“I love being a midwife; it's who I am”: A Glaserian Grounded Theory Study of why midwives stay in midwifery

Abstract Aims and objectives To understand why Western Australian (WA) midwives choose to remain in the profession. Background Midwifery shortages and the inability to retain midwives in the midwifery profession is a global problem. The need for effective midwifery staff retention strategies to be implemented is therefore urgent, as is the need for evidence to inform those strategies. Design Glaserian grounded theory (GT) methodology was used with constant comparative analysis. Methods Fourteen midwives currently working clinically area were interviewed about why they remain in the profession. The GT process of constant comparative analysis resulted in an overarching core category emerging. The study is reported in accordance with Tong and associates’ (2007) Consolidated Criteria for Reporting Qualitative Research (COREQ). Results The core category derived from the data was labelled—“I love being a midwife; it's who I am.” The three major categories that underpin the core category are labelled as follows: “The people I work with make all the difference”; “I want to be ‘with woman’ so I can make a difference”; and “I feel a responsibility to pass on my skills, knowledge and wisdom to the next generation.” Conclusion It emerged from the data that midwives’ ability to be “with woman” and the difference they feel they make to them, the people they work with and the opportunity to “grow” the next generation together underpin a compelling new middle‐range theory of the phenomenon of interest. Relevance to clinical practice The theory that emerged and the insights it provides will be of interest to healthcare leaders, who may wish to use it to help develop midwifery workforce policy and practice, and by extension to optimise midwives’ job satisfaction, and facilitate the retention of midwives both locally and across Australia.


| INTRODUC TI ON
The inability to retain midwives in the midwifery profession is both an international and local problem (Adegoke, Atiyaye, Abubakar, Auta, & Aboda, 2015;Papoutsis, Labiris, & Niakas, 2014). This issue was highlighted in 2006 by the World Health Organization (WHO), and efforts were employed to improve the retention of midwives.
Regardless of endeavours to improve the situation, the global retention of midwives remains of great concern (UNFPA, 2014; WHO, 2006). The WHO (2006) declared that midwives are the foundation to the decrease in maternal mortality, and has anticipated that in the event that the workforce maintenance issue is not tended to, at that point increments in maternal and neonatal mortality will follow. In The need for effective midwifery staff retention strategies to be implemented is therefore urgent, as is the need for evidence to inform those strategies (WHO, 2019).
The number of studies investigating midwives' job satisfaction is low in number; however, the research that has previously been undertaken describes and explains the drivers of midwifery workforce attrition to include lack of recognition, stress, exhaustion, high workplace demands, rosters, on call, lack of management support, lack of family and social life, self-neglect, staff shortages, lack of autonomy, inadequate budget, inadequate education and training, medical dominance, policy and protocols and wages. Collectively, these factors are all reportedly causing midwives to leave the profession (Curtis, Ball, & Kirkham, 2006;Geraghty, Speelman, & Bayes, 2018;Lavender & Chapple, 2004;Papoutsis et al., 2014;Wakelin & Skinner, 2007).

| BACKG ROU N D
A recent integrative review undertaken by Bloxsome, Ireson, Doleman, and Bayes (2018) highlights a dearth in the research as to why midwives stay in the profession, with only two studies (Sullivan, Lock, & Homer, 2011;Watson, Potter, & Donohue, 1999) focusing on Australia. Neither provides an in-depth account of the phenomenon.
Further, there has been no work on this topic in Western Australia (WA), which arguably has additional workforce retention challenges due to its isolated geographical location. WA is the largest state in Australia with a total land area at over 2.5 million km 2 and a population of over 2.5 million people (Australian Bureau of Statistics, 2019); this large vast space and large population leads to intrastate distance, and isolation of healthcare professionals in rural areas.
The distance between WA and other states in Australia is between 2,000-4,000 kms (Google Maps, 2016) leading to interstate isolation. In 2014, 34,687 women gave birth in WA, which represents an increase of 2.2% from 2013 and is reported as being the highest annual number since 1974 when reporting began. A large number of these births (78.5%) were in the metropolitan health region and the remainder in country regions. The number of tertiary, public, private and homebirths was 16.5%, 41.6%, 40.5% and 0.6%, respectively (Government of Western Australia, 2018). WA has the second highest number of private hospitals in Australia, which anecdotally may help explain the high number of caesarean sections (34.9% in 2014); the rate has tripled over the past 22 years and is the second highest in the country (Government of Western Australia, 2018). Due to these unique geographical and population characteristics, findings from other contexts about why midwives stay or leave the profession are unlikely to apply in full to WA.

