A qualitative study of contributing factors to burnout among Jordanian midwives

Abstract

Background

The healthcare system, particularly the midwifery profession in Jordan, faces significant challenges that negatively impact midwives and the quality of maternal care, primarily due to resource limitations and increasing service demands. While quantitative research has examined burnout levels among Jordanian midwives, there is limited qualitative insight into their lived experiences, particularly in the southern region of Jordan.

Objective

This study aimed to explore the factors contributing to burnout among midwives in southern Jordan and to gain a deeper understanding of their professional experiences within the current healthcare context.

Methods

A qualitative descriptive approach was employed between 2023 and 2024. Ten midwives were purposively recruited from public hospitals and community health centers in southern Jordan. Data were collected through semi-structured, in-depth interviews and analyzed using thematic analysis. Trustworthiness was ensured using Lincoln and Guba’s criteria: confirmability, credibility, dependability, and transferability.

Results

Two main themes emerged from the analysis: 1) the emotional and physical toll of undervaluation and its negative impact on job satisfaction, and 2) limited professional autonomy and challenges related to empowerment in clinical settings. These findings reflect both personal and structural contributors to burnout.

Conclusion

Burnout among midwives in southern Jordan is driven by emotional strain, lack of recognition, and restricted autonomy. These challenges affect not only job satisfaction but also the quality of care provided. Addressing these issues through supportive policies, improved working conditions, and greater professional recognition is critical for strengthening the midwifery workforce. The findings also offer valuable insights for other countries with similar healthcare structures and midwifery challenges.

Background

In the healthcare sector, personnel well-being is closely linked to job satisfaction and motivation. When these factors decline, various psychological disorders can emerge, including burnout syndrome (Suleiman-Martos et al., 2020). Burnout is a psychological condition that results from persistent emotional and personal tension in the workplace (Mohammad et al., 2020). Commonly associated with healthcare practitioners and first responders, burnout is characterized by widespread skepticism toward one’s work, mental blockages, anxiety, fatigue, and decreased productivity (Alemu et al., 2024).

Among the various healthcare specialties, maternity care stands out as particularly crucial due to its far-reaching impact on societal health, both now and in the future (Kruk et al., 2018). Recognizing this, the International Confederation of Midwives (ICM) and the United Nations Population Fund have stressed the importance of establishing midwifery associations. These organizations play a vital role in workforce development and in advancing sexual and reproductive health and rights (Mattison et al., 2021).

Despite its importance, maternity care is a field where healthcare personnel—especially midwives—face a significantly high risk of burnout. This is largely due to the demanding nature of their work (Stoll & Gallagher, 2019). Studies indicate that burnout rates among midwives range from 20% to 40%, which is notably higher than in other healthcare professions (Alemu et al., 2024; Suleiman-Martos et al., 2020). Contributing factors include a global shortage of healthcare workers (Mengistie et al., 2024), emotionally intensive tasks, overwhelming workloads, insufficient resources in maternal health services, exposure to pain, anxiety, stress, and even workplace violence. These challenges are compounded by emotional exhaustion, inadequate compensation, and a lack of recognition, all of which intensify midwives’ experiences of burnout (Mengistie et al., 2023).

In Jordan, these issues are further magnified by systemic and structural challenges. Continuous midwifery care for individual mothers remains uncommon (Khader et al., 2018), and the growing medicalization of maternity services limits midwives’ autonomy in clinical decision-making (Mohammad et al., 2020). These limitations not only restrict midwives' professional practice but also add to their sense of disempowerment and emotional fatigue.

Empirical evidence from Jordan supports the urgent need for intervention. A study by Mohammad et al. (2020) revealed that more than three-quarters (77.5%) of Jordanian midwives experience personal burnout, as well as work- or client-related burnout at moderate to severe levels. These findings highlight the critical necessity for a national strategy to support midwives' mental health. Similarly, another study emphasized that fostering a positive and supportive work environment is essential for improving job satisfaction and retention among midwives in Jordan (Alnuaimi et al., 2020).

