Midwives are a very important group of health professionals, as they play a key role in the continuity of maternal care. On the other hand, midwives experience burnout, which refers to a syndrome that mainly has symptoms of emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment [1]. The World Health Organization [2] has declared this phenomenon as an occupational disease, highlighting the need for targeted research and intervention in the workplace.

Burnout among midwives not only threatens their health, but also compromises the standards of care provided to patients. Research in various healthcare settings suggests that burnout among healthcare professionals can lead to errors, less patient satisfaction, and a higher turnover rate among healthcare professionals [3]. The demanding nature of midwifery, which includes long hours, intensive work, and managing high-risk pregnancies and deliveries, makes them vulnerable to higher levels of stress than those seen in most other areas of the medical profession [4].

In Greece, where private health care is of primary importance in maternal care, research on burnout among midwives is rare, especially in private maternity hospitals. This may lead to specific and burdensome challenges, such as profit-driven care systems. These challenges can manifest themselves in a number of ways within healthcare settings. Knowledge of the unique characteristics of the midwifery profession is vital to designing effective interventions that address the specific needs of this demographic.

In addition, resilience [5], defined as the ability to maintain good personal well-being and professional effectiveness in stressful situations, has been identified as a key barrier against burnout. Several studies have shown that resilience increases when workplace support is provided and coping strategies and positive work environment are created - all of which significantly reduce the effects of burnout [6].

Although midwives play an essential role in the health and well-being of mothers and newborns, there is still a lack of research on the prevalence and impact of burnout and resilience among midwives providing maternity services in private hospitals in Greece. Most research that has been conducted on burnout among health professionals has focused on the public health sector or outside of Greece. Thus, there is a lack of data that could provide local stakeholders and policy makers with guidelines to inform their practices. This disparity is worrying, especially considering that working conditions in private healthcare facilities are often in stark contrast to those in public ones, which may influence the level of stress and potential coping strategies of healthcare workers [7].  Furthermore, although the concept of mental resilience is considered essential for addressing burnout syndrome, there is insufficient information on what resilience looks like among midwives, particularly in private clinics, and how it can be maintained. Such a research gap leads to the inadequacy of those responsible to create effective strategies to develop resilience and prevent burnout, which is essential not only to improve the working status of midwives, but also to maintain the level of maternal and infant care in the country.

The costly recognition of burnout and resilience among midwives working in private maternity hospitals in Greece is an important task for a number of reasons outlined below. The nature of stress in the case of the private healthcare system which takes forms such as, ongoing customer satisfaction and thorough scrutiny of employee performance, may result in a different effect on healthcare workers [8]. These types of specific stressors are unique to the work environment of private hospitals and, therefore, the need for unique studies tailored to these health care institutions has been further highlighted.

In addition, midwives work on two fronts. Every day they face emotional and physical situations that are important for maternal health and neonatal care. Excessive fatigue and burnout among midwives could not only reduce their ability to provide high quality care but also lead to adverse maternal and neonatal outcomes [9]. In the same way, addressing burnout is helpful for both the mental and emotional health of midwives and the entire healthcare system because without healthy midwives, maternity services are unable to function effectively.

Finally, building resilience can be interpreted as a shield against possible burnout. The exploration of the particular mechanisms that enrich resilience particularly in private maternity care in Greece can be used in policy making to develop guidelines. These interventions are important for addressing burnout and the sustainability of these professionals, thus supporting the provision of quality health services [6]. This review fills an important gap by examining burnout and resilience among midwives in private practice, two topics that, although important, have received remarkably little attention in the literature. It is also important to understand and prevent burnout not only for the wellbeing of health workers, but also for the wellbeing of patients, which is very important, particularly in modern circumstances [3].

The Concept of Burnout

Burnout is a psychological syndrome that arises as prolonged reaction to interpersonal stressors in the workplace. The concept, which was originally described by Freudenberger [10] and later expanded by Maslach and Jackson [11], encompasses three main dimensions of burnout including emotional exhaustion, depersonalisation and reduced personal fulfilment.

