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“Every year, about 25,000 (UK) women who give birth — approximately 4 per cent — are so distressed that they meet the diagnostic criteria for post-traumatic stress disorder. That makes birth one of the biggest causes of PTSD in the UK according to the Birth Trauma Association charity – probably coming second only to sexual abuse and rape. Hundreds of thousands more women are traumatised. This is a major health crisis. And yet it is barely discussed…

According to figures from NHS Resolution, the arm of the Department of Health and Social Care that handles litigation, 62 per cent of the total clinical negligence cost of harm in 2022-23 (£6.6 billion) related to maternity.”

When my husband and I left for hospital on a Friday afternoon, we had no idea what would happen. The next few hours would change my life. For good and bad. It had all started with a cervical sweep the day before. I was 40 weeks and 4 days pregnant and, frankly, I’d had enough. My pregnancy had been uncomplicated in terms of my baby — she was healthy throughout, albeit had spent much of her time in the back-to-back position. But I had found the nine months increasingly difficult. From around 20 weeks I’d suffered from pelvic girdle pain, which, for me, meant increasingly agonising pain in my lower back. Walking and other everyday movements became difficult. The only place I felt vaguely comfortable was in water. Swimming was a relief.

Women are offered a sweep to help induce labour. A midwife inserts their finger and sweeps around your cervix. It’s about as basic as you can get. They’re trying to separate the membranes of the amniotic sac that surround the baby from your cervix. This then releases hormones, which may help start your labour. “Some women find the procedure uncomfortable or painful,” NHS guidelines say. I found it excruciating.

“Oh,” the midwife said, as I lay in a rather compromised position. “I might have broken your waters.” This didn’t make sense to me. I’d always assumed that when my waters broke, I’d know about it. Apparently not always, and I was instructed to call the hospital if contractions hadn’t begun within 24 hours as I was now potentially at risk of infection.

They didn’t start. And I did what I’d been asked. The voice on the phone was chirpy — everything sounded fine, stay at home, we’ll be seeing you soon enough. Half an hour later, my phone rang. “Where are you? You’re meant to be at the hospital,” the woman said angrily. I needed to come in immediately to be examined.

It was late Friday afternoon and it was busy. We took the last of the beds in maternity triage. And my waters broke in earnest. That solved the mystery, I suggested. No, I was told, and the water birth I’d hoped for was out of the question — too risky.

Strong and regular contractions started immediately. We were moved to a glorified cupboard that had been turned into a makeshift holding room. I was denied any pain relief because it was “too early”, and told that someone would bring me some paracetamol when they came to “examine” me.

It seems obvious when you think about it, but I had never been told what being “examined” meant. Nor thought about it. It sounds medical. But it’s literally a midwife sticking their fingers inside you. I was 3cm dilated. Plenty of time to go, apparently. It was 9.30pm. I felt sick and in enormous pain. Both were dismissed — until I vomited everywhere. And lost control of my bowels. This would happen several more times over the coming hours. I felt utterly ashamed. Again, it’s common — but I hadn’t been told.

I continued to ask for pain relief and continued to receive none. An hour later, I was 7cm dilated — in full labour — and finally received some paracetamol. There was no space on the labour ward. In just another half an hour, I was fully dilated and ready for the baby to come out. No one seemed to know what to do. The midwives were panicking. And that made me scared. This was my first baby. I didn’t know what to expect. We were rushed to the ward. Already, nothing had gone the way I wanted, or the way it had been talked about at National Childbirth Trust (NCT) classes. Eventually, I was given gas and air to ease the pain. But only for about 20 minutes. Apparently it was “distracting” me too much and I needed to push.

Two hours later there was still no baby and I was in agony. A doctor arrived, took a brief look and said cheerily, “You’re going to be fine. You’re going to get that baby out.” And then he left. My maternity notes state, “PLAN: continue pushing.” I have no idea what this refers to — like so many of my notes. There was no plan. If there was, it wasn’t one I had agreed to. Finally, after another hour the decision was made that the doctor would use a ventouse — a suction cup that sits on your baby’s head — to help deliver my baby. Apparently I consented to this, but I have no recollection of doing so. And I’m ashamed to say I didn’t know what was being asked of me. My doctor didn’t use the word ventouse. He used “Kiwi”, which is a type of ventouse. At the time, I didn’t know what either were.

I remember screaming in pain and then my daughter finally being born. She was placed on my chest for less than a minute. I was examined, told I had a fourth-degree tear that must be repaired and that I needed to sign a consent form for surgery straight away. “Look at the state of her,” my usually mild-mannered husband said. “How can she possibly sign a form?” I couldn’t. The writing on that form is barely legible, but they would not proceed without it.

