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ORIGINAL ARTICLE
Coping with Maternal Deaths: The Experiences of Midwives
Dartey Anita Fafa1*, Phetlhu Deliwe Rene2, Phuma-Ngaiyaye Ellemes3
OPEN ACCESS
Citation: Dartey Anita Fafa, Phetlhu
Deliwe Rene, Phuma-Ngaiyaye Ellemes.
Coping with Maternal Deaths: The
Experiences of Midwives. Ethiop J Health
Sci. 2017;29(4):495.
doi:http://dx.doi.org/10.4314/ejhs.v29i4.11
Received: January 6, 2018
Accepted: April 8, 2019
Published: July 1, 2019
Copyright: © 2019 Dartey A.F., et al .
This is an open access article distributed
under the terms of the Creative Commons
Attribution License, which permits
unrestricted use, distribution, and
reproduction in any medium, provided the
original author and source are credited.
Funding: Nil
Competing Interests: The authors
declare that this manuscript was approved
by all authors in its form and that no
competing interest exists.
Affiliation and Correspondence:
1University of Health and Allied
Sciences- Nursing, Ghana
2University of the Western Cape, South
Africa –Nursing, Cape Town, Western
Cape, South Africa

[email protected]
ABSTRACT
BACKGROUND: Life is said to be meaningful only when the
individual is able to cope with challenges associated with it.
Challenges at the workplace, whether physical, psychological or
social, all contribute to occupational trauma. Coping with the
challenges of work is an important part of achieving occupational
wellbeing, irrespective of how difficult the job may be. Midwives
are trained to be responsible for safe motherhood. However, when
faced with maternal deaths, work becomes difficult as they have to
cope with trauma resulting from their encounters with these
deaths. Thus, the aim of this study was to explore and describe the
coping challenges of maternal deaths among midwives in the
Ashanti Region of Ghana.
METHOD: An exploratory descriptive qualitative design was used
in the study. Data were collected by means of semi-structured
interviews (18) and focus group discussions (8) with inclusion
criteria of being a midwife with at least one year working
experience and having witnessed maternal death while on duty.
Data were audio recorded, transcribed and analysed using thematic
content analysis.
RESULTS: Four themes emerged from the study: difficulty
accepting maternal death, exhibition of grief reactions, difficulty
forgetting the deceased and lack of concentration.
CONCLUSION: The study concluded that since the midwife’s
ability to cope with maternal deaths is challenged, occupational
workplace programmes, for example, Employee Assistance
Programme (EAP) should be employed in Ghanaian hospitals to
help midwives get debrief after maternal death occurs.
KEYWORDS: Coping, challenges, experiences, maternal death,
midwives
INTRODUCTION
Occupational challenges that workers face all over the world and
across various fields of work are related in one way or the other (1).
Health and safety measures have become a growing concern in our
work settings to create sound and healthy work environments that
induce desired productivity and worker performance (2,3).
Healthcare delivery is highly associated with nerve-wracking
psychosocial problems owing to the sensitive and relational nature of
hospital work (4). In 1996, the International Labour Organization
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(ILO) commissioned a stress-prevention manual
which could guide coping with stress, grief,
anxiety and depression experienced by nurses and
midwives, in recognition for the importance of
managing harmful occupational exposure (5,6,7).
For these reasons, advanced countries have
developed support programmes that facilitate the
operation of occupational healthcare practices,
which offer employees’ services like psychosocial
counselling to mitigate cognitive work-related
challenges of health workers (1,2).
The development of this manual is evident
that nursing and midwifery, by nature, and in
practice, are very stressful professions associated
with many occupational health challenges
(8,9,10). Additionally, given that midwives are
women and are familiar with birth trauma creates
natural bonds between them and their clients (4).
This relationship, integral to midwifery practice,
may certainly make midwives, especially
vulnerable and sensitive to psychosocial hazards
that result from untoward events of maternal death
(11). A midwife’s continuous exposures to these
challenges interfere with her mental wellbeing,
thereby threatening her ability to cope (12). This
may also lead to low performance, and lack of
mental attentiveness, thereby affecting healthcare
services provided to other pregnant women
(13,14) and personal problems such as low selfesteem and the portrayal of negative attitude (15).
The findings of (14) show a global representation
of the little attention to the severity and prevalence
of maternal death distress among midwives.
Literature suggests that midwives need
support to develop coping abilities relating to
maternal death challenges (12). As such, it is
important to identify with the phenomena of
maternal deaths, particularly, challenges with
coping, to develop possible approaches to
managing them. This study, explored coping
challenges associated with maternal deaths among
midwives in the Ashanti Region of Ghana.
