Burnout is a common symptom occurring among health professionals, and midwives are unfortunately not an exception. The emotionally and physically exhausting work of midwives, i.e. providing support for women at the edge of their capacities is highly demanding. Large amounts of stress and high workloads contribute to high levels of exhaustion. It is difficult to live up to the tasks of the often conflicting principles of the hospital requirements and to be capable of building a trusting relationship with women during the birth process at the same time. There have been changes in midwifery during the past decades, which resulted in somewhat different tasks and methods in providing care. One reason might be that in many institutions technology has replaced midwifery skills carried out for centuries by midwives during births. The continuous change of the profession requirements might cause stress in the job. The latter, among other important factors, may cause midwives experiencing lower job satisfaction and burnout.

Burnout is defined as a syndrome of psychological problems arising as a result of work stress, mostly experienced by people working in healing and caring professions. According to Maslach and Jackson it can be described through three factors: emotional exhaustion, depersonalization and reduced personal accomplishment (1). The factor of emotional exhaustion refers to the feelings of being overextended and exhausted in an emotional sense. In connection with exhaustion the people experiencing burnout start to feel depersonalized from the people they work with. Depersonalization can be understood both as depersonalization of patients and of self, however. It manifests through general dislike, and a detached and callous – even dehumanized – attitude towards clients, who are perceived as energy drains or stressors. Being depersonalized of one’s self is connected to the last factor of reduced personal accomplishment. It is the negative self-perception of one’s competence and dissatisfaction with achievements at work. The Maslach Burnout Inventory (MBI) measures burnout using the aforementioned subscales.

Various studies have been conducted in search for the factors which may influence midwives’ experienced stress and burnout. High workloads, lack of resources and low autonomy when caring for women appear to be among the most influential factors. In a study made in UK community midwifes and hospital midwives were compared regarding burnout (2). The Maslach Burnout Inventory showed high levels of emotional exhaustion among hospital midwives. The protective factors for community midwives were working in a team, working flexi-time and the supportive management. For higher burnout levels among hospital midwives low autonomy, role conflicts, high workloads, and bullying from colleagues and clients were signalled. Three key factors in order to stay with the job were: autonomy in occupation, social support and development of meaningful relationships with women. Unfortunately, the model of continuous midwifery care does not match the Hungarian way of care. It is separated into two professions: the midwife might have the contact with the pregnant women a few weeks before the birth term, but usually focuses on the actual birth event. The antenatal and postnatal visits at home are carried out by a special protective child’s nurse. Another study measured burnout among Swedish midwives and additionally raised the question of how satisfied midwives were in their profession and whether they have thought of leaving their profession (3). Burnout was measured using the Copenhagen Burnout Inventory (CBI), which is developed as an alternative inventory to the MBI. This inventory consists of three subscales: personal burnout, work burnout and client burnout. Personal burnout was found to be relatively high, nearly 40%, while the other two subscales were around 15%. Lack of staff and resources and stressful work environment were associated with burnout. Nearly one third of midwives have reported to have considered leaving their work. Additionally, the same study raises an important notion that however exhausting the type of emotional care might be, the trusting relationship with mothers appears to be rewarding for midwives. This proves to be an essential factor to stick with the job. Research done in Australia shows a somewhat similar pattern (4). The study made by Jordan and colleagues tried to determine the level of midwives’ burnout and the contributing and protective factors which might have an effect on burnout. Burnout was measured with CBI, and results show high burnout levels on the personal and work-related scale, but low levels on the patient-related scale. This probably means that midwives find it less stressful when they actually care for the women. Although we know how important the empathetic care midwives provide during supporting women during birth is (5, 6), midwives often find themselves caught in the middle between two, often contradictory roles; their role of a woman-centred caregiver and the role of a hospital worker. Another Australian study suggests that in today’s woman-focused care-giving, midwives themselves should be taken care of as well (7). In hospitals demand is escalating to do more work with less and less resources. They state that the ‘moral distress’ midwives experience when doing their job is very high, because there is always the dilemma of being able to provide affectionate, reassuring, gentle care where women feel empowered and safe arising from the relationship with women and, on the other hand, to be able to obey the sometimes impersonal hospital practice and rules where monitoring and various interventions are ‘overused’. The continuous shortages of skilled birth midwives cause a problem as well.

