Work Situation of Midwives in Spain: Perception of Autonomy and Intention to Leave the Profession: A Cross-Sectional Study

Citation: Iglesias-Casás, S.; Vila-Candel, R.; Mena-Tudela, D.; Martín-Arribas, A.; Leon-Larios, F. Work Situation of Midwives in Spain: Perception of Autonomy and Intention to Leave the Profession: A Cross-Sectional Study. Healthcare 2024, 12, 1994. https://doi.org/10.3390/ healthcare12191994 Academic Editor: Masafumi Koshiyama Received: 11 September 2024 Revised: 2 October 2024 Accepted: 4 October 2024 Published: 6 October 2024 Copyright: © 2024 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/). healthcare Article Work Situation of Midwives in Spain: Perception of Autonomy and Intention to Leave the Profession: A Cross-Sectional Study Susana Iglesias-Casás1, Rafael Vila-Candel 2,3,4,5,* , Desirée Mena-Tudela 5,6 , Anna Martín-Arribas 7 and Fátima Leon-Larios 8 1Primary Care Management of Tenerife, 38650 Tenerife, Spain; [email protected] 2Faculty of Health Sciences, Universidad Internacional de Valencia (VIU), 46002 Valencia, Spain 3La Ribera Primary Health Department, 46600 Alzira, Spain 4Foundation for the Promotion of Health and Biomedical Research in the Valencian Region (FISABIO), 46020 Valencia, Spain 5PECAWOL (Perinatal care and Women’s Health), Joint Research Unit FISABIO-UJI, 46020 Valencia, Spain; [email protected] 6 Nursing Department, Health Science Faculty, Instituto Feminista, Universitat Jaume I, 12071 Castellón, Spain 7 Ghenders Research Group, School of Health Sciences Blanquerna, Universitat Ramon Llull, 08025 Barcelona, Spain; [email protected] 8Nursing Department, School of Nursing, Physiotherapy and Podiatry, University of Seville, 41009 Seville, Spain; [email protected] *Correspondence: [email protected] or [email protected] Abstract: Background: Developed countries report specific issues regarding the declining midwifery workforce, and their shortage could have serious consequences for women’s sexual and reproductive health. The aim was to understand the perception of autonomy among midwives working in Spain, as well as factors related to their intention to leave the profession and their work environment. Method: A descriptive and cross-sectional study using an online questionnaire. Population: midwives working in Spain in any field (clinical, research, teaching, or management). Results: A sample of 1060 midwives was obtained. Of these, 53.7% (n= 569) feel autonomous in their work, 92.4% (n= 978 ) perceive that their profession frequently suffers from external interference, 46.6% (n= 494) have experienced sexist behaviors at work, and 53% (n= 561) have considered leaving the profession in the last year. Midwives with less than 10 years of experience (57.7%), those aged 31–45 years (59.8%), those with temporary contracts (38.3%), and those working in hospital care (71.9%) show a higher rate of considering leaving the profession (p< 0.001). Conclusions: Considering the current midwifery workforce crisis in Spain, it seems urgent to improve the working conditions of midwives to ensure the continuity and quality of women’s sexual and reproductive healthcare. Keywords: midwifery workforce; job autonomy; job satisfaction; quality of healthcare; workplace environment; continuity of care 1. Introduction The midwife, as a professional figure of reference, contributes to the survival, improvement in health, and well-being of women and their newborns [ 1 , 2 ]. In 2023, the Bucharest Declaration called for political action and a commitment to protect, support, and invest in healthcare workers across Europe and Central Asia, as well as to address the pressing challenges facing this group [3,4]. Developed countries are reporting specific issues regarding the decline in the midwifery workforce or doubts about whether their numbers are sufficient to meet the current or future needs of the population [5–7]. The shortage of midwives could have serious consequences for the care of women during pregnancy, childbirth, and the early parenting period [ 8 , 9 ]. It has been documented that, in countries with low development indices, interventions provided by midwives Healthcare 2024,12, 1994. https://doi.org/10.3390/healthcare12191994 https://www.mdpi.com/journal/healthcare Healthcare 2024,12, 1994 2 of 12 through basic universal coverage could prevent 41% of maternal deaths, 39% of neonatal deaths, and 26% of stillbirths, which equates to 2.2 million avoidable deaths annually [ 10 ]. The International Confederation of Midwives (ICM) defined midwives’ autonomy as their ability to determine and control the standards for their own education, regulation, and practice, recognizing that in some countries, midwives face difficulties in this area