Pregnancy and childbirth are a natural and healthy function of the body rather than a disease (1), and childbirth is among the most beautiful and valuable experiences for the family (2). However, both normal birth and cesarean section (CS) have become a bad memory for many pregnant women, and the preferences of them are ignored in Turkey (1). Factors that cause this situation include poor conditions in delivery rooms, lack of attention to the psychological needs of pregnant women, inadequate information of pregnant women, and unnecessary surgical initiatives (1, 3). All these factors lead to the perception of childbirth as unknown and unpredictable experienced by women which results in the fear of childbirth (4). The CS rate has increased dramatically in Turkey (5), and the highest CS rate among the Organisation for Economic Co-operation and Development (OECD) countries belongs to Turkey since 2008 (6). The CS rate in Turkey has reached up to 53.1% by 2016 (6), whereas the ideal CS rate is generally accepted as 10-15% in the scientific literature (7). Furthermore, the World Health Organization (WHO) reports that the CS rate above 10% cannot be associated with decreases in maternal and neonatal mortality rates (5).

     There are several reasons for high cesarean rates. Research indicates that low priority to improving the ability of women to give birth, limited awareness about potential harms of CS, and fear of birth contribute to the high CS rate (8). However, evidence-based mother-friendly practices can help cope with these factors (9). Therefore, Turkey’s Ministry of Health (TMH) decided to launch an MFH initiative to reduce CS rate, support evidence-based practices, and improve mother-baby friendly maternity care (10).

     The MFH initiative in Turkey has launched in 2015 by TMH, and Manisa Province has been selected as a pilot region. This initiative aims to increase the quality and quantity of maternal health services to ensure safe and high-quality maternity care. The focus of the system is the mother and baby which aims at encouraging normal birth and reducing intervention rates (10).

     For a hospital to be mother-friendly, it must meet the criteria collected in 10 steps (10). These criteria are similar to the Coalition for Improving Maternity Services' (CIMS) MFH criteria (11). The CIMS was established in the United States in the 1990s to promote and support normal birth and breastfeeding and launched the mother-friendly childbirth initiative and 10 evidence-based steps in 1996. Safe and quality monitoring in pregnancy and maternity services are seen as a natural right of the pregnant women in the MFH initiative. The service should be comprehensive, including pre-pregnancy counselling, as well as prenatal and postnatal care. Moreover, it is important to protect the privacy of the pregnant women. The physical environment of the hospitals should meet the standards, and non-evidence-based interventions should be avoided. The service should be monitored periodically with various indicators and statistical analysis (10).

     With the mother-friendly hospital initiative, some organizational factors, such as working conditions and physical conditions have changed. The related literature states that changes in organizational factors may affect job satisfaction level (12), which reflects a positive or negative attitude of an employee toward his/her job. Nowadays, a competitive environment increases the importance of job satisfaction of health workers (i.e., physicians, nurses, and physiotherapists) for organizations that want to survive and succeed (13). Moreover, job satisfaction level of health workers (i.e., physicians, nurses, and physiotherapists) affects various factors, such as the quality of health services, effectiveness, health care costs (14), employee performance (15), intention to leave (16), and patient safety (17). The healthcare team consists of different professionals. Notably, midwives and physicians play a critical role in maternity services (18). However, there is no scientific data on obstetricians and midwives’ job satisfaction, changed working conditions, and opinions about the MFH initiative. Therefore, this study aimed to analyze the views of the obstetricians and midwives regarding the MFH setting and determine their job satisfaction levels.

Materials and Methods

This study was conducted based on a cross-sectional descriptive design. The total sample of the study consisted of 24 obstetricians and 69 midwives working in four hospitals located in Manisa Province, Turkey using the MFH initiative. These are the first hospitals using the MFH initiative in Turkey. It was aimed to reach all population without applying any sampling method. The data were collected by the researchers between December 2017 and February 2018 with the participation of 16 obstetricians and 61 midwives who volunteered to participate in the study with a response rate of 82.8%.

The inclusion criteria consisted of obstetricians and midwives with a minimum of three months of experience in the delivery room in which they were employed. On the other hand, medical and midwifery students, obstetricians, and midwives who refused to participate were excluded from the study. Moreover, the questionnaires with missing answers were not included in the data evaluation.

The data were collected using a questionnaire containing 19 items based on the literature review, the research team’s experience, as well as TMH and CIMS' MFH criteria. In total, eight items elicited sociodemographic (i.e., age, gender, level of education) and occupational characteristics (i.e., profession and experience). Another eight items asked the participants' thoughts about the MFH initiative. These Yes/No items were prepared according to TMH and CIMS' MFH criteria (10, 11).