| AIMS
The aim of this study was to understand why WA midwives chose to remain in the profession and was conducted for the purpose of understanding the factors leading to midwives remaining in their jobs.
The broad research question guiding this study was as follows: Why do WA midwives stay in midwifery?

| Study design
This study was undertaken using Glaserian grounded theory methodology (Glaser & Strauss, 1967). Grounded theory (GT) has become a widely used approach that can be employed in both What does this paper contribute to the wider global clinical community?
• The inability to retain midwives in the profession is a global issue; the number of studies investigating midwives job satisfaction is low in number.
• The findings from this study add a valuable contribution to the body of work on midwifery workforce retention by providing an account of the factors that keep midwives' in the profession.
• Identification of the reasons why midwives stay in midwifery is imperative to the sustainability and longevity of the profession.
qualitative and quantitative studies due to its flexibility (Roberts, 2008). GT can be defined as "seeking to identify and explain what is happening in a social setting" (Roberts, 2008, p. 679). GT uses an inductive process to generate a theory that can then be generalised and applied. The emergent theories are then said to be "grounded" as the theory emerges from the data (Schneider & Whitehead, 2013). Due to its nonprescriptive and objective approach, GT was deemed the most suitable methodology to answer the research question. By employing the steps in GT, a middlerange theory that both describe and explain the phenomenon of interest emerged from the findings.
The study is reported following the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist as advocated by Tong, Sainsbury, and Craig (2007) (see File S1).

| Study setting
The setting for this study was public and private metropolitan, rural and community midwifery practice sites within WA.

| Participants
At the time this study was undertaken, there were just over 2,000 midwives registered in WA (Nursing & Midwifery Board of Australia, 2018a). In keeping with GT methodology, recruitment, data collection and data analysis occurred as a cyclical/iterative process (Glaser & Strauss, 1967). Three forms of sampling were used to recruit participants from this population. First, purposive sampling, also known as nonprobability sampling, was employed (Creswell, Hanson, Clark Plano, & Morales, 2007;Schneider & Whitehead, 2013). Currently practicing midwives with a minimum of 12 months of experience were invited via an electronic bulletin posted on the Facebook page of the authors' employing organisation (which a number of midwives are known to "like" and "follow," and which is available to view by anyone including those who are not Facebook users), to participate in the study. Second, the snowball technique was used. The snowball technique asks individuals who meet the study inclusion criteria to assist in recruiting others (Schneider & Whitehead, 2013). This approach was employed to ensure sample heterogeneity through maximum variation, and to ensure the theory generated from this study represented all midwifery practice contexts within WA, and occurred in this study through midwives who saw the Facebook post sharing it with their wider professional networks either on Facebook or by email. As data analysis progressed and emergent categories were saturated (after six interviews with midwives), theoretical sampling was employed (using the same process as was used initially) as the third recruitment strategy. Strauss and Corbin (1990) discuss theoretical sampling as a process of sampling on the basis of emerging concepts that can contribute to building the opening and axial coding of the theory. Theoretical sampling was used to "thicken" the data categories and generate a substantive theory of the factors that contribute to why WA midwives stay in the profession.
The sample for investigation involved midwives who had been practising for a minimum of 12 months and who were working in clinical midwifery environments in WA. A total of 23 midwives were provided with an information sheet via email, 16 verbally consented to participate, and 14 provided written consent and proceeded to be interviewed on one occasion each.

| Data collection
Data were collected from December 2017-November 2018.
Interview duration ranged from 60-120 min (average length of 60 min) with a total of 18.5 hr of interview data obtained. Data were listened to and transcribed verbatim by the first author, and to maintain participants' anonymity in the reporting of direct quotes to support the narrative, codes were given to each participant, for example MW1 (which denotes the first participant midwife to be interviewed).
Semi-structured, open-ended in-depth interviews were used to gather data for this study. This approach involved asking participants an initial set of open-ended questions (see Table 1) that became more refined and guided by the interviewer as the participants' responses emerged. Knox and Burkard (2009) support the use of this approach for qualitative studies, as to the participant it may seem more like a friendly conversation than a data-gathering interview.
Interviews were conducted by the first author either face to face, via Skype™, or over the phone depending on the participant's geographical location and choice. All interviews were audio-recorded with participants' permission and transcribed verbatim. In keeping with grounded theory methodology, memos and field notes were taken during and after each interview.

