Vicarious Trauma Experienced by Health Care Providers Involved in Traumatic Childbirths: A Meta-Synthesis

Witnessing trauma

Health care providers who reported that they were traumatized by adverse events during childbirth were often new and inexperienced, and such events had greater impacts on them as compared to those who were more senior in the profession (Beck & Gable, 2012; Davies & Coldridge, 2015; Rice & Warland, 2013; Sheen et al., 2016). Facing the death of a newborn, witnessing the violent and abusive deliveries, participating in emergency situations, and observing the coercion of women to comply during labor were the examples of traumatic scenarios described by midwives, L&D nurses, and student midwives (Beck & Gable, 2012; Davies & Coldridge, 2015; Goldbort et al., 2011; Rice & Warland, 2013; Sheen et al., 2016; Toohill et al., 2019). The studies exclusively focused on L&D nurses (Beck & Gable, 2012; Goldbort et al., 2011) highlighted that the L&D nurses “felt like an accomplice to crime” as they witnessed something unnecessary but harmful being done to the laboring women. The “unusual severity” of these occurrences was difficult for them to mentally process and “too big for the brain to grasp,” leaving them overwhelmed, horrified, in shock, and in “disbelief.” Such responses to trauma were contributed by health care providers’ empathetic attitudes toward their patients as reported in three of the studies (Davies & Coldridge, 2015; Rice & Warland, 2013; Sheen et al., 2016).

Empathizing with patients

Student midwives perceived that empathizing with women was an imperative quality that a midwife should possess, and they felt satisfaction from providing compassionate care (Coldridge & Davies, 2017; Davies & Coldridge, 2015). However, several students expressed that empathizing with women was painful, distressing, overwhelming, and not encouraged by some midwives (Coldridge & Davies, 2017; Davies & Coldridge, 2015). Midwives who had built meaningful relationships with their patients felt connected to their patients’ trauma, such that it affected them emotionally as well (Rice & Warland, 2013; Sheen et al., 2016). Some midwives also mentioned the lack of continuity of care especially when their shifts were passed on to their colleagues, leaving them concerned about their patients’ well-being (Rice & Warland, 2013). In one study conducted in China, midwives empathized with women who were pressured by their families to give birth to a boy and to have a vaginal delivery and furthermore neglected by their families postpartum (Huang et al., 2019).

Role confusion

After witnessing a traumatic birth, health care providers especially midwives and L&D nurses often questioned themselves whether they had done their best in fulfilling their roles and duties. In eight of the studies, obstetricians, midwives, nurses, and student midwives all reported being powerless and helpless in traumatic situations which they could not control. Most midwives and L&D nurses expressed that they had failed to advocate for women, especially when witnessing them fighting against unwanted medical interventions or struggling against violent approaches used by obstetricians (Beck & Gable, 2012; Beck et al., 2015; Halperin et al., 2011; Huang et al., 2019; Rice & Warland, 2013; Sheen et al., 2016; Toohill et al., 2019; Wahlberg et al., 2020). Similarly, student midwives who were often “spectators” in traumatic scenarios felt “useless” for being unable to assist women in fulfilling their birthing wishes (Coldridge & Davies, 2017; Davies & Coldridge, 2015). Midwives and L&D nurses frequently reflected on what they could have done better or differently for these women and if they had exhausted their efforts to protect them from unnecessary suffering (Beck & Gable, 2012; Edqvist et al., 2014; Rice & Warland, 2013; Sheen et al., 2016; Toohill et al., 2019; Wahlberg et al., 2020).

The professional hierarchy was accentuated in the delivery room, whereby obstetricians had the most authority in making decisions, often disregarding midwives’ recommendations (Halperin et al., 2011; Rice & Warland, 2013; Toohill et al., 2019; Wahlberg et al., 2020). However, obstetricians also reported feeling responsible and powerless when their actions did not result in a desired or positive outcome (Rönnerhag et al., 2019; Wahlberg et al., 2020). Consequently, feelings of self-blame, guilt, shame, and anger were common emotional responses experienced by health care providers.

