Factors Associated with Child Removal Among American Indian and Alaska Native People in an Alcohol Intervention Study.

This study was a secondary data analysis of factors associated with alcohol-related child removal among American Indian/Alaska Native (AI/AN) adults enrolled in a clinical trial of an alcohol intervention. Among 326 parent participants, 40% reported ever having a child removed from their care in part because of the parent's alcohol use, defined here as alcohol-related child removal. Seventy-five percent of parents reported at least one separation during their own childhood (M = 1.3, SD = 1.0). In a multivariable analysis, alcohol-related child removal was associated with parental boarding school attendance. No relationship was found between alcohol-related child removal and alcohol intervention outcomes. Results may provide evidence of multigenerational child removal impacts of boarding schools on AI/AN adults receiving an alcohol use disorder intervention. Assessment of parental history of child removal by practitioners, strategies to prevent alcohol-related separation and to support reunification should be integrated into addiction treatment in AI/AN communities.

Prevention of Substance Use Disorders.

Methods to prevent substance use disorders (SUDs) act on the individual risk factors for addiction. Most adults with SUD initiated substance use during their teenage years, so preventive interventions during adolescence are critical. Antisubstance use messaging, routine screening, and pathways for referral to treatment can be extended into all settings whereby trusted adults interact with adolescents such as sports, mentoring programs, child protective services, and juvenile justice settings. Pediatric primary care is an ideal place to incorporate preventive counseling and screening for substance use. Evidence-based technologic interventions for primary, secondary, and tertiary prevention are needed.

Child abuse and neglect in a pediatric emergency department: epidemiology and outcome.

INTRODUCTION: Managing child abuse and neglect in pediatric emergency departments (PEDs) is difficult because of the complexity of screening and the prolonged care process. This study's main objective was to measure the child protection activity in a PED. METHODS: A retrospective, single-center study was conducted in the PED of the Lille University Hospital from 16 September∫2017 to 11 February 2019. All patients who required a social evaluation by the PED staff were included. Children admitted at first to the PED but for whom social management was exclusively performed by other units were not included. The whole population was analyzed first and then by type of abuse. The primary endpoint was the rate of patients who needed social management in the PED. The length of stay in the PED, the number of reports for investigation by child protective services, and reports to a judge were secondary assessment criteria. RESULTS: The study involved 245 patients (median age, 5 years; interquartile range [IQR], 2-13; boys, 49%), accounting for 0.6% of the PED visits. The main reasons for visiting the PED were somatic complaints (31%), sexual assault (23%), and behavioral disorders (20%). The median length of care in the PED was 5 h (IQR, 3-13). Thirty-three percent of the patients were monitored in the short-stay unit of the PED; 78% returned home. The main social measures taken were reports to child protective services (34%) and reports to a judge (24%); 51% of the patients required further actions by the PED physician after discharge. CONCLUSION: Management of child abuse in the PED is important and time-consuming. A hospital team specialized in child protection is essential for the initial care and monitoring of child victims.

Factors associated with the decision of a French hospital to report child abuse to judicial rather than administrative authorities.

OBJECTIVES: Two independent sectors manage the child protection system in France: judicial and administrative protection. The choice between judicial or administrative reporting depends on the seriousness of the case. The goal of this study was to determine the characteristics associated with the decision in a French pediatric hospital to report child abuse to judicial instead of administrative authorities. METHODS: A retrospective study was conducted. Participants were all the children (n=83) who were admitted from 2017 to 2018 to the emergency department (ED) and the general ward of a pediatric university hospital in France, and were reported for suspicion of child abuse by the professional teams. The children who were suspected victims of sexual abuse were excluded. Multivariate logistic regressions were used. RESULTS: A total of 47 children were reported to judicial authorities, and 36 to administrative authorities. Their median age was 7 years. Suspicion of physical abuse (odds ratio [OR]: 21.2; 95% confidence interval [CI]: 4.5-99.1), cases reported by the pediatric ward team (OR: 9.1; 95% CI: 1.9-43.6), adult person different from parents who accompanied the child to the ED (OR: 5.8; 95% CI: 1.2-28.6), and perception of parental behavior as inappropriate and non-cooperative (OR: 6.6; 95% CI: 1.4-29.6) were associated with a higher risk of the case being reported to judicial authorities. Data were often unavailable for parental health issues, history of child abuse, and intimate partner violence. CONCLUSION: Some factors associated with the choice of report type were most likely quite subjective. Better documentation and standardization are needed.

