)1444 (62.6)
      Locum295 (26.9)5 (29.4)583 (25.3)
      Years of experience
      3–10 years (ref.)167 (23.0)5 (29.4)
      0–3 years168 (23.1)1 (5.9)
      >10 years391 (53.9)11 (64.7)
      Type of practice
      Urban (ref.)309 (42.6)6 (35.3)
      Rural187 (25.8)4 (23.5)
      Combination of urban and rural230 (31.7)7 (41.2)
      a Kenens et al. [
      • Kenens R.
      • Van der Velden L.
      • Vis E.
      • Batenburg R.
      Cijfers uit de registratie van verloskundigen, peiling 2018.
      ].
      Table 2Intention to leave the profession, reasons for consideration to leave (N = 726), and the combinations of reasons to leave. Split into the total group of community midwives, experienced midwives (EM, n = 558) and newly qualified midwives (NQM, n = 168).
      Total N (%)EM n (%)NQM n (%)X2 (p)
      EM compared to NQM.
      726 (100)558 (76.9)168 (23.1)
      Intention to leave midwifery practice
      Yes245 (33.7)194 (34.7)51 (30.4)1.12 (0.29)
      Reasons for consideration to leave (n = 245)
      Dissatisfaction with organisation of maternity care103 (14.2)92 (16.5)11 (6.5)10.48 (0.00)
      Statistically Significant.
      Family commitments88 (12.0)77 (13.7)11 (6.5)6.63 (0.01)
      Statistically Significant.
      Health62 (8.4)54 (9.7)8 (4.8)3.99 (0.05)
      Dissatisfaction with own organisation55 (7.6)48 (8.6)7 (4.2)3.63 (0.06)
      Dissatisfaction with my role as a midwife44 (6.1)35 (6.3)9 (5.4)0.19 (0.06)
      Dissatisfaction with my pay33 (4.5)24 (4.3)9 (5.4)0.33 (0.57)
      Planned change in career23 (3.2)18 (3.2)5 (3.0)0.03 (0.87)
      Planned retirement11 (1.5)11 (2.0)0 (0)1.10 (0.30)
      Planned location move9 (1.2)5 (0.9)4 (2.4)0.33 (0.13)
      Other95 (13.1)64 (11.5)31 (18.5)5.54 (0.02)
      Statistically Significant.
      Combinations of reasons to leave (n = 245)
      Family commitments + Dissatisfaction with organisation of maternity care44
      Health + Dissatisfaction with organisation of maternity care25
      Dissatisfaction with organization of maternity care + Dissatisfaction with own organization24
      Dissatisfaction with own organisation + Family commitments21
      Family commitments + Health + Dissatisfaction with organisation of maternity care15
      EM = Experienced midwives (>3 years working experience), NQM is Newly Qualified Midwives (<3 years of working experience).
      a EM compared to NQM.
      b Statistically Significant.
      Most midwives (61.2%) who responded to the survey were younger than 40 years of age, were parents/guardians with their children living at home (56.9%), were married, or lived together with their partner (83.7%) (Table 1). Of the interview participants, 35.5% were younger than 40 years of age. Most of them were parents/guardians (76.5%) and were living with a partner (82.4%). Regarding workplace characteristics, most midwives worked as community midwives (respondents: 98.1%; participants 82.4%), were owners of a midwifery care practice (respondents: 64.2%; participants: 41.2%), had more than 10 years of experience in midwifery care (respondents: 53.9%; participants: 64.7%) and had an urban-based practice (respondents: 42.6%; participants: 35.3%). Compared to the population of midwives in the Netherlands, our sample respondents had a similar age distribution and similar figures in employment status (self-employed and locum midwives) [
      • Kenens R.
      • Van der Velden L.
      • Vis E.
      • Batenburg R.
      Cijfers uit de registratie van verloskundigen, peiling 2018.
      ].

      3.2 Rate of intention to leave (survey study)

      One third (33.7%) of the respondents did consider leaving the profession (see Table 2), with no significant differences between newly qualified midwives and experienced midwives. The main reasons mentioned were: ‘dissatisfaction with organisation of midwifery care’, ‘family-commitments’ and ‘health’. We found significant differences between newly qualified midwives and experienced midwives regarding reasons for potentially leaving. Experienced midwives were significantly more likely to report that they were potentially planning to leave because they were dissatisfied with the organisation of maternity care. In addition, they significantly more often reported family commitments related to reasons for consideration to leave as compared to Newly Qualified Midwives.

