This descriptive cross-sectional study was conducted from September 1, 2022, to March 1, 2023. The study was conducted in the maternity ward of Gynecology and Obstetrics Department of CHUYO. The study population consisted of healthcare providers in the delivery room, namely, doctors, midwives, and male midwives.

Providers were selected using non-probabilistic sampling methods. We calculated the sample size using OpenEpi software with the following formula: n = [ DEFF ∗ N p ( 1 − p ) ] / [ d 2 / Z 1 − α / 2 2 ∗ ( N − 1 ) + p ∗ ( 1 − p ) ] . The total population N was 83 providers; proportion p = 54.4% (results of compassionate behaviors observed in the delivery room at CHUYO in 2015 during a study [12]), a confidence level of 95%, and a margin of error d = 5%. The sample size (n) was 71 providers.

All qualified healthcare providers who participated in the care of women in labor in the delivery room and provided their verbal or written, free, and informed consent to participate in the study were included.

Were not included:

heathcare providers who were not in the delivery room during the study period. healtcare providers who were in the delivery room but did not provide care to the woman in labor. healthcare providers who cared for women in labor with whom they had familial ties. any trainee healthcare provider other than those specializing in obstetrics and gynecology.

The variables were as follows:

socioprofessional characteristics of healthcare providers: age, sex, professional qualification, and seniority in the department; working conditions of healthcare providers: workload, salary, equipment, materials, and infrastructure, workplace relationships, communication with superiors, participation in decision-making;providers’ behavior: healthcare provider-patient relationship, factors perceived as influencing behavior.

Two forms were developed as data collection tools:

A grid for observing the provider-patient interaction and the infrastructure, equipment, and medical-technical materials; A form for interviewing healthcare providers about socio-professional variables, working conditions, and perceived factors influencing providers’ behavior.

The data collection techniques used were interviews and observations of working conditions and provider-patient interactions. We obtained free, voluntary, and informed consent from the healthcare providers. Healthcare providers were included as soon as they started their work shifts. We observed interactions between the provider and patient at different stages of care: reception and initial assessment, labor monitoring, delivery, immediate postpartum, and working conditions. Each provider was interviewed. Data were collected using a personal computer. The analysis was performed using Epi Info version 7.2.

The concept of compassionate behavior in maternity care implies that care is extended to include respect for women’s fundamental rights, including respect for autonomy, dignity, feelings, choices, and preferences, including the choice of a companion during childbirth. In other words, the relationship between a woman and her maternity care providers during pregnancy and childbirth must be characterized by compassion, empathy, support, trust, empowerment, and gentle, respectful, and effective communication to facilitate informed decision-making [13]. The classification criteria refer to the elements used to assess the healthcare worker’s behavior during the different stages of childbirth, based on 37 items (questions) to be answered or checked off with a yes or no on the questionnaire. The questionnaire was designed after a review of the literature on compassionate behaviors. The questionnaire was validated by peers. A “yes” answer corresponds to 1 and a “no” answer to 0. The scores were then summed to obtain a total score for each provider at each stage and for the entire childbirth process. The overall evaluation score was divided into a three-level scale:

level 1: from 0 to 1/4 of the total score corresponding to non-compassionate behavior; level 2: from 1/4 to 3/4 of the total score corresponding to moderately compassionate behavior; level 3: from 3/4 to the total score corresponding to compassionate behavior. Thus, we can refer to non-compassionate, moderately compassionate, and compassionate providers according to the following characteristics; the healthcare provider’s attitude towards the patient during reception, scored out of 8: 0 to 2 for non-compassionate behavior; 2 to 6 for moderately compassionate behavior; and 6 to 8 for compassionate behavior; the healthcare provider’s attitude during labor monitoring and delivery, scored out of 13: 0 - 4 for non-compassionate behavior; 4 - 10 for moderately compassionate behavior; and 10 - 13 for compassionate behavior; the healthcare provider’s attitude towards the patient in the immediate postpartum period and counseling, scored out of 16: 0 - 4 for non-compassionate behavior; 4 - 12 for moderately compassionate behavior; and 12 - 16 for compassionate behavior; The healthcare providers’ overall attitude, taking into account the attitude towards the patient during reception, labor monitoring and delivery, and the immediate postpartum period, scored out of 37: 0 - 12 for non-compassionate behavior; 12 - 24 for moderately compassionate behavior; and 24 - 37 for compassionate behavior.

