Risky modelling for child abuse: could these methods actually increase abuse, maltreatment and violence?
“What kind of love is it that has violence as a silent partner?” Keri Hulme- The Bone People
This week the Guardian reported “Vast quantities of data on hundreds of thousands of people is being used to construct computer models in an effort to predict child abuse and intervene before it can happen” https://www.theguardian.com/society/2018/sep/16/councils-use-377000-peoples-data-in-efforts-to-predict-child-abuse
The software can be used to generate revenue for the council through the Troubled Families payments-by-results scheme. Under the Troubled Families scheme, councils are paid £1,000 for each family they sign up to the programme, with a further payment of £800 when the family meets certain criteria.
This move is described as a way to reduce costs in a context of increasing austerity, cuts to services and deprivation within a neo-liberal agenda. There are calls for complex thinking and modelling increasing use of technology
Should the UK be increasingly going down the road of predictive modelling? Is there any evidence that this approach can pre-emptively predict abuse risk and prevent outcomes- complexity thinking often finds unintended negative consequences when changing complex system
This topic has been extensively explored as a predictive modelling system for child abuse was created and modelled in New Zealand
There are many possible serious consequences to trying to model risks to children of future child abuse:
1 Ethical and legal: Is it ethical or legal to share or use peoples data in such a way?
it may also not be legal under GDPR (which asks that ‘You can only use the personal data for a new purpose if either this is compatible with your original purpose, you get consent, or you have a clear basis in law’.
Who will be able to access this data, and what will it mean for people and families who are scored in a high risk category?
Issues relating to the ethical principles:
Existing risk instruments lead to an unacceptably high level of false positives (families inaccurately deemed to be high risk) and a high level of false negatives (dangerous families wrongly judged safe)
2 Stigmatisation of already vulnerable and marginalised groups:
“As the variables used rely more heavily on data about mothers (as is more available in the data), and use socio-economic status (SES) as a variable, female caregivers will overwhelmingly be identified as ‘risky’” (Keddell 2015)
This is likely to result in increased public stereotyping and rejection “assigning the label ‘risky’ permanently to people who have not harmed and may never harm their children based solely on statistical association.” (Keddell 2015)
Whilst we might know factors that are associated with abuse, these are NOT causal. Labelling people as ‘at risk’ to their children is likely to reinforce existing structural inequalities
3 Individualisation and increasing risks:
“Where risks are individualised, for example, this clearly reflects a neo-liberal concern with personal responsibility and a limited role of the nation state.”
So we ignore the fact that people that are living in areas with very real risks and concerns, noise, pollution, debt, violence, food insecurity, disability, lack of access to healthcare, education, culture, art, community, safety and instead blame them for their individual ‘choice’ to engage in any kind of perceived ‘risky’ behaviour. This takes responsibility away from the state for having to work to reduce inequality and improve living conditions.
4 Complexity and ‘machine’ learning:
Big data is seen as an answer to the huge issues we as a society are facing but data is useless if we are not asking the right questions or if we are unable to understand, interpret or use the results. The complexity of the methodological processes make it difficult to predict the ethical consequences of big data systems
“The whole point about big data analytics is that the number and form of calculations that need to be carried out exceed the scale and complexity which people can comprehend directly” (McQuillan 2018)
McQuillian goes on to equate this to the use of drone technology. If we risk score populations then we are removed from the individuals and the real consequences to them, both of knowing they are believed to be ‘a risk’ but also of their story and personal circumstances, which could result in dehumanisation.
Unconstrained machine learning can become a drone perspective, a targeting gaze that blurs legality and divides the social along decision boundaries of “us and them.”
5 Unintended consequences:
Another recent example of risk modelling looked at teen dating behaviour and whether a theoretically informed, empirically based algorithm that could adequately estimate the likelihood of physical and sexual TDV perpetration during vulnerable developmental periods. The study found that adolescents with positive test results on the algorithms were over twice as likely to perpetrate dating violence over the course of 6 years. (Cohen, Shorey et al. 2018)
The authors themselves, and commentators on the study recognise that labelling teenagers as potential future perpetrators of dating violence could be highly stigmatizing and lead to a self-fulfilling prophesy where individuals believe they are destined to enact violence. (Thurston and Howell 2018)
This sort of modelling is also used in the criminal justice system and has historically led to increasing fragmentation and alienation of those deemed ‘risky’ (for example ethnic minorities, those with serious mental health conditions, children leaving care etc.) and increases in the very behaviours which are being flagged in this misguided effort at prevention
“The policy implications of these findings are stark. Developmentally speaking, experiences of reduced fairness correlate with social isolation, deprivation of dignity, reduced faith in public institutions, and an increased propensity towards activities and behaviours deemed risky or socially non-normative” (Nichols 2017)
Once a person or placed is categorised as ‘at risk’ is it possible for that label to be removed? And under what conditions. This is also important in communities
“It is increasingly common to use measures to determine relative degrees of vulnerability across a particular institutional geographic context (e.g. the designation of Neighbourhood Improvement Areas and Vulnerable Schools by the municipality and the school board, respectively). Officially, the scales are used to ensure equitable distribution of limited resources, but they also result in particular spaces being coded institutionally (through crime or school achievement data, for example) as vulnerable or unsafe. These designations justify the use of place-based public sector interventions that are not always experienced as resources or supports by people who become their focus.” (Nichols 2017)
I presented at the Public health England conference last week about an asset based community development project on the Wirral that I am evaluating. Interviewing individuals across the area it is clear to see people are very aware of the reputation of the area that they live in.
Also at the conference I attended a session on using data to model future trends, this is increasingly used by councils to plan services and predict trends:
It’s also possible that the current interest in screening for adverse childhood experiences (ACE) could be used to feed into these models rather than thinking ‘what happened to you’ but what who might this mean you could harm in the future?
The data used to feed into these algorithms are what we know about associated risk factors for child abuse and maltreatment, upstream efforts should be looking at what we already know, not focusing on identifying families where abuse is occurring but looking at the wider environment around the family and prevent the conditions that lead to abuse occurring. (Keddell 2018)
“Since rates of maltreatment decline as material supports increase (Pelton, 2015), efforts to reduce poverty must be pursued” (Gillingham 2017)
Risk modelling to prevent child abuse, but also the wider uses of big data and machine learning need to be robustly evaluated to evaluate whether it is ethical and results in better predictive values or improved outcomes or unintended increases in risk.
Safeguards should be in place to prevent data being manipulated in this way without consent and for public discourse about the wider societal ramifications of using big data and machine learning (Amrit, Paauw et al. 2017)
Amrit, C., et al. (2017). “Identifying child abuse through text mining and machine learning.” Expert systems with applications 88: 402-418.
Cohen, J. R., et al. (2018). “Predicting teen dating violence perpetration.” Pediatrics: e20172790.
Gillingham, P. (2017). “Predictive risk modelling to prevent child maltreatment: insights and implications from Aotearoa/New Zealand.” Journal of public child welfare 11(2): 150-165.
Keddell, E. (2015). “The ethics of predictive risk modelling in the Aotearoa/New Zealand child welfare context: Child abuse prevention or neo-liberal tool?” Critical Social Policy 35(1): 69-88.
Keddell, E. (2018). “The vulnerable child in neoliberal contexts: the construction of children in the Aotearoa New Zealand child protection reforms.” Childhood 25(1): 93-108.
McQuillan, D. (2018). “People’s councils for ethical machine learning.” Social Media+ Society 4(2): 2056305118768303.
Nichols, N. (2017). “Technologies of evidence: An institutional ethnography from the standpoints of ‘youth-at-risk’.” Critical Social Policy 37(4): 604-624.
Thurston, I. B. and K. H. Howell (2018). “To screen or not to screen: overreliance on risk without protective factors in violence research.” Pediatrics 141(4): e20180075.
Further discussion of UK councils using data to model child abuse risk
I’m not able to do as much doula work as I’d like nowadays, as a full time working single mum, parenting a teenager and school child with #ADHD I’m pretty busy. I still do one to one sessions and teach workshops when I can. But doula work is in your bones, the doula mindset I now use in my everyday life all the time, approaching difficult people as if they were in labour can work wonders. If someone has unpredictable behaviours, extreme emotions, confusing needs- you can do well by loving presence, deep listening, going barefoot, breathing slowly, mirroring calm. Finding a transcendent part of you that sees the sacred in our everyday transactions. looking at the environment you are in- can it be changed to reduce peoples anxieties? Lights turned down, think about the acoustics, the smell. This week my son has been very anxious and worried, he has ADHD and probably ASD and the change from school to holidays combined with his birthday had led to him needing to be within touching distance of me at all times at home, this can be very tiring and stressful and he was worried about bedtime and sleeping too. A friend of mine called round whilst he was spiralling into panic and took him into the garden, they talked about the plants and he suggested my son chew and smell a few herbs, that it helped him if he was anxious. I took my son back to bed and he lay smelling his leaf while we read a story and until he calmed down and fell asleep.
Last year after our dog died of old age and I decided to get two sibling girl cats. They have been lovely to watch, very close. I thought about getting them neutered but decided to let them have one litter of kittens. As a child we had lots of pets and I witnessed two litters of puppies be born and grow up, this shaped my own interest in physiological birth and was one of the reasons I became a doula. I thought it was important for my children to see the normality of the life cycle.
My son watched in interest as local male cats started to frequent our garden after the cats went into heat, one male in particular seemed to have a close bond with my two sisters. We even witnessed them mating one morning so could introduce the birds and bees conversation with my son naturally. We then observed our cats behaviour start to change, to eat more, to become more solitary, not as close with her sister she would hiss if she came too close, she started eating more and I told our son we needed to be gentle with her, not pick her up too much or scare her. The male cat still showed regularly in the garden.
Eventually as I went away for a weekend, I thought the kittens would be due in about a week. I wondered how she would manage with her first litter. One dog I had as a young adult had a litter of puppies (she was a rescue dog and already pregnant otherwise I would have had her neutered) and coped well with the birth, until disturbed by my then partner returning with our other dog and friends, after which she left a puppy in its sac and did not care for it as she had the previous puppies and I had to intervene.
After the weekend I returned to find cats, neither of which looked pregnant. I quickly searched the garden and house for kittens, finally finding them in a cupboard in my bedroom, six kittens, all well and healthy, no mess, she’d done it fine all on her own.
She’s been a great mother, breastfeeding the babies on demand, purring loudly, but not let her sister too close. One early morning I found the daddy cat in the room too, chirruping at the cat and watching his kittens. A week later I found both sister cats in with the kittens. I was glad to see them friendly again, and when I looked at the kittens, I noticed one smaller all black kitten, her sister had had a kitten herself, just one. They are now co-feeding all the kittens, mostly found all together in a big heap of furry cats and loud purring. I was worried about the mother with six kittens who was struggling to keep weight on, so this should help her manage the load.
My young experience of watching puppies feeding, I’m sure influenced my own determination to breastfeed, and helped give me determination when my first baby was sleepy after a long labour and diamorphine. Kept me going through the pain of a tongue tie for over a year when she self weaned. I always felt is was important to breastfeed anywhere and everywhere, not covering up, to normalise breastfeeding in society, as I’m sure hiding breastfeeding away means that people feel it is something to be ashamed of and also stops girls learning what it looks like to latch a baby on. You end up with attitudes like this (and this is a man whose wife did breastfeed!)
