Sophie Manolas has two sons, and she experienced both births as traumatic.
So much so that despite wanting a third child, she feels completely unable to go through with another pregnancy and birth.
"There's things that I'll be dealing with for the rest of my life," Ms Manolas says.
"There's a lot of numbness because there's so much scar tissue.
"There was a big effect on our sex life and I'm not sure if it'll ever be the same."
In Australia, one in three women identify their birth as traumatic — an experience associated with mental health problems including depression and post traumatic stress disorder (PTSD) — and suicide is the highest contributor to maternal death.
What is birth trauma?
The Australasian Birth Trauma Association (ABTA) defines birth trauma as a wound, serious injury or damage — it can be physical or psychological (deeply upsetting and distressing) or a combination of both.
Physical birth trauma can present as perineal tears, pelvic floor muscle damage, pelvic organ prolapse (POP), pelvic fractures (public bone, coccyx, sacrum) and caesarean wounds.
Psychological trauma can occur with or without physical trauma and can present as: postnatal depression and/or anxiety (PNDA), postpartum post-traumatic stress disorder (PTSD) and obsessive compulsive disorder (OCD); for example, having obsessive thoughts that can affect behaviour such as checking on the baby constantly or recurring thoughts that impact your enjoyment of daily life.
ABTA founder Amy Dawes says factors either side of the birth can contribute to trauma including the journey through pregnancy, feeding challenges, infertility challenges, premature birth and pregnancy loss.
And while certain things can cause trauma for one woman, they may not for another depending on the care and treatment received.
The main cause of birth trauma
Ms Dawes says the main contributing factor to birth trauma was expectations of birth not lining up with reality.
"There is a lot of influence from social media and there's expectations of wanting a drug-free, water birth with no emergency caesarean, but it doesn't go to plan for so many of us," she says.
"So we enter motherhood with a feeling of failure, like 'my body didn't do what it was supposed to do'."
Sophie says she felt "really sad" because she had expectations of having a calm birth, which wasn't the case with either of hers.
"I felt like my body mainly had failed and that I probably wasn't meant to give birth."
Huge gaps in antenatal information
ABC Everyday: Wiriya Sati
)Sophie attended birthing classes but says they didn't help her understand what a caesarean delivery might be like.
"You think you won't be able to feel anything, but [I felt] every cut and the baby being pulled out of [my] uterus.
"[Immediately afterwards] I couldn't hold my baby, I couldn't open my eyes, I couldn't see him."
Her recovery was extensive and she says the experience made her feel like she hadn't given birth at all.
"I was made to feel like 'You should be happy, your son's healthy', which I of course am, but the experience of birth was like a blackout."
Ms Dawes says the ABTA ran a survey aiming to understand what women learnt during antenatal classes, how they feel about what they learnt, and what they wish they'd been told.
It confirmed there are huge gaps in antenatal information.
"There are too many women left asking: Why didn't anyone tell me this could happen?"
The ABTA created Think Natal, to provide information to birthing families. The site offers a series of educational resources aimed at providing support and information on a variety of topics that are often excluded or underrepresented in existing antenatal education.
Lack of care continuity and a loss of control
Supplied: Sophie Manolas
)After her first birth experience Sophie was determined to have a vaginal birth.
She educated herself on the risks of a VBAC (vaginal birth after caesarean) knowing that some hospitals do not encourage the practice.
Despite her asking for midwife-led care, she was told it was not procedure in her hospital and she saw a different obstetrician at each antenatal visit.
"I was getting a different opinion and was mentally prepared for a different scenario every time."
When she went into labour her waters broke, and she was in labour for three days.
Adamant she did not want a caesarean, Sophie was yelled at by the obstetrician on duty.
"I had a massive panic attack and I don't commonly have panic attacks, but it was such a stressful situation.
"On the third day [of labour] I came to the hospital, I said I still don't want a C-section.
"A midwife hid her badge and said, 'Please don't tell my name, but at this hospital you can be induced. Ask for this because I know they can do it if you ask.'"
Supplied: Sophie Manolas
)She had to fight for her induction, but got it. Then despite having a birth plan that stated she did not want an episiotomy, the midwife performed one.
"I didn't feel like I could fully consent to it because I couldn't talk for one thing. But it all happened so quickly," Sophie says.
"Immediately after the birth, again, I was robbed of being able to hold my baby and have that skin-on-skin because I was rushed to surgery with a third-degree tear.
Woman are in a vulnerable situation
Sophie says she believes the hospital environment needs to reassess how it is supporting women through labour and birth.
"I think we're made to feel that the best and only outcome from a birth is that you're both living and surviving.
"I don't think that's the best outcome for mothers."
ABC Everyday: Wiriya Sati
)Founder and executive director at Centre of Perinatal Excellence (COPE), Nicole Highet, says health professionals need to acknowledge the power dynamic.
Ms Highet says when a birth isn't going to plan, it often becomes directed by the health professional, without much consultation with the birthing mother, contributing to that trauma.
"When things don't go to plan … it's about having loss of power and control. Women are in a very vulnerable position physically and emotionally.
Sophie says she felt quite angry because she believes she wasn't adequately supported by the birthing system.
"Some information is withheld and then other information is yelled and screamed at you," she says.
"There's a difference between providing information and trying to coerce a woman into what you think."
What does birth trauma look like further down the road?
The different levels of trauma and perceptions of trauma will vary from one person to another, Dr Highet says.
"It's beyond really just feeling disappointed or depleted after birth, it's much more," she says.
It can mean the inability to move past the birth, feeling shock and disbelief at what has happened, or feeling numb and a fear of birth in the future, Dr Highet says.
She adds that talking about the event can cause people to relive the experience causing intense anxiety and distress, so they'll often avoid the conversation.
Hypervigilance can be another sign of trauma.
"Parents will put more pressure on themselves to be successful at breastfeeding or other factors — because they feel like they failed at birth — to feel validated as a mother and to restore their confidence as a new parent."
ABC Port Macquarie: Wiriya Sati
)Sophie was on a few different mothers' groups and birth groups on Facebook but says she couldn't bear to see anything birth related come up.
"It was a very visceral reaction.
"I felt very physically ill just seeing it and that's when I realised this probably isn't a healthy reaction."
How to avoid birth trauma
Ms Dawes, founder of ABTA, says their vision is to prepare every woman and health professional with the tools, knowledge and power to have a trauma-free birth.
"Trauma is so unique to each individual, so what could look like a normal birth to one person can be deeply traumatising to another," she says.
Research has shown the level of obstetric intervention experienced and the perception of inadequate care during labour were consistently associated with the development of acute trauma symptoms.
According to the ABTA, giving birthing families unbiased information to have meaningful conversations with health professionals is the key to preventing birth trauma.
"Looking at the birthing parents' unique wants, how can we best prepare her for what she wants, and what if things don't go to plan," Ms Dawes says.
"If it doesn't go to plan, perhaps you'll be in a better place mentally because you've made an informed decision about what happens to your body rather than ending up blindsided by your injuries.
"Women naturally want to put their baby first, but we need to acknowledge the fact that what baby needs is a healthy mum and it's so much more than 'Well, at least the baby's healthy'."
Healing from trauma
There are very effective psychological treatments involving working with a therapist with experience in this area, according to Dr Highet.
"Really coming to terms with what might have unfolded and recognising what the circumstances were and reinforcing that it's not anyone's fault.
"It's not [your] fault."
She says it's also about focusing on the important role that continues beyond birth.
"The experience of the birth itself doesn't define someone, just because that might have been their entry experience into motherhood."
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