Embedded Cultures in Maternity Care: When “That’s Just How It Is” Becomes the Most Dangerous Sentence in the Room

There is a reason some maternity spaces feel heavy before a word is even said.

It’s not the woman. It’s not the baby. It’s not even the complexity.

It’s culture.

The unspoken rules. The hierarchy. The tone. The invisible consequences. The way certain behaviours are normalised because “that’s how it’s always been.”

And the taboo question we don’t ask loudly enough is this:

Why do caring professions so often become places where staff are broken?

The myth of “resilience” and the reality of systems

We have been taught to explain staff distress as an individual issue.

Not coping. Too sensitive. Not resilient enough. But moral distress, burnout and trauma are not personal failures when the workplace conditions are structurally unsafe.

Midwives worldwide describe the psychological toll of their work, including burnout, trauma exposure, anxiety, depression and moral distress and importantly, models with continuity can be protective (Small et al., 2025). That matters. Because it tells us the harm is not inevitable. It is shaped by structure.

So why do we keep responding with yoga posters and resilience training, while leaving the culture untouched?

The second victim phenomenon: the trauma no one names

In maternity care, a single event can echo for years.

A shoulder dystocia. A postpartum haemorrhage. A neonatal resus. A stillbirth. A complaint. A coroner. A call from management.

And then there is the aftermath.

Second victim phenomenon describes what happens when clinicians are traumatised after an adverse event, medical error, or unexpected outcome, carrying guilt, fear, shame, hypervigilance and isolation (Scott, 2017; Sachs & StatPearls, 2023). Often, the wound is not only the event itself. It is what happens afterwards:

Silence. Blame. Whispers. Isolation. A subtle shift in how you’re treated.

And in a profession built on compassion, the lack of compassion for staff in these moments can be devastating.

Bullying, incivility, and “rite of passage” harm

Bullying in healthcare is not rare. It is not “just personality clashes.” It is a pattern and it is culturally maintained.

Research across nursing and midwifery describes bullying and workplace violence as widespread issues with significant psychological impacts, including burnout and secondary traumatic stress (Galanis et al., 2024; Wuni et al., 2025). In midwifery contexts specifically, bullying is described as entrenched, sometimes openly displayed, and often occurring in environments where perpetrators are not fearful of repercussions (Simpson et al., 2023). In Australia and New Zealand contexts, workplace violence and bullying concerns include leadership inaction, especially where the aggressor holds senior power (Capper et al., 2022).

That sentence alone should stop us:

Managers did not act because the bully was “high up.” (Capper et al., 2022)

Which leads to the real question:

If a culture protects the senior person over the harmed person, what exactly is it protecting?

Why people conform, and why those who “speak up” still sit back

This is the hardest part to write, because it is so deeply human.

People do not stay silent because they don’t care.

They stay silent because they are calculating survival.

Speaking up in healthcare is often framed as a moral choice, but it is also an organisational risk, especially in cultures where raising concerns leads to ridicule, dismissal, reputational damage, or career consequences (Asante et al., 2024). The evidence is clear that staff weigh the personal and professional costs, not just the safety issue in front of them (Asante et al., 2024; Jones et al., 2021).

So when we ask, “Why didn’t they speak up?” we must also ask:

What did speaking up cost the last person who tried?

Because when psychological safety is low, silence becomes strategy.

And when silence becomes strategy, harm becomes normal.

The invisible grief: staff mental health, distress, and suicide risk.

We need to speak carefully here, but we cannot stay silent.

There is substantial evidence that healthcare worker mental ill-health is linked to workload, trauma exposure, bullying, violence, and cultures where support is inconsistent or stigmatised (Jain et al., 2024; Wuni et al., 2025). Global research has found wide-ranging prevalence of suicidal ideation and suicide-related behaviours among nurses, across multiple countries, with workplace stressors, including bullying, identified among influencing factors (Yang et al., 2025).

This is not about sensationalising suicide.

This is about refusing to ignore what toxic cultures do to humans.

If a workplace repeatedly exposes staff to trauma, then adds blame, then removes support, then punishes vulnerability, then expects compassion to remain infinite…

What do we think happens?

“Senior behaviour” is not individual; it becomes policy by default

Seniority is power.

Power shapes culture.

A senior eye-roll becomes the atmosphere. A senior joke becomes the norm. A senior dismissal becomes organisational permission.

In many maternity units worldwide, embedded hierarchies mean the behaviour of senior staff quietly teaches everyone else what is safe to say, what is unsafe to challenge, and what happens if you try.

This is how cultures replicate.

Not through written policy.

Through what is tolerated.

The Taboo Questions We Must Stop Avoiding

Why do maternity systems insist on “informed consent” for women, yet so often fail to provide relational safety for the clinicians delivering that information?

Why are midwives publicly celebrated as heroes, yet privately treated as replaceable?

Why is kindness framed as optional, but compliance demanded without question?

Why do complaint processes sometimes feel punitive rather than restorative, as though raising concern is an act of disloyalty rather than professional integrity?

Why do staff fear being labelled “difficult” more than they fear the consequences of silence?

Why are individuals asked to be courageous within systems that remain structurally retaliatory?

