Traumatic birth inquiry finds the number of negative experiences 'are simply not good enough,' and my own poor maternity care still leaves me angry
Findings from the inquiry require urgent action
An inquiry into traumatic birth experiences has found the 30,000 reported negative experiences per year to be 'simply not good enough.' I'm sadly one of the women who can relate to being left in blood-soaked sheets and not being listened to.
Finding out you are pregnant can present so many options. From making friends in antenatal class to discussing whether you'll be trying hypnobirthing or a water birth, the positive line on the pregnancy test opens up an entirely new world, simultaneously exciting and terrifying. What women really need during this time, are supportive medical professionals to see them seamlessly through this defining moment in their lives.
Results from the parliamentary inquiry into birth trauma published on May 13 however, suggest this to be far from the case. The findings conclude maternity care is failing women quite spectacularly, with good care for pregnant women the "exception rather than the rule", resulting in "shockingly poor" maternity services where suboptimal care is "frequently tolerated as normal".
The inquiry was set up by Conservative MP Theo Clarke, who felt she was going to die when giving birth to her daughter in 2022. The 12 recommendations coming from the report include appointing a maternity commissioner in a newly created role. NHS chief executive Amanda Pritchard, commented that the experiences reported by women in the report were "simply not good enough."
The report also comes amid news that the number of women dying during or shortly after pregnancy, has hit a 20-year high, with care coming down to a "postcode lottery." Considerations have also been made relating to the investigation into Shrewsbury and Telford Hospital NHS trust, that concluded failures had contributed to the deaths of 201 babies and nine mothers over a 20-year period.
According to Sky, the inquiry commissioned by Theo Clarke found 30,000 women will suffer a negative experience before, during or after delivery. Women are reporting being left on blood-soaked sheets for hours, being berated, not listened to and eventually dismissed by midwives, and suffering serious birthing injuries that were missed or inadequately treated. Even more harrowingly, some babies have been left with life-altering conditions or have lost their lives due to mistakes and failures. Some of these were found to have been covered up, before and during labour.
While my baby and I came out the other side of poor maternity care relatively unscathed physically, I'm still haunted by my own poor experience. Like most women, I'd attended antenatal class, and listened carefully to everything I'd been told I needed to do and expect. I'd attended all my midwife appointments, and by the end just wanted to have my baby and start life as a mum.
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I went into labour around 7pm on a Saturday night. Knowing I wouldn't be allowed into the hospital until the contractions were a certain amount of time apart, I ran a bath, then diligently laboured all night, timing my contractions as I went. I'd told my husband to sleep all night - there was no point both of us being tired and I'd need him to support me through the hardest part that was yet to come. However, I woke him in the morning when my contractions were erratic, and a searing pain in back just felt really, really wrong.
I called and explained this to the hospital, who told me to come in. When I arrived and was examined, I was devastated to find that having already been in labour for over 12 hours, I was only 2cm dilated. With the pain I was in, I'd honestly expected to be told the baby must be imminent. The examination also found that with every contraction, my baby's heartbeat was getting really, really slow. I looked worriedly at the midwife on hearing this, but she offered no explanation. The next thing I was told was to go home, and not return until I was "screaming in agony." Yes, those were the words they actually said - that line was even delivered cheerfully.
I thought it was a really odd thing to say, like being in a fever dream, but they were the professionals and I assumed they knew what they were doing. Less than two hours after going home, my husband called the hospital back to say I should probably come back in - I'm one of those people who hates to make a fuss, and although I refused to scream in the required agony, I was silent screaming like a demented Edvard Munch painting, freaking my husband right out.
So back we went, and there was a flurry of something resembling concern when not only was there zero progression in dilation, but fairly lengthy periods of time my baby's heartbeat stopped altogether - you know, that pretty fundamental thing he needed to sustain life etc. I worked in healthcare myself at the time, and discussed the entire episode with colleagues when I went back to work, some of whom had been midwives. In their professional opinion, this should've been the time I was given a caesarean.
Instead, an internal monitor was placed on my baby's head to time the periods without a heartbeat, and the searing back pain and serious lack of dilatory progress attributed to the baby being back-to-back. This was news to me - apparently it had been in my notes, but everyone had failed in communicating this to me. On reflection, it was the reason for the back pain and nothing really moving along.