      3.3 Reasons for consideration of leaving the profession (open-ended questions survey)

      In response to the open question, 91 respondents left a comment. These comments varied in length, from single-word comments to comments containing a few sentences. The code tree of this part of the study is presented in Fig. 3. This figure also shows the results of the in-depth interviews.
      Fig. 3
      Fig. 3Code tree including themes and categories of the intention to leave and reasons to leave; analysis of the open-ended survey question (N = 91), and the in-depth interviews (N = 17), thickness of the lines is related to the number of codes assigned.
      Several qualitative demands (work-home conflict, being on-call 24/7 and traumatic events) and one quantitative demand (work overload) were mentioned. The amount of administrative and organisational tasks was also mentioned as an important reason for the intention to leave the job. Respondents described a lack of job resources as reason for their intention to leave the profession. Several social resources were perceived as deficient, such as the involvement of partners, collaboration problems, support from colleagues and not feeling recognised as a professional midwife. Discrepancies between their professional values and actual practice were attributed to as a lack of organisational resources, as well as dissatisfaction with pay and employment status. Lack of developmental resources consisted of both the perceived lack of career opportunities and a lack of learning resources. The category of responsibilities was added to the original code structure. The respondents described the responsibilities they face in their job as demanding.

      3.4 Reasons for leaving (interview study)

      Fig. 3 shows the code tree of the themes and categories related to the reasons for leaving the profession. This figure shows that the reasons for the intention to leave and the reasons for ultimately leaving the job are very similar. Regarding the intention to leave (survey study), one category emerged that was unique: responsibilities (Qualitative job demand). The interviews revealed five unique categories: unpleasant team atmosphere (lack of social resource), lack of challenges, concerns about autonomy (lack of work resources), and lower commitment and lower performance (outcomes).

      3.4.1 Job demands

      The job demands mentioned were reasons related to qualitative (emotional and mental demands), quantitative (workload) and organisational aspects of their work.

      3.4.1.1 Qualitative demands

      Participants indicated that it was difficult to balance their work and personal life, which was reflected in the difficulties with planning their work and personal time. The perception that they did not have enough time and attention for their own children and the feeling of being less involved in organisational tasks within the practice led to work-life conflicts.I thought it was really difficult when, after a night shift, my daughter wasn’t at day care and I had to look after a baby. I couldn’t sleep and I also had to rush to my father to care for him, no sleep, as I said… and then the additional management tasks. If a shift was quiet, I would complete those as well during my shift. So I went to my manager at some point and said: I simply cannot handle it any more like this. (P14)
      Being on-call and working in community care with shifts of 24 h or more were reasons for participants to quit. The burden of availability, irregular working hours (never knowing when you need to work) and having 24/7 shifts were reasons for leaving in the long run. Some older participants particularly found it difficult working night shifts. They indicated that they needed more time to recover from the hours they worked at night.At one point, the night shifts were causing me so much stress that I was suffering from stomach ache two days in advance. Eh, so almost all week I would have this sort of brick in my stomach, because I had to do another night shift… how was I going to do this? After the night shift, I then had to do home visits for 12 hours on end, I don’t know, just going on and on for 24 hours… (P06)
      The life events were related to events in a participant’s personal life that interfered with their work as a midwife. For instance, a pregnancy-related life event was making it hard for a participant to work with pregnant women. Traumatic events during shifts, such as the resuscitation of newborns and death of newborns, affected their work. One midwife said that the impact of this event affected her self-confidence. She doubted whether she could handle the enormous responsibility of working as a midwife.

      3.4.1.2 Quantitative demands

      Work overload was mentioned as a quantitative job demand related to leaving the profession. Participants stated that they were overloaded during their shifts, i.e. making home visits, supporting home births and receiving a high level of phone calls affected their wellbeing.So, during your shift, these are all things that you get asked to do: Can you arrange this, can you do that, can you, this lady feels, eh, less movement, but my consultations are running really late, can you go and have a look at her? (P03)

      3.4.1.3 Organisational demands

      Participants mentioned two different organisational demands: setting up partnerships, and the amount of administrative and organisational tasks. Setting up partnerships refers to the efforts it took to agree with colleagues about work procedures and collaboration within the practice. Building up an organised practice took time and effort, to reach consensus about work procedures. Furthermore, participants felt that the time spent on administrative and organisational tasks had increased over the years. Increasing tasks at the organisational level, such as regional meetings, meetings with insurance companies and financial matters of the practice were perceived as overshadowing their work. They experienced this part of their work as interfering with the more satisfying aspects of the profession; working with pregnant individuals.And then there were all these new things and at one point I thought, I just don’t want to do this anymore. I thought, I don’t feel like changing anymore, it is already costing me so much energy. I am not going to spend time reading up on care standards and… I don’t want this anymore, I don’t want any more changes, I no longer had the energy to change. (P04)

      3.4.2 Lack of job resources

      Job resources relate to social, work, organisational and developmental resources. During the interviews, a lack of job resources was perceived as a deficiency.

