Talking about birth trauma with Dr Rebecca Moore of Make Birth Better | Legal Thinking Podcast

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So I'd like to welcome to the podcast the wonderful Dr Rebecca Moore, a perinatal psychiatrist and the founder of Make Birth Better. Welcome, Rebecca. We're here today  

to talk about birth trauma, how to recognise you might be suffering from the effects of a traumatic birth and the practical support that's available to mothers.  

We're going to do a little whistlestop tour today of birth trauma, and we're going to leave links to all the resources mentioned in the podcast.  

First of all, if I can ask you Rebecca, to kindly introduce yourself and explain a little about the work of Make Birth Better.   

Yes. Thank you. So, as you said, I'm a consultant perinatal psychiatrist and have been working in perinatal psychiatry since 1999, a long time ago, and I set up Make Birth Better with my co-founder Emma Svanberg in around 2017 and really we are a collective of parents and professionals.  

We're aiming to reduce trauma for people who are passing through the maternity system but also for those that work within the maternity system as well and we do that by campaigning, training, and we're involved in research as well. 

Thank you. That's great. What I wanted to dive into is that in the postpartum chaos of looking after a newborn it's so often difficult to recognise that you might have suffered a traumatic birth.  

As mothers we often are focused on the new baby and our own mental and physical recovery falls down the list of priorities.

So it'd be useful if you could explain what it might look like if you're suffering from the effects of a difficult or traumatic birth? 

Yeah. Of course. So I think we increasingly think about perinatal trauma. So sometimes people are traumatised by birth itself but sometimes it might be something that's happened in their pregnancy or even postnatally as well, and what it really means is that you come away from that experience feeling that there was something about it that felt incredibly difficult, frightening, out of control, and that you perhaps felt very dismissed or silenced or powerless.  

And it can be, as I've said, one thing or perhaps multiple things that you experienced and, like you said, it's sometimes difficult amongst the kind of fog of new motherhood when you feel very tired and there's so much change, to really begin to put together how you're feeling. But after a traumatic birth you might feel a host of different symptoms, feelings, experiences and so it's really about us trying to raise awareness of what they might be.  

We know that a huge amount of women and birthing people sadly are traumatised by some part of their perinatal experience. So this is happening to lots of people each year, and partners as well.  

So typically we would look for, kind of, four different types of groups of symptoms.  

So that is either:  

• thinking about your birth continually and that might be in the day, you might replay it in your dreams, it might be nightmares, or it might be that you just don't want to talk about it, can't think about it at all.  
• Along with that you might avoid anything that reminds you of your birth. So you don't want to have sex, you don't want to have another pregnancy, you don't want to hear anybody's pregnancy announcements, you don't want to talk about your birth, you don't want to go near the hospital, you drive a different route and then along with that, you have this kind of sense of threat.  
• Because something bad happened, often then after trauma people will be left feeling they're on high alert because something else might happen. So you might be angry, jumpy, you might be checking on the baby a lot because you're worried that something might happen to the baby as well and alongside that, you can get changes in your mood.  
• Sometimes people feel very guilty, particularly with birth trauma, you know, I often hear women say they feel they've failed or their body didn't birth well enough or they couldn't breastfeed well enough. So lots of guilt and shame.  

And what you're looking for is each person will have a mix of any of all of those symptoms going on. So you can see that that's, you know, really tough when you're also trying to be a new parent as well. 

Do people find it hard to recognise that in themselves because they're going through the chaos of it all? And do you find that it takes a while for someone to go, “This might not be okay”? Or does it take a loved one to maybe point something out to them?

I think it can be both. I think, you know, sometimes it takes us a while after giving birth to really tap into how we're feeling because, like you said, we're not sleeping, we're tired, there's lots of physical things going on and, you know, we are caring for the baby. So it can take a while to think, “You know what, actually, I don't feel quite right and this is not how I would normally be feeling”.  

Sometimes, absolutely, it might be a loved one who knows you best to say, “I've noticed that, you know, you seem really distressed about this”. But I think also sometimes we don't do very well as a society because we minimise what people have experienced. We say, “Well at least the baby's healthy”, and really what that does is silence people.  

