Rhea Dempsey
Birthing Wisdom

blog archive:

The causes of birth trauma aren’t what you might think

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.

Where’s the love bomb? Birth, relationships and love

This Valentine’s Day I’m pondering the link between birth and our adult loving relationships. A strange link, you might think, but it’s an important one. Our understanding of what psychologists call ‘attachment styles’ – the way we connect with and relate to others (or not) – is that these ways of being with others are created in our early loving connections.

And our early loving connections, in turn, are greatly helped by the cocktail or hormones, particularly the oxytocin ‘love bomb’, that is present during normal physiological child birth.

As I say in my book Birth with Confidence, what saddens me about Australia’s unnecessarily high intervention rates is what women and their babies are missing out on. Most women giving birth in Australia today miss out on a naturally unfolding hormone- driven birth—and all the (often downplayed) benefits this kind of birth will bring.

An unintended consequence of our current birth culture is that many births do not end up relying on either the baby’s or the mother’s hormonal input. Ideally in birth, the baby and mother share a connected dance of readiness and response.

Hormonally, the baby triggers the birth, initiating its own birth timing: the mother responds, and their birth dance begins.

In Australia, if we add together the births that use synthetic hormones to artificially kick-start them (induction, 25%) or get the hurry-up (augmentation, 19%) and the babies delivered by ‘elective’ caesarean with no labour at all (18%), then we have 62% of babies definitely not calling the shots on the timing of their births.

Added to this is the huge number of vaginal births in which the final oxytocin surge or ‘love bombing’ in third stage is overridden by an injection of synthetic oxytocin. These intervention rates mean we have a majority of births occurring with neither baby nor mother fully following their own instinctive rhythms or being exposed to the full blast of our evolutionarily programmed love and bonding hormones.

Does it mean anything that the mother and baby are not sharing the hormonal cocktail of normal physiological birth? Does it mean anything that at a societal level so many births occur without any love hormones, let alone the full ‘love bomb’ hormonal cocktail?

Does it matter that in such high numbers of births natural oxytocin is replaced by drips of synthetic oxytocin (which, while able to drive contractions, doesn’t cross the blood-brain barrier and therefore doesn’t initiate bonding behaviours)? That in so many births pethidine and epidural anaesthesia replace natural endorphins and intense human support? That synthetic oxytocin delivers the placenta, replacing the surge of natural oxytocin that facilitates bonding and loving connections?

Well, social anthropologists, physiology researchers and neuro- biologists say it means a lot. And so do many of the mothers who have unwittingly ended up with one of these ‘no love hormone’ births. Much of the new discipline of neurobiology takes as its basic premise the importance of our species’ need for social connectedness (read oxytocin) and empathy. In other words—love. They don’t specifically look at what happens during birth, but they do look at the earliest interactions of babies with their carers, generally mothers. They take as their starting point this early infant period and the absolute need for the human infant to be securely attached to nurturing caregivers for its ongoing physical, mental and relational ‘thriving’. They know that the quality of our early interactions and nurturing (or not) affect our biology.

So if, in our era of high interventions, we so regularly interfere with the physiological, biological basis of the capacity for early bonded interactions in both the mother and the baby … what might be the implications?

This is what I find myself pondering on this day that celebrates love. I hope your Valentine’s Day is full of that ‘tend and befriend’ oxytocin hormone. And I hope too, that our birth culture will get much better at allowing the wonderful hormonal cocktail that comes with normal birth to unfold for birthing women to come.

What does it mean for birthing?

January’s over and my New Year’s resolutions are already a month old. Have you reflected on and declared any New Year’s intentions and resolutions? How are they holding up?

My 2015 intention is to speak truth about birthing and to continue championing normal physiological birth. To honour this intention I intend to write an occasional blog on the theme ‘What does it mean for birthing?’

‘Birth’ is the lens through which I view the, social, cultural and relational world around me. The query, ‘what does it mean for birthing?’ is the open-ended question that shapes my reflections and ponderings on social trends and cultural shifts and drives my passion for birth work, education and activism.

I’m a product of the 70s movement to reclaim ‘natural’ birth. I’ve held fast to my passion for championing natural birth—or, as I now call it, normal physiological birth—through the changed social and cultural conditions that have eroded birthing capacity.

I, along with many others, have become dispirited over the years as these changes have affected birth. These changes include second wave feminism, where the unintended consequence of the pushback against biological determinism was a weakening of our celebration of women’s biological power; post-modernism; commercialism; commodification; medicalization; sedentary, comfort-seeking, pain-avoiding lifestyles; and pharmacological and technological invasions into the birth space. All have had an eroding impact.

The latest ‘Australia’s mothers and babies 2012’ report (birth stats have a two-year lag time) from the Australian Institute of Health and Welfare gives little to raise the spirits of any who understand the importance of normal physiological birth. That is, who understand the importance of a birth starting, continuing and being completed by the undisturbed finely tuned hormonal physiology shared by the mother and baby.
[For those of you not convinced of this importance please check out Dr Sarah Buckley’s recent report: ‘Hormonal Physiology of Childbearing: Evidence and Implications for Women, Babies and Maternity Care’.]

