Job Satisfaction and Associated Factors Among Midwives Working in Health Centers of Central Zone, Ethiopia

Background: Job satisfaction depends on the interactions of employee’s personal characteristics, values and expectations with the work environment and the organization. Low job satisfaction among midwives is supposed to be a problem to achieve organizational goals. Due to this reason, it is a must to determine their level of satisfaction and the contributing factors. The objective is to assess job satisfaction and associated factors among midwives working in Health Centers of Central Zone of Tigray, Ethiopia, 2019 Method: - An institution-based cross sectional study was conducted on March 2019 at Central Zone of Tigray among 140 midwives selected using simple random sampling. Logistic regression analysis was used to identify factors related to job satisfaction. Variables which have p-value less than or equal to 0.05 with corresponding AOR at 95 condence interval was considered to declare the signicance association. Result: This study revealed that job satisfaction of health professional working Central Zone of Tigray was 43.57%. Of which respondents’ 92 (65.7%) were females and 128(91.4%) were Orthodox region followers. Majority of the respondents 85(60.7%) were under the age of 30 and almost half 69(49.3%) of the respondents were married. Motivation, management system, and work were identied as signicant factors associated with midwives’ job satisfaction level. Regarding motivation, the probability of being satised among midwives not motivated to do their job, were 76% times less likely compared to their counterpart, whereas the management system, the probability of not satised with the management system were 79.2% times less likely satised than who were satised with the management system. Work satisfaction, the probability of not satised with their work was 91.6% times less likely satised than those who were satised with their work. Conclusion: Job satisfaction of midwives in central zone health centers was found to be low. Motivation, management system, and work were identied as signicant factors associated with midwives’ job satisfaction level.


Introduction
Job satisfaction depends on the interactions of employee's personal characteristics, values and expectations with the work environment and the organization throughout their lives (1). The increase in the number of births attended by skilled health personnel is one of the major strategies to minimize maternal and child mortality (2). Low motivation of midwives further exacerbates the situation (3). Satisfaction with jobs largely determines the productivity and e ciency of human resource for health (4).
Job satisfaction of midwives is highly important in building up employee motivation (5). This has the potential to have a negative impact on the delivery of patient care because there is con rmation to suggest that reduction in health professional staff below a certain level is related to poor patient outcomes (6, 7, 8, and 9). Midwives who were dissatis ed at work were found to distance themselves from their patients, resulting in suboptimal quality of care. Dissatisfaction with their work can cause poor job performance, lower productivity, and staff turnover and is costly to organizations. (10).
The negative consequence of less satisfaction is high turnover; costs related to recruitment, orientation of new health professionals; loss of skilled health professionals; periods of short sta ng accompanied by tirelessly for remaining midwives, or use of temporary agency staff who are less familiar with the setting than employees; and potential for increase in adverse client outcomes and reduced organizational performance (11,12,13). Low job satisfaction among health care providers is supposed to be a problematic. Overall, 86% study subjects were dissatis ed, with about 26% higher dissatis ed with their job (15,16,17).
Job satisfaction is a function of numerous variables, including salaries or wages and allowances, the work environment and other non-monetary factors. 40% of public health workers interviewed had moderate satisfaction, neither high nor low and another 40% low and very low job satisfaction, that is, only 20% had high or very high job satisfaction (18). 40% of public health workers interviewed had moderate satisfaction, neither high nor low and another 40% low and very low job satisfaction, only 20% had high or very high job satisfaction. It means that midwives are not satis ed with their jobs (19,20,21). There have not been programmed initiatives despite recent deliberate policies aimed at improving and encouraging the career development of health workers (16). Job satisfaction is a construct closely related to motivation; it is a direct result of motivational processes, of which it is the affective component (22).
Dissatisfaction result in tiredness, absenteeism, examination incorrectly, burnout, and excessive turnover have been reported (23). From the total respondents 83.7% of health professionals' have intention to leave the hospital, and about 30.4% of the respondents from the study hospitals have intention of leaving their job because of low government salary scale and seeking better job for better pay, and about 17.4% of the respondents from the study hospitals have reported that low government salary scale force them seeking better job elsewhere for better pay (24,25).
The world needs midwives than ever, we need to retain the exits. Understanding employee perspectives and measuring their satisfaction factors are critical to an organization's success. It may help public and private organizations, including health centers at Regional and woreda level to be clearly aware of midwife's job dissatisfaction and related factors in the study area. This may inspire them to go beyond and make some sort of interventions towards alleviating this critical problem. It may help midwives to know their challenges, strengths and weaknesses in the working area. Finally,by adding 10% non-response rate the estimated sample size will be: 140 140 midwives were included in the studies who were working in Health Centers of Central Zone of Tigray. Accordingly, 140 midwives were selected for a structured interview. Besides, 7 midwives were selected purposely for semi-structured interviews.

