This post is by a Developing Doulas graduate who volunteers for the March With Midwives campaign – a UK wide campaign, started by doulas in our community to protest against the poor working conditions that midwives are enduring and how these conditions impact on the women and people they serve. Elle’s essay beautifully explains what effect birth trauma has and how it can so often be caused by something as simple as staff just not having the time. This is a story of pain, but also one of strength through adversity – and ultimately, a celebration of how we can use our own suffering as fuel in our journey to becoming doulas.
I’ve been admitted into my local maternity hospital, onto the antenatal ward, for an induction. I’ve been having contractions for a week now; I’m exhausted, I can’t keep my blood sugar up. I’m quickly checked, a pessary inserted. I say a teary goodbye to my husband, who isn’t allowed to stay with me. I’m scared and overwhelmed and sad. This wasn’t the labour I wanted. Contractions ramp up almost immediately, like someone has hit a gas pedal, so close and strong I can’t catch my breath. My pelvis feeling like it’s going to shatter. I sway, I walk, I bounce on my ball. I lean forward on the bed to lift the pressure. I find my rhythm, I’m doing this. I’m amazing. But now it is monitoring time. They wrap me in bands and make me lie still in a bed. “It will be about 20 more minutes”, they say over and over for hours, as the monitor shows my uterus contracting too much, too hard. Their computer won’t sign me off and no one has time to chase it down between the emergencies that send them scurrying back and forth across the ward in a frenzied buzz. I am in tears, pressing the button again and again for help. Staying still is agony, I have to get up, I need them to help me. A face in the door; “I’ll go check, it should be about 20 more minutes”. Again and again. By the time I’m set free I’m a shaking mess. I can’t make myself stop crying. I beg one midwife to let my husband back in to give me a hug. “Everyone here is in the same situation,” she says. She doesn’t mean to be cruel. She’s just stating a fact. But it’s these words that break me. Her student comes in a few minutes later to check on me. I try to tell her how I feel and I can see the tears welling up in her eyes too. “This is inhumane,” I manage through sobs. “I know, I’m so sorry, I know,” she says. She’s called out of the room – there’s some kind of code down the hall. She has to go. They have to triage every moment; I’m not dying. Just falling apart.
Midwives are stretched so thin across the NHS. The Royal College of Midwives (RCM) estimated in 2018 that the UK was short about 3,500 midwives (2,3). They warned us that the NHS gains just 1 midwife for every 30 trained by universities. For context, that means that in 2018 the number of NHS midwives rose by only 67, despite our universities churning out 2,132 qualified graduates in 2017 (2,3). At that rate, to make up the numbers our services need, we’d have to train over 100,000 new midwives. Sadly, we haven’t heeded this warning; the problem is only getting worse. NHS staffing reports from April this year showed that the number of NHS midwives had fallen by nearly 300 in just two months – the fastest fall on record (1,4). 60% of UK Midwives surveyed are considering leaving the profession; 57% said they planned to leave in the next year (1). The effect such a drop would have on maternity services is almost unthinkable.
