Impact of ethical dilemmas in midwifery practice: An interpretative phenomenological analysis

Study design and setting

This study employed a qualitative phenomenological research design using an Interpretative Phenomenological Analysis (IPA) approach as developed by Smith et al., ²² to explore midwives’ lived experiences of the impact of ethical dilemmas in clinical practice. IPA, grounded in hermeneutic phenomenology, is particularly suited to understanding how individuals make sense of complex, emotionally charged experiences, while acknowledging the interpretative role of the researcher. ²³ This approach was considered appropriate because ethical dilemmas in midwifery are deeply contextual, influenced by sociocultural norms, institutional policies, and professional responsibilities. By using IPA, the study captures not only what midwives experience but also how they interpret and give meaning to these experiences, providing rich insights into the personal and professional consequences of ethical challenges.

The study was conducted between January 2 and April 30, 2026, in three referral hospitals located in northwestern Ethiopia, within the Amhara regional state. The Amhara region, situated in the northwestern and north-central parts of Ethiopia, contains 108 hospitals, including eight referral hospitals, and 885 health centers. Of these eight referral hospitals, five were located in the northwest part of Ethiopia, in the region. Among the 4935 midwives serving in the region, ²⁴ 548 were working in referral hospitals, with 300 midwives working in the selected northwestern referral hospitals. These hospitals provide comprehensive maternal and newborn health services and serve both urban and rural populations. At the time of the study, the region was affected by ongoing conflict, which posed challenges such as restricted movement, safety concerns, and resource shortages. These contextual conditions were considered integral to understanding the ethical dilemmas faced by midwives, as they directly influenced working conditions, decision-making processes, and professional responsibilities.

Study population

The study population comprised midwives employed in the selected referral hospitals who were actively involved in maternal and newborn care. Midwifery ward heads were first informed about the purpose of the study and asked to facilitate access to potential participants. Eligible midwives were those with at least 2 years of clinical experience in the selected hospitals^9,25 and who had directly experienced ethical dilemmas in practice, ensuring that participants could provide rich and meaningful insights into their lived experiences. During recruitment, potential participants were asked screening questions such as: “Have you ever faced a situation at work where you were unsure what the right decision was because doing one thing might go against your professional duties or personal values?” Only those who self-identified having experienced ethical dilemmas and were willing to reflect on these experiences were included. Midwives who were on long-term leave or enrolled in further education during the study period were excluded. Potential participants received an information sheet explaining the study objectives, procedures, and ethical considerations. Those who expressed interest voluntarily shared their contact information with the principal investigator. The principal investigator (PI) then contacted them by phone to confirm eligibility and willingness and to arrange a convenient time and location for the interview.

Participant recruitment and selection

The study referral hospitals were selected purposively from among the referral hospitals of northwestern Ethiopia. A purposive sampling strategy was then applied to recruit midwives with direct experience of ethical dilemmas in clinical practice. Purposive sampling was employed to identify information-rich participants capable of providing detailed and meaningful insights relevant to the study’s aim. ²⁶ This approach aligns with IPA, which prioritizes the selection of participants who can provide rich, in-depth accounts of their lived experiences rather than representativeness at a population level. ²⁷

Initially, thirty midwives were identified as eligible for the study. From these, 22 were purposively selected based on IPA principles of homogeneity in relation to the phenomenon of interest, while allowing limited variation in age (20–40 years), gender (male and female), and years of clinical experience (2–10 years) to support information-rich accounts and depth of interpretation. Seventeen midwives agreed to participate, while five declined due to time constraints. Following data collection and iterative analysis, 13 participants were included in the final IPA analysis, as their accounts provided sufficient depth and convergence of experiential meaning, ensuring interpretive sufficiency and analytic adequacy (Figure 1).OPEN IN VIEWER

Participant recruitment and data collection were conducted concurrently and continued until interpretive sufficiency and idiographic adequacy were achieved, consistent with IPA principles emphasizing depth of analysis, experiential richness, and detailed case-by-case interpretation rather than data saturation. ²⁸

After eleven interviews, sufficient experiential material had been generated to support rich idiographic analysis and meaningful identification of convergence and divergence across cases. Two further interviews were included to enhance the depth and breadth of the interpretative account and strengthen engagement with variation in lived experience. The final sample of thirteen midwives was therefore considered ideographically adequate, providing sufficient depth for detailed interpretative engagement and cross-case analysis. Collaborative coding by two researchers supported the credibility and consistency of the interpretative process.

Experience of ethical dilemmas

It was operationalized as self-reported involvement in situations during clinical practice in which the midwife perceived a conflict between moral values, professional obligations, or competing courses of action requiring a difficult decision.

