Matern Child Health J DOI 10.1007/s10995-014-1601-1
Predictors of Death Anxiety Among Midwives Who have Experienced Maternal Death Situations at Work Rhoda Suubi Muliira • Vito Bosco Sendikadiwa Fred Lwasampijja
•
Springer Science+Business Media New York 2014
Abstract One of the hardships faced by midwives in developing countries is dealing with maternal death. Taking care of pregnant women who end up dying makes midwives mindful of their own mortality and this experience provokes discomfort and anxiety. To determine the predictors of death anxiety among midwives who have experienced maternal death at work in order to recommend interventions to facilitate effective coping with the distress. An exploratory, descriptive design was used to collect data about death anxiety from 224 midwives working in two rural districts of Uganda. Death anxiety was measured using a subscale of the Death Distress Scale. The majority of participants were female (80 %) and with associate degree level professional education (92 %). Participant’s mean age and years of professional experience were 34 (±6.3) and 4 (±2.1) years, respectively. Most participants (74.6 %) had moderate or high death anxiety. The predictors of death anxiety were: having witnessed two and more maternal death in the past 2 years [odds ratio (OR) = 3.175; p B .01]; being in charge of four or more maternal deaths (OR = 5.13; p B .01); lack of professional training in handling death situations (OR = 3.32; p B .01); and coping with maternal death situations using methods such as: planning (OR = 4.90;
R. S. Muliira (&) College of Nursing, Sultan Qaboos University, AlKhod, P.O. Box 66, Muscat, Oman e-mail: [email protected] V. B. Sendikadiwa Mubende District Local Government, P.O. Box 93, Mubende, Uganda F. Lwasampijja Mityana District Local Government, P.O. Box 332, Mityana, Uganda
p B .01), active coping (OR = 3.43; p B .05) and acceptance (OR = 2.99; p B .05). Multiple exposure to maternal death situations is associated with an increase in death anxiety among midwives working in rural settings. Employers need to provide deliberate support to enable midwives to cope effectively with death anxiety at work. Keywords Coping Death anxiety Maternal death Midwives Uganda
Introduction Death is an inevitable part of all living organisms and death anxiety is a term used to conceptualize the apprehension generated by death awareness [1]. Confronting death and the anxiety generated by knowledge of its inevitability is a universal psychological predicament for human beings [2]. For midwives working in rural settings of developing countries maternal death is still a reality in clinical practice as is the joy of birth [3]. Experiencing death situations such as maternal death for a prolonged period of time or multiple times is common in rural areas of developing countries, because of the general shortage and the low quality of the resources available to provide maternity services [4]. Therefore maternal deaths are one of the situations that are a source of stress and anxiety in midwifery practice in developing countries. For instance sudden death occurring in obstetric wards is reported to be traumatic to midwives and other health care providers involved in the mother’s care due to its unexpected nature [5, 6]. Thus maternal death is something midwives do not enjoy experiencing and causes discomfort and anxiety [7, 8]. The resulting death anxiety can be worsened by working in stressful environment or unpredictable circumstances [2].
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The lack of knowledge and skills related to death and dying, does not only increase anxiety levels and emotional discomfort [7], but also makes health care providers unable to effectively cope with their own feelings and care for patient at the same time during death situations. Literature shows that many health care providers currently in practice did not receive specific training or preparation in dealing with death situations [9–11]. Witnessing patient death and the quality of death witnessed, affects the level of anxiety experienced by the health care provider [5]. When maternal death occurs the midwives are faced with a difficult task of informing the relatives, dealing with the body, and taking care of their own emotions which can exacerbate stress and anxiety [12]. Thus the aim of the study was to determine the predictors of death anxiety among Ugandan midwives who have experienced maternal death at work in order to recommend effective interventions to facilitate coping with the distress. In this study death anxiety was defined as the negative feelings midwives have about fear of their own death and death of others after experiencing maternal death at work [1]. Maternal death is defined as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to, or aggravated by the pregnancy or its management but not from accidental or incidental causes [13]. Experiencing maternal death is defined as witnessing or being present at work when death occurred of a woman within 42 days of termination of pregnancy.
county level population and offers preventive, promotive, curative, maternity and in-patient services. HC level IV serves the county level population (or health sub-district) and provides all services of HC level III, plus surgery, supervision of the lower-level HCs II and III [14]. Participants All the 238 midwives employed in the rural health care units (RHCU) in the two selected rural districts were approached to participate in the study. In order to participate in the study the participants had to be; an officially registered midwife by the Uganda Nurses and Midwives Council; directly involved in maternal health care services; employed at the RHCU for at least the past 6 months; having no history of chronic illness; and have witnessed at least one maternal death at work within the past 2 years. Of the 238 midwives employed in the two districts, 224 (94.1 %) midwives met the inclusion criteria, and consented to participate in the study. Education of midwives in Uganda is either at the associate or the bachelor’s degree level. Midwives undertaking the associate degree are trained at hospital based midwifery training institutions whereas those midwives undertaking the bachelor degree level education are trained at the University. The associate degree level midwifery training takes 3 years while the bachelor level training takes 4 years plus 1 year of clinical internship. Ethical Considerations
Methods Study Design An exploratory, descriptive design was employed in this study. Study Setting The study was conducted among professional midwives working in two rural districts (Mubende and Mityana) located in central Uganda. The districts were randomly selected from the 21 rural districts of central Uganda. In Uganda the Maternal Mortality Ratio (MMR) is 435 maternal deaths per 100 000 live births and the majority of these maternal deaths occur in rural areas where most of population live [14]. The midwives were employed in government or private Health Centres (HC) level II, HC level III and HC level IV. HC level II serves the parish level population and provide preventive, promotive, and curative services to outpatients. HC level III serves the sub-
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Permission to conduct the study was obtained from the research and ethics committees of the Uganda National Council for Science and Technology, the two districts (Mubende and Mityana) and all the RHCU’s where the midwives were employed. The research was conducted in accord with prevailing ethical principles of informed consent, voluntary choice to participate, ensuring anonymity and confidentiality and protection from discomfort and harm [15]. All the participants gave voluntary written informed consent before receiving the questionnaire used for data collection. The risk level of the respondents was low because of the non-interventional nature of the research. Data Collection Procedure After approval of the study by the research and ethics committees and prior to data collection, the researchers conducted two pre-visits to the RHCU’s to meet the health facility managers and to explain the purpose of the study. The other purpose of the pre-visits was to study the duty