due to medical hierarchies, government authorities seeking to control and limit the scope of their work, and the misuse of healthcare policies and protocols [11]. It has been recommended that midwives’ roles be expanded, along with an improvement in their working environment, support for their emotional well-being, adequate recognition and salaries, and their inclusion in policy development and leadership roles to ensure proper staffing of the profession [ 1 ]. Factors such as excessive workload staff shortages, inability to provide continuity of midwifery care, harassment, and lack of effective managerial support have been described as determinants of midwives’ emotional well-being [ 12 , 13 ]. There is a link between high levels of emotional distress and the intention to leave the profession [ 14 ]. Other obstacles, such as healthcare systems dominated by the medical model, lack of financial resources to adequately staff teams, and gender biases (the midwifery profession is highly feminized), prevent them from reaching their full potential [15]. In Spain, the competencies of midwives include a wide range of responsibilities focused on women’s sexual and reproductive health [ 16 ]. The current ratio is 6.1 midwives per 10,000 women aged 14–65, which is lower than the European median of 9.1. This low national ratio limits their availability to fully exercise all their professional competencies, meaning that the healthcare system cannot offer equitable and comprehensive sexual and reproductive healthcare. The Federation of Spanish Midwives (FAME) and the Spanish Midwives Association (AEM) have recently warned about the current shortage of midwives, as well as the lack of planning to ensure generational turnover, calling on the government to take an active and responsible role [16,17]. Given the current context, the main objective of this study was to understand the perception of autonomy among midwives working in Spain. As secondary objectives, we aimed to analyze the differences in their intention to leave the profession according to sociodemographic and professional variables and to explore certain aspects of their work environment. 2. Materials and Methods 2.1. Design A descriptive, cross-sectional study was conducted using an online questionnaire. The questionnaire was hosted on a secure platform (Google Forms©) and was available from 7 February to 8 March 2023, after which it was closed to prevent further responses. Data collection allowed only one response per user, and participants were required to agree to the terms (purpose of the research, the voluntary nature of participation, and assurances regarding data privacy) to proceed before beginning the survey. 2.2. Study Population Midwives practicing in Spain in any field (clinical, research, teaching, or management) agreed to participate in the study. The study was promoted by the Canary Islands Midwives Association (ACAMAT), which contacted all nursing colleges and midwifery associations in Spain via email, requesting their collaboration in disseminating the survey and explaining its objectives. The questionnaire was distributed via email and social media. The study population consisted of 8084 midwives actively working in Spain as of 31 December 2022 [ 16 ]. A total of 1060 midwives participated in the survey, representing 13.1% of the registered midwives in the country. The online survey was primarily disseminated through nursing colleges that chose to collaborate by sharing the survey link via their social media channels, encouraging their members to participate. The inclusion criteria required participants to be active midwives in Spain during the study period and to agree on the Healthcare 2024,12, 1994 3 of 12 terms of survey. Exclusion criteria specified that the survey targeted only those currently practicing in Spain. To ensure data completeness, all survey items were mandatory, and incomplete responses were not accepted. 2.3. Variables and Data Collection Tool An ad hoc electronic form was designed and organized into four distinct parts: (1) Sociodemographic and professional data of the participants: gender (woman/man), age (in full years), autonomous community of residence, years of work experience (in full years), healthcare sector (public healthcare/private healthcare), midwifery academic background (Resident Nurse Intern—RNI in Spain, non-Spanish university, or other), type of contract (interim, temporary, permanent, or self-employed), main practice (hospital care, primary care/ambulatory clinic, home birth/birthing center, or other: teaching, research, or management) (2) Perception of midwives’ autonomy, selected by the research team after reviewing the available literature on the subject [ 18 – 21 ]. The 25 items included in this section were rated on a Likert scale from 1 to 5 (5 strongly agree–1 strongly disagree). (3) Work environment evaluation: harassment (refers to whether the participant has experienced or witnessed workplace harassment), sexism (evaluates whether there are sexist and discriminatory attitudes, comments, or behaviors based on gender), questioning (refers to whether the worker feels that her work, decisions, or abilities are constantly doubted without justified reason), disrespect (examines whether the worker has been treated disrespectfully by superiors, colleagues, or subordinates), intrusiveness (refers to the presence of individuals performing tasks or roles for which they are not qualified, creating an inappropriate work environment). All these variables had dichotomous (yes/no) responses, and their definitions were provided to the participants. Additionally, questions were included on perceived work environment: hostile (describes a competitive and conflict-prone environment), chaotic (indicates a disorganized environment with a lack of structure), depressing (describes an environment that demotivates and negatively affects employees’ mood), stressful (describes a high-pressure environment where employees feel constantly overwhelmed), cordial (reflects a friendly and collaborative work environment), motivating (refers to an environment that encourages employees to improve and achieve their goals). Finally, there were questions about midwives’ feelings towards their workplaces: accomplished (feeling that he/she is meeting her goals and realizing her potential), invalidated (feeling his/her abilities are being ignored or suppressed), exhausted (experiencing feelings of burnout or saturation), recognized (perceiving that his/her work is valued by others), tired (feeling physically or mentally exhausted), content (experiencing a sense of well-being and satisfaction), fearful (feeling fear, whether for her safety, job stability, or due to workplace conflicts), angry (experiencing anger or frustration due to workplace situations), burnt out (showing signs of emotional or physical exhaustion from work), satisfied (feeling satisfaction with her performance and outcomes), powerless (feeling he/she has no control or ability to influence workplace situations). For each feeling, participants could select from five categories (very little, little, quite a lot, a lot, always). In January 2023, a pilot survey was conducted with 10 participants, all midwives with over 15 years of work experience. The evaluation was positive in terms of item comprehension and acceptability, and no changes were made. Participants reported that it took about 5 min to complete the survey. 2.4. Data Analysis Descriptive statistics were used to analyze the characteristics of the sample, with the mean and standard deviation (SD) applied for quantitative variables and ranges and percentages for qualitative variables. Some variables were categorized to facilitate analysis and comprehension of the results, such as work experience (<10 years/10–19 years/ >20 years ) Healthcare 2024,12, 1994 4 of 12 and age (<30/30–44/45–65). To analyze the participants’ expressed intention to leave the profession, responses were grouped into two categories: Yes (agree/strongly agree) and No (neither agree nor disagree/disagree/strongly disagree). To assess the reliability of the questions used in the study, two internal consistency coefficients were calculated: McDonald’s Omega and Cronbach’s Alpha. The Chi-square test ( χ2 ) was used to describe the distribution of midwives’ experiences and the possibility of leaving the profession according to their sociodemographic variables. Data analysis was performed using the statistical software package SPSS v.28.0 (IBM Corp. 2018. IBM SPSS Statistics for Windows, Armonk, NY, USA). A p-value < 0.05 was considered statistically significant. 2.5. Ethical Considerations At the beginning of the form, participants were informed about the study’s purpose, and it was made clear that by accessing and completing the form, they were consenting to the use of the data collected. Anonymity, voluntary participation, and the proper use of the data were guaranteed. Contact details for the research team were provided. 