The Effects of Musculoskeletal Disorders on Professional Quality of Life Among Midwives Working in Delivery Rooms.

Background: This study was conducted to determine the effects of musculoskeletal disorders on professional quality of life among midwives working in delivery rooms. Aim: The aim of the study was to determine the effect of musculoskeletal disorders of midwives working in delivery rooms on the quality of professional life.
Methods: This descriptive study was conducted with 88 midwives who worked in delivery rooms and delivered babies. The data were collected using the Nordic Musculoskeletal Questionnaire (NMQ) and the Professional Quality of Life Scale (ProQOL R-IV). Statistical Analysis Used: The data were analysed with IBM SPSS V23 using MANOVA and path analysis.
Results: Of the midwives, 80.7% reported that they had pain in the waist in the last year. According to the result of path analysis for NMQ and ProQOL R-IV, only the path coefficient between the 12-month disability and burnout was found to be statistically significant (p = 0.012). The multivariate analysis showed that single midwives had higher job satisfaction than married ones (p = 0.030) and those who chose their profession willingly had higher job satisfaction than others (p = 0.043).
Conclusion: It was observed that most of the midwives suffered from low back pain. Additionally, there may be a relationship between musculoskeletal problems experienced by midwives and their professional burnout levels. Relevant strategies to reduce occupational risks, especially musculoskeletal disorders, and to increase the professional quality of life of midwives should be implemented urgently. Copyright:

INTRODUCTION

Musculoskeletal disorders (MSDs) are common health issues in all employees, having a harmful impact on cost, work life and productivity. The Turkish Social Security Institution reported 422,463 work-related accidents in 2019, where 1,147 were fatal, and the number of people suffering from occupational disease was reported as 1088. However, the number of people with occupational diseases in Turkey is estimated to be much higher than those reported by the Institution.[1]

The World Health Organization estimates that the world needs 9 million more nurses and midwives to achieve universal health coverage by 2030.[2] The Health Workforce Goals and Health Education for 2023 Report published by the Turkish Ministry of Health has estimated the number of health workers to be needed in 2023 by occupational groups, predicting a surplus of physicians and nurses but a need for midwives.[3] There are studies suggesting that working conditions such as lengthened work hours, extended work shifts and stress due to heavy workload cause musculoskeletal symptoms.[45]

Physical workload conditions including working in awkward positions and manual handling are the most common risk factors for MSD in healthcare professionals.[6] One Chinese study determined that 85% of all delivery room employees including midwives have serious musculoskeletal disorders.[7] There is a high risk of developing MSD among midwives, causing loss of workforce, decreasing professional quality of life and leading midwives to leave the profession. There are a limited number of studies on the health status of midwives in Turkey, and especially data related to their musculoskeletal disorders are quite limited.[8] Moreover, there are no data on the effects of musculoskeletal disorders on midwives’ professional quality of life. In line with this information, this study, which determines the effects of musculoskeletal disorders on professional quality of life among midwives working in delivery rooms, will contribute to the literature.

METHODS

Aim

The aim of the study was to determine the effect of musculoskeletal disorders of midwives working in delivery rooms on the quality of professional life.

Design

This is a descriptive study.

Sample/Participants

The population of the study was composed of midwives (N: 91) who worked in delivery rooms of all public hospitals in Kocaeli, Turkey. However, three midwives who were on sick leave during the data collection process did not participate in the study. Therefore, the study was completed with 88 midwives.

Data collection

The data were collected using an introductory information form, which was created by the researchers in line with the literature, the Nordic Musculoskeletal Questionnaire, and the Professional Quality of Life Scale.

The introductory information form consisted of a total of 12 questions, including 7 questions about the midwives’ socio-demographic characteristics and 5 questions about their work-related characteristics.

The Nordic Musculoskeletal Questionnaire (NMQ), developed by Kuorinka et al.[9] (1987), is the most commonly used tool for determining musculoskeletal health problems. The scale questions musculoskeletal disorders in three different dimensions and nine different body regions, where the presence or absence of pain is answered as ‘yes’ and ‘no’.

The Professional Quality of Life Scale (ProQOL R-IV) was developed by Stamm (2005).[10] The scale consists of 30 items and three subscales (compassion satisfaction, burnout and compassion fatigue).