My son I fed till he also self weaned at nearly three and a half. Breastfeeding past a year is less common now in European countries, but historically was the norm and is usual in countries around the world today. In some countries breastmilk is also given to invalids and women commonly share breastfeeding with their sisters and friends like my cats
I personally have nursed a few other peoples babies, mainly when they have been having early breastfeeding difficulties and the baby was hungry and struggling to latch
Mothering can be very hard in today’s society, without the ‘village’ community, women trying to learn all the skills on their own without prior experience and without support, levels of postnatal depression are high, but it is often the bonds we make with other new mothers that are sustained friendships throughout our adult lives and get us through those sometimes dark early days, sleepless nights and the continued joys and sorrows of parenthood
Just like other animals, we humans are primed through evolution to birth our babies, breastfeed and live in community, supporting each other
Last week I got to attend a lovely home waterbirth. This hadn’t been a planned event, I was asked to come do one of my overdue sessions as the labouring woman’s waters had broken for 24 hours and labour was not established. After doing some rebozo and bellydancing active labour began fast and furious and I stayed to help fill the pool and wait for midwives to arrive.
This is Anoushka’s birth story (shared with her permission)
Baby was eventually born on the 14/6 at 1045 weighing 8.8lbs. I had a long latent labour of ten days where contractions were happening irregularly then waters went on wed. Contractions didn’t speed up and that, so after 24 hours of waters having gone it was looking likely that I’d have to go in to hospital to be induced. On the thurs morning, I asked a doula friend Selina to come over to talk about induction and she’s also a Maternal movement for Fetal positioning practitioner, so she said she would see if some movements might help things along. Jade my birthing partner had stayed with me that night to see if a chilled out night without Ramy night help bring things along, it hadn’t! So, Selina came over at 8am ish Thursday, we had a good chat about the hospital birth plan, contractions still ten ish mins apart. Selina then did some rebozo, inversions and belly dancing moves and within the space of that half hour, contractions changed to being very intense and 3 min intervals. Selina suggested to jade the get the pool filling as the contractions continued to pick up intensity and speed. I asked for the midwife to be called as I was starting to panic at the speed that the contractions were coming. I really needed to get into the pool as could feel pressure but it wasn’t full, so jade and Selina were throwing buckets of water in to try and get it filled faster. I think I got in the pool at about 10am, Emma my midwife arrived at 1020 and baby was out at 1045. It was so quick and surreal, jade said I seemed really in control but I felt the opposite. There was nothing that I could consciously do except feel baby move down and out, it was like I was inside my body just watching. Jodhi was born in his membranes (sac) but the waters inside had gone and I was able to pull him out of the water myself, which was amazing. He needed a couple of breaths as went a bit limp and we had to get out of the pool as I bled a bit more than usual but we were happy on the sofa. The second midwife Nikki arrived afterwards and they both stayed until late afternoon, making sure we were both fine. We ordered Domino’s and had some lovely calm time My parents arrived soon after Jodhi was born and my Dad got to cut the cord. They went to get Ramy and we surprised him with his new baby brother when he got home. Ramy is besotted and is a brilliant big brother as I knew he would be. As I expected Jodhi had a tongue tie which was snipped on day 3, lucky us he had 2 ties! So feeding has been quite worrying but thankfully he’s lost a normal amount of weight so is getting enough milk, we are just waiting for poops to come! I can’t thank my parents enough and jade and Selina helping for J into the world, he would have been born on the floor if Selina wasn’t there filling that pool up! Can’t recommend Selina’s services enough https://www.facebook.com/UnlockingBirth
Anyone who would like to try the techniques I used to encourage active labour to start, I describe them in my blog post here:
Do you know the difference between gender and sex? Probably not, neither did I until recent years, but its becoming increasingly important (especially for parents) to know the difference.
(caveat: I am not an academic scholar of gender or social science, although I do research in public health, this post is mainly made up of my own understanding of sex and gender and experiences as a woman, mother and doula)
Sex = male and female
Gender = masculine and feminine
Sex refers to biological differences; chromosomes, hormones, internal and external sex organs.
Gender is socially/culturally constructed and describes the characteristics that a society or culture thinks are masculine or feminine.
People and organisations often use these words interchangeably, especially when talking about things like equality (how can you have equality in a socially constructed characteristic?) so are frequently using gender when they mean sex.
Part of this is to do with British prudishness and the fact we use the same word for male/female (sex) and reproduction (sex) so many forms ask instead for your ‘gender’ and then list male or female (sex) which for the majority of people is thought to be the same thing, but if gender is actually ‘the characteristics that a society or culture thinks are masculine or feminine.’ then maybe you’re gender isn’t quite so simple as male/female? If you don’t fit with the characteristics your society thinks are feminine and you are a woman, what is your gender?
I very rarely wear make up, I don’t often wear dresses or skirts. I don’t like the colour pink much. I like to light fires and camp and fish and chop wood.
Does this mean I am more masculine? Is my gender male? On the other hand I’m definitely biologically female. I’ve given birth twice! #confused
If only organisations/people understood that in most instances when we say gender, we mean sex.
Gender roles vary by historical time, country, religion and group etc. Originally gender roles came from sex differences or biology (women are pregnant, give birth, produce milk to feed babies etc.) so women stayed close to home and raised babies and young children while men hunted and protected (this again would vary by culture, time, place etc.) but from these roles came all our stereotypes of what it means to be a woman or a man (you can probably easily list what society sees as men’s things and womens things) and like the nursery rhyme above the idea that the sexes are different is reinforced from a very young age, even more so in recent years, with ‘gender (sex?) reveal parties and an obsession with boy/girl differences in clothing and toys.
Most people see gender roles as’ Stereotyping and limiting, trying to make little girls and boys fit into a prescribed box which limits their possibilities, and think it might be these gender roles that cause many of the problems in society, for example the high suicide rate in young men, may be in part caused by the idea that men ‘should’ be strong and silent, that its weak to ask for help or share feelings and so have to face their problems alone.
Gender roles have also limited women and girls (don’t get your dress dirty, don’t play rough, be nice, be pretty etc.) but its mainly biological sex not gender that globally leads to so much ineqality for women (e.g. femicide, selective abortion, unwanted pregnancy , rape, FGM, child brides, prostitution)
Only 100 years ago most women could not vote…
Around the world girls are still much less likely to go to school than boys and in many countries women and men do not have the same rights
(this should read sex equality not gender)
This is known as ‘patriarchy’ where men hold the power, and has been a common feature of most societies throughout history
In the last few decades many people have attempted to subvert and move away from gender roles and stereotyping.
And nowadays many people try to do what is termed ‘gender neutral parenting’ where boys and girls are treated the same, and not socialised into roles base on their sex. This can mean not always dressing them in blue/pink. Buying toys that aren’t branded for boys/girls etc.
Some people decide to ‘cross dress’ their children from a young age (deliberately, regularly dressing boys as girls)- this is different to children having access to a range of dress up clothes and toys and choosing their own as they wish, but more a parental choice. There is evidence that raising children without a sense of their own sex (and suggesting sex can be changed) is leading to more children with gender identity disorder.
Children’s sense of themselves is built by how adults and the world around them treats them, they follow our lead, so its important to consider carefully what we are telling them.
Parents may now worry that if their child is attracted to opposite sex toys/clothes that that is a sign they are transgender, rather than it being a child’s normal curiosity. Many children love to dress up and have different interests, this can be effected by their siblings, culture, parents, personality. It is common for children to go through a period of ‘trying on’ different personas, and living as characters in their imaginary world or from media they watch, this does not mean they are transgender.
This reinforcing a binary rather than freeing children from the constriction of gender roles
There have also always been people that didn’t fit with societies views of sex and gender. Sometimes people deliberately tried to be different to cause controversy (like artists) . And men and women have cross dressed for entertainment or access to lives they couldn’t live as themselves (especially women who were unable to publish books as themselves, go into medicine, be pirates…)
So what is gender ideology and why is it harmful?
In the last few years there has increasingly been a change in the way gender and sex are talked about, with the idea that gender is not a binary and that people can be on a spectrum. That has led to people calling themselves a variety of names from non-binary, to queer and trans-gender. They have started describing people that are not trans as ‘cis’. What this means is that people born male and female are happy to describe their gender as masculine or feminine (but as I described earlier, gender is socially constructed ideas of what masculinity or femininity look like, they change all the time, and stereotype people, limiting them to a set of behaviours as ‘normal). I would argue that all people are ‘gender fluid’ to a degree. Our behaviour and self view changes.
This idea is regressive because it reinforces a gender binary. Instead of freeing people from having to behave in prescribed ways, it says that if you behave in male ways you could be a man (born in the wrong body) and visa versa.
In clinical psychology and psychiatry, individuals who experienced distress because they did not identify with their biological sex used to be known as ‘transsexuals’ A diagnosis of ‘transsexualism’ appeared first in DSM-III in 1980. Recently the name of the diagnosis changed to ‘gender dysphoria’ .
The term ‘assigned‘ sex or ‘assigned’ gender is now frequently used, which refers to when a baby is born and it is declared a boy or girl based on the appearance of external genitals. Between 0.018 and 1.7% of the population (dependent on definition https://www.ncbi.nlm.nih.gov/pubmed/12476264) have a ‘intersex‘ condition which can mean they have genitals that appear male/female when they are the opposite sex.
Gender and Sex are separate from sexuality, which is usually described as heterosexual (being attracted to the opposite sex) homosexual (being attracted to the same sex so lesbian or gay) or bisexual (attracted to both sexes) with additions in recent years of pansexual and asexual
Also known as LGB minority sexualities are discriminated against globally and face violence and are only now beginning to get equal rights in some areas (like same sex marriage).
Trans people were added to LGB in the late 1980’s, although strictly speaking trans is concerned with biological sex or gender not sexuality. The initialism has widened to include intersex and queer in recent years (LGBTQI) and gender identities appear to be ever increasing
Some people that feel that their gender identity does not match their biological sex (I would argue most of us feel this at times) want their body to resemble the gender/sex they feel more affinity to. There are a number of aesthetic and medical changes they can make
and legally people in the UK can apply for a ‘Gender recognition certificate’ to legally change their sex on their birth certificate to that which matches their preferred gender. In contrast to some systems elsewhere in the world, the Gender Recognition process does not require applicants to be post-operative (so a man can legally be a woman with a functioning penis and testicles, and a woman a man with uterus and breasts-that’s why you’ve seen newspaper articles about men having babies). They need only demonstrate to a Gender Recognition Panel that they have suffered gender dysphoria, have lived as “your new gender” for two years, and intend to continue doing so until death.
“Transgender activists say that the process of legal gender recognition is unnecessarily invasive, humiliating and lengthy. The UK government has proposed to reform the Gender Recognition Act to de-medicalise and speed up the process. The aim is to introduce a process based on self-declaration with no medical gate-keeping.”
