The United States has the highest maternal mortality rate of any high-income country and Indiana has the third worst rates of maternal death in the country; people of color are suffering even more egregiously (Thumm et al., 2022). The literature is overwhelmingly clear that increasing access to midwives would improve these outcomes, and while the Biden Harris administration did craft legislation to address maternal mortality, including increasing access to midwives, we face exceedingly high rates of midwifery burn out. No one seems to be investigating this either. One study seems to have been conducted into midwifery burn out since 1986.
In the United States, the majority of births are attended in hospitals by physicians, despite evidence that outcomes are improved when healthy women are attended by midwives, and women report having greater satisfaction (Thumm et al., 2022). Nurse-midwives attend fewer than 10% of births in the United States, and more than half of US counties do not have access to nurse-midwives. In fact, more than 48% of the counties in the US do not have any maternity provider whatsoever.
What is Does it Mean to Burn Out?
Professional burnout is a psychological condition that results from chronic stress to pathologic extremes. Midwifery is an exceedingly difficult profession and not simply because we are lifeguards of mothers and babies, with at least one in ten newborns requiring some level of resuscitation. We manage obstetrical emergencies, mental health crisis, domestic violence, sexual assault, limited resources, sexism, racism, inequalities in every respect and none of this even speaks to the assaults we endure from our colleagues, the poor working conditions, horrible hours, incredible liability, lack of safeguards, imbalance of power, and low pay. The emotional exhaustion is profound. Midwives are dehumanized and the entire healthcare infrastructure is not equipped to properly care for women and babies, hence our deplorable maternal and child health outcomes.
Burn out creates destabilization among the profession. It reduces productivity and effectiveness, reduces professional engagement, and increases detachment and dissociation. Admittedly obstetricians and gynecologists are right on our heels with regards to burn out (Rayburn, 2017). Worse though, is that burn out is associated with even worsening patient outcomes and even greater racial bias (Dyrbye et al., 2019). Clinicians who are burnt out are more likely to make mistakes or be negligent in their care, and they are more likely to practice defensively which reduces women's agency and autonomy. Sadly as well, in a study with maternity nurses, more than half reported not comforting their patients on their last shift (Clark & Lake, 2020). This study found that nurses experiencing burn out are four times more likely to not do necessary patient care.
Nurses report that workplace hostility impacts their ability to practice to the best of their skill. Not being included in decisions that impact the care they provide within their organization matters to nurses and ultimately contributes to their compassion fatigue and burn out (Lake et al., 2019). Further, nurses are not appropriately utilized when policies are created, even when they practice as clinicians at an advanced level; nurse-midwives are not often offered an equal seat at the table, if a seat at all. When nurse-midwives have more autonomy and can offer greater continuity of care, burn out is lower (Suleiman-Martos et al., 2020). Nurse-midwives have identified that practice leadership, as well as their participation and support in the midwifery model of care, is integral in their sense of burn out (Thumm et al., 2022). Organizational interventions are more effective in reducing burnout than individual-level interventions; we need a healthcare infrastructure overhaul.
Two in Five Nurse-Midwives in Clinical Practice, in the United States, are Experiencing Burn Out
Studies have indicated more than half of all perinatal healthcare workers are suffering burnout, upwards of 58% (Govardhan et al., 2012) and this was prior to the pandemic. Midwives experience more burn out than even nurses. Obstetricians may have a slight lead over midwives, depending on the research you evaluate, but if midwives were supported, as well as the midwifery model of care that allows the autonomous practice of midwifery, including building of relationships with their clients, then a growing midwifery profession would only reduce the workload of obstetricians and certainly assist in retaining their practice as well.
If the United States going to make any strides in addressing the maternal and child healthcare crisis, we must better understand and address the issue of burn out among maternity providers. Investment in initiatives that increase the workforce is great, if there are midwives to provide such care and the workforce can retain them.
References
Clark, R. R. & Lake, E. (2020). Burnout, job dissatisfaction and missed care among maternity nurses. Journal of Nursing Management, 28(8), 2001-2006.
Dyrbye, L., Herrin, J., West, C. P., & Wittlin, N. M. (2019). Association of racial bias with burnout among resident physicians. JAMA Networking Open, 2(7), 197457.
Govardhan, L. M., Pinelli, V., & Schnatz, P. F. (2012). Burnout, depression and job satisfaction in obstetrics and gyencology residents. Conn Med, 76(7), 389-395.
Lake, E. T., French, R., O'Rourke, K., Sanders, J., & Srinivas, S. K. (2019). Linking the work environment to missed nursing care in labour and delivery. Journal of Nursing Management, 28(8), 1901-1908.
Rayburn, W. F. (2017). The obstetrician-gynecologist workforce in the United States: facts, figures, and implications. American Congress of Obstetrics & Gynecologists.
Suleiman-Martos, N., Albendin-Garcia, L., & Gomez-Urquiza, J. L. (2020). Prevalence and predictors of burnout in midwives: a systematic review and meta-analysis. International Journal of Environemtnal Res Public Health, 17(2), 641.
Thumm, E. B., Smith, D. C., Squires, A. P., Breedlove, G., & Meek, P. M. (2022). Burnout of the US midwifery workforce and the role of the practice environment. Health Services Research, 57(2), 351-363.
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