3. Results The total sample analyzed consisted of 1060 midwives. The study sample was predominantly composed of 95.1% (n= 1008) women. The average age of the sample was 39.48 (9.4) years, with an average work experience of 12.33 (9.2) years. Regarding academic qualifications, 87.9% (n= 932) of the participants held the RNI (Resident Nurse Intern) qualification from Spain. Concerning contract type, 60.1% (n= 637) had interim or temporary contracts. In terms of activities performed in the past year, 61.6% (n= 653) of participants were engaged in specialized care. The sociodemographic characteristics are shown in Table 1. Table 1. Midwives’ sociodemographic characteristics (n= 1060). Variable n(%) Work Experience <10 years 495 (46.7) 10–19 years 342 (32.3) >20 years 223 (21.0) Age <30 years 196 (18.5) 30–44 years 587 (55.4) 45–65 years 274 (25.8) Missing 3 (0.3) Sex Men 52 (4.9) Women 1008 (95.1) Midwifery Academic Background RNI Spain 932 (87.9) Non-Spanish University 97 (9.2) Other 31 (2.9) Contract Type Interim 319 (30.1) Temporary 318 (30.0) Permanent 403 (38.0) Self-employed 20 (1.9) Healthcare sector Public healthcare 1013 (95.6) Private healthcare 47 (4.4) Main Practice Hospital care 653 (61.6) Primary care/ambulatory clinic 378 (35.7) Home birth/birthing center 11 (1.0) Other (teaching, research, management) 18 (1.7) RNI: Resident Nurse Intern (Spain). Healthcare 2024,12, 1994 5 of 12 Table 2presents the descriptive results regarding midwives’ perceptions of autonomy. In relation to the perception of autonomy, 92.7% (n= 982) of midwives agree or strongly agree that they advocate for sexual and reproductive rights. A further 96% (n= 1018) agree or strongly agree that they promote natural childbirth. On the other hand, only 22.8% ( n= 242 ) agree or strongly agree that the team is led by midwives, and a mere 17.2% (n= 182 ) believe that their managers value their work. Regarding Continuing Education and Autonomy, 49.2% (n= 522) agree or strongly agree that they receive adequate continuing education, and 53.7% (n= 569) feel autonomous in their work. Concerning workload and work–life balance, 63.6% (n= 674) disagree or strongly disagree that the workload is appropriate, and 46.3% (n= 491) feel they can effectively balance their personal and professional lives. Lastly, regarding the intention to leave the profession, 53% (n= 561) have considered leaving the profession in the last year. The reliability analysis showed an Omega coefficient of 0.88 and a Cronbach’s Alpha of 0.89, indicating good internal consistency. Table 2. Midwives’ perception of autonomy (n= 1060). Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree Item n(%) n(%) n(%) n(%) n(%) In my work, I advocate for women’s sexual and reproductive rights 25 (2.4) 14 (1.3) 39 (3.7) 374 (35.3) 608 (57.4) One goal of my profession is to promote the physiological process of childbirth 22 (2.1) 7 (0.7) 14 (1.3) 220 (20.8) 707 (75.2) I work in a team led by midwives 315 (29.7) 339 (32.0) 164 (15.5) 155 (14.6) 87 (8.2) I have the adequate training to develop my profession at all levels (care, teaching, and research) 30 (2.8) 179 (16.9) 152 (14.3) 440 (41.5) 259 (24.4) I have the skills and knowledge necessary to perform my role 14 (1.3) 12 (1.1) 33 (3.1) 494 (46.6) 507 (47.8) Managers value me and recognize my contribution to the sexual and reproductive health care of women 301 (28.4) 344 (32.5) 233 (22.0) 146 (13.8) 36 (3.4) I have the support and endorsement of my management 238 (22.5) 316 (29.8) 300 (28.3) 168 (15.8) 38 (3.6) I have access to the necessary equipment and resources to work with quality 78 (7.4) 271 (25.6) 229 (21.6) 414 (39.1) 68 (6.4) I have adequate access to continuing education resources 78 (7.4) 244 (23.0) 217 (20.5) 427 (40.3) 94 (8.9) I am recognized as a professional by the medical team 56 (5.3) 143 (13.5) 204 (19.2) 511 (48.2) 146 (13.8) The medical team recognizes my contribution to the sexual and reproductive health care of women 102 (9.6) 271 (25.6) 277 (26.1) 344 (32.5) 66 (6.2) In my work, there is a hierarchical relationship of subordination of midwives to medical professionals 35 (3.3) 164 (15.5) 206 (19.4) 403 (38.0) 252 (23.8) I have the support of my colleagues in the multidisciplinary team 43 (4.1) 182 (17.2) 312 (29.4) 426 (40.2) 97 (9.2) In my work, I am able to refuse to perform practices I consider unnecessary or harmful 41 (3.9) 251 (23.7) 240 (22.6) 414 (39.1) 114 (10.8) I am autonomous in my work 48 (4.5) 207 (19.5) 236 (22.3) 450 (42.5) 119 (11.2) I feel comfortable with the level of responsibility required by my job 41 (3.9) 168 (15.8) 132 (12.5) 527 (49.7) 192 (18.1) I am asked to participate in creating protocols that I will use in my daily work 147 (13.9) 262 (24.7) 204 (19.2) 321 (30.3) 126 (11.9) In my job, I apply protocols based on high-quality scientific evidence that are periodically reviewed 106 (10.0) 217 (20.5) 195 (18.4) 388 (36.6) 154 (14.5) Conflicts between the medical model and the midwifery model in caring for women are common in my job 55 (5.2) 233 (22.0) 256 (24.2) 322 (30.4) 194 (18.3) There are enough midwives in my job, and the workload allows me to perform my duties with quality 299 (28.2) 375 (35.4) 