Are women too frightened of childbirth?

In today’s Mail, a former antenatal teacher forcefully expresses the view that horror stories in the media, and programmes such as Call the Midwife,  are responsible for peddling the idea that childbirth is frightening and dangerous. Reading or seeing horror stories, her argument goes, makes women feel frightened, and the fear itself increases the risk of a difficult labour and worse outcomes.

It’s a view I’ve heard expressed a lot recently – including last week, at a training day for midwives on mental health, at which I was also speaking. I couldn’t help recalling a talk I’d given a year ago, at the end of which an obstetrician expressed the view that the two most dangerous days of a woman’s life are the day she’s born and the day she gives birth. She went on to say that one of the reasons women felt traumatised by a difficult birth was that women these days were going into birth with expectations that were too high: they assumed that they would be able to give birth normally, with help from breathing exercises and a birthing ball, and were bitterly disappointed to discover that giving birth is much harder than they’d imagined.

So there you have it. In one view, women these days are too frightened of birth, which leads to them having a traumatic birth; in the other, women are too blasé, which leads to them being traumatised by birth.

What strikes me now, however, is that both views – that women should be either more positive, or more wary ­–­ are mistaken. Whether a woman has a good experience or a bad experience of birth has little, in reality, to do with how she feels about it beforehand, and a great deal more to do with how she is looked after by the people responsible for helping her birth her baby. Some things, of course, are out of everybody’s control: physiological problems that result in a long or particularly painful labour, or lead to a postpartum haemorrhage, are hard to predict and avoid.

But what we can do something about is how well the woman is treated. Is she being cared for on a one-to-one basis, or is her midwife, as a result of staff shortages, having to dash between multiple labouring women? Will the midwife ask the woman’s consent before carrying out an internal examination or breaking her waters? If the woman is in a great deal of pain, and asks for pain relief, will that request be taken seriously, or ignored or even belittled? If the woman feels the urge to push, will there be a check to see that she’s in second stage labour, or will it be assumed that she can’t possibly be that far along, as she hasn’t been in labour long enough? If something goes badly wrong, such as the baby getting stuck in the birth canal, or the woman haemorrhages after labour, will that emergency be dealt with not only quickly and efficiently but with kindness? Will someone explain to the woman what is being done and why? If she is feeling distressed, will someone take the time to hold her hand and comfort her?

All these things, as new research has confirmed, make a difference as to whether a woman finds her birth traumatic or not. It’s possible to have a potentially frightening experience, such as a shoulder dystocia delivery or a huge postpartum haemorrhage, without feeling traumatised, as long as the woman feels confident that the people looking after her are both capable and caring. Ultimately, whether the woman goes into labour feeling serene, or absolutely terrified, should make no difference, because if she is well looked after, then there is every reason to expect that she will come out of her birth experience feeling relieved and happy.


Serena Williams and why health professionals don’t listen

Last week, tennis player Serena Williams gave a remarkable interview to Vogue about her traumatic birth.

She had her baby, Alexis Olympia, by emergency casesarean section after the baby’s heartrate dropped dramatically during labour.

Williams has a history of blood clots, but she had to come off anticoagulants because of the c-section, so when she felt short of breath the following day, she found a nurse and told her she needed a CT scan with contrast and IV heparin (a blood thinner) right away.

According to Williams, the nurse thought her pain medication was making her confused. Luckily, Williams stood her ground, and a doctor performed an ultrasound on her legs, while Williams insisted that what she needed was not an ultrasound, but a CT scan. When the ultrasound found nothing, they sent her for a CT scan, which revealed several small blood clots in her lungs and they were able to treat her with anticoagulants.

That wasn’t the end of it. As Vogue tells it:

“Her fresh C-section wound popped open from the intense coughing spells caused by the pulmonary embolism, and when she returned to surgery, they found that a large hematoma had flooded her abdomen, the result of a medical catch-22 in which the potentially lifesaving blood thinner caused hemorrhaging at the site of her C-section. She returned yet again to the OR to have a filter inserted into a major vein, in order to prevent more clots from dislodging and traveling into her lungs. Serena came home a week later only to find that the night nurse had fallen through, and she spent the first six weeks of motherhood unable to get out of bed.”

