Childbirth trauma in cross-cultural perspective
In Western countries, parents are expected to respond to childbirth with happiness and joy.
But when anthropologist Wenda Trevathan reviewed childbirth in other cultures, she discovered that joy is not very common (Trevathan 1987).
In many cultures, birth is recognized as a potentially dangerous event. Women don’t respond to newborns with immediate euphoria. After delivery, parents and attendants may seem emotionally subdued or indifferent. Celebrations--if they come--wait until mother and child are judged to be safe and well (Jordan 1993; Trevathan 1987).
This caution might seem unwarranted if you have access to excellent medical care. But living in a high-tech society is no guarantee you won’t have a traumatic childbirth. Mothers – and fathers too – may experience helplessness and fear. When deliveries are difficult or medical staff disrespectful, negative memories of birth can cast a shadow over the postnatal period.
How common is lasting, psychological childbirth trauma?
That depends on your definition and where you look.
In a study tracking 890 healthy Australian women before and after childbirth, 29% reported having felt threatened during childbirth, and 14% said their feelings at the time were intense fear, helplessless, or horror (Boorman et al 2013).
But while these women experienced trauma, they weren't necessarily traumatized.
In the worst-case scenario, women who experience severe distress during childbirth may develop post traumatic stress disorder (PTSD), a condition characterized by flashbacks, anxiety, and nightmares (Bailham and Joseph 2003). That's what I'm concerned with here.
How many women get PTSD? Different studies have yielded different estimates.
In some European studies, reported rates of full-blown childbirth-related PTSD are very low, hovering around 1-3% (e.g., Britain: Ayers and Pickering 2001; Sweden: Widjma et al 1997 and Söderquist et al 2009; Germany: Pantlen and Rohde 2001; and Italy: Maggioni et al 2006).
But other studies report higher rates. For instance, a study of Nigerian women found that almost 6% of new mothers developed PTSD (Adewuya et al 2006). In Canada and the United States, recent estimates are in the range of 8-9% (Verreault et al 2012; Beck et al 2011). A French study reports a rate of 13% (Montmasson et al 2012). In Iran, the rate may be as high as 20% (Modarres et al 2012).
And keep in mind: These represent the worst cases, and we're missing much of the picture if we look only at full-blown PTSD.
Many women who don’t meet all the criteria for PTSD nevertheless develop several symptoms of the disorder. In Western societies, reported rates of “subsyndromal” PTSD are in the range of 20-30% (Polachek et al 2012; Maggioni et al 2006; Soet et al 2003; Creedy et al 2000).
So it's reasonable to think that as many as 1 in 4 women are feeling haunted by their childbirth experiences. What exactly are these women going through?
What does PTSD and "subsyndromal" PTSD look like?
Mothers who experience symptoms are bothered by intrusive thoughts and memories. These “playbacks” may inspire feelings of fear, horror, or helplessness, and they interfere with daily life.
For example, some women may avoid routine medical care because it reminds them of the childbirth experience. They may also fear subsequent pregnancies and avoid sex (Bailham and Joseph 2003).
In addition, mothers often feel socially isolated, lonely, angry, or depressed, and these symptoms may make it more difficult for women to bond with their babies (Reynolds 1997).
In some cases, PTSD sufferers experience heightened anxiety about the health of their babies. They live in constant fear that their babies could die (Affleck et al 1991).
In other cases, women can't stop ruminating over distressing memories -- memories about medical procedures or the behavior of hospital staff.
There are no hard and fast guidelines about what kinds of experiences will trigger long-term emotional problems. But in the last decade, researchers in the United Kingdom (Bailham and Joseph 2003) and the Netherlands (Olde et al 2006) reviewed published studies on postpartum PTSD to identify common risk factors.
They found that women are more likely to develop symptoms if they have
• premature births or miscarriages
• difficult deliveries that require instrumental interventions (e.g., forceps)
• emergency caesarean sections
• feelings of fear for well-being of their babies or for themselves
• feelings of helplessness or a lack of control during labor
• a history of other traumatic experiences, such as sexual abuse
• a history of psychological problems or trait anxiety
• insufficient social support from partners and/or staff
Some of these risk factors are beyond our control. But others can be helped, and they may actually matter the most.
In a recent analysis of the experiences of 675 survivors of difficult childbirth, researchers in London focused on "hotspots," or moments of extreme distress during a traumatic event (Harris and Ayers 2012).