MATERIALS AND METHODS
The study applied qualitative research approach
with exploratory design. The research setting was
Ashanti Region of Ghana, a region that
consistently recorded maternal death rate of 139 in
2014; 168 in 2015,129 in 2016, 162 in 2017 and in
221 in 2018 per 100,000 (16) as compared to 3 per
100,000 women in countries like Finland, Greece,
Iceland and Poland of Europe with the lowest
maternal deaths (17). The study was conducted in
nine health facilities that included a teaching
hospital, a regional referral hospital, four district
referral hospitals and three health centres.
Purposive sampling technique was employed to
select fifty-seven (57) ward midwives and
supervisors (18). Eighteen (18) semi-structured
interviews and eight (8) focus group discussions
were conducted. Participants had worked as
midwives for at least one year and had
experienced maternal death while on duty. Focus
groups ranged between four to seven participants.
In each facility, the research team explained the
objectives of the study to the managers and
potential participants. A convenient meeting was
scheduled with interested participants
individually. All the participants selected hospital
offices for the interviews. A thematic content
analysis technique by Holloway and Wheeler (19)
was used to analyse data. Data analyses
considered trustworthiness strategies:
dependability, transferability, credibility and
confirmability (20). Data analysis started with
validation, confirmation and transcription, within
24 hours of data collection to avoid missing
relevant information. Data cleaning and coding
was done to organize the different data collected.
Data analysis computer software, Atlas ti version
7.1.7 was used. Participants’ privacy and
confidentiality were preserved by the use of
alphabets and numbers in place of participants’
name, [E.g. Focus Group 1 midwife 1 (FG1M1),
Individual Midwife 1 (M1)]. Themes were created
as recurring patterns were generated. Three people
independently analysed the data and results
compared and harmonized.
The study got ethical clearance from the
Senate of the University of Western Cape, South
Africa and Ghana Health Service.
RESULTS
All participants were females, ranked from Staff
midwife to Director of midwifery. The majority
(52.6 %) were junior ranked officers. Their ages
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ranged between 22 to 61 years with the majority
(56.1%) less than 46 years. Most participants
(58%) worked more than 10 years as midwives,
meaning most of them had extensive working
experiences and possible multiple exposure to
maternal death. Four themes emerged from the
analysed data: difficulty accepting maternal death,
exhibition of grief reactions, difficulty forgetting
the deceased and lack of concentration.
Difficulty accepting maternal death: Participants
reported it was difficult to accept maternal deaths
that occurred in the wards. They testified that most
pregnant women who died were not sick and that
most presented with normal conditions. Cases
were presented as below:
M11: The woman was pregnant; she wasn’t sick.
Pregnancy is not a sickness, so she should
deliver and go home happily, but why did she
die?
M16: I personally do not want to hear about
maternal death because pregnancy is not a
disease; the woman had no pathological
condition. The woman came in healthy so why
she should die is something that bothers me.
FG2M3: A woman who is not sick or does not
have any disease whatsoever dies in trying to
deliver; it’s difficult.
Participants further explained that pregnant
women, who were unwell on admission, did not
present deadly conditions in most cases. The
majority of pregnant women walked into the
wards unaided. The deaths of these women,
according to the participants, were unexpected and
difficult to accept This is demonstrated in the
following statements:
FG4M1: The mother came in healthy. Mother
was not bleeding, not in any bad condition and
the mother died, you will not accept it.
FG4M3: When you as a midwife attending to a
pregnant woman who walks in healthy, and
even if there are risk factors relating to her
situation, and you lose her, it is difficult to
accept it.

communicated well on admission and recovering,
and those who regularly attended antenatal clinics.
Coping was more challenging to midwives as seen
in these quotes:
FG6M3: I don’t know what happened, because
she was communicating with you. I was talking
to her, so why all of a sudden? You will always
be thinking about the patient, why the patient
died!
FG1M1: Sometimes, your disbelief gets worse
when the client is a regular attendant of
Antenatal Care, has been on the ward for a
while and has been managed very well. One
gets surprised when such a thing occurs to her.
FG7M6: Sometimes, they are recovering or
getting better, and they lost their lives at the
end.
Some participants demonstrated knowledge in
conditions that killed pregnant women. This
prepared them for the worse scenarios, but their
anguish didn’t wither. The following were said:
FG4M4: There are some conditions such as
Post-Partum Hemorrhage (PPH) which puts
pregnant women in danger, but when a mother
is not bleeding or nothing of the sort, and a
mother dies, it puts you in a bad mood.