While existing research has addressed the prevalence and associated factors of burnout among Jordanian midwives through quantitative methods, there remains a significant gap in understanding the lived experiences of midwives—particularly in southern Jordan. To date, no qualitative studies have explored the specific factors contributing to burnout in this region. Addressing this gap, the present study aims to explore these contributing factors in depth. By doing so, it seeks to enhance our understanding of the challenges faced by midwives and to inform policies and interventions that prioritize their well-being and improve their working conditions.

This study aimed to explore the contributing factors that lead to midwife burnout in southern Jordan.

Methods

Study Design

This qualitative descriptive study explored the contributing factors leading to midwife burnout in southern Jordan. A qualitative approach was chosen as it is commonly used to gain a deeper understanding of lived experiences and perceptions, particularly in areas where little is known about the phenomenon under investigation (Doyle et al., 2020). Grounded in naturalistic inquiry and interpretivism, this study emphasized understanding individuals’ experiences within their real-world contexts (Colorafi & Evans, 2016). The study followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines (Tong et al., 2007) and was conducted between October 2023 and January 2024.

Participants

Participant recruitment was facilitated through social media platforms by midwifery department administrators. An information sheet outlining the study’s purpose, eligibility criteria, and contact details for the principal investigator (PI) was shared in professional groups for nurses and midwives in southern Jordan. To ensure diverse perspectives, participants were selected based on various backgrounds, including age, years of experience, and marital status. Eligible participants were midwives aged between 20 and 40 years with at least one year of active experience. Midwives who were on maternity or other forms of leave or who declined to participate were excluded.

A total of 27 potential participants contacted the PI via email. After initial screening, 20 midwives were deemed eligible and selected from different healthcare settings, including public hospitals and community health centers. These individuals were recruited using a purposive sampling strategy.

Data Collection

Data collection began after receiving Institutional Review Board (IRB) approval. The PI coordinated the interview schedules and connected participants with the designated interviewer. All interviews were conducted by the third author, a female researcher with a PhD in nursing and over seven years of experience conducting in-depth interviews in health research. She holds an academic position as a lecturer and had no prior professional or personal relationship with the participants. Initial contact was made via email to provide further details, followed by a phone call to explain the study’s purpose and interview procedures. Of the 20 eligible midwives, 17 agreed to participate, while three declined due to scheduling conflicts.

A total of 10 face-to-face interviews were ultimately conducted, as data saturation was achieved at that point. The remaining seven willing participants received a thank-you letter and an apology for not being included. Interviews were conducted in a private room at each participant’s workplace to ensure confidentiality and comfort, allowing them to openly share their experiences and challenges.

A semi-structured interview guide was used, beginning with the question: “Please tell me what key factors midwives perceive as challenging in their practice?” Probing questions followed to encourage deeper responses based on participants' answers. The interview questions were reviewed and validated by three content experts. Note-taking was employed alongside audio recordings using an Android smartphone to support the analysis process. Interviews lasted between 45 and 60 minutes, were conducted in Arabic, and continued until three consecutive interviews yielded no new information, confirming data saturation. The research team reviewed the data collaboratively to confirm saturation was reached by the tenth interview.

Data Analysis

Data were analyzed using Atlas.ti software (version 9.1) through thematic analysis, following the approach by Clarke and Braun (2017). Interviews were transcribed verbatim in Arabic and then uploaded to the software. Two researchers independently read the transcripts multiple times to familiarize themselves with the data and identify key nuances. Each researcher independently coded the transcripts at the sentence or paragraph level. Code names were assigned, and any discrepancies—about 15% of codes—were resolved through discussion. Inter-coder reliability was high (Cohen’s κ = 0.82), and all final themes were reached through consensus.

In total, 456 initial codes were generated. These were clustered and grouped into 23 categories, from which two overarching themes emerged, reflecting the midwives’ perspectives. Selected quotes were translated into English by a bilingual researcher and back-translated by a second independent translator to ensure accuracy and cultural fidelity.

