Concerns about the level of birth trauma women are experiencing are rising, to the extent an Inquiry has been set up by the All-Party Parliamentary Group (APPG) on Birth Trauma. Neil Stewart, editorial Director of the Maternity and Midwifery Forum, explores the reasons behind the rise and challenges midwives and maternity professionals to speak up for those in their care.
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When did you really discover the scale of birth trauma? For me it started a decade ago at a Maternity & Midwifery Festival in London attended by 700 midwives. We have always known that some women suffered lasting trauma during and after childbirth: the difficult birth with tears and haemorrhage, the panic of a baby rushed to the neonatal unit, the deep and lasting postnatal depression that takes some to suicide. But no numbers were collected, just mother and baby mortality. Mother and baby alive, box ticked, was a crude description, but one shared by many mums carrying serious trauma thinking perhaps that they were the exception and should be and were glad the baby survived.
And the public and policy makers preferred to think they were the exceptions in a story of progress from the start of the NHS. But on that day 10 years ago something strange happened. The whole conference tried to go to a small introductory parallel session on making birth less traumatic.
Such was the demand the room was not big enough, that we had to repeat the session and send the presentation to everyone. Plus, in the session many midwives were talking, not just about what had happened to the mothers in their care, but about what had happened to them in childbirth. Experienced maternity professionals saying out loud how they were shocked, devastated and many still suffering from their own birth trauma.
Moving forward through the decade we had The Lancet Report in 2014 providing research-based evidence of what good midwifery can achieve but also revealing how little was researched compared to other areas of healthcare and disease. We are still on the research road to discovery in midwifery 10 years later and still having to insist on policy made on evidence, not news stories. In the Irish Republic waterbirths have been banned by politicians for almost a decade following one terrible episode. Maternity services and midwifery itself are still vulnerable to ancient taboos, fears and prejudices.
Civil society began to recognise the trauma of miscarriage and then stillbirth. Services and midwifery contact had tended to stop when there was no live birth whether at home after miscarriage or in hospital after stillbirth, but these were traumas that needed to be addressed and slowly were, with the work of groups like SANDS, who have been working for 40 years but are now getting the recognition and midwifery co-operation of health services. The Birth Trauma Association (BTA) started in 2004 and its work has expanded from recognition of postnatal depression to the full range of clinical, professional behavioural and administrative trauma.
On a separate track was the arrival of internet blogs, including Mumsnet and other similar platforms. Amongst the peer support, collective advice, uplifting stories on these websites there was a growing chorus of pain and discontent about maternity services, and midwives – and a horror story always gets more attention on the web than happy outcomes.
It was easy for midwives and professionals to despair and roll their eyes at the negative focus of so much online comment on childbirth experience. The shout-outs and hostility of a vocal minority, angry about their personal treatment and alienated from midwives, medical staff and the NHS about the way they had been treated. Some professionals openly worried that this disproportionate focus on bad experiences was increasing Tokophobia, the fear of pregnancy, and should not be listened to.
But as we know, not listening is the first and most dangerous mistake a profession can make.
For up next was the devastating report by Donna Ockenden into Shrewsbury and Telford – what happens when women are not listened to. What set out as an inquiry into differential rates of stillbirth, allegations of safety risks, following Morecambe Bay and East Kent widened into maternal deaths and the revelations and reporting of a wide range of unaddressed birth traumas and grievances. Donna Ockenden has now moved on to her next inquiry into Nottingham services and more of the same is expected.
Suddenly the statistical claim of the BTA and others of 30% of mothers reporting some kind of birth trauma during pregnancy, childbirth or post-natal began to look systemic and not exceptional.
On 19th October 2023 the UK parliament officially discovered birth trauma in its first ever debate on the subject, sponsored by Conservative member Theo Clark MP whose own experience and those of other MP’s, as well as their constituents, were widely reported in the media. Like that first seminar at the Maternity and Midwifery Festival a decade before they were talking about themselves as well as their constituents and seeing this as systemic rather than exceptional.
Strong assertive, professional women, describing having their choices ignored, feeling disrespected, suffering clinical dangers and pain, not being listened to, dominated the debate with some MP’s having to pause on their feet, speaking in parliament, to compose themselves. Supported cross party by Rosie Duffield MP they have launched an Inquiry into Birth Trauma which aims to conclude in March and publish perhaps as early as April 2024 ( a wise move to avoid getting lost in an election) and is taking submissions till 6th Feb at this link [email protected].
Midwives, midwifery and maternity professionals and the many specialist charities need to make submission to this to ensure all voices are heard.
The narrative about maternity safety is running ahead and too often without professional maternity voices. A big media story like birth trauma and stillbirth grows faster with a baddie and a target for blame and many will have noticed how midwives are cast in that role in the reporting of recent inquiries, even when the detail points elsewhere for immediate action.
Yes, services are short staffed, yes money is scarce but that is not enough to explain many of the episodes of lasting trauma which should have been tackled. I do not know any midwives who read through the long lists in the Donna Ockenden Shrewsbury and Telford report who did not despair and were shocked at what had happened, been allowed to happen, been ignored, covered up or was downright unprofessional or clinically unsafe.
Birth Trauma is a broad term encompassing every step of the pregnancy, childbirth and the postnatal journey from poor contraceptive support, through miscarriage, risk conditions, perinatal experience including induction and Caesarean section rates into postnatal recovery, breastfeeding, mental health and recovery from clinical and birth related morbidities.
In addition, a great many birth traumas reported are from loss of control, disrespect, poor and insensitive professional behaviour or legal and administrative defensiveness when things go wrong.
Donna Ockenden will do a great service to better understanding of childbirth and improvement in maternity if she can help categorise more clearly the sources and different types of birth trauma so they can be better researched, understood, mapped, prevented, and tackled more urgently when they occur.
Government and professions are finally moving on this with announcements about better mental health checks with new mothers through GP’s. But they need to catch up with the express train that is rolling in the media. Midwifery and maternity professionals need to make their voices heard in the public debate, make submissions, highlight existing research and best practice and get funded for the staffing and systems that work to prevent and tackle all kinds of birth trauma. To do that they need to put themselves alongside the pregnant women and young mothers and defend their choices, voice their needs and meet their demands.
Neil Stewart
Editorial Director, Maternity and Midwifery Forum
January 2024