Childbirth-Related Trauma and PTSD
By Kalina Christoff
Being traumatized during childbirth is much more common than most people think. Unfortunately, trauma is one of the hidden costs of childbirth, a cost that women often bear in silence and without recognition or support.
So far there has been virtually no research on childbirth trauma in Canada, but research from the UK, Australia, and US -- countries with similar maternity health care system to Canada's -- show that about one third of women experience their childbirth as traumatic. Between 2% and 6% experience childbirth-related Post-Traumatic Stress Disorder (PTSD), a severe and long-lasting (months or years) response to the trauma they experienced during childbirth.
About 30,000 women give birth each year in the Greater Vancouver Area. This means that, in our area, between 600 and 1,800 women each year develop PTSD following the birth of their child. The total number of women with PTSD is probably much higher because PTSD can last for years especially if it remains unacknowledged and untreated. Furthermore, tens of thousands must feel traumatized and experience some PTSD symptoms even though they may not go on to develop full-blown PTSD.
The following symptoms may occur shortly after the birth and are highly suggestive of maternal psychological trauma: inability to sleep; delayed and/or reduced milk production; agitation and a sense of vigilance or constant danger; emotional numbing (something also known as dissociation); intrusive, upsetting flashbacks of the birth or the events surrounding it; avoidance of all reminders of the birth (or birth in general); feeling sad, angry, or helpless about the birth.
The symptoms are almost always confused by health care practitioners for post-partum depression. The reason for this is that post-partum depression is the "star of the show" these days -- everyone is on the look out of it. A traumatized mother will score highly on post-partum depression tests such as the Edinburgh Post-Partum Depression Scale because her anxiety levels are high (a normal consequence of going through trauma) and possibly because she has not been allowed to mentally process her traumatic birth. Traumatized women are often told by well-meaning friends and relatives to "just get over it" and "be grateful they have a health baby". This unfortunate lack of understanding and denial of their trauma only re-traumatizes women further and worsens their symptoms.
Why are women traumatized during childbirth in such great numbers? The reasons have a lot to do with the extremely high rates of medical interventions during childbirth these days and the inappropriate and sometimes even abusive behaviours of health care providers who follow hospital protocols developed to serve the hospital's interests, often to the detriment of the birthing woman's welfare.
Being subjected to a high number of medical interventions while giving birth is one of the main factors leading to maternal psychological trauma and PTSD. There are many interventions, such as emergency C-section, forceps or vacuum delivery, induction of labour, and manual removal of the placenta, that are highly traumatic, both physiologically and psychologically. In practice, they always go hand in hand with multiple other interventions, such as electronic fetal monitoring (EFM), intravenous drugs and catheters. The outcome is often a stunned, traumatized mother who feels that the baby was literally "yanked out of her", while she played little or no role in the actual birth.
The other main factor that can lead to birth trauma is the mother's exposure to an unsupportive or abusive birthing environment. The hospital staff may assume a hostile attitude towards the birthing mother, especially if she tries to decline any interventions they would like to perform on her. Many health care practitioners, especially obstetricians, do not believe that a woman should play an active role in the birth of her own child. In practice that translates into excluding the mother from medical decision making and performing procedures on her without explanation or consent, and sometimes even without her knowledge. Concerns for the baby, whether they are real or not, are usually used to convince, and if necessary coerce, the mother and her partner into agreeing to procedures that are primarily for the hospital’s or the doctor's benefit.
There are many misconceptions about birth trauma. Many people believe that women who have been traumatized by childbirth must have prior history of trauma (e.g., childhood sexual abuse) or some other mental health problems (e.g., depression or anxiety). This is not true. The primary determinant of trauma and PTSD is the severity of the traumatic event, and not the history of prior trauma. Any person, even the strongest, healthiest individual, can be traumatized by a sufficiently strong traumatic event.
How can a woman recover from a traumatic birth?
Before the healing process can begin, the mother will first have to overcome the enormous societal pressure on women to be happy with their birth experience and to put their baby's health and needs before their own. Many new mothers after a traumatic birth frequently disregard their own symptoms and are reluctant to admit to a negative birth experience. When they talk about their birth, they often have difficulty discussing its negative aspects and feel that it's necessary to follow each negative comment with assurance that they were happy to have a healthy baby. Overcoming these societal pressures and admitting to the reality of one's traumatic birth experience is the first step on the road to recovery.