So all you would need to do is say you feel like a woman or man to legally change sex. This potentially cause issues in same-sex institutions like prisons
The number of people applying for a GRC has been low (in line with what you would expect for people with dysphoria) but lately things have changed, many more people are identifying as gender non-conforming, non-binary-queer or transgender and correspondingly numbers of people requesting medical treatment to match the gender (sex) they feel more comfortable with. There are several groups that are transitioning more frequently
- Middle aged men
There could be several reasons for this steep rise in referrals
I feel it is concerning that so many more children are being referred for gender reassignment. This usually involves first socially transitioning children (as young as 3) by giving them an opposite sex name and dressing them as the opposite sex, then giving a child puberty blockers (untested as to long term consequences of blocking puberty for many years) and then giving cross sex hormones so the child develops opposite sex characteristics (e.g. a deeper voice in girls, facial hair and a higher voice in boys). Girls are advised to first bind their breasts and then have them removed (double mastectomy). Boys can be given artificial breasts and both boys and girls can have artificial sex organs (obviously all of this comes with medical risk)
These are often referred to as ‘top surgery’ and ‘bottom surgery’.
However much women or men change themselves, and even with legal recognition from a GRC it is not currently possible for humans to change biological sex and many transgender people choose not to go through medical or aesthetic procedures and are happy to remain anatomically the opposite sex to that which they identify.
There is increasing pressure for transwomen and transmen to be regarded as the sex they identify with (with the mantra ‘transwomen are women’) and language changed accordingly (so if transwomen (men) who self-identify as women (based on their gender identity) they should be accepted as women, despite still having male genitalia (leading to the conclusion that ‘not all women have vaginas’ and for transmen (women) not only women get pregnant or breastfeed. This has led to many organisations changing the terminology they use so as not to offend (using ‘pregnant people’ not women and ‘chest feeding’ not breastfeeding’)
So… to recap…
Sex refers to biological differences; chromosomes, hormones, internal and external sex organs. (except now it doesn’t)
Gender is socially/culturally constructed and describes the characteristics that a society or culture thinks are masculine or feminine. (except now it doesn’t)
If this is confusing, imagine how much more confusing it is for children, who are now having lessons in school about gender identity and being told they can be born in the wrong body…
Many children have neuro developmental conditions (like autism and ADHD) which leads to difficulties with executive functioning. This means their understanding of concepts around identity can be delayed, and they are also more likely to be gender non comforming. (50% of referrals of children to the Tavistock clinic are on the autistc spectrum)
My son has ADHD. Even at six and a half he still lives in a wonderful world where anything is possible. Fantasy and reality overlap, combine. A couple of weeks ago he told me he was the daddy of our two young cats (and yes, in case you were wondering trans species is a thing, like trans race and trans gender)
I talk to him a lot about his ‘science’ brain. About working out whats real and whats not, because whilst its cute to go along with fantasies about toys coming alive and super powers, its probably more likely to harm him than help him (though I’m sure a vivid imagination will benefit him as he grows)
And what about teenagers? I have one of them too, and she already has trans gender friends, and those describing themselves as pansexual and queer (she’s 14). I just hope she’s heard me talking about sex and gender to realise that its perfectly okay to step outside of the constraints of gender roles but that doesn’t mean you were born in the wrong body…
Teenagers are all about risk taking, and finding somewhere to belong. There are all sorts of groups encouraging gender questioning teens to see themslves as transgender, sending girls free chest binders (which can lead to irreperable damage to growing breast tissue or even gangrene) and telling them where to go (or even order online) testosterone.
Parents are advised to go along with affirming their childs new opposite sex identity, even if they had never expressed a similar desire before, with the threat of suicide risk
Self harm and suicida ideation are common in teenagers and both, puberty blockers & cross-sex hormones both carry risk of depressive side-effects and there is very little accurate data (especially now many surveys ask for gender, if this is all about identity then we can’t reliably know how many girls or boys are feeling this way)
“If we fail to record the biological sex of young people we are unable to try to understand why suddenly such a disproportionate number of young women want to ‘identify’ out of womanhood. Is ‘identifying as a boy’ just the latest coping mechanism for girls brought up in a culture where images of women being sexually abused in porn are casually passed around in playgrounds, and the internet ensures no escape from the pressure on girls to be ‘perfect’? And is the world so dangerous for lesbians that being seen as a man is a safer alternative?”
Data is important, its not just about high income countries, this type of ideology could effect global data collection which is vital to prevent violence to women and girls (VAWG)
VAWG data is essential to help quantify and qualify problems, inform policies and design programs based on evidence. The need for better collection of data related to violence against women has been recognised by the EU, the Council of Europe and, at international level, by the United Nations in their commitment to eradicate violence against women
Our kids grew up with Harry Potter, they love the idea that there is magic, transmutation, and that the inner you can ‘sort’ you into groups based on your true identity…
Belief in magical thinking (pseudoscience) and conspiracy theories are increasingly popular with adults too: anti-vaccines, gut instinct (logical falacies/cognitive biases) homeopathy, climate change denial, chem trails, flat earth…
There’s also many teenagers involved in cosplay and anime whch is all about dressing up and changing sex/species etc, is there any wonder kids are struggling with identity issues, especially if we are telling them in primary school that its possible to change to the opposite sex.
Many studies have found that a large percentage of children that question their gender (sex) identity will eventally desist and accept their sex (with many of these coming out as lesbian or gay) but if they have already been socially transitoned as young children, had puberty delayed and or cross sex hormones they may be infertile, have an inability to have a satisfying sex life and/or have had sexual organs removed.
I would argue its unethical to make descisions like these for children that will affect their long term futures, these descisons are better made as adults
Its become very difficult to talk about these issues openly as globally, gender ideology has been accepted as truth without discussion and the majority of people don’t understand the concepts well enough to see the future implications of descisions like self decleration of sex and tranitoning children. People that speak up are labelled as intollerant, bigots, right wing. It was only after I was thrown out of a parenting group (which was for evidence based parenting) for questioning if there was research evidence about transitioning children that I began to understand who serious this situation had become. (people who speak up about trans gender ideology are known as gender critical or terf’s: terf stands for trans exclusionary radical feminist and is used as a threat by trans activists)
A woman was recently suspended from the Labour party for saying women don’t have penises..
Please if it concerns you too, speak up, talk to you’re children and teenagers about sex and gender. Talk to your friends and colleagues.
What is a woman? Barbie doll’s? Is it make up and hair styles and shoes (sugar and spice and all things nice…)
Are men GI Joe’s tough, muscley, silent, no emotions? (puppy dogs tails…)
Not all trans people support this ideology, many are horrified by whats happening, and speak out
Lets go back to all working together to reduce the limiting constraints of gender roles, embracing the feminine within men and boys and the masculine within girls and women, fighting to stop violence against all people and equal rights whatever our sex or sexuality
Thanks to all those actively subverting against gender norms (like the artist Grayson Perry in the picture below and the recent Welsh Government campaign #thisisme which challenges gender sterotypes to tackle violence against women, domestic abuse and sexual violence) and speaking out about gender ideology. We need a completely different construction of gender to make room for trans people without harming human rights.
My girl. On your 14th birthday. Thank you. Being your Mother has taught me everything that is important to know.
Waiting for you taught me about longing, about wanting something so much you don’t know if you can live without it. It taught me surrender and acceptance and then you taught me joy.
Being pregnant with you my life changed, I made so many friends that I love today, I learnt about a woman’s power, about choice about consent.
Your birth was hard and I learnt stamina and pain and the amazement of recognition of another soul grown in your body.
It changed the course of my life, led me to a love of research and my work now in Public health, and of supporting other people’s journeys to parenthood through being a doula.
Learning how to be a mother, to be in relationship with another person, unconditional love that is bottomless and ever expanding. Being a home to someone, physically and emotionally, being a safe place of succour and life, giving more.
How to grit your teeth and keep breastfeeding, swearing through pain, because damn it I was going to do this, and the ease of feeding once we got through the early days, learning what you liked as a person (being rocked in the baby chair so hard it was like a roller coaster and being upright all the time). The contentment of knowing this was the only important thing I needed to do at this time, to nurture this person. Being in a physical relationship of the comfort of anothers body and learning how to let others rest in you.
Bravery to embody my choices with joy, to mother by living my life with you in it, learning yes I could take babies to festivals, parties, travelling.
Supporting other mothers and fathers walk the path, realising the absolute importance of friendship and comradeship through life.
And as you grew you taught me so much about letting go, giving space to another to evolve and become themselves
“Your children are not your children.
They are the sons and daughters of Life’s longing for itself.
They come through you but not from you,
And though they are with you yet they belong not to you.
You may give them your love but not your thoughts,
For they have their own thoughts.
You may house their bodies but not their souls,
For their souls dwell in the house of tomorrow,
which you cannot visit, not even in your dreams.
You may strive to be like them,
but seek not to make them like you.
For life goes not backward nor tarries with yesterday.
You are the bows from which your children
as living arrows are sent forth.
The archer sees the mark upon the path of the infinite,
and He bends you with His might
that His arrows may go swift and far.
Let your bending in the archer’s hand be for gladness;
For even as He loves the arrow that flies,
so He loves also the bow that is stable.”
Khahil Gibran on Children
I am so proud of the person you are becoming, the woman you are growing up to be. Sharing life with me, always resilient and courageous, no nonsense, a wonderful big sister, picking up the slack when I need help. Working together as a family through our life.
Excerpt from a poem I wrote about my girl a few years ago:
I can’t write a poem about my girl,
She’s too big for the page,
She’d argue with everything I wrote down
Stick out her pointy little chin
And karate chop me.
Or cover me in glittery lip gloss kisses.
Her tight brown silky ringlets bouncing,
Eyes like melted chocolate covered daggers,
Skin a creamy frappuccino.
It only seems like yesterday she was born, stargazing,
Stubborn from the start.
When you were two you led a troop of toddlers across the field of Africa Oye
To the ice cream van,
You held out your warm, grubby, empty little hand
And like a miracle,
He handed out each of you an ice cream:
You knew he would,
Your will could move mountains.
Shaking your booty to 4Music
Singing your heart out to R n B tunes,
Wanting to know where your brown mother is.
Sorry huni, there’s just me…
I have previously discussed some of the issues which complicate the discourse around ‘normal’ birth’ and ‘safe’ birth and the concept of risk.
The term ‘normal’ is problematic as it has social meaning (i.e what is usual) and also that what is not ‘normal’ is ‘abnormal’ .
I prefer to use the term ‘physiological’ which means the usual fuctioning of a living organism.
There is current discussion on the push for ‘normasl’ birth and to reduce the CS rate and/or unneccessary interventions.
This is a complex issue, there is still much to learn about how and why risk status changes during the birth process and when it is necessary to intervene to prevent risk.
For my Masters in Public health dissertation I was interested in the differences in post birth condition of mothers and babies after vaginal births with and without common interventions.
For this I used the current definition of ‘Normal birth’ (from http://www.birthchoiceuk.com/Professionals/BirthChoiceUKFrame.htm?http://www.birthchoiceuk.com/Professionals/statistics.htm )
women have a “normal birth” if they do not have any of the following procedures:
- induction of labour (with prostaglandins, oxytocics or ARM)
- epidural or spinal
- general anaesthetic
- forceps or ventouse
- caesarean section
I looked at ‘The Incidence of Women giving birth in Liverpool in 2005-07 having a ‘Physiological Birth’ as compared to ‘Normal Births’ and ‘Cephalic Vertex Births’: Are there differences in health outcomes for mothers and babies by type of birth?’. This was a quantitative hospital-based cross-sectional study using delivery records’ data available at Liverpool Women’s Hospital (LWH). All birth records with a gestation of 37-42 weeks from 01.01.2005 to 31.12.2007 were obtained for mothers who gave birth to live singleton infants and whose delivery records had been entered on the hospital database (13, 963 Vaginal births)
I presented my results at the ‘Normal Birth confernce in 2009.
