Moral Injury – an Introduction for midwives

by | 4 Mar, 2021 | Blog | 5 comments

* trigger warning – birth trauma/abuse *

The concept of ‘moral injury’ in midwifery is being recognised at last. Here, we repost in full an article by Lynn Genevieve originally published in our magazine, Midwifery Matters in Summer 2019. Lynn introduces a concept related to post-traumatic stress in this analysis of the harm it causes when we are forced to collude with a system against our values.

I stand rooted to the spot and just stare at the scene before me. The woman is struggling against the staff as she is pushed onto the bed and her legs are pulled into the stirrups. I want to step forward and stop them, but I do not. She’s already crying out in pain and I know why. How can they miss the massive scars almost the full length of her legs, both sides the result of extensive hip surgery?

“Please don’t,” she begs through her tears, “it hurts my hips.” My eyes sting, and I consciously adopt my wellpracticed professional face, blank, emotionless. It is a real effort, but I’ve had lots of practice now.

Lynn Genevieve
It’s all my fault, as it was I who called for assistance. There she was, labouring beautifully, a primip progressing so fast that I believed her to be fully dilated in less than 2 hours. Usually I’d just let them push, the old trick, doing good by stealth; confirm full dilatation when the vertex is visible as this gives a woman much more time for second stage. But today I have a student with me and I should do things properly. So when my offer of a vaginal examination is accepted, I go ahead, hopeful that she will progress through second stage as rapidly.

Following the guidelines

There’s my first mistake; instead of simply the confirmation of full dilatation, which she is, I discover it’s a breech. Undiagnosed, I took over her care after she transferred from the ward in labour. My second mistake, I follow ‘the guidelines’ and press the emergency bell; I must be a good example for this student. I have only been qualified a couple of years and do not yet have the confidence to share my true philosophy with everyone I work with. Any controversial challenge of practice guidelines could make things complicated for a student, I believed then.

This was just weeks before I left hospital midwifery practice forever. A rather fortuitous course of events meant that I was able to second to a private birth centre covering a maternity leave before moving on to community midwifery in another Trust. Fortunate indeed, as if I’d stayed, it was always going to be a choice between my health and wellbeing, or my career.

What I did not know at the time, was that I was accumulating experiences that were contributing to a form of Post Traumatic Stress Disorder (PTSD) that I now realise, never really left my practice completely. Years later, as an independent midwife, every time I entered a hospital I felt the creeping fear and panic of those early experiences. By this time, though, I had really mastered the professional facade, my armour was strong.

A lot has been written about PTSD and birth, but the vast majority is from the woman’s perspective rather than the midwife’s. I’ve met a lot of traumatised midwives in my time, and most of us were woefully ignorant of our damage.

Lynn Genevieve Mary Cronk
Lynn just after attending her first breech birth as primary midwife with her mentor, Mary Cronk

Moral Injury does not only affect soldiers

Recently I came across the term ‘moral injury’, and immediately I understood why I had suffered, in silence, whilst working within the NHS. This term has been used mostly with regard to war and conflict, referring to soldiers and why they suffer post traumatic stress. It is not always simply a case of witnessing horror, it is knowing that you are complicit in a situation that causes harm, or part of a group causing harm that is completely at odds with your own philosophy. What a perfect description of how I felt that day on labour ward, and so many other times. The description in relation to soldiers is often described as “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.” It has even been said that it is “a deep soul wound that pierces a person’s identity, sense of morality, and relationship to society.” That is it exactly. That is what I felt, too often, working within the NHS as a midwife.

One of the problems is recognising moral injury, as the condition was pertinent in relation only to soldiers initially. When it came to health workers, the term burnout has been more often, erroneously applied. Most of us are quite familiar with burnout, and the collection of symptoms associated with it. Indeed today, I’m certain that most midwives suffer one or more of these in their work, at least some of the time such as: cynicism, decreased productivity, exhaustion.

Midwives stay in the system as they are committed. They have a ‘calling’, a vocation to be a midwife, and have come through a challenging training often involving debt, sacrifice, and guilt. I reminded myself of my own journey in researching this article by reading my ‘Diary of a Student Midwife’ which was published regularly in the early 1990’s in the NCT magazine New Generation. I’d forgotten much. It wasn’t unusual for me to drive over 100 miles to deposit children at a grandparent in the holidays before going on a shift. I described shifts ending in tears, the stress of completing a course that demanded 100% attendance in lectures and shifts; if sick, we had learning contracts to complete for theory and spent days off working to make up time. To suggest that any midwife is not ‘resilient’ is insulting, I believe.

Examinations and assault

Back in 2003, Jenny Hall wrote a comment in The Practising Midwife (TPM) about an aspect of moral injury without using the term, but her words clearly recognise this problem. In ‘Examinations and assault – what is going on?’ (Hall, 2003) Jenny raises a very serious issue that seemed to be on the increase concerning abuse of women during vaginal examinations. Today in the USA they sometimes use the term ‘birth rape’; a shocking description. Horrific as this is, sometimes the onlookers are forgotten in the argument. Jenny questions in her piece about the power relationship over such observers, why they do not act, and the knock on effect. Moral injury is a good place to start, to question, and move on to solutions. I have observed, that once a ‘condition’ is recognised, given a name, people begin to take it seriously, at least in the world of medicine.

