Speech to Rita: a midwife's experience of birth trauma

The birthday theatre group 

It was 2002. I'd begun my new position as consultant midwife, and part of my role involved listening to women and families in an attempt to influence and improve our maternity service. I did this through various channels, going out to meet parents in local communities, responding to complaints, and involving willing individuals in many aspects of service delivery (peer support) and improvement. This work fed into our MSLC, and I communicated activities via a newsletter. 

I also developed a service where I listened to women who were suffering from fear of childbirth, either as a result of a previous traumatic birth experience, or because of negative stories from others, either friends or family, or in the media. 

‘I was really scared when I was pregnant again, it was awful hanging over you, that this might happen again and it might be worse this time’ [Ann] (Thomson & Downe 2010). 

This fear was like I’d never known before, and I learnt so much about childbirth in the eight years I spent hearing such detailed accounts of consequential self-loathing, anguish, nightmares and horrific flashbacks, relationship breakdown, poor parent-infant attachement and distress. At this stage I had been a midwife for decades, so why had women not talked about these feelings to me before? In my world, birth trauma wasn’t reported in the same way as it is today. I remember speaking to one of my consultant obstetrician colleagues about how birth was affecting some women, and how I felt this was just the tip of the iceberg. He told me he hadn’t come across it, and maybe the women I was seeing were ‘unstable’ already. I was horrified, and saddened by his lack of understanding and compassion, but then I was reminded of the frustration I felt listening first hand in my small office, to personal accounts of horror. Supporting the women referred to me to overcome their fear and distress was my main focus, but it was going to be a challenge sharing the underpinning messages behind the stories of traumatised individuals and their families with those who worked in our maternity unit, and beyond.  There were many reasons why women felt damaged, and my findings reflect those of others. Interestingly, labour ‘pain’ didn’t feature heavily in the overall themes that emerged, as most women who I saw had had epidural anesthesia.  Overwhelmingly, women reported feeling powerless, and totally disconnected from the birth of their baby. Some felt violated. 

'Don't feel I gave birth and had a baby on that day, I just felt I went into a room and was just assaulted'.  [Claire] (Thomson & Downe 2008)

Women frequently described feeling that their baby had been ‘extracted’ not born, and that the process belonged to others, not them.  My increasingly apparent dilemma remained, for a time, unanswered - how could we improve the care we gave, to prevent this from recurring over and over again, when there was just me hearing about these experiences?

I worked closely with Professor Soo Downe at the University of Central Lancashire, and she suggested that we asked the women who had accessed my support, how we could improve services to prevent birth trauma. And so that's what we did. We invited those who had given permission for me to contact them, and invited them for coffee…

Seven women attended that first meeting, and after long chats the women present felt the most important thing was to offer authentic feedback to maternity workers, about their experiences.  One woman suggested using theatre to help them to do this, with themselves as the actresses! Some of the group felt worried about this – not being thespians – but after a couple more meetings they became totally engaged with the idea. So we asked a midwife lecturer who was also an actress, the wonderful Kirsten Baker, if she would help. At the time Kirsten was the owner of the Progress Theatre Group – a team of midwives, parents and maternity workers who use forum theatre to influence change.  Kirsten asked a playwright to transform the mothers' stories into a theatre piece, and 'Speech to Rita' was born.

The women who were keen to be involved needed support and reassurance, to be in a safe place to begin to work through the process of telling their stories. It was a long journey, with many tears shed.  Even though most of the group had had a 'redemptive birth' (Thomson & Downe 2008), reliving their personal experiences in front of others was harder than they had expected. We met in my kitchen, so the environment was non-threatening.  We ate cake, drank lots of tea, and laughed and cried together.  Kirsten did relaxation, breathing and vocal training to help with acting, and I tried to be the nurturer. Once the group felt strong enough, we rehearsed in our local village hall, acting out the 'Speech to Rita' script. The theatre session wasn't about criticising or blaming maternity care workers, but about highlighting the things that potentially cause upset or distress. In the busyness of maternity services, where organisational culture and staff shortages impact on time and emotions, midwives and doctors can become conditioned to just 'getting through' each day. And then there's the fear. Often unaware of the consequences of their actions or words, maternity workers do their best. Listening to feedback can help us to see that simple things like changing the language we use, and connecting compassionately, doesn't take more time but makes a difference. 

Early days in my kitchen

Rehearsals in the village hall

pre-performance rehearsal 

during the first performance normal birth conference, 2004

After years of touring, the group became more pressed for time, due to family and work commitments. Sadly, we needed to disband. But we felt proud that we tried to be the change, to make a difference, and according the this article - we had some impact (Byrom et al 2007).

I made a short film all those years ago, to say thank you to each courageous woman who stood tall, and tried to make a difference. We are still on that journey, trying to maximize potential for ALL women to have a positive birth experience, wherever or however she gives birth. It’s this that keeps me going.

I want to honour the women that taught me so much about childbirth, and my work as a midwife. Kirsten Baker, thank you for believing in and helping me. 

For Helen, Sarah, Maria, Debbie, Sue, Jeanette, Sarika, Nicky and Anna, you gave me, and the world of childbirth, more than you’ll ever know. 

Things you taught me…

• More about the importance of birth experience than I ever learnt in a classroom, or during my years as a clinical midwife
• That listening means more to you than me speaking
• It’s the little things that matter, the language I use, and the compassion I show
• Do ‘with you’, not ‘to you’
• Pain isn’t necessarily an issue, it’s the feeling of powerlessness and lack of dignity that impacts on you the most
• That antenatal education and preparation is important, but where you give birth, and who cares for you has the greatest influence on outcomes
• Our continuity of care model made a positive difference to the birth you had
• Developing respectful, authentic relationships with obstetricians, midwives and neonatologists is crucial when facilitating your choices, and maximising yours and your baby’s safety
• Birth trauma is self diagnosed, and not dependant on mode of birth
• That my actions hold the potential to influence your and your baby's future...
• That I am so fortunate to have met you all, my wisest of teachers.

References:

Byrom S, Baker K, Broome C, Hall J (2007) A Speech to Rita: giving birth to a voice. The Practising Midwife (10) 1 Pp 19-21 (Accessed here)

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

Thomson G, 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

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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