M5: Normally, maternal mortality cases in this
hospital concern those that were referred from
other district hospitals, where a woman’s
condition was not good, yet was not referred
on time for further treatment to save her life. In
that case, one cannot do much.
Exhibition of grief reactions: The study found
that participants exhibited grief reactions. Denial
was reported as one of the main reactions to loss:
FG1M3: You keep on denying the death
because you see a patient on the ward going
through a recovery process and unexpectedly,
you see the patient’s condition deteriorating
just like that.
M6: When maternal death happens, at times
they [attending midwives] have denial and you
[supervisor] need to support them. They feel
they have not done what they needed to do.
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In some cases, participants were easily angered
anytime maternal deaths occurred. This is
demonstrated in the following:
FG6M2: The recording of maternal death
comes with tension mixed with anger, surprise
and shock from the news. FG5M6: Maternal
death affects me personally; the little thing
someone does or says annoys me.
Similarly, participants reported having to bargain
with the pain of loss. Bargaining makes a person
linger in the past to escape the pains of loss (21).
Self-blame is associated with bargaining:
FG6M3: Is it that she has to die that she died?
Sometimes, you have to bargain, bargain, and
bargain, but you wouldn’t get answers to why
the patient died even though you tried
everything you could do for the patient, but she
still died.
M14: Sometimes, some midwives bargain
persistently and question themselves why
maternal death happened.
Difficulty forgetting the deceased: The results of
the study also showed that participants had
difficulty forgetting the death of pregnant women.
Participants explained that numerous
circumstances reminded them of deaths that
occurred in the past:
FG1M4: Sometimes, you try so hard, but you
can hardly forget especially when you have
been emotionally attached to the client.
FG3M2: There was this particular client I had
become friends with. The next day I came to
work, she had died. For that woman’s death,
coping was very difficult because, every day I
will reflect on how she could have died.
Additionally, the data presented significant time
difference individual participant could cope with
maternal death challenges. While some midwives
coped within a shorter time, others took much
longer. Other participants couldn’t tell how much
time it took them:
M4: It takes a while for one to forget, but one
must still come to work, though you remember
when you see a pregnant woman.
M6: It takes me some time to forget maternal
death when I experience one.
Some other participants take weeks to forget and
cope with maternal death:
M15: To forget or cope with maternal death,
it takes about a week to two for me to forget
it.
FG3M4: When I experienced one at the
theatre, It took me about two weeks before I
could stop thinking of it.
Other participants, who took much longer time to
forget about maternal deaths, confirmed their
experiences:
FG5M2: I experienced one two years ago. It
took me weeks to recover. Yes, more than a
month.
FG6M1: I have experienced some before, in
2010 (four years ago) and I still think about the
patient, what happened and how the patient
died, I don’t know!
After years of experiencing maternal death, this
participant could tell exactly what happened that
night:
M4: We were at work, about seven years ago.
We were there in the labour ward and then
this woman came with some friends that when
they were home, they saw her in labour and
she had locked herself up in her room so they
had to call someone break the door, so after
breaking the door, they brought the patient.
You could see that the patient had laboured
in her room for a long time, so one of her legs
was very swollen, very red. We did all we
could…, but the patient could not survive.
The study further reported that midwives who
lived and worked in the same communities, were
constantly reminded of the deaths of clients, as
they met known family members of the deceased,
especially, children delivered before death. This is
what participants had to say:
M1: Sometimes, if you see the child she left
behind in the future, it reminds you of the
loss.
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M9: We are reminded of the death by family
members, we meet in town and at church.
M10: I cannot forget totally. The family of
the deceased must be visited and counselled
on the care of the child left behind.
Lack of concentration: The findings also
demonstrate that most participants found it
difficult to concentrate on the work at hand. This
affected their output in many ways. This is
captured in the following quotes:
FG2M2: I try to get it off my mind so I will be
able to concentrate on work, but I still become
quiet throughout the day.
FG5M3: Sometimes,…you are not able to
concentrate on the work.
Other participants reported the lack of
concentration on their own selves, and family as
mentioned by these participants:
FG4M1: It affects me as an individual; I do
not eat well, can’t concentrate when chatting. I
cannot do anything for myself.
M2: When I go home, instead of doing other
things with my family (husband or children), I
cannot do it so it affects me and my family at
large.