| Data analysis
Data analysis occurred simultaneously with data collection using the constant comparison approach consistent with the tenets of GT methodology (Glaser & Strauss, 1967). Each interview was transcribed verbatim and "first level" coded using Microsoft Word™. This meant data were analysed line-by-line and each incident relevant to the research question coded with a keyword or phrase. These codes were then compared to each other and alike codes grouped; codes were also considered against all emerging categories to ensure correct "fit" and with one another (Strauss & Corbin, 1990). Analysis of each interview occurred within one week of it occurring. As new data were obtained, the codes from them were compared to the previously developed categories, and this continued until no new information was heard (after six interviews) (see Table 2). At this point, theoretical saturation was reached (Strauss & Corbin, 1990). Theoretical sampling was then employed to ensure heterogeneity and to confirm and "thicken" the emergent theory; this occurred after 14 interviews.

| Data management
All participants were assured of confidentiality and anonymity and were provided with letters of introduction, information sheets and the opportunity to ask questions before consenting to participate, plus an explanation of the proposed research. Participants were assured that their involvement in the research was voluntary and that they were free to withdraw from the project at any time.
All raw data were stored in password-protected computer files,

| Trustworthiness
This study was overseen by an experienced grounded theorist who was involved in every step of the research to ensure rigour of the process. To ensure trustworthiness in this study, a number of measures were employed. A bracketing exercise was undertaken prior to the commencement of data collection to ensure prior knowledge and assumptions were put to one side in order to remain openminded (Husserl & Boyce, 1931). In keeping with grounded theory methodology, memos and field notes were taken during and after each interview (Glaser & Strauss, 1967). These memos and field notes formed part of the audit trail, whilst data analysis was occurring. Member checking also occurred with participants. This involved contacting participants for clarification of findings to ensure accuracy (Creswell et al., 2007). A further formal face-to-face member checking group was conducted with members of the research team and midwives from a range of WA practice contexts who had not participated in the study to confirm the trustworthiness of the analysis. The group was presented with the analysis of the data and the developed categories, and feedback was sought in relation to the credibility, authenticity and representativeness of the emergent theory. During the formal member checking group, all participants unanimously agreed that the findings and the final theory resonated strongly with them and were likely to represent why midwives stay in the profession.

| Participant characteristics
The sample of 14 participants comprised eight midwives practising in rural locations in WA and six working in the greater Perth metropolitan area (see Table 3).
The core category derived from the data was labelled-"I love being a midwife; it's who I am," and comprised three contributory major categories that together represent why WA midwives stay in midwifery. The three major categories that underpin the core category are labelled as follows: "The people I work with make all the difference"; "I want to be 'with woman' so I can make a difference"; and "I feel a responsibility to pass on my skills, knowledge and wisdom to the next generation." The core category and one major category are two-dimensional ( Figure 1).

| Core category: I love being a midwife; it's who I am
It was overwhelmingly clear throughout the interview process that participants loved midwifery, were highly committed to the profession and felt that once one was a midwife, one was always a midwife: TA B L E 2 An example of the original expressions in the interviews, their substantive codes and categories

Original Quote Substantive codes Categories
"I go to work each day because I love the people that I work with… It's a huge reason why I stay" (MW14). "feel[ing] well supported within the team.. they are very supportive and encouraging" (MW2).
The people I work with make all the difference Having a supportive team is crucial The people I work with make all of the difference "it was my calling; once you do it you can't undo it and not consider yourself a midwife…If I had to describe myself it would be 'Mama Midwife'" (MW10). "when I had my children I decided that I couldn't actually see myself doing anything else. It wasn't originally my calling but then it became it" (MW9).

