Health workforce governance, workload alignment, and job satisfaction among skilled birth attendants in urban primary health care: a mixed-methods study from Ethiopia

Health workforce governance, workload alignment, and job satisfaction among skilled birth attendants in urban primary health care: a mixed-methods study from Ethiopia | 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 Health workforce governance, workload alignment, and job satisfaction among skilled birth attendants in urban primary health care: a mixed-methods study from Ethiopia Amaha HaILE ABEBE, Rose Mmusi-Phetoe This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8666418/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Background: Health workforce motivation and retention are central to achieving high-quality maternal and newborn care globally. However, evidence on how staffing allocation, workload, and work environment interact to influence skilled birth attendants’ job satisfaction in urban primary health-care settings in low- and middle-income countries (LMICs) remains limited. Methods An explanatory sequential mixed‑methods study was conducted in 50 public health centers between January and April 2021. Quantitative data were collected through face‑to‑face interviews with 338 midwives providing maternal and newborn health services. A structured health‑center questionnaire was administered through interviews with maternity unit heads, direct observation, and register review. Qualitative data were generated through in‑depth interviews with 20 midwives and 13 health‑center managers. Quantitative data were analyzed descriptively, while qualitative data were analyzed thematically using Colaizzi’s method. Results Only 38.2% of skilled birth attendants reported overall job satisfaction. Staffing allocation was poorly aligned with service workload, resulting in wide variation in annual deliveries per SBA across facilities. Despite generally adequate infrastructure and essential supplies, dissatisfaction was driven by low remuneration, limited access to professional development, weak performance-based recognition, and high workload. Qualitative findings highlighted governance gaps in staffing norms, limited managerial accountability, and the absence of incentive mechanisms as key contributors to low motivation. Conclusion This study demonstrates that adequate physical resources alone are insufficient to ensure a motivated maternal health workforce. Misalignment between staffing allocation and workload, weak performance management systems, and limited professional development opportunities undermine job satisfaction among SBAs. These findings have implications for urban primary health-care systems across LMICs, underscoring the need for workforce policies that link staffing, workload, and performance incentives to improve motivation and quality of maternal and newborn care. Health Policy Job satisfaction mentorship obstetric and newborn care physical resources skilled birth attendants workload Figures Figure 1 Figure 2 Introduction The availability of competent, motivated, and adequately supported obstetric care providers is a cornerstone of high-quality maternal and newborn care. The World Health Organization (WHO) identifies the availability of competent and motivated human resources as one of the eight core domains of quality maternal and newborn health care and emphasizes the continuous presence of skilled health workers with appropriate competencies and skill mix to provide routine intrapartum care and manage obstetric and newborn complications [ 1 , 2 ]. WHO standards further highlight the importance of effective managerial and clinical leadership, supportive supervision, and work environments that promote staff motivation and continuous quality improvement [ 2 ]. Despite these global standards, service readiness and quality-of-care assessments across sub-Saharan Africa indicate that fewer than half of primary health-care facilities meet minimum staffing requirements for round-the-clock obstetric care [ 3 ]. In many low- and middle-income countries (LMICs), staff shortages, inequitable deployment, and weak workforce management practices continue to undermine service availability, provider motivation, and the quality of maternal and newborn care. In Ethiopia, midwives constitute the primary cadre delivering obstetric and newborn services at the health-center level and are central to achieving national maternal and newborn health targets. However, studies have documented persistent workforce challenges, including limited access to supportive supervision and in-service training, weak career-progression pathways, and high workload, all of which negatively affect motivation and performance [ 4 ]. These challenges reflect broader health workforce governance issues rather than isolated facility-level constraints. Job satisfaction among midwives is a critical determinant of quality of care, workforce retention, and health-system performance. Low job satisfaction has been associated with reduced motivation, poorer performance, and increased turnover intentions, ultimately compromising continuity and quality of maternal and newborn care. Evidence from Ethiopia and other LMICs consistently identifies low remuneration, limited professional development opportunities, inadequate recognition, and weak management support as major drivers of dissatisfaction among midwives [ 5 ]. Although the literature on midwives’ job satisfaction in LMICs is expanding, most studies focus on rural settings or higher-level hospitals, with limited attention to urban primary health-care facilities. Rapid urbanization across LMICs has substantially increased service demand in city health centers, often without corresponding adjustments in staffing norms, workload distribution, or workforce governance arrangements. Understanding how staffing allocation, workload, and work environment interact to influence job satisfaction in urban primary care settings is therefore critical for informing responsive and sustainable health workforce policies. This study examines how staffing allocation, workload, and work environment influence job satisfaction among skilled birth attendants in urban primary health-care facilities in Ethiopia. By focusing on workforce governance and workload alignment, the study contributes evidence relevant to rapidly urbanizing LMIC contexts where primary health-care systems face increasing service demand without commensurate adaptation of workforce policies and management practices. Research methods Study design and setting An explanatory sequential mixed‑methods design was employed. The study was conducted between January and April 2021 in 50 public health centers under the Addis Ababa City Administration, Ethiopia. During the quantitative phase, face-to-face interviews were conducted with 338 midwives in the study health centers. An in-depth interview was conducted with 33 midwives and managers using an interview guide during the qualitative phase. Study population The quantitative component included all midwives aged 18 years and older who were working in maternal and newborn care units of the selected health centers during the study period. Midwives assigned to other departments or those who were seriously ill at the time of data collection were excluded. The qualitative component included maternity unit heads, deputy heads, and health‑center managers who had worked in their respective facilities for at least six months.. Sample size and sampling technique Of the 90 public health centers providing delivery services in Addis Ababa, 50 were selected using stratified simple random sampling, with five health centers drawn from each of the ten sub‑cities. All eligible midwives available during the study period in the selected facilities were included, yielding a final sample of 338 midwives. For the qualitative component, 20 midwives and 13 managers were purposively selected until data saturation was reached. Data collection instruments and Operational definition Data collection tools were adapted from the WHO obstetric and newborn care quality standards and relevant literature. The work environment was assessed in terms of staffing levels, workload, availability of support and motivation mechanisms, and physical resources. Job satisfaction was measured using 20 Likert‑scale items, with a composite score of ≥ 75% indicating satisfaction. Data collection and analysis A structured face-to-face interview was conducted with 338 midwives with informed consent. The health centre survey questionnaire was administered through interviews with maternity unit heads, observation, and a review of registers. Data were entered into EpiData and analyzed using SPSS version 20. Qualitative interviews were audio‑recorded, transcribed verbatim, and thematically analyzed