Midwives are important members of the healthcare team who contribute in ensuring that quality maternity services are rendered to patients. According to the Pretoria News newspaper (Hospital Maternity Staff Quit in Numbers 2016:1), it was reported that the selected public hospital in Tshwane District had an alarming turnover of midwives. The hospital serves as a referral institution providing the highest level of care for high-risk conditions. Besides other disciplines of healthcare services provided in this hospital, the focus of this research study was mainly on maternity healthcare services with midwives taking a central focus. The maternity services provided are high-risk antenatal, high-risk labour, postnatal and neonatal care. In this study, neonatal care was excluded as the main research question was on the maternity staff. The institution is a teaching hospital with doctors who have specialised in obstetrics and gynaecology, trainee doctors, midwifery students and other health disciplines. The student midwives placed to undergo continuous clinical training are from different nursing institutions and universities. The midwifery staffing of the units appears to be subminimum as there is evidence of consistent reliance on the agency staff to cover daily shifts.

Maternal and neonatal care is at the crux of every healthcare system. According to World Health Organization (WHO 2016a:1), there is a shown evidence that midwifery plays a vital role and is associated with improved quality care, and rapid and sustained reductions in maternal and newborn mortality. Poor maternal and newborn care is the determinant of maternal and neonatal morbidity and mortality (WHO 2016a:1). Midwifery has come to the fore because maternal and newborn health was made the focus of the Millennium Development Goals (WHO 2013:804).

Midwives play a key role in reducing maternal and neonatal mortality and are further regarded as the warriors on the frontline of healthcare, battling to ensure that women survive child birth and that babies are born safely, even in the most marginalised areas (WHO 2013:804).

In a study conducted by the WHO (2016a:10), it has been found that midwifery, including family planning and interventions for maternal and newborn health, could avert a total of 83% of all maternal deaths, stillbirths and neonatal death. Midwives who work within the framework for maternal and newborn care and within an enabling environment have the potential to bring care close to women and communities and tailor it to their social and cultural needs (Ten Hoope-Bender et al. 2014:6).

Shortage of midwives was found to be a problem in developed countries as well as in the middle-income countries (Pugh et al. 2012:498). The United Nations Population Fund (UNFPA 2014:14) report on State of the World’s Midwifery 2014 brings to light that midwives make up to 36% of the midwifery workforce across the 73 countries. Their specific contribution to the physiological process of normal birth and their high degree of focus on sexual reproductive, maternal and neonatal health (SRMNH) continuum of care makes them essential.

There is a global call for urgent investment in high-quality midwifery to prevent maternal and newborn deaths (Afenyandu, Adegoke & Findley 2017:1067). Barker (2016:826) asserts that the abnormal working patterns of midwives contribute towards them leaving the profession. In addition, Barker adds that midwives continue to go the extra mile through staying late and missing breaks to ensure that they get through what is often a heavy and challenging workload. For midwives, the ever increasing dedication and crisis management can seem to be the only response to rising workloads, whereas staffing deficits may contribute to poor clinical outcomes and may affect midwives’ health, morale and retention. Staffing levels models using birth rate plus have been adopted successfully in other European countries such as the UK, England and others to evaluate staffing needs (Yelland et al. 2013:579).

The shortage of midwives in the public sector influences maternal care outcomes in a negative manner. Poor-quality workplace in health system weakens the ability of institutions to meet their performance targets and quality healthcare outcomes, and makes it more difficult to attract, motivate and retain staff. The researcher, during clinical accompaniment of the midwifery students, observed that many midwives are resigning which leads to shortage. Mentoring and supervision of students including the provision of quality care to mothers and babies in the maternity unit are affected, hence the need for the researcher to explore the midwives’ perceptions on shortage of staff and how the challenge can be addressed.

The aim of the study was to explore midwives’ perceptions on shortage and retention of midwives in a public hospital in the Tshwane District, Gauteng Province.

The objective was to explore the specific factors associated with the midwives’ intentions to stay or leave their primary employment in the public sector of Tshwane District, from the midwife’s perspective. The research question for this purpose was as follows: What are experiences and perceptions on the shortage and retention of midwives in the maternity wards of the public sector hospital?

In this qualitative study, a generic inductive approach with a descriptive design was followed to explore the perceptions on the shortage and retention of midwives. A qualitative design investigates people’s reports of their subjective opinions, attitudes, beliefs or reflections on their experiences of things in the outer world (Percy, Kostere & Kostere 2015:78). Focus groups and individual face-to-face semi-structured interviews were conducted among participants.

Three themes which emerged from the data were shortage of midwives, reasons for leaving the profession and reasons for staying in the profession.

