Ci a ion: Iglesias-Casás, S.;
Vila-Candel, R.; Mena-Tudela, D.;
Ma ín-A ibas, A.; Leon-La ios, F.
Wo k Si ua ion o Midwi es in Spain:
Pe cep ion o Au onomy and
In en ion o Lea e he P o ession: A
C oss-Sec ional S udy. Heal hca e 2024,
12, 1994. h ps://doi.o g/10.3390/
heal hca e12191994
Academic Edi o : Masa umi
Koshiyama
Recei ed: 11 Sep embe 2024
Re ised: 2 Oc obe 2024
Accep ed: 4 Oc obe 2024
Published: 6 Oc obe 2024
Copy igh : © 2024 by he au ho s.
Licensee MDPI, Basel, Swi ze land.
This a icle is an open access a icle
dis ibu ed unde he e ms and
condi ions o he C ea i e Commons
A ibu ion (CC BY) license (h ps://
c ea i ecommons.o g/licenses/by/
4.0/).
heal hca e
A icle
Wo k Si ua ion o Midwi es in Spain: Pe cep ion o Au onomy
and In en ion o Lea e he P o ession: A C oss-Sec ional S udy
Susana Iglesias-Casás1, Ra ael Vila-Candel 2,3,4,5,* , Desi ée Mena-Tudela 5,6 , Anna Ma ín-A ibas 7
and Fá ima Leon-La ios 8
1P ima y Ca e Managemen o Tene i e, 38650 Tene i e, Spain; [email p o ec ed]
2Facul y o Heal h Sciences, Uni e sidad In e nacional de Valencia (VIU), 46002 Valencia, Spain
3La Ribe a P ima y Heal h Depa men , 46600 Alzi a, Spain
4Founda ion o he P omo ion o Heal h and Biomedical Resea ch in he Valencian Region (FISABIO),
46020 Valencia, Spain
5PECAWOL (Pe ina al ca e and Women’s Heal h), Join Resea ch Uni FISABIO-UJI, 46020 Valencia, Spain;
[email p o ec ed]
6
Nu sing Depa men , Heal h Science Facul y, Ins i u o Feminis a, Uni e si a Jaume I, 12071 Cas ellón, Spain
7
Ghende s Resea ch G oup, School o Heal h Sciences Blanque na, Uni e si a Ramon Llull, 08025 Ba celona,
Spain; [email p o ec ed]
8Nu sing Depa men , School o Nu sing, Physio he apy and Podia y, Uni e si y o Se ille, 41009 Se ille,
Spain; [email p o ec ed]
*Co espondence: a ael. ila@p o esso .uni e sidad iu.com o [email p o ec ed]
Abs ac : Backg ound: De eloped coun ies epo speci ic issues ega ding he declining midwi e y
wo k o ce, and hei sho age could ha e se ious consequences o women’s sexual and ep oduc i e
heal h. The aim was o unde s and he pe cep ion o au onomy among midwi es wo king in
Spain, as well as ac o s ela ed o hei in en ion o lea e he p o ession and hei wo k en i onmen .
Me hod: A desc ip i e and c oss-sec ional s udy using an online ques ionnai e. Popula ion: midwi es
wo king in Spain in any ield (clinical, esea ch, eaching, o managemen ). Resul s: A sample o
1060 midwi es
was ob ained. O hese, 53.7% (n= 569) eel au onomous in hei wo k, 92.4%
(n= 978
)
pe cei e ha hei p o ession equen ly su e s om ex e nal in e e ence, 46.6% (n= 494) ha e
expe ienced sexis beha io s a wo k, and 53% (n= 561) ha e conside ed lea ing he p o ession in
he las yea . Midwi es wi h less han 10 yea s o expe ience (57.7%), hose aged 31–45 yea s (59.8%),
hose wi h empo a y con ac s (38.3%), and hose wo king in hospi al ca e (71.9%) show a highe a e
o conside ing lea ing he p o ession (p< 0.001). Conclusions: Conside ing he cu en midwi e y
wo k o ce c isis in Spain, i seems u gen o imp o e he wo king condi ions o midwi es o ensu e
he con inui y and quali y o women’s sexual and ep oduc i e heal hca e.
Keywo ds: midwi e y wo k o ce; job au onomy; job sa is ac ion; quali y o heal hca e; wo kplace
en i onmen ; con inui y o ca e
1. In oduc ion
The midwi e, as a p o essional igu e o e e ence, con ibu es o he su i al, im-
p o emen in heal h, and well-being o women and hei newbo ns [
1
,
2
]. In 2023, he
Bucha es Decla a ion called o poli ical ac ion and a commi men o p o ec , suppo ,
and in es in heal hca e wo ke s ac oss Eu ope and Cen al Asia, as well as o add ess
he p essing challenges acing his g oup [3,4]. De eloped coun ies a e epo ing speci ic
issues ega ding he decline in he midwi e y wo k o ce o doub s abou whe he hei
numbe s a e su icien o mee he cu en o u u e needs o he popula ion [5–7].
The sho age o midwi es could ha e se ious consequences o he ca e o women
du ing p egnancy, childbi h, and he ea ly pa en ing pe iod [
8
,
9
]. I has been documen ed
ha , in coun ies wi h low de elopmen indices, in e en ions p o ided by midwi es
Heal hca e 2024,12, 1994. h ps://doi.o g/10.3390/heal hca e12191994 h ps://www.mdpi.com/jou nal/heal hca e
Heal hca e 2024,12, 1994 2 o 12
h ough basic uni e sal co e age could p e en 41% o ma e nal dea hs, 39% o neona al
dea hs, and 26% o s illbi hs, which equa es o 2.2 million a oidable dea hs annually [
10
].
