The midwives’ challenges, and the factors motivating them to remain in their workplace in the DRC, are summarised in one main category – Loving one’s work makes it worthwhile to remain in one’s workplace, despite a difficult work environment and low professional status – consisting of three generic categories: Midwifery is not just a profession; it’s a calling, comprising the three subcategories (1) Saving lives through midwifery skills, (2) Building relationships with the women and the community, and (3) Professional pride; Unsupportive organisational system, comprising the three subcategories (1) Insufficient work-related security, (2) No equitable remuneration system, and (3) Hierarchical management structures; and Inadequate pre-conditions in the work environment, comprising the two subcategories (1) Lack of resources and equipment and (2) Insufficient competence for difficult working conditions. (Table 3).
Midwifery is not just a profession; it’s a calling
The generic category Midwifery is not just a profession; it’s a calling concerns the midwives’ motivation in their work, which included saving lives through midwifery skills, building relationships with the women and the community, and having professional pride.
Saving lives through midwifery skills
Saving the lives of mothers and newborns was a strong motivating factor. Specifically, it was motivational to have skills within the midwifery domain, such as managing the full continuum of care during pregnancy and labour, supporting women in having normal physiologic births, or being able to handle complications:
I feel very good when I can handle the complications during a birth and afterwards; for example, if a woman comes in unconscious and I can handle it. (FGD1)
The midwives felt that their main role was to save lives and thereby contribute to decreasing the country’s high maternal mortality rate. Saving a woman’s life was valued as a measurement of high-quality care. This was a driving force in their daily work and made them feel motivated, as their work made a difference for the survival of women in the DRC:
I have given my life to save lives (FGD3) // We have decided to always be at the women’s side, to save their lives. We cannot break this promise to save their lives. (FGD2) //I want to continue working at my workplace to be able to make a difference and decrease the maternal mortality. (FGD4)
Building relationships with the women and the community
Building relationships with the women and playing a significant role in the community were central to and valued by the midwives. They repeatedly expressed having strong feelings of love for the women and for the community, and experienced their work as important and meaningful:
It’s the love for the sick that motivates us. (FGD7) // I want to continue this work because of the love for our country and the population. (FGD1)
Mutual trust and a duty to the community characterised the midwives’ perceptions of their relationships with the women. They felt appreciated and trusted by both the women and the community. They emphasised that they wanted to continue their work in order to be loyal to their patients and to society as a whole:
I feel good when the woman has trust in us … she surrenders herself in confidence to us. (FGD6) // We have built trust with the women and made them feel safe. (FGD5) // If we abandon our work, we leave a people that will suffer. (FGD2)
The midwives radiated professional pride; they had a profession that they enjoyed and believed in. Their position in society to help women also gave them feelings of satisfaction and accomplishment:
We have studied to work as midwives. We are proud of our profession, to help women. (FGD4) // The greatest motivation is that we are midwives and we love the profession. (FGD1)
The midwives felt that their role as midwives was essential because of their ability to help women. This resulted in feelings of commitment, duty, and resilience, despite their difficult working conditions, which in turn characterised their sense of professional identity and gave them motivation. Sacrificing themselves for the belief in their profession was motivational, in the sense of making a difference for the women:
Because we are midwives, we have to continue helping the women. We are midwives whether or not we are motivated. (FGD2) // It is our profession! We have chosen our profession and must continue. We have committed ourselves and will continue to be midwives, regardless of the situation. This is our calling; we exist to work as midwives. (FGD6)
Unsupportive organisational system
The generic category Unsupportive organisational system describes how midwives were challenged by insufficient work-related security, hierarchical management structures, and the lack of an equitable remuneration system.
Insufficient work-related security
The midwives’ work environment was surrounded by insecurity. Especially during night shifts, due to the darkness, they often felt frightened on their way to and from work. Many years of conflict and continuous instable security in society had installed a fear in them, and they were afraid of being victim of aggression, including rape. Practical constraints increased their insecurity, such as a lack of transportation to and from work and the inability to pay for secure transport such as a taxi or a motorbike, or not having a flashlight or money to pay for batteries, further amplified their feelings of insecurity and fear:
Working at night makes us insecure… we are always afraid in the dark. (FGD3) // We are all scared of the military, scared of being raped… The conflict was in 2018 and there were two doctors and midwives who were killed then. (FGD2)
A professional identity card could protect them, but not all midwives had received such a card from their employer:
We bring ID card to work. When the military comes and we can show our ID card, there are no approaches from the military. (FGD1)
No equitable remuneration system
There was no equitable remuneration system in place, and the midwives stressed the lack of regular payment or compensation for their employment. There was no fixed amount of money for their services that was paid on a monthly basis. Some expressed that their salary was too low and was not sustainable for them to live on, while others described having more of a monetary incentive, equal to USD 5, than any actual salary. At some facilities, they were dependent on the patient fees in order to get paid. This meant that sometimes the midwives had to take up a second job in order to meet their everyday needs, which resulted in feelings of increased everyday stress and being underappreciated:
We cannot live on our salary. We work shifts and then have to work in the fields on our days off. (FGD6) // We don’t receive any income from the state, only through patient fees. Our work is voluntary work, we don’t even get soap. (FGD9)
Hierarchical management structures
Another challenge involved hierarchical management structures within the healthcare facility. Several midwives expressed feeling insecure and uncertain in their employment and their relationships with their supervisors. Many midwives had no employment contract, while others could be punished for, for example, being late to work by losing their job or being sent home for three months without work or payment. Not feeling safe in their job caused the midwives to feel uncertain in their everyday work situation:
We cannot complain, we lose our job if we complain… We have never signed anything when we started our employment here, we don’t have any contracts. (FGD4) // If you question the supervisor you can be let go without pay for three months… So I don’t say anything, because then I won’t get paid. (FGD1) // I am afraid that I won’t get to work on time, which can be due to not being able to find a motorbike or not being able to pay for it. (FGD4)
A few midwives who worked at a private healthcare facility did not have such an unsecure working condition. They could even question work routines without being afraid of losing their job.