Ethical Considerations

Ethical approval was obtained from the Jordanian Ministry of Health (Reference No. MOH/REC/2023/244). All participants were informed about the study’s objectives and procedures and provided written consent prior to participation. They were assured that participation was voluntary, data would remain confidential, and they could withdraw from the study at any time without any consequences. Data access was restricted to the principal investigator to maintain participant privacy.

Trustworthiness

To ensure rigor, the study applied Lincoln and Guba’s criteria for trustworthiness (Guba & Lincoln, 1989). Credibility was established through verbatim transcripts, member checking, and ongoing discussion within the team. Transferability was enhanced by providing detailed descriptions of the study setting, participant characteristics, and data collection methods. Dependability was maintained by documenting the study process thoroughly, and confirmability was supported through data triangulation, involving multiple sources to validate the findings.

Results

A total of 10 female midwives participated in the study, ranging in age from 24 to 40 years, with a mean age of 32.7 years. All participants held a three-year midwifery diploma. The majority were married (60%), with the average number of children being 2.2. Participants’ monthly income varied, ranging from less than 500 Jordanian Dinars (JD) to more than 1000 JD. In terms of professional experience, the participants had between 1.5 and 19 years of midwifery practice, with a mean of 10.1 years (see Table 1).

Table 1.

Characteristics of Study Participants (n = 10)

Variable	Midwives, n (%)
Gender and Age
Female	10 (100%)
Age range (years)	24–40
Mean age (years)	32.7
Educational Level
Midwifery diploma (3 years)	10 (100%)
Marital Status
Married	6 (60%)
Single	3 (30%)
Widow	1 (10%)
Husband’s Occupation
Military	3 (30%)
Private sector	2 (20%)
Registered Nurse (RN)	1 (10%)
Monthly Income (Jordanian Dinar - JD)
Less than 500 JD	4 (40%)
500–1000 JD	4 (40%)
More than 1000 JD	2 (20%)
Years of Experience as a Midwife
Range	1.5 – 19 years
Mean	10.1 years
Number of Children
Range	0 – 4
Mean	2.2

Two main themes emerged from the data analysis: 1) the emotional and physical toll of undervaluation and its impact on job satisfaction, and 2) professional autonomy and empowerment.

Theme 1: Emotional and Physical Toll of Undervaluation and Its Impact on Job Satisfaction

Midwives frequently experience physical and emotional strain due to inadequate recognition of their roles in healthcare. This lack of appreciation often results in negative outcomes such as fatigue, burnout, and job dissatisfaction.

Subtheme 1.1: Fatigue, Burnout, and Job Dissatisfaction

Many midwives expressed feeling overwhelmed and exhausted due to the constant demands of their jobs and the lack of recognition. Participant 2 emphasized the importance of appreciation as a motivator, stating, “Appreciation gives me motivation and increases my engagement in my duties” (Participant 2, female, 15 years of experience), illustrating how the absence of acknowledgment contributes to fatigue and reduced engagement.

The feeling of being overlooked also reduced job satisfaction. As one participant stated, “When you are not appreciated, it is hard to stay passionate about your work” (Participant 3, female, 1.5 years of experience).

Another major challenge midwives face is the demanding nature of their profession and the difficulty in balancing work with family life. Participant 5 shared, “We have no real support when it comes to managing both our job and family life. The long shifts make it hard even to see my children.” (Participant 5, female, 6 years of experience). This lack of support intensifies the emotional and physical fatigue midwives experience, ultimately leading to burnout and dissatisfaction with their profession.

Theme 2: Professional Autonomy and Empowerment

Subtheme 2.1: Limited Professional Autonomy

A significant concern raised in the interviews was the limited autonomy midwives have within their scope of practice. Unlike models in other countries where midwives may enjoy more decision-making freedom, midwives in Jordan are often bound by strict regulations requiring physician approval for many actions.

Participant 1 shared, “The doctors are under much pressure, which also catches on to us” (Participant 1, female, 8 years of experience). This reliance on physicians for approvals delays midwives’ ability to act—especially in urgent situations like labor—ultimately affecting patient care.