The In e na ional Con ede a ion o Midwi es (ICM) de ined midwi es’ au onomy as
hei abili y o de e mine and con ol he s anda ds o hei own educa ion, egula ion,
and p ac ice, ecognizing ha in some coun ies, midwi es ace di icul ies in his a ea due
o medical hie a chies, go e nmen au ho i ies seeking o con ol and limi he scope o
hei wo k, and he misuse o heal hca e policies and p o ocols [11].
I has been ecommended ha midwi es’ oles be expanded, along wi h an imp o e-
men in hei wo king en i onmen , suppo o hei emo ional well-being, adequa e
ecogni ion and sala ies, and hei inclusion in policy de elopmen and leade ship oles
o ensu e p ope s a ing o he p o ession [
1
]. Fac o s such as excessi e wo kload s a
sho ages, inabili y o p o ide con inui y o midwi e y ca e, ha assmen , and lack o e -
ec i e manage ial suppo ha e been desc ibed as de e minan s o midwi es’ emo ional
well-being [
12
,
13
]. The e is a link be ween high le els o emo ional dis ess and he in en-
ion o lea e he p o ession [
14
]. O he obs acles, such as heal hca e sys ems domina ed
by he medical model, lack o inancial esou ces o adequa ely s a eams, and gende
biases ( he midwi e y p o ession is highly eminized), p e en hem om eaching hei
ull po en ial [15].
In Spain, he compe encies o midwi es include a wide ange o esponsibili ies
ocused on women’s sexual and ep oduc i e heal h [
16
]. The cu en a io is 6.1 midwi es
pe 10,000 women aged 14–65, which is lowe han he Eu opean median o 9.1. This low
na ional a io limi s hei a ailabili y o ully exe cise all hei p o essional compe encies,
meaning ha he heal hca e sys em canno o e equi able and comp ehensi e sexual and
ep oduc i e heal hca e. The Fede a ion o Spanish Midwi es (FAME) and he Spanish
Midwi es Associa ion (AEM) ha e ecen ly wa ned abou he cu en sho age o midwi es,
as well as he lack o planning o ensu e gene a ional u no e , calling on he go e nmen
o ake an ac i e and esponsible ole [16,17].
Gi en he cu en con ex , he main objec i e o his s udy was o unde s and he
pe cep ion o au onomy among midwi es wo king in Spain. As seconda y objec i es,
we aimed o analyze he di e ences in hei in en ion o lea e he p o ession acco ding
o sociodemog aphic and p o essional a iables and o explo e ce ain aspec s o hei
wo k en i onmen .
2. Ma e ials and Me hods
2.1. Design
A desc ip i e, c oss-sec ional s udy was conduc ed using an online ques ionnai e. The
ques ionnai e was hos ed on a secu e pla o m (Google Fo ms©) and was a ailable om
7 Feb ua y o 8 Ma ch 2023, a e which i was closed o p e en u he esponses. Da a
collec ion allowed only one esponse pe use , and pa icipan s we e equi ed o ag ee o
he e ms (pu pose o he esea ch, he olun a y na u e o pa icipa ion, and assu ances
ega ding da a p i acy) o p oceed be o e beginning he su ey.
2.2. S udy Popula ion
Midwi es p ac icing in Spain in any ield (clinical, esea ch, eaching, o managemen )
ag eed o pa icipa e in he s udy. The s udy was p omo ed by he Cana y Islands Midwi es
Associa ion (ACAMAT), which con ac ed all nu sing colleges and midwi e y associa ions in
Spain ia email, eques ing hei collabo a ion in dissemina ing he su ey and explaining
i s objec i es. The ques ionnai e was dis ibu ed ia email and social media. The s udy
popula ion consis ed o 8084 midwi es ac i ely wo king in Spain as o 31 Decembe
2022 [
16
]. A o al o 1060 midwi es pa icipa ed in he su ey, ep esen ing 13.1% o
he egis e ed midwi es in he coun y. The online su ey was p ima ily dissemina ed
h ough nu sing colleges ha chose o collabo a e by sha ing he su ey link ia hei social
media channels, encou aging hei membe s o pa icipa e. The inclusion c i e ia equi ed
pa icipan s o be ac i e midwi es in Spain du ing he s udy pe iod and o ag ee on he
Heal hca e 2024,12, 1994 3 o 12
e ms o su ey. Exclusion c i e ia speci ied ha he su ey a ge ed only hose cu en ly
p ac icing in Spain. To ensu e da a comple eness, all su ey i ems we e manda o y, and
incomple e esponses we e no accep ed.
2.3. Va iables and Da a Collec ion Tool
An ad hoc elec onic o m was designed and o ganized in o ou dis inc pa s:
(1)
Sociodemog aphic and p o essional da a o he pa icipan s:
gende (woman/man), age (in ull yea s), au onomous communi y o esidence,
yea s o wo k expe ience (in ull yea s), heal hca e sec o (public heal hca e/p i a e
heal hca e), midwi e y academic backg ound (Residen Nu se In e n—RNI in Spain,
non-Spanish uni e si y, o o he ), ype o con ac (in e im, empo a y, pe manen , o
sel -employed), main p ac ice (hospi al ca e, p ima y ca e/ambula o y clinic, home
bi h/bi hing cen e , o o he : eaching, esea ch, o managemen )
(2)
Pe cep ion o midwi es’ au onomy, selec ed by he esea ch eam a e e iewing he
a ailable li e a u e on he subjec [
18
–
21
]. The 25 i ems included in his sec ion we e
a ed on a Like scale om 1 o 5 (5 s ongly ag ee–1 s ongly disag ee).
