Thinking positively about childbirth – why did Milli Hill’s article provoke such an angry response?

 

Two weeks ago, Milli Hill published an article in the Telegraph about why we shouldn’t focus on pain when we talk to pregnant women about childbirth. Originally published under the clickbaity headline (which Hill didn’t write, and has since been changed), “The myth of the painful birth – and why it’s not nearly so bad as women believe”, the article argued that by emphasising the pain of childbirth when we talk to women, we are “setting them up to fail”.

The article provoked a number of responses challenging Hill’s view, including my own piece in the Independent, a characteristically robust blogpost by “skeptical OB” Dr Amy Tuteur in which she accused Hill of “gaslighting” women and an article by Cath Janes in Standard Issue, which talked about her own experiences of a painful birth that triggered severe PND and PTSD. Cath’s piece was, as is her style, both dark and funny – but Hill didn’t like it and asked Standard Issue to take it down. The magazine initially complied, and then republished it minus one sentence that Hill had particularly objected to, and also gave Hill a right-of-reply. The whole saga also provoked a debate on Mumsnet about who was right, with Tuteur, Janes and Hill all weighing in.

There is probably not much hope at this point of a calm, rational debate about the issue. Hill, I think, was taken by surprise at the impassioned response to her article – she thinks of herself as one of the good guys, whose sole aim is to help women have a better experience of childbirth. So what is it about her piece that made women so angry?

Minimising women’s pain

Judging by comments I’ve seen on Mumsnet, Twitter and Facebook, the answer is that, for many women, their experience is the opposite of what Hill describes. Rather than going into childbirth frightened, they went in feeling positive and upbeat – and were then shocked that the experience was much more painful and unpleasant than they expected. Instead of feeling that the pain of childbirth was overstated, they felt it was minimised. When women have had a particularly traumatic birth, they often find that other people play down their experience and tell them that it can’t have been as bad as they thought, that they must be exaggerating, that the health professionals who let them down during labour had their best interests at heart – and in any case, they have a healthy baby, so what else matters? This is why Hill’s article touched a nerve – if you’re already used to having your experience minimised by others, the idea that you shouldn’t talk about the pain of childbirth feels like yet another attempt to get you to shut up.

Think positive!

People also took issue with Hill’s article argument that going into labour with a more positive attitude can help women have a better experience. In her words: “At the moment, we simply do not know what birth would be like for women if they were given more positive messages and went into labour feeling strong, confident and capable.”

The idea that “positive thinking” can help create a different reality is one of the most pervasive – and pernicious – ideas of our times. Even cancer patients are exhorted to think positively about their illness, as if mere thinking can banish one of the most deadly of diseases. It’s a view that Barbara Ehrenreich has magnificently demolished in Smile or Die: How Positive Thinking Fooled America and the World.

For anyone on the receiving end of this view, it’s worse than exasperating – being told that a positive attitude can reduce pain has an unspoken corollary, which is that if you felt pain anyway, it must have been your fault for not being positive enough. The most inflammatory part of Hill’s piece reads: “…when you talk to women who are prepared to break with convention and say their labour was not painful, words like ‘intense’ and ‘powerful’ come up again and again. It suggests that it’s the way that these women talk and think about these sensations that’s different, rather than the sensations themselves.”

Well, no. What it suggests to me is that women have vastly different experiences of childbirth – some women experience “intense feelings” while others feel extreme pain. Even the book of Genesis, written 3,500 years ago, talks about the pain of childbearing, with no word from God, unfortunately, about focusing on the positive.

No wonder some women, reading Hill’s article, felt that their desire to tell their own story was, once again, being undermined. It’s a wearily familiar pattern: a news report in the Telegraph this week reveals that women reporting gynaecological problems to their GP are often ignored or belittled.

So, here’s my bold suggestion: why not listen to what women actually say about their experiences, rather than telling them how they ought to feel? If we all, health professionals included, do that, there’s a chance, just a chance, that women’s experience of childbirth will improve.