using Colaizzi’s seven‑step approach. Ethical considerations Ethical approval was obtained from the University of South Africa and the Addis Ababa City Administration Health Bureau. Written informed consent was obtained from all participants, and confidentiality was maintained throughout the study. Results Participant Characteristics Of the 338 midwives interviewed, 74% were female. The mean age was 28.9 years (SD = 4.0), and the mean work experience was 5.8 years (SD = 3.4). Nearly 59% held a bachelor’s degree (Table-1). Table-1: Percentage distribution of midwives by socio-demographic characteristics (N=338) Socio Demographic Variables Frequency Percent Sex Male Female 88 250 26.0 74.0 Age 20-24 years 25-29 years 30-34 years >/=35 Year 20 209 80 29 5.9 61.8 23.7 8.6 Years of Work Experience 1-3 Years 4-6 Years 7-9 Years ≥ 10 Years 78 139 90 31 23.1 41.1 26.6 9,2 Educational Status Diploma Bachelor’s degree Master's degree and above 135 199 4 39.9 58.9 1.2 Availability and Workload of Skilled Birth Attendants A total of 439 SBAs were assigned to maternity care in the 50 health centers, of whom 90% were midwives. The average number of SBAs per health center was nine. However, the number of skilled birth attendants per health center varies from a minimum of 3 to a maximum of 22. During the 2012 Ethiopian Fiscal Year, the mean workload was 69 deliveries per SBA per year, with wide variation across facilities. There was wide variation in the annual number of deliveries per SBA among the 50 health centres, ranging from 8 to 211 deliveries per SBA. No significant correlation was observed between staffing levels and workload (Figure-1). Support, motivation, and physical resources Most health centers had standard recruitment procedures and conducted performance appraisals, but appraisal results were rarely linked to rewards. Access to mentorship, drills, and recent training was limited (Table-2, and Figure 2). Table-2: Distribution of health centers by the avilablity of mechanisms to support and motivate skilled birth attendants (N=50) Support and motivation of SBAs in the 50 health centers No (%) Yes (%) Has a written staffing policy and plan 44 56 Has standard procedures for the recruitment and deployment of staff 6 94 Has performed staff performance appraisals in the past year 8 92 Has recognized or rewarded staff who performed well in the past year 60 40 The maternity service had supportive supervision in the past year 0 100 The maternity service had mentorship support in the past year 46 54 The maternity service had a drill exercise in the past year 20 80 While most facilities met national standards for infrastructure and essential supplies, deficits were noted in water supply and staff amenities, indicating that environmental adequacy did not translate into improved staff motivation (Table-3). Table 3: Percentage distribution of health centres with the physical resources for skilled birth attendants to function (N=50) Availability of physical resources for SBAs at MNHC service area No (%) Yes (%) The maternity unit has 75% of the 44 essential medical equipment, supplies, and drugs for obstetric and newborn care 0 100 The maternity unit has a delivery room with two or more second-stage delivery couches and meets the national standard for a health centre 0 100 The maternity unit has a prenatal and postnatal care room with four or more beds, and meets the national standard for a health centre 4 96 The labour and delivery room had good illumination (could read 12 font script) 6 94 The labour and delivery room had good ventilation (cross-ventilating doors and windows) 4 96 The maternity unit has a newborn corner 4 96 The maternity unit has a waiting area for companions 16 84 The maternity unit has an area in the labour and delivery unit for staff to work on records 6 94 The maternity unit has an area in the labour and delivery unit for staff to rest 4 96 The maternity unit has an uninterrupted supply of electricity power 8 92 The maternity unit has an uninterrupted supply of water 72 28 The maternity unit has a toilet room for clients 6 94 The maternity unit has a toilet room for staff 30 70 The maternity unit has a shower room for clients 18 82 The maternity unit has a shower room for staff 34 66 Job satisfaction of skilled birth attendants Only 38.2% of midwives met the threshold for overall job satisfaction. The highest levels of dissatisfaction were reported regarding salary, incentives, opportunities for further education, and performance‑based recognition. In contrast, midwives reported relatively high satisfaction with teamwork, professional respect from colleagues, and the perceived quality of care they provided (Table-4). Table-4: Percentage of midwives satisfied with their jobs (N=338) Job-related variables Dissatisfied % Not sure % Satisfied % Availability of human resource policy and guidelines 12.7 11.5 75.7 Supportiveness of the management 19.2 21.9 58.9 Mechanism of performance appraisal and recognition 35.8 20.4 43.8 Respect and recognition from the management 27.2 16.0 56.8 Respect and recognition from professional colleagues 5.3 2.7 92.0 The respect and recognition you receive from clients 6.8 4.1 89.1 Opportunity for peer learning 8.6 5.6 85.6 Supervision and mentorship 22.2 20.1 57.7 Access to trainings and updates 31.4 18.6 50.0 Opportunity for further education 56.8 16.0 27.2 Physical attractiveness of the work environment 17.2 8.6 74.3 Teamwork in labour and delivery care 1.5 3.0 95.6 Safety of staff, including prevention of infection 10.7 8.3 81.1 Availability of facility, equipment, drugs, and supplies 10.5 8.9 80.8 Quality of obstetric care delivered 6.2 3.3 90.5 The workload at the workplace 20.4 14.2 65.4 Flexibility and fairness of the duty schedule and rotation 8.6 8.3 83.1 Ease of getting annual leave 24.9 10.9 64.2 Amount of salary 63.0 13.3 23.7 Incentives (housing and allowances) 75.7 11.5 12.7 Qualitative Findings Qualitative data highlighted high workload, low remuneration, infection risk, and limited professional development as major demotivating factors. Intrinsic motivation derived from saving mothers’ and newborns’ lives remained a key source of job satisfaction. The qualitative study also revealed the fact that the number of midwives assigned per health centre was not linked to the workload and needs a policy to address that. A midwife said: “There are no significant differences in staffing for health centres with high and low caseloads. The city health office should revise the policy to link staffing with workload.” Taken together, the quantitative and qualitative findings indicate a systemic disconnect between workforce deployment policies and service delivery realities. While health centers largely met infrastructure and equipment standards, human resource management practices—particularly staffing allocation, performance appraisal, and professional development—were not responsive to workload variation or staff motivation needs. Discussion This study provides important insights into health workforce governance challenges affecting skilled birth attendants in urban primary health-care settings in LMICs. Despite relatively well-resourced facilities, job satisfaction among SBAs in Addis Ababa public health centers was low, highlighting that material readiness alone does not ensure a motivated workforce. These findings align with evidence from other LMICs, including Kenya, Uganda, Tanzania, and Ghana, where inadequate remuneration, high workload, limited professional development, and weak management support have been consistently associated with low health worker motivation and retention. A key contribution of this study is the demonstration that staffing allocation was not aligned with workload across facilities, resulting in substantial variation in service burden per SBA. Similar mismatches between staffing norms and service volume have been reported in urban primary health-care facilities in other LMICs, suggesting that rigid staffing policies and weak workforce planning systems are common governance challenges. This misalignment undermines efficiency, contributes to burnout, and reduces job satisfaction even in contexts where absolute staff numbers appear adequate [ 5 , 6 , 7 ]. Overall job satisfaction among SBAs is lower than levels reported in other Ethiopian studies [ 5 , 10 ]. Major sources of dissatisfaction included low salary and incentives, high workload, limited access to training and further education, weak management support, and occupational health risks such as exposure to HIV and hepatitis infection. The findings highlight critical governance gaps in the management of the maternal health workforce. First, staffing policies that do not account for service volume and case mix limit the effectiveness of workforce investments. Dynamic staffing models that link