Do student midwives have elevated levels of anxiety, depression and stress?

Introduction

Clinical placement is acknowledged as a fundamental aspect of learning and professional development for students undertaking education in healthcare disciplines, as it enables students to integrate theoretical knowledge with clinical practice to develop skills and competencies (Graj, Sheen, & Dudley, 2019). Studies from different countries show that some clinical programmes have consistently demonstrated that health care students have higher stress and anxiety levels than the general population (Riberio & Pereira, 2018).1, 2, 3, 4, 5

Few studies have been completed on student midwives’ mental health in Australia. Similar studies looking at midwifery student burnout outside Australia have also highlighted the lack of research exploring student midwife secondary traumatic stress and burnout (Beaumont & Durkin, 2016). Student midwives are involved in the same undertakings as registered midwives; however, they do not have access to the many workplace-initiated mental health supports made available to registered midwives by their employers or unions. It is widely known that there needs to be ongoing mental health recognition, development and support for registered midwives, as multiple studies have shown they experience elevated levels of anxiety and depression due to the nature of their job (Kuipers & Mestdagh, 2023).

Stress is the body’s reaction to a trigger and is usually a short-term experience, whereas anxiety is a sustained mental health disorder that can be triggered by stress and can adversely affect social, occupational and other areas of functioning (Bennett, 2017). While some degree of stress acts as a stimulus for learning, excessive stress can disrupt the cognitive processes involved in memory and learning, negatively affecting academic outcomes (Dalton & Davidson, 2011). Depression is characterised by reduced self-esteem, apathy and anhedonia (Garcia & Martins, 2022). If students are exposed to high levels of anxiety, stress and depression, this can impact the quality of care they provide as well as their future in midwifery.

Australia is experiencing an increased need for student midwives due to a dire nurse/midwife shortage (Kuipers & Mestdagh, 2023). Poor psychological well-being can impact students’ completion of their studies, further exacerbating the problems of recruitment and retention in the midwifery workforce (Wynter & Redley, 2021). To maximise student retention, it is imperative that their experiences while undertaking the bachelor of midwifery are positive, and unnecessary challenges minimised, specifically mental health challenges (Fenwick & Gamble, 2016). Midwives are experts in their level of care, but often the road to becoming a midwife is not easy. They may encounter various outcomes, including both straightforward and complex pregnancies, which can have a profound impact on their emotional and mental well-being (Leinweber & Rowe, 2010). Midwives can indirectly experience traumatic events by witnessing them or listening to accounts of birthing episodes that encompass trauma exposure (Sheen & Spiby, 2015). Student midwives are also part of these discussions and also indirectly experience these traumatic events.

In 2017 a cross-sectional study found 20% of registered midwives in Australia reported moderate/severe/extreme levels of depression, anxiety and stress, having a medium-size effect on burnout (Creedy, Sidebotham, & Gamble, 2017). A study completed in the United Kingdom in 2017 for registered midwives found elevated levels of work-related burnout, stress, anxiety and depression (Hunter, Fenwick, & Sidebotham, 2019). Experiencing traumatic events as a midwife has been known to lead to feelings of shame, blame, isolation, helplessness and despair, which often makes them the second victim (McDaniel & Morris, 2020). The act of caring for people who have experienced trauma can sometimes lead to extreme consequences for the caregiver, including post-traumatic stress disorder, secondary traumatic stress and compassion fatigue (Leinweber & Rowe, 2010). A study completed on American midwives in 2018 examined stress and its sources and found that 97.1% experienced traumatic birth events, leading to increased depression and burnout (Wright, 2018), again confirming the traumatic exposure that midwives and student midwives are often privy to.6, 7, 8, 9

These stress disorders are often linked with depression, stress and anxiety, particularly the idea of burnout. Burnout is due to emotional exhaustion and low sense of personal accomplishment, often affected by occupational and sociodemographic variables (Altiparmak & Yilmaz, 2021). Due to these factors, burnout and depression are often linked, depending on the level of burnout the individual experiences (Altiparmak & Yilmaz, 2021). As well as dealing with the events of the job, other studies have also suggested that students can be adversely affected by having to manage individual behaviours and personalities of the registered midwives in the practicing environments (Baird & Gamble, 2022).

Stressful situations can have long-term impacts on midwives’ professional and personal identities (Halperin & Goldblatt, 2011). However, people often forget that student midwives can experience the same burnout as registered midwives, as they experience the same situations as their primary midwives. They may also have a minimal understanding of what took place, leaving many questions to remain unanswered after self-debriefs.

If student midwives are better equipped, with more and earlier mental health support, it is possible this number may decrease. A 2017 study of student midwives in the United Kingdom found that mindfulness interventions, work-based resilience workshops, and partnered mentoring programmes, created positive outcomes for student midwives (Pezaro & Fulton, 2017). Proper support and debriefing after adverse events can help students articulate their needs and develop resilience (Davies, 2015).10, 11, 12

Aim

The aim of this study was to address and provide evidence-based research on the mental health of student midwives. Psychological stress, anxiety and depression have been shown to have significant impacts on health care providers, impacting the quality of care they provide to women and the ability of midwives remaining in the profession (Cates & Mackenzie, 2024). With the increased need for registered midwives, it is important that the psychological well-being of students be prioritised, as it can impact the completion of student midwives’ studies, leading to implications in retention of students.

