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ARTICLE IN PRESS

Midwifery (2010) 26, 7687

www.elsevier.com/midw

The costs of being with the woman: secondary traumatic


stress in midwifery
Julia Leinweber, BSc (Midwifery), MPH, Heather J. Rowe, BSc (Hons), PhD

Key Centre for Womens Health in Society, School of Population Health, Faculty of Medicine,
Dentistry and Health Sciences, University of Melbourne, Vic. 3010, Australia

Corresponding author.

E-mail address: julia.leinweber@gmx.at (J. Leinweber).

Received 18 January 2008; received in revised form 5 April 2008; accepted 13 April 2008

Abstract
Objective: it is widely acknowledged that caring can cause emotional suffering in health-care professionals. The
concepts of compassion fatigue, post-traumatic stress disorder and secondary traumatic stress are used to describe the
potential consequences of caring for people who are or have experienced trauma. Empathy between the professional
and patient or client is a key feature in the development of secondary traumatic stress. The aim of this paper is to
contribute to the conceptual development of theory about dynamics in the midwifewoman relationship in the context
of traumatic birth events, and to stimulate debate and research into the potential for traumatic stress in midwives who
provide care in and through relationships with women.
Method: the relevant literature addressing secondary traumatic stress in health-care professionals was reviewed.
Findings: it is argued that the high degree of empathic identication which characterises the midwifewoman
relationship in midwifery practice places midwives at risk of experiencing secondary traumatic stress when caring for
women experiencing traumatic birth. It is suggested that this has harmful consequences for midwives own mental
health and for their capacity to provide care in their relationships with women, threatening the distinct nature of
midwifery care.
Conclusions: opportunities for research to establish the existence of this phenomenon, and the potential implications
for midwifery practice are identied.
& 2008 Elsevier Ltd. All rights reserved.
Keywords Secondary trauma; Midwifewoman relationship; Empathy; Traumatic birth; Compassion fatigue; Woman-centred care;
Post-traumatic stress disorder (PTSD)

Introduction
In recent decades, there has been a re-orientation
in midwifery care. Being with the woman,
woman-centred care and partnership with women are emerging terms associated with midwifery care in Australia and elsewhere (Corolan and

Hodnett, 2007). There is a wealth of evidence


for advantageous outcomes for the childbearing
mother when care is provided in and through
relationships with the woman (Hodnett, 2002;
Homer et al., 2002; Hodnett et al., 2003). Midwives
consider their relationship with the childbearing
woman as a major source of job motivation and

0266-6138/$ - see front matter & 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.midw.2008.04.003

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The costs of being with the woman: secondary traumatic stress in midwifery
satisfaction (Kirkham et al., 2006), and argue
that this relationship is the very essence of
midwifery care and denes its distinctive nature
(Thompson, 2001; Kirkham, 2007). Despite this,
little is known about how midwives experience
their engagement in a close relationship with the
childbearing woman or about potential consequences for their well-being.

The emotional costs of caring


It is now widely acknowledged that caring, which is
the process of preventing, treating and managing
illness and preserving mental and physical wellbeing, is facilitated through both physical and
mental presence, and involves addressing the
emotional needs of the patient (Rothschild, 2006).
Meeting the emotional needs in another person
necessitates a health-professionals own emotional
involvement, which has the potential to cause
emotional stress in health-care professionals (Thomas and Wilson, 2004; Sabo, 2006). In the elds
of mental health care, social work and nursing,
it is recognised that caring for people who are
or have been experiencing suffering, pain and
trauma can cause traumatic stress reactions in
professional helpers (Stamm, 2002; Rothschild,
2006). Various responses emerge as coping reactions
after experiencing or witnessing duty-related traumatic events, which are considered to constitute a
serious threat to professionals mental health and
their capacity to provide sensitive care (Figley, 2002;
Laposa et al., 2003; Rothschild, 2006).
The costs of caring concept has been described
in a number of ways. First, as compassion fatigue,
which in its simplest form refers to stress, strain
and weariness of caring for others who are suffering
from medical illness or a psychological problem. It
is associated with exhaustion and loss of vigour and
vitality. A person experiencing compassion fatigue
is tired of helping and being compassionate
(Thomas and Wilson, 2004).
Second, post-traumatic stress disorder (PTSD) is
dened as an anxiety disorder that develops after
direct exposure to a traumatic event. Criterion A in
the fourth edition of the Diagnostic Statistical
Manual (DSM IV) of the American Psychiatric
Association (American Psychiatric Association,
2000) denes the necessary characteristics of an
event in order that it be classied as traumatic.
The type of exposure must be experiencing,
witnessing or being confronted with and the
nature of the event an actual or threatened death
or serious injury, or a threat to the physical