deployment to workload indicators could improve both efficiency and staff well-being. Second, although performance appraisal systems were reportedly in place, their lack of linkage to incentives or recognition reduced their motivational value. Evidence from LMICs indicates that performance-based recognition—financial or non-financial—can significantly enhance motivation and retention of health workers. Third, limited access to training, mentorship, and career advancement opportunities undermines professional development and contributes to dissatisfaction, despite SBAs’ strong intrinsic motivation to provide quality care [ 7 , 8 , 9 ]. These findings underscore that improving maternal and newborn health outcomes require not only investments in infrastructure and supplies but also strengthened health workforce governance. Policies that integrate staffing allocation with workload, institutionalize supportive supervision and mentorship, and link performance appraisal to meaningful incentives are essential. As urban populations continue to grow across LMICs, addressing these workforce governance challenges in primary health-care settings will be critical for sustaining quality obstetric and newborn care. Conclusion This study highlights that low job satisfaction among skilled birth attendants persists even in relatively well-resourced urban primary health-care facilities. Misalignment between staffing allocation and workload, weak performance-based incentive systems, and limited professional development opportunities undermine workforce motivation. These challenges reflect broader health workforce governance issues common to many LMICs. Addressing them through adaptive staffing policies, strengthened performance management systems, and sustained investment in professional development is critical for improving SBA motivation, retention, and the quality of maternal and newborn care. Abbreviations COVID-19 Coronavirus Disease of 2019 HIV Human Immunodeficiency Virus SBA Skilled Birth Attendants SDGs Sustainable Development Goals SPSS Statistical Package for the Social Sciences UNISA University of South Africa WHO World Health Organization Declarations Ethics approval and consent to participate The research protocol was reviewed and approved by the Research Ethics Committee of the Department of Health Studies of the University of South Africa. The research protocol was again reviewed and approved by the Ethical Review Committee of Addis Ababa City Administration Health Office. Once the research protocol had been approved by the ethical review committees, support letters were written from the Addis Ababa city administration health office and sub-city health offices to study health facilities. The research was conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from all study participants, and interviews were conducted in a setting that ensured privacy and confidentiality. Consent for publication Not applicable. Our manuscript does not contain data from any individual person Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests Authors' contributions Amaha Haile Abebe, Corresponding author have conceptualized and designed the study protocol, coordinated, supervised, and conducted the data collection, data entry, analysis, and report write-up. Prepared the manuscript. Prof. Rose Mmusi-Phetoe, co-author, supervised and contributed to conceptualizing and designing the study protocol, data analysis, and report write-up and review. She further reviewed and refined the manuscript. Acknowledgments We would like to thank the University of South Africa for financing the study. We would like to thank women, midwives, and health center heads in Addis Ababa city for participating in the study. I would like to thank the research assistants who conducted the qualitative data collection, namely, Sr. Hawa Ali, Sr. Hasna Musema, Sr. Aselefech Negewo, and Sr. Abeba Gebrehiwot. Funding University of South Africa provided financial support to undertaking of the study. References Tunçalp Ӧ, Were W, MacLennan C, Oladapo O, Gülmezoglu A, Bahl R (2015) Quality of care for pregnant women and newborns—the WHO vision, Bjog , p. 1045 WHO (2016) Standards for improving quality of maternal and newborn care in health facilities. WHO, Geneva Kruk M, Leslie H, Verguet S, Mbaruku G, Adanu R, Langer A (2016) Quality of basic maternal care functions in health facilities of five African countries: an analysis of national health system surveys. Lancet Glob Health 4(11):845–855 ; EPHI, FMoH, AMMD (2018), Ethiopian Emergency Obstetric and Newborn Care (EmONC) Assessment 2016, EPHI, Addis Ababa Bekru E, Cherie A, Anjulo A (2017) Job satisfaction and determinant factors among midwives working at health facilities in Addis Ababa city. Ethiopia PLoS ONE 12(2):1–16 Fikre R, Berhanu M (2018) Current evidence on basic emergency obstetric and newborn care in primary health care unit of Gedeo zone, South Ethiopia, 2018. Biomedical J Scientific Technical Research 17(3):12838–12843 Sendawula K, Kimuli S, Bananuka J, Muganga G (2018) Training, employee engagement and employee performance: evidence from Uganda’s health sector. Cogent Business Managemen 5(1):1–12 Muthuri R, Senkubuge F (2020) and H. H, Determinants of motivation among healthcare workers in the East African community between 2009–2019: a systematic review, Healthcare , vol. 8, no. 164, pp. 1–24 Idowu A (2017) Effectiveness of performance appraisal system and its effect on employee motivation. Nile J Bus Econ 5:15–39 Muluneh M, Moges G, Abebe S, Hailu Y, Makonnene M, Stulz V (2022) Midwives’ job satisfaction and intention to leave their current position in developing regions of Ethiopia. Women Birth 35(1):35–47 Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted 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-8666418","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":578552511,"identity":"9800ea5d-ae67-42bf-9658-97c9f904975d","order_by":0,"name":"Amaha HaILE ABEBE","email":"data:image/png;base64,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","orcid":"https://orcid.org/0000-0002-1858-090X","institution":"Yeroam Consultancy","correspondingAuthor":true,"prefix":"","firstName":"Amaha","middleName":"HaILE","lastName":"ABEBE","suffix":""},{"id":578552512,"identity":"53efc79d-4f18-49d5-bbba-50f7ec2c5c09","order_by":1,"name":"Rose Mmusi-Phetoe","email":"","orcid":"","institution":"University of South Africa","correspondingAuthor":false,"prefix":"","firstName":"Rose","middleName":"","lastName":"Mmusi-Phetoe","suffix":""}],"badges":[],"createdAt":"2026-01-22 07:12:10","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-8666418/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8666418/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":100945882,"identity":"1f30c632-0005-4abe-bc8f-17db377f6f6d","added_by":"auto","created_at":"2026-01-23 06:17:35","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":80752,"visible":true,"origin":"","legend":"","description":"","filename":"HealthworkforcegovernanceandjobsatisfactionofSBAsAmixedmethodsstudy21012026.docx","url":"https://assets-eu.researchsquare.com/files/rs-8666418/v1/4fd634b24a5519ef90f82e52.docx"},{"id":100952242,"identity":"9a838043-254c-4667-b126-f816a77c30ec","added_by":"auto","created_at":"2026-01-23 07:12:19","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":342,"visible":true,"origin":"","legend":"","description":"","filename":"rs8666418.json","url":"https://assets-eu.researchsquare.com/files/rs-8666418/v1/7dba204f538f6ef122840e99.json"},{"id":100945886,"identity":"ac6a9782-1226-470d-a3c4-4e339ce21e1e","added_by":"auto","created_at":"2026-01-23 06:17:35","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":58468,"visible":true,"origin":"","legend":"","description":"","filename":"rs86664180enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-8666418/v1/4132c6428b32cdf62b67386a.xml"},{"id":100945880,"identity":"a4e24110-ee74-4d5e-b94b-72d5e9e4c1e2","added_by":"auto","created_at":"2026-01-23 06:17:34","extension":"png","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":22675,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8666418/v1/496c01e6dd99c1737fae3ee8.png"},{"id":100945887,"identity":"aa572f20-c4aa-42d1-9dd6-b1fc06ed4d4d","added_by":"auto","created_at":"2026-01-23 06:17:35","extension":"png","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":10095,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8666418/v1/d86bd551294221c243c179cb.png"},{"id":100945885,"identity":"627b7895-d2bd-4106-9c17-7f9e75323691","added_by":"auto","created_at":"2026-01-23 06:17:35","extension":"xml","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":56167,"visible":true,"origin":"","legend":"","description":"","filename":"rs86664180structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8666418/v1/94232b8318487858fac1849f.xml"},{"id":100945884,"identity":"d55cc84d-50d2-4ae1-b083-ca807f1bb99a","added_by":"auto","created_at":"2026-01-23 