Why we need to make birth better
To mark Birth Trauma Awareness Week, Dr Emma Svanberg outlines a model of birth trauma and efforts to raise awareness and share stories.
12 July 2019
Over ten years ago I was sitting in a room in a SureStart centre in Tower Hamlets, East London. Having had a long standing interest in perinatal mental health, I was on my last trainee placement in the Children’s Centre team with parents to be and parents of under fives.
I was with a mum who had been diagnosed with Post Natal Depression, and I happened to ask about her birth experience. At this point, although we’d had some training about attachment and parenting, I don’t recall anyone having encouraged me to ask about birth except my supervisor at the time. I hadn’t done much trauma focused training, and I let her go ahead and relive the whole experience. As my client told me her story, I felt like I’d opened up not just a new piece of the puzzle – but a whole new puzzle.
I don’t have permission to share her particular story, but I have heard echoes of it many times since then – both clinically and personally. Women [*] who gave birth alone on antenatal wards, trying to stay quiet because they had been told they couldn’t possibly be in active labour. Women who were sent home from hospital because they were ‘only’ 3 cms and gave birth at home a couple of hours later. Women who felt that a particular intervention derailed their labour. Those who felt that their concerns were dismissed. Those who listened to medical staff arguing and felt unsafe. Those who felt coerced into interventions they later felt were unnecessary. Those who were told they were ‘silly’, to ‘be a good girl’, not to ‘make a fuss’. And, it turned out, my client did have some symptoms of post natal depression, but was also struggling with nightmares, was avoiding walking past the hospital in which she gave birth, hypervigilant and worried about leaving her baby for a moment.
At this time, the only thing I could find to read about birth trauma was from the fairly new Birth Trauma Association, founded in 2004. I’d been lucky enough to have some teaching with Deborah Lee on compassion focused therapy for trauma, and trauma symptoms and PTSD was a notable part of our course at University College London. But until that point, I’d always associated trauma with war, terrorism, abuse, assault. I had imagined that women who had been through medical emergencies or left with birth injuries might be left with trauma, but not that women with seemingly straightforward births might also feel traumatised.
I hadn’t yet heard women talking about birth using those same terms – feeling that they had been through battle, violated by those who they had expected to care for them.
What makes birth trauma different
Birth trauma is defined as not just PTSD but also subclinical symptoms of trauma which are related to the birth and maternity experience. 1 in 25 women experience PTSD in the perinatal period, while a third report some symptoms of trauma. This may include the birth itself, particularly where there has been operative birth, dissociation during birth and poor interpersonal care, but also the fertility journey, pregnancy experiences, post natal care, feeding experiences and so on. The key is that it is entirely subjective: as Cheryl Beck has said, it is ‘in the eye of the beholder’.
As well as the birth experience itself, individual factors related to birth trauma have been identified, and summarised in Susan Ayers’ Diathesis Stress framework. These include pre-natal factors such as depression during pregnancy and fear of birth and postnatal factors such as poor coping strategies and lack of social support.
As with other traumatic stress reactions, we would expect to see elements of re-experiencing, avoidance, a heightened threat response and associated mood changes. Where this makes early identification and treatment crucial is that these symptoms can make it very difficult to look after a baby (who may be seen as a trigger for a traumatic response) and affect relationships with the baby, other children, partners and wider friends and family.
While a new area of research, so far the literature has demonstrated that birth trauma can impact on the attachment relationship with the baby. The couple relationship can be affected due to the events of the birth itself – with women reporting feeling let down or unsupported – but also longer term in the impact on the body and sex, trust and the partner’s own potential to be traumatised by what he or she witnessed. The shame associated with trauma can also deeply impact on a person’s view of themselves as a parent, challenging long-held ideals of motherhood and leading to a vicious cycle of blame and shame.
What makes birth trauma different to other traumatic events is that we expect birth to be the happiest day of our lives. Coupled with this is another narrative that still places women and their bodies as secondary to the needs of the baby (something that we are witnessing more and more clearly over the Atlantic). This can create an additional barrier both to the person who has been through the traumatic birth (and those who may have witnessed it) and to those who are offering support. Women may find it difficult to identify their experience, dismissing it as just ‘part of birth’ and something to be expected. Where people do describe symptoms of trauma, they can often find them misdiagnosed as Post Natal Depression or invalidated with ‘The baby is ok, so what are you worried about?’
What also makes birth trauma so different is that, in many cases, it may be preventable. There is a growing body of research to suggest that interpersonal factors are key to many experiences which later feel traumatising.
Learning about birth
My experience hearing about birth trauma led me to hypnobirthing, on a search for the ways in which women and their partners could inform and empower themselves in order to promote a positive experience. While there has been little high quality research on its effectiveness, much of hypnobirthing is about psychoeducation and information – on the physiological process of birth, anxiety management techniques and utilising support.
