The slippery slope of traumatic childbirth
Ayers et al. (2016) conducted a meta-analysis of vulnerability and risk factors for birth-related PTSD in 50 studies from 15 countries. The strongest pre-birth vulnerability factors included prenatal depression, fear of childbirth, poor health or prenatal complications, a history of PTSD, and counseling for pregnancy or birth. During birth, the strongest predictors of PTSD were a negative labor and delivery experience, assisted vaginal or Cesarean birth, lack of support, and dissociation. During the postpartum period, significant risk factors included poor coping and stress and a comorbidity with depression.
Results from another meta-analysis identified the prevalence of postpartum PTSD in community samples to be 3.1% and in at-risk samples 15.7% (Grekin and O’Hara 2014). Significant risk factors in the community samples included current depression, labor experiences with obstetrical healthcare providers, and a history of psychopathology. In the at-risk samples, significant predictors were current depression and infant complications (Grekin and O’Hara 2014).
Traumatic childbirth can be considered a slippery slope which involves “a process or series of events that is hard to stop or control once it has begun and that usually leads to worse or more difficult things” (www.merriam-webster.com/dictionary/slippery). An early example of the use of this metaphor can be traced to 1886 in The Mirror of True Womanhood: A Book of Instruction for Women in the World. O’Reilly (1886) used this metaphor when discussing women winning the hearts of their children. When talking about mothers who make no effort to win the love of their children, he wrote “It is not with them we are concerned: they will not be taught or reformed; so, they will go down the steep and slippery slope on which the heartless move, to perdition” (p. 142).
The research reported in this chapter on traumatic childbirth and its resulting slippery slope is part of the author’s program of research. All except one of the studies were phenomenological studies conducted via the Internet. An international sample of women was recruited from a notice posted on Trauma and Birth Stress’ (TABS) website (www.tabs.org.nz). TABS is a charitable trust located in New Zealand. Mothers who participated in these studies were from the United States, New Zealand, the United Kingdom, and Australia. The sample sizes ranged from 11 to 52 women who had experienced birth trauma.
4.1 Birth Trauma
From her qualitative research on traumatic childbirth, Beck (2004a) found that just like beauty, birth trauma is in the eye of the beholder. How women perceive their birth may be quite different than how obstetrical clinicians view it. Clinicians may view the birth as routine, whereas the mother may view it as traumatic. Beck (2004a) defined birth trauma as “an event occurring during the labor and delivery process that involves actual or threatened serious injury or death to the mother or her infant” (p. 28). In 2010, Beck amended her definition. In her series of research studies, she had discovered that some women develop PTSD not because they feared for their life or that of their unborn child but rather they perceived their birthing experience as dehumanizing and stripping them of their dignity (Beck and Watson 2010).
Why perhaps could one woman have a severe postpartum hemorrhage and be fine, while another woman could also have a severe postpartum hemorrhage and develop PTSD? One reason offered by Beck is based on her series of qualitative studies on birth trauma. Some women who perceive their births as traumatic have systematically been stripped of protective layers during labor and delivery. As one mother shared, “I am amazed that 3 ½ hours in the labor and delivery room could cause such utter destruction in my life. It truly was like being the victim of a violent crime or rape” (Beck 2004a, p. 32). What could have turned what should be one of the most precious events in a woman’s life into a rape scene?
Women described being stripped of their dignity, feeling abandoned and alone, and not respected as individuals. Some mothers revealed that they felt like a piece of meat on an assembly line. The bottom line was that mothers who perceived their births to be traumatic did not feel cared for during labor and delivery. These women were also stripped of communication with their healthcare providers. Often mothers felt invisible as clinicians talked to each other as if the laboring woman were not present as illustrated by the following quote: “When she checked me I was 3 ½ dilated, however, the doctor did not tell me this. She called the nurse to get me a wheelchair and rush me to get an ultrasound. I didn’t know what was happening. While all this happened they were talking as if I was not in the room. They were saying something about my baby having an enlarged heart. I think I had a right to be informed just like any other patient.”
Many times women reported not being kept apprised of what was happening during the birthing process. Since most mothers were not healthcare professionals, they tended to think the worst when situations were not explained to them. For example, one woman who was in the delivery room needed a vacuum extraction to speed up the birth. The vacuum cap popped off which can often happen. The obstetrician then used forceps to successfully deliver the baby. The problem was that no one communicated with this mother during those few minutes. This mother explained that when the vacuum popped off, she thought that her baby’s head had been ripped off his body. This woman developed PTSD with reoccurring nightmares of this scenario.
Another aspect of traumatic childbirth involved mothers’ perceptions that what they had to endure to give birth was glossed over and pushed into the background as clinicians, family, and friends all celebrated what they perceived as a successful birth. The infant was alive, with no birth defects, and had good Apgar scores. As this woman disclosed, “I was congratulated for how ‘quickly and easily’ the baby came out and that he scored a perfect 10! The worst thing was that nobody acknowledged that I had a bad time. Everyone was so pleased it had gone so well! I felt as if I had been raped!” (Beck 2004a, p. 34).
