Caring Under Pressure: A Mixed-Methods Study of Work-Related Stress Among Skilled Health Personnel Providing Maternity Care in Nigeria

Caring Under Pressure: A Mixed-Methods Study of Work-Related Stress Among Skilled Health Personnel Providing Maternity Care in Nigeria | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Caring Under Pressure: A Mixed-Methods Study of Work-Related Stress Among Skilled Health Personnel Providing Maternity Care in Nigeria Hauwa Mohammed, Duncan Shikuku, Yusupha Sanyang, Eniola Kadir, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9097656/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background Nigeria bears the highest burden of maternal deaths globally; however, limited evidence exists on the work environments in which Skilled Health Personnel (SHPs) deliver maternity care and how these conditions shape care processes. Work-related stress (WRS), which arises when job demands exceed available resources, may undermine workforce wellbeing, care quality, and patient safety. Although workforce shortages and resource constraints are widely recognised challenges in LMICs, empirical evidence linking workplace stress to maternity service delivery remains limited. This study assessed the burden, drivers, consequences, and coping strategies associated with WRS among SHPs in Northern Nigeria. Methods We conducted a convergent mixed-methods study involving 194 SHPs from 48 public and private facilities in Kaduna, Bauchi, and Kwara States. Quantitative data were collected using the USDAW Workplace Stress Questionnaire, a single-item current stress measure, and a 1–10 stress severity scale and analysed using descriptive statistics and bivariate tests (Spearman’s correlation, t-tests, and ANOVA). Qualitative data from 7 focus group discussions and 8 key informant interviews were thematically analysed. Results Overall, 76% (147/194) of SHPs reported current stress, and 73% (107/147) attributed their stress primarily to work-related factors. Workload pressures were prominent: 36.6% worked > 60 hours/week, and 24.7% saw > 40 patients/day. Frequently reported stressors were heavy workload (39.2%), overcrowding (32.5%), and lack of equipment (31.4%). Stress severity was strongly correlated with heavy workload (r = 0.58, p < 0.01) and inadequate breaks (r = 0.50, p < 0.01). Mean stress scores differed significantly by cadre (F(12,181) = 2.58, p = 0.004; η² = 0.145), with higher levels among junior cadres. Qualitative findings described physical and emotional strain and perceived impacts on consultation quality of provider–patient interactions. Most participants (88.1%) reported no formal workplace stress support systems. Conclusion WRS among SHPs providing maternity care in Northern Nigeria is widespread, driven by structural and organisational conditions. Addressing WRS through workload-responsive staffing, supportive supervision, and institutionalised psychosocial support should be integrated into maternal health system strengthening efforts. Strengthening workforce wellbeing may be critical for sustaining safe, responsive, and high-quality maternity care delivery in high-burden settings. Work-related stress Skilled Health Personnel maternity care Figures Figure 1 Introduction Maternal and newborn mortality remain critical global health challenges, with significant disparities between high-income and low- and middle-income countries (LMICs). According to the World Health Organization (WHO), approximately 260,000 women died from pregnancy-related complications in 2023, with 95% of these deaths occurring in LMICs [ 1 ]. Similarly, 2.3 million neonatal deaths were recorded in 2022 [ 2 ]. To address these challenges, global initiatives including Every Woman Every Newborn Everywhere [ 3 ], implement solutions that aim to reduce maternal mortality to the Sustainable Development Goals (SDGs) targets of less than 70 deaths per 100,000 live births and neonatal mortality to below 12 per 1,000 live births by 2030 (SDGs 3.1 and 3.2) [ 4 ]. Achieving these targets requires expanding access to skilled birth attendance (SBA), improving healthcare infrastructure, and ensuring the availability of essential medicines and equipment. Skilled Health Personnel (SHPs) are central to achieving skilled births and improving maternal and newborn outcomes. In line with the WHO definition, SHPs refer to maternal and newborn health professionals who are educated, trained, and regulated to meet national and international standards and are competent to provide evidence-based, respectful, and culturally appropriate care, facilitate physiological childbirth, and identify, manage, or refer complications. However, their ability to perform these roles depends on an enabling work environment with adequate resources, supportive supervision, and policies prioritising their well-being [ 5 ]. Despite their essential contributions, SHPs in LMICs face multiple occupational challenges, including work-related stress (WRS). Work-related stress is defined as the response people may have when presented with work demands and pressures that are not matched to their knowledge and abilities and which challenge their ability to cope [ 6 ]. The WHO recognises WRS as a key occupational health risk that contributes to burnout, job dissatisfaction, and workforce attrition [ 7 ]. Globally, up to 49% of healthcare workers experience burnout [ 8 ]. In the UK, 71% of General Practitioners report compassion fatigue [ 9 ]. Mental health support, work-life balance, and stress management policies are essential for sustaining a motivated workforce; however, such interventions remain limited in many LMICs [ 10 ]. In Nigeria, the incidence of WRS among healthcare workers is alarmingly high. Recent studies indicate that up to 65% of the surgical workforce reports moderate to severe WRS, driven by excessive workload, high cognitive demands, inadequate remuneration, poor infrastructure, limited institutional support, and insecurity [ 11 ]. These system-level pressures have contributed to rising burnout and a worsening retention crisis, with increasing migration among SHPs, thereby threatening the sustainability and quality of maternal and newborn health services [ 12 – 14 ]. Over 9,000 healthcare professionals reportedly left Nigeria between 2016 and 2018, with approximately 74% of those remaining expressing an intention to emigrate [ 15 ]. This persistent brain drain has further strained the overstretched workforce, deepening the burden on those left behind and threatening the sustainability of the maternal and newborn health services. Nigeria accounted for over one-quarter (28.5%) of all estimated global maternal deaths in 2023, with approximately 75,000 maternal deaths. The maternal mortality ratio (MMR) is 993 deaths per 100,000 live births, and neonatal mortality is 34 per 1,000 live births [ 16 ]. However, these national averages obscure substantial regional disparities, with maternal mortality ratios in Northern Nigeria nearly double those in the South (709 vs. 365 per 100,000 live births) [ 17 ]. These inequities highlight the urgent need to strengthen health system performance in high-burden regions. Beyond infrastructure and service expansion, sustained reductions in maternal mortality depend on the well-being and effectiveness of the health workforce. To address these gaps, Nigeria has implemented several policies to strengthen maternal and newborn health services. One key initiative is the Midwives Service Scheme (MSS), launched in 2009 to deploy newly graduated, unemployed, and retired midwives to underserved rural communities to increase skilled birth attendance and reduce maternal mortality [ 18 , 19 ]. Second, in 2024, the Federal Government of Nigeria launched the Maternal Mortality Reduction Innovation Initiative (MAMII), which aims to expand access to maternal health services, train healthcare workers, and improve resources in maternity units [ 20 ]. While these interventions can potentially contribute to improving service availability and access, they have largely neglected the welfare, working conditions, and systemic support of SHP. These factors are equally critical for improving maternal and newborn outcomes and ensuring workforce sustainability [ 21 , 22 ]. Evidence is needed to inform policies and interventions that mitigate the effects of WRS on the delivery of maternal and newborn health services. This study addresses this gap by examining WRS among SHPs delivering maternity care in Northern Nigeria and situating stress experiences within the realities of routine service delivery. Moving beyond prevalence estimates, the mixed-methods design integrates quantitative and qualitative findings to provide deeper insight into how institutional, interpersonal, and workload-related stressors shape providers’ well-being and influence maternity care processes. Specifically, this study aims to (i) describe the burden and perceived severity of work-related stress among SHPs, (ii) identify key structural, organizational, and relational stressors, (iii) examine the health and care delivery consequences associated with stress, and (iv) explore the coping strategies and support systems available to SHPs. The findings are intended to inform context-specific, system-level interventions that strengthen workforce support, improve care quality, and ultimately contribute to better maternal and newborn health outcomes in high-burden settings. Methods Study Design A convergent mixed-methods design was employed; whereby quantitative and qualitative data were collected concurrently, analysed separately, and integrated during interpretation to provide complementary insights into work-related stress among SHPs. Study Settings The study was conducted in three states in Northern Nigeria: Kaduna (Northwest), Bauchi (Northeast), and Kwara (North-Central), selected based on accessibility, security, and representativeness. Within each state, three Local Government Areas (LGAs) were selected to capture sub-regional variations. Study Population and Sampling Data were collected from 48 functional health facilities that actively provided maternity services and routinely reported service data through DHIS2. These included 18 Primary Health Centres (PHCs), nine secondary facilities, three tertiary hospitals, and 18 private and faith-based facilities. Facility selection was conducted in collaboration with the State and LGA health authorities. The study population comprised SHPs working in maternity units across selected facilities in Kaduna, Bauchi, and Kwara States, including doctors, midwives, nurses, and Community Health Extension Workers (CHEWs), who play a central role in primary-level maternity care in Nigeria [ 23 ]. Quantitative sampling For the quantitative survey, a census of all eligible SHPs present during the data collection period was conducted at the selected facilities. The inclusion criteria required at least six months of experience in the current maternity unit. Within each selected facility, the participant information sheet was shared with all eligible SHPs through unit heads one week prior to the data collection. Recruitment targeted staff in antenatal clinics, labour wards, postnatal wards, family planning units, and obstetric wards. Participation was voluntary. Non-participation primarily occurred due to workload constraints at the time of data collection. Sample Size Calculation (Quantitative Component) The sample size for the quantitative component was calculated using the formula for determining the sample size for cross-sectional studies [ 24 ]. n = Z²P(1–P)/d². Where: n = required sample size Z = standard normal deviate at 95% confidence level = 1.96 P = estimated prevalence (86.2%), based on a prior study in three high-volume hospitals in Lagos, Nigeria [ 25 ]. d = margin of error (5%) The calculated sample size was 185 , and a 5% non-response buffer was added, yielding a final sample size of 194 . Data Collection tools Quantitative data were collected using the Union of Shop, Distributive, and Allied Workers (USDAW) Workplace Stress Questionnaire [ 26 ]. The instrument assesses work-related stress across six domains: job demands (including workload), control over work, role clarity, managerial and peer support, workplace relationships, and organisational change. The USDAW questionnaire has demonstrated internal consistency in public sector and healthcare settings and aligns with the UK Health and Safety Executive (HSE) Management Standards for assessing workplace stress. It has also been applied in low- and middle-income countries, including healthcare settings in India, supporting its relevance in resource-constrained environments [ 27 – 29 ]. In addition to the USDAW domains, participants were asked whether they were currently experiencing stress (yes/no). All respondents were asked to rate their perceived stress severity on a scale of 1–10, where 1 indicated minimal stress and 10 indicated extreme stress. The sociodemographic and professional characteristics collected included age, gender, cadre, and years of experience. Data were collected using a self-administered electronic questionnaire developed on the SurveyCTO platform and administered on study tablet devices. Qualitative Sampling and Data Collection Purposive sampling was used to recruit SHPs involved in maternity care at participating facilities. During the quantitative data collection, an additional participant information sheet outlining the qualitative component was distributed to eligible SHPs. Those who expressed interest and provided written informed consent were contacted and interviewed. The FGDs were stratified by cadre (doctors, nurses/midwives, and CHEWs) to encourage open discussion among professional peers, while maternity unit heads were purposively selected for key informant interviews. The interview and focus group discussion guides were developed specifically for this study based on the study objectives and relevant literature. The interview guide is provided as Supplementary File 1. Eight KIIs were conducted with maternity unit heads across different levels of care. Seven FGDs were conducted across the three states (three in Kaduna, two in Bauchi, and two in Kwara). Discussions were held in neutral, non-facility venues to ensure confidentiality and minimise workplace-related influences. Participants were provided with modest refreshments and reimbursement for transportation in accordance with ethical guidelines. Interviews were conducted by the first author and trained research assistants who were not affiliated with facility management and had no supervisory relationship with participants. Data collection was conducted primarily in English; where necessary, participants expressed themselves in local languages, which were translated during transcription. The qualitative data collectors were fluent in both Hausa and English. Interviews were audio-recorded, transcribed verbatim, and anonymised prior to analysis. Reflexive field notes were maintained to enhance the study’s trustworthiness. Data saturation was assessed iteratively and was reached when no new themes emerged from successive interviews and discussions. Data Analysis Quantitative data were analysed using SPSS version 28. Descriptive statistics (frequencies, percentages, means, and standard deviations) were used to summarise stress exposure and participant characteristics. Item-level responses from the USDAW questionnaire were reported using the original response categories (“Never”, “Sometimes”, “Often”). Current stress prevalence was calculated as the proportion of participants reporting active stress at the time of the survey. Among those who reported stress, work-attributed stress was defined as the proportion of those who identified work as the primary source. Mean severity scores were computed from the 1–10 self-rated scale. Associations between stress scores and selected variables were examined using Spearman’s correlation and one-way analysis of variance (ANOVA). Independent samples t-tests were used to compare mean stress scores by sex. Where significant differences were observed, post-hoc tests were conducted to identify specific group differences. Qualitative data were analysed using NVivo 12, following Braun and Clarke’s six-step thematic analysis framework [ 30 ]. Coding was conducted inductively, with themes being iteratively refined and mapped to the study objectives. The integration of quantitative and qualitative findings occurred at the interpretation stage. Ethical Considerations Ethical approval for this study was obtained from the Liverpool School of Tropical Medicine Research Ethics Committee, the National Health Research Ethics Committee of Nigeria, and the relevant State Health Research Ethics Committees. Written informed consent was obtained from all participants prior to data collection. Participation was voluntary, and confidentiality was ensured through anonymisation and secure data handling procedures. This study was conducted in accordance with the principles of the Declaration of Helsinki. Results Participant Characteristics A total of 194 SHPs participated in this study. Over half were Nurses and Midwives (51.0%), followed by CHEWs and CHOs (30.9%). Residents accounted for 7.2%, while House Officers and Medical Officers each represented 4.6% of the sample. Consultants comprised 1.5% of the participants. The workforce was predominantly female (84%). A more detailed breakdown of the professional categories is provided in Supplementary Table 1. [Table 1 here] Table 1 Distribution of Skilled Health Personnel by Cadre and Sex (N = 194) Cadre Males Females Total (n) Percentage (%) Nurses and Midwives † 5 94 99 51.0 CHEWs and CHOs ‡ 11 49 60 30.9 House Officers 3 6 9 4.6 Medical Officers (MO and SMO) 6 3 9 4.6 Residents (JR and SR) 4 10 14 7.2 Consultants (Obstetricians & Gynaecologists) 2 1 3 1.5 † Includes registered nurses, registered midwives, nurse-midwives, and BSc/NYSC nurses ‡ Includes Junior and Senior CHEW and Community Health Officers Work Settings and Work Patterns of Study Participants Most SHPs were deployed in labour and delivery units (n = 83, 43.3%) and antenatal clinics (n = 67, 34.5%). The remainder worked in postnatal clinics, family planning units, gynaecological emergency units, and antenatal wards. Workload indicators demonstrate substantial service demands. Most