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, blogger Sarah Oakes 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 Sarah’s 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 Sarah’s post. It’s time women’s stories were heard. It’s time to #BreakTheSilence.

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.

Should we think of birth as normal, or as dangerous?

 

A few weeks ago I gave a talk to a group of health professionals about the impact of a traumatic birth on relationships. At the end of the talk, an obstetrician in the audience took me gently to task for using the phrase “when birth goes wrong”: problems such as retained placenta or postpartum haemorrhage were so commonplace, she said, that they were a routine part of the experience, rather than a sign of something going wrong. She added: “The day she gives birth is – apart from the day she’s born – the most dangerous day of a woman’s life.”

It was a striking comment, and one I’ve been thinking about ever since. There is an alternative view of childbirth, which is that it’s a “normal, physiological process”. It’s a view that’s endorsed by the Royal College of Midwives (RCM), and some NHS trusts have appointed midwives to act as “normal birth leads”, helping women to “achieve” a normal birth. Many midwives believes that an important part of their job is to support women to give birth “normally” – that is, without a caesarean section or intervention such as forceps or Ventouse. Proponents of normal childbirth would argue that an over-cautious approach to risk is in itself damaging, leading to unnecessary interventions that result in a more traumatic experience for mother and baby.

Childbirth is possibly unique amongst medical specialisms in that it is dominated by two professional groups who to some extent have competing views of what the job is about. Obstetricians see risk and danger; their job is to make sure that mother and baby come out of the process alive and, ideally, unharmed. Midwives see their job as supporting women to do what their bodies are designed to do: women have, after all, given birth for the entirety of human existence, and are therefore quite capable of doing so today.

You can see, of course, that both arguments have merit. Lots of women do have straightforward births, with minimal intervention. In the past, certainly, unnecessary medical intervention (the eagerness to induce labour, or speed it up artificially, or to give women episiotomies as a matter of routine, or to force them to give birth lying down) worked against the female body’s ability to do what it is designed to do, which is to push a baby out.

On the other hand, you can’t deny that, left to labour without intervention, things don’t always go according to plan: the baby is in an awkward position, or the birth canal is too narrow, or the baby’s shoulder gets stuck on the way out, or the placenta is retained and the woman haemorrhages.

Are women’s expectations too high? Or too low?

I hesitate to suggest there should be a happy medium, because I don’t know what a happy medium would look like. But what bothers me about all this is that women are caught in the middle of two competing narratives. Obstetricians at the talk I gave expressed the view that the reason some women find birth traumatic is that their expectations are too high: they think that they can give birth “normally”, with minimum intervention, and are then disappointed to find that that isn’t the case.

But where does that expectation come from? Not, surely, from an innate sense of hubris or over-confidence, but from imbibing the message that it’s possible to achieve a normal, problem-free childbirth by taking a positive mental attitude: if you believe in your own body’s capacity to give birth, the argument goes, then you’re much more likely to have the birth you want than if you approach it fearfully.

Thus are women caught in a Catch-22: going into birth in the hope and expectation that your experience will be “normal” means that you are more likely to be traumatised when things don’t work out as planned; going into birth with an awareness of all the potential problems and risks mean potentially that your own feelings of fear and anxiety will make the experience more difficult and painful.

And women get the blame. Women’s choices are mocked: they are “too posh to push”, for example, or they are “selfish” for wanting a home birth, free of intervention. They are naïve or silly for imagining they can give birth naturally; or they are wasting the NHS’s money by demanding a planned caesarean. A woman’s place is in the wrong, James Thurber once wrote: and if we’re talking about giving birth, then Thurber hit the nail squarely on the head.

 

 

 

 

When childbirth goes badly wrong: one woman’s account

Nilufer Atik has written a striking account of her experience of PTSD after childbirth. Atik was in labour for 53 hours, after which she was given an emergency caesarean.

But it shouldn’t have happened like that. Atik’s labour started with contractions that were “sharp and hard, beginning four minutes apart and lasting between 50 to 90 seconds each time.” The hospital – St George’s in Tooting – told her not to come in because she wasn’t in active labour. She stayed at home in increasing pain for 19 hours until eventually she could stand it no longer. At hospital:

“I was taken to a pre-delivery bay and more torturous hours passed with the contractions increasing in intensity and frequency. I cried out for pain relief and was given the powerful painkiller pethidine four times (most women are only allowed two injections) but it did little to help. With no sleep, food or water, and feeling so exhausted I could barely speak, I became fearful that, if the baby did come, I wouldn’t have the energy to push him out.”

She was eventually given an epidural, followed by a caesarean section when the baby appeared in distress. But the most remarkable part of her story is this:

“Poor Milo was in a bad birthing position with his back against mine and his head hyperextended. It meant not only that my labour was much more painful than it should have been, but I would never have been able to deliver him vaginally. His head was blocking my cervix from dilating, which was why I was having contractions for so long with no progress.”

The time that Atik spent in labour was wasted – physiologically, she wasn’t able to give birth. Why staff at St George’s didn’t realise this is an interesting question, but it may have been to do with the fact that when Atik arrived at the hospital in labour, the maternity ward was extremely busy.

