The traumatic experiences some women and partners experience at birth is once more in the news. Neil Stewart, Editorial Director, looks at the ongoing developments related to birth trauma and points to the political responses going forward.
_________________________________________
Childbirth comes with risk. Mothers are not ill with an infection; pregnancy is not a disease, it is a natural process, but it is a time of risk. What is sad and remarkable is that the public are just discovering what those risks are and seeing behind the reassuring storylines of “Call the Midwife” and other entertainment programmes. Yes, those programmes deal with tragedy, loss and sadness, but these are still seen as exceptional, at the margin, not the common experience that women can expect in childbirth. Midwifery and maternity services have been built over decades to offset and deal with those risks, to reassure and then act in emergencies. This approach has served the majority of women in childbirth and the NHS well, with minimal intervention.
All that is changing and with it the attitude of women to maternity services and midwifery as a profession is being challenged. There is a common theory in management of change that “you can only change what you can count”. The problem in maternity services is that when it comes to birth trauma no one was counting, until now, and what counts now is far from clear.
What was counted was stillbirth and maternal death; other experiences were not counted, little researched or investigated. The first jolt came a decade ago when it was revealed that the NHS, the jewel in the national crown, was not at the top of the European league table of preventing stillbirths. Not only was Sweden getting better results but a string of other countries including some emerging from Eastern Europe were now getting better outcomes. National pride demanded that something must be done, and the outcome was a strategy for ”Saving Babies lives” published in 2016
In parallel the report on Maternity Services at Morecambe Bay in March 2015 kicked off a ferocious media debate about attitudes and ambitions among midwives, maternity services and pregnant women on what having a “normal birth” meant. The report pointed, among many other “dysfunctional” failures among management and clinicians, to a bias among midwives towards having, and holding out for a physiological vaginal birth that had put women and children at risk. This last point was to become the dominant narrative in reporting over the coming years, tapping into fundamental fears among women, and connecting to large accounts of traumatic experiences in childbirth. The “Better Births” National Maternity review came from the Morecambe bay report and a desire to consult on what maternity services should look like going forward.
The Maternity and Midwifery Forum first saw the scale of trauma at a London Festival attended by 700 maternity and midwifery staff. A side seminar on preventing birth trauma which was expected to attract 30 -40 saw virtually the whole conference wanting to attend. In the repeated sessions midwives were not just talking about how much trauma they were seeing women were going through in childbirth but talking about the trauma they had gone through in giving birth to their own children and as midwives in the birth setting. It was clear there was a systemic problem that not even experienced professional midwives felt they had any control over in their own births. But what was the scale, and what did birth trauma mean?
The Commons select Committee report on Safety of Maternity Services in 2021 brought out more information about the state of neonatal services and the different levels of care available that were contributing to the UK not being able to match Sweden, producing a calculation that if the UK had the same provision then 1000 stillbirths and neonatal deaths could have been avoided. Important recommendations about bringing all neonatal services up to the highest standard and introducing better equipment for monitoring babies in the womb were overshadowed by continued arguments about “normal birth” and allegations that women were being steered to vaginal birth when a Caesarean section would be a better option. One impact of this argument is that individual maternity units no longer have to publish their c-section rates.
Into this debate some statistics have dropped from the MBRACCE-UK 2018 report. Black women were 5 times more likely to die in childbirth than the average, women of South Asian heritage 2 times more. A lot more was going on.
There is still no clear answer on numbers or categorisation of birth trauma but there is a growing consensus that 30% of women experience some kind of birth trauma in childbirth and its postnatal period.
Birth trauma covers much more than a threat to life or emergency clinical intervention and it can be caused not just by emergency interventions like forceps birth or c-section or postnatal physical and clinical problems like tears and incontinence, but also the treatment and disrespect of individuals in dealing with complaints or physical and mental problems.
The Birth Trama Association which was formed 20 years ago started off mostly as a mental health charity tackling some of the worst postnatal traumatic stress disorders. Over the years its work has expanded as the recognition of trauma covers a wider range of clinical, mental health and wellbeing issues.