SHPs reported working 48–60 hours per week (n = 79, 40.7%), while 36.6% (n = 71) worked more than 60 hours weekly. In terms of patient volume, 33.5% (n = 65) attended to 20–40 patients daily, and nearly one-quarter (24.7%, n = 48) managed more than 40 patients per day. Night duties were also frequent, with 40.2% (n = 78) reporting 7-14-night shifts per month. The detailed workload distributions are presented in Table 2 . [Table 2 here] Table 2 Work Patterns of Skilled Health Personnel (N = 194) Work Pattern indicator Category Numbers Percentage Number of Working Hours /Week < 48hrs 44 22.7 48– 60hrs 71 36.6 Number of Patients Seen /Day < 20 81 41.8 20– 40 48 24.7 Number of Night Duties /Month 14 days 7 3.6 Prevalence and Perceived Severity of Work-Related Stress Work-related stress was assessed using the USDAW Workplace Stress Questionnaire, supplemented by a single-item measure of current stress and a self-rated severity scale (0–10) completed by all the participants. Across the USDAW domains, workload and organisational factors emerged as the most prominent stressors. Within the work processes domain, heavy workload was the most frequently reported stressor (39.2% reporting “often”), followed by inadequate breaks (23.7%). In the work environment domain, overcrowding (32.5%) and lack of equipment (31.4%) were the most reported. Regarding workplace relationships, harassment from patients or relatives (21.6%) and lack of communication from management (17.0%) were the leading stressors (Table 3 ). Overall, 76% (147/194) of the SHPs reported experiencing stress at the time of the survey. Among those who reported stress, 73% attributed their stress primarily to work-related factors. Among respondents who completed the severity scale (n = 189), the mean stress rating was 5.6 (SD 2.35) on a 10-point scale. Despite this burden, 88.1% of SHPs reported no access to formal stress support systems. However, 51.5% of the respondents reported being completely satisfied with their jobs. [Table 3 here] Table 3 Most Frequently Reported Workplace Stressors (“Often”) Among SHPs Category Stressor % Reporting Often Work Processes Heavy workload 39.2 Work Processes Inadequate breaks 23.7 Work Environment Overcrowding 32.5 Work Environment Lack of equipment 31.4 Workplace Relationships Harassment (patients/relatives) 21.6 Workplace Relationships Lack of communication from management 17.0 Note: Percentages represent the proportion of SHPs reporting that the stressor occurred “often”. Full item-level distributions are presented in Supplementary Table S2 . One-way ANOVA demonstrated no statistically significant differences in mean stress scores across age groups (F = 1.06, p = 0.395), maternity unit type (F = 1.29, p = 0.255), or years since their qualification (F = 0.42, p = 0.742). In contrast, stress levels differed significantly across professional cadres (F (12, 181) = 2.58, p = 0.004), with a large effect size (η² = 0.145). Post hoc analysis indicated significantly higher stress levels among junior and transitional clinical cadres, particularly House Officers/NYSC doctors and Junior Registrars, compared with several nursing and community health cadres. Differences were also observed between junior and senior medical ranks. The detailed pairwise comparisons are presented in Supplementary Table S3. Correlation Between Stress Levels and Workplace Factors Spearman’s correlation analysis indicated that perceived stress was most strongly associated with work process-related factors. Heavy workload demonstrated the strongest positive correlation with stress (r = 0.58, p < 0.01), followed by inadequate breaks (r = 0.50, p < 0.01). Unfair distribution of work (r = 0.38, p < 0.01) and shift work (r = 0.26, p < 0.01) also showed significant positive correlations. Within the work environment domain, noise (r = 0.32, p < 0.01) and overcrowding (r = 0.29, p < 0.01) were moderately correlated with high stress levels. Poor maintenance of equipment (r = 0.25, p < 0.01) and lack of equipment (r = 0.19, p < 0.01) showed weaker but statistically significant relationships. In the workplace relationships domain, harassment from patients or relatives (r = 0.36, p < 0.01) and lack of communication from management (r = 0.33, p < 0.01) were moderately associated with stress. Other relational factors showed weaker but significant correlations. Across domains, workload-related factors demonstrated stronger correlations with stress than environmental or relational variables. The detailed correlation matrices are presented in Supplementary Tables S4–S6. Consequences of Work-Related Stress: Physical and Psychological Symptoms Several physical and psychological symptoms consistent with occupational strain were reported. The most frequently reported symptoms occurring “often” were backache (34.0%), headache (29.4%), sleeplessness (19.1%), and neck pain (17.0%). Psychological symptoms were also evident, with irritability (10.8%), anxiety (10.8%), and inability to concentrate (11.3%) reported as occurring “often.” The full symptom distributions are presented in Table 4 . [Table 4 here] Table 4 Physical and Psychological Symptoms Associated with Work-Related Stress Among SHPs in Nigeria Symptom Never Sometimes Often Headache 22 (11.3) 115 (59.3) 57 (29.4) Anxiety 93 (47.9) 80 (41.2) 21 (10.8) Chest Pain/Palpitations 111 (57.2) 69 (35.9) 14 (7.2) Indigestion/Nausea 125 (64.4) 54 (27.8) 15 (7.7) Sleeplessness 69 (35.6) 88 (45.5) 37 (19.1) Irritability 100 (51.5) 73 (37.6) 21 (10.8) Backache 39 (20.1) 89 (45.9) 66 (34.0) Neck Pain 72 (37.1) 89 (45.9) 33 (17.0) Stomach Disorders 119 (61.3) 67 (34.5) 8 (4.1) Inability to Concentrate 102 (52.6) 70 (36.1) 22 (11.3) Qualitative Findings: Lived Experiences of Work-Related Stress The qualitative findings describe how SHPs experience and respond to the WRS within maternity care settings. Five interrelated themes emerged: (1) workload pressures and role strain, (2) resource constraints and organisational dysfunction, (3) relational tensions and hierarchical conflict, (4) physical, emotional, and professional consequences, and (5) coping strategies, support systems, and retention drivers. Workload pressures and role strain Participants consistently described excessive workload as the dominant source of stress, driven by understaffing, high patient volumes, and extended shifts, especially during afternoon and night shifts. One tertiary-level unit head explained how workload intensity varied by shift and staffing patterns “ Morning hours you have a full complement of staff. But in the afternoon and night, you may only see two nurses in the labour room manning 10–12 patients. The stress is much more in the afternoon and evening shifts.” (Male Head of O&G, Tertiary Centre) Workload stress was amplified by role strain, as SHPs reported taking on duties beyond their clinical scope due to limited ancillary staff. A nurse-midwife described the cumulative burden of clinical care and logistics tasks as follows: “ In our facility, even the attendant, we don’t have enough… imagine you will be the one to take patients to the theatre, go to the lab to collect blood, and still take it back to the theatre.” (Female Nurse Midwife, General Hospital) Workforce gaps caused by staff absences, including maternity leave, were also described as stress-provoking and sometimes created tension among colleagues: “… Almost half of the residents are on maternity leave, and more are going now. So that puts a lot of stress on those who are not pregnant and the males… The workload is much in this environment .” (Female HOD, O&G, Tertiary Centre) These accounts align with the quantitative pattern showing heavy workload and inadequate breaks as frequently reported stressors. Resource constraints and organisational dysfunction Participants described resource shortages and operational bottlenecks as routine, with staff often expected to deliver care without reliable equipment, supplies or functional systems. Several SHPs perceived managerial engagement as inconsistent, with resources appearing mainly during visits by external officials “ Management is like a ghost… they come, inspect, and suddenly everything’s available, but not for everyday practice.” (Male Doctor, General Hospital) A related concern was the perception that leadership prioritised revenue generation over staff welfare or safe practice. “ Their only concern is how much revenue your unit generates. But for you that are working there… they don’t care .” (Female Nurse, Tertiary) Relational tensions and hierarchical conflict Stress was also shaped by relational dynamics within maternity teams and across professional hierarchies. Junior staff described intimidation and disrespect as routine experiences that undermined morale and teamwork. “ Some senior doctors will insult you… and honestly, once my senior insults me or intimidates me, the patient suffers .” (Male Doctor Intern, Tertiary Centre) Tensions between cadres were commonly reported, particularly regarding communication norms and perceived disrespect. A nurse described an encounter with a junior doctor that escalated the workplace strain: “… Some of the doctors take themselves so high (proud)… A house officer came to do a procedure, didn’t even greet us, but later needed our help. We had to remind him about basic courtesy .” (Female Nurse, General Hospital) Patient-related hostility was another major relational stressor, with SHPs describing verbal aggression and threats from patients or relatives, particularly during delays: “ If you don’t attend to a patient immediately, there will be chaos. Even with security, it doesn’t help .” (Female Nurse, General Hospital) “ Some men even say they will beat you. We usually have such incidents.” (Female Head of Maternity, General Hospital) Physical, emotional, and professional consequences of stress Participants described stress as physically depleting and emotionally draining, often worsened by missed meals, long shifts, and lack of protected breaks. Several accounts highlighted dizziness and hypoglycaemia episodes linked to continuous work without food “ I remember when I passed out (from hypoglycaemia) … I’m always with Coke, morning review, I am always with my tea, on rounds I am always with my food.” (Female Intern, Tertiary Hospital) “ Yes, there was dizziness… I had to rush to get her a drink because there was not enough staff, and she had to continue working .” (Female Head of ANC, General Hospital) Some participants described severe consequences with no perceived organisational empathy or support: “… I started spotting due to the workload, running up and down. I was rushed to another hospital, and when I called to inform them, their only response was ‘why didn’t you come to our facility?’ No empathy.” (Female Nurse, General Hospital) Stress was also described as affecting care processes through fatigue, reduced concentration, and hurried interactions. A medical officer explained how exhaustion shaped patient engagement: “ Most times you are tired… you just ask, ‘Okay, what is your problem?’ You write one or two lines, and that’s it. In the long run, it affects the patients.” (Male Medical Officer, General Hospital) Emotional exhaustion also contributed to irritability and strained communication with patients. “ If you’re not happy, you won’t treat the patient well… We get complaints about rudeness, doctors not listening, and patients feeling ignored. It’s all part of stress.” (Female HOD, Tertiary Centre) The effects extended into their personal lives, with SHPs describing strained relationships and the need for family members to adapt to post-shift exhaustion: “ My daughter now expects me to leave for work every day. If she sees me at home, she feels something is wrong.” (Female Nurse, General Hospital) Coping strategies, support systems, and retention drivers Participants described coping strategies as largely informal and self-directed. Peer support and emotional venting were common. “ Sometimes it’s just complaining to a colleague… or going for tea or Coke when I can.” (Female Doctor, Tertiary Hospital) Many SHPs relied on their intrinsic motivation and passion for maternal care to sustain them: “… Because I have a passion for my job… I do not even count it as stress at times. The joy I have for the job keeps me going.” (Female Nurse, General Hospital) Rest management was a prominent coping mechanism, often requiring explicit negotiation within households. “ Everyone in my family knows not to call me within certain hours because I will be sleeping. Sunday is my rest day breakfast, sleep, lunch, sleep again. During the week, I barely sleep .” (Male Consultant, General Hospital) Recreational activities and self-care practices were also used to decompress after shifts. “…I burn turaren wuta (incense), it makes me happy… it gives me joy.” (Female Doctor, Tertiary Hospital) Support systems Most participants described the absence of formal workplace stress support mechanisms, with relief depending on informal, ad hoc decisions by supervisors “ Support system? I will say there is none, but… if they see it’s genuine (your stress), they (supervisors) allow you to go (and rest).” (Female Doctor, Tertiary Hospital) Some unit heads described informal internal coping arrangements such as shift swaps and temporary relief: “ When they are stressed, we usually sit with them and discuss issues. Sometimes we give them time off… or swap shifts with staff from less stressful units.” (Female Head of Maternity, PHC) In the absence of institutional support, domestic help and family members were described as essential external buffers. “ I have my sister with me, she cooks before I get home, so I just eat, pray, and rest.” (Female Nurse, General Hospital) Retention drivers Despite stress, many SHPs described their continued commitment to maternity care, often grounded in their professional identity and fulfilment from positive outcomes. “ What gives me joy, being a midwife, is seeing the mother and the baby in good health .” (Female Nurse, General Hospital) Workplace relationships and appreciation were repeatedly cited as reasons for staying: “ If there’s love and appreciation from superiors and colleagues, I feel encouraged to stay.” (Male Doctor, Tertiary Hospital) Recognition, both formal and informal, was described as morale-boosting: “ Every year they rate the nurses and doctors… end-of-the-year parties… it makes you feel appreciated .” (Female Nurse, General Hospital) However, pay dissatisfaction and perceived inequities were strongly demotivating: “ The workload is more than the salary we are taking… the salary is too small, while the workload is big.” (Female Nurse, General Hospital) “ My salary is not even up to 60,000 naira ($42), but on ANC days, I see up to 60 patients alone .” (Female midwife, PHC) Together, these findings highlight a workforce navigating sustained operational pressure with limited institutional support, relying largely on personal resilience and informal networks to remain engaged in maternity care delivery. Discussion This mixed-methods study examined the prevalence, determinants, and consequences of WRS among SHPs who provide maternity care in Northern Nigeria. We identified a high burden of perceived stress, driven primarily by heavy workloads, inadequate breaks, overcrowding, and resource constraints. Stress levels varied significantly across professional cadres, with junior cadres reporting higher stress levels, which were most strongly associated with workload intensity and organisational pressures. By linking stress exposure to perceived implications for clinical performance and care delivery, this study extends the existing evidence beyond individual well-being to position WRS as a system-level challenge within maternal health service delivery. Among respondents who reported current stress, 73% identified work-related factors as the primary source. This attribution is consistent with the strong quantitative associations observed between stress and workload or organisational factors, as well as the qualitative narratives centred on staffing shortages, resource constraints, and hierarchical pressures. Together, these findings indicate that the stress experienced by SHPs in this setting was predominantly occupational. These findings can be interpreted through the Job Demands-Resources (JD-R) framework, which conceptualises occupational stress as arising when job demands exceed the available job resources [ 31 , 32 ]. In this study, high job demands, particularly workload intensity, time pressure, shift burden, and role strain, coexisted with constrained job resources, including inadequate staffing, limited supervision, insufficient breaks, and the absence of structured stress-support mechanisms. Both quantitative associations and qualitative narratives illustrate how this imbalance was experienced in the routine delivery of maternity care. Although the JD-R framework was not prospectively operationalised in the study design, the convergence of findings suggests that the demand-resource imbalance provides a coherent explanatory lens for understanding WRS among SHPs in low-resource maternity settings. Importantly, this interpretation situates WRS within systemic service delivery conditions rather than framing it solely as individual vulnerability. To further synthesise these relationships, we developed a conceptual pathway linking structural demands, stress-related strain, and potential implications for maternity care delivery (Fig. 1 ). Within this conceptual framing, job demands in our study were reflected in structural and organisational conditions, including staffing shortages, heavy workloads, long working hours, and limited infrastructure. These pressures were consistently reported across all cadres and were associated with higher perceived stress severity. Similar demand-driven stress patterns have been documented in other LMIC maternity settings, where workforce shortages, high patient volumes, and infrastructural deficits contribute to occupational strain among frontline providers [ 33 – 35 ]. Sustained exposure to high job demands in the absence of adequate organisational resources aligns with the health-impairment pathway of the JD-R framework. SHPs in this study described psychological and physical manifestations consistent with this pathway, including emotional