Midwives’ experiences of the consequences of navigating barriers to maternity care

Abstract

Midwives in Low- and middle-income countries, experience myriad barriers that have consequences for them and for maternity care. This article provides insight into the consequences of the barriers that Ghanaian midwives face in their workplaces. Glaserian Grounded Theory methodology using semi-structured interviews and non-participant observations was applied in this study. The study participants comprised of 29 midwives and a pharmacist, a social worker, a health services manager, and a National Insurance Scheme manager in Ghana. Data collection and analysis occurred concurrently while building on already analyzed data. In this study it was identified that barriers to Ghanaian midwives’ ability to provide maternity care can have physiological, psychological, and socioeconomic consequences for midwives. It also negatively impacted maternity care. Implementing new ameliorating measures to mitigate the barriers that Ghanaian midwives encounter, and the consequences that those barriers have on them would improve midwife retention and care quality.

Midwives in Low and middle-income countries report navigating significant barriers that have consequences for them as well as on the maternity care they provide. In this study the physiological, psychological, and socioeconomic consequences of the barriers that midwives experience in their workplaces are delineated. Identifying the consequences of midwives’ barriers reveals the immensity and dimensions of the midwife’s workplace challenges. Recognizing those consequences will focus improved measures that are implemented, including ways of increasing midwife retention rates, and improving midwives’ ability to provide quality maternity care.

Background

The United Nations’ (UN) Sustainable Development Goals initiative focuses, among other targets, on the reduction of high global maternal and child mortality. However, years after the implementation of the initiative the issue of high maternal and neonatal mortality persists, especially in low and middle-income countries (LMIC) (Kennedy et al., 2018; Sangy et al., 2023).

Like many sub-Saharan African countries, Ghana’s maternal and neonatal mortality rates of 310 deaths per 100,000 live births and 25 deaths per 1000 births respectively are both high, even though there has been an increase in recent years in the number of women who access skilled attendance at birth (Blake et al., 2016; Gabrysch et al., 2019; Manu et al., 2022).

The persistence of high maternal and neonatal mortality in LMICs is largely attributed to low-quality care (Freedman, 2016). Quality care is broad and multifaceted, but in maternal and neonatal health it can generally be defined as the extent to which maternity services are likely to ensure timely appropriate care to produce desired outcomes (Matthews et al., 2010; Tunçalp et al., 2015). The adoption of the midwifery model of care that supports the attendance of skilled, well-educated, and regulated midwives at births, is seen as an efficient remedial measure to the known shortage of health care workers in LMICs. Midwives can perform most of the evidence-based practices that ensure positive outcomes for women and neonates (Renfrew et al., 2014; Tunçalp et al., 2015). The midwifery model of care is also believed to have positive effects on general health, education, and economic empowerment (ten Hoope-Bender et al., 2016). However, midwives in LMICs face myriad professional, social, and economic barriers that negatively impact their ability to provide quality care to women and neonates (Filby et al., 2016; Ismaila et al., 2021b; Munabi-Babigumira et al., 2017).

Midwives in LMICs report heavy workloads and long working hours, for example, as the cause of extreme exhaustion and fatigue, ill health, and/or nosocomial infections; and further that they are at risk of physical attack while attending shifts, all of which negatively impacts care quality (Banchani & Tenkorang, 2014; Filby et al., 2016; Rouleau et al., 2012).

Psychologically, midwives experience fear, anxiety, anger, and sadness when dealing with medical emergencies (Moshiro et al., 2018; Paula Tibandebage et al., 2016). Combining these experiences with the excitement and happiness that they feel during the safe birth of healthy babies exerts a huge work-related emotional burden on them (Mizuno, 2011; Moshiro et al., 2018; Tibandebage et al., 2016).

Other psychological consequences of the barriers that midwives experience include constant pressure, stress, desperation, insecurity, anxiety, and demotivation (Geraghty et al., 2019; Harris et al., 2011; Prytherch et al., 2013; Schack et al., 2014). The anxiety that midwives experience is reported to sometimes engender panic attacks (Spendlove, 2018). Members of the profession have also been found to exhibit depression and symptoms of post-traumatic stress disorder because of dealing with upsetting events in their work (Abou-Malham et al., 2015; Leinweber & Rowe, 2010; Moshiro et al., 2018).