In this qualitative study, the perceptions of midwives on shortage and retention of staff were summarised in three main themes as emerged from the data analysis. The three themes were shortage of midwives, reasons for leaving the profession and the reasons for staying in the profession. The midwives expressed the frustrations of working under the conditions of limited staff in a shift as having a negative impact on their workload. These research findings relate to those of Thopola and Lekhuleni (2015:508) that increased workloads result from several factors such as inadequate number of midwives who are on duty and feeder clinics that are not adhering to referral criteria.

Midwives seem to be dissatisfied with the manner in which the referral system is managed. In the study conducted in Limpopo Province of South Africa, it was revealed that shortage of midwives, limited material resources, medico-legal hazards and substandard midwifery care were the factors impeding the provision of optimal midwifery practice in maternity units of public hospitals (Thopola & Lekhuleni 2015:511).

Furthermore, the impossible demands of the midwives’ workload could place them in an ethical dilemma of how to prioritise care (Filby, McConville & Portela 2016:10). In order to remedy the situation, midwives find themselves being obliged to work overtime which consequently affects their provision of quality care.

According to Filby et al. (2016:10), in their research study report concerning African countries, inadequate staffing and working excessive overtime were found to compromise safety for women receiving maternal care as well as midwives.

Filby et al. (2016:4) further assert that moral distress and burnout result in midwives becoming disempowered to provide quality care. Midwives are experiencing low morale in relation to their working conditions. Hildingson and Fenwick (2015:180) assert that paying more attention to establishing healthy work environment where midwives feel recognised and valued is likely to improve midwives’ perceptions of themselves and the quality of their working life. Warriner, Hunter and Dymond (2016:194) point out that stress within the midwifery profession has a negative impact on the health and well-being of individual midwives, as well as the care of women.

Midwives are a pillar of reproductive health programmes, and it is crucial to understand their role in the health system and support them (WHO 2013:804). Like all other healthcare staff, midwives are known to experience higher levels of stress (Pezaro et al. 2015:2). While they may be suffering from their own personal stressors and having to sometimes deal with uncooperative patients and disrespectful doctors, midwives report that they struggle to function professionally.

In all health systems, it is essential for personnel to receive some level of continuous training to ensure personnel development and quality improvement. Some midwives in the study feel left out in matters of personal development as they revealed that they are not awarded opportunities to attend peer symposia, such as annual midwifery symposia held in different provinces in the country. Hauck et al. (2017:47) recommended the importance of professional development support and access to senior midwives within the clinical environment in order to ensure quality and sustainability of midwifery workforce. The utilisation of temporary employed midwives is a positive measure to relieve them of their heavy workloads. The midwives in the study perceive employment of temporary midwives as a burden citing the fact that it still remains their duty to orientate and supervise the temporary employed midwives.

The use of temporary employed midwives has its own disadvantages, as cited in a study conducted in South Africa on the indirect cost of agency nurses including: poor attitudes of agency staff, perceived lack of commitment, disloyalty, unreliability, reluctance to take on ‘extra duties’, time taken on supervision and a perception that they do not have the same ‘culture of caring’ when compared to the permanent staff (Rispel & Moorman 2015:5).

Dixon et al. (2017:6) explored the reasons midwives are leaving the profession and find a range of issues related to following: the working conditions within the national health service; lack of resources; lack of management support; not having control over work; and not having time to develop or sustain the relationships with women and colleagues (Dixon et al. 2017:6). The midwives in this study reported a few reasons similar to the ones cited by Dixon et al. (2017). Although the midwives do not have any intentions to leave the profession, they are likely to leave the institution hoping for better conditions elsewhere because of shortage which leads to stress and burnout. The midwives however are sensitive to the fact that shortage of staff is a universal crisis.

Changing employers may provide a sense of relief from the known unchanging environment. Versaevel (2011:30) suggests that the underlying reasons for midwives leaving include not feeling valued, long working hours, poor organisational culture, lack of support, low morale and increasing struggles with work–life balance

Lack of managerial support as highlighted by participants was one challenge which according to them contributes to the exodus of midwives. In the study conducted in Malawi, the common reason for intention to leave was poor management (Chimwaza et al. 2014:3). According to Chipeta et al. (2016:6) staff retention improves when staff feel supported by the nurse manager and is often linked to manager’s approachability, openness and balance when dealing with problems which arise during work.

The participants commonly agree that they are excluded in many decision-making processes which affect their daily work and would prefer to be involved and own the decisions. Ditlopo et al. (2014:8) emphasise that nurses’ participation in the development of policies and strategies enhances their job satisfaction and retention in the health sector. Through role managing and leading maternity units the midwives can use this knowledge to influence policy and service direction (Bannon, Alderdice & McNeill 2017:659). According to Pezaro et al. (2015:2), midwives could be at an increased risk of work-related psychological stress, because of the fact that they are independent practitioners and working in an area of high litigations. According to Jervis and Choucri (2016:21), midwives are being investigated by their professional bodies for issues resulting from failings in the system, lack of midwifery support or leadership, low staff levels, bullying, policy and protocol, not evidence based, obstetric dominance, lack of funding and lack of services.

