In the two recent decades, the health systems of the developed and developing countries have implemented corrective plans due to the lack of proper responsiveness to the health demands and people’s expectations. The factors that necessitates the admini-stration of amendments in the health system of Iran include health management challenges in various domains, epidemiologic and demographic changes, increased healthcare expenditures, and inequality in receiving
In 2005, the Iranian government established a new reform in health services composed of family physician plan (FPP) and universal health insurance in all rural areas and cities with a population of more than 20,000 people (2). This plan provides a good opportunity for the urban and rural areas to gain access to health services. In the FPP and referral system, general physicians and their teams are responsible for the households and people’s health under their coverage; furthermore, they are in charge of following up the individuals’ conditions after referring them to other special professional care services (3).
The FPP midwives, as a part of the healthcare team, have a remarkable role in providing care to mother and children. Accordingly, they play a key role in three dimensions of care systems, namely health centers, family, and society (4). However, this plan has been faced with multiple challenges, such as the annual designation and transfer of about 25-30% of the physicians, lack of
team members’ familiarity with this plan,
and community-oriented medical education system (5). Therefore, the midwives are affected by numerous challenges in the FPP.
In a study conducted in Kerman, Iran, it was reported that the implementation of this plan resulted in increased loss of physician and midwives. This loss was due to several reasons, such as education, employment status, environmental factors, as well as low job stability and security (6). On the other hand, there are various challenges that the individuals are faced with in their job life. These challenges include concerning about job, socio-economic factors, organizational expectations from the staff, technological improvements, management problems, and staff expectations (7).
In a study conducted by Ghorbani et al. on the satisfaction level of the midwives in the FPP, job satisfaction was not reported as the welfare aspect of the occupation (8). Job satisfaction can affect performance, employee turnover rate, level of commitment to the organization, and absenteeism. This state also reduces stress, which can affect occupational performance as well as mental and physical health (9).
Although working with women and children and providing them with health services are the main job motivations for the majority of midwives (10-12), the existing challenges among these health care professionals cause occupational deficiency (13). These challenges are caused by situational and environmental factors (e.g., organizational commitments and hierarchy, lack of occupational resources such as insufficient payments, high work pressure, contrast or lack of clarity in the roles,
low occupational advancement, and lack
of feedback) and individual factors (e.g., population factors, individual characteristics, external locus of control, occupational satisfaction, job abandonment, and lack of social support).
Regarding this, lack of directing proper attention to the challenges of this group may result in the reduction of their efficiency. The FPP is a new plan in the health system of Iran, which has been given special attention and aimed to improve the rural health. Regarding this, the identification of the challenges of the health teams who are active in the framework of this plan has a significant role in the success of this project. The utilization of a qualitative design is usually appropriate when the available theories or literature related to a phenomenon are limited. Moreover, this method is effective in the exploration of deep concepts and individuals’ experiences (14).
To the extent of the researchers’ knowledge, no study has been conducted in Iran investigating the midwives’ challenges as a part of the health system. However, it is important to note that the value of nursing and midwifery knowledge is in direct relation with the comprehension of humanistic experiences. To achieve such conceptu-alization, more studies are required to investigate all aspects of this experience, which is accomplished by the implementation of qualitative research (15).
With this background in mind, the present study was conducted with the aim of investigating the midwives’ perceptions and experiences about the challenges in the FPP. The findings of the present study can be helpful for the managers to identify the midwives’ challenges in the FPP and assist them in solving their organizational problems to enhance their efficiency in the fulfillment of organizational goals.
Materials and Methods
The present qualitative study was conducted on 23 employed midwives in FPP, who lived in Mashhad, Iran, in 2013. Ethical aspects were observed throughout the research; accordingly, approval was obtained from the Ethics Committee of Mashhad University of Medical Sciences, Mashhad, Iran. Since sampling with maximum variation is usually preferred for qualitative studies (16), the data were collected using purposive sampling with maximum variation.
The participants were selected from a wide age range (i.e., 24-40 years), different levels of academic degree, and different health care centers. The inclusion criteria were at least one year of occupational experience in the FPP and living in Mashhad Healthcare centers. Mashhad Healthcare centers were selected since they were easily accessible. After informing the participants about the study objectives, informed consent was obtained regarding the recording of the data. Furthermore, the subjects were assured about the confi-dentiality of their data. At this stage, two participants did not give consent about the recording of the data; therefore, data collection was performed through note taking.