(3)
Wo k en i onmen e alua ion: ha assmen ( e e s o whe he he pa icipan has
expe ienced o wi nessed wo kplace ha assmen ), sexism (e alua es whe he he e
a e sexis and disc imina o y a i udes, commen s, o beha io s based on gende ),
ques ioning ( e e s o whe he he wo ke eels ha he wo k, decisions, o abili ies
a e cons an ly doub ed wi hou jus i ied eason), dis espec (examines whe he he
wo ke has been ea ed dis espec ully by supe io s, colleagues, o subo dina es),
in usi eness ( e e s o he p esence o indi iduals pe o ming asks o oles o
which hey a e no quali ied, c ea ing an inapp op ia e wo k en i onmen ). All hese
a iables had dicho omous (yes/no) esponses, and hei de ini ions we e p o ided o
he pa icipan s.
Addi ionally, ques ions we e included on pe cei ed wo k en i onmen : hos ile (de-
sc ibes a compe i i e and con lic -p one en i onmen ), chao ic (indica es a diso ganized
en i onmen wi h a lack o s uc u e), dep essing (desc ibes an en i onmen ha de-
mo i a es and nega i ely a ec s employees’ mood), s ess ul (desc ibes a high-p essu e
en i onmen whe e employees eel cons an ly o e whelmed), co dial ( e lec s a iendly
and collabo a i e wo k en i onmen ), mo i a ing ( e e s o an en i onmen ha encou ages
employees o imp o e and achie e hei goals).
Finally, he e we e ques ions abou midwi es’ eelings owa ds hei wo kplaces:
accomplished ( eeling ha he/she is mee ing he goals and ealizing he po en ial), in ali-
da ed ( eeling his/he abili ies a e being igno ed o supp essed), exhaus ed (expe iencing
eelings o bu nou o sa u a ion), ecognized (pe cei ing ha his/he wo k is alued by
o he s), i ed ( eeling physically o men ally exhaus ed), con en (expe iencing a sense o
well-being and sa is ac ion), ea ul ( eeling ea , whe he o he sa e y, job s abili y, o due
o wo kplace con lic s), ang y (expe iencing ange o us a ion due o wo kplace si ua-
ions), bu n ou (showing signs o emo ional o physical exhaus ion om wo k), sa is ied
( eeling sa is ac ion wi h he pe o mance and ou comes), powe less ( eeling he/she has
no con ol o abili y o in luence wo kplace si ua ions). Fo each eeling, pa icipan s could
selec om i e ca ego ies ( e y li le, li le, qui e a lo , a lo , always).
In Janua y 2023, a pilo su ey was conduc ed wi h 10 pa icipan s, all midwi es
wi h o e 15 yea s o wo k expe ience. The e alua ion was posi i e in e ms o i em
comp ehension and accep abili y, and no changes we e made. Pa icipan s epo ed ha i
ook abou 5 min o comple e he su ey.
2.4. Da a Analysis
Desc ip i e s a is ics we e used o analyze he cha ac e is ics o he sample, wi h he
mean and s anda d de ia ion (SD) applied o quan i a i e a iables and anges and pe -
cen ages o quali a i e a iables. Some a iables we e ca ego ized o acili a e analysis and
comp ehension o he esul s, such as wo k expe ience (<10 yea s/10–19 yea s/
>20 yea s
)
Heal hca e 2024,12, 1994 4 o 12
and age (<30/30–44/45–65). To analyze he pa icipan s’ exp essed in en ion o lea e he
p o ession, esponses we e g ouped in o wo ca ego ies: Yes (ag ee/s ongly ag ee) and
No (nei he ag ee no disag ee/disag ee/s ongly disag ee).
To assess he eliabili y o he ques ions used in he s udy, wo in e nal consis ency
coe icien s we e calcula ed: McDonald’s Omega and C onbach’s Alpha. The Chi-squa e
es (
χ2
) was used o desc ibe he dis ibu ion o midwi es’ expe iences and he possibili y
o lea ing he p o ession acco ding o hei sociodemog aphic a iables.
Da a analysis was pe o med using he s a is ical so wa e package SPSS .28.0 (IBM
Co p. 2018. IBM SPSS S a is ics o Windows, A monk, NY, USA). A p- alue < 0.05 was
conside ed s a is ically signi ican .
2.5. E hical Conside a ions
A he beginning o he o m, pa icipan s we e in o med abou he s udy’s pu pose,
and i was made clea ha by accessing and comple ing he o m, hey we e consen ing o
he use o he da a collec ed. Anonymi y, olun a y pa icipa ion, and he p ope use o he
da a we e gua an eed. Con ac de ails o he esea ch eam we e p o ided.
3. Resul s
The o al sample analyzed consis ed o 1060 midwi es. The s udy sample was p e-
dominan ly composed o 95.1% (n= 1008) women. The a e age age o he sample was
39.48 (9.4) yea s, wi h an a e age wo k expe ience o 12.33 (9.2) yea s. Rega ding aca-
demic quali ica ions, 87.9% (n= 932) o he pa icipan s held he RNI (Residen Nu se
In e n) quali ica ion om Spain. Conce ning con ac ype, 60.1% (n= 637) had in e im o
empo a y con ac s. In e ms o ac i i ies pe o med in he pas yea , 61.6% (n= 653) o
pa icipan s we e engaged in specialized ca e. The sociodemog aphic cha ac e is ics a e
shown in Table 1.
Table 1. Midwi es’ sociodemog aphic cha ac e is ics (n= 1060).
