By Tanya Cawthorne, MWomenChldH, LCCE, FACCE

Australia is finally talking about birth trauma.

After decades of silence, the physical consequences of childbirth are beginning to receive the attention they deserve. Women living with severe perineal tears, pelvic organ prolapse, chronic pain, incontinence and other life-changing birth injuries have spent far too long being told that these were simply the inevitable consequences of motherhood. Their injuries were under-recognised, under-researched and too often dismissed. Greater awareness, better prevention, improved access to specialist treatment and increased investment in research are all long overdue.

Yet as birth trauma has moved into the public spotlight, another question has quietly emerged.

Who gets to define it?

This question has become increasingly important following the release of Birth Trauma Australia’s report, The Cost of Birth Trauma in Australia. The report estimates that birth injuries and ongoing physical conditions cost Australia $17.5 billion annually, providing an important economic argument for greater investment in prevention, diagnosis and treatment. It is likely to become an influential document, informing policymakers, clinicians and the media about the scale of the problem.

However, despite its title, the report is not actually an analysis of birth trauma in its broadest sense. It is an analysis of physical birth injuries and the ongoing conditions that arise from them. The report explicitly excludes psychological birth trauma where no physical injury is present, limiting its analysis to physical birth injuries and the mental health consequences that arise directly from those injuries. For the purposes of economic modelling, that decision may be methodologically defensible. The report is transparent about its scope and does not claim to quantify all forms of birth trauma.

The difficulty lies not in the methodology itself, but in the influence this report is likely to have on public policy. Birth Trauma Australia has become Australia’s most prominent and influential voice on birth trauma. It is the organisation governments, health departments, professional colleges and the media increasingly turn to when seeking consumer perspectives. As a result, the organisation’s framing of birth trauma inevitably shapes the national conversation about what birth trauma is, whose experiences count, and where future investment should be directed.

That matters because there is now an equally substantial body of evidence demonstrating that psychological birth trauma carries enormous personal, social and economic costs, even in the absence of physical injury. Women who develop post-traumatic stress disorder (PTSD), anxiety or depression following traumatic maternity care are more likely to require ongoing mental health treatment, experience impaired maternal-infant attachment, encounter difficulties establishing breastfeeding, experience relationship strain, delay or avoid subsequent pregnancies, reduce workforce participation and require ongoing health and social support. The impacts extend well beyond the individual woman, affecting infants, partners, families and, ultimately, the broader economy.

We already understand the enormous economic burden associated with perinatal mental ill health. Australian modelling has estimated that untreated perinatal depression and anxiety costs billions of dollars through increased healthcare utilisation, lost productivity, reduced workforce participation and adverse developmental outcomes for children. Psychological birth trauma contributes directly to this burden. It is therefore difficult to separate the economics of birth injury from the economics of traumatic maternity care.

Public policy inevitably follows the evidence that is measured. What is counted becomes visible. What is visible becomes funded. What is funded becomes the priority. This is why the way we define birth trauma matters. When Australia’s most influential birth trauma organisation adopts a narrower definition of birth trauma – even for understandable methodological reasons – it also narrows the policy conversation. The risk is not simply that psychological birth trauma is overlooked in one report, but that it gradually disappears from the national reform agenda altogether.

This narrowing of the conversation is difficult to reconcile with what decades of maternity research have consistently demonstrated.

The Australian Birth Experience Study (BESt), together with subsequent Australian and international research, has repeatedly found that women’s experiences of childbirth are shaped less by the mode of birth itself than by the quality of the care they receive. Feeling ignored, dismissed or powerless; poor communication; lack of informed consent; coercion; disrespect; racism; abandonment; and the loss of dignity and autonomy emerge consistently as some of the strongest predictors of psychological birth trauma.

These findings were echoed throughout the NSW Parliamentary Inquiry into Birth Trauma. Women described procedures performed without consent, repeated vaginal examinations they experienced as violating, being threatened or coerced into interventions, experiencing racism, having their concerns dismissed and feeling invisible during one of the most vulnerable moments of their lives. Many had uncomplicated births. Some sustained no lasting physical injury. Yet many described symptoms entirely consistent with post-traumatic stress.

The common thread was not what happened during birth, it was how they were treated, and it is this distinction fundamentally changes where we look for solutions. If birth trauma is understood primarily as physical injury, then our response naturally focuses on preventing pelvic floor damage, improving obstetric techniques, expanding pelvic health services and investing in reconstructive treatment. These are important and necessary goals.

