World Health Organization declared coronavirus disease (COVID-19) as global pandemic on 11th of March 2020 [1]. In Egypt, till November 25, 2021, the total number of cases confirmed with COVID-19 was 353442 and 20109 deaths (https://www.worldometers.info/coronavirus) [2]. According to Royal College for Obstetrics and Gynecology [3], infected pregnant women are considered at slight increased risk if they are infected with COVID-19. Others have reported that COVID-19 might jeopardize the health of pregnant women [4]. Consequently, obstetric healthcare workers (HCWs) caring for those women are considered at risk to COVID-19 as well. It has been noted that obstetric HCWs are struggling to meet healthcare needs and provide safe care to pregnant women at risk to COVID-19. Thus avoiding maternal deaths and pregnancy-related consequences are considered a priority to obstetric HCWs [5]. Such a situation, in addition, to work during the outbreak of COVID-19, has added more pressure on obstetric HCWs leading to an increased need for staff and facilities and causing higher levels of job-related stress [6].

The literature has emphasized the impact of COVID-19 on HCWs in general. For example, HCWs were found to suffer physical and psychological anxiety, distress, and exhaustion due to the constant caring of patients with COVID-19 [6, 7]. The shortage in healthcare systems' infrastructure, lack of well-prepared facilities, and decreased in-services training for such an emergency situation have also contributed to an increased burden on HCWs [7, 8]. This has led to fragile psychological resilience among obstetric HCWs causing higher levels of job stress [8, 9]. Notably, job stress is reported to cause physical and emotional harm among HCWs and deteriorates their physiological and psychological wellbeing leading to lower productivity and performance [10-12]. During the COVID-19 pandemic, in particular among obstetric HCWs, factors such as affective commitment and presenteeism are considered significant contributors to job stress that have been neglected in the literature [13]. Presenteeism refers to a problem of healthcare workers being on the job but due to illness or medical problems they cannot fully function and are less productive at work [14]. Presenteeism is considered a significant issue as there is no way to connect the low performance of a worker with a medical problem unless the worker himself speaks out for his problem [14, 15]. Therefore, presenteeism connects the problems that undermine job performance contributing to productivity loss due to invisible medical, psychological or illness issues.

On the other hand, affective commitment refers to the willingness of workers to stay at work and positions due to emotional connectedness and attachment to the firm [14, 15]. The literature addressed these two concepts, affective commitment and presenteeism, and found to affect HCWs' wellbeing, performance, productivity, and patients' safety [13, 14]. Moreover, affective commitment motivated employees to complete their job responsibilities, improve their performance, develop work abilities, and reduce presenteeism [15]. This would raise the question of whether affective commitment would positively effect presenteeism and buffer the negative impact of job stress among obstetric HCWs.

The great shortage of HCWs in Egypt compared to other Arab countries, in addition to the greater demands due to outbreak of COVID-19, has called for an emergency plan in the country. 4.52 physicians and 19.26 nurses and midwives per 10000 patients in Egypt indicate critical shortage of HCWs compared to international figures [16]. During COVID-19 pandemic, it is expected that the shortage of obstetric HCWs will contribute to lower quality of care which might compromise pregnant women's wellbeing too [11-14]. As aforementioned, obstetric HCWs are among the most affected and at risk of infected with COVID-19 leading to higher levels of job stress and psychological disturbances. Increasing the demands of care for pregnant women, who, if infected, will be slightly at risk for being severely unwell, add more to job stress causing negative impacts on the quality of care provided. Such a situation needs to evoke attention towards obstetric HCWs and the assumed effect of increased job stress, high level of presenteeism, and low level of affective commitment on the quality of obstetric healthcare provided. Therefore, this study aims at investigating the relationships among presenteeism, job stress and affective commitment in obstetric HCWs in Egypt and to test the moderation effect of affective commitment on the relationship between challenge stress and hindrance stress on presenteeism controlling for the selected demographic characteristics of Egyptian obstetric healthcare workers during COVID-19 pandemic.

The research questions were:

• What is the moderation effect of affective commitment on the relationship between job stress and presenteeism of Egyptian obstetric healthcare workers during COVID-19 pandemic in Egypt?
• Are there differences in job stress, presenteeism and affective commitment in relation to demographic characteristics of obstetric healthcare workers in Egypt?

Design: A cross-sectional and correctional design was used to achieve the objectives of this study. The study was conducted using an anonymous online survey targeting obstetric HCWs caring for clients diagnosed with COVID-19.

Settings: Data was collected from one major university-affiliated hospital in Egypt. The hospital provided secondary and tertiary levels of care to different age groups called the medical castle in the Egyptian Delta. The hospital has a capacity of 1512 beds and it includes 44 departments and central sterilization and operation wards. The number of clients to the outpatient clinics reached 455971 between July 1st, 2017 and June 30th, 2018 and the number of clients to gynecology and obstetrics emergency department reached 14230 cases. The number of operations conducted in the same period was 18531 in addition to 1416 minor operations in the outpatient clinic.

Sample and sampling: A total of 221 obstetric HCWs approached, 207 agreed and participated in the survey with a response rate of 94%. Using an online format of data collection eventually contributed to such high response rate. Inclusion criteria included: 1) age of 18 years or above, 2) work as obstetric HCW, 3) able to use electronic software devices designated for data collection, and 4) work at the hospital for at least three months to ensure familiarity with rules, regulation, and protocols of working during COVID-19 pandemic.