Here’s just a glimpse of what’s happening according to these latest Australian stats. Firstly, let’s look at the onset of labour, the beginnings of the intricate hormonal birth dance between the mother and baby. According to latest figures only 55.6% of births start spontaneously, 26.3% are induced using synthetic hormones and 19.4% are elective caesareans without any flow of birth hormones involved at all.

Next, what happens during the labour itself? Well, of the 55.6% of births that start spontaneously, a third of these go on to be augmented or speeded up with synthetic hormones. Medical pain relief is used by 76.5% of all women who labour (86.7% for first labours) and if we add in the 19.4% of women having elective caesareans the reality is more like 81% of all births involve medical pain relief. Now obviously some of this medical pain relief is an absolute necessity, but so often it comes down to medical pain relief just being the default setting in our birth culture.
[For more discussion on this, as well as pain, power, pain dynamics and support issues see my book ‘Birth with Confidence: savvy choices for normal birth’.]

Now, onto the actual method of birth: the caesarean rate over all is 32.4% (elective and emergency), leaving 67.6% vaginal births. However instrumental vaginal births (forceps/vacuum) are 12.4%, leaving a non-instrumental vaginal birth rate of only 55.3%. But even that low percentage does not represent the figures for normal physiological birth as that 55.3% non-instrumental vaginal birth figure can include any or all of the following interventions and disturbances: induction, augmentation, synthetic hormones, medical pain relief, continuous fetal monitoring, scalp electrodes, just-in-case antibiotics, episiotomy, and so on.

Finally, what happens with the delivery of the placenta and the precious moments of surging hormones facilitating the loving gaze, bonding and breastfeeding? Well the stats don’t cover whether this third stage of labor unfolds physiologically or is routinely managed as a medical procedure involving synthetic hormones and disturbance of those precious moments of the mother’s and baby’s earliest connection. Perhaps the report doesn’t bother to mention it because it’s pretty well medically managed across the board.

So you see that not too many mothers and babies get through with anything looking like normal physiological birth. We are well and truly playing around with the biological, physiological foundations of human birth and by default of bonding and breastfeeding.

What does this mean for birthing?

It’s definitely not an encouraging picture. In fact, it’s so discouraging that we might say that normal physiological birth is now an endangered activity and place it alongside all manner of other endangered activities, species and habitats.

endangered greatbarrierreef

In Australia, we have to estimate the rate for normal physiological birth—where the birth starts, continues and is completed by the undisturbed finely tuned hormonal physiology shared by the mother and baby—because it doesn’t even register in these official stats. The best estimate for normal physiological birth is only 1 to 5%. (I’m basing this estimation on adding together the figures for births that we can probably assume are close to normal physiological birth: birth centre births, 2.3%; home births, 0.4%; and ‘back seat of the car’, ‘nature strip’, ‘door stop’ births and the like, that are officially documented as ‘other’ in the stats, 0.4%.)

So I definitely feel we can call normal physiological birth an ‘endangered human activity’.

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You may already know about the IUCN: International Union for Conservation of Nature’s ‘red list’ of endangered species. Their red list describes vulnerable species along a continuum: ‘least concern’, ‘near threatened’, ‘vulnerable’, ‘endangered’, ‘critically endangered’, ‘extinct in the wild’ and ‘extinct’.

Well, I’ve taken liberties with their continuum and adapted it to represent the present state of birthing in Australia and many other developed nations.

redlist

Normal physiological birth, it’s a clumsy phrase I know, but at the very least it needs naming … normal physiological birth, normal physiological birth, normal physiological birth … it also critically needs all the passionate championing it can get.

A call to action is urgently required, so I’m borrowing from these words by poet and social activist Drew Dillenger in his powerful poem and call to action on the environment –

 

Hieroglypic Stairway’ – Drew Dillenger

It’s 3.23 in the morning, and I’m awake

Because my great, great grandchildren won’t-let-me-sleep

My great, great grandchildren ask me in dreams

what did you do, while the planet was plundered?

what did you do, while the earth was unravelling?

surely you did something, when the seasons started failing

as the mammals, reptiles, and birds were all dying?

did you fill the streets with protest when democracy was stolen?

what did you do

once

you

knew

 

‘Birthing Urgency’ – Rhea Dempsey

Drew, I too am awakened at 3.23 in the morning

because my great, great grandchildren won’t-let-me-sleep

They implore me in my dreams

what did you do while our instinctive birthing legacy was plundered?

what did you do when the biological, hormonal foundation of human loving connection was unravelling?

surely you did something when women’s bodies started failing

as physiological birth, bonding and breastfeeding were dying?

did you fill the streets with protest when women’s birthing power was stolen?