I stay because midwifery is my calling I stay because midwifery is my calling
It's who I am "…coaching women through her contractions can be tiring, but it's so satisfying" (MW11). "it is about being 'with woman'"(MW1). I want to be "with woman" so I can make a difference Being "with woman" I want to be "with woman" so I can make a difference that it was in your heart and even if you left for a short period you would always return. The core category that represents why WA midwives stay in midwifery has two dimensions to it: "I love being a midwife" and "It's who I am."

| Dimension 1: I love being a midwife
Participants unanimously agreed they stay in midwifery because they love it. Although participants were unable to define "love" when asked, it was a word they used repeatedly. Participants said for example, that they "… love the job" (MW2), that they "..definitely stay for the love" (MW4), they "… stay because I love it" (MW6) and that they "… love being a midwife" (MW7 and MW9

| Dimension 2: It's who I am
Midwives reported midwifery to be a large component of their lives; they also said it could not be "undone." Being a midwife was who they were as a person, a mother, a wife, a friend and One participant described the collegial support she was afforded as a safeguard and felt that because her colleagues "had her back" she would be less likely to make a mistake: "I know the midwives I work with at home, we all have each other's back and we support each other.
I know the chances of me making a mistake at home are much less because I've got somebody who will be with me, we watch each other and we safe guard each other and we safe guard the woman together and it's a lovely way of working, and that second midwife doesn't go until the first midwife is happy that everything is ok." The overwhelming support participants felt from the people they work with was voiced strongly throughout the interviews,

| Major category 2: I want to be "with woman" so I can make a difference
This second major category comprises two dimensions. The first is labelled "I empower women through education" and the second labelled "Advocating for women is important to me."

Demographic variable Category Frequency
Years as a midwife Midwives being "with woman" is the central tenet to providing woman-centred midwifery care in partnership with women; it is embedded in midwifery philosophy as well as the Australian midwife standards of practice (Nursing & Midwifery Board of Australia, 2018b). The relationship midwives have with women was a priority for the participants interviewed. Being "with woman" were words that featured strongly throughout interviews with participants and the concept was spoken of with high regard. MW1 states "it is about being 'with woman'," and MW2 and MW3 echoed the same view that they enjoyed being "with woman" and felt that midwifery was in fact a profession that was aimed at being "with woman." Participants described that they enjoyed being "with woman" because they felt they could make a significant difference to women in their care. This difference could be in the antenatal period, during labour and birth and/or helping the woman make the transition to motherhood. The difference participants said they could make to women represented a strong reason for choosing to stay in the midwifery profession. MW11 described the difference she feels that she When participants spoke about the difference they feel they make they beamed with pride, and in some participants' stories, the difference they recalled having made was so considerable that tears welled in their eyes as they told their stories. The selfless dedication to women heard in the participants' narratives was truly remarkable and was clear evidence of truly loving their job.

| Dimension 1: I empower women through education
The  One participant referred to herself as "being like a dog with a bone," when it comes to advocating for women, particularly when the woman's wishes were at odds with medical opinion, and expressing that surely her arguments would have an impact if she has "the discussion" enough times with the doctor.
"My managers have come to recognise that with me and they kind of roll their eyes and I say, you know I have to do this, you know I have to have this discussion with you, you know I have to take this to a doctor and I know that last week for another woman they said no but this is this woman, and I have to do it. I guess part of me is like a dog with a bone in thinking eventually surely it'll have an impact." Some participants referred to themselves as a "gate keeper" and described feeling the need to keep doctors out of the labour and birth room to enable women to have the birth they want:

| Major category 3: I feel a responsibility to pass on my skills, knowledge and wisdom to the next generation
As stated above, the average age of the Australian midwife is 48 years, with a large number of midwives facing retirement in the next 10-15 years (see Figure 2). It was therefore not surprising to hear that participants, many of whom were in this age bracket, were forward-thinking and reported a drive to pass on their skills, knowledge and wisdom to the next generation as another reason for staying in the profession.
To feel able to retire, the older participant midwives described needing to know that the next generation is going to be able to continue to stay strong and resist the medical dominance. One participant said she felt she had to "keep the fight going and teach students that are our next generation" (MW1). Midwife participants felt strongly about the need to stay in the profession so they could help and support not only student midwives but also junior midwives to protect and promote midwifery. "We have to continue to fight the fight for the women otherwise the medical model will just take over… I need to keep the younger ones (midwives) strong enough to resist the changes" Further responses from midwives revealed they would "pass on the baton" and "hang up their Pinard's" when the next wave was ready to support women. "I am at that part of my career now that, not to pass the baton on but to get the next wave there, ready to step up" This is an important job."

