Links update: August 2019
This is a guest post by Elizabeth Ford who is based in the UK so is writing from a UK perspective. Elizabeth explored birth trauma for her PhD and generously agreed to write a post for MidwifeThinking. There are lots of references for students and/or those who like to access original sources of information.
For most women, birth is not the blissful event of three easy pushes and welcoming their precious baby into the world. Even for those women who have a short straightforward vaginal birth, it can be a tough slog and a real test of the depth of their resources. However, for some women, birth is much more than that. It is a physical and psychological trauma. The aftermath of a traumatic birth can affect a woman for months or years and impact on her bond with her baby, her relationship with her partner, her decision to have another baby and even her willingness to engage with future health care.
Birth as a trauma
Childbirth is a common event in society so is viewed by most people as “normal”. It may therefore be difficult to understand how it can be traumatic for some women. However, case studies and other research make it clear that women can suffer extreme distress as a consequence of their experiences during childbirth. A small proportion of pregnancies and births involve events that most people would agree are potentially traumatic, such as stillbirth, severe complications, or undergoing invasive medical interventions without effective pain relief. Other women may have a seemingly normal birth but feel traumatized by aspects such as loss of control, loss of dignity, or the dismissive, hostile or negative attitudes of people around them.
Post-Traumatic Stress Disorder
Recently it has become recognised that women who experienced a traumatic birth can develop post-traumatic stress disorder (PTSD). Some women experience childbirth as threatening and frightening and go on to develop PTSD symptoms.
The American Psychiatric Association defines the symptoms of PTSD as (1):
- Persistently re-experiencing the event, by flashbacks, nightmares, intrusive thoughts, and intense distress at reminders of the event.
- Persistent avoidance of reminders of the event, and emotional numbing and estrangement from others
- Persistent symptoms of increased arousal. This means difficulty falling or staying asleep, irritability or outbursts of anger, difficulty concentrating, hypervigilance or an exaggerated startle response
For a diagnosis, patients must report experiencing all three types of symptoms for longer than one month. Many women (around 30%) experience these symptoms in the days or weeks following birth, and this is a normal way of coming to terms with a stressful or overwhelming event. It is only when symptoms do not get better that PTSD is diagnosed (in 1 to 5% of women).
What causes trauma & PTSD?
Research has been carried out into what makes someone more likely to develop PTSD following childbirth. These risk factors fall into three categories: those that exist before the birth; aspects of the birth itself; and the type of support and care women get after birth.
Some women will be more vulnerable to a traumatic birth because of pre-existing problems. For example women with a history of psychiatric problems and previous trauma are more likely to be traumatised by their experience of birth. In particular, a history of sexual trauma or abuse is associated with PTSD after birth. There is some evidence that women with a history of trauma will be more vulnerable to PTSD following birth if they have inadequate support and care during the birth (2-5).
During the birth, certain complications and events may be more stressful to women than others. Broadly speaking, women are more likely to get PTSD if they have an emergency caesarean or assisted delivery (forceps or ventouse). However, women who have a vaginal birth are still at risk (4, 6). Other stressful aspects of birth, such as blood loss, a long labour, a high level of pain, or a large number of interventions are not clearly related to getting PTSD. Importantly, women who feel out of control during birth or who have poor care and support from midwives and doctors are more likely to get PTSD (3, 5, 7). Furthermore, if a woman is overwhelmed by the experience and copes by dissociating (feeling like she is mentally “not there any more”, or having an “out of body experience”), she will be at higher risk of PTSD (8, 9).
Following the birth, support from friends and family, and possibly that from health professionals, may help women resolve their experiences and recover from a traumatic birth (5, 10). Conversely, a lack of support may prevent recovery or possibly cause more stress and thereby increase symptoms.
Feeling angry when birth is mismanaged
In some cases births are mismanaged and a woman can feel unable to get past her experience. She may go over and over the events in her head and feel angry that she was denied the experience she could potentially have had (11). This can form part of the symptoms of PTSD (intrusive thoughts, irritability & anger). However, PTSD is considered to be an anxiety disorder, and so for this anger and preoccupation to be diagnosed as PTSD, the other symptoms listed above must also be experienced. A woman who feels very angry is struggling with a valid emotional response to being discounted or not listened to during the birth, or even being mistreated or assaulted. Even when women don’t fit into the “PTSD box” (fulfilling all the symptom criteria), they may have a spectrum of subclinical trauma reactions which would benefit from support, counselling, or psychotherapy.
