The birth trauma myth: it's not bad luck, it's not your fault, and it's not fair on any of us

A black and white image of a couple holding hands over a table

While it is an utter failing of our culture that childbirth is so closely equated with trauma, it is not without basis. Around 600,000 women give birth each year and up to 45% of them experience trauma. Or at least have their trauma recorded. In my experience many more feel let down, harmed and ignored but have neither to confidence, time or wherewithal to externalise it. Birth trauma is so prevalent, and so damaging to the women who experience it, that we have a national body dedicated to raising awareness and providing support for those affected by it. This week is the Birth Trauma Association (BTA) Awareness Week, and it’s well worth popping by their IG account to see BTA’s Kim Thomas in conversation with Donna Ockenden about consent. It’s also a good time to think about how it is that we continue to tolerate this for our sisters, mothers, daughters, aunts, nieces, friends, wives and partners.

The myth of simplistic binaries

Birth is a normal physiological process. We know it isn’t inherently traumatising, because many, many women have their babies in all manner of circumstances and are not traumatised by the experience. It strikes me that a significant part of the problem is that there isn’t a clear understanding of what triggers birth trauma. When people ask new mums how their baby was born, it’s because there’s some form of cultural confusion about the relationship between the objective measures of how birth happened and whether or not it was ‘a good one’. Spontaneous labour? Great! No drugs? Wahey, lucky you! No intervention? Brilliant, because we all know that intervention is horrendous….which must mean the converse is true, and vaginal birth is ‘best’.

This is a huge old unhelpful myth. I speak to plenty of women whose births looked normal and ‘good’ on paper, but feel they were violated and betrayed. There are others whose births sound really very daunting, but who came away feeling positive and empowered (including my sisters second birth, a shoulder dystocia). It is evident that the simplistic binaries of ‘vaginal/caesarean’, ‘pain relief/no pain relief’, ‘home/hospital’ are enough to either explain birth trauma, or help women plan to avoid it. However, it is important to recognise that ignoring female physiology, the complex interrelation between our bodies, hormonal systems, brains and environments is a contributing factor. Birth trauma is not bad luck or bad planning. It’s a systemic flaw in the system.

The flaws in the system

Maternity services in the UK – and everywhere in the world, as far as I can make out – are set-up with risk management front and centre, and physiology lagging a good way behind. You can see evidence of this everywhere, but as a starter for 10 let’s consider the notion of it being ‘normal’ for women to give birth in hospital. There were good pragmatic drivers behind the 1970 Domiciliary, Midwifery and Maternity Beds Needs Report and 1971’s Peel Report which recommended facilities should be provided in the NHS for 100% of births to happen in hospital.

However, the drivers for these strategic recommendations were born from a limited conceptualisation of what constitutes a risk to women in birth, and did not arise from respect for women’s bodies, or the importance of birth, or the value of motherhood. You might argue, for example, that moving birth away from psychologically safe environments into hospital environments that compromise physiology is in increasing the likelihood of interventions that have the potential to cause long-term harm to women’s bodies, presents a considerable risk to women.

(It’s important to note here that I am not underestimating the circumstances the authors of these reports were attempting, in good faith, to resolve. Rather, I’m suggesting that their androcentric perspective gave them the wrong answers to the right questions).

So, the system as we now know it was not set up by mothers. It was not set up with birth conceptualised as a normal human experience, but as a high-risk endeavour requiring medical observation and management. As a result, medical protocols are prioritised, so human factors became the ‘cherry on the cake’ at best, and unattainable at worst. I’ve said it before, and I’ll say it again, Covid evidenced exactly where women sit in the hierarchy of risk, power and birth. This is not to suggest women’s aspirations are at odds with those of the medical establishment. Women are not stupid. Of course they want their babies to live, to thrive and to be healthy. It’s just that women – mothers – know that there is more to it than simply surviving. The idea that medics are concerned with risk, safety and survival and that mothers are careless n’er-do-wells recklessly bothered with things that put their babies at risk is a false correlation that is used as a stick to beat us with.

