Intentions to leave and actual turnover of community midwives in the Netherlands. A mixed method study exploring the reasons why | 109 Participants perceived changes in the working context which related to a change of the needs of clients over the years. According to the participants, clients wished to have more pain relief during their births, consequently leading to more referrals for secondary care. Community midwives could therefore support fewer women during home births. They felt that they lost their clients halfway through the birthing process. Another thing is the clients themselves... I am a very physiological thinker and to see that someone has a baby whose position has been measured with an ultrasound and then the baby turns out to be slightly bigger than expected. Then she goes to see the gynaecologist who decides to induce labour at 38 weeks. Then you’ll have a baby weighing 3,500 grams, which is perfectly normal, but is struggling to come out... And then the client says they’re happy they went to the hospital. (P08) Participants also felt that their jobs had become less challenging over the years. The more experienced they became as a midwife, the fewer challenges they met in their work. Some midwives mentioned their own need for more challenging work. Participants expressed concerns about their autonomy. They felt that their autonomy as midwives had changed over the years. National debates about integrated midwifery care, integrated funding of maternity care and changes in the organisation of maternity care affected their autonomous decision-making and practice in community care. These developments contributed to a perceived greater dependence on obstetricians and hospital midwives, resulting in a loss of job autonomy. At the beginning, we still had a hospital in [city] with old gynaecologists and they said, I don’t need to know everything you do, but I trust it will go well, and to be honest it sometimes scares me, but you can always call when something happens. ... Then you just knew, okay, I’ll send this lady to them, it’ll be okay. And now everyone is interfering with everyone. (P11) Lack of organisational resources A lack of organisational resources was seen in discrepancies in values, unfair pay, and dissatisfaction with their employment status. Participants mentioned discrepancies between their own professional values and working in practice. They initially worked towards empowering women during childbirth and supported them to cope with pain. The discrepancy between these values and their work in reality had an impact on their job satisfaction.
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