The incidence of physiological birth in Liverpool in 2005-07 was 24.5%
19.1% of women having their first baby had a physiological birth.
Physiological birth was associated with-
- Greater odds of breastfeeding after delivery and on discharge
- Lower odds of having a post partum hemorrhage
- Lower odds of having a perineal tear
- Lower odds of babies being born in a compromised condition
The powerpoint I prsented at the conference with the full results is attached below. This data is currebntly unpublished although I have been working on a journal article for some time.
Can birth be painless?
A recent article by Milli Hill in the Telegraph suggested that birth not be as bad as people fear.
But this has created a backlash from people who feel that this view contributes to the trauma of women who go into labour convinced they can birth without needing pain relief, or at home, or without ‘losing it’.
As a doula I have accompanied many women through birth and given birth myself twice. So I have seen labours that were unbearable from the early stages to women having ecstatic birth, women singing through their second stage.
In my previous blog I talked about how childbirth is a profound event for women, where pain creates an altered state of consciousness which may help women cope with the pain of childbirth and prime women to experience the psychological shift to becoming a mother.
I agree with Milli that it’s well known that fear and anxiety can lead to greater pain during birth. The associations between expectation, cultural conditions, personal outlook (including locus of control) memory and preparation in relation to pain during childbirth are complex. It has also been suggested that attachment style can effect labour pain.  and can also effect whether the presence of a partner during labour reduces pain
People can be surprised by their own response to the sensations of birth, some people cope better than they imagined. One aspect which has not been discussed is the role of malposition- the position of the baby effects:
- Length of pregnancy (more likely to go overdue and therefore have an induction)
- Length of latent phase (https://magicalbirth.wordpress.com/2014/11/24/prolonged-latent-labour/)
- Length of First stage (with increased need for augmentation)
- Length of second stage (with increased likelihood of assisted birth or emergency caesarean)
Pain– women with a baby in a malposition (OP/back to back, asynclitic, deflexed etc.) are more likely to experience extreme pain from early in labour, this combined with a greater length of labour and exhaustion make it more likely they will need pharmacological pain relief (and malposition is also associated with breakthrough pain during an epidural and needing more top ups of pain medication[5, 6]) Increased pain during labour, is itself is a marker for CS risk
There are a number of ways women’s pain is assessed and documented in labour. One recent tool is the Roberts ‘Coping with labour’ algorithm which provides a mechanism for pain documentation, and care suggestions for the laboring woman. This has been assessed in a large tertiary care hospital as more useful and helpful than a numeric rating scale. 
There is some evidence that antenatal birth preparation can reduce anxiety about birth and decrease labour pain experienced.[11, 12, 13] and there are numerous papers describing environmental factors (circadian, lighting, music, furniture, place of birth[14,15]) non pharmalogical pain relief methods (water, massage, aromatherapy) support (continuity of care, doulas, midwives) and maternal factors (fitness, exercise, personality, preparedness, movement etc.)[16,17]
Severe pain in labour has been associated with both postpartum depression  and PTSD
The coping with labour algorithm looks like a useful tool to combine a better understanding of the factors that can effect coping in labour and ways to help women cope.
The new algorithm was designed in part to reduce dissatisfaction with the numerical pain rating scale, women found the questions intrusive and distracting. The coping with labour tool can be used by midwives from observation and queries about coping to women are only made on arrival, when noticing changes or a shift change. There is also an understanding that not coping in labour can signal the ‘transition’ between first and second stage and be a sign of rapid progress, when reassurance of the physiology of normal labour could reassure women and reduce anxiety in relation to overwhelming sensations.
One woman I spoke to found being asked about pain, contributed to her focus on the pain, and made her doubt her coping ability:
“The ONLY reason I had pethidine with my first was because the midwife (after a shift change the first never mentioned it) kept saying ‘did I want pethidine’ ‘are you sure you don’t want pethidine?’ ‘it’s only going to get worse, would you like the pethidine now?’ – I gave in to stop her asking”
Both distraction and catastrophizing have substantial effects on perceived pain, so questioning women about pain in labour could effect women’s perception of coping.
Looking at longer term outcomes, in a five-year follow-up study of a randomised controlled trial; “The Ready for Child” trial. To compare the long term perspective of the birth experience in nulliparous women attending a structured antenatal programme to that of women allocated to standard care. Birth characteristics of women reporting a less positive birth experience in the long term, irrespective of group allocation, were significantly more likely to experience an epidural, cardiotocography monitoring, and less likely to used water as pain relief and have a spontaneous vaginal birth.
Another study to investigate women׳s use of pharmacological and non-pharmacological labour pain management techniques in relation to birth outcomes, found that:
•Water use for pain decreases the likelihood of special care nursery admission.
•Epidural use for pain increases the likelihood of special care nursery admission.
•Epidural use for pain increases the likelihood for instrumental childbirth.
•Epidural and pethidine use decrease the likelihood of continuing breast feeding.
•Breathing techniques and massage increase likelihood of continuing breast feeding
So can labour be painless?
Yes sometimes, and there are ways to help cope better in labour, but a large part is down to luck/ chance and not within our concious control, needing pain relief when pain is severe and unremitting is not a failing
“my inner sex
stabbed again and again with terrible pain like a knife.
I have lain down.
I have lain down and sweated and shaken
and passed blood and feces and water and
slowly alone in the centre of a circle I have
passed the new person out”
(from ‘The language of the brag’ by Sharon Olds)
- A huge number of factors combine to effect how women experience pain and cope with labour
- Malposition is an important factor that can increase pain and negative outcomes
- Women who experience severe pain may have a malpositioned baby, if this does not resolve, pharmacological pain relief may be needed
- Birth preparation can provide women and their birth partners with tools that can help women cope with labour
- Focusing on pain in labour can increase pain, use of language related to ‘coping’ with labour might be more appropriate
- Offering pain relief in labour may
- Women that experience severe pain and require pharmacological pain relief, despite intensive birth preparation are not personally responsible for the level of pain they experience, it is likely that a combination of childhood experience, cultural environment and malposition combine to create intolerable pain
- There should be no shame in needing more pain relief than was planned
Mayberry, L., & Daniel, J. (2016). ‘Birthgasm’ A Literary Review of Orgasm as an Alternative Mode of Pain Relief in Childbirth. Journal of Holistic Nursing, 34(4), 331-342.
- Costa-Martins, J.M., et al., The role of maternal attachment in the experience of labor pain: a prospective study. Psychosomatic medicine, 2014. 76(3): p. 221-228.
- Krahé, C., et al., Attachment style moderates partner presence effects on pain: a laser-evoked potentials study. Social cognitive and affective neuroscience, 2015. 10(8): p. 1030-1037.
- Sng, B.L., et al., Incidence and characteristics of breakthrough pain in parturients using computer-integrated patient-controlled epidural analgesia. Journal of clinical anesthesia, 2015. 27(4): p. 277-284.
- Wong, C.A. The Influence of Analgesia on Labor—Is it Related to Primary Cesarean Rates? in Seminars in perinatology. 2012. Elsevier.
- Hess, P.E., et al., An association between severe labor pain and cesarean delivery. Anesthesia & Analgesia, 2000. 90(4): p. 881-886.
- Alexander, J.M., et al., Intensity of labor pain and cesarean delivery. Anesthesia & Analgesia, 2001. 92(6): p. 1524-1528.
- Ismail, S., S. Chugtai, and A. Hussain, Incidence of cesarean section and analysis of risk factors for failed conversion of labor epidural to surgical anesthesia: A prospective, observational study in a tertiary care center. Journal of anaesthesiology, clinical pharmacology, 2015. 31(4): p. 535.
- Roberts, L., et al., The coping with labor algorithm: An alternate pain assessment tool for the laboring woman. Journal of Midwifery & Women’s Health, 2010. 55(2): p. 107-116.
- Fairchild, E., et al., Implementation of Robert’s Coping with Labor Algorithm© in a Large Tertiary Care Facility. Midwifery, 2017.
- Firouzbakht, M., et al., The effect of perinatal education on Iranian mothers’ stress and labor pain. Global journal of health science, 2014. 6(1): p. 61.
- Toohill, J., et al., A Randomized Controlled Trial of a Psycho‐Education Intervention by Midwives in Reducing Childbirth Fear in Pregnant Women. Birth, 2014. 41(4): p. 384-394.
Brixval, C. S., Axelsen, S. F., Thygesen, L. C., Due, P., & Koushede, V. (2016). Antenatal education in small classes may increase childbirth self-efficacy: results from a Danish randomised trial. Sexual & Reproductive Healthcare, 10, 32-34.
Bernitz, S., Øian, P., Sandvik, L., & Blix, E. (2016). Evaluation of satisfaction with care in a midwifery unit and an obstetric unit: a randomized controlled trial of low-risk women. BMC Pregnancy and Childbirth, 16(1), 143.
van Haaren-ten Haken, T. M., Hendrix, M. J., Nieuwenhuijze, M. J., de Vries, R. G., & Nijhuis, J. G. (2017). Birth place preferences and women’s expectations and experiences regarding duration and pain of labor. Journal of Psychosomatic Obstetrics & Gynecology, 1-10.
Jones, L. V. (2015). Non-pharmacological approaches for pain relief during labour can improve maternal satisfaction with childbirth and reduce obstetric interventions. Evidence-based nursing, ebnurs-2014.
Levett, K. M., Smith, C. A., Bensoussan, A., & Dahlen, H. G. (2016). Complementary therapies for labour and birth study: a randomised controlled trial of antenatal integrative medicine for pain management in labour. BMJ open, 6(7), e010691.
- Kwok, S., et al., Childbirth pain and postpartum depression. Trends in Anaesthesia and Critical Care, 2015. 5(4): p. 95-100.
- Soet, J.E., G.A. Brack, and C. DiIorio, Prevalence and predictors of women’s experience of psychological trauma during childbirth. Birth, 2003. 30(1): p. 36-46.
Campbell, C. M., Witmer, K., Simango, M., Carteret, A., Loggia, M. L., Campbell, J. N., … & Edwards, R. R. (2010). Catastrophizing delays the analgesic effect of distraction PAIN®, 149(2), 202-207.
Maimburg, R. D., Væth, M., & Dahlen, H. (2016). Women’s experience of childbirth–A five year follow-up of the randomised controlled trial “Ready for Child Trial”. Women and Birth, 29(5), 450-454.
Adams, J., Frawley, J., Steel, A., Broom, A., & Sibbritt, D. (2015). Use of pharmacological and non-pharmacological labour pain management techniques and their relationship to maternal and infant birth outcomes: Examination of a nationally representative sample of 1835 pregnant women. Midwifery, 31(4), 458-463.
** EDITED 09.08.18 to add information on this study:
Das, R. K., Tamman, A., Nikolova, V., Freeman, T. P., Bisby, J. A., Lazzarino, A. I., & Kamboj, S. K. (2016). Nitrous oxide speeds the reduction of distressing intrusive memories in an experimental model of psychological trauma. Psychological medicine, 46(8), 1749-1759.