We obtained authorization from the head of the department. Free, informed, and voluntary consent was obtained from all participants. The anonymity of the data collection forms and confidentiality of the responses were ensured.

The average age was 37.4 years ± 6.7, ranging from 22 to 54 years. There were 27 male (38%) and 44 female (62 %) providers. The average length of service was 6.45 years ± 4.57, with a range from 8 months to 23 years, and 67.1% had no more than 10 years of service. The socioprofessional characteristics of the workers are presented in Table 1.

Table 1. Socioprofessional characteristics of healthcare providers.

The quality of the infrastructure, equipment, and medical-technical materials in the emergency section of the maternity ward was average or poor in some rooms. These pieces of equipment and medical-technical materials were insufficient in number. The daily healthcare staff consisted of two midwives or maieuticians and three doctors, with a daily workload of approximately 20 - 50 patients. Table 2 presents the healthcare providers’ perceptions of working conditions in the maternity emergency department.

Table 2. Healthcare providers’ perception of working conditions.

3.3.1. Healthcare Providers’ Attitudes According to Their Behavior

Providers were evaluated at different stages of childbirth based on their compassionate behaviors, followed by an overall assessment of the entire childbirth process. Figure 1 presents the healthcare providers’ behavior toward women in labor.

Figure 1. Healthcare providers’ behavior towards women in labor during care.

3.3.2. Factors Associated with Healthcare Providers’ Behaviors

Table 3 presents the bivariate analysis between socio-professional variables and provider behavior. The workplace relationship was the only factor statistically associated with healthcare provider behavior.

Table 3. Bivariate analysis between socio-professional variables and providers’ behavior.

3.3.3. Factors Perceived by Providers as Influencing Their Behavior

Figure 2 presents the factors perceived by healthcare providers as influencing their behavior in the maternity emergency room.

Figure 2. Factors perceived by healthcare providers as influencing their behavior.

The average age of the healthcare providers was 37.4 years ± 6.7, with a range of 22 - 54 years. Our result is close to that of Zongonaba’s 2015 study on compassionate behavior in the delivery room in the same service, which found an average age of 35.34 years [12], Naseri’s in Iran, 31.84 years among nurses [14], Ergin’s in Turkey, 37.47 years [15], and Wesson’s in Namibia, 37.4 years [16]. In Kenya, 68.8% of healthcare providers were under the age of 40 [7]. These results reflect the youth of the study population. This youthfulness may be explained by the general youth of our population and the need to assign young staff owing to the workload in emergency services and the presence of resident doctors, who are relatively younger.

Females predominated, accounting for 62% of the providers. Several authors have also reported this female predominance [2][5][14][17]. For example, Afulani in Kenya [7], Ndwiga in Kenya [18], and Wesson in Namibia [16] reported female proportions of 62.5%, 82.1%, and 91.1%, respectively. However, in Kasaye’s study, males predominated at 55.4% [19]. Our results could be explained by the fact that the study was carried out in the maternity delivery room, where there were more midwives (MWs).

In our study, 53.5% of the participants were MWs/maieuticians, which might be explained by the country’s healthcare system, where the number of paramedical staff is generally higher than that of physicians. However, the relatively high number of physicians in our study may be due to the presence of residents in the obstetrics and gynecology department. Our results are similar to those of other studies in the literature, where the MWs, maieuticians, and nurses category predominated, ranging from 55.72% to 95% [16][18]-[21].

The average length of service was 6.45 years, ranging from 8 months to 23 years. More than half of the respondents (67.6%) had between 0 and 10 years of service. Naseri et al. reported a similar average of 5.71 years [14]. The same was true in Fachon’s study in the United States, where 58.7% had less than 10 years of service [2]. According to Afulani, 93.7% of providers held their posts for no more than four years [7]. In another study, 78.3% had no more than 10 years of service in the health facility [15]. This could be explained in part by the majority presence of residents, whose training lasts four years, representing different cohorts, and in part by the youth of the study population.

