Prevalence of and factors associated with burnout in midwifery: A scoping review

INTRODUCTION Midwifery care meets the triple aims of health system improvement, i.e. good health outcomes, high client satisfaction, and low per capita costs. Scaling up access to midwifery care is a global priority yet the growth and sustainability of the profession is threatened by high levels of burnout and attrition. This scoping review provides a comprehensive review of the existing literature on burnout in midwifery, with a focus on prevalence, associated factors and potential solutions. METHODS Four electronic databases were searched to locate relevant literature up to July 2019. A total of 1034 articles were identified and reduced to 27 articles that met inclusion criteria. We summarize sample sizes, settings, study designs, burnout measures, prevalence of burnout, associated factors and potential solutions, and recommendations. RESULTS Prevalence of burnout was highest among Australian, Western Canadian and Senegalese midwives and lowest among Dutch and Norwegian midwives. Midwives working in caseload/continuity models reported significantly lower burnout compared to midwives working in other models. We identified 26 organizational and personal factors that were significantly associated with burnout, such as high workload, exposure to traumatic events, and fewer years in practices. Organizational support to improve work-life balance and emotional well-being, as well as more continuing education to raise awareness about burnout and how to cope with it, emerged as common strategies to prevent and address burnout. CONCLUSIONS Burnout is a serious and complex occupational phenomenon. More qualitative research is needed in this area, to better understand the lived experience of burnout.


INTRODUCTION
There is a large and growing body of literature documenting the positive impact midwives have on the healthcare system. Midwifery care is linked to fewer birth complications, reducing the need for obstetrical intervention, alleviating provider shortages in underserved communities, and making more efficient use of health care funding 1 . While there is mounting evidence that midwifery care meets the triple aims of health system improvement (good outcomes, high patient satisfaction/good experiences of care, and low per capita costs) the growth and sustainability of the midwifery profession in some countries and regions is threatened by high levels of burnout and attrition 2,3 . For example, in a Danish study of burnout among 15 professional groups, midwives reported the highest personal and work-related burnout scores 4 . Recognizing the experiences of health care providers and the effect of burnout on quality of care, the triple aims were expanded to include a fourth aim: improving the work lives and well-being of health professionals 5 . This scoping review focuses on provider experiences, specifically prevalence, associated factors and potential solutions to burnout.
Burnout -defined as chronic occupational-stress resulting in a loss of energy, dissociation from work, depersonalization, and emotional exhaustion -has received increasing attention in the literature 3,6 . Central to this conversation has been the association observed between high burnout and poorer quality of care, low job satisfaction, and employee resignation 3,6,7 . Midwives, in particular, are vulnerable to experiencing burnout for several reasons: they report having fewer resources than their peers in other health care professions, their work often extends past their contracted time forcing them to miss breaks, and they feel inadequately compensated for the work they perform 3,8,9 . As well, several individual factors such as having a high level of empathetic identification with women and struggling to process poor maternal-fetal outcomes have Eur J Midwifery 2020;4(February):4 https://doi.org/10.18332/ejm/115983 Research paper also been indicated as factors that contribute to a midwife's vulnerability to burnout 10,11 .
Despite the well-recognized problem of burnout in midwifery, there are comparably few studies that have systematically examined the prevalence of and factors that are associated with burnout in the midwifery profession. The research question guiding this review was: 'How common is burnout in midwifery, which factors are associated with burnout and which solutions or recommendations have been published, to address this issue?'.

METHODS
We adopted a scoping review methodology as outlined by Arksey and O'Malley 12 . A scoping review is a type of descriptive literature review that maps key concepts in a certain area of the literature. Unlike a systematic review, which addresses a well-defined study question from a narrow range of appropriately designed studies, a scoping review is best suited for broadly defined research aims for when the literature is widely heterogenous in study design, theoretical framework, or outcomes measured -as was found to be the case for burnout in midwifery. Accordingly, a five-step approach for conducting a scoping review was used: 1) Identifying a research question (see Introduction); 2) Identifying relevant studies; 3) Selecting relevant studies; 4) Charting the data; and 5) Collating, summarizing, and reporting the results.

