Moral Distress in Midwifery

The experience of moral distress is not simply about stress, compassion fatigue or emotional fatigue, but is also an issue that can erode the foundation or heart of what it means to be a nurse or midwife, eventually resulting in a deterioration surrounding quality of care: to provide care that is relational, respectful, woman-centred, and grounded in autonomy and trust. When midwives are prevented from upholding these principles, the result is a form of psychological suffering that can have lasting consequences affecting patient care outcomes, mental health and overall wellbeing. 

According to Australian research on moral distress in midwifery, moral distress arises when nurses and midwives are either compelled to act in ways that conflict with their moral values and integrity or feel unable to act due to moral constraints, such as remaining silent, failing to advocate, or not challenging unsafe or unethical practices. Whether through action or inaction, this compromise of moral integrity and the accompanying sense of powerlessness can lead to significant emotional and psychological harm. Importantly, it should be noted that moral distress does not arise from the act of caring itself, but rather the systemic constraints and distress caused by hierarchical pressures, fear of punitive consequences, and a lack of institutional support in healthcare that prevents midwives from practicing in alignment with their professional and personal values. 

Moral distress is not a personal failing. It must be emphasised that the experience of moral distress does not stem from a lack of resilience or personal strength, nor is it from a lack of coping ability. Moral distress occurs from being placed in situations that prevent ethical practice and a moral conflict. Framing moral distress as an issue of resilience or simple dilemmas, unfairly places the emphasis of the problem on the midwife, while failing to acknowledge the organisational responsibility to provide working environments that are ethically and morally sensitive. Framing moral distress as a personal failing ignores the systemic and structural factors that create it, and risks compounding the harm experienced by those already morally and ethically constrained by the system in which they work. 

Moral distress exists on a continuum (or a 'moral distress scale') of severity beginning at moral frustration, moving to moral distress and culminating at moral injury.

Moral Frustration

Moral Frustration is often the starting point of moral distress and can be defined in healthcare as a short-term unease that arises when a midwife’s values are challenged. Usually, in experiences of moral frustration, you're able to recognise what has happened, can process the emotions, and remain positive about your future practice. It can be a transient experience which, while uncomfortable, does not have a sustained negative psychological outcome at the time of the event. However, over time, repeated exposure to these seemingly minor ethical compromises can have a cumulative effect, potentially escalating into moral distress or even moral injury if left unresolved. 

Moral Distress

Moral distress is characterised by a more significant and prolonged psychological impact that can last from weeks to months and may result from a single profoundly distressing event or accumulate gradually through repeated exposure to everyday moral frustrations. Moral distress presents with feelings of guilt, powerlessness, anger, and frustration. Unlike moral frustration, midwives experiencing moral distress often have a less optimistic view of their future practice. Common symptoms of moral distress include self-blame, emotional exhaustion, difficulty "switching off" after shifts, and emotional flashbacks to morally challenging situations or persistent ethical dilemmas. In response, some midwives adopt coping strategies such as reducing their hours, going casual, or even leaving the profession entirely.

Moral Injury

Moral injury represents a severe form of psychological harm that can emerge when moral distress remains unresolved over an extended period of time. It is the crescendo effect of the moral distress scale, the severity of which is typically the result of prolonged exposure to ethically compromising situations where you feel unable to act in alignment with your professional value. Unlike moral distress, moral injury is characterised by deep emotional trauma including feelings of shame, anger, and guilt. It is a persistent psychological impact that goes beyond occasional emotional discomfort. In some cases, the symptoms can resemble those of post-traumatic stress disorder (PTSD). This level of psychological harm can significantly affect a midwife’s well-being, identity, and long-term ability to remain in the profession. 

One of the complexities of moral distress is that morality is deeply individual. What feels ethically compromising to one midwife may not affect another in the same way. This is shaped by personal values, cultural background, professional experience, and the degree of moral sensitivity and care. For example, one midwife may feel morally injured by being unable to support a physiological birth due to policy constraints, while another may not experience the same situation as distressing. 

This subjectivity does not make moral distress any less real. It highlights the need for workplaces to create space for ethical reflection and dialogue, rather than assuming a one-size-fits-all approach to professional wellbeing. While morality is experienced individually, an ethical climate should always be maintained within the workplace.

Maternity services are particularly prone to moral distress for several reasons. 

