Exploring working conditions and job stability of midwives in Spain: results from a National Survey

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Challenges persist, including suboptimal remuneration, competency misalignment, and employment precarity (92.7% temporary contracts in 2024), aggravating professional dissatisfaction, reduced job satisfaction, and well-being deficits. Influential factors include workload, contractual stability, and work–life balance, emphasizing the imperative for empirical analysis of labor conditions. This study describes midwives' perceptions of Spanish work environments and assesses contract-type variations. Methods We conducted a cross-sectional, quantitative survey of registered midwives in Spain using a self-administered, 23-item web questionnaire (five domains) on EUSurvey to assess working conditions, capturing demographics, job characteristics, training/competence, and entitlements, and evaluating differences in professional perceptions by contract type. Results Of the 2,499 responses, 2,310 met the requirements (27.8% of practicing midwives in Spain). The majority worked in public hospitals (66.1%); 43.4% had permanent contracts, a figure that increased with age and experience. Temporary contracts, more common in the private sector, were associated with lower salaries and less salary satisfaction (4.0–4.1 vs. 4.6/10; p < 0.001) and greater exposure adverse employment actions due to staff shortages (requests for off-hours shifts: 90.2%, denied leave: 55.4%, approved leave canceled: 22.8%; p < 0.001). Role intrusion was frequent (77.1%). Despite widespread participation in continuous training, only 15.8% felt fully competent in all core competencies. Conclusions Temporariness and staffing shortages worsen conditions, enable role intrusion, and reduce pay satisfaction. Despite accessible continuous training, key developed competencies remain unimplemented in the health system; job stability, adequate coverage, and equal opportunities to professional development are needed to protect quality and equity. Health Policy Nursing Maternal & Fetal Medicine Midwifery Working conditions Temporary workers Continuous training Clinical Competencies Figures Figure 1 1. Background Global healthcare sustainability faces significant challenges, including the growing burden of chronic diseases and recurrent infectious disease outbreaks. A critical concern is the projected shortage of health professionals, with an estimated deficit of 4.5 million nurses and 310,000 midwives by 2030, according to the World Health Organization (WHO) [ 1 , 2 ]. Midwives play an essential role in women’s sexual and reproductive health across the lifespan, providing care during pregnancy, childbirth, and the postnatal period for both mothers and newborns [ 3 , 4 ]. The third global State of the World’s Midwifery 2021 report (SoWMy 2021) highlights five key benefits of investing in midwifery: improved health outcomes, increased workforce and economic activity, positive socioeconomic impact of healthcare investments, inclusive employment growth for women, and enhanced economic stability [ 5 ]. Nonetheless, political action has been urged across European governments to strengthen investment in midwifery staffing, training, and working conditions [ 6 ]. In Europe, the median ratio of midwives is 9.1 per 10,000 women aged 14–65, whereas Spain reports one of the lowest ratios at 6.1, thereby constraining workforce capacity and limiting the ability to provide equitable and safe coverage of care demands [ 3 ]. To qualify as a midwife in Spain, candidates must first obtain registration as a general nurse and then complete a two-year specialization in Obstetric-Gynaecologic Nursing, a programme known by its Spanish acronym EIR ( Enfermero Interno Residente ) [ 7 ]. This pathway differs from qualification models in other European countries, such as Germany and France, where candidates directly access a bachelor’s degree in Midwifery, or the United Kingdom, where both models coexist [ 8 ]. The Spanish core curriculum for midwives was established in 2009, aligned with a practice framework for care delivery in primary and acute care settings across public and private sectors [ 9 ]. However, demographic and social transformations in Europe have generated new care demands, expanding midwives’ roles beyond traditional perinatal care [ 10 ]. These demands include adopting new technologies, collaborating effectively with other healthcare professionals, and managing the prescription, dispensation, and administration of medicines and health products [ 4 ]. Despite midwives’ recognition as key healthcare providers within the Spanish health system, unresolved issues remain regarding fair remuneration and the adaptation of competencies to current care needs [ 11 ]. These limitations hinder professional development, contributing to frustration and negatively impacting well-being among midwives [ 12 , 13 ]. Job satisfaction, which encompasses outcomes such as optimal utilization of professional skills, recognition, and self-esteem, may be affected by these circumstances [ 14 ]. Rodríguez Marín [ 15 ] identified multiple factors influencing job satisfaction and well-being, including the physical work environment, workload demands (e.g., shift work and overload), job description, financial and contractual conditions (e.g., salary adequacy and job stability), role performance, technological changes, interpersonal relationships, professional development opportunities, organizational characteristics, and work–family balance. Job stability remains a major weakness in the Spanish healthcare system due to the high prevalence of temporary employment among health professionals. In 2024, 92.7% of contracts signed by midwives were temporary, and 76.8% were full-time [ 16 ]. Spanish labor regulations define three types of contracts based on duration: permanent contracts, typically obtained through competitive selection processes involving examinations and curriculum assessment; interim contracts, which are temporary without a fixed term and used for substitutions or to cover positions pending permanent allocation or leave of absence; and temporary contracts, which have a defined duration based on production needs [ 17 ]. Following the modification of the Spanish regulation on relative to healthcare workforce 2022 [ 18 ], healthcare professionals can remain under interim status for a maximum of three years. If the position has not been filled permanently within this period, the interim professional is offered a non-permanent, undefined-term contract, which provides greater stability and protection. Prior to this modification, more than 40% of the Spanish healthcare workforce was employed under interim or temporary contracts, in some cases for notably long periods [ 19 ]. Employment instability limits professional development and increases the risk of well-being problems [ 20 ]. It is often associated with job insecurity, limited access to training opportunities and exposure to workplace discrimination. This can even lead to adverse employment action being taken against some professionals. [ 21 ]. The existing literature on midwives’ working conditions remains limited among the sources reviewed. However, a comparable study was conducted with a smaller sample in the same geographical context, although it did not focus specifically on job stability [ 12 ]. The relationship between employment instability and working conditions, such as salary, workload, continuous training and adverse employment actions, remains unclear. This study therefore aims to describe midwives’ perceptions of working conditions in Spain, including the implementation of developed competencies, and to examine differences according to contract type. 2. Materials and methods 2.1. Study Design This study employed a cross-sectional, quantitative, descriptive, and correlational design. Data were collected through a self-administered, web-based sociodemographic survey aimed at assessing the working conditions of registered midwives working in Spain. The reporting of this study adheres to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement [ 22 ] and follows the Consensus-Based Checklist for Reporting of Survey Studies (CROSS) [ 23 ]. 2.2. Questionnaire details The tool was developed by the research team in collaboration with 15 expert midwives representing different Spanish regions (Autonomous Communities). The self-administered survey was uploaded to the EUSurvey platform (v1.5.3, Public License, European Commission). The initial version of the tool was piloted with a sample of 25 midwives to ensure proper functionality, improve ease of completion, and estimate the time required to complete the survey. Five members of the expert panel assessed the first draft of the questionnaire and adapted items accordingly. The final version of the questionnaire included 23 items grouped into five sections: demographic characteristics, work status, training, competencies, and adverse employment actions. The variables were classified as demographic characteristics (age group), job details (years of experience, type of contract, area of practice, involvement in research and teaching, annual income, care time per patient, and role intrusion), and training and competencies (participation in continuous training, perception of implemented competencies, and competency gaps). The comparative variable was the type of contract, which was grouped into three categories: permanent, interim, and temporary. The complete survey tool is provided in Supplementary Table 1. 2.3. Sample characteristics According to the census available on December 31, 2023, there were 8,301 active (non-retired) registered midwives in Spain [ 24 ]. A geographical quota sampling strategy was applied to ensure representation across the 17 autonomous regions and 2 autonomous cities of Spain. The study included registered midwives actively working in the Spanish healthcare system, while non-practicing midwives, midwifery trainees, and retired midwives were excluded. Based on a 95% confidence level, a 0.05 margin of error, and an assumed proportion of 0.5, the required sample size was calculated as 387 respondents. Details of the quota distribution are depicted in Supplementary Fig. 1. 2.4. Survey Administration The questionnaire was administered through an EUSurvey link. Based on the pre-test, the estimated completion time was approximately 10 minutes, although no time limit was imposed. All items in the questionnaire were mandatory. To prevent automated submissions, the platform required participants to complete a CAPTCHA challenge before submitting their responses, and each IP address was restricted to a single submission. The survey link was distributed nationwide via corporate emails and professional social media channels of the General Council of Nurses and the 52 regional Nursing Colleges across the country. The survey remained open for responses throughout March 2024. Respondent-related and measurement-related sources of common method bias (CMB) were addressed through procedural measures, including survey design strategies (e.g., clear instructions, assurance of anonymity, and avoidance of ambiguous items) and methodological separation (e.g., use of varied item formats and distinct measures for in- dependent and dependent variables) [ 25 ]. 2.5. Statistical Analysis Analyses were conducted using IBM SPSS Statistics software, version 29.0 (SPSS Inc., Chicago, IL, USA). All variables analysed were categorical and expressed as response counts and percentages, presented in frequency tables. Associations with the independent variable (type of contract) were tested using contingency tables and Pearson’s Chi-square tests. The predictive strength of contract type over other variables was estimated through multivariable logistic regression models. Results were expressed as Odds Ratios (OR) with 95% Confidence Intervals (95% CI). A p-value of less than 0.05 was considered statistically significant for all analyses. 