Promising observational instruments of parent-child (0-12 years) interaction within the child protection system: A systematic review.

BACKGROUND: Parent-child interaction (PCI) is considered a critical environmental factor that affects child development. In the field of child and family intervention, assessment of caregiver-child interaction has great relevance for decision-making. OBJECTIVE: The aim of this study is to report the results of a systematic review of the best observational instruments to assess the quality of PCI, taking into account the most advanced protocols. METHODS: Firstly, one search was conducted to identify eligible observational instruments, and a second search was conducted to identify studies reporting on the psychometric properties of the instruments previously identified. To assess and rate the quality of the psychometric properties of the tools, the COSMIN (Consensus-based Standards for the Selection of Health Measurement Instruments) checklist was applied. RESULTS: The nine PCI observational tools selected (with category B - promising) are widely used by researchers and clinicians across different stages of childhood. The Keys to Interactive Parenting Scale (2-71 months) obtained the highest rating. CONCLUSIONS: The most reported and robust psychometric property was inter-rater reliability, but validity evidence is understudied. This systematic review can help clinicians keep up-to-date, provide evidence for policymakers to judge risks and benefits of health care behaviors, as well as assess the evaluation programs in child abuse and neglect context.

Effect of COVID-19 lockdown on child protection medical assessments: a retrospective observational study in Birmingham, UK.

OBJECTIVES: To determine any change in referral patterns and outcomes in children (0-18) referred for child protection medical examination (CPME) during the COVID-19 pandemic compared with previous years. DESIGN: Retrospective observational study, analysing routinely collected clinical data from CPME reports in a rapid response to the pandemic lockdown. SETTING: Birmingham Community Healthcare NHS Trust, which provides all routine CPME for Birmingham, England, population 1.1 million including 288 000 children. PARTICIPANTS: Children aged under 18 years attending CPME during an 18-week period from late February to late June during the years 2018-2020. MAIN OUTCOME MEASURES: Numbers of referrals, source of disclosure and outcomes from CPME. RESULTS: There were 78 CPME referrals in 2018, 75 in 2019 and 47 in 2020, this was a 39.7% (95% CI 12.4% to 59.0%) reduction in referrals from 2018 to 2020, and a 37.3% (95% CI 8.6% to 57.4%) reduction from 2019 to 2020. There were fewer CPME referrals initiated by school staff in 2020, 12 (26%) compared with 36 (47%) and 38 (52%) in 2018 and 2019, respectively. In all years 75.9% of children were known to social care prior to CPME, and 94% of CPME concluded that there were significant safeguarding concerns. CONCLUSIONS: School closure due to COVID-19 may have harmed children as child abuse has remained hidden. There needs to be either mandatory attendance at schools in future or viable alternatives found. There may be a significant increase in safeguarding referrals when schools fully reopen as children disclose the abuse they have experienced at home.

Assisting decisions in child protection service institutions with the RIC - The Risk Indication in Child sexual abuse.

BACKGROUND: The RIC (Risk Indication in Child sexual abuse) and its screening version (RIC:SV) are actuarial risk assessment instruments, developed at the Austrian Federal Evaluation Centre for Violent and Sexual Offenders and designed for child protection services to assess the likelihood of sexual recidivism in male contact child sexual abusers who still or again live within a family including children. OBJECTIVE: The RIC was designed to require a minimum of forensic information, with the RIC:SV completely waiving such information. PARTICIPANTS: Nine factors related to sexual recidivism could be identified by analyzing five-year follow-up data of N = 324 male contact child sexual abusers. SETTING: The data was collected retrospectively from files between the years 2002 and 2011. METHOD: Chi-Square Tests and ROC-analyses were calculated. RESULTS: The RIC and the RIC:SV were found to significantly predict sexual recidivism with AUC values of .84 (RIC) and .78 (RIC:SV). The items of the RIC are: (a) offender has never had a live-in relationship, (b) unstable family background of the offender, (c) impulsivity of the offender, (d) previous psychiatric treatment(s) of the offender, (e) offender has prior prison sentence/s, (f) problems of the offender to accept rules and norms, (g) offender was a stranger to his former victim(s), (h) offender had at least one male victim, and (i) offender has ever committed an extrafamilial contact child sexual abuse offense. CONCLUSION: The RIC and the RIC:SV need no extensive training to be used. The results may help CPS workers to justify risk related interventions.

