August 14 – 21, 2017 is Birth Trauma Awareness Week. First of all, it profoundly saddens me that we need to set aside even one day of the year, let alone an entire week to raising awareness of birth trauma. But when between a third to half of all Australian women describe their birth as traumatic, we need to talk about birth trauma and we need to talk about it NOW.  

Melbourne-based midwife, PhD candidate and researcher, Arimaya Yates has recently completed her thesis entitled; Women’s experiences of emotionally and psychologically traumatic birth; hegemony and authoritarianism in Victorian public maternity settings.

Her comprehensive research is both compelling and deeply alarming.

“Birth trauma is currently experienced by approximately half of all birthing women in Victoria (Alcorn et al. 2010; Boorman et al. 2014). Birth trauma has been associated with negative experiences for women and this holds potentially long-term negative consequences for the new mother, her baby and family. The consequences of this trauma in turn impacts on the woman’s community through loss of income, participation, fragmented relationships and withdrawal from community participation (Boorman, et al. 2014; D’Oliveira, 2002; Fernandez, 2013; Kitzinger, 2012; Midgley, 2006). Also reported has been an increase demand on the economic and health workforces as birth traumatised women tend to increase their use of medical services (Alcorn, et al. 2010). Birth trauma and obstetric violence is now highlighted in the professional medical and allied health literature as an offence to human rights (D’Oliveira, 2002; Hodges, 2009).

What is Birth Trauma?

Birth trauma has been defined by Simkin (2015) as “when the individual mother, father, or other witness believes the mother’s or her baby’s life was in danger, or that a serious threat to the mother’s or her baby’s physical or emotional integrity existed” (Simkin, 2015).”

“But surely all that matters is a healthy mum and a healthy baby, right?”

This has become the catch-all phrase for the current generation of women who, for the most part, find themselves being hurtled along the conveyor belt of birth. They don’t receive individualised, woman-centred care from a known care provider. They are subjected to routine interventions, many of which are not medically necessary and are not based on evidence and they are chewed up and spat out on the other end with a newborn baby and little to no practical support in the critical early days and weeks postpartum.

“But Australian women are so fortunate. We have such amazing healthcare here.”

When you consider that the maternal mortality ratio (MMR) in Southern Sudan is 2,054 deaths per 100,000 women, and you compare this to Australia, which has a MMR of 7.1 deaths per 100,000 women, there is no question where we would choose to give birth. Purely from a “will my baby and I survive birth?” point of view, Australia is one of the safest places in the world to give birth.

However, if our only measurement of success is to compare ourselves against the bleakest worldwide statistics, we are fooling ourselves into believing that Australian women are enjoying the crème de la crème of maternity care.

For the average Australian woman, her decision-making process behind where, and with whom she gives birth goes something like this;

1. “My period is late. OMG! I might be pregnant”. Go to chemist and buy pee-on-a-stick kit.
2. Pee on stick. “OMG! I am pregnant!”
3. Go along to GP to confirm pregnancy and get referral for antenatal care.
4. GP asks; “do you have private health insurance with maternity care coverage?”
   Option a) “Yes, I do” she says. GP gives her a referral to a private obstetrician.
   Option b) “No, I don’t”. GP tells her that she is zoned to public hospital X.
5. Woman either hires a private OB and books in to have her baby at Private hospital Y, or contacts local hospital where she will most likely have her first appointment somewhere between 10-16 weeks of pregnancy.

Within the public hospital system, the majority of Australian women will access standard maternity care, which means seeing a different midwife and/or obstetrician at every antenatal appointment. During labour and birth, she will also be cared for by whoever happens to be on shift and assigned to her for the period of her shift. Come shift change, she will be assigned a new midwife – and so on, and so forth, until her baby is born.

A small percentage of women will be fortunate enough to be a part of a continuity of care model, such as caseload midwifery, which basically means that a woman will see the same midwife or small team of midwives throughout her pregnancy, and one of those known midwives is guaranteed to support her during labour. However, according to research, less than 15% of Australian women have access to this model of care, also known as woman-centred care, despite the fact that we know this to be the gold-standard of midwifery care.

Even fewer women will hire their own independent midwife, partly because most women are unaware that hiring a private midwife is even an option, but also because of the financial barrier. Unlike private obstetric care, most private health insurance companies will not rebate any fees associated with the labour and birth when a private midwife is the primary care provider, but will only partially rebate some of the fees for antenatal and postnatal care. Independent midwifery care is in crisis in Australia, with many private midwives being forced to close their practices due to impossibly high insurance premiums which are simply unaffordable for most midwives. Case in point; when was the last time you saw a midwife drive around in a Porsche?

