When my husband and I left for hospital on a Friday winter afternoon, we had no idea what would happen. The next few hours would change my life. For good and bad. It had all started with a cervical sweep the day before. I was 40 weeks and four days pregnant and, frankly, I’d had enough. My pregnancy had been uncomplicated in terms of my baby – she was healthy throughout, albeit had spent much of her time in the back-to-back position. But I had found the nine months increasingly difficult. From around 20 weeks I’d suffered from pelvic girdle pain (PGP), which, for me, meant increasingly agonising pain in my lower back. Walking and other everyday movements became difficult. The only place I felt vaguely comfortable was in water. Swimming was a relief.
Women are offered a sweep to help induce labour. A midwife inserts their finger and sweeps around your cervix. It’s about as basic as you can get. They’re trying to separate the membranes of the amniotic sac that surround the baby from your cervix. This then releases hormones, which may help start your labour. “Some women find the procedure uncomfortable or painful,” NHS guidelines say. I found it excruciating. “Oh,” the midwife said, as I lay in a rather compromised position. “I might have broken your waters.” This didn’t make sense to me. I’d always assumed that when my waters broke, I’d know about it. Apparently, not always, and I was instructed to call the hospital if contractions hadn’t begun within 24 hours as I was now potentially at risk of infection.
They didn’t start. And I did what I’d been asked. The voice on the phone was chirpy – everything sounded fine, stay at home, we’ll be seeing you soon enough. Half an hour later, my phone rang. “Where are you? You’re meant to be at the hospital,” the woman said angrily. I needed to come in immediately to be examined.
It was late Friday afternoon, and it was busy. We took the last of the beds in maternity triage. And my waters broke in earnest. That solved the mystery, I suggested. No, I was told, the water birth I’d hoped for was out of the question, and still too risky.
Strong and regular contractions started immediately. We were moved to a glorified cupboard that had been turned into a makeshift holding room. I was denied any pain relief, because it was “too early”, and told that someone would bring me some paracetamol when they came to “examine” me.
It seems obvious when you think about it, but I had never been told what being “examined” meant. Nor thought about it. It sounds medical. But it’s literally a midwife sticking their fingers inside you. I was 3 centimetres dilated. Plenty of time to go, apparently. It was 9.30pm. I felt sick, and in enormous pain. Both were dismissed – until I vomited everywhere. And lost control of my bowels. This would happen several more times over the coming hours. I felt utterly ashamed. Again, it’s common – but I hadn’t been told.
I continued to ask for pain relief and continued to receive none. An hour later, I was 7cm dilated – in full labour – and finally received some paracetamol. There was no space on the labour ward. In just another half an hour, I was fully dilated and ready for the baby to come out. No one seemed to know what to do. The midwives were panicking. And that made me scared. This was my first baby. I didn’t know what to expect. We were rushed to the ward. Already, nothing had gone the way I wanted, or the way it had been talked about at National Childbirth Trust (NCT) classes. Eventually I was given gas and air to ease the pain. But only for around 20 minutes. Apparently, it was “distracting” me too much and I needed to push.
Two hours later there was still no baby, and I was in agony. A doctor arrived, took a brief look and said cheerily, “You’re going to be fine. You’re going to get that baby out.” And then he left. My maternity notes state: “PLAN: continue pushing.” I have no idea what this refers to – like so many of my notes. There was no plan. If there was, it wasn’t one I had agreed to. Finally, after another hour, the decision was made that the doctor would use a ventouse – a suction cup that sits on your baby’s head – to help deliver my baby. Apparently, I consented to this, but I have no recollection of doing so. And I’m ashamed to say I didn’t know what was being asked of me. My doctor didn’t use the word ventouse. He used “Kiwi”, which is a type of ventouse. At the time, I didn’t know what either were.
I remember screaming in pain and then my daughter finally being born. She was placed on my chest for less than a minute. I was examined, told I had a fourth-degree tear that must be repaired, and that I needed to sign a consent form for surgery straight away. “Look at the state of her!” my usually mild-mannered husband said. “How can she possibly sign a form?” I couldn’t. The writing on that form is barely legible, but they would not proceed without it.
