Some of us around here don’t believe in too much small talk and I don’t believe that’s what you are reading the blog for. So, let’s talk about… birth trauma!
This is something that 100% needs to be addressed and spoken about way more than it is in the birth worker community as a whole. Secondary traumatic stress is a real thing after being in emergency situations, and it’s also one of the major causes of burnout. On top of just the ‘normal’ (and really, abnormally high) rate of post-traumatic stress in any medical profession, studies are starting to show that midwives are even more at risk. Why? Because of the hormone oxytocin, best known for being the hormone that causes both contractions (Pitocin is the synthetic version) and warm, happy feelings. Clearly at births, and in my experience especially at out-of-hospital births, everyone there is being exposed to high levels of oxytocin. It’s the reason mothers bond with their babies and why often even the midwife will cry happy tears when the baby is born. It’s a good thing. However, it also has some potentially not-so-great side effects since it strengthens memories in the brain1. So, if something traumatic happens while you’re being exposed to high levels of oxytocin (like at births), the memory will be intensified as opposed to how it would be without the oxytocin exposure. This, in turn, increases the likelihood of feeling fearful, anxious, and traumatized during similar events in the future. Hence why midwives have high levels of secondary traumatic stress and have trauma responses at later births. Even when no emergency is necessarily going on, your brain has stored that trauma intensely due to oxytocin exposure and has learned to expect more trauma. It’s fascinating, and, unfortunately to anyone who’s experienced birth trauma, it makes a lot of sense.
Even taking oxytocin out of the picture, healthcare workers in general suffer extremely high rates of posttraumatic stress disorder from their work, and often have limited support. In healthcare systems though, there are some resources and systems in place to protect their workers’ mental health; there’s definitely still not nearly enough, but there is something. Midwives in the United States, however, often operate outside of the system, and so they don’t even have that. We have no systems in place, and so our midwives and students fall through the cracks2. While research has shown that having support and debriefing traumatic events can significantly lower the incidence of lasting trauma, we often have no way to be able to do that. There are also huge obstacles to seeking support independently either within or outside of our own communities.
Unfortunately, even within the midwifery community, this is not something that’s often talked about. Midwifery circles can be… a little intense honestly. Midwives wanting to debrief a traumatic birth likely don’t want other midwives critiquing (to their face or behind their back) what they could have done differently. Which isn’t to say at all that there’s not a need for accountability; (I’m all for peer review). However, a midwife who hasn’t gotten to debrief a traumatic birth is more likely to make huge mistakes the next time something similar happens because trauma responses impede our ability to make good logical decisions. As much as research shows that debriefing is a great way to mitigate trauma3, I do understand why sometimes it’s difficult for midwives to discuss births with other midwives.
And in some ways discussing births with anyone outside of the midwifery community is even harder. Most people don’t understand medical/birth terminology well enough to follow along with a birth story that isn’t well explained- and it’s hard to explain something clearly when you haven’t debriefed it. On top of that, our mainstream culture as a whole (while becoming way more open to it) isn’t yet friendly towards midwifery: at worst people think it’s dangerous and at best they don’t understand why anyone would want to have their baby out of hospital. Traumatic birth stories aren’t exactly going to open their minds anymore, and as birth workers we know that. Often it’s even more so a problem with our relationships with hospital based birth workers. I would say it’s very rare that a midwife feels like she can go to an OB or L&D nurse to help her debrief a traumatic birth. They often already have very strong negative feelings about out of hospital birth (although that too is changing). This would be so much easier, and we’d have so many less traumatized birth workers, in hospital and out of hospital, if we would all support each other… but that’s a soapbox for a different day.
For better or worse, even if the reasons shouldn’t exist, it’s often really difficult for midwives to find someone to debrief traumatic births with. And in many cases it’s even harder for students. I mean ideally, they would debrief with their preceptors, but oftentimes that’s not an option. On top of all the obstacles midwives themselves face, students also have the weight that anything they say to anyone could be taken as criticizing their preceptor. It’s even more complicated when the birth really WAS badly managed, and the trauma could have been preventable… because situations like that do happen. But no matter what, anything that is said, even if it’s not intended as criticism, could be taken as such if they try to speak to their preceptor or anyone else in the community about it. And so, all too often students end up just not talking about it, which of course leaves them more susceptible to lasting trauma4.