Identifying relevant studies
Several electronic databases were searched to identify relevant studies up to July 2019: Medline, CINAHL, PsychINFO, and PubMed. Keywords chosen in the search included 'midwife' (and its variations, e.g. midwifery, midwives), in combination with burnout-related terms including 'burnout,' 'exhaustion,' and 'compassion fatigue. ' The search strategies were tailored for each of the databases' thesaurus terms and field headings. A total of 1034 articles were identified (Medline=219; CINAHL=203; PsychINFO=151; PubMed=461). Eliminating all non-English articles and removing duplicates reduced this number to 598 articles eligible for title and abstract review. From these, 92 articles were deemed to be relevant and underwent closer review. Articles were evaluated on the following inclusion criteria: 1) Article must be on practicing midwives (e.g. studies involving nurse-midwives were included, but articles on student midwives or retired midwives were excluded); 2) Article must report on burnout among midwives; if other healthcare providers were included, results must be stratified, so that midwifery-specific results can be extracted; 3) Article must identify associated factor(s); and 4) Article must be written in English and have full-text available. A total of 27 articles met these criteria (Table 1).

Charting the data
Authors RS and BS collaborated extensively via a shared spreadsheet to review inclusion criteria and select articles, with any and all differences being settled through discussion or input from the supervising author, KS. Articles meeting the inclusion criteria were reviewed and data were extracted and charted pertaining to study setting, study design, burnout measures, study results, factors associated with burnout, and recommendations to address burnout. Factors that were significantly linked to burnout in quantitative studies were independently extracted by the first two authors and are summarized in Table 2. The supervising author reviewed all data points reported in Tables 1 and 2.

RESULTS
Samples sizes across the 27 included studies varied, from a small survey study of 50 Danish midwives 13 , to over 1000 midwives in studies from Australia and New Zealand 14,15 . There was less variation with the study designs: all included studies used surveys to collect data; in one study two surveys were administered over a two-year period 16 .

Measuring burnout
The most commonly used measures to assess burnout were the Maslach Burnout Inventory (MBI), utilized in 11 of the studies 11,16,[22][23][24][29][30][31][32][33][34] , and the Copenhagen Burnout Inventory (CBI), which was used in 12 of the 27 studies 3,7,[13][14][15][17][18][19][20][21]27,28 . See Table 1   Research paper exhaustion, depersonalization, and reduced personal accomplishment. Each item or statement is assessed on a 7-point Likert scale. The 9 items on the emotional exhaustion subscale measure feelings of being emotionally drained and exhausted by work. The 5 items on the depersonalization subscale assess the degree to which people are impersonal in their treatment of clients/ patients 35 . Personal accomplishment is measured with 8 items that assess feelings of competence and achievement with respect to work. Scores on the MBI subscales are always reported separately, whereas the CBI has both a fullscale score and three subscale scores: personal burnout, work-related burnout, and client-related burnout. Personal burnout is measured with 6 items that assess general burnout and can be completed by anyone, regardless of occupational status. Work-related burnout is measured with 7 items that ask respondents to rate the degree of physical and psychological fatigue related to work. The client-related burnout subscale includes 6 items that measure fatigue and exhaustion related to caring for others 36 .  29 , and highest among midwives in Senegal (80% scored in the moderate to high range on the EE subscale) 16 . Prevalence of burnout varied by model of care, with case loading midwives consistently reporting less burnout than midwives who work in other models 13,15,17,18,20,21 . Most of this evidence comes from Australia and New Zealand. Studies utilizing burnout inventories were able to expand on their findings by describing the prevalence of burnout subdomains. Of those using the MBI, the 'emotional exhaustion' subscale emerged as the most frequently cited dimension of burnout, followed by 'depersonalization', and then 'personal accomplishment' 11,31,32 . Respondents with a Research paper high score in emotional exhaustion and depersonalization, and a low score in personal accomplishment are considered severely burnt-out. In their sample of 56 Australian midwives, Mollart et al. 11 found 60.7% to have moderate to high levels of emotional exhaustion, higher than in other studies from the US (41.8 %) 30 and Iran (41.9 %) 31 but lower than those reported by midwives in Senegal (80%) 37 . A similar pattern emerged amongst studies using the CBI: 'personal burnout' was the most prevalent dimension of burnout, followed closely by 'work-related' burnout, and then 'client-related' burnout in a distant third-place 3,7,[19][20][21]27 . Stoll and Gallagher 3 reported the moderate-to-severe burnout prevalence of these subscales amongst Canadian midwives as 74.9%, 42.5%, and 20.3%, respectively, compared to Fenwick et al. 20 who reported these figures as 64.9%, 43.8%, and 10.4%, respectively, among Australian midwives.