I had no idea what had happened. I lay in an operating theatre, in pain, silent tears rolling down my face. I was frightened. The anaesthetist was amazing and stayed with me while I was repaired. I am so grateful for that, at least. But I also feel guilty about it. It was half past three on a Saturday morning, and she was the only anaesthetist on duty at the London hospital. Other women may well have not received the pain relief they needed because of me. “Will I be able to have any more children?” I asked as I stared at the ceiling.
After surgery I was moved to the High Dependency Unit (HDU) and reunited with my daughter. I finally held and fed her for the first time. That morning is a blur. My notes tell me we stayed in HDU for five hours before being moved to a ward. It was there that I attempted to understand what had happened to me. I was in pain, barely able to move and soaked in blood. I asked various midwives to explain what had gone on. They repeated that I’d had a fourth-degree tear, but I didn’t know what that meant. One line, in scribbled handwriting, stands out when I look at my notes: “We don’t have any written info about fourth-degree tears.”
Eventually a midwife appeared with some information they’d printed off after googling it. As I read it, I sobbed. I was 35 years old and thought my life was over; that I would be incontinent. And still no doctor came to explain. The medic who’d delivered my daughter was eventually marched to my bedside more than 48 hours later.
I am perhaps unusual in that I’ve always wanted children. Even as a child I knew I wanted to be a mum. We had done what many middle-class suburban couples did at that time and attended NCT classes. The underlying message of these was: try to avoid a Caesarean section at all costs. “Natural” births were best, and even better to just breathe through it. No need for pain relief. I remember in our penultimate class bringing up the subject of tearing during labour. I had seen a TV feature on it that week, and it struck me as important. “If most of us are going to tear, to some degree, it would be really helpful to talk about that,” I remember saying. “It would be good to know how best to care for ourselves afterwards, that kind of thing.” The answer was no, there was no need. Instead, we proceeded to get on all fours and “moo” like cows, and then practise putting nappies on a doll.
Up to nine in ten first-time mothers who have a vaginal birth will experience some sort of tear. The least invasive kind involves only the skin from the vagina and the perineum – the area between a woman’s vagina and anus. These tears usually heal quickly and without any treatment. Second-degree tears involve the muscle of the perineum and require stitches. Third- and fourth-degree tears are the most serious. These involve not just tearing of the skin and muscle of the perineum but the muscle of the anus. In fourth-degree tears, the injury can extend into the lining of the bowel. These deeper tears need proper surgical repair under anaesthetic.
I don’t really have any happy memories of the first few days or weeks after we left the hospital. I was completely in love with my baby, but I felt shell-shocked. I couldn’t process what had happened, and there was no one who offered to help me. A different midwife was sent to our house every couple of days to weigh our daughter. I had no milk the first few days and she had lost a fair bit of weight. Even when my milk came in, I found breastfeeding painful and difficult, in large part because it hurt so much to sit down.
I cried, quietly, every day for several months. Every single day. Often it would come completely out of nowhere. I’d be talking or watching television, and I would just start to cry. Several midwives wrote in my notes in those early weeks the same phrase: “Mum is anxious.” I don’t think I was. I was traumatised. Several weeks later, I was told that I was “lucky” by the midwife examining my stitches. Apparently, the doctors had done a “wonderful” job at repairing me, and it looked “beautiful”. I now know that I was fortunate to be repaired properly, and immediately after the birth. But the last thing I felt – then or now – was lucky.
After several months I desperately needed to have some control over my life again. I had never felt so helpless, lost and infantilised. But my overarching feeling was anger. I wrote to the chief executive and chair of the hospital to complain and was invited in for a debrief. The head of midwifery was lovely, apologised and followed through on her promise to try to prevent other women facing the appalling lack of communication I had. The hospital now has a specialist perineal health clinic too.
But the attitude of the consultant obstetrician whom I met with my husband floored us both. It was about six months after the birth, but I was still under the care of a consultant urogynaecologist. (I subsequently had two further surgeries: the first 14 months after giving birth to remove an undissolved stitch that was causing pain but hadn’t been spotted, and another six months after that.) My urogynaecologist had told me not even to consider giving birth vaginally again. The risk was too great, he explained. If I tore again, there was a 30 per cent chance I couldn’t be repaired and I’d be incontinent. The obstetrician said the opposite – don’t rule it out! I saw red. “How dare you,” I growled. I remember saying that he would never be so cavalier about a man’s body. Even though I felt nothing but contempt for that doctor, something shifted after those meetings. It had been helpful to speak some of what I felt out loud. This was more than seven years ago. But the details of what happened are permanently etched in my mind.
