Turnover Intention and Associated Factors Among Midwives in Jimma, Southwest Ethiopia

Introduction

Turnover intention is a measurement of employees’ plans to leave their positions (voluntary) or whether that organization plans to remove employees from positions (involuntary) or to give up the profession altogether.^1,2 Midwives, as a part of the health-care team, play remarkable role in providing health to women, newborns, families and societies.²

In Africa, health system clinical staff are currently faced with weak institutional frameworks and distortive incentive structures, ineffective management practices and adverse work environments.^2,3 According to World Health Organization (WHO), Ethiopia had designated as having a “critical” health workforce shortage characterized by an absolute shortage and “brain drain” of health workers to more developed countries that offer better compensation.⁴

A shortage of midwives poses a serious obstacle to increasing skilled midwifery care in Ethiopia and, consequently, to improving maternal and newborn health outcomes.⁵

In many low-resource countries including Ethiopia, women and babies are dying because of a severe shortage of qualified midwives, and the shortage has worsened due to poor working conditions in ill-equipped facilities, low salaries, and the lack of supervision and opportunities for career advancement. Midwives remain relatively invisible and marginalized in health-care policy decision-making.⁶

This situation has led to numerous midwives being overburdened by heavy workloads to seek better opportunities in cities and other countries.^5–7 Literature revealed on reasons that midwives turned on their duty because of not happy with staffing levels at work (52%), the quality of care (48%), the workload (39%), the support from their manager (35%) and working conditions (32%).⁸ Another study conducted in United Kingdom revealed that 66.6% had reported turnover intention due to dissatisfaction levels at work and quality of care.⁹ Additionally, study conducted in developing regions of Ethiopia, such as: The Afar Regional State, Benishangul-Gumuz Regional State, Gambella Regional State, and Somali Regional State revealed that 39% of midwives intended to leave their current position and job satisfaction was listed as one factor for intention to leave.¹⁰

In addition, although turnover research has been conducted on nurses in Ethiopia,^11,12 very little research has examined turnover intention among midwives. The correct prediction of intended turnover enables employers and policy makers alike to intervene and thus preventing actual turnover¹³ and determining the likelihood of staff leaving the organization helps to find opportunities to reduce overall actual turnover.¹⁴ Research that analyzes the turnover intention among midwives in southwest Ethiopia is scarce, only one study is based on all health professionals in southwest Ethiopia, of which only 13% midwives participated.¹⁵ Therefore, this study aimed to determine turnover intention and its associated factors among midwives working in Jimma, southwest Ethiopia. This information could help to design useful policies to improve midwives’ attrition, and intention to leave, and reduce midwives displacement in Ethiopia.

Methods and Materials

Study Area and Period

This study was conducted from May 19/2022 to June 6/2022. Jimma town is located in the Jimma zone, Oromia region, in the southwestern part of Ethiopia, approximately 354km from Addis Ababa, the capital city of Ethiopia. The town has four public health, and two public hospitals. Minimum of four and maximum of seven midwives were found in each health center, whereas more than 100 midwives were found in Jimma university medical center, and around 20 midwives were found in Shenen-gibe general hospital.

Study design: An institutional-based cross-sectional study was among midwives working in public health institutions in Jimma, southwest Ethiopia.

Study Participants

All midwives working in Jimma town public health institutions were the source population. All selected midwives working in Jimma town public health institutions were the study participants.

Eligibility Criteria

Full-time midwives working in public health institutions in Jimma town were included and midwives with less than six months of work experience during the data collection period were excluded.

Sample Size Determination

To determine the sample size and representativeness of the target population, the study used the Yemane (1967) formula:

= 109.62≈110, after adding a non-response rate of 10% (11) =121

Where: n = Sample size, N = Population size, e = Precession rate and 1-n = 1–95%.

Sampling Techniques and Procedure

Study participants were selected using a simple random sampling technique with lottery methods and assigning numbers generated by a computerized method (excel). The sample size was distributed to each study site using proportional allocation and the following formula:

Where Ni = sample size N = total population of midwives and Ni = total population of midwives at each public health facility. Finally, Eighty-eight from Jimma Medical Center, fourteen midwives from Shenen-Gibe Hospital, six midwives from Jimma Health Center, five midwives from higher-two health center, four midwives from Bocho-bore Health Center and four midwives from Mendara-Kochi Health Center.

Data Collection Instrument and Quality Control

After reviewing previous studies,^16–19 a questionnaire was adapted to address the objectives of the study. To ensure the quality of the data, the tool was prepared in English and then the reliability and validity of the instrument were checked using Cronbach alphas’ (0.75) and subject expertise (public health nursing). A pre-test was done on 5% of the total sample size in another health center. Modifications such as wording, rephrasing, adding and deleting some information for clarity were made to the tool accordingly. Data collectors and supervisors were trained in the data collection process for one day. Data were checked for completeness and consistency of the information provided by the principal investigator.

Study Variables

Dependent Variable

Turnover intention among midwives.