 

 

 

 

 

A new mental health toolkit for pregnant women and new mothers

Some good news: the Royal College of General Practitioners has launched a perinatal mental health toolkit – in layperson’s terms, resources that help doctors and nurses in primary care support women who experience mental health problems during pregnancy or after giving birth.

The resources are very comprehensive, and include links to NICE guidance, links to advice on medication for pregnant and breastfeeding women and links to relevant charities and support groups such as Sands (the stillbirth and neonatal death charity) and the Birth Trauma Association.

It’s particularly good to see the RCGP recognise that mental health problems don’t exist in a vacuum. The resources include links to information about sexual violence and domestic abuse and to information about supporting refugee women.

The GP is often the first port-of-call for new mothers suffering from mental health problems such as depression and PTSD, so it’s essential that GPs have access to information about these conditions. While new mothers are now routinely screened for postnatal depression, PTSD often goes under the radar. This toolkit is, I hope, an important step towards making sure that mothers suffering from PTSD receive the treatment they need.

What should the RCOG advise women about risk?

The Royal College of Obstetricians & Gynaecologists (RCOG) is to consider giving pregnant women advice about the relative risks of vaginal births and caesarean sections, according to the New Scientist.

The magazine reports that the RCOG has been prompted to look at the issue by a 2015 UK Supreme court ruling awarding damages for a baby who sustained brain damage during a vaginal delivery. The report continues:

“The plaintiff had a higher than usual risk of having a difficult birth, due to having a small pelvis and diabetes. But doctors didn’t inform her of these increased risks – an act of ‘medical paternalism’, said the presiding judge, who decided in the mother’s favour.”

A decision by the RCOG to warn women of the risks of vaginal birth will be controversial, because vaginal birth is the default option – this is how babies are supposed to be born. When it goes well, a vaginal birth is much easier for a woman to recover from than a caesarean. It seems to be better for the baby too (though the evidence isn’t completely clear-cut).

But of course, not all vaginal births go well and, as the article states, the risks of injury to a woman’s pelvic floor muscles increase as she gets older. Many women are now having first babies in their 30s and 40s, making them more susceptible to injury than younger women. The article points out that older women are also more likely to need emergency caesareans, which carry higher risks than planned caesareans.

The big problem is that decisions to do with birth are not black-and-white: they’re all about assessing relative risk. Some older women have straightforward, uncomplicated vaginal births. Some younger women require emergency caesareans or have difficult forceps deliveries.

In an ideal world, health professionals would be able to assess factors such as a woman’s age, general health, pelvic size and position of baby and advise her of the most sensible course of action accordingly. Until someone collects and analyses the data, however, we can’t confidently predict what combination of risk factors mean that a woman will find it difficult to give birth vaginally.

When women talk about their experience of birth trauma, some report being coerced into having a caesarean (usually an emergency caesarean) when they wanted to continue trying for a vaginal birth, while others who wanted a caesarean have been forced against their will to attempt – or continue attempting – a vaginal delivery. Both are traumatic, and both can result in physical and mental health problems. The worry is that sometimes the advice given to women is driven not necessarily by what’s best for them and their baby but by targets, ideology or a desire to save money.

So where does this leave the RCOG? My view is that they should make women aware of the likely risks both of planned caesarean and of vaginal birth (and also that the risks of attempted vaginal birth include an emergency caesarean). Women should be allowed the opportunity to make decisions based on the best available evidence.

Caesarean sections – a feminist issue?

A Canadian doctor has provocatively argued that women should be able to choose to deliver their babies by planned caesarean section. (Normally women are only offered a planned section if they have particular obstetric problems that would make it dangerous to deliver vaginally.)

Dr Magnus Murphy treats pelvic floor dysfunction – bladder and bowel problems often caused by a vaginal delivery. He is quoted as saying: “There are a lot of women who do feel that the feminist movement has dropped the ball on this.” Murphy adds that the feminist movement has allied itself to the movement for natural childbirth, abandoning women who might want a caesarean section.

