The big issue: Breaking the birth trauma taboo
Therapy Today, October 2024

Illiyin* had always planned to have a home birth. But, after hours of slow dilation and the realisation that she would like pain relief, the then 25-year-old felt she had no choice but to go into hospital. Knowing that slow dilation progress often results in an emergency C-section, Illiyin knew what was likely to happen when she went into hospital.

But that didn’t make the experience any less distressing. Lying on the operating table after five attempts to insert a spinal anaesthetic, Illiyin noticed the smell of burning flesh. ‘They had started the surgery without me knowing,’ she tells me over a voice note (six years on, she has two children and a busy schedule). The doctors had been operating for a full three minutes before she realised. Illiyin describes the experience of not being consulted or informed during the process as shocking and traumatic: ‘This was supposedly happening with me but ended up totally happening to me.’ 

Illiyin’s experience of maternal care – which, while not being fatal, ended up leading to lasting trauma following the birth – isn’t so anomalous. Earlier this year an All-Party Parliamentary Group (APPG) on Birth Trauma report revealed the extent to which poor medical care during labour results in birth trauma in the UK.¹ The report described ‘mistakes and failures’ by services as leading to outcomes such as stillbirth, premature birth, babies born with cerebral palsy caused by oxygen deprivation, and life-changing injuries to women as the result of severe tearing. 

What the report also highlighted was that women from ethnic minority backgrounds were more likely to experience trauma due to particularly poor care, as well as racism and discrimination from services. Numerous women told the researchers that, like Illiyin, procedures were performed without fully informed consent and awareness, including non-consensual vaginal examinations and breaking of waters. An important life event, which many mothers hope will be a memorable and special experience, is still leaving many feeling violated, disempowered and traumatised. 

42% of black mothers felt the standard of care they received during childbirth was poor or very poor³

Although the APPG report found that women from all ethnic groups reported feeling like they were objectified, dismissed and denied autonomy over their birthing experiences in the UK, women from racially minoritised groups were found to be most at risk from birth trauma, both psychologically and physically. Between the years 2019-2021, black women were almost four times more likely to die during or up to six weeks after pregnancy than white women.² The Black Maternity Experiences Survey from the black maternal health organisation Five X More found that 42% of black mothers felt the standard of care they received during childbirth was poor or very poor.³ The same percentage of respondents felt that their safety had been put at risk by professionals during labour or the recovery period. Illiyin tells me: ‘When you are at risk of prejudice, at risk of bias, at risk of racism, at risk of poor care, this means that there is an increased chance that you will suffer trauma.’ 

Therapy Today, October 2024

Trauma 

An inclusive definition of traumatic childbirth experiences developed by Professor in Midwifery Julia Leinweber and colleagues describes it as ‘a woman’s experience of interactions and/or events directly related to childbirth that caused overwhelming distressing emotions and reactions, leading to short- and/or long-term negative impacts on a woman’s health and wellbeing’.⁴ Some people also use the term to refer to injuries sustained during birth, or simply the subjective perception of threat during the experience of childbirth.  

Although awareness of birth trauma is growing, it still largely goes unrecognised and untreated, leading to potentially serious mental health issues – particularly in women from racially minoritised backgrounds. An analysis by The Guardian found that black women were more than three times as likely to be admitted to hospital for ‘severe instances of perinatal mental illness and behavioural disorders associated with the six weeks immediately after childbirth’, when compared to their white counterparts.⁵ This includes diagnoses like postpartum psychosis. Black women also experience postpartum depression at higher levels than any other group.⁶ 

Yet few women are offered post-birth support for trauma, or made aware of the possible lasting impact on their mental wellbeing. Patrice Dantzie, who is a counsellor and works with black communities at the pregnancy and baby loss charity Sands, tells me that black women are less likely to get the support they need. ‘Many women feel pressured to embody the “strong black woman” persona, or are told things such as “it was God’s will”, which suggests that showing sadness or seeking support indicates a lack of faith,’ she says. This can ultimately lead women to feeling isolated and misunderstood, further exacerbating mental distress.

