Everyday I sit with another woman. The pain is etched across her face, tears fall from red swollen eyes and words tumble, revealing the trauma that is leaving its mark. Birth trauma is in many ways finally be recognised, more women and partners, are speaking up and telling their stories. The conversation is more open and this means that we are looking at ways to offer support to those affected. Yet this raises the question are we REALLY supporting women with birth trauma, or do we need to look a little closer?
Understanding Birth Trauma
In order to offer women and families the support they need after a traumatic birth requires that we first understand what birth trauma is. Birth trauma is complex, individual and affects each women, partner and family differently. Trauma can be a result of medical complications, loss of a wanted birth experience, infant or maternal damage, loss of a baby or poor care within the maternity setting. However trauma can also result even when a birth may appear to others to be a positive experience. Language used, a feeling a loss of control, dignity, or not being treated with respect can also lead to women feeling their birth was traumatic.
Trauma after a difficult birth can leave women struggling with so many aspects of life with a new baby. For many of the women I support they are so affected by their experience that when required to attend the hospital again for postnatal checks, they find it deeply distressing and in some cases impossible. For others for whom poor care has been the source of their trauma, loss of trust in healthcare professionals means avoiding where possible any contact with those they feel have let them down.
Birth Trauma can also be isolating, while everyone around them is celebrating the birth, it can be hard to voice how deeply women are struggling, and asking for help even harder. Sometimes even when managing to voice their feelings, those affected are met with dismissal, being told to ‘move on’, to ‘forget it’ or to concentrate on their baby. For many they will never seek the support they need and try to bury the trauma deep inside, only to find it resurfaces in subsequent pregnancies/births.
For us to understand trauma means hearing those affected, it means giving space to their stories. Understanding birth trauma means putting aside what we think it is, and learning from those affected what it actually is. Understanding birth trauma can also mean us acknowledging that we can be the cause, even unknowingly, and that we need to look at our own practice in caring for women and families. Understanding how birth trauma really affects women is to accept that it happens, that it is real and that if we want to offer them the right support then we have to consider how we design services for those who need them most. Understanding birth trauma is to clearly see how a traumatic birth is linked to the mental health of a woman, her family and also her baby.
Services that are co-produced with women
With the opening up of conversations around birth trauma especially in relation to how it impacts on perinatal mental health there are movements to offer services to those affected. This is very much needed yet the question this raises is, are these services what women really need, do they help heal, or is there a risk that we can in fact cause more damage?
The key to providing services that support birth trauma is co-producing them with those who have lived with birth trauma. Why is this important?
Well we said before that trauma is individual and can have a number of causes. If we produce services based on what we may think trauma is, instead of what women are telling us it is, we a likely to get it very wrong.
Also, we need to think about where we are offering the support, and by whom. Would we ask a victim of violent crime to return to the place for therapy that they were attacked, or would we ask someone who has be injured by another perosn to go back to them for help? Of course not! Women who have suffered a traumatic birth may struggle to even drive past the hospital, let alone go inside, however many services offered require them to do just that. De-briefs that enable women to review their medical notes of the birth are usually in the very hospital that the trauma took place. Also the debriefs often focus on the medical side, with a midwife or doctor but without the consideration for the emotional side. In some cases a debrief can be helpful, if the woman has been also getting the right support, but many women have voiced that the appointments were matter of fact, without understanding of how they have been affected emotionally. For some a debrief if done without an understanding of birth trauma can cause more damage. Women have told me about learning their baby had to be resuscitated or other medical concerns that they previously were unaware of. After such difficult appointments women and their partners are sent home without the offer of a follow up or support for their mental wellbeing.
Of course if poor care or medical neglect has been the cause of birth trauma going back to a hospital and seeing those associated with what has caused the trauma can be again deeply distressing.