After five days of struggle, my baby has been cut from my stomach. She’s perfect, so perfect. Her skin so soft. She has a thin fuzz of white fur, like a little monkey, all across her shoulders. I thought I would find that off-putting, but it’s the most beautiful thing I’ve ever seen. She’s so small, but the whole gravity of my world has shifted around her. But something’s wrong, very wrong. Her dad has been sent home again and she’s been wrapped up like a little burrito across the room from me. I’ve been trying to feed her every couple of hours but she’s so sleepy. She sucks for a few minutes and falls off. She’s sleeping more and more. My breasts, dripping thick yellow colostrum before she came, feel empty now. I can’t express a drop. Sometimes someone pops in to take my blood pressure or do a heel prick and I feel like I’m grasping at their shirt-tails saying “please, please help us”. But there is no time, someone down the hall is bleeding out; a woman’s blood pressure is shredding her liver; the delivery unit needs another midwife; a baby is coming now. “You’ll get the hang of it, it takes time”… “The latch looks fine to me,”… “Milk takes a while to come in” … all said by the corner of the mouth of a face already turning away to the next emergency. We are sent home after only a day because they need the bed back. Bags packed, car seat installed, a tiny infant welcomed home. Two days later we’re doing the process in reverse to take her back in. She’s lost too much weight. Her sodium is up. Her blood glucose is down. I have an infection, and legs that won’t quiet because my iron is too low. I feel jittery and exhausted all at the same time. A doctor stands above me saying words like “hypoglycaemia” and “threatened seizure”. My tears falling onto the fuzz of her arms while I whisper “I’m sorry, I’m so sorry my love, I’m sorry I’ve already failed, I’m sorry I didn’t keep you safe” into her sweet neck. Vomiting with panic over and over in the parents restroom of the infant ward while a nurse rubs my back, bile rising every time I think of her cracked, dry lips.
The knock-on effect of this understaffing is that individual midwives are having to work harder to try and meet the needs of the service. A midwife is supposed to work an average of 37.5 hours a week (6), already often at unsociable hours or on irregular shift patterns, but more than 60% of midwives report doing at least 3-5 extra hours a week of unpaid overtime (8).
The demands on shift are often overwhelming – from the moment a midwife steps through the doors to work they will be caught up in a whirlwind, a tornado, a ward of a thousand little fires needing to be put out immediately. How can they stop to catch their breath, when so many people need them and there’s so little help? In a damning RCM report, 87% of midwives revealed they regularly have to delay or skip bathroom breaks at work due to lack of time (8). 75% are skipping meals, including more than 25% who say they have to do this almost or every day (8). Over 50% of midwives report feeling dehydrated most
or all of the time at work (8). So the workers doing the precious, irreplaceable work of looking after our women, our families, our babies, are doing this while battling through huge discomfort, often dizzy with hunger or lightheaded with exhaustion, lips cracking for want of a few quiet seconds to drink some water.
As if to add one last, insulting cherry on top, many midwives are also under huge financial stress. This begins for most during their years as a student. A full time midwifery course is 3 years. In England students have to self-fund or take out loans to cover living costs, but even for those who get bursaries the prospect is bleak – 91% of students in Scotland, Wales, and Northern Ireland report that their training bursary is not enough to live on (7). A newly qualified midwife in England earns just £24,907 a year (6), but graduates with an average of £41,000 in debt (7). And while the average salary of a midwife appears to have risen in the last decade, once you adjust for inflation the picture looks very different; in real world terms midwives have taken an average pay cut of £1,813 in the last 10 years (30). For midwives who are also mothers, the costs of childcare, often around unpredictable hours, can be astronomical (1).
All of this sets off a vicious, terrible cycle. Exhausted, anxious, shattered… pushed beyond their limits, increasing numbers of midwives are being forced to walk away. And with training and recruitment falling woefully short of needed levels, what’s the result? Even more work piled onto the aching shoulders of the staff that remain. More than 80% of midwives planning to leave cite inadequate staffing levels as a main motivation to do so (1). Midwives often do a superhuman job, but they are not in fact super human. They cannot go on like this much longer, they really can’t.
Balls are dropping and plates are smashing left, right, and centre. As of July 2021, 41% of all maternity services in the UK were rated “inadequate” or “requires improvement” for safety (5). Infant mortality in the first week of life has been rising in England since 2014 – potentially due to increase in preterm birth resulting from inadequate maternal healthcare provision (12). This haunts midwives, and is a major contributor to burn out – 67% of midwives planning to leave say that a huge reason is they are unhappy with the quality and safety of care they can currently deliver (1).
This safety gap is not a burden shared out equally among all those who birth in the UK. Maternal mortality is twice as high for Asian mothers and a full four times higher for black mothers than for white mothers in this country; statistics that haven’t improved in the last decade at all, despite increased attention (11,31).
