title: Midwifery at the crossroads in Estonia: attitudes of midwives and other key stakeholders.
abstract: BACKGROUND
  Since the initiation of health sector reforms in Estonia in 1992, the Baltic state has experienced a steep decline in the number of midwives and midwife graduates. At the same time, there has been a rapid increase, first in sexually transmitted infections and then in human immunodeficiency virus. The aim of this study was to draw on the perceptions of Estonia's midwives and other health care stakeholders to delineate the current situation of midwifery in the country, in the context of a sexually transmitted infection/human immunodeficiency virus epidemic.
  
  
  METHODS
  Data were obtained by sending a 32-question questionnaire, based on an agenda developed through semistructured interviews, to all midwives in Estonia. A nominal group technique was employed with key stakeholders to determine the extent of their agreement with the questionnaire's major findings.
  
  
  RESULTS
  The response rate to the questionnaire was 75%. There was no significant association between work satisfaction and independent variables of age, ethnicity, work abroad, increased responsibility, and involvement in postpartum care and counseling. There was, however, a significant association between work satisfaction and salary. The group process revealed that although there is no agreement on the role of family doctors and midwives in antenatal care, there is a general agreement that midwives should be more involved in postpartum care and that their tasks need to be better defined.
  
  
  CONCLUSIONS
  Almost half of the responding Estonian midwives are dissatisfied with their job, especially their salary. Increased responsibility for antenatal and postpartum counseling, with concurrent salary adjustments, may help stop the decline in the number of midwives, as could the opening up of new areas of work. A further reduction of the high abortion and sexually transmitted infection/human immunodeficiency virus rates is a critical challenge for Estonia, and midwives could be employed in services to do this, similar to their Nordic neighbors. Current indications suggest, however, that the number of midwives, especially new graduates, will continue to decline.
authors.affiliation: Department of Community Medicine, Lund University, Sweden. jeffrey.lazarus@smi.mas.lu.se
authors.forename: Jeffrey V
authors.initials: JV
authors.lastname: Lazarus
authors.forename: Vibeke
authors.initials: V
authors.lastname: Rasch
authors.forename: Jerker
authors.initials: J
authors.lastname: Liljestrand
mesh_terms: D000328:Adult; D000367:Age Factors; D001291:Attitude of Health Personnel / Q000208:ethnology*; D002321:Career Choice; D037001:Directive Counseling / Q000458:organization & administration; D004957:Estonia; D006801:Humans; D007588:Job Satisfaction; D008875:Middle Aged; D008880:Midwifery / Q000458:organization & administration*; D009721:Nurse Midwives / Q000523:psychology*; D024802:Nurse's Role; D011181:Postnatal Care / Q000458:organization & administration; D012456:Salaries and Fringe Benefits; D011795:Surveys and Questionnaires