Data collection procedure

Data were collected using in-depth, face-to-face, semi-structured interviews. An interview guide was developed based on the review of relevant literature and aligned with the study’s focus on the impacts of ethical dilemmas. The guide included open-ended questions designed to encourage participants to describe their experiences freely and in detail (see supplemental file 1). Before the main data collection, the interview guide was pretested with two midwives who were not a part of the final sample, and minor adjustments were made for clarity. Interviews were conducted by the PI (TG) in the private rooms within the hospitals to ensure confidentiality and minimize interruptions. Interviews were carried out in Amharic, the participants’ native language, to facilitate rich and authentic expression. Each interview lasted approximately 35–45 min and was audio-recorded with the participants’ permission. Field notes were taken to capture non-verbal cues, emotional expression, and contextual observations. Participants were informed that they could pause or terminate the interview at any time if they experienced discomfort or emotional distress. Data collection and preliminary analysis occurred iteratively, allowing emerging insights from earlier interviews to inform subsequent data collection.

Data processing and analysis

Audio-recorded interviews were transcribed verbatim in Amharic and then translated into English by two authors (TG and GA). Translations were checked for accuracy and consistency against the original records by authors who transcribed verbatim. Data were analyzed using IPA, following its iterative and inductive process. Analysis was guided by the seven IPA stages: Reading and re-reading, initial noting, developing emergent themes, searching for connections across themes, moving to the next case, looking for patterns across cases, and developing higher-order interpretations ²⁹ (Supplemental file 2). Analysis was underpinned by IPA’s double hermeneutic, whereby participants interpret their lived experiences and the researchers, in turn, interpret these meaning-making processes. ³⁰ This involved continuous reflexive engagement with the data, where researchers critically examined how their own perspectives influenced interpretation throughout the analytic process.

Each transcript was read repeatedly to ensure immersion in the data. Initial noting involved detailed descriptive, linguistic, and conceptual comments, enabling an interpretative engagement that extended beyond surface-level coding. Codes were treated as preliminary interpretative insights and were iteratively developed into emergent themes through processes of abstraction, clustering, and conceptual interrogation. This analytic movement ensured that interpretation extended beyond coding to the construction of experiential meaning. Themes were first developed within individual cases to preserve idiographic depth and then examined across cases to identify patterns of convergence and divergence. This process allowed for the development of higher-order themes while maintaining sensitivity to individual lived experiences. Throughout the analysis, the research team engaged in regular discussions to compare interpretations, refine thematic structures, and enhance analytical rigor. Atlas.ti (version 23) qualitative data management software was used to support data organization, retrieval, and systematic coding.

Researcher reflexivity

The research team consisted of qualified midwives with formal training in qualitative research, most of whom had prior experience with qualitative methodologies. This shared professional identity positioned the researchers as insiders within the midwifery context, which facilitated rapport, trust, and openness during interviews. However, this insider status also introduced the possibility that participants selectively emphasized or normalized certain experiences based on assumed shared understanding, potentially shaping the depth and nature of disclosure, including potential power dynamics between researcher and participant. At the same time, the researchers’ professional background carried potential implications for interpretation. Their familiarity with midwifery practice may have influenced how data were initially understood, particularly through taken-for-granted professional norms, clinical assumptions, and moral expectations embedded within midwifery practice. This created a need to critically interrogate how such assumptions may have shaped coding decisions and interpretative emphasis, particularly in relation to issues of care, responsibility, and professional judgment.

Reflexivity was therefore maintained throughout the research process as an ongoing critical practice rather than a procedural step. Researchers engaged in reflective journaling and analytical memo-writing to examine how personal experience, professional identity, and emotional responses influenced interpretation. Regular peer debriefing sessions were also conducted to challenge assumptions, question emerging interpretations, and minimize unexamined professional bias. Interpretations were grounded in participants’ narratives, with ongoing reflexive awareness of how researchers’ assumptions could shape interpretation. This reflexive process supported awareness of how insider positioning and professional allegiance may have shaped both data generation and interpretative analysis.

Trustworthiness

The trustworthiness of data is also confirmed by establishing credibility, transferability, dependability, and confirmability. ³¹ Credibility was enhanced through prolonged engagement with participants during data collection and in-depth, iterative analysis of the data. Interviews were supported by field notes, and member checking was conducted to validate participants’ accounts. In line with the interpretative nature of IPA, reflexivity was maintained throughout the research process, with the researcher critically reflecting on their assumptions and influence on data interpretation. Dependability was supported through a systematic and transparent analytic process, including careful documentation of coding decisions and theme development. Confirmability was ensured by grounding interpretations in participants’ verbatim quotations. Transferability was facilitated through rich, thick descriptions of the study context and participants’ experiences, enabling readers to assess the applicability of the findings to similar settings.