Is PTSD the same as postnatal depression?
PTSD has different symptoms to depression. Depression symptoms encompass a depressed mood i.e. feeling sad, empty, tearful or irritable, in addition to diminished interest or pleasure in activities; significant weight loss or weight gain or decrease or increase in appetite; insomnia or hypersomnia; fatigue or loss of energy; feelings of worthlessness or excessive or inappropriate guilt; and a diminished ability to think or concentrate, or indecisiveness.
In contrast, trauma symptoms are focussed on the traumatic event (re-experiencing it, avoiding reminders of it) and a diagnosis of PTSD is not possible without having experienced a traumatic event. This is not the case with depression. However, in practice symptoms overlap and a majority of women who have PTSD will also have depression (3, 4). Effective treatments for PTSD and depression differ. Recommended treatment for PTSD is psychotherapy, and only long-lasting or complex cases of PTSD benefit from anti-depressants.
Do women expect too much from childbirth?
A question that is often asked by health professionals is whether women have too high expectations of achieving a natural or drug-free birth, contributing to them being traumatised when birth does not go as expected. The answer to this is rather complicated but research studies point towards it not being the case. Firstly women’s expectations are found, on average, to be similar to their experiences (12, 13). That is, if a woman has broadly positive expectations she is more likely to have a positive experience. Secondly, if unrealistic expectations were linked to PTSD we might expect to find more trauma responses in first time mothers. This has been found, but subsequent analysis suggests it is due to the higher rate of intervention in these women (14). Finally, one study looked at this question directly and found that a difference between expectations and experience in the level of pain, length of labour, medical interventions and level of control was not associated with PTSD symptoms. However, a difference between expected support from health professionals and the level of care experienced was predictive of PTSD symptoms (13). Women don’t seem necessarily to be traumatised by the events of birth not happening as they expected, but may be affected when they do not receive the care they expect.
Implications for maternity care
Research in this field is at an early stage and more needs to be done before making policy recommendations. However, the body of evidence points towards several considerations. Firstly, some women enter pregnancy and birth with existing risk factors for PTSD, and these women may need particular care. Health professionals should be aware that women with a history of trauma, abuse (particularly sexual abuse) and psychiatric problems are at higher risk of PTSD following birth. There is some evidence that a lack of support during the birth may put these women at particular risk (5).
Secondly, interactions with other people have a strong effect on trauma reactions. For example, PTSD is more likely following events which are perceived to have been intentionally perpetrated rather than following accidents (15). This effect of personal relationships and care is particularly relevant to childbirth (16). There is substantial research showing support during labour and birth improves both physical and psychological outcomes (17), and that perceptions of inadequate support and care are predictive of traumatic stress responses. Women who are traumatised often describe negative interactions with staff such as feeling rushed, bullied, judged, ignored or put off when asking for pain relief.
Understanding the importance of support helps explain why, for example, level of pain is not consistently associated with PTSD symptoms. It may not be the level of pain per se which is traumatising for women, but the experience of unbearable pain in combination with the perception of being denied pain-relief by an uncooperative caregiver. Women also report caregivers proceeding with interventions, such as forceps deliveries or episiotomies, without consent, and sometimes even when the woman has clearly expressed her wish not to have the intervention. Negligent care such as leaving women naked in stirrups with the door open can be intensely degrading and stressful. Many of the traumatising aspects of childbirth could be reduced with consistent and considerate care from maternity staff.