exhaustion, fatigue, sleep disturbances, headaches, and musculoskeletal discomfort. Comparable symptom patterns have been reported among healthcare providers in other LMIC contexts, where workload pressures and weak institutional support structures are linked to burnout and stress-related strain [ 36 – 38 ]. Importantly, the pathway also identifies informal job resources and buffering mechanisms, including peer support, intrinsic motivation, family support, and self-care practices. While these resources provide partial protection against stress, their informal and inconsistent nature underscores the absence of institutionalised support mechanisms and limits their capacity to sustainably offset high job demands. Taken together, this empirically grounded application of the JD-R framework situates work-related stress as a system-level determinant of maternity care performance rather than solely an occupational health concern. By linking workforce conditions, stress-related strain, care process impairment, and potential delivery risks, the framework offers a transferable lens for understanding how healthcare worker stress interacts with service delivery in resource-constrained maternity systems. These findings highlight the need for integrated interventions that strengthen both organisational resources and workforce conditions as core components of maternal health system strengthening. Qualitative accounts described delayed emergency responses, rushed consultations, and emotional detachment during patient engagement as effects of work-related stress. Although patient outcomes were not directly measured, the participants consistently linked stress to reduced attentiveness and impaired decision-making capacity, suggesting potential implications for care quality. These findings align with evidence from other LMICs, including Ghana, Kenya, Ethiopia, and South Africa, where workforce shortages, long shifts, and weak institutional support have been associated with burnout and reduced healthcare provider performance [ 13 , 34 , 39 – 42 ]. Stress levels did not significantly differ by gender, age, or years since qualification, suggesting that occupational stress in this setting is more closely linked to structural and professional conditions than to individual demographics. This contrasts with studies from Kenya and Ghana, which reported higher stress among female providers, attributed to emotional labour and role conflict [ 13 , 34 ]. Such differences may reflect the contextual variations in workforce structures and social norms. Nonetheless, our findings are consistent with broader evidence indicating that institutional and environmental conditions are stronger predictors of stress and burnout than demographic characteristics alone [ 10 , 40 ]. In contrast, cadre-specific disparities were observed. Junior CHEWs, House Officers/NYSC doctors, Senior Medical Officers, and Junior Registrars reported significantly higher stress levels than other cadres. These differences likely reflect the structural and role-based vulnerabilities within the health system. Transitional and mid-level cadres often carry substantial clinical responsibilities with limited decision-making authority, inadequate supervision, and constrained institutional support. Junior cadres may be disproportionately exposed to frontline emergency care and prolonged shifts, whereas senior mid-level clinicians may shoulder supervisory and administrative burdens without commensurate resources. Most LMIC studies on work-related stress do not disaggregate findings by professional cadre [ 10 ]. By identifying cadre-level disparities within maternity care teams, this study provides context-specific evidence to inform targeted interventions, such as structured mentorship, workload redistribution, and stress-support mechanisms tailored to transitional and lower-tier cadres. Workload emerged as the strongest quantitative correlate of stress (r = 0.58, p < 0.01), with over one-third of SHPs working more than 60 hours weekly and nearly one-quarter attending to more than 40 patients per day. While excessive workload has been widely documented as a stressor in Nigeria [ 11 , 12 ], our mixed-methods findings illustrate how WRS is experienced in routine maternity care settings in Northern Nigeria. Respondents described ongoing fatigue, impaired concentration, and emotional strain, noting that these challenges compromised consultation quality and clinical judgement. These findings suggest that workforce stress may have direct implications for care safety and service performance. These accounts provide contextual insights into how sustained workload pressures shape care provision in high-demand maternity units. Institutional gaps further intensified stress exposure. The majority of SHPs (88%) reported no access to formal workplace stress-support systems, relying instead on informal peer support, family assistance, or self-care practices. Similar patterns have been reported in other African settings, where structured staff well-being policies are limited [ 36 ]. Reliance on informal coping underscores the absence of institutionalized support mechanisms capable of sustainably mitigating chronic stress. Unlike workload, shift work demonstrated only a weak association with perceived stress. This may reflect the normalisation of shift patterns within a relatively young workforce. However, studies from Saudi Arabia and Korea have reported stronger associations between shift work and burnout [ 43 ], and systematic reviews have highlighted its adverse consequences for sleep and long-term health [ 38 ]. These differences reinforce the importance of context-specific interpretations of the drivers of occupational stress. Environmental and infrastructural deficits, including overcrowding, inadequate ventilation, poor lighting, and equipment shortages, were moderately associated with stress in our study. These facility-level constraints appear to exacerbate psychological strain and function as chronic stress amplifiers in resource-limited maternity units. Interpersonal stressors were also prominent. Hierarchical conflict, poor supervisory relationships, and harassment from patients or relatives were the recurrent themes in the qualitative narratives. Although their quantitative associations were moderate, the qualitative narratives revealed a substantial emotional toll. Similar findings have been reported in Ethiopia and Saudi Arabia, where poor communication from management and strained supervisory relationships were significant predictors of stress [ 41 , 43 ]. These results suggest that leadership culture and communication structures may meaningfully influence stress experiences among maternity teams. The mixed-methods design allowed for triangulation between the survey findings and lived experiences, revealing psychosocial dimensions of stress that may not be fully captured through quantitative scales alone. Notably, while quantitative analysis showed no significant sex differences in stress scores, qualitative accounts highlighted gender-specific stress experiences among female SHPs, including miscarriage, marital strain, and caregiving burdens. These findings reiterate the value of qualitative enquiry in illuminating dimensions of occupational strain that may remain statistically indistinguishable yet are practically significant. Finally, although peer support and intrinsic motivation emerged as key coping mechanisms, the heavy reliance on informal strategies reflects a culture of endurance within the maternity workforce. Suppression and avoidance coping may provide short-term adaptation but risk concealing chronic burnout. Without institutionalized support systems such as counselling services, structured debriefings, and protected rest policies, this culture of silent resilience may contribute to psychological distress, reduced job satisfaction, long-term workforce instability, patient care safety issues and poor quality of care. Strengths and Limitations A major strength of this study is that it represents, to our knowledge, the first mixed-methods investigation of work-related stress among SHPs providing maternity care in Northern Nigeria. By combining quantitative and qualitative approaches within a convergent design, the study enabled triangulation of statistical findings with in-depth experiential accounts. This integration provided nuanced explanatory insight into how stress is experienced, interpreted, and managed within routine maternity care settings. The inclusion of multiple facility types public and private and across primary, secondary, and tertiary levels enhanced contextual breadth and strengthened the applicability of findings across the health system. Importantly, the study examined stress across diverse professional cadres of SHPs, allowing for identification of both cadre-specific disparities and system-level stress patterns that are frequently underexplored in LMIC research. The use of a validated instrument to assess psychosocial working conditions further enhances methodological rigor and comparability with global literature. This study has several limitations. The use of non-probability sampling and self-reported measures introduces potential selection and reporting biases. The cross-sectional design limits causal inference, and the stress-care delivery pathways were not formally tested. Additionally, limited facility-level data restricted a deeper analysis of how institutional characteristics may shape stress patterns. The study was conducted in selected northern states; therefore, the findings should be interpreted as contextually transferable rather than nationally generalisable. Implications to policy and practice Addressing work-related stress among SHPs requires moving beyond individual coping strategies toward structural and institutional reforms within maternity care systems. Based on these findings, the following actions are recommended: Strategic workforce planning and redistribution , particularly in primary and secondary facilities, are required to address staffing shortages and workload concentration. Implementation of workload-responsive staffing models , including task-sharing and clearer role delineation, to reduce the pressure on overburdened cadres. Institutionalization of structured staff-support systems , such as regular debriefings, protected rest periods, psychosocial support services, and stress management programmes, should be integrated into routine facility management. Strengthening leadership and communication structures to reduce hierarchical conflict, improve supervisory support, and foster collaborative team culture. These interventions should be embedded within existing health system governance and workforce frameworks to enhance their feasibility, sustainability, and alignment with broader maternal health system strengthening efforts. Conclusion Work-related stress is pervasive among SHPs providing maternity care in Northern Nigeria and is driven primarily by structural and organisational conditions, particularly heavy workload, limited rest, resource constraints, and weak institutional support. Although SHPs demonstrate resilience through informal coping strategies, these mechanisms are insufficient to offset sustained demand-resource imbalances. Addressing WRS in maternity services requires systemic action, including workload-responsive staffing, protected rest policies, strengthened supervisory and communication structures, and institutionalized psychosocial support for the staff. Integrating workforce well-being into maternal health system strengthening efforts is essential for sustaining provider resilience and care quality. Abbreviations ANC Antenatal care CHO Community Health Officer CHEW Community Health Extension Worker JCHEW Junior Community Health Extension Worker SCHEW Senior Community Health Extension Worker HO House Officer MO Medical Officer SMO Senior Medical Officer OBGYN Obstetrician and Gynaecologist SHP Skilled Health Personnel USDAW Union of Shop, Distributive and Allied Workers WRS Work-Related Stress. Declarations Ethical Approval and Consent to Participate Ethical approval was obtained from the Liverpool School of Tropical Medicine Research Ethics Committee (Ref: 22-017) and the National Health Research Ethics Committee of Nigeria (NHREC/01/01/2007/23/08/2022). Additional approvals were obtained from the State Health Research Ethics Committees of Kaduna (HREC/17/03/2018; MOH/ADM/744/VOL.1/942), Bauchi (NREC/03/11/19B/2021/61), and Kwara (ERC/MOH/2022/08/072). Written informed consent was obtained from all participants prior to data collection. This study was conducted in accordance with the principles of the Declaration of Helsinki. Consent for Publication Not applicable. Availability of Data and Materials The datasets generated and/or analysed during the current study are not publicly available due to ethical and confidentiality considerations but are available from the corresponding author upon reasonable request. Competing Interests The authors declare no competing interests. Funding This study was conducted as part of the first author’s doctoral research. The research was supported by a grant from the Johnson & Johnson Foundation awarded to Prof. Charles Ameh (Project/Grant/RBPS No: ROC8398342CA). The funder had no role in the study design, data collection, analysis, interpretation of the data, or preparation of the manuscript. Authors’ contributions HM: Conceptualization; Methodology; Investigation; Data curation; Formal analysis; Project administration; Writing – original draft; Writing – review & editing. DS: Formal analysis; Methodology; Writing – review & editing. YS: Methodology; Writing – review & editing. EK: Investigation; Data curation; Writing – review & editing. MA: Investigation; Data curation; Writing – review & editing. AL: Methodology; Formal analysis; Writing – review & editing. FD: Methodology; Formal analysis; Writing – review & editing. SW: Methodology; Formal analysis; Writing – review & editing. AT: Methodology; Supervision; Writing – review & editing. JP: Conceptualization; Supervision; Methodology; Writing – review & editing. CAA: Conceptualization; Methodology; Supervision; Funding acquisition; Writing – review & editing. All authors read and approved the final manuscript. Acknowledgements The authors gratefully acknowledge the Johnson & Johnson Foundation for supporting the broader research programme under which this study was conducted. We also thank the Ministries of Health and the Primary Health Care Development Boards of Kaduna, Bauchi, and Kwara States, as well as the management and staff of the participating hospitals and primary health care facilities, for their support during the study. Most importantly, we sincerely appreciate the Skilled Health Personnel who generously shared their time and experiences to participate in this research. References Trends in maternal mortality 2020–2023.pdf> [Internet]. 2025. Available from: https://data.unicef.org/resources/trends-in-maternal-mortality-2000-to-2023/?utm_campaign=Trends%20in%20maternal%20mortality&utm_medium=email&utm_source=Mailjet UNIGME 2024 Child Mortality Report [Internet]. 2024. Available from: https://data.unicef.org/wp-content/uploads/2025/03/UNIGME-2024-Child-Mortality-Report_28-March.pdf WHO. Every Woman Every Newborn Everywhere. 2025 [Available from: https://ewene.org/ Sustainable Development Goals Report 2021 [Internet]. 2021. Available from: https://unstats.un.org/sdgs/report/2021/goal-03/ Defining competent maternal and newborn health professionals [Internet]. 2018. Available from: http://apps.who.int/iris/bitstream/handle/10665/272817/9789241514200-eng.pdf Work Organisation and Stress [Internet]. 2003. Available from: https://www.who.int/publications/i/item/9241590475?utm_source Caring for those who care; National Programmes for Occupational Health for Health Workers: POLICY BRIEF [Internet]. World Health Organization. 2020 [cited 15/05/2024]. Available from: https://iris.who.int/handle/10665/336479 Shanafelt TD, Hasan O, Dyrbye LN, Sinsky C, Satele D, Sloan J et al. Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014. Mayo Clin Proc. 2015;90(12):1600–13. Campbell D. Seven in 10 GPs in UK suffer from compassion fatigue, survey finds. The Guardian. 2025. Adriaenssens J, De Gucht V, Maes S. Determinants and prevalence of burnout in emergency nurses: a systematic review of 25 years of research. Int J Nurs Stud. 2015;52(2):649–61. Bashar JM, Aliyu D, Anyebe EE, Gabriel I, Nasir A, Mangari AS, et al. Perceived work-related stress and associated factors among the surgical workforce in a Nigerian tertiary health facility: A cross-sectional study. PLOS Glob Public Health. 2024;4(11):e0003959. Onigbogi CB, Banerjee S. Prevalence of Psychosocial Stress and Its Risk Factors among Health-care Workers in Nigeria: A Systematic Review and Meta-Analysis. Niger Med J. 2019;60(5):238–44. Odonkor ST, Adams S. Predictors of stress and associated factors among healthcare workers in Western Ghana. Heliyon. 2021;7(6):e07223. Global strategy on human resources for health: Workforce 2030 [Internet]. 2016. Available from: https://apps.who.int/iris/bitstream/handle/10665/250368/9789241511131-eng.pdf Falola HO, Ojebola OO. Assessing the Challenges of Medical Practitioners’ Retention and Its Implications in a Developing Economy. The Changing Landscape of Workplace and Workforce: IntechOpen;; 2024. Trends in maternal mortality 2000–2020 [Internet]. World Health Organisation. 2021 [cited 16/06/2024]. Available from: https://www.who.int/publications/i/item/9789240068759 Meh C, Thind A, Ryan B, Terry A. Levels and determinants of maternal mortality in northern and southern Nigeria. BMC Pregnancy Childbirth. 2019;19(1):417. Okpani AI, Abimbola S. The midwives service scheme: a qualitative comparison of contextual determinants of the performance of two states in central Nigeria. Glob Health Res Policy. 2016;1:16. Abimbola S, Okoli U, Olubajo O, Abdullahi MJ, Pate MA. The midwives service scheme in Nigeria. PLoS Med. 2012;9(5):e1001211. Abujah RFG, Launches MAMII, Project To Combat Alarming Maternal Mortality Rates Online. : Science Nigeria; 2024 [Available from: https://sciencenigeria.com/fg-launches-mamii-project-to-combat-alarming-maternal-mortality-rates/ Aluko OISa. Work Related Stress Management and the Performance of Workers in Public Health Facilities in Kwara State. Nigeria: Kwara State University (Nigeria); 2023. ten Hoope-Bender P, Lopes ST, Nove A, Michel-Schuldt M, Moyo NT, Bokosi M, et al. Midwifery 2030: a woman's pathway to health. What does this mean? Midwifery. 