‘There is not enough research, understanding, respect or admiration…’

Birth Shock: How to Recover from Birth Trauma (Pinter & Martin, 2020) by perinatal clinical psychologist Mia Scotland is out now. Michelle Cree, consultant clinical psychologist and author of The Compassionate Mind Approach to Postnatal Depression: Using Compassion Focussed Therapy to Enhance Mood, Confidence and Bonding (Robinson, 2015) spoke to Mia about the book.

Michelle: I felt all sorts of emotions as I read your book, from angry, sad to feeling alive, excited and empowered. In my opinion this is an incredibly important book.

I was struck by your comment right in the preface where you said: ‘It was not your fault. You did nothing wrong. Read on to see why I can emphatically say that to you, even though I don’t know you’. I can imagine people being surprised by that, yet in my work too, this is what breaks my heart the most – that women believe it is their fault. Why do you think that women do blame themselves?

Mia: It’s a strange thing isn’t it? I guess its similar with other mental health problems too – people think it’s their fault that they are depressed, or anxious. I think a lot of it is based in a basic misunderstanding of what mental health problems are, coupled with a basic misunderstanding of what birth is. In the book, I talk about the fact that you can’t ‘try harder’ to birth a baby any more than you can ‘try harder’ to digest your food, and yet our society seems to have missed this basic principle of birth. It is also, in my opinion, a feminist issue. There is not enough research, understanding, respect or admiration towards women as birthing beings, and the transformation involved. I also talk in the book about how institutionalised attitudes towards birthing women have a part to play.

Michelle: Yes, I agree, this issue seems deep and broad, running through many different aspects of our lives.

I was really interested in your discussion about our attitudes towards sexual violence and how you have connected this with our attitudes towards birth. I must say I had a strong visceral reaction when I was looking through the contents page and saw the section on ‘obstetric violence and birth rape’. I can imagine there will be some strong responses to this. What was important to you in including these terms?

Mia: I absolutely witness ‘obstetric violence’ in my birth doula work regularly, and I see midwives and doulas traumatised by witnessing it too. It is very important to include these terms, because language is power and influence. If we don’t label it, we can’t communicate it. I get what you mean about the words eliciting strong responses. I have to admit, I did do an internet search on the word ‘violence’ before writing it, to double check that it includes verbal assault as well as physical! People will object, I’m sure. However, I believe that objections are based on not knowing enough about what is actually happening in birthing rooms and postnatal wards. I’m afraid they can be very brutal places indeed. And that’s not to say that they can’t also be very caring and compassionate places too.

Michelle: That is just so hard to hear, the use of the words ‘brutal’ and ‘violence’ in the context of a baby coming into the world from a woman’s body. I imagine that the vast majority of healthcare professionals would be horrified and devastated that a birth was experienced as ‘brutal’ as this is not why they came into the job. Some of the biggest struggles in the women I work with are where they feel ashamed of the strength of the words they are wanting to say. As humans we are incredibly vulnerable compared to many other animals. We don’t even have much hair on our bodies, let alone scales, or horns or sharp teeth. We depend instead on our incredible ability to communicate and to manage the complexity of social groups. When physical contact occurs, it can affect us at a very profound, unconscious level, which can be perturbing. Even uncertainty that we will be safe such as having an unfamiliar doctor or midwife enter the room, or not being sure why something is being done, is enough to move us into threat, without anything obviously threatening happening. So, we need to really listen to the words a woman is trying to find as she knows at some level that her life, or her baby’s life, might depend on them.

You talked a great deal about how crucial listening is. I am aware that it is often seen as a ‘soft skill’, yet as you explained, it is one of the most important interventions going on in the room. What message would you like people to take away from your book about this?

Mia: I completely agree with you about how easy a labouring woman can have her threat system activated, by something which we would not consider threatening, such as an unfamiliar person coming into the room. As you say, we rely on others to help us feel safe – rather than horns or scales. And that must be even more so for a woman in labour, who has no physical defences at all to draw on! That’s why being listened to is so key – it has the power to move a woman from her threat system (I don’t feel safe, I’m not sure this person has my back) into her calm mode (I’m in safe hands here). Doctors and midwives may know this intuitively, but I’d love to see it taught more widely and explicitly as a part of their training. Hopefully this book will help move forward the value that this is given in maternity care.

Michelle: So, that old ‘magic wand question’; if you could transform maternity care overnight, with nothing to hold you back, how would you have it be?

Mia: Haha you go first! Maybe with regards perinatal mental health services…

Michelle: Ah, that’s not fair! Well I must say I have been very pleased to see the recent investment in perinatal mental health services and now into psychological services connected more specifically to maternity. This is beyond anything I had ever imagined. I think if I could do anything then it might include mental health practitioners having placements with doulas, midwives and obstetricians. I would want practitioners to be able have some sense of the words that new parents might be trying to find. Over the years in my work I have become more and more aware of things that are hard to say and are kept tucked away by a sense of shame and a fear of disconnection, or even that their baby may be taken away. These can be difficult places for mental health practitioners to be able to venture, let alone parents so I would want experiences and training available which go to this deeper level.

But more than anything I would like this potential for shame and trauma to be addressed at a cultural level, and certainly in the antenatal period, as well as of course, the experience of the birth itself, so that it doesn’t occur in the first place. Over to you!

Mia: Haha not sure I can follow that! I would want the psychology of postnatal wards to be considered as critical. Lots of thought and money has gone into making midwifery led units psychologically safe places, with birth pools, mood lighting etc. It’s now time to step that up for postnatal wards too, to prevent trauma there. Women need the right hormones to bond with their babies, and to establish breastfeeding. They need stress free environments, they need to feel safe. Giving mother and baby the right start in life, sets them up for life. Let’s invest in those wards, with compassionate staff who have time to care, and with privacy, dignity, and respect. I live near a wonderful NHS midwifery unit with 6 postnatal beds, and in the 20 years I’ve known about it, I’ve only ever heard women say good things about it. They remember those special days for the rest of their lives. I would like to see many more of those.

Michelle: Yes these can indeed be precious and wonderful times. I sincerely hope your book will become part of the conversation around transforming maternity care so that the experiences will be ones that parents will wish for their children. I certainly want my children to read your book before they have children.

- Read an extract from Birth Shock: 'The power of attentive listening', with kind permission from the publisher Pinter & Martin.

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