06:17:35","extension":"html","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":63797,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8666418/v1/a6b69065d6460472af035100.html"},{"id":100952095,"identity":"c8f92183-4ee9-421a-aa23-c952be7329c2","added_by":"auto","created_at":"2026-01-23 07:11:52","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":63144,"visible":true,"origin":"","legend":"\u003cp\u003eCorrelation between the number of skilled birth attendants and total number of deliveries during the EFY 2012 (July 7, 2019, to July 8, 2021)\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8666418/v1/af5408799028fc25c855d8a4.jpg"},{"id":100945879,"identity":"a5e66581-21fc-4300-a7d3-9849788de699","added_by":"auto","created_at":"2026-01-23 06:17:34","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":135809,"visible":true,"origin":"","legend":"\u003cp\u003ePercentage distribution of midwives who had training, support and supervision (N=338)\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8666418/v1/c411b5bd6f45142f77aa3b20.jpg"},{"id":100952998,"identity":"51a09563-cd28-41ff-8747-a31edc535c6f","added_by":"auto","created_at":"2026-01-23 07:19:12","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":841052,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8666418/v1/22f8f257-3826-4fb1-a607-500c961b2e9a.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eHealth workforce governance, workload alignment, and job satisfaction among skilled birth attendants in urban primary health care: a mixed-methods study from Ethiopia\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe availability of competent, motivated, and adequately supported obstetric care providers is a cornerstone of high-quality maternal and newborn care. The World Health Organization (WHO) identifies the availability of competent and motivated human resources as one of the eight core domains of quality maternal and newborn health care and emphasizes the continuous presence of skilled health workers with appropriate competencies and skill mix to provide routine intrapartum care and manage obstetric and newborn complications [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. WHO standards further highlight the importance of effective managerial and clinical leadership, supportive supervision, and work environments that promote staff motivation and continuous quality improvement [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite these global standards, service readiness and quality-of-care assessments across sub-Saharan Africa indicate that fewer than half of primary health-care facilities meet minimum staffing requirements for round-the-clock obstetric care [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In many low- and middle-income countries (LMICs), staff shortages, inequitable deployment, and weak workforce management practices continue to undermine service availability, provider motivation, and the quality of maternal and newborn care.\u003c/p\u003e \u003cp\u003eIn Ethiopia, midwives constitute the primary cadre delivering obstetric and newborn services at the health-center level and are central to achieving national maternal and newborn health targets. However, studies have documented persistent workforce challenges, including limited access to supportive supervision and in-service training, weak career-progression pathways, and high workload, all of which negatively affect motivation and performance [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. These challenges reflect broader health workforce governance issues rather than isolated facility-level constraints.\u003c/p\u003e \u003cp\u003eJob satisfaction among midwives is a critical determinant of quality of care, workforce retention, and health-system performance. Low job satisfaction has been associated with reduced motivation, poorer performance, and increased turnover intentions, ultimately compromising continuity and quality of maternal and newborn care. Evidence from Ethiopia and other LMICs consistently identifies low remuneration, limited professional development opportunities, inadequate recognition, and weak management support as major drivers of dissatisfaction among midwives [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough the literature on midwives\u0026rsquo; job satisfaction in LMICs is expanding, most studies focus on rural settings or higher-level hospitals, with limited attention to urban primary health-care facilities. Rapid urbanization across LMICs has substantially increased service demand in city health centers, often without corresponding adjustments in staffing norms, workload distribution, or workforce governance arrangements. Understanding how staffing allocation, workload, and work environment interact to influence job satisfaction in urban primary care settings is therefore critical for informing responsive and sustainable health workforce policies.\u003c/p\u003e \u003cp\u003eThis study examines how staffing allocation, workload, and work environment influence job satisfaction among skilled birth attendants in urban primary health-care facilities in Ethiopia. By focusing on workforce governance and workload alignment, the study contributes evidence relevant to rapidly urbanizing LMIC contexts where primary health-care systems face increasing service demand without commensurate adaptation of workforce policies and management practices.\u003c/p\u003e"},{"header":"Research methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and setting\u003c/h2\u003e \u003cp\u003eAn explanatory sequential mixed‑methods design was employed. The study was conducted between January and April 2021 in 50 public health centers under the Addis Ababa City Administration, Ethiopia. During the quantitative phase, face-to-face interviews were conducted with 338 midwives in the study health centers. An in-depth interview was conducted with 33 midwives and managers using an interview guide during the qualitative phase.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy population\u003c/h3\u003e\n\u003cp\u003eThe quantitative component included all midwives aged 18 years and older who were working in maternal and newborn care units of the selected health centers during the study period. Midwives assigned to other departments or those who were seriously ill at the time of data collection were excluded. The qualitative component included maternity unit heads, deputy heads, and health‑center managers who had worked in their respective facilities for at least six months..\u003c/p\u003e\n\u003ch3\u003eSample size and sampling technique\u003c/h3\u003e\n\u003cp\u003eOf the 90 public health centers providing delivery services in Addis Ababa, 50 were selected using stratified simple random sampling, with five health centers drawn from each of the ten sub‑cities. All eligible midwives available during the study period in the selected facilities were included, yielding a final sample of 338 midwives. For the qualitative component, 20 midwives and 13 managers were purposively selected until data saturation was reached.\u003c/p\u003e\n\u003ch3\u003eData collection instruments and Operational definition\u003c/h3\u003e\n\u003cp\u003eData collection tools were adapted from the WHO obstetric and newborn care quality standards and relevant literature. The work environment was assessed in terms of staffing levels, workload, availability of support and motivation mechanisms, and physical resources. Job satisfaction was measured using 20 Likert‑scale items, with a composite score of \u0026ge;\u0026thinsp;75% indicating satisfaction.\u003c/p\u003e\n\u003ch3\u003eData collection and analysis\u003c/h3\u003e\n\u003cp\u003eA structured face-to-face interview was conducted with 338 midwives with informed consent. The health centre survey questionnaire was administered through interviews with maternity unit heads, observation, and a review of registers. Data were entered into EpiData and analyzed using SPSS version 20. Qualitative interviews were audio‑recorded, transcribed verbatim, and thematically analyzed using Colaizzi\u0026rsquo;s seven‑step approach.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eEthical considerations\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eEthical approval\u003c/strong\u003e \u003cp\u003e was obtained from the University of South Africa and the Addis Ababa City Administration Health Bureau. Written informed consent was obtained from all participants, and confidentiality was maintained throughout the study.