And I think also sometimes women feel because perhaps, you know, there is a lack of understanding for all about birth trauma, they think, well, that trauma just happens to soldiers or after war and so I can't be experiencing the same thing.  

So there's all these different things kind of going on at once that can mean it takes a while for people to kind of really begin to think about how they are. 

Yeah and I think it's quite often that two people could possibly have the same birthing experience but have completely different reactions to it. So I think it's quite easy to externally look at it and think, well they're fine, I should be fine. Or perhaps look at someone else's birth that could be more medically complex and think, well then perhaps why am I struggling but that's not what it's about. It's about your own experience of feeling out of control. 

Yeah, that's such a good point.  

So birth trauma or perinatal trauma is your felt, subjective sense. It's not what happened medically. It's not what's on paper.  

So if you put ten women in a room after birth trauma, one might have had a very quick unmedicated vaginal birth. One might have needed an emergency caesarean. One might have had a straightforward experience of birthing. But it was about the fact that the person looking after her made her feel dismissed or afraid or frightened.  

So all trauma in general, and birth trauma, is about each person's experience of it. It's what they find traumatic. It's not about what I, as a doctor or anybody else on paper, might say, “But you had a vaginal birth”. Doesn't matter; it's that person's sense of it. 

Yeah and like you said about the societal pressures, I think we perhaps all need to get better at not wearing these things as badges of honour and I think there's often a comparison, “Oh, well, you know, didn't that go well for you or…”, you know, we all need to just have our own experience and not perhaps comment too much on other people's. I think there is that tendency to say, “Well, it went okay”, or… 

Yeah, I think we all probably need to learn to listen more and offer our judgment less, you know.  

I think it's really hard for women because they might be part of an NCT group and, you know, five people have had what they consider to be a really good birth experience and then it's very difficult then to say, “Well, you know what, actually, I don't really understand what happened and I'm feeling really conflicted about it and it's really troubling me”. 

So we definitely need to give space to hear all the stories of birth really, because for most people, you know, they're not all good or all bad. They're messy and in the middle and we need to kind of listen to people when they're wanting to try to talk about their birth experience. We don't often allow people time to talk about that, really. 

That's great. So yeah, listen more, judge less. I definitely think that's a huge thing we can all do.

We've touched on this briefly but we've talked about sort of birth trauma but I wanted just to get your input on the features of post-traumatic stress disorder because you can have a traumatic birth and be suffering from birth trauma but might not necessarily have PTSD. It doesn't mean if you don't have PTSD that you shouldn't perhaps get help or seek support for your traumatic birth. So, can you just explain a little bit more about that distinction?

Yeah. Of course. So that’s really important because often I see birth trauma sort of somehow being used as a term that means it equals PTSD and it doesn't.  

So if you think about the population at large, 30 to 40% of all women and birthing people will find some aspect of their perinatal journey traumatic. So that's the big group of people that have felt something about it was subjectively traumatic. But then only 3 to 8% will go on to have a clinical PTSD, and really what that means is that to have PTSD we have a checklist and you have to check off all the symptoms but you can still be traumatised.  

Like you said, that still warrants care and attention and treatment because you might have most of the symptoms of PTSD but you just haven't reached the threshold for that formal diagnosis. 

Okay. That's really useful. Thank you. I suppose I wanted to move on now to get your help on how you move forward from this, how you recover from your traumatic birth? So, what your advice is on that and potentially what potential treatment options are available to you?  

So the biggest and most difficult and most courageous thing is always to try to begin to voice what you're feeling, and we know that many women sadly don't ever do that because, you know, they feel ashamed or they feel worried that they'll be judged.  

So trying to find somebody to begin that conversation with is the most important part really, and that might be a healthcare professional like your GP or health visitor, it might be a friend, it might be your partner, it might be a peer support group like Pandas or Make Birth Better or the Birth Trauma Association. So it's about starting that conversation with somebody that you feel able to talk to.  

We have actually just collaborated with Pandas on a free downloadable, I suppose you'd call it a worksheet that lists symptoms that you can kind of tick and you can take it with you to your GP or health visitor. If you don't feel you can say it yet, you can take it and show them and perhaps that begins a conversation. So that's the first step is just sort of starting to voice, “I don't feel that something's quite right here”.   