2016;32:1–6. Minimum Standards for Primary Health Care in Nigeria [Internet]. 2015. Available from: http://www.nphcda.gov.ng/Reports%20and%20Publications/Minimum%20Standards%20for%20Primary%20Health%20Care%20in%20Nigeria.pdf Pourhoseingholi MAVM, Rahimzadeh. Sample size calculation in medical studies. Gastroenterol Hepatol Bed Bench. 2013;6:14–7. Obasohan MO, Ayodele KO. Assessment of job stress among clinical health workers in three selected health-care industries in Lagos State, Nigeria. IFEPsychologIA. 2014;22(2). USDAW. Work Stress Questionnaire. Available from: https://usdawlive.b-cdn.net/live/media/e34ftiek/stress-questionnaire.pdf Kivimaki M, Virtanen M, Elovainio M, Kouvonen A, Vaananen A, Vahtera J. Work stress in the etiology of coronary heart disease–a meta-analysis. Scand J Work Environ Health. 2006;32(6):431–42. (HSE) HaSE. Management Standards for Work-Related Stress. London: Health and Safety Executive 2004 [Available from: Arumugam B, Prasad A, Nagalingam S. Work-Related Stress - A Major Occupational Health Issue. Int J Curr Res. 2015;7(6):16991–5. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Res Psychol. 2006;3(2):77–101. Demerouti E, Bakker AB, Nachreiner F, Schaufeli WB. The Job Demands Resource Model for Burnout. J Appl Psychol. 2001;86(3):499–512. Bakker AB, Demerouti E. Job demands-resources theory: Taking stock and looking forward. J Occup Health Psychol. 2017;22(3):273–85. Wright T, Mughal F, Babatunde OO, Dikomitis L, Mallen CD, Helliwell T. Burnout among primary health-care professionals in low- and middle-income countries: systematic review and meta-analysis. Bull World Health Organ. 2022;100(6):385–A401. Afulani PA, Ongeri L, Kinyua J, Temmerman M, Mendes WB, Weiss SJ. Psychological and physiological stress and burnout among maternity providers in a rural county in Kenya: individual and situational predictors. BMC Public Health. 2021;21(1):453. Dugani SAH, Hirschhorn LR, et al. Prevalence and factors associated with burnout among frontline primary health care providers in low- and middle-income countries: A systematic review [version 3; referees: 2 approved]. Gates Open Res. 2018;2:4. Bradley S, Kamwendo F, Chipeta E, Chimwaza W, de Pinho H, McAuliffe E. Too few staff, too many patients: a qualitative study of the impact on obstetric care providers and on quality of care in Malawi. BMC Pregnancy Childbirth. 2015;15:65. Govender IM, Okonta E. Stress among medical doctors working in public hospitals of the Ngaka Modiri Molema district (Mafikeng health region), North West province, South Africa. S Afr J Psych. 2012;18(2):42–6. Kecklund G, Axelsson J. Health consequences of shift work and insufficient sleep. BMJ. 2016;355. Kruk ME, Gage AD, Arsenault C, Jordan K, Leslie HH, Roder-DeWan S, et al. High-quality health systems in the Sustainable Development Goals era: time for a revolution. Lancet Glob Health. 2018;6(11):e1196–252. Mengist B, Amha H, Ayenew T, Gedfew M, Akalu TY, Assemie MA, et al. Occupational Stress and Burnout Among Health Care Workers in Ethiopia: A Systematic Review and Meta-analysis. Arch Rehabil Res Clin Transl. 2021;3(2):100125. Baye Y, Demeke T, Birhan N, Semahegn A, Birhanu S. Nurses' work-related stress and associated factors in governmental hospitals in Harar, Eastern Ethiopia: A cross-sectional study. PLoS ONE. 2020;15(8):e0236782. Lee HL, Wilson KS, Bernstein C, Naicker N, Yassi A, Spiegel JM. Psychological Distress in South African Healthcare Workers Early in the COVID-19 Pandemic: An Analysis of Associations and Mitigating Factors. Int J Environ Res Public Health. 2022;19(15). Al-Makhaita HM, Sabra AA, Hafez AS. Predictors of work-related stress among nurses working in primary and secondary health care levels in Dammam, Eastern Saudi Arabia. J Family Community Med. 2014;21(2):79–84. Additional Declarations No competing interests reported. Supplementary Files SupplementaryFile1InterviewGuide.docx.docx SupplementaryFile2SupplementaryTables.docx.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 22 Apr, 2026 Reviewers agreed at journal 20 Apr, 2026 Reviewers agreed at journal 16 Apr, 2026 Reviewers invited by journal 15 Apr, 2026 Editor assigned by journal 13 Apr, 2026 Editor invited by journal 20 Mar, 2026 Submission checks completed at journal 18 Mar, 2026 First submitted to journal 18 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9097656","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":627784411,"identity":"b360f52d-f388-4be2-b019-5b35fc1cf963","order_by":0,"name":"Hauwa Mohammed","email":"data:image/png;base64,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","orcid":"","institution":"Liverpool School of Tropical Medicine, Nigeria Office, Abuja","correspondingAuthor":true,"prefix":"","firstName":"Hauwa","middleName":"","lastName":"Mohammed","suffix":""},{"id":627784413,"identity":"8c8a6212-f619-4f2d-b3cb-6cfecc2fc738","order_by":1,"name":"Duncan Shikuku","email":"","orcid":"","institution":"Liverpool School of Tropical Medicine","correspondingAuthor":false,"prefix":"","firstName":"Duncan","middleName":"","lastName":"Shikuku","suffix":""},{"id":627784417,"identity":"91535d90-28ac-4666-9a7c-10d825384fba","order_by":2,"name":"Yusupha Sanyang","email":"","orcid":"","institution":"Liverpool School of Tropical Medicine","correspondingAuthor":false,"prefix":"","firstName":"Yusupha","middleName":"","lastName":"Sanyang","suffix":""},{"id":627784426,"identity":"af8f9f23-e6e9-44c3-9a34-9cacaa8b6fed","order_by":3,"name":"Eniola Kadir","email":"","orcid":"","institution":"University of Ilorin Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Eniola","middleName":"","lastName":"Kadir","suffix":""},{"id":627784427,"identity":"242b1a81-ee05-4eba-8282-c71c5e609f74","order_by":4,"name":"Michael Toyin Adeyemi","email":"","orcid":"","institution":"General Hospital Omu-Aran","correspondingAuthor":false,"prefix":"","firstName":"Michael","middleName":"Toyin","lastName":"Adeyemi","suffix":""},{"id":627784428,"identity":"506821db-99b0-4cd8-9f3e-9d49dff08c7b","order_by":5,"name":"Alice Ladur","email":"","orcid":"","institution":"Liverpool School of Tropical Medicine","correspondingAuthor":false,"prefix":"","firstName":"Alice","middleName":"","lastName":"Ladur","suffix":""},{"id":627784429,"identity":"96e476ec-1213-4513-8636-886801703648","order_by":6,"name":"Fiona Dickinson","email":"","orcid":"","institution":"Liverpool School of Tropical Medicine","correspondingAuthor":false,"prefix":"","firstName":"Fiona","middleName":"","lastName":"Dickinson","suffix":""},{"id":627784430,"identity":"337d21dc-2a5f-4a3b-9610-97fdd05f0fd1","order_by":7,"name":"Sarah White","email":"","orcid":"","institution":"Liverpool School of Tropical Medicine","correspondingAuthor":false,"prefix":"","firstName":"Sarah","middleName":"","lastName":"White","suffix":""},{"id":627784432,"identity":"7a6ece10-c8f6-49ea-b9b0-7ea7f507d08c","order_by":8,"name":"Abera Tura","email":"","orcid":"","institution":"Liverpool School of Tropical Medicine","correspondingAuthor":false,"prefix":"","firstName":"Abera","middleName":"","lastName":"Tura","suffix":""},{"id":627784433,"identity":"bceb95ee-2e3f-4978-b512-4df08dc6dfef","order_by":9,"name":"Justin Pulford","email":"","orcid":"","institution":"Liverpool School of Tropical Medicine","correspondingAuthor":false,"prefix":"","firstName":"Justin","middleName":"","lastName":"Pulford","suffix":""},{"id":627784435,"identity":"f2a90667-5425-48da-8b16-f125b2c1f2f8","order_by":10,"name":"Charles Anawo Ameh","email":"","orcid":"","institution":"Liverpool School of Tropical Medicine","correspondingAuthor":false,"prefix":"","firstName":"Charles","middleName":"Anawo","lastName":"Ameh","suffix":""}],"badges":[],"createdAt":"2026-03-11 19:23:29","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9097656/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9097656/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107635208,"identity":"b65112dd-acab-4a28-9de9-2348a5ee1b31","added_by":"auto","created_at":"2026-04-23 12:25:22","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":133737,"visible":true,"origin":"","legend":"\u003cp\u003eConceptual Pathway Linking Work-Related Stress to Maternity Care Delivery Risks\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9097656/v1/46a1b2b07aa2a7d064e1902b.jpg"},{"id":107707345,"identity":"548c08a1-73fb-4efe-96ba-08e7842cf3cf","added_by":"auto","created_at":"2026-04-24 09:20:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":536295,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9097656/v1/6c998b80-76c4-4a6e-a1d9-ff7ee7ca86e7.pdf"},{"id":107634950,"identity":"790b2239-7472-48ac-b345-3b13882b4fe6","added_by":"auto","created_at":"2026-04-23 12:24:30","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":16978,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFile1InterviewGuide.docx.docx","url":"https://assets-eu.researchsquare.com/files/rs-9097656/v1/66bfa513a8f768dde08f91ee.docx"},{"id":107635029,"identity":"9d00e0c3-12d0-46fc-987f-34cd2bf44c17","added_by":"auto","created_at":"2026-04-23 12:24:54","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":31689,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFile2SupplementaryTables.docx.docx","url":"https://assets-eu.researchsquare.com/files/rs-9097656/v1/384d40513f34938e70ef5a5a.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Caring Under Pressure: A Mixed-Methods Study of Work-Related Stress Among Skilled Health Personnel Providing Maternity Care in Nigeria","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMaternal and newborn mortality remain critical global health challenges, with significant disparities between high-income and low- and middle-income countries (LMICs). According to the World Health Organization (WHO), approximately 260,000 women died from pregnancy-related complications in 2023, with 95% of these deaths occurring in LMICs [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Similarly, 2.3\u0026nbsp;million neonatal deaths were recorded in 2022 [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. To address these challenges, global initiatives including Every Woman Every Newborn Everywhere [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], implement solutions that aim to reduce maternal mortality to the Sustainable Development Goals (SDGs) targets of less than 70 deaths per 100,000 live births and neonatal mortality to below 12 per 1,000 live births by 2030 (SDGs 3.1 and 3.2) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Achieving these targets requires expanding access to skilled birth attendance (SBA), improving healthcare infrastructure, and ensuring the availability of essential medicines and equipment.\u003c/p\u003e \u003cp\u003eSkilled Health Personnel (SHPs) are central to achieving skilled births and improving maternal and newborn outcomes. In line with the WHO definition, SHPs refer to maternal and newborn health professionals who are educated, trained, and regulated to meet national and international standards and are competent to provide evidence-based, respectful, and culturally appropriate care, facilitate physiological childbirth, and identify, manage, or refer complications. However, their ability to perform these roles depends on an enabling work environment with adequate resources, supportive supervision, and policies prioritising their well-being [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite their essential contributions, SHPs in LMICs face multiple occupational challenges, including work-related stress (WRS). Work-related stress is defined as the response people may have when presented with work demands and pressures that are not matched to their knowledge and abilities and which challenge their ability to cope [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The WHO recognises WRS as a key occupational health risk that contributes to burnout, job dissatisfaction, and workforce attrition [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Globally, up to 49% of healthcare workers experience burnout [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In the UK, 71% of General Practitioners report compassion fatigue [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Mental health support, work-life balance, and stress management policies are essential for sustaining a motivated workforce; however, such interventions remain limited in many LMICs [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn Nigeria, the incidence of WRS among healthcare workers is alarmingly high. Recent studies indicate that up to 65% of the surgical workforce reports moderate to severe WRS, driven by excessive workload, high cognitive demands, inadequate remuneration, poor infrastructure, limited institutional support, and insecurity [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. These system-level pressures have contributed to rising burnout and a worsening retention crisis, with increasing migration among SHPs, thereby threatening the sustainability and quality of maternal and newborn health services [\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOver 9,000 healthcare professionals reportedly left Nigeria between 2016 and 2018, with approximately 74% of those remaining expressing an intention to emigrate [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. This persistent brain drain has further strained the overstretched workforce, deepening the burden on those left behind and threatening the sustainability of the maternal and newborn health services.\u003c/p\u003e \u003cp\u003eNigeria accounted for over one-quarter (28.5%) of all estimated global maternal deaths in 2023, with approximately 75,000 maternal deaths. The maternal mortality ratio (MMR) is 993 deaths per 100,000 live births, and neonatal mortality is 34 per 1,000 live births [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. However, these national averages obscure substantial regional disparities, with maternal mortality ratios in Northern Nigeria nearly double those in the South (709 vs. 365 per 100,000 live births) [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. These inequities highlight the urgent need to strengthen health system performance in high-burden regions. Beyond infrastructure and service expansion, sustained reductions in maternal mortality depend on the well-being and effectiveness of the health workforce.\u003c/p\u003e \u003cp\u003eTo address these gaps, Nigeria has implemented several policies to strengthen maternal and newborn health services. One key initiative is the Midwives Service Scheme (MSS), launched in 2009 to deploy newly graduated, unemployed, and retired midwives to underserved rural communities to increase skilled birth attendance and reduce maternal mortality [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Second, in 2024, the Federal Government of Nigeria launched the Maternal Mortality Reduction Innovation Initiative (MAMII), which aims to expand access to maternal health services, train healthcare workers, and improve resources in maternity units [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. While these interventions can potentially contribute to improving service availability and access, they have largely neglected the welfare, working conditions, and systemic support of SHP. These factors are equally critical for improving maternal and newborn outcomes and ensuring workforce sustainability [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEvidence is needed to inform policies and interventions that mitigate the effects of WRS on the delivery of maternal and newborn health services. This study addresses this gap by examining WRS among SHPs delivering maternity care in Northern Nigeria and situating stress experiences within the realities of routine service delivery. Moving beyond prevalence estimates, the mixed-methods design integrates quantitative and qualitative findings to provide deeper insight into how institutional, interpersonal, and workload-related stressors shape providers\u0026rsquo; well-being and influence maternity care processes. Specifically, this study aims to (i) describe the burden and perceived severity of work-related stress among SHPs, (ii) identify key structural, organizational, and relational stressors, (iii) examine the health and care delivery consequences associated with stress, and (iv) explore the coping strategies and support systems available to SHPs. The findings are intended to inform context-specific, system-level interventions that strengthen workforce support, improve care quality, and ultimately contribute to better maternal and newborn health outcomes in high-burden settings.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eA convergent mixed-methods design was employed; whereby quantitative and qualitative data were collected concurrently, analysed separately, and integrated during interpretation to provide complementary insights into work-related stress among SHPs.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy Settings\u003c/h3\u003e\n\u003cp\u003eThe study was conducted in three states in Northern Nigeria: Kaduna (Northwest), Bauchi (Northeast), and Kwara (North-Central), selected based on accessibility, security, and representativeness. Within each state, three Local Government Areas (LGAs) were selected to capture sub-regional variations.\u003c/p\u003e\n\u003ch3\u003eStudy Population and Sampling\u003c/h3\u003e\n\u003cp\u003eData were collected from 48 functional health facilities that actively provided maternity services and routinely reported service data through DHIS2. These included 18 Primary Health Centres (PHCs), nine secondary facilities, three tertiary hospitals, and 18 private and faith-based facilities. Facility selection was conducted in collaboration with the State and LGA health authorities.