Additionally, a lack of support from leaders and low appreciation in a context of heavy workloads and challenging working conditions have been reported to cause feelings of frustration, demotivation, and depersonalization among midwives (Bremnes et al., 2018; Lavender & Chapple, 2004). This demonstrates a clear link between midwives’ mental and emotional wellbeing and the quality of the care that they provide. For example, Mselle and colleagues found that heavy workload results in frustration in midwives, which leads to poor client relations (Mselle et al., 2018). In a study by Richard et al. (2009), it was identified that midwives perceived that audits were ‘unfriendly’ because of the absence of anonymity and the focus on the negative aspects of cases. The issues of anger and resulting poor interactions with clients have been found in other studies to be caused by the spillover of high levels of frustration (Ndwiga et al., 2017; Wesson et al., 2018). In their review of the literature related to factors that affect midwives’ ability to provide care to the standard they would like to, Filby and colleagues theorize that the barriers that midwives face causes them to experience moral distress and burnout, characterized by feelings of guilt, anger, depersonalization and demoralization (Filby et al., 2016).

The social effects of the barriers that midwives experience which affects their ability to provide quality maternity care, includes difficulties in fulfilling domestic roles, destabilization of marriages, the breaking of social networks because of the requirement to work away from their original communities of abode and difficulty in starting a family (Filby et al., 2016; Prytherch et al., 2013).

Economically, it has been identified that midwives perceive their wages to be low and as such not commensurate with their heavy workloads (Jones et al., 2016; Ndwiga et al., 2017). Nonetheless, midwives in LMICs are often faced with the burden of having to use their own money in the process of caring for women who cannot pay for various services, to prevent negative outcomes (Filby et al., 2016).

In Ghana, it has been found that, apart from medical doctors, midwives are the professionals who are most capable of providing sufficient quality emergency obstetric and neonatal care (Lohela et al., 2016). Ghana has been in the process of implementing the midwifery model of care for several years now (Kyei-Nimakoh et al., 2016). Over the past decade the country has invested in training more midwives who are then assigned by the Ghana Health Service (GHS) to posts around the country based on where their services are needed most. The changing of work locations is reported as daunting by midwives (Prytherch et al., 2013), and can be considered another stressor that impacts midwives’ capacity to provide quality care.

Given the extent of the barriers that midwives in LMICs face, it is important to understand the consequences for them, so that efforts by stakeholders to implement the midwifery model of care can consider these barriers and overcome the resulting consequences. In this article, findings from a study by Ismaila (2020) on the barriers faced by midwives in Ghana (Ismaila et al., 2020), the consequences of those barriers, and the coping strategies that midwives adopt to continue performing their care duties are delineated (Ismaila et al., 2021b). In this article, the findings on the consequences of midwives’ workplace barriers are presented.

Methodology

Glaserian, or Classic Grounded Theory (GT) methodology was used in this study (Glaser & Strauss, 1967). The methodology was chosen by the authors because it enables researchers to explore the ongoing behaviors of participants and the way they solve their issues of concern (Glaser, 2002). There are two other variants of GT (Charmaz, 2008; Strauss & Corbin, 1998), each of which was considered for this study; however, the choice was made to utilize the Glaserian version because the lead researcher (YI) did not have comprehensive knowledge in midwifery. Using the Glaserian method allows for the research to be truly inductive and does not require comprehensive knowledge of the field under inquiry.

The study was conducted in the Greater Accra Region of Ghana from mid-January to mid-August 2018. Data collection took place in 10 purposefully selected public hospitals from seven districts as follows: four health facilities from metropolitan areas, three facilities from peri-urban areas and three facilities from rural areas. The study population included 33 participants, comprising 29 midwives who worked in the labor wards of health facilities and a pharmacist, a social worker, a health services manager, and a National Insurance Scheme manager.

Data were collected through semi-structured interviews and non-participant observations. The non-participant observations were carried out by YI in the maternity areas of the selected health facilities while the midwives went about their duties and was on their working environments, including equipment and supplies, water and sanitation, infrastructure, and work aids such as protocols. Notes were taken during the non-participant observation stage. The data that was acquired were analyzed and the codes and incidents obtained were used for probing during the interview stage. The interviews lasted between 45 min to one hour and were conducted in English in the relevant health facility in a suitable place chosen by the participant to ensure privacy. All the interviews were conducted by the lead researcher (YI) and were audio recorded with the consent of the participants. The audio recorded interviews were listened to and transcribed verbatim by YI. The data were analyzed through open and theoretical coding. The codes that emerged from analyzing the data acquired through interviews with midwives were constantly compared with those codes that emanated from the data acquired from the non-midwives during theoretical coding. This is similar to what happens in triangulation. This allowed for the findings from different perspectives to be illuminated and it enhanced the dependability of the findings.