I had no idea what had happened. I lay in an operating theatre in pain, silent tears rolling down my face. I was frightened. The anaesthetist was amazing and stayed with me while I was repaired. I am so grateful for that, at least. But I also feel guilty about it. It was half past three on a Saturday morning and she was the only anaesthetist on duty at the London hospital. Other women may well not have received the pain relief they needed because of me. “Will I be able to have any more children?” I asked as I stared at the ceiling.

After surgery I was moved to the high dependency unit (HDU) and reunited with my daughter. I finally held and fed her for the first time. That morning is a blur. My notes tell me we stayed in the HDU for five hours before being moved to a ward. It was there that I attempted to understand what had happened to me. I was in pain, barely able to move and soaked in blood. I asked various midwives to explain what had gone on. They repeated that I’d had a fourth-degree tear, but I didn’t know what that meant. One line, in scribbled handwriting, stands out when I look at my notes: “We don’t have any written info about fourth-degree tears.”

Eventually, a midwife appeared with some information they’d printed off after googling it. As I read it, I sobbed. I was 35 years old and thought my life was over; that I would be incontinent. And still no doctor came to explain. The medic who’d delivered my daughter was eventually marched to my bedside more than 48 hours later.

I am perhaps unusual in that I’ve always wanted children. We had done what many middle-class suburban couples did at that time and attended NCT classes. The underlying message of these was: try to avoid a caesarean section at all costs. “Natural” births were best, and even better just to breathe through it. No need for pain relief. I remember in our penultimate class bringing up the subject of tearing during labour. I had seen a TV feature on it that week and it struck me as important. “If most of us are going to tear to some degree, it would be really helpful to talk about that,” I remember saying. “It would be good to know how best to care for ourselves afterwards, that kind of thing.” The answer was no, there was no need. Instead, we proceeded to get on all fours and “moo” like cows and then practise putting nappies on a doll.

Up to nine in ten first-time mothers who have a vaginal birth will experience some sort of tear. The least invasive kind involves only the skin from the vagina and the perineum — the area between a woman’s vagina and anus. These tears usually heal quickly and without any treatment. Second-degree tears involve the muscle of the perineum and require stitches. Third and fourth-degree tears are the most serious. These involve not just tearing of the skin and muscle of the perineum but the muscle of the anus. In fourth-degree tears, the injury can extend into the lining of the bowel. These deeper tears need proper surgical repair under anaesthetic.

I don’t really have any happy memories of the first few days or weeks after we left the hospital. I was completely in love with my baby, but I felt shellshocked. I couldn’t process what had happened and there was no one who offered to help me. A different midwife was sent to our house every couple of days to weigh our daughter. I had no milk the first few days and she had lost a fair bit of weight. Even when my milk came in, I found breastfeeding painful and difficult, in large part because it hurt so much to sit down.

I cried quietly every day for several months. Often it would come completely out of nowhere. I’d be talking or watching television and I would just start to cry. Several midwives wrote in my notes in those early weeks the same phrase: “Mum is anxious.” I don’t think I was. I was traumatised. Several weeks later, I was told that I was “lucky” by the midwife examining my stitches. Apparently the doctors had done a “wonderful” job at repairing me and it looked “beautiful”. I now know that I was fortunate to be repaired properly and immediately after the birth. But the last thing I felt — then or now — was lucky.

After several months I desperately needed to have some control over my life again. I had never felt so helpless, lost and infantilised. But my overarching feeling was anger. I wrote to the chief executive and chair of the hospital to complain and was invited in for a debrief. The head of midwifery was lovely, apologised and followed through on her promise to try to prevent other women facing the appalling lack of communication I had. The hospital now has a specialist perineal health clinic too.

But the attitude of the consultant obstetrician whom I met with my husband floored us both. It was about six months after the birth, but I was still under the care of a consultant urogynaecologist. (I subsequently had two further operations: the first 14 months after giving birth to remove an undissolved stitch that was causing pain but hadn’t been spotted, and another six months after that.) My urogynaecologist had told me not even to consider giving birth vaginally again. The risk was too great, he explained. If I tore again, there was a 30 per cent chance I couldn’t be repaired and I’d be incontinent. The obstetrician said the opposite — don’t rule it out! I saw red. “How dare you,” I growled. I remember saying that he would never be so cavalier about a man’s body.

Every year, about 25,000 women who give birth — approximately 4 per cent — are so distressed that they meet the diagnostic criteria for post-traumatic stress disorder. That makes birth one of the biggest causes of PTSD in the UK according to the Birth Trauma Association charity – probably coming second only to sexual abuse and rape. Hundreds of thousands more women are traumatised. This is a major health crisis. And yet it is barely discussed.