3. Results The survey collected 2,499 responses, with adequate representation from all Spanish regions and a mean provincial participation rate of 36.9%. Participation rates by province are listed in Supplementary Table 2 and represented in Supplementary Fig. 2. Of the total responses, 142 were excluded because they were completed by non‑practicing professionals and 47 were excluded because they were completed by midwifery trainees. Consequently, 2,310 responses were included in the analysis, representing 27.8% of the active population of registered midwives in Spain. The distribution of sample demographics categorized by contract type is presented in Table 1. The most represented age group was 31–50 years. Most participants worked in direct patient care within public hospitals (66.1%), and 43.4% of respondents reported having permanent contracts. Table 1. Distribution of Participants’ Demographics categorized by contract type. The proportion of permanent contracts increased progressively with age and work experience, reaching up to 90% among midwives aged 61–67 years and those with more than 20 years of professional experience. Most permanent contracts were concentrated in public hospitals (41.2%), whereas temporary contracts were more prevalent in private healthcare settings (50.5%). Table 2 presents the distribution of midwives’ responses regarding working conditions, continuous training, and competencies considered necessary within the healthcare system, categorized by contract type. Most midwives reported annual salaries between €35,000 and €45,000, with lower salaries associated with temporary contracts and higher salaries linked to permanent contracts. The mean satisfaction score related to salary was 4.3 ± 2.2 on a 10-point scale, with higher scores among midwives holding permanent contracts (4.6 ± 2.3) compared to those with interim (4.1 ± 2.2) and temporary contracts (4.0 ± 2.2) ( p < 0.001 ). Table 2. Working conditions including continuous training and competencies categorized by contract type. Most midwives working in Primary Care (76.1%) considered it necessary to increase the time allocated for direct patient care, a concern significantly more pronounced among those with temporary contracts compared to permanent employees. A majority of participants (77.1%) reported witnessing role intrusion, although only 5.5% had formally taken legal actions. Nearly all respondents reported engagement in continuous training regardless of contract type; however, only 15.8% believed that all clinical competencies developed for safe midwifery practice are fully implemented in their region. The most frequently identified competency gaps included ultrasound, menopause care, sexual and reproductive health, perinatal grief care, and pelvic floor management, whereas pregnancy and breastfeeding care were most commonly perceived as fully implemented (Fig. 1 ). Similar response patterns were observed between hospital and primary care midwives regarding competency gaps, although hospital-based midwives expressed greater concern about breastfeeding care and cancer screening competencies. Midwives' perceptions of implementation gaps across competencies in a multiple-choice item. Response rates among hospital care (n = 1,464) and primary care (n = 846) midwives * Other answers included in an open conditional item were: home postnatal care; sexually transmitted infections (STIs) in adolescents; assisted reproduction and fertility; adolescent menarche, puberty and menstrual cycle care; perinatal mental health; teaching; and research. Table 3 summarizes midwives’ adverse employment action resulting from the uncovered staff shortage in units, categorized by contract type. A total of 90.2% of participants reported at least one request to cover shifts outside their regular schedule, while 55.4% experienced rejection of single-day leave or unpaid leave requests. Additionally, 22.8% reported cancellations of previously approved annual leave. Regression analyses indicated that midwives with temporary contracts were the most affected in all these situations (p < 0.001). These issues may be linked to the limited availability of replacement staff to cover absences such as annual leave, part-time shifts, and sick leave, as reported by 38.9% of participants. This lack of coverage was considered problematic by the vast majority of respondents (98.3%), who believed it contributes to work overload. Table 3. Adverse employment actions associated with midwife shortages, by contract type. 4. Discussion This study aimed to describe midwives’ perceptions of working conditions in Spain, focusing on the implementation of competencies, continuous training, and adverse employment actions, and examining how these are associated with contract type. The study found that job stability increased with age and years of experience. Temporary midwives had lower salaries and were less satisfied with them. They were also more likely to be asked to work outside normal hours, have leave requests denied and have approved annual leave cancelled. The proportion of respondents working in the public sector was high but still lower than that reported in other studies conducted in comparable populations, such as previous research in Spain (95.6%) [ 12 ], the UK (88.6%) [ 26 ], and Australia (89.8%) [ 27 ]. Conversely, the proportion of midwives working exclusively in the private sector in Spain was similar to that observed in the UK (0.8%) and markedly lower than in Australia (10.6%). Overall salary satisfaction among Spanish midwives was moderate to low, with particularly low levels reported by temporary and interim staff. Given that salary satisfaction is a known determinant of overall job satisfaction [ 28 ], this finding warrants further attention. Other studies, however, have highlighted additional components of job satisfaction beyond remuneration [ 29 , 30 ]. Regarding time allocated for patient care, responses showed relatively little variability, with a slight preference for an additional 10 minutes per consultation. Similar concerns have been raised in international contexts. For instance, a study in Peru [ 31 ] questioned the quality of care delivered by primary care midwives due to the brevity of patient interactions, with midwives averaging 4–5 minutes per patient despite dedicating more total minutes per shift to direct care than nurses or physicians. Overall low satisfaction with workload can be deducted from our results, consistent with previous national results [ 12 ], while temporariness reveals significant differences. Nevertheless, further research is needed to explore the nature of midwives’ care activities in different healthcare settings to enable meaningful comparisons and to assess care needs from multiple perspectives. 4.1. Training In our study, most respondents obtained their midwifery qualification through the EIR pathway, a proportion consistent with the findings of Iglesias-Casas et al. [ 12 ], who reported that this training pathway graduates professionals who feel well-prepared, confident, and competent in their professional role. No differences were observed between contract types in relation to participation in continuous training, suggesting that engagement in continuous training was not age‑dependent. This contrasts with evidence from the nursing profession, where continuous training has been more commonly associated with older age groups in previous studies [ 32 , 33 ]. 4.2. Competencies According to the analysis reported by the Spanish Federation of Midwives’ Associations [3, Spanish midwives have one of the broadest ranges of competencies in Europe. Among the competencies included in midwives’ training programs, the most relevant are related to pregnancy care, childbirth, postnatal care, and women’s reproductive and sexual-affective health [ 9 ]. However, participants in our study reported that many of these competencies are not fully implemented in real practice. Most participants identified gaps in the implementation of developed competencies within their regional health services, while only nurses practicing in Catalonia and Navarre expressed some alignment between competencies acquired during training and those applied in clinical practice. The major gaps were identified in ultrasound, menopause care, pelvic floor health, and reproductive and sexual health. This issue may be related to findings from a review conducted by Watkins et al. [ 34 ], which indicated that gaps in competency implementation are influenced by factors such as systemic fragmentation of services and negative perceptions of midwives within organizations, communities, and other professional disciplines. Further studies should explore geographical and social barriers to midwives’ competency implementation. As a breach of professional recognition and development, midwives’ competencies may encounter interdisciplinary challenges [ 35 ]. Well-structured interprofessional collaboration is essential for woman-centred care, given the fundamental differences between disciplines such as midwifery, medicine, physiotherapy, and others [ 36 ]. Otherwise, interdisciplinary conflicts such as role intrusion or intrusiveness may arise. Pradelli et al. [ 37 ] stated that role intrusion “occurs when healthcare professionals overstep the boundaries of their specific professional competencies, encroaching on the responsibilities of others.” Most respondents reported having witnessed role intrusion, although only a small proportion pursued legal action, with doulas being the most frequently cited professionals involved. The proportion of midwives reporting role intrusion in our study is slightly lower than that observed by Iglesias‑Casas et al. (92.4%) [ 12 ]; however, this difference may be explained by the fact that our question referred specifically to witnessed cases, rather than capturing broader perceptions of the existence or prevalence of role intrusion. Role intrusion is scarcely addressed in the literature but is perceived as a barrier to effective teamwork and poses significant risks to both patients and providers [ 35 , 37 ]. The adoption of non-clinical professionals, such as doulas, is showing potential benefits for perinatal care and is becoming increasingly widespread [ 38 ]. According to DONA International, the international representative organization for doulas, they are “trained professionals who provide continuous physical, emotional, and informational support to their clients before, during, and shortly after childbirth to help them achieve the healthiest, most satisfying experience possible” [ 39 ]. Although doulas do not perform clinical activities, integrative models propose their inclusion as a liaison role between women and healthcare providers during perinatal care [ 40 ]. In this regard, the adoption of doulas in Spain is not formally regulated, nor is their inclusion within the healthcare system, which underscores the importance of preventing role intrusion by establishing clear practice boundaries between regulated healthcare professions and other agents. 4.3. Adverse employment actions Data show that midwives with temporary contracts have a higher likelihood of experiencing adverse employment actions, such as working extra hours, covering additional shifts due to staff shortages, denial of requests for days off, and cancellations of previously approved annual leave. Following the 2008 economic crisis, healthcare systems in the most affected countries shifted toward employment models favouring temporary contracts. Our findings align with those of a recent cross-sectional study conducted among nurses in Greece [ 41 ], which concluded that temporary employment is associated with lower perceptions of job security and well-being, as well as a higher prevalence of mental health issues, regardless of age and gender, without significant effects on work capacity at that time. Moreover, studies conducted in Ireland [ 42 ], Sweden [ 43 ], Denmark [ 44 ], and Norway [ 45 ] found relationships between mental health issues and deficiencies in work capacity, with some participants expressing willingness to leave their jobs. However, longitudinal research designs, such as cohort studies, may provide a more realistic view of the long-term effects of temporary employment. Fagerström et al. [ 46 ] concluded that optimal management of nursing staff is essential to achieve acceptable standards of care, and Griffith et al. [ 47 ] affirmed that quality of care improves when staffing levels exceed the minimum required threshold. In relation to this, evidence shows an association between daily workload per nurse and patient safety incidents and mortality [ 46 ], which is three to five times higher when workloads remain at medium-high levels compared to low levels (below optimal thresholds) [ 48 ]. Further research should extend to different nursing specialties and other healthcare disciplines in diverse contexts. This would allow exploration of functional and structural barriers within healthcare systems, supporting the adaptation of staffing and professional profiles to current care demands. 