Sampling technique and procedure
Purposive sampling technique was employed to include 7 midwives used for qualitative data collection. Besides, 140 midwives were included who ful ll the inclusion criteria for quantitative. Systematic random sampling technique method used from Zonal Health Beurou registration book to lter the study participants for quantitative study. Total midwives in central zone have 421 in number, so every k interval re nes the total sample size systematically. Out of the rst 3 respondents select from the registration book randomly then select every three interval. Out of which midwives from Zonal Health Beurou registration book were selected and re ned to only those who ful ll the inclusion criteria for both quantitative and qualitative study.

Variables
Dependent Variables: job satisfaction Independent Variables Socio-demographic factors: gender, age, monthly salary, work experience, educational quali cation, and marital status; Management factors; work appraisal, recognition, supervision, and justice; Organizational factors: work environment, resource availability, and incentives; Job related factors: autonomy, use of skills, work r/n ship, motivation, training, and work Operational de nitions of basic terms Job satisfaction: Being like or unlike a job Satis ed: Satisfaction more than to the mean value (computing all Likert scale variables: justice, physical working environment, availability of resources, work overload, interpersonal relationship, work appraisal, supervision, decision making, staff-client interaction, incentives, educational opportunity, skill, autonomy, health risks) Not satis ed: Satisfaction less than or equal to the mean value

Methods of analysis
Both qualitative and quantitative methods of data analysis were employed. The collected data using structured interview was initially checked, coded, and analyzed using frequency, percentage, mean and standard deviation, after entering into a computer using SPSS version 20.0. The mean scores were calculated for midwives' job satisfaction sub-scale and the overall satisfaction of those whose scores above the mean were considered as satis ed and those whose score less than or equal to the mean were considered not satis ed. After the normality of the data was checked crude odds ratio was calculated for each exposure variable using 95% CI, then to do the adjusted odds ratio with p value of <0.2 under bivariate analysis entered into multiple logistic regression models in order to identify independent predictors of midwives' job satisfaction. On the other hand, the collected data using semi structured interview were analyzed with the help of a tape-recorder, transcribed and translated to English then analyzed using thematic analysis. Cut point value of P < 0.05 to say statistically signi cant.

Ethical clearance
The study was done in accordance with the declaration of Helsinki. Ethical clearance was taken from Mekelle University College of Health Science ethical review committees. A formal permission letter was obtained from the Central zone health beurou. Respondents were provided information on the purpose of the study, its procedures and their right to refuse or decline participation in the study at any time. Written informed consent was taken from all study participants after a clear description of the objectives of the study and its procedures by the data collectors before proceeding data collection.

Socio-demographic factors
The response rate of this study was 100%. Of which respondents' 92 (65.7%) of the respondents were females. Regarding to their religion, 128(91.4%) were Orthodox. The table also revealed that 85(60.7%) of the respondents were under the age of 30 and 30-40 age of the respondents were 31(22.1%). 69(49.3%) and 41(29.3%) of the respondents were married and single respectively. Regarding to their educational quali cations, the majority 122 (87.1%) were diploma holders. We saw 73 (52.1%) of the respondents work experience was less or equal to ve years and nearly half of the respondents get monthly salary of >2000 birr per month (Table 1).