Va iable n(%)
Wo k Expe ience
<10 yea s 495 (46.7)
10–19 yea s 342 (32.3)
>20 yea s 223 (21.0)
Age
<30 yea s 196 (18.5)
30–44 yea s 587 (55.4)
45–65 yea s 274 (25.8)
Missing 3 (0.3)
Sex Men 52 (4.9)
Women 1008 (95.1)
Midwi e y Academic Backg ound
RNI Spain 932 (87.9)
Non-Spanish Uni e si y 97 (9.2)
O he 31 (2.9)
Con ac Type
In e im 319 (30.1)
Tempo a y 318 (30.0)
Pe manen 403 (38.0)
Sel -employed 20 (1.9)
Heal hca e sec o Public heal hca e 1013 (95.6)
P i a e heal hca e 47 (4.4)
Main P ac ice
Hospi al ca e 653 (61.6)
P ima y ca e/ambula o y clinic 378 (35.7)
Home bi h/bi hing cen e 11 (1.0)
O he ( eaching, esea ch, managemen ) 18 (1.7)
RNI: Residen Nu se In e n (Spain).
Heal hca e 2024,12, 1994 5 o 12
Table 2p esen s he desc ip i e esul s ega ding midwi es’ pe cep ions o au onomy.
In ela ion o he pe cep ion o au onomy, 92.7% (n= 982) o midwi es ag ee o s ongly
ag ee ha hey ad oca e o sexual and ep oduc i e igh s. A u he 96% (n= 1018)
ag ee o s ongly ag ee ha hey p omo e na u al childbi h. On he o he hand, only
22.8% (
n= 242
) ag ee o s ongly ag ee ha he eam is led by midwi es, and a me e 17.2%
(n= 182
) belie e ha hei manage s alue hei wo k. Rega ding Con inuing Educa ion
and Au onomy, 49.2% (n= 522) ag ee o s ongly ag ee ha hey ecei e adequa e con inu-
ing educa ion, and 53.7% (n= 569) eel au onomous in hei wo k. Conce ning wo kload
and wo k–li e balance, 63.6% (n= 674) disag ee o s ongly disag ee ha he wo kload
is app op ia e, and 46.3% (n= 491) eel hey can e ec i ely balance hei pe sonal and
p o essional li es. Las ly, ega ding he in en ion o lea e he p o ession, 53% (n= 561) ha e
conside ed lea ing he p o ession in he las yea . The eliabili y analysis showed an Omega
coe icien o 0.88 and a C onbach’s Alpha o 0.89, indica ing good in e nal consis ency.
Table 2. Midwi es’ pe cep ion o au onomy (n= 1060).
S ongly
Disag ee Disag ee Nei he Ag ee
no Disag ee Ag ee S ongly
Ag ee
I em n(%) n(%) n(%) n(%) n(%)
In my wo k, I ad oca e o women’s sexual and
ep oduc i e igh s 25 (2.4) 14 (1.3) 39 (3.7) 374 (35.3) 608 (57.4)
One goal o my p o ession is o p omo e he physiological p ocess
o childbi h 22 (2.1) 7 (0.7) 14 (1.3) 220 (20.8) 707 (75.2)
I wo k in a eam led by midwi es 315 (29.7) 339 (32.0) 164 (15.5) 155 (14.6) 87 (8.2)
I ha e he adequa e aining o de elop my p o ession a all le els
(ca e, eaching, and esea ch) 30 (2.8) 179 (16.9) 152 (14.3) 440 (41.5) 259 (24.4)
I ha e he skills and knowledge necessa y o pe o m my ole 14 (1.3) 12 (1.1) 33 (3.1) 494 (46.6) 507 (47.8)
Manage s alue me and ecognize my con ibu ion o he sexual
and ep oduc i e heal h ca e o women 301 (28.4) 344 (32.5) 233 (22.0) 146 (13.8) 36 (3.4)
I ha e he suppo and endo semen o my managemen 238 (22.5) 316 (29.8) 300 (28.3) 168 (15.8) 38 (3.6)
I ha e access o he necessa y equipmen and esou ces o wo k
wi h quali y 78 (7.4) 271 (25.6) 229 (21.6) 414 (39.1) 68 (6.4)
I ha e adequa e access o con inuing educa ion esou ces 78 (7.4) 244 (23.0) 217 (20.5) 427 (40.3) 94 (8.9)
I am ecognized as a p o essional by he medical eam 56 (5.3) 143 (13.5) 204 (19.2) 511 (48.2) 146 (13.8)
The medical eam ecognizes my con ibu ion o he sexual and
ep oduc i e heal h ca e o women 102 (9.6) 271 (25.6) 277 (26.1) 344 (32.5) 66 (6.2)
In my wo k, he e is a hie a chical ela ionship o subo dina ion o
midwi es o medical p o essionals 35 (3.3) 164 (15.5) 206 (19.4) 403 (38.0) 252 (23.8)
I ha e he suppo o my colleagues in he mul idisciplina y eam
43 (4.1) 182 (17.2) 312 (29.4) 426 (40.2) 97 (9.2)
In my wo k, I am able o e use o pe o m p ac ices I conside
unnecessa y o ha m ul 41 (3.9) 251 (23.7) 240 (22.6) 414 (39.1) 114 (10.8)
I am au onomous in my wo k 48 (4.5) 207 (19.5) 236 (22.3) 450 (42.5) 119 (11.2)
I eel com o able wi h he le el o esponsibili y equi ed by
my job 41 (3.9) 168 (15.8) 132 (12.5) 527 (49.7) 192 (18.1)
I am asked o pa icipa e in c ea ing p o ocols ha I will use in my
daily wo k 147 (13.9) 262 (24.7) 204 (19.2) 321 (30.3) 126 (11.9)
In my job, I apply p o ocols based on high-quali y scien i ic
e idence ha a e pe iodically e iewed 106 (10.0) 217 (20.5) 195 (18.4) 388 (36.6) 154 (14.5)
Con lic s be ween he medical model and he midwi e y model in
ca ing o women a e common in my job 55 (5.2) 233 (22.0) 256 (24.2) 322 (30.4) 194 (18.3)
The e a e enough midwi es in my job, and he wo kload allows
me o pe o m my du ies wi h quali y 299 (28.2) 375 (35.4) 121 (11.4) 213 (20.1) 52 (4.9)
My job allows me o sa is ac o ily balance pe sonal and
p o essional li e 121 (11.4) 241 (22.7) 207 (19.5) 406 (38.3) 85 (8.0)
My igh s in case o p egnancy, ma e nal b eas eeding, ma e ni y,
o pa e ni y a e e ec i ely p o ec ed in my job 70 (6.6) 159 (15.0) 224 (21.1) 458 (43.2) 149 (14.1)
My wo king condi ions (sala y, b eaks, ype o con ac , wo kload)
a e digni ied 261 (24.6) 373 (35.2) 149 (14.1) 238 (22.5) 39 (3.7)
My p o ession is known and espec ed by socie y 67 (6.3) 328 (30.9) 260 (24.5) 360 (34.0) 45 (4.2)
Conside ed lea ing in las yea 292 (27.5) 270 (25.5) 132 (12.5) 209 (19.7) 157 (14.8)
Heal hca e 2024,12, 1994 6 o 12
Table 3desc ibes he wo k si ua ions a ec ing he p o essional en i onmen o he
su eyed midwi es. Rega ding p o essional in usion, 92.4% (n= 978) o he midwi es
pe cei e ha hei p o ession equen ly su e s om in usion. Mo eo e , 46.6% (n= 494)
ha e expe ienced sexis beha io s, and 82.5% (n= 875) ha e encoun e ed classis a i udes.