This study was carried out between 15 June 2019 and 15 March 2020 with midwives working in the delivery rooms of all public hospitals in Kocaeli, Turkey.

Ethical considerations

Ethical approval (KOU KAEK 2018/164) and written permission from the institutions where the research was conducted were obtained before starting to collect data. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors.

Data analysis

The data were analysed with IBM SPSS V23. Unlike other studies, path analysis and MANOVA were used as advanced techniques, which aim to examine and analyse the results separately. MANOVA was used to determine the independent factors affecting musculoskeletal disorders and professional quality of life among the midwives. In particular, since the observations were independent, the sample was chosen completely randomly, the variables were categorical, the scales were used, and MANOVA was preferred.

Path analysis was performed to examine the causality relationship between musculoskeletal disorders and professional quality of life among the midwives. This was because our data included the solution of multiple linear regression equations. Additionally, path analysis was applied since it was assumed that the dependent variables were approximately normally distributed for all equations and that the relationships between the variables were causal, linear and additive. Path analysis was conducted in the AMOS program. The ‘multivariate c.r.’ value was obtained as 0.824. This value showed that multivariate normality was achieved.[11] The skewness values for each observed value in the model ranged from -0.05 to 0.570, while the kurtosis values ranged from -0.537 to -0.081. The significance level was set to P < 0.05.

RESULTS

The data obtained from 88 midwives in the study were evaluated. The mean age of the midwives was 35.18 ± 8.52 (min: 22; max: 64) years. Their mean work experience was 14.19 ± 10.22 (min: 1; max: 46) years. Table 1 presents the demographic characteristics of the midwives included in the study.

Table 1

Demographic characteristics

	Mean-SD	Min-Max
Age	35.18±8.52	22-64
	n	%
Marital status
Married	66	75.0
Single	22	25.0
Having children
Yes	27	30.7
No	61	69.3
Work experience in delivery room
1-5 years	33	37.5
6-10 years	25	28.4
11 years and above	30	34.1
Average number of pregnant women provided care per day
1-10	37	42.0
10-20	33	37.5
Over 20	18	20.5
Willingness to choose the profession
Yes	68	77.3
No	20	22.7
Having health-related leave due to work-related musculoskeletal disorders
Yes	18	20.5
No	70	79.5

Table 2 presents the musculoskeletal disorders experienced by the midwives. Accordingly, in the last 12 months, 80.7% of the midwives experienced pain in their waists and 71.6% had pain in their necks and backs. In the last 12 months, 60.2% had a disability in their waists and 52.3% had a disability in their necks. In the last 7 days, 55.7% had a problem in their waists, 52.3% had a problem in their backs, and 51.1% had a problem in their necks.

Table 2

Musculoskeletal disorders experienced by midwives

	12-month pain		12-month disability		7-day problem
	n	%	n	%	n	%
Neck	63	71.6	46	52.3	45	51.1
Shoulders	61	69.3	43	48.9	42	47.7
Elbows	18	20.5	13	14.8	11	12.5
Wrists/hands	50	56.8	33	37.5	27	30.7
Back	63	71.6	41	46.6	46	52.3
Waist	71	80.7	53	60.2	49	55.7
Hips/thighs	25	28.4	21	23.9	17	19.3
Knees	31	35.2	20	22.7	20	22.7
Ankle/feet	42	47.7	25	28.4	25	28.4

According to the results of path analysis for NMQ and ProQOL R-IV, only the path coefficient between 12-month disability and burnout was found to be statistically significant (p = 0.012) [Table 3]. None of the path coefficients between ProQOL R-IV and other NMQ subscales were found to be statistically significant (p > 0.05). The analysis results are presented in Table 3. Only the model fit values of GFI = 0.981 and CFI = 0.977 were within the acceptable limits [Figures 1 and 2].