4.4. Study limitations This study has several limitations related to potential sources of population bias arising from the use of sampling method employed, which may affect population validity and introduce self-selection and non-response bias, as commonly observed in survey-based research. The Spanish census of midwives [ 24 ] and the sample from a similar study [ 12 ] comprised 91.2% and 95.6% women, respectively, indicating a highly feminized professional population. Given this demographic distribution, meaningful gender‑based comparisons would not be methodologically reliable and gender was not included as a variable in the survey tool. Although procedural measures were implemented to mitigate common method bias (CMB), statistical techniques for its assessment could not be applied because they typically require continuous or normally distributed indicators [ 49 ]. In our study, most questionnaire items were nominal, which would have required specialized adaptations and analytical tools that were not accessible to the research team at the time of analysis. Consequently, conclusions regarding the strength of the observed relationships should be interpreted with caution. 5. Conclusions Our study revealed that job temporariness among midwives negatively impacts working conditions and rights, including a higher demand to cover extra hours and shifts, increased risk of denied day-off requests, and unforeseen cancellations of previously approved annual leave. According to our findings, most midwives practice within the public healthcare sector, where they report low to medium levels of salary satisfaction, despite having more time per patient to provide direct care. Overall, midwives emphasize the need for regional healthcare systems to adopt more clinical competencies that align with those developed through Spain’s unique qualification program, which is specifically designed to address current care demands. After qualifying, midwives continue to engage in ongoing professional development and express the need for expanded training content in several specialized areas. The challenges described in this study—combined with staff shortages and high levels of job temporariness among midwives in the Spanish healthcare system—may negatively affect the quality of care. Moreover, these issues are associated with job inequity between professionals, impacting their well-being and performance capacity. However, addressing systemic structural deficiencies requires complementary qualitative studies and comparisons with other healthcare disciplines. Declarations Acknowledgements The authors express their gratitude to all study participants for their valuable contributions. Author contributions NRB: Conceptualization; Investigation; Data Curation; Formal analysis; Writing-original draft; Writing-review & editing. JSM: Data Curation; Formal analysis; Writing-review & editing. DAM: Resources; Writing-review & editing. GFV: Investigation; Writing-review & editing. MAP: Resources; Writing-review & editing. ADG: Resources; Investigation. RGM: Methodology; Investigation, Project administration; Visualization; Supervision; Writing-original draft; Writing-review & editing. All authors read and approved the final manuscript. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Data availability The datasets generated and/or analysed during the current study are available in the “Encuesta a Matronas” repository in the EUSurvey platform, https://ec.europa.eu/eusurvey/publication/MATROENCUESTA2024 . Ethics approval and consent to participate Participation in the survey was voluntary, and the completion and submission of the questionnaire implied informed consent. The survey interface displayed contact details and a cover text outlining the purpose of the study, emphasizing the absence of right or wrong answers, and ensuring anonymity and confidentiality. The study was conducted in accordance with the Declaration of Helsinki [50], which states that research involving human subjects and potentially affecting their well-being requires ethical approval. However, studies assessing opinions on working conditions and job satisfaction through self-administered online surveys do not expose participants to direct health-related risks or involve health-related data, and are therefore exempt from ethical approval by an Ethics Committee or Institutional Review Board. This exemption is supported by national and European regulations: the Spanish Law 14/2007 (July 3rd) on Biomedical Research, which requires ethics approval only for studies involving clinical interventions or handling personal health data; and the European General Data Protection Regulation (GDPR, 2016/679), which does not mandate ethics approval for opinion-based surveys unless sensitive health data or other special categories of information are collected (Article 9). Our study did not process any sensitive personal data or special categories. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. 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Int J Nurs Stud. 2016;60:46–53. https://doi.org/10.1016/j.ijnurstu.2016.03.008. Kock F, Berbekova A, Assaf AG. Understanding and managing the threat of common method bias: Detection, prevention and control. Tour Manag. 2021;86:104330. https://doi.org/https://doi.org/10.1016/j.tourman.2021.104330. World Medical Association. World Medical Association Declaration of Helsinki: Ethical Principles for Medical Research Involving Human Participants. JAMA. 2025;333:71–4. https://doi.org/10.1001/jama.2024.21972. Tables Table 1. Distribution of Participants’ Demographics categorized by contract type. Type of contract Total Permanent Interim Temporary p-value N 2310 (100) 1002 (43.4) 508 (22.0) 800 (34.6) Age group < 30 year 331 (14.3) 11 (3.3) 51 (15.4) 269 (81.3) 31-50 year 1546 (66.9) 608 (39.3) 422 (27.3) 516 (33.4) 51-60 year 289 (12.5) 250 (86.5) 27 (9.3) 12 (4.2) <0.001 61-67 year 144 (6.2) 133 (92.4) 8 (5.6) 3 (2.1) Work Experience < 2 years 135 (5.8) 3 (2.2) 10 (7.4) 122 (90.4) 2-5 years 403 (17.4) 19 (4.7) 82 (20.3) 302 (74.9) 6-10 years 537 (23.2) 93 (17.3) 199 (37.1) 245 (45.6) 20 years 515 (22.3) 469 (91.1) 37 (7.2) 9 (1.7) Public hospital (Yes) 1527 (66.1) 629 (41.2) 291 (19.1) 607 (39.8) <0.001 Private hospital (Yes) 208 (9.0) 48 (23.1) 55 (26.4) 105 (50.5) <0.001 Primary care (Yes) 846 (36.6) 386 (45.6) 218 (25.8) 242 (28.6) <0.001 Private suite (Yes) 73 (3.2) 17 (23.3) 22 (30.1) 34 (46.6) 0.002 Home childbirth (Yes) 34 (1.5) 12 (35.3) 13 (38.2) 9 (26.5) 0.070 Research (Yes) 18 (0.8) 9 (50.0) 6 (33.3) 3 (16.7) 0.230 Teaching (Yes) 108 (4.7) 60 (55.6) 26 (24.1) 22 (20.4) 0.005 Data are presented as number of responses (percentage). p-value calculated using the Chi-square test according to contract type. Table 2. Working conditions including continuous training and competencies categorized by contract type. Total Permanent Interim OR (95% CI) p-value temporary OR (95% CI) p-value WORKING CONDITIONS Income (€/year) < 25000 362 (15.7) 65 (18.0) 53 (14.6) 6.02 (3.04-11.9) <0.001 244 (67.4) 72.1 (28.2-184.5) <0.001 25000 - 30000 770 (33.3) 234 (30.4) 207 (26.9) 6.53 (3.55-12.0) <0.001 329 (42.7) 27.0 (10.8-67.4) <0.001 30000 – 45000 1064 (46.1) 607 (57.0) 235 (22.1) 2.86 (1.57-5.20) <0.001 222 (20.9) 7.02 (2.82-17.5) 45000 (Ref) 114 (4.9) 96 (84.2) 13 (11.4) - - 5 (4.4) - - Time per patient* Yes (Ref) 202 (23.9) 107 (53.0) 53 (26.2) - - 42 (20.8) - - No, 5 min/patient 292 (34.5) 127 (43.5) 79 (27.1) 1.22 (0.80-1.87) 0.354 86 (29.5) 1.56 (1.02-2.42) 0.039 No, 10 min/patient 352 (41.6) 152 (43.2) 86 (24.4) 1.18 (0.79-1.78) 0.418 114 (32.4) 1.85 (1.23-2.79) 0.003 CONTINUOUS TRAINING/COMPETENCIES Continuous training No (Ref) 45 (1.9%) 25 (55.6) 9 (20.0) - - 11 (24.4) - - Yes 2265 (98.1) 977 (43.1) 499 (22.0) 1.42 (0.66-3.06 0.373 789 (34.8) 1.84 (0.90-3.75) 0.096 Fully Implemented competencies No (Ref) 1944 (84.2) 809 (41.6) 424 (21.8) - - 711 (36.6) - - Yes 366 (15.8) 193 (52.7) 84 (23.0) 0.83 (0.63-1.10) 0.196 89 (24.3) 0.53 (0.40-0.69) <0.001 Role intrusion witnessed No (Ref) 528 (22.9) 275 (52.1) 82 (15.5) - - 171 (32.4) - - Yes 1782 (77.1) 727 (40.8) 426 (23.9) 1.97 (1.49-2.59) <0.001 629 (35.3) 1.39 (1.12-1.73) 0.003 Acted against role intrusion No (Ref) 2178 (94.3) 946 (43.4) 470 (21.6) - - 762 (35.0) - - Yes 132 (5.7) 56 (42.4) 38 (28.8) 1.37 (0.89-2.09) 0.152 38 (28.8) 0.84 (0.55-1.29) 0.427 Data are presented as number of responses (percentage). OR = odds ratio, estimated using permanent contract type as the reference category; p-value = calculated using the Chi-square test. *For the item “The time assigned for direct care per patient is adequate,” only nurses practicing in Primary Care were included in the analysis (n = 846). Table 3. Adverse Employment Actions Associated with Midwife Shortages, by Contract Type. Total Permanent Interim OR (95% CI) p-value Temporary OR (95% CI) p-value Contracts to cover leave No (Ref) 898 (38.9) 386 (43.0) 235 (26.2) - - 277 (30.8) - - Yes 1412 (61.1) 616 (43.6) 273 (19.3) 0.72 (0.59-0.90) 0.004 523 (37.0) 1.18 (0.98-1.44) 0.088 Staff shortage leads to work overload* No (Ref) 15 (1.7%) 11 (73.3) 2 (13.3) - - 2 (13.3) - - Yes 876 (98.3) 371 (42.4) 233 (26.6) 3.45 (0.76-15.7) 0.109 272 (31.1) 4.03 (0.89-18.3) 0.071 Denied leave entitlements due to shortage of midwives No (Ref) 1031 (44.6) 492 (47.7) 242 (23.5) - - 297 (28.8) - - Yes 1279 (55.4) 510 (39.9) 266 (20.8) 1.06 (0.86-1.31) 0.591 503 (39.3) 1.63 (1.35-1.98) <0.001 Cancelled annual leave due to staff shortages No (Ref) 1784 (77.2) 816 (45.7) 391 (21.9) - - 577 (32.3) - - Yes 526 (22.8) 186 (35.4) 117 (22.2) 1.31 (1.01-1.70) 0.041 223 (42.4) 1.69 (1.35-2.12) <0.001 Cover extra shifts due to staff shortages No (Ref) 227 (9.8) 120 (52.9) 50 (22.0) - - 57 (25.1) - - Yes 2083 (90.2) 882 (42.3) 458 (22.0) 1.25 (0.88-1.77) 0.216 743 (35.7) 1.77 (1.27-2.47)) <0.001 Data are presented as number of responses (percentage). OR = odds ratio, estimated using permanent contract type as the reference category ; p-value = calculated using the Chi-square test. *For the question “Staff shortage leads to work overload,” only 891 participants were included; the remaining respondents left this item blank. Additional Declarations The authors declare no competing interests. Supplementary Files Supplementaryfigure1.png Supplementary figure 1. Geographical distribution of quota sampling*. Quota sample is expressed as the number of registered midwives (n) estimated in each province to achieve the overall sample size estimated (n=387). * Based on data on active registered Specialist Nurses in Obstetrics and Gynaecology (midwives) were provided by the Official Colleges of Nurses in each province to the National Institute of Statistics of Spain (INE). [24]. Supplementaryfigure2.png Supplementary figure 2. Geographical representation of response rates by province. Response rate is expressed as the percentage of survey respondents relative to the number of registered midwives in each province. * The data on active registered Specialist Nurses in Obstetrics and Gynaecology (midwives) were provided by the Official Colleges of Nurses in each province to the National Institute of Statistics of Spain (INE). [24]. Supplementarytable1.docx Supplementary table 1. Survey tool about midwives’ working conditions, training, competencies and adverse employment actions. SupplementaryTable2.docx Supplementary table 2. Geographical distribution of responses by province. 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. 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09:12:52","extension":"html","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":123059,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8657168/v1/ed9d1b05b1a47777fbe7b20d.html"},{"id":100870406,"identity":"ece4b3e5-8531-4226-85c5-f744e4fea063","added_by":"auto","created_at":"2026-01-22 09:12:43","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":161366,"visible":true,"origin":"","legend":"\u003cp\u003eGaps in Competency Implementation Among Midwives in Primary and Hospital Care.\u003c/p\u003e\n\u003cp\u003eMidwives' perceptions of implementation gaps across competencies in a multiple-choice item. Response rates among hospital care (n=1,464) and primary care (n=846) midwives * Other answers included in an open conditional item were: home postnatal care; sexually transmitted infections (STIs) in adolescents; assisted reproduction and fertility; adolescent menarche, puberty and menstrual cycle care; perinatal mental health; teaching; and research.\u003c/p\u003e","description":"","filename":"Figure1600.png","url":"https://assets-eu.researchsquare.com/files/rs-8657168/v1/de9da3724147ef865342cb8e.png"},{"id":100952866,"identity":"d4b4f429-0baf-4b45-a0d2-bce5179d33b1","added_by":"auto","created_at":"2026-01-23 07:18:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1303107,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8657168/v1/95a3a690-23b5-4317-a6fa-e53d5e55a569.pdf"},{"id":100870409,"identity":"008fdd94-a101-4d2c-ad7e-583b709a5bc0","added_by":"auto","created_at":"2026-01-22 09:12:44","extension":"png","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":159922,"visible":true,"origin":"","legend":"\u003cp\u003eSupplementary figure 1. Geographical distribution of quota sampling*.