A hero’s tale of childbirth

Birth trauma is a poorly acknowledged phenomena, but one that is gaining momentum within social media channels.  As I reflect on my work from over a decade ago with women who experienced devastating birth trauma, it is important to highlight Gill's work. I was fortunate enough to meet Dr. Gill Thomson in 2005, when she began her PhD studies at the University of Central Lancashire. Gill has written extensively on the topic of women's experience of childbirth, and has kindly provided key insights from her PhD for my blog. I hope this helps to raise more awareness of the effects of childbirth on women and their families, and society as a whole. Thank you Gill.

dr Gill thomson 

My PhD study, completed in 2008 focused on how women who had experienced diverse birth events.  It aimed to explore how women experience and internalise a subjectively determined traumatic birth event, as well as how they were able to develop the strength and resilience to achieve a subsequent positive birth and the impact of this experience on maternal wellbeing.  I used a philosophically informed theoretical and methodological framework, drawing on the work of Martin Heidegger and Hans Georg Gadamer.  Through purposive sampling methods, a total of fourteen women were engaged over two recruitment phases.  In phase one an interview was held with ten women who had already experienced a self-defined traumatic and positive birth.  In phase two, four women were recruited on a longitudinal basis; interviews were held after a traumatic (interview 1) and subsequent birth (interview 2).  In addition, all women (across both phases) were also involved in a final interpretation meeting.  Thirty-two interviews were held in total. 

I present women’s childbearing journey of tragedy and joy through seven interpretive themes and used a theoretical framework to re-conceptualise the women’s birth narratives as a hero’s tale.  A heroic journey of adversity, trials, courage, determination and triumph.  A traumatic birth was a growth-restricting life event; an abusive, deeply distressing experience characterised by a lack of control, isolation, poor care practices and an embodied sense of loss.  The aftermath of trauma held wide scale negative implications for poor maternal health and functioning; women described how it had negatively impacted on their sense of self, they often struggled to form positive relationships with their infants and blamed themselves (and often their partners) for what had occurred.  These women had held what they considered to be realistic expectations of labour and birth, they actively prepared for the birth during pregnancy, and to become a parent was often a long awaited for, and positively anticipated life event. However, the reality left women feeling broken and unable to experience love for their infant.  A trauma birth was imbued with an inherent sense of secrecy as women felt unable or unwilling to discuss their experiences for fear of being perceived as not coping – ‘a bad mother’.  A healthy baby was the only outcome of consideration, and women’s birth experience rendered as a means to an end.  

For a number of the women in my study it took them years before they could consider having another child. They had not originally intended to have large age gaps between their children. However, the impact of a traumatic birth meant this was inevitable, and to a large extent robbed them of their family ideals.  However, becoming pregnant again, and the reality of having a potentially similar birth operated as a catalyst to receive support as women ‘broke down’ during antenatal appointments.  The power and determination to have control and to achieve the birth that they wanted was evident in their narratives.  A number of different strategies and methods were adopted in planning for a subsequent birth.  These included discussing the birth with a midwifery professional, and how this afforded them the opportunity to understand what happened and why it happened.  This was described as highly beneficial in terms of relinquishing self-blame as well as offering reassurance and hope for their forthcoming birth.  Other strategies involved re-visiting the delivery suite, attending further antenatal classes and using homeopathic medicines. A further salutary strategy involved creating multiple birth plans for different birth eventualities – a preparatory approach that helped the women to develop their capacities to respond to the uncertain and erratic nature of childbirth. 

A subsequent positive birth was experienced as a euphoric, joyful, healing life event - an occasion to be celebrated and embraced.  Women experienced person-centred ‘care’ from professionals who they trusted, and who understood what they wanted to achieve. They felt in control over what occurred during the birth and felt they were actively involved in decision-making.  Women felt that they had given birth, irrespective of how the birth had occurred; for example, a woman who had a second caesarean felt that she had given birth due to feeling so involved and connected to the birth process.  In my study, I describe a subsequent positive birth as a ‘redemptive’ experience; a cathartic and self-validating experience that confirmed how bad their former experience had been and enabled women to release and relinquish self-internalisations of blame and guilt.  The transformational nature of redemption was evident through women describing themselves as ‘whole’ and ‘complete’ and able to find ‘the parts of me that were missing’ following a healing, positive birth.  To experience such a different birth on occasion induced anger and discord through women through feeling ‘robbed’ or ‘cheated’ of not achieving this ideal the first time.  However, women spoke of how their subsequent redemptive birth had provided ‘a perfect happy ending’; an occasion that enabled them to hold positive and happy memories of childbirth, rather than ones encroached by trauma and dysphoria.  Similar to insights from wider trauma literature, all of the women referred to how they had, or wanted to engage in altruistic behaviours by sharing their birth experiences to protect, help and inform others. 