Participant 4 elaborated, “It’s frustrating; the delivery might be delayed for the mother because I have to wait for doctors to write orders… I cannot do anything without orders, which negatively affects the quality of care” (Participant 4, female, 19 years of experience). This lack of autonomy compromises timely care and undermines midwives’ confidence in their clinical skills.

Another participant echoed this frustration: “I often feel like I am just following orders rather than practicing my profession. I am trained to make certain decisions but need a doctor's signature for even the simplest things” (Participant 3, female, 1.5 years of experience).

Subtheme 2.2: Workplace Dynamics

Midwives reported facing difficulties in collaborating with other healthcare professionals due to a challenging and, at times, negative work environment. While some participants mentioned having good relationships with practical nurses and fellow midwives, many reported strained interactions with doctors.

Participant 5 noted, “We always have to chase them for orders, which is a huge challenge” (Participant 5, female, 6 years of experience), emphasizing how the hospital culture fosters a reliance on physicians that hampers midwives' autonomy.

Additionally, there were conflicts surrounding job responsibilities. Participant 7 stated, “There is tension about whose job is whose. There is a lot of pressure and uncertain roles within the team” (Participant 7, female, 5 years of experience). This role ambiguity contributes to stress and complicates an already demanding work environment. Overlapping and unclear responsibilities burden midwives further, impacting their efficiency and job satisfaction.

Subtheme 2.3: Inequitable Treatment

This subtheme highlights disparities in salary, promotion opportunities, and professional respect. Participant 4 remarked, “Midwives are underappreciated. Their salary is lower than other nurses, despite working long hours” (Participant 4, female, 19 years of experience). This financial disparity has led to significant frustration, as many midwives feel their compensation does not reflect their workload or responsibilities.

Participants also reported unequal access to professional development. As Participant 5 shared, “There are courses for senior staff and nurses, but we are often excluded. We never get to attend the same training sessions” (Participant 5, female, 6 years of experience). These discrepancies further widen the gap between midwives and other medical staff, limiting their career growth.

Moreover, several participants felt marginalized by the healthcare team. Participant 7 explained, “Sometimes it feels like we are not seen as equals by doctors or nurses. They don’t always take our opinions seriously, even though we’re the ones working closely with the patients” (Participant 7, female, 5 years of experience). This perceived lack of respect reinforces a sense of inferiority, despite the essential role midwives play in patient care.

Subtheme 2.4: Limited Training and Professional Development

Limited access to training and ongoing education not only affects job satisfaction but also the quality-of-care midwives can provide. Participant 3 expressed concern: “Without regular training, we rely on old knowledge and sometimes outdated methods, which can put both the mother and the baby at risk” (Participant 3, female, 1.5 years of experience).

Participants also acknowledged the link between professional development and self-confidence. Participant 7 stated, “When we do not get proper training, it affects our ability to work and how we feel about our job. It is hard to feel confident when you know you are not getting the tools you need to improve” (Participant 7, female, 5 years of experience).

Similarly, Participant 8 noted, “We rarely have the opportunity to enroll and participate in workshops or conferences. Our professional development is frequently neglected” (Participant 8, female, 12 years of experience). These limitations not only affect technical skills but also erode morale and motivation, ultimately hindering the ability of midwives to provide high-quality care.

Discussion

Principal Findings

This study explored the factors contributing to burnout among midwives in southern Jordan. The findings emphasize the need for systemic reforms to enhance job satisfaction and well-being among Jordanian midwives.

Midwives in southern Jordan reported experiencing significant emotional distress due to a lack of recognition within the healthcare system. This lack of appreciation contributed to fatigue, burnout, and job dissatisfaction. These results align with the findings of Cramer and Hunter (2019), who highlighted that midwives’ emotional well-being is adversely affected by various work-related stressors. Similarly, Yörük and Açıkgöz (2022) found a positive correlation between emotional well-being and job satisfaction among midwives. Amede et al. (2023) also emphasized the prevalence of work-related burnout and the need for collaborative solutions involving hospital management.