Another common finding is that the midwives’ age and the years of experience within the profession are negatively correlated with burnout (3, 4). This means that increasing age and years spent in the profession are usually associated with lower burnout scores. Jordan et al. have come to the conclusion that midwives younger than 35 were 2.4 times more likely to suffer from burnout than participants over 35 years of age (4). In the same study other personal variables found to be associated with burnout levels were being single and having no children. Participants with more than 10 years spent in the profession scored high in the personal, work and client domains of the CBI. Interestingly, midwives who have spent more than 20 years in the profession scored high in the first two domains, but no one was identified as suffering from burnout in the client domain. Midwives who were not having any recreation leave or sick leave within the previous three months before the date of the study were 2.5 more likely to experience burnout. A possible explanation for less midwives experiencing burnout might be that caregivers over 35 might have gained more competency and practical skills through the large amount of various experiences, which might help them overcome stress more effectively (8). Lipiennè et al. previous study on the topic does not verify this in the Hungarian context (9). We have measured burnout in the Hungarian midwife population using the Maslach Burnout Inventory. Regarding the various factors of burnout, midwives scored high on the MBI, namely 23% on the emotional exhaustion scale and 33% on the depersonalisation scale. The highest percentage (36%) was found on the reduced personal accomplishment scale. In other words, it can be stated that nearly every third midwife in Hungary experiences high burnout. Furthermore, we were interested to see whether there is connection between the age of midwives and the burnout scores. According to our findings the MBI burnout scores were not related to age, burnout appeared to be equally strong among midwives of all age groups.

Fear of litigation is also a stressor that has been linked to burnout and midwives’ well-being (10). As Lipiennè et al. suggest in their earlier article, midwives in Hungary probably have lower responsibility while providing care compared to many other countries (9). Usually all interventions are carried out by doctors, or under their supervision, even the anaesthetic and analgesic measures. At the same time, midwives are usually in charge to estimate when the time comes to call the gynaecologist doctor. Due to these differences the fear of litigation contributes to a lower extent to the stress encountered at work. On the other hand, according to research, lower autonomy at work contributes to experience burnout (2).

As previously stated, burnout is most common with health professionals and professions which require high levels of community engagement. As a result, people are more likely to suffer from any health related problems (11). Professionals working in the health sector are usually expected to be able to cope with the challenges of the daily work of caring for patients. Hunter suggests that the high level emotional work provided by midwives stays professionally unacknowledged and this is a key element which might make them internalise the negative emotions from any source as their own personal dilemmas and failings (12). A Dutch study measured burnout among community midwives who, according to the Dutch model, provide care during births at the home of women in up to 50 percent of their cases (13). According to the findings of the study, midwives who carried out a higher percentage of home births showed lower depersonalisation on the MBI scale. This was associated with those who have more passive coping styles, however. Another important finding of the study is that midwives receiving more social support were less emotionally exhausted and depersonalised, and felt higher personal accomplishment. Social support between people is present when a human being recognises another person’s identity, values that person and sometimes even helps him or her. In other words, it is the perceived support from significant others. According to this, midwives shall cope better with the high workloads and other problematic issues when they feel supported by their colleagues. In research done by Mollart et al., if we take a closer look at the personal accomplishment factor of the MBI, midwives who worked in mixed day and night shift had the lowest feelings of personal accomplishment (8). This has shown to have an impact on their belief to deal effectively with clients’ problems. Those having only night duty felt at least that they have the capacity to positively influence other people through their work. The same group scored poorly on the depersonalisation scale, stating that they ‘do not really care’ what happens to clients. This is contradictory to the type of empathetic and compassionate care, which is a key element of the midwifery profession.

Research has been conducted to identify the type of health-related aspects of the midwives’ profession. Work-related stress and the possibility for vicarious trauma are relevant issues which need to be dealt with. In a Slovak study trying to determine the most common stressors Banovcinova and Baskova have found that death and dying of patients were reported as the most stressful factor (14). The next most influential stressing factor was conflict with a superior, usually a doctor, whereas the conflict with co-workers was perceived as contributing only to a lower extent to work stress. Stressors might have alternative sources in the work environment. As part of an initiative, midwives who provide continuous care in some local health services in Australia and the United Kingdom, were given the task to screen mothers for potential psychosocial risks, such as domestic violence, depression and child protection issues at the first antenatal visit (11, 15, 16). Midwives have reported difficulties coping with issues which have arisen. They felt helpless, not being able to offer effective help, and high emotional stress was experienced. Professional supervision which, unfortunately, was not offered simultaneously would have been necessary to overcome this high emotional impact. Mollart et al., investigating the impact of structured antenatal psychosocial assessment on midwives’ emotional wellbeing, who carried out focus group interviews discovered that midwives have difficulty handling the disclosure of trauma, and lack ability to manage their own emotion (11). Midwives in Hungary do not provide care at antenatal visits, since this is arranged by the protective child’s nurse of the district, where the mother lives. Midwives usually meet the pregnant women in the hospital or another consulting-room only a few times for fetal non-stress test (NST) before the actual date of birth. Despite that, midwives are usually well aware of women’s fears and of the potential trauma which mothers experienced during a previous birth. They have to keep all this in mind when supporting birthing mothers. Dealing with traumatic birth events as stressors may need to be acknowledged by the management at each birth unit.