Is he right? Well, last month the outspoken Australian obstetrician Hans Peter Dietz presented research at the International Continence Society in Montreal showing that “between 20 and 30 per cent of first-time mothers having a vaginal birth will suffer severe and often permanent damage to their pelvic floor and anal sphincter muscles”.

Dietz notes that in New South Wales, the rate of forceps birth has doubled in 10 years as the result of attempts to reduce the caesarean rate – with the result that women experience much more physical damage.

His colleague Elizabeth Skinner interviewed women who had suffered traumatic vaginal deliveries and found that two-thirds suffered PTSD symptoms. She, like Murphy, believes that feminists need a change of heart: “Previously feminists fought to return control to women giving birth. This is still true but the new 21st Century feminist issue is ensuring that women are correctly assessed for their risk of complications and given full and frank information to prevent such injuries.”

For a very long time, women in the 20th century fought to regain control of childbirth from the medical profession. Childbirth was as a medical process in which doctors were in complete charge: instead of being allowed to give birth naturally, to walk about, to squat, to give birth in their own time, women were strapped to delivery tables with legs in stirrups forced to have episiotomies and epidurals, hooked up to monitors, passively waiting for their baby to be delivered by an obstetrician. Feminists did an important job in rescuing childbirth, in making sure that women could give birth unfettered, undrugged and free to move about as they wish. It has, for many women, been an empowering experience.

And yet, could Murphy and Dietz be right? Babies are getting bigger, and for some women childbirth is a long, arduous and painful experience. Having to deliver a baby in a way that permanently damages your pelvic floor and may even leave you incontinent doesn’t seem like such a great victory for feminism. Neither does it seem particularly “natural” or “normal”, epithets that are often applied to the process of vaginal birth.

When you’ve fought to take control of birth back from the medical profession, caesarean sections, which put the process entirely in the hands of surgeons, can feel like a retrograde step. And yet if it is a choice freely made by a woman who doesn’t want to risk long-term injury and incontinence, isn’t that a choice that feminists should be fighting for?

The terrible consequences of a difficult birth

An Australian study has made some troubling findings about the problems that can arise from a difficult vaginal birth.

In an earlier post, I quoted Professor Hans Dietz, who believes that the “increasing push towards natural birth is having the unintended consequence that more women are having longer, more difficult labour”.

Dietz and his colleague Elizabeth Skinner have published qualitative research on the psychological consequences of a traumatic vaginal birth. They spoke to 40 first-time mothers who had suffered physical damage to their pelvic floor or anal sphincter muscles while giving birth.

From the interviews with the women, they identified certain key themes, including conflicting advice from clinicians before, during and after birth; nil postnatal assessment of injuries; dismissive reactions from clinicians to the women’s injuries; and experience of PTSD symptoms.

The authors write: “Major somatic [physical] maternal trauma after vaginal birth is one of the main causes of pelvic floor dysfunction, and it also seems to be associated with significant psychological morbidity up to and including postpartum post-traumatic stress disorder”.

For those of us who have heard many women’s stories of traumatic deliveries, this is all too familiar. It’s particularly concerning that women often receive conflicting advice from midwives and obstetricians; along with my colleagues at the Birth Trauma Association, I firmly believe that midwives and obstetricians should share some of their training, so that they can agree on best practice when it comes to supporting a woman during birth and assessing risk. Poor working relationships between midwives and obstetricians was one of the problems that led to the deaths of one mother and 11 babies, according to the Morecambe Bay investigation report.

But we have also heard, many times, stories from women who have said that their doctors don’t take their injuries seriously enough, and we are only too aware that a traumatic birth experience that results in physical damage can cause PTSD – something that clinicians are still unaware of. The consequences for women can be both profound and long-lasting. The research authors say: “Mothers after traumatic birth are likely to have a reduced quality of life due to both psychological and somatic morbidity.”

