In this qualitative interview study with midwives working in two of the 26 provinces of the DRC, the results show that the main force motivating and driving the midwives to work is a strong feeling of love for their work. Their working conditions are extremely difficult. However, they regard midwifery as not just a profession but a calling, which makes the job worthwhile. In tune with what was recently found in the global consultation mentioned earlier, they are generally very committed to providing care to women and newborns due to a high professional conscience and loyalty to their patients, despite their tough working environments [13].
The DRC midwives in our study were motivated to continue working and building relationships with the women and the community, driven by feeling a strong professional pride, and having the skills to save lives. On the other hand, they faced challenges in remaining in their work due to factors such as an unsupportive organisational system, with inadequate pre-conditions of the work environment. This is in line with a conceptual framework on health worker motivation presented by Franco et al. [18], which defines key determinants influencing workers motivation at individual, organisational, and cultural and community levels.
Among the challenging work factors that the DRC midwives in our study experienced was an unsupportive organisational system, which was linked to insufficient work-related security, a lack of a proper remuneration system, and hierarchical management structures. Filby et al. have concluded that such factors are the result of the lack of status of, and respect for, the midwifery profession. This in turn puts midwives’ occupational health and safety at risk [14].
The lack of a proper remuneration system and insufficient security when going to and from work that was experienced by the DRC midwives in our study has also been confirmed to be highly problematic in other studies in low- and middle-income settings [14, 15], leading to serious challenges in managing daily life and accentuating the profession’s low status. In settings where salaries are extremely low or unpredictable, proper remuneration is seen as crucial to worker motivation [23–25].
The World Health Organization (WHO) emphasises work security, proper remuneration, and professional health and safety as aspects of strengthening the health workforce and ensuring decent employment terms. This can serve as guidance for health systems in general, in order to build more reliable and supportive organisational systems [26].
With regard to remuneration in particular, the midwifery workforce in the DRC, as was also found in the global consultation of midwives, suffer from insufficient and irregular remuneration [13]. This corresponds to staff within weaker professions in the DRC who also work without being on a payroll, and thus depend on fees levied by health facilities on patients. In contrast, it has been reported that there are many cases of ghost workers, i.e. people who are paid but are non-existent in the health services [27]. According to a recent study by WHO, this could be detected and prevented through increased transparency and accountability in payroll processes, improved recordkeeping and strong record management systems, monitoring of human resources for health, and the use of specific technology tools [28]. Removing such ghost workers could result into substantial savings that could be used to improve remunerations of working healthcare professionals.
For midwives in the DRC and elsewhere, to be able to provide their full scope of midwifery practice informed by the International Confederation of Midwives [29], and thereby contribute to improved health outcomes for women, newborn, and families [1], it is of critical importance that they be deployed within their specific professional area; i.e., sexual, reproductive, and maternal care. The midwives in our study described being moved around by management to different departments far from their competence area, which resulted in their competence not being fully used. It also made them feel devalued and underappreciated. This is not unique to midwives in the DRC, however; midwives in many parts of the world experience that there is a poor understanding and use of their professional competence, and they often feel undervalued [13–15].
Strengthening the midwifery association has been identified as one way to improve the status of the midwifery profession. This was also mentioned by the midwives in our study. It is known that ensuring strong midwifery associations, and thereby establishing autonomy and recognition for the profession, is imperative for raising midwives’ status and enabling them to provide quality care [13]. Thus, in accordance with a global study conducted by Lopes et al. [30] including 73 midwives’ associations representing 67 countries, it is also necessary for the DRC to strengthen the country’s midwifery association, and to include midwives in policy discussions concerning the profession – which, although it is stable and recognised by the government, still struggles to ensure education, regulation, and respect for the autonomous profession [9] .
Inadequate pre-conditions of the DRC midwives’ work environment was another challenge found in our study. The midwives lacked both functioning healthcare facilities and materials, which added to their already difficult work situation. Constantly having a shortage of resources and equipment prevented them from working safely, and jeopardised their provision of quality care. Lacking safety equipment is known to make midwives more vulnerable to infectious diseases [14], and having appropriate facilities and sufficient resources is regarded as necessary for worker motivation and performance [26]. Therefore, it is important that health systems improve the availability of resources and functioning facilities to fit the care services, in order to enable midwives to provide care of high quality.
The midwives in this study expressed a need for additional professional competence as part of their continuing professional development. The education system for midwives in the DRC is known to need significant improvement [9], and if reformed could increase both the capabilities and status of the profession. Already burdened by a high maternal mortality rate and heavy workloads, and with inadequate competence, time, and resources to do more than the absolute necessary work, the midwives in this study were left feeling frustrated and less motivated. These findings correspond to the global consultation [13], in which midwives experienced difficult work situations due to heavy workloads and shortage of staff, high levels of maternal and newborn mortality rates, and a lack of sufficient competence to autonomously manage work tasks, which made them feel frustrated, guilty and inadequate. As such, this can contribute to distress and burnout, which in turn prevents midwives from being able to provide quality care and can eventually cause them to leave the profession [14]. This phenomenon does not seem to differ between settings in high -, middle- and low-income countries [17, 31]. Therefore, in order to retain midwives in their work positions and enable them to provide quality care, it is crucial to create supportive work environments by ensuring sufficient pre-conditions [32]. Hence, midwives needs to take the power to influence their own situation [14]. When midwives are included in customising their work environments, it has proven to result in improved quality of care for women and newborns around the globe [13], and it is suggested that the DRC also embrace this.
Methodological considerations
This study has limitations. Two that particularly stand out are common criticisms of FDGs when it comes to obtaining valid data: (ii) the possibility that the participants may not have expressed their honest and personal opinions about the topic under discussion, and (ii) compared to individual interviews, there is no guarantee of depth in the topic being discussed [33]. However, we chose to conduct FGDs to encourage a discussion among the participants that would enable them to be inspired by each other and continue with reflections stimulated by each other’s statements. Our conviction is that this methodology favoured openness as it enhanced a sense of community, sharing common problems. We therefore ensured that everyone could express their opinions through the open questions, and by being attentive to allowing everyone the opportunity to talk. The number of participants per group – six to eight – enabled a good discussion climate and ensured that everyone’s views were heard. A strength was that the participants represented different healthcare facilities, both public and private, and different regions, and thereby offered deeper and more varied experiences and reflections. Despite that the interviews were conducted in only two out of 26 provinces, we find them valuable as a predominant strength of the study is that the working environment of the midwives in the DRC has not been made visible in earlier studies. In general, there is a shortage of recent studies on what motivates midwives in their work globally, which this study addresses. It is worth noting that the findings regarding the challenges and motivating factors for remaining in their workplace mentioned by the midwives in this study are context-specific, and that different countries and settings must interpret these in light of their own context.