What causes so much birth trauma?

by Carla Sargent


This blog post includes multiple quotes, all sourced from the Birth Trauma Survey we conducted in 2015. To read the survey report in full, click here.

While birth trauma is sometimes a case of unavoidable bad luck, in my experience the vast majority of birth-related trauma is avoidable. Let me just clarify right now that by ‘avoidable’ I do not mean to imply that a woman’s trauma is in any way her fault, or that had she done things differently she could have prevented a traumatic birth taking place. Women will naturally endeavour to make the best choices possible for themselves and their babies given the information and support they have available to them. Let's talk more about such support and information...

How well are women set up to make positive birth choices for themselves? How well respected are women's birth choices? How compassionate, kind and respectful are the care providers who support birthing women? Are women made aware of their rights and responsibilities, and those of their care providers, prior to labour? Because overwhelmingly, for the majority of women who share their traumatic birth stories with me, it is the disempowerment they experience through disrespectful, negligent, coercive, or just plain insensitive care, that ultimately results in a traumatic birth experience. It isn’t about how or where they end up giving birth so much as it is about the lack of compassion, respect and support they encounter in that process.

When survey respondents were asked, "What was the nature of your birth trauma?" some of the answers included:

Feeling completely overruled in decisions relating to my body.
Obstetric rape by obstetrician - painful violent internal [vaginal examination] after refusing CS without a trial of labour.
Stripped of all choices and no opportunities to consent or refuse.

Empowering birth experiences are more likely to result when women are supported to maintain autonomy over decisions relating to their bodies and their babies. Part of that equation is having sufficient unbiased information with which they can make their decisions, and then being supported by their midwife and other care providers to enact those choices.

Jessie’s story provides a clear demonstration of this. Her first birth was a traumatic experience. She had poor pregnancy and labour support, including heavily biased information on which to base important decisions, such as whether or not to have her labour induced. Her induction and the emergency caesarean that followed left her feeling devastated. During her second pregnancy Jessie sought some help to understand why things had gone the way they did with her first, and to better prepare for her next birth. She decided to plan a home birth this time and carefully chose a midwife whom she trusted and felt incredibly well supported by. Jessie’s labour began at home, an experience she felt set her up, hormonally and psychologically, to feel positive and empowered in how her birth unfolded. During her labour, Jessie’s baby became distressed and the decision was made to transfer to hospital for another emergency caesarean. But this experience was vastly different from her first. The difference? Wonderful support and lots of information, enabling her to make the decisions that were best for her and her baby.

While a positive birth experience is a shared responsibility between the birthing woman, her support people, and her birth care providers, the reality is that many women are let down by a system of birth care which denies the importance of autonomy in childbirth. The emotional and psychological wellbeing of new mothers and their babies are frequently given little consideration. Too many doctors view their role solely in terms of controlling the physical birth machine (aka the woman’s faulty body) and its passive, fragile cargo (the baby). They have a biased agenda regarding which risks they are willing, or not, to take in order to safely (but only in the physical sense of the word) extract the baby from its mother. All too frequently, the midwife takes up the submissive role of obstetric handmaiden, too fearful to challenge the harmful discourse playing out before her.

Examples of mistreatment by birth care providers as quoted by survey respondents:

Felt like doctors ganged up on me and pushed me into a birth I didn’t want.
Physically forced to do things against my wishes. Powerlessness.
Professionals need to listen to the mothers and their needs/wants… treat them with honour and trust the mother’s instincts. Too many times trauma could have been avoided if they listened to the mum in the first place.

With all this in mind, key tips for achieving a positive birth experience include:

  • Becoming fully informed about a wide range of labour options and interventions
  • Understanding hormonal influences on labour, and knowing how to increase ‘helpful hormones’ 
  • Having a range of pain management techniques to try in labour, and knowing the pros and cons of medical pain relief
  • Choosing a care provider who supports informed decision making
  • Choosing a birth place which supports the natural birth process, and which enables you to feel safe and private
  • Knowing your rights and responsibilities, and those of your care providers
  • Choosing a birth support person/people who appreciate the importance of all of the above points

Some survey respondents described what helped them to heal from their trauma:

My twins are now 18 years old and I’ve only recently truly healed. 8 months ago I had an amazing home birth with my daughter. And an awesome midwife that I’ll never forget.
Having a subsequent empowering birth that was entirely my own [helped me heal after my traumatic birth]

The other main cause of birth related trauma is ‘bad luck’. This type of birth trauma is more commonly recognised and accepted as valid within our society. It includes trauma related to baby loss, premature birth, severe maternal complications, such as haemorrhage, seizures, and other near-death experiences, and complications with the baby, especially where death and/or disability may potentially ensue. However, even those impacted by this type of trauma are not always given support which recognises the depth of their experience.