Independent Variables

Socio-Demographic/Personal Background Variables

Age, sex, marital status, level of education, year of experience, monthly salary, year of education and family arrangement.

Health Facility-Related Factors/Service-Related Factors

Working department/unit, current position in the organization, types of organization (hospital/health center) and workload.

Midwives Job Satisfaction Related Factors Components

Benefits and payment, health-care policy and strategy, working environment, supervisor support, recognition, current workload status, performance appraisal, autonomy, training and professional development and co-workers’ relation.

Mutual Support Among Midwives

Requesting assistance and assisting colleagues, providing feedback and caution during dangerous situations.

Operational Definitions

Turnover Intention

Turnover intention is known as the organization workers’ intent or plan to leave their current workplaces/position. Three (3) questions with Likert scale items of (1) Strongly Disagree, (2) Disagree, (3) Neutral, (4) Agree and (5) Strongly agree. The number of responses was calculated and the score was considered to have turnover intention (Yes) they score greater than or equal to the mean score of the total score and did not have turnover intention (No) if they had a score less than the mean score of the total score on the scale.^13,14,20 The reliability of the tool measured using Cronbach’s was 0.75.

Job Satisfaction

These items were answered on a 5-point Likert scale with response options ranging from 1 (very dissatisfied) to 5 (very satisfied).^10,14 The reliability of the tool measured using Cronbach’s was 0.85.

Mutual Support Among Midwives

Mutual support is the providing of task aid, social support, and feedback, as required, to one or more team members’ and was measured using four questions having yes and no options. The number of responses was calculated and the score was considered there is mutual support if they had above mean score of the total score and no mutual support if they responded below the mean of the total score on scale. The reliability of the tool measured using Cronbach’s α was 0.71.

Data Processing and Analysis

After checking data completeness and consistency, the collected data were coded and entered into Epi-data version 4.4.2.1 (www.epidata.dk/download.php), exported into SPSS for cleaning and analysis. Descriptive statistics were used to generate frequency tables, graphs, and logistic regression modeling was used to estimate crude (p < 0.25) and adjusted odds ratios (p < 0.05). We used the overall level of turnover intention as the dependent/outcome. The independent variables, with a p-value less than 0.05 were considered statistically significant with the outcome variable. Data were collected anonymously to maintain confidentiality of the study participants.

Ethics Approval and Consent to Participate

An ethical clearance letter was obtained from the department of management, college of business and economics (BECO), Jimma University with Ref.No.MGMT/503/2022. Permission letters were written for all public health institutions. Verbal informed consent was acceptable and approved by Jimma University. Data were collected after obtaining written consent from the health facility medical directors after explaining the purpose of the study. Oral informed consent was obtained from all study participants (midwives). Finally, they voluntarily participated in the interviews and had the right to withdraw at any time without any penalties. All data collected from the midwives were kept strictly confidential and were used only for study purposes.

Results

This study used to measure the turnover intention among midwives to their current position, from the total sample of one hundred twenty one (121) participants; all sampled midwives of them agreed to be involved in the study and gave response rate of 100%.

Sociodemographic and Facility/Institutional Related Characteristics of Midwives

In this study, the majority (65, 53.7%) of midwives were females. The median age of the midwives was 28 with an inter-quartile range^21–25 years. The mean duration of work experience was 3.42 years. Majority (84, 69.4%) of the midwives had no alternative job opportunities. Eighty-six (71.1%) of respondents had lived far from the family members concerning to family arrangements and a significant proportion (96.7%) of the midwives had a bachelor’s degree (Table 1).

Table 1 Background and Health Facility Variables of Midwives Working in Jimma Town Public Health Institutions, Southwest Ethiopia (n=121)

Midwives Level of Job Satisfaction

In this study, the overall level of job satisfaction among midwives was approximately 56 (46.3%) which was lower than midwives having dissatisfaction with their jobs 65 (57.3%), but midwives had different levels of satisfaction for each the domains of job satisfaction such as performance appraisal, autonomy and recognition. Almost half 65 (53.7%) of midwives were satisfied with performance appraisal but only 48 (39.7%) of midwives were satisfied with their autonomy and 19 (15.7%) of midwives were satisfied on recognition of their work (Table 2).

Table 2 Level of Job Satisfaction Among Midwives Working in Jimma Town Public Health Institutions, Southwest Ethiopia (n = 121)

Turnover Intention Among Midwives

Midwives’ turnover intention was assessed using three comprehensive items. Twenty-nine (24%) of midwives often agree think about quitting their current jobs. A majority of 39 (32.2) strongly agree with the probably to look for a new job in the next year. Regarding to leave the organization, 40 (33.1%) strongly agreed that they were most likely, as they will leave the organization. The overall mean and standard deviation for turnover intention were 3.47 and 1.306, respectively (Table 3).

Table 3 Turnover Intention Among Midwives Working in Jimma Town Public Health Institutions, Southwest Ethiopia (n = 121)

Prevalence of Turnover Intention Among Midwives

The study showed that there was a significantly higher level of turnover intention 48.76% (95% CI: 39.86–57.74) among midwives (Figure 1).

