Healthcare professionals' perspectives on traumatic childbirth - interpreting the data.

Abstract

We would like to thank Cauldwell and Bewley 1 for their encouraging comments regarding our recent manuscript “Blame and guilt – a mixed methods study of obstetricians’ and midwives’ experiences and existential considerations after involvement in traumatic childbirth 2.” The manuscript is the first publication from a large interdisciplinary study and more data and analyses will follow. While we agree that it is an important finding that 87% agreed with “Memories of what happened to the patient kept troubling me for a long time after the event,” we do not share the authors’ interpretation of the item to be representative of intrusive memories. Thinking about what happened to the patient for a long time after the event is seen as an account of genuinely caring for the patient and the long-term outcomes after a traumatic childbirth, not as related to the symptom complex of posttraumatic stress disorder. Intrusive memories are recurrent, distressing, and involuntarily triggered and may take the form of distressing recollections of the event, including images, thoughts or perceptions 3, which this particular item did not address explicitly. Still, we fully acknowledge that being troubled by memories of what happened to the patient may take its toll on the healthcare professional. The quote highlighted by the authors is a poignant account of how devastating these memories and thoughts can be, but labeling them as intrusive would be reading more into the results than our data allow. We have unpublished data from two items on “intrusive thoughts” and “recurring nightmares,” and they seem to endorse the differentiation between troubling and intrusive memories or thoughts. We would be hesitant to compare midwives and obstetricians in a Danish setting to attrition rates of emergency physicians in Taiwan 4, but we agree with the proposed emphasis on the group who has left the profession after a traumatic event. We have data on midwives and obstetricians who have left the labor ward, which we will address in detail in a manuscript about psychosocial health and wellbeing in Danish midwives and obstetricians currently under review. The authors suggest a further look at the 23% who had considered leaving the profession. It should be noted that half of these had considered this to a great or some extent, and half only to a small extent. It is an interesting point of discussion whether becoming a second victim is an avoidable or an inevitable part of midwifery and obstetrics. The manuscript is one part of the first author's PhD thesis, in which it is proposed that we should consider traumatic childbirth as a fundamental condition in midwifery and obstetrics. This approach, or explication, appears contrary to the dominating idea of preventability in the patient safety culture. Perceiving traumatic childbirth as a fundamental condition does not exclude careful attention to safety and prevention of error, but it accentuates the natural unpredictability of childbirth and it gives a voice to the midwife and obstetrician who go to work with no intention to cause harm. Admittedly, the full potential of the material is not unfolded in this single manuscript. Reporting from a mixed methods study in the same manuscript will invariably reduce the depth of the presentation and discussion. This is a challenge often described in the mixed-methods literature 5 and is perhaps a general limitation when disseminating scientific knowledge in the form of journal articles. For this reason the analyses carried out have been of a descriptive nature, as a first step of basic research. However, we will look forward to engaging in further work and discussions about consequences for patients, healthcare professionals and birth culture, and to contributing to the development of adequate support systems for midwives and obstetricians.