But if a substantial proportion of birth trauma arises because women experience disrespectful, coercive or dehumanising care, then preventing trauma requires something much broader. It requires genuine informed consent rather than procedural consent. It requires continuity of care. It requires trauma-informed maternity services, cultural safety, respectful communication and healthcare systems that recognise women as active participants in decision-making rather than passive recipients of care.

Perhaps most importantly, it requires us to recognise that these are not competing groups of women. Many women who sustain catastrophic physical injuries also experience profound psychological trauma. Equally, many women who sustain no lasting physical injury nevertheless develop life-altering post-traumatic stress because of how they were treated. The false distinction between physical and psychological birth trauma serves neither group.

There is another consequence of narrowing our definition of birth trauma that receives far less attention.

Philosophers describe epistemic injustice as the harm that occurs when people’s experiences are dismissed, disbelieved or excluded from the production of knowledge. Women who experience psychological birth trauma have long described being told, “At least you have a healthy baby,” “Nothing actually happened,” or “You should just be grateful.” Their experiences have often been minimised precisely because they leave no obvious physical evidence.

If our dominant definition of birth trauma increasingly privileges visible physical injury over lived psychological experience, we risk perpetuating that same injustice in a new form. Women’s experiences become less credible not because they are unsupported by evidence, but because they fall outside the framework through which birth trauma is now being understood.

Internationally, birth trauma is increasingly understood as encompassing both physical injury and psychological trauma arising from women’s experiences of maternity care. The UK Birth Trauma Association, for example, defines birth trauma primarily in terms of psychological distress following traumatic birth while recognising that trauma may arise with or without physical injury. Likewise, the UK Parliamentary Inquiry into Birth Trauma concluded that failures in communication, informed consent, compassion and respectful care were among the defining features of traumatic birth experiences. Australia’s policy conversation risks moving in the opposite direction, narrowing the definition of birth trauma at precisely the moment international evidence is broadening it.

Birth Trauma Australia has every right to advocate for women living with catastrophic physical birth injuries. Their voices deserve to be heard.

But they cannot become the only voices that governments hear.

Australia already possesses a substantial body of evidence demonstrating that a significant burden of birth trauma arises not from what childbirth does to women’s bodies, but from what our maternity system does to women. As policymakers look to reform maternity care, they must resist the temptation to adopt a definition of birth trauma that is narrower than the evidence itself.

If we fail to do that, we risk replacing one form of invisibility with another.

Tanya Cawthorne is a maternal health educator with more than 15 years’ experience in childbirth education and maternal health advocacy. She holds a Master of Women’s & Children’s Health and is a member of the Editorial Board of the Journal of Perinatal Education.

Further Reading

Birth Trauma Australia & Nous Group. The Cost of Birth Trauma in Australia (2026). https://birthtrauma.org.au/birth-trauma-awareness-week-2026/

The Australian Birth Experience Study (BESt) and subsequent publications on women’s experiences of maternity care and birth trauma. https://birthexperiencestudy.com/best-australia

Frank G. Understanding Women’s Experiences of Traumatic Birth and Maternity Care (PhD thesis, University of Technology Sydney). https://opus.lib.uts.edu.au/bitstream/10453/178224/1/thesis.pdf

NSW Parliament. Birth Trauma Inquiry (Inquiry into Birth Trauma, submissions, hearings and final report). https://files.parliament.nsw.gov.au/fileapi/ParlFiles/GetArtifact?serverRelativeUrl=%2Flcdocs%2Finquiries%2F2965%2FFINAL+Birth+Trauma+Report+-+29+April+2024.pdf

Bohren MA et al. “The Mistreatment of Women during Childbirth in Health Facilities Globally: A Mixed-Methods Systematic Review.” PLOS Medicine (2015). https://pubmed.ncbi.nlm.nih.gov/26126110/

World Health Organization. The Prevention and Elimination of Disrespect and Abuse during Facility-Based Childbirth (2014), and subsequent WHO publications on respectful maternity care. https://www.who.int/publications/i/item/WHO-RHR-14.23 and https://www.who.int/publications/i/item/9789240110939

The Gidget Foundation. The Cost of PNDA in Australia (2019). https://www.gidgetfoundation.org.au/health-professionals/the-cost-of-pnda

Birth Trauma Association (UK). The hidden cost of birth trauma: a report on survey findings (July, 2026) https://static1.squarespace.com/static/645b78325e03ca278fdd150e/t/6a54897a8668e102f938c25f/1783925114537/Cost+of+birth+trauma+report_final.pdf