Parliamentary Inquiry into Birth Trauma: Call for Evidence - AIMS Submission

Introduction to AIMS and why AIMS is making a submission

Since 1960, AIMS has been the leading advocate for improvements in UK maternity care. We have national and international links and a membership that includes midwives, health visitors, obstetricians and lay people. Collectively, our volunteers have decades of experience researching, advocating on and campaigning for improvements in UK maternity care. Importantly, we also support women directly to navigate the maternity system. We use our knowledge, influence and experience to instigate policy change at local and national level. We run an email and telephone helpline which provided support to more than 650 women over the last two years. We also have a large network via our volunteers and members, who engage with mothers, health care providers and others on social media and at meetings.

Our Journal frequently features articles describing experiences or exploring the causes of birth trauma such as:

Traumatised-midwives,traumatised-women by Jenny Patterson

The Night that was neither Silent nor Holy by Beth Whitehead

An open letter to my midwives by Heather Spain

Common themes leading to birth trauma

The Europe-wide Research Network DEVOTION CA118211 comments in their parents’ leaflet on birth trauma (available here Birth trauma resources | AIMS) “During labour and birth, traumatic events may relate to obstetric complications and/or interventions. However, interpersonal trauma… has been found to be twice as likely to cause long-term PTSD symptoms.”

In AIMS experience, a major cause of birth trauma is obstetric violence, which is any form of disrespectful or abusive treatment carried out by maternity services staff during pregnancy, childbirth or shortly after birth. (see WHO statement - The prevention and elimination of disrespect and abuse during facility-based childbirth WHO_RHR_14.23_eng.pdf)

Many women, who contact AIMS for support or to share their maternity experience for our Journal, report suffering obstetric violence carried out by doctors and midwives resulting in birth trauma. Obstetric violence and medical intervention without informed consent are long-standing issues which continue to occur in the UK despite the existence of laws which guarantee the right to bodily integrity and autonomy, including the right to decline any medical treatment. There appears to be widespread ignorance of maternity service users’ rights to make their own decisions and to have these supported even if their doctor or midwife disagrees with them. This frequently leads to women being harassed, coerced, manipulated and threatened into accepting interventions that they do not want or consent to. Sometimes interventions are scheduled without the woman’s agreement or informed consent and in this situation it can be hard to assert the right to decline.

Obstetric violence can be both direct and structural. We have supported women who have been subjected to direct forms of this violence including being denied pain relief during labour or after giving birth, including after caesarean surgery; sutured without anaesthesia; physically restrained during birth; subjected to interventions without consent including vaginal examinations, membrane sweeping, rupturing the membranes, episiotomy, forceps/ventouse; administered drugs without consent; ignored when they withdraw consent i.e. unable to stop staff from continuing an intervention; verbally humiliated and abused. Women have described to us the violence suffered during their births using terms such as ‘brutal’, ‘barbaric’, ‘torture’, 'like rape’ and ‘dehumanised’. They described feeling threatened, bullied, helpless, ignored, invisible, trapped, being held hostage and not listened to. Mothers tell us about how shocked and degraded they felt about the way the staff treated them, overruling their autonomy. Mothers approaching subsequent births come to us seeking ways to avoid being assaulted again.

We also hear many experiences of structural violence. These are exacerbated by the increase in medicalisation of childbirth with interventions such as caesarean birth and induction of labour being seen as routine. Women are increasingly being forced or coerced into interventions on the grounds that these are in line with hospital and/or national guidelines without consideration of their legal and human rights, decisions, wishes or individual circumstances. These often lead to women suffering invasive, intrusive and painful procedures. One increasing trend we have observed is for women to be threatened with referral to Children’s Services if they express their intention to decline certain medical tests or procedures, when there are no other grounds for a referral.

Other common forms of structural violence include forcing women to birth on their backs, often with their legs in stirrups for no clinical reason, and the overuse of continuous fetal monitoring, both of which are forms of indirect restraint and can cause labour to be longer and more painful, and birthing to be more difficult; use of coercive control to enforce compliance with interventions which the woman has declined; understaffing and lack of continuity of care leading to neglect by staff, for example being left alone during labour, an induction or after giving birth; policies which restrict food or drink intake without clinical justification. All these forms of obstetric violence can lead to both physical and psychological injuries that can last a lifetime, as well as having serious consequences for the whole family.

Identify areas where maternity care could be improved

AIMS believes strongly that full implementation of all the recommendations of the Better Births review NHS England » Better Births: Improving outcomes of maternity services in England – A Five Year Forward View for maternity care would go far towards addressing the causes of birth trauma. In particular, to ensure maternity service provision that is personalised and safe, AIMS believes that a robust and sustainable model of relational care (or Continuity of Carer) should underpin all maternity service provision, for all service users, across the UK. Such a model enables the development of a relationship based on mutual trust and respect between midwife and service user, with highly focused attention on individual needs and autonomy. (See our position paper aims-position-paper-continuity-of-carer.pdf) AIMS is frequently told by service users that a Continuity of Carer model has, or would have, made a substantial positive difference to their care in terms of physical and psychological outcomes. These benefits for both women and care-providers have been fully documented in national maternity improvement plans for the four nations of the UK.

Many callers to the AIMS Helpline report that hospital-based ‘Birth Afterthoughts’ debriefing services actually reinforced their trauma. We believe that what is needed is an independent complaints and resolution service accessible through self-referral to all who need it. Ideally, it would be possible for maternity service users to contact this at any stage of their maternity journey, including during pregnancy and in labour as well as postnatally.

Our position paper aims-position-paper-obstetric-violence.pdf identifies the following factors that are needed to tackle obstetric violence:

• A recognition throughout society that obstetric violence exists and is unacceptable.

• Initial and ongoing education and training for all relevant staff (including frontline maternity staff, management at the provider level, social services staff and the police) to understand and respect the autonomy of maternity service users in making decisions about their maternity care, both to prevent cases of obstetric violence and to ensure good support for victims

• Independent information to be provided to all maternity service users explaining the concept of obstetric violence, their rights and the complaints pathways available. Such information should also be made available to partners/supporters and other family members.

• A new mechanism offering an independent pathway for all maternity complaints, staffed by those with the specialist training to understand the issue of obstetric violence, ensuring that lessons learnt are shared nationally.

• A new national framework for monitoring and dealing with incidents of obstetric violence, with transparency for the public, including an annual review and the timely publication of data around complaints of obstetric violence, by maternity service provider.