The sample size was calculated based on World Bank population estimates. This allows making the ratio of healthcare workers to service users of obstetric care. The sample size required was 207 subjects according to Raosoft sample size calculator based on 95% confidence level, 6.81% margin of error, the anticipated response of 50%, putting into consideration the healthcare workers sitting of work is changing every single day and total target Egyptian population size of 82160 physicians (0.79 physicians/1,000 population) and 197600 nurses (1.9 Nurse/1000 population) [17, 18].

COVID-19 has influenced the capacity of healthcare professionals and exhausted healthcare systems [24]. One particular group is obstetric HCWs who are struggling to meet the increased needs of pregnant women and have attempted to adapt to the crisis of COVID-19 pandemic. This study aimed at exploring the moderation effect of affective commitment on the relationship between job stress and presenteeism among Egyptian obstetric healthcare workers during COVID-19 pandemic. In general, the study found that obstetric HCWs had a moderate level of presenteeism and moderate to high levels of affective commitment and job stress. Moreover, it has been found that affective commitment has a positive moderation effect on the relationship between job stress and presenteeism. Affective commitment and challenges were positively associated with presenteeism, while hindrance was negatively associated with presenteeism. The results of the study infer that affective commitment and challenges were protective factors against developing higher levels of presenteeism. In other words, obstetric HCWs with higher levels of challenges and affective commitment are more likely to have higher level of functionality and performance at the workplace (lower scores of presenteeism) despite their sickness and medical or health problems that they could use to waive themselves from job responsibilities. Hindrance was found to be a risk factor for presenteeism, indicating that a higher level of hindrance among obstetric HCWs is associated with a less performance, functionality, and creating faked reasons to escape their responsibilities and duties. The results indicate that obstetric HCWs might have considered COVID-19 pandemic as one positive challenge; thus, they enhanced their commitment and adherence to their responsibilities and duties (affective commitment) as sources of power to counteract hindrance and presenteeism. Presenteeism is not about pretending to be sick to be waved from job responsibilities, and rather, it is being less productive due to real health issues. This creates a novel way to make a clear distinction between presenteeism, absenteeism, malingering, and wasting time at work. The findings sustain that although obstetric healthcare workers are suffering real health problems, they are still struggling to perfect their work using their positive perception of challenges and affective commitment. The literature has provided evidence that there is a clear connection between work performance and internal resources such as locus of control and job demands [25]. It has also been reported that the quality of care provided to patients with COVID-19, and healthcare professional capabilities to provide care to individuals with COVID-19 have been influenced by societal, organization and personal factors confirming the challenge that HCWs are confronting during COVID-19 [26-29]. Such explanation would also be accepted in all emergency situations that have been explained previously where moral commitment to agency or organization would create challenges for better performance among workers [30]. This one novel finding in this study helps understand the factors that may contribute to lower levels of job stress and its influences on productivity, performance, and quality of care at various health care settings during COVID-19 and similar future situations. Another significant issue to be emphasized here is related to the low to fair magnitudes of correlation found in this study which might affect the clinical significance of the relationships among the variables. In other words, the magnitude of correlation needs to be interpreted cautiously rather than for absolute indication. Previous studies reported that affective commitment has a negative impact on presenteeism and those who reported a higher level of presenteeism are more likely to report a low level of hindrance [15]. Our study supports the notion that stress-related factors at work, individual factors, and health status of HCWs are significantly related to presenteeism [15], while others [31] found that only the health status of workers was the mediator for presenteeism, which has not been supported with findings in our study. One explanation could be related to the timing and type of sample in our study in which working during the outbreak of COVID-19 and being a healthcare worker would add more moral responsibilities than in a normal situation and not being a healthcare worker.

The moderate to high level of presenteeism reported before COVID-19 has also been observed among health workers in various working settings [15]. On the other hand, during COVID-19, it has been reported that effective commitment has a positive and significant effect on organizational citizenship among nurses handling COVID-19 which supports the results of this study [32]. Moreover, hindrance has been an issue due to the nature of COVID-19 and related public and health care policies and procedures adopted to control the outbreak of COVID-19. Precaution is taken by governments to limit the spread of COVID-19 including lock down and curfew which resulted in increased levels of job stress among healthcare workers. The results, related to increased level of job stress among our participants, are supported by several previous studies that high occupational stress and psychological distress among healthcare workers have been observed; especially among nurses who are at the frontlines to combat COVID-19 [33]. International reports have also sustained the notion that COVID-19 has altered working conditions in healthcare settings causing huge pressure and job stress among HCWs [33].

One limitation of this study was related to using cross-sectional and convenience sampling techniques and relying on using an online survey format of data collection which may affect the generalizability of the findings. Another limitation is related to the sample size in which a larger multi-site sample might be more informative and delineate the contextual connection among the variables of the study.

Obstetric HCWs are the main cornerstone for improving the quality of maternal and child healthcare services. The current study shows moderate to high levels of affective commitment and positive effect on the relationship between job stress and presenteeism among Egyptian obstetric HCWs. Managers and policymakers should pay attention to job-related stressors, which directly increase HCWs presenteeism especially during pandemic era. This is also considered for other emergency and pandemic situations that indicate the need for agencies' preparedness and managing work-related stressors. Future policy should focus on mitigating presenteeism by reducing workplace tension for healthcare workers, enhancing working environments, and creating more chances for staff to improve their affective commitment. A challenging and positive moral and working environment would be the main enhancers for functionality and quality of obstetric healthcare services.