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schedules of the midwives and their availability on the unit or ward during day, evening, and night shifts. The 224 midwives were approached to participate in the study during their shift breaks or times when they were not actively involved in patient care (day and evening shifts). The midwives who agreed to participate in the study were taken to a private room, where information about the study procedures, purpose and consent process was provided. The consent process was completed by signing a consent form. The consent form was collected separately from the completed questionnaire to ensure that no signed consent form is linked to any completed questionnaire (to maintain anonymity of the participants). The midwives were given up to 40 min to complete the questionnaire, before handing it into the waiting research assistant. The research assistant checked the questionnaire in front of the participant for completeness and clarity. Study Instrument In this study data was obtained using a self-administered questionnaire (SAQ) written in English. Midwives and other health professionals in Uganda are educated in English (official language of instruction at all levels of education) and English is the official national language used for all official business and in all health care settings. The SAQ had sections on demographic characteristics, maternal death experiences, the Death Distress Scale (DDS), the Brief COPE Scale and the Perceived Wellbeing Scale (PWS). Permission to use the DDS, Brief COPE Scale and PWS standardized tools was obtained from the respective authors [16–18]. The death anxiety subscale of the DDS, the Brief COPE and PWS were used to measure death anxiety, ways used by midwives to cope with maternal death experiences and well-being, respectively. The death anxiety subscale of the DDS has 8 items (see Table 2) with a total score of ranging from 8 to 40. The participants respond to each of the 8 items of the death anxiety subscale on a five point likert scale (‘‘No’’ = 1, ‘‘Little’’ = 2, ‘‘Moderate’’ = 3, ‘‘Much’’ = 4 to ‘‘Very much’’ = 5). The respondents read each statement and decide the extent to which it describes their feelings and behaviours in view of their exposure and experience with maternal death in the past 2 years. The higher scores on the death anxiety subscale denote high death anxiety [16]. In this study the Cronbach’s alpha for the death anxiety subscale was a = 0.75. In other studies the reliability of death anxiety subscale using Cronbach’s alpha has been found to range from 0.78 to 0.84 [1, 16]. The Brief COPE Scale assesses the different coping behaviours and thoughts people may have in response to a specific situation [17]. Midwives were asked about the way
they cope with maternal death using items on the Brief COPE Scale. The Brief COPE Scale contained 26 items, on a four-point likert scale (‘‘I haven’t been doing this at all’’ = 1, to ‘‘I have been doing this a lot’’ = 4. The scale has 14 subscales; self-distraction, active coping, denial, substance abuse, use of emotional support, use of instrumental support, behavioural disengagement, venting, positive reframing, humour, planning, religion, and selfblame of two items each [17]. Higher scores in each subscale represent greater use of that specific coping strategy. In this study the Cronbach’s alpha of the Brief COPE Scale was found to be 0.81. In other studies the Brief COPE Scale has been found to have Cronbach’s alpha ranging from 0.71 to 0.96 [19, 20]. The PWS is a self-reported measure of mental and physical well-being. It contains 14 items and is rated by the seven-point likert scale namely; ‘‘strongly agree’’, ‘‘agree’’, ‘‘moderately agree’’, ‘‘undecided’’, ‘‘moderately disagree’’, ‘‘disagree’’ and ‘‘strongly disagree’’. The respondents read each statement and their responses indicated the extent to which they agree or disagree with it. The items related to psychological well-being include aspects such as the presence of positive emotions such as happiness, joy and peace of mind and the absence of negative emotions such as fear, anxiety and depression. The items related to physical well-being include aspects such as self-rated physical health, vitality and perceived absence of physical discomforts. The reliability and validity of the PWS in other studies indicate high Cronbach’s alpha values of the domains; psychological well-being (a = 0.80), physical well-being (a = 0.79) and general well-being (a = 0.85) [18]. In this study, Cronbach’s alpha of the PWS was found to be 0.890. The internal consistency of the domains for physical well-being and psychological well-being were 0.82 and 0.88, respectively. Data Analysis Completed questionnaires were entered, cleaned and analyzed using SPSS (Statistical Package for Social Sciences) version 20. Descriptive statistics (presented in tables) were used to describe the participant’s characteristics and experiences with maternal death. Pearson’s Chi Square test was used to determine the factors associated with death anxiety as a result of experiencing maternal death at work. The factors considered were midwives’ experiences with maternal death, modifiable demographic characteristics, midwives well-being and methods used to cope with maternal death. Logistic regression analysis was used to determine the relative contribution of each significantly associated variable (Chi square test) to the likelihood of a midwife having death anxiety after experiencing maternal death at work.
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Matern Child Health J Table 1 Demographic characteristics of participants (N = 224)
Table 2 Participant’s scores on the death anxiety scale (N = 224)
Variable
Death Distress Scale
Gender Age in years (M = 34, SD = 6.3)
Response
f (%)
Male
46 (20.5)
Female
178 (79.5)
18–30
87 (38.8)
31–50
124 (55.4)
C51 Marital status
Highest level of professional education
13 (5.8)
Single, Separated/ divorced
101 (45.1)
Married or living with partner
123 (54.9)
Associate degree
207 (92.4)
Ward/unit of clinical practice in the health center
Type of health center where midwife is employed
High (score 30–40)
Total Number of participants who experienced maternal death
n
%
n
%
n
%
n
%
(M = 22.25; SD = 7.89)
24.5
122
54.5
45
20.1
224
100
57
M mean, SD standard deviation
Participant’s Scores on the Death Anxiety Scale
12 (5.3)
Masters’ degree in nursing
Years of experience in current ward or unit of practice in the health center (M = 3, SD = 1.34)
Moderate (score 19–29)
Death anxiety subscale
Bachelors’ degree in nursing
Years of professional experience as a midwife (M = 4, SD = 2.1)
Mild (score 8–18)
2 (2.3)
0–3
84 (37.5)
4–5
60 (26.8)
C6
80 (35.7)
\1
30 (13.3)
1–2
85 (38.0)
3–4
56 (25.0)
C5
53 (23.7)
Antenatal clinic
97 (43.3)
Delivery ward or labour room
74 (33.0)
Postnatal ward Health centre level II
53 (23.7) 110 (49.1)
Health centre level III
75 (33.5)
Health centre level IV
39 (17.4)
M mean, SD standard deviation, f frequency, % percentage
The results presented in Table 2 show that from the death anxiety scale 54.5 % of the midwives had moderate death anxiety, 25.4 % had mild death anxiety and 20.1 % had high death anxiety. The mean score on the death anxiety scale (22.25 ± 7.89) for the sample is equivalent to moderate anxiety level (score 19–29). Relationship Between Death Anxiety, Midwives Maternal Death Experiences, and Self-Rated WellBeing As shown in Table 3, there was a significant relationship between death anxiety and midwives’ experiences with maternal death such as; number of maternal deaths witnessed in the past 2 years v2 (1, n = 224) = 47.24, p = .000; number of times a midwife was in charge of a mother who died v2 (1, n = 224) = 10.97, p = .012; receiving professional training or preparation in how to handle death situations v2 (1, n = 224) = 7.69, p = .006; and perceived effectiveness of professional training in handling death situations v2 (1, n = 224) = 11.38, p = .003. Additionally, there was a significant relationship between death anxiety and midwives selfrated psychological and physical well-being in the past on 1 year, v2 (1, n = 224) = 36.41, p = .000 and v2 (1, n = 224) = 36.01, p = .000, respectively.