      3.4.2.1 Lack of social resources

      Participants perceived a lack of back-up from colleagues in their team, an unpleasant team atmosphere and a lack of professional recognition. They felt dissatisfied in terms of collaboration with colleagues. This related to the problems of collaboration between the team of midwives in community care practices and to collaboration problems between community care and hospital care.
      Regarding the lack of support from colleagues in organising their practice, participants experienced a lack of engagement with colleagues about innovations or adjustments they needed for their own wellbeing and health, for example. This lack of commitment led to feelings of withdrawal.Just be nice to each other for once… we are all doing 24-hour or 48-hour shifts… Let’s have a good look at this situation together: Is this healthy? Isn’t it time to make a change? Not as in, yes, this is how we do it because that’s how we have been doing it for years…, but I couldn’t really identify with the group of midwives around me. (P14)
      For less experienced midwives, the lack of support from fellow midwives and the lack of being able to consult with colleagues during their shift was one of the reasons for leaving the job.What I was missing a bit was a sort of general safety, or maybe more of a culture in which, when you have just finished your studies, you are more supported by others, or it is normal to discuss cases and things. (P17)
      Some participants perceived hierarchical relationships in the collaboration between community and hospital-based midwifery care. They also felt a lack of professional recognition for their position as a midwife.I really want to work together, but only on an equal footing and everyone on their own, everyone as an expert in their own field. I am not going to tell a gynaecologist to do a caesarean, like this and this lady should be lying like that, I don’t know. That is not my area of expertise. So, I don’t want it the other way around either. And if that had happened but if we still would have had, this mutual respect between us, I would still have been there, yes. (P11)

      3.4.2.2 Lack of work resources

      A lack of work resources was mentioned as a reason for leaving the midwifery profession. This included the following: changing client demands, a lack of challenging tasks and concerns about the autonomy of midwives.
      Participants perceived changes in the working context which related to a change of the needs of clients over the years. According to the participants, clients wished to have more pain relief during their births, consequently leading to more referrals for secondary care. Community midwives could therefore support fewer women during home births. They felt that they lost their clients halfway through the birthing process.Another thing is the clients themselves… I am a very physiological thinker and to see that someone has a baby whose position has been measured with an ultrasound and then the baby turns out to be slightly bigger than expected. Then she goes to see the gynaecologist who decides to induce labour at 38 weeks. Then you’ll have a baby weighing 3,500 grams, which is perfectly normal, but is struggling to come out… And then the client says they’re happy they went to the hospital. (P08)
      Participants also felt that their jobs had become less challenging over the years. The more experienced they became as a midwife, the fewer challenges they met in their work. Some midwives mentioned their own need for more challenging work.
      Participants expressed concerns about their autonomy. They felt that their autonomy as midwives had changed over the years. National debates about integrated midwifery care, integrated funding of maternity care and changes in the organisation of maternity care affected their autonomous decision-making and practice in community care. These developments contributed to a perceived greater dependence on obstetricians and hospital midwives, resulting in a loss of job autonomy.At the beginning, we still had a hospital in [city] with old gynaecologists and they said, I don’t need to know everything you do, but I trust it will go well, and to be honest it sometimes scares me, but you can always call when something happens.… Then you just knew, okay, I’ll send this lady to them, it’ll be okay. And now everyone is interfering with everyone. (P11)

      3.4.2.3 Lack of organisational resources

      A lack of organisational resources was seen in discrepancies in values, unfair pay, and dissatisfaction with their employment status. Participants mentioned discrepancies between their own professional values and working in practice. They initially worked towards empowering women during childbirth and supported them to cope with pain. The discrepancy between these values and their work in reality had an impact on their job satisfaction.I was part of the workgroup on waters breaking without labour starting and was thinking, but wait, we are talking about primary care and why is maternity care here and why is the paediatrician here? Why are we even creating these multidisciplinary guidelines? … I don’t like this, because then you end up with compromises in your own work, created by someone who doesn’t even do this work. (P11)
      Participants perceived their payment as unfair over the years as due to a lack of acknowledgement of their years of experience in terms of financial rewards.… and then there are these young girls who have a very decent income and I found that really unfair at one point. (P06)
      Employment status was perceived as another issue leading to dissatisfaction with the job. Some participants did not opt for the self-employed status as new midwife but found that they had to when they wanted to work in community care. Working as a locum was more challenging than they had expected. Financial matters, temporary work, and dependence on their colleagues for getting more shifts as a locum were perceived as tough and dissatisfying.