Table 3

Path analysis results

ProQOL		NMQ	β0	β1	SH	Test statistics	P
ProQOL 1	<---	NMQ 1	0.214	0.85	0.655	1.298	0.194
ProQOL 2	<---	NMQ 2	0.381	0.839	0.334	2.509	0.012
ProQOL 3	<---	NMQ 3	0.042	0.135	0.479	0.282	0.778
ProQOL 2	<---	NMQ 1	0.158	0.393	0.392	1.002	0.316
ProQOL 3	<---	NMQ 1	0.258	0.859	0.522	1.645	0.100
ProQOL 1	<---	NMQ 2	-0.219	-0.768	0.559	-1.375	0.169
ProQOL 3	<---	NMQ 2	0.091	0.269	0.445	0.604	0.546
ProQOL 1	<---	NMQ 3	0.081	0.309	0.601	0.514	0.607
ProQOL 2	<---	NMQ 3	-0.292	-0.7	0.359	-1.947	0.052

ProQOL: Professional Quality of Life, NMQ: Nordic Musculoskeletal Questionnaire, ProQOL 1: compassion satisfaction, ProQOL 2: burnout, ProQOL 3: compassion fatigue, NMQ 1: 12-month pain, NMQ 2: 12-month disability, NMQ 3: 7-day pain, β0: standardised path coefficients, β1 Non-standardised path coefficients

Figure 1

Non-standardised path coefficients

Figure 2

Standardised path coefficients

A multivariate analysis was performed to examine the midwives’ NMQ and ProQOL R-IV mean scores based on their marital status, status of having children, work experience in the delivery room, average number of pregnant women who were given care daily and willingness to choose the profession, which were considered to affect both professional quality of life and musculoskeletal disorders.

As a result, their job satisfaction mean scores were found to differ depending on marital status (p = 0.030), where the mean score was 33.7 for the married and 36.5 for the single participants. Having children was effective only on job satisfaction (p = 0.046). Willingness to choose the profession also had a significant effect only on job satisfaction (p = 0.043). Apart from these, there was no statistically significant effect of other factors on other dimensions [Table 4].

Table 4

Factors affecting professional quality of life and Nordic subscales by MANOVA

Factor	Dimension	Sum of squares	df	Mean of squares	F	P	Partial eta squared
Marital status	Job satisfaction	320.370	1	320.370	4.902	0.030*	0.058
	Burnout	5.119	1	5.119	0.192	0.663	0.002
	Compassion fatigue	149.880	1	149.880	3.073	0.083	0.037
	12-Month pain total	0.001	1	0.001	0.000	0.988	0.000
	12-Month disability total	4.738	1	4.738	0.761	0.386	0.009
	7-Day pain total	0.034	1	0.034	0.007	0.936	0.000
Having children	Job satisfaction	267.710	1	267.710	4.096	0.046*	0.049
	Burnout	1.406	1	1.406	0.053	0.819	0.001
	Compassion fatigue	248.093	1	248.093	5.087	0.027	0.060
	12-Month pain total	0.369	1	0.369	0.079	0.779	0.001
	12-Month disability total	0.110	1	0.110	0.018	0.894	0.000
	7-Day pain total	0.756	1	0.756	0.147	0.703	0.002
Willingness to choose the profession	Job satisfaction	276.988	1	276.988	4.238	0.043*	0.050
	Burnout	47.974	1	47.974	1.797	0.184	0.022
	Compassion fatigue	226.058	1	226.058	4.635	0.034	0.055
	12-Month pain total	1.603	1	1.603	0.344	0.559	0.004
	12-Month disability total	0.504	1	0.504	0.081	0.777	0.001
	7-Day pain total	0.220	1	0.220	0.043	0.837	0.001
Work experience in delivery room	Job satisfaction	56.744	2	28.372	0.434	0.649	0.011
	Burnout	23.854	2	11.927	0.447	0.641	0.011
	Compassion fatigue	52.914	2	26.457	0.542	0.583	0.013
	12-Month pain total	20.506	2	10.253	2.204	0.117	0.052
	12-Month disability total	7.013	2	3.506	0.563	0.572	0.014
	7-Day pain total	16.074	2	8.037	1.558	0.217	0.037

*P<0.05; statistically significant

DISCUSSION

Several factors of the work environment may combine with other risk factors, causing work-related and other diseases. In particular, musculoskeletal diseases (MSDs) are one of the most common work-related diseases. MSDs affect millions of workers across Europe, causing costs of billions of euros to employers.[12] This study focused on midwives working in delivery rooms to examine the effects of musculoskeletal disorders on their professional quality of life.

