Beyond the Birth Suite: An Overview of the NSW Birth Trauma Report

One year after the NSW Parliamentary Select Committee on Birth Trauma (the Committee) exposed systemic failures in maternity care, we review the report’s key findings and recommendations.

The Inquiry drew over 4,000 submissions, primarily from women and birthing parents, sharing deeply personal accounts of trauma. These stories revealed a troubling pattern of ignored consent, inadequate pain management, and clinical interventions performed without explanation or empathy. Many submissions described not just medical complications, but the lasting psychological harm that resulted from clear systemic failures in maternity care.

Definitions

• Birth trauma was defined in the Inquiry as any physical injury (such as pelvic floor damage), psychological distress (such as fear for the life of the mothers or baby, or loss of control) or disrespectful treatment (such as dismissing or ignoring the mothers birth wishes) that has potential to have negative effects on women’s health or wellbeing.1
• Obstetric violence was defined as inappropriate, disrespectful, neglecting or abusive treatment before, during and after birth. Examples included coercive language, discrimination, a lack of informed consent, failing to respect dignity, confidentiality and a lack of informed choice.2

Background

The Inquiry was prompted by increasing awareness of the widespread nature of birth trauma and its profound impact on women and their families. In December 2022, a study by Western Sydney University found that 28% of women in NSW had experienced birth trauma, with more than one in ten reporting some form of obstetric violence.

That same year, the Health Care Complaints Commission received a complaint on behalf of 30 women who had endured traumatic births at Wagga Wagga Base Hospital. Their accounts – detailing experiences of disrespectful and abusive treatment – gained national attention and highlighted broader concerns about maternity care. These revelations spurred further investigations into obstetric care at both local and state levels.

In response, the NSW Parliament established the Select Committee on Birth Trauma, tasked with examining the causes, prevalence, and systemic drivers of birth related trauma across the state.

Specifically, the Committe was tasked to inquire into:

• the potential causes and contributing factors to birth trauma;
• the impact of birth trauma;
• the barriers to providing and receiving continuity of care;
• methods of delivery and access of educational information on maternity care; and
• what steps could be taken, if any, to improve the maternity health care system within NSW to help reduce the prevalence of birth trauma.3

This inquiry built on the findings of an earlier investigation into health outcomes and access to hospital services in rural, regional, and remote NSW, which had identified significant barriers to continuity of maternity care for women in rural and regional areas of NSW.

Findings and Recommendations

The Committee’s findings from the Inquiry unveiled the widespread, systemic nature of preventable birth trauma in NSW. The findings confirm what many women and families have long voiced – the current maternity care system often fails to provide safe, respectful and informed care.

Several key systemic issues were identified including:

Caption: Preventable birth trauma in NSW; key issues: lack of continuity of care; lack of trauma informed practices; inadequate antenatal education; inadequate informed consent practices; lack of respect for women’s birthing choices and experiences; and lack of inclusivity and culturally-appropriate services within in maternity care.

The Committee also found that some of these issues were exacerbated by maternity workforce shortages and resource constraints. Importantly, the Committee urged that these issues required urgent attention.

The Committee issued 43 recommendations to the NSW Government aimed at reducing preventable birth trauma, with a key recommendation being that all women should have access to continuity of care models with a known healthcare provider throughout their maternity journey.

Some of the key reforms proposed by the Committee include:

• Continuity of care midwifery models – calling for state-wide expansion of Midwifery Group Practices to ensure women have ongoing continuous care with a known midwife;
• Trauma informed practice – mandatory training in trauma-informed care for all maternity health practitioners;
• Informed consent – including the development of minimum standards for antenatal education, implementation of informed consent laws and improved evidence-based birth plans and pain relief guides;
• Mental health and postpartum services – further Medicare-funded psychological services, better physiotherapy access for women and debriefing support for clinicians; and
• Facility and environmental improvements – encouraging the redesign of birthing spaces to support individualised experiences as well as publicly funded homebirth options.

If implemented, the key reforms proposed by the Committee would establish a transformative roadmap for preventing avoidable birth trauma and enhancing maternity care across NSW – and potentially the nation as a whole. These recommendations signal a fundamental shift towards more respectful, patient-centred and trauma-informed approach to childbirth.

You can read the full report here.

In our next article, we will examine the accountability pathways outlined in the Committee’s report and draw comparisons with the legal and regulatory options available to individuals in Victoria, who have experienced or witnessed birth trauma.

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1 Report 1 – May 2024 – 2.29
2 page 22 – 2.41
3 1.4 of Report