How must the image of my face, twisted in pain and worry, play in the haunted minds of the midwives who cared for me? I know it must; I’ve heard as much from my friends and family who’ve been on the other side. How they lie awake thinking of the women they couldn’t help, the trauma they couldn’t stop, the choices they were forced to make. The desperate survival mode. Fight or flight or freeze or fawn. Making it by another day when you’ve been given a pittance and asked to turn it into a fortune. The self blame when you can’t, when the impossible really isn’t possible. How many times has the student who cried with me thought of the moment when she had to turn her back on my tears? I wish I could tell her it’s okay. That I understand. That I know she did the best she could for me. It wasn’t enough, of course it wasn’t. But it’s also not her fault. Does she know it’s not her fault?
The toll on midwives isn’t just physical; there is a huge emotional and mental burden associated with the job right now. Almost all – 92% to be exact – of midwives and maternity support workers (MSW) said that they did not feel their work was valued by the current government (1). And who can blame them? This is a government that has allowed their pay to drop while their hours got longer, that has failed to ensure safe and humane working conditions, that responds to complaints and cries for help with stock letters trumpeting the virtues of Better Births. Continuity of care is an amazing model for birthing people, but it simply cannot be delivered with staffing levels where they are now – midwives working in early adopter sites of continuity of care in England report that their working conditions have worsened and the shift pattern is untenable, especially for those with caring responsibilities for children. They say without significant concessions, such as greater autonomy and increased pay, they simply cannot continue on under this continuity model (32).
Midwives not only work under huge strain, they all too often shoulder the pain of those under their care. By and large people enter this profession because they care – deeply. Imagine then the emotional impact of being unable to deliver the care they want, of repeatedly having to witness mothers in tears, in pain, unsafe, shell shocked… because they don’t have time to provide the care these women need. The effects are literally traumatising. In one study done in 2014, 33% of midwives in the sample displayed symptoms of clinical PTSD (9). The 2018 UK WHELM study showed similarly stark statistics: over a third of participants were found to be suffering from moderate, severe, or extreme levels of stress (36.7%), anxiety (38%), and depression (33%) – well above both population norms and midwives from other countries in the WHELM study. 83% of participants were suffering from personal burnout and 67% were suffering from work-related burnout (10). A staggering 96% of student midwives reported mental health problems since the beginning of the COVID-19 pandemic (7).
I am writing this with hands that won’t stop shaking. Crying at my desk on a Monday morning. I need you to know that, if you know nothing else. How I feel my throat try to close when people ask me about my baby’s birth, trying desperately to keep the words in so I won’t have to relive what happened. How I go to a work event about consent and end up sobbing, image and sound turned off on my browser, when I think of what was done to my body and how I couldn’t make it stop. Because they needed the bed back and the staff free. How I played the tape of those days over and over, trying to write over it, trying to change what happened more than a year ago. How I obsessed for months tracking my daughter’s milk intake, every minute of breastfeeding, every ounce of bottle. How I completely crumbled in a coffee shop when she had her first cold and didn’t want to nurse, the threat of a hospital readmission flashing in my mind like the echo of an ambulance siren. How many hours of talking it out it took before I could feel the grasping hand of panic loosen on my heart. I don’t want to tell you, because it feels like re-living some secret mothering shame. Like I should have been strong enough to not have broken this way. But I need you to know. How it doesn’t stay in the past.
Giving birth, meeting your new darling little person, should be a dream. Hard, absolutely, so hard, but also so joyous, so empowering, so full of love and the pure knowledge of your own strength. This is unfortunately far from the reality for many of us. An estimated 30,000 birthing people a year experience birth trauma in the UK (13). Up to 30% of women surveyed describe their birth as traumatic, and similar percentages show clinical symptoms of PTSD after giving birth in consistent, repeated studies (14,15,16,17,18). Up to 5.6% of birthing people will be formally diagnosed with PTSD (14,15).