77

integrity of self or others. Further, the response


to the event must involve intense fear, helplessness or horror (Weathers and Keane, 2007).
Three core sets of symptoms of PTSD are described
in DSM VI. First, re-experiencing the trauma in
some way such as becoming upset when confronted
with a reminder of the traumatic event or thinking
about the trauma when trying to do something else.
Second, avoidance and numbing, involving staying
away from places or people that remind the
sufferer of the trauma, isolating the self from
other people, or feeling numb. The third set of
symptoms involves increased arousal and includes
things such as feeling on guard, irritable or
startling easily (American Psychiatric Association,
2000). PTSD is known to lead to signicant life
impairment and occupational dysfunction by reducing an individuals capacity to interact with
others, decreasing self-esteem and self-efcacy,
and causing physical and mental fatigue and
exhaustion (Weathers and Keane, 2007).
The third concept, secondary traumatic stress, is
very similar in both conceptualisation and pathology to post-traumatic stress and PTSD (Figley,
2002). Secondary traumatic stress describes the
development of traumatic stress as a result of
exposure and involvement with those who have
been or are enduring trauma (Figley, 2002).
Finally, vicarious traumatisation is a concept that
has been classied as being different from compassion fatigue and secondary traumatic stress, as
its emphasis is on transformation in the helping
professional, affecting his or her private and
professional life (Thomas and Wilson, 2004).
These denitions emphasise the distinct features
of each concept; however, there is controversy in
the literature about the denitions themselves and
the degree of overlap between them (Baird and
Kracen, 2006). Figley (1995, p. 7) operationalised
compassion fatigue as ythe stress resulting from
helping or wanting to help a traumatized person.
He considers symptoms of secondary traumatic
stress as almost identical to symptoms of PTSD,
and uses the concepts of secondary traumatic stress
and compassion fatigue interchangeably. In nursing,
Sabo (2006) argues that compassion stress and
fatigue are adequate substitutes for secondary
traumatic stress. This is because she considers
compassion fatigue as the term that refers to an
emotional stress response resulting from being
exposed to the traumatised individual, rather than
to the traumatic event itself.
Thomas and Wilson (2004) argue that secondary
trauma, compassion fatigue and vicarious trauma are
distinct but inter-related forms of occupationalrelated stress response syndrome, all describing

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78
trauma like states in the professional, that arise as
coping reactions caused by his or her exposure to
patients who suffer from acute or chronic physiological and psychological injuries.
In this paper, the three terms, secondary traumatic stress, PTSD and compassion fatigue, are
considered to be describing a similar phenomenon.
Witnessing trauma or its reactions in patients may
provoke similar symptoms or even full-blown
disorder in health professionals caring for them.
However, as the focus of this paper is on midwives
exposure to trauma in childbearing woman, the
terms secondary traumatic stress and PTSD are
given preference, as these concepts refer to the
emotional stress resulting from being exposed
to the traumatic event itself as well as to the
traumatized individual.
It has been argued that all professional caregivers will at some point in their professional lives
be at risk of secondary traumatic stress (Gentry
et al., 2002). This paper aims to review the
evidence for traumatic stress in health professionals, and to consider whether particular features
of midwifery practice make this cost of caring
pertinent to the midwifery profession.

Search strategy
A search of the literature was undertaken using the
CINAHL, Medline, MIDIRS, PsychINFO and Web of
Science databases and the search terms: secondary traumatic stress, compassion fatigue, PTSD
vicarious traumatization and health care professionals. Additionally, the terms midwifewoman
relationship, care and birth trauma and PTSD
and birth were used. The literature search
identied articles reporting empirical research,
opinion and case studies. Reference lists of articles
were searched and relevant sources were identied, retrieved and included. Empirical research on
secondary traumatic stress and its related concepts
as well as papers that added to the understanding
of these concepts have been included in the review.
Additionally, extracts from empirical research on
midwives experiences of their relationships with
women as well as theoretical considerations about
the nature of this relationship have been included.

