Exploring moral distress in Australian midwifery practice

Published:October 12, 2021DOI:



      Australian midwives are considering leaving the profession. Moral distress may be a contributing factor, yet there is limited research regarding the influence of moral distress on midwifery practice.


      Moral distress was first used to describe the psychological harm incurred following actions or inactions that oppose an individuals’ moral values. Current research concerning moral distress in midwifery is varied and often focuses only on one aspect of practice.


      To explore Australian midwives experience and consequences of moral distress.


      Semi-structured interviews were used to understand the experiences of moral distress of 14 Australian midwives. Interviews were recorded and transcribed verbatim. Data were analysed using thematic analysis and NVIVO12©.


      Three key themes were identified: experiencing moral compromise; experiencing moral constraints, dilemmas and uncertainties; and professional and personal consequences. Describing hierarchical and oppressive health services, midwives indicated they were unable to adequately advocate for themselves, their profession, and the women in their care.


      It is evident that some midwives experience significant and often ongoing moral compromise as a catalyst to moral distress. A difference in outcomes between early career midwives and those with more than five years experiences suggests the cumulative nature of moral distress is a significant concern. A possible trajectory across moral frustration, moral distress, and moral injury with repeated exposure to morally compromising situations could explain this finding.


      This study affirms the presence of moral distress in Australian midwives and identified the cumulative effect of moral compromise on the degree of moral distress experienced.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Women and Birth
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Harvie K.
        • Sidebotham M.
        • Fenwick J.
        Australian midwives’ intentions to leave the profession and the reasons why.
        Women Birth. 2019; 32: e584-e593
        • Fontein-Kuipers Y.
        • Duivis H.
        • Schamper V.
        • Schmitz V.
        • Stam A.
        • Koster D.
        Reports of Work-Related Traumatic Events: A Mixed-Methods Study.
        • Hildingsson I.
        • Westlund K.
        • Wiklund I.
        Burnout in Swedish midwives.
        Sex. Reprod. Healthc. 2013; 4: 87-91
        • Cox P.
        • Smythe L.
        Experiences of midwives’ leaving Lead Maternity Care (LMC) practice.
        N. Z. Coll. Midwives J. 2011;
        • Hunter B.
        • Fenwick J.
        • Sidebotham M.
        • Henley J.
        Midwives in the United Kingdom: levels of burnout, depression, anxiety and stress and associated predictors.
        Midwifery. 2019; 79102526
        • Jarosova D.
        • Gurkova E.
        • Palese A.
        • Godeas G.
        • Ziakova K.
        • Song M.S.
        • et al.
        Job satisfaction and leaving intentions of midwives: analysis of a multinational cross-sectional survey.
        J. Nurs. Manag. 2016; 24: 70-79
        • Pelvin B.
        ICM international code of ethics for midwives.
        J. Midwifery Womens Health. 2004; 49: 264-265
        • International Confederation of Midwives
        International Code of Ethics for Midwives.
        • Kinnane J.H.
        Everyday Encounters of Everyday Midwives: Tribulation and Triumph for Ethical Practitioners.
        Queensland University of Technology, 2008
        • Pezaro S.
        • Clyne W.
        • Turner A.
        • Fulton E.A.
        • Gerada C.
        ‘Midwives Overboard!’ Inside their hearts are breaking, their makeup may be flaking but their smile still stays on.
        Women Birth. 2016; 29: e59-e66
        • Patterson J.
        Traumatised midwives; traumatised women.
        Aims Int. J. Manag. 2019; 30
        • Leinweber J.
        • Rowe H.J.
        The costs of ‘being with the woman’: secondary traumatic stress in midwifery.
        Midwifery. 2010; 26: 76-87
        • Creedy D.
        • Sidebotham M.
        • Gamble J.
        • Pallant J.
