Job Satisfaction and its Related Factors in Midwives Working in the Health Services System in Iran: A Systematic Review

Document Type : Systematic Review


1 PHD student in Reproductive Health, Student Research Committee, Shahid Beheshti University of Medical Sciences, Tehran, Iran

2 Professor, Department of Midwifery, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran

3 Professor, Department of Biostatistics, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran

4 MD, MPH, PhD, Skin and Stem Cell Research Center, Tehran University of Medical Sciences, Tehran, Iran

5 Assistant Professor, Social Determinant of Health Research Center, Clinical Research Institute, Urmia University of Medical Sciences, Urmia, Iran


Background & aim: Job satisfaction of midwives plays an important role in the efficiency and performance of health centers and the quality of midwifery services. This study reviewed job satisfaction and its related factors among midwives working in health systems in Iran.
Methods: In this systematic review, the databases of Web of Science, Scopus, PubMed, PsycINFO, Embase, Google Scholar and Magiran, were searched between 2000 and 2021 using keywords of midwife, job satisfaction, occupational stress, and Iran. The research steps were based on PRISMA. For quality assessment, the articles were evaluated according to the inclusion criteria by two researchers with the Newcastle-Ottawa scale. 
Results: A total of 23 articles including 3,352 midwives working in the health and medical centers were reviewed. The level of job satisfaction was moderate, and the job satisfaction of midwives working in hospitals was lower than that of those working in health centers. The highest level of satisfaction was related to the job positions and relationships with colleagues, and the lowest level was in relation to the salary and job benefits. Marital status, age, income, salary, organizational position, education, employment status, interest in the field of education, and workplace had a relationship with increasing job satisfaction. Tensions in the workplace environment was associated with decreasing job satisfaction.
Conclusion: It is necessary to provide conditions to improve job satisfaction of midwives in order to identify and removing barriers and improving professional belonging to promote occupational health and optimize the quality of providing midwifery services.



Job satisfaction is considered the most commonly investigated variable in organizational research, as it is of critical importance for employers to know the deterrent factors from working proceeding, and how to pay the workers' reward (1-2). Job satisfaction by creating new ideas and creativity has basically affected the behavior of people in the organization from different aspects (3). It affects many positive variables of the organization such as improving personnel efficiency, belongingness, commitment to the organization, quality of life, and also patients’ satisfaction (4-5). Many studies have indicated the effect of 

various factors on the job satisfaction of the personnel that includes competition in payment, adequate man power (6), job security and development, job opportunity promotion (7), balanced work amount, control and management, recognition, and positive relationship with the colleagues (8), job independence, appropriate work place, and possible rewards (9). Meanwhile, lack of job satisfaction leads to burnout, high turnover of employees, deteriorated defect of the current workforce (7), negative effects on the physical and mental well-being of the health personnel, and decreasing the quality of the health care services provided for the patients (10).

Generally, midwives, as the basic members of the health care team, along with other health specialists, play a key role in providing high quality health care services for mothers in three levels of hospital, health centers, family, and society (11). Job satisfaction of midwives varies in different countries, reported to be 41% in the U.S., 38% in Scotland, 36% in England, 33% in Canada, and 17% in Germany (12). In the study done in Tehran, less than half of the midwives (48%) had moderate job satisfaction (13). The findings of a review study in 2017 showed that midwives' job satisfaction is affected by different factors such as not supported by the health centers' managers, low salary and income, inadequate human resources, no enough time for professional activities, no balance between work and family life, heavy work load, inappropriate work place, and not developing professionally, so that job dissatisfaction would be one of the consequences (14).

Although many midwives are interested in this profession, job satisfaction has been somewhat variable in different studies, requiring the investigation of the most important reasons for the reduction of job satisfaction and relevant inhibitors. Various studies have been conducted during the last decade regarding job satisfaction among midwives and related factors resulting in different findings. Considering the importance of job satisfaction in improving the quality-of-service delivery, as well as the deep effects of external and internal factors for this important outcome, and since no review study has been conducted in Iran on midwives’ job satisfaction and the related factors, therefore, the researchers decided to perform this systematic review aimed to determine the most important factors affecting job satisfaction of midwives so that it can be used as a practical result in ministerial decisions and policies.