Financial challenges are broadly mentioned as contributory factors to job dissatisfaction by many researchers. According to Ditlopo et al. 2013:138, financial incentives are commonly used as a strategy to improve health worker motivation and retention. According to Ditlopo et al. (2013:139), the South African government introduced Occupation Specific Dispensation (OSD) as a financial strategy to attract, motivate and retain health professionals in the public sectors in the clinical specialities; however, numerous problems with the implementation left nurses dissatisfied.

Midwives have a strong belief in the independent function of midwifery and feel that their autonomous status is currently compromised. A number of midwives consulted during the ICM Triennial Congress workshop felt that the status they are given is not as high as that experienced by other members of health profession (WHO 2016b:26). According to the International Confederation of Midwives, the scope of practice for midwives must support and enable autonomous midwifery practice and should therefore include prescribing rights, access to laboratory/screening services and admitting and discharge rights (Oyetunde & Nkwonta 2014:43). The South African Nursing Council has, meanwhile, been criticised over not recognising midwifery as a profession in its own right (Duma et al. 2012:6). This is perhaps the reason why midwifery as an independent function is still undervalued. The challenge of under-defined job descriptions posed more frustrations as midwives are perceived as all-rounders, having to perform all kinds of duties including working with files and serving meals. Too much paperwork is taking the midwives’ time from providing the necessary care to the women, as there is too much repetition of documentation. The obstetric book is a document meant to cover all information pertaining to the woman, from antenatal care to puerperium. More documentation is added according to the participants in the study, such as the ICU observation charts regardless of the woman’s condition in the ward.

The reasons to stay in the profession are both personal and professional. Some midwives are fearful of change and others have no other place to work, while others have a passion for midwifery and cannot imagine deviation from what they know. Midwives are passionate about the care they provide to women and their families and the positive impact they have on the outcome of the pregnancy. They expressed substantial pride in their work, especially when faced with emergency complicated maternal cases such as attending to an eclamptic mother and are able to actually save a life. Training opportunities are cited as the contributory factor for inclination to stay in the profession. Among the factors that promote retention is training opportunities according to Ghapanchi and Aurum (2011) as cited in Kossivi, Xu and Kalgora (2016:262). The midwives working in high dependency obstetrics, as the participants in the study, require knowledge and skills beyond those required to provide care to ‘well’ women (Eadie & Sheridan 2017:6).

According to Asegid, Belachew and Yimam (2014:3), career opportunities and training afford individuals the prospect of further developing themselves and growing within the ranks of their career. A conducive work environment is essential to retain the staff. The participants cited availability of resources as compared to other public hospitals being part of that which keeps them from leaving.

This study revealed a need for a collaborative effort by management of maternity wards to attract and retain the midwives in the profession through participative management in maternity healthcare services.

The interviews were conducted during working hours because of the availability of participants which might have affected the data collection based on the pressure to prioritise their primary function while participating in the interviews. Most of the participants were not willing to avail themselves for participation while they were off duty stating reasons of fatigue.

The shortage of midwives is influenced by many factors surrounding the profession itself. This chronic shortage is a compelling factor to midwives performing overtime which has a direct effect on the quality maternity care. Midwives in this research study indicated that the challenges of poor supervisory support have the biggest impact on the midwives’ decision to continue in the profession.

Managers should understand the pressures midwives work under, therefore should not add to the pressure but bring encouragement through positive feedback and constructive criticism.

Communication platforms need to be created in order for managers to listen to the concerns and views of staff. Where policy-making is involved, a representative from the maternity unit should be present to assist in determining the feasibility of implementation considering the status quo.

More flexible retention strategies are needed to retain midwives as opposed to the currently implemented policy in Gauteng Province. To retain midwives, the relevant stakeholders need to create opportunities where midwives could share their feelings and be reassured of the support from management.

The research findings reveal that many students do not choose to practise as midwives because of fear of litigation. The training institutions should conduct a situational analysis not only looking at the availability of material resources and patients, but the human resources, in order to safeguard the welfare and training of students. Further study is therefore recommended in investigating the impact of excessive use of overtime hours on shortage of staff and the quality of midwifery care.

Midwives are at the forefront of maternity services and need to be perceived by managers of hospitals as such. It is evident that lack of supervisory support affects midwives’ decision to remain or leave the profession. Positive feedback and constructive criticism is important in the development of midwives in their profession. Provision of material and human resources including a good working environment is essential in ensuring the provision of quality services to women and to avoid litigation. Despite the fact that midwifery is included in the four-year course leading to the registration as nurse (general, community and psychiatry) and midwife, it still remains a scarce skill as many after registration do not volunteer to practise as midwives. To attract and retain midwives continues to be a battle which needs collaborative efforts.