\u003c/p\u003e \u003cp\u003eThe study population comprised SHPs working in maternity units across selected facilities in Kaduna, Bauchi, and Kwara States, including doctors, midwives, nurses, and Community Health Extension Workers (CHEWs), who play a central role in primary-level maternity care in Nigeria [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eQuantitative sampling\u003c/h3\u003e\n\u003cp\u003eFor the quantitative survey, a census of all eligible SHPs present during the data collection period was conducted at the selected facilities. The inclusion criteria required at least six months of experience in the current maternity unit. Within each selected facility, the participant information sheet was shared with all eligible SHPs through unit heads one week prior to the data collection. Recruitment targeted staff in antenatal clinics, labour wards, postnatal wards, family planning units, and obstetric wards. Participation was voluntary. Non-participation primarily occurred due to workload constraints at the time of data collection.\u003c/p\u003e\n\u003ch3\u003eSample Size Calculation (Quantitative Component)\u003c/h3\u003e\n\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThe sample size for the quantitative component was calculated using the formula for determining the sample size for cross-sectional studies [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;Z\u0026sup2;P(1\u0026ndash;P)/d\u0026sup2;. Where: \u003cb\u003en\u003c/b\u003e\u0026thinsp;=\u0026thinsp;required sample size\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eZ\u003c/b\u003e\u0026thinsp;=\u0026thinsp;standard normal deviate at 95% confidence level\u0026thinsp;=\u0026thinsp;1.96\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eP\u003c/b\u003e\u0026thinsp;=\u0026thinsp;estimated prevalence (86.2%), based on a prior study in three high-volume hospitals in Lagos, Nigeria [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003ed\u003c/b\u003e\u0026thinsp;=\u0026thinsp;margin of error (5%)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThe calculated sample size was \u003cb\u003e185\u003c/b\u003e, and a 5% non-response buffer was added, yielding a final sample size of \u003cb\u003e194\u003c/b\u003e.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData Collection tools\u003c/h2\u003e \u003cp\u003eQuantitative data were collected using the Union of Shop, Distributive, and Allied Workers (USDAW) Workplace Stress Questionnaire [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. The instrument assesses work-related stress across six domains: job demands (including workload), control over work, role clarity, managerial and peer support, workplace relationships, and organisational change. The USDAW questionnaire has demonstrated internal consistency in public sector and healthcare settings and aligns with the UK Health and Safety Executive (HSE) Management Standards for assessing workplace stress. It has also been applied in low- and middle-income countries, including healthcare settings in India, supporting its relevance in resource-constrained environments [\u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn addition to the USDAW domains, participants were asked whether they were currently experiencing stress (yes/no). All respondents were asked to rate their perceived stress severity on a scale of 1\u0026ndash;10, where 1 indicated minimal stress and 10 indicated extreme stress. The sociodemographic and professional characteristics collected included age, gender, cadre, and years of experience.\u003c/p\u003e \u003cp\u003eData were collected using a self-administered electronic questionnaire developed on the SurveyCTO platform and administered on study tablet devices.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eQualitative Sampling and Data Collection\u003c/h3\u003e\n\u003cp\u003ePurposive sampling was used to recruit SHPs involved in maternity care at participating facilities. During the quantitative data collection, an additional participant information sheet outlining the qualitative component was distributed to eligible SHPs. Those who expressed interest and provided written informed consent were contacted and interviewed. The FGDs were stratified by cadre (doctors, nurses/midwives, and CHEWs) to encourage open discussion among professional peers, while maternity unit heads were purposively selected for key informant interviews.\u003c/p\u003e \u003cp\u003eThe interview and focus group discussion guides were developed specifically for this study based on the study objectives and relevant literature. The interview guide is provided as Supplementary File 1.\u003c/p\u003e \u003cp\u003eEight KIIs were conducted with maternity unit heads across different levels of care. Seven FGDs were conducted across the three states (three in Kaduna, two in Bauchi, and two in Kwara). Discussions were held in neutral, non-facility venues to ensure confidentiality and minimise workplace-related influences. Participants were provided with modest refreshments and reimbursement for transportation in accordance with ethical guidelines.\u003c/p\u003e \u003cp\u003eInterviews were conducted by the first author and trained research assistants who were not affiliated with facility management and had no supervisory relationship with participants. Data collection was conducted primarily in English; where necessary, participants expressed themselves in local languages, which were translated during transcription. The qualitative data collectors were fluent in both Hausa and English. Interviews were audio-recorded, transcribed verbatim, and anonymised prior to analysis. Reflexive field notes were maintained to enhance the study\u0026rsquo;s trustworthiness. Data saturation was assessed iteratively and was reached when no new themes emerged from successive interviews and discussions.\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eQuantitative data were analysed using SPSS version 28. Descriptive statistics (frequencies, percentages, means, and standard deviations) were used to summarise stress exposure and participant characteristics. Item-level responses from the USDAW questionnaire were reported using the original response categories (\u0026ldquo;Never\u0026rdquo;, \u0026ldquo;Sometimes\u0026rdquo;, \u0026ldquo;Often\u0026rdquo;). Current stress prevalence was calculated as the proportion of participants reporting active stress at the time of the survey. Among those who reported stress, work-attributed stress was defined as the proportion of those who identified work as the primary source. Mean severity scores were computed from the 1\u0026ndash;10 self-rated scale.\u003c/p\u003e \u003cp\u003eAssociations between stress scores and selected variables were examined using Spearman\u0026rsquo;s correlation and one-way analysis of variance (ANOVA). Independent samples t-tests were used to compare mean stress scores by sex. Where significant differences were observed, post-hoc tests were conducted to identify specific group differences.\u003c/p\u003e \u003cp\u003eQualitative data were analysed using NVivo 12, following Braun and Clarke\u0026rsquo;s six-step thematic analysis framework [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Coding was conducted inductively, with themes being iteratively refined and mapped to the study objectives. The integration of quantitative and qualitative findings occurred at the interpretation stage.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eEthical Considerations\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eEthical approval\u003c/strong\u003e \u003cp\u003e for this study was obtained from the Liverpool School of Tropical Medicine Research Ethics Committee, the National Health Research Ethics Committee of Nigeria, and the relevant State Health Research Ethics Committees. Written informed consent was obtained from all participants prior to data collection. Participation was voluntary, and confidentiality was ensured through anonymisation and secure data handling procedures. This study was conducted in accordance with the principles of the Declaration of Helsinki.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eParticipant Characteristics\u003c/h2\u003e \u003cp\u003eA total of 194 SHPs participated in this study. Over half were Nurses and Midwives (51.0%), followed by CHEWs and CHOs (30.9%). Residents accounted for 7.2%, while House Officers and Medical Officers each represented 4.6% of the sample. Consultants comprised 1.5% of the participants. The workforce was predominantly female (84%). A more detailed breakdown of the professional categories is provided in Supplementary Table\u0026nbsp;1.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e[Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e here]\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDistribution of Skilled Health Personnel by Cadre and Sex (N\u0026thinsp;=\u0026thinsp;194)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCadre\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMales\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemales\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNurses and Midwives\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e51.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCHEWs and CHOs\u003csup\u003e\u0026Dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e30.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHouse Officers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedical Officers (MO and SMO)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResidents (JR and SR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e7.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConsultants (Obstetricians \u0026amp; Gynaecologists)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e\u0026dagger; Includes registered nurses, registered midwives, nurse-midwives, and BSc/NYSC nurses\u003c/p\u003e \u003cp\u003e\u0026Dagger; Includes Junior and Senior CHEW and Community Health Officers\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eWork Settings and Work Patterns of Study Participants\u003c/h2\u003e \u003cp\u003eMost SHPs were deployed in labour and delivery units (n\u0026thinsp;=\u0026thinsp;83, 43.3%) and antenatal clinics (n\u0026thinsp;=\u0026thinsp;67, 34.5%). The remainder worked in postnatal clinics, family planning units, gynaecological emergency units, and antenatal wards.\u003c/p\u003e \u003cp\u003eWorkload indicators demonstrate substantial service demands. Most SHPs reported working 48\u0026ndash;60 hours per week (n\u0026thinsp;=\u0026thinsp;79, 40.7%), while 36.6% (n\u0026thinsp;=\u0026thinsp;71) worked more than 60 hours weekly. In terms of patient volume, 33.5% (n\u0026thinsp;=\u0026thinsp;65) attended to 20\u0026ndash;40 patients daily, and nearly one-quarter (24.7%, n\u0026thinsp;=\u0026thinsp;48) managed more than 40 patients per day. Night duties were also frequent, with 40.2% (n\u0026thinsp;=\u0026thinsp;78) reporting 7-14-night shifts per month. The detailed workload distributions are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e[Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e here]\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eWork Patterns of Skilled Health Personnel (N\u0026thinsp;=\u0026thinsp;194)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWork Pattern indicator\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNumbers\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercentage\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eNumber of Working Hours /Week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;48hrs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e22.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48\u0026ndash;\u0026lt;60hrs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e40.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;60hrs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e36.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eNumber of Patients Seen /Day\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e41.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u0026ndash;\u0026lt;40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e33.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e24.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eNumber of Night Duties /Month\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;7 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e109\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e56.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u0026ndash;14 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e40.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;14 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003ePrevalence and Perceived Severity of Work-Related Stress\u003c/h2\u003e \u003cp\u003eWork-related stress was assessed using the USDAW Workplace Stress Questionnaire, supplemented by a single-item measure of current stress and a self-rated severity scale (0\u0026ndash;10) completed by all the participants.\u003c/p\u003e \u003cp\u003eAcross the USDAW domains, workload and organisational factors emerged as the most prominent stressors. Within the work processes domain, heavy workload was the most frequently reported stressor (39.2% reporting \u0026ldquo;often\u0026rdquo;), followed by inadequate breaks (23.7%). In the work environment domain, overcrowding (32.5%) and lack of equipment (31.4%) were the most reported. Regarding workplace relationships, harassment from patients or relatives (21.6%) and lack of communication from management (17.0%) were the leading stressors (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOverall, 76% (147/194) of the SHPs reported experiencing stress at the time of the survey. Among those who reported stress, 73% attributed their stress primarily to work-related factors. Among respondents who completed the severity scale (n\u0026thinsp;=\u0026thinsp;189), the mean stress rating was 5.6 (SD 2.35) on a 10-point scale.\u003c/p\u003e \u003cp\u003eDespite this burden, 88.1% of SHPs reported no access to formal stress support systems. However, 51.5% of the respondents reported being completely satisfied with their jobs.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e[Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e here]\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMost Frequently Reported Workplace Stressors (\u0026ldquo;Often\u0026rdquo;) Among SHPs\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStressor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e% Reporting Often\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWork Processes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHeavy workload\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e39.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWork Processes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInadequate breaks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWork Environment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOvercrowding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWork Environment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLack of equipment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWorkplace Relationships\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHarassment (patients/relatives)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWorkplace Relationships\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLack of communication from management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e \u003cem\u003eNote: Percentages represent the proportion of SHPs reporting that the stressor occurred \u0026ldquo;often\u0026rdquo;. Full item-level distributions are presented in Supplementary Table \u003cspan refid=\"MOESM2\" class=\"InternalRef\"\u003eS2\u003c/span\u003e.\u003c/em\u003e \u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOne-way ANOVA demonstrated no statistically significant differences in mean stress scores across age groups (F\u0026thinsp;=\u0026thinsp;1.06, p\u0026thinsp;=\u0026thinsp;0.395), maternity unit type (F\u0026thinsp;=\u0026thinsp;1.29, p\u0026thinsp;=\u0026thinsp;0.255), or years since their qualification (F\u0026thinsp;=\u0026thinsp;0.42, p\u0026thinsp;=\u0026thinsp;0.742).\u003c/p\u003e \u003cp\u003eIn contrast, stress levels differed significantly across professional cadres (F (12, 181)\u0026thinsp;=\u0026thinsp;2.58, p\u0026thinsp;=\u0026thinsp;0.004), with a large effect size (η\u0026sup2; = 0.145). Post hoc analysis indicated significantly higher stress levels among junior and transitional clinical cadres, particularly House Officers/NYSC doctors and Junior Registrars, compared with several nursing and community health cadres. Differences were also observed between junior and senior medical ranks. The detailed pairwise comparisons are presented in Supplementary Table S3.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eCorrelation Between Stress Levels and Workplace Factors\u003c/h2\u003e \u003cp\u003eSpearman\u0026rsquo;s correlation analysis indicated that perceived stress was most strongly associated with work process-related factors. Heavy workload demonstrated the strongest positive correlation with stress (r\u0026thinsp;=\u0026thinsp;0.58, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), followed by inadequate breaks (r\u0026thinsp;=\u0026thinsp;0.50, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Unfair distribution of work (r\u0026thinsp;=\u0026thinsp;0.38, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) and shift work (r\u0026thinsp;=\u0026thinsp;0.26, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) also showed significant positive correlations.\u003c/p\u003e \u003cp\u003eWithin the work environment domain, noise (r\u0026thinsp;=\u0026thinsp;0.32, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) and overcrowding (r\u0026thinsp;=\u0026thinsp;0.29, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) were moderately correlated with high stress levels. Poor maintenance of equipment (r\u0026thinsp;=\u0026thinsp;0.25, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) and lack of equipment (r\u0026thinsp;=\u0026thinsp;0.19, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) showed weaker but statistically significant relationships.\u003c/p\u003e \u003cp\u003eIn the workplace relationships domain, harassment from patients or relatives (r\u0026thinsp;=\u0026thinsp;0.36, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) and lack of communication from management (r\u0026thinsp;=\u0026thinsp;0.33, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) were moderately associated with stress. Other relational factors showed weaker but significant correlations.