Why birth is traumatic – and how we can make it better

During birth trauma awareness week in August, dozens of women took the opportunity to tell their birth stories.

Psychologist Emma Svanberg collected 75 stories and published them on her site, Make Birth Better. They make for a harrowing read as women recount experiences of being left for hours in pain, being torn apart in childbirth, coping with infections, being ignored by doctors and midwives, suffering from incontinence problems, fearing their baby was about to die, and much more.

As well as publishing the stories, Emma analysed them and picked out five themes. Anyone who has heard women talk about their traumatic birth will find them familiar: A force bigger than me; Heroes and villains; Delivery into parenthood; I had no idea; Make birth better. Together, the five themes give both a powerful account of what is wrong with the way women are treated in birth and a guide to how we can do it better.

Violence and brutality

“A force bigger than me” talks about the overwhelming physicality of birth. This includes things like the unbearable pain, physical damage such as pelvic fracture or bowel problems, but it also includes the sense of violation: “Being stitched up was a violence”, “Everything in my labour felt like a war”, “It was comparable to rape”. Many spoke of actions being taken without consent.

The “Heroes and villains” theme makes for particularly dispiriting reading. Women write of having staff talk over them, of arguing with colleagues, of shouting at them and of ignoring them. It hardly needs saying how distressing this is for women who are giving birth, and already fearful about whether they or their baby will survive. But when a midwife is kind or supportive, that makes an impact too. “I got the most amazing midwife who I remember as my superhero,” one writes.

“Delivery into parenthood” provides a vivid account of the psychological impact of a traumatic birth both on themselves and their partners. They have flashbacks and nightmares; they feel ashamed or like failures. They may feel permanently changed and scarred by what has happened to them. They feel they’ve missed out on the opportunity to form a bond with their baby. For partners, it was the “most brutal thing he has witnessed” or ‘he thought that was going to be the last time he saw us”.

Pull yourself together

The fourth theme, “I had no idea”, recounts women’s feelings of shock at the experience of birth, which they were often ill-prepared for, compounded by a lack of communication from health professionals who didn’t tell them what was happening. Another topic that comes up is what is often these days referred to as “gaslighting”: a deliberate minimising by health professionals of the trauma the woman has gone through: “Dr telling me there was no need to cry”, “she told me to stop wasting time”, “stop making a fuss”, “pull myself together”. In many cases women felt they had nowhere to turn for help.

Finally, in “Make Birth Better”, women talk about what they think women should know before giving birth, and what health professionals and providers should know. They talked about the need to be better informed, without scaremongering, about what birth could be like. They talked about the need for health professionals to keep them informed about what was happening, and to think about the language they used. And they talked about the need for better support after a traumatic birth rather than leaving them to fend for themselves.

I felt a weary sense of familiarity in reading women’s accounts of what happened to them. In the UK, 700,000 women give birth every year. Birth is an unpredictable business, and emergencies can happen very suddenly. It’s understandable that sometimes health professionals have to act quickly without much time to talk. And yet is it really necessary to treat women as if they’re idiots? To argue with colleagues in front of a labouring woman? To perform invasive procedures without asking their consent? To abandon a woman who has been distressed by a traumatic birth and tell her she simply has to get on with things? Calm, informative communication doesn’t require an investment in resources, simply a willingness to treat women in labour as autonomous adults, deserving of normal amounts of respect and kindness.

Until we put women and their needs at the forefront of maternity care, however, then stories like this will keep on coming.

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If we really want to help women with birth trauma, we need to learn to listen

One of the things that practically everyone involved with mental health seems to agree on is that we need to talk more. People bottle their problems up, which makes everything worse, and sometimes leads to depression and suicide. If only we talked more about our feelings, everything would be much better.

This truism is trotted out time and time again. It’s rare, however, for someone to make the simple point that talking is only of any value if someone is listening. Yet that, in my experience, is where the real problem lies.

“Listening” doesn’t, of course, just mean listening. Real listening is hard work: it means paying attention to what the other person is saying, trying to understand their point of view, not telling them about your similar experience or suggesting they cheer up or offering advice about what they should do.

Women who have experienced postnatal PTSD come up against this problem all the time. A characteristic of PTSD is the urge to talk about the traumatic experience continually, to try to make sense of it. This isn’t surprising, as PTSD sufferers often find themselves reliving the trauma: it doesn’t feel like something that happened in the past, but that is always present.

Yet when they talk to their partners, their family or even to health professionals, they come up against the same response over and over again:

“You’ve got a healthy baby – focus on that instead.”

“The health professionals were only doing their best for you.”

“Other women have had babies and don’t make this amount of fuss.”

“It’s time to move on and put it all behind you.”

