Calls for midwife-led birth experience to improve care of expectant mothers

Women who have experienced some form of trauma while giving birth speak out about their experiences with the maternity healthcare system. Report by Áine Kenny
Calls for midwife-led birth experience to improve care of expectant mothers

Maternity services have also been brought to the fore in relation to Covid restrictions, with women speaking out about the trauma caused by their partners not being allowed to attend scans, early labour or visit them post-birth. File Picture: Pexels

Women who have experienced some form of trauma while giving birth speak out about their experiences with the maternity healthcare system. Report by Áine Kenny

You had a baby - so what was the experience like?

For the vast majority of women, it was a joyous time. However, for a small percentage, it wasn’t so positive. 

Now these women who have experienced some form of trauma while giving birth are speaking out about their experiences with the maternity healthcare system.

Some say their birth preferences were not listened to, while others feel like they were "worn down" into consenting to procedures leaving them anxious about any future pregnancies or interactions with maternity services in the future.

A recent Hiqa's National Maternity Experience Survey, found 85% of women were happy with their maternity care.

However, some 30% of women said they had no 'debriefing', meaning they didn’t get to ask questions about the labour and birth after their baby was born.

While improvements are being made, this is mainly through the initiative of individual hospitals, as opposed to a top-down approach.

Last February, HIQA criticised the HSE's implementation of the 2016 National Maternity Strategy and urged it to develop a "comprehensive, time-bound and costed" implementation plan.

Health Minister Stephen Donnelly committed to this last July, however, opposition politicians and groups representing women and healthcare workers say the delays are unacceptable.

Maternity services have also been brought to the fore in relation to Covid restrictions, with women speaking out about the trauma caused by their partners not being allowed to attend scans, early labour or visit them post-birth.

Chair of the Association for Improvements in Irish Maternity Services (AIMS), Krysia Lynch, says birth trauma can be a complicated issue.

"If you go into hospital you might hope the birth goes a certain way, or hope you'll get treated in a certain way.

"If people speak to you in a way that's unkind, or not thought-out, it can seem okay to everyone else in the room, but to you it isn't okay."

She said if there was an issue with the baby or with the pregnancy, this can also be traumatic.

"You can be distressed by what happened, or hurt, but people say 'come along, you've got this newborn baby now and you have to look after it'. And you have to look after that baby, no matter what you're feeling inside."

Some women, she said, feel like they were not treated with dignity, kindness or respect, as opposed to being treated clinically badly.

She points to the recent Hiqa study on maternity services, which she was involved in.

"15% of people said they were unhappy with their care experience, meaning they were not treated with all of those things. That's about 450 mothers walking around now with a nine, ten-month-old baby who had a very difficult start - these are real people."

In terms of clinical diagnosis of post-traumatic stress disorder or postnatal depression or anxiety, Ms Lynch says it's quite low, 17-19%.

"There's an under-diagnosis. 

We also know there's a large disparity in the way people receive post-natal care.

Some post-natal care is actively focused on identifying trauma, while others do not.

"A lot of people say their post-natal care is focused on the baby, not on them."

Ms Lynch said in terms of the Hiqa study, which she was involved in, 85% of women were happy with their care.

"Most women say they have excellent clinical care in Ireland. But they will say the way they received their care can be improved, and speak of a lack of information, the lack of partnership."

Ms Lynch said a lot has been done to improve postnatal care, with the Rotunda being a model example of this. The Coombe in Dublin has a good debriefing service for women to attend post-birth, with a birth reflection midwife.

"I know there are plans to roll this out to other hospitals, but I am not sure what stage those plans are at.

"They are really responding to this... but we need a country-wide service that deals with the issues of post-natal anxiety, or the issue of coming to terms with a birth that didn't go to 'plan'.

"The trauma may be a result of the care, and that's actually quite difficult to get the health service to understand."

But informed consent needs more work.

"People who are going through birth need to have a sense that they are a partner in their own care. They need to be involved and have a rapport with staff."

She said there's a lot of women who won't speak out about their birthing experience if it is different to what they expected, and a lot of antenatal care focuses on getting a specific outcome at birth, rather than coping skills.

There is also an opportunity to have a true shared partnership in maternity services, with detailed informed consent, more birth reflection midwives, better postnatal care, and more community-based services to support new mothers.