Ethics considerations

This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Ethical clearance was obtained from the Institutional Review Board of the Debark University, College of Health Sciences, before the commencement of the study (Ref No: DKU/COHS/RCS/42/2026). Permission to conduct the research was obtained from relevant hospital authorities and managers. All participants provided written informed consent before participating in the interviews. They were fully informed about the study objectives, potential benefits and risks, the right to withdraw at any time during data collection, and the measures taken to maintain confidentiality. Emotional support was made available to participants both during and after the interviews if they experienced any distress.

Sociodemographic characteristics

A total of 13 midwives participated in this study (Table 1). The participants in this study had a mean age of approximately 31.9 years, with ages ranging from 25 to 40 years. Their work experience ranges from 2 to 10 years, with a mean experience of about 5.8 years. More than half of the participants were male.

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Table 1.

Sociodemographic characteristics of the study participants in referral hospitals, northwestern Ethiopia, 2026 (n = 13).

ID	Age	Level of education	Experience
R01	26–30	BSc	6–10
R02	26–30	Diploma	2–5
R03	36–40	MSc	6–10
R04	30–35	MSc	6–10
R05	30–35	MSc	6–10
R06	36–40	MSc	2–5
R07	20–25	BSc	2–5
R08	25–30	MSc	6–10
R09	25–30	BSc	6–10
R10	36–40	BSc	6–10
R11	36–40	BSc	6–10
R12	36–40	Diploma	2–5
R13	30–35	BSc	2–5

Impact of ethical dilemmas in midwifery practice

Ethical dilemmas in midwifery practice have far-reaching consequences for patients, midwives, and healthcare systems. These dilemmas arise from complex interactions between personal belief, professional responsibilities, institutional constraints, and sociocultural factors. Analysis of the qualitative data revealed four overarching themes of impact, each with multiple subthemes, demonstrating the multidimensional consequences of ethical challenge in midwifery practice (Table 2).

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Table 2.

Thematic summary table showed lived experience of the impact of ethical dilemmas on midwifery practice of the study participants in referral hospitals, northwestern Ethiopia, 2026.

Title	Main themes	Sub-themes
Experiencing the impacts of ethical dilemmas	Experiencing the impact on patients	⁃ Restricted autonomy ⁃ Compromised and inequitable access to quality care ⁃ Emotional harm ⁃ Compromised the survival of the unborn fetus
	Experiencing the impact on midwives	⁃ Moral distress and guilt ⁃ Fear, anxiety, and professional frustration ⁃ Emotional exhaustion and burnout ⁃ Reduced job satisfaction and motivation ⁃ Compromised decision-making
	Experiencing the impact on the healthcare system	⁃ Inefficient use of workforce ⁃ Ethical and legal challenges ⁃ Reduced patient trust ⁃ Care inequities

Theme 1: Experiencing the impact on patients

Midwives reflected deeply on how ethical dilemmas in their practice shaped their perceptions of patient care, highlighting the tension between professional obligations, cultural norms, and institutional limitations. Their accounts revealed not only the consequences for women and unborn children but also the moral and emotional weight carried by the midwives themselves as they navigated these conflicts.

Restricted autonomy

Women’s autonomy was experienced by midwives as being shaped through family involvement in decision-making, where authority often shifted from the woman to her husband or other family members. Midwives made sense of these situations as reflecting culturally structured decision-making systems in which individual autonomy was often negotiated within family and social hierarchies, rather than exercised independently.

“When a patient was a woman, the final decision regarding her care was often made by her husband or father, rather than by the woman herself.” (30-year-old midwife)

Midwives experienced these situations as ethically constraining, as their ability to support women’s preferences was mediated by family authority. Autonomy, therefore, was not absent but negotiated within relational structures rather than exercised individually. These accounts suggest that such situations reflect ongoing structural constraints rather than isolated ethical dilemmas, positioning midwives between professional commitments to women-centered care and culturally mediated decision-making. This created a persistent moral strain, as midwives navigated the gap between what they considered appropriate care and what could be enacted in practice.

Emotional harm

Midwives experienced truth-telling and confidentiality as emotionally charged aspects of practice, where decisions about disclosure were often made in moments of uncertainty and emotional sensitivity. In these situations, they made sense of their role as requiring careful ethical judgment, particularly when balancing honesty with the need to protect women from immediate emotional distress.

