Whispers of dedication; unraveling motivational narratives among midwives in reproductive healthcare: a qualitative exploration

INTRODUCTION

Family planning is a cornerstone of reproductive healthcare, crucial for individuals and couples to make informed decisions about the number and spacing of children. Its significance cannot be overstated, as it is vital for achieving Sustainable Development Goals (SDGs) related to maternal and child health.¹ Access to family planning services has the potential to reduce maternal and infant mortality rates, prevent unplanned pregnancies, and improve the health and well-being of women and children.¹

However, in Pakistan, the utilization of modern contraceptives remains alarmingly low.^2,3 Despite efforts, the prevalence of modern contraceptive methods has stagnated at around 25% over the past five years.⁴ This low uptake contributes to a substantial unmet need for family planning among married women, with 17% expressing a desire to avoid or delay pregnancy but facing barriers to accessing contraceptives.⁴ Moreover, there has been an increase in unwanted pregnancies among married teenage girls, leading to an estimated 2.2 million abortions annually.^5,6

These unmet needs have far-reaching consequences beyond reproductive health, impacting societal, economic, and healthcare realms. To address these challenges and improve the use of modern contraception, it is crucial to recognize the pivotal role of midwives in providing family planning services to the community.

Motivation plays a crucial role in driving midwives to offer family planning services despite various obstacles stemming from patients' religious, cultural, and social beliefs.^7-9 Understanding midwives' motivations is essential, as it influences their readiness to achieve objectives and persevere in the face of difficulties.¹⁰

If motivation is strong, individuals tend to show perseverance in the face of obstacles.^11,12 Additionally, individuals prioritize their goals based on their beliefs and mindset, including career choices.^10,13

Therefore, an in-depth exploration of midwives' beliefs, expectations, and motivations is necessary to understand their perspectives on family planning and their commitment to providing these services. This study aims to examine the factors influencing midwives' attitudes towards family planning, their reasons for engaging in family planning services, their motivation for seeking training in this area, and the challenges they encounter during service delivery. Through this investigation, we seek insights that can inform strategies to enhance the provision and quality of family planning services, particularly in resource-constrained settings like Pakistan.

METHODS

A six-day Master training workshop in June 2021 was conducted for midwives for trickle down training at Karachi by United Nations Population Fund under the proposed project of Sihaat mand Khaandaan (SMK) project-the name means “Healthy Families” in Urdu through accelerating Family Planning program. The workshop was attended by thirty-six midwives from a public health facility with low resource setting. The workshop included information regarding modern contraceptive methods followed by hands-on training on models for Postpartum intrauterine contraceptive device (PPIUCD) and insertion of contraceptive implants. To explore the midwives’ motivation for offering family planning services and the factors that influence their attitudes towards family planning, a focus group discussion (FGD) was conducted with ten participants. The midwives were selected using purposive sampling, based on their experience and willingness to participate in the study.

The focus group discussion was conducted in a quiet room in the health facility, and the discussion was facilitated by a trained moderator. The discussion guide was developed based on the research objectives and included open-ended questions on midwives' motivation for getting training in modern contraceptives, offering family planning services, factors that influence their attitudes towards family planning, and suggestions for improving the quality of family planning services. The FGD lasted for approximately 90 minutes until data saturation was reached indicating no new themes or insights emerged from the subsequent discussion. The FGD was audio-recorded with the participants' consent. The audio recordings were transcribed verbatim, since the audio recordings included interview in both English and local language Urdu, the recordings were translated in English by two researchers proficient in both English and Urdu language. The data was analyzed using thematic analysis. The transcripts were read several times to identify common themes, and the data was coded and organized into categories based on the research objectives. The categories were reviewed by the research team, and the themes were identified through consensus.

Ethical considerations were considered throughout the research process. Informed consent was obtained from all participants before the FGD, and confidentiality was ensured by assigning pseudonyms to the participants and removing any identifying information from the transcripts. The participants were informed about the intent of the study and the right to choose to participate or withdraw at any time. The research protocol was reviewed and approved by the ethical committee of the health facility.