      3.4.2.4 Lack of developmental resources

      A lack of development resources – such as career opportunities and available learning opportunities – was stated by community midwives as a reason for leaving the job. Some midwives indicated that they had to leave the profession if they wanted to gain further professional development.And somewhere there’s still this dream of mine and then I think, the experience I am gaining now, the worldwide systems and structures, if I could bring some of that back to midwifery, that’s what I would really like… (P17)

      3.4.3 Lack of personal resources

      Participants indicated that their own personal characteristics were also a reason for leaving the job. They perceived a lack of flexibility and feelings of insecurity as a hindrance in terms of providing care for women. One participant described that she considered herself as unable to cope with the changes in the organisation of midwifery care. Other participants mentioned their own uncertainty and doubts about making decisions in their work. This day-to-day feeling of uncertainty ultimately led to them to becoming unhappy in their jobs.I am thinking of an example, but I can’t find it, but I had this idea that my colleagues were more capable than I was. (P02)

      3.4.4 Outcomes

      Midwives really do quit when they see no way out, when they no longer feel any possibility of adjusting work conditions, either in reducing job demands or increasing job resources.And I always had the feeling, in those 20 years that we knew each other, that we were together and that we could solve it together. And for the first time I discovered that it wasn’t about solving things together… and in the end I left the partnership. (P06)
      Participants perceived changes in their performance, their work employability, and their commitment in the period before quitting their job. They felt less involved with the women they cared for and with their team. Moreover, they felt less engaged with changes in the organisation. The realisation of these feelings led some of them to ultimately make the decision to leave midwifery practice. Other participants were forced to leave midwifery due to a progressive illness or due to physical and/or psychological constraints developed because of their work. Personal life events were also mentioned as part of the decision for leaving the midwifery profession.I can’t muster up the empathy anymore. I think that, yes, maybe it had to do with grief. That I was more focussed on myself or something, not intentionally, but… (P02)

      3.5 Outcomes of the narrative analyses

      Participants perceived the final decision to leave midwifery practice as a process over time. They mentioned, among various other reasons, the fact that they were unable to change their job circumstances as a reason for deciding to leave the profession. A variety of factors, such as different job demands and a perceived lack of job resources sometimes combined with a lack of personal resources, contributed to leaving the profession. For example, the combination of the problems of the long shifts, the interdependence of the business partners (in this case, fellow midwives) in the midwifery practice, the changing demands of the clients and, at the same time, caring for their own families all contributed to their final decision to leave their jobs.I already knew I wasn’t going to do this forever. And I noticed the balance shifting more and more. In the beginning, the work energised me, and towards the end, it only depleted my energy. And then I really had a bit of a burnout, after that move. And even before that, I already thought things weren’t going very well. That was when I wanted to quit for a while… (P08)