121 (11.4) 213 (20.1) 52 (4.9) My job allows me to satisfactorily balance personal and professional life 121 (11.4) 241 (22.7) 207 (19.5) 406 (38.3) 85 (8.0) My rights in case of pregnancy, maternal breastfeeding, maternity, or paternity are effectively protected in my job 70 (6.6) 159 (15.0) 224 (21.1) 458 (43.2) 149 (14.1) My working conditions (salary, breaks, type of contract, workload) are dignified 261 (24.6) 373 (35.2) 149 (14.1) 238 (22.5) 39 (3.7) My profession is known and respected by society 67 (6.3) 328 (30.9) 260 (24.5) 360 (34.0) 45 (4.2) Considered leaving in last year 292 (27.5) 270 (25.5) 132 (12.5) 209 (19.7) 157 (14.8) Healthcare 2024,12, 1994 6 of 12 Table 3describes the work situations affecting the professional environment of the surveyed midwives. Regarding professional intrusion, 92.4% (n= 978) of the midwives perceive that their profession frequently suffers from intrusion. Moreover, 46.6% (n= 494) have experienced sexist behaviors, and 82.5% (n= 875) have encountered classist attitudes. A total of 13.8% (n= 146) report having suffered harassment, and 26.9% (n= 285) of the respondents feel that they are treated with disrespect. Also, 51.1% (n= 541) of the midwives feel that their professional opinions are questioned. Table 3. Work situations experienced by midwives (n= 1060). Situation Yes n(%) No n(%) My profession frequently suffers from intrusion 979 (92.4) 81 (7.6) I have experienced sexist behaviors 494 (46.6) 566 (53.4) I have experienced classist attitudes 874 (82.5) 186 (17.5) I have suffered harassment 146 (13.8) 914 (86.2) I am treated with disrespect 285 (26.9) 775 (73.1) My professional opinion is questioned 542 (51.1) 518 (48.9) Table 4shows significant positive feelings and perceptions about the work environment, such as feeling accomplished, recognized, happy, and satisfied, alongside notable concerns about stress, exhaustion, and a perception of a hostile and chaotic environment. Positive perceptions are significant, with 53.2% (n= 564) finding the environment quite cordial and 46.3% (n= 491) feeling quite accomplished. In contrast, negative perceptions and feelings are also prominent, with 40.3% (n= 427) finding the environment quite stressful and 35.5% (n= 376) feeling quite exhausted. Table 4. Questions about work environment (n= 1060). Very Little n(%) Little n(%) Quite a Lot n(%) Much n(%) Always n(%) Work Environment Hostile 440 (41.5) 395 (37.3) 158 (14.9) 54 (5.1) 13 (1.2) Chaotic 273 (25.8) 466 (44.0) 245 (23.1) 64 (6.0) 12 (1.1) Cordial 36 (3.4) 168 (15.8) 564 (53.2) 234 (22.1) 58 (5.5) Stressful 102 (9.6) 337 (31.8) 427 (40.3) 154 (14.5) 40 (3.8) Motivating 135 (12.7) 433 (40.8) 348 (32.8) 116 (10.9) 28 (2.6) Depressing 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) Overlooked 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) Exhausted 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) Fearful 412 (40.0) 424 (40.0) 168 (15.8) 47 (4.4) 9 (0.8) Angry 249 (23.5) 421 (39.7) 242 (22.8) 126 (11.9) 22 (2.1) Burned Out 210 (19.8) 381 (35.9) 254 (24.0) 171 (16.1) 44 (4.2) Satisfied 56 (5.3) 290 (27.4) 435 (41.0) 222 (20.9) 57 (5.4) Powerless 179 (16.9) 335 (31.6) 272 (25.7) 224 (21.1) 50 (4.7) Table 5shows a comparative analysis of midwives’ experiences regarding their sociodemographic and occupational variables. Regarding professional intrusion, there are statistically significant differences related to age, with a higher perception of intrusion in the 31–45 years group (p< 0.001). Additionally, men perceive less intrusion compared to women (p= 0.031). Healthcare 2024,12, 1994 7 of 12 Table 5. Distribution of midwives’ experiences and consideration of leaving the profession by sociodemographic variables (n= 1060). Intrusiveness Sexism Classism Harassment Disrespect Questioning Abandonment No Yes No Yes No Yes No Yes No Yes No Yes No Yes Variable n(%) n(%) p*n(%) n(%) p*n(%) n(%) p*n(%) n(%) p*n(%) n(%) p*n(%) n(%) p*n(%) n(%) p* Work Experience <10 years 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 years 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 years 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 years 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 years 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 years 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) Contract Type Interim 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 Temporary 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) Permanent 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) Self-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 Professional Field Public healthcare 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 Private healthcare 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 