In the third of our Birth Trauma takeover posts, Zaina Mahmoud takes us through the violent experiences of birthing in the UK and how such trauma can be rendered outside the norm.
The Birth Trauma Inquiry (the Inquiry) draws together the lived experiences of 1,311 women and birthing people, uncovering ‘a pattern of poor maternity care across the country, resulting in many women1 being deeply traumatised’ (APPG Birth Trauma, 2024). As the first government publication addressing the realities of a maternity healthcare system where ‘poor care is all-too-frequently tolerated as normal’ (APPG 2024; emphasis added), the Inquiry is rightly heralded as a welcome and significant step forward. Importantly, the Inquiry validated experiences of poor maternal healthcare, providing the epistemic tools for women and birthing people to understand and make sense of what happened.
The Inquiry amplifies previously silenced or unheard voices, ‘making visible what was invisible, defining as unacceptable what was acceptable and insisting that what was naturalized is problematic’ (Kelly, 1991, p.139). Simultaneously, the Inquiry buries the lede by naming the testimonies as experiences of birth trauma, leaving little room for holding accountable the perpetrators of trauma—healthcare professionals and institutions—and contributing to the over-medicalisation of maternity care. I explore how, by invoking trauma discourse, the Inquiry reproduces the structures of oppression that led to these experiences, insinuating that these experiences arose from events that were out of the norm—rather than manifestations of obstetric violence inherent in contemporary maternity care.
Interrogating Trauma
Concepts related to harm have progressively broadened over the last few decades, either by expanding horizontally to incorporate new phenomena, or vertically to cover less severe phenomena (Haslam et al. 2020). “Trauma” is one such concept, broadened from referring exclusively to physical wounds to including psychological injuries in the early 20th century (Baes et al., 2023). Events are not inherently traumatic; instead, the label of trauma is only applicable retrospectively when describing how an event was experienced, with this experience shaped by social and cultural contexts.
Applying Pierre Bourdieu’s (1986) theory of cultural capital to trauma discourses, Britt and Hammett (2024) reveal how (mis)using the trauma label reinforces oppressive structures, demonstrating how trauma can act politically, reproducing power dynamics. Bordieu’s theory of cultural capital is a framework that explains how people perceive themselves and use various signifiers to distinguish themselves from others; these signifiers (be it ideas, symbols, preferences) are shaped by power and social structures and may be strategically used as resources (or capital) in social action. Britt and Hammett (2024) argue that trauma may be (mis)used as cultural capital, redirecting attention away from the perpetrators of trauma and exacerbating the trauma experienced by survivors of the trauma. Applied in the context of the Birth Trauma Inquiry, describing the experiences as ‘tolerated’ ‘poor’ care that was out of the norm shifts the discussion away from how these experiences occurred and places the attention on those affected. In this way, describing an event as traumatic has important discursive power, and can re-entrench existing structural injustice, by shaping collective understandings.
The Inquiry refers to a lack of consent as well as pregnant people neither being listened to, nor being offered pain relief (APPG, 2024), as the result of ‘tolerated’ and ‘poor’ care. By earmarking these healthcare experiences as ‘tolerated’ poor care, the blame is shifted onto individual healthcare providers who ‘made mistakes’ assuming patients were ‘over-anxious or over-dramatic when they express[ed] concerns’ (APPG, 2024). By individualising blame in this way, the Inquiry obscures the routinisation of harmful practices inherent in maternity care. Accordingly,it is important to highlight that the shared experiences of birth trauma results from routinised harmful practices inherent in maternity care, due to the underpinning biomedicalised construction of pregnancy and birth. This is in line with early feminist objections to defining trauma as outside the range of normal or expected human experience (Brown, 1991).
In reality, maternity healthcare providers expect conformity with medical norms that intersect with ‘broad cultural expectations placed on pregnant women to be “good” and “self- sacrificial”’ mothers (Nelson, 2024). Obstetrics as a discipline inherently subjugates the experiential knowledge of women and birthing people, favouring the knowledge of medical professionals. Maternity care in the UK is underpinned by a ‘technocratic’ understanding of birth, whereby women and birthing people’s bodies are essentially ‘defective machines requiring obstetric interventions to conform to the assembly-line model of factory production’ (Davis-Floyd, 2001).
Through this lens, women and birthing people’s needs are subordinate to ‘standardised institutional practices and routines’ (Davis-Floyd, 2001). The recounted discrepancies between guidelines and practice described in the Inquiry are not unusual nor evidence of tolerated poor care, but inherent in a paternalistic maternity care system where information is tailored ‘to ensure the selection of what the health care expert considers the best choice’ (McLeod and Sherwin, 2000). It is therefore unsurprising that the Inquiry uncovered significant evidence of patients feeling marginalised and dismissed as sources of knowledge- something discussed in subsequent posts in this takeover.
The Inquiry’s insistence on describing participants’ narratives as ‘traumatic’ reinforces that they are out of the ordinary, pathologising those who experience such events as traumatic as needing to be “cured” through psychological intervention. Of course, it is necessary to offer support (including psychological support where desired) to those who have experienced these traumatic experiences. However, provision of support without concurrently addressing the systemic drivers giving rise to these harmful interactions, is inadequate. Indeed, doing so would bolster the medicalisation of trauma and fail to hold inherently oppressive systems accountable: in this case, maternity care and obstetrics qua medical field.
