Everything seemed fine until the little boy was born.
He wasn't breathing, but his heart was strong, recalled Stephanie Avila, the midwife attending the baby's birth at a Rhode Island hospital back in 2012. But it soon became clear that the boy had suffered a brain injury during labor.
Eleven days later, after an MRI confirmed the severity of the injury and the family withdrew life-support, the child died. His official diagnosis: hypoxic ischemic encephalopathy, a brain injury caused by oxygen deprivation.
"I was prepared to stand by the family through this trauma," Avila said in an interview. "But I fully expected I'd get sued — and it was going to get ugly, or uglier."
Of course, the little boy's family was devastated. "I just went into my own world," said his mother, Sarah Jagger, speaking about the loss of her son.
But Avila suffered too. "I was a wreck," she said.
Immediately after the birth, Avila said, she remained on call overnight at the hospital, Women & Infants, in Providence. "I retreated to the call room and curled up in the fetal position and prayed that no other people in labor would show up. I cried, had the worst headache I've ever had in my life, and felt like I'd vomit. For days I felt emotionally and physically terrible. I'd be walking down the street and suddenly could no longer move."
At the time, Avila had two small children of her own. "And whenever my 2-year-old would do this cute thing, I'd think, their baby will never walk around in his mother's high-heeled shoes. I'd get these terrible thoughts and I'd never know when it would strike."
The Psychological Toll
After a traumatic birth — or any traumatic medical event — attention, rightly, turns to the grieving family. But research has been mounting in recent years that health care providers, sometimes called "the second victims," also sustain long-lasting emotional damage following such a trauma.
A new study published by Danish researchers underscores the phenomena: Midwives and obstetricians who experienced a traumatic birth — one involving severe injuries or death — report that the psychological toll of such an event is deep and long-lasting.
More than one third of those surveyed said that they always would feel some sort of guilt when reflecting on the event, researchers report. Nearly 50 percent agreed that the traumatic birth had made them think more about the meaning of life. "This tells us that health care professionals are affected, not only professionally, but also at a personal and even existential level," said Katja Schrøder, the study's first author and a Ph.D. fellow at the University of Southern Denmark.
'Changed My Life Forever'
This was indeed the case for Avila. "I feel as though that day — even to this day — changed my life forever in many ways," she said. And while the "acute" nature of the trauma has passed, she said, the enormity of it continued to grip her, sometimes unexpectedly and at random times.
In the Danish study, published in Acta Obstetricia et Gynecologica Scandinavica, a journal of the Nordic Federation of Societies of Obstetrics and Gynecology, more than 1,200 Danish obstetricians and midwives responded to a survey on the aftermath of a traumatic birth. Of those respondents, 14 were selected for a followup interview.
Many of the providers spoke of not being able to shake the trauma, whether they were blamed for the bad outcome or not. "Although blame from patients, peers or official authorities was feared (and sometimes experienced), the inner struggles with guilt and existential considerations were dominant," researchers report.
From the paper:
One mid-wife explained that even now, 12 years after the event, she would still think about that particular mother and child when passing through their town...
Most participants described having spent many hours agonizing and wondering whether they could have prevented the adverse outcome. One midwife said that her sense of guilt would never disappear because she knew that the parents would have to live with the consequences of her handling of the delivery.
Still, the researchers found that for many providers, "the traumatic childbirth had given rise to personal development opportunities of an emotional and/or spiritual character ...for instance by achieving a more humble and profound understanding of both professional roles and of life as a whole."
A Meaningful Meal
About a month after her infant son's death, Jagger did something unusual: She asked Avila to meet for lunch. Up until then, the two women had been in touch -- Avila had called to check in often, offering to help out and attend followup medical appointments with Jagger.
But the lunch date marked a turning point, the women agreed. First, it became clear that Jagger didn't blame Avila for the boy's death, and did not want to focus on the tragedy going forward.
"We had this little boy who had a such a short life," Jagger said. "I didn't want his life to be clouded in anger. I wanted his life to be about love...and not focus on the horrible part."
But the meeting also underscored the growing bond between the women. When it was over, they walked outside and Jagger posed a question: "I said to her, 'If I have another baby, would you deliver it?' And I think she was horrified. But I think because I trusted her so completely, through the birth, and his death, and her calls and the followup, I felt like she was there with me, like this was our loss, it wasn't just my loss."
The Danish research paper quotes Donald Berwick, a pediatrician who served in the Obama administration and is also a patient safety guru of sorts. In a 2009 interview published in the Journal of Patient Safety, Berwick speaks about those "second victims":
Health care workers’ egos can be big. But believe me, their superegos are a lot bigger. You carry into work — as a nurse, or doctor, or a technician or pharmacist-- the intent to do well. And when something goes wrong, almost always you feel guilty, terribly guilty. The very thing you didn’t want to happen is exactly what happened. And if you don’t understand how things work, you feel like you caused it. That creates a victim. My heart goes out to the injured patient and family, of course. That’s the first and most important victim. But health care workers who get wrapped up in error and injury, as almost all someday will, get seriously hurt too. And if we’re really healers, then we have a job of healing them too. That’s part of the job. It’s not an elective issue, it’s an ethical issue.
In the past decade or so, various institutions and nonprofits have emerged with tools and systems to better support medical professionals who have endured a traumatic event.
One of those groups, MITSS, or Medically Induced Trauma Support Services, based in Massachusetts, provides trauma tool kits used around the country.
Linda Kenney, the founder of MITSS, was herself the victim of an anesthesia error that nearly killed her. She said that for her, connecting with the anesthesiologist who caused her injury (he called her afterwards to express his regrets) and creating the nonprofit to help others, helped her heal.
But for health care providers, sometimes talking to peers at a hospital, or others in the institution, isn't enough and can actually feel isolating, Avila, the Rhode Island midwife, said. Because of the omnipresent fear of lawsuits, and also due to patient privacy laws, she said, "there are very few environments where we can freely discuss what happened."
A Second Chance
In 2013, a few days shy of what would have been her son's first birthday, Jagger went into labor with her second child, and she called on Avila to attend the birth. By that time, Avila was no longer working for the same midwifery group, but the practice arranged for her to have insurance during the birth, and Avila left a family gathering on Block Island to get to Providence on time.
Jagger's little girl is now a healthy 2-and-a-half-year-old who considers Avlia her "auntie."
"It was this amazingly cathartic experience for all of us," Jagger said.
Avila is now a family nurse practitioner and attends births less frequently as part of her work. These days, she and Jagger are extremely close: They've vacationed together, bake each other birthday cakes and talk almost daily.
"I never would have expected our relationship to evolve to this point," Avila said. "But despite how close we are now, I would sacrifice it in a moment if I could change the outcome of that first birth."