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eParticipant Characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOf the 338 midwives interviewed, 74% were female. The mean age was 28.9 years (SD = 4.0), and the mean work experience was 5.8 years (SD = 3.4). Nearly 59% held a bachelor\u0026rsquo;s degree (Table-1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable-1: Percentage distribution of midwives by socio-demographic characteristics (N=338)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 68.2692%;\"\u003e\n \u003cp\u003eSocio Demographic Variables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16.3462%;\"\u003e\n \u003cp\u003eFrequency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15.3846%;\"\u003e\n \u003cp\u003ePercent\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 68.2692%;\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3462%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e88\u003c/p\u003e\n \u003cp\u003e250\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.3846%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e26.0\u003c/p\u003e\n \u003cp\u003e74.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 68.2692%;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003cp\u003e20-24 years\u003c/p\u003e\n \u003cp\u003e25-29 years\u003c/p\u003e\n \u003cp\u003e30-34 years\u003c/p\u003e\n \u003cp\u003e\u0026gt;/=35 Year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3462%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003cp\u003e209\u003c/p\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.3846%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5.9\u003c/p\u003e\n \u003cp\u003e61.8\u003c/p\u003e\n \u003cp\u003e23.7\u003c/p\u003e\n \u003cp\u003e8.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 68.2692%;\"\u003e\n \u003cp\u003eYears of Work Experience\u003c/p\u003e\n \u003cp\u003e1-3 Years\u003c/p\u003e\n \u003cp\u003e4-6 Years\u003c/p\u003e\n \u003cp\u003e7-9 Years\u003c/p\u003e\n \u003cp\u003e\u0026ge; 10 Years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3462%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e78\u003c/p\u003e\n \u003cp\u003e139\u003c/p\u003e\n \u003cp\u003e90\u003c/p\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.3846%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e23.1\u003c/p\u003e\n \u003cp\u003e41.1\u003c/p\u003e\n \u003cp\u003e26.6\u003c/p\u003e\n \u003cp\u003e9,2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 68.2692%;\"\u003e\n \u003cp\u003eEducational Status\u003c/p\u003e\n \u003cp\u003eDiploma\u003c/p\u003e\n \u003cp\u003eBachelor\u0026rsquo;s degree\u003c/p\u003e\n \u003cp\u003eMaster\u0026apos;s degree and above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3462%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e135\u003c/p\u003e\n \u003cp\u003e199\u003c/p\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.3846%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e39.9\u003c/p\u003e\n \u003cp\u003e58.9\u003c/p\u003e\n \u003cp\u003e1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability and Workload of Skilled Birth Attendants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 439 SBAs were assigned to maternity care in the 50 health centers, of whom 90% were midwives. The average number of SBAs per health center was nine. However, the number of skilled birth attendants per health center varies from a minimum of 3 to a maximum of 22.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDuring the 2012 Ethiopian Fiscal Year, the mean workload was 69 deliveries per SBA per year, with wide variation across facilities. There was wide variation in the annual number of deliveries per SBA among the 50 health centres, ranging from 8 to 211 deliveries per SBA. No significant correlation was observed between staffing levels and workload (Figure-1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSupport, motivation, and physical resources\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMost health centers had standard recruitment procedures and conducted performance appraisals, but appraisal results were rarely linked to rewards. Access to mentorship, drills, and recent training was limited (Table-2, and Figure 2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable-2: Distribution of health centers by the avilablity of mechanisms to support and motivate skilled birth attendants (N=50)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"624\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 74.0385%;\"\u003e\n \u003cp\u003eSupport and motivation of SBAs in the 50 health centers\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.5%;\"\u003e\n \u003cp\u003eNo (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4615%;\"\u003e\n \u003cp\u003eYes (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 74.0385%;\"\u003e\n \u003cp\u003eHas a written staffing policy and plan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.5%;\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.4615%;\"\u003e\n \u003cp\u003e56\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 74.0385%;\"\u003e\n \u003cp\u003eHas standard procedures for the recruitment and deployment of staff\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.5%;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4615%;\"\u003e\n \u003cp\u003e94\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 74.0385%;\"\u003e\n \u003cp\u003eHas performed staff performance appraisals in the past year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.5%;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4615%;\"\u003e\n \u003cp\u003e92\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 74.0385%;\"\u003e\n \u003cp\u003eHas \u0026nbsp;recognized or rewarded staff who performed well in the past year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.5%;\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4615%;\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 74.0385%;\"\u003e\n \u003cp\u003eThe maternity service had supportive supervision in the past year\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.5%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4615%;\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 74.0385%;\"\u003e\n \u003cp\u003eThe maternity service \u0026nbsp;had mentorship support in the past year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.5%;\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4615%;\"\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 74.0385%;\"\u003e\n \u003cp\u003eThe maternity service had a drill exercise in the past year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.5%;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4615%;\"\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;While most facilities met national standards for infrastructure and essential supplies, deficits were noted in water supply and staff amenities, indicating that environmental adequacy did not translate into improved staff motivation (Table-3).\u003c/p\u003e\n\u003cp\u003eTable 3: Percentage distribution of health centres with the physical resources for skilled birth attendants to function (N=50)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"628\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 75.7962%;\"\u003e\n \u003cp\u003eAvailability of physical resources for SBAs at MNHC service area\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.465%;\"\u003e\n \u003cp\u003eNo (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.7389%;\"\u003e\n \u003cp\u003eYes (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 75.7962%;\"\u003e\n \u003cp\u003eThe maternity unit has 75% of the 44 essential medical equipment, supplies, and drugs for obstetric and newborn care\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.465%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.7389%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 75.7962%;\"\u003e\n \u003cp\u003eThe maternity unit has a delivery room with two or more second-stage delivery couches and meets the national standard for a health centre\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.465%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u0026nbsp;0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.7389%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u0026nbsp;100\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 75.7962%;\"\u003e\n \u003cp\u003eThe maternity unit \u0026nbsp;has a prenatal and postnatal care room with four or more beds, and meets the national standard for a health centre\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.465%;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.7389%;\"\u003e\n \u003cp\u003e96\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 75.7962%;\"\u003e\n \u003cp\u003eThe labour and delivery room had good illumination (could read 12 font script)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.465%;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.7389%;\"\u003e\n \u003cp\u003e94\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 75.7962%;\"\u003e\n \u003cp\u003eThe labour and delivery room had good ventilation (cross-ventilating doors and windows)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.465%;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.7389%;\"\u003e\n \u003cp\u003e96\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 75.7962%;\"\u003e\n \u003cp\u003eThe maternity unit \u0026nbsp;has a newborn corner\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.465%;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.7389%;\"\u003e\n \u003cp\u003e96\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 75.7962%;\"\u003e\n \u003cp\u003eThe maternity unit has a waiting area for companions\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.465%;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.7389%;\"\u003e\n \u003cp\u003e84\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 75.7962%;\"\u003e\n \u003cp\u003eThe maternity unit has an area in the labour and delivery unit for staff to work on records\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.465%;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.7389%;\"\u003e\n \u003cp\u003e94\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 75.7962%;\"\u003e\n \u003cp\u003eThe maternity unit has an area in the labour and delivery unit for staff to rest\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.465%;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.7389%;\"\u003e\n \u003cp\u003e96\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 75.7962%;\"\u003e\n \u003cp\u003eThe maternity unit has an uninterrupted supply of electricity power \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.465%;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.7389%;\"\u003e\n \u003cp\u003e92\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 75.7962%;\"\u003e\n \u003cp\u003eThe maternity unit has an uninterrupted supply of water \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.465%;\"\u003e\n \u003cp\u003e72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.7389%;\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 75.7962%;\"\u003e\n \u003cp\u003eThe maternity unit has a toilet room for clients\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.465%;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.7389%;\"\u003e\n \u003cp\u003e94\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 75.7962%;\"\u003e\n \u003cp\u003eThe maternity unit has a toilet room for staff\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.465%;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.7389%;\"\u003e\n \u003cp\u003e70\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 75.7962%;\"\u003e\n \u003cp\u003eThe maternity unit has a shower room for clients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.465%;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.7389%;\"\u003e\n \u003cp\u003e82\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 75.7962%;\"\u003e\n \u003cp\u003eThe maternity unit has a shower room for staff\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.465%;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.7389%;\"\u003e\n \u003cp\u003e66\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eJob satisfaction of skilled birth attendants\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOnly 38.2% of midwives met the threshold for overall job satisfaction. The highest levels of dissatisfaction were reported regarding salary, incentives, opportunities for further education, and performance‑based recognition. In contrast, midwives reported relatively high satisfaction with teamwork, professional respect from colleagues, and the perceived quality of care they provided (Table-4).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable-4: Percentage of midwives satisfied with their jobs (N=338)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55.7692%;\"\u003e\n \u003cp\u003eJob-related variables\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3462%;\"\u003e\n \u003cp\u003eDissatisfied\u003c/p\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4615%;\"\u003e\n \u003cp\u003eNot sure\u003c/p\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.4231%;\"\u003e\n \u003cp\u003eSatisfied\u003c/p\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55.7692%;\"\u003e\n \u003cp\u003eAvailability of human resource policy and guidelines\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3462%;\"\u003e\n \u003cp\u003e12.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4615%;\"\u003e\n \u003cp\u003e11.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.4231%;\"\u003e\n \u003cp\u003e75.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55.7692%;\"\u003e\n \u003cp\u003eSupportiveness of the management\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3462%;\"\u003e\n \u003cp\u003e19.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4615%;\"\u003e\n \u003cp\u003e21.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.4231%;\"\u003e\n \u003cp\u003e58.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55.7692%;\"\u003e\n \u003cp\u003eMechanism of performance appraisal and recognition\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3462%;\"\u003e\n \u003cp\u003e35.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4615%;\"\u003e\n \u003cp\u003e20.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.4231%;\"\u003e\n \u003cp\u003e43.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55.7692%;\"\u003e\n \u003cp\u003eRespect and recognition from the management\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3462%;\"\u003e\n \u003cp\u003e27.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4615%;\"\u003e\n \u003cp\u003e16.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.4231%;\"\u003e\n \u003cp\u003e56.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55.7692%;\"\u003e\n \u003cp\u003eRespect and recognition from professional colleagues\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3462%;\"\u003e\n \u003cp\u003e5.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4615%;\"\u003e\n \u003cp\u003e2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.4231%;\"\u003e\n \u003cp\u003e92.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55.7692%;\"\u003e\n \u003cp\u003eThe respect and recognition you receive from clients\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3462%;\"\u003e\n \u003cp\u003e6.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4615%;\"\u003e\n \u003cp\u003e4.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.4231%;\"\u003e\n \u003cp\u003e89.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55.7692%;\"\u003e\n \u003cp\u003eOpportunity for peer learning\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3462%;\"\u003e\n \u003cp\u003e8.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4615%;\"\u003e\n \u003cp\u003e5.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.4231%;\"\u003e\n \u003cp\u003e85.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55.7692%;\"\u003e\n \u003cp\u003eSupervision and mentorship\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3462%;\"\u003e\n \u003cp\u003e22.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4615%;\"\u003e\n \u003cp\u003e20.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.4231%;\"\u003e\n \u003cp\u003e57.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55.7692%;\"\u003e\n \u003cp\u003eAccess to trainings and updates \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3462%;\"\u003e\n \u003cp\u003e31.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4615%;\"\u003e\n \u003cp\u003e18.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.4231%;\"\u003e\n \u003cp\u003e50.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55.7692%;\"\u003e\n \u003cp\u003eOpportunity for further education\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3462%;\"\u003e\n \u003cp\u003e56.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4615%;\"\u003e\n \u003cp\u003e16.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.4231%;\"\u003e\n \u003cp\u003e27.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55.7692%;\"\u003e\n \u003cp\u003ePhysical attractiveness of the work environment\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3462%;\"\u003e\n \u003cp\u003e17.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4615%;\"\u003e\n \u003cp\u003e8.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.4231%;\"\u003e\n \u003cp\u003e74.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55.7692%;\"\u003e\n \u003cp\u003eTeamwork in labour and delivery care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3462%;\"\u003e\n \u003cp\u003e1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4615%;\"\u003e\n \u003cp\u003e3.