A number of practice implications were generated from this study including: proactive opportunities for women to reflect and discuss their birth experience; to encourage the use of expressive writing for women to detail the often ‘unspeakable’ nature of trauma; further research to identify suitable interventions/approaches to help ameliorate the impact of a traumatic birth; for antenatal preparation to be more reflective of the realities of childbirth, and to encourage co-creation of multiple birth plans to prepare women for different birth trajectories; and for appropriate training to be provided to health care providers to enable them to be cognizant of how women experience and internalise trauma, and care practices that promote a positive, fulfilling childbirth event. 

I want to conclude on what I consider to be one of the key revelations from this study.  When I embarked on this project, I had had three experiences of childbirth, one that was highly medicalised (i.e. induction, epidural, episiotomy and forceps) and two that would meet definitions of normality.  I considered, similar to wider literature, that a positive birth was fundamentally related to a ‘normal’ birth that was drug/intervention free, and involved a natural, vaginal delivery.   This is not what was revealed in these women’s accounts.  A number of the negative/traumatic births were straight forward vaginal deliveries, whereas some of the positive births involved a cascade of interventions, operative births and postnatal morbidities (third degree tears, haemorrhages).  These insights highlight that it is not what happens during the birth, but rather how it happens that is crucial.  To a large extent, the current discourses of childbirth serve to dichotomise and polarise women’s experiences; with fulfilment and renewed life meaning achieved through normality - and complexity, complications and interventions associated with adversity.  This study offers a new perspective, of how a birth that is managed with care and sensitivity and for woman’s views and beliefs to be central and considered in all decision-making is one that needs to be strived for.  To provide a model of care based on humanistic values of respect, trust, genuineness, honesty and empathy to enable women, irrespective of how they give birth to achieve an ‘ordinary miracle’ of childbirth.

Please get in touch for further information:  GThomson@uclan.ac.uk

Publications from PhD study:

Thomson, G. & Downe, S. (2013).  A hero’s tale of childbirth.  Midwifery 29(7):765-71.

Thomson, G. and Downe, S.   (2010).  Changing the future to change the past:  Women’s experiences of a positive birth following a traumatic birth experience.  Journal of Reproductive and Infant Psychology, 28(1), 102-112.

Thomson, G. & Downe, S.  (2008) Widening the trauma discourse:  the link between childbirth and experiences of abuse.  Journal of Psychosomatic Obstetrics & Gynaecology, 29(4), 268-273.

Thomson, G.  (2011).  Abandonment of Being in Childbirth.  In:  Thomson, G., Dykes, F.,  Downe, S.  (eds). Qualitative Research in Midwifery and Childbirth:  Phenomenological Approaches.  Routledge:  London.

Thomson , G.  (2009). Birth as a Peak Experience.  In Walsh, D. and Downe, S.  (Eds)  Intrapartum Care (Essential Midwifery Practice), Wiley Blackwell Publishers:  Oxford.

Thomson, G. and Kirk, J.  Tales of Healing.  In Walsh, D. and Byrom, S. (Eds) ‘Birth Stories for the Soul: Tales from Women, Families and Childbirth Professionals’.  Quay Publishers:  London.

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A Normal Birth week! With Mary Ross-Davie

3rd-7th June 2013

Well, what a week! It was busy, busy, but it was like being in midwives’ heaven. It's one thing being able to listen to inspirational individuals talking about a topic you are passionate about, and quite another being surrounded by like minded ‘maternity’ people for a whole week! Wow.

And Mary Ross-Davie and I were together for that week, at three different Normal Birth events!  So, whilst now missing each other’s company, we decided to write a joint post on our reflections of each event, and to share the pleasure with you all. Hope you find it useful…

The first event was the Royal Society of Medicine, Maternal and Infant Health Normal birth Symposium, in London on the 3rd June 2013.

Congratulations must to go to RCM President Prof Lesley Page, on the organisation of such a stimulating and successful study day!

With more than 300 delegates, the whole day felt alive with passion, inspiration and hope for the future…and it was wonderful to see vibrant, enthusiastic student midwives such as Oli Armshaw, Hana Ruth Abel and Natalie Buschman mingling with midwifery greats such as Caroline Flint and Nicky Leap. These students are our future (and we have so much faith in them!!), and they are hungrily receiving the baton.

The programme was a great mix of speakers sharing research findings, experience from clinical practice and exploring and celebrating normal birth. 