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eQuota sample is expressed as the number of registered midwives (n) estimated in each province to achieve the overall sample size estimated (n=387). * Based on data on active registered Specialist Nurses in Obstetrics and Gynaecology (midwives) were provided by the Official Colleges of Nurses in each province to the National Institute of Statistics of Spain (INE). [24].\u003c/p\u003e","description":"","filename":"Supplementaryfigure1.png","url":"https://assets-eu.researchsquare.com/files/rs-8657168/v1/d473036a5dfd82d0431e0e0b.png"},{"id":100870369,"identity":"1889a5f6-eb0f-400b-9739-5224b5381869","added_by":"auto","created_at":"2026-01-22 09:12:31","extension":"png","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":85890,"visible":true,"origin":"","legend":"\u003cp\u003eSupplementary figure 2. Geographical representation of response rates by province.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eResponse rate is expressed as the percentage of survey respondents relative to the number of registered midwives in each province. * The data on active registered Specialist Nurses in Obstetrics and Gynaecology (midwives) were provided by the Official Colleges of Nurses in each province to the National Institute of Statistics of Spain (INE). [24].\u003c/p\u003e","description":"","filename":"Supplementaryfigure2.png","url":"https://assets-eu.researchsquare.com/files/rs-8657168/v1/4159af73b9eddbe32e05c1c8.png"},{"id":100870416,"identity":"bd4f5f1f-a9dc-45c3-8139-44c85da08fdc","added_by":"auto","created_at":"2026-01-22 09:12:46","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":22647,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSupplementary table 1.\u003c/strong\u003e Survey tool about midwives’ working conditions, training, competencies and adverse employment actions.\u003c/p\u003e","description":"","filename":"Supplementarytable1.docx","url":"https://assets-eu.researchsquare.com/files/rs-8657168/v1/954754dc1383a0237a14ad5b.docx"},{"id":100870419,"identity":"62ebdc65-7fd8-43d6-9252-4245ef27f922","added_by":"auto","created_at":"2026-01-22 09:12:46","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":22359,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSupplementary table 2. \u003c/strong\u003eGeographical distribution of responses by province.\u003c/p\u003e","description":"","filename":"SupplementaryTable2.docx","url":"https://assets-eu.researchsquare.com/files/rs-8657168/v1/6420b330ef907b9f9bcac241.docx"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eExploring working conditions and job stability of midwives in Spain: results from a National Survey\u003c/p\u003e","fulltext":[{"header":"1. Background","content":"\u003cp\u003eGlobal healthcare sustainability faces significant challenges, including the growing burden of chronic diseases and recurrent infectious disease outbreaks. A critical concern is the projected shortage of health professionals, with an estimated deficit of 4.5\u0026nbsp;million nurses and 310,000 midwives by 2030, according to the World Health Organization (WHO) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Midwives play an essential role in women\u0026rsquo;s sexual and reproductive health across the lifespan, providing care during pregnancy, childbirth, and the postnatal period for both mothers and newborns [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The third global \u003cem\u003eState of the World\u0026rsquo;s Midwifery 2021\u003c/em\u003e report (SoWMy 2021) highlights five key benefits of investing in midwifery: improved health outcomes, increased workforce and economic activity, positive socioeconomic impact of healthcare investments, inclusive employment growth for women, and enhanced economic stability [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNonetheless, political action has been urged across European governments to strengthen investment in midwifery staffing, training, and working conditions [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In Europe, the median ratio of midwives is 9.1 per 10,000 women aged 14\u0026ndash;65, whereas Spain reports one of the lowest ratios at 6.1, thereby constraining workforce capacity and limiting the ability to provide equitable and safe coverage of care demands [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. To qualify as a midwife in Spain, candidates must first obtain registration as a general nurse and then complete a two-year specialization in Obstetric-Gynaecologic Nursing, a programme known by its Spanish acronym EIR (\u003cem\u003eEnfermero Interno Residente\u003c/em\u003e) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This pathway differs from qualification models in other European countries, such as Germany and France, where candidates directly access a bachelor\u0026rsquo;s degree in Midwifery, or the United Kingdom, where both models coexist [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The Spanish core curriculum for midwives was established in 2009, aligned with a practice framework for care delivery in primary and acute care settings across public and private sectors [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. However, demographic and social transformations in Europe have generated new care demands, expanding midwives\u0026rsquo; roles beyond traditional perinatal care [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. These demands include adopting new technologies, collaborating effectively with other healthcare professionals, and managing the prescription, dispensation, and administration of medicines and health products [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite midwives\u0026rsquo; recognition as key healthcare providers within the Spanish health system, unresolved issues remain regarding fair remuneration and the adaptation of competencies to current care needs [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. These limitations hinder professional development, contributing to frustration and negatively impacting well-being among midwives [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Job satisfaction, which encompasses outcomes such as optimal utilization of professional skills, recognition, and self-esteem, may be affected by these circumstances [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRodr\u0026iacute;guez Mar\u0026iacute;n [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] identified multiple factors influencing job satisfaction and well-being, including the physical work environment, workload demands (e.g., shift work and overload), job description, financial and contractual conditions (e.g., salary adequacy and job stability), role performance, technological changes, interpersonal relationships, professional development opportunities, organizational characteristics, and work\u0026ndash;family balance.\u003c/p\u003e \u003cp\u003eJob stability remains a major weakness in the Spanish healthcare system due to the high prevalence of temporary employment among health professionals. In 2024, 92.7% of contracts signed by midwives were temporary, and 76.8% were full-time [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Spanish labor regulations define three types of contracts based on duration: permanent contracts, typically obtained through competitive selection processes involving examinations and curriculum assessment; interim contracts, which are temporary without a fixed term and used for substitutions or to cover positions pending permanent allocation or leave of absence; and temporary contracts, which have a defined duration based on production needs [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Following the modification of the Spanish regulation on relative to healthcare workforce 2022 [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], healthcare professionals can remain under interim status for a maximum of three years. If the position has not been filled permanently within this period, the interim professional is offered a non-permanent, undefined-term contract, which provides greater stability and protection. Prior to this modification, more than 40% of the Spanish healthcare workforce was employed under interim or temporary contracts, in some cases for notably long periods [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEmployment instability limits professional development and increases the risk of well-being problems [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. It is often associated with job insecurity, limited access to training opportunities and exposure to workplace discrimination. This can even lead to adverse employment action being taken against some professionals. [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The existing literature on midwives\u0026rsquo; working conditions remains limited among the sources reviewed. However, a comparable study was conducted with a smaller sample in the same geographical context, although it did not focus specifically on job stability [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe relationship between employment instability and working conditions, such as salary, workload, continuous training and adverse employment actions, remains unclear. This study therefore aims to describe midwives\u0026rsquo; perceptions of working conditions in Spain, including the implementation of developed competencies, and to examine differences according to contract type.\u003c/p\u003e"},{"header":"2. Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1. Study Design\u003c/h2\u003e \u003cp\u003eThis study employed a cross-sectional, quantitative, descriptive, and correlational design. Data were collected through a self-administered, web-based sociodemographic survey aimed at assessing the working conditions of registered midwives working in Spain.\u003c/p\u003e \u003cp\u003eThe reporting of this study adheres to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] and follows the Consensus-Based Checklist for Reporting of Survey Studies (CROSS) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2. Questionnaire details\u003c/h2\u003e \u003cp\u003eThe tool was developed by the research team in collaboration with 15 expert midwives representing different Spanish regions (Autonomous Communities). The self-administered survey was uploaded to the EUSurvey platform (v1.5.3, Public License, European Commission). The initial version of the tool was piloted with a sample of 25 midwives to ensure proper functionality, improve ease of completion, and estimate the time required to complete the survey. Five members of the expert panel assessed the first draft of the questionnaire and adapted items accordingly.\u003c/p\u003e \u003cp\u003eThe final version of the questionnaire included 23 items grouped into five sections: demographic characteristics, work status, training, competencies, and adverse employment actions. The variables were classified as demographic characteristics (age group), job details (years of experience, type of contract, area of practice, involvement in research and teaching, annual income, care time per patient, and role intrusion), and training and competencies (participation in continuous training, perception of implemented competencies, and competency gaps). The comparative variable was the type of contract, which was grouped into three categories: permanent, interim, and temporary. The complete survey tool is provided in Supplementary Table\u0026nbsp;1.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3. Sample characteristics\u003c/h2\u003e \u003cp\u003eAccording to the census available on December 31, 2023, there were 8,301 active (non-retired) registered midwives in Spain [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. A geographical quota sampling strategy was applied to ensure representation across the 17 autonomous regions and 2 autonomous cities of Spain. The study included registered midwives actively working in the Spanish healthcare system, while non-practicing midwives, midwifery trainees, and retired midwives were excluded. Based on a 95% confidence level, a 0.05 margin of error, and an assumed proportion of 0.5, the required sample size was calculated as 387 respondents. Details of the quota distribution are depicted in Supplementary Fig.\u0026nbsp;1.