Characteristics of the Participants
Relationship Between Death Anxiety and the Methods Used by Midwives to Cope with Maternal Death Experiences
As shown in Table 1, the majority of participants were; female (79.5 %); in the age range of 31–50 years (55.4 %); married or living with partner (54.9 %); educated at associate degree level (92.4 %); employed at HC level II (49.1 %); and working in antenatal clinics (43.3 %). The midwives were relatively young (mean age 34 ± 6.3 years) and had an average of 4 years of professional experience.
The most common methods used by midwives to cope with maternal death experiences were; planning (65.2 %); active coping (63.4 %); instrumental support (63 %); acceptance (62.5 %); self-distraction (59.8 %); religion (58.9 %); emotional support (57.2 %); positive reframing (54 %); denial (50.9 %); venting (48.7 %); behavioural disengagement (43.3 %); self-blame (34.8 %); and substance abuse (25.5 %). As indicated in Table 4 the main methods used to cope with
Findings
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Matern Child Health J Table 3 Factors associated with death anxiety as a result of midwives experiences with maternal death Variable
Experiences with maternal death
Items
Responses
Mild n = 57 f (%)
Moderate or high n = 167 f (%)
54 (24.1)
143 (63.8) 24 (10.7)
Frequency of experiencing maternal deaths at work
Not often Often or very often
3 (1.4)
Last time a midwife experienced a maternal death at the workplace
\1-6 months ago
7 (3.2)
37 (16.5)
C7 months
50 (22.3)
130 (58.0)
Number of maternal death witnessed in past 2 years (M = 2, SD = 1.97)
1 death
14 (6.3)
24 (10.7)
2–3 deaths C4 deaths
35 (15.6) 8 (3.6)
128 (57.1) 15 (6.7)
Number of times a midwife was in charge of a mother who died (M = 2.60, SD = 1.22)
None
14 (6.3)
28 (12.5)
1–3 deaths
38 (17.0)
98 (43.8)
C4 deaths
Self-rated well-being in the past 1 year
Levels of death anxiety (N = 224)
5 (2.1)
41 (18.3)
Received support at work after experiencing a maternal death
Yes
25 (11.2)
72 (32.1)
No
32 (14.3)
95 (42.4)
Received professional training preparation about how to handle death situations
Yes
37 (16.5)
135 (60.3)
No
20 (8.9)
32 (14.3)
How well professional training prepared midwives to handle death situations
Well prepared
38 (17.0)
135 (60.3)
Not well prepared
18 (8.0)
23 (10.3)
Not prepared at all
1 (0.4)
9 (4.0)
Positive
46 (20.5)
135 (60.3)
Negative
11 (4.9)
32 (14.3)
Psychological well-being Physical well-being
Positive
4 (1.8)
12 (5.3)
Negative
53 (23.7)
155 (69.2)
v2
df p value
2.76
1
.097
1.92
1
.166
47.24
1
.000
10.97
1
.012
0.30
1
.558
7.69
1
.006
11.38
2
.003
36.41
2
.000
36.00
2
.000
M mean, SD standard deviation, v2 Pearson’s’ Chi Square, df degree of freedom, f frequency, % percentage
moderate or high death anxiety were: planning v2 (3, n = 224) = 105.25, p = .000; acceptance v2 (3, n = 224) = 81.32, p = .000; active coping v2 (3, n = 224) = 78.15, p = .000; instrumental support v2 (3, n = 224) = 76.01, p = .000; self-distraction v2 (3, n = 224) = 68.30, p = .000; and religion v2 (3, n = 224) = 65.61, p = .000. The methods used to cope with mild death anxiety included: behavioural disengagement v2 (3, n = 224) = 52.07, p = .000; instrumental support v2 (3, n = 224) = 76.01, p = .000; emotional support v2 (3, n = 224) = 64.50, p = .000; and active coping v2 (3, n = 224) = 78.15, p = .000. Predictors of Maternal Death Anxiety Among Midwives Logistic regression was used to determine the relative contribution of each of the variables with significant Chi square test results to the likelihood of having death anxiety (see Table 5). The significant predictors of death anxiety among midwives who experienced maternal death
at work included: witnessing two and more maternal deaths in the past 2 years [odds ratio (OR) = 3.18; p B .01]; being in charge of four or more maternal deaths (OR = 5.13; p B .01); lack of professional training in handling death situations (OR = 3.32; p B .05); and coping with maternal death situations at work using methods such as: planning (OR = 4.90; p B .01), active coping (OR = 3.43; p B .05); and acceptance (OR = 2.99; p B .05. The goodness-of-fit test was used to determine whether the model was correctly specified as presented in Table 5. Hosmer–Lemeshow goodness-of-fit test yielded a v2 (6, n = 224) = 3.08, p = .799 which was not significant (p [ .05), suggesting that the model was correctly specified.
Discussion In this study we explored the predictors of death anxiety among midwives who had experienced maternal death at
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Matern Child Health J Table 4 Distribution of midwives methods of coping and maternal death anxiety Methods of coping
Responses
Levels of death anxiety (N = 224) Mild n = 57 f (%)
Self-distraction
v2
df
p value
68.30
3
.000
Moderate or High n = 167 f (%)
Not at all or a little
37 (16.5)
33 (14.7)
Moderate or a lot
20 (9.0)
134 (59.8)
Active coping
Not at all or a little Moderate or a lot
36 (16.1) 21 (9.3)
25 (11.2) 142 (63.4)
78.15
3
.000
Denial
Not at all or a little
39 (17.4)
53 (23.7)
59.04
3
.000
Moderate or a lot
18 (8.0)
114 (50.9)
Not at all or a little
49 (21.9)
110 (49.1)
49.71
3
.000
Moderate or a lot
8 (3.5)
57 (25.5) 64.50
3
.000
76.01
3
.000
52.07
3
.000
59.24
3
.000
Substance abuse Emotional support Instrumental support Behavioural disengagement Venting
Not at all or a little
36 (16.1)
39 (17.4)
Moderate or a lot
21 (9.3)
128 (57.2)
Not at all or a little
36 (16.1)
26 (11.6)
Moderate or a lot
21 (9.3)
141 (63.0)
Not at all or a little
31 (13.8)
70 (31.3)
Moderate or a lot
26 (11.6)
97 (43.3)
Not at all or a little
41 (18.3)
58 (25.9)
Moderate or a lot
16 (7.1)
109 (48.7)
Positive reframing
Not at all or a little
37 (16.5)
46 (20.5)
61.87
3
.000
Planning
Moderate or a lot Not at all or a little
20 (9.0) 44 (19.6)
121 (54.0) 21 (9.3)
105.25
3
.000
Moderate or a lot
13 (5.9)
146 (65.2)
Not at all or a little
40 (17.9)
27 (12.1)
81.32
3
.000
Moderate or a lot
17 (7.5)
140 (62.5)
Not at all or a little
37 (16.5)
35 (15.6)
65.61
3
.000
Moderate or a lot
20 (9.0)
132 (58.9) 55.81
3
.000
Acceptance Religion Self-blame
Not at all or a little
44 (19.6)
89 (39.7)
Moderate or a lot
13 (5.9)
78 (34.8)
v2 Pearson’s’ Chi Square, df degree of freedom, f frequency; % percentage
work and working in rural areas. The majority of participants had moderate or high death anxiety. The level of death anxiety found in midwives in the study may have been influenced by young age, limited years of professional experience, and lack of professional training to handle death situations. Studies done among other health care professionals who experienced death situations at work show that gender (female), young age, having limited professional experience, and lack education or training on issues of death and dying, often report higher levels of death anxiety [21–23]. The majority of the participants in the study were female. In this study significant predictors of having death anxiety in midwives who had experienced maternal death at work were; witnessing two and more deaths in the past 2 years; being in charge of four or more maternal deaths; lack of professional training in handling death situations; and coping with maternal death situations using methods such as active
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coping, planning and acceptance. According to Bryan [5] witnessing sudden or unexpected death such as those deaths occurring in obstetric wards, often causes high levels of anxiety among health care professionals. Additionally, when health care professionals experience frequent patient deaths without training on coping with death situations they tend to get exacerbation of the distress and anxiety caused by death of a patient [5, 24]. It is important to note that when health care professionals are in-charge of patients when they die, often leads to feelings of guilt, failure, inadequacy and worsening of death related anxiety [24, 25]. In this study midwives were mostly coping with maternal death experiences using methods such as planning, acceptance and active coping. In this study planning was defined as a strategy or steps taken to manage death anxiety. Acceptance was defined as accepting the reality of the fact that maternal death happened and learning to live with it and
Matern Child Health J Table 5 Predictors of death anxiety among midwives Variable
Responses
b
SE
Wald
df
Sig.