My story is far from unique. And, compared to thousands of other women, I suppose I was indeed lucky. Every year, about 25,000 women who give birth – approximately 4 per cent – are so distressed that they meet the diagnostic criteria for post-traumatic stress disorder. That makes birth one of the biggest causes of PTSD in the UK, according to the Birth Trauma Association charity – probably coming second only to sexual abuse and rape. Hundreds of thousands more women are traumatised. This is a major health crisis. And yet it is barely discussed.
“Birth trauma is a broad term, but generally, it’s overwhelming distress that leads to a detrimental impact on well-being,” explains Susan Ayers, professor of maternal and child health at London’s City University. Estimates “range massively”, she says, but having conducted research into birth trauma for almost 30 years, Ayers puts it at about a third. “If you ask women whether they thought they or their baby were going to die or be severely injured, then it’s around 19-20 [per cent] in the UK. But if people just ask women, ‘was your birth traumatic?’ some of those estimates are up to 50 per cent.”
Trauma is an overused word these days. It has crept into political discourse; it’s sometimes pounced upon by those waging culture wars. For those who don’t like the word, we can call it something else – the impact on women is the same. In the US, 20 per cent of women have reported experiences of “mistreatment” in birth, the numbers being higher among ethnic minorities.
“I’m Beatrice’s mum,” Emily said, introducing herself to a committee of MPs in March. “Beatrice died during labour at full term in May 2022.” Emily is one of a number of brave women who have shared their traumatic birth stories with the all-party parliamentary group (APPG) on birth trauma, during the first-ever parliamentary inquiry into this issue.
“As soon as my labour started,” Emily explained, “I knew it wasn’t right, wasn’t normal.” The details are harrowing: a series of obvious but missed red flags, and an attitude from medical professionals that can only be described as cruel. The midwife who shrugged her shoulders when Emily’s waters were meconium-stained; the consultant obstetrician who laughed at the “slimy” feel of that meconium, while her hand was still inside Emily.
“The ultrasound scanning machine was brought in and showed that Beatrice’s heartbeat had stopped,” she explained. “At that point I begged, pleaded like I’ve never pleaded for anything in my life, for a Caesarean, and that consultant obstetrician refused. She said no. And she left.”
“It’s destroyed my life,” Emily says now. “I’m not the person I was before.”
This inquiry has been led by the APPG’s co-chairs, the Conservative MP Theo Clarke and Labour’s Rosie Duffield. They received more than 1,200 written submissions after asking women to share their experiences; that number doubles if you count the letters and emails they’ve been sent informally. Both have shared their own experiences of birth injuries publicly.
“The thing that’s really struck me is there seems to be a taboo around talking about the risk of childbirth,” Clarke tells me when I sit down with both women in Westminster. There shouldn’t be, she adds. “Something we’ve heard from a number of the mothers coming to speak to us is that there’s such a focus on the baby post-delivery, they almost forget there’s a second patient in the room, and that’s the mother.”
Duffield says the similarities in experience for women all over the country were stark. “It’s really obvious that they had the same kind of lack of treatment and lack of joined-up care.” As a constituency MP, Duffield has spent years speaking to mothers impacted by the maternity scandal at the East Kent NHS Trust, where dozens of mothers and babies died or were injured unnecessarily during childbirth. Duffield contributed to the inquiry into the Trust’s failings. “The number-one thing that came out of that is: women just need to be listened to. We know our bodies. We know when something’s wrong.”
“I was constantly told by GPs that I had nothing wrong with me,” one mother, Sarah, told the MPs. She experienced a major tear that doctors and midwives failed to diagnose. “I was discharged two days later with [an] untreated tear, which very quickly led to enormous amounts of pain, incontinence, faecal incontinence, and thinking I was going mad.”
“A tear is very painful,” explained Jenny, who also experienced a serious tear that was left untreated, “but the long-term consequences of an unrepaired tear is that I had to give up my job. I’ve suffered PTSD, anxiety, depression, my activities are restricted. My life is impacted in that I have to meticulously plan my day around toilets.”
