The Birth Trauma Inquiry - Did The Government Deliver?

Last week’s news saw plenty of talk on the release of the report by the All-Party Parliamentary Group (APPG) on Birth Trauma on Monday, May 13th.

Having followed some of the parliamentary debates preceding this report, I was not holding much hope to be hearing anything new and now that I have read the 67 pages, including the APPG ‘vision’ of what ‘good’ looks like in maternity, I have come to the conclusion that

a) the APPG visionaries seem to need new glasses and

b) the government along with the governing bodies and Royal Colleges are set on regurgitating the same old stale strategies for ‘quality improvement’ and ‘risk reduction’ as always.

This report, like all the other reports, will make no difference whatsoever.

Or, actually, it might!

In 18 years of service in the NHS I have witnessed the drafting and implementation of report after report, strategy after strategy and guideline after guideline and I fear that this report, just like all the others that have come before it, will serve to drive us further into medicalisation and leave women with fewer choices, not more.

The report, as harrowing as it is to read, and as much as it represents the lived experiences of many women who are living with birth trauma, sadly is not offering any revelations at all. Instead we see the same kinds of stories that we have been hearing about in the various maternity reviews over the last few years; and most concerningly we see the same recommendations offered in order to resolve the underlying problems.

What we don’t see anywhere in the report or in the reactions from our maternity spokespeople (again) is the question of whether our over reliance on technology, pharmaceuticals, flow charts, tick boxes, measuring tapes and risk assessments may be at the heart of the issues faced by the women who shared their experiences to be published in the report.

If you are aware of the Morecambe Bay Investigation Report from back in 2015, the 2022 Ockenden Report outlining the shortcomings in Shrewsbury and Telford Hospital NHS Trust and the report of the independent investigation into maternity and neonatal services in Kent also published in 2022, you know what this one is going to say.

We also already knew that according to the Care Quality Commission, half of the maternity services in England require improvement or are inadequate, so the stories that are captured in this report, as shocking as they are, come as no surprise.

Here in Northern Ireland we are still awaiting the publication of a report into midwifery services currently being drawn up by Professor Mary Renfrew. I am equally as excited as I am despondent to read it when it finally hits the internet.

The APPG report is entitled ‘Listen to Mums: Ending the Postcode Lottery on Perinatal Care’ and it aims to give recommendations for a ‘base standard’ in maternity services across the UK in a quest to prevent birth trauma.

Before we get to the heart of the report I must say this:

If you are one of the parents who submitted your story or if you are reading this and are affected by birth trauma of any kind, my heart goes out to you. If you were ignored, shouted at, dismissed, not listened to, if you or your baby got injured or if you lost your baby, my thoughts are with you.

May you find ease and healing over time.

May you find solace in the fact that voices like yours are finally being captured and talked about.

Birth Trauma awareness is shifting into the public sphere and that’s good.

The question is whether we want to put our trust in those who have led us here. Will relying on the same institutions lead us out of the maternity crisis or will we have to take ownership back into our own hands in order to find our way to safe and fulfilling birth experiences?

If you have been reading my blogs for a while, you’ll know where I think the answer lies and you’ll also know where my biases lie, so interpret everything you read here at your own discretion.

Before the ‘Listen to Mums: Ending the Postcode Lottery on Perinatal Care’ report was authored, women were invited to submit their stories to the APPG. In this process the voices of 1311 women who experienced birth trauma were captured. An analysis of the submissions found that:

• 694 women gave birth by caesarean section (in almost all cases, this was an emergency rather than planned)
• 378 women gave birth by forceps
• 247 women had a baby who spent time in intensive care or special care
• 106 women experienced a third-degree tear
• 41 women experienced a fourth-degree tear

The inquiry also received over 100 submissions from ‘maternity professionals’ and heard the testimony of parents, ‘experts’ and academics in parliament earlier this year.

It is worth noting here that 1072 out of 1311 women had either a caesarean section or a forceps birth. We don't know if any of the remaining 239 women had an entirely unmedicated labour and birth and we don't know how many of the 147 women who sustained a significant tear of their birth passage were also in the group of women who had an instrumental birth.

Given that the vast majority of these births were obviously medicated it seems plausible to suggest that medicalisation itself may be a major factor in birth trauma and yet there has been little to no conversation about this. Midwifery leaders are not interested in this conversation. Instead, the Royal College of Midwives immediately toed the line (no news there) and  issued a nice press release with some more lip service around 'putting women at the centre of their own care', a 'practical guide' called ‘How to Fix the Midwifery Staffing Crisis’ and a 'perinatal roadmap' (this time women are to be put at 'the heart of perinatal mental health services') together with a little bit of self promotion (did you know that we provided evidence on Birth Trauma to the parliament?).