        • Fenwick J.
        Prevalence of burnout, depression, anxiety and stress in Australian midwives: a cross-sectional survey.
        BMC Pregnancy Childbirth. 2017; 17: 1-8
        • Foster Wendy
        • McKellar Lois
        • Fleet Julie Anne
        • Sweet Linda
        Moral distress in midwifery practice: A concept analysis.
        Nursing Ethics. 2021; (In press): 1-20
        • Marsh W.
        • Robinson A.
        • Shawe J.
        • Gallagher A.
        Removal of babies at birth and the moral distress of midwives.
        Nurs. Ethics. 2019; 27: 1103-1114
        • Garel M.
        • Etienne E.
        • Blondel B.
        • Dommergues M.
        French midwives’ practice of termination of pregnancy for fetal abnormality. At what psychological and ethical cost?.
        Prenat. Diagn. 2007; 27: 622-628
        • Jameton A.
        Nursing Practice: The Ethical Issues.
        Prentice-Hall, 1984
        • Hanna D.R.
        The lived experience of moral distress: nurses who assisted with elective abortions.
        Res. Theory Nurs. Pract. 2005; 19: 95-124
        • Fourie C.
        Who is experiencing what kind of moral distress? distinctions for moving from a narrow to a broad definition of moral distress.
        AMA J. Ethics. 2017; 19: 578-584
        • Campbell S.M.
        • Ulrich C.M.
        • Grady C.
        A broader understanding of moral distress.
        Moral Distress in the Health Professions. Springer, 2018: 59-77
        • McCarthy J.
        • Monteverde S.
        The Standard Account of Moral Distress and Why We Should Keep it.
        • Wilkinson J.
        Moral distress: a labor and delivery nurse’s experience.
        J. Obstetr. Gynecol. Neonatal Nurs. 1989; 18: 513-519
        • Oelhafen S.
        • Cignacco E.
        Moral distress and moral competences in midwifery: a latent variable approach.
        J. Health Psychol. 2018; 25: 2340-2351
        • Oelhafen S.
        • Monteverde S.
        • Cignacco E.
        Exploring moral problems and moral competences in midwifery: a qualitative study.
        Nurs. Ethics. 2019; 26: 1373-1386
        • Mizuno M.
        Confusion and ethical issues surrounding the role of Japanese midwives in childbirth and abortion: a qualitative study.
        Nurs. Health Sci. 2011; 13: 502-506
        • Lamiani G.
        • Borghi L.
        • Argentero P.
        When healthcare professionals cannot do the right thing: a systematic review of moral distress and its correlates.
        J. Health Psychol. 2017; 22: 51-67
        • Henrich N.J.
        • Dodek P.M.
        • Gladstone E.
        • Alden L.
        • Keenan S.P.
        • Reynolds S.
        • et al.
        Consequences of moral distress in the intensive care unit: a qualitative study.
        Am. J. Crit. Care. 2017; 26: e48-e57
        • Zolala S.
        • Almasi-Hashiani A.
        • Akrami F.
        Severity and frequency of moral distress among midwives working in birth centers.
        Nurs. Ethics. 2019; 26: 2364-2372
        • Reiger K.
        • Lane K.
        ‘How can we go on caring when nobody here cares about us?’ Australian public maternity units as contested care sites.
        Women Birth. 2013; 26: 133-137
        • Colorafi K.J.
        • Evans B.
        Qualitative descriptive methods in health science research.
        HERD: Health Environ. Res. Des. J. 2016; 9: 16-25
      1. SAGE research methods.
        The SAGE Encyclopedia of Qualitative Research Methods. 2008
        • Bradshaw C.
        • Atkinson S.
        • Doody O.
        Employing a qualitative description approach in health care research.
        Glob. Qual. Nurs. Res. 2017; 42333393617742282
        • Gourlay A.
        • Mshana G.
        • Birdthistle I.
        • Bulugu G.
        • Zaba B.
        • Urassa M.
        Using vignettes in qualitative research to explore barriers and facilitating factors to the uptake of prevention of mother-to-child transmission services in rural Tanzania: a critical analysis.
        BMC Med. Res. Methodol. 2014; 14: 21
        • Jenkins N.
        • Bloor M.
        • Fischer J.
        • Berney L.
        • Neale J.
        Putting it in context: the use of vignettes in qualitative interviewing.