Of women with a PTSD diagnosis, about 75% will also be diagnosed with maternal postpartum depression (PPD) (19,20). But PPD is even more terrifyingly prevalent – affecting more than 10% of mothers within their babies first year of life (21). Maternal suicide is still the leading cause of death within a year of giving birth, and the second largest cause within the first 6 weeks (11,22).
Many factors contribute to a birthing experience being traumatic, but a few consistent themes do emerge. Crucially when looking at the staffing crisis, a perception of inadequate care during labour and negative interactions with medial personnel are both consistently associated with the development of acute trauma responses following childbirth (15,16)
I am walking with a friend who has just had her baby a couple of months ago. My daughter is older; sitting and gurgling, smiling and giggling, beautiful and thriving. We never really managed to get breastfeeding back on track, and that grief is a little knife in my chest. There are so many little knives. But I can also
see how she’s blossoming, and as that joy expands I find I have less and less room for regret. I’ve reached a little peace. My mind is beginning to understand one core, true, bright thing: it wasn’t my fault. And from this realisation, a trickle of forgiveness is beginning to flow. I am finding a place in my heart for grace. My friend’s wounds, on the other hand, are much fresher. Her baby came into the world through surgery, like mine. But unlike me she is alone in this city. Her family across oceans and continents, her friends separated through lockdowns and distancing and the weird impossibility of trying to explain motherhood to someone who isn’t living it. She spends her days crying, mostly. Her partner is working again, so when their daughter screams she puts in her headphones and sobs with her for hours. Her GP has prescribed antidepressants, but she doesn’t want to take them; she’s been down that road before. She needs help, clearly, but I can only see that prescription note as a bandaid clinging to a gaping wound. After that I try and bring her dinner once a week. A cake, a listening ear. It’s woefully inadequate, but it’s all I can do.
The effects of this crisis don’t remain in the birth room. Trauma can follow families, like a choking, grasping ghost, for months or years. A lack of support in the early weeks ripples out across a whole childhood.
Breastfeeding is hugely affected by understaffing. At the last UK-wide Infant Feeding Survey in 2010, 81% of mothers reported initiating breastfeeding (23,24), but by 6 months the rate of exclusive breastfeeding (as recommended by the WHO)(25) falls to just 1% (23,24). 80% of women stop breastfeeding sooner than they intended, with the leading cited causes including pain, perceived low milk supply, and lack of support. Arguably it’s all lack of support; both pain and supply problems can usually be addressed with the help of a trained professional such as a lactation consultant (26). The RCM has expressed concern that the staffing shortfall in the UK means that the majority of maternity units in the country don’t have enough appropriately trained midwives and maternity service workers to support breastfeeding (27). The long term health impacts, for both mothers and babies, of stopping breastfeeding early are significant, and widely documented. It’s rarely mentioned though that these levels have economic implications for the NHS too; one economic analysis showed that doubling the breastfeeding rates in the U.K. would save the NHS over £40 million a year in treatment costs for childhood illness, asthma, allergies, diabetes, and cancer (33). Not investing in maternity support isn’t just unethical, it doesn’t make economical sense.
Postpartum depression also has huge long term consequences, for both parents and infants. Unsurprisingly, traumatised and depressed parents have a significantly harder time attuning to and bonding with their baby (20,28). There is a strong association between maternal PPD and physical health concerns in infants. This can be literally killer; some studies have found up to a three-fold increase in risk of infant mortality up to 6 months of age and a two-fold increase in mortality up to 12 months of age to infants of mothers with PPD (28,29). There have been numerous studies showing maternal PPD is a significant predictor of infant motor, language, emotional, social, and behavioural development (28). PPD also strongly contributes to relationship breakdown – depressed parents have higher rates of sexual dysfunction and pain, lower romantic relationship satisfaction, and higher rates rates of difficulties such as relationship breakdown and divorce (28).