None of this is helpful, because it minimises the experience and also makes the woman feel as if she’s being unreasonable. It’s also useless, because PTSD is not something anyone has control over – no-one chooses to experience flashbacks, or to be constantly anxious, or to feel terror every time they walk past the place they experienced the trauma (usually a hospital, for women with postnatal PTSD). PTSD causes real, physical changes in the brain – they don’t disappear by force of will.

The reason why the blogpost “I had a shit birth. Here’s six reasons why I really want others to know” went viral is that the writer accurately captured this need to have people actually stop and listen, without judgement. As the blog’s author says: “Silencing anyone who has lived through trauma is not okay.”

Her follow-up post, How to avoid birth trauma, by expert commenters of the interweb, after her story was featured in national news sites, nicely captures that failure to listen, from people on the internet who have never experienced trauma and have no clinical or academic expertise in the subject, but nonetheless have a view on how other people should deal with it.

One last thing. During Awareness Week, the Birth Trauma Association was inundated by emails from women desperate to tell their story. Reading those stories shows that the listening problem starts well before the trauma: story after story relates how women told medical professionals there was something wrong, or that they were in severe pain or distress, only to be told that everything was normal. There are even stories of women who knew they were ready to push being told that they weren’t ready to push. In one extraordinary account, a woman describes how, post-birth, her extreme pain was dismissed by doctors and midwives alike, until a healthcare assistant spotted her racing heart – the first sign of septic shock – and called for help, thus saving her life. Even allowing for understaffing, this seems negligent.

Yes, it’s good to talk. But it’s even better to listen.

Breaking the silence – why we need birth trauma awareness week

Next week – August 14 to 18 – is birth trauma awareness week. It has two main aims. One is to make more people aware of what birth trauma is and how it affects women (and their families) who experience it.

The other aim is to raise money so that the Birth Trauma Association can start extending its services to women by offering peer support by phone and face-to-face.

If you’re interested in helping, there are a few things you can do:

  • Tweet links to women’s birth stories using the hashtag #BreakTheSilence
  • Hold a fundraising event – you can download a fundraising pack for ideas
  • Follow the Birth Trauma Association on Twitter
  • Change your social media profile pic to include the Birth Trauma Association logo
  • Register with Thunderclap to post a message about birth trauma awareness on your timeline at 5pm on Monday 14th – the more people who register, the more impact the message will have

It’s long been clear that there’s a huge unmet need for support services for women suffering from birth trauma. Although it’s hard to know the exact number, the current best guess is that 20,000 women every year suffer from postnatal PTSD in the UK (3% of the total number of women giving birth).

One of the reasons the condition is little known about is because women don’t speak about it. And the reason they don’t speak about it is that people don’t listen. Women are used to hearing the dismissive phrase: “All that matters is that you have a healthy baby.”

Two weeks ago, a blogger who writes under the name of Mummy Truths wrote a post called: I had a shit birth. Here’s six reasons why I really want others to know.

It’s a wonderful, eloquent, powerful piece about what it’s like to experience birth trauma. Within a matter of days, it had received 90,000 hits, having been shared on Facebook parenting groups, midwife groups and birth groups. Sarah brilliantly describes how women with birth trauma are silenced, about how dignity and respect are neglected in birth and how it feels to experience the constant hypervigiliance of PTSD: “The triggers are many and they are everywhere. A letter for a smear test, a shadow flickering past the window when you’re alone in the house at night. Shouting. The baby crying. It can all trigger symptoms – feelings of fear and threat – reducing a mother’s ability to parent well.”

The reason the post was shared so often was because it resonated with so many women. They read it, thinking, Yes, that’s how I felt. That’s what it was like for me.

If you want to know why birth trauma is important, then read Mummy Truths’s post. It’s time women’s stories were heard. It’s time to #BreakTheSilence.

Too many babies are dying at birth

Last week saw the publication of two reports on the deaths of newborn babies. Each Baby Counts, published by the Royal College of Obstetricians and Gynaecologists (RCOG), found that three-quarters of the babies who die or are brain damaged during childbirth in the UK might have been saved by better medical care.

The MBRRACE report found that between 2013 and 2015, the stillbirth rate fell from 4.2 to 3.87 per 1,000 births. That’s good news, though the report noted that the stillbirth rate is still higher than many similar European countries and that there is “significant variation” across the UK – variation that can’t be explained simply by factors such as poverty or maternal age. In other words, the difference is likely to be the result of different practices in different hospitals.

Each Baby Counts investigated the cases of 1136 cases of babies born in the UK in 2015 who either suffered brain damage during birth, or died during delivery or in the next week. Of those, the report estimates that 550 babies could have been saved. Shockingly, in 409 cases, the Each Baby Counts team wasn’t able to determine whether the babies could have been saved because the information provided wasn’t good enough.

And that’s the real scandal. The best way to improve medical care and prevent unnecessary deaths is through the collection and analysis of evidence so that we can determine best practice that can then be followed by every hospital in the country.