This study is part of a broader study trying to determine the burnout level of the Hungarian midwife population and to reveal whether it can be matched with any socio-demographic data and other health-related issues (9). The current study aims to investigate the satisfaction level of midwives, along with how overloaded they feel in their work. Additionally, we are interested in the level of appreciation midwives perceive during their care for women. Furthermore, we would like to see whether levels of satisfaction, feelings of work overload and perceived appreciation can be matched with the burnout scores.

Midwives in our study were given a questionnaire, which consisted of three sections. The first was collecting socio-demographic data, the second was gathering information regarding health-related issues and how midwives feel in their profession when providing care to women. The final part was the Maslach Burnout Inventory (MBI). As stated above, as burnout is a complex phenomenon, the MBI measures it using three subscales, which are: emotional exhaustion, depersonalisation and personal accomplishment. Answering each question respondents had to give two scores for each; one being the frequency of a certain event perceived, the other the intensity of a particular feeling. Additionally, for the purpose of our current study we analysed the answers given to the questions assessing job satisfaction, workload and appreciation. For example, regarding workload the question sounded: ‘How often do you feel overloaded?’, and the other two were: ‘How satisfied/appreciated do you feel in your profession?’. Participants were asked to give their answers on a 4-point scale in the first (from ‘always’ to ‘never’), and on a 5-point scale in the latter two questions (from ‘fully’ to ‘not at all’). Data were analysed using the SPSS.

Participants were recruited from many hospitals and clinics across Hungary. We paid close attention that an almost equal number of questionnaires were given out in the capital city of Budapest and other hospitals across the country. Of the 500 distributed questionnaires, 283 were completed and returned. The response rate was 56.6%. Finally, 275 questionnaires were analysed, because another 8 had to be eliminated due to missing data. Midwives stayed anonymous throughout the study as only non-identifiable data were collected. If the midwife completed and returned the questionnaire, we regarded this as their consent to taking part in the study.

Our analysis first aimed to reveal how the participants scored on the various factor scales of the Maslach Burnout Inventory. The mean value of the emotional exhaustion factor was the highest: 28.42 (SD = 13.16), which was followed by the factor of reduced personal accomplishment (M = 20.41 and SD = 11.08) and the factor of depersonalization (M = 8.34 and SD = 6.48) (fig. 1). Midwives in our study appear to be mainly affected by emotional exhaustion in their profession.

Analyzing the satisfaction level of the midwifes participating in the study, we have found that almost two thirds (65.9%) of the sample was satisfied either ‘mostly’ or ‘fully’ (mostly 44.9%, fully 21.0%), while 25% was ‘moderately’ satisfied with the profession (fig. 2). The cumulative percentage of the ‘not at all’ satisfied and ‘slightly’ satisfied group was 9.2%. We can deduct that every tenth midwife in our sample is not content with her profession.

The next important characteristic we aimed to reveal in our study was how appreciated midwives felt in their profession. The largest percentage of midwives signalled to be only ‘slightly’ appreciated (31.1%), while another 30% to be ‘moderately’ appreciated (fig. 3). The cumulative percentage of the ‘mostly’ and ‘fully’ appreciated participants was 25.3%, indicating that only every fourth midwife in our study felt appreciated in their everyday work. 13.6% indicated to be ‘not at all’ appreciated.

The last characteristic we wanted to determine was the level of work overload our respondents perceived. They could indicate their answers on a 4-point Likert scale, ranging from ‘never’ to ‘always’. 11.6% felt ‘always’ and another 57.5% ‘often’ overloaded, which means that more than two-thirds of midwives felt regularly overloaded (fig. 4). 29.8% perceived ‘rarely’ and only 1.1% indicated ‘never’ to be overloaded during work.