Effectiveness of child protection practice models: a systematic review.

BACKGROUND: Attempts to improve child protection outcomes by implementing social work practice models embedded in a particular theory and practice approach, have increased internationally over the past decade. OBJECTIVE: To assess the evidence of the effectiveness of child protection practice models in improving outcomes for children and families. PARTICIPANTS AND SETTING: Children < 18 years and their families involved in child protection services. METHODS: A systematic review was conducted to synthesize evidence regarding the effectiveness of child protection practice models. Systematic searches across 10 electronic databases and grey literature were conducted to identify quasi-experimental studies minimally. Included studies were critically appraised and the findings summarized narratively. RESULTS: Five papers, representing six studies, focusing on three practice models (Solution-Based Casework; Signs of Safety; and Reclaiming Social Work) met the inclusion criteria. All studies applied a quasi-experimental design. Overall, the quality of the evidence was rated as being poor, with studies suffering from a risk of selection bias, small sample sizes and short-term follow up. CONCLUSIONS: Despite the popularity of practice models, the evidence base for their effectiveness is still limited. The results suggest that high-quality studies are urgently needed to evaluate the impact of practice models in improving the outcomes of child-protection-involved families. The findings also illustrate the difficulties of conducting high-quality outcome evaluations in children's social care, and these challenges and future directions for research, are discussed. PROSPERO registration number: CRD42018111918.

Using Child Protective Services Case Record Data to Quantify Family-Level Severity of Adversity Types, Poly-victimization, and Poly-deprivation.

BACKGROUND: Child protective services (CPS) case records contain a vast amount of narrative information that is underutilized for estimating risk, conceptualizing family needs, and planning for services. OBJECTIVE: The current study applied a novel method for quantifying family-level severity of maltreatment and non-maltreatment-related adversity types to narrative information reflecting a family's full CPS history. PARTICIPANTS AND SETTING: Cases were randomly sampled (N = 100) from two regions of Connecticut that were referred over a specified 6-month period. METHODS: De-identified data were extracted through comprehensive chart review of electronic and paper case records. The Yale-Vermont Adversity in Childhood Scale (Y-VACS; Holbrook et al., 2015) was used to quantify adversity severity across a range of intrafamilial and extrafamilial experiences. RESULTS: Several family-level adversity severity ratings were associated with administrative data on allegations and investigative outcomes. Poly-victimization (ß = .47, p < .001) and poly-deprivation (ß = .25, p = .005) significantly predicted total allegation types and total substantiation types (ß = .30, p = .002; ß = .26, p = .008, respectively) across the case history. Poly-victimization significantly predicted the presence of a new allegation within 12 months of the index report, OR = 1.72, SE = .25, p = .027. CONCLUSIONS: Findings support the feasibility of a novel method that uses narrative case record information to quantify severity of maltreatment and non-maltreatment-related adversity types, as well as cumulative measures of threat- and deprivation-based adversities at the family level. Implications for utilizing case record data to inform CPS intervention are discussed.

Accessing Alternative Response Payways: A Multi-Level Examination of Family and Community Factors on Race Equity.

BACKGROUND: Although research has identified factors associated with child welfare involvement, less attention has been paid to how Black families are assigned to types of child welfare responses. The advent of alternative response pathways allows child protection workers to assign child abuse and neglect responses to families based on the type and seriousness of the maltreatment, history of prior reports and age of the child. OBJECTIVE: The effects of family and community characteristics on alternative response pathways are examined by exploring decision-making at two points in the child welfare system: access to an alternative response child welfare system and assignment to either an investigative or alternative response pathway. PARTICIPANTS AND SETTING: Black and White families reported for child abuse and neglect (N = 31,802) in New York State were studied. METHODS: Using data from the National Child Abuse and Neglect Data System matched with New York State county socioeconomic indicators, logistic and multi-level analyses examined the effect of county-level variables on family characteristics. RESULTS: The analysis determined that Black children and families were not assigned to alternative response pathways similarly to White families especially in counties where indication rates were higher. CONCLUSION: Findings imply that Black families involved in the child welfare system may benefit from increased access to culturally responsive interventions that target neighborhoods with high indication rates.