Distribution of job satisfaction related variables
Respondents were requested about variables related to job satisfaction. Accordingly, 60 (42.9%) of the respondents replied that there was adequate training in their institution. Whereas, 80 (57.1%) were agreed that there was no adequate training. Similarly, the response obtained from in-depth interview, two midwifery's interviewees replied; …...There is no adequate training given in this health center; even when training programs are arranged by other concerned bodies, the chance is given to others out of the department.
Respondents were also requested regarding to their salary. Accordingly, the nding revealed that 120 (85.7%) of the respondents were not satis ed. The data which was also obtained by the use of in-depth interview showed that almost all participants were not satis ed with their monthly salary. In supporting this view, a 25 year working experiences midwife stated: We are dissatis ed with our salary as well as duties and risk payments. We are working half of the health center activities. We work more than 20 hours per day and the payment is not delivered accordingly. We have children and we are working only for the sake of feeding them and to sustain our lives. We still ask for the betterment of our payment, though no change is being made. It is already known that the risk and duty payment of each individual is 470 birr per month and 80 birr per day respectively. But no one can be paid according to the standard and taxed 30% together with our salary: surprisingly, we get only 8 hours duty per day.
Regarding to motivation, the nding revealed that 72 (51.4%) were not motivated to do their job in their health center. Similarly, one midwives stated: …… There is no any signi cant motivator given to ours ……. Even, midwives are just lumped as a nurse.
Concerning the management system, 93 (66.4%) of the respondents were not satis ed with the management system of the health centers. The rest, 47 (33.6%) were satis ed. Respondents were requested about the availability of equipment in their health center. Accordingly, 80 (57.1%) of the respondents replied that the health center equipment was not ful lled. In the same way, one MCH case team coordinator midwives said: … Some midwives work with only one glove; work with no antiseptic, not supported by the system, but because of passion; few midwives planned to leave the profession to do their own private business, because they have lost satisfaction in the profession.
A single item was prepared to measure midwives related to their work that they are providing to their customers. Accordingly, the response obtained from the majority of respondents showed that 88 (62.9%) were not satis ed with the work they are providing. The remaining, 52 (37.1%) were satis ed ( (25%) of the respondents were dissatis ed. One midwife interviewee on the qualitative study was also replied: We work a lot and engaged in labor and delivery, ANC, family planning, under ve, and immunization. We are always on duty on behalf of our colleagues when they leave for break and when they are asking sick leave. This is mainly due to less number of midwives in our health center.
Respondents were also asked regarding the level of their interpersonal relationship.  Regarding to educational opportunity, the majority of respondents 92(65.7) and 28(20.0) were very dissatis ed and dissatis ed respectively. Whereas 10 (7.1%) were satis ed. On the qualitative result from one interviewee: …….. There is no any opportunity for further education; few of them start to upgrade their education by their own. Sometimes when we are starting to learn by ourselves higher o cial gave a written warning. Even we are also upset by other people sayings like "there is no need of learning more than diploma and no need of more than two midwives in one health center!!!" This leads us job dissatisfaction.
Respondents were requested whether they were applying their skills in their work they are assigned. …. I am dissatis ed with my job due to professional bias. Even though midwifery was my choice, due to different factors I am very disappointed; I considered myself below other health professionals. Other people also perceive midwifery as less interesting department than other health professions. We also hate our profession. ….. Midwifery is the lowest job from the alternative professions. There is no any midwife expert who evaluates, comment and give feedback for the program in general and for us in particular.
From all measuring Likert scale variables, the lowest levels of job satisfaction are obtained from educational development (Mean = 1.66 ±1.143) followed by the salary (Mean = 1.14 ±0.351) and then workload (Mean = 1.94±1.326). The highest level of satisfaction was get from applying their skills in the working areas.
Based on this value the overall job satisfaction of midwives using Likert scale question items, the nding revealed, 61 (43.57%) were satis ed, the remaining 79 (56.43%) were not satis ed. Two midwifery participants during in-depth interview said gure 1): …. I am dissatis ed with my job due to professional bias. Even though midwifery was my choice, due to different factors I am very disappointed; I considered myself below other health professionals. We also hate our profession. ….. Midwifery is the lowest job from the alternative professions. There is no any midwife expert who evaluates, comment and give feedback for the program in general and for us in particular.
Factors associated with job satisfaction Job satisfaction results of the bivariate analysis result like socio demographic factors, training, salary, motivation, management system, equipment, and work. From those variables motivation, management system, and work in the multivariate analysis were again statistically signi cant for the overall satisfaction. Regarding motivation with the overall satisfaction, the probability of being satis ed with their job among midwives with not motivated to do their job were 76% times less likely compared to their counterpart [AOR=0.24; 95% CI (0.087, 0.665)]. When we see the management system in relation to the overall satisfaction, the probability of not satis ed with the management system were 79.2% times less likely satis ed with their job than those who were satis ed with the management system [AOR, 0.208, 95% C.I, (0.074, 0.583)]. On the other variable which was the most statistically signi cant from the alternative in multivariate analysis was work satisfaction, the probability of not satis ed with their work was 91.6% times less likely satis ed with their job than those who were satis ed with their work [AOR=0.084; 95%, CI (0.03, 0.234)] (Table 4) .