I wonder how much it cost the Royal College of Midwives to produce the pretty flowcharts and I am struck that the RCM seems to have lost faith in the capabilities of our government, too. Their 'practical guide'  with 'solutions for the next UK Parliament' that the RCM felt they needed to publish to help any future parliament with staffing their maternity services looks like it could be a 'Midwifery Recruitment for Dummies' handbook. 

The APPG report makes for harrowing reading and hearing those stories and the resulting conclusions will be difficult, particularly if you are currently pregnant, so be aware that I will be repeating some of the report verbatim and paraphrasing other parts of it in the next few paragraphs.

We are told ‘poor care is all-too-frequently tolerated as normal’ and that ‘women are treated as an inconvenience’. The report points out the obvious, that women value kindness and the sad observation by one of the women which is that ‘where it exists, [it] stands out for its rarity’. Whilst women reported meeting ‘truly wonderful staff’ during their time with maternity services, sadly there are several accounts of women who have been dismissed, shouted at, ignored and laughed at.

We hear from women who felt pressured to breastfeed but had no help, who were told things like ‘you’ve got no milk there’ whilst having their shirt lifted and breast touched. Women felt stranded in their beds with no access to water even, sitting on dirty sheets, no idea how to call for help or pressing the buzzer but nobody arrived.

One of the women felt herself bleeding heavily in the postnatal ward. She pressed the call bell to no avail and another new mum went to get help. She describes her distress:

‘In that moment, I believed I was dying and my baby was going to be there in the hospital alone, with his mother dying next to him and nobody there who loved him or even knew his name. I was terrified.’

There are stories of abandonment during lockdown. One woman felt completely shell shocked after her traumatic birth experience and was left totally alone with her baby. She describes crying and crying. The midwife told her to “stop being a baby” and that it was “time to grow up.’

The list goes on. We hear of the experiences of several mothers belonging to marginalised groups and we hear from spouses who felt traumatised by witnessing their beloved life partners in situations of duress and harm.

There are stories of pre-term birth and of baby loss, of birth injuries going unnoticed and situations escalating as a result.

Staffing is identified as an issue and the loss of masses of experienced midwives who are being replaced by midwives who are only just trying to find their feet in a service that fails to offer support and guidance.

The authors of the report acknowledge that birth trauma is costly for everyone involved.

The quality of relationships is the currency that the parents and babies pay in.

The NHS is seeing higher cost in mental health services for emotional trauma and in gynae services for physical trauma.

The economy suffers because any kind of trauma results in a delay in women being able to return to the workforce.

Their recommendations involve the routine implementation of the OASI (obstetric anal sphincter injury) care bundle which comes as no surprise given that almost 150 out of the 1300 women were affected by injuries to their anal sphincter muscles some of which were life changing and permanently debilitating. While reading about the lasting effects of this kind of injury on any woman is heart wrenching, I also know that implementing the OASI care bundle is not the answer for all women. Whilst it may help prevent some injuries for women who are having other aspects of their births medicalised, it also comes with wider considerations in that it hinders undisturbed physiological birth and the kind of injury that it seeks to prevent is most likely to happen in technocratic models of birth.

I can just see how this will impact women's experiences because balanced counselling around interventions is not often available. I already hear from women who are coerced to give birth on their backs when they had looked at the evidence and decided that they didn't want the OASI bundle implemented.

Aside from OASI we are told that we need the digitalisation of maternity records to avoid birth trauma (bless Encompass), more staff (true), more and better staff training (in how to medicalise birth no doubt), evidence based care (one of the old favourite Pandora's boxes), antenatal education (when delivered by the NHS this effectively primes you for compliance) and a list of other recommendations that generally evolve around the conduct of midwives and other maternity care professionals in their communication with women. Given that someone somewhere vouched for the 'good character' of every single midwife working in the UK today so that they could enter the NMC register, it baffles me that those even need to be pointed out in a report.

Oh, yes, and consent, we need informed consent (another all-time favourite; In many cases this is aka 'we inform and you consent'). 

It is also pointed out that we need to be aware that women who give birth may have already experienced trauma through sexual violence or through obstetric violence (hopefully this call for trauma informed care will finally make it mainstream) and

(drumroll)

We need to LISTEN to women!

Boom, there you have it.