The prevalence and risk factors for trauma


reactions in health care
A number of interview guides and self-report
measures have been developed to assess the

J. Leinweber, H.J. Rowe


prevalence of compassion fatigue, PTSD and secondary traumatic stress in the health-care professions. The limited published empirical prevalence
data are summarised in Table 1.
In midwifery and nursing, the cost of caring
has been conceptualised and measured as the
occurrence of PTSD and compassion fatigue. For
example, Abendroth and Flannery (2006) found
that hospice nurses are vulnerable to compassion
fatigue because caring for dying patients, many
with complex disease processes, and being empathic to families in psychosocial and spiritual
crisis has been observed to lead to high levels
of occupational stress. Abendroth and Flannery
(2006) assessed compassion fatigue in nurses using
a standardised scale and asked about their degree
of agreement with the statements I feel as though
I am experiencing the trauma of someone I have
helped and As a result of my helping I have sudden
unwanted frightening thoughts. Scores of a majority of nurses placed them in the moderateto high-risk category for compassion fatigue.
Similarly, Maytum et al. (2004) interviewed nurses
who work with children with chronic diseases and
their families and found that compassion fatigue
was commonly experienced and considered as an
unavoidable part of the nurses everyday work life.
Caring for kids with chronic conditions and being a
sounding board for too many sad situations (p. 175)
was described by the nurses as a trigger for
compassion fatigue.
Laposa et al. (2003) found traumatic stress
symptoms, assessed with a standardised scale, in
a substantial proportion of Canadian emergency
nurses. Similarly, Jonsson and Segesten (2004)
measured PTSD prevalence using a standardised
measure in ambulance personnel in Sweden. A
majority reported that they had had experience
of what they described as traumatic situations and
a proportion met diagnostic criteria for PTSD.
Health professionals from a range of disciplines
described their experiences of traumatic stress in
their professional roles (Raingruber and Kent,
2003), and similarly, men described PTSD symptoms
in their accounts of being present during the birth
of their children (White, 2007).
There are some important limitations in the
interpretation of empirical data about prevalence
and severity of these reactions in health professionals. First, traumatic stress in nurses is not likely
to be focused around a single event, like a
catastrophe, but rather to result from repeated
exposure to different duty-related traumatic
events. Therefore, studies investigating PTSD in
nurses have not standardised the time interval
between the exposure to the traumatic event and

Traumatic stress in health professionals and carers.

Author/date

Health
profession

Conceptualisation

Study design

Methods

Measures

Findings

Abendroth and
Flannery (2006)

USA

Nurses, hospice

Compassion fatigue

Cross-sectional

216

Survey

26% scored in
high-risk
category for
compassion
fatigue; 78%
moderate to
high risk

Maytum et al.
(2004)

USA

Nurses,
paediatrics

Compassion fatigue

Descriptive
qualitative

20

Interview

Professional
Quality of Life
Compassion
Satisfaction
and Fatigue
Subscales:
Revision-III
(Stamm, 2002)
Probe questions
about
compassion
fatigue

Laposa et al.
(2003)

Canada

Nurses,
emergency

Post-traumatic stress
disorder

Observational

51

Questionaire

Raingruber and
Kent (2003)

USA

Social work and


nursing
students,
psychiatrists,
and social work
and nursing
faculty
members

Secondary traumatic
stress

Phenomenological

47

Interview

Jonsson and
Segesten (2004)

Sweden

Ambulance
personnel

Post-traumatic stress
disorder

Phenomenological

10

Interview

NS

Fathers
witnessing birth

Post-traumatic stress
disorder

Phenomenological

21

Narrative

White (2007)

Post-traumatic
Stress
Diagnostic
Scale (PDS)
(Foa et al.,
1993)
Open-ended
questions

Impact of Event
Scale (IES-15)
(Horowitz
et al., 1979)

Compassion
fatigue is
commonly and
episodically
experienced
12% PTSD
diagnostic
criteria; 20%
PTSD symptoms

Secondary
traumatic
stress is
experienced
frequently in
the form of
physical
perceptions
and sensorybased
memories
15% PTSD,
often linked to
shame and guilt
Fathers
describe PTSD
symptoms