Shocking as it may seem, her story isn’t that untypical. For most women, birth doesn’t cause disastrous complications and have near-fatal consequences, but it happens to enough women that it shouldn’t come as a surprise.

Women don’t want reassurance – they want to be taken seriously

The fact that Williams had a pre-existing condition should have meant that medical staff were extra-alert to the possibility of complications. That they were so blasé about it is worrying. And how fortunate that Williams knew what was wrong with her: patients with chronic conditions often become experts in them and can make a rapid diagnosis of a particular set of symptoms.

Not everyone is a fan of the skeptical OB, but she has a good record of pointing out that the high maternal mortality rate among black women in the US is largely a result of pre-existing conditions, such as heart problems. Doctors need to be aware of those conditions and take account of them when a woman is pregnant. Talking about Williams’s case, she notes the familiar advice of William Osler: “Listen to your patient, [s]he is telling you the diagnosis.”

In Williams’s account, that was literally the case – she told the nurse what was wrong with her and what she needed to do. The nurse assumed she was “confused”. I’ve heard a similar story time and time again, along with the other comments the skeptical OB notes:

Don’t worry; your baby isn’t moving less. He just has less room to move now.

Don’t worry; your headache isn’t serious. It’s just nerves.

Abdominal pain after birth? Don’t worry; that’s normal.

Denial and cover up

A story in Saturday’s Mail about a woman whose baby died also had a familiar ring: Sarah Hawkins was refused admission to the maternity suite because, despite being in agony, she was told that her contractions were too far apart, and she wasn’t in established labour. The subsequent denial and cover-up are all-too-familiar too. Sarah’s husband, Jack, a consultant at Nottingham University Hospital Trust where Harriet Hawkins was stillborn, says:

“We asked the Trust how many similar deaths there were to Harriet’s and we discovered there were 35 in just over two-and-a-half years.”

It seems hardly credible that so many babies should die in such a short space of time without any action being taken. And yet the response of the trust is not to investigate and improve, but to obfuscate and deny.

The Hawkins family weren’t alone in being turned away. The Guardian today has a story about women turned away from hospital because they supposedly weren’t in labour, only to give birth shortly afterwards – in one case, on the pavement. Luckily their stories had happier endings, but once again it’s a case of a woman knowing her own body better than the medical professionals.

The simple lesson from all of this is to listen to what women are saying: if they say there is a problem, don’t reassure them – take notice of what they’re telling you. They might actually be right.








Birth, sweat and trauma: why don’t doctors learn from their mistakes?


Lotty’s labour was long and painful, and she eventually gave birth to her daughter by forceps. It was a difficult and traumatic experience, but it didn’t end there. Mistakes made by the medical team during her labour meant that a few weeks after giving birth, Lotty nearly died. I don’t want to give away her story, but you can listen to her recount it in this new podcast from The Backstory, part of a series that talks to people about their personal struggles and tragedies.

The story Lotty tells so movingly is her own, and has its own unique elements. I’ve heard lots of stories of traumatic births now, but none has been exactly the same as Lotty’s. And yet there are so many common features to these stories that I start to tick them off as I hear them

  • Multiple medical mistakes – tick
  • Fobbing off the woman’s concerns that something is wrong – tick
  • An unwillingness to explain the problem properly – tick
  • Attempts to minimise the gravity of the situation – tick
  • A lack of compassion and sensitivity – tick
  • The non-apology apology when your mistakes have nearly killed a patient: “I’m sorry you felt upset…” – tick

It’s not that I don’t value the work that obstetricians and midwives do. Lotty was in so much pain during labour that she bit the midwives, which can’t be a lot of fun – most of us, however annoying we find our work, don’t expect to be bitten. And labour is a difficult and unpredictable business – it’s not surprising that in a stressful, rapidly changing situation, mistakes are made.

BUT. The mistakes made by the health professionals looking after Lotty were easily avoidable. They were basic errors of care. If a simple checklist had been followed, the problem that ended up nearly killing Lotty could have been identified and dealt with immediately.