It is also tempting to avoid dealing with the trauma and try to just "move on" and forget about it. In fact, this is the most frequent advice the traumatized mother is likely to receive by well-meaning but poorly informed relatives, friends and health-care providers, who may become impatient and even angry with her for "dwelling on the past too much". But there is no way to begin the healing process without thinking about the trauma. And without healing, the trauma will remain unresolved, which can be devastating. Unresolved trauma can lead to depression and addictions. It can take a big toll on family life and interpersonal relationships. It can trigger real physical pain, symptoms, and disease. And it can lead to a range of self-destructive behaviours.
Only when the mother has acknowledged her traumatic birth experience will she be ready to start on the road to recovery.
Once it has begun, the process of healing tends to proceeds in three stages.
The first stage consists of remembering the birth and reconstructing it mentally. The initial memories of a traumatic birth are likely to be fragmented and disconnected. Frightening feelings and images of the birth may be remembered with no time or context attached to them. It may be difficult, if not impossible, to remember the sequence in which they happened and there may be huge unaccounted gaps of time between them. This is normal and is how all traumatic memories work. The process of trying to connect these memories, fill in the gaps, and mentally construct a coherent story of what happened is healing in and of itself. The most important thing is to allow as much time as necessary for this stage of recovery and to keep in mind that remembering and reconstructing the events of a traumatic birth takes a huge toll on the mother’s emotions. To succeed with this slow, incremental and often painful reconstructive process the traumatized mother needs a lot of determination, patience, and deeply supportive personal interactions with other trusted, understanding individuals.
The second stage consists of feeling the feelings associated with the birth. One of the most common feelings associated with trauma is fear. In the aftermath of trauma, fear can be continuously present. The mother may feel a persistent sense of fear that does not seem clearly related to the present. It may also seem unrelated to any particular memory or traumatic event. Unless the mother identifies the origin and source of this fear and understands for herself how the traumatic events during the birth came about, the fear will probably remain nebulous and undifferentiated, causing her a sense of constant anxiety and vigilance. Another common emotion is anger. Anger at what happened and the suffering it caused is one of the most natural reactions to trauma. But many people fear anger and women, in particular, often "forbid" themselves to feel anger because it is generally not acceptable in our society for women to be angry. Needless to say, suppressing anger does not make it go away but only makes it stronger. Another major emotion after birth trauma is grief. It is also a natural, necessary response to trauma, because trauma inevitably involves a big loss. The grief needs to be experienced at a deep, profound level, in order for it to eventually subside and allow the mother to move beyond it.
The third stage involves achieving a sense of empowerment. Achieving any degree of recovery, as slow or as partial as it may be, is hugely empowering in and of itself. It is easy to neglect the progress that has been made and, instead, look at what remains to be done until "full recovery" is reached. There is no such thing as "full recovery" in the sense that the traumatic experience will always be part of the mother's past. Harnessing one's rage about the traumatic birth is empowering too. The mother is entitled to feel rage at whatever pain, injustices or abuse she may have suffered during her traumatic birth. She can use this rage as an energy mobilizing her to do something to change the societal or medical system that contributed or led to her own birth trauma and to try to help other women recover from their own birth traumas. Many women start working as doulas after going through a traumatic birth, in an attempt to help other women avoid going through the same kind of trauma. Any action the mother takes is empowering because it counteracts the sense of helplessness that was part of her trauma in the first place. By definition, during trauma a person is rendered helpless and becomes immobilized in a "freeze" response. By helping others, or oneself, to achieve recovery, the traumatized mother can successfully counteract the sense of helplessness and immobility left over from the traumatic birth.
There are many ways to deal with trauma. Finding the way that works best for each individual mother and trusting herself rather than others who may advise her on "better" ways, is part of the process of her empowerment. She must be able to control every aspect of her recovery and to get back in control of her life and environment. She must also arrive at her own explanation of how and why the trauma occurred, and trust her own explanation more than any other, regardless of what authority the other accounts may claim. She may or may not choose to confront the people who were responsible for the trauma, pursue lawsuits or file formal hospital complaints. Whatever she chooses to do, the fact that it was her choice and she decided on this without succumbing to pressure or guilt from others will counteract the powerlessness that was forced on her during the traumatic birth.
For more information and resources on birth trauma, or to connect with women from the Vancouver area who have been through childbirth trauma, please go to: http://www.vancouverbirthtrauma.ca
Healing after a Traumatic Birth
Stage 1: Remembering the birth and reconstructing it mentally
This can be difficult and can take many months and some times years. Remembering, at least at the beginning, often makes the mother feel worse. But remembering what happened and being able to share it with trusted others or express it in some other way (in writing or painting), is one of the most powerful ways to recover. By re-associating the traumatic memories with an environment of safety, the sense of terror and panic they bring about will gradually lessen. Psychological counselling including therapies such as imagery re-scripting can aid this process.
