It’s Birth Trauma Awareness week. Birth trauma means a lot of different things to different people. As I write there is a debate unfolding on Twitter about how birth trauma should be defined. At one pole is the argument that only physical trauma is a legitimate definition, at the other is the argument that birth trauma should be defined by the birthing woman in any way she wishes. I don’t have a definitive position on that argument. As a researcher, I am interested in the way that official birth records represent birthing women and their bodies. This week I thought that it might be interesting to use my analytical skills to look at the most recent Queensland Perinatal Data Collection report (the statistics for 2019) and see how birth trauma is accounted for in an official record.
All hospitals and maternity care providers in Queensland (an Australian mainland state) are legally required to report particular data to the Perinatal Data Collection service. Data from the Perinatal Data Collection are taken very seriously, used to demonstrate improvements (or not) in care over time, and support arguments for how government money is used in maternity care. A committee of people have selected what is, and is not, collected and how the various terms are defined. The list of data required is therefore a socially determined product, and hidden within it are the beliefs, values, and assumptions of the people who have played their part in generating the list since it began. Analysis of the products of their work can provide a glimpse into these beliefs, values, and assumptions that informed the development of the data collection service and its reports.
Searching for the word “trauma” identified six tables. The tables reported labour and birth complications according to mode of birth and provided detailed lists of different types of genital tract trauma, sorted according to whether surgical repair was performed and the professional designation of the accoucher. In total, 59,540 women gave birth in Queensland in 2019, with 38,506 giving birth vaginally (65%). Of the women who gave birth vaginally, 4% (1,608) had a forceps assisted birth and 12% (4,562) had a vacuum assisted birth. 21,918 women (35%) gave birth by lower segment or classical caesarean section.
I have chosen table 6.19B for further analysis as it provides the most detail about types of genital tract trauma. A data collection manual set out the definitions that were to be used when clinicians completed the perinatal data collection form. The “nil” option was defined as no damage to the perineum, the category “graze or tear” as a slight abrasion, and the remaining forms of trauma related either to lacerations or surgical incision in the form of episiotomy. Two “other” options sat at the bottom of the table and were not defined in the manual. A summary statement in the manual said:
Perineal laceration (tear) may cause significant maternal morbidity in the postnatal period. Episiotomy is an indicator of management during labour and to some extent intervention rates.p 60
23.7% of women were represented as having no genital tract trauma. The most commonly assigned category was second degree laceration (28.4% of women). 19.3% of women were reported to have had an episiotomy, 2.7% of women to have damage to the anal sphincter complex (third- and fourth-degree trauma) either in association with an episiotomy or without.
Looking at this data from an analytical perspective, here were the things I noticed. (You might spot others – if you do, please post a comment and share.) First, the only way in which trauma was visible in this official account of what happens to women’s bodies in birth was with respect to physical trauma to the vagina, vulva, and rectum. Any sense of trauma as a form of psychological distress was missing from the data. This focusses organisational efforts on preventing and repairing perineal trauma. It is not particularly surprising then, that program such as the perineal bundle have been widely introduced in Australia and the United Kingdom, and that debates rage on Twitter about the legitimacy of psychological trauma as a form of birth trauma.
Second, the wording provided in the manual reflects a common belief in maternity care. The statement I quoted above implies that any form of perineal laceration is pathological and likely to result in symptoms after birth. It is also possible to hold the belief that most forms of minor perineal trauma occur as a physiological safety mechanism to permit women to give birth to a bigger baby than will fit through an intact vaginal opening, and they typically heal quickly and well. Episiotomy on the other hand is seen as an indication that the birthing woman has received the active care and consideration of her care provider, and is not seen as an intervention in and of itself (the quote says it only reflects intervention rates). Statements such as this quote both reflect and generate beliefs that spontaneous perineal trauma is bad, but the same degree of trauma electively created by a care provider is good management. It is easy to see how this might drive the use of episiotomy in practice.
Finally, there is a very common form of genital tract trauma that remains absent from the tables. The uterus is part of the genital tract. Caesarean section involves creating an opening large enough for the baby to fit through where there was no natural opening before. This is also a form of surgical trauma, in the same way that episiotomy is, but with more extensive changes to the anatomy. Caesarean section rates are presented in an earlier table, but in this table those women are presumably collected under the “nil” trauma category. The presentation of caesarean section as only a mode of birth and not as a form of genital tract trauma supports the belief that it causes less damage to a woman’s body than vaginal birth. Here we can see how it becomes possible for people to see caesarean section as a way to avoid trauma, rather than a different type of genital tract trauma.
I’m not arguing that we need to change the data collection systems we use and redefine the information we gather in them. But I do believe there is value in being aware that official records such as these were created by particular people, with particular beliefs about birthing women’s bodies, and that these beliefs potentially are expressed once again when we make use of the data contained within. As clinicians, but particularly as researchers and managers, a critical reading of the evidence is vital if we wish to reform, rather than recreate, our maternity care systems.