Emotional response

Guilt was most reported by midwives who felt that they had contributed to the negative outcomes in delivery, such as sphincter tears, infant demise, or even unnecessary suffering for the women (Edqvist et al., 2014; Lindberg et al., 2013; Rice & Warland, 2013; Schrøder et al., 2016; Sheen et al., 2016; Wahlberg et al., 2019). As a result, many midwives blamed and doubted themselves for “missing something” during their care that possibly led to undesirable consequences for the women and their babies (Edqvist et al., 2014; Sheen et al., 2016). Obstetricians and midwives alike faced shame for their incompetence, lack of knowledge, and “bad judgments” for failing to protect their patients from adverse outcomes (Edqvist et al., 2014; Wahlberg et al., 2019). Feelings of anger was also mentioned by a few midwives who were “forced” to comply with medical procedures or interventions that they were opposed to (Toohill et al., 2019). However, for the L&D nurses, the experience was much more intense as they watched the “abusive deliveries” like “watching a rape” (Beck & Gable, 2012). They were “helpless” and “powerless” and felt as if they “did not protect their patients” (Beck & Gable, 2012; Goldbort et al., 2011).

Communication and teamwork

A pleasant childbirth experience often involves effective communication and trust among the obstetricians, midwives, and their patients. Health care providers recognized that respectful communication and coordination among team members optimized their decision-making process, especially in critical situations (Rönnerhag et al., 2019). However, in many cases, obstetricians and midwives had disagreements and misunderstandings with regard to patient care (Rönnerhag et al., 2019; Wahlberg et al., 2020). Midwives struggled with voicing their opinions due to the hierarchical structure that gives obstetricians more power in decision making, resulting in some midwives feeling disrespected within the health care team (Toohill et al., 2019; Wahlberg et al., 2020). Furthermore, the escalation of disagreements frequently led to hostility among team members (Toohill et al., 2019). Obstetricians also reported that midwives were sometimes unwilling to cooperate and that they felt pressured when their decisions were not supported by midwives (Wahlberg et al., 2020). Student midwives who were entangled in such conflicts highlighted that instead of a strong supportive culture within the health care team, “finger-pointing” was more prominently observed (Coldridge & Davies, 2017). Health care providers also acknowledged that decision making and communication should involve patients, but this was difficult to achieve during emergency situations (Rönnerhag et al., 2019).

Collegial relationship: Realities and hopes

During stressful situations in childbirth, collegial relationships can either improve or worsen the traumatic experience of the health care providers. Some obstetricians and midwives reported positive experiences of camaraderie among their colleagues by sharing their traumatic encounters with one another, gaining objective viewpoints and critique as well as obtaining validation, reassurance, and emotional support (Beck et al., 2015; Sheen et al., 2016; Toohill et al., 2019). However, the majority of the midwives and a few obstetricians shared unpleasant incidences of colleagues gossiping about them and pointing “invisible fingers” at them, intensifying their feelings of abandonment and betrayal (Beck et al., 2015; Halperin et al., 2011; Lindberg et al., 2013; Rice & Warland, 2013; Schrøder et al., 2016; Sheen et al., 2016; Toohill et al., 2019; Wahlberg et al., 2020). Some midwives also expressed fear of judgment by their colleagues and feelings of loneliness and rejection (Halperin et al., 2011; Lindberg et al., 2013; Schrøder et al., 2016).

Student midwives felt a lack of “safe” space to share their concerns, and being silenced into compliance was part of the midwifery culture (Coldridge & Davies, 2017). Furthermore, midwives reported that their senior colleagues and managers were often more concerned about the legal implications of the adverse childbirth event rather than acknowledging their distress and supporting them (Sheen et al., 2016). Conversely, obstetricians felt respected and appreciated by their managers who provided them with support (Toohill et al., 2019). Health care providers generally wished for a multidisciplinary team debrief session after a traumatic event to discuss and share their thoughts and feelings with one another, with the hope of “getting through” the bad outcome “together” (Beck & Gable, 2012; Davies & Coldridge, 2015; Goldbort et al., 2011; Halperin et al., 2011; Lindberg et al., 2013; Toohill et al., 2019).