Ethical consideration

Ethical approval for the study was granted by the Human Research Ethics Committee of the authors’ University (number 18162), as well as the Ethical Board of the Ghana Health Service in Accra, Ghana (GHS-ERC: 009/10/17). During the recruitment of participants, the aims of the study were explained and information sheets that provided full details of the study were provided. All participants in this study signed a consent form prior to inclusion in the study. In line with the ethical requirements of this study a trained counselor was organized to be available to provide any counseling to the participants if required, however no participant requested this service. To protect the privacy of participants pseudonyms have been used in the findings section. The names of the facilities where midwives were sampled have also not been provided.

Results

The participants in this study comprised 29 midwives, 1 pharmacist, 1 social worker, 1 National Insurance Scheme manager, and 1 health services manager. The midwives were aged between 26 and 59 years and had worked for an average of eight years. The demographic information of the midwives is presented in Table 1 (Ismaila et al., 2021a, 2021b).

Table 1. Demographic characteristics of midwife participants.

Demographic variable	Category	Frequency
Age	25–29 years	4
	30–35 years	12
	36–39 years	3
	40–45 years	3
	46–49 years	2
	56–59 years	5
Years of experience	1–5 years	12
	6–10 years	8
	11–15 years	6
	16–20 years	3
Education	Diploma in midwifery	25
	Bachelor of midwifery degree	4
Health Facility type	District Hospital	22
	Health Center	7
Health facility location	Urban	16
	Peri-urban	7
	Rural	6
Sex	Female	28
	Male	1

In this study, it was discovered that the barriers that midwives face in their workplaces have significant physiological, psychological, and socioeconomic consequences for them. These in turn, constrain their ability to provide quality care. The overarching category in the data which represents the consequences for midwives of working within the myriad barriers in their workplaces is labeled ‘I go off track’. This label is an In-Vivo Code chosen to denote the negative consequences of the barriers midwives faced in their workplaces. The findings in this study are illustrated by three subcategories: 1) ‘It’s exhausting and fatiguing; it stresses me out’—in which midwives’ physiological consequences are delineated; 2) ‘It’s frustrating; it makes us angry, and we go off track’—in which the psychological consequences of the barriers midwives face are examined; and 3) ‘It affects my household, my friendships and my community standing’—that indicates the social and economic consequences of the barriers midwives face. Each of these sub-categories will be discussed in turn below.

Exhaustion, fatigue, and stress

In the sub-category ‘It’s exhausting and fatiguing; it stresses me out’, the barriers to midwives’ ability to provide quality care was identified to leave them feeling overwhelmed, exhausted, and fatigued which thereby affects their ability to provide quality care. As Kafui indicated, in addition to their exhaustion and fatigue they experience “mental stress”. The midwives described how they take care of women through the whole process of childbearing and thus the necessity for them to stay close to the women for long periods of time to be able to monitor them throughout the birthing stages. The high numbers of women that the midwives need to take care of coupled with chronic staff shortages, however, results in an extremely demanding workload. As indicated by Akwele, “there is always a lot at hand”. Adding to the burden of increased workloads and the related stress is the lack of or broken equipment, or the shortages of vital supplies. Midwives find themselves going back and forth to other medical units hoping to borrow essential equipment and look for essential supplies, making the whole process of providing care a struggle. The midwives indicated that they are left exhausted and fatigued by the time their shifts are finished. For example, Asibi stated that:

Because of the pressure [high workload], I feel very tired, especially when I get home. Toward dawn, I feel so tired. But I have to come to work. It is not easy.

The midwives also stated that because they must either stand or bend for long periods of time while supporting the women giving birth, they end up with back pain. Selasie explained that back injuries often occur in emergencies: “When she [the woman] is bleeding you become restless, you just want to save the client”. The midwives cited the poor condition of birthing couches and their need to transfer clients from one surface to another without the right equipment as the cause of their injuries. Further adding to their burden, in most cases, the cost for treating workplace injuries must be borne by the midwives themselves. Fafa provided an example:

I am having spondylosis, they referred me from here to [the referral hospital]. I take treatment at my own expense. Nobody cares.