One of these criteria is to support employees with in-service training as "Have you received any in-service training about the MFH?". Kuder Richardson-20 (KR-20) was used to evaluate reliability. The internal consistency of these items was acceptable (KR-20 coefficient=0.57). Moreover, the intention to leave was measured by a single Yes/No question (i.e., would you leave your current job in the next year if possible?) (19). Moreover, the participants rated their job satisfaction level ranging from 0 to 10 on a linear scale, where 0 and 10 represent "not satisfied" and "very satisfied", respectively. A higher score means higher levels of job satisfaction. The single item approach reflects job satisfaction as a whole with high reliability and validity (20) and has been used successfully in previous studies (21, 22). Additionally, an open-ended question was used to ask about the participants' suggestions regarding the MFH initiative.

Initially, the study protocol was approved by the Ethics Committee of the Faculty of Medicine, Manisa Celal Bayar University, Manisa, Turkey (No: 0.478.486), and then the permission was obtained from each institution in which the study was conducted. This study has been conducted according to the Declaration of Helsinki, and the participants were informed about the research objectives and procedure. After obtaining the informed consent form, the participants were asked to complete the questionnaire, and they were assured of the confidentiality of the data since they were anonymous. All data were used for scientific purposes only and not shared with anyone or for commercial purposes. All participants had the opportunity to withdraw from the study at any time.

The data were analyzed using Jamovi, which is an open-source freely available software (23). Furthermore, descriptive statistics, the Kruskal-Wallis test, and the Mann-Whitney U test were used to analyze the data. Post hoc analyses were accomplished by applying the Tukey's HSD test. A p-value less than 0.05 was considered statistically significant. Since the standard deviation was large, the standard error was used to evaluate the job satisfaction level.

Results

The mean age of women was 31.07±6.55 Out of 24 obstetricians and 69 midwives, 16 obstetricians and 61 midwives with a mean age of 39.45±5.4 years completed the questionnaire (82.8% response rate) at the four hospitals using the MFH initiative. As can be seen in Table 1, 79.2% of the participants were midwives, and 84.4% of the cases were female. Moreover, 46.8% of the subjects had a bachelor's degree, and they had 28.0±11.48 years of experience in the delivery room. Furthermore, 66.2% of the participants evaluated their workload as moderate, and 40.3% of the cases had the intention to leave (Table 1).

Table 2 summarizes the obstetricians' and midwives’ opinions about the mother-friendly hospital initiative. In total, 94.8% of the participants reported that pregnant women were satisfied with the MFH initiative, and 84.4% of them reported that their colleagues were satisfied with the MFH. Moreover, 90.9% of the cases reported that this initiative contributed to their profession and increased the quality of maternal services. Furthermore, the majority of them (92.2%) received in-service training about the MFH initiative, and nearly three-quarters of them (72.7%) reported that their hospital had adequate physical conditions for the MFH (Table 2).

On the other hand, more than half of the participants (54.5%) reported concerns about the MFH initiative. The most common source of

concern was reported as the presence of a companion in the delivery room (71.4%), increased workload (50.0%), and overtime work (7.1%) in descending order (Table 2).

 Some of the illustrative suggested quotations to improve the MFH initiative are presented in Table 3. The suggestions to improve the MFH initiative included the improvement of the physical environment, paperwork reduction, pregnant women and family training, and an increase in the number of the employees (Table 3).

The mean job satisfaction score of the participants was obtained at 7.92 (SE=0.26). Regarding the evaluation of the job satisfaction scores, a statistically significant difference was found among the participants' job satisfaction levels in terms of the workplace (i.e., hospital), workload perception, and intention to leave

Participants who worked in hospital 1 considered their workload as heavy, and those who had the intention to leave had lower job satisfaction scores. Furthermore, no statistically significant difference was found among the mean scores of the participants' job satisfaction in terms of age, gender, marital status, profession, level of education, experience, or overtime work (Table 4).

Discussion

This study aimed to analyze the views of the obstetricians and midwives regarding the MFH setting and determine their job satisfaction levels. The participants had positive attitudes towards the MFH initiative. According to the results, obstetricians, midwives, and pregnant women at the hospitals using the MFH initiative had a high level of satisfaction (Table 3).

The MFH initiative emphasizes reducing surgical interventions, thereby promoting increased midwives’ autonomy (10). Although the midwife/population ratio in Turkey is in a better position, compared to the in many OECD countries (6), Turkish midwives have low autonomy and the existing laws do not support their independent initiatives. However, the midwife-oriented service approach is encouraged by the MFH initiative (10). It is predicted that the rate of surgical intervention will decrease due to the professional midwife support in low-risk births, and it will make a positive contribution to mother and baby health.