Exp (b)
Experiences with maternal death Number of maternal deaths witnessed in the past 2 years
Number of times a midwife was in charge of a mother who died
1 death**
1.00
2–3 deaths
1.16
.152
5.87
1
.00*
3.18
[4 deaths
1.78
.720
5.99
1
.00*
4. 13
None**
0.00
1–3 deaths Perception of professional training to handle death situations
0.00
.039
[4 deaths
1.64
Well prepared**
0.00
Not well prepared Not prepared at all
1.00 .377
1.06
1
.304
.618
6.99
1
.008*
1.48 5.13 1.00
-1.08
.653
2.75
1
.098
.338
1.20
.372
10.41
1
.001*
3.32
.582
14.126
1
.000*
Method used to cope with maternal death situations at work Planning Active coping Acceptance
Not at all or a little**
0.00
Moderate or a lot
2.19
Not at all or a little**
0.00
Moderate or a lot
1.23
Not at all or a little**
0.00
Moderate or a lot
1.10
1.00 4.90 1.00 .558
4.873
1
.027*
3.43 1.00
.591
3.434
1
.042*
2.99
2
Hosmer–Lemeshow Goodness-of-fit test v (6, n = 224) = 3.081, p = .799 Cox and Snell R Squared = .359 Nagelkerke R squared = .537 b = Parameter estimates, S.E = Standard Error, Wald statistics, df = degree of freedom, Exp (b) = Odds ratio, ** Reference category, * significant level
active coping was defined as trying to take action to make the situation better [17]. These methods are problem-focussed coping strategies which are usually used to handle distressing situations by performing certain behaviours [26]. However in this sample these problem-focussed coping strategies were not effective in preventing the death anxiety experienced in midwives. Therefore there is need for deliberate interventions to support midwives to cope with death situations and associated death anxiety. Literature shows that effective interventions that can facilitate coping with the distress and anxiety stemming from experiencing death situations to be death education and training, counselling, open communication using debriefing sessions, respite care, support and mentoring [27–30]. When midwives are faced with maternal death and death situations, they are expected to provide support for patients, families and help maintain the emotional well-being of all involved [8, 31]. However, midwives can only support and help patients and families if they are well educated, trained and mentored in matters of death and dying. The training and education about death and handling death situations empowers the midwives to communicate bad news, cope with patient death, and provide optimal care for other patients and their families without significant detriment to their own well-being [27, 32].
Employers of midwives can initiate support programs for midwives who have experienced death anxiety situations to promote positive coping. The support programmes can focus on activities such as peer support, counselling, mentoring, debriefing sessions after death experiences. The support activities can provide midwives with opportunities for sharing experiences sharing, interpersonal learning, catharsis, self-awareness, self-care and to establish a healthy basis for handling future death experiences. Therefore we recommend that employers and managers of units where maternal death situations are common to regularly monitor death anxiety among midwives: who have witnessed two and more maternal deaths, have been in charge of four and more maternal deaths, who do not have any professional training to handle death situations. Because these factors predict death anxiety among this population. However, employers and managers can intervene as appropriate to facilitate coping with death anxiety using strategies shown in literature to be effective and which are summarized under the acronym ‘‘CORES’’: •
C: Counselling services by a professional counsellor help midwives open up, explore and understand their
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•
•
•
•
feelings in order to come to terms with the maternal death situation [33, 34]. O: Open communication through debriefing sessions following a maternal death at the workplace to allow all team members a chance to speak up, raise questions and show emotions [30]. R: Respite care by taking time away from health care activities following a maternal death to help reduce death anxiety [35]. E: Education and training to increase the midwives understanding of issues pertaining to death and dying and to help them cope with the stress and anxiety associated with maternal death [9, 21]. S: Support from peers to provide opportunities to receive care from colleagues involved in similar work tasks and with whom they can comfortably share their emotions [34, 35].
employers to provide deliberate support to enable midwives to cope with death anxiety at work. What the paper adds to existing knowledge •
• •
The study highlights the predictors of death anxiety among midwives who have experienced maternal death at work. Describes methods of coping resulting from experiencing maternal death at work. Recommends interventions that employers and managers can use to facilitate coping with death situations and death anxiety at the work place.
Acknowledgments The authors would like to thank Sultan Qaboos University Medical Library for allowing them to use their databases. Conflict of interest of interest.
The authors declare that they have no conflict
Limitations There was very limited literature about midwives’ experiences with death anxiety stemming from maternal death in Uganda, Africa and internationally. During data collection the midwives had to recall feelings about death situations that took place in the past 1–24 months and this could have affected the way they answered the questions. Education on issues of death and dying is covered in more details during the bachelor’s degree curricula than in the associate degree midwifery curricula and this could have affected the way the midwives could have interpreted or answered the questions. The study was conducted among professional midwives in two districts of central Uganda, therefore results may not be generalized to the whole country. The study did not include midwives who worked outside the health centres and yet there are many births that occur at home. The study did not address the issue of caring for the infant after maternal death occurred which could have exacerbated midwives death anxiety. Therefore the results should be interpreted with caution.