As well as potential back pain and the risk of injury, the participants in this study perceived that the high workload and long working hours also affected their physical health generally resulting in frequent requests for time off, which impacted their ability to care for their clients. The midwives’ high workload and long working hours also made it difficult for them to take care of their own nutritional needs, for example as intimated by Selasie: “The stress can make you lose your appetite”. The midwives speculated that their various medical conditions were acquired due to their heavy workloads. Asibi gave an example:

I have developed [peptic] ulcer because of the work. At times we say it is the wrong profession, but we are in it. What can we do? We don’t have time for ourselves at all. We always look tired and sick. Always you have body pains and waist pains. Some [of us] are consulting physiotherapists because of lifting of cases.

The midwives reported that because of the heavy workloads on the labor wards, they often stayed longer than their paid working hours. Additionally, demands are placed on them to work longer hours when there are staff shortages or when colleagues report to work late. The midwives in the urban and peri–urban health facilities reported that they often travel long distances to their workplaces, because they do not have their own means of transport. The main consequence is, as indicated by Nakie, “going back home is a problem”. Participants indicated that when they work on afternoon shifts, by the time they return to their homes it can be very late at night, which then impacts their ability to get to work on time the next day, thus compounding the problem and affecting care delivery. Further, some midwives reported being attacked by criminals as they were returning home from work at night. Either the experience of this crime or the fear of this crime occurring was so stressful that, as Khadija explained, she and some of her colleagues had made the difficult choice not to return to their homes and family when working late because of the threats to their wellbeing and safety:

If your house is far and you are staying [working longer hours], you have to sleep here and go home the following day, because of the fear that you will be attacked. They [criminals] attacked some of my midwives from this hospital and collected their mobile phones from them.

Participants in this study also reported experiencing verbal attacks and threats of physical attacks from clients, families, and community members when these parties perceived negative outcomes to have resulted from the midwife’s negligence. The participants reported that this affected their ability to care for their clients. Dela illustrates the significance of this issue:

A woman gave birth [while] I was on shift. The baby’s cord, there are times you have it straight and there are times that you have it coiled like macaroni. The lady was delivered [safely] and went home. In the night we heard some young men hitting the door with stones and sticks [threatening to attack]. We were like what is it? And they were like their sister said she delivered the baby with a rosary and the midwife has taken the rosary home. I could not help it, so I started laughing. Me laughing made them even more upset…

Further, the participants reported that they faced the risk of infection every day due to the lack of, or broken-down autoclaves and the shortage of personal protective equipment. As indicated by Elsie, midwives also fear that they will “transfer an infection to the women”. The participants reported that due to the frequent shortage of supplies such as surgical gloves, masks, gowns, and other equipment, they are forced to perform procedures without the right personal protective equipment. Midwives mentioned using examination gloves instead of surgical gloves, using short gloves instead of long gloves or doing mouth-to- mouth to resuscitate babies of unknown infection status due to the absence of ambubags. Elsie gives an example of the risks posed to her and others due to insufficient infection control supplies and equipment:

For some of the procedures, you need an elbow glove, maybe to go into the uterus for examination, but we only have the surgical ones which are short. You end up bringing your hand out and your whole arm is bloody. With this hepatitis, HIV and syphilis [prevalence], you do it and you run to put your hand in the bleach. You remove it, wash your hands, and use sanitiser too, hoping that all will be well.

The participants stated that because there were only a few instrument sets, they had to be shared between the high number of births occurring, but in the setting where the autoclave is not working, they are forced to sterilize the equipment with bleach instead so that they can immediately use them again. This exposes the midwives, the women, and neonates to infections because the midwives reported that sometimes the process is hastily done. Mansah explained why midwives did this:

We have 10 birthing packs. We can do many deliveries and it will get finished. So, when we put it into the bleach for 10 minutes and we wash it and put it in another one for 5 minutes then we use it for them [women and neonates]. We cannot say that because we have used up all our instrument women should go to another facility.

According to the midwives, their stress and fatigue were made worse by the perception that their managers did not support them when things went wrong. As indicated by Sika: “The health worker is not their [management] priority, it is the patient [that is their priority]”. The participants perceived that the health facility management always sided with the clients, even when it was clear to the midwives that other factors such as the lack of care resources was the cause of a negative outcome. As Mercy stated:

Whatever you have, you use it. It stresses me out. I get tired. Like yesterday the baby was dying. You don’t have suction machine. At the end of the day too, they [the baby’s family and the management] will put the blame on you. I get anxious.

