The Effect of Leadership Style on Midwives’ Performance, Southwest, Ethiopia

Introduction

Healthcare is an important aspect of human business as it participates in every one and provides the need for every individual born and unborn, for a healthy life.¹ In healthcare organizations, human resources are the most important assets and midwives comprise the largest workforce.²

African health systems are challenging because of staff shortages and health professionals are currently faced with weak organizational frameworks and in effective management and support.³ The World Health Organization (WHO) has classified Ethiopia as having a shortage of trained/qualified health workforce working in health care organizations.⁴

Leadership is the art of influencing followers so that they will work towards the achievement of specific goals and the achievement of organizational goals can only happen if leaders are able to manage their human resources in their organization including in health institutions.^5,6 There are different leadership styles in every organization and each style has its own positive and negative effects on workers’ performance in achieving organizational goals: such as autocratic, democratic and Laissez-faire leadership styles.^7–12

Studies indicate that leadership styles can affect employee performance both negatively and positively and have varying effects on employees and productivity.^8,13 Perceived low levels of team work, job satisfaction, support, recognition and opportunities for development among midwives can contribute to exhaustion, high turnover rate, anxiety/stress and low organizational performance and quality of care.¹⁴ Basically, the performance is what employees do or do not and is the result of work or activity functions in the form of behavior and outcome of behavior.¹⁵

Maternity and child health care improvement activities can be effective if equal and continuous focus is given to support the midwifery workforce.¹⁶ Promoting emotionally active midwifery supervisors, heads, leaders and managers is helpful in supporting the provision of high quality, compassionate, respectful care and has implications for maintaining high standards of care or practice.¹⁷

The leadership of midwifes’ leaders, managers, heads and supervisors has been reported as missing the necessary skills to midwives effectively, although midwives trying to provide holistic care to improve outcomes for women and newborns up to now.¹⁸ In Ethiopia, there is no published evidence of the effects of different leadership styles on midwives’ performance. Therefore, this study aimed to determine which type of leadership style is dominant in practice and assess the effect of each leadership style on performance among midwives working in Jimma, south west Ethiopia.

Methods and Materials

Study Area and Period

The study was conducted at public health institutions in Jimma Town. Jimma Town is in the Jimma zone, in the southwestern part of Ethiopia, and is approximately 352km from Addis Ababa. The town has four public health centers (Mendrakoch Health center, higher-second Health centers, Jimma Health center, and Bechobore Health center), and two public hospitals (Jimma University medical center and Shenen gibe hospital). In each Health center, there were 4–7 midwives, more than hundred midwives were found in Jimma medical center, and around twenty midwives were found in shenen gibe general hospital. Data were collected from May 19/2022-June to 6/2022.

Study Design

An institution-based cross-sectional study was conducted.

Population and Eligibility Criteria

Source Population

The source populations for this study were all midwives working in the JimmaTown public health institutions.

Study Population

All sampled midwives working in the Jimma Town public health institutions were considered.

Eligibility Criteria

Only permanent midwifery professionals who provide care were included in this study.

Exclusion Criteria

Temporary midwives/less than 6 months and heads/managers were excluded.

Sample Size Determination

The study used Yemane (1967) formula to determine the sample size research:

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

Sampling Techniques and Procedure

A simple random sampling technique was used to assign the numbers generated using a computerized method (excel). And proportional allocation, using the formula: Finally, 88 from Jimma medical center, 14 from shenen-gibe hospital, 6 from Jimma health center, 5 from higher-two health center, 4 from Bocho-bore health center and 4 midwives from Mendara-Kochi health center were taken which was a total of 121 midwives.

Study Variables

Dependent Variable

Midwives’ performance.

Independent Variables

Three leadership styles: autocratic, democratic and laissez-faire.

Operational Definitions

Midwife

A person with diploma, BSc. and MSc. for midwifery and currently practicing midwifery.¹⁹

Midwifery Performance

Overall midwives’ performance was measured using thirteen.¹³ Likert scale items with scores of (1–5); (1) strongly disagree, (2) disagree, (3) neutral, (4) agree and (5) strongly agree items, six (6) items were about achieving an organizational goal, three (3) items were about customer satisfaction and four (4) items were about teamwork in organizational performance.

Leadership Style

In this study leadership style is a leader, manager, head, supervisor practice and attitude toward leading, managing, and supervising midwives,¹¹ and is measured using Likert scale items of strongly disagree (1), disagree (2), neutral (3), agree (4) and strongly agree (5).