| D ISCUSS I ON
This study essentially highlights that midwives' ability to employ what intrinsically motivates them leads directly to job satisfaction and the intention to stay in their jobs and in the profession.
A number of theories and models have been used to explain the phenomenon of job satisfaction, for example Maslow's hierarchy of needs theory (Maslow & Lewis, 1987), Herzberg's motivator-hygiene theory (Herzberg, 1968) and Hackman's (1980) job characteristics model.
In a previous study relating to midwives' intention to stay (Papoutsis et al., 2014), the findings were related to Herzberg's six factors for job satisfaction, namely "achievement," "recognition," "the work itself," "responsibility," "advancement" and "growth" (Herzberg, 1968). All but one of these factors, however, represents extrinsic organisational drivers, whereas for our participants, only the job itself, and working in a team that was supportive and respectful and having the opportunity to develop and share skills, knowledge and abilities were the key considerations. Deci and Ryan's (1985) self-determination theory (SDT), which provides a broad framework by which to explain human motivation and personality, helps explain the findings of this study. SDT posits three needs that are essential to maintain or enhance intrinsic motivation: the need for competence, relatedness and autonomy (Deci & Ryan, 2000). Competence refers to feeling a sense of accomplishment in activities and being capable of overcoming challenges.
Relatedness reflects the need to have meaningful relations with significant others and a sense of belongingness and autonomy relates to the ability to have choice and not be controlled by others (Deci & Ryan, 2000).
The core category derived from our data, "I love being a midwife; it's who I am," and represents that participants found their jobs both motivating and satisfying. It was clearly evident in the data that the title "midwife" is one participant took seriously, that they love their job and that they love being "with woman" when they are at their most vulnerable. McAra-Couper et al. (2014) reported participants in their study also expressed "that midwifery is 'more than a job'; a midwife is someone they become; and a way of life" (p. 31).
La Guardia (2009) discusses fulfilling the need for competence relies on "doing," or the engagement of activities that a person finds satisfying.
Being a midwife is seemingly part of one's identity. Being a midwife permeates into all aspects of one's life, it is who they are, and for some participants, it is what they have always wanted to be. La Guardia (2009) explores the concept of "who am I?" relating to identity and self; the importance of identity arising from the innate environment seemingly fulfils one's true or authentic potential. When a person's values and identity come together, this results in self-determined motivation (Deci, Cascio, & Krusell, 1975).
The term professional identity addresses an individual's affiliation and attraction to a profession and their sense of belonging.
Professional identity is made through one's beliefs and attitudes, values, motives and experiences that people align themselves in their current or anticipated career (Trede, Macklin, & Bridges, 2012).
Hunter and Warren (2013) describe professional identity as integrated with personal identity. Hunter and Warren report that when midwives feel a sense of professional belonging and professional identity this contributed to resilience.
The joy being a midwife brings was reported by participants and reflects findings in other studies (Kirkham, Morgan, & Davies, 2006;Sullivan et al., 2011;Versaevel, 2011). A person engages in intrinsically motivated activities for the satisfaction and enjoyment it brings (Deci et al., 1975). The commitment midwives felt to the women in their care clearly represents their dedication to their values and beliefs and the identity achievement evidenced when this commitment is made (La Guardia, 2009).
Participants in this study felt intrinsically motivated when they were "with woman" and could see the difference their care made.
The findings in this study reflect those found in other studies McAra-Couper et al., 2014;Papoutsis et al., 2014). The sheer enjoyment this engendered to the midwives in our study was an important factor in meeting their individual fulfilment needs (Deci et al., 1975) and by extension their job satisfaction.
Second to this, the major category, labelled "the people I work with make all the difference," demonstrated the need for participants to feel they had meaningful significant relationships with others. This too was identified as an important reason for staying in the profession. Similarly, McAra-Couper et al. (2014) identified in their study that midwives spoke of the midwifery community as whole, and these relationships assisted in the sustainability of practice. This is also seen in other studies Lavender & Chapple, 2004;Papoutsis et al., 2014;Sandall, 1997;Sullivan et al., 2011) who all report the people they work with led to an increased job satisfaction and staff morale. Ryan and La Guardia (2000) enumerate that if relatedness is fulfilled, intrinsic motivation will result.
Essentially, women need midwives who are happy in their profession, the relationship that midwives have with their colleagues plays a crucial role in their ability to remain in their jobs. When midwives feel supported and encouraged, they can make and stand by their clinical decisions that can make a difference to the quality of the woman's childbearing experience. The relationship that participants have with their colleagues plays a crucial role in their ability to remain in the midwifery profession. The respect, support and family-like work environment, all contribute to the participant's ability to be sustainable as a midwife.
There is a strong linkage between autonomy and competence (Nix, Ryan, Manly, & Deci, 1999). Nix and colleagues postulate that if a person is autonomously motivated, they will feel a positive state of vitality resulting in enhanced energy. If the needs for autonomy and competence are allowed, intrinsic motivation will result (Deci & Ryan, 2000) as well as factors of resilience (Vansteenkiste & Ryan, 2013). Autonomy generally relates to an individual, in these findings it was seen to relate to the woman in the midwife's care, as well as to the midwives themselves.
Autonomy is an important aspect in the sustainability of the midwifery profession. When individuals are able to autonomously regulate their own behaviour even when under pressure, their ability to cope with their environment is enhanced (Deci, Olafsen, & Ryan, 2017). This was also evident in Hunter and Warren's study who found that a strong sense of autonomy was central to resilience (Hunter & Warren, 2013). This is not a new finding in midwifery retention studies with a number of papers alluding to the same (Curtis et al., 2006;Kirkham et al., 2006;McAra-Couper et al., 2014;Sullivan et al., 2011). The ability to practice autonomously increases midwives resilience due to the sense of independence felt; the satisfaction midwives feel when they are able to use their knowledge increases their "sense of usefulness" (Sabzevari & Rad, 2019). The degree of autonomy that midwives can practice is strongly influenced by the hierarchy of power due to the medical ideology in which midwives in WA are forced to practice. Although midwives report their frustration and find it challenging working within this medical ideology, they have a realistic expectation of what they can control and optimise their scope of practice accordingly (Kruger & McCann, 2018).
To date, there are no known Australian or international research studies undertaken on the use of SDT in the midwifery profession.
SDT has, however, been employed in other areas as a way to increase job satisfaction. Arshadi (2010) supports the use of SDT with autonomy support in the workplace as a way to increase job satisfaction and intrinsic motivational needs and ultimately work motivation and job performance. We found this to be the case in our study, in that our findings suggest that if basic psychological needs are met this leads to positive work outcomes and increase job satisfaction.