And then in terms of treatment there are loads and loads of different treatments available, some within the NHS, some privately. Typically in the NHS there's two or three classical routes.  

So one is that you might be offered a debrief so you can go back and speak to a midwife about your birth, look through your records, think about, you know, ask questions. Sometimes that can feel helpful, sometimes not. The evidence for that is not great as in terms of a treatment. It can sometimes feel helpful but it's not actually treating your distress necessarily.  

For most people then they would probably be offered therapy within NHS talking services, every area has those, but waiting lists vary and sometimes the wait can be way too long. They would offer you trauma-focused treatment to properly assess for and treat your trauma.  

And then sometimes people might have medication or might prefer medication to a therapy route. Those are the main sources of treatment within the NHS.  

In terms of treating birth trauma there are a host of other things that can be helpful. Exercise, movement, yoga you know, physiotherapy if you've had a birth injury, if you've had a tear or if you have urinary incontinence, for example. Or perhaps couples therapy or even there's a specialist type of therapy that you can do with your baby if you feel kind of disconnected from baby or that you're struggling to bond.  

So there's a whole host of things that can help. Sometimes it's going to be limited by what you can access but I think, you know, I feel really strongly that women should know all the choices that are out there. I think sometimes part of the problem is we make systems so complicated to navigate that people often don't know where to start or where to look and so we need to make it easier for people to find resources as well. 

That's a great round up and I've seen on your website, Make Birth Better, you've got a great visual on there. I think it's a video of the NHS treatment that might be available to someone. Because I think it can be overwhelming; like where do you start and your life is already so busy.

But you think the best starting point is speaking to someone, be it a medical person or someone you trust as a good step to express that, that's the best place to start and then you can take it from there?

Yeah. Or if you can't speak it, write it. So sometimes people find writing it down really helpful; in a journal, in a letter.  

It can sometimes be very difficult to tell it and tell the whole story, so sometimes writing it down can be another way to start. But then once you've done that often that's a real relief for people just to begin to start that process of actually saying, “I don't feel quite right”.  

I think the other thing that we need to change is, again, going bigger, you know, as a society, because I often speak to people and they're given a leaflet or they're given a phone number. And that's brilliant, but I do feel really strongly that we can't always just expect women to source their own care when they're really struggling. So there's got to be something about the way we screen for and reach out to women and families as well, because I've spoken to so many people over the years who were like, “I know where to go, I had the number, but I just couldn't, I couldn't call”. So we can't always expect people, you know, we always hear about, you know, reach out and that is important but I also think we need to reach back a bit better as well.  

Yeah and I think, you know, that that comes into we've spoken on, on another podcast before about sort of the postnatal care and how, you know, I have personal experience of, you know, not feeling supported at that six-week GP check and those various points and it's not really a question that was put to me.

So then the ball is firmly put back in your court to go, “Well find out where you can get the support and get it”. So yeah, I imagine there's many steps in your postpartum journey where they could…well hopefully someone could perhaps more formally reach out and check that you're okay?

Yeah, I'd really love – I've been talking about this for years; forever, it seems – for us to screen for trauma at sort of the eight month developmental check, say, or, you know, to really pick up on points where we're going to have contact and to really think about families.  

Of course, the baby is important, vitally important but, you know, how is partner doing? How is the family doing?  

So I think we have got these points where we could be screening better for trauma because trauma symptoms can sit there for years for people and they can delay having another pregnancy. It can, you know, crop up again in a further pregnancy.  

So I think we do need to screen for things a bit more long term because often in some of the literature we know that birth trauma symptoms actually peak later at sort of six to 12 months, postnatally. So could we screen for it within that time as well. 

That's interesting, I didn't know that. Why is that that they would peak slightly later? Is it because they just…you've got all your hormones and you're feeding or, you know..?

I mean, I think – just from my opinion from working with people is – I think that initially people are quite numb and detached and they're just a bit on autopilot.  

They know that something's happened that they can't quite put their finger on, but practically they have to look after their baby, get up, feed. They're just sort of carrying on and then I think often it hits people a bit later, so then they start to have kind of nightmares or flashbacks or, you know, feel very triggered by certain situations.  