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4. Survey Administration\u003c/h2\u003e \u003cp\u003eThe questionnaire was administered through an EUSurvey link. Based on the pre-test, the estimated completion time was approximately 10 minutes, although no time limit was imposed. All items in the questionnaire were mandatory. To prevent automated submissions, the platform required participants to complete a CAPTCHA challenge before submitting their responses, and each IP address was restricted to a single submission. The survey link was distributed nationwide via corporate emails and professional social media channels of the General Council of Nurses and the 52 regional Nursing Colleges across the country. The survey remained open for responses throughout March 2024.\u003c/p\u003e \u003cp\u003eRespondent-related and measurement-related sources of common method bias (CMB) were addressed through procedural measures, including survey design strategies (e.g., clear instructions, assurance of anonymity, and avoidance of ambiguous items) and methodological separation (e.g., use of varied item formats and distinct measures for in- dependent and dependent variables) [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5. Statistical Analysis\u003c/h2\u003e \u003cp\u003eAnalyses were conducted using IBM SPSS Statistics software, version 29.0 (SPSS Inc., Chicago, IL, USA). All variables analysed were categorical and expressed as response counts and percentages, presented in frequency tables. Associations with the independent variable (type of contract) were tested using contingency tables and Pearson\u0026rsquo;s Chi-square tests. The predictive strength of contract type over other variables was estimated through multivariable logistic regression models. Results were expressed as Odds Ratios (OR) with 95% Confidence Intervals (95% CI). A p-value of less than 0.05 was considered statistically significant for all analyses.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eThe survey collected 2,499 responses, with adequate representation from all Spanish regions and a mean provincial participation rate of 36.9%. Participation rates by province are listed in Supplementary Table\u0026nbsp;2 and represented in Supplementary Fig.\u0026nbsp;2. Of the total responses, 142 were excluded because they were completed by non‑practicing professionals and 47 were excluded because they were completed by midwifery trainees. Consequently, 2,310 responses were included in the analysis, representing 27.8% of the active population of registered midwives in Spain.\u003c/p\u003e \u003cp\u003eThe distribution of sample demographics categorized by contract type is presented in Table\u0026nbsp;1. The most represented age group was 31\u0026ndash;50 years. Most participants worked in direct patient care within public hospitals (66.1%), and 43.4% of respondents reported having permanent contracts.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;1. Distribution of Participants\u0026rsquo; Demographics categorized by contract type.\u003c/p\u003e \u003cp\u003eThe proportion of permanent contracts increased progressively with age and work experience, reaching up to 90% among midwives aged 61\u0026ndash;67 years and those with more than 20 years of professional experience. Most permanent contracts were concentrated in public hospitals (41.2%), whereas temporary contracts were more prevalent in private healthcare settings (50.5%).\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;2 presents the distribution of midwives\u0026rsquo; responses regarding working conditions, continuous training, and competencies considered necessary within the healthcare system, categorized by contract type. Most midwives reported annual salaries between \u0026euro;35,000 and \u0026euro;45,000, with lower salaries associated with temporary contracts and higher salaries linked to permanent contracts. The mean satisfaction score related to salary was 4.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2 on a 10-point scale, with higher scores among midwives holding permanent contracts (4.6\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3) compared to those with interim (4.1\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2) and temporary contracts (4.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2) (\u003cem\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/em\u003e).\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;2. Working conditions including continuous training and competencies categorized by contract type.\u003c/p\u003e \u003cp\u003eMost midwives working in Primary Care (76.1%) considered it necessary to increase the time allocated for direct patient care, a concern significantly more pronounced among those with temporary contracts compared to permanent employees. A majority of participants (77.1%) reported witnessing role intrusion, although only 5.5% had formally taken legal actions. Nearly all respondents reported engagement in continuous training regardless of contract type; however, only 15.8% believed that all clinical competencies developed for safe midwifery practice are fully implemented in their region. The most frequently identified competency gaps included ultrasound, menopause care, sexual and reproductive health, perinatal grief care, and pelvic floor management, whereas pregnancy and breastfeeding care were most commonly perceived as fully implemented (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Similar response patterns were observed between hospital and primary care midwives regarding competency gaps, although hospital-based midwives expressed greater concern about breastfeeding care and cancer screening competencies.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eMidwives' perceptions of implementation gaps across competencies in a multiple-choice item. Response rates among hospital care (n\u0026thinsp;=\u0026thinsp;1,464) and primary care (n\u0026thinsp;=\u0026thinsp;846) midwives * Other answers included in an open conditional item were: home postnatal care; sexually transmitted infections (STIs) in adolescents; assisted reproduction and fertility; adolescent menarche, puberty and menstrual cycle care; perinatal mental health; teaching; and research.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;3 summarizes midwives\u0026rsquo; adverse employment action resulting from the uncovered staff shortage in units, categorized by contract type. A total of 90.2% of participants reported at least one request to cover shifts outside their regular schedule, while 55.4% experienced rejection of single-day leave or unpaid leave requests. Additionally, 22.8% reported cancellations of previously approved annual leave. Regression analyses indicated that midwives with temporary contracts were the most affected in all these situations (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). These issues may be linked to the limited availability of replacement staff to cover absences such as annual leave, part-time shifts, and sick leave, as reported by 38.9% of participants. This lack of coverage was considered problematic by the vast majority of respondents (98.3%), who believed it contributes to work overload.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;3. Adverse employment actions associated with midwife shortages, by contract type.\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis study aimed to describe midwives\u0026rsquo; perceptions of working conditions in Spain, focusing on the implementation of competencies, continuous training, and adverse employment actions, and examining how these are associated with contract type. The study found that job stability increased with age and years of experience. Temporary midwives had lower salaries and were less satisfied with them. They were also more likely to be asked to work outside normal hours, have leave requests denied and have approved annual leave cancelled.\u003c/p\u003e \u003cp\u003eThe proportion of respondents working in the public sector was high but still lower than that reported in other studies conducted in comparable populations, such as previous research in Spain (95.6%) [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], the UK (88.6%) [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], and Australia (89.8%) [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Conversely, the proportion of midwives working exclusively in the private sector in Spain was similar to that observed in the UK (0.8%) and markedly lower than in Australia (10.6%).\u003c/p\u003e \u003cp\u003eOverall salary satisfaction among Spanish midwives was moderate to low, with particularly low levels reported by temporary and interim staff. Given that salary satisfaction is a known determinant of overall job satisfaction [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], this finding warrants further attention. Other studies, however, have highlighted additional components of job satisfaction beyond remuneration [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRegarding time allocated for patient care, responses showed relatively little variability, with a slight preference for an additional 10 minutes per consultation. Similar concerns have been raised in international contexts. For instance, a study in Peru [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] questioned the quality of care delivered by primary care midwives due to the brevity of patient interactions, with midwives averaging 4\u0026ndash;5 minutes per patient despite dedicating more total minutes per shift to direct care than nurses or physicians. Overall low satisfaction with workload can be deducted from our results, consistent with previous national results [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], while temporariness reveals significant differences. Nevertheless, further research is needed to explore the nature of midwives\u0026rsquo; care activities in different healthcare settings to enable meaningful comparisons and to assess care needs from multiple perspectives.\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e4.1. Training\u003c/h2\u003e \u003cp\u003eIn our study, most respondents obtained their midwifery qualification through the EIR pathway, a proportion consistent with the findings of Iglesias-Casas et al. [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], who reported that this training pathway graduates professionals who feel well-prepared, confident, and competent in their professional role. No differences were observed between contract types in relation to participation in continuous training, suggesting that engagement in continuous training was not age‑dependent. This contrasts with evidence from the nursing profession, where continuous training has been more commonly associated with older age groups in previous studies [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e4.2. Competencies\u003c/h2\u003e \u003cp\u003eAccording to the analysis reported by the Spanish Federation of Midwives\u0026rsquo; Associations [3, Spanish midwives have one of the broadest ranges of competencies in Europe. Among the competencies included in midwives\u0026rsquo; training programs, the most relevant are related to pregnancy care, childbirth, postnatal care, and women\u0026rsquo;s reproductive and sexual-affective health [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. However, participants in our study reported that many of these competencies are not fully implemented in real practice. Most participants identified gaps in the implementation of developed competencies within their regional health services, while only nurses practicing in Catalonia and Navarre expressed some alignment between competencies acquired during training and those applied in clinical practice.\u003c/p\u003e \u003cp\u003eThe major gaps were identified in ultrasound, menopause care, pelvic floor health, and reproductive and sexual health. This issue may be related to findings from a review conducted by Watkins et al. [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], which indicated that gaps in competency implementation are influenced by factors such as systemic fragmentation of services and negative perceptions of midwives within organizations, communities, and other professional disciplines. Further studies should explore geographical and social barriers to midwives\u0026rsquo; competency implementation.\u003c/p\u003e \u003cp\u003eAs a breach of professional recognition and development, midwives\u0026rsquo; competencies may encounter interdisciplinary challenges [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Well-structured interprofessional collaboration is essential for woman-centred care, given the fundamental differences between disciplines such as midwifery, medicine, physiotherapy, and others [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Otherwise, interdisciplinary conflicts such as role intrusion or intrusiveness may arise. Pradelli et al. [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e] stated that role intrusion \u0026ldquo;occurs when healthcare professionals overstep the boundaries of their specific professional competencies, encroaching on the responsibilities of others.