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

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1 Midwifery (2010) 26, 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 Women s Health in Society, School of Population Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Vic. 3010, Australia Corresponding author. 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 midwife woman 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 identification which characterises the midwife woman 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 identified. & 2008 Elsevier Ltd. All rights reserved. Keywords Secondary trauma; Midwife woman 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 /$ - see front matter & 2008 Elsevier Ltd. All rights reserved. doi: /j.midw

2 The costs of being with the woman : secondary traumatic stress in midwifery 77 satisfaction (Kirkham et al., 2006), and argue that this relationship is the very essence of midwifery care and defines 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-professional s own emotional involvement, which has the potential to cause emotional stress in health-care professionals (Thomas and Wilson, 2004; Sabo, 2006). In the fields 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 defined 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) defines the necessary characteristics of an event in order that it be classified 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 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 significant life impairment and occupational dysfunction by reducing an individual s capacity to interact with others, decreasing self-esteem and self-efficacy, 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 classified 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 definitions emphasise the distinct features of each concept; however, there is controversy in the literature about the definitions 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

3 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 midwife woman relationship, care and birth trauma and PTSD and birth were used. The literature search identified articles reporting empirical research, opinion and case studies. Reference lists of articles were searched and relevant sources were identified, 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

4 Table 1 Traumatic stress in health professionals and carers. Author/date Country Health profession Abendroth and Flannery (2006) Maytum et al. (2004) Laposa et al. (2003) Raingruber and Kent (2003) Jonsson and Segesten (2004) Conceptualisation Study design n Methods Measures Findings USA Nurses, hospice Compassion fatigue Cross-sectional 216 Survey Professional Quality of Life Compassion Satisfaction and Fatigue Subscales: Revision-III (Stamm, 2002) USA Canada USA Sweden Nurses, paediatrics Nurses, emergency Social work and nursing students, psychiatrists, and social work and nursing faculty members Ambulance personnel White (2007) NS Fathers witnessing birth Compassion fatigue Post-traumatic stress disorder Secondary traumatic stress Post-traumatic stress disorder Post-traumatic stress disorder Descriptive qualitative 20 Interview Probe questions about compassion fatigue Observational 51 Questionaire Post-traumatic Stress Diagnostic Scale (PDS) (Foa et al., 1993) Phenomenological 47 Interview Open-ended questions Phenomenological 10 Interview Impact of Event Scale (IES-15) (Horowitz et al., 1979) 26% scored in high-risk category for compassion fatigue; 78% moderate to high risk 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 Phenomenological 21 Narrative Fathers describe PTSD symptoms The costs of being with the woman : secondary traumatic stress in midwifery 79 ARTICLE IN PRESS

5 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 findings 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 first 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 significant difference in PTSD severity between the two groups of nurses was identified 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 professional client 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 identification, or emotional resonance and synchrony with another person, manifests in different levels of intensity. They suggest that the greater a professional s empathic identification with a client, the higher is his or her risk of experiencing compassion fatigue or secondary traumatic stress. This hypothesis is supported by findings from nursing and midwifery research. Abendroth and Flannery (2006) interpreted nurses endorsement of an item about self-sacrifice 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) identified 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 define 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

6 The costs of being with the woman : secondary traumatic stress in midwifery 81 strategies they used. Opportunities to reflect 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) identified 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 reflect 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 individual s 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 individual s 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 defined 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 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 identification 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 financial 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 fluids, the horror of cut or torn flesh, and the fear of her own or her baby s 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 individual s perception of threat is crucial for the subsequent development of PTSD. There is no dose response 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