Organizational support: Expectations and certainties

Besides collegial support, midwives and student midwives highlighted the importance of formal support from the management, such as professional help from a social worker or psychologist or a formal debrief session by a “mentor,” to guide them through difficult times (Coldridge & Davies, 2017; Davies & Coldridge, 2015; Halperin et al., 2011; Rice & Warland, 2013). Such support was usually inadequate or unavailable, except in one study that mentioned team simulations were held to prepare health care providers for emergency situations by encouraging communication and teamwork (Beck & Gable, 2012). Issues on insufficient staffing, heavy workload, and poor staff mix were also raised by several midwives as hazards that contributed to adverse events or worsening of such events (Goldbort et al., 2011; Sheen et al., 2016; Toohill et al., 2019; Wahlberg et al., 2020).

Haunting of memories

In four of the studies, obstetricians and midwives reported that they were able to “vividly” recall memories of traumatic childbirth situations, which included the smells, sounds, sights, and touch (Goldbort et al., 2011; Halperin et al., 2011; Sheen et al., 2016; Wahlberg et al., 2020). Some of the L&D nurses experienced nightmares and recurring flashbacks that “haunted” them for years (Beck & Gable, 2012; Beck et al., 2015; Goldbort et al., 2011; Halperin et al., 2011). A few others became “numb” to protect themselves from the mental trauma (Wahlberg et al., 2020). In one case, an obstetrician experienced a mental block and was unable to recall the incidents related to the traumatic event (Wahlberg et al., 2020). Student midwives observed that some midwives had become “cold,” “mechanical,” and “emotionless” toward their patients as a form of emotional avoidance to continue their care professionally (Coldridge & Davies, 2017).

Keeping it professional

Most student midwives struggled with compartmentalizing and controlling their emotions in front of their patients (Coldridge & Davies, 2017). Midwives and nurses shared that detaching from their emotions was necessary for them to focus on completing other tasks or procedures, such as providing support for women or delivering a decapitated infant (Beck & Gable, 2012; Sheen et al., 2016). However, many health care providers still expressed difficulty in suppressing their emotions in front of patients and their families, especially when relaying bad news (Beck & Gable, 2012; Coldridge & Davies, 2017; Goldbort et al., 2011; Lindberg et al., 2013). Apart from the emotional aspects, maintaining professionalism for midwives meant focusing on the best interest of the patient and challenging the authority of obstetricians as needed (Halperin et al., 2011).

Shouldering the blame

When childbirth involved injury and death, facing litigation was not uncommon for the health care team. Health care providers especially obstetricians and midwives revealed feelings of anger, betrayal, fear, anxiety, and dread after being named in a lawsuit (Beck et al., 2015; McCool et al., 2009). Even if they were eventually exonerated, the long and tortuous legal process forced them to relive the traumatic events and realize that they were still partially responsible for the adverse outcomes (Beck et al., 2015; Schrøder et al., 2016). Some studies also reported that obstetricians and midwives were publicly humiliated through mass media and in some cases even “harassed” and “attacked” by the media (McCool et al., 2009; Schrøder et al., 2016; Wahlberg et al., 2019). Some distraught patients and their families turned aggressive and verbally abusive toward health care providers, with one obstetrician receiving years of “long, long, long, evil letters” from a woman who had lost her infant in a traumatic childbirth (Schrøder et al., 2016; Wahlberg et al., 2019). Obstetricians and midwives were often left feeling frustrated, threatened, and wronged, yet sorry and miserable (Wahlberg et al., 2019). This “culture of blame” in health care was highlighted in several studies, resulting in serious implications on how health care providers perceived their career (Coldridge & Davies, 2017; Sheen et al., 2016; Toohill et al., 2019).