RESULTS

All ten midwives were between the ages of 34-47, mean 39 SD±3.8 years. All belonged to the rural area of province Sindh of Pakistan. During the focus group discussion, the midwives were asked about their motivation for taking the family planning course. The discussion led to enquiry into various aspects of their motivation for training which were categorized into subthemes and grouped into four major themes.

Pinnacle aspirations: unveiling the inspirations for training excellence

Professional growth

Most of the midwives agreed that as midwives it is their responsibility to provide accurate information and services to patients. Hence family planning being crucial aspect of reproductive health, training in family planning was essential for their professional development.

“I took the course to upgrade my knowledge and skills as a trained midwife and be able to teach others as master trainer.”

“I wanted to develop my skills further to help me achieve expertise and develop my potential as master trainer.”

Personal interest: All midwives agreed that they have a personal interest in family planning and want to learn more about the different contraceptive methods and how they work. Having this knowledge enables them to counsel their clients better and recommend the most appropriate method based on their needs and preferences.

“I took the course because of my own interest, as I wasn’t knowledgeable and trained for newer methods like implants PPIUCD, it was out of my own interest and choice I came here”

Client requisition: Another reason identified was the demand of patients for different methods of contraception. Most of the midwives mentioned that the increasing demand for family planning services from their clients motivated them to take the course.

“Patients are now very keen to know about recent trends in modern contraception they ask us about different methods as they hear from their relatives or get information from social media so it was important for me to get skilled and trained for different methods”.

“Even in villages people have information about modern contraceptives, recently patient asked me to insert an implant, but I was not trained to do so and had not much information about it so taking this course has helped me to at least satisfy my client demands”.

Overall, the midwives' motivation for taking the family planning course was driven by their desire for professional development and the need to provide quality services to their patients. Their personal interest and patient demand also played a role in their decision to take the course.

During the focus group discussion, the midwives were asked about the challenges they face when providing family planning services. Following themes and subthemes emerged from the discussion:

Navigating the terrain: a journey of challenges and obstacles

When delivering family planning services, midwives confessed confronting a variety of problems, including inadequate resources, cultural and religious views, misinformation,

Resource constraints: All midwives accepted that it is challenging for them to provide quality care and service to their patients due to the frequent lack of family planning supplies like contraceptives. Additionally, they stated how the lack of adequate infrastructure and equipment at the hospital where they work has an impact on the standard of the services provided.

“We are working in a setup that offers very little resources except for pills and barrier methods we don’t have other methods to offer and if we try to arrange it, we don’t have the equipment to facilitate it”.

“Most of the time we are constrained with limited methods to offer and equipment. If the setup does not provide the basic tools and equipment like instruments, how can I perform effectively?”

Sacred traditions

According to the midwives, cultural and religious beliefs have a profound effect on women’s attitudes on family planning. Women refuse to utilize contraception for various myths and beliefs, making it difficult for midwives to provide services.

“There are so many stores patients narrate, and all are hear say about contraception specially IUCD and implants that it becomes difficult to convince them specially most women are refused by their relatives sometimes their religious scholars who they follow tell them not to use it”.

“Patients have been told by their religious leaders if you use contraception you will go to hell and if you have tubal ligation, when you die your namaz e janaza (funeral prayers) will not be offered. It becomes difficult at times to tell them otherwise and convince them about its use”.

Dispelling misinformation

According to the midwives, some clients have misconceptions about family planning, which affects their willingness to use contraception. Some clients believe that contraception causes infertility or other health problems, making it difficult for midwives to encourage them to use contraception.

“Patients are so misinformed specially by their relatives that contraception causes infertility it can cause cancer of uterus, that people are afraid to seek help from us and this becomes challenging “

“A patient told me that my family tells me that all contraceptives cause cancer and make you sterile”.

Family resistance

“Most patients I counsel are stopped by their husbands to use modern contraception. In my practice I have seen most of the time it’s the husband who is not allowing the wife to take contraception”.

