'They Don't Need Your Permission'
Birth trauma and how it led me here
The shouting began soon after my son was born. “Inversion! We've got an inversion!” the doctor yelled to his team.*
I was lying on the operating table, freezing and exhausted from 48 hours of labor followed by a Cesarean section I had desperately hoped to avoid. Moments earlier, a nurse had pressed my newborn son against my chest. I bent to kiss his dark curls through my surgical mask before he and my husband were escorted out of the operating room.
Now I was alone, shaking as I listened to the chaos around me. The lower half of my body was shielded by a sheet, but I could feel the doctor tugging and pulling inside my abdomen.
I found myself gripping the hand of an anesthesiologist, who had told me his name was Mason.
“Mason,” I asked, “What's happening? What's wrong?”
“Everything's fine,” he said, unconvincingly.
Panic rose in my chest. I had no idea what “inversion” meant; I just knew this surgery was taking way too long.
After the birth, the doctor tried to encourage my body to release the placenta by tugging on my umbilical cord. But when he pulled, my entire uterus flipped inside out. That was the inversion. The placenta had grown so deeply into the womb that it had to be removed by hand (a rare complication known as placenta accreta). If the doctor had not acted quickly, I could have lost my uterus.
I knew none of this, however, and was furious. I hated how powerless I felt. Many months later, I would realize why being pinned down while someone entered my body without my consent felt so terrifying, and so familiar. It felt like being raped.
I’m a survivor of sexual assault, as are roughly 20% of women in the United States. For us, even seemingly normal labor and delivery experiences can be re-traumatizing.
“It’s about other people having access to your body,” Leslie Butterfield, a clinical psychologist and board member at Prevention & Treatment of Traumatic Childbirth, told me. A woman may not want a particular exam or procedure to happen but feels she must allow it to keep her baby safe. “You’re protecting somebody else at your own expense,” Butterfield says.
About 1 in 3 new mothers report a traumatic experience during childbirth. Two years ago, researchers from Harvard Medical School surveyed 685 women who had recently given birth, and those who had been previously sexually assaulted were more likely to have complications such as unplanned C-sections, and “clinically significant traumatic stress responses to childbirth.”
I ended up with both.
I had been reporting on maternal mortality for three years before I gave birth. Some part of me thought this knowledge would protect me in the delivery room. It didn’t.
For most of my pregnancy, I was thrilled to be carrying a child I had spent years trying to conceive. I was that annoying pregnant lady, hiking with an enormous belly in the mountains near my North Carolina home. It was 2020 and the world had been shut down by the COVID-19 pandemic, but I was happier than I had been in a long time.
Because I was 40, my otherwise healthy pregnancy was classified as high-risk. I repeatedly questioned my doctor about the possibility of a C-section, but he was so eager to assuage my concerns that he didn’t want to discuss it. “Let me worry about that,” he said.
Butterfield says this kind of dismissal—not being included in decision-making, and not being informed about what’s happening—infuriates birthing people, and can lead to a traumatic birth.
During eight months of prenatal visits, none of my health care providers asked me if I had ever been sexually assaulted, as the American College of Obstetricians and Gynecologists has recommended since 2011. Many providers don’t know how to have that conversation. And if a patient says she has been abused, most providers aren’t trained to offer the help she needs. “Unless we’re making time for this, and we have interventions in place to address it, nothing’s going to change,” says Mickey Sperlich, co-author of the 2008 book “Survivor Moms: Women’s Stories of Birthing, Mothering and Healing after Sexual Abuse.”
My doctor didn’t ask too many questions. He knew I wanted a vaginal delivery; he just didn’t know I was petrified of the alternative.
Three days after my due date, he said it was time to induce labor. Forty-eight hours and countless contractions later, he calmly informed me that I needed to have a C-section because my labor was not progressing. Then he told me he would not be performing the procedure. “My wife has a horse show in South Carolina,” he said. “If I want to stay married, I have to be there.”
My husband nearly punched him.
In the chaos that followed, the medical team didn’t have time to ask about prior trauma that would make surgery uncomfortable for me. I had been given numerous drugs to ease the pain of labor and wasn’t in any condition to discuss it. But as soon as my epidural was removed, I started sobbing. I was exhausted and terrified. “It hurts,” I kept saying, until someone replied, “Yeah, you’re in labor.”
As insulting as this was, I knew I was treated better than many other birthing people. Black women are three times more likely to die from pregnancy-related complications than white women. They are also more likely to be mistreated by a health care provider. In a 2019 survey of more than 2,700 women across the U.S., 32.8% of Indigenous women, 25% of Latina women, and 22.5% of Black women reported some form of mistreatment during childbirth, compared to 14% of white women.
Many providers don’t believe an ordinary birth can be traumatic. Unless a person in labor is near death, they think she shouldn’t be complaining about a procedure that happens every day, Butterfield says. This lack of sympathy is compounded by the medical hierarchy. “You do what they say, and they don’t need your permission,” Butterfield says of doctors and midwives. “That relationship mirrors an abusive relationship.”
It doesn’t have to be this way. “I think we need to treat everyone as if they are potentially survivors,” Sperlich says. As a midwife and assistant professor at the University at Buffalo School of Social Work, she co-created a program to help new mothers deal with trauma and break the cycle of childhood abuse. She advises providers to be gentle, ask for consent, explain what they're doing, help birthing patients anticipate what’s coming next, make sure they feel supported, and give them options so they feel more in control.
This approach, also known as trauma-informed care, has four basic principles:
Realize that many people have experienced trauma.
Recognize the signs and symptoms of such trauma.
Integrate that knowledge into your practice.
Avoid re-traumatizing the individual.
The American College of Obstetricians and Gynecologists has endorsed this practice. “Obstetrician/gynecologists should implement universal screening for current trauma and a history of trauma,” the organization recommended in April 2021, adding that providers should adopt “a trauma-informed approach across all levels of their practice.”
Unfortunately, most birthing people don't receive that kind of care. There’s a misconception that a trauma-informed approach will take too long, Butterfield says, and a doctor’s time with patients is already limited. But kindness and targeted conversations don't require a lot of extra time.
Neglecting these conversations comes at a steep cost. I spent five months struggling with undiagnosed postpartum anxiety. I later learned that prior sexual abuse, having a traumatic birth, and struggling to conceive were all risk factors for my condition. My baby was thriving, but I couldn’t shake the feeling that no one was taking care of me.
Eventually, I found a nurse practitioner and a therapist who specialize in postpartum issues. With their help, I began to heal and fell deeply in love with my son. But many new moms aren’t so fortunate. They deserve universal trauma-informed care.
Butterfield has attended births where, even as a patient was hemorrhaging, the midwife paused to ask if she could administer medication to stop the bleeding. “It takes so little time to ask one more question,” Butterfield says. “It just has to show: I pay attention to you.”
I often wonder what would have happened if someone had taken that time with me.
*An earlier version of this essay appeared in STAT News in Feb. 2023. I’ve included it here to help new readers understand why I started this newsletter.