A personal reflection on the Birth Trauma Inquiry Report

This week brings a very welcome focus on birth trauma, with the publication of the Birth Trauma Inquiry Report on Monday 13 May. The report draws together the personal birth stories of 1,311 women and birthing people alongside the feedback from 92 maternity professionals and their professional bodies. 

The stories are harrowing and painful to read, but in many ways that was not that surprising to me as a perinatal psychologist. These are the exact stories that we hear day in and day out. The stories that bring women and birthing people into our therapy rooms experiencing psychological distress and often desperate for someone to listen, to care and to help. 

They tell us about being ignored, belittled, dismissed, manipulated, coerced, intrusively touched and intervened with, refused pain relief, shouted at, and abused – many with far-reaching consequences. The report goes on to call for one central maternity improvement strategy, which is led by a new Maternity Commissioner, and links this with 12 further recommendations related to: 

• staffing and recruitment
• trauma-informed care training
• the six-week postnatal check
• roll-out of the OASI bundle
• birth reflections and antenatal education
• respect
• support for non-gestational parents
• better continuity of care
• extending the time for medical negligence litigation
• tackling racial inequalities and increasing access to interpretation services
• more research

So, lots on the face of it to get excited about - and lots that ties in with our priorities in the Perinatal Psychology Faculty.

This report is groundbreaking in so many ways and will, I hope, lead to many more conversations and action related to birth trauma that might not have happened otherwise. As someone who is still in the perinatal period and experienced birth just 10 months ago, this report felt both personal and professional, and there were some aspects of the report and attending the event that left me feeling uncomfortable and upset. Within a blog, I can't reflect on each of the individual recommendations, but I have tried to pull out some themes below.

The report was written by the incredible CEO of the Birth Trauma Association, who was supported by as special advisory group of very eminent third sector leaders and advocates in the birth field. This is a group of people I deeply respect and admire but, for all their strengths, it is not a diverse group and that may in part explain how some of the focus lands in the final report.

What and who to prioritise

In my opinion, the single biggest problem in maternity services (and arguably all public health and social care services) are the huge disparities and inequalities in health outcomes and experiences for those with marginalised identities – underpinned largely by systemic racism and discriminatory practice.

The most recent MBRACE report shows us again that Black women and birthing people are four times more likely than White women and birthing people to die in pregnancy, birth or the postnatal period, and Asian women and birthing people were twice as likely to die. Similarly, the report found that Black and Asian women and birthing people are at a much higher risk of stillbirth compared to their White counterparts. This should have been the headline of the report. 

These should have been the stories at the event that were given a platform, especially as it is Black Baby Loss Awareness Week this week. But the voices of Black and Brown women and birthing people, as well as those who identity as neurodivergent, from the LQBTQIA+ community, young people, people experiencing disabilities, people in larger bodies – were not amplified, which felt to me like a missed opportunity. And many of these same women and birthing people were seemingly invited to the launch event, which made their invisibility in what was discussed at the event, even more discombobulating and palpable in the room. 

Although chapter seven of the report focused on marginalised groups, the linked recommendation of addressing racial inequalities by ensuring funding for each NHS Trust to maintain a pool of interpreters seems rather modest and singular in its focus. It is of course important, but I think to embed anti-racist and anti-discriminatory culture in our NHS we need to be more ambitious and think more broadly.

The inquiry seemed to have done an excellent job of hearing from a diverse group of women and birthing people across their evidence gathering sessions and it felt like a shame that some of the language used in the report did not consistently reflect this inclusive stance. For example, the title of the report is 'Listen to Mums' – so all non-binary and trans-people are left feeling excluded from this report before they have even read the very first page. 

There is unfortunately no additive gendered language in the report – not even in the paragraphs that focus on the birth experience of those who do not identify as women. I am aware that I am writing this from a position of much privilege – as a white, cis-gendered, able-bodied person – but I can only imagine that reading this report for many was another re-traumatisation that does not touch on many of the root issues.

Getting to the root of the problem

I hope that this report is the start of a story and that it will lead on to more detailed, worked through ideas that sit behind these recommendations – and try to get to the deeper, underlying issues. Although recruiting more midwives and obstetricians is of course hugely important – how do we do this? And how do we do support their wellbeing and retention when they are in role to prevent them burning out? And how do we structure services to enable maternity professionals to be kind, to be respectful, to be informed, to listen and empower women and birthing people to birth in a person-centred and inclusive way? 

Trauma-informed care is proposed as a training that will bring us towards this goal. And I don't disagree. Trauma-informed care training has the potential to be the most impactful when it is reflective (encourages people to think about their own relationship to trauma/kindness/power etc), experiential (encourages people to actively step into the role of a vulnerable birthing person and engage in thoughts, feelings, wishes and desires), when it is linked to ongoing supervision, and when it is embedded and facilitated in service design and pathways. 

So, it is much more than a one-hour standalone, drop-in session – it requires investment both psychologically and practically if real culture change is to be achieved. And, perhaps more importantly, I think we also need to think about core professional training, supervision, service structures and maternity culture much more broadly.

Rollout of birth afterthoughts services

Providing protected and dedicated space for women and birthing people to speak to a trained professional about their birth experience is so important. However, when we are working with trauma – it is also so essential that practitioners are trained, supervised and use evidence-based models. This is something I feel very personally worried about due to the rise of some currently non-evidenced based techniques in these settings, such as the Rewind Technique (sometimes also called the three-step programme). 

