The mean age of the participating midwives was 37.09 (8.50) years, and their mean years of employment in maternity wards was 12.54 (8.11). Among the participants, seven had a bachelor’s degree and three a master’s degree in midwifery and one was a PhD student in this discipline. Most participants were married (63.6%) and over half of them had one or two children (55.5%). Table 2 shows the demographic and personal information of the participants. All the participants allowed the interviews to be audio recorded. Each participant was interviewed in one session, except for one interview, which remained incomplete and required another session. Based on a previous appointment, the researcher contacted this participant again to determine the time and place of the second interview session with her, but she refused to continue, and upon her request not to disclose her statements at all, the transcript of the first session of the interview with her was also deleted and excluded from the study.
Table 2
The personal and demographic information of the midwives participating in the study
Participant number | Age | Work experience (year) | Place of work | Midwifery degree | Marital status | Number of children |
P1 | 46 | 22 | Public teaching hospital | Master’s degree (Midwifery Instructor) | Married | 2 |
P2 | 28 | 8 | Public teaching hospital | Master’s degree (Midwifery Instructor) | Single | - |
P3 | 46 | 21 | Non-teaching public hospital | Bachelor’s degree | Married | 2 |
P4 | 31 | 8 | Non-teaching public hospital | Bachelor’s degree | Married | 1 |
P5 | 34 | 5 | Public teaching hospital | Master’s degree (Midwifery Instructor) | Single | - |
P6 | 38 | 14 | Private birth center | Bachelor’s degree | Married | - |
P7 | 24 | 1 | Non-teaching public hospital | Bachelor’s degree | Single | - |
P8 | 30 | 3 | Non-teaching public hospital | Bachelor’s degree | Married | 2 |
P9 | 41 | 16 | Public teaching hospital | PhD student (Midwifery Instructor) | Single | - |
P10 | 51 | 25 | Non-teaching public hospital | Bachelor’s degree | Married | 2 |
P11 | 39 | 15 | Non-public hospital | Bachelor’s degree | Married | 1 |
After removing the duplicate codes, the 65 final codes extracted from the interview texts were classified into 18 subcategories, seven categories, and three themes (Table 3). “STS stimuli”, “Traumatic outcomes” and “Risk management” were the main themes of this study.
Table 3
The extracted themes, categories, subcategories, and codes
Theme | Main Category | Subcategory | Code |
STS stimuli | Discriminatory approach to midwifery | The declining position of midwifery | Poor approach to teamwork Lack of autonomy in decision-making Missed experiences Lack of job control Ambiguity in the job position |
Unbalanced distribution of power | Coercion in obedience Influence of superior authorities Satisfying the physician |
Poor legislation | Negligence of midwifery stakeholders in legislations Lack of union support Lack of awareness about legal rights Unaccountability of the authority in charge |
The nature of the midwifery profession | A community in transition | Attitudes toward the importance of childbearing Changes in expectations Increased needs of the advancing community |
Functional paradox | Medicalized approach to midwifery Physiological care Conflicts of interest Hastiness |
The risky process of labor | Perinatal risk factors Unpredictable events |
Traumatic outcomes | Psychological-emotional trauma | Adjustment problems | Regret about making an uninformed choice Regret for not being able to make up for the accident Disappointment about any improvement in professional conditions |
Thought disorder | Mental stabilization of the trauma Obsessive-compulsive disorder Rumination Fear of trauma being repeated |
Depression and anxiety symptoms | Feelings of guilt, remorse, and self-blame Sadness and crying Irritability Decreased self-esteem Hypervigilance |
Physical trauma | Physical complications | Skin complications Feeling exhausted Chills |
Vegetative symptoms | Posttraumatic insomnia Nightmares Anorexia & Weight loss |
Social trauma | Weakened professional belonging | Aversion to the profession Distrust of colleagues Blemished professional records Struggle to keep one’s position |
Weakened interpersonal communication | Influence on family relationships Weakened relationships with colleagues |
Risk management | Proactive approach | Promoting scientific abilities | Strive for acquiring up-to-date knowledge Benefiting from the successful experiences of peers Performance based on professional policies |
Promoting professional abilities | Caution and constant care Improved communication with the patients Documenting activities and services Active participation in intra-departmental meetings Improved empathy with the patients |
Reactive approach | Avoiding risky situations | Learning from the accident Avoiding the recurrence of the accident Justification of the problem |
Systematic analysis of the incident | Transferring experience to peers Analysis of colleagues’ experiences Reflection on the unsafe act |
Secondary traumatic growth | Becoming interested in the profession Enjoying the health of the mother after the accident Positive attitude to the incident Trying to reduce fear Gratitude |
1 Sts Stimuli
This theme had two main categories, including discriminatory approach to midwifery and the nature of the midwifery profession, each with three subcategories. This theme consists of categories that make midwives prone to STS.
