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.

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.

Why do so many babies die – and why aren’t we doing something about it?

Why, asks an article in the Telegraph, do 2,000 babies die needlessly during childbirth every year?

It’s a question that ought to bring us up short. Two thousand deaths is a huge number: compare it to, say, the number of people killed in road accidents in the UK, which is now down to about 1,700 a year.

The article’s writer, Mary Riddell, is talking about needless deaths: in total, there are 3,600 stillbirths a year in the UK, representing one in every 200 births. Some deaths can’t be avoided. So why aren’t we doing more about the ones that can?

It’s curious how complacent we are as a society about the problem of medical negligence. In the US, a study has estimated that medical errors are the third leading cause of death, behind heart disease and cancer. Somewhere between 210,000 and 440,000 patients who go to hospital in the US each year “suffer some type of preventable harm that contributes to their death”. As far as I know, however, no similar study has been carried out in the UK.

Childbirth injuries and deaths can be avoided

We do know that NHS doctors and midwives make mistakes during birth. According to the Telegraph article, compensation claims for childbirth errors have tripled in 10 years. It compares figures for England with those for Sweden:

“In the last five years, Sweden has reduced the number of serious birth injuries from 20 per 100,000 babies to five, compared with the English rate of 30 in every 100,000 babies.”

The Swedish figures show that many injuries and deaths relating to childbirth are avoidable. The Telegraph article goes on to look at a hospital that has got it right: Southmead Hospital in Bristol, which it describes as “probably the safest place in the world to give birth”. Fifteen years ago, Southmead introduced Practical Obstetric Multi-Professional Training, or PROMPT – a method of collaborative working and learning from mistakes. During that time, there has been a 50-70% reduction in common birth injuries.

How the PROMPT approach works

What PROMPT does is to make sure that all members of a team – obstetricians, midwives, anaesthetists – are on the same page when it comes to responding to a medical emergency. A representative group of professionals receive the training together and then take it back and train other staff in their own hospital. It means that if, for example, a baby’s shoulder becomes stuck, everyone knows what to do.

The only extraordinary thing about this is that it’s not already universally applied: you’d hope health professionals would all know exactly how to respond to any likely childbirth emergency. But in the less effective maternity units, that doesn’t seem to be the case – the Kirkup Review into failings at the maternity unit of Furness General Hospital exposed an apparently casual attitude towards safety. In James Titcombe’s account of his son Joshua’s death at Furness, it was striking that none of those involved seemed interested in understanding why he had died or putting measures in place to stop anything similar happening again.

A fundamental change in approach is needed. Everyone makes mistakes, but human error can be minimised if agreed best procedures are in place; and a culture of openness where people are encouraged to own up to, and reflect on, their mistakes enables everyone to learn and improve their practice in future. This is how the aviation industry treats mistakes, and it works well.

The government’s proposed rapid resolution and redress scheme, in which litigation claims could be settled quickly without recourse to the courts may help to end the culture of secrecy and cover-up and bring about a more open approach. The proposals are not without their flaws (safeguards need to be in place to make sure that rapid redress is also accompanied by a desire to learn from mistakes – which isn’t a given), but they are surely a step in the right direction. Certainly many families will be grateful for not having to wait years for compensation while litigation drags on.

It could be that we are finally on the cusp of a change that campaigners have been fighting for over many years. If so, we may look back on those 2,000 baby deaths every year and wonder why we ever tolerated it.

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.

 

 

 

 

 

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.

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.

Is it a good idea to reduce the caesarean rate?

Caesarean section rates in western countries have been rising for a long time – but the rate varies widely between different countries. In Sweden, for example, it’s 17%, while in Cyprus it’s 52%.

It’s not at all clear why rates differ so much. Reasons often cited for high caesarean rates include: the increase in older first-time mothers (for whom pregnancy and labour is riskier); the increase in overweight mothers (ditto); the fact that babies are getting bigger; a trend for women to request a planned caesarean section; increased medical management of labour, which sets labour on a path culminating in emergency caesareans; and a cautious approach by doctors who fear litigation.

This is informed speculation, however: the only way to know for sure would be to record and collate the reason for every caesarean section, and that doesn’t seem to happen. I am slightly sceptical of the idea that the increase is down to women requesting the procedure. It provides a handy narrative and another pejorative term for women (“too posh to push”) but the truth is that the majority of caesarean sections are performed as an emergency procedure, and there are often medical reasons for planned sections (breech presentation, placenta praevia).

Does it matter?

This is the interesting question. In Australia, one in three babies is born by caesarean, one of the highest rates in the world. There is pressure to reduce the rate: caesareans, it is argued, pose an increased risk to the mother and baby. An article in the Sydney Morning Herald quotes Andrew Bisits, the medical co-director of maternity services at the Royal Hospital for Women in New South Wales:

“People forget that a caesarean is a relatively major operation. It’s an instant trauma to the body. It’s anything but keyhole surgery. I think that fact sometimes gets lost and people forget that you can get through a normal birth with no scratches or just a few scratches.”

In New South Wales, a policy to reduce the c-section rate and increase the “normal” birth rate has been unsuccessful, with c-section rates remaining fairly static. According to the Herald article, there has even been an increase in the number of women having induced labour and forceps deliveries. More women “are having major haemorrhages after they give birth.”

One obstetrician, Professor Hans Dietz, argues that the “increasing push towards natural birth is having the unintended consequence that more women are having longer, more difficult labours”. He says:

“In the past it was two to three hours of unsuccessful pushing before obstetricians intervened, now it may be six. It has the advantage that some women will push their baby out, but the risk that some will be left with a post-partum haemorrhage.”

The article goes on:

“He estimates that for every 10 caesareans prevented, it is likely that four additional tears to a woman’s levator muscle – which holds the pelvic organs and bowel in place – occur, and four additional sphincter tears.”

Dietz is also sceptical about the oft-cited dangers of caesareans:

“In my entire clinical life, how many women with major later life health problems due to caesarean have I ever seen? I can’t remember a single one. How many after forceps will I see? Several a week, at least 100 a year, maybe 200 a year,” he says.

So, is the drive to push down the caesarean rate misguided?

The short answer is: I don’t know. I suspect that nobody else does either. The Herald article demonstrates that people who work in maternity services have vastly differing views on the subject.

For women, it’s bewildering. Few, I imagine, are delighted at the prospect of surgery to deliver their baby; but even fewer want what Dietz describes as the potential consequences of a difficult vaginal birth: “urinary and fecal incontinence, prolapse, sexual dysfunction, years or decades later.”

What we need is more data: why caesareans are performed; the health consequences for women (and their babies) who deliver this way; whether reducing the caesarean rate results in better outcomes for women and their babies; the particular factors that lead to an assisted delivery; the physical and mental health consequences for women and their babies who have an assisted delivery; the correlation between factors such as age, weight and social class and method of birth.

Until we have that data, women will continue to be the unwitting victims of an argument that rages between professionals without coming to a satisfactory conclusion.