Another mother, Neera, lost three litres of blood and required more than ten hours of life-saving emergency surgery the day her daughter was born. The haemorrhage had not been picked up by staff. She said she is fortunate to have had the “means and support” to access mental healthcare over four-and-a-half years of her five-year-old’s life. “I have personally spent over £6,000 and received over 50 hours of mental health support,” she told parliament.
The impact of birth trauma on mental health can be profound and last for years, decades even. Women can find it difficult to reconcile such a terrible experience with the idea we have of motherhood, as the clinical psychologist Dr Anna Galloway explains: “How do I talk about this thing which has been incredibly traumatising with this idea that, of course, this is a baby that I want, and I love?” Many of Galloway’s clients won’t seek her out until years after a bad birth experience. “Often I will see people when they start considering another pregnancy,” she says, when they’re able to process what’s happened. “I’m seeing a woman at the moment who has not been able to leave the house because she has such severe PTSD from her birth… You see the effect on relationships, the ability to be intimate with a partner again.”
“The thing that I hear most commonly from the mothers that I see is, ‘why wasn’t I told this was possible?’” says Dr Ranee Thakar, president of the Royal College of Obstetricians and Gynaecologists (RCOG). While not all injuries are preventable, she says, some are. And for the ones that aren’t, women should know what to expect.
Serious tears like the one I experienced are referred to by doctors as an obstetric anal sphincter injury (OASI). They’re estimated to occur in around six out of 100 births for first-time mums, and around two in a 100 births for women who have given birth before. The rate tripled between 2000 and 2012, but it’s difficult to identify any meaningful trend.
“To be frank, our data on the incidence of OASI is not very good,” says Professor Mike Keighley, a retired colorectal surgeon who often repaired severe perineal injuries in women. He co-founded the charity Masic to reduce the incidence of OASIs, as well as supporting new mums who may have suffered one in childbirth. The data we have, Keighley says, only applies to the tears identified at the time of birth – not those that are found later. “A huge number are missed. I believe that the incidence of identifiable injury that should be repaired at birth is at least 10 per cent for first-time mothers.”
The women who have spoken with politicians as part of the inquiry into birth trauma had different medical experiences. But there were obvious similarities. Their concerns and their pain were dismissed. They were not treated with respect, or, in some cases, like human beings. They felt helpless, angry and scared. “Nobody really cares about women,” says Kim Thomas, CEO of the Birth Trauma Association. “What we tend to find with most of these stories is there’s failure after failure after failure. Lots of things go physically wrong… and that continues afterwards in the postnatal period with really poor care.” Almost all women seeking out the charity say their experience was made much worse by the way they were treated during labour. “The number of stories we hear of women being shouted at by midwives or laughed at by midwives; it’s quite extraordinary.”
Birth doesn’t have to be this way. And it isn’t for many women. But women, in England in particular, could – and should – be having better experiences than they are.
Let’s start with serious tears. The number-one risk factor is being a first-time mum. There’s nothing much that can be done about that. But the next is having an instrumental vaginal delivery – and in particular one that uses forceps. “Data indicates that we use more forceps than other parts of Europe,” Thakar says. While rates in several European countries hover at around 0 per cent, a 2023 study of assisted births in 13 high-income countries found England used forceps in a higher proportion of births – about 11 per cent – than any other.
There are cases where forceps must be used. When babies are premature, suction would cause too much damage to the head. But that’s doesn’t explain the discrepancy. “It’s education,” Thakar explains. “We should be trained to do both [forceps and ventouse] so that we provide the best care to women and use the right instrument for the right baby and the right mother.”
Keighley agrees, telling me that it’s in part a cultural issue – it’s the way we’ve always done it – rather than one dictated by medical necessity. “We need to reduce the use of forceps delivery because we absolutely do know that forceps carry a much higher injury rate.”
The risk of a severe tear when forceps are used is at least twice as high as with ventouse: 8-12 per cent compared with 4 per cent. Women should be told this. The recent parliamentary inquiry heard other suggestions that might explain why forceps use in England is so high. The consultant gynaecologist and obstetrician Dr Nitish Raut explained that when poor outcomes of childbirth become part of litigation, the question “why were forceps not applied earlier?” will be asked. Although they can cause injury to mothers, forceps are the most effective instrument for getting a baby out. If a doctor tries and fails to deliver a baby with the less invasive ventouse first, a record will be made at the hospital trust. It was suggested by others that this might also be pushing some doctors straight to forceps use, even when they might not be necessary.