Data Collection Questionnaires and Data Quality Control

The questionnaire was adapted from published and unpublished literature^20–25 to address the objectives of the study and was prepared in English. Data were collected by distributing questionnaires consisting of information on socio-demographics, leadership styles and midwives’ performance to each participant (self-administered) (please refer to questioner support data under the Supplementary Material).

Different measures were taken to ensure the data quality. The validity and reliability of the instrument were assessed using subject expertise (public health, midwifery, health services and human resource management) and Cronbach’s alpha method (Table 1), respectively.

Table 1 Reliability Test for the Questioner to Determine the Effects of Leadership Style Midwives’ Performance, May/2022

To identify any inconsistencies in the instrument, pretesting of the tool was performed on 5% of the total sample of midwives who were not included in the study and some modifications such as wording, rephrasing, adding and deleting some information were made accordingly. Data collectors and supervisors were trained on how to collect and supervise data. The principal investigator checked the questionnaires on a daily basis.

Data Processing, Analysis and Presentation

Collected data were coded and entered into Epi-data version 4.4.2.1, for cleaning and editing and exported into SPSS version 24 for analysis. Multicollinearity and normality were checked using the variance inflation factor (VIF) and correlation analysis. Descriptive statistics such as frequency tables and statements were used to present the results.

Percentages, means, standard deviations and frequencies are reported using descriptive statistics. The relationship between the dependent variables (midwives’ performance) and the independent variables (autocratic, democratic and laissez faire leadership styles) was determined using Pearson’s correlation coefficient (r). To evaluate the effects of the independent variables on midwives’ performance (dependent variable) a one-way ANOVAand multiple regressions were performed.

Ethics Approval

An ethical clearance letter was obtained from the department review committee of Jimma University, college of business and economics, department of management with Ref. NO. MGMT/503/22. Permission letters were written for each institution. Data were collected after obtaining consent from each health institution’s administrator.

All participants were informed about the purpose of the study, were asked their permission before data collection and the ethics committee approved the verbal consent process. To ensure the confidentiality of the information, the names of the participants were not written in any part of the questionnaire. All methods in the study were performed in accordance with the declaration of Helsinki as a statement of ethical principles for medical research involving human subjects.

Results

All (121) midwives participated in this study, with a response rate of 100%.

Sociodemographic Characteristics of the Midwives

Of the total participants, 53.7% were female. The majorities (57.9%) of the participants had an age category of 26–30 and median age of 28 years. Most of the participants (67.8%) were married (Table 2).

Table 2 Background Information of Midwives Working in Public Health Institutions in Jimma Town, May/2022

Midwives Perceptions About Their Supervisors/Coordinators Leadership Style

Autocratic Leadership Styles

The autocratic leadership examined using the five items had a registered and over all mean value of 2.996 and standard deviation of 1.39 (Table 3).

Table 3 Autocratic Leadership Style Among Midwifery Leaders Working Jimma Town, May /2022

Democratic Leadership Style

In this study, democratic leadership style had a pooled mean value and standard deviation of 2.632 and 1.6, respectively (Table 4).

Table 4 Democratic Leadership Style Among Midwifery Managers Working in Jimma Town, May/22

Laissez-Faire Leadership Style

In this study, the Laissez-faire leadership style accounted for approximately 2.49 mean and 1.047 standard deviations, respectively (Table 5).

Table 5 Lassie-Faire Leadership Style Among Midwifery Managers Working in Jimma Town, May/22

Result Summary

The findings of this study revealed that autocratic leadership was the first leadership style perceived by most midwives to be in practice by their managers followed by democratic and Laissez-faire leadership styles among midwives working in Jimma Town public Health institutions (Table 6).

Table 6 Types of Leadership Style Practiced in Jimma Town Public Health Institutions, May/22

Relation of Autocratic Leadership Style and Midwives’ Performance

This study indicates a negative relationship between autocratic leadership style and midwives’ performance (r=−.352**, n=121, p=0.000) (Table 7).

Table 7 The Relationship Between the Autocratic Leadership Style and Midwives’ Performance, May/22

The Correlation Between Democratic Leadership Style and Performance of Midwives

There was a positive correlation between democratic leadership style and midwives’ performance (Pearson’s Correlation r=0.544**, N=121 and p=0.00) (Table 8).

