Comment
Our findings show that interviewees overwhelmingly felt that the COVID-19 pandemic has magnified the existing and escalating staffing crisis, impacting on the ability to provide safe and personalised care. Even pre-pandemic, there were growing concerns about the wellbeing of maternity staff, with high levels of anxiety, depression and burnout noted amongst UK obstetricians and midwives (7, 8). In line with our findings, recent research demonstrates that being unable to practise the person-centred and autonomous midwifery care they aspired to is often cited as a reason why midwives consider leaving the profession, although lack of autonomy, pay and conditions are also relevant factors (9,10)
Maternity professionals are subject to a broad range of occupational factors that can inhibit their ability to be compassionate, resulting in compassion fatigue and inability to provide quality care (11). The problem does not lie within the job itself – providing relational care may in fact protect against burnout (8). The inability to work in ways that are congruent with vocational identity and professional requirements risks psychological and physical safety for women and babies. These stressors result in a culture of self-sacrifice where maximum levels of effort are required to maintain care, with minimal resources (12). They include working long hours/beyond allotted hours without breaks, lack of time, lack of professional autonomy, challenging clinical situations, lack of support, high levels of fear relating to compromised safety and potential retribution, and witnessing the mistreatment and/or traumatic treatment of women whilst feeling unable to intervene (9,10). Many of these pressures may be exacerbated by insufficient staffing (10). In line with this, safe staffing may mitigate the impact of these stressors on psychological wellbeing (9). As these stressors increase and the ability to provide compassionate care decreases, workers may experience a lack of professional accomplishment, emotional exhaustion, cognitive dissonance, and moral distress (12). As a result, they can withdraw from women and their commitment to the profession. This is aptly described as ‘fighting a losing battle’ (10).
Our findings demonstrate how COVID-19 has exposed fundamental flaws in a system where organisational priorities and professional values come into daily conflict. It is increasingly evident that the NHS functions as a result of the goodwill of its workers, which is rapidly running out. It appears from our data that the coping mechanisms (for example, peer support within a well-established, sustainable team, and the freedom to offer compassionate, relational care) that made this working environment manageable are breaking down, leading to burnout and a critical tipping point of collapse. There is growing anecdotal evidence that an increasing number of those working in maternity services are questioning why they come to work every day and are looking elsewhere for employment that is associated with less fear, and less potential for psychological harm.
Our data indicate the extent to which these underlying fault lines have been magnified by the pandemic, to the point where they have become unsustainable. This unique opportunity for a post-pandemic rebuild of the maternity services needs to start by examining how such long-standing flaws in maternity service design and delivery can be built out, to avoid a similar collapse of wellbeing and morale under future organisation-wide stressors. Understanding the protective factors which sustain psychological and physical wellbeing amongst maternity staff, such as flexible and autonomous practice, the ability to provide person-centred, relational care, and strong peer networks, should underpin future efforts to train, recruit and retain this valuable professional workforce.
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Authorship as per BJOG Criteria:
SC was a research site lead, coordinated and undertook interviews, transcribed data, contributed to the analysis framework, analysed interviews, interpreted analysis, contributed to the concept for paper, coordinated and took responsibility for drafting and revising the paper, approved the final version, and agrees to be accountable for all aspects of the work.
GM transcribed data, contributed to the analysis framework, analysed interviews, interpreted analysis, contributed to the concept for paper, contributed to writing the paper, supported the coordination of drafting and revising the paper, approved the final version, and agrees to be accountable for all aspects of the work.
SD was responsible for study conception, design, ethics, and transcribed data, contributed to the analysis framework, analysed interviews, interpreted analysis, contributed to the concept for paper, contributed to writing the paper, supported the coordination of drafting and revising the paper, approved the final version, and agrees to be accountable for all aspects of the work.
JC contributed to the analysis framework, analysed interviews, interpreted analysis, contributed to the concept for paper, contributed to writing the paper, supported the coordination of drafting and revising the paper, approved the final version, and agrees to be accountable for all aspects of the work.
AS contributed to the analysis framework, analysed interviews, interpreted analysis, contributed to the concept for paper, contributed to writing the paper, supported the coordination of drafting and revising the paper, approved the final version, and agrees to be accountable for all aspects of the work.
CK contributed to project design, obtaining ethics approval, coordinating and managing data collection, developing a framework, revising the paper critically for important intellectual content, approved the final version, and agrees to be accountable for all aspects of the work.
DP contributed to data acquisition, analysis of data, developing a framework, revising the paper critically for important intellectual content, approved the final version, and agrees to be accountable for all aspects of the work.
CF contributed to data acquisition, developing a framework, revising the paper critically for important intellectual content, approved the final version, and agrees to be accountable for all aspects of the work.
Joanne Cull is funded by a National Institute for Health Research (NIHR) Wellbeing of Women Doctoral Fellowship.  The views expressed in this paper are those of the authors and not necessarily those of Wellbeing of Women, the NHS, the NIHR or the Department of Health and Social Care