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Country

The costs of being with the woman: secondary traumatic stress in midwifery

Table 1

79

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80
the measurement of symptoms. Second, the instruments used for assessing compassion fatigue and
traumatic stress have, for the most part, been selfreport measures, and interpretation of their scores
is limited by their lack of available external
validation data. Further, scores on these measures
have uncertain reliability in discriminating between levels of severity of traumatic stress. Finally,
the small sample sizes mean that ndings may not
be readily generalisable across a variety of traumatic experiences or different contexts (Motta
et al., 2004; Ting et al., 2005; Sabo, 2006). Despite
these methodological limitations, it appears that
nurses in particular contexts face a heightened risk
for duty-related traumatic stress and compassion
fatigue.
Additionally, it is important to note that there is
no consistency in the literature regarding the
distinction between primary and secondary trauma. However, Figley (2002) claims that symptoms
of primary and secondary traumatic stress may be
similar in type and severity, and some empirical
research appears to support this. For example,
Laposa and Alden (2005) compared the consequences of exposure to a traumatic event in
two groups of emergency nurses. The rst group
had direct (primary) exposure, for example, to
the death of a child or the care of a person with
severe burns, and the second group had indirect
(secondary) exposure, through witnessing a traumatic situation, such as observing a colleague
caring for a dying child or a patient with massive
bleeding or dismemberment. No signicant difference in PTSD severity between the two groups
of nurses was identied in scores on the Posttraumatic Stress Diagnostic Scale (Foa et al., 1993)
which measures the presence of six PTSD symptoms
according to DSM IV criteria.
It is important to note that not all individuals
who are indirectly exposed to traumatic experiences develop traumatic stress reactions, just as is
the case for those exposed to primary trauma
(Lerias and Byrne, 2003). The literature on secondary trauma suggests that a history of trauma, lack
of psychological well-being, poor social support,
female gender, low education and low socioeconomic status are associated with an elevated
risk of experiencing secondary traumatic stress
after indirect exposure to a traumatic event as part
of professional work (Lerias and Byrne, 2003;
Abendroth and Flannery, 2006; Sprang et al.,
2007). However, two recent meta-analyses from
general trauma research suggest that factors
operating during or after the trauma, such as
trauma severity, lack of social support and additional life stress, rather than pre-trauma risk

J. Leinweber, H.J. Rowe


factors, such as reported childhood abuse, family
psychiatric history, trauma history or low level
of education, increase the risk of developing PTSD
(Brewin et al., 2000; Ozer et al., 2003).

The role of empathy in traumatic stress


Empathy is described by Gallese (2006) as the
capacity to experience what others experience and
to participate in their experience. It is considered
central to the professionalclient relationship in
psychology and counseling, and a key professional
skill in nursing (Figley, 1995; Walker and Alligood,
2001; Rothschild, 2006; Sabo, 2006). There is wide
agreement in the literature about the key function
of empathy in the development of secondary
trauma and compassion fatigue (Figley, 2002;
Stamm, 2002; Jonsson and Halabi, 2006; Rothschild, 2006).
Thomas and Wilson (2004) argue that empathic
identication, or emotional resonance and synchrony with another person, manifests in different
levels of intensity. They suggest that the greater a
professionals empathic identication with a client,
the higher is his or her risk of experiencing
compassion fatigue or secondary traumatic stress.
This hypothesis is supported by ndings from
nursing and midwifery research. Abendroth and
Flannery (2006) interpreted nurses endorsement
of an item about self-sacrice for others needs as
excessive empathy and found an association with
this and a heightened risk for the development of
compassion fatigue. Similarly, Maytum et al. (2004)
identied an association between becoming overly
involved (p. 176) with patients and the development of compassion fatigue in nurses. Both Abendroth and Flannery (2006) and Maytum et al. (2004)
suggest that too much empathy in nurses leads to
a blurring of the professional boundaries, which
normally dene and constrain the roles and
responsibilities of patients and professionals, leading to greater vulnerability to secondary traumatic
stress.

Prevention, management and consequences


of traumatic stress reactions
In order to gain understanding about factors that
protect helping professionals from secondary traumatic stress, Raingruber and Kent (2003) interviewed nursing students, psychiatrists, and social
work and nursing and midwifery faculty members
and asked about their experiences and the coping

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The costs of being with the woman: secondary traumatic stress in midwifery
strategies they used. Opportunities to reect on an
experience of secondary trauma and share it with
peers emerged as a useful way to protect professionals against the development of secondary stress
after exposure to a traumatic experience in their
patients. Similarly, nurses in Maytum et al. (2004)
identied developing supportive and honest professional relationships (p. 175) as the most
important long-term personal strategy to cope with
duty-related traumatic stress. Stamm (2002) argues
that educating practitioners about the potential
of care-giving in traumatic situations to become a
self-changing or harming experience should be a
key strategy in the prevention of secondary traumatic stress. None of the suggested prevention
or coping strategies have been evaluated in terms
of effectiveness in reducing distress (Bober and
Regehr, 2006). However, trials of midwife-led
opportunities for women to reect on their traumatic birth experiences and review the management of their labour have had mixed success in
assisting emotional recovery in women after a
traumatic birth (Gamble et al., 2002; Small et al.,
2006).
Prevention strategies that focus on education
and augmentation of coping skills emphasise the
individuals responsibility in prevention of secondary trauma reactions. It is argued that this
approach unduly individualises the problem and
that a better solution may be to apply a more
systemic approach to recognising and addressing
workplace stressors, which are beyond the control
of the individual. Parikh et al. (2004) suggest that
the demands of shift work and undue time pressure
are salient to the development of any form of dutyrelated stress and therefore warrant attention.
The experience of secondary traumatic stress can
reduce an individuals capacity to adapt to subsequent stress because it weakens stress adaptation systems in the body and brain (Wilson and
Thomas, 2004). Burnout is one of the earliest
conceptualisations of the consequences of workplace stress and is dened as the inability to cope
with job stress (Maslach, 1982). Figley (2002)
observed that burnout could emerge gradually as
a reaction to the repeated experience of secondary
traumatic stress. It is manifested as emotional
exhaustion and reduced personal and professional
accomplishment, and is known to lead to absenteeism and workplace turnover (Maslach, 1982).
Nurses in a study by Maytum et al. (2004) described
how the progression of symptoms of compassion
fatigue led to a more serious or long-lasting
problem of burnout.
Sprang et al. (2007) argue that burnout could
protect a professional from secondary traumatic

