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

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

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

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

Violence and brutality

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

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

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

Pull yourself together

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Breaking the silence – why we need birth trauma awareness week

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

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

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

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

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

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

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

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

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

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

Too many babies are dying at birth

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

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

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

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

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

Doctors don’t always know best

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

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

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

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

The drug that could cut deaths from postpartum haemorrhage by a third

Every year, about 100,000 women die from haemorrhage after childbirth. Most of these deaths are in poorer countries such as Somalia or Sierra Leone where many give birth at home, without access to medical care. Even women who haemorrhage in hospital may still die, though sometimes doctors will perform a life-saving hysterectomy.

In Western countries, although postpartum haemorrhage (PPH) is relatively common (in England, 13.8% of women haemorrhage after childbirth), most women who need it will receive an instant blood transfusion. Deaths from PPH are rare.

So it’s extremely good news that a new trial has shown that administering a simple, cheap drug called tranexamic acid, which works by stopping blood clots from breaking down, could potentially save the lives of about a third of women who currently die from PPH. The study was carried out by the London School of Hygiene and Tropical Medicine in collaboration with 193 hospitals in Africa and Asia.

The most extraordinary part of this story is that tranexamic acid was discovered in the 1960s by a Japanese husband-and-wife research team, Shosuke and Utako Okamoto. They were unable to persuade doctors to perform a clinical trial, so the drug has mostly been used as a treatment for heavy periods and to reduce bleeding as a result of trauma.The WHO currently recommends its use for PPH as a second line treatment if the first line treatment of uteronics (drugs to contract the uterus) fails. This new research shows its efficacy as a first line treatment.

Even though its impact will be smaller, it is also good news for women in developed countries. Many women who suffer from PTSD after childbirth trace it back to their experience of severe PPH, and the terror of believing they were about to die. If administering tranexamic acid eventually becomes standard practice to reduce haemorrhage, then for those women, birth will become a less frightening experience.

At last: the NHS acts on maternal mental health

Good news: in the next five years, NHS England will create 20 new specialist treatment centres for women who suffer from mental health problems during pregnancy or after birth.

This has been a long time coming. For years the government has promised to address the poor quality of mental health care for new mothers, and finally it’s putting its money where its mouth is. Admittedly it’s not very much money – the centres will be funded to the tune of £40m, which is unlikely to cope with the scale of the problem: an estimated one in five new mothers (about 120,000 women a year) experience mental health problems.

The majority of these women suffer from postnatal depression, but a substantial minority will have post-traumatic stress disorder (PTSD). The most conservative estimate for PTSD after childbirth is 1.5% (about 10,000 women a year in England and Wales), but researchers now think that the true figure is probably double that. PTSD can’t be cured with a pill: treatment, usually trauma-focused CBT or eye movement desensitisation and reprocessing (EMDR) takes several weeks, and is expensive.

Having spoken to many women suffering from postnatal PTSD, I know that it can be hard to find specialist help. It’s not unusual for women to have to wait months for treatment, during which time they suffer the stress of flashbacks, nightmares, anxiety and terror. They are often frightened to leave the house and avoid contact with other new babies, making them isolated on top of everything else. All of these things have an impact on their relationship with their baby and with their partner. It’s not surprising that ­– according to the Guardian report of the NHS’s plans – perinatal mental health problems cost the UK £8.1bn a year.

So while I welcome the new centres as a step in the right direction, much more needs to be done to make sure that women with PTSD and other mental health problems receive the support they require. Even more importantly, I would love the NHS work towards preventing these mental health problems from arising in the first place. Most women with postnatal PTSD believe that it was caused, not solely by a traumatic birth, but by the feelings of helplessness and lack of control during the experience, and by the casual and sometimes even cruel attitude of healthcare professionals looking after them.

Some of this can be addressed by better recruitment and better staff training. But the NHS also needs to adopt rigorous standards of care that hold health professionals accountable: making sure that procedures aren’t carried out on women without their consent, for example, or that women are denied necessary pain relief. In a 21st century health service, in a wealthy democracy these things shouldn’t be difficult, but the stories I hear from traumatised women about poor care show we still have a very long way to go.

It’s time we talked about perineal trauma

Today’s Victoria Derbyshire programme had an excellent film about perineal injuries during childbirth. You can read the associated article and see the film here (it’s about 15 minutes long). Four women shared their experience of having third or fourth degree tears during childbirth, resulting for some of them in urinary or bowel incontinence.

One of the striking facts in the film was that between 2000 and 2012, the rate of severe tearing during vaginal delivery increased from 2% to 6%. Although the programme was careful to state that this was “very rare”, in practice this translates into about 30,000 women a year. This huge increase in the rate, an obstetrician told the programme, was down to three main factors: the older age at which women have their first baby; an increase in the size of babies being born; and women themselves being bigger and heavier. But this isn’t necessarily the full explanation: the increase may simply be down to better recognition of tears as a result of the implementation of standard classification.

The programme also read out text messages from viewers. What was sad was the clear variability in treatment available. Although some women said their injuries had healed, others said they had been fobbed off when they complained about their perineal injuries, or that the injuries had persisted over months and years. One of those interviewed on the programme was effectively told that it was all in her head.

The good news is that the professionals are now taking this seriously: the Royal College of Obstetricians and Gynaecologists (RCOG) and the Royal College of Midwives (RCM) have developed an intervention package to reduce tearing in childbirth. The package is really just a simple change to the recommended way in which midwives deliver the baby, which has been shown to reduce tearing. It is being piloted in a number of hospitals and will eventually be rolled out throughout England.

Nonetheless, it’s shocking that in this day and age that a problem affecting so many women isn’t talked about or even taken particularly seriously. It was clear from the programme that many doctors aren’t adequately trained to deal with perineal tears. That – as well as better care during delivery – needs to change.