Burnout has been defined differently over the years, especially since the World Health Organization included it in the 11th revision of the International Classification of Diseases (ICD-11) in 2019 [2]. The WHO recognizes burnout as a specific phenomenon that refers to the work environment, not as a medical condition but as an occupational phenomenon that can affect health status (World Health Organization, 2019). This characterization emphasizes organizational factors in the development and maintenance of burnout, a concept that moves away from the disease model and looks at the issue from a systems perspective. Studies conducted after 2019 are dedicated to further documenting burnout as a multifaceted phenomenon, especially in the healthcare sector, where the pressure is enormous and the effects can be critical. Wiederhold [12], points out in this regard that due to the emotional nature of work, midwives and other healthcare workers are at greater risk, as the main characteristic of burnout is emotional exhaustion. This emotional exhaustion is often a consequence of chronic stress and is experienced as burnout that presents as overload and physical fatigue [13].

Salyers et al. [14], for example, have pointed out that burnout results from environmental factors within the workplace and the structure of the workplace. These studies call for systemic change in terms of policy and structures as a way of reducing the factors that lead to burnout. According to the study, improving work resources such as social support from colleagues and managers and decision-making power can significantly reduce the effects of burnout from high job demands [15].

Understanding the underpinnings of burnout is crucial not only for developing effective interventions but also for creating a healthcare environment that promotes the well-being of both providers and patients. As this body of research expands, particularly in settings unique to private healthcare systems such as those in Greece, it becomes critical to tailor interventions that address specific organizational and cultural contexts to effectively combat burnout among midwives.

Burnout Among Midwives

It is worrying that burnout is high among midwives, as the effects translate directly into the care of mothers and newborns. The stressors that characterize midwives include: fatigue and working long and irregular hours, taking on emotional demands resulting from the high-risk scenarios they face during childbirth, and the need for close interaction with patients during a dramatic period in their lives [16]. These issues lead to high levels of emotional exhaustion, which is the most common dimension of burnout in this group.

In addition to hands-on care, midwives perform educational and supportive tasks for expectant mothers, which contribute to their depersonalization - one of the symptoms of burnout. Whenever midwives experience depersonalization, they treat their patients in a very cold manner, which is not good for the patients as it reduces their trust in the midwives caring for them [17].

 In addition, there is a lack of personal fulfilment that can be particularly daunting in midwifery work, where personal and professional self-image is consistent with patient experience and outcomes.

Current studies reveal that burnout among midwives negatively affects their physical and mental wellbeing as well as job satisfaction and increases turnover rates, which in turn contributes to existing staff shortages and causes increased workloads for remaining staff, creating a cycle of burnout [4]. Therefore, combating burnout in this type of profession is therefore vital not only for the health of midwives, but also for maintaining effective, efficient and safe maternity care.

Another reason that may contribute to burnout among midwives is organisational factors. Lack of adequate support from management, poorly designed jobs and lack of access to professional development lead to burnout making midwives feel unappreciated and overburdened [18].

Preventive interventions, which include strategies aimed at modifying the work context, which include the promotion of better working conditions, including teamwork, adequate rest and a positive climate, are essential to address these sources of stress.

In addition, enhancing midwives' career advancement and participation in decision making is considered effective in reducing burnout through increasing perceived competence or sense of accomplishment among others [19]. Measures such as these not only affect employee satisfaction, but also play their role in providing better patient care.

Regarding the influence of burnout on midwives, there is a need to address the problem at the organizational and policy level to promote the creation of approaches that enhance midwives' work environment to be healthy and that promotes their professional and personal well-being. This not only helps in retaining skilled midwives, but also, maternal and neonatal care is maintained to be compassionate and of good quality, thus helping the society as a whole [20].