      4. Discussion

      This mixed methods study of midwives’ intentions and reasons for leaving the midwifery profession in the Netherlands reveals that one third (33.7%) of midwives considered leaving the profession. Split into newly qualified midwives and experienced midwives, we have revealed almost the same figures. Dissatisfaction with the organisation of midwifery care and family commitments were the main reasons for their intentions to leave the job. Reasons for actually leaving the job comprised an accumulation of qualitative and organisational demands combined with a lack of work resources. Conflicts between work and home life, problems with the length of shifts and on-call shifts, a lack of commitment within the team, a lack of social support from colleagues and a lack of work resources led them to leave the profession. Illness or physical limitations and the inability to change working conditions were also reasons for leaving the job as a midwife.
      Compared to international studies, it is remarkable that our findings indicate that fewer midwives intend to leave their jobs. Other studies reported rates ranging between 40% and 60%, whereas we found a rate of 34% [
      • Hunter B.
      • Fenwick J.
      • Sidebotham M.
      • Henley J.
      Midwives in the United Kingdom: levels of burnout, depression, anxiety and stress and associated predictors.
      ,
      • Harvie K.
      • Sidebotham M.
      • Fenwick J.
      Australian midwives’ intentions to leave the profession and the reasons why.
      ,
      • Stoll K.
      • Gallagher J.
      A survey of burnout and intentions to leave the profession among western Canadian midwives.
      ]. This difference might be explained by the different work context of Dutch midwives. Previous research shows that working as an autonomous, self-employed midwife protects them from burnout symptoms [
      • Suleiman-Martos N.
      • Albendín-García L.
      • Gómez-Urquiza J.L.
      • et al.
      Prevalence and predictors of burnout in midwives: a systematic review and meta-analysis.
      ], and is associated with high work engagement [
      • Kool L.
      • Feijen-de Jong E.I.
      • Mastenbroek N.J.J.M.
      • Jaarsma A.D.C.
      Midwives’ Occupational Wellbeing and Its Determinants. A Cross-sectional Study Among Newly Qualified and Experienced Dutch Midwives.
      ]. Since most midwives in the Netherlands (about 66%) are self-employed in the community [
      • Kenens R.
      • Van der Velden L.
      • Vis E.
      • Batenburg R.
      Cijfers uit de registratie van verloskundigen, peiling 2018.
      ], these working conditions might therefore be a reason for a substantial group of midwives to stay.
      The process of moving from the intention to leave to actually leaving the job seems, in our findings, to be the result of a process in which midwives first try to adapt to their working conditions, followed by feelings of frustration over the lack of opportunities to change their working conditions. Finally, they feel less engaged in their work. This process of decreasing engagement in their work is consistent with previous research findings: less engagement led to withdrawal behaviour and decreased performance [
      • Takase M.
      A concept analysis of turnover intention: implications for nursing management.
      ,
      • Kivimäki M.
      • Vanhala A.
      • Pentti J.
      • et al.
      Team climate, intention to leave and turnover among hospital employees: prospective cohort study.
      ]. Potentially, this process may indirectly affect the quality of care that midwives provide.
      Community midwives mentioned having problems in dealing with the changing demands of clients, which affect midwives’ work resources. In the Netherlands, women's demand for pain medication during childbirth often leads to an obligatory referral to the hospital, which results in the transfer of the responsibility for the care to mother and child to the hospital-based midwife or gynaecologist. These referrals lead to discontinuity of care, frustrating midwives in the community. From the literature, it is known that continuity of care is important for midwives if they are to intend on staying in midwifery [
      • Bloxsome D.
      • Ireson D.
      • Doleman G.
      • Bayes S.
      Factors associated with midwives’ job satisfaction and intention to stay in the profession: an integrative review.
      ]. In the Netherlands, the professional scope of midwives is limited to physiological pregnancies, births, and postpartum periods, with a strict separation between primary and secondary care including strictly defined guidelines regarding referrals. Thus, the changing client demands combined with the Dutch healthcare system and its strict boundaries lead to discontinuity of care, also leading to midwives’ dissatisfaction with their work.
      Another important finding was the conflict between work-life balance of community midwives in the Netherlands. This finding is consistent with a study on Canadian midwives, who felt the impact of their work conflicting with their personal lives, not the other way around [
      • HakemZadeh F.
      • Neiterman E.
      • Chowhan J.
      • et al.
      Work-life interface and intention to stay in the midwifery profession among pre-and post-clinical placement students in Canada.
      ]. In addition, being on-call and long working hours disrupt family life and cause stress and anxiety in midwives [
      • Cramer E.
      • Hunter B.
      Relationships between working conditions and emotional wellbeing in midwives.
      ], thereby reducing their wellbeing [
      • Suleiman-Martos N.
      • Albendín-García L.
      • Gómez-Urquiza J.L.
      • et al.
      Prevalence and predictors of burnout in midwives: a systematic review and meta-analysis.
      ]. Such negative psychological reactions may lead to the intention to leave the profession and eventually to quit the profession.
      Our findings also reveal an issue which has not been addressed in previous findings. Community midwives in the Netherlands are often self-employed. This means that they have their own business (midwifery practice) and, most of the time, work in collaboration with other midwives. These midwives negotiate with healthcare insurance companies about their rates and are fully responsible for managing their own practice. In general, midwives who want to work in the community have little to no choice but to become self-employed. In the literature, this work situation is considered the same as being a ‘necessity entrepreneur’, meaning that someone starts their own business out of necessity instead of out of opportunity [

      Global entrepeneurship monitor. GEM Global Entrepreneurship Monitor. [Cited 2022 Jan 20]. Available from: https://www.gemconsortium.org.

      ]. Dutch midwives can be considered as necessity entrepreneurs. The research addressing the mental wellbeing of necessity entrepreneurs shows that this group has less subjective wellbeing in comparison to the general population [
      • Larsson J.P.
      • Thulin P.
      Independent by necessity? The life satisfaction of necessity and opportunity entrepreneurs in 70 countries.
      ], The work of necessity entrepreneurs exhibits higher levels of uncertainty, responsibility, and complexity, which are associated with lower mental wellbeing [
      • Stephan U.
      Entrepreneurs’ mental health and well-being: a review and research agenda.
      ].
      Another issue regarding self-employment as a midwife concerns autonomy and work involvement. Midwives, particularly those in community care, have a high degree of autonomy regarding how they want to provide care to women. Midwives indicated that they value their job autonomy and expressed concerns about the decreasing level of autonomy in the profession due to the shift towards integrated midwifery care in the Netherlands [
      • Wildschut H.
      • de Groot C.
      • Galjaard R.
      • de Wert G.
      Integrale geboortezorg–medisch-verloskundige en sociaal-maatschappelijke aandachtspunten.
      ]. Within this system there might be a change from separate payments for community and hospital-based care to bundled payments for maternity care collaborations. For some participants, this was one of the reasons for leaving the job.
      Furthermore, we found that a lack of social resources contributed to the decision to leave the job. A lack of commitment within the team of colleagues contributed to frustrations and conflicts, which also led to increased job demands. Previous research shows that social support from colleagues is a primary contributing factor for wellbeing at work [
      • Suleiman-Martos N.
      • Albendín-García L.
      • Gómez-Urquiza J.L.
      • et al.
      Prevalence and predictors of burnout in midwives: a systematic review and meta-analysis.
      ,
      • Pairman S.
      • Dixon L.
      • Tumilty E.
      • et al.
      The midwifery first year of practice programme supporting New Zealand midwifery graduates in their transition to practice.
      ]. The lack of social resources is associated with a higher risk of experiencing a burnout, an indicator for leaving a job [
      • Dixon L.
      • Guilliland K.
      • Pallant J.
      • et al.
      The emotional wellbeing of New Zealand midwives: comparing responses for midwives in caseloading and shift work settings.
      ]. Not feeling supported by their colleagues, who at the same time are equal business partners, led to increased job demands, i.e., being dependent on the goodwill of business partners for adjustments in work. Previous research confirms that there is a knowledge gap regarding the role of midwives as entrepreneurs, together with being a business partner as an important social resource [
      • Stephan U.
      Entrepreneurs’ mental health and well-being: a review and research agenda.
      ].