Mary Ross-Davie presented her ground breaking PhD research findings. Now I believe Mary’s work has the potential to change midwifery services, and if used, can add strength to influencing staffing levels. Mary's study, SMILI (Supportive Midwifery in Labour Instrument) looked into the nature of midwifery support in labour. The results are powerful yet not surprising, and include evidence that having enough midwives makes a difference to normal birth rates and satisfaction of childbearing women.  Mary's thesis can be found here.

Mary said:

When I started my PhD studentship in 2009 I hadn’t imagined that at the end of it the President of the RCM would be inviting me to speak about my study at a Normal Birth symposium alongside Professor Nicky Leap, Professor Cecily Begley and Professor Lisa Kane Low.

Nicky Leap has written widely about the power of midwives’ approaches to pain in shaping women’s experiences: where we talk about ‘pain relief’ rather than talking positively about the pain of labour we can undermine women’s confidence in their own abilities. Nicky encourages midwives to use the phrase ‘Working with Pain’, and pointed delegates to an NCT resource http://www.nct.org.uk/birth/working-pain-labour) . Nicky’s most recent research has reaffirmed the power of listening to women’s words and stories to learn how to provide better care. It also reminded me of the great impact that film can have in getting women’s voices heard. Nicky and the team of researchers from Kings College London, used videos of women talking about their experiences of care in a learning package for staff.  Nicky showed a short extract of one of the films and the message from the women was clear: what midwives say and do and how we do it has a huge impact.   You can see what Nicky has to say about workshops for maternity workers when working with women who request epidural anaesthesia in labour.

Consultant Obstetrician Amali Lokugamage never fails to silence an audience. Her articulate, sure, yet gentle style is immediately capturing. And Amali is a unique speaker in that she provides delegates with a detailed and understandable insight into the world of medical practitioners. Maternity services frequently fail women and families when collaboration between health professionals is absent, and so often we hear of tensions between midwives and obstetricians. If health professionals understand each other's back stories and perspectives, and the underlying reasoning behind those perspectives, then there is potential for positive relationships to develop and flourish. After having a home birth, Amali is able to draw on both that experience, and her medical training, to help us to consider the best way forward. Amali's book, The Heart in the Womb, is a must read. Really.

To be honest, the third stage of labour has never really captured my imagination as much as other parts of the childbirth journey, but Cecily Begley’s talk, along with seeing Dr David Hutchon at the Mama Conference  earlier this year, has changed that.  Her research into Third Stage Management has included a Cochrane systematic review and the ‘MEET’ study which explored Irish and New Zealand midwives’ expertise in expectant management of third stage.  There is a growing body of work about the impact of early cord clamping and the importance of taking time to get that first hour after the baby is born right. Cecily powerfully argued that physiological management of third stage should be a basic midwifery competency.

 Kenny Finlayson from UCLan reported on the feasibility issues of The SHIP Trial (Self Hypnosis for Intrapartum Pain)  which is due to be reported on at the end of 2013. We look forward to that.

Kathryn Gutteridge shared some of her philosophy of birth and how she has worked to make this a reality at the new birth centre where she is consultant midwife in Birmingham.  She spoke about getting the physical and emotional environment right for women, for them to have the most positive birth experience possible: she and staff at the unit approach the labour and birth as a unique day in a woman’s life much like a wedding day.  Imagine if we treated all the families we look after as if we were their wedding planners for the day…

Mary said:

I loved presenting my research alongside these and other great speakers on the day.  As a new researcher presenting my findings I have found it so helpful and encouraging to get instant feedback from people after my presentations through Twitter.  Research can be quite an arduous and lonely process, peoples’ responses raise my spirits and encourage me to keep going. What people pick out to tweet shows me what messages really come across strongly.  You can find comments (Tweets) about Mary’s talk, amongst the others, here! 

The next event was UCLan's Normal Birth conference, Grange over Sands 5th-7th June, 2013

        ‘Getting it right first time: normal birth and the individual, family, and society’

This famous international conference, organised by Professor Soo Downe and her team from UCLan, always attracts researchers, obstetricians, doulas and midwives from all over the world. This year delegates travelled from many countries including New York,  Netherlands, Germany, Brazil, Australia and Italy. The conference has a unique atmosphere – a beautiful location where the sun always seems to shine, with a relaxed feel that belies the serious research that is presented.

