Secondary Traumatic Stress in Midwives
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Compassion fatigue and burnout are common among all healthcare professionals but midwives, in particular, can experience high levels of secondary traumatic stress.
Yet the emotional cost of caring goes largely unrecognised, leaving many midwives feeling emotionally divorced from their work, or wanting to quit the profession altogether.The Emotional Cost of Caring
Whilst it’s true to say that any healthcare professional, working in any speciality, can experience compassion fatigue and burnout, the high degree of empathic identification which characterises the midwife-birthing parent relationship places midwives at particularly high risk of experiencing secondary traumatic stress (Leinweber and Rowe 2010).
Secondary traumatic stress is known to be an occupational hazard for healthcare professionals, as they may develop symptoms of posttraumatic stress disorder (PTSD) following exposure to their traumatised patients (Beck, LoGiudice and Gable 2015).
Midwives are particularly susceptible to this type of stress because of the close bond that is often formed with the mother and the strong emotional reactions that can arise in response to witnessing birth trauma, especially if the trauma is care-related.
As Leinweber et al. (2017) found, almost one-fifth of midwives surveyed met the criteria for probable posttraumatic stress disorder.
Creedy et al. (2017) agree, suggesting it’s a problem that often goes unacknowledged and underreported with a prevalence of 20% to 59% noted in both the United Kingdom and Australia.
Most researchers agree that the incidence of midwives with secondary traumatic stress is shockingly high.
Why is This?
One probable answer to this question lies in the fact that midwives are increasingly being asked to work with a disjointed and fragmented care model that requires them to override their natural yearning to be ‘with woman' and remain present and intuitively aware throughout labour and delivery (Williams 2018).Risk Factors
Physical damage, powerlessness and fear are three key elements generally associated with traumatic stress.
For midwives, these criteria are all too often a reality of their working day. For example:
- Long shifts with inadequate breaks may cause physical damage.
- Lack of control organising off duty can be stressful.
- Being moved by managers from area to area with little notice creates feelings of powerlessness.
- Constant anxiety about making a mistake in a litigious culture creates a climate of fear.
Not everyone is susceptible to the same stressors however and this can create a challenge in seeking a universal solution.
Welford (2018) notes that midwives who are at higher risk tend to be:
- Under 40 years of age;
- Have less than ten years' clinical experience;
- Work full-time in busy clinics;
- Live alone.
The Royal College of Midwives (2017) also suggest the following factors can be associated with high levels of professional burnout:
- Perceptions of low levels of resources;
- Perceived low levels of management support;
- Lack of professional recognition and opportunities for development.
Conversely, midwives who had responsibility for their own caseload and shift patterns coped significantly better with stress than midwives who worked full-time within a standard care model.
Interestingly, working on-call also did not seem to contribute to stress where midwives had a flexible contract (Welford 2018).Shame, Blame and Guilt
When a traumatic event occurs during labour or delivery, midwives can be left feeling unprepared, unsupported, or simply overwhelmed with residual feelings of failure or even personal bereavement.
As Patterson (2019) suggests, when organisational demands leave midwives unable to provide compassionate care or feeling complicit in poor care, this creates a sense of shame, blame and guilt that only serves to deepen the hurt.
Added to this, the under-resourced pressured environments that midwives typically work in mean that they can struggle to disengage and process these emotions, leaving them highly vulnerable to secondary traumatic stress and PTSD.
For some midwives, secondary traumatic stress can diminish over time. For others, it can weaken their ability to adapt and lead to future cycles of burnout, increased errors and more stress.
Perhaps worse still is when a midwife loses confidence in the natural process of birth itself. Diminished self-confidence alongside associated fears of causing harm, receiving criticism, or facing litigation can all lead to increased vigilance, risk management and increased medical intervention.
Not only can this lead to reduced job satisfaction on the part of the midwife but it can also raise the level of stress and anxiety for everyone associated with the birth and compromise the level of personal care offered to the mother.
As Patterson (2019) reflects, improving the workplace culture and addressing midwives’ needs will improve not only the working lives of midwives but also their interactions with women, improving the mental wellbeing of all concerned.Restoring Resilience
It is said that resilience is a learned process, facilitated by a range of coping strategies such as accessing support and improving self-awareness (Hunter and Warren 2014).
The need for all practitioners to take responsibility for practising self-care and developing resilience is widely accepted.
However, when midwives experience trauma through being prevented from providing high standards of care due to systemic pressures or being disrespected, undermined or bullied, then as Patterson (2019) suggests, the responsibility for improvement should lie with the organisation rather than the individual.
Beaumont et al. (2016) agree suggesting that cultivating environments that foster compassionate care for self and others can play a significant role in helping midwives face the rigours of training and clinical practice.
In recent years the mental health of midwives has come under increasing scrutiny, with a survey conducted by the Royal College of Midwives (2017) indicating that emotional wellbeing is compromised to such an extent that two-thirds of respondents were considering leaving the profession.
As a result of this survey some important action steps were recommended:
- Introducing evidence-based interventions for workforce wellbeing support.
- Ensuring that midwives are given ‘protected’ time to attend wellbeing events.
- Providing proactive support for younger, recently qualified midwives.
- Facilitating a sense of shared leadership amongst midwives at a team level.
Further recommendations suggest that when midwives experience trauma from witnessing adverse obstetric events or poor interpersonal care towards women, they require a non-judgemental culture in which their normal human responses and subsequent needs are acknowledged and appropriately responded to (Patterson 2019).