Even in the face of this perceived lack of support from management, midwives showed a great sense of responsibility in their work. This was due to a general acknowledgement among the participants that their ability to provide care impacts the woman giving birth, the neonate and the woman’s family. Elie captured this view in her statement:

You are not only dealing with the mother [woman]; you are not only dealing with the child [newborn]. You are dealing with the whole family. Mother is here but children are in the house waiting for mother, husband is in the house waiting for mother, even grandmother is depending on mother, so you are dealing with the whole family. Should something go wrong the whole family will be affected.

The midwives involved in this study concluded that theirs is a huge responsibility and that this is an additional source of pressure on them, apart from the other barriers they face in the workplace.

As well as the stressors noted above, other aspects of the job exacerbated the midwives’ stress thereby causing emotional tension and thus affected the way they cared for their clients. One significant factor mentioned by the participants was that, because of the infrastructural constraints in their workplace, they do not have access to the equipment and other resources needed to care for women or newborns who might need Intensive Care Unit (ICU) or Neonatal Intensive Care Unit (NICU)-level care. Due to this, midwives must refer and transfer most emergency cases to other health care sites. However, none of the facilities had an ambulance. The urban and peri-urban facilities depended on the National Ambulance Service while the rural health facilities depended on the availability of taxis. Delays in getting ambulances or other means of transport to convey clients to referral facilities, as well as getting referral facilities to accept referred women and/or neonates, were mentioned by the participants as major sources of additional stress and anxiety. Margaret described a typical emergency transfer scenario:

You are now going to put the person into a car [taxi] and send the person to [another hospital]. When you get there [the other hospital], [they] will say the place is full, you go to another place [a different hospital], they also [that hospital] says it is full and you are the midwife in the car. Your heart will be pounding. You will get anxious.

Another cause of anxiety for midwives is the uncertainty in accessing the required medication and supplies. Participants indicated that although the hospital pharmacies stock most of the required medication, sometimes there were shortages. According to the participants, when this happens, the clients’ relatives must go to pharmacies outside the health facilities to buy the medication. As Ayele questioned: “So if someone does not provide it [medication] when labour starts what do you do?” The shortages of supplies such as instrument sets, surgical gloves, elbow gloves, sutures, syringes, and transfusion set for babies were indicated by participants to cause additional stress. Kafui summarized:

There is also mental stress. I think too much. When I want to do something, I get confused. I don’t know what to do. Maybe you come to work you need drugs, you need syringes, and these are not available, and you still have to work. You have to go about looking for some, if you don’t get, you manage with what you have.

Unreliable patient history was also mentioned by midwives to cause them anxiety and stress thereby affecting their ability to provide quality care. The participants stated that in some cases, women either intentionally or unintentionally provide inaccurate medical history, they also indicated that often, women who had not attended antenatal clinics (ANC) would suddenly report to the labor ward without any medical or obstetric history. Amina explained this further:

It causes anxiety. If a scan has been done and everything is clear, it is easy. But if the person has not done all the tests, no scan, you still have to manage her because if you don’t manage her, she will go back to the house. Anything can happen to her.

Frustration, anger, and demotivation

In the second sub-category, “It’s frustrating; it makes us angry, and we go off track”, the respondents reported that they get frustrated when the absence of the required inputs makes it difficult for them to achieve positive outcomes for women and neonates. The midwives’ situation is complicated by delays due to the unavailability of resources such as medicines, equipment, or other infrastructural challenges. The participants reported that high levels of frustration in some cases resulted into anger, which they believed, negatively affected the way they interacted with women. Asibi spoke frankly about how the working conditions can impact on midwives’ interactions with women:

When you have a lot of people [high workload] or when you are under pressure, you tend to vent out that frustration on patients and you end up talking to them anyhow. People take it like midwives are rude but sometimes you have to be in this situation to know what it takes. We try [do our best].

The participants in this study stated that they predominantly direct their anger toward their managers, immediate superiors, and/or colleagues from other departments when they perceive that they are not doing enough to help them get the needed resources to complete their work. As Buruwah said:

We report to the appropriate quarters but if nothing is done what will you do? At the individual level, I get angry, I report [to my superiors].

However, even this reporting of the problems to those in positions of power is a source of frustration for midwives especially when, as Buruwah noted:

They don’t say anything. We don’t see any effect. Nothing is implemented, so you talk and talk and talk but nothing happens.

The participants reported that the frustration and anger that they experienced by having to constantly demand for the much-needed resources and having to wait for long periods of time before they are provided, cause demotivation among midwives. According to the midwives, feelings of demotivation increased when there are poor maternal or neonatal outcomes, because they perceive that if the full complement of equipment and supplies needed for the provision of optimal care had been provided, outcomes may have been different. Mariama describes the frustration she felt because of the barriers she experienced and their impact on her ability to provide quality care, as ‘going off track’:

…it puts me off. Maybe I need something to do my work and it is not there. For a while I may go off track just because I don’t have what I actually need.

