Midwifery is recognised as a profession with a heavy psychological toll (Hunter et al, 2019; Taylor et al, 2023). Many midwives leave the profession before the usual retirement age because of this strain (Royal College of Midwives, 2016; Hunter et al, 2019). Mental health diagnoses and suicide rates are higher than would be expected for this demographic (Kinman et al, 2020). However, there has been a reluctance to address this on a systematic or preventative level (Kinman et al, 2020). This article looks specifically at an uncustomary perspective of post‑traumatic stress disorder in midwives.
As defined by the American Psychiatric Association (2022), post‑traumatic stress disorder is characterised by exposure to a traumatic event, which leads to disruptive symptoms persisting longer than 1 month. Symptoms fall into four different categories, all of which must be represented for a diagnosis:
- Intrusion: nightmares, psychological or physical symptoms when presented with reminders of the trauma
- Avoidance: pushing away thoughts about the trauma, staying away from the location or people involved
- Negative changes to cognition/mood: feeling the world is an untrustworthy place, lack of interest in hobbies
- Changes to arousal/reactivity: irritability, hypervigilance, difficulty sleeping, poor concentration.
Research investigating the prevalence of post‑traumatic stress disorder among midwives has shown varied results. A systematic review found that studies reported rates of maternity healthcare professionals showing some symptoms of post‑traumatic stress disorder ranging from 35–66%, with 3–46% having symptoms severe enough to reach the threshold for a clinical diagnosis (Uddin et al, 2022). These studies did not take into account survivorship bias, that is, the unknown numbers of people who have left the profession because of psychological damage and are thus excluded from the research.
There has been a move in some psychological circles to acknowledge that post‑traumatic stress disorder is not rooted in ‘disorder,’ but as an advantageous evolutionary tool designed to keep us safe (Hansen, 2021). Our stone age ancestors had a vested interest in staying away from places where they narrowly escaped death, whether from predators, a weather event, an unfriendly tribe of people or another cause. They would have also benefitted from avoiding situations that were similar to those from which they had previously had narrow escapes, as they would also be potential sites of danger. People who did not have an instantaneous mental shortcut between a reminder of a previous frightening situation and an overwhelming fear response did not generally live long enough pass along their genes (Ranganath, 2024).
That adaptation is less helpful in the modern world, where the threat of being eaten or succumbing to the elements is not the same as it once was. However, in our DNA, brain structure and endocrine system, we are essentially cavepeople, and we cannot shake that fact. It is not a design flaw, but an instrumental part of how we now have a population of 8 billion and rising.
One of the functions of dreams appears to be to help us sort through our memories (Walker, 2017). Some information needs to stay easily accessible to help us survive and thrive in our daily lives. Some can be put into long‑term storage, their recall prompted by a conversation or by active effort (O'Keane, 2022). Many inconsequential things can be forgotten altogether with no adverse consequences. Dreaming about the specific event is not required; the fact of ‘dreams happening’ appears to facilitate this ordering process. Somewhat unhelpfully, disturbed sleep is often a feature of post‑traumatic stress. That is not the fault of the person; it is just how we are.
There is some evidence that telling the story of traumatic events to a person who is in the right frame of mind to hear it can be helpful (Hansen, 2021). As an analogy, it is similar to returning to the place in the forest where we were nearly mauled by a bear, but coming to no harm. The listener could be a professional counsellor, but it does not need to be. However, it should be someone who is able to listen attentively, without steering the conversation to being about them and what they have done (or might have done). They should also not be tempted to try to cheer the other person up by bringing up other people who have experienced worse situations. Often, the story needs to be told more than once. However, because revisiting the situation that caused post‑traumatic stress symptoms feels frightening and unpleasant, the person may be incapacitatingly reluctant to talk about it.
Opening up our trauma response to another person can be frightening for another reason that we are not normally aware of. Although the dominant 21st century culture values independence, our human ancestors needed the security of their tribe in order to survive. With nobody to help fend off predators, work together to find food or look after them when they were sick or injured, people who were on their own faced a much‑shortened life expectancy. Admitting our vulnerabilities to another person feels risky in that we might be ejected from our ‘tribe,’ which is equal in our subconscious minds to a death sentence.
Needing outside help to work through traumatic events is sometimes stigmatised, and people may fear that they will be judged harshly for the perceived weakness (Kinman et al, 2020). This is incongruent with how we view almost every other type of condition in healthcare. People with high blood pressure or diabetes are not expected to manage their condition just by knowing that they have it and without specific treatment. However, we often absorb the insinuation that we should be able to stop having mental health symptoms just by deciding not to.
If we were physically injured and fractured a leg, we would be unlikely to criticise ourselves and think of ourselves as weak for having a broken leg. It might help to frame post‑traumatic stress symptoms in a similar way, as a psychological injury caused by something outside of our control, rather than as we are culturally conditioned to do and see it as a personal shortcoming.
More traditional counselling and psychological therapies are effective for some people (National Institute for Health and Care Excellence, 2018). There is a particular type of therapy called eye movement desensitisation and reprocessing that often achieves particularly good results for people with post‑traumatic stress symptoms (Van der Kolk, 2014). It involves following a therapist's finger, pen or a dot on a screen back and forth while telling the story of the traumatic event. One theory behind its efficacy is that when someone moves their eyes in this way, it replicates what happens in rapid eye movement sleep, when we dream, and enhances the hippocampus' ability to file memories in the appropriate place (Landin-Romero et al, 2018).
Medications have their place too, for helping people to jump the well‑worn track of going over and over the same thoughts in their mind (National Institute for Health and Care Excellence, 2018).
Social support is important, but being with people can also make us feel vulnerable. While we are regularly reminded to reach out for support, this is often too onerous for someone at a low ebb. People experiencing difficulties dealing with traumatic experiences may need someone to ‘reach in’ to them.
Exercise, especially outside, can be helpful (McGonigal, 2019). It does not need to be formal ‘exercise’, such as joining an exercise class or participating in a 5K race. The simple act of putting one's shoes on and walking to the end of the street is preferable to remaining sedentary for extended periods of time.
Although there is evidence for all of the above suggestions, not every treatment works equally well for everyone (National Institute for Health and Care Excellence, 2018). Just as labetalol works to lower blood pressure in some people but not others, people may need to try a few options before discovering what will work best for them.
There is an increasing discussion of post‑traumatic growth in academic and scientific literature (Henson et al, 2021). We are likely to be permanently changed by exposure to traumatic events. As much as we would not wish people to experience these events, they can have positive benefits for someone in the long run and for the quality of care they are able to provide. It takes some time and some work, but things do not always feel as ‘raw’ as they do initially. We can be ‘healed’ without being ‘cured’, and that is far more powerful (Mate and Mate, 2022).
Conclusions
In the long term, a stronger evidence base is needed to inform ways of working that protect midwives' psychological health. In the meantime, turning our attention to our evolutionary past may be one way of reframing our response to traumatic events. When we gain a broader understanding of why post‑traumatic stress symptoms occur, we can gain a new perspective on our (and our colleagues') reactions to upsetting events. We can also look at strategies that might be helpful in shortening the duration or intensity of symptoms.