Providing an emotionally, culturally and medically safe birth environment can break the fear-feedback loop around birth and actually make it safer.
As Birth Trauma Awareness Week draws our attention to the prevalence of postnatal trauma and PTSD, it’s right that we ask how best to support women experiencing these. But just as important is addressing the underlying causes—and they aren’t what you might think.
When we hear the term birth trauma, many of us assume what we are talking about is trauma arising from life-threatening situations in labour and birth. We think of drama, of something going wrong and of the mother, baby, or both, being in danger.
But while events like these are obviously distressing, the truth is that they are not always experienced as traumatic. A birthing woman may require an emergency medical intervention, but research shows that when women are well supported emotionally through these events they don’t necessarily experience the birth as traumatic. And the reverse is also true: poor personal treatment can be traumatic in the absence of an actual emergency.
In fact, research into what causes birth trauma and into the prevalence of postpartum post-traumatic stress disorder (PPPTSD) has identified ‘interactions with care providers as a more important factor than medical intervention or type of birth’, as researchers Rachel Reed, Rachael Sharman and Christian Inglis report.
This is certainly the case for the majority of women I speak with in my postnatal counselling practice who come to me to debrief traumatic birth experiences and address subsequent PPPTSD. They all have individual nuances to their stories, but time and again I encounter the same basic themes contributing to their distress. Their experience of care—or rather the lack of expected respectful, nurturing care—is a key factor in predicting distress, regardless of the actual outcome of the birth.
It is important to highlight the paramount contribution of inadequate care to birth trauma for three key reasons.
Firstly, because when we don’t, the many new mothers who have not experienced a medical emergency or physical trauma during their labours—but are nonetheless traumatised—are left without an explanation for their distress.
Secondly, because even for those women who do experience medical or physical trauma, it is the personal care they receive that relieves or exacerbates that trauma. (As a midwife once put it to me, first respondent fire-fighters are often better at supporting people through trauma than our maternity system is.)
And finally, we need to highlight the role of care, because when we don’t, we fail to identify the systemic issues within our maternity system that actually play a part in those emergencies and related physical trauma that we are more likely to recognise as trauma in the first place.
Some in the obstetric profession who work to highlight birth trauma, looking at the issue solely from the point of view of physical trauma, will argue that the answer is to bypass labour altogether with caesarean births. If we look at pelvic floor injuries and other physical trauma out of the context of the care the birthing woman receives, this might sound reasonable. But if we look at the bigger picture, we begin to see how the environment and birthplace culture the woman is labouring in will lessen (or, as is sadly most often the case) increase her chances of physical trauma.
The systemic issues relating to maternity care are complex. For birthing women they create a fear–feedback loop that contributes to the levels of birth trauma in our culture. The loop goes like this. Australia has very high levels of medical intervention in birth (looking at World Health Organisation statistics, far higher than would be expected for true medical need). Women therefore hear many stories of medical interventions from other women, which make birth seem very dangerous. Women then approach labour feeling afraid. Unsurprisingly, and whether consciously or not, they expect the hospital to soothe their fears.
And here we come to the heart of the matter. The hospital environment is not able to soothe the fearful birthing woman. Its physical environment, although well equipped for the rare times we would expect a birth to go off course, is hardly the home-like, cosy, calm, undisturbed environment that research shows helps a woman relax into her labour. But more crucially still, hospitals are not able to soothe birthing women because they have so downgraded the kind of one-on-one, encouraging ‘with woman’ human care that can do this.
Women who, as I’ve said, are consciously or unconsciously expecting soothing care, feel abandoned, unsafe and unable to cope. Here the feedback loop continues. Feeling unsafe can trigger adrenaline, which slows or stalls the labour and will often result in the use of synthetic oxytocin. Or an epidural becomes the default medical response to a woman’s abandonment distress. (As researchers Nicky Leap and Billie Hunter describe ‘they act as a substitute for hands on, emotionally engaged support’.) In both cases, and via other similar pathways, the medical intervention becomes the beginning of a ‘cascade’.
In this way, births that with the right attuned care, may have unfolded without the need for intervention, become another one of those stories women hear that make birth sounds so dangerous. And so the fear–feedback loop comes full circle.
I would like to be able to say that the failure of care in women’s traumatic birth experiences is only one of absence. Certainly in many cases, overworked midwives operating in what researchers term ‘fractured care’ settings, would dearly love to provide the kind of one-on-one, continuous care they know women need. But sadly there is more to it than merely ‘fractured’ care. As many birth researchers and activists have highlighted for years now, ‘power over’ coercion, including manipulation, punishment, judgement, even assault—what is now called out as ‘obstetric violence’—are also part of the story (hence the hashtags #metoointhebirthroom, #birthisafeministissue and others).
Birth trauma has been defined by midwifery researchers as ‘an event occurring during the labour and delivery process that involves actual or threatened serious injury or death to the mother or her infant’ where ‘the birthing woman experiences intense fear, helplessness, loss of control and horror’. (Note how these feelings are ones that could be alleviated or avoided through appropriate support.) Importantly, the definition now also includes ‘an event occurring during labour and delivery where the woman perceives she is stripped of her dignity’ (my emphasis). Sadly many birthing women today do not only feel abandoned in the birth setting, but actively bullied.
Birth trauma arises when power-over structures in the birth place result in coercive and bullying behaviour; when birthing women lack autonomy and respect in the birth setting; and, as I witness time and again in my counselling practice, the birth experience triggers existing present or past life trauma. In these cases, the lack of appropriate care has appalling impacts. As the authors of Traumatic Childbirth write: ‘It is our most fragile and vulnerable women who are at most risk of perceiving their labour and delivery as so traumatic as to lead to elevated post-traumatic stress symptoms.’
As Karen Pickering writes of her experience of postpartum post-traumatic stress in a letter to her pre-baby self in The Motherhood: ‘You’ll hit on something soon: that your experience was about structural sexism and misogyny in the medical community.’
Birth activist and author of Give Birth Like a Feminist Milli Hill wrote to me, ‘Our public conversations are so often about how we can help those who have been traumatised by birth. Very rarely does anyone ask, why are these women traumatised?’
Perhaps we don’t ask why because the systemic causes are complex. It is easier instead to blame women’s bodies and advocate for more caesarean births. Easier to focus on the physical trauma and ignore its emotional causes. Easier to ignore the myriad ways our current system contributes to both.
But if the causes are complex, the answer is less so: the likelihood of birth trauma decreases when we provide women with attuned, woman-centered, midwifery continuity of care. This gold standard care reduces the need for medical pain relief and the likelihood of consequent interventions is therefore reduced. More importantly, with this kind of care, even when such interventions are truly medically necessary the birthing woman will be less likely to experience them as traumatic.
Why is this care not mainstream? Research shows clearly it is what women want, yet only 8% of Australian women can access it.
When we talk about birth trauma, the conversation must be wide enough to encompass our lack of best-practice care. Because truly addressing birth trauma and postpartum PTSD is not just about addressing physical trauma after birth, it is about making an emotionally, culturally and medically safe birth environment available to all birthing women.