Conclusion Frequent exposure to maternal deaths situations at work is associated with an increase in death anxiety among midwives working in rural settings. The midwives who get death anxiety after experiencing maternal death situations can be predicted using factors such as: number of maternal deaths witnessed, number of maternal deaths one has been in-charge of, lack of professional training in handling death situations, and coping with maternal death situations using problem-focussed methods. Therefore there is need for
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Predictors of Death Anxiety Among Midwives Who have Experienced Maternal Death Situations at Work Rhoda Suubi Muliira • Vito Bosco Sendikadiwa Fred Lwasampijja
•
Springer Science+Business Media New York 2014
Abstract One of the hardships faced by midwives in developing countries is dealing with maternal death. Taking care of pregnant women who end up dying makes midwives mindful of their own mortality and this experience provokes discomfort and anxiety. To determine the predictors of death anxiety among midwives who have experienced maternal death at work in order to recommend interventions to facilitate effective coping with the distress. An exploratory, descriptive design was used to collect data about death anxiety from 224 midwives working in two rural districts of Uganda. Death anxiety was measured using a subscale of the Death Distress Scale. The majority of participants were female (80 %) and with associate degree level professional education (92 %). Participant’s mean age and years of professional experience were 34 (±6.3) and 4 (±2.1) years, respectively. Most participants (74.6 %) had moderate or high death anxiety. The predictors of death anxiety were: having witnessed two and more maternal death in the past 2 years [odds ratio (OR) = 3.175; p B .01]; being in charge of four or more maternal deaths (OR = 5.13; p B .01); lack of professional training in handling death situations (OR = 3.32; p B .01); and coping with maternal death situations using methods such as: planning (OR = 4.90;
R. S. Muliira (&) College of Nursing, Sultan Qaboos University, AlKhod, P.O. Box 66, Muscat, Oman e-mail: [email protected] V. B. Sendikadiwa Mubende District Local Government, P.O. Box 93, Mubende, Uganda F. Lwasampijja Mityana District Local Government, P.O. Box 332, Mityana, Uganda
p B .01), active coping (OR = 3.43; p B .05) and acceptance (OR = 2.99; p B .05). Multiple exposure to maternal death situations is associated with an increase in death anxiety among midwives working in rural settings. Employers need to provide deliberate support to enable midwives to cope effectively with death anxiety at work. Keywords Coping Death anxiety Maternal death Midwives Uganda
Introduction Death is an inevitable part of all living organisms and death anxiety is a term used to conceptualize the apprehension generated by death awareness [1]. Confronting death and the anxiety generated by knowledge of its inevitability is a universal psychological predicament for human beings [2]. For midwives working in rural settings of developing countries maternal death is still a reality in clinical practice as is the joy of birth [3]. Experiencing death situations such as maternal death for a prolonged period of time or multiple times is common in rural areas of developing countries, because of the general shortage and the low quality of the resources available to provide maternity services [4]. Therefore maternal deaths are one of the situations that are a source of stress and anxiety in midwifery practice in developing countries. For instance sudden death occurring in obstetric wards is reported to be traumatic to midwives and other health care providers involved in the mother’s care due to its unexpected nature [5, 6]. Thus maternal death is something midwives do not enjoy experiencing and causes discomfort and anxiety [7, 8]. The resulting death anxiety can be worsened by working in stressful environment or unpredictable circumstances [2].
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The lack of knowledge and skills related to death and dying, does not only increase anxiety levels and emotional discomfort [7], but also makes health care providers unable to effectively cope with their own feelings and care for patient at the same time during death situations. Literature shows that many health care providers currently in practice did not receive specific training or preparation in dealing with death situations [9–11]. Witnessing patient death and the quality of death witnessed, affects the level of anxiety experienced by the health care provider [5]. When maternal death occurs the midwives are faced with a difficult task of informing the relatives, dealing with the body, and taking care of their own emotions which can exacerbate stress and anxiety [12]. Thus the aim of the study was to determine the predictors of death anxiety among Ugandan midwives who have experienced maternal death at work in order to recommend effective interventions to facilitate coping with the distress. In this study death anxiety was defined as the negative feelings midwives have about fear of their own death and death of others after experiencing maternal death at work [1]. Maternal death is defined as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to, or aggravated by the pregnancy or its management but not from accidental or incidental causes [13]. Experiencing maternal death is defined as witnessing or being present at work when death occurred of a woman within 42 days of termination of pregnancy.
county level population and offers preventive, promotive, curative, maternity and in-patient services. HC level IV serves the county level population (or health sub-district) and provides all services of HC level III, plus surgery, supervision of the lower-level HCs II and III [14]. Participants All the 238 midwives employed in the rural health care units (RHCU) in the two selected rural districts were approached to participate in the study. In order to participate in the study the participants had to be; an officially registered midwife by the Uganda Nurses and Midwives Council; directly involved in maternal health care services; employed at the RHCU for at least the past 6 months; having no history of chronic illness; and have witnessed at least one maternal death at work within the past 2 years. Of the 238 midwives employed in the two districts, 224 (94.1 %) midwives met the inclusion criteria, and consented to participate in the study. Education of midwives in Uganda is either at the associate or the bachelor’s degree level. Midwives undertaking the associate degree are trained at hospital based midwifery training institutions whereas those midwives undertaking the bachelor degree level education are trained at the University. The associate degree level midwifery training takes 3 years while the bachelor level training takes 4 years plus 1 year of clinical internship. Ethical Considerations
Methods Study Design An exploratory, descriptive design was employed in this study. Study Setting The study was conducted among professional midwives working in two rural districts (Mubende and Mityana) located in central Uganda. The districts were randomly selected from the 21 rural districts of central Uganda. In Uganda the Maternal Mortality Ratio (MMR) is 435 maternal deaths per 100 000 live births and the majority of these maternal deaths occur in rural areas where most of population live [14]. The midwives were employed in government or private Health Centres (HC) level II, HC level III and HC level IV. HC level II serves the parish level population and provide preventive, promotive, and curative services to outpatients. HC level III serves the sub-
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Permission to conduct the study was obtained from the research and ethics committees of the Uganda National Council for Science and Technology, the two districts (Mubende and Mityana) and all the RHCU’s where the midwives were employed. The research was conducted in accord with prevailing ethical principles of informed consent, voluntary choice to participate, ensuring anonymity and confidentiality and protection from discomfort and harm [15]. All the participants gave voluntary written informed consent before receiving the questionnaire used for data collection. The risk level of the respondents was low because of the non-interventional nature of the research. Data Collection Procedure After approval of the study by the research and ethics committees and prior to data collection, the researchers conducted two pre-visits to the RHCU’s to meet the health facility managers and to explain the purpose of the study. The other purpose of the pre-visits was to study the duty