In some environments, belonging to the inner circle, the “top tier”, the chosen few, carries more perceived security than critically reflecting on the culture within the four walls. Survival becomes strategy. Conformity becomes protection. Silence becomes rational.

This is not an individual failing. It is a predictable human response to power, hierarchy and risk.

What Would Real Reform Look Like?

Not a poster. Not a wellbeing newsletter. Not an annual resilience workshop.

Real reform would require structural commitment.

•Psychological safety is measured and audited as rigorously as clinical outcomes, not promoted as rhetoric (Jones et al., 2021; de Lisser et al., 2024).

•Immediate, structured and confidential second-victim support following adverse events, independent of popularity or seniority (Scott, 2017; Sachs & StatPearls, 2023).

•Zero tolerance for bullying with enforceable consequences regardless of role or tenure (Capper et al., 2022; Galanis et al., 2024).

•Leadership accountability for workplace culture, recognising that culture does not shift without redistribution of power.

•Models of care designed to protect workforce wellbeing as well as clinical output, with continuity of care models identified in Australian research as protective against burnout for midwives (Small et al., 2025).

These are not aspirational ideals. They are evidence-based necessities.

The Work Beneath the Work

If it was not going to be Rosebuds, it was going to be attempting a PhD.

Because this conversation has never been about surface reform. It has always been about what sits beneath the daily tasks, the rostering, the policies and the performance metrics.

It is about the second victim phenomenon.

It is about how midwives burn brightly and then burn out.

It is about how staff are isolated after adverse events, subtly blamed, or quietly managed out of systems that once relied on their devotion.

It is about how speaking up becomes professionally dangerous.

It is about how “just get on with it” becomes a cumulative psychological injury.

International literature consistently demonstrates the association between toxic workplace cultures, bullying, moral distress and adverse mental health outcomes among healthcare professionals, including depression, burnout and increased suicide risk. When retaliation, humiliation or exclusion follow disclosure or error, staff learn quickly what is safe to say and what is not. Silence becomes self-preservation.

And here is the sentence maternity services globally must be willing to sit with:

You cannot build safe care for women inside unsafe cultures for staff.

Culture is not separate from care. Culture is care.

If we want systems where women are genuinely respected, informed and protected, then we must build environments where clinicians are supported, heard and safeguarded in their humanity.

Because when staff are protected, care deepens. When staff are silenced, harm multiplies.

The future of maternity care depends on which we choose.

Check the Literature out for yourselves……

References (APA 7th)

Asante, K., Sørensen, E. E., & Hansen, C. (2024). To speak up or not to speak up: Organisational and individual factors influencing speaking up in healthcare. Nursing Open. https://pmc.ncbi.nlm.nih.gov/articles/PMC12080099/

Capper, T. S., O’Hara, M., & Homer, C. S. E. (2022). Workplace violence in the Australian and New Zealand midwifery workforce: A qualitative evidence synthesis. Women and Birth. https://pmc.ncbi.nlm.nih.gov/articles/PMC9804698/

de Lisser, R., Lane, T., & Aiken, L. (2024). Psychological safety is associated with better work outcomes in healthcare. Health Affairs Scholar, 2(7). https://academic.oup.com/healthaffairsscholar/article/2/7/qxae091/7715573

Galanis, P., Vraka, I., Fragkou, D., Bilali, A., & Kaitelidou, D. (2024). Association between workplace bullying, job stress, and burnout among nurses: A systematic review and meta-analysis. Healthcare, 12(6), 623. https://www.mdpi.com/2227-9032/12/6/623

Jain, L., Mehta, S., & Kumar, R. (2024). Suicide in healthcare workers: An umbrella review of systematic reviews. Frontiers in Psychiatry. https://pmc.ncbi.nlm.nih.gov/articles/PMC11375687/

Jones, A., Kelly, D., & Irwin, J. (2021). Interventions promoting employee “speaking-up” within healthcare workplaces: A systematic review. International Journal of Nursing Studies. https://www.sciencedirect.com/science/article/abs/pii/S0168851021000026

Sachs, C. J. (2023). Second victim syndrome. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK572094/

Scott, S. D. (2017). The second victim phenomenon: A harsh reality of health care professions. AHRQ PSNet. https://psnet.ahrq.gov/perspective/second-victim-phenomenon-harsh-reality-health-care-professions

Simpson, N., McKenna, L., & McLelland, G. (2023). Midwifery students’ knowledge, understanding and experiences of workplace bullying and violence. Midwifery. https://www.sciencedirect.com/science/article/pii/S2666142X23000280

Small, K., Sidebotham, M., Gamble, J., & Fenwick, J. (2025). The psychological impact of working as a midwife in Australia. Midwifery. https://www.sciencedirect.com/science/article/pii/S0266613825000968

Wuni, A., Asamoah, E., & Kumi, E. (2025). Workplace bullying among nurses and its implications for nursing care: A review. Nursing Open. https://pmc.ncbi.nlm.nih.gov/articles/PMC12276762/

Yang, X., Zhang, Y., & Li, M. (2025). Factors of suicide-related behaviors based on stress-vulnerability model among nurses: A systematic review. Frontiers in Psychiatry. https://pmc.ncbi.nlm.nih.gov/articles/PMC11788286/