Midwives: are we responsible for birth trauma? A discussion

[mothercat]

I recently posted a thread giving a list of resources for dealing with disappointing births and birth trauma. Then I was invited to the birth trauma tribe. So, now I have to ask:

Are we as midwives acknowledging and accepting that we may be contributing to the trauma that women are suffering at and following birth?

[Malga]

That is a very good question. I have thought about this myself before. I know a midwife I worked with has attended some births that seemed traumatic to the mother-- maybe some are not as committed to having a natural birth or vaginal delivery as others and this is something that should be addressed. I know of one mother who said she didn't want to have any more children after a long, hard birth with a long pushing stage. Now some would have seen this as a wonderful, supported natural birth, but this mother felt differently after the fact.

[JunipersMom]

I feel as a midwife I must accept and acknowledge that I cannot control others perceptions at all times, and I cannot be everything to everyone. Therefore it is possible and probable that someone will perceive my attendance and actions as contributing to trauma. You just cant be a part of such a huge life changing emotional time in peoples lives and please everyone all the time.
But, I also know in my heart that I do my best to serve my families.

[sevenkids]

Of course! Sometimes, birth isn't what was planned and it can get hairy at times. Sometimes I may suggest things that the mother does not want, but what I feel is in her and the baby's best interest.

One birth I recently attended, the baby was persistently posterior and asynclitic and I suspect by the amount of pubic pain, sucking a hand, and labour was not progressing, even with many position changes, lunges, rebozo, moxa, a loooong nap, and powerful contractions. I finally suggested she lay on her back in the classic hospital position, which pre-labor she was determined not to do, but after 10-15 minutes, the baby rotated and crowned and then born with a compound hand. She certainly felt traumatized, she was expecting an easier labour than with her first (which was pretty fast and very sweet and gentle) and was not prepared for such a hard time. Did I contribute? Well, I suggested a very uncomfortable position that by many accounts should be avoided at all costs. When she wanted to move after the first contraction, I asked that she try for a few more. I'm sure I did contribute to her feeling traumatized. But honestly, she was at the end of her rope and was begging for a c-section; 15 minutes later the baby was born. I know I felt terrible about keeping her on her back when it hurt so much, but I do think it saved her a transport and a c-section or at least a birth in the car.

I think we do have to acknowledge when women feel traumatized by our actions, and when we acknowledge that, we have to accept that what we did, while done in the best interest of the woman and baby, affected how she feels about her birth.

[MsBlack]

This is something I have thought about a lot actually...not that I have come to any solid conclusions! I will say this--there are times I hear birth stories wherein the mom is blaming the mw for contributing to trauma, and I can see it. Mostly this has to do with the mw's approach to her power in the situation--there are times when mws do things, or fail to do things, based on their sense of authority in the matter of birth. For instance, insisting on things like AROM, or a certain pushing position, insisting on transport or on staying home when the mom wants to transport. This can lead to a woman's sense of having been betrayed and ripped off by her mw instead of supported and respected.

Then again, I hear some stories where it is not nearly so clear as all that, not at all. The only clear 'fact' seems to be that the mom does feel traumatized--but it is not so clear that the mw could have done anything any differently under the circumstances, or indeed may have actually gone above and beyond the call of duty and respect and putting her own neck on the line. Well, things *always* 'could be done differently' in any situation--just trying to convey that it appears that there is no 'reason' to blame the mw--she probably did as much, and as respectfully, as anyone could have.

