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Mothers need better care to reduce post-traumatic stress after childbirth

Post-traumatic stress can result from life-threatening events such as military combat, violent assault or natural disasters. Women who feared that they or their baby would die or be seriously damaged during…

Emotional health problems after childbirth are burdonsome and common. storyvillegirl/flickr

Post-traumatic stress can result from life-threatening events such as military combat, violent assault or natural disasters. Women who feared that they or their baby would die or be seriously damaged during labour and birth can also develop severe anxiety.

For many women, giving birth is a normal life event and, for some, it’s joyous and empowering. Other women, however, experience childbirth as frightening and life-threatening. Indeed, about a third of women report that, for them, giving birth was traumatic.

These women experience three or more symptoms of post-traumatic stress disorder (PTSD) in the first few weeks after giving birth.

The symptoms they report relate to re-experiencing birthing, emotional numbing or avoidance and hyperarousal about the birth. Between 2% and 6% of women develop a condition called acute stress disorder. Unlike PTSD, which requires symptoms to be present for at least a month, acute stress disorder can be diagnosed between two days and one month after a traumatic event, and involves more dissociative symptoms (when a person feels disconnected from their thoughts, feelings or memories) .

Factors contributing to the development of trauma symptoms are:

  • poor medical care, such as a poorly performed procedure causing unnecessary pain or care inconsistent with the best available evidence;
  • poor communication by care providers;
  • physically traumatic or emergency birth, such as emergency caesarean section;
  • physical damage to the baby, or;
  • admission to the special care nursery or intensive care unit.

Previous traumatic childbirth, sexual abuse, intimate partner violence and other traumas also play a role, but many women without known predisposing factors experience birthing as traumatic.

Stories of traumatic childbirth are frequently peppered with accounts of being excluded from decision-making, lack of informed consent, or patronising, impersonal, disrespectful and abusive interpersonal communication. Such treatment by health professionals is associated with feelings of loss of control, but women often blame themselves. They say they should have asserted their rights, should have prepared themselves more fully, and should somehow have known how to avoid the treatment and care they received.

Fortunately, most women are resilient and recover from traumatic childbirth. This is more likely when they have adequate social support (especially from their partner) and are mostly free from other life burdens likely to impede recovery, such as financial stress. But for other women, PTSD can be intractable and have negative impacts on them, their babies and their relationships with others.

Experiencing PTSD or acute stress disorder following a traumatic childbirth can have a negative impact on a woman’s future birth choices. But a recent Coroner’s inquest into deaths of babies born at home to women considered at higher risk of birth complications paid scant attention to evidence that a previous traumatic birth led some women to avoid hospital and medical intervention.

Conversely, some women may request to birth under general anaesthetic and have no awareness of the birth, or avoid pregnancy and birth altogether.

Post-traumatic stress disorder commonly occurs with other psychological conditions. A recent longitudinal study found 65% of women with PTSD also had depression 11 months after giving birth. Emotional health problems after childbirth are burdensome and common. Spontaneous recovery is rare and these problems persist over time.

Even though many women would like more advice and assistance, mental health problems are frequently not discussed or diagnosed and few women receive the help they need. Post-traumatic stress disorder doesn’t just affect mothers. Little is known about the consequences of maternal PTSD for the next generation, but there’s evidence emerging that maternal mood disorders predispose infants to a range of adverse psychological conditions later in life.

Efforts have been made over the last decade to introduce new interventions for women dealing with traumatic birth experiences. Over the last decade, our team has tested a counselling intervention called PRIME – Promoting Resilience in Mothers' Emotions. This intervention aims to support women to express their feelings and enable them to identify and work through distressing elements of childbirth.

Mothers are provided with the opportunity to review the birth and gain a realistic perception of events. The programs focus on developing individual situational supports for the present and near future, affirming that negative events and feelings can be managed and developing a simple plan for achieving this. This combination of strategies diminishes emotional distress, promotes constructive coping mechanisms and allows recovery to start.

Widespread and persistent calls to demedicalise and humanise maternity care have resulted in national commitment to reform maternity services. A key to this reform is rolling out midwifery caseload models of care, in which women are assigned a primary midwife who provides care during pregnancy, birth and early parenting.

Positive, caring interactions with a named midwife can influence how women manage their pregnancy and use available health-care services. And building social support networks is a key feature of woman-centred care and promotes maternal resilience and resourcefulness.

Childbirth can be traumatic for some women and contributes to a range of potentially long-lasting symptoms. Post-traumatic stress disorder can be debilitating for mothers and affect the development of their child. Reducing the level of unnecessary medical intervention in childbirth and reorienting maternity services to put women at the centre of care will help address this.