Practice Home Birth Care 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 Hospital Care 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) Primary Care/Ambulatory 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) Birth Center 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/Research 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) Other 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-squared test. Healthcare 2024,12, 1994 8 of 12 In terms of sexism, significant differences were found, with a higher perception of sexism in the groups with less than 10 years and 10-20 years of experience (p< 0.001), in the 31–45 years group (p< 0.001), and in midwives with temporary contracts (p< 0.001). Regarding classism, a higher perception is observed in the groups with less than 10 years and more than 20 years of experience (p< 0.001), in the 31–45 years and >46 years groups (p< 0.001), in midwives with temporary contracts (p< 0.001), and in those who have worked in primary care in the past year (p< 0.001). For harassment, a higher incidence is perceived in the 31–45 years group (p< 0.001), in temporary contracts (p= 0.002), in public health (p= 0.017), and in hospital care (p= 0.009). Finally, the questioning variable shows statistically significant differences in the groups with less than 10 years and more than 20 years of experience (p< 0.001), in the <=30 years and 31–45 years groups (p< 0.001), in midwives with temporary contracts (p< 0.001), and in those working in hospital care (p< 0.001). The results of the comparative analysis regarding the intention to leave the profession. Midwives with less than 10 years of experience (57.7%), those in the 31–45 age group (59.8%), those with temporary contracts (38.3%), and those working in hospital care (71.9%) show the highest rates of considering leaving the profession (p< 0.001). 4. Discussion The purpose of this study was to understand the level of autonomy perceived by midwives working in Spain, as well as to analyze the variables associated with the development of autonomy. Previous studies have highlighted that midwives’ autonomy remains a vague and difficult-to-define concept at a general level [ 19 ], and it is determined by the legal, cultural, and professional context of each country [ 20 ]. In the most recent definition of the term, five key themes were identified: adequate education, competence, experience, quality care, and collaboration with stakeholders, emphasizing the need for interprofessional education to strengthen midwives’ collaboration and autonomy [ 21 ]. However, this term was not defined or studied in Spain until 2023, establishing it as a novel area that requires further research [22]. Regarding the professional profile of the study participants, we found professionals primarily trained in Spain with an average of 10 years of professional experience and job stability. These aspects may contribute to a deeper analysis of the reality of midwives’ autonomy. Similar to studies conducted in other countries, midwives are identified as well-trained, confident, and competent in their professional role, especially when given the opportunity to work in a supportive environment [23–25]. The workplace, whether hospital or primary care, can significantly influence midwives’ perception of autonomy. In this study, we found that autonomy tends to be lower in hospital settings, a result similar to other authors [26,27]. This study also identified that interprofessional hierarchical relationships constitute a significant barrier to achieving professional autonomy. Midwives who participated in this study identified areas for improvement in management support and collaboration with other professional groups, feeling inadequately supported by them [ 19 , 26 , 28 ]. Thus, supportive relationships and quality leadership are perceived as empowering and promote professional development. Therefore, well-implemented supervision or coordination, aimed at professional support rather than rigorous monitoring and control of employees’ actions, can improve both the professional and personal development of midwives [ 29 , 30 ]. The results of this study show that midwives identified the need to be more active in developing protocols, as reflected in their competencies [ 4 ]. They are not always included in working groups established to develop these protocols, and their participation is often limited. However, when midwives are included in participation, planning, and decisionmaking processes, both clinical practice and professional satisfaction improve [30,31]. Among the barriers identified for optimal professional development of midwives are working conditions, family reconciliation, and