After her stillborn daughter Bella was taken away, Naomi Bowden had to stay in a maternity ward surrounded by labouring women and crying newborns.
Then, at a six-week check-up, she was asked where her baby was by a healthcare worker who had not read her medical records.
More than a decade after her daughter died, Ms Bowden laid bare her lingering heartache in the hope her story could prevent others from suffering birth trauma.
"I know we can do better, we must do better," she told a NSW inquiry into birth trauma in September.
After six hearings and thousands of written submissions, a parliamentary committee on Wednesday made 43 recommendations to address birth trauma in the state's hospitals.
Better investment in continuity of care was among the key recommendations, along with improvements to mental health care and postpartum treatment for those who suffered birth injuries.
The inquiry was told continuity of care, in which a patient sees the same medical team throughout pregnancy and childbirth, dramatically reduced the risks of trauma.
"Birth trauma can be prevented in many cases if there is trauma-informed care, continuity of midwifery care with a known provider, informed consent and respectful treatment of new parents," committee chair Emma Hurst said.
Mothers Jess and Katherine stood holding their babies as Ms Hurst released the report.
Jess, who asked that her surname not be published, gave birth to her son Kaya one week ago in a "powerful and satisfying" experience four years after experiencing birth trauma.
The inquiry received 4000 submissions including from patients, doctors, midwives and experts around Australia, and attracted international attention.
Witnesses told of humiliating birth injuries, non-consensual procedures and insensitive or abusive treatment by staff.
Studies by Western Sydney University showed one-third of Australian women have experienced birth trauma, which can range from near-death experiences to injuries.
Specialists told the inquiry no one goes to work at a hospital intending to cause harm and decisions to intervene in childbirth weighed the risks to patients and babies.
The committee's report paid tribute to the bravery of witnesses, who shared highly vulnerable and intimate moments for the sake of others.
"The large scale of submissions received speaks to the impactful and complex nature of birth trauma for the individual giving birth, their support people, the health practitioners involved and the broader community," it said.
Health Minister Ryan Park said the government would review the findings, while NSW Health's maternity blueprint would lead to policy changes to better inform and engage patients.
Mr Park also thanked witnesses for sharing their experiences and those who work in birthing units across the state.
"They do an incredible job, often under high pressure, and I want to take the time just to acknowledge that," he said.
"(I) also acknowledge that this is an area that we do need to continue to improve."