A o al o 13.8% (n= 146) epo ha ing su e ed ha assmen , and 26.9% (n= 285) o he
esponden s eel ha hey a e ea ed wi h dis espec . Also, 51.1% (n= 541) o he midwi es
eel ha hei p o essional opinions a e ques ioned.
Table 3. Wo k si ua ions expe ienced by midwi es (n= 1060).
Si ua ion Yes n(%) No n(%)
My p o ession equen ly su e s om in usion 979 (92.4) 81 (7.6)
I ha e expe ienced sexis beha io s 494 (46.6) 566 (53.4)
I ha e expe ienced classis a i udes 874 (82.5) 186 (17.5)
I ha e su e ed ha assmen 146 (13.8) 914 (86.2)
I am ea ed wi h dis espec 285 (26.9) 775 (73.1)
My p o essional opinion is ques ioned 542 (51.1) 518 (48.9)
Table 4shows signi ican posi i e eelings and pe cep ions abou he wo k en i on-
men , such as eeling accomplished, ecognized, happy, and sa is ied, alongside no able
conce ns abou s ess, exhaus ion, and a pe cep ion o a hos ile and chao ic en i onmen .
Posi i e pe cep ions a e signi ican , wi h 53.2% (n= 564) inding he en i onmen qui e co -
dial and 46.3% (n= 491) eeling qui e accomplished. In con as , nega i e pe cep ions and
eelings a e also p ominen , wi h 40.3% (n= 427) inding he en i onmen qui e s ess ul
and 35.5% (n= 376) eeling qui e exhaus ed.
Table 4. Ques ions abou wo k en i onmen (n= 1060).
Ve y Li le n(%) Li le n(%) Qui e a Lo n(%) Much n(%) Always n(%)
Wo k
En i onmen
Hos ile 440 (41.5) 395 (37.3) 158 (14.9) 54 (5.1) 13 (1.2)
Chao ic 273 (25.8) 466 (44.0) 245 (23.1) 64 (6.0) 12 (1.1)
Co dial 36 (3.4) 168 (15.8) 564 (53.2) 234 (22.1) 58 (5.5)
S ess ul 102 (9.6) 337 (31.8) 427 (40.3) 154 (14.5) 40 (3.8)
Mo i a ing 135 (12.7) 433 (40.8) 348 (32.8) 116 (10.9) 28 (2.6)
Dep essing 436 (41.1) 381 (35.9) 171 (16.1) 57 (5.4) 15 (1.4)
Daily Feelings
Accomplished 61 (5.8) 206 (19.4) 491 (46.3) 251 (23.7) 51 (4.8)
O e looked 415 (39.2) 424 (40.0) 169 (15.9) 44 (4.2) 8 (0.8)
Fed Up 205 (19.3) 385 (36.3) 292 (27.5) 150 (14.2) 28 (2.6)
Recognized 119 (11.2) 406 (38.3) 392 (37.0) 120 (11.3) 23 (2.2)
Exhaus ed 105 (9.9) 327 (30.8) 376 (35.5) 204 (19.2) 48 (4.5)
Happy 38 (3.6) 243 (22.9) 475 (44.8) 251 (23.7) 53 (5.0)
Fea ul 412 (40.0) 424 (40.0) 168 (15.8) 47 (4.4) 9 (0.8)
Ang y 249 (23.5) 421 (39.7) 242 (22.8) 126 (11.9) 22 (2.1)
Bu ned Ou 210 (19.8) 381 (35.9) 254 (24.0) 171 (16.1) 44 (4.2)
Sa is ied 56 (5.3) 290 (27.4) 435 (41.0) 222 (20.9) 57 (5.4)
Powe less 179 (16.9) 335 (31.6) 272 (25.7) 224 (21.1) 50 (4.7)
Table 5shows a compa a i e analysis o midwi es’ expe iences ega ding hei so-
ciodemog aphic and occupa ional a iables. Rega ding p o essional in usion, he e a e
s a is ically signi ican di e ences ela ed o age, wi h a highe pe cep ion o in usion in
he 31–45 yea s g oup (p< 0.001). Addi ionally, men pe cei e less in usion compa ed o
women (p= 0.031).