Finally, compounding the frustration and anger experienced by the midwives, that causes them to go ‘off track’, is the ever-present specter of clinical audits which, according to the participants, is a highly emotional challenge. When a mother or a neonate dies intrapartum, the midwife who provided care must attend a maternal or neonatal audit meeting (known in other contexts as Root Cause Analysis meetings) to explain what happened. As indicated by Asibi, at this meeting, “they make you [feel] useless, as if you don’t know your left from your right.” The audit process caused midwives a great deal of frustration because they cannot always pinpoint exactly what they could have done differently. Akwele further explains:

When you care for somebody and unfortunately the person goes off (dies), the kind of thinking that you the midwife you will go through… It is not only because you will be going for auditing and they will be asking you a lot of questions, but you will ask yourself “what went wrong?” You were trying to do your possible best and at the end of the day you did not know what went wrong. It has happened to me before. I did not sleep. I sat for the whole night for about 2 days. I was frustrated because I was trying my best but…

In this quotation it is evident that the need for, but absence of any emotional support for midwives is a major source of frustration.

Negative effects on household, friendships and community standing

In the third sub-category, “It affects my household, my friendships and my community standing”, the participants indicated that because of the constant heavy workloads and the long working hours, they are always exhausted by the time they get home after their shifts. The midwives’ constant exhaustion coupled with other demands of the profession, such as having to work on weekends and on holidays, caused them to perceive that they are always at the workplace. As Akos stated: “All the time I am here [at the facility].” All the participants in the study reported that it is difficult for them to spend quality time with their family. Ashokor went so far as to say that: “Once you are here, you cannot have family life”. The inability of midwives to spend time with their families seemed to be particularly difficult for those who have school-aged children. As Asibi declared: “They [her children] hardly see me at home”.

The participants also indicated that the constant exhaustion resulting from the high workload makes it difficult for them to complete their household chores. Clara stated that:

By the time you finish your work and the documentation, you will be exhausted. When you go home, you must pick [up] your children and do other things. I do not get enough time for my household chores.

The participants reported that the high workload on the labor ward affected breastfeeding midwives. These midwives are not able to leave the labor wards earlier to attend to their own babies, even though there is a policy provision for them to do so. This is because they found it difficult to leave when there are so many clients and an insufficient number of midwives to take care of them. Margaret reported that:

The young ones too, it is affecting them. As somebody who is having a child, they say they should do exclusive breastfeeding but if you see the ward, you can’t leave … because if your colleagues are there and they have cases and you see them going up and down, you cannot say you are going [home].

As well as the implications of working as a midwife in a context of scarce resources and support, the participants indicated that their marriages and/relationships are being negatively affected because of the shift work and having to work on weekends, on holidays, and during other festive occasions. According to the midwives in this study, because of their work schedule, they were unable to join their partners or families for celebrations such as weddings and other events, or for state or religious holidays. For some newly trained midwives, being separated from their husbands because of their postings to distant health facilities negatively affected their marriages. Elsie explained:

Taking transfer from one place to the other, that one, it will take more than six months, at times a year. If your partner is one who cannot hold on to his ego or libido, you will end up going to meet another woman in your matrimonial home, because nobody is there to cook, clean the house or satisfy him emotionally.

Having to work on weekends and/or on public holidays means that midwives are often unable to attend social events, thereby causing isolation from their extended families and their communities. As a result, the participants were concerned that they in turn were perceived as uninterested or uncommitted family or community members. Amina explained:

To be frank with you, it has been a problem because we Muslims, when you are around [in your community], naming ceremonies, marriage ceremonies, and funerals, you need to be attending, even if not all of them. But because of this work, when something happens, I can’t go. So, people will say that I don’t care about anybody.

All the above affected the peace of mind of the respondents and consequently the quality of the care that they provide.

The midwives that work in rural facilities were also faced with the challenge of not being able to take their annual leave though they often live very far away from their families and friends; this is because of the effect that going on leave could have on care provision as it is difficult to find relieving midwives. Sika, who works in a rural area, indicated that she has not been on leave for two years. Sika stated that: “I feel that when I leave my clients will come and I will not be there.”