“Birth trauma is a broad term, but generally it’s overwhelming distress that leads to a detrimental impact on well-being,” explains Susan Ayers, professor of maternal and child health at City University in London. Estimates “range massively”, she says, but having conducted research into birth trauma for almost 30 years, Ayers puts it at about a third. “If you ask women whether they thought they or their baby was going to die or be severely injured, then it’s around 19-20 [per cent] in the UK. But if people just ask women, ‘Was your birth traumatic?’ some of those estimates are up to 50 per cent.”

“I’M BEATRICE’S MUM,” EMILY SAID, introducing herself to a committee of MPs in March. “Beatrice died during labour at full term in May 2022.” Emily is one of a number of brave women who have shared their traumatic birth stories with the all-party parliamentary group (APPG) on birth trauma, during the first parliamentary inquiry into this issue.

“As soon as my labour started,” Emily explained, “I knew it wasn’t right, wasn’t normal.” The details are harrowing: a series of obvious but missed red flags and an attitude from medical professionals that can only be described as cruel. The midwife who shrugged her shoulders when Emily’s waters were meconium-stained; the consultant obstetrician who laughed at the “slimy” feel of that meconium while her hand was still inside Emily.

“The ultrasound scanning machine was brought in and showed that Beatrice’s heartbeat had stopped,” she explained. “At that point I begged, pleaded like I’ve never pleaded for anything in my life for a caesarean, and that consultant obstetrician refused. She said no. And she left.”

“It’s destroyed my life,” Emily says now. “I’m not the person I was before.”

This inquiry has been led by the APPG’s co-chairs, the Conservative MP Theo Clarke and Labour’s Rosie Duffield. They received more than 1,200 written submissions after asking women to share their experiences; that number doubles if you count the letters and emails they’ve been sent informally.

“The thing that’s really struck me is there seems to be a taboo around talking about the risk of childbirth,” Clarke tells me when I sit down with both women in Westminster. There shouldn’t be, she adds. “Something we’ve heard from a number of the mothers coming to speak to us is that there’s such a focus on the baby post-delivery, they almost forget there’s a second patient in the room, and that’s the mother.”

“I was constantly told by GPs that I had nothing wrong with me,” one mother, Sarah, told the MPs. She experienced a major tear that doctors and midwives failed to diagnose. “I was discharged two days later with [an] untreated tear, which very quickly led to enormous amounts of pain, incontinence, faecal incontinence and thinking I was going mad.”

“It’s very painful,” explained Jenny, who also experienced a serious tear that was left untreated, “but the long-term consequences of an unrepaired tear are that I had to give up my job. I’ve suffered PTSD, anxiety, depression. My activities are restricted. My life is impacted in that I have to meticulously plan my day around toilets.”

Another mother, Neera, lost three litres of blood and required more than ten hours of life-saving emergency surgery the day her daughter was born. The haemorrhage had not been picked up by staff. She said she is fortunate to have had the “means and support” to access mental healthcare over four and a half years of her five-year-old’s life. “I have personally spent over £6,000 and received more than 50 hours of mental health support,” she told parliament.

The women who have spoken to politicians as part of the inquiry had different medical experiences. But there were obvious similarities. Their concerns and their pain were dismissed. They were not treated with respect or, in some cases, like human beings. They felt helpless, angry and scared. “Nobody really cares about women,” says Kim Thomas, CEO of the Birth Trauma Association. “What we tend to find with most of these stories is there’s failure after failure after failure. Lots of things go physically wrong… and that continues afterwards in the postnatal period with really poor care.” Almost all women seeking out the charity say their experience was made much worse by the way they were treated during labour. “The number of stories we hear of women being shouted at by midwives or laughed at by midwives is quite extraordinary.”

Birth doesn’t have to be this way. And it isn’t for many women. But women, in England in particular, could — and should — be having better experiences than they are.

Let’s start with serious tears. The number one risk factor is being a first-time mum. There’s nothing much that can be done about that. But the next is having an instrumental vaginal delivery — and in particular one that uses forceps. “Data indicates that we use more forceps than other parts of Europe,” says Dr Ranee Thakar, president of the Royal College of Obstetricians and Gynaecologists (RCOG). While rates in several European countries hover at around 0 per cent, a 2023 study of assisted births in 13 high-income countries found England used forceps in a higher proportion of births — about 11 per cent — than any other.