“I face similar issues, women are willing for spacing but their husband or family members tell them against it”.

Upon enquiry into their expectations and intrinsic motivation towards family planning service following theme was generated with subthemes.

Dismal work realities: deciphering expectations in the professional sphere

Most midwives acknowledge the nobility of their work and take pride in their service; however, a prevailing sense of professional underappreciation persists. They expressed a desire for either financial remuneration, acknowledgment of their achievements, or recognition through attaining a position as equal contributors in health service delivery.

Incentive dearth

The midwives reported having received less incentive or perks as family planning provider.

“We have travelled from far to get training but there should be ways to incentivize our training in form of monetary help or financial assistance to keep us motivated to continue our training and service”.

“We feel our work is precious so we should be given some kind of monetary support or higher pay”.

Recognition void

“We often feel left out as we are taken for granted, we are not nurses nor are we doctors but our work is so important we should be given recognition and worth of our work by either giving me promotion or any position that makes me feel I achieved something”.

“Yes! we are hardworking and serve community we should be given some kind of position equal to other health professionals to at least have a sense of pride in our work”.

During the interview question on how their training would help the community in long term, they were enthusiastic towards their work and their interviews derived the following theme and subthemes.

Women empowered: contraception leaders for healthier generations

Transcending knowledge

“I think we are capable to train other midwives in rural areas because now we are trained better, and this would help the community we serve. We teach other midwives who can then teach midwives of their respective community”.

“I agree I feel once we teach others there should be some kind of monitoring so that its monitored what we are teaching, and we monitor others who are teaching so this can be a better trickle down training program rather having one training and leaving it for others to do it on their own”.

Elevating expertise

Midwives agreed that training would help them to educate women and counsel their families to clear their misconceptions and recommend most appropriate method based on the women’s needs and preferences. They felt training on modern contraceptive techniques would improve their skills and knowledge for better understanding of different latest contraceptive methods and would enable them to train others in their setup.

“Taking the training has improved my knowledge of the latest methods available and how to use them safely specially PPIUCD and this information is so important to clear the patients and their families’ misconceptions about contraception.”

“My knowledge has improved about latest contraceptive methods and I feel this information would help me to give proper information and education patients and their families. Once they realize child spacing is not harmful rather helpful for both mother and child the patients would be more receptive and midwives can be very helpful in playing the role of educator”.

Empower “Her”

Nearly all emphasized educating families for contraception use its efficacy and safety is an important aspect for contraception uptake. Empowering women to take up contraception of their choice and on their choice would enable effective contraception to use and allay the anxiety and fear faced by women to abandon it due to family pressure and misconception.

“Women in our community don’t have a say in family matters I think we as midwives can play a significant role in empowering women and this can only be done if we educate the husbands as well”

“The man of the house has more power in society especially in rural areas educating women and their families about the choice of contraception suitable for women should be left to the women to choose or deny, it should be a personal choice or at least let the couple mutually decide it should not be only a man’s decision as he doesn’t know anything about contraception so why should he decide? We can help women understand their rights by educating them”.

Access, plan, thrive

All midwives agreed that they would be able deliver a broader range of family planning services to their patients with the information and abilities gained from the training. Women would be able to select the most appropriate contraceptive technique suitable to them, increasing the likelihood of effective child spacing.

“Providing different services for contraception and access to it would help patients in their choice to select contraceptive suitable to them”.

“Many women don’t use contraception because it’s not available to them we as midwives can be a good source to provide information as well as provide them effective family planning methods”.