Recommendations
Most authors offered recommendations for improving working conditions for midwives and reducing the prevalence of burnout. There was a diversity of suggestions offered to reduce midwife burnout, many of which overlap with and appear to target factors identified in Table 2.
The most widely reported recommendations were: offering more work-related education, improving organizational support, and working in a caseload-model of midwifery practice. Other recommendations included: better support after traumatic events, education for midwives to learn ways of coping with occupational stress and interprofessional education or programs to reduce interprofessional bullying and conflict. Less frequently reported suggestions included: offering part-time work options or career development opportunities, and promoting exercise and physical activity, as a way to reduce stress. See Table 1 for a full description of recommendations.

DISCUSSION
The purpose of this article was to present an up-to-date and comprehensive review of the existing literature on burnout in midwifery, with a particular focus on understanding the factors that are associated with burnout. In total, we included 27 peer-reviewed articles meeting our stated inclusion criteria. The findings of this scoping review lend some credence to previous calls of alarm, depicting a field fraught with high occupational burnout, and identifying several associated factors and recommendations to address it.
Despite the breadth and diversity of the literature across geography, measures, models of practice, and sample size and composition, our review noted that all included studies featured quantitative research methods, most often cross-sectional study designs. While these methodologies are certainly valuable for producing data that can be easily compared across groups and countries, they do little to answer the 'why' or 'how' questions that could shed light on the lived experience of midwives who are struggling with burnout. Without disparaging the value and significance of the existing research in broadening our understanding of burnout in midwifery, the addition of qualitative research studies would provide much needed insight into how midwives experience burnout, and more meaningfully involve midwives in identifying factors and possible solutions. This may be especially relevant when exploring sensitive topics, such as burnout and mental health. Cross-sectional designs, which allow researchers to explore associations between variables, prevent us from identifying causal and temporal effects between burnout and other factors. Longitudinal study designs would allow us to ascertain which factors cause burnout or which solutions or strategies alleviate it. Only one paper from the review utilized a longitudinal study design, a study in Senegal that measured job satisfaction in a cohort of 226 midwives over a three-month period, and then two years later examined the effect on burnout, intention to quit, and job turnover 16 .
While not the crux of our investigation, it quickly became apparent that, when reported, response rates for surveys tended to be low, often much less than 50%. A low response rate may be concerning as it might indicate a higher potential for sampling or non-response bias, should the included respondents not be representative of the midwifery population being studied. Given that most results were obtained via voluntary, self-reported questionnaires, it may be assumed that those experiencing burnout, or those more familiar with the topic, were more likely to complete and return the questionnaires. This would ultimately overestimate the prevalence of burnout in midwifery. Alternatively, it could also be theorized that those suffering the most from burnout were less likely to complete the questionnaires because of their 'burnt-out' state and as a result underestimate the true prevalence of burnout in the profession. Irrespective, future studies investigating burnout amongst midwives, especially those limited to selfreported surveys, should implement strategies to increase the response rate. A 2009 study investigating low response rates in postal surveys of healthcare professionals found that while response rates were not significantly different Eur J Midwifery 2020;4(February):4 https://doi.org/10.18332/ejm/115983 Research paper between healthcare professions, they were higher when reminders to complete the surveys were sent 39 .

Burnout measures
We used different assessment tools to measure burnout. The most commonly used tools for measuring burnout were the MBI 35 and CBI 36 . An important difference between these two scales is their theoretical underpinnings: the MBI describes burnout as a syndrome of depersonalization, reduced personal accomplishment, and emotional exhaustion as related to 'people work' 35 , whereas the CBI describes burnout as 'fatigue and exhaustion' resulting in personal, work-related and client-related burnout 36 . While these differences may appear to be nuanced, they ultimately make it difficult to make direct comparisons between burnout studies. We recommend that future studies consider using the CBI in preference to the MBI for several reasons including: 'depersonalization' is perhaps better seen as a coping mechanism rather than a dimension of burnout, the MBI questions do not always adapt well to diverse cultures, and to reduce potential issues regarding distribution rights as some versions of the MBI are not in the public domain 35 .