Tracy Donegan, former midwife and founder of GentleBirth, a birth positive education programme, has conducted a birth trauma survey with 624 respondents, with some of the responses making for harrowing reading.

Many of the women who had experienced traumatic births said they were not offered any debriefing by their medical team afterwards. Some were so traumatised from their experience they said they were afraid to get pregnant again.

Of the respondents, 74% said they experienced trauma during the birth itself, while 8% said trauma occurred during antenatal care, and 18% experienced trauma in the hospital post-birth.

Some of the women said they felt like they were "bullied" into agreeing to episiotomies, the use of forceps, and having their waters being broken manually. She adds that while consent is supposed to be given before medical procedures, in reality many women feel like they were "badgered into compliance".

Others claimed that their babies were taken away from them after a traumatic birth with no skin-to-skin contact offered, even if the baby was healthy.

According to Ms Donegan, many of these women are now suffering from anxiety, panic attacks and post-traumatic stress disorder, and some say they are either too scared or in too much pain to have sex.

Ms Donegan says, from her work and research, it's clear there is a small minority who have had traumatic experiences, and more needs to be done by the country's maternity services to prevent this.

Tracy believes one way of doing this is making maternity care in Ireland midwife-led, as opposed to the current consultant-led system.

An academic study called 'Midwife-led maternity care in Ireland – a retrospective cohort study' was published in 2017. It looked at Ireland's two midwife-led maternity units compared to consultant-led units. 

The study found that interventions such as amniotomy (the obstetrician breaking the waters) and episiotomy (an incision being made by the obstetrician in the perineum) were more common in consultant-led units.

It concluded that midwife-led care is a safe option that should be offered to a larger proportion of healthy pregnant women.

Model of care to help cope with trauma

Consultant obstetrician and gynaecologist Dr Meena Ramphul, Director of Midwifery and Nursing Fiona Hanrahan, and candidate for Advanced Midwifery Practitioner in perinatal mental health, Ursula Nagle, who all work at the Rotunda Hospital. Picture: Cormac Mc Adam

Consultant obstetrician and gynaecologist Dr Meena Ramphul, Director of Midwifery and Nursing Fiona Hanrahan, and candidate for Advanced Midwifery Practitioner in perinatal mental health, Ursula Nagle, who all work at the Rotunda Hospital. Picture: Cormac Mc Adam

This issue of birth trauma is not being ignored by obstetricians, gynecologists, and midwives.

However, due to the underfunded and long-delayed implementation of the 2016 National Maternity Strategy, the approach to birth trauma has unfolded organically, with differing levels of care available, depending on where the woman gives birth.

A good model of care is now available in Dublin's Rotunda Hospital, which has a three-pronged approach to birth trauma.

There is a birth reflection service, a complex postnatal clinic, and a birth trauma service within the perinatal mental health service.

Fiona Hanrahan, director of midwifery and nursing at the Rotunda, is hoping they can lead by example.

"The National Women and Infants Programme is tasked with bringing the National Maternity Strategy to life," says Ms Hanrahan. 

"The programme had funding for perinatal mental health, and from that funding the hospital has developed a robust perinatal mental health team."

Ms Hanrahan says when she was assistant director of midwifery, they set up a 'next birth after caesarean clinic'. From this clinic, they realised that many women had questions about their birth that weren't addressed before they went home.

"We put a proposal forward to set up a birth reflections service, for women to debrief on their births in a supported way, in a week or so after their birth."

She says some women who attend birth reflections can then be referred to the complex postnatal clinic, headed by consultant obstetrician and gynecologist Dr Meena Ramphul, or the specialist perinatal mental health service, where Ursula Nagle, a candidate for advanced midwifery practitioner in perinatal mental health, works.

Ms Hanrahan worked as a community midwife for a long time, visiting women in their homes after birth, and says she knows trauma can occur in many circumstances, not just ones with adverse clinical outcomes.

"We are going to work with our staff. It's all very well to have these services after the event, but often the start of the trauma can be the language that's used, people not explaining stuff properly.

"We are going to have a trauma-informed approach to all our care, so staff are aware of the language they use, their body language. 