1.1 Discriminatory Approach To Midwifery
Midwives often believed that the discriminatory approach of the health system to midwifery puts them at risk of STS in the face of adverse events in the workplace. This category had the following three subcategories.
1.1.1 The Declining Position Of Midwifery
Most midwives believed that their job position in the maternity ward was unclear. They did not have autonomy in making decisions about the mothers to whom they provided care. Their professional experiences were neglected, and they complained about a lack of job control.
“We have no autonomy. We are neither a nurse, who is comfortable and just follows the physician’s instructions, nor are we completely independent. There are no longer any good midwifery days now” (P10).
“The professional circumstances of midwifery have deteriorated. Midwives do not dare make any comments on the patients’ state. You think you have no power” (P1).
1.1.2 Unbalanced Distribution Of Power
The obligation to follow the more experienced colleagues and being under pressure in traumatic situations were extracted from the young interviewees’ statements. Also, the unbalanced distribution of power between gynecologists and the midwives engaging in labor care in the maternity ward laid the ground for shifting responsibility and negligence towards them [the midwives]. An interviewee said:
“I told the shift manager that the fetus is large and the mother can’t have a vaginal delivery and I won’t do it. She said ‘You have this responsibility and you should learn to not disagree with the shift manager’. Then when the baby came out and his hand dropped like this, I began crying before the mother did. They did not trust me because of my little work experience. The physician also trusts her. They paid no heed to my words” (P4).
Some midwives also stated that they had to get the physician’s consent to gain some benefits that they considered rightfully theirs.
“Previously, there was some collusion between the midwives and the specialists, either out of fear, or because of a weakness the midwife might have had; so, to avoid the problem being reported to the authorities, she had to cooperate with the physician like that” (P10).
1.1.3 Poor Legislation
Most participants believed that ignorance about their legal rights would lead to fear in the case of adverse events. Some also complained of the non-accountability of the superiors, whether the midwife in charge of the shift or the resident physician, and stated that even though they were responsible for deciding about the delivery, in the case of accidents, responsibility fell on the midwife. Besides, midwives do not have proper union support and the current legislation poorly supports midwifery professionals and the stakeholders of this field are not involved in legislative processes. Several interviewees commented:
“When there’s a complication in childbirth, we are the first defendants on the line. There is no barrier or protector to help us not engage directly with the clients. We must attend the courts ourselves. Hospitals do not insure us. We must always take responsibility on our own” (P10).
“In very serious cases, such as the case involving maternal death, the physician didn’t support my colleague and claimed that ‘she had not informed me [the physician] from the beginning’, which ended up having bad consequences for my colleague” (P8).
“If it were up to me, it might not have happened. The shift manager applies fundal pressure and does not write anywhere that I (the delivery agent) am involved” (P4).
1.2 The Nature Of Midwifery
Midwifery is a profession with high responsibility and accountability, and the unique aspects of this profession, such as empathy and having a care approach emphasizing physiological delivery, on the one hand, and the unpredictability of some midwifery accidents, emergency medical interventions, and exposure to the clients’ expectations, on the other hand, are considered factors involved in creating STS in midwives. This category had three subcategories, as follows.