Relationality

Midwifery is inherently relational, with a foundational belief of building and maintaining a relationship with the patient and their family. In midwifery, relationality is both a source of meaning, intrinsic to care and a site of vulnerability. Moral distress often emerges when a midwife feels ethically compromised in her ability to maintain meaningful relationships, especially when institutional constraints force her to act in ways that violate her relational commitments. In many ways, moral distress is not just about "what happened" it's about "what happened to undermine the relationship, the trust and the care between the midwife and the woman". 

Hierarchical Decision-Making

In many settings, midwives are expected to defer to medical authority, despite the autonomous nature of their practice, even when they believe a patient’s preferences are being ignored or overridden or it goes against their own moral beliefs. This can create ethical dissonance, especially when advocacy is discouraged or punished in a workplace 

Ethically Unsafe Cultures

Environments where there is a lack of informed care, coercion is normalised, or disrespectful care is tolerated all contribute to an environment of moral compromise and distress. Midwives may feel they are participating in, or complicit to, care or methods that contradicts their values, with no safe avenue to speak up. Often, this leads to feelings of guilt and shame that they ‘allowed’ this to occur.

Lack of Ethical Foundations

Many maternity services lack formal structures for ethical consultation, debriefing, or reflection. Compounding this is the presence of institutional policies and practices that are not ethically informed, often utilising methods that prioritise efficiency or risk management over relational, patient-centred care. These systems can prevent midwives from acting in alignment with their Code of Ethics, forcing them into roles that conflict with their professional values and personal integrity, ultimately culminating in moral distress. Without spaces to process these experiences, moral distress often goes unaddressed, festering in silence and gradually eroding both personal well-being and the ethical climate of the workplace. 

Addressing moral distress in midwifery requires more than individual resilience, it demands systemic review and intentional change. Discussions around understanding moral distress should must prioritise ethically sound and relationally focused policies that: 

• Centre the voices of midwives in decision-making. 

• Protect time for reflective practice and ethical dialogue. 

• Create psychologically safe environments where concerns surrounding moral distress can be raised without fear. 

• Ensure that policies support relational, respectful, and autonomous care. 

By acknowledging the reality of moral distress and taking steps to address its root causes, maternity services can foster a culture where midwives are not only clinically safe, but ethically safe as well. 

When it comes to strategies for working through moral distress, it's most important to acknowledge and name the experience. It is vitally important that all midwives recognise that moral distress is a valid response to being in ethically challenging or morally compromising situations. Calling out the experience and naming it can reduce the stigma surrounding moral distress and is the first step to challenging the narrative. If something feels wrong, this is the time to explore the situation and not suppress the feeling.

Engage in reflective practice in relation to yourself. Key questions to explore your own thoughts and feeling about a situation that has occurred could be

• Which of my values do I feel were compromised through this situation? 

• What was in my control, and what wasn't? You are responsible for care, not for outcomes you cannot control.

• What do I need to recover from this experience? 

• Is this empathy or over identification?

Connecting with likeminded/like value orientated colleagues can assist to help reaffirm your own values, moral action and purpose and can be a buffer to further harms that may arise affecting your overall health, including feelings of isolation and depression. Many organisations including the ANMFSA have further information, community forums, resources and support groups for moral distress where midwives from across the state are invited to share experiences, debrief and learn from each other. This can be a great way to feel connected to the midwifery community at large while also forming supportive relationships.

For any form of emotional distress, it's important to take care of yourself and understand when to seek professional help. If you find yourself withdrawing, are experiencing growing anxiety, are feeling cynical or unable to manage, experiencing sleep issues, having increasing feelings of distress or are questioning your capacity to stay in the profession, speak to a mental health professional with experience in distress, trauma or burnout. Early support can prevent escalation into more serious conditions. 

Moral distress is not a sign of weakness. Managing moral distress requires self-awareness, support, and a culture that allows midwives to practise in alignment with their ethics. Whether you're a midwife, nurse or working in broader healthcare, healing and change through moral distress are both possible, but it will take individual, professional care and systemic resolve to get there. 

Wendy Foster is a midwife and an academic, currently working towards completing her PhD in Midwifery. Wendy has worked in many areas of midwifery including tertiary, rural and remote practice, education and research and has a passion for understanding and enhancing workforce preparedness, sustainability of the maternity care workforce as well as educational innovation and design in health care.