Still nobody seemed concerned. There's now a chunk in the middle that I can't remember that well, probably because I developed a gas and air addiction which was akin to lining up 12 tequilas and having a bender. But there was some progress! There were still moments where the heartbeat stopped, alarms sounded and some people came running, but the midwife just shrugged when I mentioned I was worried about this. But I finally made it to 9cm - where I stayed for the next 10 hours...
My midwife-trained colleagues were absolutely horrified by this news. In their minds, I had gone well past the need for a caesarean hours ago, yet I'd been kept stuck and agonised, with a decelerating baby, by those who should've known better. By this time, the feeling of having been out on a happy gas and air induced night out was failing. It was being replaced by the comedown of walking home afterwards - familiar to anyone whose had some big nights out. The agony was unbearable, I was frightened, and scared my husband by telling him I thought I was dying.
"I don't see the problem," the midwife said with an edge to her voice when he demanded that she do something. When I burst into tears, she barked "Why are you crying?" Not being one of those make-a-fuss people, I managed to reply weakly "I've been like this for hours, you're not doing anything to help and I just want this to be over, I can't do it." I was greeted with just another dismissive shrug.
My husband left the room at this point, to try and find somebody else to take over. Nobody was listening to us or even seemed to care. She did spring into action at this point to say maybe she could get someone to give me an epidural if I wasn't coping, to see me through the last bit. It really shouldn't have taken walking out to get that result. This should have been discussed hours ago, but because antenatal classes had drummed into us that we'd not get an epidural at the 9cm stage because it was too late, I didn't think to ask. I was unable to advocate for myself, and my midwife didn't assess my pain levels or advocate for me.
My baby was eventually born at 11pm, 28 hours after this all started. It didn't end there - he was born with the umbilical cord wrapped around his neck and took a long time and many people working on him before I knew he was even alive. I needed a couple of stitches, then just like that, everyone disappeared. Me and my tiny newborn were left in blood soaked sheets until 4am, when somebody came back to take me to the ward.
For 24 hours, nobody did any observations on me at all. The bare minimum should be every four hours, but this should be even higher post-epidural. There could have been serious complications missed. At the 24 hour mark, a midwife picked up my chart and in a raised voice asked "Nobody has done your observations?" I wasn't quite sure why I felt like I as being told off for this abject failure.
Unsurprisingly, my baby didn't want to feed either. I rang the bell to ask for help several times, and each time the level of help offered was for someone to squeeze my nipple like a stress ball and throw my baby's face at it in a manner that would make a shot-putter proud. Then somebody came around to discharge me. I was torn between knowing I hadn't been checked over properly and concern over the feeding problems, to knowing I wasn't going to get any help anyway and wanting to get the heck out of there.
And yes, what followed was weeks of feeding problems (kudos to my health visitor though, who was every kind of awesome,) flashbacks, and the misery of feeling like a failure when I heard the 'positive' birth stories from my antenatal friends. We wrote a letter of complaint about our experience, which was acknowledged but not a lot more than that. We were both, thankfully (and some might say miraculously) physically unscathed at the end of this utter debacle, but it didn't end there.
After my second baby (who had a very positive birth,) I ended up experiencing a postnatal depression that almost turned to postpartum psychosis. I always wondered whether the trauma from my first birthing experience contributed. My son has since had to attend some medical appointments, where we've always been asked about his birth - I've now lost count of the amount of times I've had to recount this tale.
It's been hinted at but there's a huge reluctance to confirm, that this birth experience could be a big factor in why he's needed medical input. This, and the sheer avoidability and callous nature of it all has left me really, really angry. Maternity services cannot continue to fail women in this way, and the sooner serious action is taken to rectify the findings of the birth trauma inquiry, the better.
For more on postnatal care, we explain postnatal depression and the treatments available. We've also looked at postnatal exercise, and how to go about your fitness journey after a baby should you want to, and how to deal with lack of sleep in those tough, early days of parenthood.
Lucy is a mum-of-two, multi-award nominated writer and blogger with six years’ of experience writing about parenting, family life, and TV. Lucy has contributed content to PopSugar and moms.com. In the last three years, she has transformed her passion for streaming countless hours of television into specialising in entertainment writing. There is now nothing she loves more than watching the best shows on television and sharing why you - and your kids - should watch them.
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