Discussion
The nding revealed that 79 (43.57%) midwives were satis ed with their job. The reasons obtained mainly from educational development (Mean = 1.66 ± 1.143) followed by the salary (Mean = 1.14 ±0.351) and then workload (Mean = 1.94±1.326). Variables in the multivariate analysis like motivation, management system, and work satisfaction were statistically signi cant for the overall satisfaction under multivariate analysis (p<0.5). Socio-demographic variables were not statistically signi cant. Less than half midwives were Satis ed with their job. The result obtained from the qualitative study also supported this result that majority of the participants were dissatis ed with their job. For instance, one case team coordinator midwife replied ……… I am dissatis ed with my job. Most people hate our job and always say you are not a health professional. Always one activity: always similar thing: illiterate can do your job!!" Similarly, another midwifery interviewee stated … Our profession is never respected by other groups of the society. Some people dislike our profession as well as our job and repeatedly says "midwife is exactly like a goalkeeper……". This in turn makes us very dissatis ed. ….. Majority of midwives is dissatis ed with their job as well as other intervention programs like duty payment, work load, educational opportunity evaluation system, professional bias, recognition given to them by other groups of the society……...
Both the qualitative and the quantitative results of this study showed that midwives were less satis ed with their job. It seems consistent study in Jimma (14). This similarity is there may be similar health policy, work load, payment and training opportunity. On the other side this nding seems inconsistent with many other research ndings in different countries. For instance, the research work in Iran showed 38.9% of midwives were not satis ed with their job (8). In Pakistan overall, 86% study subjects were dissatis ed (15). In turkey the percentage of satis ed health care workers was 60% and midwives had the lowest satisfaction scores (12). This inconsistent between this result and literatures may be due to some item difference for the overall satisfaction and the areas covered by the study and economic status difference. Even though the level of satisfaction was different, areas of most dissatisfaction were similar.
Regarding the signi cant variables in the multivariate logistic regression management system, motivation and work satisfaction were statistically signi cant. With analysis result of motivation the probability of being satis ed among midwives with not motivated to do their job were 76% times less likely compared to their counterpart [AOR=0.24; 95%, p≤ 0.5), CI (0.087, 0.665)]. It indicated that motivation affected the overall satisfaction of midwives. This result supported by the qualitative study one midwifery interviewee replied that: …. There is no any motivation given to us including job autonomy.
In supporting this, one other midwife also replied …. there is no any form of motivation for midwives. Midwives are inadequately motivated, we have no promotional outlets speci cally as a midwife from the lowest to highest cadre as a specialty; midwives are just lumped as a nurse….
Midwives who were doing with motivation in central zone health center are statistically signi cant with their overall job satisfaction. So, motivation highly affects midwives job satisfaction which has statistically signi cant with the overall satisfaction (P<0.5). It seems consistent study in Jimma hospital on health workers dissatis ed with motivation of staffs (14). Work is statistically signi cant with overall satisfaction (P = 0.016) (28). The similarity may be due to similar sample size, salary, bene t, risk and similar health policy.
Majority of the participants were not satis ed with the management systems of the health centers. The other signi cant variable for overall job satisfaction in the multivariate regression was management system. The probability of midwife's satisfaction who were working in health centers not satis ed with the management system was 79.2% times less likely satis ed than those who were satis ed with the management system. With supporting this result on the qualitative study one midwife replied As a midwife as well as a program coordinator, I am dissatis ed with the management systems of this health center. Management bodies are not willing to solve problems together. They denied our right. They are not involving us in a management system to decide even the issue is concerned us…….
Similarly, a study in Jimma hospital also indicated that the majority of the participants were not satis ed with the management system of their hospitals, but it is not statistically signi cant with the overall satisfaction. The nding of this literature study indicated that the majority of the respondents were not satis ed with the management system of their respective institution (14). This inconsistency may be due to different analysis method, and technical management system.
Majority of the respondents were not satis ed with their work that they are providing. From those variables which entered into multivariate, the most statistically signi cant variables from the alternative in multivariate logistic regression were work. The probability of satis ed with their work were 91.6% times less likely satis ed with their work than those who satis ed with their current work.
The above result is supported by qualitative study, one midwife participant during semi-structured interview session stated: ……. Distance between health centers and towns, transportation problem, scarcity of working rooms, shortage of water, budget constraints, scarcity of electricity and absence of telephone are the major barriers that hinder the service delivery. This makes me dissatis ed with my work.
This result seems inconsistent with a study conducted in the Turkey the proportion of health care staff satis ed with their work statistically signi cant with the overall satisfaction, midwives had the lowest satisfaction scores (P < 0.05) (12). This result seems consistent with a study in Jimma health worker respondents felt not satis ed from the work they do (8). A consistent nding in Gondar with their work explained the overall job satisfaction (29). The assumption could be helping a person in labor may give satisfaction which showed that helping mothers in the case of severe pain was the main reason for their job satisfaction.
Socio-demographic variables of this study were not statistically signi cant with the overall satisfaction. The ndings revealed that demographic factors were not linked to job satisfaction. This is consistent with other research, a number of such as age; gender, marital status, and work experience of the profession (P > 0.05) were not linked to the overall job satisfaction (12). The other consistent study in Jimma hospital of health workers, However, there was no statistically signi cant association between overall job satisfaction and socio-demographic variables (p≥ 0.05) (14) Strength And Limitations Of The Study Use of mixed methods (both qualitative and quantitative).The study is not inclusive. Midwives in different Hospitals of the zone were not included on the assumption that the problem may be much more sever in health centers. Purposive sampling method used for qualitative data that may result bias and it might not represent the whole population.