Job satisfaction is an important component that affects the quality of the service (24). Although there have been radical changes in the working conditions and delivery of services with the MFH initiative, study results show a high level of job satisfaction of obstetricians and midwives. These results are consistent with the findings that state high levels of job satisfaction of obstetricians (25) and midwives (26, 27). Contrary to these findings, a low level of job satisfaction was reported among obstetricians in Romania (28), Iran (29), and among midwives in Iran (30). These results revealed the difference between the countries in terms of the job satisfaction of obstetricians and midwives. Additionally, research indicates that obstetricians are the ones with the lowest job satisfaction among physicians (29, 31).

However, despite a high level of job satisfaction, 40.3% of the cases had the intention to leave. This is an unexpected result since the employees with high levels of job satisfaction have less intention to leave (16). High intention to leave may cause serious problems. Furthermore, with an increase in the world population, more health professionals are needed, and the importance of skilled health professionals increases. The WHO foresees that the global deficit of skilled health professionals will reach about 12.9 million by 2035 (32). As a result, as widely known, it is becoming more and more important to keep employees in the organization. In 2017, Turkey has the lowest physician/population ratio with 1.87 among OECD countries. On the other hand, there are 53, 571 professionally active midwives in Turkey, and this population is considerably more, compared to those in any other OECD countries. Nonetheless, the duties, responsibilities, and autonomies of the midwives vary across countries. In countries, such as England, France, Australia, and New Zealand, midwives work collaboratively with other members of the health team (33), whereas prenatal and postnatal care is given under the responsibility and supervision of obstetricians in Turkey (34).

Approximately, one-quarter of the respondents reported that their hospitals had no adequate physical conditions for the MFH. However, physical improvements in hospitals are continuing rapidly, and one year after data collection, the MFH-1 was moved to a completely new service building (10).

As seen in Table 2, the MFH initiative seems to cause concern among the respondents. The most common factors that cause concern are the presence of a companion in the delivery room, increased workload, and overtime work in descending order. However, these concerns are estimated to decrease over time. Moreover, the presence of a companion in the delivery room will contribute to the empowerment of the pregnant women and the naturalization of the childbirth (35).

Participants from MFH-1 obtained lower job satisfaction scores. This is an expected consequence since it was the worst hospital in terms of physical conditions. As stated above, one year after the data collection, MFH-1 was moved to a completely new service building. Therefore, further studies are recommended to investigate the effects of this development.

Participants who considered their workload as heavy had lower job satisfaction. Lack of paid incentives may worsen this situation since the statements from respondents indicate that increased responsibilities and workloads are not financially rewarded (Table 3). Moreover, the heavy workload may affect work performance negatively (36).

Participants who had the intention to leave had lower job satisfaction. Numerous studies previously reported the relationship between intention to leave and job satisfaction (37, 38). Employees are more likely to leave their current jobs because of dissatisfaction.

This study suffered from several some limitations. Although there were many scales to measure job satisfaction, it was measured with a single question. Moreover, there were no specific scales for evaluating the obstetricians' and midwives’ perspectives about MFH, which is the significant limitation of this study. However, the internal consistency of the items used in the questionnaire was acceptable (KR-20 coefficient=0.57). Another important limitation of the study was the small sample size. Only four hospitals were using the MFH initiative in Turkey at the time when this study was conducted. Therefore, the total sample of the study was limited to obstetricians and midwives working in these hospitals. However, an increase in the number of hospitals using the MFH initiative up to 55 allows conducting similar studies in a wider sample. On the other hand, the strengths of this study include the high response rate (82.8%) and the context in which this study was being conducted. This is the first study that demonstrates the view of the obstetricians and midwives regarding the MFH setting in Turkey.

Health professionals' concerns and suggestions provide managers with valuable data in terms of evaluation of the MFH initiative and improvement of the process. Determination of the satisfaction level of pregnant women, the other stakeholder of the process, will allow for a broader evaluation of the MFH initiative. Notably, the comparison of the satisfaction levels of pregnant women in the hospitals using the MFH initiative with those in other hospitals may provide new evidence for the effectiveness of this initiative.

Conclusion

     The participants had positive attitudes towards the MFH initiative. The results show that obstetricians and midwives who are working in hospitals using the MFH initiative had a high level of satisfaction. According to the positive opinions of the participants and the factors, such as supporting the process with in-service training and improvements in physical conditions, it can be observed that the MFH initiative is successfully implemented and contributes to maternal services.

Acknowledgements

      The proprietary code of the Ethics Committee was 20.478.486-10 (16.12.2017).  We would like to thank all midwives and obstetricians who participated in this study and Manisa Provincial Health Directorate authorities for their permissions that made this study possible.

Conflicts of interest

Authors declared no conflicts of interest.