Labour anxiety 

Many women feel apprehensive about childbirth, but for black women it can be a time of significant anxiety. Black women are 1.5 times more likely to develop pre-eclampsia, a serious pregnancy complication that left untreated can lead to potentially lifethreatening complications for the mother and the baby, and six times more likely to experience some of the most serious birth complications during hospital delivery across England than their white counterparts.⁷ Stillbirths are significantly higher for babies of black and Asian ethnicity, regardless of socioeconomic status. These discrepancies led to the revelation this year that black women were twice as likely to have their births investigated for NHS safety failings.⁷ 

Perhaps most shocking of all is the statistic that black women are six times more likely than white women to die in childbirth.⁸ Sandra Igwe, Chief Executive of The Motherhood Group, an organisation that aims to empower black mothers, believes being faced with this ‘is one of the many reasons why black mothers are now even more anxious and stressed over their birthing experience and postpartum journey’. US research found that tokophobia, fear of childbirth, which increases the odds of pre-term birth, was most prevalent in women who are black or have lower incomes or less education.⁹ 

Yet instead of having their anxieties managed during maternity care, many black women encounter cultural barriers in services where staff aren’t adequately trained to work with migrant communities and communities of colour. For example, in some cultures, screaming during childbirth is not the norm, which leads mothers to be disbelieved about their progress or pain. ‘When you’re already feeling vulnerable, the last thing you want is to explain your cultural context to a healthcare provider,’ says Igwe. ‘The dearth of representation in mental health professions doesn’t help either – it’s hard to open up when you don’t see yourself reflected in those meant to help you.’

23% of women who died in the postnatal period suffered from mental health disorders¹⁰ 

Despite glaring issues in treatment, it can be difficult for black women to advocate for themselves, as this can see mothers further stereotyped or discriminated against. This was Mel Green’s experience when she attempted to speak to doctors about her treatment during childbirth: ‘I was told that I was aggressive.’ 

A lecturer and researcher, and mother of two, Green was told that she was having ‘tetanic’ contractions, strong and sustained contractions that last longer than usual, and that her baby was lying ‘back-to-back’ in the womb, making delivery more prolonged, but was still denied pain relief. ‘Instead I was told that unless I calmed down, my baby would die. My husband was advocating for me until I passed out from the pain,’ she says. 

After being subsequently swept off to emergency surgery, Green also experienced disempowerment when her husband was not allowed to come into the operating room, despite originally being told that he could. ‘He was left for over an hour without knowing my status. He said all he could hear were my screams.’ After the birth, her baby was put in a crib next to Green’s bed, while her husband was shut outside, and Green was unable to pick up her baby. She says: ‘My newborn child was left without the important skin-to-skin contact in those crucial early moments.’ 

Postnatal PTSD 

The emotional impact of birth trauma can be long-lasting, Illiyin discovered. ‘I really struggled with parenting for the first 12 weeks,’ she says. ‘I was getting lots of flashbacks to the smell of burning flesh from the section.’ 

There is growing awareness of the frequency of postnatal PTSD. This affects women from all heritages, but one factor that has been found to increase a mother’s chances of PTSD is a negative subjective birth experience, which many black women evidently have. Dantzie tells me: ‘There are many symptoms of postnatal stress that can present in the counselling room, such as trauma re-experiencing, heightened threat perception, and avoidance behaviours. Postnatal PTSD is a more severe form, with these symptoms being persistent and significantly impacting daily life.’ 

