Health workforce governance, workload alignment, and job satisfaction among skilled birth attendants in urban primary health care: a mixed-methods study from Ethiopia

Background Background: Health workforce motivation and retention are central to achieving high-quality maternal and newborn care globally. However, evidence on how staffing allocation, workload, and work environment interact to influence skilled birth attendants’ job satisfaction in urban primary health-care settings in low- and middle-income countries (LMICs) remains limited. Methods An explanatory sequential mixed‑methods study was conducted in 50 public health centers between January and April 2021. Quantitative data were collected through face‑to‑face interviews with 338 midwives providing maternal and newborn health services. A structured health‑center questionnaire was administered through interviews with maternity unit heads, direct observation, and register review. Qualitative data were generated through in‑depth interviews with 20 midwives and 13 health‑center managers. Quantitative data were analyzed descriptively, while qualitative data were analyzed thematically using Colaizzi’s method. Results Only 38.2% of skilled birth attendants reported overall job satisfaction. Staffing allocation was poorly aligned with service workload, resulting in wide variation in annual deliveries per SBA across facilities. Despite generally adequate infrastructure and essential supplies, dissatisfaction was driven by low remuneration, limited access to professional development, weak performance-based recognition, and high workload. Qualitative findings highlighted governance gaps in staffing norms, limited managerial accountability, and the absence of incentive mechanisms as key contributors to low motivation. Conclusion This study demonstrates that adequate physical resources alone are insufficient to ensure a motivated maternal health workforce. Misalignment between staffing allocation and workload, weak performance management systems, and limited professional development opportunities undermine job satisfaction among SBAs. These findings have implications for urban primary health-care systems across LMICs, underscoring the need for workforce policies that link staffing, workload, and performance incentives to improve motivation and quality of maternal and newborn care.