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.




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.


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.


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.