Occupational risks were described first by Bernardino Ramazzini (1633–1714), an Italian physician, at the beginning of the eighteenth century. Ramazzini identified two major occupational risks in midwifery: infections and awkward postures.[13] In the present study, the musculoskeletal problem most experienced by midwives in the last 12 months was pain in the lumbar region (80.7%), followed by back (71.6%) and neck (71.6%) pain. In Turkey, there is no study to identify musculoskeletal disorders in midwives, but there are studies of operating room nurses reporting that they had most pain in the waist (95.2%), back (88%) and neck (87.5%) regions.[14] One English study reported the most common musculoskeletal disorders of midwives as pain in the waist (71%), neck (45%) and shoulders (45%).[15] Midwives may work in awkward positions, especially when managing a normal delivery or an abnormal condition (cord prolapse, etc.) that may cause musculoskeletal disorders during delivery. Similarly, the same results are possible for dentists and veterinarians who work in standing and awkward postures for a long time.[1617]

The path analysis revealed that one unit of increase in the 12-month disability increased burnout by 0.839 units. According to Ramazzini, the greatest danger for midwives in modern times is burnout.[13] Although there are studies on the psychosocial effects of traumatic delivery experiences on midwives,[1819] there is no study on their physical effects. One study conducted in Poland compared nurses working in hospitals and midwives working in maternity hospitals and determined that burnout was significantly on a higher level in midwives.[20] Another study conducted with nurses in Iran in 2016 has reported that burnout, especially due to psychosocial factors, was effective in having musculoskeletal disorders.[21]

The multivariate analysis revealed that the single midwives had higher job satisfaction levels than the married ones, and the midwives who chose their profession willingly had higher job satisfaction levels than the others. One study reported that musculoskeletal disorders could cause midwives to leave the profession, but the study did not present a rate in this regard.[22] One retrospective cohort study conducted with nurses determined that the presence of musculoskeletal disorders may lead to quitting in the future.[23] Another study reported that neck and back pain caused 11% of nurses to change their jobs.[5] Cohort studies should be conducted to define the relationship between midwives’ musculoskeletal disorders and their fatigue and burnout levels.

This study did not find a statistically significant relationship between the midwives’ NMQ mean scores and their work experience. This finding may be explained by the relatively low working years and mean age of the midwives in our sample. As another reason, midwives who developed an MSD coping strategy may have changed fields of work or retired.[15] In the study by Long et al.[24] in Australia, it was reported that the incidence of MSD was affected by individual factors such as age and years of employment, but the effects were not significant. The finding in our study was similar to their study. In another study, it was reported that MSD increases with increasing age and longer years of work.[25]

In recent years, the concept of caseload midwifery has come to the fore in some developed countries to improve midwifery care and reduce the cost of care. This concept is used to mean that the pregnant woman receives care in the antenatal, intrapartum and postpartum periods from a single midwife or a substitute midwife.[26] One study conducted in Australia compared midwives in obstetrics clinics with and without the caseload model, and it found that midwives in clinics where the caseload model was applied had lower burnout and higher job satisfaction levels compared to the others.[27]

There are no studies on the effects of musculoskeletal disorders on professional quality of life among nurses both in Turkey and across the world. Current studies focus more on the prevalence of a single musculoskeletal problem.

CONCLUSION

In our study, it was determined that the majority of the midwives suffered from low back pain and more than half of them had neck and back pain. Additionally, it was found that the musculoskeletal problems experienced by the midwives may cause occupational burnout. Furthermore, the job satisfaction scores of the midwives who were single and those who chose their profession willingly were higher than the scores of the others. Reducing musculoskeletal disorders in midwives should be a priority, not only for relieving individual pain, but also for improving their professional quality of life.

Limitations

This study had several limitations. Only midwives who worked in delivery rooms and delivered babies were included in the study, and those who worked in other fields with different working conditions were excluded from the study. Therefore, the population and sample of the study were limited. We aimed to reach the entire population, and the data collection process was prolonged due to the working conditions of midwives (working in shifts) and their rotational leave statuses.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.