To make it worse, no-one listened to Lotty when she told them something was wrong. When they finally did something about it, they all – apart from one doctor, an old schoolfriend – refused to acknowledge the seriousness of the problem. And when she did finally complain, they pretended that it was her fault for being irrationally upset, not their fault for nearly killing her.

Does it have to be like this?

As I mentioned in my last post, the new Healthcare Safety Investigation Branch will investigate cases of stillbirth and severe brain injury as a result of birth. It won’t, however, investigate mistakes that lead to less serious outcomes. And yet what cases like Lotty’s show is that mistakes that lead to near-misses should be reviewed and learned from. The response when a patient nearly dies as the result from an error shouldn’t be, “Sorry you feel upset about this” but “We made a mistake. What did we do wrong – and how can we stop it happening next time?”

Even better would be if each maternity unit gathered the data on its mistakes and shared them nationally so every other maternity unit could learn from them. There are 700,000 births a year: imagine what a rich data set that would provide. Imagine how much better we could make birth if we learnt from every incident of a birth going wrong.

Until that’s in place, stories like Lotty’s – and stories that have a much more tragic outcome – will keep on happening.





Halving the stillbirth rate by 2025: ambitious, but doable

Some good news: parents of babies who are stillborn, or have suffered a severe brain injury, will be offered the option of an independent review of their care. Currently reviews are carried out, to a varying standard, by individual hospitals. Health secretary Jeremy Hunt is to announce that a new Healthcare Safety Investigation Branch (HSIB) will, from next April, take over investigation of the 1,000 deaths of new babies and mothers and unexplained serious injuries.

This will, it is hoped, achieve two things: one is to have a greater culture of openness, with a quick resolution after a terrible mistake. This is important because currently some hospitals lie and obfuscate about their role in a baby’s death or injury – the Joshua Titcombe case was a particularly egregious example, but the urge to cover up is widespread. More significantly, the existence of an independent review body could, Jeremy Hunt hopes, halve the numbers of stillbirths, neonatal deaths and severe birth-related brain injuries by 2025.

Hunt’s announcement comes the day after the publication of a MBRRACE report, which revealed that the rate of intrapartum death had halved since 1993. Back then, there were 0.62 deaths for every 1,000 births; now that figure is down to 0.28. This is particularly worth celebrating because during that time, the age of women giving birth has been rising, and more women have conditions relating to being overweight. Both of those factors increase the risk of stillbirth.

(“Intrapartum death” refers to deaths of “normally formed babies of 2.5 kg or more who were stillborn or died within the first week of life where the death was related to problems during labour”. This isn’t the same as stillbirths in general: the overall stillbirth rate has dropped by just over a fifth, and neonatal death by a third, in the same time frame.)

Most intrapartum deaths could be prevented by better care

But it was shocking to read that, of the 78 deaths the MBRRACE team looked at, 80% could have been prevented by better care in labour. The biggest single cause was an issue with capacity – in other words, not having enough staff. We’ve known for some time that the NHS doesn’t have enough midwives and obstetricians, and that the government needs to address this immediately.

Other important findings included a delay in inducing babies who were due to be induced, staff failing to recognise that a woman had moved to the second stage of labour, a lack of urgency in offering a caesarean section when needed, and a failure to monitor the baby’s heartrate correctly.

We know, from women’s own stories, and from NHS litigation records, that these are complaints that come up time and time again. An inability to read the CTG trace that monitors the heartrate appears frequently in litigation. But this – along with the ability to identify the change to second stage labour – could be improved with better training. Even more importantly, it could be improved by an independent review of what went wrong.

No-one is perfect; everyone makes mistakes. But when the same mistake is repeatedly leading to babies dying, then something is wrong. Reviewing the deaths of babies, and identifying the causes, can lead to better training and better practice. The launch of the HSIB offers real hope that we can bring about an end to babies dying unnecessarily in labour.


Michel Odent Speaks Out About Caesareans

Michel Odent, the man who, in the words of the Guardian, “encouraged women to experience pain-free labour in warm pools of water and was the first to write about the importance of placing newborn babies to the breast” has now warned about the dangers to the human race of the rise in caesarean sections.

