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.

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.

 

 

Piers Morgan is wrong

I know the words “Piers Morgan is wrong” are about as remarkable as “The sky is blue” or “Winter is cold” but this time he’s excelled himself.

In brief, Lady Gaga told an interviewer that she suffered PTSD as the result of being raped when she was 19. Morgan managed a double dose of wrongness, first by casting doubt on whether she’d been raped, and then by stating that PTSD was something suffered by “soldiers returning from battlefields” (and by implication, not by people who have experienced other forms of trauma).

We should all of us, even talentless self-publicists, be aware by now that victims of sexual assault don’t tend to report it – largely because they fear not being believed. In that, they are right. Of the hundreds of children and women assaulted by Jimmy Savile, most kept the attack private. The few who did report it found themselves either ignored or accused of lying. If their reports had been taken seriously, Savile would have ended up in prison years ago, and many of his victims would have been spared. The fact that Morgan refuses to believe Lady Gaga now pretty much proves the point.

And if he knows anything at all about PTSD, he should know that soldiers are only one of the groups who suffer from it. Victims of sexual assault, people who have been in a car crash, people who have been attacked by a partner or a stranger, refugees fleeing terror, paramedics who have witnessed a violent death and, of course, women who have been through a traumatic birth can and do suffer from PTSD.

So which are the biggest groups of sufferers? Not soldiers. Rape Crisis reports that 97,000 people in England and Wales (85,000 women and 12,000 men) are raped each year. We know that about 50% of rape victims experience PTSD – that translates into nearly 50,000 people a year, so they may well represent the biggest group. But then there are also victims of domestic violence, asylum seekers and children being sexually abused. A rough estimate suggests that 2% of women giving birth experience postnatal PTSD, equivalent to about 20,000 people a year in England and Wales.

Whichever way you look at it, that’s a lot of PTSD sufferers. A huge number of people experiencing a major mental health problem that is under-diagnosed and under-treated. And what they don’t need, what they really don’t need, is an irresponsible idiot with a high media profile telling them that they’re lying about their experience and lying about their illness.

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.

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.

Can having an epidural in labour reduce the risk of postnatal depression?

Research has found that women who receive an epidural in labour may be less likely to experience postnatal depression. The study, by Grace Lim of the University of Pittsburgh Medical Centre, looked at the medical records of 201 women who had an epidural and had their pain assessed on a 0 to 10 scale during labour.

They calculated the percentage improvement in pain (PIP) throughout labour after a woman had an epidural. The researchers then looked at depression risk using the Edinburgh Postnatal Depression Scale (EPDS) six weeks after birth. They found the higher the PIP scores, the lower the EPDS scores.

We have to be cautious about how we interpret the results. It was a small study, which hasn’t yet been published (the news story was based on a conference paper). We can’t be sure about the causal relationship. And we know that in France, where epidurals are common, PND rates are roughly the same as in the UK.

But it wouldn’t be completely surprising to find a causal relationship. One national 2014 survey found that only 63% of women received the pain relief they wanted during labour. Anecdotally, I’ve heard plenty of stories of women being denied epidurals on the grounds that it was too early in labour or too late, or that there was no anaesthetist available.

The truth is that for some women labour is agonizingly painful, and it would be strange if being left in extreme pain for hours didn’t have a psychological impact. Certainly some women with postnatal PTSD talk about the denial of pain relief as a contributing factor to their PTSD. One woman I spoke to for my book was told by her husband that during the hours of being denied an epidural, she threatened to throw herself out of the hospital window. (This is a memory that she had, perhaps fortunately, blocked out.)

Epidurals carry risks, so sometimes health professionals can be reluctant to let women have them when they ask for them. But not giving an asked-for epidural can also carry risks – something that is all too easily forgotten.

Therapy can help – and it should be available to every new mother who needs it

The children’s author Louisa Leaman has an excellent piece in the Guardian about how cognitive behavioural therapy (CBT) helped her recover from a traumatic birth. Louisa’s experience sounds harrowing:

“A diagnosis of placenta previa major – a serious obstetric complication – meant that by the time Emil was delivered via emergency C-section I’d had 14 haemorrhages, three blue-light ambulance rides, four blood transfusions, five weeks in hospital and two months of bed rest.”

Both she and her baby, she was told, could have died.

It’s not surprising that, after such an awful experience, she suffered from post-traumatic stress disorder (PTSD).

What’s encouraging about Louisa’s story, however, is that she lived in a part of London where new mothers with mental health problems are referred to therapy, and she was lucky enough to see an NHS therapist specialising in CBT. After 10 sessions – at which Louisa was allowed to bring her baby – she felt much better. As she puts it: “No more flashbacks. No more crazy paranoia. No more guilt.”

So many of the stories from women who have suffered a traumatic birth are ones where there is no resolution, no happy ending. Some women live in parts of the country where there is no automatic referral to a therapist of any kind, let alone one who specialises in perinatal health. Women offer suffer symptoms – those flashbacks, that paranoia – for years. Louisa’s story shows that it doesn’t have to be like that: good therapy from a sympathetic, qualified therapist can work wonders.

Which is why we must hope that David Cameron follows through on his promise to provide specialist psychological support for women who suffer mental health problems related to giving birth. At the moment, it’s not clear what this support will involve, nor where the money is going to come from. But there’s absolutely no doubt that it’s needed. As Simon Stevens, chief executive of the NHS, is quoted as saying in the Guardian report:

“At the moment about 40,000 women who are pregnant or within the first year of having their baby have a severe mental health problem. But of those 40,000 only about 10,000 are at the moment getting access to specialist perinatal mental health services. Three out of four are missing out. But by the end of the decade we are going to make that a universal offer, so all 40,000 will get access to a local specialist team.”