Heal hca e 2024,12, 1994 7 o 12
Table 5. Dis ibu ion o midwi es’ expe iences and conside a ion o lea ing he p o ession by sociodemog aphic a iables (n= 1060).
In usi eness Sexism Classism Ha assmen Dis espec Ques ioning Abandonmen
No Yes No Yes No Yes No Yes No Yes No Yes No Yes
Va iable n(%) n(%) p*n(%) n(%) p*n(%) n(%) p*n(%) n(%) p*n(%) n(%) p*n(%) n(%) p*n(%) n(%) p*
Wo k Expe ience
<10 yea s 30 (37.0) 465 (47.5)
0.186
244 (43.1) 251 (50.8)
<0.001
61 (32.8) 434 (49.7)
<0.001
435 (47.6) 60 (41.1)
0.212
349 (45.0) 146 (51.2)
0.002
191 (46.2) 116 (37.3)
<0.001
284 (40.9) 211 (57.7)
<0.001
10–19 yea s 30 (37.0) 312 (31.9) 178 (31.4) 164 (33.2) 61 (32.8) 281 (32.2) 286 (31.3) 56 (38.4) 242 (31.2) 100 (35.1) 135 (32.7) 104 (33.4) 239 (34.4) 103 (28.1)
>20 yea s 21 (26.0) 202 (20.6) 144 (25.4) 79 (16.0) 64 (34.4) 159 (18.2) 193 (21.1) 30 (20.5) 184 823.7) 39 (13.7) 87 (21.1) 91 (29.3) 171 (24.6) 52 (14.2)
Age
<30 yea s 13 (16.0) 183 (19.0)
<0.001
93 (16.5) 103 (20.9)
<0.001
16 (8.7) 180 (20.6)
<0.001
176 (19.3) 20 (13.7)
0.268
138 (17.9) 58 (20.4)
0.028
84 (20.3) 35 (11.3)
<0.001
117 (16.9) 79 (21.6)
<0.001
30–44 yea s 32 (39.5) 555 (57.0) 295 (52.4) 292 (59.1) 88 (47.8) 499 (57.2) 501 (55.0) 86 (58.9) 417 (54.0) 170 (59.6) 218 (52.8) 168 (54.4) 368 (55.3) 219 (59.8)
45–65 yea s 36 (4.5) 238 (24.0) 175 (31.1) 99 (20-0) 80 (43.5) 194 (22.2) 234 (25.7) 40 (27.4) 217 (28.1) 57 (20.0) 111 (26.9) 106 (34.3) 206 (29.8) 68 (18.6)
Sex
Men 8 (9.9) 44 (4.5) 0.031 29 (5.1) 23 (4.7) 0.725 14 (7.5) 38 (4.3) 0.068 41 (4.5) 11 (7.5) 0.113 34 (4.4) 18 (6.3) 0.197 16 (3.9) 16 (5.1) 0.413 31 (4.5) 21 (5.7) 0.362
Women 73 (90.1) 935 (95.5) 537 (94.9) 471 (95.3) 172 (92.5) 836 (95.7) 873 (95.5) 135 (92.5) 741 (95.6) 267 (93.7) 397 (96.1) 295 (94.9) 663 (95.5) 345 (94.3)
Con ac Type
In e im 27 (33.3) 292 (29.8)
0.197
182 (32.2) 137 (27.7)
<0.001
65 (34.9) 254 (29.1)
<0.001
279 (30.5) 40 (27.4)
0.002
239 (30.8) 80 (28.1)
0.153
128 (31.0) 98 (31.5)
<0.001
199 (28.7) 120 (32.8)
<0.001
Tempo a y 18 (22.3) 300 (30.6) 139 (24.6) 179 (36.2) 33 (17.7) 285 (32.6) 282 (30.9) 36 (24.7) 221 (28.5) 97 (34.0) 127 (30.8) 61 (19.6) 178 (25.6) 140 (38.3)
Pe manen 36 (44.4) 367 (37.6) 236 (41.7) 167 (33.8) 82 (44.1) 321 (36.7) 341 (37.3) 62 (42.5) 303 (39.1) 100 (35.1) 152 (36.8) 147 (47.3) 308 (44.4) 95 (26.0)
Sel -employed 0 (0.0) 20 (2.0) 9 (1.6) 11 (2.2) 6 (3.2) 14 (1.6) 12 (1.3) 8 (5.5) 12 (1.5) 8 (2.8) 6 (1.5) 5 (1.6) 9 (1.3) 11 (3.0)
Main P o essional Field
Public heal hca e 3 (3.7) 44 (4.5) 0.74 20 (3.5) 27 (5.5) 0.127 12 (6.5) 35 (4.0) 0.141 35 (3.8) 12 (8.2) 0.017 32 (4.1) 15 (5.3) 0.426 17 (4.1) 11 (3.5) 0.392 21 (3.0) 26 (7.1) 0.002
P i a e heal hca e 78 (96.3) 935 (95.5) 546 (96.5) 467 (64.5) 174 (93.5) 839 (96.0) 879 (96.2) 134 (91.8) 743 (95.9) 270 (94.7) 396 (95.9) 300 (96.5) 673 (97.0) 340 (92.9)
Main P ac ice
Home Bi h Ca e 1 (1.2) 8 (0.8)
0.561
4 (0.7) 5 (1.0)
0.064
3 (1.6) 6 (0.7)
<0.001
5 (0.5) 4 (2.7)
0.009
6 (0.8) 3 (1.1)
<0.001
2 (0.5) 4 (1.3)
<0.001
6 (0.9) 3 (0.8)
<0.001
Hospi al Ca e 42 (52.0) 611 (62.4) 329 (58.1) 324 (65.6) 80 (43.0) 573 (65.6) 551 (60.3) 102 (69.9) 447 (57.7) 206 (72.3) 223 (54.0) 173 (55.6) 390 (56.2) 263 (71.9)
P ima y Ca e/Ambula o y Clinic 36 (44.4) 342 (34.9) 222 (39.2) 156 (31.6) 97 (52.2) 281 (32.2) 340 (37.2) 38 (26.0) 305 (39.4) 73 (25.6) 180 (43.6) 126 (4.5) 283 (40.8) 95 (26.0)
Bi h Cen e 0 (0.0) 2 (0.1) 0 (0.0) 2 (0.4) 1 (0.5) 1 (0.1) 2 (0.2) 0 (0.0) 2 (0.3) 0 (0.0) 0 (0.0) 1 (0.3) 2 (0.3) 0 (0.0)
Teaching/Resea ch 1 (1.2) 7 (0.7) 4 (0.7) 4 (0.8) 2 (1.1) 6 (0.7) 8 (0.9) 0 (0.0) 8 (1.0) 0 (0.0) 6 (1.5) 2 (0.6) 6 (0.9) 2 (0.5)
O he 1 (1.2) 9 (0.9) 7 (1.2) 3 (0.6) 3 (1.6) 7 (0.8) 8 (0.9) 2 (1.4) 7 (0.9) 3 (1.1) 2 (0.5) 5 (1.6) 7 (1.0) 3 (0.8)
* Chi-squa ed es .
