Secondary Traumatic Stress and Moral Injury in Maternity Care Providers: A Narrative and Exploratory Review

Abstract

IntroductionA significant percentage of maternity providers have experienced secondary traumatic stress following a traumatic birth. Previous studies identified it as an issue, but this literature review is 5–9 years old. In addition, the construct of moral injury has significantly increased our understanding of secondary trauma for military veterans. In the wake of COVID-19, this construct also applies to healthcare providers.ObjectivesThe present article updates these reviews and compares findings for three groups: labor and delivery nurses, midwives, and obstetricians. The second portion of this review re-examines previously published qualitative research to determine whether moral injury might more accurately describe the experiences of maternity personnel.MethodsA comprehensive review of PubMed, Scopus, Web of Science, PsychINFO, and CINAHL was conducted in June 2021 using search terms such as compassion fatigue, secondary trauma, moral injury, labor and delivery, nurses, midwives, and obstetricians. Forty articles were identified, but only 16 focused on secondary trauma or moral injury.ResultsSecondary trauma is a significant concern affecting at least 25% of maternity staff. However, some countries have very low rates, which correspond to low rates in childbirth-related trauma in mothers. Secondary trauma can lead to several symptoms, including re-experiencing, avoidance, negative changes in mood and cognitions, and hyperarousal, which can cause significant impairment. As a result, many providers decide to leave the field in the wake of a traumatic birth. The incidence of moral injury is unknown, but a re-examination of previously published qualitative data suggests that this construct, generally used to describe combat veterans, does describe some of what providers have reported. Acts of omission, i.e., failure to stop the harmful acts of others had long-term negative effects on labor and delivery nurses, consistent with data from military samples. Two possible mediators were proposed: hierarchical and gendered relationships in hospitals and agency of care.ConclusionThe effects of traumatic birth on providers can be severe, including possible psychological sequelae, impaired job performance, and leaving the field. Moral injury expands upon the construct of secondary traumatic stress. This construct better describes the experiences of maternity staff in non-primary roles who witness traumatic births and are often haunted by events that they could not prevent, but often question whether they should have.

The Relationship Between Restrictive Regulation of Midwives, Practice Environment, and Professional Burnout

“…Restrictive regulation that limits midwifery practice authority has been associated with increased operative and preterm birth, which can lead to moral injury and secondary trauma for the medical team, which, in turn, is associated with attrition from employers or the workforce. 23,41 Furthermore, other state regulations that limit midwives' ability to practice, such as lack of Medicaid reimbursement parity with physicians, have been associated with fewer midwife births and also have the potential to affect the wellbeing of the workforce (eg, increasing the financial burden on a practice with CNMs). 42 Consequently, policymakers are encouraged to advocate for uniform and equitable state-level regulation of midwives as a strategy to strengthen the CNM/CM workforce and improve maternal health outcomes.…”

Which events are experienced as traumatic by obstetricians and gynaecologists, and why? A qualitative analysis from a cross-sectional survey and in-depth interviews

“… 24 25 Specific investigation into the concept of moral injury in maternity care providers, especially in the context of trauma exposure, is limited. 26 However, the role of moral injury in predicting subsequent PTSD has been identified in contexts outside of maternity care. 27 This is a concept of particular relevance in the current COVID-19 pandemic.…”

“…Where there were issues about busyness and competing demands these may relate to the concept of moral injury, where professionals cannot deliver a service according to their expected standards 24 25. Specific investigation into the concept of moral injury in maternity care providers, especially in the context of trauma exposure, is limited 26. However, the role of moral injury in predicting subsequent PTSD has been identified in contexts outside of maternity care 27.…”

Psychological Trauma and Breastfeeding: What We Know So Far

“…Similarly, a study of 907 women in the Netherlands found that 1.2 percent of women had birth-related PTSD, and 9 percent identified their births as traumatic 41 . Interestingly, maternity care providers also have lower rates of PTSD and secondary trauma in these same countries that use a midwifery model of care 42 .…”