      4.1 Strength and limitations

      One strength of this study is its mixed methods design. The findings are based on both quantitative and qualitative data among the target population of midwives in the Netherlands. By means of this design, we could study the process of the intention to leave to actual turnover from different perspectives. Moreover, respondents were able to express themselves freely in the survey because of the anonymity of this type of research technique. Within the in-depth interview, we were able to explore and deepen our data. Nevertheless, there is a possibility that participants may have given more socially desirable answers during the interview. The interviewer who carried out most of the interviews is a midwife, which could be a limitation. This may have influenced the participants, either helping or hindering them from telling their own story. However, we do not think that this led to bias because all participants completed a member check and we did not need to make any adjustments. Furthermore, the samples comprised both a representative sample of the population for the quantitative study together with a good variability in participant characteristics for the qualitative study [
      • Kenens R.
      • Van der Velden L.
      • Vis E.
      • Batenburg R.
      Cijfers uit de registratie van verloskundigen, peiling 2018.
      ]. Another strength of this study is the use of the JD-R model for the methods and analysis of this study. The JD-R model is a heuristic model that demonstrates the possibilities of identifying the demands and resources for a specific occupational group [
      • Schaufeli W.B.
      • Taris T.W.
      A critical review of the job demands-resources model: implications for improving work and health.
      ].
      One weakness of this study is the generalisation to midwives in other countries. In comparison to other countries, midwifery care in the Netherlands is organised differently and the population consists of a large number of community midwives. However, we believe that our results can be used internationally to refine and reorganise maternity care so that midwives can practise in a sustainable way.

      4.2 Recommendations

      Further research is recommended on the intentions to leave for hospital-based midwives, and on the reasons to stay for all midwives in the Dutch midwifery context. With this information, a complete overview of the sustainability of midwifery in the Dutch healthcare system can be obtained, as well as any information on how to reduce job demands and optimise work resources. In addition, we recommend distinguishing between midwives’ intentions to remain in a hospital setting and in a community setting, due to the differences in work contexts.
      Considering the findings of this study, we would recommend midwifery academies to pay more attention in their educational programme to the management- and collaboration skills of midwives who are focused on working in their own business, as a locum and in an organisation. Potentially, when recruiting students, midwifery academies should also encourage students who like to work both as entrepreneurs and healthcare professionals.
      A recommendation for policymakers is that it is important to evaluate the optimal organisational structure, both in the community and in the hospital setting, to initiate a transition that will make the organisational structure a job resource rather than a demand. A collaboration of practice, education and research with an action research design could be useful in building a sustainable midwifery workforce in the Netherlands.
      At a national and an international level, we recommend addressing the issues of retaining a sustainable workforce while taking into consideration the values of practising midwives, increasing opportunities for social support in the workplace and improving the working conditions of midwives. We advise that priorities should be given to programmes for retaining older midwives in the profession, including, for example, more flexible on-call and night shifts. Furthermore, we recommend the arrangement of care pathways in which the continuity of the care is strengthened.
      Maintaining a sustainable midwifery workforce in the shift to integrated midwifery care requires a well-considered strategy. Due to the self-employment of community midwives, midwives have a great deal of control over the organization of their own practices in terms of workload and services. The shift to integrated midwifery care affects this autonomous position and therefore requires solutions that contribute to the wellbeing of the midwifery profession. The contribution of community midwives to these solutions is of great importance.

