Women and Birth
Volume 22, Issue 3 , Pages 82-88, September 2009

Midwives’ emotional wellbeing: Impact of conducting a Structured Antenatal Psychosocial Assessment (SAPSA)

  • Lyndall Mollart

      Affiliations

    • Antenatal Services, Gosford Maternity Services, Central Coast Health, Northern Sydney Central Coast Area Health Service, PO Box 361, Gosford NSW 2250, Australia
    • Corresponding Author InformationCorresponding author. Tel.: +61 2 43202461; fax: +61 2 43202220.
    • ,
  • Carol Newing

      Affiliations

    • Northern Sydney Central Coast Area Health Service, Australia
    • ,
  • Maralyn Foureur

      Affiliations

    • Northern Sydney Central Coast Area Health Service and University of Technology, Sydney, Australia

Received 6 January 2009; received in revised form 2 February 2009; accepted 2 February 2009.

Article Outline

Summary 

Research problem

To investigate the impact of conducting structured antenatal psychosocial assessments (SAPSA) on midwives’ emotional wellbeing. The SAPSA includes screening and assessment tools for domestic violence, childhood trauma, drug and alcohol use, depression, and vulnerability factors.

Participants and methods

Registered midwives who had conducted the SAPSA with women during the first hospital booking visit at two hospitals in NSW. Data was collected by means of focus group interviews.

Results

Four sub-themes were identified that directly impacted upon the midwives’ emotional wellbeing: cumulative complex disclosures, frustration and stress, lack of support for midwives and unhealthy coping strategies.

Discussion and conclusions

There was a cumulative emotional effect with some midwives utilising unhealthy strategies to cope with feelings of frustration, inadequacy and vicarious trauma. Establishment of structured referral pathways for women and supportive systems for midwives is essential prior to implementing the SAPSA.

Keywords: Antenatal, Antenatal psychosocial assessment, Midwives, Emotional wellbeing, Focus groups

 

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Introduction 

Awareness and identification of psychosocial issues such as domestic violence, childhood sexual abuse/assault and mental illness appear to be increasing in Australian society.1, 2, 3 Midwives and other health professionals are recognising the impact of these psychosocial issues on pregnancy, parenting, and physical and mental wellbeing of the woman, her partner, her infant and children.4, 5, 6 Reports such as the NSW Health Supporting Families Early,7 Woman's Mental Health Consortium8 and several research studies9, 10, 11, 12, 13 recognise a range of bio-psychosocial factors that can contribute to health problems and disorders for mothers and infants. Evidence highlights the importance of the child's early years of life for the development of vital physical, cognitive and emotional competencies, including emotional self-regulation, habitual patterns of responding, binocular vision, language and literacy.7 Prevention and early intervention initiatives, targeting early identification of families at risk of experiencing problems during the perinatal period are now being implemented through the NSW Health ‘SAFE START’ strategy, previously known as ‘Integrated Perinatal Care’.7 The initiatives focus on identifying women at risk of mental health and psychological problems during the perinatal period which has now become an integral part of quality antenatal care. Studies have recognised that the midwife is well positioned to raise awareness about the prevalent nature of these issues and their harmful effects, and provide opportunities for emotional support to women during pregnancy.14, 15, 16, 17

However, the experience of one NSW Area Health Service with a pilot project of midwives implementing formal psychosocial assessments of pregnant women, raised some concerns. As detailed below in the background to this study, midwives’ emotional wellbeing appeared to suffer as a result of their experience in undertaking the assessments. Therefore a study was designed to examine this issue formally. In the following paper we describe the qualitative study which aimed to examine the impact on midwives of conducting the SAPSA screening and resultant disclosure from pregnant women. As the literature review reveals, the few studies undertaken in this area also raise concerns about the impact on midwives emotional wellbeing. The findings from this study concur with other research, that midwives may suffer unless support is provided in the form of effective preparation and ongoing clinical supervision.