This study found that Nitrous oxide speeds the reduction of distressing intrusive memories in an experimental model of psychological trauma- but in dissociated individuals N2O aggravated PTSD-like symptomatology.
Considering that nitrous oxide (gas and air) is commonly used during labour it may be that this effects women birthing that have PTSD or the development of PTSD after a traumatic birth.
*This post evolved out of my birth experiences, attending over 40 births as a doula, and conversations with women and their partners at the home-birth group in Liverpool that I ran over a number of years. Quotes come from conversations on the #MatExp Facebook group. This is a long post, there is a summary of points made and implications for practice at the end
Transition to Motherhood
The transition to motherhood is a profound psychological event, which has been described as a ’normative crisis’ in the female life cycle requiring the giving up of one identity and the assimilation of another. This can be accompanied by changes in behaviour, mood and self that can feel overwhelming. There is little professional or public literature which agrees on the psychological symptoms women experience.
In antenatal classes women are prepared for childbirth and motherhood, mainly through factual accounts of the physical processes occurring, how the baby develops and grows, the changes in the body, how the cervix dilates, uterus contracts to push the baby out. Breasts produce milk for the baby. But there is little preparation for the mental changes that occur in pregnancy, birth and postnatally, except for warnings about low mood. Psychological changes are seen in the lens of deficit and crisis.
Adolescence too, whilst historically and culturally celebrated, in the western world is also increasingly seen as a ‘risky’ time and surveillance encouraged for potentially pathological symptoms. 
These transitory times of life which include psychological ‘crises’ include puberty, marriage, birth, and death, have been marked by initiation rituals since prehistoric times. Native and premodern societies used rituals during these transitional periods in life, (which are viewed as normal and expected personal development and growth) to celebrate and assign social identity.
The social meaning given up to Motherhood in Western modern society is that woman should be happy, content, enjoy mothering and that mothering comes naturally.  This comes in a social setting where there is increasing pressure on women to be financially independent, leading to later age to start a family, and fewer women experienced in childrearing of younger siblings. There has also been a movement away from organised religion.Thus the removal of childbearing experiences from the religious realm has created a culture with “no sacraments for the blessing of childbirth, no ritual to support a woman in childbirth”; this, in turn, “robs this part of feminine life of all its psychological depth and importance”
Three phases have been said to occur during all initiatory processes: separation, liminality, and integration. (For motherhood, this could be marked by pregnancy, birth and postnatal phases)and childbirth can be seen as similar to initiation ritual through several psychological elements, such as the experience of pain or powerful bodily sensations, an altered state of consciousness(’laborland’) a symbolic experience of death and rebirth, self-‐ transcendence, or an ecstatic feeling of unity.
Mental state during childbirth
Although little literature exists to describe to expectant women how being in labour feels, there are cultural expectations of women’s experience and behavior during birth, which usually revolve around pain and drama. Midwives describe using women’s behavior to assess whether active labour has begun and how labour is progressing.[10-12] this behavior is described as ‘labour-land ‘or being ‘In the zone’ and is thought to be due to the hormones released during labour and the pain of contractions.
“Hormones also have an effect on the way pain is experienced in labour. The hormone called beta-endorphin is an opiate or pain-killer that occurs naturally in the body. It is similar in a number of ways to the synthetically produced drugs pethidine and morphine. The subtle balance of hormones changes again when the cervix reaches full dilation. This phase is called the ‘transition”
“Labor land is like a deep meditative state. It is like an out of body experience except that it occurs so internally, totally within your body and in the meditative part of your mind. Being in this state allows the mom to get into the rhythm of her contractions and to develop a routine of what works for her to stay on top of the intensity of her labor.
It is important that no one tries to talk to her or pull her into her conscious mind when she is in labor land. This can take her out of her zone and make it more difficult for her to deal with the sensations she is experiencing.
Some people don’t appreciate the power and importance of labor land and interpret this altered state of consciousness from the outside as a state of weakness where the woman is incapable of dealing with what is around her. This is not a state of weakness but a state of great strength. This is where a woman accesses the full power she has within. Being able to go so internal does leave her vulnerable to outside stimulation. As a support person you are the protector of her space. Your job is to take care of all the external factors so she can stay internal through the birth.”
These changes of behavior in active labour include:
- Sense of separation of mind and body
- Altered time perception
- Zoning or spacing out
- Feeling like things are unreal
- Being unaware of things happening
Women and midwives have also described:
- Not wanting to eat or drink (altered taste perception)
- Altered sense of smell
- Sensitivity to noise and light
- Not wanting to speak, be touched, and communicate
These types of behaviour are known in psychology as ‘dissociation’ and describe a ‘detachment from reality’. This detachment can be temporary (linked to a particular experience) or on-going/repeating.
Dissociation is thought to be a normal human function and is a spectrum that encompasses daydreaming, meditation, hypnotherapy. Dissociation is used by athletes to cope with performing at the limit of their capabilities for long periods. . Lack of an ability to dissociate may be linked to anxiety disorders.
Dissociation is also the means by which the mind protects itself from trauma (and is associated with post-traumatic stress disorder-PTSD). When an experience is traumatic the mind dissociates, however sometimes (especially if the experience is repetitive in nature) or happens during childhood, the dissociation can reoccur in situations that are not currently traumatic or even lead to multiple identities developing.
Altered states of consciousness and dissociation during childbirth
There have been few studies that have looked at how common experiences of dissociation are during childbirth. Two recent studies found a prevalence of approximately 10% (11.3% of the sample experienced significant dissociation.) 
One of these studies found that important predictors of dissociation in labor included both predisposing (e.g. childhood maltreatment trauma, pre-existing psychopathology) and precipitating (e.g. perception of care, negative appraisal of labor) factors. 
Other studies have found much higher rates using qualitative methods (it may be the reports depend on factors such as when women were asked, what instrument is used to measure experience and cultural factors). In Anderson’s study on women’s experience of the second stage of labour sense of separation of mind and body was one of the strongest findings in her study the author concluded that disassociation was not a frightening experience but it enabled the women to keep in control. 
It may be that a woman’s interpretation of her experience as unexpected and/or different/abnormal may affect whether the experience of disassociation during childbirth is adaptive (useful/helpful) or maladaptive (frightening/trauma inducing).
Whilst in a dissociative state “Some sensory cues are likely to provoke alarm in us all, such as sudden unexpected loud noise or rough aggressive touch” (from http://www.iriss.org.uk/resources/trauma-sensitive-practice-children-care)
“At the heart of trauma is terror”
Another consideration is what occurs during disassociation (if the woman experiences interventions, upsetting care, coercion or difficulties during the birth).
A combination of negative emotions prior to and during birth (particularly shame) with dissociation and an instrumental delivery appear highly correlated with developing PTSD after birth. Both dissociation and shame can adversely affect interpersonal relationships (which may make it difficult for midwives and other care-givers to create and maintain a positive relationship with a woman during childbirth, and suggests that continuityof care may mitigate this by building up trust and respect prior to labour.)
This may also be why changes of shift can be difficult for women who have built up a positive relationship with a midwife as they can interpret their leaving as abandonment or feel unable to build a relationship with a new caregiver.
Transfer from one environment to another (MLU to CLU or home to hospital) can also be trauma inducing. 
The hospital environment itself can be triggering, as an unfamiliar environment may present as a threat (which is why making birth environments as home-like as possible is not just window dressing but may actively prevent trauma).
Place of birth appears to effect both optimism and resilience, with home and natural hospital births being associated with a better childbirth experience. 
The recent UK NHS maternity review suggested low-risk women should be encouraged to birth at home or in a midwife led unit. 
I asked women on the #MatExp Facebook group (over 1000 women, partners and healthcare providers interested in improving maternity care) about their experiences of disassociation during labour.
“My first labour I freaked… I hated everything about it, and if I could have exited my body there and then I would have. I felt “spaced” and drunk and I didn’t know what time it was. I can’t really describe it well – sorry. Second time round I listened to hypnosis during labour and it really grounded me, as a result I felt much more in control and towards the end I even announced I was bored!”
“I remember getting so annoyed at the midwives talking with my second. I had my headphones in and I could still hear them even though they were being respectful (and it turned out there was some pretty scary stuff happening with my baby) but I could hear them whispering and I wanted to tell them to shut up because I was concentrating, but I couldn’t find my voice. And when they touched my arm to get my attention I was SO angry with them for breaking my little bubble. Feelings I’d never have usually.”
“It was definitely like a trip. First time, 2nd was too quick and I was too in my rational head until the last 5mins. But first time I had that amazing experience of connection: to all the mothers who were labouring with me in that moment around the world, to all the mothers who ever had been and all the mothers who ever would be. It was enormous and wonderful and comforting. The daffodils out of the window meant something deep and meaningful too, but can’t for the life of me remember what! Anyway, definitely like one of those trips where you’re convinced you’ve got the answer to life, the universe and everything!”
“Like being in a parallel universe. Human interactions are difficult and confusing. Strangers are scary. I was unable to speak, unable to even access the vocabulary! All sensations on high alert and almost unbearable: slightest noise, smell, taste, light. Everything is very black and white like when you’re a child.”
“My first labour I had birth trauma. I felt like a bystander with everything happening to me but no involvement from me, a nightmare that ended up with a fully dressed baby that could have been anyone’s handed to me. I watched myself being cut open via the lights in theatre &it was like watching it happen to someone else on a YouTube video. My vbac’s were very different, I did still have an “out of body” experience when in active labour, I was very aware of touch & vocal about whether I liked it or not. I also hypnobirthed & felt more aware of what was happening in my own body, I knew my 3rd baby was on his way well before my midwife did & didn’t need a VE to tell me otherwise.”
“Being in an altered state is the only place to be in labour in my view. Enabled me to transcend some less than idea birth environments and supporters. Did not protect from ptsd in first (difficult) birth – I think because the sensations are kind of imprinted deep in the psyche when you are in that state. Even now I long to dance in the stars as I once did – and thank the Goddess for those amazing experiences.”
“Yes definitely an altered state, that wasn’t scary for me as it’s how I’ve always got through severe pain or fear and it feels like something I can control (lack of control – now that does scare me!) The down side was that I seem very quiet and calm and I don’t think anyone around me realised how bad the pain and exhaustion had got. I also found it impossible to maintain that and have a conversation and make decisions. Unfortunately as we hadn’t planned at all for things going wrong and I didn’t know the midwives there wasn’t really anyone I could hand over to.”
“This is how gas and air made me feel! Everything was spinning, I was detached, couldn’t form a sentence, it was awful..”
“Second time was definitely a trip! I had no drugs at all. At times I completely went inside my body and experienced the contractions as balls of intense creation energy, sorry if that sounds so hippie but there is no other way to describe it! I felt like a goddess! In between I felt stoned or slept. Amazing! Afterward I felt healed from my first (highly medical) birth.”