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.4231%;\"\u003e\n \u003cp\u003e95.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55.7692%;\"\u003e\n \u003cp\u003eSafety of staff, including prevention of infection\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3462%;\"\u003e\n \u003cp\u003e10.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4615%;\"\u003e\n \u003cp\u003e8.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.4231%;\"\u003e\n \u003cp\u003e81.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55.7692%;\"\u003e\n \u003cp\u003eAvailability of facility, equipment, drugs, and supplies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3462%;\"\u003e\n \u003cp\u003e10.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4615%;\"\u003e\n \u003cp\u003e8.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.4231%;\"\u003e\n \u003cp\u003e80.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55.7692%;\"\u003e\n \u003cp\u003eQuality of obstetric care delivered\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3462%;\"\u003e\n \u003cp\u003e6.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4615%;\"\u003e\n \u003cp\u003e3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.4231%;\"\u003e\n \u003cp\u003e90.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55.7692%;\"\u003e\n \u003cp\u003eThe workload \u0026nbsp;at the workplace\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3462%;\"\u003e\n \u003cp\u003e20.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4615%;\"\u003e\n \u003cp\u003e14.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.4231%;\"\u003e\n \u003cp\u003e65.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55.7692%;\"\u003e\n \u003cp\u003eFlexibility and fairness of the duty schedule and rotation\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3462%;\"\u003e\n \u003cp\u003e8.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4615%;\"\u003e\n \u003cp\u003e8.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.4231%;\"\u003e\n \u003cp\u003e83.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55.7692%;\"\u003e\n \u003cp\u003eEase of getting annual leave\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3462%;\"\u003e\n \u003cp\u003e24.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4615%;\"\u003e\n \u003cp\u003e10.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.4231%;\"\u003e\n \u003cp\u003e64.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55.7692%;\"\u003e\n \u003cp\u003eAmount of salary\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3462%;\"\u003e\n \u003cp\u003e63.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4615%;\"\u003e\n \u003cp\u003e13.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.4231%;\"\u003e\n \u003cp\u003e23.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55.7692%;\"\u003e\n \u003cp\u003eIncentives (housing and allowances)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3462%;\"\u003e\n \u003cp\u003e75.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4615%;\"\u003e\n \u003cp\u003e11.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.4231%;\"\u003e\n \u003cp\u003e12.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eQualitative Findings\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eQualitative data highlighted high workload, low remuneration, infection risk, and limited professional development as major demotivating factors. Intrinsic motivation derived from saving mothers\u0026rsquo; and newborns\u0026rsquo; lives remained a key source of job satisfaction. The qualitative study also revealed the fact that the number of midwives assigned per health centre was not linked to the workload and needs a policy to address that. A midwife said:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;There are no significant differences in staffing for health centres with high and low caseloads. The city health office should revise the policy to link staffing with workload.\u0026rdquo;\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTaken together, the quantitative and qualitative findings indicate a systemic disconnect between workforce deployment policies and service delivery realities. While health centers largely met infrastructure and equipment standards, human resource management practices\u0026mdash;particularly staffing allocation, performance appraisal, and professional development\u0026mdash;were not responsive to workload variation or staff motivation needs.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study provides important insights into health workforce governance challenges affecting skilled birth attendants in urban primary health-care settings in LMICs. Despite relatively well-resourced facilities, job satisfaction among SBAs in Addis Ababa public health centers was low, highlighting that material readiness alone does not ensure a motivated workforce. These findings align with evidence from other LMICs, including Kenya, Uganda, Tanzania, and Ghana, where inadequate remuneration, high workload, limited professional development, and weak management support have been consistently associated with low health worker motivation and retention.\u003c/p\u003e \u003cp\u003eA key contribution of this study is the demonstration that staffing allocation was not aligned with workload across facilities, resulting in substantial variation in service burden per SBA. Similar mismatches between staffing norms and service volume have been reported in urban primary health-care facilities in other LMICs, suggesting that rigid staffing policies and weak workforce planning systems are common governance challenges. This misalignment undermines efficiency, contributes to burnout, and reduces job satisfaction even in contexts where absolute staff numbers appear adequate [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOverall job satisfaction among SBAs is lower than levels reported in other Ethiopian studies [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Major sources of dissatisfaction included low salary and incentives, high workload, limited access to training and further education, weak management support, and occupational health risks such as exposure to HIV and hepatitis infection.\u003c/p\u003e \u003cp\u003eThe findings highlight critical governance gaps in the management of the maternal health workforce. First, staffing policies that do not account for service volume and case mix limit the effectiveness of workforce investments. Dynamic staffing models that link deployment to workload indicators could improve both efficiency and staff well-being. Second, although performance appraisal systems were reportedly in place, their lack of linkage to incentives or recognition reduced their motivational value. Evidence from LMICs indicates that performance-based recognition\u0026mdash;financial or non-financial\u0026mdash;can significantly enhance motivation and retention of health workers. Third, limited access to training, mentorship, and career advancement opportunities undermines professional development and contributes to dissatisfaction, despite SBAs\u0026rsquo; strong intrinsic motivation to provide quality care [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThese findings underscore that improving maternal and newborn health outcomes require not only investments in infrastructure and supplies but also strengthened health workforce governance. Policies that integrate staffing allocation with workload, institutionalize supportive supervision and mentorship, and link performance appraisal to meaningful incentives are essential. As urban populations continue to grow across LMICs, addressing these workforce governance challenges in primary health-care settings will be critical for sustaining quality obstetric and newborn care.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study highlights that low job satisfaction among skilled birth attendants persists even in relatively well-resourced urban primary health-care facilities. Misalignment between staffing allocation and workload, weak performance-based incentive systems, and limited professional development opportunities undermine workforce motivation. These challenges reflect broader health workforce governance issues common to many LMICs. Addressing them through adaptive staffing policies, strengthened performance management systems, and sustained investment in professional development is critical for improving SBA motivation, retention, and the quality of maternal and newborn care.