\u0026rdquo; Most respondents reported having witnessed role intrusion, although only a small proportion pursued legal action, with doulas being the most frequently cited professionals involved. The proportion of midwives reporting role intrusion in our study is slightly lower than that observed by Iglesias‑Casas et al. (92.4%) [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]; however, this difference may be explained by the fact that our question referred specifically to witnessed cases, rather than capturing broader perceptions of the existence or prevalence of role intrusion.\u003c/p\u003e \u003cp\u003eRole intrusion is scarcely addressed in the literature but is perceived as a barrier to effective teamwork and poses significant risks to both patients and providers [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. The adoption of non-clinical professionals, such as doulas, is showing potential benefits for perinatal care and is becoming increasingly widespread [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. According to DONA International, the international representative organization for doulas, they are \u0026ldquo;trained professionals who provide continuous physical, emotional, and informational support to their clients before, during, and shortly after childbirth to help them achieve the healthiest, most satisfying experience possible\u0026rdquo; [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Although doulas do not perform clinical activities, integrative models propose their inclusion as a liaison role between women and healthcare providers during perinatal care [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. In this regard, the adoption of doulas in Spain is not formally regulated, nor is their inclusion within the healthcare system, which underscores the importance of preventing role intrusion by establishing clear practice boundaries between regulated healthcare professions and other agents.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e4.3. Adverse employment actions\u003c/h2\u003e \u003cp\u003eData show that midwives with temporary contracts have a higher likelihood of experiencing adverse employment actions, such as working extra hours, covering additional shifts due to staff shortages, denial of requests for days off, and cancellations of previously approved annual leave.\u003c/p\u003e \u003cp\u003eFollowing the 2008 economic crisis, healthcare systems in the most affected countries shifted toward employment models favouring temporary contracts. Our findings align with those of a recent cross-sectional study conducted among nurses in Greece [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e], which concluded that temporary employment is associated with lower perceptions of job security and well-being, as well as a higher prevalence of mental health issues, regardless of age and gender, without significant effects on work capacity at that time. Moreover, studies conducted in Ireland [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e], Sweden [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e], Denmark [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e], and Norway [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e] found relationships between mental health issues and deficiencies in work capacity, with some participants expressing willingness to leave their jobs. However, longitudinal research designs, such as cohort studies, may provide a more realistic view of the long-term effects of temporary employment.\u003c/p\u003e \u003cp\u003eFagerstr\u0026ouml;m et al. [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e] concluded that optimal management of nursing staff is essential to achieve acceptable standards of care, and Griffith et al. [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e] affirmed that quality of care improves when staffing levels exceed the minimum required threshold. In relation to this, evidence shows an association between daily workload per nurse and patient safety incidents and mortality [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e], which is three to five times higher when workloads remain at medium-high levels compared to low levels (below optimal thresholds) [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFurther research should extend to different nursing specialties and other healthcare disciplines in diverse contexts. This would allow exploration of functional and structural barriers within healthcare systems, supporting the adaptation of staffing and professional profiles to current care demands.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e4.4. Study limitations\u003c/h2\u003e \u003cp\u003eThis study has several limitations related to potential sources of population bias arising from the use of sampling method employed, which may affect population validity and introduce self-selection and non-response bias, as commonly observed in survey-based research.\u003c/p\u003e \u003cp\u003eThe Spanish census of midwives [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] and the sample from a similar study [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] comprised 91.2% and 95.6% women, respectively, indicating a highly feminized professional population. Given this demographic distribution, meaningful gender‑based comparisons would not be methodologically reliable and gender was not included as a variable in the survey tool.\u003c/p\u003e \u003cp\u003eAlthough procedural measures were implemented to mitigate common method bias (CMB), statistical techniques for its assessment could not be applied because they typically require continuous or normally distributed indicators [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. In our study, most questionnaire items were nominal, which would have required specialized adaptations and analytical tools that were not accessible to the research team at the time of analysis. Consequently, conclusions regarding the strength of the observed relationships should be interpreted with caution.\u003c/p\u003e \u003c/div\u003e"},{"header":"5. Conclusions","content":"\u003cp\u003eOur study revealed that job temporariness among midwives negatively impacts working conditions and rights, including a higher demand to cover extra hours and shifts, increased risk of denied day-off requests, and unforeseen cancellations of previously approved annual leave.\u003c/p\u003e \u003cp\u003eAccording to our findings, most midwives practice within the public healthcare sector, where they report low to medium levels of salary satisfaction, despite having more time per patient to provide direct care.\u003c/p\u003e \u003cp\u003eOverall, midwives emphasize the need for regional healthcare systems to adopt more clinical competencies that align with those developed through Spain\u0026rsquo;s unique qualification program, which is specifically designed to address current care demands. After qualifying, midwives continue to engage in ongoing professional development and express the need for expanded training content in several specialized areas.\u003c/p\u003e \u003cp\u003eThe challenges described in this study\u0026mdash;combined with staff shortages and high levels of job temporariness among midwives in the Spanish healthcare system\u0026mdash;may negatively affect the quality of care. Moreover, these issues are associated with job inequity between professionals, impacting their well-being and performance capacity. However, addressing systemic structural deficiencies requires complementary qualitative studies and comparisons with other healthcare disciplines.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eThe authors express their gratitude to all study participants for their valuable contributions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAuthor contributions\u003c/p\u003e\n\u003cp\u003eNRB: Conceptualization; Investigation; Data Curation; Formal analysis; Writing-original draft; Writing-review \u0026amp; editing. JSM: Data Curation; Formal analysis; Writing-review \u0026amp; editing. DAM: Resources; Writing-review \u0026amp; editing. GFV: Investigation; Writing-review \u0026amp; editing. MAP: Resources; Writing-review \u0026amp; editing. ADG: Resources; Investigation. RGM: Methodology; Investigation, Project administration; Visualization; Supervision; Writing-original draft; Writing-review \u0026amp; editing. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003eData availability\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study are available in the \u0026ldquo;Encuesta a Matronas\u0026rdquo; repository in the EUSurvey platform, https://ec.europa.eu/eusurvey/publication/MATROENCUESTA2024 .\u003c/p\u003e\n\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eParticipation in the survey was voluntary, and the completion and submission of the questionnaire implied informed consent. The survey interface displayed contact details and a cover text outlining the purpose of the study, emphasizing the absence of right or wrong answers, and ensuring anonymity and confidentiality.\u003c/p\u003e\n\u003cp\u003eThe study was conducted in accordance with the Declaration of Helsinki\u0026nbsp;[50], which states that research involving human subjects and potentially affecting their well-being requires ethical approval. However, studies assessing opinions on working conditions and job satisfaction through self-administered online surveys do not expose participants to direct health-related risks or involve health-related data, and are therefore exempt from ethical approval by an Ethics Committee or Institutional Review Board. This exemption is supported by national and European regulations: the Spanish Law 14/2007 (July 3rd) on Biomedical Research, which requires ethics approval only for studies involving clinical interventions or handling personal health data; and the European General Data Protection Regulation (GDPR, 2016/679), which does not mandate ethics approval for opinion-based surveys unless sensitive health data or other special categories of information are collected (Article 9). Our study did not process any sensitive personal data or special categories.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eBoniol M, Kunjumen T, Nair TS, Siyam A, Campbell J, Diallo K. 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Healthcare professional perspective on barriers and facilitators of multidisciplinary team working in acute care setting: a systematic review and meta-synthesis. BMJ Open. 2025;15:e087268. https://doi.org/10.1136/bmjopen-2024-087268.\u003c/li\u003e\n \u003cli\u003eWaymouth M, James K, Uscher-Pines L. Advancing Equity in Maternal Health With Virtual Doula Care. JAMA Health Forum. 2024;5:e234833\u0026ndash;e234833. https://doi.org/10.1001/jamahealthforum.2023.4833.\u003c/li\u003e\n \u003cli\u003eW\u0026oacute;jcik-Brylska K, Pawlicka P, Tataj-Puzyna U, Szlendak B, Węgrzynowska M, Pięta B, et al. Cooperation between midwives and doulas in the context of perinatal care - a integrative review of qualitative and quantitative studies. Midwifery. 2023;124:103731. https://doi.org/https://doi.org/10.1016/j.midw.2023.103731.\u003c/li\u003e\n \u003cli\u003eMabiala-Maye G, Olabanji K, King KM, Maloney S, Abresch C. Exploring innovative models of doula services in maternity care: A qualitative study on advancing equity and addressing disparities. Women\u0026rsquo;s Health. 2025;21:17455057251345574. https://doi.org/10.1177/17455057251345574.\u003c/li\u003e\n \u003cli\u003eKatsaouni M, Tripsianis G, Constantinidis T, Vadikolias K, Kontogiorgis C, Serdari A, et al. Assessment of qualify of care, job insecurity and work ability among nursing, working either under temporary or permanent terms. Int J Occup Med Environ Health. 2024;37:98\u0026ndash;109. https://doi.org/10.13075/ijomeh.1896.02245.\u003c/li\u003e\n \u003cli\u003eDoherty J, O\u0026rsquo;Brien DrD. Giving of the self and Midwife Burnout \u0026ndash; An exploration of the consequences of being \u0026lsquo;with woman\u0026rsquo; and how individual midwives can reduce or prevent burnout. Women and Birth. 2023;36:349\u0026ndash;56. https://doi.org/https://doi.org/10.1016/j.wombi.2022.12.002.\u003c/li\u003e\n \u003cli\u003eHildingsson I, Westlund K, Wiklund I. Burnout in Swedish midwives. Sexual and Reproductive Healthcare. 2013;4:87\u0026ndash;91. https://doi.org/10.1016/j.srhc.2013.07.001.