Moral injury was initially coined as a notion relating to the military. Soldiers who were forced to witness or participate in unethical acts or atrocities in opposition to their moral compass and end up with secondary trauma from the event were considered to have experienced Moral Injury.
A definition of Moral Injury might be: “A betrayal of what’s right by someone who holds legitimate authority in a high-stakes situation” or “[Moral] Injury is brought about by witnessing immoral acts, failure to stop them or perpetuating them” Richardson et al 2020 J Trauma Stress 33 p575-586. This is closely related to Secondary Trauma whereby birth trauma that is seen, is also experienced as a trauma to the witness. However, it is differentiated from regular trauma experienced at difficult births where care was compassionate and appropriate. In contrast, moral injury trauma, might occur during any type of birth, even a straightforward one, but where the care was violent and inappropriate.
In the hierarchical hospital system, unfortunately, birthing mothers are often the lowest ranking, most powerless person there and can readily become the victim. She is emotionally vulnerable and hormonally unstable during birth and cannot easily assert herself. Physically, she is even more vulnerable. Lying on her back in a hospital bed, she may be unable to get up or move, tethered to monitors, IV lines and other paraphernalia. Doulas and birth partners are also in the low ranks with midwives’ position only slightly higher. Doctors are the highest-level decision makers in the battlefield of birth. Cruel caregivers, be they doctors, (male or female), and midwives have been known to act violently towards laboring women, usually in the mistaken guise of ‘helping’. Abuse in the maternity setting has been internationally recognized and is termed obstetrical violence. Unfortunately, it is common to one degree or another in many hospitals.
As birth workers, we are sometimes exposed to unnecessarily violent obstetric acts, or we are coerced to be an unwilling participant in them. Kind midwives who identify and empathize closely with their patients, who experience this are often left with secondary traumatic stress, like that of the soldiers described above. This article is not about obstetrical violence from the birthing mother’s perspective, as that deserves its own separate commentary. This piece is from the viewpoint of midwives (and I include doulas) as they experience abusive care from a similar vantage point.
What sort of scenarios occur in the birth world which may lead to Moral Injury? The most common abusive act I have seen in the hospital setting is the performing of an internal cervical exam without gaining consent. Worse is during the performing of a cervical exam (with initial permission), the practitioner does a cervical stretch and sweep without warning or permission for that. A cervical sweep is an extremely painful procedure for most women and requires informed verbal consent before going ahead. The practitioner may think he or she is doing a ‘favor’, helping her labor progress, and doesn’t desist, even when the woman is crying “Stop!! Stop!!”. I have seen this with my own eyes during my work in hospitals. The patient feels utterly violated and traumatized, as the exam was painful and without her consent. This is just one example of many occurrences of obstetric violence that I have sadly been a witness to.
How does the birth worker react during this kind of scenario? Doulas and midwives in the room are sometimes paralyzed by shock or indecision as to what to do whilst witnessing a violent act and don’t manage to effectively protest. This might be due to the gendered hierarchy found in the hospital settings, where midwives and doulas are women and doctors are usually men. The inbuilt submissiveness females have towards male doctors is hard to dismiss. Even more so, female doctors can sometimes be just as abusive to patients as male doctors, as they strive to prove their machoism and toughness in the male dominated medical field. Some midwives, although females, are downright bullies and intimidate other birth workers. If some protest is mounted, it might be ignored, and short of physically pushing the abusive practitioner aside, there’s little that can be done in the moment. A protester may fear for her job or her status if she makes too much of a fuss. The act is often over before the observer has a chance to gather her thoughts and make a plan of action. Therefore, it is vital to raise awareness of potential violation, so that we are ready to act appropriately in the moment when it is needed. It is incumbent on anyone present to object, even vociferously, to an inappropriate act as everyone in the room has more capacity to object than the mother lying on the bed.
After being a witness to obstetric violence the midwife/doula questions herself. Why didn’t I speak up? Did I do everything I could to protect my client? She will agonize about what she should have done differently and feel frustrated and angry towards the staff. She observed how the practitioner violated her patient and she will feel as an accomplice to the crime. This leaves her with feelings of helplessness, uselessness and powerlessness. Looking back on a violent birth event, she questions everything, she blames herself and is angry with herself that she let it happen. Rumination will keep her up at night and leave deep feelings of guilt and shame.
The behaviors witnessed can overturn deeply held assumptions about the health care system, that it exists to help patients, not to do them harm. When this belief system is turned on its head, it challenges one’s belief in the system and will lead to disillusionment. The midwife will question if this is a place she can continue practising if it keeps challenging her moral values and leads to feelings of despair. Isn’t there a better paradigm? Isn’t there a path to give birthers modern medical care, while treating them with humanistic values?
An informal survey of doulas and midwives who experienced obstetric violence revealed that it gradually led to a loss of faith in the system and burnout. Doulas stopped accompanying clients to certain celebrated hospital delivery rooms, midwives left for different settings or if that wasn’t possible, became numb. Some doulas only work with clients who are willing to do the pre-labor work of understanding their rights in childbirth and are willing to be assertive regarding them.
What can we do to help ourselves? First, we must not stand silently by when we witness an event, we must speak up in real-time to protect the birthing mother. Even if we couldn’t prevent the act in the moment, we feel less guilt knowing that we at least tried to prevent it. Secondly, we must report it to managers and increase awareness of abusive bedside manners. This will gradually trickle down and inform medical training regarding acceptable behaviors. Thirdly, we must support each other as birth workers. Co-workers are our most vital resource and can help reduce feelings of guilt and shame and prevent the otherwise inevitable burn-out. We must take time to process our moral injury, when we have experienced it, and take care of our physical, mental and spiritual health. And lastly, we must educate ourselves, our mothers and their birth partners about rights in childbirth. We must role play with them about being assertive, about demanding proper informed consent and informed refusal of care. The message IS slowly trickling through. We hear about it in social media. The more we talk about it, the closer we will get to respectful care for all birthing mothers.
Working together as a birthing community, the day will come when abusive behaviors will not be commonplace and we can carry on doing the job we love so much of serving pregnant women without fear or guilt or shame.