When the woman is in hospital, we are the ones in charge so she might not feel very empowered. It's our job to make her empowered.

Ms Hanrahan says the aim of their services is to examine whether the hospital setting and staff is part of the problem, and to solve this issue.

"The services have grown organically around each other," she says. 

"The idea is to catch women at the earliest opportunity if they run into a problem or are developing birth trauma."

Antenatal education is also key. Ms Hanrahan says there is no regulation around this type of education in Ireland, and oftentimes women will give birth in the Rotunda but won't have attended antenatal classes there.

"We have no control over the information they have been given."

This can lead to women having unrealistic expectations about how the birth is going to go, or not being adequately prepared for different circumstances. "Women should be prepared for every eventuality. We take a 'real birth' approach with our antenatal classes at the Rotunda."

She adds that things can be unexpected, and this is why debriefing is important. 

"Things can change quite rapidly, and people can be called to action quickly. The important thing is to go back to a couple afterwards and take them through the steps of what happened."

Ms Hanrahan says the most common complaint women have is about communication. "Communication is key, what we are trying to do is close a loop. Very often a consultant or a registrar is involved in an emergency birth, then they are called somewhere else."

Ms Hanrahan says if a woman feels like she has not been respected or her dignity has been impacted, that can have a massive effect on her wellbeing. "It's the women who know their trauma better than us. The birth reflection service can pick this up."

She says it is important to listen to these women, as post-traumatic stress disorder can develop, and women may delay getting pregnant because their first birth is traumatic.

The complex postnatal clinic offers women a physical review and a discussion with a consultant, two to three weeks after discharge.

Patient-focused approach

Dr Meena Ramphul, who heads up the clinic, says it's for women who had very complicated births or ended up in a high-dependency unit.

Her service's philosophy is to provide a patient-focused approach. "Where the complex postnatal service fits in is where women have had a complicated course during pregnancy, birth, or postnatally."

She says initially the clinic focused on women who had adverse clinical outcomes, such as a haemorrhage, but it has since expanded to include women identified by staff on the ward who had a difficult time, or women who have self-referred to the service.

Dr Ramphul says it's a team-based approach, and the women can be referred for physiotherapy, perennial, and incontinence services.

"My clinic, in particular, would focus on events of the pregnancy and delivery, having an open and factual discussion about what happened. We go through any issues and concerns, as well as plans for their next pregnancy.

"It's the opportunity to deal with any anxieties about the future, and reassure them there are strategies which can be adopted to prevent postpartum haemorrhage."

Pain management is an area which the clinic is also planning on tackling.

"We are expanding to include an anaesthetist as part of our service. This is going to be formalised so women can discuss the pain they had during labour and birth with an anaesthetist."

Dr Ramphul says there is no one-size-fits-all approach. Some women will need to be seen a few times and they can attend as many times as they need. Partners are also critical to the debrief.

"They may not have gone to any antenatal classes, they may have had very different expectations. Our focus is very often on the mother and baby."

She says a team member will go out to the partner to explain what has happened to the woman and baby if there is an emergency and the partner has been asked to leave the delivery room.

"We do try to debrief on the wards after the birth as well before they go home, especially if we haven't been able to engage with the mother during the delivery or labour because it was a medical emergency, we try to talk to them as soon as possible."

When extra help is needed

A perinatal birth trauma clinic has also been established as part of the hospital's specialist perinatal mental health service. Ursula Nagle, a candidate for advanced midwifery practitioner in perinatal mental health, works there.

"We identified a need over the last number of years to support women who may need extra help after having a particularly traumatic birth. Women need different supports, some may need information about the birth, or details on things they weren't clear about."

She says some women will be given information about the birth but still have some ongoing difficulties.

"We know that up to a third of women will report having a traumatic birth experience. Our purpose is to identify women who may be at higher risk of developing post-traumatic stress symptoms."

However, Ms Nagle says many of the women who attend her service have "subclinical symptoms". She says they may have some difficulties following the birth, such as anxiety or mild depression, and they can be offered low psychological interventions.

A small number of women need more detailed interventions.

"Women who may be displaying symptoms of PTSD, we offer a very detailed one-to-one assessment, and we would bring those women back for one to one interventions," says Ms Nagle.

