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Moral distress in midwifery

Moral distress is the negative psychological impact when a midwife’s actions are inconsistent with their own morals.

It is often a challenge for midwives to reconcile what they have been taught at university and their lived experience within the work setting, particularly when they are working within a hospital environment. 

Situations when moral distress occurs

If midwives if they find themselves in situations that ask them to compromise their moral code or that constrain them morally, they may experience moral distress.

These situations are common to every workplace. For midwives, these include:

  • differences in philosophies and practice beliefs 
  • differences in values
  • the cumulative effect of wrestling with the philosophy of birth taught during their training and the reality of hospital midwifery practice
  • feeling that they cannot support a woman’s choice because of hierarchical restrictive structures and policies 
  • working in an environment of fear because that do not feel able to speak up for women who are choosing care outside of guidelines, and 
  • working with unreasonable workloads and staff shortages.

Workplace conflicting values

Many midwives hold an inalienable belief in the physiological process of birth. However, many also work in a medical model of care that relies heavily on interventions during the birth process. 

Midwives can be challenged when they feel that a woman is exposed to unnecessary interventions, or that a woman has not provided adequate consent. Midwives describe being overwhelmed with feelings of guilt because they believe that they 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 guilt, anger, frustration

The consequences of moral distress for midwives can lead to negative outcomes. Short term consequences include having difficulty switching off following shifts and often blaming themselves for poor outcomes, particularly if they felt they failed to act or were unable to support the choices they believe a woman wanted to make. 

Key psychological impacts include negative feelings and emotions such as anger, guilt, and frustration. 

Persistent exposure – flashbacks, inability to work

Longer term, midwives can experience flashbacks about a clinical situation where they have been unable to provide the care that they wanted to provide. 

Persistent exposure to moral distress can result in midwives choosing to reduce their hours of work, or to work in casual settings or if the coping skills of the midwife is severely challenged midwives may choose to leave the profession altogether.

Cumulative effect

Repeated events, often over years, where a midwife feels unable to speak up lead to emotional exhaustion. Collectively the moral distress can be difficult to reconcile because midwives constantly believe that they are powerless to change the current system. 

Awareness – part of seeking help

Being aware of and understanding the phenomena of moral distress goes a long way if you are experiencing it. Midwives often do not understand it themselves, but it is talking and working through scenarios with managers and other midwives that crystalises the concept and allows them to better understand how they feel. Ask for clinical supervision

Clinical supervision is an opportunity to discuss particularly challenging situations and to reflect on your practice. Midwives working in continuity care models have this available to them, but this is often not available to midwives working in traditional midwifery models. 

Here at NMHPA, experienced midwives can talk with you if you feel you might be experiencing moral distress or just have concerns about what is happening in your work setting. 

When you’re not ok

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

A midwifery focused definition of moral distress is offered as ‘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’. (Foster et al., 2022a)

A qualitative study with 14 midwives identified key themes that suggested that participants might feel unable to effectively advocate for themselves, their profession, or the women they care for, with more experienced midwives with greater than five years’ experience appearing to potentially suffer from repeated exposures to instances that result in a cumulative impact. (Foster et al., 2022a)

Being aware and understanding the phenomena of moral distress goes a long way in being able to support midwives who experience it.
Amanda Singleton, 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 Foster, midwife, clinical educator and researcher