Students are also at higher risk of consciously or unconsciously believing that births in general are bound to be traumatic for the simple fact that they’ve seen less of them! This means that for every traumatic birth, they have less normal ones to compare it to. This applies especially to students who witness traumatic births early on in their apprenticeship; they have few or no “normal births” to compare to and so in their mind, traumatic births become their normal. Oftentimes they can’t even discuss it with older midwives and be assured that most of the time birth is normal (because it is), for fear of retribution by the community. And so instead of believing that most of the time, traumatic births are very much the exception and out of hospital midwives as a whole have great outcomes5, they end up being scared of births. And then we wonder why we have anxious students who burnout at ridiculously high rates and leave the profession traumatized before ever fully beginning it.
Of all the issues in the maternal-child health and midwifery world, student midwives being treated well is one of the hills that I’m most willing to die on. One because I’ve experienced the issue, but really more so because almost every single student I know has experienced it too. I was a student who ended up with severe birth trauma very early on in my apprenticeship. I had no one to debrief with since my preceptor took questions as criticism and the community as a whole was not friendly. I later had midwives criticize me for being anxious at births because “don’t you know that birth is normal?” They said I must just be too young to handle the stress… but really it was that I already had handled too much stress with too little support. I couldn’t acknowledge that it was birth trauma because that would mean having to admit that those births that caused it were traumatic. I couldn’t talk about those births because what I had experienced was so far outside of normal that any birth worker listening would automatically blame my former preceptor, no matter how respectfully I told the story. And so, I shoved it down because unless I wanted to quit midwifery, that was the only option.
But shoving things down really only goes so far. Every time someone started to bleed after a birth I started to panic. I hid it as much as I could, not wanting the midwives I was working under to think that I was questioning their ability to manage it (again, this is a thing where students’ questions and fears are taken as criticism). But it wasn’t criticism, it was just that every time someone started to hemorrhage I could see where this ended before: no one knowing where the Pitocin was, the mom passing out on the floor, a birth pool filled with blood, EMS arriving, struggling to find a blood pressure… It’s the worst case scenario that I have never seen since. But since I had seen it, at every birth that’s what I was expecting. And everyone wondered why I seemed jumpy.
Student after student I talk to tells this same story. I’ve watched my peers quit midwifery at astounding rates from a combination of birth trauma and abusive apprenticeships that give them no space to process it (not to mention tons of other detrimental effects from working under burnt out midwives…). If this were just me and I were the exception, I would be quiet because for me, I know that this story ends well. The problem is that too often for other students, it doesn’t. This is our normal and as a community, we are traumatizing our students. It’s at the point where if students even try to talk to other students about it they’ll hear, “well, that’s unfortunate but isn’t that just what it’s like to be a student?” Unfortunately, yes in many cases that is just what it’s like to be a student, but it shouldn’t be. Just because it’s normal does not make it right. It’s definitely not okay that birth trauma is something that students are supposed to just stuff down and never talk about for the sake of their preceptor’s pride.
And again, I get it. I’ve seen how unfriendly the birth worker community can be, and I’ve seen midwives get blamed for outcomes that weren’t their fault. But still, something has to change so that the weight of everything that’s wrong with the birth worker community doesn’t fall on the shoulders of traumatized new students. There’s a lot that needs to change for that to happen, but one of the main things is that we as a community need to be standing in the gap for our students. Student midwives are the next generation of midwives; they are not the competition, they are not free labor, and they cannot be the collateral damage of traumatic births because older midwives like to tear apart each other’s reputations. There’s a lot I could say about that, but mostly, to every student out there (and I know there’s a lot of you) who have experienced this: it’s not okay and it absolutely should not be normal.
Thankfully, I was lucky in many many ways in my apprenticeship. I never quit, even though I came close to it, and I eventually found a preceptor who’s well, exactly the kind of midwife I hope and plan to be. Finally, I was in a place where students were treated like students, who are there to learn and be taught and who above all else need to be treated gently, same as the mothers we serve. It was there that, almost a year later, I began to process the birth trauma that should have been debriefed a long time ago. I saw hemorrhages handled well, and it’s been a very long time since I’ve encountered EMS. I was able to unpack why those births ended like they did, what could have been done differently and what really was just the unpredictability of birth. Instead of believing “that’s just how births are”, I recognized what I would do differently, and as I stepped into primaries, started to act on those things. I’m not afraid of birth. As a team, we know where supplies are, we know what we’re doing, and we risk out prenatally when needed. When emergencies come we handle them, but really most of the time, birth is completely normal!