81

stress because it interferes with the development


of empathy in the professional and thereby with
the transmission of distress. Jonsson and Segesten
(2004) conducted interviews to explore how emergency ambulance personnel handle duty-related
traumatic events. The interviewees described
intrusive memories of traumatic events that were
often accompanied by feelings of guilt and shame.
This was especially so when the respondents had
felt responsible for the event, or had empathised
with the patient and his family to the extent
of giving a promise that the outcome would be
positive (Jonsson and Segesten, 2004).
Several authors suggest that duty-related traumatic stress can lead health-care professionals to
distancing and withdrawal from their patients and
their experiences, which might reduce the quality
of care provided (Figley, 1995; Baranowsky, 2002;
Jonsson and Segesten, 2004). Interviews with
ambulance staff revealed that these professionals
avoided identication with the patient and attempted to numb feelings of empathy in order to
cope when on duty and prevent new traumatic
experiences (Jonsson and Segesten, 2004).
Secondary traumatic stress affects professionals
health and well-being and can interfere with their
capacity to provide sensitive care. This has farreaching consequences including burnout, leading
to poor job performance, sick leave, high job
turnover and inevitable nancial costs to the
health-care system (Parker and Kulik, 1995).

Traumatic stress and post-traumatic stress


disorder in childbearing woman
The experience of trauma in childbearing woman
is now well documented (Olde et al., 2006).
An apparently normal labour can deteriorate
rapidly into an emergency, involving intrusive
medical interventions which are necessary to save
the life of mother or baby. Excruciating and
uncontrollable pain, disgust at the sight of blood
and other bodily uids, the horror of cut or torn
esh, and the fear of her own or her babys death
may lead to post-traumatic stress symptoms. A
growing body of literature has explored psychological birth trauma even in the absence of apparent
emergency situations (Olde et al., 2006). It is now
acknowledged that an individuals perception of
threat is crucial for the subsequent development of
PTSD. There is no doseresponse relationship
between the objective severity of an event and
the degree of post-traumatic stress, so that even
births that do not deteriorate into emergencies can

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82
provoke traumatic reactions (American Psychiatric
Association, 2000; van Son et al., 2005). Up to 30
per cent of childbearing women develop symptoms
of traumatic stress which originate from a traumatic birth experience. In 26 per cent of these
women, the symptoms are severe enough to meet
the full diagnostic criteria for PTSD, as dened by
the fourth edition of DSM IV (American Psychiatric
Association, 2000; Olde et al., 2006).
Midwifery care aims for safe childbirth with
optimal outcomes in childbearing womens physical
and mental well-being (International Confederation
of Midwives, 2005). Providing women with opportunities for exercising choice, participation in
decision-making and promoting feelings of control
in childbirth, as well as the maintenance of trust
and mutual respect between the midwife and the
woman are central components of midwifery care
(Fleming, 1998; Lundgren and Berg, 2007). These
aspects of midwifery care are intended to reduce
feelings of helplessness and fear, which are key
features of an event which is experienced as
traumatic (American Psychiatric Association,
2000). A womans perception of unsupportive care
is a recognised risk factor for post-traumatic stress
symptoms and the diagnosis of PTSD (Olde et al.,
2006). Mothers in Menages (1993) study reecting
on their traumatic births, which resulted in PTSD,
described how they felt assaulted by the care they
(did not) receive: You begin to feel like a thingy
I felt abusedy like a piece of meat on a slab, I was
a carcass to be dealt withy it felt undeniably like a
rape (p. 226).
Beck (2004) analysed the birth stories of 40 US
mothers and identied that birth trauma is often
experienced by women who perceived that the
clinicians considered their birth events as normal.
She discovered four themes that described the
essence of mothers experiences of care in their
birth trauma. To care for me: was that too much to
ask?; To communicate with me: why was this
neglected?; To provide safe care: you betrayed
my trust and I felt powerless and The end justies
the means: at whose expense? at what price?. In a
subsequent study, Beck (2006) analysed narratives
of 11 women and her ndings reafrmed the crucial
role of the way in which clinicians provide care for
the womans experience of childbirth. The reports
of the women who had experienced trauma due to
an obstetric intervention emphasised that it was
the glaring absence of caring and effective
communication that exacerbated their feelings of
helplessness, fear and horror (Beck, 2006, p. 464).
Waldenstrom (2004) analysed data from a longitudinal cohort study of 2428 women collected
1 year after birth, in order to understand why some