Resilience in Healthcare Professionals

Employee resilience in healthcare is now recognised as a valuable asset, in addition to being used to address burnout and improve personal health and satisfaction. Described as the ability to manage health and work productivity despite stressors, resilience allows an individual to recover from failures, adapt to new circumstances, and continue to grow throughout life [21]. This ability is vital in healthcare settings because most employees often come into contact with patients who are in high-stress situations.

 Coping is not a matter of an individual's character, but can be a process that is learned based on certain techniques and resources. Studies have shown that healthcare workers with higher levels of resilience are less prone to burnout and are more prone to report higher job satisfaction and better quality of life [15]. Promotional resources are those that create the individual's ability to manage stress effectively and include positive influences, assessment and coping resources, as well as organisational resources, which involve organisational support and positive work characteristics.

 Current research focuses on the value of professional development courses containing resilience training for health care staff. It should also be noted that these programmes use elements of mindfulness, stress management and communication skills [22]. These interventions have been shown to be effective in reducing stress as well as enhancing adaptive coping approaches among healthcare workers.

 Another important determinant is organizational strategies that also contribute to improving resilience. Elements such as encouraging leadership, effective communication and strong teamwork are the important building blocks of a strong workforce. For example, information and team building can improve cohesion and social support, which are important elements in coping with stress [23].

 Also, promoting healthy work-life balance conditions, as well as recognising health professionals, can be helpful in enhancing resilience. Other organisational commitments such as flexible working hours, personal development and the provision of wellness programmes are additional organisational factors that promote a positive organisational culture by making health professionals feel valued [3].

 The nature of stress is most evident in the critical areas of an organisation, such as midwifery and emergency departments, where staff are under immense pressure. Employees in these areas gain much from resilience programmes that are useful not only for coping with stress but also for enhancing staff focus on patient care [24].

Resilience Strategies for Midwives

The nature of midwifery requires great physical and emotional stress, hence the need to be resilient. Approaches to increasing midwives' resilience are useful not only for the psychological wellbeing of midwives but also to ensure that they are able to deliver primary care effectively and efficiently. Specific strategies are needed to enhance midwives' resilience due to identified difficulties, such as coping with the consequences of difficult deliveries, regulating the emotions of pregnant women and leotards, and handling high density labour.

 An important technique for building resilience in midwives is structured resilience training programmes. It is not uncommon for these programmes to address aspects such as mindfulness, application of cognitive-behavioural concepts and stress coping strategies. For example, Crowther and Smythe [25] described how mindfulness-based stress reduction programmes offered benefits in reducing stress and increasing resilience in midwives. Such programmes help midwives to be more aware of their mental states in stressful situations, and this improves their ways of handling such situations.  Midwifery support groups are another important form of resilience strategy embraced in patient care. These groups are essential because they allow midwives to interact with their colleagues, share their experiences, talk about the problems they face and be supported by others. Friendship in these groups can reduce feelings of loneliness and can make someone feel that it is normal to have emotional problems due to the nature of the job. Hunter et al. [4] also stated that job satisfaction and burnout symptoms among midwives were found to have positive effects with peer support programmes, highlighting the importance of social relationships in developing resilience.

 Mentoring can also be very effective in enhancing this aspect of resilience as well. The knowledge, skills and experience of midwives who have served longer than new staff can advise, comfort and guide them on how to manage the pressures that come with the job. These relationships help to create a learning culture that enhances midwives' experience, their value and therefore their ability to cope [26].

Strategies at the organisational level are also important in terms of midwives' resilience. To prevent stress and burnout in the workplace, there should be enough staff, people should be able to have flexible working hours and they should also be given some opportunities for career development. In addition, the leadership of healthcare organisations should recognise the need to create a positive organisational climate. This can be achieved by encouraging open communication, listening to the struggles faced by midwives and conducting annual health checks [7].