Background to the study 

In May 2002 a NSW maternity service was selected to implement the Integrated Perinatal Care (IPC) Pilot Project. This maternity service provides care for families in an area of NSW identified with high social disadvantage; high numbers of reports for domestic violence, child abuse and neglect; high unemployment, housing problems and sole parents.18 The project objectives required a structured antenatal psychosocial assessment (SAPSA) to be incorporated into the standard first antenatal visit (known as the booking-in visit). In addition to the ‘traditional’ information gathered during an antenatal assessment such as medical, surgical, and obstetric history, the SAPSA included the woman's social history, and the completion of the Edinburgh Depression Scale,19 Domestic Violence anda Childhood Trauma Tool,20 Substance Use Assessment Form,21 and questions relating to stressors or stressful life events.4 Eighteen months after the introduction of the SAPSA, focus groups conducted with the midwives of the maternity service revealed some worrying trends. Some of the midwives reported experiencing possible symptoms of stress, burnout and vicarious trauma.22 The midwives felt they had received insufficient education about the SAPSA and identified that ongoing support was required to continue implementing the tool. Following the implementation of the SAPSA, midwifery managers anecdotally reported an increase in staff on sick leave though it was unclear whether these two issues were related. Further study into the impact of conducting the SAPSA was warranted.22

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Literature review 

An initial search of the literature identified several studies on the reactions of midwives when screening for domestic violence or depression.23, 24, 25, 26 However, we could locate no studies that investigated the impact of conducting comprehensive antenatal psychosocial assessments.

A further search for relevant literature was undertaken using CINHAL, Medline, and Pubmed databases to locate any published research relating to the midwife's role and/or impact on midwives conducting the antenatal psychosocial screening for domestic violence, childhood trauma, mental health (depression) and child protection issues, either as single issues or as combined screening components. Only six studies were found which met the search criteria. The studies focussed on the midwives’ perceptions of the barriers or factors preventing them from identifying psychosocial risk factors when screening for domestic violence,17, 27, 28 depression15 or child protection issues.16 The studies identified issues such as workplace safety, lack of time, lack of appropriate skills or training, and a referral system that did not work for either the women or the midwives.11, 17, 27

Two studies17, 27 discussed the midwives’ personal response to the screening and these two studies will be reviewed below. Using focus groups and semi-structured interviews, Mezey et al.27 investigated UK midwives’ perceptions and experiences of screening for domestic violence (DV). This study concentrated on the barriers to screening in relation to midwives feelings. Midwives “…described feelings of helplessness, about their apparent inability to offer an effective solution which, as midwives, they felt they were expected to provide, or if, having given advice, this advice was disregarded” (p. 748).27 The article acknowledged that the emotional impact on the midwives was ‘considerable’ and reported that the midwives involved accessed the researchers for support in an attempt to cope with issues that arose during the DV screening.27 The authors highlighted the need for organisational structures and support systems to be set up before implementing DV screening.27

McCosker-Howard et al.17, 29 explored the impact on midwives undertaking mandatory antenatal screening for DV in an Australian setting. As with the UK study27 focus groups provided midwives with the opportunity to talk about the DV screening process. They identified it as a “…disconcerting experience, arousing feelings of discomfort and embarrassment” (p. 52).17 Midwives disclosed feelings of hopelessness and helplessness and “need for supportive systems and organisational structures in order to enable them (midwives) to deal with the impact of screening” (p. 53). These studies identified the emotional impact on midwives of conducting a single screening component, such as domestic violence, of an antenatal psychosocial assessment. However we were unable to find any published studies concerning the impact of a more comprehensive assessment such as the SAPSA. It is obvious from the available literature that the impact on midwives encompasses a complex range of issues and is in need of further exploration.