what did you do

once

you

knew

 

x Rhea   


 

2014 Happy Birthday! 1 Year Old This Week!

Birth_With_Confidence_bookBirth with Confidence: savvy choices for normal birth

Yes, ‘Birth with Confidence: savvy choices for normal birth’ was launched one year ago on Friday 24th May 2013

A lot can happen in a year …

Some of the things I’ve absolutely loved during this first year of my books publication –

Meeting fellow birth passionistas
Hearing what’s happening in regional, interstate areas.
Seeing so many student midwives at the book events – a hopeful way forward surely!
Hearing birth stories of all types—passionate, distressing, traumatic, blessed, triumphant, peaceful, love bombed—all sacred.
Witnessing the truth of changing birth one birth at a time.

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Thank you everyone for the opportunity to connect and share some birth chat. x Rhea

What now?

A few exciting things –

The first print run is almost gone so we are just set for a new print run … an eBook version is on it’s way … getting the book up on Amazon, etc. … setting up a YouTube channel … getting into Book II … and of course always up for any opportunities to talk about birth!

x rhea

Avid Reader Bookshop

Up to Brisbane to another bookshop event at the Avid Reader.

This is another bookshop with a strong community presence and following that regularly offers book talks.

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New faces but also some colleagues from my years of involvement with CAPEA.

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Thank you Avid team x

Lotus Chiropractic – Mt Eliza

Down to the peninsular for another great night of birth chat.

Midwife Sue Holland, a passionate advocate for women and normal physiological birth organized the night at the beautiful Lotus Centre in Mt Eliza.

Pregnant women, couples, practitioners, midwives and some old friends from my days (long ago) teaching at Somers school camp when I was on the Physical Education Staff. (You can find reference to this in my book on pages 131-132) Also some mothers with teens and twenty year olds whose births I’d attended way back then.

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During this time of sharing my book, catching up with women/couples who’s baby’s births I’ve attended over the years has been very, very special, especially if the grown babies have come along as well – can you image!

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Thanks Sue and Lotus team x

The Grumpy Swimmer Bookshop

Nothing grumpy about this night, which was the first book event in an actual bookshop.  The Grumpy Swimmer in Elwood.

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It, like most successful bookshops, regularly present a program of book talks and has a loyal following including Sarah from Nurtured Birth mentioned earlier.

On the night the participants were a mixture of birth people as well as regular grumpy swimmer supporters. This gave scope for my ‘crisis of confidence’ model to be applied in a more general way over many other challenging life events as well as specifically to birth – juicy conversation.

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Thank you Clifford and Sarah x

Red Beard Bakery – Trentham

This was a charming opportunity to hang out at the famous Red Beard Bakery Red Beard Bakery the vision and sweat of John Reed and his partner Thais. I had the privilege of being with them for two babies. Their great story with their second son finishes off my book. (You’ll find it on pages 198-200)

This birth event turned out to be a real treat for a number of reasons. Catching up with passionate birth women including Kaggi (you’ll find a great quote from her on pages 156-157 of my book) as well as Thais and John and their now grown up kids. Mmmm … can’t imagine it gets much better than reminiscing on birth stories with the mother and with the grown young men who were the baby’s in the stories!

Thank you Thais x

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Warrnambool

More passionate birth activists, beautiful venue, opportunities to talk my talk and share with pregnant women, couples, midwives, midwifery academics, student midwives, doulas, new and old friends … couldn’t do better.

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As well as the actual book event, where I get a chance to read a bit and speak directly to the issues in the book, a public lecture Pain and Power in Birthing was also on the program.

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The book event was held in the Warrnambool art gallery – we felt the art piece ‘Hymns of Creation by Bruce Vinall provided an on theme background.

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The organizers also managed to get an article in the local paper and get me interviewed on the local ABC breakfast radio show. (You can listen to a recording of this via my birthing wisdom website)

Thank you Delise, Suellen and all others involved x

Wagga Wagga – Wagga BaBs

Off to Wagga Wagga in country NSW after an invite from Wendy Harper on behalf of the local Wagga BaBs group.

BaBs groups—Birthing and Babies peer support groups—are an initiative of the Maternity Coalition Maternity Coalition.

With the support of midwifery lectures from the School of Midwifery, Charles Sturt University in Wagga Wagga, I had the opportunity to present a seminar, Boosting Birthing Capacity: what helps, what hinders, what heals. Then in the evening the book event again offered an opportunity for me to speak about the birth issues I’m passionate about, whilst also offering an opportunity for me to hear about what was happening in Wagga Wagga—sadly the usual—small pockets of enlightened (well really just evidenced-based!!!!) practice that are hard to access in a generally medical/obstetric dominated birth scene.

Staying positive and continuing to strive for change continues to be the challenge for those of us passionate about normal physiological birth.

Thank you everyone in Wagga who supported the events – food, venues, words and positive energy for change x