In this study it was discovered that the midwives’ workplace barriers have economic consequences for them. Midwives do not want to be held accountable for any resource shortages-related negative outcomes; therefore, they often contribute their own money to buy essential medications or supplies, blood, and even food for women. As Elsie stated: “Even if it is the last money on you, you are forced to give it out.” Midwives who work in rural areas are also often burdened with the cost of conveying patients to referral facilities. Although those midwives get a significant number of referrals of this nature, it is only on a few occasions that their monies are refunded. The participants felt that they had no choice but to use their own money to provide the necessary care to avert negative outcomes. Tani stated that:

The midwives who were on duty had to contribute money to go and buy blood to serve as a standby. The midwives didn’t want a situation whereby the woman will go into labour and develop any complications and it will be on them. It is not that they want to give the money. They are forced to, because they don’t want it [negative clinical outcomes] to happen on their shift or even in the unit.

A further financial implication for midwives who work in urban and peri-urban health facilities includes their need to employ someone else to assist with household chores and the care of their own children. The midwives in this situation found it difficult to complete their household chores due to exhaustion and fatigue resulting from their high workload. Also, because of their long working hours, they were absent from their own children for long periods. Akua described the impact on her family:

I am not able to see my girl [her daughter] for maybe 2 to 3 weeks. I only call and send money. I pay 70 [Ghana cedis] every week, and at the end of the month I have to pay 150 [Ghana cedis] to her [the nanny] for taking care of my baby.

Discussion

In this article, the authors present findings on the consequences of the barriers faced by midwives in their efforts to provide quality care to women and neonates. To provide quality midwifery care, midwives must be with women throughout the birthing process and the puerperium (Bradfield et al., 2018). In this study, the midwives, especially those who work in the urban and peri-urban health facilities indicated that their high workloads, coupled with the unavailability of essential equipment made them extremely exhausted, which affected the quality of care. Examining this finding considering the findings of other studies in LMICs on the effects of workforce shortages and challenging work environment on midwives underscores the negative impact that these factors have on care quality due to the extreme exhaustion that they cause midwives (Ndwiga et al., 2017; Prytherch et al., 2013; Rouleau et al., 2012). Other effects of high workloads that were identified in this study included physical injury, back pain, other medical conditions such as high blood pressure and peptic ulcers, and the risk of acquiring nosocomial infections. Experiences of fear due to the risk of acquiring nosocomial infections and also due to verbal and/or physical attacks that midwives sometimes receive from clients’ families or other community members after negative outcomes resulting from poor working environments, but which are perceived by their attackers to be due to negligence was also identified in this study. Earlier studies in similar contexts also reported the fear of physical attacks by midwives (Filby et al., 2016). In this study, however, the midwives also mentioned the fear of contracting nosocomial infections while working due to the lack of resources. This finding was corroborated only by the findings in another study also conducted in Ghana and could be investigated in other LMIC settings (Banchani & Tenkorang, 2014).

In this study, midwives were found to be experiencing pressure due to: The sense of responsibility that they felt about saving the lives of mothers and newborns; and the expectations on them to deliver quality care despite the lack of care resources. Other sources of pressure include increasing workloads as well as the lack of support from facility management. Other authors have shown that the responsibility to manage the feelings of women and their families is a source of pressure and stress to midwives (Geraghty et al., 2019; Hunter & Warren, 2014). Furthermore, the pressure that midwives experience because of staff shortages has also been underscored in other LMIC settings (Abou-Malham et al., 2015; P. Tibandebage et al., 2016).

The anxiety and stress experienced by midwives because of the lack of the essential necessities of care, as well as due to the uncertainty of accessing equipment and other resources when needed, is important because in another study in the same context it was also reported that anxiety on the part of midwives can have negative consequences on their emotional wellbeing (Schack et al., 2014). In the study, midwives were shown to be stressed by the uncertainty of accessing support from colleagues and physicians. Midwives’ anxiety is an issue of concern because it has been identified that when it occurs because of inadequacies in the workplace, it could cause them to have panic attacks (Spendlove, 2018). Midwives have also been reported to show symptoms of traumatic stress disorder because of dealing with traumatic events in their workplaces (Leinweber & Rowe, 2010). The issue of anxiety among midwives should be taken more seriously also because it can influence them to adopt a defensive practice and thus skew their practice toward the biomedical model of care, to the detriment of the midwifery model that supports natural birth. This can affect the satisfaction level of birthing women.

