One third of birthing parents has a traumatic birth.[i] [ii] [iii]
“The system is broken.”
One in 8 new parents enters parenthood with postpartum PTSD from the experience.[iv]
“The system is broken.”
Depending on where you live, one third, one half, or almost everyone has a surgical birth.[v]
“The system is broken.”
One in 6 women are abused during their births.[vi]
“The system is broken.”
If we say it enough, we might believe it. However, the “system” is decidedly NOT broken. It is doing exactly what it was set up to do by any means available to it.
The “system” is how we deliver maternity services. It began when male-midwives, those physicians who broke social etiquette, began attending women in birth. They were barbaric in means because they were sanctioned by the Catholic church to carry sharp instruments that women were forbidden to use. Male barber-surgeons, the Chamberlains, invented the forceps but kept their secret hidden for a century. A few centuries of witch hunts where midwives and female healers were persecuted and executed taught the public to shy away from learning these skills – if they were women. The collusion of religion and medicine ensured that men gained and maintained a monopoly over sick care and what women were allowed to do with their own bodies.[vii]
Eventually, through clever marketing, the male midwife became the preferred attendant as they were considered superior in intellect.[viii] [ix] Women were forbidden to attend universities, practice medicine, or serve in leadership in religions that ruled the western politic, thus unable to influence how women were treated in childbirth.[x]
Sure enough, these clever men discovered how much more profitable it was to bring birthing clients to them rather than going out to their homes.[xi] And so emerged the ‘lying-in’ hospital. The wholesale slaughter of women in these death traps was on par with the witch hunts of a few centuries prior. One in ten women died from puerperal fever, brought on by the unwashed hands of physicians who went from cadaver to the birthing vagina.[xii] Despite the protests of the offensive Semmelweis to wash their hands, ego and elitism prevented them from adopting this simple strategy for many more years thus ensuring the needless deaths of countless more women.[xiii]
Ignaz Semmelweis washing hands with chlorine-water, 1846
Once chloroform and other means of anesthesia were available for use in childbirth, the medical societies lobbied the government to grant them exclusive access. Not that they were any more qualified to use these powerful drugs than any other discipline, they merely had the ear of those in power who made these decisions.[xiv] Next followed the most effective smear campaign in all of history to drive midwives and alternative healing modalities out of business. [xv] [xvi] By the end of WW2 the campaign was almost complete. Next came effective lobbying to ensure governments were only favourable to their approach and the money, legislations, and endorsements flowed to hospital based technocratic birth where the obstetrician is royalty.
Even today, midwives around the world are persecuted and legislated out of business for offering client-centred care and serving women outside of hospitals.
Leaning heavily on Henry Ford’s conveyor belt system of turning out cars, optimisations and standardisations were implemented to cut costs, increase revenue, and turn the business of birth into a well-oiled machine.[xvii]
What we have is an effective system of profit for those industry players who set it up this way.
Of course, women are abused in birth! It’s an effective means of getting them to submit to a routine, one-size-fits-all, conveyor belt, in-and-out, profitable baby factory.
Even the current schedule of prenatal visits has no basis in science, evidence, or benefit. It was created by those same male-midwives who took a good thing and made it $tandard. Certainly, diagnosing and treating medical issues is an important healthcare strategy, whether pregnant or not. In light of the evidence that today’s current schedule and routines have not produced the promised results of healthier pregnancies or births, the industry recommended and implemented a strategy to convince the public that the process of pregnancy could not be trusted to stay normal without their surveillance.[xviii]
Now let’s talk about the people.
Some people enter this industry because it’s proven itself as a profitable endeavour. Obstetrics includes a great deal of power and control over a physiological process that in most cases would unfold quite simply without them. This appeals to some people. It’s a position of elitism and sits higher on the social hierarchy. There’s nothing to see there. Nothing to reach. Nothing to change.
And some enter this industry because they believe they have something valuable to offer during one of the most sacred and vulnerable times in a person’s life. They believe in the importance of how new humans are greeted into this world.
But because they have entered a highly successful system, they witness and sometimes participate in horrific abuses of mothers and babies. Some are broken by this and are the walking and working wounded, grappling with trauma, burnout, PTSD, and even suicidal ideation. Some survive and continue doing the best they can without the learned skillset of trauma-informed care that protects them and their clients. And some become part of the system of abuse and profit as their initial purpose is co-opted by internalised patriarchy and misogyny.