Materials and Methods

The research steps of the present study were performed according for writing standard of the systematic studies, PRISMA Meta-analysis (15). The research population of the study included the articles on job satisfaction of midwives in Iran. To find the related articles, databases of Embase, Magiran, SID, Web of Science, Scopus, PubMed, PsycINFO, and Google Scholar search engines were searched for Persian and English articles during 2000-2021.

The search was done using the keywords "Birth Attendant", "Traditional Birth Attendants", "Job Satisfaction", "Occupational Stress,", "Midwife", and "Midwifery," combined with the operators AND and OR (Table 1). The inclusion criteria were: Persian or English articles published in the past two decades, Iranian midwives working in health and medical centers of the country, using a standard scale to measure job satisfaction and necessary explanations about how to evaluate this variable by researchers, the number of sample proportion to the study design, access to the full text of the articles, and observational studies (descriptive, cross-sectional, cohort and case studies).

The exclusion criteria were: the articles in which the participants were health care providers other than midwives (physicians, nurses, and health workers), similar articles published in different journals, studies with designs incompatible with the inclusion criteria of the present study (interventional studies, review studies, posters, editorials, cover letters), and no access to the full texts of the articles. After investigating the inclusion and exclusion criteria, 23 articles remained for the final investigation based on the PRISMA checklist. The stages of identification, screening, eligibility, inclusion and final selection of the articles in the

The process of the present systematic review was initiated by searching the related databases. Accordingly, 201 articles were obtained during the initial search and then entered the END Note Software. After the deletion of the 102 duplicate articles by the software, the titles and the abstracts of 99 articles were examined. Thus, 52 articles were excluded from the study because they were not relevant to the purpose

of the present study. Then, the full texts of the remained articles (47 articles) were reviewed and examined by two researchers independently; in the cases of disagreement or doubt on similarities as well as the inclusion or exclusion criteria of the study, the opinion of the third researcher was used. Finally, 23 articles that met the inclusion were investigated in the phase of quality assessment.

The process of searching the articles lasted from December 2020 to February 2021. The eligibility of the selected articles was evaluated qualitatively by two researchers independently with the NOS scale (Newcastle-Ottawa) for observational studies according to the inclusion criteria (16). According to this scale, the articles were graded from zero (the weakest articles) to 10 (the strongest studies), while the articles with scores higher than 4 were regarded as high quality papers.

After quality assessment, in order to extract data from the texts of the qualified articles, two researchers independently extracted the related data according to the names of the authors, date of publication, type of the study, place of the research, sample size, sample properties, standard research tools, and main findings by a research-devised form (Table2).


In the present study, all the published articles were examined in the databases according to the purpose of the study. A total of 23 articles relevant to the job satisfaction of the midwives working in the health and medical centers (10 articles on health centers, 6 of the medical centers, 7 of both health and medical centers). Smith-Kendal-Hullin questionnaire was the most used tool to determine the level of job satisfaction of the midwives. Also, researcher-made tools were used in some studies. Other questionnaires included Herzberg Questionnaire, Minnesota Questionnaire, and Wysocki-Kromm Questionnaire (Figure 1).

Job satisfaction of the midwives working in the health-medical centers

In all the studies examined, 3352 midwives working in medical health centers had been investigated, while, the least sample size was in the study done by Ebrahimipour et al. (2014) with 37 midwives of health care from 271 member of health teams participated in the study (17), and the biggest sample size was in the study of Kousha et al. (2018) with 420 midwives (28).

Overall, in the majority of studies, the job satisfaction of midwives was average (12-13, 18,20,29,35), while the highest job dissatisfaction was reported in the study done by Fallah et al. (2018), in which 60% of the midwives expressed dissatisfaction with their job (22).

On the other hand, comparing the mean scores of job satisfaction of the midwives in 8 studies on two groups of midwives working in hospitals and health centers showed that in 3 studies, job satisfaction of two centers was equal (18,22,29), and in 4 studies, job satisfaction of the midwives working in hospitals was less than those working in health centers (5,28,30,33), and in one study, job satisfaction of midwives working in hospitals was more than those working in health centers (24). The level of job satisfaction was moderate in the majority of the midwives working in hospitals and health centers, and high job satisfaction was seen in a few midwives working in hospitals (5).