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCOVID-19 Coronavirus\u0026nbsp;Disease of 2019\u003c/p\u003e\n\u003cp\u003eHIV\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Human Immunodeficiency Virus\u003c/p\u003e\n\u003cp\u003eSBA \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Skilled Birth Attendants\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSDGs\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Sustainable Development Goals\u003c/p\u003e\n\u003cp\u003eSPSS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Statistical Package for the Social Sciences\u003c/p\u003e\n\u003cp\u003eUNISA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;University of South Africa\u003c/p\u003e\n\u003cp\u003eWHO \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;World Health Organization\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe research protocol was reviewed and approved by the Research Ethics Committee of the Department of Health Studies of the University of South Africa. The research protocol was again reviewed and approved by the Ethical Review Committee of Addis Ababa City Administration Health Office. Once the research protocol had been approved by the ethical review committees, support letters were written from the Addis Ababa city administration health office and sub-city health offices to study health facilities.\u003c/p\u003e\n\u003cp\u003eThe research was conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from all study participants, and interviews were conducted in a setting that ensured privacy and confidentiality. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable. Our manuscript does not contain data from any individual person\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthors\u0026apos; contributions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAmaha Haile Abebe, Corresponding author have conceptualized and designed the study protocol, coordinated, supervised, and conducted the data collection, data entry, analysis, and report write-up. Prepared the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eProf. Rose Mmusi-Phetoe, co-author, supervised and contributed to conceptualizing and designing the study protocol, data analysis, and report write-up and review. She further reviewed and refined the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAcknowledgments\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank the University of South Africa for financing the study. We would like to thank women, midwives, and health center heads in Addis Ababa city for participating in the study. \u0026nbsp;I would like to thank the research assistants who conducted the qualitative data collection, namely, Sr. Hawa Ali, Sr. Hasna Musema, Sr. Aselefech Negewo, and Sr. Abeba Gebrehiwot.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eUniversity of South Africa provided financial support to undertaking of the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eTun\u0026ccedil;alp Ӧ, Were W, MacLennan C, Oladapo O, G\u0026uuml;lmezoglu A, Bahl R (2015) Quality of care for pregnant women and newborns\u0026mdash;the WHO vision, \u003cem\u003eBjog\u003c/em\u003e, p. 1045\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWHO (2016) Standards for improving quality of maternal and newborn care in health facilities. WHO, Geneva\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKruk M, Leslie H, Verguet S, Mbaruku G, Adanu R, Langer A (2016) Quality of basic maternal care functions in health facilities of five African countries: an analysis of national health system surveys. Lancet Glob Health 4(11):845\u0026ndash;855\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e; EPHI, FMoH, AMMD (2018), Ethiopian Emergency Obstetric and Newborn Care (EmONC) Assessment 2016, EPHI, Addis Ababa\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBekru E, Cherie A, Anjulo A (2017) Job satisfaction and determinant factors among midwives working at health facilities in Addis Ababa city. Ethiopia PLoS ONE 12(2):1\u0026ndash;16\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFikre R, Berhanu M (2018) Current evidence on basic emergency obstetric and newborn care in primary health care unit of Gedeo zone, South Ethiopia, 2018. Biomedical J Scientific Technical Research 17(3):12838\u0026ndash;12843\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSendawula K, Kimuli S, Bananuka J, Muganga G (2018) Training, employee engagement and employee performance: evidence from Uganda\u0026rsquo;s health sector. Cogent Business Managemen 5(1):1\u0026ndash;12\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMuthuri R, Senkubuge F (2020) and H. H, Determinants of motivation among healthcare workers in the East African community between 2009\u0026ndash;2019: a systematic review, \u003cem\u003eHealthcare\u003c/em\u003e, vol. 8, no. 164, pp. 1\u0026ndash;24\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIdowu A (2017) Effectiveness of performance appraisal system and its effect on employee motivation. Nile J Bus Econ 5:15\u0026ndash;39\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMuluneh M, Moges G, Abebe S, Hailu Y, Makonnene M, Stulz V (2022) Midwives\u0026rsquo; job satisfaction and intention to leave their current position in developing regions of Ethiopia. Women Birth 35(1):35\u0026ndash;47\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[{"identity":"d0ee82ce-69f4-4b17-8d27-a862f4d4b392","identifier":"10.13039/501100008227","name":"University of South Africa","awardNumber":"00000","order_by":0}],"hasAdminPriorityOnWorkflow":true,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"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":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Job satisfaction, mentorship, obstetric and newborn care, physical resources, skilled birth attendants, workload","lastPublishedDoi":"10.21203/rs.3.rs-8666418/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8666418/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eBackground: Health workforce motivation and retention are central to achieving high-quality maternal and newborn care globally. However, evidence on how staffing allocation, workload, and work environment interact to influence skilled birth attendants\u0026rsquo; job satisfaction in urban primary health-care settings in low- and middle-income countries (LMICs) remains limited.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eAn explanatory sequential mixed‑methods study was conducted in 50 public health centers between January and April 2021. Quantitative data were collected through face‑to‑face interviews with 338 midwives providing maternal and newborn health services. A structured health‑center questionnaire was administered through interviews with maternity unit heads, direct observation, and register review. Qualitative data were generated through in‑depth interviews with 20 midwives and 13 health‑center managers. Quantitative data were analyzed descriptively, while qualitative data were analyzed thematically using Colaizzi\u0026rsquo;s method.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOnly 38.2% of skilled birth attendants reported overall job satisfaction. Staffing allocation was poorly aligned with service workload, resulting in wide variation in annual deliveries per SBA across facilities. Despite generally adequate infrastructure and essential supplies, dissatisfaction was driven by low remuneration, limited access to professional development, weak performance-based recognition, and high workload. Qualitative findings highlighted governance gaps in staffing norms, limited managerial accountability, and the absence of incentive mechanisms as key contributors to low motivation.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis study demonstrates that adequate physical resources alone are insufficient to ensure a motivated maternal health workforce. Misalignment between staffing allocation and workload, weak performance management systems, and limited professional development opportunities undermine job satisfaction among SBAs. These findings have implications for urban primary health-care systems across LMICs, underscoring the need for workforce policies that link staffing, workload, and performance incentives to improve motivation and quality of maternal and newborn care.\u003c/p\u003e","manuscriptTitle":"Health workforce governance, workload alignment, and job satisfaction among skilled birth attendants in urban primary health care: a mixed-methods study from Ethiopia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-23 06:17:30","doi":"10.21203/rs.3.rs-8666418/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cfa892c1-3c56-40ce-a69a-f066f55799e0","owner":[],"postedDate":"January 23rd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":61558271,"name":"Health Policy"}],"tags":[],"updatedAt":"2026-01-23T06:17:30+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-23 06:17:30","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8666418","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8666418","identity":"rs-8666418","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}