What struck me during my hypnobirthing training, and subsequent work with women and their partners, was how often the physiological process of birth was interrupted and interfered with by standard maternity practices. Possibly my interest in birth trauma grew when I realised, when pregnant with my first child, that this knowledge had left me with a strong desire to avoid hospital at all costs.
Yet this is something that most of us are not educated about. School education around pregnancy and birth generally focuses on the ‘don’t do it’ angle. Many women know little about their physiology until they become pregnant themselves. Many men were sent out of the room while their female counterparts were told about periods and birth. The only stories we tend to hear about birth are from our own mothers and friends when we become pregnant ourselves- and, in an environment which doesn’t encourage conversation about birth – these often come out in an unprocessed and sometimes frightening way. While this is changing, with organisations such as the Positive Birth Movement, most people’s experience of birth is that it is mysterious, and scary.
We can add to this the idealised narratives that pervade around birth and motherhood. Paula Nicolson’s depiction of postnatal depression – as linked to the double whammy of experiencing the hardships of motherhood while simultaneously being told how magical it is – resonates deeply with stories around birth too. While most people hear only negative stories about birth, it is talked about as the most joyful day of our lives. The emphasis that is then placed on the wellbeing of the baby over the mother creates its own double whammy. Add to this the pressure that we place on women during pregnancy and birth (we just need to look at Meghan Markle’s experience for that). Women are left questioning why they can’t ‘get over’ what everyone is telling them is a normal experience of birth, and feel ashamed that they can’t take solace in simply having a baby.
Where we are now
In the years since, thanks to clinicians such as Pauline Slade and Kirstie McKenzie-McHarg and the campaign work of the Birth Trauma Association, we now know what birth trauma is and how it affects women and their families. Birth was finally recognised as a possible traumatic event in the NICE Guidelines on Antenatal and Postnatal Mental Health in 2014. There have been major strides in birth trauma research thanks to Susan Ayers and others, and the creation of a validated measure for Birth Trauma – The City Birth Trauma Scale. There have also been recent best practice guidance developed, such as the Tokophobia Toolkit and the new guidelines coming next year from NHSE on trauma informed pathways.
Yet there is still a huge amount of misunderstanding – and women are often left feeling that their experience is not validated. Over recent years, with the Maternity Transformation Programme, NHS 5 Year Forward Plan and now the Long Term Plan, perinatal mental health has become prioritised, with associated funding (arguably, though, not enough and this year not ring-fenced). However, while increased funding has gone into specialist perinatal mental health services, simultaneously we have witnessed the reduction of the early intervention and prevention services offered by SureStart and allied health professionals. While 1 in 25 women will experience PTSD in the perinatal period, of the third of women who experience subclinical symptoms, few will meet the threshold for a perinatal mental health referral. Instead, they will be referred to IAPT and offered a brief intervention, usually with little flexibility offered around appointments making it difficult to attend with a new baby.
Many services will offer a Birth Afterthoughts or Birth Reflections session as standard. Usually this will be a session with a midwife or consultant midwife. While it is understandable that this has developed as a response to the growing awareness of traumatic birth, findings on their effectiveness are mixed. Some women seem to find them helpful, others find that they are highly focused on avoiding a complaint, and others still find that they can be re-traumatising. Some Trusts (such as Northumbria Healthcare) have developed trauma informed birth reflections sessions to counter this. However, many women won’t feel able to attend these appointments with the staff they see as the perpetrators of their trauma, in the location in which it happened.
And still, women feel discouraged from sharing their experiences. We still hear from women regularly whose experiences have been dismissed with a ‘but you’ve got a healthy baby’ as if their feelings don’t count.
What has also changed in the last ten years is that maternity services (and the NHS in general) have been stretched far beyond their limits. The impact of this on staff has been documented in reports such as the WHELM study from the Royal College of Midwives, demonstrating the levels of stress, depression and burnout in midwives and the Workforce Report from the Royal College of Obstetricians and Gynaecologists showing a high level of rota gaps and more undermining and bullying behaviour than any other speciality. Dr Sally Pezaro has linked this to ‘compassion fatigue’, and there has been increasing attention to the impact of this on the mental health of both patients and in staff. As one midwife in our Network told us, ‘I have seen many, many births over the years – some have been euphoric, almost dream-like and others have been a horrific endurance. It can, and does, happen both ways but I think that the current normal system of maternity care sets mums up for the latter experience (with a lack of continuity of care, a focus on arbitrary time limits and a lack of truly family-centred care).’