There are numerous barriers to mothers accessing support in the postpartum period, says Igwe: ‘Many black women also carry a deep-seated fear of judgment or misunderstanding from healthcare providers, which can be paralysing.’ This mistrust of state services is often very much grounded in reality, as there can be serious material consequences of speaking out. She tells me a bit about Sarah,* a ‘vibrant’ member of The Motherhood Group, who found herself struggling with postpartum depression:‘Sarah was terrified that if she expressed her mental health concerns, social services might get involved and take her children away. This fear, deeply rooted in the historical mistrust many in the black community feel towards authorities, kept her from getting the support she so desperately needed.’ Similarly, black people continue to be more likely to be pushed into the sharp end of the mental health system, with higher rates of detention under the mental health act. This can also result in avoidance of services, or a fear of being honest with medical professionals. 

The result of various forms of silencing means that many black women end up repressing their experiences, with nowhere to take them. Green tells me: ‘I don’t really think I have dealt with the trauma of my last birth, even though my son is now four. This is actually the most I have described it to anyone other than my husband since the birth.’ 

Disrupting the system 

It is clear that a cultural shift is needed. The APPG report made several recommendations that would improve birth experiences for all mothers, but would particularly ameliorate issues that disproportionately affect black women. For example, it suggested that there should be better training and awareness on birth trauma, and trauma-informed care. It also specifically recommended that the Government commit to tackling inequalities in maternity care among ethnic minorities, particularly black and Asian women. 

Last year a University of Bedfordshire report on behalf of Wellbeing of Women flagged up removing barriers to accessing early antenatal care for women from ethnic minorities as a key factor in protecting the health of both women and babies.¹⁰ 

The Black Maternity Experiences Survey makes a number of recommendations specific to improving black women’s outcomes, including an annual maternity survey targeting the group, training for healthcare professionals on conditions that specifically or disproportionately affect black women, more community-based approaches, and improved feedback systems. Crucially, it also recommends more training for healthcare professionals on ethnic disparities in maternal outcomes. 

Simultaneously, black women who have experienced birth trauma are increasingly utilising and pioneering interventions from outside the system. Illiyin, for example, is now a midwife and birth debrief facilitator, spending her time supporting other people to have a better birthing experience than she did. Meanwhile, Green employed a doula, which helped prepare her for the birth of her second child. She says: ‘Without her aftercare, I don’t know if my husband or I would have overcome the experience of our eldest’s birth.’ 

Similarly, Igwe founded The Motherhood Group in order to tackle and address some of these disparities, using what she describes as a ‘multipronged approach’. This includes a peer support network for black mothers, and campaigns for better maternal care and mental health services for black women. The group also trains healthcare professionals on cultural competence, helping them understand and address the unique needs of black mothers. 

Of course, wider cultural attitudes projected onto black women must also be challenged, including ideas that black women internalise about themselves. Illiyin feels that black women are broadly encouraged to unconditionally accept poor treatment: ‘People say this is just what we do, it’s just how it’s done. But in our communities, there needs to be a shift in the narrative around what is actually normal, and a real reinforcement of the fact that we are worthy to feel dissatisfied and complain.’ 

However, it cannot fall on black women alone to disrupt the complex interaction between racism and sexism that sees them experience such poor treatment at every stage of the birth process. The dehumanisation of black women, the reduction of their personhood to crude stereotypes, and the dismissal of their desires and pain are all complex issues, many of which can be traced to economic factors, and histories of enslavement and colonialism. These forces cannot be dismantled wholesale within the nation’s health systems. But better education and understanding of these issues might better equip professionals with the tools to challenge them.

13% of women struggle with their mental health after birth¹¹ 

In the meantime therapists can help by educating themselves and being aware that postnatal trauma can impact women’s health several years after birth. The general principle of creating a safe, non-judgmental space is important for supporting women who have experienced birth trauma, says Dantzie. She also emphasises attentiveness: ‘It’s essential to listen for cues and observe body language and tone without making assumptions. If either changes when discussing their birth, it would be something to explore, asking questions that help you enter the client’s frame of reference. An awareness of how post-birth trauma may present itself, as well as ways to work with trauma, will also help.’

* Names changed for anonymity 

• Black Maternal Mental Health Week UK 2024, Transforming and Advancing Change, runs from 23 to 29 September. For more information please visit The Motherhood Group.