Simple action steps such as providing protected time to talk through events have the overriding benefit of not only diffusing feelings of self-blame or incompetence but if handled well they can also become a valuable source of personal growth and enhanced knowledge.
As Creedy et al. (2017) point out, given midwives’ role in promoting the perinatal health of mothers, the wellbeing of the midwifery workforce warrants close and regular scrutiny.
It’s a view strongly echoed by Beck, LoGiudice and Gable (2015), who suggest the midwifery profession should acknowledge secondary traumatic stress as a professional risk.
The mental wellbeing of midwives has been ignored for too many years and yet it has clear implications for safe practice, staff retention and perhaps above all, maternal satisfaction.
As Creedy et al. (2017) reflect, if midwives suffer emotional exhaustion they are more likely to be emotionally withdrawn, communicate poorly with birthing parents, their families and colleagues, distance themselves from women in their care and ultimately perform poorly in the workplace.References
- Beaumont, E, Durkin, M, Hollins Martin, C and Carson, J 2016, ‘Compassion for Others, Self-compassion, Quality of Life and Mental Well-Being Measures and Their Association with Compassion Fatigue and Burnout in Student Midwives: A Quantitative Survey’, Midwifery, [online] 34, pp.239-244, viewed 10 December 2019, https://www.sciencedirect.com/science/article/abs/pii/S0266613815002843
- Beck, C, LoGiudice, J and Gable, R 2015, ‘A Mixed-Methods Study of Secondary Traumatic Stress in Certified Nurse-Midwives: Shaken Belief in the Birth Process’, Journal of Midwifery & Women's Health, [online] 60(1), pp.16-23, viewed 7 December 2019, https://www.ncbi.nlm.nih.gov/pubmed/25644069
- Creedy, D, Sidebotham, M, Gamble, J, Pallant, J and Fenwick, J 2017, ‘Prevalence of Burnout, Depression, Anxiety and Stress in Australian Midwives: a Cross-Sectional Survey’, BMC Pregnancy and Childbirth, [online] 17(1), viewed 7 December 2019, https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-016-1212 -5
- Davies, S 2016, ‘Caring for Future Midwives’, AIMS Journal, [online] 28(1), viewed 7 December 2019, https://www.aims.org.uk/journal/item/caring-for-future-midwives
- Hunter, B and Warren, L 2014, 'Midwives’ Experiences of Workplace Resilience', Midwifery, [online] 30(8), pp.926-934, viewed 7 December 2019, https://www.ncbi.nlm.nih.gov/pubmed/24742637
- Leinweber, J, Creedy, D, Rowe, H and Gamble, J 2017, ‘Responses to Birth Trauma and Prevalence of Posttraumatic Stress Among Australian Midwives’, Women and Birth, [online] 30(1), pp.40-45, viewed 7 December 2019, https://www.ncbi.nlm.nih.gov/pubmed/27425165
- Leinweber, J and Rowe, H 2010, ‘The Costs of “Being with the Woman”: Secondary Traumatic Stress in Midwifery’, Midwifery, [online] 26(1), pp.76-87, viewed 7 December 2019, https://www.midwiferyjournal.com/article/S0266-6138(08)00044-2/fulltext
- Patter son, J 2019, ‘Traumatised Midwives; Traumatised Women’, AIMS Journal, [online] 30(4), viewed 7 December 2019, https://www.aims.org.uk/journal/item/traumatised-midwives-traumatised-women
- Royal College of Midwives 2017, 'Work, Health and Emotional Lives of Midwives in the United Kingdom: The UK WHELM study', [online] School of Healthcare Sciences Cardiff University, viewed 7 December 2019, https://www.rcm.org.uk/media/2924/work-health-and-emotional-lives-of-midwives-in-the-united-kingdom-the-uk-whelm-study.pdf
- Welford, C 2018, ‘What Factors Influence Professional Burnout in Midwives?’, MIDIRS Midwifery Digest, [online] 28(1), pp.35-40, 7 December 2019, https://insights.ovid.com/midirs-midwifery-digest/mmwd/2018/03/000/factors-influence-professional-burnout-midwives/9/00115386
- Williams, H 2018, ‘Burnout in Midwifery: An Occupational Hazard?’, Health Times, viewed 7 December 2019, https://healthtimes.com.au/hub/midwifery/38/news/hw/burnout-in-midwifery-an-occupational-hazard/3504/
Anne is a freelance lecturer and medical writer at Mind Body Ink. She is a former midwife and nurse teacher with over 25 years’ experience working in the fields of healthcare, stress management and medical hypnosis. Her background includes working as a hospital midwife, Critical Care nurse, lecturer in Neonatal Intensive Care, and as a Clinical Nurse Specialist for a company making life support equipment. Anne has also studied many forms of complementary medicine and has extensive experience in the field of clinical hypnosis. She has a special interest in integrating complementary medicine into conventional healthcare settings and is currently an Associate Tutor, lecturing in Health Coaching and Medical Hypnosis at Exeter University in the UK. As a former Midwife, Anne has a natural passion for writing about fertility, pregnancy, birthing and baby care. Her recent publications include The Health Factor, Coach Yourself To Better Health and Positive Thinking For Kids. You can read more about her work at www.MindBodyInk.com. See Educator Profile