Most, if not all, the experts providing evidence to the APPG’s inquiry highlighted shortfalls in training and knowledge that were preventing better care being given to women. And that applied to everyone involved in births – anaesthetists, obstetricians, and midwives. There was agreement that all healthcare professionals need to be more aware of what can go wrong.
“Training is a really key part of everything here,” Posy Bidwell, deputy head of midwifery at South Warwickshire Foundation Trust, told MPs. “If we can train people, we can prevent these injuries happening. Many midwifery students wouldn’t know the impact that these injuries are having on women.”
Newly qualified midwives did not know enough about perineal damage, and yet they’re providing one-to-one care to women. Current training did not seem to see it as a priority: while several aspects of maternity care are mandatory each year, suturing and perineal protection are not.
Neither doctors nor midwives appear to be taught how to routinely examine women after they have given birth, either. Where this was once part of mandatory medical training, doctors are no longer encouraged to do it, Raut explained.
England is short of as many as 2,500 midwives, the Royal College of Midwives (RCM) estimates, although people are wanting to train and join the profession. Donna Ockenden, who is reviewing maternity services at Nottingham and who previously reviewed maternity care at Shrewsbury and Telford Hospitals NHS Trust, cautions against being too optimistic, however. The focus needs to be on retention. “Two midwives don’t equal two midwives,” she told parliament, “if we are losing midwives with 20, 30, 35 years’ experience… and they’re then being replaced by a more junior workforce, who are not being supported in those early days of their career.” The foundations of maternity services, Ockenden believes, are based around “appropriate funding and staffing. And unless we can look ourselves in the mirror and say that we’ve got it, and we’re confident, then I think we are putting mothers and fathers at risk of significant psychological trauma.”
In the past decade and a half, the UK has seen several NHS maternity scandals – in Morecambe Bay, Shrewsbury and Telford, and East Kent. In all these cases, some of the poor care provided to mothers and their babies was because of a push towards “normal” or “natural” birth, and a desire to keep Caesarean section rates low. In his 2015 report into the Morecambe Bay scandal, in which the deaths of 12 mothers and babies were linked to major care failures, Dr Bill Kirkup described how there was a growing move among midwives to pursue “normal” childbirth “at any cost”. Seven years later, when he reported on East Kent, he noted that “the way in which ‘normal birth’ was spoken about… created an expectation that it was an ideal that staff and women should strive to achieve. On some occasions, this pressure of expectation seemed to contribute to staff decisions not to escalate concerns or to intervene, decisions that were otherwise inexplicable.” Similarly, in her damning report on Shrewsbury and Telford, where hundreds of babies were left brain damaged or died, Ockenden highlighted how the maternity unit had been praised for its lower than average Caesarean section rate, and “that some mothers and babies had been harmed by this approach”.
A Caesarean is not a walk in the park. It is major abdominal surgery. I had one with my second child. The NHS explains that there are benefits to a vaginal delivery: babies are less likely to experience breathing difficulties and there are hints in the literature that elective Caesareans may result in more instances of asthma and eczema. But we don’t have really good data on how to compare the risks or benefits of different birthing methods. And for each woman it will vary.
Yet targets for reducing Caesareans and prioritising vaginal deliveries introduced in 2012 have caused untold damage. And it was the RCOG itself, along with the NCT and the RCM, that recommended them. This guidance urged hospitals to reduce their C-section rates to 20 per cent, and to increase the proportion of “normal births”. These were defined as “without induction, without the use of instruments, not be Caesarean section and without general, spinal or epidural anaesthetic before or during delivery”.
The RCM ended its campaign for “normal births” in 2017, but its legacy persists. Some NHS trusts still talk about them today. A culture of cover-ups and a lack of care remains in others. Just last month, the Care Quality Commission found that staff at Great Western Hospital in Swindon had been downgrading third- and fourth-degree tears, “which meant they were not investigated as thoroughly as they should”. The C-section target was only officially dropped in 2022. Does RCOG now accept that it was a mistake? “It’s difficult for me to say years later, whether it was a mistake or not,” its president Dr Thakar tells me. “I think there was a general trend at the time to put figures to Caesarean section rates. But now, we know that we don’t do that.” It was now right that women were offered a choice, and she insists she hasn’t seen an attitude against Caesareans more recently.