So I think it almost takes a little bit of time to unfold. Not always but, you know, for a lot of people, I think that does happen like that. 

So you said that in clinic you see people that might have suffered birth trauma years and years ago. So this is something that can affect someone perhaps if they've not got treatment for many, many years. And have you seen people where it's prevented them having like a bigger family, further children? That's the impact it can have?

Yeah, I've seen people that have never had another pregnancy or have had another pregnancy but it's been incredibly difficult for them. So often, you know, classically, I suppose it would be women then wanting to have a planned caesarean birth to try to control it a lot more.  

I’ve seen people, you know, present wanting to be sterilised because they just can't face having another pregnancy again, and I've seen people have terminations because the thought of being pregnant again has just felt too overwhelming. But also, you know, I would like to say that it's very treatable and people can do incredibly well but we need – they need to get to the right person and the right place.  

So if people don't feel able to share or disclose then they can have this sort of rumbling trauma that carries on and on for a very long time. 

Thank you and so if someone could speak to their GP and they think they might be a candidate for talking therapies and there's a long, long wait; and maybe access to private treatment is not a possibility for them; are there charities that sort of plug the gap there? I know, obviously Make Birth Better, they've got great resources and it may be that a support group can help them in the meantime.

So there are some lovely peer support groups online.  

So the Birth Trauma Association has a peer group. Those can be incredibly helpful for people. It's people with lived experience that are perhaps further down the line of healing and recovery. So that can be really powerful to hear from somebody that yes, things are going to get easier over time for you.  

Each area will vary but yes, there are definitely low-cost charities that provide support or counselling for free. Things like Petals, you know, they will sometimes have links with certain NHS Trusts, but not all and they absolutely sometimes can plug that kind of gap while people are waiting on a waiting list. 

Great. Thank you. I imagine those peer support groups are invaluable and I bet people share their experience that if they've had support and they've gone on to have another child, that perhaps that process has been quite healing for the original trauma in some circumstances.

I imagine and having access to, like you say, people with lived experience must be…or just people validating you must be…it must be a wonderful thing in a non-judgmental environment?

Yeah. I think that kind of compassionate listening and validating and normalising really helps reduce shame and stigma for people, and sometimes helps reduce people from blaming themselves for what happened.  

Also I think it's just really powerful when people sit together and share stories, you know. There's real value in that and a lot of people talk about that as being one of the most healing things that happens for them. 

Yeah they found each other in the end and that they get that support and speak to each other. I think that's a wonderful thing and people give up…they continue to give up their time to support other women or birthing people, I think that's fantastic. 

We are also publishing an information leaflet about support that's available. So we will make all of those groups known to anyone that is not aware. I think that is a good round up, a good place to leave it, because I think that gives a really good summary as to where to go for help, what to do, first of all.  

If there's any last minute advice that you could give to someone that might be sitting here thinking, “Am I in a good spot with this, how was my birth?”, what would you say to them?

I’ll just say two very quick things:  

So one is not to forget that partners can also experience birth trauma and PTSD, and even grandparents that might have been in the room. So think about the kind of ripple effect of trauma as well. I think go gently with yourself and trying to unpick it all. You know, there's…it's so difficult often to do that through the lens of being tired and your hormones are all over the place. So try and be gentle with yourself in trying to explore what's going on and I think the worksheet that I referenced earlier is a really good starting point because it's got loads of different feelings and you could, if you feel able, you could just have a look at that and you might think, “Gosh, yes, I really feel like that, and that applies to me, but that doesn't”. Then try and share that with somebody who can perhaps go through it with you in more detail.  

And last thing I promise, is that I just want to say to people that whatever happened, whatever twists and turns your birth took, how you were made to feel, how you felt, it's really important to know that nothing you did was ever your fault and that it's usually about how you were cared for or not cared for. It wasn't you failing in any way, and however difficult it feels now, you can move forward and it will feel easier with the right care. 

Thank you Rebecca. I think that's really comforting advice and a really great place to start that information leaflet that that we will reference below. So thank you so much for that. I really appreciate your time today and giving us sort of a rundown of birth trauma and where to get help. So thank you very much.