Beck (2006a) conducted a second study on birth trauma and this time used a narrative analysis design. Narrative analysis allowed the sequence of a series of events that occurred during labor and delivery to be kept together and revealed the multiple traumatic experiences each woman endured during childbirth. Using Burke’s (1969) method of narrative analysis, the most problematic ratio imbalance for mothers during birth trauma was the interaction of the act with agency, that is, how the act was performed to the women. Below is one such example provided by one woman who was laboring to give birth to her infant who had died in utero:
My husband went to get the nurse. The nurse said, you have only just had the gel, you couldn’t be having IT yet. I said, yes. She is about to be born. The nurse checked and the head was visible. She looked shocked and said wait. I’ll have to get a dish and returned with a green kidney shaped dish. The way she held the dish and the look on her face, I knew she did not want to be in the room. My husband held the dish for her. I then gave a little push and my daughter (still in her little sack) slipped quietly in the dish. The nurse took the dish from my husband and covered my daughter with a sheet. She then walked off without saying a word about where she was going. I called to her. Where are you taking her??? (I had not even seen her properly as she was still in her sack). The nurse said, I have to take IT to the doctor. She wants to see IT. Also the nurse continued to refer to me by my last name, not my first name. I said but I want to see my daughter. She said, Why? IT’S dead. She then said I have to get someone to wash IT so IT can be examined. (Beck 2006a, p. 461)
The uncaring way clinicians performed activities with women during childbirth supported earlier findings of Beck’s (2004a) phenomenological study of birth trauma.
4.2 PTSD Due to Childbirth
In Beck’s (2004b) research on PTSD following a traumatic childbirth, five themes were identified that together described the essence of PTSD in new mothers (Fig. 4.2). Women repeatedly experienced uncontrollable intrusive thoughts of their traumatic births. Mothers described this as having loop tracks in their brains that had the movie of the birth trauma on automatic replay. As this mother described, “Everything that happened during my emergency cesarean runs and reruns during the day in my mind like a horror movie. I see the nurses’ and doctors’ faces. I also wake up screaming and crying at night because of the nightmares.”
Five essential themes of PTSD due to childbirth (Reprinted with permission from Beck, C.T. (2004b). Posttraumatic stress disorder due to childbirth: The aftermath. Nursing Research, 53, p. 220)
Numbness and detachment were other features of PTSD in new mothers. This woman who had a terrifying experience giving birth to her twins admitted, “I found the easiest way to deal with things was often to just shut down, to drag myself once more through the day. I cuddled my babies, read to them, and cared for their every need except for their emotional needs.”
While struggling with PTSD, some mothers experienced a trio of dangerous emotions of anger, anxiety, and depression which at times spiraled up to rage, panic, and thoughts of ending their lives. Women’s dreams of what they had envisioned new motherhood would be like were shattered. Just as anyone with PTSD, efforts were made to avoid reminders of the trauma. For women, this entailed avoidance of reminders of motherhood which led some women to isolate themselves from other women and babies and also to their own infants. This woman suffered through a severe postpartum hemorrhage 3 years earlier, and as this quote captures she is still struggling to connect with her child:
My child turned 3 years old a few weeks ago. I suppose the pain was not so acute this time. I actually made him a birthday cake and was grateful that I could go to work and not think about the significance of the day. The pain was less, but it was replaced by a numbness that still worries me. I hope that as time passes I can forge some kind of real closeness with this child. I am still unable to tell him I love him, but I can now hold him and have times when I am proud of him. I have come a long, long way. (Beck 2004b, p. 222)
Beck (2016) conducted a metaphor analysis of mothers’ descriptions of their PTSD due to birth trauma. This was a qualitative secondary analysis of the data in Beck’s (2004b) original study. The Pragglejaz Group’s (2007) metaphor identification procedure was the method used for identifying metaphors used in the women’s narratives. Nine metaphors portrayed PTSD following a traumatic birth as a mechanical robot, a ticking time bomb, an invisible wall, a video on constant replay, an enveloping darkness, a dangerous ocean, a thief in the night, a bottomless abyss, and suffocating layers of trauma. These metaphors were used by mothers to help express more effectively what they were experiencing with their PTSD. Metaphors can provide rich insight into this anxiety disorder and help healthcare providers to identify women struggling with PTSD.
4.3 Impact of Birth Trauma on Breastfeeding
Women’s experience of breastfeeding following birth trauma was a tale of two pathways (Beck and Watson 2008). Their experiences led mothers down two strikingly different paths: one propelling women to persevere in breastfeeding and the other impeding their breastfeeding attempts (Fig. 4.3). Factors women revealed that either promoted or impeded breastfeeding are portrayed as weights on the scale in this figure. Women could have any combination of these factors that could tip the scale in one direction or another.