When the Ockenden report into Shrewsbury and Telford came out in March 2022, while the media focus was on the baby and maternal deaths, we first saw the long tail of over 1300 other cases where mother and baby had survived, (and would therefore be counted positively), but that the impact of childbirth on mother and often partner had a devastating and traumatic effect on their lives.
In the meantime, government are moving to recognise birth trauma with inclusion in the GP checks at 8 weeks after the birth, following the Better births review in 2016 and NICE guidance. But this is hardly the continuity of care expected and, while it is a welcome intervention that should pick up ongoing problems, the damage may already have been done in those critical early postnatal weeks, where the number of midwives visits have been systematically reduced
The CQC is marching on naming and shaming over half maternity units as needing improvement or inadequate creating headlines suggesting two thirds of maternity units are not safe. While this is supposed to drive on improvement in services it appears to be helping to drive a large rise in interventions and C-sections.
Remember the government decreed that individual hospitals should not publish C section rates in case this led to false competition for low rates and an over emphasise on natural vaginal birth? The national figures say that c- section rates have risen to 33% and that of these the majority were “unplanned” or “emergency”. In none of the reports is there any attempt to correlate the experience of “birth trauma” with all the different and increasing interventions from induction through to c-sections .
The RCM ended its campaign for “normal birth” in 2017 under widespread pressure but combined with the shortages of midwives, the increasing age, weight and comorbidities of mothers, and shortages of staff the pendulum seems to have swung sharply towards interventions and the traumas they can bring.
It is now not unusual to hear anecdotal evidence from senior midwives that these c-section rates are heading for or have reached 50% in many units in a surge of defensive medicine and practice, exacerbated by the challenges of COVID.
A complicating factor in all this is the price of mistakes. In the cover story for this weeks New Statesman magazine, setting an agenda on the left of politics, Hannah Barnes reports that, of the £2.6 billion spent on clinical negligence payments, £1.1billion (41%) 2022-2023 related to maternity. But more shockingly it states NHS Resolution estimated that in practice it needs to allow for £6.6 billion for this year for the retrospective claims it expects to come in or are in the pipeline. We only spend £3billion on maternity services.
The New Statesman front cover is headlined “The Trauma Ward – The hidden childbirth crisis devastating lives and costing the NHS billions” by Hannah Barnes. If any midwives want to understand how women, feminists, campaigners see maternity services this is well worth a read.
The article points out her experience of not being warned by midwives or in antenatal classes of the risks in childbirth and the rapid and dramatic interventions that might arise to keep mother and baby safe. The story women are given is not a realistic one that prepares them for the challenges that might lie ahead or describes how maternity services will escalate support and interventions to save lives.
This New Statesman article is just the first of two big stories that will impact maternity services back from Easter break. The other is the report of the All-Parliamentary Party Group on Birth Trauma, headed by Theo Clark MP (who went through her own birth trauma and spoke about it in Parliament on 19 Oct 2023) and Rosie Duffield MP (East Kent Hospital is in her constituency).
Maternity services and policy seem to be drifting, buffeted and pushed along by scandals and reports with no clear destination for the future of services configuration, philosophy and no clear numbers to help define the many causes of birth trauma we are trying to solve. Continuity of Care, the core policy of Better Births 2016 and the expressed preference of most women, has been paused or pushed back in many maternity units. Women’s choices are being narrowed or ignored.
With an election coming up there is a risk that the debate will become more polarised and ill-informed and many midwives will be left wondering whether anyone in government understands what they do and what we rely upon them to deliver for mothers and the NHS.
The newsletter will be tracking and reporting developments over the coming weeks and Theo Clark MP will be making a presentation on Birth Trauma and their report to the Midlands Maternity and Midwifery Festival, which you can watch nationally on livestream anywhere on 14 May.
Neil Stewart
Editorial Director, Maternity and Midwifery Forum | MATFLIX
April 2024
2024