But what’s to be done with those who are broken and those who are merely surviving? The system doesn’t care if they burnout and leave. Players are easily replaced by new inductees at beginner salaries. It was never set up to take care of anyone. It was set up as a profitable means of co-opting physiology for profit based on fear and coercion.
“What we have is a medical system that is literally killing people through suicide.”
Break time. Nature and birth are not always kind. Women have always benefited from the companionship and knowledge of their midwives. And when events became problematic, skilled surgeons and expert paediatricians have brought hope and life where there was once only death. This post only speaks to the system of facility-based birth that currently exists within a patriarchal, misogynistic, and technocratic paradigm.
Back to the people.
‘Burnout’ consists of three features
Emotional exhaustion – feeling emotionally depleted from being overworked
Depersonalisation and cynicism – unfeeling towards patients and peers with often negative, callous, and detached responses
Reduced personal efficacy – a reduced sense of competence or achievement in one’s work
Burnout, compassion fatigue, and trauma are often intermingled in the academic literature so it’s hard to get a sense of the enormity of the issue. However, we do know this:
Physicians
Female physicians have higher rates of burnout and less work satisfaction than males[xxiii]
Physicians have the highest rate of suicide of any profession[xxiv]
General population - 12.3 per 100,000
Physicians -28 to 40 per 100,000
Equal numbers of male and female physicians complete a suicide
Midwives
Midwives around the world report rates of burnout from 20%[xxv] to 65%[xxvi]
One third of midwives have clinical PTSD[xxvii]
Witnessing abusive care of patients creates more severe PTSD[xxviii]
Nurses
35% of labour and delivery nurses have moderate to severe secondary traumatic stress[xxix]
Witnessing or participating in abusive births is a direct contributor to trauma
24% higher rate of suicide than those outside the profession[xxx]
Nurses and Midwives
Female 192% more likely to complete suicide than females in other occupations
8.2 per 100,000 vs 2.8 per 100.000
Male 52% more likely to complete suicide than males in other occupations
22.7 per 100,000 vs 14.9 per 100.000
Male 196% more likely to complete suicide than female colleagues
22.7 per 100,000 vs 8.2 per 100.000[xxxi]
Doulas
Half of doulas report burnout[xxxii] where traumatic incidences and witnessing the mistreatment of labouring clients were direct causes of burnout. Secondary trauma causes doulas to leave the profession early, especially in light of institutional hostility, low income, and routine abuses of their clients[xxxiii]
From the client’s perspective, the simple answer is to birth outside the system.[xxxiv] It’s a reasonable option – unless you’ve drunk the Kool Aid and feel these parents are a danger to their foetus and must be punished through disrespectful care[xxxv] and calls to Childrens Apprehension Services. If enough clients choose an alternative to the system, then simple economics will drive change to bring back the customers.
Birthing families are paying a steep price for system-driven birth. High rates of trauma, postpartum PTSD, postpartum depression and anxiety, relationship breakdowns, and postpartum suicide.[xxxvi] [xxxvii] [xxxviii] [xxxix] [xl] [xli] What we have is a medical system that is literally killing people through suicide.
So, what to do with the crippling loss of health and wellness in those professionals who chose to enter the system to support families in a humane and compassionate manner? Is it even possible to bring back those who have lost their way?
Because the system of institutionalised maternity services is predicated on a patriarchal and misogynistic paradigm of control and elitism, it will never take care of those who are on the front lines. We must learn to take care of ourselves and each other.
Many good and decent people entered into the system of technocratic birth services with all the requisite technical skills and a desire to make a difference in the lives of birthing families. What was missing from their education and skills development were those specific skills that would equip them to work in that environment without losing their soul, their identity, or their life.
Fortunately, the same research that identifies the many problems with this delivery system of services, also identifies the many solutions. For those that are on a journey out of trauma and professional burnout towards recovery and professional efficacy, there are proven strategies that can help walk you towards recovery and wholeness. You can learn
A research-based understanding of the causes and consequences of birth trauma in the birthing client and how to avoid participating
A thorough understanding of secondary and vicarious trauma and its effects in healthcare providers
How to build neurological, biological, psychological, social, cultural, and structural resilience
The positive impact of affective empathy and how to use it
How to employ a trauma-informed approach with clients and peers that improves clinical accuracy, client and professional well-being, and reduces burnout, medical mistakes, and litigation
A knowledge of therapeutic modalities that are specific to trauma
Recovery is possible for those who seek it. While the system runs perfectly as it was designed to, it’s also possible that with enough recovered, equipped, and healthy participants we might see some significant changes that actually helps it to live up to its marketing of “healthy baby healthy mother”. In time, it might even include “healthy professionals”.