Attending to Obstetric Violence
Later posts in this series address the issue of obstetric violence in more detail. However, it is important to flag it here as it underscores the reality that the experiences described in the report are not ‘out of the ordinary’; instead they are an inherent product of the system within which people birth. Latin American activists coined the term “obstetric violence” to refer to harm inflicted during or in relation to healthcare during pregnancy, birth, and after birth, as expressed in the specific techniques and power relations of obstetrics (Williams et al., 2018). While the terminology may only date back a few decades, experiences of obstetric violence are present throughout history (O’Brien & Rich 2022), with modern obstetrics born during the antebellum period through experiments on enslaved Black women (Roberts, 1997).
Training in obstetrics is an initiation into a misogynistic, heteronormative, colonial, and racialised institution, an initiation into practices of reproductive injustice through obstetric violence (van der Waal et al., 2021). Obstetric violence can be resisted and prevented, whereas trauma is subjectively experienced, potentially emerging even where there is no clear-cut abuse or mistreatment.
Obstetric violence has long been recognised as occurring within the UK maternity care system (Kitzinger, 1992), emerging out of elements of obstetrics practice, including the underfunding of the NHS and wider structural problems. The Inquiry recognises ‘some problems in maternity arise from under-staffing, resulting in overworked staff experiencing burnout’ (APPG, 2024). Consequently, the Inquiry’s recommendations for tackling the incidence of birth trauma include ‘creating a standard, evidence-based model that works and can be applied throughout the country’ (APPG, 2024). In making this recommendation, the Report obscures the structural and systemic violence which cause birth to be experienced as traumatic.
The Inquiry’s reticence to describe the testimonies as manifestations of obstetric violence echoes criticisms of the term as confusing ‘the root causes of obstetric mistreatment’ (Grünebaum and Chervenak, 2024); this reticence will be explored in more detail in posts later in the series. Underpinning the Inquiry is the view that maternity care is dedicated to the health and wellbeing of pregnant and fetal patients and that mistreatment is never an intended component of professional maternity care, when, in reality, it is an inherent part of its provision due to the existing power structures and the normalisation of violence therein.. For this reason, the Inquiry is a significant step forward in breaking the taboo. However, recognition and validation of these lived experiences must be accompanied by labelling the causes of the abuses experienced, not as tolerated poor care, but as routinised obstetric violence, so that perpetrators of trauma (and how they are trained) are held accountable and the harmful over medicalisation of maternity care is undone.
Note
1. The use of ‘women’ here should not be taken as erasure of people with the physiology to gestate who do not identify as women; inclusive terminology is crucial to prevent the erasure of minorities struggling to access adequate reproductive healthcare. Here, ‘women’ is used as this is the terminology adopted by the Inquiry.
About the author
Zaina Mahmoud is a lecturer in law at School of Law and Social Justice, University of Liverpool. Her research interests include (assisted) reproduction and gestation from a legal and health regulatory perspective. Follow her on Twitter/X at @zaina_mahmoud94.
References
All-Party Parliamentary Group on Birth Trauma. 13 May 2024 2024. Listen to Mums: Ending the Postcode Lottery on Perinatal Care. (London).
Baes, N., E. Vylomova, M. Zyphur, and N. Haslam. 2023. The semantic inflation of ‘trauma’ in psychology. Psychology of Language and Communication 27(1): 23-45.
Bordieu, Pierre. 1986. Distinction: A social critique of the judgement of taste.Cambridge, MA: Harvard University Press.
Britt, Lucy, and Wilson H Hammett. 2024. Trauma as Cultural Capital: A Critical Feminist Theory of Trauma Discourse. Hypatia: 1.
Brown, Laura S. 1991. Not outside the range: One feminist perspective on psychic trauma. American Imago 48(1): 119.
Davis-Floyd, Robbie. 2001. The Technocratic, Humanistic, and Holistic Paradigms of Childbirth. Int J Gynecol Obstet 75 (S1): S5.
Grünebaum, A., and F. A. Chervenak. 2024. Using the term ‘obstetric violence’ in a broad and unsuitable manner introduces an unfortunate ambiguity. Am J Obstet Gynecol 231(4): e161.
Haslam, N., B. C. Dakin, F. Fabiano, M. J. McGrath, J. Rhee, E. Vylomova, M. Weaving, and M. A. Wheeler. 2020. Harm inflation: Making sense of concept creep. European Review of Social Psychology 31(1): 254-286.
Kelly, Liz. 1991. Surviving Sexual Violence. Cambridge: Polity Press.
Kitzinger, Sheila. 1992. “Birth and violence against women: Generating hypotheses from women’s accounts of unhappiness after childbirth.” In Women’s Health Matters, edited by Helen Roberts. London: Routledge.
McLeod, Carolyn, and Susan Sherwin. 2000. “Relational autonomy, self-trust, and health care for patients who are oppressed.” In Relational autonomy: Feminist perspectives of autonomy, agency and the social self, edited by Catriona Mackenzie and Natalie Stoljar. Oxford: Oxford University Press.
Nelson, Anna. 2024. Medical authority and expectations of conformity: crystallising a key barrier to person-centred care during labour and childbirth. Journal of Medical Ethics. Online first.
O’Brien, Elizabeth, and Miriam Rich. 2022. Obstetric violence in historical perspective. The Lancet 399(10342): 2183.
Roberts, Dorothy E. 1997. Killing the Black Body: Race, Reproduction, and the Meaning of Liberty. New York: Pantheon Books.
van der Waal, Rodante, Veronica Mitchell, Inge van Nistelrooij, and Vivienne Bozalek. 2021. Obstetric violence within students’ rite of passage: The reproduction of the obstetric subject and its racialised (m)other. Agenda 35(3): 36-53.Williams, CR, C Jerez, K Klein, M Correa, JM Belizán, and G Cormick. 2018. Obstetric Violence: A Latin American Legal Response to Mistreatment During Childbirth.BJOG—Int J Obstet Gy 25(10): 1208.