| CON CLUS IONS
The findings from this study add a valuable contribution to the body of work on midwifery workforce retention by providing an account of the factors that keep midwives in the profession. It emerged from the data that midwives' ability to be "with woman" and the difference they feel they make to them, the people they work with and the opportunity to "grow" the next generation together underpin a compelling new middle-range theory of the phenomenon of interest.
There are a number of limitations to the study, the first of which is that the data represent one geographical location and may not be generalisable across other midwifery contexts in Australia and internationally. Second, no male midwives, new graduate midwives, or Aboriginal or Torres Strait Islander midwives were interviewed; therefore, it cannot be assumed that these subgroups' reasons for staying in the profession are the same as for those who participated, and further research is needed to understand what keeps these midwives in midwifery. These limitations notwithstanding the findings provide valuable previously unknown insights into what drives retention in this profession.
The correlation between job dissatisfaction and employee turnover is evident in the literature and is indisputable. To deflect the impending midwife shortage, it is vital that workplace policies focus on the maximisation of midwives' job needs fulfilment. The support to practice autonomously clearly enhances job satisfaction.
Reference to motivation strategies would be helpful, alongside the wider adoption of continuity of midwifery models that increase midwives' autonomy and enable them to be "with woman." The provision of time to effectively mentor less-experienced midwives is also potentially crucial to workforce retention. Those involved in preregistration midwifery education may wish to consider the findings from our study in the employability and career development aspects of their courses. System change may also ensue as a result of imbuing midwifery students with knowledge about what keeps midwives in midwifery, as new graduates may then demonstrate a preference for jobs in workplaces that demonstrably support those professional needs.

| RELE VAN CE TO CLINI C AL PR AC TI CE
The findings from this research have uncovered the reasons as to why midwives stay in the profession in one state in Australia. The theory that emerged and the insights it provides will be of interest to healthcare leaders. Similarly, the insight provided by the findings will help develop midwifery workforce policy and practice, and by extension to optimise midwives' job satisfaction, and facilitate the retention of midwives both locally and across Australia.

ACK N OWLED G EM ENTS
The authors would like to thank the participants who took time out of their day to be interviewed.

CO N FLI C T O F I NTE R E S T
"No conflict of interest has been declared by the authors."