And it’s impossible to disagree with their conclusion: “There is a great need to learn how to better help women who have sustained these injuries by acknowledging their concerns and providing diagnostic and therapeutic services. This is unlikely to occur unless health practitioners learn how to diagnose maternal birth trauma properly and account for women’s perceptions and needs following traumatic vaginal childbirth.”

Traumatic births: women tell their stories

It can be hard for women to speak out about their traumatic birth experiences. There’s a widespread perception that all that matters is a healthy baby, and that women should be grateful for a modern system of medical care that means they are unlikely to die in childbirth.

Of course, it’s great that most of us don’t die in childbirth any more. But not dying is setting the bar pretty low for our expectations for medical care. If we go into hospital for surgery, for example, we do usually expect a bit more from the care we receive than simply “not dying”.

So I welcome it when women are prepared to talk about what happened to them in childbirth and to highlight some of the poor practice that still exists. A new photo series called Exposing the Silence gives a voice to women who have experienced shockingly bad care.

The women in the photos speak of having procedures such as episiotomies or membrane sweeps performed without their consent or of being able to feel themselves being cut during caesarean-sections. A lot of the women speak of the trauma they felt after having their preferences ignored or dismissed.

These stories come from the US, but I’ve heard similar experiences in the UK. The story recounted by one of the women is not, sadly, uncommon:

“‘Do you understand you are doing this without my consent?’ As they are putting needles into my arm, I’m telling them, ‘You are doing this against my will.’ Their response, even as my strong contractions grew faster and I was in active labor, was, ‘I can’t wait all night, and we are doing this now.’ Less than an hour later, he was born, taken from me before I could hold him longer than a minute or two, and not returned until almost three hours later, even though he had no complications. I cried every minute and couldn’t stop thinking, this isn’t supposed to be like this.”

A new drug treatment for PTSD? An MIT study looks promising

Scientists have made good progress in recent years in working out the mechanics of how PTSD affects the brain. But there is still much work to be done when it comes to finding treatments.

So I was interested to read of new research from MIT suggesting a possible drug treatment for PTSD.

The study looked at the chemical process by which trauma imprints memories in the brain and contributes to flashbacks. According to the MIT press release, the research found that “chronic stress causes cells in the amygdala to express many more 5-HT2C receptors, which bind to serotonin.” When a traumatic experience occurs, the heightened sensitivity to serotonin causes the memory to be encoded more strongly, contributing to the “strong flashbacks that often occur in patients with PTSD”.

The way to stop this happening, the researchers suggest, is to use drugs that interfere with serotonin – either before the person has developed PTSD symptoms, or shortly after. One such drug, agomelatine, already exists and may be helpful.

Equally interesting was the suggestion that many antidepressant drugs – those known as SSRIs – may actually make PTSD worse because they enhance the effect of serotonin. If true, this is significant, because many PTSD sufferers (particularly women suffering PTSD after birth) are either misdiagnosed with depression or, in some cases, suffer depression as well as PTSD. In either case, the antidepressants commonly prescribed for them may be delaying recovery rather than helping it.

What else is available?

In England and Wales, the National Institute for Health and Care Excellence (NICE) regards two treatments as having a strong enough evidence base to justify their use: trauma-focused cognitive behaviour therapy (CBT) and eye movement desensitisation and reprocessing (EMDR) therapy.

Both treatments require a number of one-to-one sessions between the patient and the therapist. They are expensive. Numerous alternatives are being investigated, including techniques such as rewind therapy and emotional freedom therapy, but there is a lack of solid evidence at the moment to support them.

The range of treatments being tried for PTSD is wide. In the US, one of the most common treatments used with veterans is prolonged exposure therapy, in which the sufferer is asked to recount the story of their trauma over and over again. It now turns out that this may be ineffective and even counter-productive.

But I’ve also seen articles suggesting that medical marijuana, yoga, keeping dogs as pets and taking part in virtual reality simulations of traumatic situations can help alleviate PTSD. They may work or they may not ­ – we won’t know until more research is carried out.

The MIT study, which has shown the mechanism by which PTSD affects the brain, is a promising step in the right direction.