\u003c/p\u003e \u003cp\u003eAcross domains, workload-related factors demonstrated stronger correlations with stress than environmental or relational variables. The detailed correlation matrices are presented in Supplementary Tables S4\u0026ndash;S6.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eConsequences of Work-Related Stress: Physical and Psychological Symptoms\u003c/h2\u003e \u003cp\u003eSeveral physical and psychological symptoms consistent with occupational strain were reported. The most frequently reported symptoms occurring \u0026ldquo;often\u0026rdquo; were backache (34.0%), headache (29.4%), sleeplessness (19.1%), and neck pain (17.0%).\u003c/p\u003e \u003cp\u003ePsychological symptoms were also evident, with irritability (10.8%), anxiety (10.8%), and inability to concentrate (11.3%) reported as occurring \u0026ldquo;often.\u0026rdquo; The full symptom distributions are presented in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003e[Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e here]\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePhysical and Psychological Symptoms Associated with Work-Related Stress Among SHPs in Nigeria\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSymptom\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNever\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSometimes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOften\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeadache\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22 (11.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e115 (59.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e57 (29.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e93 (47.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e80 (41.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e21 (10.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChest Pain/Palpitations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e111 (57.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e69 (35.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14 (7.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndigestion/Nausea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e125 (64.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e54 (27.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15 (7.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSleeplessness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e69 (35.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e88 (45.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e37 (19.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIrritability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e100 (51.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e73 (37.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e21 (10.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBackache\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e39 (20.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e89 (45.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e66 (34.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeck Pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e72 (37.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e89 (45.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e33 (17.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStomach Disorders\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e119 (61.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e67 (34.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8 (4.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInability to Concentrate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e102 (52.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e70 (36.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e22 (11.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eQualitative Findings: Lived Experiences of Work-Related Stress\u003c/h2\u003e \u003cp\u003eThe qualitative findings describe how SHPs experience and respond to the WRS within maternity care settings. Five interrelated themes emerged: (1) workload pressures and role strain, (2) resource constraints and organisational dysfunction, (3) relational tensions and hierarchical conflict, (4) physical, emotional, and professional consequences, and (5) coping strategies, support systems, and retention drivers.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eWorkload pressures and role strain\u003c/strong\u003e \u003cp\u003eParticipants consistently described excessive workload as the dominant source of stress, driven by understaffing, high patient volumes, and extended shifts, especially during afternoon and night shifts. One tertiary-level unit head explained how workload intensity varied by shift and staffing patterns\u003c/p\u003e \u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eMorning hours you have a full complement of staff. But in the afternoon and night, you may only see two nurses in the labour room manning 10\u0026ndash;12 patients. The stress is much more in the afternoon and evening shifts.\u0026rdquo;\u003c/em\u003e (Male Head of O\u0026amp;G, Tertiary Centre)\u003c/p\u003e \u003cp\u003eWorkload stress was amplified by role strain, as SHPs reported taking on duties beyond their clinical scope due to limited ancillary staff. A nurse-midwife described the cumulative burden of clinical care and logistics tasks as follows:\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eIn our facility, even the attendant, we don\u0026rsquo;t have enough\u0026hellip; imagine you will be the one to take patients to the theatre, go to the lab to collect blood, and still take it back to the theatre.\u0026rdquo;\u003c/em\u003e (Female Nurse Midwife, General Hospital)\u003c/p\u003e \u003cp\u003eWorkforce gaps caused by staff absences, including maternity leave, were also described as stress-provoking and sometimes created tension among colleagues:\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u0026hellip;\u003cem\u003eAlmost half of the residents are on maternity leave, and more are going now. So that puts a lot of stress on those who are not pregnant and the males\u0026hellip; The workload is much in this environment\u003c/em\u003e.\u0026rdquo; (Female HOD, O\u0026amp;G, Tertiary Centre)\u003c/p\u003e \u003cp\u003eThese accounts align with the quantitative pattern showing heavy workload and inadequate breaks as frequently reported stressors.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eResource constraints and organisational dysfunction\u003c/strong\u003e \u003cp\u003eParticipants described resource shortages and operational bottlenecks as routine, with staff often expected to deliver care without reliable equipment, supplies or functional systems. Several SHPs perceived managerial engagement as inconsistent, with resources appearing mainly during visits by external officials\u003c/p\u003e \u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eManagement is like a ghost\u0026hellip; they come, inspect, and suddenly everything\u0026rsquo;s available, but not for everyday practice.\u0026rdquo;\u003c/em\u003e (Male Doctor, General Hospital)\u003c/p\u003e \u003cp\u003eA related concern was the perception that leadership prioritised revenue generation over staff welfare or safe practice.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eTheir only concern is how much revenue your unit generates. But for you that are working there\u0026hellip; they don\u0026rsquo;t care\u003c/em\u003e.\u0026rdquo; (Female Nurse, Tertiary)\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eRelational tensions and hierarchical conflict\u003c/strong\u003e \u003cp\u003eStress was also shaped by relational dynamics within maternity teams and across professional hierarchies. Junior staff described intimidation and disrespect as routine experiences that undermined morale and teamwork.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eSome senior doctors will insult you\u0026hellip; and honestly, once my senior insults me or intimidates me, the patient suffers\u003c/em\u003e.\u0026rdquo; (Male Doctor Intern, Tertiary Centre)\u003c/p\u003e \u003cp\u003eTensions between cadres were commonly reported, particularly regarding communication norms and perceived disrespect. A nurse described an encounter with a junior doctor that escalated the workplace strain:\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u0026hellip;\u003cem\u003eSome of the doctors take themselves so high (proud)\u0026hellip; A house officer came to do a procedure, didn\u0026rsquo;t even greet us, but later needed our help. We had to remind him about basic courtesy\u003c/em\u003e.\u0026rdquo; (Female Nurse, General Hospital)\u003c/p\u003e \u003cp\u003e Patient-related hostility was another major relational stressor, with SHPs describing verbal aggression and threats from patients or relatives, particularly during delays:\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eIf you don\u0026rsquo;t attend to a patient immediately, there will be chaos. Even with security, it doesn\u0026rsquo;t help\u003c/em\u003e.\u0026rdquo; (Female Nurse, General Hospital)\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eSome men even say they will beat you. We usually have such incidents.\u0026rdquo;\u003c/em\u003e (Female Head of Maternity, General Hospital)\u003c/p\u003e \u003cp\u003e \u003cstrong\u003ePhysical, emotional, and professional consequences of stress\u003c/strong\u003e \u003cp\u003eParticipants described stress as physically depleting and emotionally draining, often worsened by missed meals, long shifts, and lack of protected breaks. Several accounts highlighted dizziness and hypoglycaemia episodes linked to continuous work without food\u003c/p\u003e \u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eI remember when I passed out (from hypoglycaemia) \u0026hellip; I\u0026rsquo;m always with Coke, morning review, I am always with my tea, on rounds I am always with my food.\u0026rdquo;\u003c/em\u003e (Female Intern, Tertiary Hospital)\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eYes, there was dizziness\u0026hellip; I had to rush to get her a drink because there was not enough staff, and she had to continue working\u003c/em\u003e.\u0026rdquo; (Female Head of ANC, General Hospital)\u003c/p\u003e \u003cp\u003eSome participants described severe consequences with no perceived organisational empathy or support:\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u0026hellip;\u003cem\u003eI started spotting due to the workload, running up and down. I was rushed to another hospital, and when I called to inform them, their only response was \u0026lsquo;why didn\u0026rsquo;t you come to our facility?\u0026rsquo; No empathy.\u0026rdquo;\u003c/em\u003e (Female Nurse, General Hospital)\u003c/p\u003e \u003cp\u003eStress was also described as affecting care processes through fatigue, reduced concentration, and hurried interactions. A medical officer explained how exhaustion shaped patient engagement:\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eMost times you are tired\u0026hellip; you just ask, \u0026lsquo;Okay, what is your problem?\u0026rsquo; You write one or two lines, and that\u0026rsquo;s it. In the long run, it affects the patients.\u0026rdquo;\u003c/em\u003e (Male Medical Officer, General Hospital)\u003c/p\u003e \u003cp\u003eEmotional exhaustion also contributed to irritability and strained communication with patients.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eIf you\u0026rsquo;re not happy, you won\u0026rsquo;t treat the patient well\u0026hellip; We get complaints about rudeness, doctors not listening, and patients feeling ignored. It\u0026rsquo;s all part of stress.\u0026rdquo;\u003c/em\u003e (Female HOD, Tertiary Centre)\u003c/p\u003e \u003cp\u003eThe effects extended into their personal lives, with SHPs describing strained relationships and the need for family members to adapt to post-shift exhaustion:\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eMy daughter now expects me to leave for work every day. If she sees me at home, she feels something is wrong.\u0026rdquo;\u003c/em\u003e (Female Nurse, General Hospital)\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCoping strategies, support systems, and retention drivers\u003c/strong\u003e \u003cp\u003e Participants described coping strategies as largely informal and self-directed. Peer support and emotional venting were common.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eSometimes it\u0026rsquo;s just complaining to a colleague\u0026hellip; or going for tea or Coke when I can.\u0026rdquo;\u003c/em\u003e (Female Doctor, Tertiary Hospital)\u003c/p\u003e \u003cp\u003eMany SHPs relied on their intrinsic motivation and passion for maternal care to sustain them:\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u0026hellip;\u003cem\u003eBecause I have a passion for my job\u0026hellip; I do not even count it as stress at times. The joy I have for the job keeps me going.\u0026rdquo;\u003c/em\u003e (Female Nurse, General Hospital)\u003c/p\u003e \u003cp\u003eRest management was a prominent coping mechanism, often requiring explicit negotiation within households.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eEveryone in my family knows not to call me within certain hours because I will be sleeping. Sunday is my rest day breakfast, sleep, lunch, sleep again. During the week, I barely sleep\u003c/em\u003e.\u0026rdquo; (Male Consultant, General Hospital)\u003c/p\u003e \u003cp\u003eRecreational activities and self-care practices were also used to decompress after shifts.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;I burn turaren wuta (incense), it makes me happy\u0026hellip; it gives me joy.\u0026rdquo;\u003c/em\u003e (Female Doctor, Tertiary Hospital)\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eSupport systems\u003c/strong\u003e \u003cp\u003e Most participants described the absence of formal workplace stress support mechanisms, with relief depending on informal, ad hoc decisions by supervisors\u003c/p\u003e \u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eSupport system? I will say there is none, but\u0026hellip; if they see it\u0026rsquo;s genuine (your stress), they (supervisors) allow you to go (and rest).\u0026rdquo;\u003c/em\u003e (Female Doctor, Tertiary Hospital)\u003c/p\u003e \u003cp\u003eSome unit heads described informal internal coping arrangements such as shift swaps and temporary relief:\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eWhen they are stressed, we usually sit with them and discuss issues. Sometimes we give them time off\u0026hellip; or swap shifts with staff from less stressful units.\u0026rdquo;\u003c/em\u003e (Female Head of Maternity, PHC)\u003c/p\u003e \u003cp\u003eIn the absence of institutional support, domestic help and family members were described as essential external buffers.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eI have my sister with me, she cooks before I get home, so I just eat, pray, and rest.\u0026rdquo;\u003c/em\u003e (Female Nurse, General Hospital)\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eRetention drivers\u003c/strong\u003e \u003cp\u003eDespite stress, many SHPs described their continued commitment to maternity care, often grounded in their professional identity and fulfilment from positive outcomes.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eWhat gives me joy, being a midwife, is seeing the mother and the baby in good health\u003c/em\u003e.\u0026rdquo; (Female Nurse, General Hospital)\u003c/p\u003e \u003cp\u003eWorkplace relationships and appreciation were repeatedly cited as reasons for staying:\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eIf there\u0026rsquo;s love and appreciation from superiors and colleagues, I feel encouraged to stay.\u0026rdquo;\u003c/em\u003e (Male Doctor, Tertiary Hospital)\u003c/p\u003e \u003cp\u003eRecognition, both formal and informal, was described as morale-boosting:\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eEvery year they rate the nurses and doctors\u0026hellip; end-of-the-year parties\u0026hellip; it makes you feel appreciated\u003c/em\u003e.\u0026rdquo; (Female Nurse, General Hospital)\u003c/p\u003e \u003cp\u003eHowever, pay dissatisfaction and perceived inequities were strongly demotivating:\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eThe workload is more than the salary we are taking\u0026hellip; the salary is too small, while the workload is big.\u0026rdquo;\u003c/em\u003e (Female Nurse, General Hospital)\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eMy salary is not even up to 60,000 naira ($42), but on ANC days, I see up to 60 patients alone\u003c/em\u003e.\u0026rdquo; (Female midwife, PHC)\u003c/p\u003e \u003cp\u003eTogether, these findings highlight a workforce navigating sustained operational pressure with limited institutional support, relying largely on personal resilience and informal networks to remain engaged in maternity care delivery.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis mixed-methods study examined the prevalence, determinants, and consequences of WRS among SHPs who provide maternity care in Northern Nigeria. We identified a high burden of perceived stress, driven primarily by heavy workloads, inadequate breaks, overcrowding, and resource constraints. Stress levels varied significantly across professional cadres, with junior cadres reporting higher stress levels, which were most strongly associated with workload intensity and organisational pressures. By linking stress exposure to perceived implications for clinical performance and care delivery, this study extends the existing evidence beyond individual well-being to position WRS as a system-level challenge within maternal health service delivery.\u003c/p\u003e \u003cp\u003eAmong respondents who reported current stress, 73% identified work-related factors as the primary source. This attribution is consistent with the strong quantitative associations observed between stress and workload or organisational factors, as well as the qualitative narratives centred on staffing shortages, resource constraints, and hierarchical pressures. Together, these findings indicate that the stress experienced by SHPs in this setting was predominantly occupational.