The birth of a child is usually cause for celebration, but the recent UK birth trauma inquiry report, led by Theo Clarke MP, showed how often it can involve complications that lead to injury or death.
Author
Susan Ayers
Professor of Maternal and Child Health, City, University of London
My research, conducted in collaboration with a European network of experts in birth trauma, shows that for around one in three women, the experience of labour is traumatic. One in 25 women develop post-traumatic stress disorder (PTSD) as a result, affecting mother, child and wider family members.
Traumatic births usually occur because of complications during birth, poor care or mistreatment, leading to long-term consequences for the mental health of mothers, including flashbacks, nightmares and negative thoughts, emotional detachment and a tendency to avoid reminders of the birth.
Traumatic births also carry economic consequences, generating substantial healthcare costs. In the UK, a large portion of NHS clinical negligence claims are maternity related (63% of the total - £6.6 billion - in 2022-23).
Following government reports into serious events in maternity services, such as Morecambe Bay and Shrewsbury and Telford, the UK inquiry report, titled Listen to Mums: Ending the Postcode Lottery on Perinatal Care, was published in May 2024. Support for birth trauma is also one of five priorities in the UK's 2024 women's health strategy.
But it's not just the UK. Preventing traumatic births is a priority for many countries and international organisations.
In 2015, the World Health Organization called for every woman to have dignified and respectful maternity care. This was repeated in the European parliament's 2022 resolution on women's sexual and reproductive rights. The Australian government inquiry into birth trauma was led by Emma Hurst, MP.
It is clear, then, that effective strategies to prevent traumatic births are overdue. It is less clear what needs to happen to achieve this.
The UK inquiry report and my research with the European network of experts in birth trauma both make recommendations that cover clinical practice, policy and research.
The UK inquiry was based on submissions from over 1,300 women, almost 100 maternity professionals, and seven evidence sessions held in parliament. The European network research was based on international consultations and feedback from over 200 expert researchers and doctors from 33 countries, in addition to women who have experienced traumatic birth.
What needs to happen in clinical practice?
Both sets of recommendations emphasise the importance of respecting women's rights and choices and working with women and their families to enable positive birth experiences. Examples include better continuity of care, keeping mothers together with their babies as much as possible, providing support for fathers and birth partners and making sure they are continuously informed.
Both reports also recognise the need for trauma-informed care - which takes into account how trauma can negatively affect patients and their ability to feel safe or develop trusting relationships with health care services - to be integrated into maternity services and mandatory training for maternity staff.
The UK inquiry recommendations include the use of a care "bundle" for obstetric and anal sphincter injuries (OASI) so these are less likely to occur - action midwives and doctors should take to prevent third or fourth degree tears during childbirth. According to the Royal College of Obstetricians and Gynaecologists: "OASI rates among first-time mothers tripled in England from 1.8% in 2000 to 5.9% by 2011" because of inadequate training.
The European network recommendations stress that when traumatic births do happen, it's essential to identify those affected quickly in order to offer prompt support and treatment. That support should continue after the birth and during subsequent pregnancies, which can re-trigger trauma symptoms.
When birth-related mental health difficulties arise they should be responded to with compassion, understanding and respect. The UK inquiry recommends a universal postnatal GP check for women's mental health, postnatal debriefing services, and access to specialist perinatal mental health services.
What needs to happen in healthcare policy?
Both publications show that health services need to be well resourced in order to provide respectful care, training in trauma-informed care for staff, and routine screening for traumatic births and mental health.
Maternity services also need to be resourced so they can act on patient feedback and ensure they are providing good care, which should include ensuring women's dignity, autonomy, and clear, compassionate communication with women.
For example, the Royal College of Midwives (RCM) says that NHS trusts and boards base "midwifery staffing levels on what they can afford, not women and baby's (sic) needs".
Policy should support maternity services to provide care that foregrounds women's rights and needs, including preventing mistreatment and assisting with mental health problems.
National and international guidelines for maternity and mental healthcare services should outline evidence-based strategies to help prevent, detect and treat traumatic births and PTSD. Strategies could include trauma-focused cognitive behavioural therapy and eye-movement desensitisation and reprocessing therapy (a type of psychotherapy that deals with trauma).
What needs to happen in research?
Changes to policy and practice should be based on evidence. My work with the European network shows there are significant gaps in birth-trauma research, particularly around minority ethnic groups, fathers and non-birthing partners. We also need further evidence on how best to prevent, screen and treat traumatic births.
At the moment, worryingly little is known about the potential long-term effects of traumatic birth and PTSD on babies. Research into other types of trauma suggests the possibility of transmission between generations. These gaps need to be filled quickly if we are to address the current failures in maternity care - and stop today's trauma from affecting future generations.
Putting our recommendations into practice - as part of a broad approach supporting maternity staff, women and their partners - could reduce traumatic births and improve birth experiences.
Susan Ayers receives research funding from the National Institute of Health Research, World Health Organisation, British Medical Association Foundation, Myriam de Senarclens Fondation and Barts Charity.