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Research design 

This study aimed to examine the impact on midwives of conducting the SAPSA screening and resultant disclosure from pregnant women. A qualitative descriptive design was used, in order to explore midwives’ thoughts and feelings. Three focus group interviews were conducted with small groups of registered midwives who had experience of using the SAPSA at two hospitals. This approach was considered most suitable as it enables the collection of in-depth information. According to Deery30, this allows participants to “consider their own views in relation to others, and group interaction can give rise to new insights and solutions” (p. 314).30

The focus groups were limited to between five and eight participants, as it was considered small groups would encourage discussion in an area which might be recognised as sensitive or which might evoke strong emotional reactions from the participants.17 Purposive sampling was used to recruit midwives who had first-hand experience in conducting the SAPSA.31 Approval was obtained from the area health service Ethics and Research Committee. All midwives (n=50) working in the antenatal clinics and the team midwifery programs (who also provide antenatal care) were sent information about the study and invited to participate. Written consent was obtained prior to participation. While most of the midwives were interested, 18 midwives from the two sites were able to attend the focus group meetings.

Method 

Three focus groups took place from early December 2005 to mid January 2006 and were led by an independent facilitator who was a midwife with knowledge of the subject, but was not generally known to the midwives and was not involved as a researcher. Questions were asked by the facilitator and the issues explored centred on: how the midwives’ felt during the screening; what emotions did they experience; how did they cope with the emotions they experienced; what strategies did they use to cope with the emotions; whether the screening had any impact on the midwife's relationship with the women and their families, and any difficulties that may have arisen as a result of conducting the assessment. Participants were able to talk about their own experience and identified issues that they felt were important. The focus groups were recorded on audiotape and transcribed verbatim.

Data analysis 

Transcripts of the focus groups were analysed using thematic analysis. This is a “method for the objective, systematic, and qualitative description of documentary evidence” (p. 354).32 The transcripts were read by two authors (LM and CN) who separately coded the participants’ comments in relation to the aims of the study into sub-themes. In the coding process, both authors compared the content of each statement in the sub-themes for verification, cross-referenced and revisited the written transcripts and then developed major themes.

The trustworthiness of the study was addressed through attention paid to the credibility and dependability of data collection and to the transferability of the study findings. While the midwife participants in the three focus groups were all female, they were from a range of ages and varying levels of experience. The age range of the participants enabled a variety of perspectives on the issue of using the SAPSA to be gathered. Credibility of the study findings is further enhanced through the provision of a range of quotes from the participants in the next section.33 The three focus groups were all held within a two week time frame which limited the possibility that changes in the study context could have affected the dependability of the data.33 Finally transferability of the study findings is apparent given that similar manifest and latent themes were identified in the transcripts from all three focus groups and have also been identified by other researchers in this area.33 The final test of transferability will occur when the reader who has experience of using the SAPSA reflects on whether similar themes are apparent in his/her own setting.

There are study limitations arising from the qualitative method of data collection and the small number of participants involved. Unless focus groups are skilfully facilitated it may be possible for particular voices to dominate and influence what others in the group are prepared to reveal. We endeavoured to address this by having a skilled midwife facilitator to run the group. Illustrative quotes provided in the next section come from all three focus groups and from different participants so we consider the findings to be representative. In addition, while all midwives involved in implementing the SAPSA were interested in participating in the focus groups, only 18 were able to attend. Those who were unable to attend may have experienced the SAPSA differently to their colleagues.

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Results 

The data from each focus group was treated as a whole for the purposes of analysis. The analysis revealed four sub-themes with the major theme of emotional impact (Table 1). The sub-themes were: cumulative complex disclosure, frustration and stress, lack of support, and unhealthy coping strategies. In the following section, the four sub-themes will be presented together with illustrating comments from the midwives.

Table 1. Thematic categories derived from focus groups.
Major themeSub-themes
Emotional impactEffect of complex disclosure
Frustrated and stressed
Lack of support
Unhealthy coping strategies

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Cumulative complex disclosure 

The participants talked about feeling overwhelmed with the level and incidence of trauma being disclosed by women.