I’ve got the science. I’ve got the experience. And I’ve got the tools to help. Let’s do this together.
Much love,
Mother Billie
Endnotes
[i] Garthus-Niegel, S., von Soest, T., Vollrath, M. E., & Eberhard-Gran, M. (2013). The impact of subjective birth experiences on post-traumatic stress symptoms: a longitudinal study. Archives of women's mental health, 16(1), 1-10.
[ii] Creedy, D. K., Shochet, I. M., & Horsfall, J. (2000). Childbirth and the development of acute trauma symptoms: incidence and contributing factors. Birth, 27(2), 104-111.
[iii] Schwab, W., Marth, C., & Bergant, A. M. (2012). Post-traumatic stress disorder post partum. Geburtshilfe und Frauenheilkunde, 72(01), 56-63.
[iv] Montmasson, H., Bertrand, P., Perrotin, F., & El-Hage, W. (2012). Predictors of postpartum post-traumatic stress disorder in primiparous mothers. Journal de gynecologie, obstetrique et biologie de la reproduction, 41(6), 553-560.
[v] Boerma, T., Ronsmans, C., Melesse, D. Y., Barros, A. J., Barros, F. C., Juan, L., ... & Neto, D. D. L. R. (2018). Global epidemiology of use of and disparities in caesarean sections. The Lancet, 392(10155), 1341-1348.
[vi] Vedam, S., Stoll, K., Taiwo, T. K., Rubashkin, N., Cheyney, M., Strauss, N., ... & Schummers, L. (2019). The Giving Voice to Mothers study: inequity and mistreatment during pregnancy and childbirth in the United States. Reproductive health, 16(1), 77.
[vii] Ehrenreich, B., & English, D. (2010). Witches, midwives, & nurses: A history of women healers. The Feminist Press at CUNY.
[viii] Smith Adams, K. L. (1988). From 'the help of grave and modest women' to 'the care of men of sense': the transition from female midwifery to male obstetrics in early modern England. (Master’s thesis, Portland State University.
[ix] Burrows, E. G., & Wallace, M. (1998). Gotham: a history of New York City to 1898. Oxford University Press.
[x] Minkowski, W. L. (1992). Women healers of the middle ages: selected aspects of their history. American journal of public health, 82(2), 288-295.
[xi] Tew, M. (2013). Safer childbirth?: a critical history of maternity care. Springer.
[xii] Loudon, I. (2000). The tragedy of childbed fever. New York, Oxford University Press.
[xiii] Tew, M. 2013, op. cit.
[xiv] Bonner, T. N. (1989). Abraham Flexner as critic of British and Continental medical education. Medical history, 33(4), 472-479.
[xv] Getzendanner, S. (1988). Permanent injunction order against AMA. JAMA, 259(1), 81-82.
[xvi] Weeks, John. (n.d.). “AMA ‘Thwarts’ Other Professions Practice Expansion and a Challenge to CAM-IM Fields”. The Integrator Blog. http://theintegratorblog.com/?option=com_content&task=view&id=73&Itemid=1
[xvii] Perkins, B. B. (2004). The medical delivery business: Health reform, childbirth, and the economic order. Rutgers University Press.
[xviii] Ball, J. (1993). The Winterton report: difficulties of implementation. British Journal of Midwifery, 1(4), 183-185.
[xix] Peckham, C. (2016). Medscape lifestyle report 2016: bias and burnout. New York, NY: Medscape.
[xx] Avery, Granger, M.D., (2017). The role of the CMA in physician health and wellness. Canadian Medical Association.
[xxi] Imo, U. O. (2017). Burnout and psychiatric morbidity among doctors in the UK: a systematic literature review of prevalence and associated factors. BJPsych bulletin, 41(4), 197-204.
[xxii] Wu, F., Ireland, M., Hafekost, K., & Lawrence, D. (2013). National mental health survey of doctors and medical students.