Burnout factors
In total, 26 factors were associated with burnout in the included literature and were reported in this scoping review. These factors could be broadly stratified into: 1) sociodemographic or lifestyle factors of the midwife (e.g. age, activity level, physical health, parental and relationship status); and 2) systemic and organization factors that affect the midwife (e.g. level of autonomy, inadequate facilities, low wage). The most widely supported factors for burnout included an approximately equal proportion of these two categories, suggesting that of the two there is no single domain that is disproportionately associated with burnout in the profession. 'Less work experience in maternity care' and 'younger age' are interrelated factors that emerged as the sociodemographic characteristics receiving support from the greatest number of articles. 'Insufficient organizational support /poor or stressful work environment', 'practicing in non-caseload/non-continuity models of care' (such as hospital shift work), and 'high workload', were the most prominent systemic and organizational-related factors found in the literature. Interventions for addressing burnout among midwives, therefore, may wish to consider avenues for reducing workload (e.g. hiring more midwives on staff, enabling case-load midwives to take fewer clients)especially for midwives that are of young age or are early in their careers. Closely related to reducing work-load is remuneration of midwives. Higher pay enables midwives to take on fewer shifts or carry a smaller caseload.
The largest global survey of the midwifery work force to date revealed that midwives are deeply committed to their work, but experience many challenges. For example, midwives across low-, middle-and high-income countries reported loss of autonomy and power within the healthcare system as major barriers to providing high quality care. Disrespect from senior medical staff, low pay and lack of leadership opportunities were commonly reported and illustrate the uphill battle many midwives face 40 . Findings from this report and the current scoping review demonstrate the need to improve working conditions for midwives, so they can continue providing high quality care while also enjoying better work-life balance, emotional well-being and mental health 40 .
By their nature, factors characteristic of the midwife can be difficult and often impossible to change. Accordingly, hospital administrations and clinics should first look inward and address the policies and organizational factors that might contribute to burnout among midwives and other health professionals. A recent publication from the UK supports this point. Of the close to 2000 midwives who participated in an online survey, 83% reported personal burnout, and 67% work-related burnout 41 , placing UK midwives at the top of the list when compared to burnout scores from other high-income countries that utilized the CBI (Table 1). Perceived resource inadequacy was the strongest predictor of work-related burnout. Other factors associated with burnout included younger age (40 years or less), less work experience (<30 years), having a disability and reporting low levels of support from midwifery managers and low professional recognition 41 . These results are in line with the main findings of this scoping review.
Several additional contributing factors for burnout were identified in one of the studies. These included poor selfrated physical or mental health 27,38 , low levels of physical activity 11 , night shifts only compared to mixed shifts (day and night) 11 , practice location (home versus hospital) 13 , and coping style 13 . Future research should consider including these factors in their investigations, to better understand the role they may have in contributing to burnout.
Additionally, researchers examining burnout in midwifery may also want to consider factors known to contribute to burnout in physicians, including fears of litigation, the increasing reliance on technology, and the growing uncertainties regarding the future of medicine; none of these factors was explicitly explored in the included articles. Research on physician burnout also delves into how the nature of a physician's tasks influences and aggravates their symptoms of burnout. Similar to the findings from this review, a study on Canadian physicians showed that 64% feel that their workload is excessive, and that 48% reported that their workload had increased in the past year 42 . One possible explanation for this perceived increase in workload has been the increase in mundane or clerical tasks, which have been shown to compromise a physician's sense of job satisfaction 3 . Perhaps the same can be applied to midwives: clerical tasks and other responsibilities, not directly related to healthcare, may cause them to experience a high workload and contribute to burnout. Two of the included studies 37,38 reported significant linkages between burnout and low task satisfaction. Further research on the impact of non-healthcare tasks have on the overall workload of midwives is warranted.
It is important to mention that the frequency of specific burnout factors across studies does not necessarily translate into how much significance (or 'weight') they should be assigned. A widely identified burnout factor may contribute only a small portion towards the prevalence or severity of burnout in midwifery (and vice versa for a seldom mentioned factor). This uncertainty on the weight each factor should be given is further compounded by the ambiguous or 'broadencompassing' nature of many of the specified factors. For example, in the case of 'high workload' it is not always clear how or by what measure workload is being considered or interpreted by survey respondents. This area of uncertainty regarding how burnout factors interplay, specifically how to aggregate or separate factors, and to what degree individual factors contribute to burnout would certainly benefit from additional qualitative research.
Finally, this global scoping review included studies from many different high-resource countries and one lowresource country. The context for midwifery practice is very different across countries and affect the way midwives experience work and work-related burnout. It is of interest to note that several of the included studies were conducted as part of an international working group of midwives and researchers called WHELM -Work, Health and Emotional Lives of Midwives 14 . The WHELM group uses a standardized survey to collect data about burnout, occupational stress, intentions to leave, quality of life and other factors, from midwives in many high-resource countries, including Australia, New Zealand, the UK, Canada, Germany, and Scandinavia. In the future, data from midwives from different countries participating in the WHELM study might be pooled, to better understand similarities and differences in how burnout is experienced by midwives in different countries.