1.2.1 Functional Paradox
Despite the emphasis on evidence-based care approaches, which often recommend the physiological approach and the provision of services based on the individual needs of the mother, the decision-making conditions are occasionally not as they are expected to be. In this regard, some participants stated:
“The problem with our work is that our work has become a combination of physiological delivery with the new fully medicalized method” (P6).
“Childbirth is a difficult job; it becomes even more difficult if there is a complication. Being mistreated by the mother’s family even slightly; this is a profession that deals directly with clients from all classes with any and all cultural backgrounds” (P10).
Furthermore, many midwives believed that there was a conflict of interest between midwives, specialist physicians, and gynecologist assistants that affected midwives’ paradoxical function.
“[Physicians and assistants] know that if midwives work well and scientifically, the number of natural deliveries will increase and cesarean sections will decrease and their market will shrink; so, they oppose us” (P9).
1.2.2 A Community In Transition
Over time, changes have developed in the attitude toward the importance of childbearing. Most families have fewer members and will bear one or at most two children. One of the participants discussed this matter and said:
“Families have a smaller size these days. They’ll bear one or at most two children. Families’ expectations have risen, and rightfully so. They want everything to be done without compromising the mother’s privacy” (P3).
Moreover, the expectations of midwifery service recipients and their media literacy have also changed. When women hear a scientific term from a midwife, they immediately begin to collect information about it on the web. Also, their knowledge of the laws has grown; therefore, they seek legal action with the slightest mistake. One participant described the changing needs and expectations of women in this area as follows:
“Mothers are reluctant to give birth in teaching hospitals, except for ones with high-risk pregnancies or those who have been referred there, while in the past, this was not the case. For example, the mother sees that someone who gives birth in a private hospital can enjoy the company of her mother or husband at birth, while the presence of the mother’s relatives is prohibited in teaching hospitals, and the mother is deprived even from having her cellphone on her. The mother can’t communicate with her family. This gap between the expectations and the infrastructure bothers both the mother and the midwifery personnel” (P9).
1.2.3 The Risky Process Of Labor
Midwives believed that the process of pregnancy and childbirth, despite being physiological, could be potentially dangerous and hazardous to both mothers and midwives. Some of these risks are related to underlying maternal causes that make a particular pregnancy and childbirth risky. The full awareness of the mother’s caregivers and delivery agents about the mother’s conditions can keep them alert and help prevent irreparable accidents through the adoption of appropriate measures. Nonetheless, some accidents and complications during childbirth are unpredictable and midwives should always be prepared to deal with such incidents.
“The mother gave birth, and I controlled her bleeding until 2 hours later. She did not have bleeding but had a constant drop in blood pressure. An ultrasound was taken but showed nothing. They had to perform a laparotomy on the mother, and after diagnosing bleeding from the internal varicose veins, the mother eventually underwent a hysterectomy” (P6).
“Not all cases are always without problems. It happens that we have taken a history and provided care for some hours, but the mother has not mentioned that she has had a postpartum hemorrhage in her previous delivery” (P9).
2 Traumatic Outcomes
The most important aspect of harm to midwives following adverse events in the maternity ward is the occurrence of traumatic physical, psychological, and social outcomes, which were mentioned by all the participants in this study. Outcomes are classified into three categories and seven subcategories.
2.1 Psychological-emotional Traumas
All the participants stated that disturbing psychological-emotional traumas were a consequence of their witnessing traumatic deliveries that have disturbed them for a long time. These symptoms often manifested in them in the form of adjustment problems, thought disorder, and anxiety and depression symptoms.
2.1.1 Adjustment Problems
Some of the interviewees discussed disappointment with the prospects of improvement in their professional conditions, their uninformed choice of the profession, and regret about having chosen this profession:
“Sometimes I felt extremely regretful about why my job is so risky! Why did I choose this field?” (P3).