Changing perceptions of career

Obstetrician and midwives were increasingly afraid of making mistakes and getting blamed, which caused many of them to lose confidence in their practice (Davies & Coldridge, 2015; Halperin et al., 2011; Sheen et al., 2016). Midwives reported becoming more cautious, guarded, and meticulous, and they ensured to be always “prepared for the worst” (Beck et al., 2015; Goldbort et al., 2011; McCool et al., 2009). When questioned by colleagues or faced with accountability, some midwives became increasingly defensive (Lindberg et al., 2013; Sheen et al., 2016). They were often preoccupied with fear of tarnishing their professional records and not being able to prove their competency as midwives (Halperin et al., 2011; Lindberg et al., 2013). Some midwives, L&D nurses, and student midwives expressed that they were “shaken” by this reality of midwifery; had “lost their naivety,” “faith,” and “spirit”; and felt that their philosophy of midwifery was challenged (Beck et al., 2015; Coldridge & Davies, 2017; Rice & Warland, 2013; Wahlberg et al., 2019). However, multiple studies highlighted that some midwives took the opportunity to learn from traumatic experiences through self-reflections, analysis of their own practice, and keeping up with the latest research and evidence (Lindberg et al., 2013; Rice & Warland, 2013; Sheen et al., 2016). Yet, a proportion of midwives and L&D nurses felt that the constant fear and pressure might not be worth the damage to their personal lives and well-being (Schrøder et al., 2016; Wahlberg et al., 2019). Some L&D nurses made the career move from direct patient care to less intensive settings such as graduate school, academia, or the antepartum clinics (Beck & Gable, 2012).

Affecting personal life and relationships

After experiencing traumatic situations at work, midwives and nurses reported they had decreased appetite and difficulties with concentrating, sleeping, and controlling their irritability around family members (Halperin et al., 2011). Generalized weakness, body aches, headaches, palpitations, dizziness, and hand tremors were also reported (Halperin et al., 2011). Some studies stated that midwives experienced low mood, hopelessness, and struggles to find joy in life especially with their children (Beck et al., 2015; Schrøder et al., 2016; Sheen et al., 2016). One obstetrician even highlighted a “sense of loneliness” while having thoughts of managing life and death situations. One study also mentioned that midwives became more protective of their loved ones in fear of losing them to adverse events (Sheen et al., 2016).

Personal coping

To some health care providers, coping with traumatic experiences meant accepting the fact that they had put in their best effort and acknowledging the inevitability of adverse events in L&D (Edqvist et al., 2014; Rice & Warland, 2013; Sheen et al., 2016; Toohill et al., 2019; Wahlberg et al., 2019). Discussing traumatic experiences with their spouse, family, and friends; seeking information to understand the occurrence of the adverse event; and praying were common methods of coping as reported in multiple studies (Beck & Gable, 2012; Davies & Coldridge, 2015; Halperin et al., 2011; Lindberg et al., 2013; Sheen et al., 2016; Wahlberg et al., 2019). Some midwives shared that positive delivery experiences promoted restoration, and some obstetricians expressed that receiving forgiveness from their patients helped them heal (Sheen et al., 2016; Wahlberg et al., 2019). In other cases, health care providers refrained from reminding themselves of the traumatic events by creating quiet time to “clear” their minds (Davies & Coldridge, 2015; Sheen et al., 2016).

Choosing to leave

For some health care providers, leaving their career in obstetrics was the best option for them to move on with their lives. Two studies reported that midwives struggled to return to work after a traumatic event (Halperin et al., 2011; Schrøder et al., 2016). One study revealed that L&D nurses had transferred to another department or reallocated themselves to management positions (Beck & Gable, 2012). Two studies disclosed that a few health care providers even left their positions completely (Beck et al., 2015; Wahlberg et al., 2019).

Wish list

Having encountered traumatic childbirth events, health care providers wished to be more prepared, competent, and better trained for similar situations in future (McCool et al., 2009; Rönnerhag et al., 2019; Sheen et al., 2016). They also felt that the public should be more aware of the adversities in childbirth and stressed the importance of educating the community on prenatal care (McCool et al., 2009). Especially, health care providers who were less experienced wished for an improved support network in terms of having opportunities to share their anxieties with colleagues and their managers (Davies & Coldridge, 2015; Rönnerhag et al., 2019; Sheen et al., 2016; Wahlberg et al., 2019). They wished to have a support network where open communication can be maintained without any judgments.