Birth injuries are a feminist issue. An obstetrician explains why.

For many, birth is a transformative and wonderful experience. But for some new mothers, birth can bring unexpected injuries that can last a lifetime. To coincide with birth trauma awareness week running from 17th to the 24th of July, the Australasian Birth Trauma Association (ABTA) will release the findings of their survey exploring people’s experience of birth injuries. The stories make for sobering reading. 

Trauma following pregnancy and birth is increasingly recognised, and can be both psychological or physical. The theme of this year’s awareness week is physical birth injuries. 

Physical birth injuries may include trauma to the perineum or anal sphincter (known as a third or fourth degree tear), the development of a fistula passage between organs, damage to the pelvic floor, vaginal prolapse, incontinence of bladder or bowel, as well as physical complications of caesarean birth. 

Birth injuries matter. They can cause lifelong problems to an individual, affect the ability to bond with a new born baby, and play havoc on all aspects of a women’s life, including work, exercise, mental health, sexual health, relationship breakdown, domestic violence and financial hardship. 

Merely acknowledging the impact of these injuries is a very recent phenomenon. Historically, women’s bodies have been considered less worthy of medical attention than their male counterparts. Decades of disinterest have resulted in a longstanding lack of funding and research into conditions exclusively affecting women. The hidden world of birth injuries is the poster child for medicine’s gendered blind spot.  We simply do not understand what we do not value. 

Devaluing birth injuries also sends a clear message to women; your injuries do not matter. Women have heard this message loud and clear. We have internalised it. Throughout history women’s bodies have been seen as merely reproductive vessels with the sole purpose of carrying and raising children. Whilst women are now valued for more than the contents of their womb, this engrained messaging persists. Incontinence, pain and prolapse are just what happens when you have a baby. No use complaining about it. Suffering is, after all, a woman’s lot.

To illustrate the way we systemically devalue birth injuries, it is helpful to compare our care of women after birth with the way we approach other physical injuries. 

Let’s use the example of a footballer with a broken leg. The footballer will receive immediate medical attention on the playing field, in the ambulance, and in the emergency department. They will receive pain relief, prompt x-rays and extra scans such as an MRI if needed. They can expect surgical intervention, allied health referral and an appropriate rehabilitation program with crutches and mobility supports. Their care will continue over weeks to months, will be easily accessible, and largely free of charge within the public health system. 

The story following injury in childbirth is vastly different. 

The first place we can see a clear difference is in the preparation. 

The risks of most physical activities are drilled into us since childhood and techniques to minimise injury are common knowledge. We know to stretch and warm up, to stay hydrated, to wear a helmet on a bike, to be mindful of rips in the ocean, to secure our seatbelt, play safely and apply sunscreen. 

The physical risks of childbirth, however, are not common knowledge. Occasionally there are hushed conversations between friends, or from mother to daughter. But details remain vague. Perhaps something isn’t right ‘down there’ since childbirth.  Partly this secrecy is due to shame and stigma. Partly it is because many women have never been taught the correct names and functions of their own reproductive organs and genitals.  Women have not been given the language, let alone the permission, to describe their own birth injuries accurately. 

Yet even midwives and doctors, the professionals that do possess this knowledge, rarely have these conversations with women prior to birth. How to explain our collective silence on birth injuries? Perhaps it is derived from a sense of protecting women, of not unnecessarily stoking fear prior to an upcoming birth. Perhaps it is out of a concern that if we routinely warn people of potential outcomes from vaginal birth, some may ask for an alternative that, as a system, we are not wishing to promote or provide. Perhaps it is simply that clinicians are too rushed and busy, working in a system that lacks best-practice continuity of care models, to give these conversations the time and sensitivity that they deserve.

Whatever the reasons, the reality is that very few women go into their labour fully informed of potential outcomes. Subsequently, those who experience a birth injury are frequently blindsided and almost always ask the same question; Why didn’t anybody tell me?

The second important way that our approach to birth injuries differs to other physical injuries is the way in which they are diagnosed. 

Compared to a broken limb, there is a distinct lack of urgency to identify and treat many birth injuries. Avulsion of the pelvic floor muscles from the bone, for example, occurs in approximately one in five vaginal births, and the figure is thought to be doubled when forceps are required. Yet this diagnosis is almost never made at the time of the injury. Instead, it commonly takes months or years of debilitating symptoms, incontinence, or vaginal prolapse, and repeated trips to various health professionals, before an injury is correctly identified and treatment can begin. 

Furthermore, birth injuries are not afforded the same degree of pain relief that other injuries routinely attract. Postnatal wards are perpetually short staffed, and midwives are expected to care for both mums and babies, although only the mother’s are counted in patients in staffing ratios. Adequate pain relief is frequently trumped by competing demands in an overstretched system. 