Figure 1 Turnover intention among midwives working in public health institutions southwest Ethiopia (N = 121).

Mutual Support Among Midwives

Concerned about mutual support among midwives, a majority 86 (71.1%) of midwives assisted colleagues during high workloads and almost two-third 91 (75.2%) midwives requested assistance from colleagues when they felt overwhelmed. Eighty one (66.9%) of respondents were delivered Feedback between midwifery in a way that promoted positive interactions and future (Table 4).

Table 4 Mutual Support Among Midwives Working in Jimma Town Public Health Institutions, Southwest Ethiopia (n = 121)

Factors Associated with Turnover Intention Among Midwives

The relationship between the dependent and independent variables was analyzed using a logistic regression model. After checking the assumption, and fitness of the logistic regression model, variables with a significance level of <0.25 during the bivariate analysis were transferred to adjusted multivariable logistic regression. Covariates such as gender, family arrangement, marital status, perceived leadership styles, job satisfaction and presence of mutual support among midwives were significant at p-value <0.25 in bivariate analysis and were eligible for the adjusted multivariable regression analysis. From the adjusted multivariable analysis, covariates such as sex, support/teamwork and type of institution remained independent factors for turnover intention among midwives. In this study, the odds of having turnover intention were 2.9 times more likely among male midwives than among female midwives (AOR=2.9(95% CI: 1.14–7.39)). Midwives working in hospitals were less likely to have turnover intention (AOR = 0.20(95% CI: 0.06–0.70)) than among midwives working in health centers. Midwives who had mutual support such as assist colleagues during high workload, providing feedbacks, requesting assistance with health-care providers were less likely to have turnover intention 0.17 (AOR = 0.17 (95% CI: 0.07–0.44)) (Table 5).

Table 5 Results of the Bi-Variable and Multivariable Logistic Regression Analysis of Factors Associated with Turnover Intention Among Midwives in Jimma Town, Public Health Institutions, Southwest Ethiopia (n = 121)

Discussion

This cross-sectional study was conducted to determine the level of turnover intention and factors associated with midwives. The study showed that there was a significantly high level of turnover intention 48.76%(95% CI: 39.86–57.74) among midwives. This was similar to cross-sectional study conducted in Iran, where (47.7%) of participants had turnover intention.²⁶

This was lower than a longitudinal study conducted in Senegal, where nearly two-thirds (58.9%) of midwives reported turnover intention.²⁷ The study in Senegal was a longitudinal study to examine the effects of midwives’ job satisfaction on turnover and had different socio-demographic populations, time lengths or study designs (linear regression). However, the results of our study were higher than those studies conducted in developing regions of Ethiopia,¹⁰ where 39% had turnover intention. Again, this may represent different study areas and populations (107 participants), using mixed data sources (qualitative and quantitative).

In addition, this study revealed that being male is associated with turnover intention among midwives. Turnover intention was 2.9 times more likely among male midwives than among female midwives (AOR=2.9(95% CI: 1.14–7.39)). This was supported by a study conducted in the Health Centers of Yeka Sub City, Addis Ababa, Ethiopia²⁸ North Shoa Zone, Amhara Region, Ethiopia²⁹ and hospitals in Iraq.³⁰ However, this was in contrast to studies conducted in health facilities, Kafa Zone, Southwest Ethiopia,²¹ Faith-Based Hospitals in Uganda²² and Indonesia.²³ Even though additional studies may be required to explain the relationship between sex/gender and turning over intention, evidence shows that gender has a significant impact on turnover and it is commonly heard that females are more satisfied than male in the workplace,^24,25 therefore they are less likely to plan leaving.

In this study, midwives working in hospitals were less likely to have turnover intention (AOR = 0.20(95% CI: 0.06–0.70)) than midwives working in health centers. This may be because of midwives in health centers may have an excessive workload and lack of mutual support, since they are small in numbers (4–7 midwives per health center) and may want to change to hospitals.

In this study, midwives perceived teamwork and mutual support were less likely to had turnover intention than their counterparts, which was supported by a study conducted in Ontario, Canada.³¹ This is because when midwives perceive low/poor teamwork and mutual support, they are more likely to report higher turnover intentions, and mutual support affects their well-being and helps to foster healthy work environments that contribute to retention.³² Also, low mutual support and teamwork may lead to a high probability of burnout, which may end up with intention to leave.

Limitation of the Study

The scope of this study was limited because only midwives at government-owned public health facility were sampled excluding midwives from private health institutions within the area. Being quantitative study rather than a mixed study method that could have generated better results could be considered as limitation. Social desirability bias also could be one limitation.

Conclusions and Recommendations

Overall, the turnover intention among midwives working in public health institutions Jimma town is high. Gender, teamwork and type of institution are factors associated with turnover intention. Therefore, public health organizations should review their maternity staff to establish teamwork and mutual support. Health centers administrators should modify their leadership and management practices, support midwives, and increase their workforce to lower turnover intention and displacement from health center to hospital.