Pregnancy and birth are such huge things in our lives. Women come into pregnancy with a whole universe of self...beliefs, state of health and habits, expectations, psychology/personality, support system/culture, personal history, a relationship with self and to personal power...and all of that helps to make up her 'experience' of pregnancy and birth; it all plays out in her experiences. It has been said that experience is not just what happens to you--it is what you DO with what happens to you. And I see this so intimately with the women I work with--and of course, through my own pregnancies/births. Perception really does seem to be everything here. Memory can be quite selective, and highly biased in the face of strong emotions, and in the presence of certain personality traits and/or cultures and support systems! That selectivity can definitely be both for better OR for worse: I remember my own labors as gorgeous, luscious, blissful empowering events, surrounded by loving friends, that resulted in a BABY!!!!!--even the long ones that hurt like hell for hours on end...my memory selects the wonder and tends to delete the pain. Another woman has a highly painful labor, and *her* memory is of trauma and pain, tending to delete the support, the power, the bliss, the victory.... We are all different in the way we process things, what we expect, how we name things...and so forth.

I believe generally that every person present in any moment is co-creating events...that we are all responsible for things that happen around us to some degree. Whenever I have received criticism from clients (or from my kids, or anyone, really), I have to take it seriously: both as 'their own truth' and as something that somehow is part of my truth--and I have to give it real consideration. Granted, sometimes what I wish I'd done differently was not to work with a given family--had seen signs I ignored that did speak earlier to me about the possibility that no matter what happened, she and/or her mate would not be happy with the birth or with me! But then there are times when I have learned valuable things about how better to serve families at such an important time...had things brought into my awareness that I had not thought about before, did not see in myself, but could see through client feedback were not contributing to my manifestation of my ideal as a mw.

Anyway. IMO, this is a crazy and very intense time of upheaval in human consciousness. The 'old rules'--of marriage and family, of relationships to authority and power, especially--are no longer in play for many...but we do not have any 'new rules' set up to play by. Not to mention 'overcrowding psychosis', so much suffering on the planet, so much movement/transience of communities, ever greater financial disparities, more and more kinds and instances of abuse between humans...there is a lot going on AND, we are generally ever so much more aware than ever before of all that is going on (whether we watch the TV news or not). I definitely can't say that I mourn the 'old rules and norms'--and have hopes that we as a species are in the midst of a very positive change for ourselves and all of life ultimately. However--all this chaos does take its toll in the meantime. Gestating and birthing women ARE more sensitive to input, words, vibes, etc, anyway--and now, we don't have the comfort of traditions and interpersonal expectations to lean on. Also, homebirth (and any non-conventional birth such as birth center birth) unfortunately represents a deviation from the norm that takes a lot of courage and steadfastness in this era (at least in the US)--there is a huge amount of inherent stress upon families and mws alike, at a time when life is far better served by everyone being relaxed, and mothers feeling safe!

Anyway--I sum up this ramble by saying that while I do think it is possible for mws to contribute to a woman's sense of having been traumatized, it is far from a simple question, with no simple answers. I can take responsibility enough to try to look honestly and humbly at any negative feedback I might receive after a birth...try to see where my changes would help me to be a better servant of women/families at such a precious, important time. And I can't take responsibility for another's unspoken and unmet expectations, the fact that she might be an abuse survivor who is acting out her past victimization now, or the way their family might put pressure on a mom to assay blame upon me, or a baby's position that might have led to a very painful labor, and so forth. I am only human, and have only so much control over events. I believe in taking responsbility, yes...but to take too much responsibility for events or for another's feelings/experience is only another way of making oneself, as care provider, the One with All The Power. And there is no situation, no relationship, in which I have that much power!

[pamamidwife]

Yes. Yes. Yes. I believe that any care provider is at risk for impacting another person's birth experience.

I agree with MsBlack on many of the things she wrote.

It is always my hope that women who feel negatively about their birth experience - or any part of it - tell me. Write a letter, call me one the phone, meet in person. As a care provider, I need this information and feedback.