\u003c/p\u003e \u003cp\u003eThese findings can be interpreted through the Job Demands-Resources (JD-R) framework, which conceptualises occupational stress as arising when job demands exceed the available job resources [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. In this study, high job demands, particularly workload intensity, time pressure, shift burden, and role strain, coexisted with constrained job resources, including inadequate staffing, limited supervision, insufficient breaks, and the absence of structured stress-support mechanisms. Both quantitative associations and qualitative narratives illustrate how this imbalance was experienced in the routine delivery of maternity care. Although the JD-R framework was not prospectively operationalised in the study design, the convergence of findings suggests that the demand-resource imbalance provides a coherent explanatory lens for understanding WRS among SHPs in low-resource maternity settings. Importantly, this interpretation situates WRS within systemic service delivery conditions rather than framing it solely as individual vulnerability.\u003c/p\u003e \u003cp\u003eTo further synthesise these relationships, we developed a conceptual pathway linking structural demands, stress-related strain, and potential implications for maternity care delivery (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eWithin this conceptual framing, job demands in our study were reflected in structural and organisational conditions, including staffing shortages, heavy workloads, long working hours, and limited infrastructure. These pressures were consistently reported across all cadres and were associated with higher perceived stress severity. Similar demand-driven stress patterns have been documented in other LMIC maternity settings, where workforce shortages, high patient volumes, and infrastructural deficits contribute to occupational strain among frontline providers [\u003cspan additionalcitationids=\"CR34\" citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSustained exposure to high job demands in the absence of adequate organisational resources aligns with the health-impairment pathway of the JD-R framework. SHPs in this study described psychological and physical manifestations consistent with this pathway, including emotional exhaustion, fatigue, sleep disturbances, headaches, and musculoskeletal discomfort. Comparable symptom patterns have been reported among healthcare providers in other LMIC contexts, where workload pressures and weak institutional support structures are linked to burnout and stress-related strain [\u003cspan additionalcitationids=\"CR37\" citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eImportantly, the pathway also identifies informal job resources and buffering mechanisms, including peer support, intrinsic motivation, family support, and self-care practices. While these resources provide partial protection against stress, their informal and inconsistent nature underscores the absence of institutionalised support mechanisms and limits their capacity to sustainably offset high job demands.\u003c/p\u003e \u003cp\u003eTaken together, this empirically grounded application of the JD-R framework situates work-related stress as a system-level determinant of maternity care performance rather than solely an occupational health concern. By linking workforce conditions, stress-related strain, care process impairment, and potential delivery risks, the framework offers a transferable lens for understanding how healthcare worker stress interacts with service delivery in resource-constrained maternity systems. These findings highlight the need for integrated interventions that strengthen both organisational resources and workforce conditions as core components of maternal health system strengthening.\u003c/p\u003e \u003cp\u003eQualitative accounts described delayed emergency responses, rushed consultations, and emotional detachment during patient engagement as effects of work-related stress. Although patient outcomes were not directly measured, the participants consistently linked stress to reduced attentiveness and impaired decision-making capacity, suggesting potential implications for care quality. These findings align with evidence from other LMICs, including Ghana, Kenya, Ethiopia, and South Africa, where workforce shortages, long shifts, and weak institutional support have been associated with burnout and reduced healthcare provider performance [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan additionalcitationids=\"CR40 CR41\" citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eStress levels did not significantly differ by gender, age, or years since qualification, suggesting that occupational stress in this setting is more closely linked to structural and professional conditions than to individual demographics. This contrasts with studies from Kenya and Ghana, which reported higher stress among female providers, attributed to emotional labour and role conflict [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Such differences may reflect the contextual variations in workforce structures and social norms. Nonetheless, our findings are consistent with broader evidence indicating that institutional and environmental conditions are stronger predictors of stress and burnout than demographic characteristics alone [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn contrast, cadre-specific disparities were observed. Junior CHEWs, House Officers/NYSC doctors, Senior Medical Officers, and Junior Registrars reported significantly higher stress levels than other cadres. These differences likely reflect the structural and role-based vulnerabilities within the health system. Transitional and mid-level cadres often carry substantial clinical responsibilities with limited decision-making authority, inadequate supervision, and constrained institutional support. Junior cadres may be disproportionately exposed to frontline emergency care and prolonged shifts, whereas senior mid-level clinicians may shoulder supervisory and administrative burdens without commensurate resources.\u003c/p\u003e \u003cp\u003eMost LMIC studies on work-related stress do not disaggregate findings by professional cadre [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. By identifying cadre-level disparities within maternity care teams, this study provides context-specific evidence to inform targeted interventions, such as structured mentorship, workload redistribution, and stress-support mechanisms tailored to transitional and lower-tier cadres.\u003c/p\u003e \u003cp\u003eWorkload emerged as the strongest quantitative correlate of stress (r\u0026thinsp;=\u0026thinsp;0.58, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), with over one-third of SHPs working more than 60 hours weekly and nearly one-quarter attending to more than 40 patients per day. While excessive workload has been widely documented as a stressor in Nigeria [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], our mixed-methods findings illustrate how WRS is experienced in routine maternity care settings in Northern Nigeria. Respondents described ongoing fatigue, impaired concentration, and emotional strain, noting that these challenges compromised consultation quality and clinical judgement. These findings suggest that workforce stress may have direct implications for care safety and service performance. These accounts provide contextual insights into how sustained workload pressures shape care provision in high-demand maternity units.\u003c/p\u003e \u003cp\u003eInstitutional gaps further intensified stress exposure. The majority of SHPs (88%) reported no access to formal workplace stress-support systems, relying instead on informal peer support, family assistance, or self-care practices. Similar patterns have been reported in other African settings, where structured staff well-being policies are limited [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Reliance on informal coping underscores the absence of institutionalized support mechanisms capable of sustainably mitigating chronic stress.\u003c/p\u003e \u003cp\u003eUnlike workload, shift work demonstrated only a weak association with perceived stress. This may reflect the normalisation of shift patterns within a relatively young workforce. However, studies from Saudi Arabia and Korea have reported stronger associations between shift work and burnout [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e], and systematic reviews have highlighted its adverse consequences for sleep and long-term health [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. These differences reinforce the importance of context-specific interpretations of the drivers of occupational stress.\u003c/p\u003e \u003cp\u003eEnvironmental and infrastructural deficits, including overcrowding, inadequate ventilation, poor lighting, and equipment shortages, were moderately associated with stress in our study. These facility-level constraints appear to exacerbate psychological strain and function as chronic stress amplifiers in resource-limited maternity units.\u003c/p\u003e \u003cp\u003eInterpersonal stressors were also prominent. Hierarchical conflict, poor supervisory relationships, and harassment from patients or relatives were the recurrent themes in the qualitative narratives. Although their quantitative associations were moderate, the qualitative narratives revealed a substantial emotional toll. Similar findings have been reported in Ethiopia and Saudi Arabia, where poor communication from management and strained supervisory relationships were significant predictors of stress [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. These results suggest that leadership culture and communication structures may meaningfully influence stress experiences among maternity teams.\u003c/p\u003e \u003cp\u003eThe mixed-methods design allowed for triangulation between the survey findings and lived experiences, revealing psychosocial dimensions of stress that may not be fully captured through quantitative scales alone. Notably, while quantitative analysis showed no significant sex differences in stress scores, qualitative accounts highlighted gender-specific stress experiences among female SHPs, including miscarriage, marital strain, and caregiving burdens. These findings reiterate the value of qualitative enquiry in illuminating dimensions of occupational strain that may remain statistically indistinguishable yet are practically significant.\u003c/p\u003e \u003cp\u003eFinally, although peer support and intrinsic motivation emerged as key coping mechanisms, the heavy reliance on informal strategies reflects a culture of endurance within the maternity workforce. Suppression and avoidance coping may provide short-term adaptation but risk concealing chronic burnout. Without institutionalized support systems such as counselling services, structured debriefings, and protected rest policies, this culture of silent resilience may contribute to psychological distress, reduced job satisfaction, long-term workforce instability, patient care safety issues and poor quality of care.\u003c/p\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and Limitations\u003c/h2\u003e \u003cp\u003eA major strength of this study is that it represents, to our knowledge, the first mixed-methods investigation of work-related stress among SHPs providing maternity care in Northern Nigeria. By combining quantitative and qualitative approaches within a convergent design, the study enabled triangulation of statistical findings with in-depth experiential accounts. This integration provided nuanced explanatory insight into how stress is experienced, interpreted, and managed within routine maternity care settings.\u003c/p\u003e \u003cp\u003eThe inclusion of multiple facility types public and private and across primary, secondary, and tertiary levels enhanced contextual breadth and strengthened the applicability of findings across the health system. Importantly, the study examined stress across diverse professional cadres of SHPs, allowing for identification of both cadre-specific disparities and system-level stress patterns that are frequently underexplored in LMIC research. The use of a validated instrument to assess psychosocial working conditions further enhances methodological rigor and comparability with global literature.\u003c/p\u003e \u003cp\u003eThis study has several limitations. The use of non-probability sampling and self-reported measures introduces potential selection and reporting biases. The cross-sectional design limits causal inference, and the stress-care delivery pathways were not formally tested. Additionally, limited facility-level data restricted a deeper analysis of how institutional characteristics may shape stress patterns. The study was conducted in selected northern states; therefore, the findings should be interpreted as contextually transferable rather than nationally generalisable.\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eImplications to policy and practice\u003c/h2\u003e \u003cp\u003eAddressing work-related stress among SHPs requires moving beyond individual coping strategies toward structural and institutional reforms within maternity care systems. Based on these findings, the following actions are recommended:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eStrategic workforce planning and redistribution\u003c/b\u003e, particularly in primary and secondary facilities, are required to address staffing shortages and workload concentration.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eImplementation of workload-responsive staffing models\u003c/b\u003e, including task-sharing and clearer role delineation, to reduce the pressure on overburdened cadres.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eInstitutionalization of structured staff-support systems\u003c/b\u003e, such as regular debriefings, protected rest periods, psychosocial support services, and stress management programmes, should be integrated into routine facility management.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eStrengthening leadership and communication structures\u003c/b\u003e to reduce hierarchical conflict, improve supervisory support, and foster collaborative team culture.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThese interventions should be embedded within existing health system governance and workforce frameworks to enhance their feasibility, sustainability, and alignment with broader maternal health system strengthening efforts.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWork-related stress is pervasive among SHPs providing maternity care in Northern Nigeria and is driven primarily by structural and organisational conditions, particularly heavy workload, limited rest, resource constraints, and weak institutional support. Although SHPs demonstrate resilience through informal coping strategies, these mechanisms are insufficient to offset sustained demand-resource imbalances.\u003c/p\u003e \u003cp\u003eAddressing WRS in maternity services requires systemic action, including workload-responsive staffing, protected rest policies, strengthened supervisory and communication structures, and institutionalized psychosocial support for the staff. Integrating workforce well-being into maternal health system strengthening efforts is essential for sustaining provider resilience and care quality.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eANC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAntenatal care\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCHO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCommunity Health Officer\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCHEW\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCommunity Health Extension Worker\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eJCHEW\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eJunior Community Health Extension Worker\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSCHEW\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSenior Community Health Extension Worker\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHouse Officer\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMedical Officer\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSMO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSenior Medical Officer\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eOBGYN\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eObstetrician and Gynaecologist\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSHP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSkilled Health Personnel\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eUSDAW\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eUnion of Shop, Distributive and Allied Workers\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWRS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWork-Related Stress.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Approval and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the Liverpool School of Tropical Medicine Research Ethics Committee (Ref: 22-017) and the National Health Research Ethics Committee of Nigeria (NHREC/01/01/2007/23/08/2022). Additional approvals were obtained from the State Health Research Ethics Committees of Kaduna (HREC/17/03/2018; MOH/ADM/744/VOL.1/942), Bauchi (NREC/03/11/19B/2021/61), and Kwara (ERC/MOH/2022/08/072). Written informed consent was obtained from all participants prior to data collection. This study was conducted in accordance with the principles of the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study are not publicly available due to ethical and confidentiality considerations but are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted as part of the first author\u0026rsquo;s doctoral research. The research was supported by a grant from the Johnson \u0026amp; Johnson Foundation awarded to Prof. Charles Ameh (Project/Grant/RBPS No: ROC8398342CA). The funder had no role in the study design, data collection, analysis, interpretation of the data, or preparation of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHM: Conceptualization; Methodology; Investigation; Data curation; Formal analysis; Project administration; Writing \u0026ndash; original draft; Writing \u0026ndash; review \u0026amp; editing.