Family homelessness, subsequent CWS involvement, and implications for targeting housing interventions to CWS-involved families.

BACKGROUND: Homelessness is a risk factor for family involvement with child welfare services (CWS). Housing interventions are promising-but reasons for this are not well understood, and housing resources could be better targeted to families at risk of increased CWS involvement. OBJECTIVE: We sought to better understand the relationship between homelessness and CWS involvement and examine whether homeless shelter data could combine with CWS data to enhance intervention targeting. PARTICIPANTS AND SETTING: For 4 years, we followed 2063 families investigated by the San Francisco Human Services Agency in 2011. METHODS: Matching CWS data to homeless shelter data, we fit Cox models to examine the relationship between shelter use and subsequent CWS outcomes and produced ROC curves to judge model accuracy with and without shelter information. RESULTS: Absent CWS covariates (family demographics, CWS history, and family safety and risk), past shelter entry predicted repeat maltreatment referral (HR = 1.92, p < .001), in-home case opening (HR = 1.51, p < .05), and child removal (HR = 1.95, p < .01), but not child reunification. With CWS covariates, past shelter use no longer predicted case opening and child removal, but still predicted referral (HR = 1.58, p < .01). Shelter data did not contribute to models' predictive accuracy. CONCLUSIONS: We find mixed evidence that shelter use independently leads to CWS involvement. Housing interventions might help by addressing present housing problems and family experiences correlated with past shelter use. However, we find no evidence that data matches with shelter systems could enhance targeting.

Health and public health approach to ending child abuse and neglect.

The 30th anniversary of the United Nations Convention on the Rights of the Child provides an opportunity to reflect on whether the approaches to date in dealing with child abuse and neglect (CAN) have been successful. Initial responsibility in most countries to address CAN has been given to Child Protective Services Agencies. Recently, there have been calls for CPS to take a Public Health Approach in their practice. This paper discusses the potential positive and unintended problems that such a shift in approach might entail.

Benefit-cost analysis of Promoting First Relationships®: Implications of victim benefits assumptions for return on investment.

BACKGROUND: Child abuse and neglect (CAN) cost United States society $136 billion to $428 billion annually. Preventive interventions that reduce CAN may improve people's lives and generate economic benefits to society, but their magnitude is likely to vary greatly with assumptions about victim costs avoided through intervention. OBJECTIVE: We examined the implications of different assumptions about avoided victim costs in a benefit-cost analysis of Promoting First Relationships® (PFR), a 10-session attachment and strengths-based home visiting intervention. PARTICIPANTS AND SETTING: Participants were 247 child protection-involved but intact families in Washington State randomized to receive PFR (n = 124) or resource and referral (n = 123). METHODS: We monetized intervention effects on out-of-home placements and implicit effects on CAN and calculated net present values under three scenarios: (1) benefits from avoided system costs, (2) additional benefits from avoided tangible victim costs, and (3) additional benefits from avoided tangible and intangible quality-of-life victim costs. For scenarios 2 and 3, we varied the CAN effect size and estimated the effect size at which PFR was reliably cost beneficial. RESULTS: PFR's societal net benefit ranged from $1 (scenario 1) to $5514 - $25,562 (scenario 2) and $7004 - $32,072 (scenario 3) (2014 USD). In scenarios 2 and 3, PFR was reliably cost beneficial at a CAN effect size of approximately -0.25. CONCLUSIONS: PFR is cost beneficial assuming tangible victim costs are avoided by PFR. Research into the long-term health and economic consequences of reducing CAN in at-risk populations would contribute to comprehensive, accurate benefits models.

Protecting children across borders - child protection in an international context (Germany/Switzerland) as an interprofessional teaching unit.