J. Leinweber, H.J. Rowe


womens perceptions of their childbirth experiences changed over time. Her ndings show the
positive long-term effects on the memory of the
childbirth experience of womens recollections of
empathic care. This is especially in women who had
rated their experience, directly after birth, as
negative due to an obstetric intervention. These
ndings indicate that supportive care can prevent
or ameliorate traumatic effects of an intrusive
obstetric intervention.

The midwifewoman relationship and


empathic identication
The midwifery profession describes the midwifes
relationship with the woman as characterised by a
high degree of mutuality and reciprocity, which
might even go beyond empathy (Fleming, 1998;
Kennedy et al., 2004). This is the equivalent of a
high degree of empathic identication, as described by Thomas and Wilson (2004). High levels
of empathic identication constitute a risk for the
development of (secondary) traumatic stress in
the professional and there is good reason to assume
that providing care by being with the women in a
reciprocal relationship can have a transformative
effect on the midwife herself.
Hunter (2006) explored the importance of reciprocity between community-based midwives and
women in the UK. The midwives described feeling
unprepared, unsupported and overwhelmed by
their strong emotional involvement, particularly
when caring for women who had experienced an
emotionally traumatic event: If something goes
wrong, it can be devastating. (y) When youve
been so involved with somebody its like a personal
bereavement (p. 319). Kennedy et al. (2004) used
interpretative analysis to understand 14 American
midwives narratives of their practice. The stories
described how engagement in a mutual relationship
with the woman during childbirth implies sharing
the womans experience of childbirth. The midwife
opened and allowed for this shared birth experience to become part of her own experience and
memory, and as such a part of herself and her life
journey. One midwife interviewed in Kennedy et al.
(2004) described it like this: That the ability to be
close to someone is so available and so ripe if
youre only willing to take the moment and to share
yourself, as much as we ask them to share with
usy (p. 16).
Similarly, Pembroke and Pembrokes (2007) reections on spirituality in midwifery care discuss
how reciprocity in the midwifewoman relationship

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The costs of being with the woman: secondary traumatic stress in midwifery
impacts on the midwifes self. They argue that the
midwife needs to open herself to the woman in her
care in order to mentally establish an open space
that will be lled by the womans needs and
preferences (p. 5). This is a way of describing
the necessity for the midwife to allow the birth
experience to alter her personal inner experience
in order to be fully available for the woman and
fulll her professional role of providing sensitive
care. Lundgren and Dahlberg (2002) conducted
interviews with nine experienced Swedish midwives
who concurred with this description and further
described their need to identify with the woman
and her experience of pain: follow the woman and
become more like her (p. 160).
In their secondary analysis of eight qualitative
studies exploring the midwifemother relationship,
Lundgren and Berg (2007) elucidated pairs of
concepts, describing each aspect from both the
womans perspective and from the midwifes
perspective. Availability in the midwife emerged
as the counterpart of womens ability to surrender during birth. This illustrates that it is difcult
for the midwife to fulll her professional task to be
with the woman without allowing the women to
be with her and affect her own self. Although the
term empathic identication is not used in the
midwifery literature, it is clear that midwives
employ this professional tool to facilitate their
availability for the childbearing woman and enhance the provision of sensitive care.
It has been argued that the distinct features of
midwifery practice are not captured in current
conceptualisations and measurement of healthcare, and therefore are not adequately acknowledged within the health-care system (Kennedy
et al., 2004). From the viewpoint of other professions including medicine, nursing and psychology,
the high degree of empathic identication described by midwives as part of their professional
role might be regarded as a distortion of the
appropriate boundaries between patients and
professionals. Maintenance of a distance between
patient and professional affords some emotional
protection for the professional. In midwifery and
nursing, excessive empathy and blurred professional boundaries in nurses are recognised as
problematic because they are associated with high
levels of workplace stress (Maytum et al., 2004;
Abendroth and Flannery, 2006). Historically, an
orientation to tasks rather than to the patient was
advocated as a way of placing the nurse in a
position of responsibility and power and maintaining emotional distance between nurse and patient
(Briant and Freshwater, 1998). Similarly, medicine
employs a range of means, including specic dress