During the preparation of this article, an excellent feature on a piece of research was published in the AIMS journal (2019, Patterson J, Vol 30, No 4). The title, ‘Traumatised Midwives; Traumatised Women’ caught my attention. The focus of the article is how women and midwives respond to PTSD and goes someway to explaining why a damaging and judgmental culture grows, as Patterson identifies that “. . . witnessing women experiencing potentially traumatic birth events may compromise midwives’ abilities to maintain positive interactions with women.” Essentially, midwives adapt their behaviour as a form of survival within the toxic environment of many NHS maternity services changing from offering a midwifery model of ‘Care as Gift’ to a medicalised model of ‘Vigil of Care’. Burnout is identified and belief in the birth process is eroded as midwives modify their actions enabling them to stay within their job, but leaves them struggling for any satisfaction in their role. This is where the word resilience becomes fashionable. It is bandied around like a badge of honour, that only worthwhile midwives earn, the ones not breaking down. This is at best, unfair, at worst, bullying. What is starting to be realised is that burnout in itself, is a symptom of an increasingly broken healthcare system and Patterson is clear where the responsibility lies.

What I found particularly interesting is that what Patterson discusses, includes an element of Moral Injury, I believe, although it is not specified. The nearest was a ‘Take home point’ that “ . . . conflict between models of midwifery care and working within toxic culture . . .” can lead to Secondary Traumatic Stress (STS). I was left wondering if Moral Injury appears in her PhD research at all? STS is what Patterson identifies midwives experiencing, a normal response to witnessing trauma. I have concluded that the difference between STS and Moral Injury is the resistance to modifying behaviour from a midwifery model to a medicalised model, either intentionally or by virtue of inability to change. And thank goodness for that, as to ‘give in’ or adapt, according to Patterson means midwives, “ . . . may suppress their emotions and present a hardened demeanour . . .” , so I am thankful that I did not ‘only’ experience STS. The silver lining though, is perhaps that women and midwives may not be suffering in vain and that by not conforming, by actually leaving the profession an important issue can be acknowledged. Perhaps there is hope that as more research is published, a change in the culture of the NHS can be embraced.

From Moral Injury to autonomy

And what happened to the mother and baby described in my opening scenario? Well, without downplaying the horrendous circumstances, the incident was part of my journey to a different way of practising midwifery. The Registrar on duty was a very experienced obstetrician from Africa who was skilled in breech delivery, and I observed, the kindest practitioner involved, as I involuntarily took on the role of spectator. He simply allowed the woman’s body to do the work, speaking softly in encouragement and it was all very fast and efficient in the end. I noted that he expertly guided the baby, mimicking the position it would’ve taken, had the mother been in the natural position for a breech birth, hands and knees; essentially an ‘upside-down breech birth’. Certainly, I have always believed that this experience was instrumental in my later interest in breech births and gaining the skills as a midwife.

References

5 Comments

  1. Jeannine Webster

    This was such an excellent blog and one I identified with completely. I feel now I have a name for something’s I experience every day. Thank you for writing it.

    Reply
  2. Katie Farmer

    As a newly qualified midwife questioning frequently if I lack the “resilience” required to remain in the profession and oft feeling inadequate for my doubts that plague me, this article is like a healing balm, I now wonder if those who aren’t questioning or doubting are in a worse position.
    Thankyou so much for writing it and sharing it.

    Reply
  3. Jenny Patterson

    Thanks so much for this very valuable reflection and blog. I must admit to not coming cross the term Moral Injury until after completing my PhD research and writing this article. However, it is absolutely spot on. I did come across the call for PTSD to be renamed PTSI (post traumatic stress injury). The use of the word injury is critical because it reflects what happened to someone, rather than a sense of disorder or indeed lack of resilience. I totally agree midwives are hugely resilient, in many ways this is essential so that midwives can engage with the challenging and distressing birth outcomes/procedures that can occur. BUT!! no midwife should need to develop resilience to a damaging culture – this is where we need to draw the line in expecting midwives to develop resilience. I am involved in some other work now where Moral Injury for midwives and maternity professionals is at the heart of what we are looking at. thanks Genevieve.

    Reply
    • Lynn Genevieve

      I was very pleased to hear that you are following up your work in such a valuable area, Jenny. Yes – the word injury is vital to understanding this area more fully. I look forward to to hearing more about this in the future with hopefully, action that affects positive change. I appreciated your comments thank you.

      Reply
    • Kate Greenstock

      Jenny! Hi, I would love to talk to you about your current work. I am currently working on something similar, supporting midwives to name what they are experiencing. My NHS email is k.greenstock@nhs.net. Look forward to hearing from you!

      Reply

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