Introduction: Interprofessional collaboration (IPC) in everyday clinical practice is a prerequisite for good patient care but currently this is not sufficiently anchored in the education of health care professionals. Project description: A course on child protection in the interprofessional and international domain was established at the Medical School, University of Freiburg. In this course, students of medicine, nursing science and social work acquire skills for successful interprofessional cooperation. Its participants learn across professional and national borders, not only with but also from and about each other. In this way, they deepen their insights into international IPC through a key topic that is relevant to many disciplines. The course is run as a one-day campus day. This paper presents the course setup and evaluation results. Methods: The evaluation was carried out online and in writing in a before and after format using the Freiburg Questionnaire for Interprofessional Learning Evaluation (FILE) in addition to oral feedback. Learning objectives for IPC and child protection were formulated and the participants were asked about their subjective achievements. Results: From summer semester (SuSe) 2017 to SuSe 2018, 39 participants took part in the course. It was rated as m=1.5 (using German school grades where 1=very good, 6=unsatisfactory). In 18 of the 26 FILE items, participants report a self-assessed increase in knowledge or skills/abilities. This growth in learning coincides with the learning objectives set. Discussion & conclusion: From the perspective of the participants, the course teaches interprofessional competencies in an international setting and is seen as an informative course offer. The continuation or expansion of such courses as a supplement to purely single-country interprofessional courses is desirable.

Possibilities of dissemination of specialist knowledge and acting capacity in the field of child protection in medicine: a qualitative survey.

Objective: The shortage of skilled workers and overloaded schedules make further training of health professionals difficult. In addition, child protection is not a systematic part of medical studies. The evaluation of an online course on child protection in medicine reveals positive feedback but also that the main reason for participants aborting the course is lack of time. Dissemination, as an active, targeted spreading of knowledge, can help to further spread knowledge about child protection in the target group. The aim of this article is to investigate whether and how the contents of the online course can be disseminated by professionals who have completed the online course. Methodology: The data were collected through a quantitative online evaluation and qualitative telephone interviews with doctors who had completed the online course and evaluated it using an interpretive-reductive analysis. Results: The respondents consider the need for further training and dissemination measures on the topic of child protection in medicine to be high. However, lack of time and insufficient relevance of the topic would present obstacles in the implementation of such measures. Meaningfulness and time off work or remuneration would in turn create incentives for implementation. Participants in dissemination measures could be motivated for example by further education points. In addition we were able to identify possible approaches for the implementation of such measures. Conclusion: Various parameters influence the motivation of doctors regarding the implementation/perception of dissemination measures. Based on these, recommendations for action are given for different areas of the health care system, such as supplementing the training curricula and providing ready-made materials for dissemination.

Pathways From Parental Substance Use to Child Internalizing and Externalizing Behaviors in a Child Protective Services Sample.

This study examines the role of mediation in the pathway from parental substance use to children developing child internalizing and externalizing behaviors. Using the National Survey of Child and Adolescent Well-Being II, a random half sample (i.e., split-half approach) of children aged 18 months to 17 years who remained in the home following a child welfare investigation (N = 1,633) was used to examine direct and mediated pathways from parental self-reported alcohol and drug use to, separately, parent report of child internalizing and externalizing behaviors. Four parallel mediators were examined: child-reported exposure to violence, child-reported parental monitoring, parent-reported harsh physical discipline, and parent-reported emotional maltreatment. The strongest models for both parental alcohol and drug use to internalizing and externalizing behaviors were single-mediator models through emotional maltreatment. Results suggest emotional maltreatment is a crucial intervention target for families with substance use disorders. Parenting interventions must also strengthen parent-child relationships in order to be effective at improving child outcomes.

School Absenteeism Associated With Child Protection System Involvement, Maltreatment Type, and Time in Out-of-Home Care.

Greater school absenteeism is associated with numerous negative educational outcomes. We used a retrospective cohort design with linked administrative data on 296,422 children to examine the relationship between school absenteeism and child protection system (CPS) involvement. Children with substantiated maltreatment had 4.1 times more unexplained and problem absences than children with no CPS involvement. In multivariate analyses, children with substantiated maltreatment had significantly greater "chronic" truancy (OR = 3.41) and less "acceptable" levels of absences (OR = 0.74) compared to children with no CPS involvement. Greater absenteeism was seen for children with substantiated neglect and who had their first CPS notification earlier in life. Being in out-of-home care for 3+ years was a protective factor for children who had a CPS notification before age 5. Additional adversities had a strong additive effect with CPS involvement on absenteeism and chronic truancy. This study demonstrates the potential scope for reducing problem absenteeism and helps inform the public debate regarding how the type and timing of CPS involvement might ameliorate or exacerbate harm for children.

Methamphetamine use in pregnancy, child protection, and removal of infants: Tertiary centre experience from Western Australia.