83

and the use of medical jargon, to promote and


maintain this distance (Kivatisky, 1998). Unlike
nursing and medicine, midwifery was founded on
the simple notion of the support given by one
woman to another around the time of birth. It did
not conceptualise a distinction between objective
(the professions) and subjective (the womans)
experience and knowledge (Wilkins, 2000; Page,
2003). Walsh (1999) explored how women relate to
a midwife who provided continuous care to them
during pregnancy and birth: the women valued the
intimate relationship with the midwife very highly
and many described it as friendship. It has been
argued that it is only since the rise of a professional
paradigm in midwifery late in the 20th Century that
mother and midwife exist in separate social
locations (Wilkins, 2000, p. 375).

Secondary trauma in midwifery


Most research on the consequences of workplace
stress in midwifery has focused on burnout and
emotional labour (McVicar, 2003; Hunter and
Deery, 2005; Borritz et al., 2006). Borritz et al.
(2006) developed the Copenhagen Burnout Inventory, a rating scale that distinguishes between
work-related, client-related and personal burnout
and focuses on exhaustion as a key characteristic.
They compared burnout rates among human service
employees, including health-care professionals,
and found high levels of all three forms of burnout
in midwives, with prison ofcers being the only
group scoring higher on client-related burnout.
The term emotional labour is used to capture
the under-reported, invisible component of people work. Hochschild (1983) denes it as the
induction or suppression of feelings in order to
sustain an outward appearance that produces in
others a sense of being cared for in a convivial, safe
place. It is considered a largely invisible and
unacknowledged, but key, aspect of working with
health-care clients (McQueen, 2004; Mann, 2005).
Applying the concept of emotional work to midwifery, Hunter and Deery (2005) found that midwives experience their work as highly emotional,
but feel that this aspect of midwifery work was
unacknowledged and undervalued by their professional colleagues and the hospital system in which
they worked.
Hunter (2004) compared midwives in different
settings and showed that the context of midwives
work was a key determinant of emotional work.
In hospital, midwives often experienced conict
between with women and with institution

ARTICLE IN PRESS
84
approaches to care, and powerlessness and frustration accompanying their participation in care that
they regarded as harmful to women. Emotional
work was needed to resolve this dissonance, and it
can be argued that midwives who are well
supported will be better able to provide high levels
of emotional support to women. On the other hand,
community-based midwives identied the importance of a balanced exchange between them and
the woman in their care, with give and take on
both sides. Midwifewoman transactions that were
lacking some sort of giving from the woman
required more emotional work by the midwife
(Hunter, 2006). Without exception, the literature
on emotional work in midwifery emphasises the
need for further research investigating midwives
emotional experiences, and the development of
educational curricula that prepare midwives to
deal with the emotional content of their work
(Hunter and Deery, 2005; Hunter, 2006; Tennant
and Butler, 2007).
The possibility that the traumatic experience of
the childbearing woman might also have an impact
on those who witness it has received little attention. An exception is White (2007) who analysed
narratives from men who accompanied their
partners during a birth that developed into a
traumatic event, and found that a majority of the
men reported serious and long-lasting emotional
distress after witnessing what one of them described as their partners body being invaded,
abused and traumatized (p. 44). Those who have
worked in obstetrics know that deteriorating birth
situations can have catastrophic features similar to
events in the emergency room. It is therefore likely
that staff who provide care for childbearing woman
are at heightened risk for (secondary) traumatic
stress, as are emergency personnel. However, the
concept of secondary trauma is absent for the
midwifery literature.
Empathy and exposure have been identied
as the two key factors for the risk of secondary
traumatic stress (Thomas and Wilson, 2004).
The work of midwives touches both of these. Based
on a 6 per cent prevalence of traumatic stress
symptoms in childbearing women (Creedy et al.,
2000), a midwife who provides care in a modern
hospital for an average of 200 women per year
might have 12 direct encounters with trauma
within a year. Including post-traumatic stress
symptoms that do not meet the full PTSD criteria
gives an estimated prevalence of 33 per cent in
childbearing women (Creedy et al., 2000), and the
number of potential exposures to trauma for a
midwife might then be as high as 60 per year or ve
per month.