A more helpful – and honest - point of view

This doesn’t mean ‘natural birth’ is a sure-fire way to a ‘good birth’, though. There is significant danger in focusing on those ‘simplistic binaries’, as this article from The Guardian in 2022 demonstrates. Anne Drapkin Lyerly captures it well in her 2014 book A Good Birth. She identifies six factors that are commonly present in positive birth experiences and absent in traumatic ones. None of which are about how, where or with what drugs or assistance babies are born:

Control: this isn’t a rigid holding on to desires, but faith and confidence in the situation and people around you to be able to allow the process to follow its course
Agency: the ability to act and react to the dynamics of birth authentically and appropriately for you and your situation
Personal Security: this is more than feeling you’re safe in the hands of medics, but trusting that you and the medics supporting you share the same understanding and respect for the risks you’re each concerned about
Connectedness: feeling connected to the people around you when you give birth – this means rapport with your midwife as well as with your partner
Respect: not simply the respect every woman should expect lowest bar from her care providers, but their respect for her birth, and her aspirations and anxieties about it
Knowledge: it is not your job, as a mother, to hold all the obstetric solutions. However it is very, very helpful to understand how birth works, how the institution of the NHS operates, and how you can successfully navigate it.

What Drapkin Lyerly is so clearly evidencing here is that what triggers birth trauma is not how or where your baby was born, but whether in the environment you felt physically and psychologically safe. Regardless of whether your preference is for a vaginal birth or a planned caesarean, or you consent to an induction or an episiotomy, there should be no correlation between what happens and how you experience it, because it should be possible for birth to divert from a woman’s preferred path, or to become risky, and for her to still feel that she was safe and respected and part of the process.

So what do you do?

So far, so theoretical and idealistic. But in the current maternity environment, what could it mean for you? In my opinion, after over a decade working with pregnant women and attending all sorts of different types of birth, what you should take from this is that your birth planning should include how physiological birth works and how you can optimise it (this isn’t controversial, it really is what most women prefer). It should include consideration of all your options, and contingency plans. Crucially your birth planning should also include building connections and rapport with your care providers – facilitating the control, agency, personal security, connectedness, respect and knowledge that Drapkin Lyerly describes. Given this is largely inaccessible via the NHS, what can you do? Start by talking to your midwife about all this, and see if she’s able to offer you practical support and recommendations. Of course I would say ‘hire a doula’, because this is exactly what we’re here for; to get to know you, build rapport and trust, offer advice and sign-posting based in our experience of birth, the system and you. In other words, what all women should have access to is ‘Continuity of Carer’.

I’m afraid to say, that in our current over-stretched and fragmented maternity care system this is almost impossible. And doula’s come at a cost. If a doula isn’t an option for you, get yourself on an NCT or Bump, Birth and Baby course, gather as much info as you can, and talk, talk and talk with your partner about how you’ll manage it all if you feel it’s spiralling out of control.

Tragically, the status quo persists

Which brings me back to my original question: How can we, as a society and as individuals up and down the country, accept that nearly 300,000 women and babies a year will have those vital early days irreparably marred by trauma? What stops us from shifting our perception away from the binaries of ‘vagina/caesarean’, ‘drugs/no drugs’, ‘induction/no induction’, and towards simply humanising the process? Can we really tolerate the idea that it’s ok to carry on as we are just because it’s cheaper to allow women to be emotional battered and physically injured and mop it up afterwards (or not), than to act to prevent it happening at all? (Indeed, is that calculation even accurate? I’d guess that it’s not, given that the vast majority of ‘mopping up’ is done by families, communities, charities, private healthcare and mental health services, so almost impossible to calculate).

Can we carry on like this? For the foreseeable future, whether we like it or not, we will be, I’m afraid.

Is it possible to effect change? As a slightly depressing end note, and in brutal honesty, I’m really not sure. But I’ll keep doing what I can to make changes where I can. As the Association of Improvements in the Maternity Services (AIMS) say, “it is better to light a single candle than to curse the darkness"