In a new book called The Birth of Homo, The Marine Chimpanzee, Odent argues that modern medicalised births are working against evolution. Caesarean-born babies are more likely, for example, to be autistic. From the Guardian article:

“One effect of modern obstetrics is to neutralise the laws of natural selection – the laws that foiled us all [in the past]. We have neutralised those laws. It means that at the beginning of the 20th century, a woman who could not give birth naturally would die, whereas the one in the village who could give birth easily would have 12 children. Today, the number of children one has depends on other factors than the physical capacity to give birth.

“I mainly talk about obstetrics, but we can also talk about conception. If you cannot have a child, you can have medicalised conception. So we have neutralised the laws of natural selection. It is one of the biggest problems for humanity today and people don’t realise that. Any mathematician, any statistician interested in this topic will find ways to calculate what will happen – in my book I give several examples.”

“One of the biggest problems for humanity today”? That’s a pretty big claim – particularly if you think about global warming, pollution and the decline in the bee population. And those are just the environmental problems – don’t let’s forget the rise in antibiotic resistance and the imminent threat of nuclear war.

Evolution is brutal

So is Odent right to identify modern methods of childbirth and conception as a problem? Well, in a sense, yes. A hundred or so years ago, as he points out, a woman who could not give birth naturally would die. These days, a woman who can’t give birth naturally survives, thanks to surgical intervention.

Any normal person would surely see this as a cause for rejoicing. You could argue, as Odent does, that as a result of caesareans and other interventions, we’re breeding a race of humans who are ill-equipped for survival: women who have pelvises too narrow for a baby to pass through will give birth to daughters with similarly narrow pelvises. And so on. But it’s difficult to see why this is a problem. Modern medicine is saving lots of people who would otherwise have died: premature babies, babies with disabilities, children with diseases such as measles and meningitis. Vaccines for diseases such as polio and diphtheria mean that children who would previously have been too weak to survive those diseases are now never exposed to them in the first place. Unless we abandon using modern medicine altogether, then we simply have to accept that the laws of natural selection are well and truly “neutralised”.

When he argues that caesarean sections result in more autistic children, then he is, as the Guardian points out, confusing correlation and causation. The paper quotes autism specialist Paul Wang:

“A foetus with developmental issues may have low muscle tone that can interfere with moving into proper position for natural delivery. In this and other ways, the foetus plays a crucial role in initiating and advancing natural labour.”

Don’t worry your pretty little heads about science

But suppose he’s right? Suppose caesarean sections were causing more children to be born with autism? What could we possibly do? Stop performing caesareans and allow babies and their mothers to die?

Obviously not. It’s difficult to see how the argument achieves anything other than to make pregnant women, bombarded with advice from all sides, even more worried than they already are. Odent is quoted as saying: “I put a caveat in my books – they are not for pregnant women. I tell them not to read them. They are books for people who are interested in the future of human beings – preferably ones with a scientific background, people interested in thinking in terms of the future and the future of the species. That’s the public I want to reach.”

In Odent’s mental Venn diagram, there is clearly no overlap between women who are scientists and women who are pregnant.

Pregnancy sickness is good, apparently

But Odent has form for this. While acknowledging that women used to die in childbirth before modern medicine, he accuses modern doctors of terrifying women through the use of medical terminology. In a 2013 interview with the Telegraph, he apparently “uses the example of dramatizing healthy morning sickness that indicates a thriving foetus into the much more serious condition of ‘Hyperemesis Gravidarum.’”

This sounds plausible until you meet a woman who has suffered hyperemesis to the extent where she is vomiting 24 hours a day, and cannot keep down anything, even a sip of water. Women die from untreated hyperemesis.

In the same article, Odent attacks the use of synthetic oxytocin which also, he argues (but with very little evidence), correlates with a rise in autism. (Autism has clearly become Odent’s thing.)

Odent wants us to believe he is motivated by genuine scientific curiosity. But in identifying intervention in childbirth, rather than, say, antibiotics or vaccines, as a threat to natural selection, we can see a more sinister agenda at work – a desire to turn the clock back to a time before modern medicine. Though only, of course, for women.



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.


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.