There are cases where forceps must be used. When babies are premature, suction would cause too much damage to the head. But that’s doesn’t explain the discrepancy. “It’s education,” Thakar explains. “We should be trained to do both [forceps and ventouse], so that we provide the best care to women and use the right instrument for the right baby and the right mother.”

The risk of a severe tear when forceps are used is at least twice as high as with ventouse: 8-12 per cent compared with 4 per cent. Women should be told this. The recent parliamentary inquiry heard other suggestions that might explain why forceps use in England is so high. The consultant gynaecologist and obstetrician Dr Nitish Raut explained that when poor outcomes of childbirth become part of litigation, the question, “Why were forceps not applied earlier?” will be asked. Although they can cause injury to mothers, forceps are the most effective instrument for getting a baby out. If a doctor tries and fails to deliver a baby with the less invasive ventouse first, a record will be made at the hospital trust. It was suggested by others that this might also be pushing some doctors straight to forceps use even when they might not be necessary.

“Training is a really key part of everything here,” Posy Bidwell, deputy head of midwifery at South Warwickshire Foundation Trust, told MPs. “If we can train people, we can prevent these injuries happening. Many midwifery students wouldn’t know the impact that these injuries are having on women.”

Newly qualified midwives did not know enough about perineal damage, and yet they’re providing one-to-one care to women. Current training did not seem to see it as a priority: while several aspects of maternity care are mandatory each year, suturing and perineal protection are not.

Neither doctors nor midwives appear to be taught how to routinely examine women after they have given birth either. Where this was once part of mandatory medical training, doctors are no longer encouraged to do it, Raut explained.

England is short of as many as 2,500 midwives, the Royal College of Midwives (RCM) estimates, although people are wanting to train and join the profession. Donna Ockenden, who is reviewing maternity services at Nottingham and who previously did so at Shrewsbury and Telford Hospitals NHS Trust, cautions against being too optimistic, however. The focus needs to be on retention. “Two midwives don’t equal two midwives,” she told parliament, “of we are losing midwives with 20, 30, 35 years’ experience… and they’re then being replaced by a more junior workforce, who are not being supported in those early days of their career.”

In the past decade and a half, the UK has seen several NHS maternity scandals — in Morecambe Bay, Shrewsbury and Telford, and East Kent. In all these cases, some of the poor care provided to mothers and their babies was because of a push towards “normal” or “natural” birth and a desire to keep caesarean section rates low. The RCM ended its campaign for “normal births” in 2017, but its legacy persists. Some NHS trusts still talk about them today. A culture of cover-ups and a lack of care remains in others. Just last month, the Care Quality Commission found that staff at Great Western Hospital in Swindon had been downgrading third and fourth-degree tears, “which meant they were not investigated as thoroughly as they should” have been. The c-section target was only officially dropped in 2022. Does RCOG now accept that it was a mistake? “It’s difficult for me to say years later whether it was a mistake or not,” Thakar tells me. “I think there was a general trend at the time to put figures to caesarean section rates. But now we know that, we don’t do that.” It was now right that women were offered a choice; she insists she hasn’t seen an attitude against caesareans more recently.

Aside from any physical and psychological impact, traumatic births are costing the country billions. According to figures from NHS Resolution, the arm of the Department of Health and Social Care that handles litigation, 62 per cent of the total clinical negligence cost of harm in 2022-23 (£6.6 billion) related to maternity. Of the £2.6 billion spent on clinical negligence payments that year, £1.1 billion (41 per cent) related to maternity. (As the fact-checking service Full Fact explains, the cost of harm differs from the amount actually paid out in compensation: the former includes an estimate of claims expected in the future arising from incidents in that financial year.) The year before, maternity services accounted for 60 per cent of the total clinical negligence cost of harm (£13.6 billion). NHS England spends about £3 billion a year on maternity and neonatal services.

There is such a long way to go. The government is well behind on its long-term target of halving the rates of stillbirth and neonatal mortality by 2025; the death of mothers within 42 days of the end of pregnancy is at its highest rate in almost 20 years. And while only a handful of trusts have been subject to official investigations, there are signs that poor care is happening across the country. Only half of maternity units in England are rated good or outstanding; one in ten is inadequate. That is a damning indictment of the way so many women are cared for.

One crucial area of improvement does not cost money at all. It requires a shift in attitude to one where women are treated with respect, listened to and allowed to make informed decisions about their bodies and babies.

When I first heard of parliament’s inquiry into birth trauma, it was never my intention to share my experience. Doing so has been upsetting and uncomfortable. But as I sat listening to other women talk about how giving birth had affected them so profoundly, it felt dishonest to stay quiet. Difficult births are not something we should feel ashamed of — much as I know many women will have been, myself included.

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