Stage 2. Feeling the feelings associated with the birth
To heal completely, trauma must be reconstructed not only on the mental level, but on the emotional level as well. First, the feelings generated by the trauma that were not felt at the time of birth need to be identified. And second, these feelings must be experienced, at least in part, on a gut level. This can be difficult and the feelings may get worse, before they get better. But only by experiencing and letting them into awareness will the mother become free of their all-consuming presence in her life. The goal is to find balance, a point where the feelings are neither suppressed nor all-consuming. One of the ways to find this balance is to face the feelings at times when the mother feels strong enough, but to also take breaks from the feelings when needed. It is natural to want to move through the healing process as fast as possible; after all, who wants to be in pain for the rest of their life? But dealing with trauma in manageable doses may be the only way to prevent the flood of original feelings that can be as traumatizing, or even more traumatizing than the traumatic birth itself. Also, expressing feelings (verbally, artistically, or through physical action such as dance or exercise) allows them to be accepted more easily and will eventually diminish their charge and intensity.
Stage 3. Achieving empowerment
This is the process of finding meaning in the traumatic birth and developing a survivor rather than a victim mentality. At the beginning, it may seem as though the traumatic birth defines her and her existence, but as the healing process progresses, she will eventually be able to look back at it as part of her personal history – that is, as one of the things that happened to her, alongside others. A sense of empowerment will also be achieved by accepting the psychological and physical scars of the traumatic birth trauma. As much as they are reminder of the trauma the mother went through, they are also a reminder that this trauma did not kill her; she survived it.
The healing process
The stages of healing tend to be progressive. For example, feeling the feelings (Stage 2) will be more intense and meaningful if the mother remembers some or most of what happened during the birth, than if her memory is hazy. But the healing stages do not always flow in a neat progression. For example, women may find empowerment and mastery without recalling the traumatic event. Similarly, a recovering mother may already be in the mastery stage (Stage 3), when suddenly she remembers a highly significant aspect of the birth that changes almost everything she previously thought or felt about it. Much to her surprise, the new revelation may put her back in the role of a helpless, hopeless victim.
It's important to remember that the process of recovery from trauma is a lengthy one and highly unique to each individual. Every woman needs to deal with the consequences of her negative childbirth experience in a way that works for her. She must control every aspect of her recovery. She needs to somehow get back in control of her own life and to be able to feel safe again in her environment.
Some statistics from BC relevant to childbirth trauma:
27% of first-time mothers have their labour induced artificially. The overall rate for all mothers is 22%
Induction of labour almost doubles the risk of emergency C-section. For first time-mothers, induction increases the risk of emergency C-section from 22% to 38%.
33% (1 out of 3) of first-time mothers in BC have their babies delivered by C-section. The overall rate for all mothers is 30%
Only about a third of C-sections in BC are scheduled (planned). The other two thirds are unplanned, emergency C-sections. Only 2% (1 out of 50) of C-sections in BC are done because the mothers requested them
The type of primary health care provider a women chooses for her pregnancy and birth can have a huge effect on her risk for C-section. Women who have an obstetrician as their primary health care provider have a 46% C-section rate; those who choose a family physician have a 22% C-section rate, and those who choose a midwife have only a 15% C-section rate
17% of first-time mothers in BC have instrumental vaginal delivery with forceps or vacuum
31% of women who undergo forceps delivery will have vaginal tearing that extends to include rectal damage (third- or fourth-degree tear)
Forceps causes significantly more maternal trauma than vacuum. Yet, in some large hospitals such as BC Women's Hospital in Vancouver, forceps is still used more frequently than vacuum.
The incidence of vaginal and/or rectal tearing during birth (1st, 2nd, 3rd or 4th degree) can vary from as low as 50% to as high as 90% across hospitals. The more babies a hospital delivers, the greater the risk of vaginal and rectal tearing to the mother.
(see http://www.vancouverbirthtrauma.ca/facts.html for detailed and scientific sources and references)
Kalina Christoff is an Associate Professor of Psychology at the University of British Columbia and a survivor of childbirth-related trauma. She is currently conducting research on women's childbirth experiences and on the factors that shape these experiences (see http://birthstudy.ubc.ca) and preparing to teach a UBC course on Knowledge in Birth, an undergraduate course that will examine how we come to know what we know about childbirth. She is also looking for ways to raise awareness of childbirth trauma, to improve support for women who have been through such trauma (see http://www.vancouverbirthtrauma.ca), and more generally, to raise awareness of women's rights during childbirth.