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schedules of the midwives and their availability on the unit or ward during day, evening, and night shifts. The 224 midwives were approached to participate in the study during their shift breaks or times when they were not actively involved in patient care (day and evening shifts). The midwives who agreed to participate in the study were taken to a private room, where information about the study procedures, purpose and consent process was provided. The consent process was completed by signing a consent form. The consent form was collected separately from the completed questionnaire to ensure that no signed consent form is linked to any completed questionnaire (to maintain anonymity of the participants). The midwives were given up to 40 min to complete the questionnaire, before handing it into the waiting research assistant. The research assistant checked the questionnaire in front of the participant for completeness and clarity. Study Instrument In this study data was obtained using a self-administered questionnaire (SAQ) written in English. Midwives and other health professionals in Uganda are educated in English (official language of instruction at all levels of education) and English is the official national language used for all official business and in all health care settings. The SAQ had sections on demographic characteristics, maternal death experiences, the Death Distress Scale (DDS), the Brief COPE Scale and the Perceived Wellbeing Scale (PWS). Permission to use the DDS, Brief COPE Scale and PWS standardized tools was obtained from the respective authors [16–18]. The death anxiety subscale of the DDS, the Brief COPE and PWS were used to measure death anxiety, ways used by midwives to cope with maternal death experiences and well-being, respectively. The death anxiety subscale of the DDS has 8 items (see Table 2) with a total score of ranging from 8 to 40. The participants respond to each of the 8 items of the death anxiety subscale on a five point likert scale (‘‘No’’ = 1, ‘‘Little’’ = 2, ‘‘Moderate’’ = 3, ‘‘Much’’ = 4 to ‘‘Very much’’ = 5). The respondents read each statement and decide the extent to which it describes their feelings and behaviours in view of their exposure and experience with maternal death in the past 2 years. The higher scores on the death anxiety subscale denote high death anxiety [16]. In this study the Cronbach’s alpha for the death anxiety subscale was a = 0.75. In other studies the reliability of death anxiety subscale using Cronbach’s alpha has been found to range from 0.78 to 0.84 [1, 16]. The Brief COPE Scale assesses the different coping behaviours and thoughts people may have in response to a specific situation [17]. Midwives were asked about the way
they cope with maternal death using items on the Brief COPE Scale. The Brief COPE Scale contained 26 items, on a four-point likert scale (‘‘I haven’t been doing this at all’’ = 1, to ‘‘I have been doing this a lot’’ = 4. The scale has 14 subscales; self-distraction, active coping, denial, substance abuse, use of emotional support, use of instrumental support, behavioural disengagement, venting, positive reframing, humour, planning, religion, and selfblame of two items each [17]. Higher scores in each subscale represent greater use of that specific coping strategy. In this study the Cronbach’s alpha of the Brief COPE Scale was found to be 0.81. In other studies the Brief COPE Scale has been found to have Cronbach’s alpha ranging from 0.71 to 0.96 [19, 20]. The PWS is a self-reported measure of mental and physical well-being. It contains 14 items and is rated by the seven-point likert scale namely; ‘‘strongly agree’’, ‘‘agree’’, ‘‘moderately agree’’, ‘‘undecided’’, ‘‘moderately disagree’’, ‘‘disagree’’ and ‘‘strongly disagree’’. The respondents read each statement and their responses indicated the extent to which they agree or disagree with it. The items related to psychological well-being include aspects such as the presence of positive emotions such as happiness, joy and peace of mind and the absence of negative emotions such as fear, anxiety and depression. The items related to physical well-being include aspects such as self-rated physical health, vitality and perceived absence of physical discomforts. The reliability and validity of the PWS in other studies indicate high Cronbach’s alpha values of the domains; psychological well-being (a = 0.80), physical well-being (a = 0.79) and general well-being (a = 0.85) [18]. In this study, Cronbach’s alpha of the PWS was found to be 0.890. The internal consistency of the domains for physical well-being and psychological well-being were 0.82 and 0.88, respectively. Data Analysis Completed questionnaires were entered, cleaned and analyzed using SPSS (Statistical Package for Social Sciences) version 20. Descriptive statistics (presented in tables) were used to describe the participant’s characteristics and experiences with maternal death. Pearson’s Chi Square test was used to determine the factors associated with death anxiety as a result of experiencing maternal death at work. The factors considered were midwives’ experiences with maternal death, modifiable demographic characteristics, midwives well-being and methods used to cope with maternal death. Logistic regression analysis was used to determine the relative contribution of each significantly associated variable (Chi square test) to the likelihood of a midwife having death anxiety after experiencing maternal death at work.
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Matern Child Health J Table 1 Demographic characteristics of participants (N = 224)
Table 2 Participant’s scores on the death anxiety scale (N = 224)
Variable
Death Distress Scale
Gender Age in years (M = 34, SD = 6.3)
Response
f (%)
Male
46 (20.5)
Female
178 (79.5)
18–30
87 (38.8)
31–50
124 (55.4)
C51 Marital status
Highest level of professional education
13 (5.8)
Single, Separated/ divorced
101 (45.1)
Married or living with partner
123 (54.9)
Associate degree
207 (92.4)
Ward/unit of clinical practice in the health center
Type of health center where midwife is employed
High (score 30–40)
Total Number of participants who experienced maternal death
n
%
n
%
n
%
n
%
(M = 22.25; SD = 7.89)
24.5
122
54.5
45
20.1
224
100
57
M mean, SD standard deviation
Participant’s Scores on the Death Anxiety Scale
12 (5.3)
Masters’ degree in nursing
Years of experience in current ward or unit of practice in the health center (M = 3, SD = 1.34)
Moderate (score 19–29)
Death anxiety subscale
Bachelors’ degree in nursing
Years of professional experience as a midwife (M = 4, SD = 2.1)
Mild (score 8–18)
2 (2.3)
0–3
84 (37.5)
4–5
60 (26.8)
C6
80 (35.7)
\1
30 (13.3)
1–2
85 (38.0)
3–4
56 (25.0)
C5
53 (23.7)
Antenatal clinic
97 (43.3)
Delivery ward or labour room
74 (33.0)
Postnatal ward Health centre level II
53 (23.7) 110 (49.1)
Health centre level III
75 (33.5)
Health centre level IV
39 (17.4)
M mean, SD standard deviation, f frequency, % percentage
The results presented in Table 2 show that from the death anxiety scale 54.5 % of the midwives had moderate death anxiety, 25.4 % had mild death anxiety and 20.1 % had high death anxiety. The mean score on the death anxiety scale (22.25 ± 7.89) for the sample is equivalent to moderate anxiety level (score 19–29). Relationship Between Death Anxiety, Midwives Maternal Death Experiences, and Self-Rated WellBeing As shown in Table 3, there was a significant relationship between death anxiety and midwives’ experiences with maternal death such as; number of maternal deaths witnessed in the past 2 years v2 (1, n = 224) = 47.24, p = .000; number of times a midwife was in charge of a mother who died v2 (1, n = 224) = 10.97, p = .012; receiving professional training or preparation in how to handle death situations v2 (1, n = 224) = 7.69, p = .006; and perceived effectiveness of professional training in handling death situations v2 (1, n = 224) = 11.38, p = .003. Additionally, there was a significant relationship between death anxiety and midwives selfrated psychological and physical well-being in the past on 1 year, v2 (1, n = 224) = 36.41, p = .000 and v2 (1, n = 224) = 36.01, p = .000, respectively.