Table 8 The Correlation Between Democratic Leadership Style and Midwives’ Performance May/22

The Correlation Between Laissez-Faire Leadership Style and Midwives’ Performance

In this study, there was a positive correlation between midwives’ performance and the Laissez-faire leadership style (r=0.628**, n=121, p=0.000) (Table 9).

Table 9 The Correlation Between Laissez-Faire Leadership Style and Midwives’ Performance, May/22

Summary of Correlation Between Leadership Styles and Midwives’ Performance

In this study, there was a negative relationship between autocratic leadership style and midwives’ performance, whereas there was a positive relationship between democratic, Laissez-faire leadership styles and midwives’ performance (Table 10).

Table 10 Summary of Correlation Between Leadership Styles and Midwives’ Performance May/22

Model Summary

In this study, according to the table below, the amount of variation explained by independent variables on midwives’ performance is adjusted R square=0.431 or 43.1%. This indicates that approximately 43.1% of midwives’ performance was affected by leadership style (Table 11).

Table 11 Model Summary Among Dependent and Independent Variable, May/22

Analysis of Variance (ANOVA) for Midwives’ Performance

The ANOVA results showed that the acceptability of the proposed model at p =0.000 was less than 0.05 which indicating that the overall variation was good and significant (Table 12).

Table 12 Analysis of Variance (ANOVA) for Midwives Performance, May/22

Multiple Linear Regression Results

In this study, based on the multiple linear regression results, democratic and Laissez faire leadership had a positive effect on midwives’ performance with significance values of (P=0.012) and (p=0.000), respectively, while autocratic leadership had no significant relation with midwives’ performance with a non-significance level of 0.060 lower than 0.05. Therefore, an autocratic leadership style had a negative effect on midwives’ performance (Table 13).

Table 13 Multiple Linear Regression Between Leader Ship Style and Midwives’ Performance Result, May/22

Discussion

In this study, autocratic leadership (mean=2.996 and SD =1.39) was the most prevalent leadership style followed by democratic leadership (mean=2.632 and SD =1.6), which was in line with the studies conducted in the Nigerian Oil and Gas Industry.⁸ However, this finding was opposite to that of a study conducted among nurses in Libya, Benghazi Medical Center,²⁰ which indicated that democratic leadership style was the most dominant practice in the hospital, followed by autocratic and laissez-faire leadership styles. This discrepancy may be because of differences in the study participants (nurses and midwives), and study areas (Libya and Ethiopia).

Democratic and laissez-faire leadership styles had a positive effect on midwives’ performance, which is supported by studies conducted in Nigeria,⁸ and Malaysia.^21,26 This may be because participation, inclusive and decentralized nature are characteristics of the two leadership styles. Democratic and laissez-faire leadership practices foster cooperation and trust using emotional support, by creating a healthy work environment that increases employee performance including midwives and other health care workers. Effective leadership of healthcare professionals is critical for strengthening the quality and integration of care.²²

An autocratic leadership style was negatively related to midwives’ performance, which was supported by a study conducted in Malaysia.²⁶ The study concluded that there is a significant relationship between leadership style and midwives’ performance; which is supported by systematic reviews.^22,23

In addition, the results of this study show that there are positive and negative aspects of each leadership style and that beneficial outcome for the health system can be achieved by using the most suitable leadership style for the given context.

Conclusion and Recommendation

The results of this study revealed that the autocratic leadership style is the most practiced leadership styles among midwifery managers showing that midwives’ perceptions of their leaders are exercising an autocratic leadership style. There was a significant relationship between leadership style and midwives’ performance. An autocratic leadership style was negatively correlated with midwives’ performance, whereas democratic and laissez faire styles had positive correlation.

Democratic and laissez faire leadership styles had a significant/positive effect on midwives’ performance, but autocratic leadership style had negative effect on midwives' performance. In respect of this conclusion, the health care leaders/heads/supervisors including midwives’ leaders should apply their responsibility with democratic and laissez faire leadership style.

The researcher also reminded that the most appropriate leadership styles are democratic and laissez faire especially in health care institutions that work on human lives; midwives need to be free and actively participate in every activity to increase organizational teamwork, customer satisfaction and organizational goal achievement. Finally, future researchers should consider both qualitative and quantitative data collection on representative sample sizes with the inclusion of leaders.

Limitation of the Study

The study only used quantitative data from employees/midwives for analysis and did not include health care leaders and supervisors’ opinions. As this study was conducted only on midwives working in public health institutions, it may not be generalizable.