**1. Introduction**

Tertiary work environment in the maternal healthcare service is the key role player in the psychological aspects of the multidisciplinary team members which include midwives. In some developing countries the staffing norms in tertiary hospitals is mandated by the country's maternity guidelines which require midwives with extra qualifications of advanced midwife and neonatal science to be allocated in substantial number to manage the high-risk type of patients in those level of care situation. However, due to shortage of advanced midwives in most countries, makes it impossible to meet that prescribed mandate of accumulating the required number of that category of staff which is also complicated by the high volume of patients in such a high level of

care. The high volume of patients with a shortage of staff makes the tertiary hospital environment to be psychologically stressful for healthcare providers. A psychologically stable-minded midwife's performance is depicted by the decisions taken in the management of patient care process communication with other members of the multidisciplinary team, pregnant, birthing, and post-birth women. The psychologically stable-minded midwives provide holistic care with passion, respect, dignity, and with confident to maternity patients under their care. Tertiary maternity patients are significantly unstable patients with significantly demanding high levels of care.

Tertiary maternity patients are referred patients with obstetric emergencies from lower levels of care areas which can either be a primary health care clinic, midwifery obstetric unit (MOU), district hospitals, and regional hospitals. The common indicators for obstetric emergency referrals include preterm labour; pregnancy-induced hypertension; fatal distress; previous caesarean section; malpresentation; cord prolapse, shoulder dystocia, placenta praevia, amniotic fluid embolism poor progress in labour, infections. Obstetric emergency patients are stressful to manage and necessitate a healthy environment which needs the full involvement of all professionals in the rendering of care [1]. Obstetric emergencies are the main causes of the unnecessary preventable or unpreventable loss of the mother or loss of the baby, or loss of which are stressful situation for the midwives looking after the patient. In that stressful environment, advanced midwives are keen, dedicated, and committed to support maternity women even if there are challenges like a language barrier between them and the patient, with system lack of midwife support as the maternity systems lack accessible interpretation services to support women with language needs which make midwives go through stressful experiences of falling through the net as it came out as one of the findings of study conducted by midwives [2]. The status of the type of patients who are managed in tertiary hospitals is at considerable risk of prolonged hospitalisation, complications related to their conditions, and mother or baby, or both losing lives. Prolonged patient hospitalisation creates a special bonding between patients and the midwives which is very traumatic psychologically to the midwives in situation where the outcome of care does not go as planned like in the development of severe complications and loss of life. However, in such stressful situations, advanced midwives are restricted to fully utilise their knowledge and skills. Most psychological stress is contributed by not being given full opportunity to be involved in the planning of maternity patient care which leads to lack of full utilisation of own midwifery professional knowledge and skills. Lack or no utilisation of own professional knowledge and skills in overcrowded tertiary hospitals with a lack of midwife-patient ratio, prolonged working hours, shortage of midwives, and experiences over number of each encounters with patients causes psychological stress to midwives. The underutilization of the midwifery knowledge and skills was affirmed by the study conducted in the four tertiary hospitals, where findings affirmed that the advanced midwives' skills and knowledge are not fully utilised [3]. There are several contributory factors that lead to underutilization of advanced midwives in tertiary hospitals. Lack of teamwork and lack of respect within the multidisciplinary team in tertiary obstetric working environment is the contributory factor to the midwife's psychological stresses. Studies confirm that obstetricians do recognise advanced midwives' qualifications and competencies but still see midwives as professionals who lack the skills and competency to be independent practitioners who can manage, intervene, and make confident decisions in each obstetric situation [4]. The undermining attitudes of doctors were exposed in the primary healthcare setting in the upscaling of midwives' skills to ordering medications when most doctors working in maternity hospitals were more sceptical and believing that midwives were

*The Environmental Impact on Advanced Midwives from Underutilization in Tertiary Hospital DOI: http://dx.doi.org/10.5772/intechopen.113186*

not equipped enough to order medications. The findings further suggested that as midwives they are being able to re-order medications that were prescribed by doctors first [5]. The undermining and underutilization of the possessed knowledge and skills obtained through the midwifery professional registration body in the tertiary hospitals turn the environment to be toxic causing stress to midwives. Advanced midwifery training puts the midwives into the autonomous practitioner's status.