In addition, women are commonly discharged home before they have a chance to be assessed by a physiotherapist, if one is available at all. At one major Victorian hospital, for example, there has been no funding for an inpatient maternity physiotherapy service for the last two years. This is despite inpatient physiotherapy being available on all orthopaedic and surgical wards. If a patient with a leg injury is unable to mobilise, they will be seen by a physio. If a woman has a torn anal sphincter, she will go home and wait. 

This response, at a systemic level, sets a clear expectation from the start; your birth injury is unimportant. It is little wonder that women live silently with the effects of their injuries for years without wishing to burden their doctor or allied health clinician with their complaints. 

The third important way that birth injuries are treated differently to other injuries is the lack of follow up care and rehabilitation. 

During pregnancy, women are the focus of expert care and attention. Yet once the baby is born, the focus shifts dramatically to the newborn. Contact with health professionals is frequently centred around the baby, with the wellbeing of the new mother an afterthought. Where a fractured leg will trigger multiple appointments for rehabilitation and medical reviews, an injured new mother is frequently on her own. The system for treating complex birth injuries is confusing and lacks any central coordination. It often requires an ability to self advocate and to pay out of pocket, a prohibitive barrier for many women. 

Furthermore, this ‘rehabilitation’ occurs at a time of huge physical upheaval. Rather than dedicating time and energy to healing, new mothers are likely learning to feed their babies, battling exhaustion, anaemia and sleep deprivation, as well as often struggling with mental health concerns or significant psychological trauma from their birth. 

To compound these challenges, birth injuries are hidden from view. Where crutches or a cast clearly signal that someone may be in pain or in need of extra assistance, there are no such social cues for birth injuries. The infected perineal wound, faecal incontinence, or vaginal prolapse can be debilitating, yet they remain invisible to the outside world. This contributes to the silence and the shame around birth injuries, by limiting opportunities to recognise fellow sufferers and share solidarity and wisdom. Unless, as a society, we begin to talk about these injuries, women’s experiences will continue to occur in a vacuum, with each new mother feeling isolated and alone. 

Deficiencies in the three areas described above – awareness, diagnosis and treatment- all come together to contribute to the situation that we currently find ourselves in. Women are suffering birth injuries and are left feeling unprepared, unheard, disbelieved and dismissed. This needs to change. 

There are a number of areas where improvement must occur.

The first is in the sphere of informing and preparing women for birth. Birth is a unique and special life event, and most births occur without complication or significant injury. However this does not mean we can deliberately hide information from pregnant women. For example, about five percent of people having their first vaginal birth will sustain an anal sphincter injury, rising to about eight percent of women having their first vaginal birth after a caesarean section. This information is well established, relevant, and most would agree represents a significant material risk. Choosing to withhold this information from women represents a paternalistic approach that has no place in modern maternity care. Of course, some women may choose not to be informed about potential complications prior to birth, and that wish should be respected. But for the remainder, we cannot continue to justify our collective failure to inform. 

For some women, elective caesarean on maternal request is a safe, valid and empowering choice. Australian and International guidelines agree that this option should be made available to well informed women who request this mode of birth. It is not the case however, that all women will request a caesarean birth if they are informed about potential childbirth injuries. Female obstetricians and midwives, for example, are highly aware of the possible risks. We have seen it all. Yet when it comes to our own birth experiences, the majority continue to desire and attempt vaginal birth. Rather than scaring women, the respectful provision of unbiased information is likely to equip a birthing person with power and knowledge. This knowledge can ensure that if a complication does occur, the woman is aware that this was a possibility, they feel included in discussions, and remain empowered and prepared. 

The next area where there is important work to be done is in the prevention space. It is not possible to eliminate all birth injuries, however there are several evidence based techniques that can reduce the likelihood of injuries occurring. For example the Australian Commission on Safety and Quality in Health Care recently released a National clinical care standard on third and fourth degree perineal tears which outlines the strategies that should be offered and adopted to minimise this type of birth injury, where possible. 

The final improvement that needs to be made is in the area of diagnosis and treatment. This area has been neglected for too long, and is ripe for a renewed focus of funding and research. Diagnosis and care must start immediately after an injury. This should include access to inpatient physiotherapy for all women after birth, improved postpartum education, safer midwifery staffing levels, and delayed discharge until all injuries have been properly assessed and managed. Ultrasound provides an opportunity to diagnose pelvic floor and anal sphincter injuries in the postpartum period, but requires upskilling of staff to recognise, diagnose and treat these injuries. Lastly we need a reduction in waiting times for specialised urogynaecology and colorectal care. This expert care needs to be culturally safe and delivered within the public hospital system, by dedicated birth injury clinics that include sexual health, social work and mental health support. 

It is clear that for change to happen we need two levers to move simultaneously. 

Firstly, we need the system to change. We must move from a system that ignores and dismisses women’s injuries to a system that treats birth injuries with as much respect, care and urgency as an injury sustained on a sports field. And, just as urgently, we need social change. Birth injuries must take up space in the national dialogue. We need to lift the shroud of shame and stigma and reveal the hidden burden of women’s birth injuries that have been ignored for too long.