Aside from any physical and psychological impact, traumatic births are costing the country billions. According to figures from NHS Resolution, the arm of the Department of Health and Social Care that handles litigation, 62 per cent of the total clinical negligence cost of harm in 2022-23 (£6.6bn) related to maternity. Of the £2.6bn spent on clinical negligence payments that year, £1.1bn (41 per cent) related to maternity. (As Full Fact explains, the cost of harm differs from the amount actually paid out in compensation: the former includes an estimate of claims expected in the future arising from incidents in that financial year.) The year before, maternity services accounted for 60 per cent of the total clinical negligence cost of harm (£13.6bn). NHS England currently spends around £3bn a year on maternity and neonatal services.
Perhaps economics is more likely to sway politicians than anything else. Professor Ayers believes that a proper accounting of how much birth trauma costs in terms of both damage to women and their lives, but also in terms of litigation, is needed. “I think that’s what drives policy change.” It’s thought that recent investment in perinatal mental health services was strongly influenced by researchers demonstrating how much it cost the NHS and society in the long term – £8.1bn for each one-year cohort of birth.
The APPG on birth trauma will likely report in the next few weeks. Even before it publishes any recommendations, it has scored a victory: the government agreed in January to include birth trauma in its Women’s Health Strategy. There are some other causes for optimism too: new NHS England guidance published in December 2023 calls for GPs to carry out separate six-to-eight-week checks on mothers, not just their babies. They’ll be asked about both their physical and mental health.
But there is a such a long way to go. The government is well behind on its long-term target of halving the rates of stillbirth and neonatal mortality by 2025; the UK is performing worse than many of our European neighbours when it comes to deaths of mothers within 42 days of the end of pregnancy – the figure is at its highest rate in almost 20 years. Many measures seem to declining, not improving. And while only a handful of trusts have been subject to official investigations, there are signs that poor care is happening across the country. Only half of maternity units in England are rated good or outstanding; one in ten are inadequate. That is a damning indictment of the way so many women are cared for.
One crucial area of improvement does not cost money at all. It requires a shift in attitude to one where women are treated with respect, listened to and allowed to make informed decisions about their bodies and babies. As Thakar puts it: “Women deserve it. We are 51 per cent of the population… If you look after women, you look after society.”
When I first heard of parliament’s inquiry into birth trauma, it was never my intention to share my experience. Doing so has been upsetting and uncomfortable. But as I sat listening to other women talk about how giving birth had impacted them so profoundly, it felt dishonest to stay quiet. Difficult births are not something we should feel ashamed of – much as I know many women will have been, myself included.
As well as always knowing I wanted to be a mum, I had always hoped to have more than one child. While there is no robust data on this, researchers say they have seen many women forgoing having more children after a traumatic birth. For years it wasn’t something I could begin to contemplate, physically or psychologically. Thankfully, we did have another baby, and I know I am lucky to have two happy, healthy children whom I’d kill for and die for.
Eleven weeks into my second pregnancy, I thought I had miscarried after a significant bleed. NHS staff confirmed this – over the phone. No one would see me. Not the maternity unit, which simply said it would cancel my upcoming scan. Not my GP, who said, “Yes, sounds like a miscarriage… you can try again to conceive whenever you feel ready.” After six days of heartbreak, a friend convinced me to demand a scan. It was during Covid and I had to go alone. I was dumbfounded. Beating heart. Four limbs. “Your baby is fine.” I couldn’t believe things could be OK after so much blood.
I felt anxious for the next seven months. I had something called a subchorionic haematoma, and was told I’d likely have more episodes of heavy bleeding. My incredible boss allowed me to work from home. Until my planned C-section, I feared going into labour and another vaginal birth. Fortunately, everything went smoothly – though part of my muscle was “nicked” when being sewn back together. Like I said, Caesareans are a major surgery; there are risks and recovery can take time. I have found both my pregnancies and births exceptionally difficult. Being a mum is a privilege, but I never knew that bringing two little people into the world could be so hard. I hope for other women, it won’t be.
This appeared in the 12-18 April issue of the New Statesman magazine
[See also: Our A&E crisis is killing hundreds a week – and government spin can’t hide
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This article appears in the 10 Apr 2024 issue of the New Statesman, The Trauma Ward