Our findings resonate with those of Hansson et al. (2022), who reported that lack of appreciation leads to workplace conflict and dissatisfaction among midwives in Sweden. However, contrasting perspectives emerged in a systematic review by Pérez-Castejón et al. (2024), which found that the majority of included studies reported high job satisfaction among midwives. Nonetheless, the authors acknowledged limitations due to inconsistent measurement tools and a limited number of studies, which call into question the reliability of those findings.

Neglect and disregard of midwives’ basic needs have been identified as contributing factors to low job satisfaction, supporting the conclusions of Oliver and Geraghty (2022). Our study found that midwives often feel ignored and undervalued in their roles, further exacerbating their dissatisfaction.

Work-life balance also plays a critical role in burnout. Fenwick et al. (2018) found a high prevalence of work-related fatigue among midwives, which was strongly associated with dissatisfaction around balancing work and family responsibilities. Our study similarly found that Jordanian midwives face difficulties in achieving work-life balance, often due to inadequate institutional support. Pace et al. (2022) also identified a lack of work-life balance and team conflict as key stressors in midwifery.

Professional autonomy emerged as a major concern among Jordanian midwives, who reported limited independence in their scope of practice. Their ability to make timely decisions was hindered by the need to obtain physician approval, which affected patient care and diminished their clinical confidence. In contrast, Vermeulen et al. (2023) found that 85% of midwives in Belgium operated mostly or completely independently. Interestingly, even within Belgium, midwives in Wallonia felt less autonomous—mirroring the constraints reported by midwives in our study.

Further contrast is provided by Clemons et al. (2021), who reported that midwives in New Zealand perceive autonomy as integral to their practice, especially among self-employed midwives who provide continuous maternity care. Nevertheless, Vermeulen et al. (2024) later confirmed that the midwifery profession in Belgium often lacks recognized authority, resulting in undervaluation, underutilization, and underpayment—issues that echo our findings in the Jordanian context.

Autonomy is widely acknowledged as a core element of midwifery. Zolkefli et al. (2020) emphasized that autonomy enables informed decision-making and critical thinking, which are essential for high-quality care. However, work culture plays a critical role in enabling or constraining that autonomy.

In addition to limited autonomy, our analysis identified role conflicts and strained workplace dynamics as significant challenges. Midwives reported difficulties collaborating with other healthcare professionals, leading to increased workloads and confusion around responsibilities. Geraghty et al. (2019) similarly described rising stress levels in midwifery due to environmental and contextual stressors. Although Behruzi et al. (2017) suggested that better collaboration across disciplines could enhance maternity care, they also acknowledged that achieving effective teamwork remains difficult.

Another major concern raised by Jordanian midwives involved inequities in respect, salaries, and access to professional development compared to other healthcare workers. These disparities undermine midwives’ job satisfaction and sense of professional identity. Bradley et al. (2019) likewise highlighted the low status of midwives in healthcare hierarchies, pointing to systemic disrespect. A study in Bangladesh by Akther and Khatoon (2019) found that low salaries and poor working conditions limited midwives’ ability to deliver quality care.

Ramamurthy et al. (2023) further argued that prejudice within nursing and midwifery is widespread and contributes to exclusion and inequality. Their research emphasized the need for institutional accountability and equitable educational opportunities to prevent marginalization within the healthcare workforce.

Our findings also underline the negative impact of limited access to continuing education and training. Midwives in southern Jordan expressed concern about the lack of opportunities to update their clinical skills, which diminished their confidence and affected patient care. Watson (2021) noted that midwives face several barriers to participating in continuing professional development, which could explain a decline in meeting regulatory requirements.

Wissemann et al. (2022) highlighted the importance of mentoring programs in improving midwifery retention, while McFadden et al. (2020) recommended practical training, full-scope utilization, and effective referral systems as facilitators of professional development.