\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;DS: Formal analysis; Methodology; Writing \u0026ndash; review \u0026amp; editing.\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;YS: Methodology; Writing \u0026ndash; review \u0026amp; editing.\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;EK: Investigation; Data curation; Writing \u0026ndash; review \u0026amp; editing.\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;MA: Investigation; Data curation; Writing \u0026ndash; review \u0026amp; editing.\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;AL: Methodology; Formal analysis; Writing \u0026ndash; review \u0026amp; editing.\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;FD: Methodology; Formal analysis; Writing \u0026ndash; review \u0026amp; editing.\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;SW: Methodology; Formal analysis; Writing \u0026ndash; review \u0026amp; editing.\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;AT: Methodology; Supervision; Writing \u0026ndash; review \u0026amp; editing.\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;JP: Conceptualization; Supervision; Methodology; Writing \u0026ndash; review \u0026amp; editing.\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;CAA: Conceptualization; Methodology; Supervision; Funding acquisition; Writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003cbr\u003e\u003c/strong\u003eThe authors gratefully acknowledge the Johnson \u0026amp; Johnson Foundation for supporting the broader research programme under which this study was conducted. We also thank the Ministries of Health and the Primary Health Care Development Boards of Kaduna, Bauchi, and Kwara States, as well as the management and staff of the participating hospitals and primary health care facilities, for their support during the study. Most importantly, we sincerely appreciate the Skilled Health Personnel who generously shared their time and experiences to participate in this research.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eTrends in maternal mortality 2020\u0026ndash;2023.pdf\u0026gt; [Internet]. 2025. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://data.unicef.org/resources/trends-in-maternal-mortality-2000-to-2023/?utm_campaign=Trends%20in%20maternal%20mortality\u0026amp;utm_medium=email\u0026amp;utm_source=Mailjet\u003c/span\u003e\u003cspan address=\"https://data.unicef.org/resources/trends-in-maternal-mortality-2000-to-2023/?utm_campaign=Trends%20in%20maternal%20mortality\u0026amp;utm_medium=email\u0026amp;utm_source=Mailjet\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUNIGME 2024 Child Mortality Report [Internet]. 2024. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://data.unicef.org/wp-content/uploads/2025/03/UNIGME-2024-Child-Mortality-Report_28-March.pdf\u003c/span\u003e\u003cspan address=\"https://data.unicef.org/wp-content/uploads/2025/03/UNIGME-2024-Child-Mortality-Report_28-March.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWHO. Every Woman Every Newborn Everywhere. 2025 [Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://ewene.org/\u003c/span\u003e\u003cspan address=\"https://ewene.org/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSustainable Development Goals Report 2021 [Internet]. 2021. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://unstats.un.org/sdgs/report/2021/goal-03/\u003c/span\u003e\u003cspan address=\"https://unstats.un.org/sdgs/report/2021/goal-03/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDefining competent maternal and newborn health professionals [Internet]. 2018. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://apps.who.int/iris/bitstream/handle/10665/272817/9789241514200-eng.pdf\u003c/span\u003e\u003cspan address=\"http://apps.who.int/iris/bitstream/handle/10665/272817/9789241514200-eng.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWork Organisation and Stress [Internet]. 2003. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/publications/i/item/9241590475?utm_source\u003c/span\u003e\u003cspan address=\"https://www.who.int/publications/i/item/9241590475?utm_source\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCaring for those who care; National Programmes for Occupational Health for Health Workers: POLICY BRIEF [Internet]. World Health Organization. 2020 [cited 15/05/2024]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://iris.who.int/handle/10665/336479\u003c/span\u003e\u003cspan address=\"https://iris.who.int/handle/10665/336479\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShanafelt TD, Hasan O, Dyrbye LN, Sinsky C, Satele D, Sloan J et al. Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014. Mayo Clin Proc. 2015;90(12):1600\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCampbell D. Seven in 10 GPs in UK suffer from compassion fatigue, survey finds. The Guardian. 2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdriaenssens J, De Gucht V, Maes S. Determinants and prevalence of burnout in emergency nurses: a systematic review of 25 years of research. Int J Nurs Stud. 2015;52(2):649\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBashar JM, Aliyu D, Anyebe EE, Gabriel I, Nasir A, Mangari AS, et al. Perceived work-related stress and associated factors among the surgical workforce in a Nigerian tertiary health facility: A cross-sectional study. PLOS Glob Public Health. 2024;4(11):e0003959.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOnigbogi CB, Banerjee S. Prevalence of Psychosocial Stress and Its Risk Factors among Health-care Workers in Nigeria: A Systematic Review and Meta-Analysis. Niger Med J. 2019;60(5):238\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOdonkor ST, Adams S. Predictors of stress and associated factors among healthcare workers in Western Ghana. Heliyon. 2021;7(6):e07223.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGlobal strategy on human resources for health: Workforce 2030 [Internet]. 2016. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://apps.who.int/iris/bitstream/handle/10665/250368/9789241511131-eng.pdf\u003c/span\u003e\u003cspan address=\"https://apps.who.int/iris/bitstream/handle/10665/250368/9789241511131-eng.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFalola HO, Ojebola OO. Assessing the Challenges of Medical Practitioners\u0026rsquo; Retention and Its Implications in a Developing Economy. The Changing Landscape of Workplace and Workforce: IntechOpen;; 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTrends in maternal mortality 2000\u0026ndash;2020 [Internet]. World Health Organisation. 2021 [cited 16/06/2024]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/publications/i/item/9789240068759\u003c/span\u003e\u003cspan address=\"https://www.who.int/publications/i/item/9789240068759\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeh C, Thind A, Ryan B, Terry A. Levels and determinants of maternal mortality in northern and southern Nigeria. BMC Pregnancy Childbirth. 2019;19(1):417.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOkpani AI, Abimbola S. The midwives service scheme: a qualitative comparison of contextual determinants of the performance of two states in central Nigeria. Glob Health Res Policy. 2016;1:16.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbimbola S, Okoli U, Olubajo O, Abdullahi MJ, Pate MA. The midwives service scheme in Nigeria. PLoS Med. 2012;9(5):e1001211.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbujah RFG, Launches MAMII, Project To Combat Alarming Maternal Mortality Rates Online. : Science Nigeria; 2024 [Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://sciencenigeria.com/fg-launches-mamii-project-to-combat-alarming-maternal-mortality-rates/\u003c/span\u003e\u003cspan address=\"https://sciencenigeria.com/fg-launches-mamii-project-to-combat-alarming-maternal-mortality-rates/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAluko OISa. Work Related Stress Management and the Performance of Workers in Public Health Facilities in Kwara State. Nigeria: Kwara State University (Nigeria); 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eten Hoope-Bender P, Lopes ST, Nove A, Michel-Schuldt M, Moyo NT, Bokosi M, et al. Midwifery 2030: a woman's pathway to health. What does this mean? Midwifery. 2016;32:1\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMinimum Standards for Primary Health Care in Nigeria [Internet]. 2015. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.nphcda.gov.ng/Reports%20and%20Publications/Minimum%20Standards%20for%20Primary%20Health%20Care%20in%20Nigeria.pdf\u003c/span\u003e\u003cspan address=\"http://www.nphcda.gov.ng/Reports%20and%20Publications/Minimum%20Standards%20for%20Primary%20Health%20Care%20in%20Nigeria.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePourhoseingholi MAVM, Rahimzadeh. Sample size calculation in medical studies. Gastroenterol Hepatol Bed Bench. 2013;6:14\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eObasohan MO, Ayodele KO. Assessment of job stress among clinical health workers in three selected health-care industries in Lagos State, Nigeria. IFEPsychologIA. 2014;22(2).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUSDAW. Work Stress Questionnaire. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://usdawlive.b-cdn.net/live/media/e34ftiek/stress-questionnaire.pdf\u003c/span\u003e\u003cspan address=\"https://usdawlive.b-cdn.net/live/media/e34ftiek/stress-questionnaire.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKivimaki M, Virtanen M, Elovainio M, Kouvonen A, Vaananen A, Vahtera J. Work stress in the etiology of coronary heart disease\u0026ndash;a meta-analysis. Scand J Work Environ Health. 2006;32(6):431\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e(HSE) HaSE. Management Standards for Work-Related Stress. London: Health and Safety Executive 2004 [Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e\u003c/span\u003e\u003cspan address=\"http://www.hse.gov.uk\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArumugam B, Prasad A, Nagalingam S. Work-Related Stress - A Major Occupational Health Issue. Int J Curr Res. 2015;7(6):16991\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBraun V, Clarke V. Using thematic analysis in psychology. Qualitative Res Psychol. 2006;3(2):77\u0026ndash;101.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDemerouti E, Bakker AB, Nachreiner F, Schaufeli WB. The Job Demands Resource Model for Burnout. J Appl Psychol. 2001;86(3):499\u0026ndash;512.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBakker AB, Demerouti E. Job demands-resources theory: Taking stock and looking forward. J Occup Health Psychol. 2017;22(3):273\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWright T, Mughal F, Babatunde OO, Dikomitis L, Mallen CD, Helliwell T. Burnout among primary health-care professionals in low- and middle-income countries: systematic review and meta-analysis. Bull World Health Organ. 2022;100(6):385\u0026ndash;A401.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAfulani PA, Ongeri L, Kinyua J, Temmerman M, Mendes WB, Weiss SJ. Psychological and physiological stress and burnout among maternity providers in a rural county in Kenya: individual and situational predictors. BMC Public Health. 2021;21(1):453.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDugani SAH, Hirschhorn LR, et al. Prevalence and factors associated with burnout among frontline primary health care providers in low- and middle-income countries: A systematic review [version 3; referees: 2 approved]. Gates Open Res. 2018;2:4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBradley S, Kamwendo F, Chipeta E, Chimwaza W, de Pinho H, McAuliffe E. Too few staff, too many patients: a qualitative study of the impact on obstetric care providers and on quality of care in Malawi. BMC Pregnancy Childbirth. 2015;15:65.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGovender IM, Okonta E. Stress among medical doctors working in public hospitals of the Ngaka Modiri Molema district (Mafikeng health region), North West province, South Africa. S Afr J Psych. 2012;18(2):42\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKecklund G, Axelsson J. Health consequences of shift work and insufficient sleep. BMJ. 2016;355.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKruk ME, Gage AD, Arsenault C, Jordan K, Leslie HH, Roder-DeWan S, et al. High-quality health systems in the Sustainable Development Goals era: time for a revolution. Lancet Glob Health. 2018;6(11):e1196\u0026ndash;252.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMengist B, Amha H, Ayenew T, Gedfew M, Akalu TY, Assemie MA, et al. Occupational Stress and Burnout Among Health Care Workers in Ethiopia: A Systematic Review and Meta-analysis. Arch Rehabil Res Clin Transl. 2021;3(2):100125.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaye Y, Demeke T, Birhan N, Semahegn A, Birhanu S. Nurses' work-related stress and associated factors in governmental hospitals in Harar, Eastern Ethiopia: A cross-sectional study. PLoS ONE. 2020;15(8):e0236782.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee HL, Wilson KS, Bernstein C, Naicker N, Yassi A, Spiegel JM. Psychological Distress in South African Healthcare Workers Early in the COVID-19 Pandemic: An Analysis of Associations and Mitigating Factors. Int J Environ Res Public Health. 2022;19(15).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAl-Makhaita HM, Sabra AA, Hafez AS. Predictors of work-related stress among nurses working in primary and secondary health care levels in Dammam, Eastern Saudi Arabia. J Family Community Med. 2014;21(2):79\u0026ndash;84.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Work-related stress, Skilled Health Personnel, maternity care","lastPublishedDoi":"10.21203/rs.3.rs-9097656/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9097656/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eNigeria bears the highest burden of maternal deaths globally; however, limited evidence exists on the work environments in which Skilled Health Personnel (SHPs) deliver maternity care and how these conditions shape care processes. Work-related stress (WRS), which arises when job demands exceed available resources, may undermine workforce wellbeing, care quality, and patient safety. Although workforce shortages and resource constraints are widely recognised challenges in LMICs, empirical evidence linking workplace stress to maternity service delivery remains limited. This study assessed the burden, drivers, consequences, and coping strategies associated with WRS among SHPs in Northern Nigeria.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe conducted a convergent mixed-methods study involving 194 SHPs from 48 public and private facilities in Kaduna, Bauchi, and Kwara States. Quantitative data were collected using the USDAW Workplace Stress Questionnaire, a single-item current stress measure, and a 1\u0026ndash;10 stress severity scale and analysed using descriptive statistics and bivariate tests (Spearman\u0026rsquo;s correlation, t-tests, and ANOVA). Qualitative data from 7 focus group discussions and 8 key informant interviews were thematically analysed.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOverall, 76% (147/194) of SHPs reported current stress, and 73% (107/147) attributed their stress primarily to work-related factors. Workload pressures were prominent: 36.6% worked\u0026thinsp;\u0026gt;\u0026thinsp;60 hours/week, and 24.7% saw\u0026thinsp;\u0026gt;\u0026thinsp;40 patients/day. Frequently reported stressors were heavy workload (39.2%), overcrowding (32.5%), and lack of equipment (31.4%). Stress severity was strongly correlated with heavy workload (r\u0026thinsp;=\u0026thinsp;0.58, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) and inadequate breaks (r\u0026thinsp;=\u0026thinsp;0.50, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Mean stress scores differed significantly by cadre (F(12,181)\u0026thinsp;=\u0026thinsp;2.58, p\u0026thinsp;=\u0026thinsp;0.004; η\u0026sup2; = 0.145), with higher levels among junior cadres. Qualitative findings described physical and emotional strain and perceived impacts on consultation quality of provider\u0026ndash;patient interactions. Most participants (88.1%) reported no formal workplace stress support systems.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eWRS among SHPs providing maternity care in Northern Nigeria is widespread, driven by structural and organisational conditions. Addressing WRS through workload-responsive staffing, supportive supervision, and institutionalised psychosocial support should be integrated into maternal health system strengthening efforts. Strengthening workforce wellbeing may be critical for sustaining safe, responsive, and high-quality maternity care delivery in high-burden settings.\u003c/p\u003e","manuscriptTitle":"Caring Under Pressure: A Mixed-Methods Study of Work-Related Stress Among Skilled Health Personnel Providing Maternity Care in Nigeria","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-23 12:23:12","doi":"10.21203/rs.3.rs-9097656/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"253684375733712428131783086058337480170","date":"2026-04-22T10:50:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"244346535614127648756316213246235433346","date":"2026-04-20T20:39:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"302131911854508288606850662440822921903","date":"2026-04-16T16:45:21+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-15T12:33:54+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-13T08:27:05+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-20T11:38:49+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-18T23:19:18+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2026-03-18T14:26:39+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b5c3922d-d431-4f62-a3d9-424312503721","owner":[],"postedDate":"April 23rd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-23T12:23:13+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-23 12:23:12","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9097656","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9097656","identity":"rs-9097656","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}