The aspects of job satisfaction and related professional factors among midwives

Regarding the difference between the measurements of job satisfaction in the evaluated studies, the dimensions of job satisfaction were extended as well. Among the 3 studies that used the Herzberg Questionnaire of Job Satisfaction, in a study conducted in Karaj, the highest mean score of job satisfaction was seen in the aspect of job position, and the lowest mean score of job satisfaction was in the aspect of job status and condition (18). In the other study performed in Tehran, payment and salary had the highest percentage of dissatisfaction, while colleague communication had the highest point in job satisfaction, and there was a significant relationship between job satisfaction and each aspect of satisfaction in working midwives (30). In the study in Mashhad, the aspect of recognition and acknowledgment had the highest level of satisfaction (29), while in another study performed in Abadan, the aspect of job security had the highest level of dissatisfaction (12).

Among 6 studies that used the Smith Job Satisfaction Index as the measurement tool, the highest job satisfaction was for the relationship with the colleague as well as the management and screening, while payment and benefits were the most common factor of midwives' job dissatisfaction (20,21). Among the 7 studies that used the researcher-made questionnaire, in 2 studies, the highest satisfaction was related to the relationship with the colleagues, and the lowest one was related to the payment and benefits (22,27). In one study which used the Minnesota Questionnaire, the highest score of job satisfaction was reported for the aspect of availability to the decision guidelines, and the lowest score was for the aspect of job promotion and development (13).

On the other hand, in the study performed in Rasht, the most important reasons for job dissatisfaction were related to organizational factors including facilities, job promotion, authority support in facing problems and acknowledging their functions, as well as payment and benefits, while the highest scores were obtained for using the opinions and suggestions of the midwives in decision-making, satisfaction with the performance, factors related to the working environment like the spatial atmosphere, facilities, equipment, supply 

of the consumed items, and regarding the aspect of the colleagues in job management factors, power and freedom of action in job, cooperation and collaboration of the colleagues (26).

In the evaluation of the selected articles, the highest correlation coefficient was for the aspect of screening and supervision, nature of occupation (21), the aspect of management policy making, and organizational culture (30) with job satisfaction. Furthermore, there was a significant relationship between the quality of working life (34), job tension (29), and organizational citizenship behavior with job satisfaction (31).

Job satisfaction and demographic factors related to midwives

In the examined articles, the age range of the midwives participating in the studies (20 articles) was mostly between 30-40 years old. Furthermore, in the majority of studies (19 articles), most of the participants were married (29). The majority of midwives had bachelor’s degrees (16 articles), and except in two studies, most of the midwives were contractually employed (21,25); in other articles, the participants were permanent employees, a condition that was more common among the midwives working in medical centers than those working in health centers (10 articles in health centers, 6 in medical centers, and 7 in both health and medical centers) (13,18). Working experience of the midwives in the articles was 3-20 years.

The interest of the midwives in their field of study was relatively high (18,30). In one study, there was an intermediate tendency to persist in the profession of midwifery among the health center midwives as health care providers (27); moreover, severe job tensions were higher among the midwives working in hospitals than those working in health centers (29). The findings of the extracted articles showed a significant relationship between job satisfaction and some demographic features like marital status, high salary, and payment, having an organizational position, higher academic education, more working experience, official employment status, the amount of interest, the number of populations covered by each midwife, and tension in the workplace (5,30,32). Moreover, some of these articles reported no statistically significant relationship between job satisfaction and some personal or professional features like marital status, working experience, the number of populations covered by each midwife, housing and income status, type of degree of education, and condition of employment (20,21,27,29,31).


The findings of this systematic review showed that the mean score of midwives' job satisfaction in most studies was average. Also, the job satisfaction of the midwives working in hospitals and maternity wards was significantly lower compared to those working in health centers. The most common reason for midwives' job dissatisfaction was related to the payment, then the conditions of the job, the working load, and several responsibilities compared to the private sector. The study done by Beiyrami et al. (2018) in Mashhad showed that midwives face challenges like destructive presuppositions, inadequate motivation, stressful factors, and dissatisfaction with welfare, environment, and organizational satisfaction, for which the investigation can provide valuable guidance for the managers to diagnose the challenges and solve the organizational problems, thus improving the efficiency of the midwives (37). Moreover, the study done by Fakhri et al. (2014) showed that the provision of services in the country's health system faces challenges such as inappropriate distribution, a lack of resources, and a disproportionate ratio of human resources to health needs in the society. Therefore, the managers of the health system must be careful in calculating the workload of midwives in the units for providing health services (38). Herzberg (2020), believes that these above-mentioned factors may not increase job satisfaction, but job dissatisfaction occurs when their quality reduces (39).