The first author collected the data
using individual in-depth, semi-structured interviews. The interviews were started by asking general open-ended questions, such as “What were your experiences in FPP?” and “? What difficulties did you have in FPP?” The next questions were based on the participant's response to the primary questions. Probing questions were asked for the clarification and illumination of responses to find out the depth of the women’s experience. All interviews were tape-recorded and transcribed word for word. Subsequently, the interviews and field notes were analyzed to plan for the next interviews.
The duration of the interviews was 45-60 min. In the current study, sampling was continued until data saturation. The
place of interviews was based on the participants’ choices. Data analysis was performed through the conventional method of content analysis, which is potentially one of the most important methods in social sciences (14). After reading the interview transcriptions pre-cisely for several times, they were analyzed through the open coding system to extract the primary concepts.
To this aim, first, the content of the interviews was divided into meaningful units, which were summarized in the next level
and codified accordingly. Subsequently, the obtained codes were compared and classified based on their similarities and differences, and then sorted into sub-categories and categories, which constituted the manifest content. Finally, the underlying meaning or the latent content of the categories was formulated into a theme.
Data were analyzed using the ATLAS.ti software, version 5. In order to confirm the research quality, four criteria of Lincoln and Guba (1985), including credibility, depen-dability, conformability, and transferability, were evaluated (17). In order to increase the validity and reliability of the findings,
we considered some measures, including prolonged engagement, protracted data collection and analysis, sometimes repeated interviews for data completion, repeated reading of the manuscripts, and member check.
According to the results, the majority of the participants were within the age range of 25-30 years and had an occupational experience of less than six years. Out of the 23 midwives, 8 and 15 subjects had associate diploma and bachelor’s degrees in midwifery, respectively. Data analysis resulted in the extraction of two major themes, entailing several categories and subcategories (Table 1).
In the second version of the FPP, the autonomy of the midwives has been invaded, and they cannot really work independently based on the guidelines.
Table 1. Themes, categories, and subcategories of midwives’ challenges and blessings
Professional role ambiguity
- Challenges related to referral system
- Challenges related to insurance
- Imposed conditions
- Professional incoordination
- Distortion of trust in midwives
- Affective commitment
- Commitment sustainability
- Destruction of preconception
- Insufficient motivation
- Welfare satisfaction
- Environmental satisfaction
- Organizational satisfaction
- Serving the women
Although the prescription of sonography and some medicine is within the scope of midwifery practice, in the FPP, these responsibilities have been limited based on the personal favors. Accordingly, the insurance companies do not accept the midwives’ prescriptions, and the women are forced to refer to the gynecology specialists for all simple complaints.
This process imposes higher financial burden on the families; furthermore, these unnecessary referrals can affect the women's preference for visiting a specialist. This process raises the possibility of encouraging the women to cesarean section by the specialist. According to most of the participants, the challenges, which undermined their professional autonomy, were the referral procedures of the women as well as lack of financial resources and insurance coverage.
In terms of the challenges related to the insurance system, one of the participants stated:
"Professional autonomy of midwifery is limited by FPP guidelines. You know, we always have problems with the insurance. When the pregnant mothers or patients refer to us, we do everything, but we don’t have the authority to prescribe them in their health insurance cards, and the physician writes our prescriptions in the cards”.
This lack of dependence was also evident in the statements of another participant as follows:
“We do everything for the pregnant woman, but ultimately, she has to be referred to the physician in order to have her prescription written in the insurance card.”
Professional role ambiguity
Based on the interviews, role ambiguity arises when the individual’s professional role, predictive capacity, limits, or responsibility is not defined clearly, and the people do not have any clear insight about their roles in the organization. In this study, the majority of the participants indicated ambiguity as one of the main challenges in the administration of FPP in the rural areas.
This concept was indicated by a participant as she argued:
“We don’t know what our role is in this plan? Midwives take various roles in the family physician plan. One day, we are a midwife, another day, a receptionist who gives numbers to the patients, and sometimes, we play the role of a pharmacy technician. In fact, we must work as the Jack of all trades.”
Another midwife affirmed this claim when she noted:
“The poor clients are also confused about our role. When they see that we cannot prescribe anything in their insurance card, they finally refer to a general male physician or obstetrics and gynecology doctor.”
The majority of the participants in this study considered the professional commitment as a practical necessity, which facilitates the fulfillment of the given duties without any need for supervision in its best possible level. According to some participants, professional commitment covers a number of concepts, including concern, honesty, commitment, accountability, commu- nication, beliefs, morals, as well as professional development and engagement.
