Joanne Luff, 45, gave birth to her second child on a sunny autumnal day in Sydney. At the time, she described the experience as “amazing”. The fast and furious drug-free labour had proved a welcome contrast with the birth of her first child, who was delivered via an elective caesarean. But four years later, she is still recovering from the natural birth she so desperately wanted.
“My pelvic floor muscle ripped and detached from my pelvic bone. It caused a hat-trick of prolapses – rectal, uterine and bladder,” says Luff. “Of course, I didn’t realise that at the time. I thought that the heaviness I was feeling was normal.”
Despite being in considerable pain and discomfort, Luff’s issues were not picked up at her six-week postnatal check. Nor did her GP take her seriously when she first sought help. It was only sheer persistence that won her a diagnosis and a referral.
“My uterus was sitting at the entrance of my vagina – I could see it,” Luff recalls. “I couldn’t fully empty my bladder, so I felt like I needed to wee all the time, and my bowel bulged into my vagina. No one had told me that this could happen. I didn’t know it was possible.”
Statistically, Luff’s injuries are not uncommon. A 2016 Medibank study found that as many as 31 per cent of Australian mothers who have given birth in the past five years suffered pelvic floor damage, and 10 per cent had had a pelvic organ prolapse.
Other common birth injuries include third-degree perineal tears, haemorrhoids and long-term urinary incontinence. Issues such as nerve damage, rectal incontinence and fistula (a hole between the vagina and rectum or bladder) occur much less frequently, but do happen. And yet women like Luff, whose lives are wrecked by birth injury, are often condemned to suffer in silence.
For Luff, living with a considerable birth injury caused debilitating depression. “I lost all my confidence. It affected my entire demeanour, my womanhood, my everything. I didn’t want to have sex, I didn’t want [my partner] to touch me. I’d gained weight. I couldn’t exercise, so I couldn’t lose the weight. It was like this vicious circle,” she says. “I hated my body – my body had failed me.”
Narelle Horwitz is a perinatal psychologist at the Centre for Perinatal Psychology in Sydney’s southern suburbs. She notes that there is a wall of silence around the topic of birth injury. “There is stigma attached to birth-related injuries as it often involves discussing genitalia, incontinence and sexual function. It also involves discussing the unpleasant emotions of shame, anger and guilt,” she says.
Because of this stigma, many women keep their injuries secret from friends and family. For some, this can lead to social isolation and psychological distress, which left untreated can have a long-lasting impact on a woman’s wellbeing.
“[A woman in these circumstances] may struggle to connect with her baby, withdraw from mothers’ groups, feel anger at herself for her birth choices, anger at her care providers for not keeping her safe, anger at her child for ‘causing’ her injuries, anger at her body for failing her and/or confusion over whether she could tolerate another pregnancy,” says Horwitz. “It can also take a toll on relationships and self-esteem.”
In addition to physical injury, Horwitz says as many as one in three women find their child’s birth emotionally traumatic. Physical injury can serve as an invasive reminder of this experience, which can lead to further distress.
Another common issue, she says, is that women who have suffered a birth injury often feel they should be grateful to have a healthy baby and therefore play down their own distress. This can be exacerbated by well-meaning friends and family who encourage the new mother to move on from the birth and concentrate on looking after the baby.
“A woman may be encouraged to ‘get over it’ for many reasons,” says Horwitz. “These may include a lack of understanding about her injury, discomfort at discussing ‘taboo’ topics or because this is the same advice they were given after the birth of their own children.”
This is something Dr Charlotte Elder, a practising obstetrician and gynaecologist and spokeswoman for the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, has also encountered. “As a care provider it actually makes me really sad when I hear people expressing those views about women or women expressing those views about themselves,” she says.
Elder believes the medical profession should think more broadly about what constitutes good health. “We really need to look at the health of the whole family. So that’s the woman, that’s her partner, and that’s the baby. And it’s physical and psychological health,” she says. “If a woman is feeling anxious or uncertain or scared or depressed, then that’s not good health.”
Elder wants to improve the way birth injury is dealt with in Australia. In order to do this, she says, we need to be more transparent about what is normal and what isn’t. This means having frank discussions with women during pregnancy, birth and after birth. “I think it really comes down to communication. If women are given the opportunity to ask the questions, then they will.”
Elder says normalising birth and birth recovery is also important. “If you believe what is portrayed in the media, then within two weeks you’ll be back to your pre-baby weight and you’ll have no stretch marks and you won’t have any pain around your perineum,” she says. “Unrealistic expectations are really damaging for women.”
In Luff’s case, her injuries were severe enough to require surgery, but she also credits her women’s health physiotherapist with aiding her recovery. She believes physiotherapy should be part of a standard package of care for women following birth.
Heba Shaheed, a physiotherapist and co-founder of The Pelvic Expert website, agrees. “Every woman who gives birth must see a women’s health physiotherapist. We are trained in vaginal and rectal examinations and are highly skilled in pelvic floor issues.”
Physiotherapists such as Shaheed are able to diagnose birth injuries and complications such as diastasis recti (abdominal separation) prolapse, and levator avulsion (when the pelvic floor is torn off the pelvic bone). They can also assist women in overcoming incontinence and pelvic pain. A tailor-made physiotherapy program can help women to strengthen their core muscles and pelvic floor.
Shaheed has been working with women in the postnatal period for seven years and has witnessed a spate of birth injuries from women who had no idea anything more severe than a perineal tear was even possible. “The healthcare system fails to educate women about the possible women’s health issues after birth as there is this misconception that we will scare pregnant women or that it will lead to a rise in C-sections,” she says.
But for Shaheed, educating women about the full spectrum of birth injury will help to smash the stigma experienced by so many women. “Educating women will help them to prepare for possible complications as well as prevent them,” she says. “It is important to emphasise that women’s health issues are common, but they are not normal, and we should never accept them as normal. Women deserve to live lives that are free from pain and bladder or bowel control problems.”
These days Luff is very vocal about her experience of birth injury. She says talking openly about her own ordeal has given other women in her circle an opportunity to tell their own stories. “Of course you don’t want to bring it up – ‘Oh, by the way, my uterus is hanging out.’ It’s not everyday conversation. But then when you start talking about it, it’s amazing how many women open up, too.”
Now, four years after giving birth, Luff is recovering from a second round of surgery. “I can’t tell you how lovely it is to feel normal again. Now I’m just looking forward to getting back into things. But it’s been a very long and lonely journey.”
This article was first published in the print edition of The Saturday Paper on Oct 14, 2017 as "Accident of birth". Subscribe here.