“I felt horribly out of it during my second labour. I remember telling my husband I needed the loo and he got a little cross, telling me I had to speak up and tell be midwives but I couldn’t. I was literally frozen with fear. At one point I had a senior midwife holding open my cervix with her hands, two anaesthetists, three other midwives and two doctors in the room with me, all wearing masks, all talking over me. I’ve always felt so guilty about not being able to speak up and blamed myself for a long time for what happened. I didn’t know it was a common thing for women to feel that way”
“I remember them discussing me getting an epidural as my blood pressure was so high and I was just on the bed screaming through the contractions. Everything was so fuzzy. I knew they were talking about doing something I didn’t want but couldn’t do anything about it. An anaesthetist kept coming in and out. In the end I was fully dilated before they could do it so I never had it. Terrifying.”
“I loved my first two stages of labour, didn’t feel it hurt at all, laboured unexpectedly quickly (from midwife who didn’t know me point of view -she later asked if I had a high pain threshold – I don’t remember it being painful at all until she pulled out the placenta) at home so when paramedics arrived I smiled and was happy to have them in my birthing space as only my husband was there who was an unwilling birth partner. They said they didn’t realise how far I was along as I was so calm. I remember them trying to hold my hand and I thinking I didn’t want them in my personal space. Also they tried to give me gas and air which I hadn’t asked for and being irritated I had to push it away, it was interfering in my space. Then after she came out I turned to pick her up and they shouted ‘no’ at me – it knocked me out of my zone and into fear and compliance – I feel traumatised about that. And I saw them get my baby’s first gaze, I was devastated!! She was cleaned before she was given to me and I transferred into hospital for placenta delivery after being told no midwifes available to come out to me. In retrospect I wish I’d free birthed or had a doula as everything was so lovely before anyone interfered.”
“Regards ‘altered state’ yes. I had a long induction (started in the Monday morning, baby delivered at 10am on the Thursday by forceps) where I was left alone a lot and really expected to know what was happening without anyone telling me. I felt very very isolated and detached. Wandering the corridors of the ward at night unable to sleep or eat. Labour was around 20 hours and not allowed to eat and couldn’t rest. Was put on a drip for fluids only during labour. I think lack of sleep and nourishment really contributed to my trauma. I was so spaced out. I’ve no doubt some of the midwives tried to communicate with me but I didn’t take anything in. In theatre I had a traumatic delivery. Baby was out very fast and then taken to NICU – I then had a 4.5l PPH during a further 2.5 hours of surgery to try to stop the bleeding under spinal block. I lost consciousness at one point – I really thought I had died. I really thought I could just let go. I felt like I was watching myself on the table at times. Covered in blood. The whole time I felt like I was going to fall off the table (strange angle to preserve blood flow to my head) so felt in constant danger the whole time.”
“I had gas and air at a few points too and that was mind altering in a different way, quite nice when I thought things were going well and I could chat away on it though I was a little concerned I was embarrassing myself like a drunk person! Once it was clear things weren’t going well I was given it again but it did nothing for the pain and I just got rather paranoid and scared, so I think state of mind before hand is quite important, with my third I experienced going inside my body and I actually saw my son going through the birth canal from Inside it was so weird but amazing and I had no drugs”
It seems there is a complex relationship between previous experiences, personality type, the natural process to dissociate during childbirth and experiences during childbirth (which encompass both intervention and care) which affect the sense of agency and body ownership and may or may not lead to PTSD after birth.
Pain, memory and PTSD
The relationship between pain, dissociation, childbirth and PTSD is not simple and the literature is contradictory. Studies have predominantly showed that women underestimate the pain they would experience during birth. 
Epidural anaesthesia has been associated with a lower prevalence of postpartum depression but not PTSD. Women have described feeling ambivalent about epidural pain relief. Describing relief but a change from euphoric to a ‘normal ‘state which indicated to the author that the internal experience is in focus before the use of epidural analgesia, while the more external experience is predominant after initiation of epidural analgesia. Optimal desired pain control during the birth process may decrease the prevalence of postpartum depression.  How we interpret pain has everything to do with how we will respond to it and our expectations and emotions also play a part in how we experience pain. Memory of pain and affect is influenced by the meaning and affective value of the pain experience. In a study where expectations and memory of pain were studied in women, who gave birth by vaginal delivery or Caesarean section, or underwent gynaecological surgery, surgery led to an overestimation of all but one of the recalled variables of pain. Participants who gave birth by Caesarean section were the most accurate at recalling pain and affect. Memories of pain and affect were most variable in participants who gave birth by vaginal delivery. 
Fear of childbirth results in experience of more intense labour pain and report a negative experience of birth. 
When studying women’s memory of labour pain post childbirth it was found that memory of labour pain declined during the observation period but not in women with a negative overall experience of childbirth. Women who had epidural analgesia reported higher pain scores at all time points, suggesting that these women remember ‘peak pain’.
Protective factors relating to PTSD and childbirth
A critical review of qualitative literature relating to the factors affecting women’s experiences of pain in labour found two main themes (i) the importance of individualised, continuous support and (ii) an acceptance of pain during childbirth 
In a second critical review of qualitative research this time looking at women’s experiences of coping with pain during childbirth feeling safe through the concept of continuous support was a key element of care to enhance the coping ability and avoid feelings of loneliness and fear. A positive outlook and acceptance of pain helped women cope. These findings were consistent across socio-economic, cultural and contextual differences suggesting that experiences of coping with pain during childbirth are universal. 
The ability to move during labour, and change position can be helpful both to facilitate birth without injury  and also a greater sense of control . In one study where women randomised to kneeling or sitting positions in the second stage of labour.A sitting position during the second stage of labour was associated with a higher level of delivery pain (P < 0.01), a more frequent perception of the second stage as being long (P= 0.002), less comfort for giving birth (P= 0.03) and more frequent feelings of vulnerability (P= 0.05) and exposure (P= 0.02). 
A study in Taiwan found women that were randomised to an upright pushing position had a lower pain index (5.67 versus 7.15, p=0.01), lower feelings of fatigue post birth (53.91 versus 69.39, p<0.001), a shorter duration of the second stage of labour (91.0 versus 145.97, p=0.02) and more positive labour experience .
An upright birthing position has also been shown to enhance fathers’ experience of having been positively and actively engaged in the birth process  which is important as men can also develop PTSD from childbirth [38-39], Women who report experiencing less stress in their couple relationship are less likely to report PPD symptoms even when they have a personal history of depression and or PPD  and a woman’s perceived social support has been found to buffer against the potentially traumatic effect of an emergency C-section.
Both mothers and fathers mental health after birth can effect parent-baby interaction and attachment. 
Having a high ‘sense of coherence’ was protective against PTSD following childbirth . The three constructs that underpin the SOC are ‘comprehensibility’ (one must believe that one understands the life challenge), ‘manageability’ (one has sufficient resources at one’s disposal) and ‘meaningfulness’ (one must want to cope with the life challenge).  A review of the literature found that women with strong SOC were more likely to experience uncomplicated birth and birth at home, identify normal birth as their preferred birth option in pregnancy and identify a desire to avoid epidural anaesthesia in labor compared to women with low SOC. 
Increasing pregnant women’s sense of coherence could be a modifiable factor to increase the normal birth rate, reduce PTSD and reduce improve postpartum emotional state. .
As previously discussed, pregnancy and motherhood can be seen as a ‘normative crisis’ and requires profound psychological role transition. Childbirth marks the separation of mother and child as a unit:
“The extreme nature of this experience is what makes the act of delivering a baby a psychological transition, an event of trial and ritual that marks a profound change in a mother’s life.”
There are similarities between mystical and traumatic experiences  and self-induced stress is used cross-culturally as a form of healing. 
“In rituals and with medicinal plants, people push past normal limits in order to experience power, energy, and transformation” 
Substances that that create dissociative states (like LSD, peyote, MDMA) have been used historically and culturally for ritual and healing and are also used recreationally in contemporary western contexts. Users describe the capacity of hallucinogenic drugs for healing and personal growth; even adverse experiences (“bad trips”) were regarded as valuable for these purposes  and some small studies have also looked at using hallucinogens to therapeutically treat long term PTSD and treatment resistant depression. [50-51]
Posttraumatic Growth (PTG) – deriving benefits following potentially traumatic events – has become a topic of increasing interest.
Some studies have looked at PTG after childbirth. Many women report positive changes as a result of their birth experience experience of peritraumatic dissociation and symptoms are most associated with the greatest levels of growth.  Posttraumatic growth in postpartum suggest a potential protective role of posttraumatic growth on the development of disordered eating symptoms. 
Social support has been seen to predict PTG. 
The transition to ‘motherland’ (constructing a new identity as a mother) can be hindered by traumatic birth experiences that reduce sense of coherence and the ability of the body to successfully birth or feed their baby. 
Mastering pain has been viewed as an integral part of a self-actualizing experience. Women have described a sense of achievement and feeling of pride in their ability to cope with intense pain, which increased their sense of self-efficacy. When empowered by their own attitudes and with the assistance of others, these women felt they met and mastered their birth experience, and some described giving birth as a transcendent experience. 
A study exploring first-time mothers’ experiences of birth found that women ‘processed the birth’ by ‘remembering’, ‘talking (storytelling)’ and ‘feeling’. This activity appeared to help most women resolve their feelings about the birth and understand what it actually means to be a new mother. 
I asked an antenatal teacher what they taught women and their partners about state of mind during birth:
“I talk about undisturbed birth producing sensations of an altered state of consciousness facilitated by the increase of the hormones Beta-endorphin and Oxytocin. I describe this as a natural, helpful aspect of undisturbed birth, producing feelings like being “in the zone,” “miles away” or “going off to another planet” combined with the body’s natural pain relief.
As a hypnotherapist I talk about these experiences as being a form of “birth hypnosis” / “birth trance” which can also include (positive) time distortion, altered physical sensations, and sometimes visual or auditory perceptions; all normal aspects of hypnosis. I introduce this state through a series of exercises and ask their partners to observe. We spend time on how partners can help facilitate and protect this helpful state for their partners. I teach them to practice entering this state with self hypnosis and recordings which I create for them in order to make it a welcome and familiar part of birth for the woman and her birth partner so that it is there to tap into during birth. This was certainly my own experience in my second (pain-free) birth where I used hypnotherapy and self hypnosis.
Unfortunately this state is inhibited when birth is disturbed, when a birthing woman is fearful and in the fight-flight-freeze state. I think first time birthing women often push this helpful aspect of birth away, feeling that they need to stay “on top” or “in control.” When high levels of Catecholamines: adrenalin and noradrenaline are produced, fear and pain (without the soothing effects of beta-endorphin) are part of birth. I suspect that this is where traumatic experiences arise. The combination of (negative) time distortion and possible visual and/ or auditory hallucinations with fear and pain is certainly frightening and I suspect for some women traumatising. This was the case for me in my first posterior birth.”
- The transition to motherhood is a profound psychological event, which has been described as a ’normative crisis’ in the female life cycle.
- Transitory times of life which include role changes (puberty, marriage, birth, and death) have been marked by initiation rituals since prehistoric times.
- Childbirth can be seen as similar to initiation ritual through several psychological elements, such as the experience of pain or powerful bodily sensations, an altered state of consciousness (’laborland’) and a symbolic experience of death and rebirth.
- Many cultures use substances to create dissociative states during rituals and for healing.
- Dissociative states of ‘altered consciousness’ are commonly experienced by women during childbirth.
- These states help women cope with the experience of childbirth and may prime women to experience the profound psychological shift to motherhood.
- If women are unprepared for this dissociative state they may feel frightened or ashamed, especially if women experience traumatic care or interventions, this can result in women developing PTSD.