\u003c/li\u003e\n \u003cli\u003eJepsen I, Juul S, Foureur M, S\u0026oslash;rensen EE, N\u0026oslash;hr EA. Is caseload midwifery a healthy work-form? \u0026ndash; A survey of burnout among midwives in Denmark. Sex Reprod Healthc. 2017;11:102\u0026ndash;6. https://doi.org/https://doi.org/10.1016/j.srhc.2016.12.001.\u003c/li\u003e\n \u003cli\u003eHenriksen L, Lukasse M. Burnout among Norwegian midwives and the contribution of personal and work-related factors: A cross-sectional study. Sex Reprod Healthc. 2016;9:42\u0026ndash;7. https://doi.org/10.1016/j.srhc.2016.08.001.\u003c/li\u003e\n \u003cli\u003eFagerstr\u0026ouml;m L, Kinnunen M, Saarela J. Nursing workload, patient safety incidents and mortality: An observational study from Finland. BMJ Open. 2018;8. https://doi.org/10.1136/bmjopen-2017-016367.\u003c/li\u003e\n \u003cli\u003eGriffiths P, Saville C, Ball JE, Chable R, Dimech A, Jones J, et al. The Safer Nursing Care Tool as a guide to nurse staffing requirements on hospital wards: observational and modelling study. HSDR. 2020;8:1\u0026ndash;162. https://doi.org/10.3310/hsdr08160.\u003c/li\u003e\n \u003cli\u003eJunttila JK, Koivu A, Fagerstr\u0026ouml;m L, Haatainen K, Nyk\u0026auml;nen P. Hospital mortality and optimality of nursing workload: A study on the predictive validity of the RAFAELA Nursing Intensity and Staffing system. Int J Nurs Stud. 2016;60:46\u0026ndash;53. https://doi.org/10.1016/j.ijnurstu.2016.03.008.\u003c/li\u003e\n \u003cli\u003eKock F, Berbekova A, Assaf AG. Understanding and managing the threat of common method bias: Detection, prevention and control. Tour Manag. 2021;86:104330. https://doi.org/https://doi.org/10.1016/j.tourman.2021.104330.\u003c/li\u003e\n \u003cli\u003eWorld Medical Association. World Medical Association Declaration of Helsinki: Ethical Principles for Medical Research Involving Human Participants. JAMA. 2025;333:71\u0026ndash;4. https://doi.org/10.1001/jama.2024.21972.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable\u0026nbsp;1. Distribution of Participants\u0026rsquo; Demographics categorized by contract type.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"698\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 293px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eType of contract\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePermanent\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInterim\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTemporary\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep-value\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;N\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e2310 (100)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e1002 (43.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e508 (22.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e800 (34.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026lt; 30 year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e331 (14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e11 (3.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e51 (15.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e269 (81.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003e31-50 year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e1546 (66.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e608 (39.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e422 (27.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e516 (33.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003e51-60 year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e289 (12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e250 (86.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e27 (9.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e12 (4.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003e61-67 year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e144 (6.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e133 (92.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e8 (5.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e3 (2.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWork Experience\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026lt; 2 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e135 (5.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e3 (2.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e10 (7.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e122 (90.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e2-5 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e403 (17.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e19 (4.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e82 (20.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e302 (74.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e6-10 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e537 (23.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e93 (17.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e199 (37.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e245 (45.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e11-20 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e720 (31.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e418 (58.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e180 (25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e122 (16.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026gt; 20 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e515 (22.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e469 (91.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e37 (7.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e9 (1.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePublic hospital\u0026nbsp;\u003c/strong\u003e(Yes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e1527 (66.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e629 (41.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e291 (19.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e607 (39.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrivate hospital\u0026nbsp;\u003c/strong\u003e(Yes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e208 (9.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e48 (23.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e55 (26.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e105 (50.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrimary care\u0026nbsp;\u003c/strong\u003e(Yes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e846 (36.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e386 (45.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e218 (25.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e242 (28.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrivate suite\u0026nbsp;\u003c/strong\u003e(Yes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e73 (3.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e17 (23.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e22 (30.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e34 (46.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHome childbirth\u0026nbsp;\u003c/strong\u003e(Yes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e34 (1.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e12 (35.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e13 (38.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e9 (26.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e0.070\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eResearch\u0026nbsp;\u003c/strong\u003e(Yes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e18 (0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e9 (50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e6 (33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e3 (16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e0.230\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTeaching\u0026nbsp;\u003c/strong\u003e(Yes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e108 (4.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e60 (55.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e26 (24.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e22 (20.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e0.005\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eData are presented as number of responses (percentage). \u003cem\u003ep-value\u003c/em\u003e calculated using the Chi-square test according to contract type.\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;2.\u0026nbsp;Working conditions including continuous training and competencies categorized by contract type.\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"983\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePermanent\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInterim\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eOR (95% CI)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep-value\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003etemporary\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eOR (95% CI)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep-value\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWORKING CONDITIONS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIncome\u0026nbsp;\u003c/strong\u003e(\u0026euro;/year)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026lt; 25000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e362 (15.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e65 (18.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e53 (14.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e6.02 (3.04-11.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e244 (67.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e72.1 (28.2-184.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;25000 - 30000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e770 (33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e234 (30.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e207 (26.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e6.53 (3.55-12.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e329 (42.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e27.0 (10.8-67.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp; 30000 \u0026ndash; 45000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e1064 (46.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e607 (57.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e235 (22.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e2.86 (1.57-5.20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e222 (20.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e7.02 (2.82-17.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026gt; 45000 (Ref)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e114 (4.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e96 (84.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e13 (11.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e5 (4.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime per patient*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Yes (Ref)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e202 (23.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e107 (53.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e53 (26.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e42 (20.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;No, 5 min/patient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e292 (34.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e127 (43.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e79 (27.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e1.22 (0.80-1.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.354\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e86 (29.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e1.56 (1.02-2.42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.039\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;No, 10 min/patient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e352 (41.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e152 (43.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e86 (24.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e1.18 (0.79-1.78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.418\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e114 (32.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e1.85 (1.23-2.79)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 350px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCONTINUOUS TRAINING/COMPETENCIES\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eContinuous training\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;No (Ref)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e45 (1.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e25 (55.