“I started midwifery with love and passion. You can get disappointed with any job, but this (the lack of support following traumatic events) makes you hate your job. I always said I wished I hadn’t chosen this field” (P4).
2.1.2 Thought Disorder
The participants said they were intensely scared following the incident and could not forget it for a long time and went over the event constantly in their mind.
“After the incident, whenever I closed my eyes, I only heard that sound. Nothing had happened to the child, but it had caused great fear in me” (P8).
“For five whole years, it was as if that event was always following me like my shadow” (P3).
“I kept saying to myself that it must have been my fault and I wished I had paid more attention to the patient, I wished I had not let anyone touch my patient. This issue had penetrated my brain and I couldn’t sleep” (P7).
2.1.3 Symptoms Of Anxiety And Depression
Symptoms such as sadness, crying, anxiety, guilt, and hypervigilance were the main symptoms experienced by most participants after an adverse event:
“After the hysterectomy, when I came out of the operating room, I saw the young husband of the patient saying, ‘I don’t want her anymore, she is of no use as a wife anymore’. This affected me a lot. I told myself that it must have been my fault; I wished I had paid more attention to the patient; I wished I had not let anyone touch my patient’” (P4).
“I cried day and night. The impact of what happened, although it was four or five years ago, has lingered on to this day, mostly as a feeling of guilt” (P9).
“We have a colleague who was very afraid of CP. When the fetus stays behind the perineum and develops slight bradycardia, she gets very scared. She herself rushes and then she rushes everyone else too, and transfers the stress to everyone” (P8).
2.2 Physical Traumas
The physical effects of adverse events in addition to psychological effects cause health dysfunction in those experiencing STS. This category includes the two subcategories of physical complications and vegetative symptoms.
2.2.1 Physical Complications
Several midwives believed that the recurrence of such events caused symptoms such as fatigue and some physical complications.
“Sometimes when I come home, I like to turn off the lights and not hear too much noise in the house, because there has been a lot of noise at work” (P8).
“After this incident, I developed skin problems, hair loss, and itchy skin” (P6).
2.2.2 Vegetative Symptoms
Most midwives stated that they had anorexia and weight loss, insomnia, and nightmares after the incident.
“I was very upset until I was acquitted. I lost my appetite. I thought to myself that maybe I was to blame too” (P3).
“It [the event] made me lose 4 kilos” (P4).
“I couldn’t sleep. When I went to bed, different thoughts came over me; I’d lost my appetite” (P7).
“I kept dreaming about that newborn. He [the baby] had started crawling on all fours and kept turning back and looking at me and talking to me” (P8).
2.3 Social Traumas
In addition to the mentioned traumas, most midwives believed they had experienced social traumas after what had happened in the maternity ward. Weakened professional belonging and weakened interpersonal communication were the two subcategories of this category.
2.3.1 Weakened Professional Belonging
One of the complications resulting from the incident was the blemished professional records of the participants, and they had to struggle to keep their position due to the regulations governing the maternity ward. Moreover, distrust and getting disappointed about receiving peer support contributed to the formation of such outcome.
“These conditions are now accepted and I have to keep up in this bad situation and move forward. After all, we are part of this system, they can’t remove us. But what kind of job is this? How much should we struggle?” (P5).
“Naturally it [the incident] affects you. At the very least you get disappointed about your colleagues and know you can’t count on them anymore. I think to myself that if an accident was to happen now, my colleague wouldn’t support me, and this impacts my work” (P4).
2.3.2 Weakened Interpersonal Communication
Some interviewees believed that the professional issues occurred in the workplace not only weakened their relationship with their colleagues and friends, but also affected their family relations. They had to spend a lot of energy to avoid these issues impacting their quality of family life, which caused even greater fatigue.
“I had become very aggressive with my friends and roommates. I had gotten nervous” (P7).
“When you see a bad attitude in the workplace, it unconsciously affects your life and your treatment of your children and affects your relationships and quality of life. And you should play pretend for your family to not learn of how much work pressure you’ve endured” (P1).