Burnout recommendations
'Offering more work-related education' emerged as a commonly cited recommendation. However, the content and purpose of suggested additional education varied across the studies. Offering more work-related education included: further training on increasing autonomy and clinical decision making 19 , educational workshops on preventing and addressing work-related burnout 31 , and ongoing education and clinical mentorship, to increase clinical competency and build confidence 19,37 .
Offering midwives the option to practice a caseload model of midwifery care was found to be associated with reduced burnout. In a recent cross-sectional survey of 542 Australian midwives, a direct comparison between caseload and non-caseload midwifery revealed the latter group scored higher on all three CBI subscales of burnout (p<0.001) 17 . These results are supported by other studies demonstrating that midwives practicing caseload midwifery experience less burnout than those working in non-caseload models 13,15,18,20,21 . These findings present a clear and unanimous recommendation for policy makers and healthcare administrators seeking to address burnout through changes in practice models by supporting caseload models. Studies about caseload midwives can be informative in terms of anticipating factors linked to burnout among midwives who practice this model of care. For example, Stoll and Gallagher 3 studied case-load midwives in Western Canada. Their recommendations to reduce burnout were based on open-ended comments from midwives about strategies to reduce burnout and increase job satisfaction. Recommendations fell into four general areas: more time off /better pay, more flexible practice structures /change in model of care, more respect from profession /more support from colleagues and more support with professional issues (such as help with obtaining hospital privileges or more support after critical incidents). Specific recommendations within these four areas included: part-time work options, support for sick days/vacation coverage, more pay per course of care and more pay for complex clients, salaried rather than fee-for-service payment schemes in rural and remote areas, more off-call career opportunities, and initiatives to reduce intra-professional bullying and interprofessional conflict 3 .
Similar to the concerns raised in the previous section, the level of support for a particular burnout-reduction strategy across the included literature may not necessarily be representative of its success or effectiveness in reducing burnout, should it be implemented. These inquiries would be best addressed with additional investigation, in particular from studies utilizing longitudinal designs evaluating the efficacy of these recommendations.
Burnout is a complex issue that requires complex interventions. Because it is an occupational phenomenon, the onus for change is placed on organizations, such as hospitals, professional organizations, health policy makers and regulatory bodies. Finally, this review uncovered some inconclusive findings. For example, two studies identified that being married is linked to burnout 24,38 whereas two other studies identified being single or divorced as a risk factor 7,30 . Similarly, high work-load and long hours were linked to burnout in some studies 3,15,23,30 but in another study midwives who worked more hours per week also reported higher scores on the personal accomplishment subscale of the MBI 29 . Future studies might shed light on how these factors relate to burnout, ideally using qualitative study designs. Such designs can also elicit detailed responses about the kind of partner support that buffers against burnout and how work autonomy relates to burnout.

Limitations
This scoping review is not without its limitations. First, given the evolving nature of occupational burnout as a unique state distinct from other psycho-social constructs, the search terms used for this review may not have been fully inclusive of all the terminology used -presently and historically -to describe burnout. This may have resulted in certain relevant papers not being considered for inclusion. Our review was also limited by screening out articles that were not available in English, or those that were not accessible by database subscriptions held by the University of British Columbia. Further, there may be publication bias as a consequence of studies with significant findings being preferentially selected by journals for publication -and