Intentions to leave and actual turnover of community midwives in the Netherlands. A mixed method study exploring the reasons why | 113 discontinuity of care, frustrating midwives in the community. From the literature, it is known that continuity of care is important for midwives if they are to intend on staying in midwifery. 30 In the Netherlands, the professional scope of midwives is limited to physiological pregnancies, births, and postpartum periods, with a strict separation between primary and secondary care including strictly defined guidelines regarding referrals. Thus, the changing client demands combined with the Dutch healthcare system and its strict boundaries lead to discontinuity of care, also leading to midwives’ dissatisfaction with their work. Another important finding was the conflict between work-life balance of community midwives in the Netherlands. This finding is consistent with a study on Canadian midwives, who felt the impact of their work conflicting with their personal lives, not the other way around. 31 In addition, being on-call and long working hours disrupt family life and cause stress and anxiety in midwives, 32 thereby reducing their wellbeing. 28 Such negative psychological reactions may lead to the intention to leave the profession and eventually to quit the profession. Our findings also reveal an issue which has not been addressed in previous findings. Community midwives in the Netherlands are often self-employed. This means that they have their own business (midwifery practice) and, most of the time, work in collaboration with other midwives. These midwives negotiate with healthcare insurance companies about their rates and are fully responsible for managing their own practice. In general, midwives who want to work in the community have little to no choice but to become self-employed. In the literature, this work situation is considered the same as being a ‘necessity entrepreneur’, meaning that someone starts their own business out of necessity instead of out of opportunity. 33 Dutch midwives can be considered as necessity entrepreneurs. The research addressing the mental wellbeing of necessity entrepreneurs shows that this group has less subjective wellbeing in comparison to the general population. 34 The work of necessity entrepreneurs exhibits higher levels of uncertainty, responsibility, and complexity, which are associated with lower mental wellbeing. 35 Another issue regarding self-employment as a midwife concerns autonomy and work involvement. Midwives, particularly those in community care, have a high degree of autonomy regarding how they want to provide care to women. Midwives indicated that they value their job autonomy and expressed concerns about the decreasing level of autonomy in the profession due to the shift towards integrated midwifery care in the Netherlands. 36 Within this system there might be a change from separate payments for
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