Make birth better
This was the context in which I co-founded Make Birth Better last July, alongside my colleague perinatal psychiatrist Dr Rebecca Moore. We are supported by a Network of parents and professionals who guide and inform the work, and now have a core team including three others. We had both identified that much of the birth trauma we were seeing in our work seemed to have been preventable but that the conversation we often saw – in the mainstream media, birth related conferences and on social media – still focused on dichotomies such as natural vs medicalised birth. We initially wanted to provide a platform via our blog and social media platforms to share a wide range of birth experiences from a diverse group of people – traumatic birth stories to raise awareness of birth trauma, but also stories from those who are often not represented such as BAME women (who have significantly worse outcomes and higher rates of mortality around birth), those with learning and physical disabilities, those in same-sex relationships and people who identify as trans or non-gender conforming. We also began to highlight some of the examples of clear violations, examples of obstetric violence where women were coerced, dehumanised or sometimes physically assaulted under the guise of standard maternity care. We felt that, through sharing a wider representation of birth, we could begin to challenge that black-and-white narrative.
Psychology on social media is a whole other topic, but I have found in sharing evidence based information on platforms such as Instagram has the potential to reach a huge audience. The initial post launching the Make Birth Better campaign back in 2017 led to 75 women sending me their birth stories in just a week. Our most recent survey had over 5,000 responses. Using a community psychology approach, this enables us to start thinking about change – through raising awareness and changing narratives – on a macro level, as well as reaching individuals.
What we have found in the year that followed, through talking to both parents and professionals, was that it is not enough to share birth stories and raise awareness. What we heard time and time again was that people, having become aware of their trauma, had nowhere to go due to lack of understanding within the health service. And that, for both parents and professionals, there was a keen awareness that much of this trauma was being caused by systemic issues within maternity systems and wider society.
We clearly hit a nerve. From a small meeting of 8 people a year and a half ago, the passion that people feel to see a cultural shift in maternity care has meant that we now have over 150 people who are active members of our Network, as well as over 8,000 followers on social media. Coinciding with the #metoo movement, we wondered if our conversation had come at a time where women in particular were questioning behaviours and actions which had previously been seen as acceptable.
One of the major themes of the conversations we have had is the personal responsibility that we often place on women to educate themselves in order to maximise their chances of a positive birth experience – much like my initial explorations into hypnobirthing ten years ago. But, if we are then sending those women into a system – which is, in itself, traumatised – are we setting them up to fail? Instead of that personal responsibility, perhaps there is a need for a collective responsibility to be taken to bring about some cultural change.
In collaboration with our Network members and drawing from theories such as Bronfenbrenner’s systems theory, trauma informed models of care outlined by Mickey Sperlich and Una McCluskey’s attachment at work research, we developed a conceptual model, based on trauma-informed care, to reflect this systemic understanding of the causes and potential ways to prevent birth trauma. Over the coming months we hope that we, and others, can research whether it may have an impact so that not only women but all those who care for them can start to view birth as a collaborative experience and not one that women are often blindly pushed into.
In recent months, we have expanded our aims to provide evidence based training, consultation and supervision – through this we also try to highlight examples of best practice to counteract some of the misinformation that exists around birth trauma (and trauma in general). We are involved in research on the wide ranging impact of birth trauma on both families and healthcare professionals.
One of our core team members, a mum with lived experience herself, has singlehandedly created our website which contains free resources and information, a crowd-sourced map of services, and will soon have our training manual available to buy.
One of our main aims was to have free to download resources available to all, but particularly for women to take along to appointments to describe their symptoms. This week – Birth Trauma Awareness Week – we launched a number of free to download cribsheets on our website. If you have any feedback on the website, areas you feel should be added, then please get in touch. The power of the campaign is that it is a collaborative, and we welcome as many voices as possible.
At our heart, we remain a campaigning organisation, buoyed by the many women and families who share their stories with us. While in the coming years we hope to focus on raising awareness and training professionals, our goal is to add to the growing groundswell calling for meaningful change to maternity and perinatal services.
In the ten years since I have started working with women and their families, much has changed. Women are raising their voices against practices which had previously been seen as acceptable. We know more now than ever before about the long term impacts on children when parental mental health is compromised. As Daniel Stern pointed out, when a baby is born, a mother is born too. Let’s make both of those births better.
[*] I refer to ‘women’ because it is predominantly women who I have worked with, and the birth trauma literature has so far focused on mothers and – more recently – fathers. Little is known about trauma for those who give birth who do not identify as women, or partners who are not fathers.
The Positive Birth Book, Milli Hill
How to Heal A Bad Birth, Melissa Bruijn, Debby Gould
The Compassionate Mind Approach to Recovering from Trauma, Deborah Lee