In this regard, one of the parti-cipants remarked:
“We are midwives and we are committed to help the mothers of the community. In fact, this is our responsibility.”
This sense of commitment to help others was also indicated by another participant:
“My objective is to serve the women of the society, and that’s why I have accepted all these difficulties; otherwise, I wouldn’t accept this work condition.”
Destruction of preconceptions, insufficient motivation, and stress-making factors were among the internal challenges of the midwives in the FPP.
In this respect, one of the parti-cipant expressed:
“Before signing our contracts, we had different suppositions, I assumed I would have some responsibilities, which were different from those I’m doing now, but currently, I consider that things are very different.”
Some participants believed that their stress was the result of their interaction with the environment, and that it happened when there was no harmony between the situational pressures and the available resources. One of the participants remarked:
“You have to think about all the details of a pregnant woman, even catching cold makes sensitivity. They force us to visit the patient and follow up the case. They even expect us to take the patient to the city with the ambulance until she is cured. I don’t say being sensitive is undesirable, but doing such trivial things are within the scope of the care givers’ responsibility.”
The majority of the participants believed that people’s job satisfaction, assumptions, feelings, and positive pers-pectives were affected by such factors as work environment, organizational system, and relations governing the environment. Job satisfaction was among the midwives’ challenges in the FPP. This concept was pointed out in the statement of a participant when she complained:
“When we go on group missions, everybody receives payment for their mission unless us. The pharmacist, physician, and even the receptionists have mission payment, but the midwives don’t”.
This dissatisfaction was also raised by another participant when she stated:
“When we have a problem and pose it with the head midwives, they treat us very logically and support us; therefore, we feel being heard. But when we talk with people from other fields, they treat us very rigidly and complicatedly, they don’t consider us as midwives and treat us as inferiors.”
Additionally, most of the participants expressed their dissatisfaction with the welfare perspectives. Accordingly, one of the subjects said:
“The income that we receive is not bad, but the way they pay it and calculate the work hours is different from the other midwives working in the same centers.”
Another participant declared her dis-content as follows:
“They have given me a room that is very small, and one cannot even move in it. This is against the midwives’ standards of practice.”
Working with women and children was reported as a major motive for job satisfaction by the majority of the midwives. This was apparently stated by a participant as follows:
“My interest in helping the women is an important motive for working in this village. Itis enjoyable to provide the women with health services.”
In the present qualitative study, the challenges and blessings of the midwives in the FPP were summarized in two main themes extracted from the data analysis. These two themes included professional struggles (including professional autonomy, ambiguity of role, professional commitment) and self-reflection (entailing internal challenges and internal dissatisfaction). The possibility of establishing an independent office is considered as a motivating factor for choosing this job among the midwifery students.
In a study conducted by Alizadeh et al., paying attention to the needs of the society and serving the people were reported as the variables influencing the midwives in choosing this discipline. Other factors identified in the mentioned study were exclusive relationship with children and women, possibility of personal and moral growth, personal inclination towards this field, and possibility of establishing an independent office (12). One of the reasons that midwives choose this discipline is professional autonomy. Nonetheless, this issue was among the mentioned challenges of midwifery since the majority of the patients referred to the physicians and the insurance organizations disagreed to sign contracts with the midwives.
Balancing a variety of roles while midwifery students are completing their education and preparing for their tasks are the transitional processes in constructing their professional identities. According to the role theory, role ambiguity signifies the lack of specificity and predictability for an employee’s job. It also denotes responsibility and the single or multiple roles that oppose the role incumbent, which may not be clarified in terms of expectations, priorities, behaviors, or performance levels.Role ambiguity would have a negative impact on individual’s readiness for change (19). In the present study, professional role ambiguity was considered as another challenge by the midwives. Most of the participants were assigned a variety of roles; accordingly, they had to work as a receptionist, pharmacy manager, and so forth.
Furthermore, high professional commitment was reported as one of the blessings by the midwives in the present study. In this regard, the majority of the subjects considered themselves committed to serving women and children in the country. However, in a study carried out by Hadizadeh Talasaz et al., most of the investigated midwives were reported to have low level of professional commitment (20).