It distresses me finding out the amount of sexual abuse that women experience (group participants agree). I was just amazed, every second person is disclosing that they’ve been sexually abused. And that was hard to take on board. Focus group 2 participant.

Repeated exposure to sensitive issues can have a direct effect on the psychological wellbeing of nurses and midwives.22, 34, 35 Participants in this study described the emotional impact that being exposed to repeated disclosures and stories of trauma had on their ability to manage their own emotions within the work environment.

Sometimes some family situations are just distressing! You go away and you just think about these people and you just can’t believe the difficulties that they’re living in, and the families… I’m just mind boggled as to how people live. It just distresses me to think that there are people out there. I think every person is so precious and yet they’re in such terrible situations. And it can be really distressing especially if you’ve had a real doozey. Focus group 2 participant.

It's accumulative. It's not just like one big incident that happens, that you can go and talk through. It's like six booking-ins over, Focus group 3 participant.

Participants also talked about the physical demands placed on them by the cumulative disclosures experienced using the SAPSA.

If you do more than two booking-ins [SAPSA] in one day- you’re absolutely shattered! Focus group 1 participant.

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Frustrated and stressed 

When asked to describe the impact that conducting the SAPSA has had on them personally, the participants overwhelmingly responded that the SAPSA had increased their level of stress and frustration and acknowledged the difficulty in managing the level of stress experienced. Deery30 found the pressure to meet organisational demands within models of maternity care with no acknowledged clinic ‘downtime’ meant midwives felt frustrated and unable to cope with their work.

I don’t think people realise the amount of work and time, and stuff that happens for the midwife as well. We all know what happens to the woman but I don’t think people really recognise what happens to the midwife. I don’t believe … management recognises that. Focus group 1 participant.

… I can debrief 10, 20, 30 times and the information is still with me, and I don’t know where to channel that sometimes. Sometimes you channel that into other things that are probably not appropriate. Focus group 2 participant.

I come to work the next day thinking, I can finish what I started and then you don’t get to it, and that impacts on how you feel about your standard of care, impacts on how you feel as a midwife, impacts on how you’re feeling emotionally, impacts on how you’re feeling… And you think you might be doing a really good job and that's your standard, you want to do a very good job. Sometimes that standard is decreased, and I struggle with that because I know I always want to do a good job. Focus group 2 participant.

Lack of support 

The participants commented on the importance of support from colleagues in managing the impact of disclosures and the complex vulnerabilities identified during the SAPSA. Talking with colleagues was seen as a way of coping with the distress the midwife experienced but they recognised the limitations of discussing their concerns and feelings with colleagues.

The only way I know how to deal with it is I talk to colleagues… Even sometimes when you talk to colleagues, you know they’re thinking about the booking-in they had, they’re only half listening and you actually haven’t been heard. Focus group 2 participant.

While clinical supervision is not a standard practice within the disciplines of Australian nursing and midwifery, limited opportunities for the midwives conducting SAPSA to access clinical supervision in a group format have been offered locally in the past. However, not all midwives accessed this opportunity. Participants in this study who accessed clinical supervision reported its benefits in providing a space for sharing concerns with an independent professional and a way to debrief about issues disclosed by women during the SAPSA and its consequences.

We kind of talk about particular cases that we have really stressed about or not happy about or felt that are just too much… I find is quite good actually. She [facilitator] is good. Cause she is kind of independent and … she listens and whether she is interested and everything, but she kind of helps us work a way through it. Its quite good. Focus group1 participant.

Other participants, who perceived they had no opportunity to access clinical supervision, expressed annoyance. Most participants believed clinical supervision is a vital support service for midwives conducting the SAPSA.22, 36

Our staff counsellor has clinical supervision for the sole purpose of supporting her in the role that she does, and then we ask about this stuff [clinical supervision] we don’t have that. Focus group 2 participant.