The midwives in this study reported that negative outcomes caused by the unavailability of resources and ‘bad outcome’ audits caused them to be frustrated and angry at clients as well as at their superiors and other health workers. The spillover effects of frustration among midwives that engender the transfer of anger to clients can have negative consequences for respectful maternity care. It must be noted, however, that in contrast to other studies that looked at the effects of midwives’ anger on quality care (Ndwiga et al., 2017; Richard et al., 2009; Wesson et al., 2018), this study illustrates how midwives also direct their anger at their immediate superiors and sometimes at other health workers. This is a unique finding, and we thus recommend further research on this specific phenomenon.

The failure of management to provide essential equipment for work was identified by the authors to cause midwives to be demotivated, especially when the unavailability of essential equipment resulted in negative outcomes. Midwives’ demotivation could further exacerbate their frustration and lead to depersonalization. This phenomenon may not only have negative consequences on care quality but also on the mental wellbeing of midwives and thereby cause attrition.

In this study, the socioeconomic consequences of the barriers to midwives’ ability to provide quality care that were identified include the effects on the midwives’ family responsibilities and their personal relationships. The participants in this study were found to be using their own money to purchase medications, supplies, and food for women to ensure positive outcomes. It was found in earlier studies that midwives perceived that their remuneration is not commensurate with the level of work that they do (Jones et al., 2016). Therefore, spending their own money in the course of their work is likely to fuel disenchantment (Wesson et al., 2018). This situation may also cause attrition because the cost, in literal terms, to midwives is too great. Beck and Anderson (2018) considered the emotional toll to midwives of being ‘with the woman’ in their research, however the direct financial cost to midwives working in LMICs while trying to provide quality care has not previously been described, therefore, further research on this phenomenon as well as other strategies that midwives adopt to be able to cope with their workplace barriers would contribute to knowledge that could be used to improve midwives’ practice and thereby improve care quality. This is vital because, although the authors delineated the consequences of midwives’ workplace barriers in this article, Ismaila (2020), considering together the midwives’ barriers, the consequences of those barriers that are herein presented, and the coping strategies that midwives adopt to be able to complete their duties (Ismaila et al., 2021b), discovered a middle range theory labeled “Doing magic with very little” (Ismaila et al., 2020). The theory that was discovered in the study underpins the ingenuity of midwives to provide maternity care despite their myriad workplace barriers and the consequences of those barriers due to their adoption of coping strategies.

Conclusion

Midwives are vital for the reduction of maternal and neonatal mortality given the key role that they play in ensuring that women birth safely, especially in LMICs where there are dire shortages of health workers. The authors have demonstrated through this study that midwives working in these contexts face barriers in their practice that have physiological, psychological, and socioeconomic consequences for themselves and the care quality for women and neonates. Although midwives in LMIC contexts are doing their best to provide maternity care, if there was adequate funding for maternity services, and health leaders and management provided the necessary resources and a supportive management style whereby midwives’ views are considered, both maternal and newborn outcomes and the retention rates of midwives would significantly improve.

Limitations

The data collection for this study was conducted prior to the Covid 19 pandemic, and the authors acknowledge that if this investigation was conducted during or after that period, the data would likely have referred to the additional challenges the global pandemic conferred on midwives. Further, although burnout and demoralization were not measured in this study, some of the consequences seem to be pointing to this outcome for midwives. Further exploratory research is thus required in this regard.

Ethics approval

The study received ethical approval from the Human Research Ethics Committee of Edith Cowan University, Australia, and the Ethical Board of Ghana Health Service (GHS).

Authors’ contributions

YI, SB and SG conceived the study design. YI collected all data and led the data analysis and the writing of the manuscript. SB and SG contributed to the analysis of the data and development of the manuscript. All authors read and approved the manuscript.

Consent to participate

Written informed consent was obtained from all participants that took part in the study.

Consent for publication

All participants in the study consented that data from the study could be used for publications.

Acknowledgements

This study was conducted with the support of an Edith Cowan University School of Nursing and Midwifery Scholarship granted to the first author. The Family Health Division of the Ghana Health Service as well as the Greater Accra Regional Health Administration of the Ghana Health Service were very supportive during the data collection phase. We sincerely appreciate the involvement of participants in the study who took time out of their very busy schedules to be interviewed. We are also grateful to Prof. Kodjo Senah of the Sociology Department of the University of Ghana.

Disclosure statement

No potential conflict of interest was reported by the authors.

Availability of data and materials

The research data for the study are available from the corresponding author on reasonable request.

Correction Statement

This article has been corrected with minor changes. These changes do not impact the academic content of the article.

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.