Traumatic Childbirth from the Perspective of the Healthcare Professional: A mixed methods study on midwives’ and obstetricians’ experiences with traumatic childbirth

Research output: ThesisPh.D. thesis

Abstract

Summary
The overall purpose of this PhD project was to investigate traumatic childbirth from the perspective of midwives and obstetricians. Both professions have been described to have a high incidence of stress, burnout and depression, but only few studies have investigated whether or how the expe-rience of traumatic childbirth influences the psychosocial wellbeing of the healthcare professionals involved. Healthcare professionals who experience an unanticipated adverse event are often referred to as ‘second victims’, as opposed to ‘first victims’, who are the patients and their relatives. The experience and handling of being involved in childbirths, where the infant or mother suffers presumed permanent, severe and possibly fatal injuries related to the birth can be distressing, and in those few cases where the outcome may have been a result of adverse events or misconduct, feelings of guilt and responsibility can be burdensome for the individual healthcare professional.

The first aim of this study was to investigate the self-reported psychosocial health and wellbeing of obstetricians and midwives in Denmark both in the most recent four weeks and in the aftermath of a traumatic childbirth. The second aim was to explore to what extent and in what way midwives and obstetricians feel guilt or have existential considerations in relation to these events. Feeling guilty seemed to play a pivotal part in the narratives of being involved in a traumatic childbirth as a healthcare professional, and even in cases of exoneration in subsequent complaint cases, a profound sense of guilt would still torment some of the participants. The final aim was to explore how theories on forgiveness can contribute to the understanding of the complexities of guilt and for-giveness from the perspective of the midwife or obstetrician after a traumatic childbirth.

We conducted a mixed methods study, comprising a national survey among Danish midwives and obstetricians and an interview study. The response rate was 59% (1237/2098) of which 85% stated that they had been involved in a traumatic childbirth. Eight midwives and six obstetricians par-ticipated in the interview study.

The main findings were disseminated in three publications. Study I demonstrated that profession and present work at the labor ward were associated with psychosocial health and wellbeing both within the most recent four weeks of the survey and in the immediate aftermath of the traumatic birth, whereas age, seniority and time since the traumatic birth were not. Midwives reported higher scores than obstetricians, to a minor extent during the most recent four weeks and to a greater ex-tent immediately following a traumatic childbirth, indicating higher levels of self-reported psycho-social health problems. Sub-group analyses showed that this difference might be gender related. None of the scales were associated with age or seniority in the time after the traumatic birth indicating that both junior and senior staff may experience similar levels of psychosocial health and wellbeing in the aftermath.

In study II, we formed five categories during the comparative mixed methods analysis: i) the pa-tient; ii) clinical peers; iii) official complaints; iv) guilt and v) existential considerations. Although blame from patients, peers or official authorities was feared (and sometimes experienced), the inner struggles with guilt and existential considerations were dominant. Feelings of guilt were reported by 36-49%, and 50% agreed that the traumatic childbirth had made them think more about the meaning of life. Furthermore, 65% felt that they had become a better midwife or doctor due to the traumatic incident.

During the analyses of study II, the issue of guilt recurred: Almost half of the respondents who had been involved in a traumatic childbirth agreed that they had felt guilty that things turned out the way they did, and in the interview study this was described as a psychological burden, even in cases where no blame was attached. Philosophical insight has proven to be a useful resource in dealing with psychological issues of guilt, and accordingly, in study III, we used Gamlund’s theory on forgiveness without blame to demonstrate how theories on forgiveness can contribute to the under-standing of the complexities of guilt and forgiveness from the perspective of the second victim. We showed that midwives and obstetricians may experience guilt without being at fault after a trau-matic childbirth, and that the acknowledgement of this guilt may be a decisive factor in achieving self-forgiveness. Cases with adverse outcomes, derived from the empirical study, illustrated how guilt—and hence forgiveness—may be appropriate responses, even in situations where the healthcare professionals had a justification or an excuse for their clinical decisions during the course of events. Failing to recognise and acknowledge guilt or guilty feelings precludes self-forgiveness, which could have a negative impact on the recovery of the second victim.

The findings were contextualised to the current patient safety culture. It seemed that there is an interaction working two ways: (1) The safety culture may add to the pressure on the healthcare professionals, because the inherently fallible nature of medicine is neglected and human error is constantly sought eliminated through measures adopted from the aviation or car industry. (2) The physical and emotional state of the healthcare professional impacts upon the quality and the safety of patient care. Ill health in healthcare professionals, such as burnout, stress or depression, causes more mistakes and errors, which negatively impacts upon patient safety. Furthermore, I have dis-cussed another consequence for patient safety, namely the risk of ‘defensive medicine’, where patients are subjected to unnecessary tests and procedures due to healthcare professionals’ fear of litigation, complaints or of being thrown into a personal crisis in the aftermath of a traumatic event. In an obstetric setting, I have suggested that this could be seen as a contributor to the rise in obstet-rical interventions, in the form of induction or augmentation of labour or operative deliveries.

Furthermore, an existential perspective was used to contextualize some of the findings, and I have proposed that we should consider traumatic childbirths as a fundamental condition in midwifery and obstetrics. This approach, or explication, seems in opposition to the dominating idea of pre-ventability in the patient safety culture. However, perceiving traumatic childbirths as a fundamental condition does not exclude attention to safety and prevention of error, but it accentuates the natural unpredictability of childbirths and it gives voice to the midwife and obstetrician who go to work with no intention to cause harm. I have investigated the perspective of the involved healthcare professional from an individual approach, based on the existential-humanistic traditions, where there are no hard and fast rules for responding to crisis or distressing experiences; each person has his or her distinctive way of sensing, living and expressing feelings.

Finally, I have argued that guilt and the need to forgive oneself are both profound and complex feel-ings, which may require a long, and possibly solitude, process of reconciling one’s feelings of guilt with a positive sense of self. Following this, we should be aware that while the ‘one size fits all’ de-briefings may be efficient from an organisational perspective, they may be futile from an individual perspective of personal support. Until we have accumulated more knowledge about this field, we should be cautious in our quest to develop guidelines for handling the aftermath of traumatic child-births. I have suggested four levels of implications for clinical practice, and further research in the form of an interventional study is proposed.
Original languageEnglish
Publication statusPublished - 22. Jun 2016

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