Characteristics of the Participants
Relationship Between Death Anxiety and the Methods Used by Midwives to Cope with Maternal Death Experiences
As shown in Table 1, the majority of participants were; female (79.5 %); in the age range of 31–50 years (55.4 %); married or living with partner (54.9 %); educated at associate degree level (92.4 %); employed at HC level II (49.1 %); and working in antenatal clinics (43.3 %). The midwives were relatively young (mean age 34 ± 6.3 years) and had an average of 4 years of professional experience.
The most common methods used by midwives to cope with maternal death experiences were; planning (65.2 %); active coping (63.4 %); instrumental support (63 %); acceptance (62.5 %); self-distraction (59.8 %); religion (58.9 %); emotional support (57.2 %); positive reframing (54 %); denial (50.9 %); venting (48.7 %); behavioural disengagement (43.3 %); self-blame (34.8 %); and substance abuse (25.5 %). As indicated in Table 4 the main methods used to cope with
Findings
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Matern Child Health J Table 3 Factors associated with death anxiety as a result of midwives experiences with maternal death Variable
Experiences with maternal death
Items
Responses
Mild n = 57 f (%)
Moderate or high n = 167 f (%)
54 (24.1)
143 (63.8) 24 (10.7)
Frequency of experiencing maternal deaths at work
Not often Often or very often
3 (1.4)
Last time a midwife experienced a maternal death at the workplace
\1-6 months ago
7 (3.2)
37 (16.5)
C7 months
50 (22.3)
130 (58.0)
Number of maternal death witnessed in past 2 years (M = 2, SD = 1.97)
1 death
14 (6.3)
24 (10.7)
2–3 deaths C4 deaths
35 (15.6) 8 (3.6)
128 (57.1) 15 (6.7)
Number of times a midwife was in charge of a mother who died (M = 2.60, SD = 1.22)
None
14 (6.3)
28 (12.5)
1–3 deaths
38 (17.0)
98 (43.8)
C4 deaths
Self-rated well-being in the past 1 year
Levels of death anxiety (N = 224)
5 (2.1)
41 (18.3)
Received support at work after experiencing a maternal death
Yes
25 (11.2)
72 (32.1)
No
32 (14.3)
95 (42.4)
Received professional training preparation about how to handle death situations
Yes
37 (16.5)
135 (60.3)
No
20 (8.9)
32 (14.3)
How well professional training prepared midwives to handle death situations
Well prepared
38 (17.0)
135 (60.3)
Not well prepared
18 (8.0)
23 (10.3)
Not prepared at all
1 (0.4)
9 (4.0)
Positive
46 (20.5)
135 (60.3)
Negative
11 (4.9)
32 (14.3)
Psychological well-being Physical well-being
Positive
4 (1.8)
12 (5.3)
Negative
53 (23.7)
155 (69.2)
v2
df p value
2.76
1
.097
1.92
1
.166
47.24
1
.000
10.97
1
.012
0.30
1
.558
7.69
1
.006
11.38
2
.003
36.41
2
.000
36.00
2
.000
M mean, SD standard deviation, v2 Pearson’s’ Chi Square, df degree of freedom, f frequency, % percentage
moderate or high death anxiety were: planning v2 (3, n = 224) = 105.25, p = .000; acceptance v2 (3, n = 224) = 81.32, p = .000; active coping v2 (3, n = 224) = 78.15, p = .000; instrumental support v2 (3, n = 224) = 76.01, p = .000; self-distraction v2 (3, n = 224) = 68.30, p = .000; and religion v2 (3, n = 224) = 65.61, p = .000. The methods used to cope with mild death anxiety included: behavioural disengagement v2 (3, n = 224) = 52.07, p = .000; instrumental support v2 (3, n = 224) = 76.01, p = .000; emotional support v2 (3, n = 224) = 64.50, p = .000; and active coping v2 (3, n = 224) = 78.15, p = .000. Predictors of Maternal Death Anxiety Among Midwives Logistic regression was used to determine the relative contribution of each of the variables with significant Chi square test results to the likelihood of having death anxiety (see Table 5). The significant predictors of death anxiety among midwives who experienced maternal death
at work included: witnessing two and more maternal deaths in the past 2 years [odds ratio (OR) = 3.18; p B .01]; being in charge of four or more maternal deaths (OR = 5.13; p B .01); lack of professional training in handling death situations (OR = 3.32; p B .05); and coping with maternal death situations at work using methods such as: planning (OR = 4.90; p B .01), active coping (OR = 3.43; p B .05); and acceptance (OR = 2.99; p B .05. The goodness-of-fit test was used to determine whether the model was correctly specified as presented in Table 5. Hosmer–Lemeshow goodness-of-fit test yielded a v2 (6, n = 224) = 3.08, p = .799 which was not significant (p [ .05), suggesting that the model was correctly specified.
Discussion In this study we explored the predictors of death anxiety among midwives who had experienced maternal death at
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Matern Child Health J Table 4 Distribution of midwives methods of coping and maternal death anxiety Methods of coping
Responses
Levels of death anxiety (N = 224) Mild n = 57 f (%)
Self-distraction
v2
df
p value
68.30
3
.000
Moderate or High n = 167 f (%)
Not at all or a little
37 (16.5)
33 (14.7)
Moderate or a lot
20 (9.0)
134 (59.8)
Active coping
Not at all or a little Moderate or a lot
36 (16.1) 21 (9.3)
25 (11.2) 142 (63.4)
78.15
3
.000
Denial
Not at all or a little
39 (17.4)
53 (23.7)
59.04
3
.000
Moderate or a lot
18 (8.0)
114 (50.9)
Not at all or a little
49 (21.9)
110 (49.1)
49.71
3
.000
Moderate or a lot
8 (3.5)
57 (25.5) 64.50
3
.000
76.01
3
.000
52.07
3
.000
59.24
3
.000
Substance abuse Emotional support Instrumental support Behavioural disengagement Venting
Not at all or a little
36 (16.1)
39 (17.4)
Moderate or a lot
21 (9.3)
128 (57.2)
Not at all or a little
36 (16.1)
26 (11.6)
Moderate or a lot
21 (9.3)
141 (63.0)
Not at all or a little
31 (13.8)
70 (31.3)
Moderate or a lot
26 (11.6)
97 (43.3)
Not at all or a little
41 (18.3)
58 (25.9)
Moderate or a lot
16 (7.1)
109 (48.7)
Positive reframing
Not at all or a little
37 (16.5)
46 (20.5)
61.87
3
.000
Planning
Moderate or a lot Not at all or a little
20 (9.0) 44 (19.6)
121 (54.0) 21 (9.3)
105.25
3
.000
Moderate or a lot
13 (5.9)
146 (65.2)
Not at all or a little
40 (17.9)
27 (12.1)
81.32
3
.000
Moderate or a lot
17 (7.5)
140 (62.5)
Not at all or a little
37 (16.5)
35 (15.6)
65.61
3
.000
Moderate or a lot
20 (9.0)
132 (58.9) 55.81
3
.000
Acceptance Religion Self-blame
Not at all or a little
44 (19.6)
89 (39.7)
Moderate or a lot
13 (5.9)
78 (34.8)
v2 Pearson’s’ Chi Square, df degree of freedom, f frequency; % percentage
work and working in rural areas. The majority of participants had moderate or high death anxiety. The level of death anxiety found in midwives in the study may have been influenced by young age, limited years of professional experience, and lack of professional training to handle death situations. Studies done among other health care professionals who experienced death situations at work show that gender (female), young age, having limited professional experience, and lack education or training on issues of death and dying, often report higher levels of death anxiety [21–23]. The majority of the participants in the study were female. In this study significant predictors of having death anxiety in midwives who had experienced maternal death at work were; witnessing two and more deaths in the past 2 years; being in charge of four or more maternal deaths; lack of professional training in handling death situations; and coping with maternal death situations using methods such as active
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coping, planning and acceptance. According to Bryan [5] witnessing sudden or unexpected death such as those deaths occurring in obstetric wards, often causes high levels of anxiety among health care professionals. Additionally, when health care professionals experience frequent patient deaths without training on coping with death situations they tend to get exacerbation of the distress and anxiety caused by death of a patient [5, 24]. It is important to note that when health care professionals are in-charge of patients when they die, often leads to feelings of guilt, failure, inadequacy and worsening of death related anxiety [24, 25]. In this study midwives were mostly coping with maternal death experiences using methods such as planning, acceptance and active coping. In this study planning was defined as a strategy or steps taken to manage death anxiety. Acceptance was defined as accepting the reality of the fact that maternal death happened and learning to live with it and
Matern Child Health J Table 5 Predictors of death anxiety among midwives Variable
Responses
b
SE
Wald
df
Sig.