Not surprisingly, most of the new mothers had experienced at least one "hotspot," and women who had obstetric complications had more than 3 times the odds of developing PTSD.
But women were also at higher risk if they experienced fear and a lack of control. And the biggest risk factor was social. For women who reported "interpersonal difficulties," the odds of PTST increased more than 4-fold.
Can the status quo be improved? It seems to me that fear, control, and "interpersonal difficulties" can all be addressed with excellent social support. And that's something lacking in many hospital settings.
The long-term impact of supportive childbirth companions
Research shows that women in labor benefit from a supportive companion-—a person who is continuously present, who praises and touches the women, and who explains what is going on (Trevathan 1999).
When women receive such social support, they have better childbirth experiences. They have shorter labors and fewer medical interventions (Scott et al 1999). These women also report less pain and feel they have more control over the process (Langer et al 1998).
They also have better postpartum experiences.
In several controlled studies (summarized in Klaus et al 1992), women admitted to maternity wards were assigned to receive either (1) enhanced social support or (2) routine hospital procedures only. Women who received enhanced social support had easier childbirths. Six weeks later, they also showed
• Lower anxiety levels
• Lower rates of depression
• Higher self-esteem
• Increased rates of breastfeeding
• More time spent with their infants
• More positive feelings about their families
If you’re pregnant, the implications seem clear. To make birth less difficult and reduce postpartum stress symptoms, get someone to stand by and support you during labor.
For some women, this designated supporter is the father of the child. In a Hungarian study, women who were attended by the father had less anxiety than women who were not (Szeverenyi et al 1989).
But other studies suggest that the presence of the father can intensify the mother’s stress (Ketz 1993; Kennell et al 1991; Nolan 1995). Perhaps some fathers--dealing with their own anxieties during the childbirth process--aren’t able to offer women the right kind of support. For this reason, expectant parents might consider finding a relative, friend, or doula (professional childbirth coach) to attend childbirth.
In virtually all known human cultures, women have given birth with such helpers, and it is possible that women have evolved a psychological need for such social support (Trevathan 1999).
What about hospitals?
Social support aside, it isn't hard to imagine how hospitalization might increase the likelihood of childbirth trauma. Some -- perhaps most people -- find hospital environments uncomfortable or stressful. And many advocates argue that post traumatic stress is uncommon for people giving birth at home.
But we can’t assume that hospitalization causes trauma, since women at high risk of complications are more likely to end up giving birth in a hospital--even if they began labor with the intention of delivering at home. Until somebody conducts a controlled study, it's hard to gauge the emotional impact of hospitalization.
Still, it's clear that settings matter. Can delivery rooms be better designed to minimize stress? That seems a safe bet. In a recent analysis of published studies about childbirth centers -- hospital settings that have been redesigned to feel domestic and personal -- researchers found that women who gave birth in such places experienced fewer medical interventions and higher overall satisfaction with childbirth (Hodnett et al 2012).
What to do if your childbirth experience is haunting you
If you’ve already given birth--and your experience was disappointing or traumatic--find sympathetic people who understand your situation. Talking can help.
In one prospective study, some women at risk for developing postpartum trauma symptoms were randomly assigned to receive counseling from midwives. There were just two counseling sessions in total -- a brief meeting within 72 hours after birth and a second converstaion (by telephone) 4-6 weeks later.
The counseling did not prevent everyone from developing post traumatic stress disorder. But women who received counseling had fewer symptoms than did controls. They also had fewer feelings of self-blame, and were more confident about future pregnancies (Gamble et al 2005).
So if you have a sympathetic listener in your life, take the opportunity to discuss your feelings with him or her. And don't hesitate to seek out professional help if your symptoms are intense (e.g., feeling suicidal) or if they prevent you from functioning normally.
Of course, this may be easier said than done. Not everyone is sensitive to the problem. Medical staff may be dismissive or too busy to listen. Experienced mothers might seem like ideal confidants. But some women view birth as a competitive sport, and may make sufferers of PTSD feel that their problems are signs of personal failure.
These problems inspired a group of mothers in the United Kingdom to establish the Birth Trauma Association, a website for people who have experienced childbirth trauma. The site offers diagnostic information and advice. It also includes the birth stories of real women who have experienced trauma. Some of these women are interested in being contacted by fellow sufferers. If you are haunted by your childbirth experience, this website may be a helpful place to begin the healing process.
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