Moral distress in midwifery

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

Situations when moral distress occurs

If midwives 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 they 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 believed 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 are 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, 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. 

Here at Nurse Midwife HPA, experienced midwives can talk with you if you feel you might be experiencing moral distress. 

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. Ask for clinical supervision.

While we don’t provide clinical supervision at the Nurse Midwife Health Program Australia, we strongly support its value. It complements our work as a peer support program. 

References

• Exploring moral distress in Australian midwifery practice by W. Foster, 2022, Women and Birth
• Moral distress in midwifery practice: A concept analysis by W. Foster, 2022, Nursing Ethics
• Australian midwives’ intentions to leave the profession and the reasons why by K. Harvie, 2019, Women and Birth
• The costs of ‘being with the woman’: secondary traumatic stress in midwifery by J. Leinweber, 2010, Midwifery
• How can we go on caring when nobody here cares about us?' Australian public maternity units as contested care sites by K. Reiger, 2013, Women and Birth