[xxiii] Peckham, C., 2016, op. cit.
[xxiv] T’Sarumi, O., Ashraf, A., & Tanwar, D. (2018). Physician suicide: a silent epidemic. Reunión Anual de la American Psychiatric Association (APA). Nueva York, Estados Unidos, 1-227.
[xxv] Henriksen, L., & Lukasse, M. (2016). Burnout among Norwegian midwives and the contribution of personal and work-related factors: a cross-sectional study. Sexual & Reproductive Healthcare, 9, 42-47.
[xxvi] Creedy, D. K., Sidebotham, M., Gamble, J., Pallant, J., & Fenwick, J. (2017). Prevalence of burnout, depression, anxiety and stress in Australian midwives: a cross-sectional survey. BMC pregnancy and childbirth, 17(1), 13.
[xxvii] Sheen, K., Spiby, H., & Slade, P. (2015). Exposure to traumatic perinatal experiences and posttraumatic stress symptoms in midwives: prevalence and association with burnout. International journal of nursing studies, 52(2), 578-587.
[xxviii] Leinweber, J., Creedy, D. K., Rowe, H., & Gamble, J. (2017). Responses to birth trauma and prevalence of posttraumatic stress among Australian midwives. Women and birth, 30(1), 40-45.
[xxix] Beck, C. T., & Gable, R. K. (2012). A mixed methods study of secondary traumatic stress in labor and delivery nurses. Journal of Obstetric, Gynecologic & Neonatal Nursing, 41(6), 747-760.
[xxx] Office for National Statistics. (2017). Suicide by occupation, England: 2011 to 2015.
[xxxi] Milner, A.J., Maheen, H., Bismark, M.M., & Spittal, M.J. (2016) Suicide by health professionals: a retrospective mortality study in Australia, 2001–2012. Medical Journal of Australia 205 (6): 260-265.
[xxxii] Naiman-Sessions, M., Henley, M. M., & Roth, L. M. (2017). Bearing the burden of care: emotional burnout among maternity support workers. In Health and Health Care Concerns Among Women and Racial and Ethnic Minorities (pp. 99-125). Emerald Publishing Limited.
[xxxiii] Roth, L. M., Heidbreder, N., Henley, M. M., Marek, M., Naiman-Sessions, M., Torres, J. M., & Morton, C. H. (2014). Maternity support survey: A report on the cross-national survey of doulas, childbirth educators and labor and delivery nurses in the United States and Canada.
[xxxiv] Holten, L., & de Miranda, E. (2016). Women׳ s motivations for having unassisted childbirth or high-risk homebirth: An exploration of the literature on ‘birthing outside the system’. Midwifery, 38, 55-62.
[xxxv] Vedam, S., Stoll, K., Rubashkin, N., Martin, K., Miller-Vedam, Z., Hayes-Klein, H., & Jolicoeur, G. (2017). The Mothers on Respect (MOR) index: measuring quality, safety, and human rights in childbirth. SSM-Population Health, 3, 201-210.
[xxxvi] Oates, M. (2003). Perinatal psychiatric disorders: a leading cause of maternal morbidity and mortality. British medical bulletin, 67(1), 219-229.
[xxxvii] Oates, M. (2003). Suicide: the leading cause of maternal death. The British Journal of Psychiatry, 183(4), 279-281.
[xxxviii] Lewis, G. (2007). Saving mothers' lives: reviewing maternal deaths to make motherhood safer 2003-2005: the seventh report of the confidential enquiries into maternal deaths in the United Kingdom. CEMACH.
[xxxix] Austin, M. P., Kildea, S., & Sullivan, E. (2007). Maternal mortality and psychiatric morbidity in the perinatal period: challenges and opportunities for prevention in the Australian setting. Medical Journal of Australia, 186(7), 364-367.
[xl] Palladino, C. L., Singh, V., Campbell, J., Flynn, H., & Gold, K. (2011). Homicide and suicide during the perinatal period: findings from the National Violent Death Reporting System. Obstetrics and gynecology, 118(5), 1056.
[xli] Grigoriadis, S., Wilton, A. S., Kurdyak, P. A., Rhodes, A. E., VonderPorten, E. H., Levitt, A., ... & Vigod, S. N. (2017). Perinatal suicide in Ontario, Canada: a 15-year population-based study. Cmaj, 189(34), E1085-E1092.