The wombat in the room: midwives' lived experiences of caring for pregnant women who use illicit drugs

Midwives care for all women, those who are well, informed, have a chronic illness or disability and those who are vulnerable. Vulnerable women especially those who are pregnant and use illicit drugs however are often seen as challenging and can be cared for poorly, often stigmatised and marginalised. Illicit drug use especially in women who are at reproductive age is increasing, with poly-drug use being most common. Successive Australian governments have a harm minimisation stance towards drug use, but in the social media punishment and distain are still prevalent towards illicit drug users. The wombat in the room is a metaphor for the non-acknowledgement of the issue of pregnant women and illicit drug use. The midwives who work with these women have been silent on how they manage and care for these women. This study aimed to examine and develop an understanding of the phenomenon of midwives experiences of caring for pregnant women who use illicit drugs. Hermeneutic phenomenology underpinned by Heidegger’s philosophy and Gadamer’s methodology was chosen to frame this research. The researcher was seeking a deeper understanding of a particular phenomenon. Heidegger specifically encouraged the consideration of our own ‘Dasein’, so that the ‘other’ and ‘others’ were seen and, thereby, ‘others’ lived experiences were illuminated. Data was generated with twelve participants, who shared stories of their experiences of caring for pregnant women who used illicit drugs. The researcher used an approach developed by Lindseth and Norberg (2004) inspired by Ricoeur (1976) to thematically analyse the data. Three fundamental themes emerged from the study that provided empathic interpretations of what it is like to be a midwife who cares for a pregnant woman who uses illicit drugs. These are: Making a difference, Establishing partnerships and Letting go and redefining practice. This study demonstrated that midwives want to be able to ‘make a difference’ in their work and show the importance of the relationships they established in order to provide care to women. This phenomenon is not new, however was extremely strong in the midwives participating in this study. Although the midwives often saw the vulnerable women as strong and streetwise when dealing with adversary in their social circle, the midwives also observed that the women became more vulnerable and powerless against organisational systems and the societal norms that marginalised them. The participants found that ‘Establishing partnerships’ with women who used illicit drugs were in most cases rewarding and satisfying for both women and midwives. These partnerships were required to be built on trust, honesty and understanding. The midwives had the ability to meet the individual needs of the women as well as facilitate other service providers to provide timely resources. The women in these midwives’ care appeared to find satisfaction and developed skills to make changes in their lives. However, to sustain working with women, with complex and tangled lifestyles the midwives described the need for ‘letting go and redefining practice’. This theme consisted of establishing boundaries and developing competences that are required to maintain the work and the enthusiasm to provide opportunities for all women. The midwives found working with women who also used illicit drugs was very emotional work and they expressed a range of emotions, such as love, anxiety, compassion, sadness, respect and admiration. However for the midwives to maintain this emotional connection with the women they also had to learn to let go and redefine their practice. ‘Letting go and redefining practice’ was experienced by the participants as two fold, on one hand they needed to ensure that there were boundaries in place to keep safe the women, themselves as midwives and their own families safe. On the other hand they needed to develop the competence to let go, the capacity to be resilient and bounce back, acknowledge disappointments, and be realistic in their expectations of others. They had to develop an acceptance and patience towards the women who used illicit drugs and go at their pace, as well as have the tolerance towards other staff member’s attitudes and behaviours towards the pregnant women who use illicit drugs. The aim of hermeneutic phenomenological research is enhanced only when mutual understandings are revealed through the telling and the listening of stories that resonate with others. This reciprocal understanding then enables shared possibilities for living and understanding midwifery practice. Overall, these findings add to the body of knowledge about midwifery practice and the unique challenges faced by midwives in their daily work. Whilst the findings relate specifically to midwives, many of the themes may resonate across the many professions who work with vulnerable populations. These findings also have implications for educationalists and curriculum developers, to ensure students of the relevant health disciplines have the skills to develop relationships and competencies to manage the challenges to achieve positive outcomes for these women. Additionally, these outcomes would be a useful inclusion for organisational education programs, to ensure clinicians develop understanding of this vulnerable population, enhance their skills and construct professional boundaries that will ensure improved working relationships with pregnant women who use illicit drugs.