        Qual. Res. 2010; 10: 175-198
        • Törrönen J.
        Using vignettes in qualitative interviews as clues, microcosms or provokers.
        Qual. Res. J. 2018; 18: 276-286
        • Barter C.
        • Renold E.
        The use of vignettes in qualitative research.
        Soc. Res. Update. 1999; 25: 1-6
        • Terry G.
        • Hayfield N.
        • Clarke V.
        • Braun V.
        Thematic analysis.
        The Sage Handbook of Qualitative Research in Psychology. 2017: 17-37
        • NVIVO
        NVIVO 12 Windows Coding Comparison Query.
        ([cited 2020]. Available from:)2020
        • Goodstein J.D.
        Moral compromise and personal integrity: exploring the ethical issues of deciding together in organizations.
        Bus. Ethics Q. 2000; : 805-819
        • Asgari S.
        • Shafipour V.
        • Taraghi Z.
        • Yazdani-Charati J.
        Relationship between moral distress and ethical climate with job satisfaction in nurses.
        Nurs. Ethics. 2019; 26: 346-356
        • Pauly B.
        • Varcoe C.
        • Storch J.
        • Newton L.
        Registered nurses’ perceptions of moral distress and ethical climate.
        Nurs. Ethics. 2009; 16: 561-573
        • Simha A.
        • Pandey J.
        Trust, ethical climate and nurses’ turnover intention.
        Nurs. Ethics. 2020; 00969733020964855
        • Teresi M.
        • Pietroni D.D.
        • Barattucci M.
        • Giannella V.A.
        • Pagliaro S.
        Ethical climate(s), organizational identification, and employees’ behavior.
        Front. Psychol. 2019; 10: 1356
        • Corley M.C.
        • Minick P.
        • Elswick R.K.
        • Jacobs M.
        Nurse moral distress and ethical work environment.
        Nurs. Ethics. 2005; 12: 381-390
        • Morrow K.J.
        • Gustavson A.M.
        • Jones J.
        Speaking up behaviours (safety voices) of healthcare workers: a metasynthesis of qualitative research studies.
        In. J. Nurs. Stud. 2016; 64: 42-51
        • Deady R.
        • McCarthy J.
        A study of the situations, features, and coping mechanisms experienced by Irish psychiatric nurses experiencing moral distress.
        Perspect. Psychiatr. Care. 2010; 46: 209-220
        • Sundin-Huard D.
        • Fahy K.
        Moral distress, advocacy and burnout: theorizing the relationships.
        Int. J. Nurs. Pract. 1999; 5: 8-13
        • Perni S.
        • Pollack L.R.
        • Gonzalez W.C.
        • Dzeng E.
        • Baldwin M.R.
        Moral distress and burnout in caring for older adults during medical school training.
        BMC Med. Educ. 2020; 20: 84
        • Mobley M.J.
        • Rady M.Y.
        • Verheijde J.L.
        • Patel B.
        • Larson J.S.
        The relationship between moral distress and perception of futile care in the critical care unit.
        Intens. Crit. Care Nurs. 2007; 23: 256-263
        • Hamric A.B.
        • Borchers C.T.
        • Epstein E.G.
        Development and testing of an instrument to measure moral distress in healthcare professionals.
        AJOB Prim. Res. 2012; 3: 1-9
        • Epstein E.G.
        • Hamric A.B.
        Moral distress, moral residue, and the crescendo effect.
        J. Clin. Ethics. 2009; 20: 330-342
        • Litz B.T.
        • Kerig P.K.
        Introduction to the special issue on moral injury: conceptual challenges, methodological issues, and clinical applications.
        J. Trauma. Stress. 2019; 32: 341-349
      2. Pauly B.M. Varcoe C. Storch J. Framing the Issues: Moral Distress in Health Care. Hec Forum. Springer, 2012
        • Jameton A.
        What moral distress in nursing history could suggest about the future of health care.
        AMA J. Ethics. 2017; 19: 617-628
        • Epstein E.G.
        • Delgado S.
        Understanding and addressing moral distress.
        Online J. Issues Nurs. 2010; 15
        • Fontein-Kuipers Y.
        • den Hartog-van Veen H.
        • Klop L.
        • Zondag L.
        Conflicting values experienced by Dutch midwives-dilemmas of loyalty, responsibility and selfhood.
        Clin. Res. Obstet. Gynecol. 2018; 1: 1-12
        • Marshall C.
        • Rossman G.B.
        Designing Qualitative Research.
        SAGE Publications, 2015