Many will have heard me speak previously about my experience of receiving this technique in my 20s by a (very well-meaning) counsellor who was not, it turned out, adequately trained in working therapeutically with trauma – and this led to me experiencing a series of very disturbing dissociative seizures. 

There are some people like me, who have a history of developmental trauma, where this kind of non-evidenced approach, particularly when it is with someone that has only attended a one or two-day training is very dangerous and has huge consequences. Working with trauma is complex. 

The evidence-base currently for birth afterthoughts service models is patchy (although it is clear that women and birthing people have a very positive experience of them), but I would strongly encourage practitioners working in these services to collaborate with practitioner psychologists and other qualified trauma specialists, to ensure they are safe. They also provide an important opportunity for women and birthing people to be screened for PTSD and referred on to evidence-based psychological therapy if they need it.

Preventing severe tears

One of the strongest recommendations in the report is supporting the roll-out of the OASI bundle. And this is very expected, as part of the catalyst for the inquiry, was when Theo Clarke MP (also the chair of the APPG on Birth Trauma) bravely shared her traumatic birth story that ended in a third degree tear and like many women and birthing people who experience severe tears following childbirth, she describes the many complex and worrying psychological and physiological consequences to her life and that of her family, as a result. 

This is reflected in the report itself, which highlights the association between severe tears and ongoing physical pain, incontinence, sexual dysfunction, body image difficulties, infant bonding difficulties, delays in return to work and many other issues. And this is then linked to the rollout of the OASI bundle being the proposed solution. Although we urgently need an approach to prevent severe tears and many of the interventions in the OASI bundle might be very helpful – as an academic I did not find the OASI evaluation compelling enough to warrant this level of roll out. 

The OASI evaluation did not explore which interventions in the bundle worked for whom or measure its impact on any of the adverse outcomes that the report highlights. They just measured the number and type of tear as well as episiotomy rate. No-one measured psychological or sexual wellbeing or incontinence or even pain. But also, what myself and other psychologists are seeing in practice are women and birthing people coming into therapy as they are being traumatised (and experiencing similar adverse consequences to severe tears) by OASI implementation. 

This is due to a mix of issues such as the frequent lack of informed consent to deliver one of its interventions but also the intrusive interventions themselves which can include a perineal grip during crowning, an episiotomy, and a vaginal and rectal examination immediately post-birth (even when the perineum appears intact). But also because some of these interventions are association with similar outcomes to severe tears themselves.

So if the OASI bundle is rolled out, I would love to see:

• Further evaluation of the OASI model and its impact on psychological and sexual wellbeing, pain, incontinence, as well as social and occupational functioning
• Further training for maternity professionals on conducting the OASI interventions
• For the new NHS Perinatal Pelvic Health Services being rolled out to include access to evidence based psychological therapy for mental health and sexual function problems, perhaps linking with the NHS maternal mental health services

Maternal mental health services

Although linking perinatal pelvic health services with maternal mental health services (MMHSs) is a sensible ambition, I know from perinatal psychologists on the ground that it might not be that feasible at the moment due to capacity issues. MMHSs were funded and set up in England as part of the NHS Long Term Plan, and have now gone live in all but three integrated care systems in the country. 

I am hearing more and more that these incredible and important new services designed to support women with severe mental health difficulties related to perinatal loss and birth have very quickly been inundated with referrals, and waiting lists in many places are over six months. Many perinatal psychologists report feeling overwhelmed with the need they are seeing in the service, and are left trying to manage waiting lists by creating more stringent or specific referral criteria. 

The report also emphasises the postcode lottery and the more patchy provision in the devolved nations – leaving many women and birthing people falling through the gaps. And again, it is those from the global majority and the women and birthing people with other marginalised identities that are hit the hardest. The report goes on to recommend providing 'universal access to specialist maternal mental health services across the UK to end the postcode lottery'. 

This is a very welcome recommendation and we would love to work with the report authors and policy makers to think through what this means and how it will be achieved.

Listening

The report importantly focuses on how maternity professionals and systems should intervene earlier and more effectively when risk is present. The important message being: listening to women and birthing people when they tell you 'something doesn't feel right' or 'I know there is something wrong here'. 

However, what feels less of a focus in the report is listening to, and respecting the women and birthing people who are asking for less or intervention, for whom intervention is provided to without their informed consent, and would prefer instead to have a more physiological birth. 

From a policy perspective, this is a tricky area to navigate. How do we invite maternity professionals to do less when we are also trying to prevent situations where women and birthing people are no accessing the intervention they wanted and needed in a timely manner, whilst also negotiating an increasingly risk adverse culture. 

It is complex. But I believe it is also simple. We need to get back to basic. We need to do exactly the things that this report says aren't currently happening. We need to listen. We need to be kind. We need to trust and respect the person in the room or on the end of the phone – and support them in the way they are asking us to. This is what person-centred care is all about, right? 

Summary

The publication of the Birth Trauma Inquiry Report is a monumental moment in time and a very welcome focus on birth and trauma. It has the brave, painful and raw stories of those with lived experience at its core. And although there are many challenges with the report and its recommendations, it will inevitably initiate much needed action and change. Whether it will go far enough and for the those that need it most, watch this space.