This lack of support was experienced by some survey respondents:

My GP just told me ‘yes I understand you are unhappy, but you and your baby survived, you are lucky.’
There needs to be more awareness made about baby loss. And when it does happen it’d be nice if the hospitals didn’t try and rush us away.

Thankfully, such life-death situations in birth are relatively rare. Much more commonly, families experience less life-threatening complications that, I would argue, many find traumatising. However, the interventions associated with such complications are so frequently performed that they are deemed ‘normal’ birth experiences and are therefore not generally acknowledged as having the potential to cause ongoing trauma.

A few such examples include:

  • Caesarean section
  • Forceps and ventouse births
  • Use of episiotomy
  • Manipulations (either external or internal) to change baby’s position, to shift a lip of cervix, or to remove a stuck placenta
  • Use of Syntocinon to speed up labour
  • Induction of labour
  • Multiple vaginal examinations carried out by various people
  • Poor pain relief or lack of pain relief options (including an inability to be mobile, use a pool, and have ongoing support and reassurance from a trusted midwife throughout labour)

While many families are led to believe that such interventions were either life-saving measures or just 'par for the course' when giving birth birth, they are rarely made aware that it is possibly an intervention that led to the emergency situation in the first place. 

For example, a woman is pressured to have an induction at 41 weeks of pregnancy. She has her labour sped-up by way of IV Syntocinon. Contractions become very intense and the baby suddenly gets distressed. His heart rate drops to 90 beats per minute and doesn’t recover. An emergency caesarean is carried out under general anaesthetic. The next day the surgeon advises the woman, “It was touch and go. You’re lucky your little boy is alive. If it hadn’t been for the quick actions of the hospital team, it would have been a very dire outcome.” What she isn’t told is that, had her body gone into labour naturally, chances are her boy would never have become distressed and in need of surgical removal.

Rather than leaving the hospital thinking, “Perhaps I should never have allowed that obstetrician to bully me into an induction in the first place” she leaves believing that she ought to be grateful to the medical experts and their tools for saving her baby’s life. And in what self-doubting, fearful head-space does that leave her when she next becomes pregnant? More than likely in one where she tells herself, “They know what’s best for me and my baby. Our safety is in their hands. Birth is a scary business that isn’t likely to happen naturally, at least not for me.”

Survey examples of the 'normalising' of birth interventions and the inherent disregard for the mother's psychological wellbeing is made clear in the following quotes:

Because my emergency caesarean was successful, ie. both of us are alive, I felt I should be grateful for that without acknowledging the grief feelings I was having.
Most of those around me including my midwife at the time did not see my emergency caesarean as a trauma.
Everyone was so focused on saying (me included) baby arrived ‘safely’ despite the long labour and emergency c-section, that it’s almost as though there was no acknowledgment that the birth was actually a very stressful experience in the end… there was no exploration by any professional of the emotional impact.
A debrief of reasons behind ‘protocol’ would have been helpful as I am now very fearful of hospitals and the medical profession in general.

The World Health Organisation recommends that caesarean rates ought not to exceed 10-15% (WHO, 2010). In New Zealand our caesarean section rate is 26.2% (MoH, 2015). Clearly, more caesareans are taking place than are medically necessary. Yet, I would hazard to guess that only a tiny fraction of caesarean mothers are advised, post-birth, that their caesarean was not likely to have been needed if their pregnancy or labour had been managed differently.

Encouragingly though, there appears to be a swelling number of women who are questioning the validity of the birth interventions that they underwent. More and more stories are surfacing of, for instance, the woman whose pelvis was too small to give birth to her first baby vaginally, yet who went on to naturally birth her other, larger babies.

There are two key forces at play here... 1) There are women who are recognising the importance of becoming informed and exercising their right to informed decision making and consent, and 2) there are midwives who are doing their all to ensure they support women in that right. These are no small feats in a patriarchal society where increasing rates of medicalised birth are justified in the name of ‘safety’, as espoused by our life-saving medical heroes. Never mind the carnage which drifts hopelessly in the wake of such heroism. Devastated mothers are, after all, selfish to be grieving over their births, especially when they’ve just been saved from themselves. And midwives, who are they to be speaking out against their superiors?

Heart ache, guilt, depression, anxiety, fear, self-doubt, these are the scars of birth trauma, shamelessly veiled by a culture which says, “All that matters is a healthy baby.” Across the globe women are findings ways to challenge this misogynistic paradigm. A birthing revolution is underway...

 

Postscript

This is the second of a series of posts that will be written around themes associated with the findings of the Birth Trauma Survey we conducted in 2015. We encourage those who feel able to, to read the report in full as the information shared provides important learning for health workers and consumers alike. Click here to access the full report.

If you, or someone you know, is needing support to heal after a traumatic birth, our Facebook page and the Facebook closed support group we started may be useful initial places for finding that support.