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Moral distress in midwifery

Moral distress is the negative psychological impact caused when a person's actions are inconsistent with their own morals or beliefs.

If midwives find themselves in situations that challenge their values or ask them to go against what they believe is right, they may experience moral distress. It is important that we understand it, name it and talk about it. 

“The philosophy and the code of ethics for midwifery often conflict with the environments in which many midwives are working,” says midwife, clinical educator and researcher Wendy Foster.

“Contemporary midwifery education, and the philosophy of midwifery promotes holistic woman centred approach to care, which midwives often feel they aren’t able to practise...”

Everyone responds differently to moral compromise

Moral distress is individual. There is no list of situations that are labelled morally compromising, nor degrees of severity or extent of compromise that will result in moral distress. For one midwife it can result from a single very distressing situation, for others the cumulative effect of distress over time.

“A situation that precedes my moral distress may be very different to a situation that another person feels is morally distressing,” says Foster.

Detect situations where moral distress occurs

Many midwives work under a medical model of care that intervenes heavily during the birth process. You may experience moral distress in workplaces where you:

  • wrestle with the philosophy of birth and the reality of hospital midwifery practice
  • find differences in your values, professional philosophies and practice beliefs
  • feel unable to support a woman’s choice because of restrictive structures and policies
  • fear the consequence of speaking up for women who are choosing care outside of guidelines
  • struggle with unreasonable workloads and staff shortages.

Recognise the symptoms 

If you blame yourself for poor outcomes you may be experiencing moral distress, particularly if you feel you failed to act or were unable to support a woman’s choices. 

“With moral distress, an individual perceives that there was a way that it could have been changed, but it wasn't done,” says Foster.

You may feel powerless, angry, guilty, and frustrated. Or believe you are complicit with any decision that is made without adequate consent, particularly if the woman has or perceives that she has had a poor birth outcome.

Short-term, you might struggle to ‘switch off’ after a shift. Repeated events where a you feel unable to speak up can exhaust you emotionally. Some midwives report they ‘flash back’ to a clinical situation when they were unable to provide the care that they would have chosen. 

Without the right support, midwives’ coping strategies include reducing their hours of work, moving to casual work or leaving the profession altogether.

Understand escalating symptoms

Moral distress is different to psychological distress because with the trauma of witnessing a difficult situation comes an overwhelming sense of guilt. It also differs from moral frustration, which makes you uncomfortable but you are clear about what happened and can navigate through your feelings and remain relatively unharmed.

Moral distress is more significant and may persist for months with more severe psychological impacts. And it can lead to moral injury and quite severe psychological harm with symptoms like those of PTSD.

Talk about your experiences, raise awareness

Being aware of, understanding and talking about moral distress can help you to address your symptoms. Sharing your experiences and feelings with other midwives can help crystalise the concept and understand how you feel. Working through scenarios with a manager may help you to understand your experiences.  

Talk to one of our experienced midwives if you feel you might be experiencing moral distress. 

Ask for clinical supervision

Discussing challenging situations, reflecting on your practice and any ethical or moral challenges faced can help. If you work in a continuity care model, this should be available to you. It is less often available to midwives working in traditional midwifery models. Find out more about how to ask for clinical supervision.

While we don’t provide clinical supervision at NMHPA, we strongly support its value. It complements our work as a peer support program. 

Read a recent study of midwives’ risk of moral distress 

In 2024 Ms Foster surveyed midwives to develop a method of assessing the frequency of exposure to morally distressing situation, and psychological outcomes. Go to The barometer of moral distress in midwifery: A pilot study

When you’re not ok

Seek help. Speak to a nurse or midwife who understands. 

Contact us

A definition of moral distress for midwives

‘a psychological suffering following clinical situations of moral uncertainty and/or constraint, which result in an experience of personal powerlessness where the midwife perceives an inability to preserve all competing moral commitments’.

Being aware and understanding the phenomena of moral distress goes a long way in being able to support midwives who experience it.
Amanda - midwife and academic
"What we want to frame is that this isn't a personal failing. This is a result of working in environments that are preventing someone from working in alignment with the way they know they should be."
Wendy - midwife, clinical educator and researcher

References

See also