Jenni Cole gave a keynote address on day one, which focused on Anti-microbial resistance (AMR) and the overuse of antibiotics in neonatal care. It is estimated that between 90 and 99% of antibiotics administered to newborns are unnecessary, costing the NHS as much as £150 million per annum. In August 2012, NICE published Clinical Guideline 149: setting out clear guidance on when antibiotics should be administered and when they can be withheld. Whilst in theory compliance with the guideline should have reduced antibiotic use, there is evidence that doctors and other health care workers are reluctant to change embedded behaviour patterns. Jenni is looking for English Trusts to participate in research into the issue, and wants to be contacted by email here: JenniferC@rusi.org

This year some of the keynote speakers highlighted initiatives aimed at improving normal birth rates in the USA, Brazil and the Sudan.  One of the key shared threads between these talks was the need for strong collaboration between midwives and obstetricians, to strengthen normal birth.  Dr Nasr Adalla from Sudan, where less than 50% of women give birth with a skilled attendant, spoke about his belief in the right of women to choose a  home birth with skilled support. Keynote speaker Maria do Carmo Leal spoke about the challenges faced in Brazil, with only 15% of births assisted by a nurse or midwife and a very high caesarean section rate (overall 45%, though in Rio the rate is 80-90%). A new programme of work there led by obstetricians, midwives and politicians, called ‘Rede Cocogna’ is working to change this and has led to the opening of 42 new birth centres.

So many fascinating insights have come out of the NPEU Birthplace study. Professor Christine McCourt shared some of the qualitative results in her talk. The study confirmed how far we have come from the simplistic midwife v doctor dichotomy in relation to normal birth, highlighting more tensions between midwives working in alongside midwife led units and their midwifery colleagues in consultant led units than between midwives and obstetricians.  It made me wonder what we can do to try to lessen these damaging divisions within our profession (answers on a Tweet to me please! ‘@maryrossdavie’).

Miranda Dodwell from Birthchoice UK has been working with Prof Jane Sandall’s team at Kings College London. This work has highlighted the huge variations in normal birth rates between NHS trusts in England:  ranging from 30-50%.  A number of factors appear to make a normal birth less likely for women including being over 30 years old and from the least deprived quintiles. Miranda undertook some really interesting subgroup analysis of the data and found that ‘low risk’ multips had a 75% normal birth rate compared to 15% in ‘high risk’ primiparous women.

Another fascinating source of comparative data is the Europeristat programme of work, presented by Alison MacFarlane, this compares key information about birth processes and outcomes between European countries.  Again this raises so many questions for me: why are our stillbirth and neonatal death rates in the UK so much higher than Scandanavian countries?  Why did the caesarean section rate in Scotland rise by 3% from 2004-2010, compared to a rise of 1.6% in England? Why are normal birth rates so variable: 42% in Scotland in 2010 compared to 47.2% in England and 50.2% in Finland?

The great thing about this conference (apart from the brilliant people to talk to over the wonderful food) is the sense that you get of a very lively questioning research community that is searching for the answers to how we can make positive normal birth a reality for more women.  We didn’t get to see other top speakers: Professor Billie Hunter talking about her work investigating resilience in midwifery and Mary Sheridan on her work exploring vaginal breech.

The next Normal Birth conference is being planned to be in Rio, Brazil in 2014. Now THAT should be one not to miss!

To read more about the conference, see the Twitter feed here, and Consultant Midwife Dr Tracey Cooper has written extensive notes and made them available here Normal Labour and Birth Conf 2013

Believe in Birth Study Day, Montrose, 7th June 2013

Last but not least, Mary and I (and Kathryn Gutteridge too!) were honoured to be invited to the famous Montrose Birth Centre, in Scotland, to speak at their study day ‘Believe in Birth’. When we arrived the sun was still shinning outside and in, that is there was an abundance of smiles and warm welcomes from ALL the staff who work there. Delegates were offered a visit to the Birth Centre in the morning before inspirational leader Phyllis Winters opened the day with enthusiasm and positivity.

There wasn’t a murmur in the room when consultant midwife Kathryn Gutteridge sensitively talked of the effects of child abuse on childbearing women. Kathryn’s words shook us all, and it was clear from the faces of delegates that there was recognition of suffering.

One of the wonderful Birth Centre midwives, Iona Duckett, spoke passionately about her work, building on Mary Ross Davy’s SMILI study, using the ‘TEA’ tool, for emotional assessment in labour. Another special midwife, Jane Wanless, told the story of her midwifery journey. She made us laugh and cry.

Read more about this not to be missed study day here on Twitter!

At the end of the week we felt totally invigorated and enthused to continue with drive to support and protect midwifery and obstetric practice that respects and upholds physiological childbirth. The practitioners who were fortunate to be part of these three amazing events will hopefully be uplifted too, and feel energised to take messages back to their areas of work.

We now need to follow up the suggestion from the RCM's Campaign for Normal Birth steering group (of which we are both members) for a Normal Birth week every year, and also to make events more accessible for maternity workers at all levels.

What are your thoughts on this? Please leave your comments below!