Like the focus group participants, midwives in other studies17, 27 have clearly identified the need for support systems and organisational structures in order to enable them to deal with the impact of screening and assessing psychosocial components. This support “is in addition to specific education and training” (p. 53).17

A few participants identified healthy strategies they found useful to reduce the potential for them to take home their concerns.

I think to the fact that you do the booking-ins [SAPSA] before you go home, and you don’t really get the chance to talk after that … Because if you could just talk about it a bit before you went home, I think it would make a big difference … writing that off, marking that work off and making it separate from the rest of your life. Focus group 1 participant.

While specific studies relating to midwives are limited, general and psychiatric nursing studies have found increased levels of anxiety in nurses who deal with complex psychosocial situations and dynamics of patient care.35, 37

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Unhealthy coping strategies 

Each workplace develops its own culture and ways of coping with the identification of sensitive issues and trauma and some of these are far from healthy.38, 39 Participants spoke about how they continued to think about the disclosures made by the women during the SAPSA after they had ended their day of work. The participants included concerns about the wellbeing of the woman; however they also acknowledged the emotional impact to themselves and those around them at home.

You go home and it's playing on your mind as you’re cooking. I don’t know how long it usually goes on for, probably till you get that next bad case. Focus group 1 participant.

If you have a day where there are three full-on ones [SAPSA] with lots of information, you go home and your head's spinning. You just feel like you need to tell someone. Sometimes I’ve gone home and actually worried about people, then you’ve got to remember that they told me this today and they’ve been living with this for how long? Just keep telling yourself that. Focus group 3 participant.

Participants talked about unhealthy strategies they used to deal with the information being disclosed by women. The participants also reported the impact that ‘taking it home’ has had on other members of their family.

For me, I explode at home, I don’t explode here [at work] because I know that no one would put up with that kind of behaviour. But I do it to my kids, and that's not very good. Focus group 2 participant.

That's an issue with the psychosocial [SAPSA], we drink too much wine. Focus group 3 participant.

I think sometimes that I take it home. I find that if I’ve had a really hard day, … I take it out on the kids or take it out on my partner or I take it out on myself. Focus group 1 participant.

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Discussion 

The structured antenatal psychosocial antenatal assessment is a valuable tool to identify women who have psychosocial issues that place them at risk of antenatal and postnatal depression, mental health issues, and maternal–infant attachment relationship issues.7 During the IPC Pilot Project conducted in a regional level two maternity unit between 2002 and 2004, women who completed a SAPSA during their first antenatal appointment reported they were comfortable with the questions.40 The SAPSA also provided them an opportunity to discuss their issues, sometimes for the first time, and to seek support for issues of concern or to access early intervention for depression and anxiety before it became serious.40 This supports the findings by Webster et al.23 who also reported women accept the psychosocial assessment and the majority have a willingness to share information.

While women are supportive of being asked about their experience of domestic violence, childhood trauma, drug and alcohol use, depression, and other vulnerability factors, this study has identified the potential personal cost to midwives of identifying and repeatedly being exposed to these psychosocial issues. This is similar to the findings of McCosker-Howard et al.17 who also revealed the personal cost to midwives of identifying and responding to these issues. This study has identified four sub-themes that directly impacted upon the emotional wellbeing of the midwife participants: cumulative complex disclosures, frustration and stress, lack of support and unhealthy coping strategies. The midwives described the impact of repeated exposure to women's disclosure of trauma and the emotional impact of this repeated exposure on their ability to manage their own emotions.

As a result of the SAPSA midwives have become secondary witnesses to trauma while listening to women tell their history of sexual assault, domestic violence, alcoholic families, drug use and memories of childhood abuse.41 The midwife listens, supports and validates the woman who is expressing her feelings and experiences. In this study the midwives reported being profoundly affected by hearing women talk about their trauma experiences; by supporting the women who have been victimized and by witnessing women's inability to improve their very difficult life circumstances.