- Fear of childbirth results in experience of more intense labour pain and report a negative experience of birth
- Women who have unmedicated vaginal births are more likely to forget the pain of labour. Having an epidural can make women feel disconnected from the labour process and more likely to remember their labour as painful.
- Two main factors effect women’s experience of pain in labour:
- Support and (ii) acceptance
- A positive outlook and acceptance of pain helps women cope, experiences of coping with pain during childbirth are universal
- Freedom to move and adopt upright positions in labour give women a greater sense of control and a lesser sense of vulnerability and facilitated a positive birth experience.
- Having a high ‘sense of coherence’ is protective against PTSD following childbirth
- Childbirth is “an event so primitive and profound as to be difficult to fully assimilate or put into words. . .”
- Even if birth is experience as traumatic, it is possible to women to experience posttraumatic Growth (deriving benefits following potentially traumatic events)
- Experience of peritraumatic dissociation and symptoms have been found to be most associated with the greatest levels of growth.
- Social support is a modifiable factor that effects coping with childbirth, PTSD, PPD and postpartum transition to motherhood
Implications for woman and midwives
- Antenatal education should prepares women for the possible psychological changes and experiences during pregnancy, birth and postpartum (including dissociation)
- Continuity of care is key to a feeling of safety and trust
- Preparation for childbirth should aim to reduce anxiety and enhance women’s sense of coherence and efficacy (including methods of non-pharmacological pain relief and mindfulness) [59-60]
- Maternal freedom of movement throughout labour is a simple measure to improve birth experiences for women and their partners
- Interventions to improve social support for women and enhance couple relationships in the antenatal period is key to improving postpartum mental health and improving parent/infant attachment
- Childbirth can be seen as a spiritually transforming experience, an increase in personal meaning, religiosity, and spirituality can increase well-being so access to the opportunity to incorporate personal spiritual practices or social experiences (such as mother blessings https://magicalbirth.wordpress.com/2012/05/03/hello-world/ ) could be helpful 
- Doula support can provide women and their families with continuity, one-to-one focus on their physical, emotional and spiritual needs during childbirth and postnatally to improve women’s self-efficacy and transition to motherhood and so could significantly affect women’s mental health in the peri-natal period and increase family sense of coherence
- Providing opportunities within a group for women to tell their birth stories following birth; may help women to process the birth and connect to other women.
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I decided to write this blog post after a discussion in #MatExp about the use of vaginal exams (VE’s) in labour.
There were concerns that women felt pressurised into consenting to vaginal exams in order to be admitted into birthing units in labour or to access pain relief/the use of a birthing pool etc.
It was discussed that vaginal exams can feel intrusive and be upsetting and that the evidence base for using them in labour is not strong.
Others felt that they are an essential part of labour management, needed to monitor progress and prevent harm from non-progressing labours.
People wondered if there are no other ways to assess progress?
Should vaginal exams be seen as part and parcel of normal labour care?
What are the risks/benefits to having VE’s and should women have more information antenatally about them?
My own experiences of vaginal exam in labour were not distressing to me, but as a doula I have witnessed distressing events occurring in relation to vaginal exams that include:
- A woman having 20 VE by 8 different people- her cervix swelled and she had a CS due to failure to progress at 9cm
- A woman who was asked to get out of a birth pool to check for 10cm dilation when pushing, she was told the midwife couldn’t check her in the pool, she was then not encouraged to get back in the pool
- Coercion of a woman with an abuse (sexual) history at a homebirth to consent to vaginal exams (when she had discussed not wanting them in appointments leading up to the birth) which was distressing for her
- Breaking waters during an exam without permission (I’m just breaking your waters as she did so)
- A midwife gave a vaginal exam, stated the woman’s contractions were less frequent and stated she would “Just have a little fiddle about”she then proceeded to give the most intrusive, painful and upsetting exam I have seem, which was traumatic to watch
- I have also seen good practice of very respectful care to women with abuse histories and a consultant midwife that was able to give exams when women were in pools/upright
Before we look at what vaginal exams are used for, I think it’s important to remember that for a woman having her first baby in the UK, a vaginal exam in labour might be the first time anyone has put their fingers in her vagina except during sex (which may or may not have been consensual or enjoyable)
A vaginal exam involves a health professional placing (usually two) fingers in a woman’s vagina in order to feel her cervix (the entrance to the womb) to assess her progress in labour (this can also be done as part as a membrane sweep in late pregnancy to encourage labour to start.) Vaginal exams in labour are seen as a ubiquitous part of assessing progress, and therefore diagnosing deviation from expected progress and reduce the risks associated with non-progressive labour. A vaginal exam is often one of the first routine procedures when a woman believes labour has started. A woman may have previously been offered one or more membrane sweeps in pregnancy (which is similar to a vaginal exam) to encourage labour to start.
An exam can assess if a women is in ‘active’ (also termed progressive) labour. Whether a woman is ready to go into labour is to feel her cervix, its position, thickness, texture and dilation. This can be given a bishops score (http://perinatology.com/calculators/Bishop%20Score%20Calculator.htm) which can be predictive of induction success although this seems to be more reliable in women having their first baby (nulliparous)  and is disputed as a predictor of labour outcome in women having a second of subsequent baby (multipara)Before labour a woman who has not previously had a baby will usually have a cervix which is:
- Long (thick)
Before active labour begins the cervix will more forward, soften, become thin and start to open. Sometimes this is accompanied by contractions and other signs (sometimes early or prodromal labour).
The first exam in labour is often to assess if labour has started. Early labour can potentially go on for days or stop and start again days later with no risk associated with this usually unless the bag of waters surrounding the baby breaks (which could introduce infection) although there is evidence that a long early labour can be due to a babies position and lead to a non-progressive labour and more intervention. The longer a woman spends in hospital during this early labour period the more intervention she is likely to have, also maternity units in the UK are not set up to cater for women in early labour so women are often sent home, sometimes repeatedly.
Active labour is considered to have started after 3-4cm dilation (opening) and will then usually continue with regular strong uterine contractions (which become stronger, last longer and get closer together until the baby is born). It had been thought for many years that labour is a linear process, but recent reviews of the evidence have suggested that dilation and labour length is less predictable, with the early first stage of labour (4-6cm dilation) taking longer (in the US, ACOG in part of a attempt to reduce the cesarean section rate have changed national guidelines to have active labour starting at 6cm instead of 4cm[4 5]).
How is labour progress assessed?
In order to assess labour progress, observations are made by the health professionals involved in a woman’s care. In the UK this is usually a midwife.
In NICE guidance (Intrapartum care for healthy women and babies [CG190] Published date: December 2014)
The National Institute for Health and Care Excellence (NICE) provides national guidance and advice to improve health and social care.It has since acquired a high reputation internationally as a role model for the development of clinical guidelines.
A Partogram provides a graphic overview of the progress of labour and records information about maternal and foetal condition during labour. The World Health Organization has designated management of labour with the Partograph as one of the essential elements of obstetric care at the first referral level.
In 1991 in Asia, the WHO examined over 35,000 births in the largest trial of the Partograph ever done . The study found evidence that prolonged labour, postpartum sepsis, and stillbirth were significantly reduced when the Partograph was used. Augmentation rates and caesarean rates were also reduced. Another study looked at the effect of partogram on the frequency of prolonged labour, augmented labour, operative deliveries and whether appropriate interventions based on the partogram reduced maternal and perinatal complications introduction of partogram showed significant impact on duration of labour (p<0.001) as well as on mode of delivery (p<0.01) Results also showed significant reduction in number of augmented labour (p<0.001) and vaginal examinations (p<0.001). The authors concluded by using partogram, frequency of prolonged and augmented labour, postpartum haemorrhage, ruptured uterus, puerperal sepsis and perinatal morbidity and mortality was reduced.
But findings can be contradictory, another recent study looking at the role of partogram in the management of labouring mothers with high risk pregnancies at a tertiary care centre found that partogram use had no significant impact on duration of labour, rate of operative interventions and perinatal outcome. A Cochrane review on the effect of partogram use on outcomes for women in spontaneous labour at term found no evidence of any difference between partogram and no partogram in caesarean section (risk ratio (RR) 0.64, 95% confidence interval (CI) 0.24 to 1.70); instrumental vaginal delivery (RR 1.00, 95% CI 0.85 to 1.17) or Apgar score less than seven at five minutes (RR 0.77, 95% CI 0.29 to 2.06). The authors stated ‘On the basis of the findings of this review, we cannot recommend routine use of the partogram as part of standard labour management and care’
There have been several versions of the partograph. The WHO version from 2000 starts active labour at 4cm dilation. There have also been recent studies looking at a ‘physiological partograph’ with a slower rate of expected progress in earlier active labour.
Partographs have an ‘action line’ (most also have an ‘alert’ line) which signify identification of slow progress and the point at which intervention is advised to prevent harm to the mother and baby. Many studies were done to assess the predictive value of these lines, one study found that the mean duration of active phase of labour increased as the partographic curve fell to the right of alert and action line. Increased rates of instrumental deliveries, LSCS, babies with lower APGAR score at 5 min, and NICU admissions were observed in group III (to the right of the action line) compared with groups I and II.(within normal curve or to the right of the alert line)another study found crossing the alert line in mothers who had normal vaginal delivery, with normal fetal heart rate, and with no oxytocin administration or amniotomy was predictive with high sensitivity for the need for neonatal resuscitation after birth.
How long should labour take and what are the risks of labour taking too long?
“The sun should not rise twice on a labouring woman.”(an old saying in tropical obstetrics)
Friedman’s curve has been used to assess the expected length of labour (usually 1cm per hour in active labour. With full dilation at 10cm and the pushing stage lasting approximately an hour) although other studies have suggested (especially the first time a woman gives birth) that labour takes longer, and in some places (for example the All Wales normal birth pathway) this is reflected in guidelines where women are expected to dilate 0.5cm per hour in active labour and take up to 3 hours in the second stage(pushing).
In many areas of the world, women give birth at home, without attendance by a trained health professional and only access care if they feel there is a problem with the labour. There are also cultural reasons that may discourage women from seeking help in labour as often failure to birth easily is thought to be due to actions of women during pregnancy.
In these countries, there is high maternal and neonatal mortality and morbidity relating to obstructed labour, (one of the five most common causes of maternal mortality) with many women (usually first time mothers) developing an obstetric fistula. Where the tissues that normally separate the vagina from the bladder and/or rectum are destroyed by the prolonged impaction of the presenting fetal part (usually the fetal head) against the soft maternal tissues that are trapped between the fetal head and the woman’s bony pelvis. The World Health Organization (WHO) estimates that more than 2 million women live with the condition and up to 100,000 new cases occur each year.
The formation of an obstetric fistula is a problem that originates during prolonged labor when that labor is obstructed. The critical problem in the first phase of delay is recognizing that labor is prolonged. By WHO standards, labor is prolonged if it lasts more than 24 hours.
Length of labour does not always predict fistula formation, it is strong, frequent contractions where the baby is impacted against the pelvis and does not descend. In women having second or subsequent births this more frequently results in uterine rupture.