“After a prolonged labor, the neonate was stillborn. I hesitated to tell the mother immediately, trying to find a safer moment. It weighed on me, feeling torn between honesty and causing pain.” (34-year-old midwife)

Midwives made sense of these experiences as emotionally and morally demanding aspects of their practice, where communication decisions carried significant ethical weight. They experienced themselves as being positioned between competing responsibilities of honesty, confidentiality, and emotional protection, which contributed to a sustained sense of moral burden in their role. In making sense of these tensions, they reflected on their role as involving ongoing ethical responsibility in emotionally vulnerable encounters, where clinical care and moral judgment were inseparable.

Compromised survival of the unborn fetus

Midwives experienced situations involving risk to the unborn fetus as emotionally and morally intense, particularly when urgent interventions were required but delayed due to consent processes or family decision-making. They made sense of these situations as moments where professional responsibility for fetal well-being came into tension with respect for maternal autonomy and culturally shaped decision-making practices, producing a strong sense of ethical pressure in practice.

“The woman presented with cord prolapse, and we explained the need for immediate cesarean section, but she could not decide on her own; she needed an unavailable partner for a decision. I felt powerless and worried about the baby’s survival.” (40-year-old midwife)

These experiences were understood as extending beyond isolated clinical emergencies, instead reflecting a sustained moral tension in which midwives negotiated competing responsibilities to mother and fetus under time-sensitive and relational constraints. This contributed to feelings of powerlessness and ongoing self-questioning regarding professional adequacy in critical care situations. From a theoretical perspective, these accounts can be understood in relation to concepts of relational autonomy in healthcare, where decision-making is not purely individual but shaped through family, social, and institutional relationships. They also resonate with ethics of care frameworks, which emphasize moral responsibility, responsiveness, and the emotional labor involved in clinical judgment, particularly in high-risk maternal–fetal contexts.

Compromised and inequitable access to quality care

Midwives described ethical tension arising from the gap between professional standards of care and the realities of practice within constrained and socially influenced environments. Staffing shortages, overcrowding, limited resources, and hierarchical or family-driven prioritization shaped how care was distributed, often preventing equitable and timely attention to all women. In overcrowded labor wards, midwives had to divide attention across multiple women simultaneously, which compromised privacy, delayed interventions, and heightened the risk of adverse outcomes. These conditions were further complicated when social influence determined who received priority care, reinforcing perceptions of unfairness within service delivery.

“Some women were lying on the floor while others occupied the few available beds. Sometimes essential drugs were missing, and we could not provide optimal care.” (38-year-old midwife)

Such experiences were not described as isolated operational difficulties but as sustained ethical strain embedded in everyday practice. Midwives remained accountable for care outcomes while simultaneously lacking the material and institutional conditions required to deliver safe and fair care. This tension disrupted their sense of professional integrity, as their ability to act in accordance with midwifery ideals of equity, safety, and dignity was repeatedly constrained by system-level limitations.

Theme 2: Experiencing the impact on midwives

This theme captures how repeated exposure to ethical dilemmas contributed to the erosion of midwives’ moral agency, professional identity, and ethical self-trust. Midwives described how sustained engagement with morally complex situations gradually weakened their ability to act in accordance with professional values, reshaped their sense of professional self, and diminished confidence in their ethical and clinical judgment. This erosion was experienced through interconnected emotional, relational, and institutional pressures manifested in guilt, fear, frustration, exhaustion, and reduced professional satisfaction.

Moral distress and guilt

Midwives experienced moral distress when they were unable to act in accordance with their professional and ethical judgment due to external constraints. They made sense of these situations as a persistent conflict between knowing the right clinical action and being unable to enact it, which resulted in guilt, self-blame, and a sense of professional failure.

“Sometimes I know what is best for the women, but I cannot do it. I go home feeling guilty, like I have betrayed my profession.” (32-year-old midwife)

These accounts were understood as reflecting a gradual erosion of moral agency, where midwives remained accountable for outcomes without corresponding authority to act. In terms of Jameton moral distress theory, this reflects the psychological and ethical strain that arises when clinicians are constrained from acting according to their moral judgment. Over time, this contributed to weakened ethical self-trust, as midwives questioned their own adequacy in navigating complex care decisions.

Fear, anxiety, and professional frustration

Midwives described fear and anxiety as embedded within hierarchical and punitive work environments. They made sense of this fear as shaping not only emotional well-being but also their willingness to act decisively in ethically uncertain situations. Fear was experienced as continuous and relational, emerging from anticipated blame, family pressure, and institutional authority.