3 Risk Management
In this study, the midwives’ main response to the traumatic events experienced was either passive/ reactive or active/proactive. With the heading of risk management, these responses are divided into two categories, the reactive approach, with three subcategories, and the proactive approach, with two subcategories.
The reactive approach is based on responding to events after they occur. This approach is passive and retrospective and is based on the analysis of what has happened in the past to avoid a repetition of similar incidents in the future. This approach includes the three subcategories of avoiding risky situations, systematic analysis of the accident, and secondary traumatic growth.
3.1.1 Avoiding Risky Situations
Some midwives said that, after the incident, they tried to justify themselves in some way, learn from the incident and avoid situations where the incident could happen again.
“I was upset myself. Then I said, ‘Oh, I did my job right. Everyone in my place would have done the same’” (P4).
“Not only in this incident, but in each and every case that happens, the first thing that comes to mind for everyone is that ‘I don’t want to get into trouble’” (P6).
3.1.2 Systematic Analysis Of The Incident
Most midwives said that they had tried to review the details of the incident and investigate its causes after it had occurred. They had tried to review in their mind any unsafe act and pass on these experiences to their other colleagues. Also, by reviewing and analyzing the details of their other colleagues’ experiences, they prepared to deal with such incidents and to act more intelligently in the face of similar situations.
“I asked myself where the mistake had been. Had I made a mistake? Did the mother have a problem? Was the fetus large, leading to a fourth-degree tear?” (P9).
“Cases examined in the committee on the mortality and morbidity of mothers are available in the system, and I read all of them, but some colleagues do not have much patience and time to study these cases” (P7).
3.1.3 Secondary Traumatic Growth
An important aspect after the incidence of an adverse event was the pleasant feeling the participants experienced in situations where the patient had been rescued, and they felt gratitude and appreciation for these alarming situations, especially in near-miss events. Several participants stated:
“I try not to remind myself much of these problems at the patient’s bed. I try to tell the patient to think of good things as well, since this reduces my stress and increases my self-confidence” (P8).
“It was a pleasant experience in that I was very happy we had been able to save the patient. Maybe this incident helped prevent larger events, because I usually was so reckless” (P6).
“Thank God I did and wrote [the incident and measures report] correctly. Everything was right and then I was rewarded” (P7).
3.2 Proactive Approach
This approach is an active preventive approach that includes planning for the future so that problems do not arise. After the experience of these incidents, the midwives tried to identify future threats and prevent them by taking the necessary measures and planning, so that they would not face bigger problems in the future, which, from their point of view, can be achieved by upgrading their scientific and professional abilities. This approach consists of the two subcategories of upgrading scientific abilities and upgrading professional abilities.
3.2.1 Upgrading Scientific Abilities
To prevent adverse events and the traumas caused by them, most midwives believed they should update their midwifery knowledge and commit themselves to follow evidence-based policies and protocols. They also believed that sharing the successful experiences of their peers helped other colleagues benefit from their experiences, which would then be effective in preventing future accidents.
“I always emphasize that if our scientific base is good, our performance is up to date and we do our job properly, then no one can blame us” (P9).
“These [events] made me study my lessons harder. And also read more about my rights and entitlements” (P1).
3.2.2 Upgrading Professional Abilities
Another preventative measure according to the midwives was to try to increase their professional abilities. Most midwives said that caution and continuous care played an important role in the prevention of adverse events. Some of them said that it is best to hold regular meetings within the department and discuss the incidents. Midwives should also try to record and document all their activities and actions toward the mother. Following the experience of incidents, midwives tried to increase their communication with the patients and express sympathy toward them. They believed that this would reduce their stress.
“We have an intra-departmental meeting each month, where we review issues and errors or danger signs without addressing anyone in particular, so that no errors occur again later. Also, in these meetings, they acknowledge any peers who have prevented adverse events by timely diagnoses and actions” (P10).
“I think the most important thing we learned was to keep a well-maintained record of everything that we do” (P11).