We measured the relationship between burnout and various work characteristics (overload, satisfaction and appreciation) using the Spearman’s rho values. The factor of emotional exhaustion seemed to have the strongest relationship with all three perceived work characteristics (tab. 1). The correlation coefficients were: regarding satisfaction r = -.450, work overload r = .410, appreciation r = -.367, respectively. A strong relationship was detected between the factor of depersonalization and satisfaction, appreciation and work overload (r = -.385, r = -.259, r = .238, respectively). The reduced personal accomplishment factor of the MBI seemed to have the weakest relationship to the work characteristics, although correlation was strong with satisfaction (r = -.322).

As the last step of our analysis we aimed to reveal the relationship of the various work-related features with one another. Our results are shown in table 2. The relationship was strongest between satisfaction and appreciation in profession (r = .333), which was followed by the relationship between satisfaction and work overload (r = -.246), indicating that the more midwives perceived themselves as overloaded at work, the less they were satisfied with their profession. The correlation coefficient was the lowest (r = -.149) between work overload and appreciation.

Although the largest number of midwives in our sample was satisfied, only every fourth midwife felt appreciated in her everyday work. We can conclude that midwifery as a profession requires a lot of qualified work and mastery, but midwives still seem to be dedicated, even if they do not perceive enough appreciation. The large amounts of work they need to keep up with might take its toll on their wellbeing, resulting in feelings of burnout. Regarding the relationship between MBI scores and the work characteristics, the level of satisfaction can be best associated with the MBI factors. Our sample proved to be mostly emotionally exhausted, which correlated positively with the large workloads, and negatively with satisfaction and appreciation. We have found a strong relationship between satisfaction and appreciation at work, but the connection between work overload and appreciation was the weakest among all, showing that participants do not necessarily feel more appreciated if they work more.

The main finding of our study is that satisfaction and appreciation are relevant matters for the midwives studied. If they feel appreciated and supported by birthing women and their families they provide care for and the relevant other colleagues, they are less prone to experience burnout, and they deal better with higher workloads and special issues arising. We might assume that midwives working in hospitals in Hungary can ventilate their emotional and physical difficulties with other midwives, and find the social support they need (13).

Another important notion is that when women choose midwifery as a profession, they have an overly idealistic image of the profession and are usually unconscious of the fact that there are, unfortunately, many cases of negative events around birth as well. We as educators at the health science faculty of our university see that first-year midwifery students largely focus only on the positive events and outcomes around birth. This is the primary motivation for them in wanting to become a midwife. At the time when they start taking their practical lessons, they experience a type of vicarious trauma and compassion fatigue, when facing births with an unpreferred outcome. Courses shall be offered to midwifery students during their university years to mentally prepare for dealing with possible birth trauma later in their job. Henceforth, as professional midwives they should always be given a choice of clinical supervision to cope with the tensions arising in everyday work in a healthy way. Besides, dealing with traumatic birth events as stressors may need to be acknowledged by the management in each birth unit and implement support to minimise the risks (11, 16). Giving more autonomy at work with a diversity of clients, ongoing education, working in a team in which talking about these issues is facilitated and clinical supervision should be offered in health area services to minimise the trauma attached to the daily work of midwives. The model with the possibility to build longitudinal relationships with women in continuity of care and having more autonomy in providing care have been found to be advantageous for midwives regarding burnout. Almost two years ago continuity of care was partially introduced in Hungary, namely, compulsory antenatal visits at the gynaecologists can be substituted by visits at a registered midwife if there are no complications during pregnancy. Although it is said to be difficult to make this process of reorganisation in every-day practice, once it is done, it should be regarded as a good opportunity for midwives to be more autonomous in their work, which might contribute to their increased well-being and satisfaction. Furthermore, from our study we can conclude that burnout is a complex phenomenon, which requires further exploration to decipher what exactly has led to our results regarding burnout, satisfaction and appreciation experienced in our sample.

Considering it as a strength of our study, a rather large proportion of midwives took part in our research, compared to the Hungarian population of midwives. We shall keep in mind that the results are true for our sample of midwives however, and we should be cautious with generalising them to the whole midwife population. Our study attempted to raise awareness of the fact that the emotional aspects of midwives’ work should to be kept in focus at an institutional and educational level. Although it is emotionally exhausting to develop meaningful relationships with women, at the same time, these relationships along with appreciation of the midwives’ work seem to be important factors for staying in the profession. Seeing how essential midwives’ work is to birthing women and their families, midwives themselves should be taken care of as well, and shall be motivated to stay with their job.