In my postnatal counselling practice, I regularly see women who’ve experienced trauma during their first labour making different choices second time around. What drives their choices?
The answers are key if we are to improve our trauma statistics.
Birth trauma. Hear the words and you probably think of a life-threatening situation; something going wrong and mother, baby or both being in danger. But medical emergencies are not always traumatic. A woman may require an emergency intervention but research shows that when well supported emotionally, these women don’t necessarily experience the birth as traumatic.
The reverse is also true: poor personal treatment can be traumatic in the absence of an emergency. This is the case for many women who come to debrief me about traumatic birth experiences. Time and again I encounter the same themes: their experience of care – or rather lack of the respectful, nurturing care they expected – is key in predicting distress, regardless of birth outcome.
The second-time choices these women make are often to guarantee something called “midwifery continuity of care”: continuous care from a qualified, known caregiver across pregnancy and labour. This model can provide the emotional safety that aims to negate otherwise traumatic emergencies.
I highlight care because it means identifying the systemic issues at play – recognising that our standard birthplaces can, for some women, contribute to those physical emergencies most of us more easily recognise as trauma.
And here we come to the heart of the matter.
Though well equipped for the times a birth goes off course, most hospitals are hardly the home-like, cosy, undisturbed environments that support optimal birth hormones.
More crucially still, standard birthplaces have downgraded, if not abandoned, the kind of one-on-one human care that helps.
Instead, women feel abandoned, unsafe, unable to cope. Feeling unsafe can trigger adrenaline, slowing or stalling the labour, often resulting in the use of synthetic oxytocin. Or an epidural becomes the default response to a woman’s emotional distress.
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 because the systemic causes are complex.
I would like to be able to say that the failure of care in our system is only one of absence. Certainly, many overworked midwives operating in what researchers term “fractured care” settings would dearly love to provide the one-on-one, continuous care they know is needed.
But sadly there is more to it.
As many researchers have highlighted, “power over” coercion, including manipulation, punishment, judgment, even assault – sometimes called outas “obstetric violence” – are also part of the story.
Some health professionals now describe birth trauma as “an event occurring during labour and delivery where the woman perceives she is stripped of her dignity”. Sadly, many birthing women today feel not only abandoned but actively bullied.
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 trauma can arise when structures in the birth place result in coercive and bullying behaviour; when birthing women lack autonomy and respect; and, as I witness in counselling, when the birth experience triggers existing present or past life trauma. In these cases, the lack of appropriate care has appalling impacts.
But if the causes of trauma sound complex, the answer is less so: the likelihood of birth trauma – according to some studies – has the potential to decrease when we provide midwifery continuity of care.
This “gold standard” of care has been shown to reduce the need for medical pain relief and the likelihood of consequent interventions.
More importantly, the same study showed that, even when such interventions are necessary, the birthing woman will be less likely to experience them as traumatic. (As a midwife once put it to me, first respondent fire-fighters are often better at supporting people through trauma than our maternity system currently is.)
Midwifery continuity of care is what women so often want, yet only 15% of care models in Australia offer it..
When we talk about birth trauma, the conversation must be wide enough to encompass our lack of best-practice care. Because addressing birth trauma is not just about addressing physical trauma; it’s about making an emotionally, culturally and medically safe birth environment available to all.