[MsBlack]

Yes, discussion of these things is very important to me, if a mom is unhappy. I add to Pam's list of call, write, sit down with me--arrange for a discussion with a neutral third party's assistance, if it seems safer to the mom to do so. My clients sign a "statement of responsibilities" upon hiring me (and I sign one, too, worded 'separately but equal') which affirms among other things that if a conflict arises that we are not able to sort out ourselves, they agree to meet with me in mediation. Interestingly enough--while a few clients have had complaints to discuss with me, all were resolved--happily for all--through our own conversations. There was only one who felt 'traumatized'--and after one conversation in which we agreed to stop talking for the moment and come back to it another time--basically, hearing each other out once, and then choosing to set aside for further consideration by all--their choice was to take their complaint to the state. So--they'd signed an upfront agreement to seek mediation w/me if necessary; they agreed (loosely) after our one talk, to get together again. I followed up with a letter to them a week or so later, and invited them again to discuss together further.

The response came from the State, a few months later. Just to say that for some parents, the only 'answer' is to assign blame...and if blame and need for restitution is not accepted by the mw, there is nothing more that a mw can do.

[fourgrtkidos]

I find that if the birth is talked about and worked through at the pp visits and the client knows "why" we asked them to do the things we did (like pushing on their back) and how we perceived our actions and if we could see positive outcomes that they couldn't through their pain...... they feel less traumatized or victimized.
When the birth story is not "gone over" and their is no discussion..... memories become different somehow.

[Romana]

I'm not a birth professional, but I think HCPs attending births can do a lot to minimize a possibly traumatic experience by really listening to the mother after the birth, at post-partum visits, and asking the mother to ask questions and give honest feedback. Understanding why a HCP has done something, and perhaps hearing that HCP say, "I could have said/done that more gently, thank you for telling me how that made you feel" can make a world of difference to a mother trying to sort out/work through her birth experience.

[MsBlack]

I agree Romana--people really value being heard. Sometimes, really listening with an open heart, and accepting another's truth as their truth, is the most loving, healing thing we can do. Adding a sincere apology for one's place in things--however unintended--can also help. I have seen this work in the cases where clients had a complaint (as well as among friends). It doesn't always help...or at least not enough...but often it helps both parties to move past hurt and upset into healing and understanding.

[mothercat]

This where I was hoping the conversation would go.

I feel like I have been heading into an emotional black hole. In the last few weeks I have been becoming more involved with birth trauma. It started with ICAN, then led to JanetF's birth trauma site, and then the birth trauma thread here on MDC. After reading so many postings of women's pain I was beginning to think that women were better off all going UA.

There is just so much emotional pain that is associated with childbirth. I can easily understand the normal grieving and adjustment after a birth. I don't think that birth ever goes quite as perfectly as we would like, but the trauma that these women talk about is very different.

There is such a sense of betrayal that goes along with the physical pain they have suffered. I wanted to get some sense of perspective, that other midwives were also seeing this and dealing with it in some way.

[wumanh]

A good discussion here! So many variables go into someone's experience. The best I can do is try to be clear in my communication, sensitive to the mom and try to create an open safe atmosphere for both of us. I think if we are really feeling with the mother she can sense it and that goes a long way to her not feeling traumatized. We are on the same team after all.
We can't take responsibility for another's reactions either.

[mothercat]

I wonder if that's not the problem that some midwives are having- the feeling empathy part. I know that this has come up in other discussions, that the midwife feels it's a win or lose situation. They can't see how it can be a win-win, so that the mom feels less traumatized, only how if they admit any responsibility, then they lose.

There is one midwife I know who told the mom that she (the midwife) couldn't take any responsibility for what happened because if she did, then she would be taking away the woman's responsibility and her chance to admit how she messed up her own birth. All the mom wanted was for the midwife to say is "I could have done things differently. I have learned from my mistakes."

I've seen this discussed on other boards in terms of malpractice. The family seldom wants money, what they want is for the HCP to say "sorry" and to promise that things will change. Most of the time they get no satisfaction and see the money as a way for the HCP to pay attention to their distress.

I think this is going to end up as the midwives who are mature and balanced enough to be able to empathize and minimize the woman's trauma. And then there are those who will continue to see it as a win or lose problem, and they will always need to win.

As long as this continues to happen, I think the best I can do personally is to hone my counseling skills and try to help women heal with the next birth.