Many midwives reported being placed at departments where their specific midwifery professional competence was not useful, such as surgery/internal medicine wards, the pharmacy, or the administration office. They could be moved around according to their supervisor’s preferences rather than their specific domain. Not being allowed to practise their profession and not receiving recognition for their work made it very demanding to continue their job, leading the midwives to feel frustrated and undervalued. A need of support from the local midwifery association was expressed:
They don’t make use of our potential as midwives; we have to work in other departments like medicine, paediatrics, surgery… I feel like I’m used as an object. (FGD4) // We want the state to care about midwives. (FGD6)
Inadequate pre-conditions in the work environment
The generic category Inadequate pre-conditions in the work environment describes how the midwives were challenged by inadequate pre-conditions at work, including a lack of resources and equipment as well as insufficient competence for difficult working conditions. The midwives simply lacked the means to carry out their work and provide quality care.
Lack of resources and equipment
For the midwives, a lack of resources and equipment to perform their daily work duties posed a significant challenge. This problem concerned several areas, such as space and function and a shortage of the basic, essential clinical equipment needed to provide care during labour, birth, and after. This could include a lack of birth sets, syringes, caesarean kits, blood pressure cuffs, oxygen, medicines, and vacuum extractors. There was also a shortage of personal protective equipment like work uniforms, visors, gloves, boots, soap, birth caps, and disinfectant. This caused the midwives to feel worried about being infected with communicable diseases. Working without sufficient resources impaired not only the safety of their work environment but also their sheer ability to carry out work of sufficient quality:
We have not received any external support to rebuild the hospital after the war… We’re working under tough conditions. We only have one birthing set… one vacuum extractor, but it does not work. (FGD7) // I feel bad when we have learned different techniques like vacuum extraction and revival, but cannot perform these due to a lack of material… We want work clothes; we have to pay for them ourselves. We need boots to protect us, and medicines. (FGD3)
The facilities were described as inadequate for meeting the needs of the number of patients coming to the clinics. A lack of birthing beds could mean that two to three women had to share one bed. There was often a shortage of electricity, which led to a lack of lighting and the incubator and revival machines not functioning. Lacking material and having inadequate facilities to work in served as a constant source of frustration for the midwives, and was a major challenge to their ability to provide care.
Insufficient competence for difficult working conditions
The midwives expressed having insufficient competence in providing care in critical conditions, such as resuscitation of mother and child, the third stage of labour, and the postpartum period. They described thanking God if things went well, or hoping for good outcomes, rather than trusting their competence to handle the possible complications. Another tough working condition was when poor, dirty women, for instance sex slaves, came to the hospital seeking care. This often caused the midwives to feel frustrated, wishing they had more resources to help these women. The working conditions led to the midwives often feeling tired after work and not having the time or means to eat. Insufficient competence, in combination with difficult working conditions, resulted in their undertaking an overwhelming personal responsibility and feeling inadequate at work. The midwives often brought these feelings home, which led to negative effects on their general wellbeing:
I feel bad when mother and child die… or when a birth ends with excessive bleeding… If I can’t see that I have done enough I blame myself. This effects how I feel at home, can disrupt my sleep. (FGD5)
To manage the difficult situations described above, the midwives stressed needing additional competence through proper, sufficient education and continual professional development. They felt that they needed more education and training in all areas in order to increase their general competence, as their skills were insufficient. This would result in increased confidence as midwives, and better outcomes in their work. Due to the education reform of 2013, they felt an increased need to update their knowledge. However, training was not incorporated in all working environments and, when it was provided, it often did not include everyone, which led to unequal conditions and a stagnation of the midwives’ competence:
We have the old education system and because of the new education reform we need to be updated in the new educational programme. We lack competence in how to support during labour, how to avoid bleeding… (FGD8) // We really need further education in order to increase our professional capacity. We do not receive continual training. (FGD2)