Exp (b)
Experiences with maternal death Number of maternal deaths witnessed in the past 2 years
Number of times a midwife was in charge of a mother who died
1 death**
1.00
2–3 deaths
1.16
.152
5.87
1
.00*
3.18
[4 deaths
1.78
.720
5.99
1
.00*
4. 13
None**
0.00
1–3 deaths Perception of professional training to handle death situations
0.00
.039
[4 deaths
1.64
Well prepared**
0.00
Not well prepared Not prepared at all
1.00 .377
1.06
1
.304
.618
6.99
1
.008*
1.48 5.13 1.00
-1.08
.653
2.75
1
.098
.338
1.20
.372
10.41
1
.001*
3.32
.582
14.126
1
.000*
Method used to cope with maternal death situations at work Planning Active coping Acceptance
Not at all or a little**
0.00
Moderate or a lot
2.19
Not at all or a little**
0.00
Moderate or a lot
1.23
Not at all or a little**
0.00
Moderate or a lot
1.10
1.00 4.90 1.00 .558
4.873
1
.027*
3.43 1.00
.591
3.434
1
.042*
2.99
2
Hosmer–Lemeshow Goodness-of-fit test v (6, n = 224) = 3.081, p = .799 Cox and Snell R Squared = .359 Nagelkerke R squared = .537 b = Parameter estimates, S.E = Standard Error, Wald statistics, df = degree of freedom, Exp (b) = Odds ratio, ** Reference category, * significant level
active coping was defined as trying to take action to make the situation better [17]. These methods are problem-focussed coping strategies which are usually used to handle distressing situations by performing certain behaviours [26]. However in this sample these problem-focussed coping strategies were not effective in preventing the death anxiety experienced in midwives. Therefore there is need for deliberate interventions to support midwives to cope with death situations and associated death anxiety. Literature shows that effective interventions that can facilitate coping with the distress and anxiety stemming from experiencing death situations to be death education and training, counselling, open communication using debriefing sessions, respite care, support and mentoring [27–30]. When midwives are faced with maternal death and death situations, they are expected to provide support for patients, families and help maintain the emotional well-being of all involved [8, 31]. However, midwives can only support and help patients and families if they are well educated, trained and mentored in matters of death and dying. The training and education about death and handling death situations empowers the midwives to communicate bad news, cope with patient death, and provide optimal care for other patients and their families without significant detriment to their own well-being [27, 32].
Employers of midwives can initiate support programs for midwives who have experienced death anxiety situations to promote positive coping. The support programmes can focus on activities such as peer support, counselling, mentoring, debriefing sessions after death experiences. The support activities can provide midwives with opportunities for sharing experiences sharing, interpersonal learning, catharsis, self-awareness, self-care and to establish a healthy basis for handling future death experiences. Therefore we recommend that employers and managers of units where maternal death situations are common to regularly monitor death anxiety among midwives: who have witnessed two and more maternal deaths, have been in charge of four and more maternal deaths, who do not have any professional training to handle death situations. Because these factors predict death anxiety among this population. However, employers and managers can intervene as appropriate to facilitate coping with death anxiety using strategies shown in literature to be effective and which are summarized under the acronym ‘‘CORES’’: •
C: Counselling services by a professional counsellor help midwives open up, explore and understand their
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Matern Child Health J
•
•
•
•
feelings in order to come to terms with the maternal death situation [33, 34]. O: Open communication through debriefing sessions following a maternal death at the workplace to allow all team members a chance to speak up, raise questions and show emotions [30]. R: Respite care by taking time away from health care activities following a maternal death to help reduce death anxiety [35]. E: Education and training to increase the midwives understanding of issues pertaining to death and dying and to help them cope with the stress and anxiety associated with maternal death [9, 21]. S: Support from peers to provide opportunities to receive care from colleagues involved in similar work tasks and with whom they can comfortably share their emotions [34, 35].
employers to provide deliberate support to enable midwives to cope with death anxiety at work. What the paper adds to existing knowledge •
• •
The study highlights the predictors of death anxiety among midwives who have experienced maternal death at work. Describes methods of coping resulting from experiencing maternal death at work. Recommends interventions that employers and managers can use to facilitate coping with death situations and death anxiety at the work place.
Acknowledgments The authors would like to thank Sultan Qaboos University Medical Library for allowing them to use their databases. Conflict of interest of interest.
The authors declare that they have no conflict
Limitations There was very limited literature about midwives’ experiences with death anxiety stemming from maternal death in Uganda, Africa and internationally. During data collection the midwives had to recall feelings about death situations that took place in the past 1–24 months and this could have affected the way they answered the questions. Education on issues of death and dying is covered in more details during the bachelor’s degree curricula than in the associate degree midwifery curricula and this could have affected the way the midwives could have interpreted or answered the questions. The study was conducted among professional midwives in two districts of central Uganda, therefore results may not be generalized to the whole country. The study did not include midwives who worked outside the health centres and yet there are many births that occur at home. The study did not address the issue of caring for the infant after maternal death occurred which could have exacerbated midwives death anxiety. Therefore the results should be interpreted with caution.
Conclusion Frequent exposure to maternal deaths situations at work is associated with an increase in death anxiety among midwives working in rural settings. The midwives who get death anxiety after experiencing maternal death situations can be predicted using factors such as: number of maternal deaths witnessed, number of maternal deaths one has been in-charge of, lack of professional training in handling death situations, and coping with maternal death situations using problem-focussed methods. Therefore there is need for
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