perceived professional intrusion. These Healthcare 2024,12, 1994 9 of 12 barriers have a significant impact on midwives’ daily practice and their perceptions of autonomy [ 3 ]. For example, precarious working conditions, such as a lack of resources and staff, force midwives to take on excessive workloads, which not only affects their physical and mental well-being but also limits their ability to practice autonomously, be womancentered, and provide a continuum of care [ 13 ]. This situation is consistent with findings from other studies [ 5 , 6 ], which observe how work–life balance is a constant concern for midwives, affecting job satisfaction and commitment to the profession. To gain deeper insights into how these specific barriers affect midwives’ daily practice, it is crucial to consider direct examples of their experiences. The results of this study showed that lack of support and recognition from supervisors limits the ability to make autonomous decisions in childbirth care, forcing adherence to rigid protocols that do not always meet the individual needs of women [ 32 , 33 ]. On the other hand, professional intrusion resulting from a shortage of midwives [ 16 ] prevents them from fully developing their competencies, negatively affecting their confidence and professional satisfaction [ 34 , 35 ], diluting the quality of care, creating interprofessional conflicts, and affecting the work environment. More studies are needed to determine this finding in Spain. More than half of the study participants with less than 10 years of work experience have considered leaving the profession at some point; a similar percentage was found in Australia [ 32 ]. It is observed that with greater professional experience, there is less desire to leave the profession. Previous studies have identified causes such as sexism, classism, and lack of respect, which contribute to an unfavorable work environment for the professional development of midwives [ 32 ]. These findings are consistent with the results of our research. Additionally, a lack of staff and resources has been identified as a significant stress factor contributing to an unhealthy work environment [12]. Job precariousness has also been highlighted in this research as a determinant of work burnout, with midwives experiencing greater job instability being more likely to question their continued presence in the profession [ 32 , 34 ]. Age and professional experience seem to influence the perception of situations involving classism, sexism, professional intrusion, and questioning of their professional opinions. Midwives with more years of work experience feel more frustrated by the lack of recognition and support, influenced by power and gender dynamics in the workplace. Conversely, younger midwives are more likely to feel overwhelmed and less recognized, leading them to question their competence more easily [7]. Further research is needed on these findings. The study demonstrated high internal consistency for the ad hoc survey used to assess midwives’ perceptions of autonomy in Spain, as evidenced by a robust Omega coefficient and Cronbach’s Alpha. This suggests that the survey items were cohesive and effectively measured the construct of autonomy. The Perception of Empowerment in Midwifery Scale (PEMS) originally developed in 2007 [ 36 ] and revised in 2015 (PEMS-R) [ 37 ], has been adapted to various languages, including Italian, Portuguese, and Persian [ 38 – 40 ]. However, the lack of a similar tool in Spanish has posed challenges in assessing midwives’ empowerment within the Spanish context. After our data collection was completed, González-de la Torre et al. translated and validated the PEMS scale into Spanish [ 22 ]. However, this version was not utilized in our study, as our research had already concluded by that time. It is important to note that our primary aim was not to translate, culturally adapt, or validate the PEMS or PEMS-R for Spanish midwives. Instead, our study aimed to provide a more comprehensive understanding of autonomy by incorporating additional variables specific to the Spanish midwifery context. Among the limitations of this study is the potential for response bias due to voluntary or motivated participation, as midwives with more polarized experiences in the profession, whether positive or negative, may be more interested in completing the questionnaire. Those with more neutral or less intense experiences are less likely to respond [ 8 ]. The responses provided by participants may not be representative of the midwives’ community in Spain, cannot be generalized due to voluntary participation, and should be interpreted with caution. Additionally, we did not perform prior power calculations, which is particu-