      5. Conclusion

      One third of midwives in the Netherlands have indicated that they wish to leave the profession. Although the international numbers regarding the intention to leave are higher, our findings are nonetheless a cause for concern. The intention to leave the job is an important indicator for actually leaving the profession. Furthermore, the mere intention to leave can lead to poorer job performance, which affects the quality of midwifery care. The intention to leave and the accumulation of more and more reasons ultimately leads to midwives leaving their profession. Based on our findings, the present challenge is the innovation of the organisational structure, which should focus on the continuity of care for women, job satisfaction for midwives and building a sustainable workforce. These innovations would ensure that women and their babies receive the best care possible.

      Ethical considerations (part 1 and 2)

      In the Netherlands, no ethical approval is required regarding this type of research according to the central committee on research involving human subjects (ccmo). The local Medical Research Ethics Committee of the University Medical Center Groningen confirmed this and defined this study as non-WMO (Medical Research Involving Human Subjects Act, www.ccmo.nl) research (reference number 2018/628). Informed consent was obtained prior to filling in the survey (see part 1). Regarding the interview study (see part 2), informed consent was obtained prior to the interview.

      Funding

      This work is part of the research programme Doctoral Grant for Teachers with project number 023.012.012, financed by the Netherlands Organization for Scientific Research (NWO). The Dutch Research Council has no involvement with the content of this article.

      Conflict of interest

      None declared.

      CRediT authorship contribution statement

      Esther I. Feijen-de Jong: Conceptualization, Methodology, Writing - original draft, Formal analysis, Supervision. Nicolette van der Voort-Pauw: Formal analysis, Writing - review & editing. Esther G. Nieuwschepen-Ensing: Writing - review & editing. Liesbeth Kool: Conceptualization, Methodology, Writing - review & editing, Formal analysis, Supervision.

      References

        • Kenens R.
        • Van der Velden L.
        • Vis E.
        • Batenburg R.
        Cijfers uit de registratie van verloskundigen, peiling 2018.
        Nivel, Utrecht2020
        • Hunter B.
        • Fenwick J.
        • Sidebotham M.
        • Henley J.
        Midwives in the United Kingdom: levels of burnout, depression, anxiety and stress and associated predictors.
        Midwifery. 2019; 79102526
        • Smith A.
        • Dixon A.L.
        • Page L.A.
        Health-care professionals’ views about safety in maternity services: a qualitative study.
        Midwifery. 2009; 25: 21-31
        • Bäck L.
        • Hildingsson I.
        • Sjöqvist C.
        • Karlström A.
        Developing competence and confidence in midwifery-focus groups with Swedish midwives.
        Women Birth. 2017; 30: e32-e38
        • Leversidge A.
        Why midwives leave-revisited.
        Midwives. 2016; 19: 19
        • Warmelink J.C.
        • Wiegers T.A.
        • de Cock T.P.
        • Spelten E.R.
        • Hutton E.K.
        Career plans of primary care midwives in the Netherlands and their intentions to leave the current job.
        Hum. Resour. Health. 2015; 13: 29
        • Coomber B.
        • Barriball K.L.
        Impact of job satisfaction components on intent to leave and turnover for hospital-based nurses: a review of the research literature.
        Int. J. Nurs. Stud. 2007; 44: 297-314
        • Takase M.
        A concept analysis of turnover intention: implications for nursing management.
        Collegian. 2010; 17: 3-12
        • Harvie K.
        • Sidebotham M.
        • Fenwick J.
        Australian midwives’ intentions to leave the profession and the reasons why.
        Women Birth. 2019; 32: e584-e593
        • Stoll K.
        • Gallagher J.
        A survey of burnout and intentions to leave the profession among western Canadian midwives.
        Women Birth. 2019; 32: e441-e449
        • Catling C.
        • Rossiter C.
        Midwifery workplace culture in Australia: a national survey of midwives.
        Women Birth. 2020; 33: 464-472
        • Pezaro S.
        • Clyne W.
        • Turner A.
        • Fulton E.A.
        • Gerada C.
        ‘Midwives overboard!’ Inside their hearts are breaking, their makeup may be flaking but their smile still stays on.
        Women Birth. 2016; 29: e59-e66
        • Hoonakker P.
        • Carayon P.
        • Korunka C.
        Using the job-demands-resources model to predict turnover in the information technology workforce–general effects and gender differences.
        Horiz. Psychol. 2013; 22: 51-65
        • Schaufeli W.B.
        • Taris T.W.
        A critical review of the job demands-resources model: implications for improving work and health.
        Bridging Occupational, Organizational and Public Health. Springer, 2014: 43-68
        • Bakker A.B.
        • Demerouti E.
        The job demands-resources model: state of the art.
        J. Manag. Psychol. 2007; 22: 309-328
        • Kool L.
        • Feijen-de Jong E.I.
        • Mastenbroek N.J.J.M.
        • Jaarsma A.D.C.
        Midwives’ Occupational Wellbeing and Its Determinants. A Cross-sectional Study Among Newly Qualified and Experienced Dutch Midwives.
        2021 (Manuscript submitted for publication)
        • Schaufeli W.B.
        • van Dierendonck D.
        UBOS. Utrechtse Burnout Schaal. Handleiding.
        2000
        • Schaufeli W.B.
        • Bakker A.B.
        The Utrecht Work Engagement Scale (UWES). Test Manual.
        Department of Social and Organizational Psychology, Utrecht, The Netherlands2003
        • van Veldhoven M.
        • Meijman T.F.
        • Broersen J.
        • Fortuin R.J.
        Handleiding vragenlijst beleving en beoordeling van de arbeid (VBBA)(Manual Questionnaire Perception and Evaluation of the Work Situtation).
        SKB vragenlijstservices, Amsterdam2002
        • Luthans F.
        • Avolio B.J.
        • Avey J.B.
        • Norman S.M.
        Positive psychological capital: measurement and relationship with performance and satisfaction.
        Person Psychol. 2007; 60: 541-572
      1. B. Teeuw, R. Schwarzer, M. Jerusalem. Dutch general self-efficacy scale. Retrieved November. 1994;22:2010.