What to do if this has happened to you
If you have had a traumatic birth and don’t know how to get help, the first step is to contact the Birth Trauma Association (BTA; www.birthtraumaassociation.org.uk) who give information and support. They produce a leaflet which you can print out and take to your GP explaining the condition (your GP may not have heard of postnatal PTSD), and you can ask for a referral to specialist psychotherapy services. If you’re in the UK, you can also contact the hospital where you gave birth and ask for a debriefing session with a midwife or consultant to go through your birth notes. This is not a counselling session but may help you to understand what happened during the birth and why events proceeded as they did. If you have physical problems following the birth you can also ask for a referral to a gynaecologist or physiotherapist. If you do not feel able to go back to the hospital where you gave birth, because memories are too painful or it causes you too much anxiety, you could ask your GP for a counselling referral or you could consider contacting a private psychotherapist. Make sure they are registered with the relevant professional association (BACP or BABCP in the UK). Recently in the UK you can “self-refer” to psychotherapy on the NHS through your local IAPT service (www.iapt.nhs.uk). Talking to other women who have been through similar experiences may help, the BTA can put you in touch with other mothers.
It can be traumatic watching a partner go through a harrowing experience while feeling helpless and horrified. The information on PTSD above can also apply to partners. The BTA has a section on their website for dads or partners. It is worth reading this and seeking help for yourself if you feel this applies to you.
More resources and support
I’ve added some links below (this is MidwifeThinking). Please let me know if you have any other links or resources that you think should be included.
- APA. Diagnostic and Statistic Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington DC; 2000.
- Wijma K, Soderquist J, Wijma B. Posttraumatic stress disorder after childbirth: A cross sectional study. Journal of Anxiety Disorders. 1997;11(6):587-97.
- Czarnocka J, Slade P. Prevalence and predictors of post-traumatic stress symptoms following childbirth. British Journal of Clinical Psychology. 2000;39:35-51.
- Ayers S, Harris R, Sawyer A, Parfitt Y, Ford E. Posttraumatic stress disorder after childbirth: Analysis of symptom presentation and sampling. Journal of Affective Disorders. 2009;119:200-4.
- Ford E, Ayers S. Support during birth interacts with prior trauma and birth intervention to predict postnatal post-traumatic stress symptoms. Psychology and Health. in press.
- Soet J, Brack G, Dilorio C. Prevalence and predictors of women’s experience of psychological trauma during childbirth. Birth. 2003;30:36-46.
- Cigoli V, Gilli G, Saita E. Relational factors in psychopathological responses to childbirth. Journal of Psychosomatic Obstetrics and Gynecology. 2006 Jun;27(2):91-7.
- Kennedy HP, MacDonald EL. “Altered consciousness” during childbirth: potential clues to post traumatic stress disorder? Journal of Midwifery & Women’s Health. 2002 2002/0;47(5):380-2.
- Olde E, Van der Hart O, Kleber RJ, Van Son M, Wijnen HAA, Pop VJM. Peritraumatic Dissociation and Emotions as Predictors of PTSD Symptoms Following Childbirth. Journal of Trauma & Dissociation. 2005;6(3):125-42.
- Soderquist J, Wijma B, Wijma K. The longitudinal course of post-traumatic stress after childbirth. Journal of Psychosomatic Obstetrics and Gynecology. 2006 Jun;27(2):113-9.
- Brockington I. Postpartum Psychiatric Disorders. The Lancet. 2004 January 24;363:303-10.
- Slade P, MacPherson S, Hume A, Maresh M. Expectations, experiences and satisfaction with labour. British Journal of Clinical Psychology. 1993;32:469-83.
- Ayers S. Post-traumatic Stress Disorder Following Childbirth Unpublished Ph.D Thesis, University of London; 1999.
- Soderquist J, Wijma K, Wijma B. Traumatic Stress after Childbirth: the role of obstetric variables. Journal of Psychosomatic Obstetrics and Gynecology. 2002;23:31-9.
- Charuvastra A, Cloitre M. Social Bonds and Posttraumatic Stress Disorder. Annual Review of Psychology. 2008;59:301-28.
- Ford E, Ayers S. Stressful events and support during birth: The effect on anxiety, mood and perceived control. Journal of Anxiety Disorders. 2009;23:260-8.
- Hodnett ED, Gates S, Hofmeyr G, Sakala C. Continuous support for women during childbirth. The Cochrane Database of Systematic Reviews. 2003(3):Art No.: CD003766. DOI:10.1002/14651858.CD003766.