This discrepancy between the findings of the two studies may be due to the differences in the individual and social characteristics of the study populations. Professional commitment is an important variable, which improves productivity and quality of service delivery by affecting the employees’ performance. This criterion has
been regarded as an important variable in understanding the employees’ behavior (21). Therefore, it is necessary for the managers to periodically evaluate the commitment in midwives and assess the occupational and organizational factors affecting professional commitment to improve midwives’ function.
Individuals’ satisfaction with their occu-pation was another issue, which was attractive to the people working in the area of midwifery. Paying attention to job satisfaction in midwives is considered as an important factor in the health systems for providing care to two layers of the vulnerable groups (i.e., mothers
and children). Most of the participants were
not satisfied with the welfare conditions. Furthermore, they argued that the income, payment method, and work hours are different in the FPP, compared to those in other centers. In line with the present study, in a study performed by Ghorbani et al., it was reported that the midwives of the FPP were dissatisfied with their welfare condition, income, and work hours (8).
Another challenge raised by the midwives was the dissatisfaction with physical location. Considering the fact that in the health centers, various services are provided by different groups, the FPP centers should be designed in a way that facilitates an environment to cover the needs of these groups. However, according to the participants, family physician was not considered in designing of the structure of these centers. Furthermore, special limitations of the rooms and oldness of the environment were mentioned as other challenges of this plan. It seems that the improvement of housing condition is a key point in the persistence of service delivery in the deprived and remote areas of the country.
Job satisfaction as an important factor contributing to employment success leads to higher performance level and self-satisfaction. It is believed that a satisfied employee has more effective and efficient performance, which is the basis of management promotion (22, 23). Although the midwives’ job satisfaction was at a low level in this study and other studies (24), the midwives would not compromise the quality of health care due to the high sensitivity of their job, even if they were dissatisfied.
In the present study, internal challenges, such as lack of intrinsic motivation and stress, were mentioned as the challenges of the midwives in the FPP. Work stress among the healthcare staff is regarded as the most significant issue, which has been posed in the recent decades. This issue is considered as a threatening factor for the physical and mental health of the individuals. Medical team members are exposed to high levels of pressure. Stressful factors with the synergistic effect of job dissatisfaction can threaten the individuals’ mental or psychosocial health (25, 26).
In a study conducted by Kordi, most of the midwives suffered from severe work stress. The most important factors in causing such stress were changing or leaving the job and lack or shortage of colleagues. Moreover, Kordi showed that work stress had a positive correlation with job satisfaction (27). In a study performed by Nezvik et al., the results of a job evaluation questionnaire revealed that most of the midwives had stress in this regard (28).
Furthermore, in another study, a statistically significant indirect correlation was observed between occupational stress and organizational commitment (20). Therefore, due to the nature of midwifery, the managers should take some measures targeting toward the reduction of the stressors affecting midwives in FPP. The results of a study carried out by Hezaveh et al. showed that the provision of feedback about the outcomes of the delivered services had the greatest effect on the staff motivation. In addition, career advancement opportunities and merited directors were reported to have a significant effect on the amount of the staff’s occupational motivation (29).
In a study performed by Safdarsi et al., interest in the field of study and serving the patients were reported as the factors resulting in highest occupational motivation; on the other hand, professional autonomy led to the lowest motivation. In the majority of cases, the satisfaction from the midwifery profession was at a moderate level (30).
This study was the first attempt for the identification of professional challenges among the midwives recruited in FPP in Iran using a qualitative approach. The limitation of this study was that the research findings could not be generalized to other regions of the country. Therefore, further studies are recommended to investigate the work conditions of the midwives in the FPP in various health centers. Listening to the voices of midwives provides vital information about their challenges and blessings.
Investigation of the midwives’ perspectives can provide vital information about the challenges and blessings of this population. The results of the present study can provide valuable guidelines for the managers to recognize the challenges of the midwives in the FPP and plan to solve their organizational problems in order to enhance their function to achieve organizational goals.
Recommendations for Future Studies
According to the findings of the present study, it is recommended to establish a committee, including a group of midwives to arrange some programs to recognize the factors that could enhance midwives’ commitment and job satisfaction. Moreover, it is suggested to devise a proper stress reduction program and perform similar studies in other cities of Iran.
The present study was approved by Deputy of Research of Mashhad University of Medical Sciences (910333). The researchers offer their great appreciation to the Research Deputy of Mashhad University of Medical Sciences for financial support of this research project. We also thank the midwives, who accepted to participate in our study and share their experiences with the researchers
Conflicts of interest
The authors declare that they have no conflicts of interest.