Conclusions
The overall job satisfaction of midwives in central zone health centers was coming low. This result showed that majority of midwives is not satis ed with their job in the study area. The reasons for this low satisfaction score of midwives were low educational opportunity, inadequate incentive, low work appraisal, scarcity of resources, poor physical working environment, high workload, low supervision, and poor job autonomy. From this result we conclude that better educational opportunity, reducing work load, better supervision and giving job autonomy increase the overall job satisfaction of midwives.
Overall job satisfaction of midwives was greatly affected by management system, motivation and work. This factor was statistically signi cant for the overall job satisfaction of midwives in their working area. There for improving the management system, motivation and working condition likely to increase the overall job satisfaction of midwives. In this study socio-demographic variables were not affecting the overall job satisfaction.

Recommendation
Based on the ndings of the study, the following possible recommendations are better forwarded to improve job satisfaction of midwives.
Regional Health Bureau The regional health bureau better to identify the gaps and needs of midwives so as to give further educational opportunity. Author's contribution BT conceived and designed the study, performed analysis and interpretation of data. AT and TA supervised the design conception, analysis, interpretation of data and made critical comments at each step of research. All of us drafted the manuscript. All authors read and approved the nal manuscript

Declarations
Ethics approval and consent to participate The Study was reviewed and approved by the Mekelle University ethical clearance committee. All participants were informed of the aim of the study and their full right to withdraw or refuse to participate before their verbal consent was obtained.