Childbirth is a complicated business because it can involve countless small decisions that women have to make in conjunction with their caregivers. Each one of those decisions has the potential to increase or decrease the risk of harm to the mother and baby. Decisions are rarely easy to make because every intervention (induction, foetal monitoring, epidural, episiotomy, forceps…) can increase some risks while decreasing others. This is why evidence is so important.

Doctors don’t always know best

Ben Goldacre illustrates the importance of evidence through the example of head injuries. In a blogpost, he writes:

“For many years, it was common to treat everyone who had a serious head injury with steroids. This made perfect sense on paper: head injuries cause the brain to swell up, which can cause important structures to be crushed inside our rigid skulls; but steroids reduce swelling (this is why you have steroid injections for a swollen knee), so they should improve survival. Nobody ran a trial on this for many years. In fact, it was widely argued that randomising unconscious patients in A&E to have steroids or not would be unethical and unfair, so trials were actively blocked. When a trial was finally conducted, it turned out that steroids actually increased the chances of dying, after a head injury.”

It may be that some midwives and obstetricians have instinctive beliefs about reducing the harm to mother and baby that turn out to be completely wrong. It’s hard to know until we collect the evidence. Yet we do know that some trusts, such as Southmead Hospital in Bristol, and Barking, Havering and Redbridge University Hospitals, have adopted good practice that has led to the reduction of birth injuries in the first case, and of errors relating to the CTG trace in the second (errors caused by misreading the CTG trace are a common cause of injury and death in newborn babies).

Other countries manage to have far fewer babies die at birth than we do. It’s not an impossible dream. But if we are serious about saving the lives of newborn babies, then we have to start with the absolute basics: collecting the data to find out why they are dying.

Why forceps can be dangerous

 

Forceps deliveries and Ventouse deliveries are significantly more dangerous for both mother and baby than a caesarean section, according to new research published in the Canadian Medical Association Journal. The risk of severe complications to the baby is 80% higher.

The study looked at 187,234 births. The main finding was that “among women with dystocia and prolonged second stage of labour, midpelvic operative vaginal delivery was associated with higher rates of severe perinatal morbidity and mortality compared with cesarean delivery.” To put it more simply, more babies died or were injured during an instrumental delivery than during a caesarean section. Although the study found that maternal mortality was no higher during an instrumental delivery, “rates of obstetric trauma” (this refers mainly to tearing) were higher.

This matters because in the UK, as in many other countries, there are moves to reduce the caesarean section rate, partly because caesareans are expensive, and partly because of the risks attached to abdominal surgery. The caesarean rate in this country is one in four, which many experts think is too high – and as a result, many hospitals now have “normal birth” targets.

The findings of the new research suggest that this drive is misguided. There have been a number of well-publicised cases over the past five years of babies dying after the mother was refused a caesarean section.

But there is a risk to the mother too. The Australian obstetrician Hans Peter Dietz has been outspoken about the target to reduce caesarean section rates in New South Wales, which has resulted in a huge increase in forceps deliveries, but also far more cases of women with severe pelvic floor and anal sphincter damage – something that can be absolutely devastating for women. Dr Dietz found that 81% of women who had forceps deliveries suffered internal damage.

Obviously there are caveats. A response to the research article by obstetrician Nicholas Pairaudeau argues that the decision to use or not use forceps should depend on factors such as the size of the woman’s pelvis and the positioning of the baby. He writes: “Even though I have used forceps for nearly 50 years I have, in my own practice, reduced many of the complications quoted, by careful selection of the patient, forceps, and type of pelvis. C-section is not a simple option in many cases, and is associated with major complications too.”

The question of risk in childbirth is never a simple one: often it’s a case of having to decide which is the lesser of two risky options. The worry is, however, that by setting a target to reduce caesareans, hospitals then become focused on the process rather than outcomes. A caesarean in itself is not a bad outcome: a dead or injured mother or baby is. Doctors’ decisions should be based entirely on whether they will lead to a healthy mother and baby – not on they meet an arbitrary external target.

We need better postnatal care – and Mumsnet is on the case

I’ve been delighted to see the mighty Mumsnet launch a campaign to improve postnatal care in hospitals. Women with postnatal PTSD often mention poor postnatal care as a contributing factor.

After a traumatic birth in which you have nearly died, or your baby has nearly died, or you have lost several pints of blood, or been in pain for hours but denied drugs, or experienced a violent forceps delivery, or had multiple painful stitches, or had a retained placenta, or an emergency c-section after the baby’s heartrate has dipped – or, as is often the case, a combination of several of those things – then it’s not unreasonable to imagine that you will be treated gently, with some kindness and consideration.