Workload

Healthcare providers face a heavy workload due to insufficient staff and a large number of patients attending the maternity ward. Moreover, 95.8% of the providers felt that they were overworked at their workplace. The findings of the literature support our findings. In fact, 59.73% of healthcare providers had a high workload [17]. Provider overload has been noted by many worldwide [3][4][7][16][22]-[27]. This excessive workload is a source of stress that impacts providers’ psychological health, the quality of relationships with patients, and the quality of care provided, leading to dissatisfaction [22].

Perception of employment and salary

The majority of surveyed agents (97.18 %) were satisfied with their jobs, but less so with their salaries considering their workload. This finding is similar to that of Garcia, where 88.47% of health workers reported job satisfaction [17]. Providers were proud of their usefulness and enjoyed their work, even though they faced difficulties [23]. According to Rahmani, in Afghanistan, 87.6% of providers were at least partially satisfied with their jobs [15]; 70.9% were happy with their work, and 65.5% were satisfied with providing maternal health care [19]. Job satisfaction is an important element of workplace well-being, enabling workers to contribute to the development of businesses and society and provide quality services to clients. For midwives, low pay and delays in promotions were sources of dissatisfaction at work [27]. The salary dissatisfaction found in our study has been reported in several countries (studies) according to Reddy, Carvajal, and Mannaya in their reviews [22][26][28]. This indicates that the salary situation in Burkina Faso is not an isolated case but an almost global reality. In Ghana, midwives complained about the lack of bonuses, rural allowances, and compensation, which were demotivating [24]. Low salaries were also reported by doctors in Afghanistan [23]. In Wesson’s study in Namibia, only a minority (12.1%) of providers were satisfied with their salary [16]. Salary dissatisfaction leads to worker demotivation and impacts providers’ health and quality of care. Governments must establish fair remuneration mechanisms for care providers to meet their essential needs.

Workplace relationships

Relationships at work were good in 43.66% of cases, according to healthcare providers. This rate is not satisfactory because the quality of relationships at work is a key factor in the smooth functioning of work. Indeed, psychological balance allows one to be in a good frame of mind to provide humane care, as good communication habits among providers create a positive work climate in which providers thrive in their tasks. Our results are close to those of Kasaye, where the relationships among health professionals were good in 51.4% of cases. Healthcare providers worked as a team with mutual respect in 63.5% of the cases [19]. However, as in our study, difficulties with relationships, cooperation, autonomy, and support between work teams or between subordinates and superiors or managers have been reported [16][25][26][28].

Equipment, materials and infrastructure

Moreover, 83.1% of the providers felt that the equipment was in poor condition, which often made their work difficult. Regarding the quantity of equipment, 98.6% of the providers considered the work equipment insufficient. Our findings, namely, the absence or insufficiency of equipment, materials, and infrastructure in both quantity and quality, are supported by several authors, especially in developing countries such as those in Africa [22]. According to Garcia, 42.55% of caregivers had inadequate working conditions [17].