      2. Big register. [Cited 2022 Jan 21] Available from: https://english.bigregister.nl/registration/applications-with-a-diploma-over-5-years-old/criteria-per-profession/midwife.

      3. Besluit opleidingseisen en deskundigheidsgebied verloskundige 2008. [Cited 2022 Jan 21] Available from: https://wetten.overheid.nl/BWBR0024254/2014-09-01.

      4. Beleidsregel verloskunde - BR/REG-20108. [Cited 2022 Jan 21]. Available from: https://puc.overheid.nl/nza/doc/PUC_642212_22/1/.

      5. Midwifery in the Netherlands. [Cited 2022 Jan 21]. KNOV. Available from: https://www.europeanmidwives.com/upload/filemanager/content-galleries/members-map/knov.pdf.

        • Green J.
        • Thorogood N.
        Qualitative Methods for Health Research.
        Sage, 2018
        • Schaufeli W.B.
        Applying the job demands-resources model.
        Organ. Dyn. 2017; 2: 120-132
        • Suleiman-Martos N.
        • Albendín-García L.
        • Gómez-Urquiza J.L.
        • et al.
        Prevalence and predictors of burnout in midwives: a systematic review and meta-analysis.
        Int. J. Environ. Res. Public Health. 2020; 17: 641
        • Kivimäki M.
        • Vanhala A.
        • Pentti J.
        • et al.
        Team climate, intention to leave and turnover among hospital employees: prospective cohort study.
        BMC Health Serv. Res. 2007; 7: 1-8
        • Bloxsome D.
        • Ireson D.
        • Doleman G.
        • Bayes S.
        Factors associated with midwives’ job satisfaction and intention to stay in the profession: an integrative review.
        J. Clin. Nurs. 2019; 28: 386-399
        • HakemZadeh F.
        • Neiterman E.
        • Chowhan J.
        • et al.
        Work-life interface and intention to stay in the midwifery profession among pre-and post-clinical placement students in Canada.
        Hum. Resour. Health. 2020; 18: 1-10
        • Cramer E.
        • Hunter B.
        Relationships between working conditions and emotional wellbeing in midwives.
        Women Birth. 2019; 32: 521-532
      6. Global entrepeneurship monitor. GEM Global Entrepreneurship Monitor. [Cited 2022 Jan 20]. Available from: https://www.gemconsortium.org.

        • Larsson J.P.
        • Thulin P.
        Independent by necessity? The life satisfaction of necessity and opportunity entrepreneurs in 70 countries.
        Small Bus. Econ. 2019; 53: 921-934
        • Stephan U.
        Entrepreneurs’ mental health and well-being: a review and research agenda.
        Acad. Manag. Perspect. 2018; 32: 290-322
        • Wildschut H.
        • de Groot C.
        • Galjaard R.
        • de Wert G.
        Integrale geboortezorg–medisch-verloskundige en sociaal-maatschappelijke aandachtspunten.
        Integrale geboortezorg: Samen bevalt goed. 2018; : 357-382
        • Pairman S.
        • Dixon L.
        • Tumilty E.
        • et al.
        The midwifery first year of practice programme supporting New Zealand midwifery graduates in their transition to practice.
        N. Z. Coll. Midwives J. 2016; 1
        • Dixon L.
        • Guilliland K.
        • Pallant J.
        • et al.
        The emotional wellbeing of New Zealand midwives: comparing responses for midwives in caseloading and shift work settings.
        N. Z. Coll. Midwives J. 2017;