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.

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.

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.

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.