It’s the same old rhetoric I’ve seen in 18 years of working as an NHS midwife and to be honest there have always been teams and practitioners who practice this without ever needing to be told. All of this is already laid down in the codes of conduct and the supposed general premise of maternity care and yet it just doesn't happen everywhere and, sadly, women tell me frequently that they experienced coercion, bullying and poor care in a previous birth (even by the standards issued by maternity services themselves).

I can just imagine the cogs of the maternity machine in motion now after this publication. The staff memos, the important meetings, the strategies, the drive to double down on the OASI care bundle, the finger pointing, the denial and the conversations in the staff rooms: ‘Isn’t it terrible?’

I can see the sense of helplessness among the most compassionate staff who see how far off the mark we are with supporting birth in a humane way and I can see how they struggle for support from senior management. I can see the ‘truly wonderful staff’ women are lucky to encounter on their journeys to meeting their babies. Those midwives are the shiny diamonds that pop up at your bedside. You can find them quietly kneeling beside your birth pool or making you feel safe when you struggle to see hope. And then I can see those super trouper midwives who hold onto a vision of midwifery that never existed in the NHS and who plough on regardless of the gaping lack of support for truly putting the woman at the heart of it all.

So how will this report impact my services and what I tell my clients?

It won’t!

Last Tuesday at my Essentially Birth pregnancy massage clinic in Belfast several of my clients voiced concerns about the news that day. They wondered where their luck would fall according to their postcodes and they were afraid to hand themselves over to maternity staff.

Here’s what I told them:

Ultimately the news of this report changes nothing for you. Services are the same as what they were yesterday and your options are the same as they were yesterday.

I generally make it clear to all of my clients that they always have the choice to opt out completely, in fact I offer a specific package to prepare you for a sovereign birth, and sovereign can mean making the conscious choice to opt in and advocate for yourself (now you have it from the APPG visionaries themselves that you need to be listened to!).

Most of my clients do choose to opt in and when they do, they do it from a place of knowing that they don't have to and that makes a difference. Those clients who approach me with out of system pregnancies and wish to prepare for giving birth together as a couple usually have had their minds made up before they even conceived. I celebrate my clients' choices with them always and I offer perspective to all of my clients regardless of what they choose because each journey brings with it its own set of advantages and disadvantages. 

When it came to discussing the report with my clients who want mainstream maternity care and who know that they will accept the offer of induction of labour if they don't have a baby before their timeline, the perspective I offered was this:

Yes, this makes for scary news and you have every chance of having a positive experience. In fact, many women do, particularly when they have prepared for what a medicalised birth will look like. If you know what to expect, what you may want to say 'no' to and how to gain more information to continue to make choices within the NHS maternity care paradigm, you are already going to feel more in control. It is important to remember that the stories that women and their partners told in the report were submitted by families who had experiences so bad that they felt compelled to tell their government about it. Though possible, it is not the most likely thing to happen.

I think having an idea of what the sequence of interventions offered will be and a plan for how to respond if you were to meet uncaring staff is a good idea. Know how to advocate for yourself, be ready to say 'no' to the same thing more than once and understand that staff have to offer you the interventions as per their protocol, nothin more. 

At the same time, having an overall optimistic outlook and expecting to meet only the most beautiful midwives and doctors on your journey is your best strategy.

Why wouldn't you meet them, they are there. Call them in! 

Don't make any decisions from a place of fear. 

Basing your choices on a report like this is problematic for you as a service user as much as it is for the institution itself to base any policy decisions on it. Most of those traumatic experiences for women quite likely played out in the fifty percent of settings deemed substandard by the Care Quality Commission and it does not represent the entire maternity landscape. I don't believe in using worst case scenarios to influence what you believe to be true about birth ever. What I do believe in are choices made after having evaluated the information you have available and not being afraid to step away from convention if it feels like the right thing to do. It strikes me that the authors of the report suggest evidence driven policy while at the same time ignoring the mounting evidence in support of the protective effects of birth physiology and offering a one-sided reactionary 'solution' in their well meant quest to prevent severe injuries to the birth canal. 

Do you see the slippery slope?

If you have had a previous traumatic birth and wish to explore your options for your next baby (even if you haven't conceived this baby yet) do see me for a 'Just Me' massage in Belfast or in Dungannon.

If you feel you want to unravel your birth baby's birth story and you are not local to Northern Ireland see me from the comfort of your own home for a consultation on zoom and if you are a midwife seeking to decompress from the stresses of working in a stretched system, come for one of my aromatherapy massages.

As always, I appreciate your email messages to [email protected]