I’m not going to say that I’m 100% done processing it yet, because honestly I don’t think there’s ever an ending point for us to not have to continue to deal with past birth experiences; they will come up, and they will have to be dealt with time and time again, and that is okay! Especially because those births happened so early on in my apprenticeship, I do believe that they left a lasting mark on how I view midwifery- and not necessarily all in a bad way. I clearly know the kind of midwife and preceptor that I want to become in ways that I don’t think I would have if not for the things I experienced (both difficult births and just general abuse towards students). I also know that I’m going to be okay though; the progress I’ve made is a night and day difference from when I had no way to debrief. I know first-hand now the difference that it makes to have a kind preceptor. And I know that if I ever needed to debrief any births now I could go to her (or the other student in this practice) in a heartbeat… because we’re a team and that’s how it’s supposed to be. I do think that if I’d had some way to debrief those births at the time that they happened, I wouldn’t have had as much lasting trauma from them, but I also can’t be anything besides grateful. I know that while my story ends well, for so many other students that’s not the case. They burnout, and either quit midwifery, or become traumatized, burnt out midwives who many times in turn go on to intentionally or unintentionally traumatize their own students. Traumatized midwives traumatize students, who in turn either quit, or become more traumatized midwives. And while I like to think that I would have never abused my future students anyways, I also know that I was one of the lucky ones who found a preceptor who is kind, who helped me to process, and who really stopped the cycle. If not for her, I very well could have become another burnt out midwife and passed this on to my own students one day. I truly believe this is something that can happen to any of us and that most of the midwives who perpetuate this cycle don’t do so intentionally. Most of them had very difficult apprenticeships themselves, and I’m sure they weren’t planning, when they were struggling as students, how they were going to in turn make their students struggle… and yet here we are.
The trauma from the previous generation is passed on to us, our burnout rates are higher than ever and the need for more midwives is only growing. The only way to change anything is by changing how we view and treat both students and other midwives. It’s something that needs to change in our community as a whole, and I truly believe that one at a time we can make a difference. One midwife was willing to stand in the gap for me and for other students in this community, even though that makes her the exception in this area. I know that she has made an enormous impact on the kind of midwife I’ll become. It’s sad in some ways because I know for many other students, they never find a preceptor like her. But in other ways it is encouraging because I know how much she changed things for me. And so even when progress feels painfully slow and changing midwifery culture seems impossible, I know that at the very least I can make a difference for one student. I can help her debrief a traumatic birth so that hopefully she won’t deal with lasting effects from it later on in her career. I can treat other students, and midwives, with the compassion that’s too often rare in our communities. I can tell students who have experienced awful things in their apprenticeships that while this may be the “normal” it’s not okay. I may not be able to single handedly change our culture towards students and stop this cycle for all of them, but I too can stop it for one.
One person at a time is how we make a difference, and on the days when it feels like nothing will ever change, I remember that I’m not the only one out there who believes that. One at a time but together, I believe that we’re making an impact. I look forward to a day when kind midwifery communities are everywhere, when healthy apprenticeships are the norm and abusive ones the exception, when midwives support each other and support their students, when students quitting midwifery from trauma is unheard of. I know that only then will we have enough midwives to meet the huge need for maternal child healthcare all over the world. It feels like a huge goal, but I really believe that it’s doable: step by step, moment by moment, day by day, birth by birth, we can work towards it together.
- Northwestern University. “’Love Hormone’ Is Two-Faced: Oxytocin Strengthens Bad Memories and Can Increase Fear and Anxiety.” ScienceDaily, ScienceDaily, 22 July 2013, https://www.sciencedaily.com/releases/2013/07/130722123206.htm.
- Sidhu, Rawel, et al. “Prevalence of and Factors Associated with Burnout in Midwifery: A Scoping Review.” European Journal of Midwifery, E.U. European Publishing, 11 Feb. 2020, http://www.europeanjournalofmidwifery.eu/Prevalence-of-and-factors-associated-with-burnout-in-nmidwifery-A-scoping-review,115983,0,2.html.
- “The Benefits of Debriefing after Critical Incidents in Anesthesia.” New Jersey Anesthesia Professionals, 22 July 2021, https://njanesthesiaprofessionals.com/2021/07/22/the-benefits-of-debriefing-after-critical-incidents-in-anesthesia/.
- D, Sarah, and Liz Coldridge. “’No Man׳s Land’: An Exploration of the Traumatic Experiences of Student Midwives in Practice.” Midwifery, U.S. National Library of Medicine, 31 Sept. 2015, https://pubmed.ncbi.nlm.nih.gov/26025871/#affiliation-1.
- Janssen, Patricia A., et al. “Outcomes of Planned Home Birth with Registered Midwife versus Planned Hospital Birth with Midwife or Physician.” CMAJ, CMAJ, 15 Sept. 2009, https://www.cmaj.ca/content/181/6-7/377.