Heal hca e 2024,12, 1994 8 o 12
In e ms o sexism, signi ican di e ences we e ound, wi h a highe pe cep ion o
sexism in he g oups wi h less han 10 yea s and 10-20 yea s o expe ience (p< 0.001), in
he 31–45 yea s g oup (p< 0.001), and in midwi es wi h empo a y con ac s (p< 0.001).
Rega ding classism, a highe pe cep ion is obse ed in he g oups wi h less han
10 yea s
and mo e han 20 yea s o expe ience (p< 0.001), in he 31–45 yea s and >46 yea s
g oups (p< 0.001), in midwi es wi h empo a y con ac s (p< 0.001), and in hose who
ha e wo ked in p ima y ca e in he pas yea (p< 0.001).
Fo ha assmen , a highe incidence is pe cei ed in he 31–45 yea s g oup (p< 0.001), in
empo a y con ac s (p= 0.002), in public heal h (p= 0.017), and in hospi al ca e (p= 0.009).
Finally, he ques ioning a iable shows s a is ically signi ican di e ences in he g oups
wi h less han 10 yea s and mo e han 20 yea s o expe ience (p< 0.001), in he <=30 yea s
and 31–45 yea s g oups (p< 0.001), in midwi es wi h empo a y con ac s (p< 0.001), and
in hose wo king in hospi al ca e (p< 0.001).
The esul s o he compa a i e analysis ega ding he in en ion o lea e he p o ession.
Midwi es wi h less han 10 yea s o expe ience (57.7%), hose in he 31–45 age g oup
(59.8%), hose wi h empo a y con ac s (38.3%), and hose wo king in hospi al ca e (71.9%)
show he highes a es o conside ing lea ing he p o ession (p< 0.001).
4. Discussion
The pu pose o his s udy was o unde s and he le el o au onomy pe cei ed by mid-
wi es wo king in Spain, as well as o analyze he a iables associa ed wi h he de elopmen
o au onomy.
P e ious s udies ha e highligh ed ha midwi es’ au onomy emains a ague and
di icul - o-de ine concep a a gene al le el [
19
], and i is de e mined by he legal, cul u al,
and p o essional con ex o each coun y [
20
]. In he mos ecen de ini ion o he e m,
i e key hemes we e iden i ied: adequa e educa ion, compe ence, expe ience, quali y ca e,
and collabo a ion wi h s akeholde s, emphasizing he need o in e p o essional educa ion
o s eng hen midwi es’ collabo a ion and au onomy [
21
]. Howe e , his e m was no
de ined o s udied in Spain un il 2023, es ablishing i as a no el a ea ha equi es u he
esea ch [22].
Rega ding he p o essional p o ile o he s udy pa icipan s, we ound p o essionals
p ima ily ained in Spain wi h an a e age o 10 yea s o p o essional expe ience and job
s abili y. These aspec s may con ibu e o a deepe analysis o he eali y o midwi es’
au onomy. Simila o s udies conduc ed in o he coun ies, midwi es a e iden i ied as
well- ained, con iden , and compe en in hei p o essional ole, especially when gi en he
oppo uni y o wo k in a suppo i e en i onmen [23–25].
The wo kplace, whe he hospi al o p ima y ca e, can signi ican ly in luence midwi es’
pe cep ion o au onomy. In his s udy, we ound ha au onomy ends o be lowe in hospi al
se ings, a esul simila o o he au ho s [26,27].
This s udy also iden i ied ha in e p o essional hie a chical ela ionships cons i u e
a signi ican ba ie o achie ing p o essional au onomy. Midwi es who pa icipa ed in
his s udy iden i ied a eas o imp o emen in managemen suppo and collabo a ion
wi h o he p o essional g oups, eeling inadequa ely suppo ed by hem [
19
,
26
,
28
]. Thus,
suppo i e ela ionships and quali y leade ship a e pe cei ed as empowe ing and p omo e
p o essional de elopmen . The e o e, well-implemen ed supe ision o coo dina ion,
aimed a p o essional suppo a he han igo ous moni o ing and con ol o employees’
ac ions, can imp o e bo h he p o essional and pe sonal de elopmen o midwi es [
29
,
30
].