Woman-centred care involves placing the woman as the focus of a midwife’s work, supporting a woman physically, emotionally and practically during pregnancy, birth and the postnatal period. The role of the midwife becomes that of building relationship with a woman within this working partnership, from which a foundation of trust, rapport and care is bonded (Page & McCandish, 2006).

It’s not hard to see why this model of care is so superior to standard care. When a woman can build a relationship of trust with her care provider throughout her pregnancy (and remember, appointments with midwives typically last between 45 minutes to an hour, compared to a typical appointment with an obstetrician, which would last less than 10 minutes on average), that woman will feel fully supported throughout labour and birth.

She feels safe, protected and has had months to build a relationship with midwives who now know her (and her partner, if she has one), understand her needs, concerns, fears, preferences and who will support her throughout one of the most intense, primal experiences of her life.

Stranger care cannot ever hope to achieve this, no matter how skilled the midwife. You simply cannot expect to create the same level of trust with someone you have just met. On top of this, you lose another critical part of the puzzle – continuity of care. When multiple health professionals care for you throughout pregnancy, and yet more strangers care for you during labour, it is very easy for vital information to slip through the cracks. Each health professional will have their own preferred way of doing things (even within the framework of a hospital’s policies and practices) that may – or may not – be a good fit for the pregnant woman’s own preferences, beliefs and values.

 If our only definition of a “healthy mother” is our maternal morbidity or mortality rate, then we have locked ourselves into a very narrow definition of “health” indeed. Any discussion of birth trauma requires us to broaden our perspective to see how this impacts on human rights in childbirth.

“Currently one of the most commonly found causes referenced in psychology literature associated with post-traumatic stress disorder (PTSD) are mothers experiencing birth trauma. A recent study by Harris and Ayers (2012) revealed four main categories of emotion women experience associated with birth trauma. These include: (1) Feeling invisible or out of control; (2) Feeling trapped; (3) Being treated inhumanely; and, (4) Reporting a rollercoaster of emotions”. (Yates, A. 2016)

These emotional categories lead the critical mind into the arena of human rights and, the questioning of when and how does obstetric intervention become abusive or violent.

In the United States, Childbirth Connection’s landmark national Listening to Mothers (LTM) surveys describe women’s childbearing experiences from before pregnancy through the postpartum period, and their views about these matters. One of the areas researchers wanted to explore was to understand women’s overall views about the birth process and the care to which they had access. They also asked about any pressure the mothers may have experienced to accept interventions, any offered care that they might have refused, and their knowledge of potential harms of common interventions.

Some of the responses they received included;

“I felt incredibly forced to have an epidural to the point that I was in tears from the pressure.”

“I felt like I was forced to have a c-section against my will.”

 “I was not told that I was going to need an episiotomy, and it was done without my permission. I just would have liked to know what an episiotomy was, why it happens, and what it’s like to deal with and take care of after giving birth. ”

Hauntingly similar experiences are echoed by some of the women who participated in Yates’ study here in Melbourne;

“So I was really flat, my legs were up and I was really far back so I couldn’t see what they were doing and I was thinking ‘what the hell are they doing?’ I was so scared; I think I was frozen… I couldn’t communicate with anyone and no one was communicating with me… it was really horrible.”

“I just kept thinking what the hell are they doing? I had no idea, and then I kept thinking, they’ll explain any minute now, they’ll explain what’s going on, and um, I’m still waiting for that explanation.”

“I just had to like force her to be born as soon as possible to make them all stop.”

“By the end of it I didn’t really care about the baby. I was like whatever just grab a leg and rip it out, don’t care…. I was so traumatised I just didn’t really care.”

Yates goes on to explain; “These traumas were not only momentary. Women expressed long term impacts both physically and emotionally and described the extent and seriousness to which the trauma is experienced and felt by women.”

I felt abandoned and traumatised… it was horrific. It was the absolute worst, the singular worst experience of my life. Ill carry that forever, even though I’ve dealt with it, that will always be his birth…I’ve always explained it like as I felt like I’d been gang raped, I felt like a truck had been driven through my vagina… no one cared.”

Feeling invisible or out of control.

Feeling trapped.

Being treated inhumanely.

Reporting a rollercoaster of emotions.

As we start to build the picture, it becomes easier to understand how a woman can find herself in fight or flight mode during labour and birth and how this heightened state of adrenaline overload can so easily become traumatic. And when that trauma results in full-blown depression or PTSD, then what?