 Finally, professional development activities that increase their skills and knowledge can help midwives and increase their confidence in dealing with such complications. It is also important to note that continuing professional education not only refreshes midwives' knowledge of current practice, but also enhances their skills and professional confidence, which are other pillars of the resilience framework [24].

Social Support and Its Impact on Burnout and Resilience

Existing literature suggests that social support plays a key role in determining burnout and resilience among health workers - and midwives in particular. In the broadest sense, social support includes emotional and informational support, as well as material help received from colleagues, close people and the wider community. It is particularly important in healthcare organisations, where work can be emotionally and physically demanding for the employee. Based on research, it can be concluded that there is a direct relationship between perceived social support and burnout rates, as well as between perceived social support and resilience levels [27]. In the case of midwives, the emotional aspects at play when dealing with patients are challenging and having a support network to balance the stress inherent in the job can be an important advantage. Constant positive interaction with other nurses, who are also aware of the various difficulties within their profession, reduces the likelihood of feelings of loneliness and anger. Such companionable relationships help to develop a unified purpose and perseverance towards coping with anxiety at the individual and group level [28]. Emotional support, such as encouragement and understanding from peers, is also crucial. Informational support, including peer advice and knowledge, helps midwives cope more effectively with uncertainty and difficult and complex situations, thereby reducing work stress and the risk of experiencing burnout. In addition, more tangible support through sharing responsibilities or helping with challenging and stressful situations can reduce the amount of work midwives have to do in their capacity as professional caregivers so that they can manage one aspect of their personal lives more effectively, which is vital for the long-term presence of resilience in the profession [29].

Companies that provide social support structures through formal support systems and informal support networks are not only able to maintain and enhance the health of their employees but also the health of the organization as a whole. Support networks can be further strengthened through activities such as mentoring programs, daily work group meetings and group outings, which play a critical role in creating a healthy work culture with little tolerance for burnout among midwives [30].

The Greek Maternity Healthcare Framework

The current framework of healthcare provision in Greece, which includes both the private and public sectors, raises specific issues concerning midwives and their working environment, especially in private maternity hospitals. These challenges are exacerbated by financial issues that have limited available resources and healthcare reforms that have stretched existing resources in the country [31]. In private maternity hospitals, where demand for services is high and patient expectations are high, midwives work under pressure providing high quality services with limited resources. As mentioned earlier, most private healthcare providers in Greece have market-oriented structures that focus on productivity to maximize patient turnover. This can further minimize the time spent with patients and also put additional pressure on working midwives, which can lead to further stress and therefore potential for burnout. However, these settings also give midwives the opportunity to work in a technology-rich environment - thus, the experiences of working there are different in terms of professional gains and losses compared to public hospitals [32]

An analysis of the general background of Greek maternity healthcare is considered necessary in order to understand midwives' discussed concerns about burnout and resilience in this context. Further, the effectiveness of intervention approaches to support midwives in both the public and private sectors in Greece requires contextually adapted economic, cultural and organizational approaches to maintain quality maternal care for the sustainability of health service delivery [33].

Burnout among midwives and obstetricians in private maternity hospitals in Greece is a significant challenge that can affect not only the personal well-being of health professionals but also the quality of services provided to women and newborns. Increased professional demands, intense job stress, and the emotional demands of caseloads create a highly demanding work environment that increases the risk of burnout.

However, mental resilience appears to play a key role in coping with these challenges. Midwives and obstetricians who show higher levels of resilience are better able to manage work stress and maintain their mental wellbeing, thus reducing the risk of burnout. Organised interventions, training in stress management techniques and mental health support in the work environment can make a significant contribution to maintaining the resilience of these professionals. The study highlights the need for systematic support and development of policies to enhance mental resilience in maternity hospitals in order to ensure the mental health of professionals and the quality of midwifery care in Greece. Through strengthening resilience, midwives and obstetricians will be able to cope more effectively with the challenges of the profession, ensuring a stable and supportive environment for the families they care for.

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