DISCUSSION

The focus group discussion of the midwives exploring their motivations for family planning training and provision of services determined themes which included their interest and professional growth their expectations and challenges they face as well as their usefulness as driving agents for family planning propagation. Most of the midwives agreed their motivation for training for family planning included their own self-interest, client demand as well as a mandatory requirement for their yearly appraisal performance. The majority agreed that training motivation comes from within one’s own interest and factors which help the individual’s own professional growth. A similar response was generated in a study which identified midwives’ self-interest and professional growth as motivation for pursuing training and career.¹⁰ During their interview the emerging theme on expectations and challenges included patient’s rigid beliefs, the cultural and religious beliefs against contraception and the husband being the significant obstacle in the right to choose contraception. Similar findings were noted in another study which identified husband and in laws to be significant obstacles in contraception use.³ Another study reported similar results where women feared to take contraception without husbands’ consent as this would affect their relationship.^14,15 Finding from interviews from midwives in a study found superstitious beliefs difficult to tackle by education alone, they believed involvement of influential community members in reinforcing misconceptions played a significant role.¹⁶ Cultural beliefs, spousal consent and family pressure are among very major obstacles in uptake of contraception.¹⁷ Along with cultural and personal belief’s majority of midwives accepted that lack of support and equipment impedes their work and provision of effective contraception. Similar results were reported from another qualitative interviews of midwives.^18-20 Majority of the midwives felt there should be some incentive either in form of monetary gain or certification for the work they do, such as in rural communities combating religious and cultural taboos and faced with social pressure, these midwives face tremendous hurdles in educating women their families to take up child spacing and use contraception specially the long acting one. A study in Indonesia reported midwives’ competence and motivation was seen to be associated with private income, as they earned more working privately.²¹ In our study midwives narrated having felt unrewarded or taken for granted which was a new outcome in the study they felt monetary gain or incentive in term of recognition or position could compensate for their desire to be recognized as equal health partners to other health providers. Contrary to our finding, study by Sim-Sim et al, revealed that midwives felt pride in their profession they felt honoured as they were playing an important role in the community.¹⁰ In another study midwives felt professional ambiguity, their role seemed to be lost and vague to them, they also reported being given less authority and role as health providers.¹ Similar findings were reported by Borgen et al, the midwives in their study felt unappreciated and unvalued.⁹ The declining contraception uptake by women in Pakistan and the contributing role of midwives in family planning services can help battle the situation. To keep them motivated to provide education awareness and service provision some kind of incentive should be provided to the midwives in terms of monetary benefit and refresher courses to help them keep themselves updated with recent trends.²² During the focus group discussion, the midwives were motivated to seek training on modern contraceptive methods as well as to provide education and train others to do the same. They strongly felt that their role in community helps educate women for child spacing as well as their spouses and family to encourage women and empower women for the right to choose contraception of their choice and preference. Such motivations have been observed in several studies where despite obstacles midwives still felt motivated to serve the community and educate women.^23,24 The in-depth interviews discovered the midwives’ motivations to learn and train others to help women for latest contraceptive choices and to educate their families and empower women on contraception uptake. However, the identification of demotivating factors, particularly the absence of incentives and recognition, offers valuable insights. Therefore, the development of strategies aimed at enhancing midwives' job satisfaction is imperative. This necessitates their increased involvement in hospital affairs and greater support from management. A study suggested collaborative partnership of midwives with researchers to enhance and facilitate best available evidence into practice.²⁵ A study in Jordan identified the need for involvement of midwives into active roles in hospitals to upgrade their position and role in service delivery²⁵ . Pakistan with its rising population rate and low contraception uptake family planning services are crucial to empower women for child spacing and hence reducing maternal mortality.³ The low literacy level among women in Pakistan further stresses the need to train and empower the midwives to provide modern contraceptive methods to the community.³ In Indonesia a study examined midwives’ motivation with training and long-term contraception service they emphasized that relationship between motivation and training test result was low, but training can still motivate midwives for long term contraception service.²⁶ Acknowledging midwives’ indispensable contributions and offering financial incentives and providing elevated professional standing are crucial measures to reinforce the efficacy of family planning programs. Addressing these issues, can foster an atmosphere that supports midwives'ongoing commitment, which will ultimately improve the standard and accessibility of family planning services for the good of individuals, families, and overall community.

CONCLUSION

Midwives’ motivation for family planning service and training is inherently fueled by their inner drive to learn and provide compassionate care. However, the sustainability and steadfastness of this motivation are intricately linked to the recognition they aspire for and the essential financial support required to extend their societal impact.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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