“Almost 80,000 women give birth in Victoria each year. Of these women, nearly 20 percent experience postnatal depression (PND). With such high rates of PND requiring treatment and only 23 beds in public mother baby units’ state-wide, there is a serious threat to Melbourne women’s mental health with such minimal available in-hospital treatment” (Yates, A. 2016)

If we ignore, downplay or even dismiss the very existence of birth trauma, we are complicit in contributing to a major mental health crisis in this country. Mothers are the bedrock of our society and we need our mothers to be healthy, functioning, whole human beings.

It’s time we treated them with the dignity and respect they deserve and that starts with compassionate, dignified, woman-centred maternity care where each woman is at the centre of her own care and decision-making.

The next time you walk down a busy street, go to the supermarket, or when you go to drop your children off at kinder or school in the morning – look at the women around you. If almost half of us are traumatised in childbirth, then what does that say about the mental and emotional health of our nation?

Birth trauma is not some rare occurrence that happens to “other people”. It could happen to your best friend, your partner, your sister, your colleague – or it could happen to you. Birth trauma is real and we have to talk about it. NOW.

Video courtesy of How to Heal A Bad Birth

Resources & Support:

PANDA (Perinatal Anxiety & Depression Australia)
Just Speak Up (support for Antenatal and Postnatal Depression)
The Gidget Foundation (promoting emotional wellbeing for expectant & new parents)
Beyond Blue
Human Rights in Childbirth
Maternity Choices Australia
Maternity Consumer Network
Birth Trauma Association of Australia & New Zealand (BTAANZ)
Birth Trauma Australia (HELD)
White Ribbon Alliance
Childbirth Connection
National Advocates for Pregnant Women
Improving Birth
Birth Monopoly
BirthRights
How To Heal A Bad Birth

How to lodge a complaint against your healthcare provider:

Australian Health Practitioner Regulation Agency (AHPRA)

Health Complaints Commissioner

References:

Women’s experiences of emotionally and psychologically traumatic birth; hegemony and authoritarianism in Victorian public maternity settings (Yates, 2016)

Alcorn, K., O’Donovan, A., Patrick, J., Creedy, D., Devilly, G. (2010). A prospective longitudinal study
of the prevalence of post-traumatic stress disorder resulting from childbirth events. (p 1849-
1859). Psychological Medicine. (40). Cambridge University Press.

Boorman, R., Devilly, G., Gamble, J., Creedy, D., Fenwick, J. (2014). Childbirth and criteria for
traumatic events. Midwifery. 30, 255-261.

D’Oliveira., A., Diniz., S., Schreiber, L. (2002). Violence against women in healthcare institutions. The
Lancet. (359), 265-278.

Fernandez, O. (2013). PTSD and obstetric violence. Midwifery Today. 48(3), 105-109.

Kitzinger, S. (2012). Rediscovering the social model of childbirth. Birth. 39(4), 301-304.
doi: 10.1111/birt.12005

Listening to Mothers III – Childbirth Connection http://transform.childbirthconnection.org/wp-content/uploads/2013/06/LTM-III_Pregnancy-and-Birth.pdf

Midgley, C. (2006). The trauma of childbirth. The Times (p 12). June 1st. London.

Hodges, S. (2009). Abuse in hospital-based birth settings? The Journal of Perinatal Education. 18(4), 8-
11.

Page, L. & McCandish, R. (Ed.). (2006). The New Midwifery – science and sensitivity in practice.
Second Ed. (p 112, 143). Churchill Livingston. London.

Simkin, P. (2015). Birth trauma: definition and statistics. Retrieved May 11, 2015. From:
http://pattch.org/resource-guide/traumatic-births-and-ptsd-definition-and-statistics/

World Health Organization Maternal Mortality Fact Sheet http://www.who.int/mediacentre/factsheets/fs348/en/

 Tanya Strusberg is the founder of birthwell birthright. She is a Melbourne-based Lamaze Certified Childbirth Educator, doula and a Fellow of the Association of Certified Childbirth Educators (FACCE). She is a passionate advocate for women’s maternity care and her articles have appeared in The Journal of Perinatal Education, Australian Midwifery News, Science & Sensibility, Interaction – the journal of the Childbirth and Parenting Educators Association of Australia (CAPEA), International Doula, Empowering Birth Magazine and Rockstar Birth Magazine. Through her internationally-accredited Lamaze Educator Training program, she is very excited to be training a new generation of Australian Lamaze educators. Last, but absolutely not least, she is also the mum of two beautiful children, her son Liev and daughter Amalia.