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11 Comments sorted by

  1. Sue Ieraci

    Public hospital clinician

    Thank you for an important discussion.

    It's also important to mention that it is not only the alleged "medicalisation" that can lead to post-partum mental health problems, but the very nature of childbirth itself, in the context of our current society. We now have many older mothers, professionals in their working lives, who have a greater expectation of being able to plan and control the process of labour and birth. As we know from childbirth outcomes before modern midwifery and obstetrics, the…

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    1. Olivia Hibbitt

      Medical Writer

      In reply to Sue Ieraci

      Totally agree that sometimes the events that are traumatic during a birth are absolutely necessary to protect the lives of the mother and the child. However, I think it's the way that these events are handled that really impacts that way women view their birth.

      The birth of my twins was a text book carcrash involving emergency section, PPH, HIE in both twins (who were rushed off to SCBU), I had a reaction to the anaesthetic and my heart stopped on the table, and various other complications such…

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    2. Sue Ieraci

      Public hospital clinician

      In reply to Olivia Hibbitt

      Olivia - that sounds appalling.

      My post was not to justify poor practice, but to point out that trauma can occur in the context of a physiologically normal birth - not just due to necessary interventions.

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    3. Chris Saunders

      retired

      In reply to Olivia Hibbitt

      Olivia your experience sounds absolutely atrocious. I’ve only had one operation in my life and the next morning, the surgeon was there asking how I felt. No, it was not a private hospital or a private health insurance arrangement. Just a good guy following through on his patient, but that’s what normally happens and what one does expect in Australia. My late mother’s events in hospital were treated similarly. After an experience such as yours I would be talking to the hospital administration, I’m sure they would like to be given the opportunity to work out what went wrong in your case and what remedial steps they can take to ensure it does not happen again.
      Good healing to you.

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    4. Olivia Hibbitt

      Medical Writer

      In reply to Sue Ieraci

      Hi Sue,

      I totally agree with you. I just think that sometimes what can be routine for clinicians can be traumatic for patients.

      One of my friends was traumatised by the birth of her boy. She'd had a 5 hour labour, but got to the hospital too late to have the epidural she'd been planning for 9 months and felt so out of control she had nightmares about it. Not helped by midwives who laughed at her because she was having a 'perfect birth'!

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    5. Olivia Hibbitt

      Medical Writer

      In reply to Chris Saunders

      Hi Chris... actually, my case was the subject of clinical meetings....at least according to one of the nurses in the maternity levels. Apparently they'd never experienced neuralpraxis like mine and were concerned that I had been given far too much anaesthetic (something like 6 times what is usually used for a section). Of course they didn't think to involve me in any of these discussions!

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    6. Chris Saunders

      retired

      In reply to Olivia Hibbitt

      It seems nothing much has changed since I had my children in the 60s and 70s when the young mother was strung out between the extremes of being offered a caesarean for the protection of the baby and mother and being kind of initiated by suffering pain into some big sister fraternity of nurses and midwives ‘we’ve been there, wake up this is the real world, girl’ type of sadistic hype.
      You just decided to grit your teeth, smile and get out of there as soon as you could. My daughter- in-law only recently to my alarm left one night after giving birth. The vaginal birth process went ok and she was pleased with her midwife, but she could not handle the patronising behaviour of hospital staff after the birth.

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    7. Chris Saunders

      retired

      In reply to Olivia Hibbitt

      The fact you were not included in any of those clinical discussions does reveal a culture of the only thing that went wrong was their work procedure not their patient care, liaison, after care fraternisation and inclusion.

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  2. Suzy Gneist

    Multiple: self-employed, employed, student, mother, volunteer, Free-flyer

    Birth is a very personal experience and I believe that continuity of care is one of the best ways to support women through this experience. The hospital system, as it stands, does not allow for this, turning the experience into an impersonal, discontinuous and therefore stressful one.

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  3. Dianna Arthur
    Dianna Arthur is a Friend of The Conversation.

    Environmentalist

    Thank you, Jenny Gamble and Debra Creedy for your most important article. Too many maternity services have become little more than factory production lines adjusted to suit some hospitals rather than the mothers and their children.

    Of course those who can afford private medical treatment fair better (although not always) where as women dependent upon the largesse of the public purse have less choice and perpetuate bleaker futures for themselves and their children.

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  4. Kerreen Reiger

    Honorary Research Associate at La Trobe University

    Thanks Jenny and Debra for this article which of course raises many more issues than it could actually cover! Others have been articulated by subsequent comments. Unfortunately reports of trauma are more widespread than often recognised and, although some women are certainly more vulnerable than others, the problems are actually systemic.

    The need for effective education of young women and a more responsive and respectful maternity system were key conclusions reached at a recent symposium in…

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