In some cases women maybe referred or signposted into general mental health services. Again very few of primary and secondary mental health services have training in perinatal mental health, especially birth trauma. Without the training of birth trauma women report a lack of understanding for how this is impacting them. CBT which looks at challenging thinking can be the first port of call, yet research shows that specialist therapies are needing for treating trauma such as EMDR. Sadly women often face long waits for such therapies, if they are offered at all. Although in some areas specialist perinatal mental health services do exist many of those affected do not meet the criteria for referral and treatment.
In the absence of services, private treatments have sprung up offering quick cures that are non-evidence based and by individuals with questionable training. Again there is often no follow up and women have come to me months after, when symptoms have returned, feeling let down and failed.
So what support can be healing and supportive to women and their partners?
This is where co-production is key. By including those who have been affected, and what they need to recover, we can build services that provide the right support. I recently held a number of workshops looking at how we can improve birth trauma support. What was really striking was that both staff and service users highlighted the same key points.
- A safe space to talk about their experience.
- To have their experience validated and acknowledged.
- To speak with others who had experienced trauma (peer support).
- To access support that wasn’t in a hospital setting.
- That those offering support had an understanding or personal experience of birth trauma.
- That if needed they are able access timely therapy to help them heal.
All those who took part in the workshops voiced that support was often too medical and lacked in looking a not only the woman but also the impact on her relationship with her baby.
If we want to make sure we are supporting women to heal and not damaging them further, hearing what has helped and what hasn’t, is vital. We may think we know what women need, but the reality can be very different. How will we know unless they are included in co-producing the services that are in place to help them?
What about Choice?
Another area that I am contacted about constantly is when women who have had a previously traumatic birth are pregnant again. With any other trauma that a person may go through it would be very unusual for them to face it again. Yet when it comes to birth some women will decide that would like to attempt another birth, to expand their family. Of course this means again facing a situation that was previously traumatic. For women who contact me who wish to attempt another physiological birth they do so without any resistance. Sadly this often is not the case for those who wish to chose an elective c-section. Women who feel that for the next birth experience to be calm and supported, that is protective of their mental health means the choice of an elective c-section, sadly can mean a battle though out the whole of their pregnancy. Women have told me that they have had their previous traumatic birth dismissed, being told’ “it wasn’t that bad”. Some have said they have had their request completed refused and told they ‘have’ to try to birth vaginally. Others have voiced that they have been met with cruel words, been made to feel guilty, even that they are damaging their baby by requesting an elective section. Others have be pushed into trying to birth their baby vaginally and then again suffering another traumatic birth. Others have had to move consultants, even hospitals, to have their choice supported.
More anxiety for women, partners and families, in some cases leading to declines in mental health and deep destress for all involved. One women told me how the refusal by those over her care to grant an elective c- section left her questioning whether she could continue with her pregnancy.
When we talk about birth we also talk about respecting choice. If a woman has had all the information and advice, is clear that her choice is informed and is voicing that it supports her mental wellbeing then do we not have an obligation to listen and support it? Is it for anyone else to say, ‘your birth wasn’t that bad’ or that a woman ‘must’ give birth in the way they think is best?
If we recognised that women have the right to make informed choices about their bodies and how they give birth then this must include when a woman after a previous traumatic birth, requested choices that keep her emotionally safe.
Of course for some women they will very much wish to try for their next birth to be as physiological as possible, without interventions and this too must absolutely be supported.
Whatever way a woman choses to support a birth after trauma we must respect her choice, treat her dignity but also make sure that she receives support in her next pregnancy that not only keeps her and her baby medically safe, but emotionally safe too.
Are we truly listening?
So are we REALLY supporting women with birth trauma? Well it depends on if we are truly listening to them.
Not token listening.
Not listening in order to reply.
Not listening to jump to the defensive or dismiss their stories,
Instead listening with the view to hearing and understanding.
Listening to help us co-produce the services they need.
Listening so that they know that they truly matter.
I hope that one day, I no longer sit seeing the pain of birth trauma etched across the faces of women, partners and families, till then let us at least do all we can to support them while they heal.