As a landmark NSW Government Inquiry reveals ‘unacceptable’ rates of birth trauma, Catherine Lewis investigates the reasons behind this troubling trend – and what is being done to boost maternity care across the state.
“I left my dignity at the door,” says Avalon-based mother- of-one, Fran*, of her childbirth experience. “And it’s only now, three years on, that I realise it shouldn’t be like that.” Birth trauma – be it physical or psychological – can tilt one of life’s most anticipated moments into an experience so wounding that ripples are felt long after labour. Fran is not alone, says the Australasian Birth Trauma Association. One in three Australian women and their families are affected by a ‘mixed or even very negative experience, resulting in physical and/or psychological injuries with lasting negative impacts.’
So where has it gone wrong for maternity care, even in the most privileged of postcodes? A record 4,000 submissions from patients and clinicians to the trauma inquiry reflected a health system that is falling far short of the standard of care that NSW women – 95 per cent of whom give birth in hospitals or birth centres, with 79 per cent as public patients – should expect. One in 10 have suffered preventable birth trauma or obstetric violence, which is any act that harms a pregnant, birthing or postpartum woman, such as non-consensual examinations, failing to give pain relief or making a woman feel powerless.
This is a ‘heartbreaking’ statistic, says the chair of the Select Committee on Birth Trauma, Emma Hurst. “The personal stories shared revealed systemic issues that must be urgently addressed,” Ms Hurst says. “The unprecedented scale of evidence received reflects the number of birthing parents unnecessarily traumatised giving birth.”
Easier to quantify is the physical, the perineal tears or pelvic floor damage. While the psychological – postnatal depression, anxiety, post-traumatic stress or obsessive-compulsive disorder – can leach the colour from blissful baby days in the long-term if left untreated. Even midwives who are emotionally invested at the highest peaks and lowest valleys of life, amidst a punishing schedule and a skeleton staff, can also suffer secondary traumatic stress, through witnessing trauma at work.
Avalon mother Fran believes her ‘crippling’ postnatal depression was sparked in early pregnancy. She felt ‘judged and even slightly shamed’ by a ‘young, inexperienced’ clinician while discussing her wish for an elective caesarean, due to fears linked to her own mother’s birth trauma. “She said my pregnancy was straightforward and I should try a natural birth, which I reluctantly did, only to end up suffering pain, anxiety and invasive examinations for over 24 hours before needing an emergency caesarean, which was far from the calm, planned birth I wanted,” she says. “I was then told that I should let my negative experience go as I had a healthy baby, but I now feel that, had my wishes been listened to, my birth story could have been so different.”
This deep-rooted fear of trauma has sparked record numbers of caesareans – up from 29.8 per cent in 2018, to 33.6 in public hospitals, and from 43.9 to 49.4 per cent in private, of which 40 per cent are elective, says NSW Health’s annual Mothers and Babies report. The increasing age of women giving birth in NSW is also playing a part, with 34 years the average for first time mums on the Beaches. In the Northern Sydney health district, one of the most affluent parts of the state and home to the highest number of new mothers aged over 35, almost double the number of women are opting for elective caesareans, compared to those in more regional areas.
But rising rates of surgery are sparking concern amongst midwives due to potential impacts on long-term health, says Hannah Dahlen from Western Sydney University’s School of Nursing and Midwifery. “There is mounting scientific evidence which suggests that children born by spontaneous vaginal birth, without commonly used medical and surgical intervention, have fewer health problems,” she says. Women who have caesareans may also endure longer recovery times and have less chance of a normal vaginal birth in future.
“Government must urgently act to stem the loss of midwives.” Michael Whaites, assistant general secretary of the NSW Nurses and Midwives Association
Placing women ‘at the centre’ of their own care is key, says Health Minister Ryan Park of the NSW Government’s commitments to support 42 of the trauma inquiry’s 43 recommendations for maternity care improvements. “We have heard what matters most to women, and their families and our ongoing commitment and actions, will improve their experiences,” he says. Continuity of care, in which the same midwife or team supports during pregnancy, labour, birth and post-birth and informed consent improvements are two priorities to be fast-tracked over the coming year.
But the reality is less continuity, more cuts, says the NSW Nurses and Midwives Association, warning that rumoured maternity staffing cuts at hubs including Northern Beaches Hospital will ‘compromise patient care.’ While Australia has seen record number of births in recent years – spiking post-pandemic with 315,000 – the number of midwives has slumped by more than 1,220, says NSW Health, with the National Skills Commission warning of shortages in every state and territory. “Midwives strive to deliver the best possible care to women and babies in a system that has been chronically understaffed, under-resourced and neglected. This cannot continue any longer and the State Government must urgently act to stem the loss of midwives,” warns Michael Whaites, assistant general secretary of the NSW Nurses and Midwives Association.
Mona Vale’s Karen McFadden, had positive birthing experiences with her three children at North Sydney’s Mater Hospital.
Enter a $2.5 billion cash injection over four years in the 2023/24 NSW Budget to recruit and retain more skilled nurses and midwives. This includes $419 million to recruit an additional 1,200 by 2026 in public hospitals. Other plans include greater investment in mental health support, post-partum services and trauma-informed care, as well as increased funding for psychological support for those experiencing pregnancy loss, within separate spaces in public hospitals. The $376 million Brighter Beginnings service will assist children and their families during the ‘crucial’ first 2,000 days, from pregnancy to school, while the $6 million Pregnancy Connect service will boost access to specialist care for complicated pregnancies.
It is this sense of connection that is behind the rise in midwifery-led care, with support from the same midwife or team throughout pregnancy. It’s what the International Confederation of Midwives calls the ‘most appropriate model’ due to evidence showing it can lower preterm birth risk and the need for instrument-aided delivery. On the Beaches, collaborative health services such as North Women offer one-stop-shop support to women providing ‘education, encouragement and emotional support’ from conception to post-birth, to enable the ‘pregnancy experience (women) deserve.’
MIdwivery care is a strong feature of the Mater Hospital obstetrics unit
Mona Vale’s Karen McFadden had just such a birthing experience at North Sydney’s private Mater Hospital, which welcomes more than 2,500 babies each year. “The same wonderful midwife, Wendy, delivered my first and second sons and made us feel like we were part of the family,” Karen says. “Yes, the facilities are first class, but it’s the calm, kind and genuine staff that make it an outstanding place to give birth. I went into labour with my second child, Archie, six weeks early and my obstetrician calmly laid out a clear plan to allow him to be able to breathe unassisted once he was born. We were absolutely terrified, but the staff were so supportive and reassuring, that we felt safe and optimistic that everything would be fine – and it was.”
Warriewood mother-of-three Christine Koh agrees. She spent eight days in the newborn intensive care unit at the Mater with her son after he was born with a low core temperature. “The nurses were absolutely amazing – supporting us both physically and emotionally and making us feel that no request was ever too much,” she says.
While shining a spotlight on areas ripe for improvement across local and state-wide maternity care, as the trauma inquiry has done, can only be a boon for future Beaches’ babies, until staff shortages are solved, the system will continue to labour under the strain. Ensuring midwives have the support and capacity to tailor care to the vastly differing needs of each woman must become inherent practice if the trauma trend is to be overturned. As Emma Hurst says: “Every birth must be met with dignity, respect and compassion.”
*Full name withheld upon request.