The aim of this study is to explore factors that determine infant removal by Child Protective Services and placement in out of home care, for methamphetamine-using women receiving pregnancy care with Western Australia Women and Newborn Drug and Alcohol Service. METHOD: A prospective cohort study of 112 methamphetamine-using women attending Women and Newborn Drug and Alcohol Service for pregnancy care from 2015 to 2018 was undertaken. Maternal methamphetamine use was assessed during each trimester of pregnancy using a standardised assessment tool. Drug use was by maternal self-report. Involvement of Western Australia's Department for Child Protection and Family Support and removal from maternal care were recorded. Infant development was formally assessed at 12 months with Griffiths Mental Development Scales. The comparison was made between three groups: those women who had no involvement with Child Protection, those for whom Child Protection was involved but the child remained in maternal care and those women who had their infants removed from their care. A comparison between Aboriginal and non-Aboriginal women was also undertaken. RESULTS: Of the 110 infants born to 112 women, 33 (30.3%) of infants were removed from maternal custody after delivery. Overall 60 (53.5%) of women had Child Protection involvement. Aboriginal women were overrepresented in our population 59 (52.7%) and 24 out of the 33 infants were Aboriginal were removed and placed into out of home care. Infants were removed from women with a high level of risk factors associated with MA use including those who were homeless, in prison, unemployed or continued high use of MA, mental health issues. Aboriginal infants were at increased risk of removal. Children removed from maternal care had a trend towards poorer developmental attainment at around 12 months compared to those who remained with their mother. Infants who were removed by the Child protection had lower general quotients (p = 0.132) than infants who had no involvement or some involvement. CONCLUSION: Infants removed from maternal care were more likely to be from women with high use, adverse social factors and born to mothers who identified as being Aboriginal. Resources are required that work intensively with families to reduce the number of infants being removed from maternal care to overcome the risks and challenges of addiction. IMPLICATIONS FOR PRACTICE: Resources that provide long term support and community-based models that offer a comprehensive range of maternal-child services and in-home-support would be more effective in keeping families together.

Sibling Child Protective Services Involvement Following a Child Maltreatment Fatality.

OBJECTIVE: This study examined CPS involvement of children surviving the CMF of a sibling as well as predictors of subsequent CPS reports. METHOD: Department of Human Services and Child Death Review Board data about children who died from a CMF during 1993-2003 (n = 416) and their siblings in the state of Oklahoma were used to examine CPS involvement and predictors of subsequent CPS reports for surviving siblings. RESULTS: Surviving siblings of a victim of a CMF experienced substantial CPS involvement; 81% of the original victims had siblings who were subsequently reported to CPS (n = 1,840). Original victim and family characteristics that predicted a greater rate of siblings' subsequent reports to CPS included younger original victim age, greater number of children in the original victim's home, and more previous reports of the original victim to CPS. DISCUSSION: A large portion of families with a CMF struggle to adequately care for their surviving children. Such families may need additional support after a CMF.

Removal of babies at birth and the moral distress of midwives.

BACKGROUND: Midwives and nurses appear vulnerable to moral distress when caring for women whose babies are removed at birth. They may experience professional dissatisfaction and their relationships with women, families and colleagues may be compromised. The impact of moral distress may manifest as anger, guilt, frustration, anxiety and a desire to give up their profession. While there has been much attention exploring the concept of moral distress in midwifery, this is the first study to explore its association in this context. AIM: This article explores midwives' experiences of moral distress when providing care to women whose babies were removed at birth and gives valuable insight into an issue nurses and midwives encounter in their profession. METHODS: Four mothers and eight midwives took part in this research. Narrative inquiry incorporating photo-elicitation techniques was used to generate data; mothers were interviewed face to face and midwives through focus groups. The images and audio data were collected, transcribed and analysed for emerging themes. For the purpose of this article, only the midwives' stories are reported. This research received a favourable ethical opinion from the University of Surrey Ethics committee. ETHICAL CONSIDERATIONS: This study received a favourable ethical approval from a higher education institutes ethics committee. RESULTS: Midwives who care for women whose babies are removed at birth report it as one of the most distressing areas of contemporary clinical practice. Furthermore, they report feelings of guilt, helplessness and betrayal of the midwife-mother relationship. Many of the midwives in this study state that these experiences stay with them for a long time, far more than more joyful aspects of their role. CONCLUSION: Midwives experience moral distress. Support systems, education and training must be available to them if we are to reduce the long-term impact upon them, alleviate their distress and prevent them from leaving the profession.