This research was intended to facilitate implementation of needed supports for student midwives on clinical placement and to encourage further research to be undertaken for student midwife mental health. Specifically, such mental health support would occur within university and hospital frameworks, where the students are currently on clinical placement. This study will hopefully flag the important role organisations have to play in improving environments for student midwives and preventing poor mental well-being from occurring (Kinman & Teoh, 2020).

Materials and Methods

Results

Survey results

The following results were gathered, and the DASS score was calculated for each participant. Level of severity was based on each individual’s score, and the individual was placed into a category depending on their score. The severity categories were normal, mild, moderate, severe and extremely severe. The severity labels are used to describe the full range of scores in the population; therefore, ‘mild’ is interpreted as above the population mean, but probably still below the severity of someone seeking help (Lovibond & Lovibond, 1995).

Figure 1

Do student midwifes have elevated levels of anxiety, Depression and Stress. DASS score results. Y axis determines number of participants

Figure 2

Number of clinical student midwives presenting with varying severity categories of stress, y axis determines number of participants.

Figure 3

Number of clinical student midwives presenting with varying severity categories of anxiety, y axis determines number of participants.

Figure 4

Number of clinical student midwives presenting with varying severity categories of depression, y axis determines number of participants.

The data collected provides valuable insights into various areas, including stress, anxiety, and depression while on clinical placement for midwifery students. 53 participants participated in the survey and their scores were individually tallied, and based on their score, they were placed into the appropriate range as per the DASS criteria.

Discussion

Respondents reported frequent or constant symptoms of stress, including difficulty winding down, overreacting to situations, and anxiety symptoms such as trembling, breathing difficulties and nervous energy. More than 56% of respondents displayed elevated levels of stress while on clinical placement, and above 28% showed moderate to extremely severe levels of stress. These symptoms were felt whilst on clinical placement. More than 86% showed elevated levels of anxiety while on placement, with symptoms ranging between mild and extreme, while more than 64% showed moderate to extremely severe levels of anxiety while on clinical placement. A 2019 study of nursing and midwifery students’ stress during their undergraduate programmes found that stress emanated from both clinical and academic sources, but mainly from the clinical environment (McCarthy & Trace, 2018). These results mirror the findings the results. When assessing levels of anxiety, it may also be important to take into consideration what else may be taking place in the student’s life, such as social influences. While this particular study is based on students’ symptoms while on placement, outside influences should also be taken into consideration.

Several respondents report feelings of low mood, lack of enthusiasm, and low self-worth, although these are less prevalent than stress symptoms. 41.5% showed elevated levels of depression while on clinical placement with more than 32% showing moderate to extremely severe levels of depression. A larger study completed in 2016 looked at depressive symptoms in 417 nursing and midwifery students in Ireland. Their findings indicated that 34% of participants experienced depressive symptoms (Horgan & Sweeney, 2016). Although the level of depression was not specified in the 2016 study, similar symptoms to those experienced by the Queensland student midwives were also evident in the study. A similar study which also used the DASS score to determine levels of depression in Australian midwives found 20% reported severe levels of depression, compared to this study, which found 13% (Creedy, Sidebotham, & Gamble, 2017). These levels correspond more closely to the results of the present study.

Although the participant number for this study is small, it reflects a sampling of the current mental health struggles experienced by clinical student midwives while on placement. The findings are not generalisable but rather provide insight into the challenges of some student midwives.

Supporting the emotional well-being of student midwives is crucial not only for ensuring the provision of quality care to childbearing women but also for maintaining a healthy and motivated future workforce. By addressing the anxiety and depression experienced by student midwives, we can help create a supportive environment that promotes their overall well-being and future job satisfaction. This, in turn, can lead to improved retention rates and enhance the quality of care provided to women during childbirth.

Conclusion

Based on the findings presented, midwifery students experience a notable burden of stress and anxiety during their training. A considerable proportion reported frequent or constant symptoms such as difficulty winding down, overreacting to situations, trembling, breathing difficulties and nervous energy. Elevated levels of depression were evident, showing a relationship between clinical practice and depression-related symptoms that warrants further investigation.

In light of these findings, it is imperative that educational institutions and healthcare organizations prioritise the mental well-being of midwifery students. Implementing proactive measures, such as mental health support services, stress-management programmes, and opportunities for peer support and mentorship, can help mitigate the negative impact of stress, anxiety, and depression on student midwives. Additionally, fostering a culture of open communication and destigmatising discussions around mental health can encourage students to seek help when needed and promote a supportive learning environment.

By addressing the mental health needs of midwifery students, we can ensure they are adequately equipped to provide compassionate and effective care to expectant mothers and their families. Moreover, investing in the well-being of future midwives not only benefits the students themselves but also contributes to the overall resilience and sustainability of the midwifery profession.

Midwifery health care service requires very careful and continuous work, and the quality of care that midwives provide depends on their job satisfaction (Altiparmak & Yilmaz, 2021). If mental health is not prioritised early in student midwives’ careers, the anxiety or depression they experience may be detrimental to their future experience as a registered midwife providing health care services.

Source of Funding

None.

Conflict of Interest

None.