These can include trauma-focused cognitive behavioural therapy, and from next year the Rotunda will be offering eye movement desensitisation and reprocessing, another psychological intervention.

Ms Nagle says often, the birth is perceived as traumatic and every woman's experience is subjective. "To you and I, it may have looked normal and straightforward, but it's not always perceived that way by the woman for different reasons."

She says interpersonal difficulties with caregivers, and the type of language used, can impact a woman. 

"What we are planning on doing going forward is implement a trauma-informed approach. 

"We are going to roll out large-scale education across all our healthcare professionals and allied staff in the Rotunda, to make everyone aware of what trauma is and how it impacts women, babies and families.

"The language that we use, the way we speak to people, and our body language can be perceived negatively, so we need to be aware of that."

Case study: 'My voice wasn't important. I felt like I had no power'

Linda Kelly says the attitude of her consultant at CUMH made her feel she was 'totally absent from the process'. Picture: Eddie O'Hare

Linda Kelly says the attitude of her consultant at CUMH made her feel she was 'totally absent from the process'. Picture: Eddie O'Hare

Linda Kelly said she wasn’t listened to and felt disrespected during the birth of her first daughter.

"It was 2018, I had a very normal pregnancy, I was with the Domino scheme [a midwife-led unit within Cork University Maternity Hospital], really hoping for a natural birth," she said.

Ms Kelly then went over-term and after 12 days, she went in for a scan and the staff were worried there was too much fluid around the baby.

"But because it was Friday afternoon, they didn't have the staff to do another, more detailed scan, so I was sent home for the weekend with so many questions."

She was told to come back in on Monday and to bring her hospital bag with her, as labour would probably be induced.

"I spent my entire pregnancy with the Domino scheme, and now I was going to get the exact opposite of that for the birth," she said.

"So I went home and had to accept it was going to be different."

Ms Kelly, from Cork, went back on the Monday and had the more detailed scan. She was told there was nothing wrong and to go home again.

I was roaring crying, even though it was good news. I was just distraught I was being sent home."

That Thursday at 4am, Ms Kelly's waters broke. She was admitted to CUMH that night, however, her labour did not progress.

Friday arrived, and she still had no contractions. She went down to the induction room at around 4pm. She was told by a doctor there that her baby was really big, was too high up, and was the wrong way round. Ms Kelly was shocked, as everything had been measuring normally at 36 weeks.

Her waters were broken again, and still nothing happened. A consultant came in, examined her, and started speaking about induction.

"I said, 'but if you know she's a big baby, you know she's the wrong way round [facing to the front] and really high up [at level three, the highest position in the pelvis], why can't I have a C-section?'.

"The consultant said: 'You don't really want a section, and sure we will give the induction a go.' The tone of his voice ... it was like 'don't bother questioning me'.

"I was exhausted at this stage; we had been up 36 hours. His attitude just made me feel like I was totally absent from the process, my voice wasn't important. I felt like I had no power." 

She was then put on oxytocin.

"I had antibiotics pumping through me. I have very little memory of the next 24 hours. At 4am I begged for a section. They wouldn't do it because the labour was progressing and they explained that to me."

Her epidural had to be topped up multiple times.

"At 6am, I was pushing for two hours; normally you're only supposed to push for one. Then they decided that they needed to do a section as I had been pushing too long and the baby was stuck in the birth canal," she said. 

Linda Kelly, Glanmire, and her daughter Amy-Kate. Picture: Denis Minihane.

Linda Kelly, Glanmire, and her daughter Amy-Kate. Picture: Denis Minihane.

"Then I had to wait for the doctor shifts to change over at 8am. Eventually, at 9.15 am on Saturday morning, she was born."

Ms Kelly can't remember the day her daughter was born, and she can't remember her parents coming to visit her.

"When I came to, I felt really angry. I was never offered any counselling or debriefing from the obstetrics department," she said.

Her daughter was 10lb 11oz, the size of an average three-month-old.

"Why did nobody pick this up [before delivery]?" she asked.

Later, she was told the decision to attempt a natural birth was made because she had reached 10cm dilated and therefore she could try for a vaginal delivery should she have a second child, but this was not explained to her at the time.

Ms Kelly found out at week 20 of her second pregnancy, through another consultant, that there was in fact counselling available through the CUMH social work department.