The midwives reported feeling helpless and overwhelmed in the face of the women's complex family situations. These feelings led to some midwives experiencing disruption in their interpersonal relationships and sleeping problems that may indicate a level of compassion fatigue, vicarious trauma, or burnout.39 Mathieu42 suggests while the three terms are complementary they are different from one another. Compassion Fatigue refers to the “profound emotional and physical erosion that takes place when clinicians are unable to refuel and regenerate” (p. 1)42 while ‘vicarious trauma’ is used to describe the profound shift that workers experience in their world view as a result of working with client's traumatic experiences.42 The clinician's fundamental beliefs about the world are altered and possibly damaged by being repeatedly exposed to traumatic material. This differs from ‘burnout’ which describes the physical and emotional exhaustion that clinicians can experience when they have low job satisfaction, feel powerless and overwhelmed at work.42 Burnout does not necessarily mean that the clinician's view of the world has been damaged, or that there is a loss of the ability to feel compassion. Burnout can be resolved by using strategies such as changing jobs which is not the case for compassion fatigue and vicarious trauma.42, 43

The midwives in this study identified a feeling of frustration and stress as a result of repeated disclosures and reported intrusive thoughts that impacted into their private and family life. Some midwives also disclosed using unhealthy coping strategies. Figley, a specialist in traumatology, has labelled the cumulative effect of trauma disclosure as ‘toxic emotional material”.39 The unintended consequences of exposure to such toxic emotional material (TEM) can include poor self-care, increased consumption of alcohol and other unhealthy coping strategies.39 High worker turnover, poor productivity and/ or by contrast over conscientiousness, may result.39, 43

When organisations are considering the implementation of a structured antenatal psychosocial assessment, management needs to acknowledge that midwives will be exposed to trauma disclosures and may experience compassion fatigue as revealed in this study. It is essential that organisations put in place structures and supports to minimise this risk. Studies report that clinicians exposed to trauma stories can require higher levels of organisational support to reduce the negative impact of working with trauma.17, 34, 43 Support can include opportunities to self-manage caseload with a diversity of clients as well as providing opportunities for debriefing, peer support and clinical supervision.39, 42, 43 Clinical supervision provides the opportunity for midwives to step back and become more self-aware in their interactions with clients and other colleagues. Clinical supervision has been accepted as a standard practice in the disciplines of social work and psychotherapy and more recently by the United Kingdom Department of Health for use in nursing and midwifery.44

Organisations require a thoughtful implementation plan and active monitoring, underpinned by a comprehensive ongoing education, training and a structured support program for midwives conducting the SAPSA. Strategies to assist midwives include widespread and accessible training that addresses the issues of boundary setting and awareness of the risk of over identification with the women's distress and hopelessness, counselling skills, stress management and education in referral services and pathways.13, 17, 27 Education needs to be embedded into tertiary learning and in practice as well as ongoing post-graduate workshops. Mezey et al.27 recommend that ongoing education addresses the issue that midwives may have unrealistic goals in what the health service can offer women and have “too high expectations of what advice and information is likely to achieve” (p. 751).27

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Conclusion 

The study findings have the potential to inform the educational preparation of midwives, the professional standards for midwifery practice and the institutional support required for clinical practice. Midwives are now expected to incorporate psychosocial assessment and care within their holistic scope of practice. This study has revealed the negative impact this may have on ill prepared and unsupported midwives with resultant personal costs to their emotional wellbeing. Further study is required into midwives’ levels of occupational stress and burnout relating to work load and ‘toxic emotional material’ and the effectiveness of clinical supervision for midwives working with families with complex issues.

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Competing interests 

None declared.

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Acknowledgements 

We wish to acknowledge Area Health Service for providing support for this study. We wish to thank the midwives who participated in the study.

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  • a Childhood trauma questions: Did you experience emotional abuse as a child? Did you experience sexual or physical abuse when you were growing up?

PII: S1871-5192(09)00027-4

doi:10.1016/j.wombi.2009.02.001

Women and Birth
Volume 22, Issue 3 , Pages 82-88, September 2009

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