In practice, this is far from the case. When Mumsnet asked women to recount their experiences of postnatal care, they offered depressingly similar stories of being left for hours and hours unattended, often on a noisy postnatal ward, or refused help with breastfeeding, or not being given food and drink despite being too ill to get out of bed.

Some of this can be put down to staff being overworked, but the dismissive, unkind attitude that accompanies it cannot. In an article for the Independent last year, I wrote about Rachael, who after a deeply traumatic emergency c-section resulting from placental abruption, was told by a midwife: “Don’t go thinking you’re anything special – we see bigger abruptions than you had.”

A new blogpost describes an experience that is all too typical. The writer, who blogs under the name IslandLiving, recounts an immensely difficult labour ending in c-section. Left alone with her baby afterwards, she felt petrified. She goes on:

“I stayed in a side room for two days. In those two days I struggled. I felt overwhelmed and scared. I was petrified. I was told to ring the bell, that I was not to pick up my baby myself. Yet every time I rang the bell no one came. Every time I cried for help no one came. I struggled out of bed because that was my job. I struggled to feed her because that was my job. I struggled to change her because that was my job. Yet, I didn’t know if I was doing my job properly. I didn’t know if she was getting any milk. I needed help and it didn’t come. The nights were the worse as I would feel alone, like I was ringing a bell into the great abyss. No one ever came.”

IslandLiving says, generously, that she doesn’t blame the nurses or the midwives because the unit was understaffed. But it depends whether you see caring for a woman after she’s given birth as a fundamental part of the job or not. If it’s not – if adequate postnatal care is simply a “nice to have” rather than an absolutely essential part of the midwife role – why expect women to stay in hospital at all? Why not send them straight home?

Apart from being inhumane, skimping on postnatal care makes no sense economically, because it so often leads to physical or mental health problems that need treatment. One of the women quoted by Mumsnet wrote that she asked for help cleaning round her episiotomy scar, but was told not to worry because “it’s a dirty part of the body anyway”. She ended up with a major infection.

Poor care isn’t inevitable: a few Mumsnetters gave examples of excellent care. It’s high time that other maternity units followed suit.

How can we stop so many babies dying at birth?

An investigation by the HSJ’s Shaun Lintern, also reported in the Nursing Times, has found that many babies are dying at birth as the result of a simple mistake: a failure to correctly read the CTG trace, which monitors the baby’s heart rate:

“Data from NHS Resolution – formally the NHS Litigation Authority – shows there were almost 300 clinical negligence claims between 2011 and 2016 where the primary cause of the injury was a failure to respond to an abnormal foetal heart rate.”

Lintern points out that this problem has been known about for a long time: reports by the NHS Litigation Authority in 2009 and 2012 made similar findings.

There have been recent well-publicised cases, he notes, where a failure to read the trace correctly resulted in tragedy: in February, for example, coroner David Hinchliffe said of baby Maxim Karpovich, who died in 2015:

“It was apparent that the midwives involved with Maxim’s birth and the junior obstetrician appeared not to understand that the CTG trace was abnormal on several occasions.

“This inquest and many previously have caused me to note that midwives and obstetricians lack the core skills to interpret CTG tracings.”

It’s easy at this point to blame the shortage of midwives, which is putting a lot of midwives under pressure – and indeed the Royal College of Midwives (RCM) spokesperson quoted in the piece does just that. She also blames outdated equipment and the increasing complexity of birth.

The Royal College of Obstetricians and Gynaecologists (RCOG) spokesperson, on the other hand, says that errors could be reduced with a focus on multidisciplinary training:

“There shouldn’t be a brick wall around obstetrics and a brick wall around midwifery.”

In hospitals, safety is paramount. The death of a baby should be an exceptional circumstance, and when it happens, staff should work together to review why it happened and what can be done to stop it happening again. This is what happens in organisations that have a culture of safety. The fact that in so many NHS hospitals this doesn’t happen is shocking.

Lintern goes on to mention Barking, Havering and Redbridge University Hospitals NHS Trust, which set out to tackle its rate of CTG errors. It had found that 75% of maternity “incidents” included some form of CTG error in 2015-16, but the trust had invested in staff training, equipment and an improvement in culture. In the past 11 months the trust hasn’t had a single CTG error.

According to the trust’s director of midwifery, Wendy Matthews:

“We have put in place quite a rigorous process. We’ve developed a culture of quality and safety and learning from errors which is very much about the multi-disciplinary team.”

This is a remarkable achievement. Yet it doesn’t sound as if there was a magic solution to the problem – simply that the trust approached the problem sensibly by training staff to read the CTG correctly, buying more effective equipment and working together to learn from mistakes.

In an ideal world, what would happen next is that every other maternity unit in the country would look at what Barking, Havering and Redbridge did and copy its example. This would save the NHS hundreds of millions of pounds a year in litigation – and more importantly, save the lives of hundreds of babies who die needlessly at birth.