The esul s o his s udy show ha midwi es iden i ied he need o be mo e ac i e in
de eloping p o ocols, as e lec ed in hei compe encies [
4
]. They a e no always included
in wo king g oups es ablished o de elop hese p o ocols, and hei pa icipa ion is o en
limi ed. Howe e , when midwi es a e included in pa icipa ion, planning, and decision-
making p ocesses, bo h clinical p ac ice and p o essional sa is ac ion imp o e [30,31].
Among he ba ie s iden i ied o op imal p o essional de elopmen o midwi es a e
wo king condi ions, amily econcilia ion, and pe cei ed p o essional in usion. These
Heal hca e 2024,12, 1994 9 o 12
ba ie s ha e a signi ican impac on midwi es’ daily p ac ice and hei pe cep ions o
au onomy [
3
]. Fo example, p eca ious wo king condi ions, such as a lack o esou ces and
s a , o ce midwi es o ake on excessi e wo kloads, which no only a ec s hei physical
and men al well-being bu also limi s hei abili y o p ac ice au onomously, be woman-
cen e ed, and p o ide a con inuum o ca e [
13
]. This si ua ion is consis en wi h indings
om o he s udies [
5
,
6
], which obse e how wo k–li e balance is a cons an conce n o
midwi es, a ec ing job sa is ac ion and commi men o he p o ession.
To gain deepe insigh s in o how hese speci ic ba ie s a ec midwi es’ daily p ac ice,
i is c ucial o conside di ec examples o hei expe iences. The esul s o his s udy showed
ha lack o suppo and ecogni ion om supe iso s limi s he abili y o make au onomous
decisions in childbi h ca e, o cing adhe ence o igid p o ocols ha do no always mee
he indi idual needs o women [
32
,
33
]. On he o he hand, p o essional in usion esul ing
om a sho age o midwi es [
16
] p e en s hem om ully de eloping hei compe encies,
nega i ely a ec ing hei con idence and p o essional sa is ac ion [
34
,
35
], dilu ing he
quali y o ca e, c ea ing in e p o essional con lic s, and a ec ing he wo k en i onmen .
Mo e s udies a e needed o de e mine his inding in Spain.
Mo e han hal o he s udy pa icipan s wi h less han 10 yea s o wo k expe ience
ha e conside ed lea ing he p o ession a some poin ; a simila pe cen age was ound
in Aus alia [
32
]. I is obse ed ha wi h g ea e p o essional expe ience, he e is less
desi e o lea e he p o ession. P e ious s udies ha e iden i ied causes such as sexism,
classism, and lack o espec , which con ibu e o an un a o able wo k en i onmen o
he p o essional de elopmen o midwi es [
32
]. These indings a e consis en wi h he
esul s o ou esea ch. Addi ionally, a lack o s a and esou ces has been iden i ied as a
signi ican s ess ac o con ibu ing o an unheal hy wo k en i onmen [12].
Job p eca iousness has also been highligh ed in his esea ch as a de e minan o wo k
bu nou , wi h midwi es expe iencing g ea e job ins abili y being mo e likely o ques ion
hei con inued p esence in he p o ession [
32
,
34
]. Age and p o essional expe ience seem o
in luence he pe cep ion o si ua ions in ol ing classism, sexism, p o essional in usion, and
ques ioning o hei p o essional opinions. Midwi es wi h mo e yea s o wo k expe ience
eel mo e us a ed by he lack o ecogni ion and suppo , in luenced by powe and
gende dynamics in he wo kplace. Con e sely, younge midwi es a e mo e likely o
eel o e whelmed and less ecognized, leading hem o ques ion hei compe ence mo e
easily [7]. Fu he esea ch is needed on hese indings.
The s udy demons a ed high in e nal consis ency o he ad hoc su ey used o assess
midwi es’ pe cep ions o au onomy in Spain, as e idenced by a obus Omega coe icien
and C onbach’s Alpha. This sugges s ha he su ey i ems we e cohesi e and e ec i ely
measu ed he cons uc o au onomy. The Pe cep ion o Empowe men in Midwi e y Scale
(PEMS) o iginally de eloped in 2007 [
36
] and e ised in 2015 (PEMS-R) [
37
], has been
adap ed o a ious languages, including I alian, Po uguese, and Pe sian [
38
–
40
]. Howe e ,
he lack o a simila ool in Spanish has posed challenges in assessing midwi es’ empowe -
men wi hin he Spanish con ex . A e ou da a collec ion was comple ed, González-de
la To e e al. ansla ed and alida ed he PEMS scale in o Spanish [
22
]. Howe e , his
e sion was no u ilized in ou s udy, as ou esea ch had al eady concluded by ha ime. I
is impo an o no e ha ou p ima y aim was no o ansla e, cul u ally adap , o alida e
he PEMS o PEMS-R o Spanish midwi es. Ins ead, ou s udy aimed o p o ide a mo e
comp ehensi e unde s anding o au onomy by inco po a ing addi ional a iables speci ic
o he Spanish midwi e y con ex .
Among he limi a ions o his s udy is he po en ial o esponse bias due o olun a y
o mo i a ed pa icipa ion, as midwi es wi h mo e pola ized expe iences in he p o ession,
whe he posi i e o nega i e, may be mo e in e es ed in comple ing he ques ionnai e.
Those wi h mo e neu al o less in ense expe iences a e less likely o espond [
8
]. The
esponses p o ided by pa icipan s may no be ep esen a i e o he midwi es’ communi y
in Spain, canno be gene alized due o olun a y pa icipa ion, and should be in e p e ed
wi h cau ion. Addi ionally, we did no pe o m p io powe calcula ions, which is pa icu-