J. Leinweber, H.J. Rowe

Implications
The features of care which distinguish midwifery
from other health-care professions, particularly
heightened empathic identication in midwives
relationships with childbearing women, render
them vulnerable to traumatic stress. The heart of
midwifery care, being with the women, has the
potential to cause traumatic stress in the midwife
in a similar way to how giving birth might do so for
the woman.
It is likely that midwives react to secondary
traumatic stress in similar ways to other health
professionals, with withdrawal from emotional
intensity and a reduction in their level of empathic
identication. However, empathic identication
has a central function in the provision of effective
intrapartum care. It is employed as a professional
tool by midwives and determines the extent to
which intrapartum care can mediate the development of trauma symptoms in childbearing women
(Lundgren and Dahlberg, 2002). This establishes an
unavoidable conict between the need of a childbearing woman for a midwifes empathic identication and, at the same time, a midwifes need for
withdrawal of that level of intensity as a mechanism for protection of emotional well-being.
Midwifery research indicates that there is often a
gap between ideal and actual midwifery practice
and that the with women philosophy is unlikely to
be the dominant paradigm in all midwifery workplace settings (Lange and Kennedy, 2006; Corolan
and Hodnett, 2007). It has also been argued that
not all women wish to enter into an intimate and
mutual relationship with their midwives, or that all
midwives are willing and able to facilitate care in a
mutual relationship (McCourt, 2006; Corolan and
Hodnett, 2007). However, if midwives withdraw
from this potential relationship or numb themselves against the womens experiences, provision
of optimal care will be compromised, leading to the
kind of compromised care that ignores women s
needs as described by Mander and Flemming
(2002).
Kirkham (2007) describes the hostile working
environment for midwives in the UK in the
hierarchical National Health Service. She considers
that it is almost impossible for midwives who
experience or fear workplace bullying to be able
to provide supportive and cherishing care for
childbearing women. It could be argued that
parallel processes are at work when midwives
witness birth trauma. Without acknowledgement
of the potential risk that derives from the very
close relationship with the childbearing women,
midwives mental health and their capacity to

ARTICLE IN PRESS
The costs of being with the woman: secondary traumatic stress in midwifery
provide empathic care during birth may be in
danger. Both the working environment of the
midwife and the need for empathic identication
with the childbearing woman have potential emotional consequences for the midwife. Distinguishing
the importance of each role is a key task of
midwifery research.

85

midwiferys claim to be the most adequate profession to provide care for childbearing women may be
threatened. Therefore, midwifery needs to follow
the example of other helping professions and
acknowledge secondary trauma as a professional
risk, and investigate its nature and prevalence
in midwives. This is a prerequisite for the development of an evidence base for education and
professional supervision, and for nding new means
to manage the costs of being with the woman.

Conclusions
Acknowledging the potential of secondary traumatic stress in midwives is important for a number
of reasons. First, increased awareness in midwives
of the psychological dimension of their work may
assist in the promotion and protection of their
mental well-being. Second, if management of
potential secondary trauma in midwives reduces
childbearing womens likelihood of encountering a
midwife who provides emotionally distant care,
their own risk of experiencing traumatic reactions
may also be reduced. Secondary trauma in midwives also has important health economic implications. As in other professions where secondary
traumatic stress results in absenteeism and workplace turnover, secondary traumatic stress might
be contributing to midwives leaving the profession.
In view of the current shortage in the midwifery
workforce in Australia and elsewhere, prevention
of secondary traumatic stress in midwives might
improve human resource management in healthcare systems (Australian Health Workforce Advisory
Committee, 2002).
Finally, the orientation in midwifery towards
woman-centred and independent practice has
important implications. Questions remain about
the impact of one-to-one midwifery and caseload
models of midwifery practice on the experience of
traumatic stress. In particular, does autonomous
midwifery practice increase the risk of developing
secondary traumatic stress, because of its emphasis
on intimate and mutual relationships with childbearing women, or provide protection because, as
the primary caregiver, the midwife is in a position
of greater control over the birth situation? It can
be argued that both the model of midwifery care
and the high degree of empathic identication
with childbearing women needed in midwives work
have implications for midwives emotional wellbeing. Distinguishing the relative importance of the
two remains an important research question.
Midwifery denes the relationship with the
woman as its core. If midwives capacity to engage
with childbearing woman is compromised because
of unacknowledged secondary traumatic stress,

Acknowledgements
The authors wish to acknowledge the helpful
comments of Associate Professor Jane Fisher and
Dr. Karin Hammarberg on an earlier draft of this
paper, and the suggestions of the anonymous
reviewers.

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