7 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 2 6 per cent of these women, the symptoms are severe enough to meet the full diagnostic criteria for PTSD, as defined 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 women s 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 woman s 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 Menage s (1993) study reflecting 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 identified 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 justifies the means: at whose expense? at what price?. In a subsequent study, Beck (2006) analysed narratives of 11 women and her findings reaffirmed the crucial role of the way in which clinicians provide care for the woman s 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 women s perceptions of their childbirth experiences changed over time. Her findings show the positive long-term effects on the memory of the childbirth experience of women s 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 findings indicate that supportive care can prevent or ameliorate traumatic effects of an intrusive obstetric intervention. The midwife woman relationship and empathic identification The midwifery profession describes the midwife s 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 identification, as described by Thomas and Wilson (2004). High levels of empathic identification 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 you ve been so involved with somebody it s 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 woman s 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 you re 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 Pembroke s (2007) reflections on spirituality in midwifery care discuss how reciprocity in the midwife woman relationship

8 The costs of being with the woman : secondary traumatic stress in midwifery 83 impacts on the midwife s 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 filled by the woman s 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 fulfill 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 midwife mother relationship, Lundgren and Berg (2007) elucidated pairs of concepts, describing each aspect from both the woman s perspective and from the midwife s perspective. Availability in the midwife emerged as the counterpart of women s ability to surrender during birth. This illustrates that it is difficult for the midwife to fulfill 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 identification 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 identification 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 specific dress 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 profession s) and subjective (the woman s) 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 officers 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) defines 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 conflict between with women and with institution

9 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 identified the importance of a balanced exchange between them and the woman in their care, with give and take on both sides. Midwife woman 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 partner s 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 identified 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 five per month. Implications J. Leinweber, H.J. Rowe The features of care which distinguish midwifery from other health-care professions, particularly heightened empathic identification 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 identification. However, empathic identification 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 conflict between the need of a childbearing woman for a midwife s empathic identification and, at the same time, a midwife s 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 women s 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

10 The costs of being with the woman : secondary traumatic stress in midwifery 85 provide empathic care during birth may be in danger. Both the working environment of the midwife and the need for empathic identification with the childbearing woman have potential emotional consequences for the midwife. Distinguishing the importance of each role is a key task of midwifery research. 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 women s 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 identification 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 defines the relationship with the woman as its core. If midwives capacity to engage with childbearing woman is compromised because of unacknowledged secondary traumatic stress, midwifery s 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 finding new means to manage the costs of being with the woman. 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. References Abendroth, M., Flannery, J., Predicting the risk of compassion fatigue. A study of hospice nurses. Journal of Hospice and Palliative Nursing 8, American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, revised 4th ed., Washington, DC. Australian Health Workforce Advisory Committee, The Midwifery Workforce in Australia New South Wales Health Department, Sydney. Baird, K., Kracen, A., Vicarious traumatization and secondary traumatic stress: a research synthesis. Counselling Psychology Quarterly 19, Baranowsky, A., The silencing response in clinical practice: on the road to dialogue. In: Figley, C.R. (Ed.), Treating Compassion Fatigue. Brunner-Routledge, New York. Beck, C., Birth trauma in the eye of the beholder. Nursing Research 53, Beck, C., Pentadic cartography: mapping birth trauma narratives. Qualitative Health Resarch 16, Bober, T., Regehr, C., Strategies for reducing secondary or vicarious trauma: do they work? Brief Treatment and Crisis Intervention 6, 1 9. Borritz, M., Rugulies, R., Bjorner, J., et al., Burnout among employees in human service work: design and baseline findings of the PUMA study. Scandinavian Journal of Public Health 34, Brewin, R., Andrews, B., Valentine, J., Meta-analysis of risk factors for posttraumatic stress disorder in traumaexposed adults. Journal of Consulting and Clinical Psychology 68, Briant, S., Freshwater, D., Exploring mutuality within the nurse patient relationship. British Journal of Nursing 7, 209. Corolan, M., Hodnett, E., With woman philosophy: examining the evidence, answering the questions. Nursing Inquiry 14, Creedy, D., Horshfall, I., Shochet, I., Childbirth and the development of acute trauma symptoms: incidence and contributing factors. Birth 27, 104.

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