Two weeks ago an NCT survey found that, in the Guardian’s words, “A chronic shortage of midwives across the UK means women in labour are left feeling unsafe and frightened or as if they are being treated ‘like cattle’ or ‘on a conveyor belt’.” It’s not just lack of midwives, it’s a lack of space: one woman even described giving birth on the antenatal ward, because there was no room on the delivery ward.

It’s been said so often that NHS services are at breaking point that perhaps nobody takes it seriously any more. But cases like Atik’s show that the seriousness and the urgency of the problem. When midwives are overworked, the quality of care for women is never going to be good enough. Women will suffer unnecessarily, as Atik did, and may as a result experience physical trauma or psychological trauma that will need treatment later on. Sometimes, babies will die.

 

 

Severe tearing in childbirth – not just a physical problem

NB I’ve edited this post to clarify that Liz Skinner’s research focuses primarily on women with damage to the levator ani muscle rather than with obstetric tearing.

A traumatic vaginal birth in which the levator ani and external anal sphincter muscles are damaged can cause mental health problems, including post-traumatic stress disorder (PTSD), according to a new study from Liz Skinner. About half the women also had severe tearing.

About 90% of women experience tearing during childbirth, but most are first or second degree tears, which are relatively mild and heal quickly. Approximately six percent of women have third or fourth degree tears that can damage the anal sphincter. Skinner and Hans Peter Dietz have also pioneered research into damage to the levator ani muscle (LAM), which can be devastating for women. The argue that the problems of a difficult vaginal birth tend to be overlooked in the drive to reduce caesarean sections, which are usually perceived as more risky for both mother and baby.

The study identified 40 first-time mothers with major pelvic floor trauma and interviewed them one-to-four years after they gave birth. Just over half (22) of the women had “major obstetric anal sphincter tears.”

Of the 40 women, 35 had “Multiple symptoms of pelvic floor dysfunction” causing lifestyle alteration. These symptoms included “urinary or fecal incontinence, prolapse, chronic pain, dyspareunia [painful intercourse]”.

It’s hardly surprising, then, that 27 experienced PTSD symptoms, including “poor baby bonding, flashbacks during sex, dissociation, avoidance, anxiety”.

Probably the most worrying themes to emerge from the study were the lack of awareness or communication from health professionals:

  • 36 women said there was no information provided by clinicians on potential postnatal pelvic floor morbidities
  • 36 said that there was no postnatal assessment of their injuries
  • 26 said that they experienced “dismissive reactions from poorly informed clinicians to maternal injuries. One woman said: “The midwife said that this was OK… but I knew that it was not normal… The doctors really did not understand the situation… I was in shock – devastated and unable to get any health professional to understand.”

Although the study was carried out in Australia, I’d be surprised if a UK study didn’t find something similar. I’ve now heard numerous stories about obstetric tears not being treated properly or women having their concerns dismissed as unimportant. One of the problems is that midwives often don’t see the consequences of tearing in childbirth – women are only under midwife care for 10 days after birth, so if a tear has failed to heal properly weeks, months or even, shockingly, years after birth, they’ll be dealt with by another group of health professionals entirely. So midwives may well assume, wrongly, that a tear during childbirth has healed without problems.  That may lead to an unjustified confidence that obstetric tearing isn’t a significant problem. And because LAM damage is impossible to detect without ultrasound, LAM problems are generally undiagnosed and therefore untreated.

As I’ve already reported, the RCOG is now campaigning for better understanding of obstetric tearing in childbirth, and better care for the women who experience it. But we still have a long way to go – and In the meantime, a lot of women are suffering in silence.

Maternity outcomes matter

Some good news at the Birth Trauma Association (BTA): my colleague Maureen Treadwell is leading a collaborative project called Maternity Outcomes Matter, or MOM. The idea is to reduce the incidence of stillbirth and neonatal death (both very high in this country), and also, importantly, to reduce the number of maternal injuries – a more neglected area. Several other maternity groups are involved, and we’re delighted that James Titcombe, whose baby son Joshua died as the result of a simple but catastrophic error at Furness General Hospital, has joined the group. With the help of an initial grant of £5,000, the project will produce a report to identify some of the key mistakes that are made in labour and birth and how they can be prevented in future.

It’s a small project, but an important one. One of the things the NHS lacks is a straightforward, simple way of sharing good practice and knowledge. Mistakes are often covered up (sometimes for understandable reasons) rather than shared so that lessons can be learnt. Medical practice isn’t always based on good evidence. Among members of the BTA’s Facebook group, we hear story after story of women experiencing unnecessarily traumatic births.

Recently, as part of the Royal College of Obstetricians and Gynaecologists’ campaign to reduce third- and fourth-degree tearing in childbirth, I’ve been in touch with women whose lives have been ruined by severe tearing that has left them in severe pain and in some cases incontinent. Some injuries are so severe that they have left the woman unable to work.

In 2016, this shouldn’t be happening. So this project represents is one step on the road to making childbirth safer for both women and their babies.

To find out more, contact enquiries@ birthtraumaassociation.org.uk.