In many developed countries, by formulating policies based on the community, some opportunities have been created for midwives to enhance their skills in organizing and directing the local services for women and families (40). Meanwhile, in some less-developed countries, the basic issue that midwives face is their indefinite professional identity and tasks, which sometimes, in developing countries, due to different reasons like a lack of job planning and inappropriate service conditions such as payment, reward, and educational benefits, results in no professional progress and professional burnout because of working in indefinite conditions, an insecure workplace, and a lack of a proper reference system (41). On the other hand, part of the dissatisfaction was due to the responsibility load and multiplicity of tasks assigned to the midwives (42).

Despite the dissatisfaction with the financial and organizational benefits, the reason health care midwives want to stay in the profession can be a lack of alternative jobs, a great desire to work and benefit from the acquired profession, and a sense of being useful in society (27).

Furthermore, there was a significant direct relationship between job satisfaction and working experience (43). However, a study indicated that by increasing the working years, job tensions have increased as well (44), while in the study of Ganjgah et al. (2020), the job experience showed a statistically significant reverse relationship with the internal factors of job satisfaction (45).

Research indicated a direct relationship between the two factors of age and working experience and job satisfaction (36, 34). One of the most rational reasons for such findings is that, with passing time, the expectations of people about their jobs become more logical, and they gain more compatibility with their jobs. By increasing age and work experience, people acquire a more balanced understanding of the huge work load, which can be effective in fostering compatibility and job satisfaction (36).

The findings of the present study showed a statistically significant relationship between job satisfaction and official employment status (46). While, in the study of Ganjgah Masoumi et al. (2020), the mean score of job satisfaction of the corporate midwives was significantly higher than that of the official or contractual midwives (45). In most studies, the job position and relationship with colleagues have been reported as the most important aspects of average job satisfaction (5, 30). It seems that the relationship with colleagues, type and quality of the midwifery services, the position of the job among friends, relatives, and the spiritual value of the job have a more indirect relationship with the management issues (30).

Midwives in Iran are employed in the Family Physician Program as assistants, which makes them multitaskers and can bring a load of responsibility, sometimes outside the professional duties defined in the midwifery academic training program. The existing problems of the structuring system of health care providers, the lack of trade union protection laws, and the problems of employing midwives in professions not related to the job of midwifery have caused them to face countless challenges (47-48). On the other hand, no significant relationship was observed between job satisfaction and some demographic characteristics. These differences can be due to the different tools used in different research studies, different sample sizes, and different working conditions.

The findings of this study indicated the importance of further examination of the greatest experiences of the midwives regarding the facilitators and inhibitors related to job satisfaction. Limitations of the present study included atypical personal and organizational factors related to job satisfaction, as well as differences in the tools applied to measure job satisfaction, which caused heterogeneous styles in the studies investigated and triggered great diversity in the findings of the present study.

One of the strengths of the current research was that the results of this study, taken from all the studies conducted in Iran, were reported to be able to provide reliable scientific support for those involved in health systems to be used in policies in order to increase the satisfaction of midwives.

It is recommended to perform further studies on providing solutions to increase satisfaction-related subjects and applying measures like modifying the tasks of midwifery, developing clear instructions to promote professionalism, providing physically and mentally appropriate and standard atmosphere, paying attention to the financial needs and problems, enacting supportive legal principles, and employing experienced staff in the management positions can effectively increase the midwives' job satisfaction.


The findings of this systematic review indicated that due to the stressful nature of the job, especially for the midwives working in the maternity wards of the hospitals, and the burden of responsibility and fatigue because of the task load in different working shifts, especially nights, job satisfaction decreased among midwives working in hospitals compared to the midwives working in health centers, which can directly affect their physical and mental health as well as the quality of life. On the other hand, employing midwives in jobs irrelevant to their profession made them encounter many challenges in their job.


The present study has been conducted with the support of the School of Nursing and Midwifery of the Shahid Beheshti Medical University.

Conflicts of interest

The authors declared no conflicts of interest.


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