Relatively short labours less than 12 hours in length may result in a fistula if the conditions for “a perfect storm” are present. In practical terms, this means that all cases of obstructed labor should be regarded as emergencies and treated promptly to avoid the development of serious complications.[15 16]
There are arguments about the slowest ‘normal’ rate of progress that does not result in increased risk  Quite a large number (approx. 37% in one study)of low risk women do develop dystocia, but we don’t know how to predict who will reliably. Some studies have also found that slow progress during a VBAC increases the risk of uterine rupture
Although labor dystocia (slow or difficult labor or birth) is the most frequently documented indication for primary cesarean birth, there is no universally accepted definition.” Failure to define dystocia in evidence-based, well-described, clinically meaningful terms that are widely acceptable to and reproducible among clinicians and researchers is concerning at both national and global levels.”
The frequency and reasons for vaginal examinations in labour
Even though NICE guidance states that women should be offered vaginal exams 4 hourly, a recent study found that almost 70% of women had more VEs than expected when the criteria of 4 hourly VEs was applied. The most common reason given by midwives for performing a VE was to assess labour progress and to assess the commencement of labour. 
Other reasons to do a VE include:
Ultrasound assessment of the fetal head position in labor is feasible in a busy labor ward. Digital examination is less accurate than ultrasound, in particular in cases of obstructed labor when medical intervention is more likely to be needed. Ultrasound assessment may prove useful in the prediction and diagnosis of difficult and prolonged labor
Second stage of labour
Vaginal exams are often given to diagnose the start of the second stage. Sometimes women feel an urge to push before their cervix is fully dilated (usually due to fetal malposition) and it is thought that pushing on an undilated cervix can cause swelling. There can also be a ‘lip’ of cervix remaining which can be due to asyncliticism (tilted head)
To help women push better?
In one study (Titled: “You’ll Feel Me Touching You, Sweetie”: Vaginal Examinations During the Second Stage of Labor) to determine how caregivers performed sterile vaginal examinations researchers examined videotapes of women during the second stage of labor. Results showed that the examinations were performed in a ritualistic manner by all caregivers, and the way the ritual was enacted repeatedly demonstrated the power of the caregivers over the women. The most common reason for performing the procedure, to help the woman push better, seems to be specific to the second stage of labor and is not described in the literature.
Other possible reasons include:
- Detecting baby position (especially if breech position or cord prolapse is suspected)
- Concern over babies’ heartrate and possible rapid labour progress
- Abnormal bleeding
- Making decisions about pain relief/transfer/intervention
- Deciding when to get in a birth pool
Evidence for and against vaginal exams in labour
Even though routine vaginal exams are now seen as part and parcel of intrapartum care the lack of evidence for their use is highlighted by some, with a Cochrane review concluding: “Women prefer vaginal exams to rectal exams. No other evidence was found to support or reject the use of vaginal exams. More research needed to find other ways to assess progress of labour [25 26]
What can the experience of vaginal exams in labour be like?
There have been few studies looking at women’s experiences of vaginal exams in labour, but those that have been done found that women find VEs in labour to be unpleasant, invasive, embarrassing and sometimes painful and that women felt powerless to control when and how the VE was conducted[21 27] The VE has been described as a type of health care ritual with the labouring women playing a generally passive role with no active part and the healthcare provider demonstrating that they are in control of both the woman and the process of labour itself Women have reported that they have to tolerate the pain and discomfort of the VE as it is an integral part of labour.
Studies exploring the qualitative experiences of midwives and women in relation to vaginal examination in labour have also described midwives using abbreviations or euphemisms as a means to distance themselves from the realities of the procedure. ‘Some midwives were observed washing women’s genitals in a highly ritualized manner prior to vaginal examination, apparently as a strategy for establishing power differentials. ’The authors conclude ‘It is also important to carry out vaginal examination in a way that is not demeaning and does not reinforce notions that women’s bodies are dirty.’
Previous trauma and abuse
Many women have experienced rape, abuse or other sexual offenses in their lifetime.
Based on aggregated data from the ‘Crime Survey for England and Wales’ in 2009/10, 2010/11 and 2011/12 around one in twenty females (aged 16 to 59) reported being a victim of a most serious sexual offence (rape) since the age of 16. Extending this to include other sexual offences such as sexual threats, unwanted touching or indecent exposure, this increased to one in five females reporting being a victim since the age of 16.
Many women do not disclose their experiences but the experiences during pregnancy and labour can trigger unwanted memories and fear. Worry about physical exams can stop women from accessing healthcare (for example cervical smears) and if women feel coerced or disembodied during childbirth they can be retraumatised. It is not always intimate procedures themselves that can be triggering for women, but how they are conducted, ‘re-enactment’ of abuse occurs as a result of crossing a woman’s body boundaries (and this can be a subjective internal sense) it is suggested that:
“As staff may not know of a woman’s history, they must be alert to unspoken messages and employ ‘universal precautions’ to mitigate hidden trauma. Demonstrating respect and enabling women to retain control is crucial. Getting to know women is important in the building of trusting relationships that will facilitate the delivery of sensitive care and enable women to feel safe so that the re-enactment of abuse in maternity care is minimised.”
Prior trauma is the most predictive factor of Post-traumatic stress disorder (PTSD) after birth. 
Consent to vaginal exams is necessary but women may not always understand the procedure or may feel coerced into having examinations done, as this is part of routine care, which can be traumatic, both for the woman, her birth partner/s or students, as described in this reflective piece-
It wasn’t supposed to be like this (c) S. Wallis
You thought, you would open up beautifully-like a flower does
air spreading your petals, slowly.
You thought, you would open up gently like an anemone,
red fronds unfurling with smooth salty ripples.
Not submit to this, four hourly ritual,
Spreading your legs wide, for relentless gloved fingers to press, into, you.
Assessing your readiness; your worthiness-
Like that boy at your fourteenth birthday party, after spinning the bottle.
You could taste your Mothers stolen vodka in your throat when he fingered you-
Biting your lip, trying not to cry out so the others would hear.
You thought the Universe would be moving through you,
Youe Man kneeling in worship at your feet-
With you birthing the world anew
Not strapped down,
With them crowding round and shouting that you are useless, that you aren’t trying
-that your baby is going to die if you don’t push harder.
And the student midwife is cutting you, and the senior midwife is cutting you again
And the surgeons are hovering, and your Man’s eyes are looking on with horror,
And your baby is limp and grey and quiet…
Even after she starts to cry, her eyes are screwed tightly shut,
And she is over with the medics, not on your belly like you thought
And they are stitching you up, and you are crying, and he is crying,
And you didn’t think it would be like this.
Are there other ways to assess progress in labour?
Several alternative ways to assess labour progress have been suggested, including:
Contraction shapes (fall to rise ratio is higher when labour is nonprogressive)
Changes in behaviour have been described by experienced midwives that signify active labour and progress in labour. These include:
- Breathing patterns
- Skin changes and body temperature
- Pain perception
There is good association between non-invasive ultrasound-based determination of fetal head station and clinically assessed cervical dilatation. When women were asked to compare the experience of vaginal exams and translabial ultrasound the majority (70.5%) considered VE worse than translabial ultrasound (TLUS) as compared to only 4% who felt the opposite.and has been found to be considerably less painful and may be useful to help predict which women will have vaginal births with prolonged second stage and which need assistance.
Purple line[42 43] the formation of a purple line during labour, seen to rise from the anal margin and extend between the buttocks as labour progresses has been reported. This is being looked at as an alternative measure of labour progress but may not have a high predictive value.http://www.sarawickham.com/questions-and-answers/evidence-for-the-purple-line/
What changes could we make to services to improve things?
It seems unlikely that a change of practice to stop or reduce the use of vaginal exams in labour would happen in the UK soon, so what can be done to improve things now?
In a study that looked to improve the vaginal examinations performed by midwives, suggestions included:
- Judging the necessity of vaginal examinations
- Using effective communication skills
- Informed consent
- Exploring the patient’s preferences and choices
- Providing sensitive woman-centred care
- Minimising variability during vaginal examinations
- Paying attention to the frequency of vaginal examination
- Using alternative ways to measure the progress of labour
- Managing unresolved traumatic experiences
Screening for prior experience of abuse, rape or PTSD symptoms prior to birth is also seen as key to prevent retraumatisation during birth. This screening needs to be appropriate
A thesis by Amina White ‘BEST PRACTICES FOR LIMITING RISK OF POSTTRAUMATIC STRESS RELAPSE DURING CHILDBIRTH’ outlines a three-part strategy for trauma-informed obstetrical care that calls for PTSD screening, avoiding posttraumatic stress triggers, and enhancing stress-coping resilience in order to promote the physical and mental well-being of trauma survivors during the birthing process.
‘Obstetricians have a clear duty to inquire sensitively about past trauma and to screen trauma-exposed women for PTSD’
If a woman discloses her history, a plan can be made to reduce or avoid ‘micro triggers’
Not all women will want or feel it is necessary to disclose their history, so it is important during labour to look for signs of anxiety, discomfort or distress.
Narrative accounts suggest that survivors whose clinicians ignore distressing micro-triggers are more likely to perceive those clinicians as disrespectful and as providing substandard care
In the event that the clinician and medical staff are aware of a patient’s trauma history, it becomes especially critical to avoid phrases that accentuate powerlessness such as, “Just let it happen, you can’t fight it”
I have personally seen successful birth planning of women with abuse histories with Consultant midwives in the UK that resulted in positive birth experiences, including a homebirth and a planned caesarean section.
A doula may be able to support women in labour and can concentrate of communication, comfort and emotional support.
Vaginal exams are done in labour for many reasons. The first exam is usually to assess if a woman is in active labour. Once active labour has started exams are usual every four hours in order to plot labour progress on a pictorial record (partogram). Although vaginal exams should be ‘offered’ they have very much become part of routine care and women often feel unable to opt out.
Evidence of benefit from vaginal exams is scant, and little research has been done on women’s views in relation to their experience of vaginal exams or consent.
In low and middle income countries many women and babies are damaged by obstructed labour, which leads to negative outcomes including obstetric fistula, uterine rupture and stillbirth.
There is still disagreement about how long is too long to wait for labour to progress when labour is slow in both the first and second stage without intervening.
Possible disadvantages from refusing vaginal exams are: not knowing if active labour has started (so potentially having pain relief like an epidural or diamorphine when labour has not started) not knowing if labour has stalled or for how long (with possible risks to mother and babies health)
70% of women had more VEs than expected when the criteria of 4 hourly VEs was applied
Women find VEs in labour to be unpleasant, invasive, embarrassing and sometimes painful and sometimes feel powerless to control when and how the VE was conducted
1 in 5 women have experienced rape or sexual threats, unwanted touching or indecent exposure since age 16.
Experiences during pregnancy and labour can trigger unwanted memories and fear
If women feel coerced or disembodied during childbirth they can be retraumatised
Language used is important, as being asked to tolerate pain and discomfort, or ‘just a little’ longer can be similar to phrases used during sexual abuse and coercion. Respecting women’s wishes and boundaries is key
Be alert to signs that someone is consenting under internal duress as this can be extremely distressing
NICE guidelines state VE’s should be ‘offered’ they should not be required to access pain relief, birth pools or access to a maternity unit if other signs of active labour are present
Several alternative methods can be used to assess labour progress in particular trans-labial ultrasound is a promising method to sequentially assess labour progress
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I made a Storify book summarising the twitter chat I recently hosted