She said she feels as if she will never have a "normal birth" because her second child was born during Covid-19, with visitor restrictions in place.

In response, CUMH said: "Cork University Maternity Hospital takes all patient complaints and concerns seriously and all formal complaints are fully investigated to establish how they occurred.

"Preventative measures are put in place to try to reduce the risk of such incidents happening again.

"The hospital cannot provide public comment on an individual patient’s care and case history."

Case Study: 'I shouldn't be having to fight that battle while giving birth'

For Diane Forsyth, the consultants just didn’t listen to her birth wishes.

She now wants to speak out, for herself and other women.

For her first baby, Diane was nine days overdue. 

"I came in for a routine appointment in the Rotunda and my consultant told me that because it was coming up to Christmas, she was worried that I wouldn't get a bed, so she was going to induce me now and that my husband could go home and get my bags."

Diane, from Dublin, was very surprised, as she was not expecting to be induced and had just come from Christmas shopping.

"Because it was my first baby I went along with it. She went up to a ward on her own, was induced, and left alone overnight with contractions, without her partner.

She ended up getting an epidural and a ventuouse [vaccum] delivery, which she was hoping not to have as it was "quite frightening".

"The consultant said during the delivery that she was going to give me an episiotomy in order to get the ventouse in," explains Diane.

"I said I definitely did not want that. She sighed and said 'OK, we can try without'. It worked, I didn't need an episiotomy. I feel like it was all about speeding up the delivery."

Her second child's birth came at a very difficult time for Diane. Her father became very unwell and she was overdue.

"It became clear that I am just someone who takes longer than average. I was over 42 weeks with my last three children. I knew it wasn't going to be early."

Diane had the same consultant as her first birth, and they agreed they would wait until 42 weeks and review the situation.

The Rotunda's policy then was 40 weeks plus 10 [days]. It was only because I really advocated for myself that this was allowed.

However, Diane's consultant was on leave around the time of her due date, so she would be in the care of another consultant. The first time Diane and this consultant met was at the 42-week review appointment.

"At this time my dad was extremely ill. There was a lot of pressure on me to be induced, but I wanted to go into labour naturally."

Sadly, Diane's father passed away the night before the review appointment.

However, at the appointment, the new consultant claimed Diane was "putting her baby's life in huge danger".

"I didn't know how to respond to it. My husband said to her, 'just to let you know, Diane's dad died last night'.

"She refused to acknowledge it. She just said, 'I need you to have this baby now. I am going to book you in for an induction this afternoon'."

Diane's father's funeral was the following day, and Diane really wanted to attend. She told the consultant that this appointment was only supposed to be a review, and asked for a few more days with continued monitoring of the baby.

"Up to that point, everything had been fine with the pregnancy. She even said to me I just had a 'lazy baby'."

Diane eventually got the consultant to agree to her coming in straight after the funeral.

"She then gave me a sweep (a procedure to bring on labour). I felt like I was being treated like I was in a factory, it was all about controlling the process."

However, Diane was never induced because she went into labour naturally that night and missed the funeral. 

She requested that the new consultant not be present at the birth and the hospital facilitated this. 

I had a midwife-led birth, only because I raised the roof on it. I shouldn't be having to fight that battle while giving birth."

For her last two children, she had a midwife-led home birth, which she says was a completely different experience.

In response, the Rotunda said: "In the interest of respecting patients’ privacy, it is the policy of the Rotunda to not comment on the specifics of any particular patient’s care."

However, the hospital said that they are of the opinion that the descriptions of care that occurred eight years ago "do not reflect care practices and management at the hospital in 2020".

"The Rotunda has a very clear recommendation that induction of labour in otherwise uncomplicated, normal-risk patients, should occur at 41 0/7 to 41 3/7 weeks' gestation (also referred to as term plus 7 to term plus 10).

"This professional advice to our patients is based on the optimal interpretation of the latest research on patient safety and is made in the best interests of patients, and has recently been changed from a prior cut-off of term plus 12 because of important new research.

"The Rotunda supports patients in their individual choices around their healthcare. Therefore, if a patient chooses not to follow the very clear advice of the hospital in terms of timing of postdates induction, the hospital will, of course, continue to support and care for all such patients."

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