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e9 (20.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e11 (24.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e2265 (98.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e977 (43.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e499 (22.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e1.42 (0.66-3.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.373\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e789 (34.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e1.84 (0.90-3.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.096\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFully Implemented competencies\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;No (Ref)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e1944 (84.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e809 (41.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e424 (21.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e711 (36.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e366 (15.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e193 (52.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e84 (23.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e0.83 (0.63-1.10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.196\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e89 (24.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.53 (0.40-0.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRole intrusion witnessed\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;No (Ref)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e528 (22.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e275 (52.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e82 (15.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e171 (32.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e1782 (77.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e727 (40.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e426 (23.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e1.97 (1.49-2.59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e629 (35.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e1.39 (1.12-1.73)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 350px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eActed against role intrusion\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;No (Ref)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e2178 (94.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e946 (43.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e470 (21.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e762 (35.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e132 (5.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e56 (42.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e38 (28.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e1.37 (0.89-2.09)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.152\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e38 (28.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.84 (0.55-1.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.427\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eData are presented as number of responses (percentage). \u003cem\u003eOR\u003c/em\u003e = odds ratio, estimated using permanent contract type as the reference category; \u003cem\u003ep-value\u003c/em\u003e = calculated using the Chi-square test. *For the item \u0026ldquo;The time assigned for direct care per patient is adequate,\u0026rdquo; only nurses practicing in Primary Care were included in the analysis (n = 846).\u003c/p\u003e\n\u003cp\u003eTable 3. Adverse Employment Actions Associated with Midwife Shortages, by Contract Type.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"973\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePermanent\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInterim\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eOR (95% CI)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep-value\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTemporary\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eOR (95% CI)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep-value\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eContracts to cover leave\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;No (Ref)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e898 (38.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e386 (43.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e235 (26.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e277 (30.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e1412 (61.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e616 (43.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e273 (19.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e0.72 (0.59-0.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e523 (37.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e1.18 (0.98-1.44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e0.088\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStaff shortage leads to work overload*\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;No (Ref)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e15 (1.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e11 (73.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e2 (13.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e2 (13.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e876 (98.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e371 (42.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e233 (26.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e3.45 (0.76-15.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e0.109\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e272 (31.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e4.03 (0.89-18.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e0.071\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 482px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDenied leave entitlements due to shortage of midwives\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;No (Ref)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e1031 (44.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e492 (47.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e242 (23.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e297 (28.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e1279 (55.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e510 (39.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e266 (20.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e1.06 (0.86-1.31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.591\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e503 (39.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e1.63 (1.35-1.98)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 482px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCancelled annual leave due to staff shortages\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;No (Ref)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e1784 (77.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e816 (45.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e391 (21.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e577 (32.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e526 (22.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e186 (35.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e117 (22.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e1.31 (1.01-1.70)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.041\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e223 (42.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e1.69 (1.35-2.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCover extra shifts due to staff shortages\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;No (Ref)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e227 (9.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e120 (52.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e50 (22.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e57 (25.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e2083 (90.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e882 (42.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e458 (22.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e1.25 (0.88-1.77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.216\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e743 (35.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e1.77 (1.27-2.47))\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eData are presented as number of responses (percentage). \u003cem\u003eOR\u003c/em\u003e = odds ratio, estimated using permanent contract type as the reference category\u003cem\u003e; p-value\u003c/em\u003e = calculated using the Chi-square test. *For the question \u0026ldquo;Staff shortage leads to work overload,\u0026rdquo; only 891 participants were included; the remaining respondents left this item blank.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Fundación Instituto Español de Investigación Enfermera","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":"Midwifery, Working conditions, Temporary workers, Continuous training, Clinical Competencies","lastPublishedDoi":"10.21203/rs.3.rs-8657168/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8657168/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eMidwives are essential to perinatal care in Spain's healthcare system, with roles expanding due to demographic changes to encompass technology integration, multidisciplinary collaboration, and pharmacotherapeutic management. Challenges persist, including suboptimal remuneration, competency misalignment, and employment precarity (92.7% temporary contracts in 2024), aggravating professional dissatisfaction, reduced job satisfaction, and well-being deficits. Influential factors include workload, contractual stability, and work\u0026ndash;life balance, emphasizing the imperative for empirical analysis of labor conditions. This study describes midwives' perceptions of Spanish work environments and assesses contract-type variations.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe conducted a cross-sectional, quantitative survey of registered midwives in Spain using a self-administered, 23-item web questionnaire (five domains) on EUSurvey to assess working conditions, capturing demographics, job characteristics, training/competence, and entitlements, and evaluating differences in professional perceptions by contract type.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOf the 2,499 responses, 2,310 met the requirements (27.8% of practicing midwives in Spain). The majority worked in public hospitals (66.1%); 43.4% had permanent contracts, a figure that increased with age and experience. Temporary contracts, more common in the private sector, were associated with lower salaries and less salary satisfaction (4.0\u0026ndash;4.1 vs. 4.6/10; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and greater exposure adverse employment actions due to staff shortages (requests for off-hours shifts: 90.2%, denied leave: 55.4%, approved leave canceled: 22.8%; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Role intrusion was frequent (77.1%). Despite widespread participation in continuous training, only 15.8% felt fully competent in all core competencies.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eTemporariness and staffing shortages worsen conditions, enable role intrusion, and reduce pay satisfaction. Despite accessible continuous training, key developed competencies remain unimplemented in the health system; job stability, adequate coverage, and equal opportunities to professional development are needed to protect quality and equity.\u003c/p\u003e","manuscriptTitle":"Exploring working conditions and job stability of midwives in Spain: results from a National Survey","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-22 09:11:33","doi":"10.21203/rs.3.rs-8657168/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":"f90dc33a-b4ca-4ba6-8b1f-f85516e67ea3","owner":[],"postedDate":"January 22nd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":61493552,"name":"Health Policy"},{"id":61493553,"name":"Nursing"},{"id":61493554,"name":"Maternal \u0026 Fetal Medicine"}],"tags":[],"updatedAt":"2026-02-19T07:53:59+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-22 09:11:33","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8657168","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8657168","identity":"rs-8657168","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}