Strengths and Limitations

A key strength of our study is the use of semi-structured, in-depth interviews, which provided rich, detailed insights into midwives' experiences across diverse healthcare settings in Jordan. Including participants from public hospitals and community health centers enhanced the comprehensiveness and contextual relevance of our findings. However, the small sample size of ten participants may limit generalizability. Still, the qualitative approach offers valuable depth and nuance. By focusing on the socio-cultural and professional context of southern Jordan, this study contributes unique insights to the existing literature on midwifery burnout. While emotional strain, lack of recognition, and restricted autonomy are global challenges, our findings reveal how these issues manifest in a localized setting with distinctive healthcare dynamics.

Implications of the Study

The findings of this study underscore critical challenges contributing to burnout among midwives in southern Jordan, including emotional and physical exhaustion due to lack of recognition, restricted professional autonomy, inequities in professional development, and unfavorable workplace dynamics. These challenges are not exclusive to Jordan; they reflect broader systemic issues experienced by midwives in various global contexts, particularly in low- and middle-income countries.

Implications extend beyond the national level. Addressing these concerns can serve as a blueprint for countries facing similar struggles within their maternity care systems. Globally, strengthening midwifery autonomy through policy reform, establishing midwife-led care models, and fostering inclusive, collaborative workplace cultures can greatly reduce burnout and improve retention. For example, integrating mentorship and continuing education programs—as practiced in the UK, Canada, and Australia—can enhance midwives’ professional confidence and career growth. Moreover, addressing gender-based disparities and ensuring equitable compensation, as seen in Sweden and Belgium, is vital to elevating the status of midwives within the healthcare hierarchy.

Overall, this study emphasizes the importance of investing in midwifery as a cornerstone of maternal and newborn health. Efforts to improve midwifery conditions globally must consider not only the technical competencies required of midwives, but also the social, emotional, and organizational factors that shape their daily work lives.

Conclusion

This study explored the complex factors contributing to burnout among midwives in southern Jordan, revealing a deeply rooted need for systemic transformation. Emotional fatigue, lack of appreciation, restricted autonomy, and insufficient professional support were shown to significantly impact job satisfaction and the quality of care. These issues reflect not just local but global trends, particularly in healthcare systems where midwifery is undervalued. Addressing these challenges requires a holistic, multi-level response—from national policy changes and institutional support to international collaboration and knowledge exchange. By drawing on successful global practices and tailoring interventions to local contexts, healthcare systems can foster environments where midwives are empowered, respected, and equipped to provide high-quality, compassionate care. These efforts are essential not only for midwives’ well-being but also for advancing maternal and child health outcomes on a broader scale.

Declaration of Conflicting Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Funding Statement

Funding This research received no specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Authors’ Contributions

Conception and design of the study: AA. IS; Data collection: TT; Data analysis and interpretation: AA, AN & TT; Manuscript preparation: AA, IS, DR. All authors read and approved the final manuscript.

Authors’ Biographies

Arwa Alsaraireh, DNP, RN, is an Associate Professor at the Department of Maternal and Child Health Nursing, Mutah University, Al-Karak, Jordan.

Ishraq Al-Sarairhe, MS, works at the Faculty of Nursing, Jerash University, Jerash, Jordan.

Tamador R. Al-Tarawneh, RN, MSN, PhD, is an Assistant Professor at the Department of Midwifery, Faculty of Nursing, Al-Balqa Applied University, Al-Salt, Jordan.

Divya Raghavan, M.Sc, is a Lecturer at the Department of Maternal & Child Health, College of Nursing, Sultan Qaboos University, Muscat, Oman.

Ahmad H. Al-Nawafleh, PhD, MPA, CI, RN, is a Professor of Nursing Management and Leadership at the Faculty of Nursing, Al-Karak, Jordan.

Data Availability

The data related to this research is available with the principal investigator and can be provided upon request.

Declaration of Use of AI in Scientific Writing

The authors used AI-assisted ChatGPT to improve the language proficiency and flow of sentences. After utilizing the service, the authors thoroughly reviewed and edited content as necessary and assumed full responsibility for the publication of the content.