Sitting before a parliamentary panel in a bare-walled function room of a hotel on the southeastern Australian coast, Naomi Bowden broke down several times as she recounted a series of distressing events after her daughter Stella’s stillbirth in 2009.
“Having to identify her body to the police and being forced to watch the police officer put her in a cold Styrofoam box and transfer her to the coroner.”
“Being kept in the maternity ward overnight, listening to the sounds of other mothers giving birth and then hearing their babies cry.”
“Going into my six-week check-up appointment with the hospital staff and being asked, ‘Where’s your baby’?”
This week, Bowden was among several Australian mothers who gave evidence at a parliamentary inquiry in New South Wales into birth trauma that one expert likened to the “MeToo” of childbirth.
“No means no, except apparently in childbirth, and it’s time to change that,” Hannah Dahlen, a professor of midwifery at Western Sydney University, told the inquiry when it opened on Monday. “This is the MeToo movement of birth.”
The inquiry was called after dozens of women complained about their care in one part of the state, but the deluge of submissions suggests the problem goes far wider.
More than 4,000 submissions were received in just six weeks, mostly from mothers who say they were ignored, belittled, and denied the opportunity to give informed consent.
Some lost their babies, others carried their infants home along with mental and physical trauma – for which many blame themselves.
“Women are telling us that it is basically their fault that it happened to them,” said Dahlen, who co-authored a paper that asked women across Australia if they’d do anything differently with their next birth. Of more than 6,000 replies, more than 85% said yes.
“Women take on a lot of self-blame and they feel a lot of failure and, therefore, they often don’t feel they have a right to complain because they feel it was their fault,” Dahlen said.
What is birth trauma?
International studies suggest at least one in three women have experienced birth trauma, defined by the inquiry as “inappropriate, disrespectful or abusive treatment before, during and after birth,” that leaves them with emotional or physical scars – and often both.
In medical literature, birth trauma is also referred to as “obstetric violence,” which the Lancet journal says can be interpersonal and structural, “arising from the actions of health-care providers and also from broader political and economic arrangements that disproportionately harm marginalized populations.”
In its submission to the inquiry, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) said it “strongly believes” the term is incorrect as it suggests the obstetrician intended to cause harm “and that is unfair.”
“No-one goes to work to cause trauma,” Jared Watts, RANZCOG Board Director told the inquiry. “If we need to come to the party and actually work out a solution for this, we need to use language that engages the doctors,” he said.
Birth trauma may not be the intention – and in some cases it’s unavoidable when medical staff intervene to save the life of the mother and child. But in other cases, it’s preventable, say mothers who submitted their stories to the inquiry.
Carly Griffin told the inquiry she felt ready to deliver her son but the process was cut short by an obstetrician. “The OB came in, did an examination and said, ‘No, we’re going for a C-section. This is an emergency, your baby’s in distress, but I’m just going to go for dinner first,’” she said.
“I don’t want to assume, but I feel that they wanted my birthing room,” she said. “I feel like maybe I wouldn’t have as much trauma if I knew 100% that that C-section saved my baby’s life (but) I don’t think it had any effect on him at all.”
Others told of distress that tainted their pregnancy but not the actual birth.
Jessica Holliday said her joy at becoming pregnant turned to shame when she was told that she was high-risk due to her weight.
“Despite testing negative for gestational diabetes three times in the first 20 weeks, I was encouraged to act as if I had it. I was warned of a big baby due to my size and advised early induction. The birthing pool was off limits because of my BMI (body mass index) as it was considered a workplace health and safety issue,” Holliday said.
At 30 weeks she found a private midwife and had a homebirth, delivering an average-sized baby. Still, she said her journey was “fraught with emotional turmoil, disappointment and frustration.”
Then there’s the heartbreak of losing a baby, as Amanda Macaulay recalled, telling the inquiry that she felt “broken, physically and psychologically,” after her son was stillborn days after she begged a hospital for help for severe pain.
The grief has stayed with her entire family, she said, including her husband, a shift worker who was told she’d been taken to hospital by ambulance. “He arrived and was handed his stillborn son and told that my life was uncertain at that point in time,” she said.
Afterward, she was sent home with little support.
“You feel lost, you feel alone, you leave hospital, and you still look pregnant. People ask, ‘when are you due?’ and it’s heartbreaking.”
A global problem
Committee Chair Emma Hurst says the point of the inquiry isn’t to lay blame on individuals. “It’s about finding out where the system is failing and making sure we can work towards changing those systems so it doesn’t continue to happen to other women,” she told CNN.
NSW is the first Australian state to examine the issue, and there are already calls for a national inquiry because the problems aren’t limited to that one state – or even to Australia. “The research is showing that it’s worldwide,” she said.
Amy Dawes founded the Australasian Birth Trauma Association (ABTA) after sustaining life-altering injuries during the forceps delivery of her first child in 2015. Since then, thousands of women have approached the group, a charity staffed by volunteers that relies on donations, for support and guidance.
“We are contacted by women across the world who want to start up birth trauma associations, for example, in the US. We know that there are systemic problems, and there’s actually no US-based support services for people who have experienced birth-related trauma. So that’s our second biggest market after Australia,” Dawes told CNN.
She doesn’t think the incidence of birth trauma is increasing, just that more women are starting to talk about it.
“I think that there has just been a shroud of silence, a stigma associated with it. And it’s just simply been accepted as part of becoming a mother,” Dawes said.
However, Fiona Reid, a clinical midwife with more than 36 years of experience who has trained midwives, told the inquiry the increasing intervention by medical staff has increased the risk of birth trauma.
“We are creating the culture that is increasingly medical at the expense of patient satisfaction, and we haven’t improved maternal or infant outcomes. And that is the crux of it,” she told the inquiry.
Australia has a cesarean rate of 38%, according to government figures, higher than many other countries in the Organization for Economic Co-operation and Development (OECD) – despite longstanding advice from the World Health Organization that maternal health and newborn mortality rates don’t improve beyond rates of 10-15%.
The global cesarean rate is currently 21%, up from about 7% in 1990, and predicted to rise closer to 30% in the next few years, according to the WHO. As of 2018, the highest rates were in the Americas at 39%, Europe at 25.7% and Asia at 23.1%.
Reid said medical interventions had been used to make “birth safe,” but for many it’s creating alternative risks.
“We need to look at the quality of care, not the rate of interventions,” Reid said. “We are not improving maternal and infant outcomes. In fact, we are breaking mothers.”
And medical staff are also suffering, she said, a claim supported by the Australian College of Midwives whose submission to the inquiry includes quotes from midwives conveying secondary trauma.
“I’ve seen women berated like children and told they will kill their baby if they don’t do what they’re told. I’ve seen gross omissions of information resulting in a failure to obtain true consent,” wrote one unnamed midwife from regional NSW.
Some midwives had become so tired and disillusioned they were leaving the industry, putting pressure on other staff who were already overworked, the submission said.
Reid said birth trauma will never be eliminated – “it’s an impossible request.”
But she said attention should focus on eliminating preventable birth trauma and raising standards so the measure of success isn’t merely survival.
“It’s an act of erasure to be told that the only important part of the birth experience is the end: the live baby and the live mother,” she said. “We know that this is an inadequate measure of outcome.”
The inquiry is expected to take several months with a final report due in February 2024.