Think about it; we’re sending parents home exhausted and traumatised to do the job of keeping a little person alive and guiding them through the world, essentially unsupported. And too often our tendency is to blame those who can’t manage this rather than address the underlying structures that make it so impossible. Our children are literally our future; they are the citizens who will work and vote, guide and shape society for decades to come. It genuinely isn’t an exaggeration to say that a better Earth begins with birth. Imagine it. Go on, try. Imagine a world where every parent gets the support they need. Where every birth is empowering, even when it doesn’t go to plan. Where mums and dads begin their journey knowing how strong and wonderful and ready they are. Truly ready, because they have been and will be supported at every stage. Where midwives can care for their patients the way they want to. Where they’re properly thanked and paid and treasured for their contribution. Where every baby comes into the world gently and joyfully, told from their very first breath and cry and wriggle that we value them. I do, almost every day. Whispered to myself, over and over, like a prayer. And in the end, it’s been that imagining that’s healed me.
References:
(1) RCM Media Release: RCM warns of midwife exodus as maternity staffing crisis grows
(2) RCM Media Release: NHS gains just one extra midwife for every 30 trained – new RCM report
(3) RCM State of Maternity Services Report 2018
(4) NHS Workforce Statistics – April 2021
(5) Quality Care Commission: Safety, equity and engagement in maternity services
(6) Prospects UK Midwife Job Profile
(7) RCM Media Release: Debt, dole, worry: Student midwives facing triple whammy threat
(8) RCM News and Views: Midwives skipping breaks and working overtime (9) Sheen, Slade and Spiby 2014. An integrative review of the impact of indirect trauma exposure in health professionals and potential issues of salience for midwives.
(10)Hunter et al 2018. Work, Health and Emotional Lives of Midwives in the United Kingdom: The UK WHELM study
(11)MBRRACE-UK 2015-2017 Maternal, Newborn and Infant Clinical Outcome Review Programme
(12)Nath, Hardelid, and Zylbersztejn 2021. Are infant mortality rates increasing in England? The effect of extreme prematurity and early neonatal deaths (13)The Birth Trauma Association
(14)Ayers and Ford 2012: PTSD following childbirth
(15)Creedy, Shocket, and Horsfall 2000. Childbirth and the development of acute trauma symptoms: incidence and contributing factors
(16)Soet, Brack, and Dilorio 2003. Prevalence and predictors of women’s experience of psychological trauma during childbirth
(17)Maggioni, Margola, and Filippi 2006. PTSD, risk factors, and expectations among women having a baby: A two-wave longitudinal study (18)Ayers et al 2009. Posttraumatic stress disorder after childbirth: Analysis of symptom presentation and sampling
(19)White et al 2006. Postnatal depression and post-traumatic stress after childbirth: Prevalence, course and co-occurence
(20)Parfitt and Ayers 2009. The effect of postnatal symptoms of post-traumatic stress and depression on the couple’s relationship and parent-baby bond. (21)NHS Overview – Postnatal depression
(22)Maternal Mental Health Alliance: Maternal suicide still a leading cause of death in first postnatal year
(23)UNICEF Baby Friendly Initiative Report on Breastfeeding in the UK (24)NHS 2010 Infant Feeding Survey
(25)WHO Breastfeeding Guidelines
(26)Fox, McMullen, and Newburn 2015. UK Women’s experiences of breastfeeding and additional breastfeeding support: a qualitative study of Baby Cafe services
(27)RCM Position Statement on Infant Feeding
(28)Slomian et al 2019. Consequences of maternal postpartum depression: A systematic review of maternal and infant outcomes
(29)Weobong et al 2015. Association between probably postnatal depression and increased infant mortality and morbidity: findings fro the DON population-based cohort study in rural Ghana
(30)The Health Foundation Report: How has NHS staff pay changed over the past decade?
(31)MBRRACE-UK 2021 Saving Lives, Improving Mothers Care report (32)Taylor et al. 2019. Midwives’ perspectives of continuity based working in the UK: a cross-sectional survey
(33)Pokhrel et al 2014. Potential economic impacts from improving breastfeeding rates in the UK