“There was war on my duty day, going to work could risk my life, but staying home might endanger mothers and newborns.” (40-year-old midwife)

Within these conditions, ethical decision-making became increasingly shaped by external judgment and anticipated consequences rather than professional reasoning. This was interpreted as a weakening of ethical self-trust, as midwives no longer fully relied on their clinical and ethical judgment in decision-making processes.

Midwives also expressed professional frustration when their clinical assessment and ethical judgments were overridden by hierarchical decision-making. Despite being competent, they were often excluded from decisions, leaving them responsible for outcomes without corresponding authority. This created a structural mismatch between accountability and control, which undermined professional identity and autonomy.

“Obstetricians often override decisions, even when minimal intervention would be safe and appropriate, undermining my judgment.” (36-year-old midwife)

Across these experiences, fear, anxiety, and professional frustration were interpreted as interconnected processes that progressively eroded moral agency. Midwives experienced a reduced sense of control over ethical action, a weakening of professional identity, and diminished trust in their own clinical judgment within hierarchical systems that constrained autonomous decision-making.

Emotional exhaustion and burnout

Midwives experienced emotional exhaustion as the cumulative effect of sustained ethical tension. They made sense of this exhaustion as a gradual depletion of emotional and professional capacity, affecting their engagement in care and sense of professional identity

“Handling multiple cases with conflicting ethical demands leaves me drained at the end of the day.” (37-year-old midwife)

From an ethics of care perspective these accounts reflect the emotional labor inherent in caregiving roles, where sustained attentiveness to others’ needs can lead to emotional depletion when unsupported structurally. This contributed to a weakened sense of professional identity, as midwives struggled to sustain the caring role they valued.

Reduced job satisfaction and motivation

Midwives described reduced job satisfaction when systemic and institutional constraints prevented them from providing care aligned with their professional values. They made sense of this as a loss of professional fulfillment and ethical alignment.

“During labor, I could not perform vacuum-assisted delivery even when safe. It makes me feel my judgment isn’t trusted.” (25-year-old midwife)

These experiences were interpreted as undermining both moral agency and professional identity, as midwives experienced a disconnect between what they believed constituted good care and what they were able to provide. Over time, this weakened motivation and reinforced feelings of disempowerment.

Compromised decision-making

Midwives described how fear of blame and uncertainty influenced clinical decision-making. They made sense of this as a shift from ethically grounded judgment towards defensive practice.

“Sometimes I delay decisions because I am afraid of making the wrong ethical choice.” (29-year-old midwife)

These accounts illustrate a weakening of ethical self-trust, where clinical judgment becomes secondary to anticipated consequences. From a relational ethics perspective, decision-making is shaped by accountability structures and power relations, which can restrict moral agency and lead to defensive clinical practice.

Theme 3: Experiencing the impact on the healthcare system

Midwives reflected on how ethical dilemmas extended beyond individual practice, revealing deeper patterns of institutional moral failure within the healthcare system. Rather than being limited to issues of efficiency or resource constraint, their accounts highlighted how hierarchical structures, resource limitations, and policy–practice misalignment systematically undermined ethical care, fairness, and trust in the healthcare system.

Inefficient use of workforce

Midwives experienced their clinical skills as underutilized within hierarchical systems that restricted independent decision-making. They made sense of this as a form of institutional failure to recognize and utilize professional competence, resulting in delays and reduced responsiveness in care delivery.

“My skills are underutilized because I cannot perform procedures I am competent in.” (32-year-old midwife)

These experiences were interpreted as reflecting an institutional moral failure to support timely and competent care, where organizational hierarchies not only constrained efficiency but also undermined midwives’ professional agency and ethical responsibility to act in the patient’s best interest.

Ethical and legal challenges

Midwives described ongoing tension between ethical responsibilities and institutional or legal requirements that were sometimes misaligned. They made sense of this as navigating a morally conflicted system where adherence to policy could contradict professional ethical judgment.

“A pregnant woman with HIV did not want her status disclosed. Protecting her privacy conflicted with the need to prevent harm to others.” (36-year-old midwife)

These accounts were interpreted as reflecting structural moral contradictions within the healthcare system, where midwives were positioned to carry responsibility for ethically complex decisions without adequate institutional alignment or protection, thereby intensifying moral burden and uncertainty.

Reduced patient trust

Midwives observed that breaches of privacy, communication breakdowns, and perceived inequities in care negatively affected patients’ trust in the healthcare system. They made sense of this as a relational consequence of systemic ethical shortcomings rather than isolated individual errors.

“When privacy is breached, patients lose confidence in our care.” (29-year-old midwife)

These experiences were interpreted as showing how institutional moral failure extends beyond clinical processes to damage relational trust, weakening the therapeutic relationship between patients and healthcare providers and undermining confidence in the system as a whole.