DISCUSSION
The study investigated coping challenges
associated with maternal related deaths. Its
findings suggest that midwives experienced
various coping challenges at their workplaces as a
result of these deaths. Typically, participants
reported their inabilities to accept maternal deaths,
exhibition of grief reactions, had difficulty
forgetting the deceased and also lacked
professional and social concentration. Difficulty
accepting maternal deaths is where midwives live
with disbelief that the client had died and cannot
come to terms with the loss. The midwives
admitted pregnancy was not a disease, and most
clients presented healthy. Improvements in clients’
physiological conditions were evident, yet the
unfortunate happens, causing occupational trauma
and pain for attending midwives. Bickham, (22)
agrees by postulating that the death of the patients
was a disappointing situation to midwives and
may create coping problems. Dartey and
colleagues (4) identified with the study, adding
that occupational trauma, such as death of patient
interferes with the wellbeing and performance of
midwives. WHO (2) advocates occupational
wellness for all so as to enhance mental health at
the workplace.
This study also found that participants
exhibited denial, anger, bargaining and shock
whenever maternal deaths occurred. This is
consistent with findings of Kübler-Ross et al (21)
where they brought meaning to grief through the
five stages of loss. Although these are well
documented, the stages vary from one person to
another. The study also found that grief reactions
exhibited by these participants were not in any
order. Neither did participants go through all at the
same time (23). These ascribe to the Stage Theory
of Grief that says grief reactions do not necessarily
occur in a specific order, and vary from person to
person (24). Thus, while some midwives
experienced anger, others bargained with the
reality of loss (21). Midwives sift through these
states of grief, at risks of substantial occupational
trauma as each reacted differently to these
established states of grief (25). These phases are
likely to cause strain on satisfying exchange
relationships between midwives and patients. The
good harmony of network and communication for
social wellbeing is threatened, weakening the
intellectual health statuses of midwives
(2,26,27,28).
Similarly, difficulty forgetting the deaths of
pregnant women was identified as a coping
challenge for midwives. Difficulty to forget means
midwives still remember what happened to clients
who died in their care and find it uneasy letting go
of these memories. During the course of care,
emotional relationships are established (29).
Where they are non-existent, sheer affinity by
femininity is sufficient to inspire empathy and
grief among midwives when maternal deaths
occurred. Some midwives still recount everything
that happened with clients several years on. Dartey
and colleagues (4,25) agree with this observation,
and attest that indeed, midwives find it difficult to
cope after experiencing bereavement. Wilson and
Kirshbaum (30) also agree that people find it
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difficult to forget the death of loved ones, and are
likely to become more vulnerable to dangerous
states of grief responses, which they sometimes
are unable to recover from.
Further, lack of concentration on work, family and
self was reported. This challenge stems because
midwives get preoccupied with memoirs of
patients they had cared for. They easily lose
themselves in their own thoughts, or freeze
intermittently, during care delivery and social
adventures. Participation, intuitive, initiative
drives are dampened, potentially creating enabling
environments for mistakes and errors. KublerRoss and Kessler (21) affirm with the study saying
that attending midwives had limited time to
consume the grief process. Gerow, et al.,(31)
admit that even in cases where nurses cared for the
dying, their vulnerabilities regarding patient loss
remains unknown to the world. Preoccupation, as
a result, reduces time and attention given to other
caregiving services.
The psychosocial environment of the worker
directly commensurates to his/her mental health.
Promotion of mental health at the workplace
illustrates employers’ contentment to employees
since performance goes a long way to affect
psychosocial wellbeing (2,27). All organizations
depend on employees’ wellbeing to achieve their
long-term performance and productivity objectives
(32). Midwives as pillars in maternal healthcare,
calls for urgent needs of effective intervention
programmes to mitigate the coping challenges
they face in the workplace. Failure to address
midwives’ issues would mean a failure in
maintaining or improving maternal healthcare in
Ghana.
This study established that midwives face
coping challenges with maternal related deaths. It
must be well understood that continued lack of
intervention for midwives may lead to poor
maternal health outcomes. These challenges must
be addressed in promoting the occupational health
convention of the WHO (2).
The findings of this study enhance prevailing
issues of coping challenges that midwives struggle
with as they work hard to provide healthcare
services to women and children within resourcelimited hospitals in Ashanti Region of Ghana. The
study establishes the need to develop wellnessbased intervention programmes such as Employee
Assistance Programme to ensure a positive work
environment.
The study cannot be generalized to a wider group
of midwives since it was carried out qualitatively
using a smaller population with subjective views.
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