Katja Schrøder

Blame and guilt – a mixed methods study of obstetricians' and midwives' experiences and existential considerations after involvement in traumatic childbirth

When complications arise in the delivery room, midwives and obstetricians operate at the interface of life and death, and in rare cases the infant or the mother suffers severe and possibly fatal injuries related to the birth. This descriptive study investigated the numbers and proportions of obstetricians and midwives involved in such traumatic childbirth and explored their experiences with guilt, blame, shame and existential concerns.

Psychosocial health and well-being among obstetricians and midwives involved in traumatic childbirth

OBJECTIVE this study investigates the self-reported psychosocial health and well-being of obstetricians and midwives in Denmark during the most recent four weeks as well as their recall of their health and well-being immediately following their exposure to a traumatic childbirth. MATERIAL AND METHODS a 2012 national survey of all Danish obstetricians and midwives (n=2098). The response rate was 59% of which 85% (n=1027) stated that they had been involved in a traumatic childbirth. The psychosocial health and well-being of the participants was investigated using six scales from the Copenhagen Psychosocial Questionnaire (COPSOQII). Responses were assessed on six scales: burnout, sleep disorders, general stress, depressive symptoms, somatic stress and cognitive stress. Associations between COPSOQII scales and participant characteristics were analysed using linear regression. RESULTS midwives reported significantly higher scores than obstetricians, to a minor extent during the most recent four weeks and to a greater extent immediately following a traumatic childbirth scale, indicating higher levels of self-reported psychosocial health problems. Sub-group analyses showed that this difference might be gender related. Respondents who had left the labour ward partly or primarily because they felt that the responsibility was too great a burden to carry reported significantly higher scores on all scales in the aftermath of the traumatic birth than did the group who still worked on the labour ward. 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 well-being in the aftermath. KEY CONCLUSIONS AND IMPLICATIONS: this study shows an association between profession (midwife or obstetrician) and self-reported psychosocial health and well-being both within the most recent four weeks and immediately following a traumatic childbirth. The association may partly be explained by gender. This knowledge may lead to better awareness of the possibility of differences related to profession and gender when conducting debriefings and offering support to HCPs in the aftermath of traumatic childbirth. As many as 85% of the respondents in this national study stated that they had been involved in at least one traumatic childbirth, suggesting that the handling of the aftermath of these events is important when caring for the psychosocial health and well-being of obstetric and midwifery staff.

Guilt without fault: A qualitative study into the ethics of forgiveness after traumatic childbirth.

When a life is lost or severely impaired during childbirth, the midwife and obstetrician involved may experience feelings of guilt in the aftermath. Through three empirical cases, the paper examines the sense of guilt in the context of the current patient safety culture in healthcare where a blame-free approach is promoted in the aftermath of adverse events. The purpose is to illustrate how healthcare professionals may experience guilt without being at fault after adverse events, and Gamlunds theory on forgiveness without blame is used as the theoretical framework for this analysis. Philosophical insight has proven to be a useful resource in dealing with psychological issues of guilt and Gamlunds view on error and forgiveness elucidates an interesting dilemma in the field of traumatic events and medical harm in healthcare, where healthcare professionals experience that well-intended actions may cause injury, harm or even death to their patients. Failing to recognise and acknowledge guilt or guilty feelings may preclude self-forgiveness, which could have a negative impact on the recovery of midwives and obstetricians after adverse events. Developing and improving support systems for healthcare professionals is a multi-factorial task, and the authors suggest that the narrow focus on medico-legal and patient safety perspectives is complemented with moral philosophical perspectives to promote non-judgemental recognition and acknowledgement of guilt and of the fallible nature of medicine.

Healthcare professionals' perspectives on traumatic childbirth - interpreting the data.

Sir, We would like to thank Cauldwell and Bewley (1) for their encouraging comments regarding our recent manuscript “Blame and guilt – a mixed methods study of obstetricians’ and midwives’ experiences and existential considerations after involvement in traumatic childbirth (2).” The manuscript is the first publication from a large interdisciplinary study and more data and analyses will follow. While we agree that it is an important finding that 87% agreed with “Memories of what happened to the patient kept troubling me for a long time after the event,” we do not share the authors’ interpretation of the item to be representative of intrusive memories. Thinking about what happened to the patient for a long time after the event is seen as an account of genuinely caring for the patient and the long-term outcomes after a traumatic childbirth, not as related to the symptom complex of posttraumatic stress disorder. Intrusive memories are recurrent, distressing, and involuntarily triggered and may take the form of distressing recollections of the event, including images, thoughts or perceptions (3), which this particular item did not address explicitly. Still, we fully acknowledge that being troubled by memories of what happened to the patient may take its toll on the healthcare professional. The quote highlighted by the authors is a poignant account of how devastating these memories and thoughts can be, but labeling them as intrusive would be reading more into the results than our data allow. We have unpublished data from two items on “intrusive thoughts” and “recurring nightmares,” and they seem to endorse the differentiation between troubling and intrusive memories or thoughts. We would be hesitant to compare midwives and obstetricians in a Danish setting to attrition rates of emergency physicians in Taiwan (4), but we agree with the proposed emphasis on the group who has left the profession after a traumatic event. We have data on midwives and obstetricians who have left the labor ward, which we will address in detail in a manuscript about psychosocial health and wellbeing in Danish midwives and obstetricians currently under review. The authors suggest a further look at the 23% who had considered leaving the profession. It should be noted that half of these had considered this to a great or some extent, and half only to a small extent. It is an interesting point of discussion whether becoming a second victim is an avoidable or an inevitable part of midwifery and obstetrics. The manuscript is one part of the first author’s PhD thesis, in which it is proposed that we should consider traumatic childbirth as a fundamental condition in midwifery and obstetrics. This approach, or explication, appears contrary to the dominating idea of preventability in the patient safety culture. Perceiving traumatic childbirth as a fundamental condition does not exclude careful attention to safety and prevention of error, but it accentuates the natural unpredictability of childbirth and it gives a voice to the midwife and obstetrician who go to work with no intention to cause harm. Admittedly, the full potential of the material is not unfolded in this single manuscript. Reporting from a mixed methods study in the same manuscript will invariably reduce the depth of the presentation and discussion. This is a challenge often described in the mixed-methods literature (5) and is perhaps a general limitation when disseminating scientific knowledge in the form of journal articles. For this reason the analyses carried out have been of a descriptive nature, as a first step of basic research. However, we will look forward to engaging in further work and discussions about consequences for patients, healthcare professionals and birth culture, and to contributing to the development of adequate support systems for midwives and obstetricians.