Attitude of healthcare providers

The evaluation of the entire childbirth process found no non-compassionate healthcare providers (NCPs), 56.33% moderately compassionate providers, and 43.66% compassionate providers. Similar results have been reported by several researchers. In Tarekegne’s series, 88% of patients stated that providers treated them with respect; 93.7% and 98.5% were not victims of verbal and physical abuse, respectively [29]. In the USA, over 84.8% of the staff reported that they most often treated patients with respect [2]. In Kenya, 84% of caregivers treated patients with respect and dignity most of the time or always [7]. According to a literature review, women experienced compassionate or positive behaviors and attitudes—sympathy, friendliness, kindness, politeness, attentiveness, helpfulness, good communication, and welcoming—from the health staff [28]. These results demonstrate the commitment of care providers to deliver quality, dignified, respectful, and compassionate care to achieve the goals of risk-free maternity and maternal health. However, the evaluation noted approximately 10% of non-compassionate behaviors in delivery rooms and at reception in our study. This finding is not isolated. According to Wesson, 31.2% of providers reported witnessing non-compassionate behaviors towards patients in their health facilities [16]. Non-compassionate behaviors (physical, verbal, poor communication, lack of support, and lack of autonomy) have been corroborated in several studies in various countries around the world [4][5][19][22][28]. In Ethiopia, most providers reported non-compassionate behaviors towards patients. Approximately one-third of providers commit verbal or physical violence against patients [19]. Such behaviors, regardless of their type or form, must be banned from healthcare facilities and daily life. The causes raised by providers were numerous: work overload, staff shortages, lack of infrastructure, equipment, materials, low salaries, tensions with superiors, managers, and colleagues, stressful working conditions, stress, lack of support and recognition, lack of career or training prospects, and lack of transparency and fairness [22][28].

Factors perceived by healthcare providers as influencing their behavior

Providers mentioned reasons that negatively influenced their behavior, such as: The most common reasons were staff shortages (53.5%), noncompliance with the healthcare pyramid (22.5%), and inadequate staff motivation (19.7%).

Our finding that insufficient staff negatively affects providers’ behavior toward parturients and patients in general has been reported in the literature [3][4][7][16][21][22][24][25]-[28][30]. In Namibia, more than 80% of providers reported insufficient staffing relative to the workload [16]. Carvajal et al., in a literature review of 70 studies, noted understaffing in several studies as a source of work overload and stress, thereby impacting the quality of care [26]. Providers and patients have denounced understaffing in health facilities [4]. In Ghana, the lack of midwives is a major concern in health facilities, causing midwives to work 24-hour shifts [24]. In the USA, barriers to compassionate care include workload (76.1%) and fatigue (60.9%) [2]. Staff shortages lead to work overload and stress and compromise the quality of care in a context where clients are increasingly demanding and impatient. Quality of care is at the forefront of national and international policy concerns, as well as those of health facilities and patients [26]. Under these conditions, neither the patients nor the providers are satisfied. This situation undermines the quality of the patient-provider relationship and even the physical and mental health of the providers.

Noncompliance with the healthcare pyramid results in parturients who could have been seen at lower levels ending up at the university hospital alongside patients referred from other lower-level facilities. This could be explained either by proximity to the university hospital, because the patient was followed up there during pregnancy, or because of a preference for giving birth in a better-equipped medical environment to deal with any eventuality. The same observation was made in Tanzania, where patients did not adhere to the healthcare pyramid [25].

Inadequate staff motivation, whether moral or financial, can undermine morale and providers’ commitment to delivering quality patient care. Several studies have highlighted the issue of inadequate motivation among providers, both generally and in maternal health services, leading to demotivation, dissatisfaction, low morale, and negatively impacting providers’ engagement, quality of care, and patient-provider relations [16]. The causes of demotivation include work overload, stressful and restrictive working conditions, insufficient resources, staff shortages, low salaries, lack of recognition, support, career planning and advancement opportunities, poor management, and poor workplace relationships [16].

Factors statistically associated with healthcare providers’behavior

The relationship at work was the only factor statistically associated with compassionate behavior in our study, with a p-value of 0.008. All other factors, such as workload, equipment, salary dissatisfaction, and job satisfaction, were not statistically significantly associated with compassionate behavior. Our result could be explained by the fact that good workplace relationships are a source of psychological fulfillment, mutual support and assistance, and motivation that can enable employees to overcome the material and physical conditions of their work.

Our study aimed to gather providers’ opinions on working conditions in the obstetrics and gynecology emergency department at CHU-YO and assess their impact on compassionate provider behaviors. Knowing that they were being surveyed may have influenced the providers to modify their behavior toward parturients and the care they provided. The limited sample size and the fact that the study was conducted in a single health center prevent generalization of the results. Nevertheless, it provides an idea and overview of the behaviors and working conditions in the CHUYO maternity ward. A study with a larger sample size and in several health centers, even at the national level, should be considered in the future.