In recent years there has been growing recognition of the impact of birth trauma on women, their partners and their children. While older research focused on many aspects of birth trauma, such as complications, injury or loss of a baby, the most recent literature has had a particular focus on obstetric violence – the mistreatment of labouring and birthing women which can include verbal abuse, intimidation, unwanted sexual touch, coercive control and physical injury. These studies increasingly frame obstetric violence as gendered violence and highlight the serious implications of obstetric violence, something that may be a very distressing re-traumatization for survivors of sexual abuse. During 2021-2022 there have been some particular studies examining this type of violence and its impact on woman across the world and this article highlights some of these. Articles cover the experience of women from countries and regions as diverse as Australia, India, the Mediterranean and the Netherlands, as well as the perspective of midwives.
Articles which are Open Access are marked. (In efforts to provide our members with accessible information, almost all articles below are Open Access.)
Trigger warning – some of the first-person accounts in these articles may be distressing for people who have experienced or witnessed obstetric violence and other forms of birth trauma.
Tsakmakis, P. L., Akter, S., & Bohren, M. A. (2022). A qualitative exploration of women’s and their partners’ experiences of birth trauma in Australia, utilising critical feminist theory. Women and birth: Journal of the Australian College of Midwives. https://doi.org/10.1016/j.wombi.2022.12.004
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Abstract
Background: Many women in Australia emerge from childbirth describing their experience as traumatic. Birth trauma can be both physical and psychological, with long-lasting and intergenerational impacts.
Aim: To explore women’s and their partners’ experiences of birth trauma in Australia and consider the role of gender using a feminist theoretical lens.
Methods: We used a descriptive phenomenological and constructivist/interpretivist approach and two frameworks (WHO Quality of Care framework; socio-ecological model) to explore experiences of traumatic birth. Participants were recruited through social media using purposive sampling. Data were collected through online in-depth interviews. Data were analysed thematically, considering gender and power dynamics using critical feminist theory.
Findings: 24 women and 4 male partners were interviewed. We identified 8 themes, including: Individual: birth grief and best laid plans; breastfeeding to regain identity after trauma. Interpersonal: impact of trauma on bonding with baby; partner trauma. Institutional: inadequate consent processes; to debrief or not to debrief. Community: more than a healthy baby. Policy: an augmented reality.
Discussion: Findings highlighted the impact of patriarchal maternity care systems and policies in undermining women’s sense of control during birth, evident in high levels of labour augmentation and inadequate consent processes. This study draws attention to how gender shapes how birth trauma is expressed within both women’s and their partners’ identities as parents, their relationships, and society.
Conclusions: Recommendations include the development of women-centred policies for obtaining informed consent and training in trauma-informed care in maternity services. Further research must include the voices of women from diverse backgrounds.
Keedle, H., Keedle, W., & Dahlen, H. G. (2022). Dehumanized, Violated, and Powerless: An Australian Survey of Women’s Experiences of Obstetric Violence in the Past 5 Years. Violence Against Women, 10778012221140138. Advance online publication. https://doi.org/10.1177/10778012221140138
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Abstract
Globally, significant numbers of women report obstetric violence (OV) during childbirth. The United Nations has identified OV as gendered violence. OV can be perpetrated by any healthcare professional (HCP) and is impacted by systemic issues such as HCP education, staffing ratios, and lack of access to continuity of care. The current study explored the experiences of OV reported in a national survey in 2021 by Australian women who had a baby in the previous 5 years. A content analysis of 626 open text comments found three main categories: “I felt dehumanised,” “I felt violated,” and “I felt powerless.” Women reported bullying, coercion, non-empathic care, and physical and sexual assault. Disrespect and abuse and non-consented vaginal examinations were the subcategories with the most comments.
Mayra, K., Sandall, J., Matthews, Z., & Padmadas, S. S. (2022). Breaking the silence about obstetric violence: Body mapping women’s narratives of respect, disrespect and abuse during childbirth in Bihar, India. BMC pregnancy and childbirth, 22(1), 318. https://doi.org/10.1186/s12884-022-04503-7
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Abstract
Background: Evidence on obstetric violence is reported globally. In India, research shows that almost every woman goes through some level of disrespect and abuse during childbirth, more so in states such as Bihar where over 70% of women give birth in hospitals.
Objective: 1) To understand how women experience and attach meaning to respect, disrespect and abuse during childbirth; and 2) document women’s expectations of respectful care.
Methods: ‘Body mapping’, an arts-based participatory method, was applied. The analysis is based on in-depth interviews with eight women who participated in the body mapping exercise at their homes in urban slums and rural villages. Analysis was guided by feminist relational discourse analysis.
Findings: Women reported their experiences of birthing at home, public facilities, and private hospitals in simple terms of what they felt ‘good’ and ‘bad’. Good experiences included being spoken to nicely, respecting privacy, companion of choice, a bed to rest, timely care, lesser interventions, obtaining consent for vaginal examination and cesarean section, and better communication. Bad experiences included unconsented interventions including multiple vaginal examinations by different care providers, unanesthetized episiotomy, repairs and uterine exploration, verbal, physical, sexual abuse, extortion, detention and lack of privacy.
Discussion: The body maps capturing birth experiences, created through a participatory method, accurately portray women’s respectful and disrespectful births and are useful to understand women’s experience of a sensitive issue in a patriarchal culture. An in-depth understanding of women’s choices, experiences and expectations can inform changes practices in and policies and help to develop a culture of sharing birth experiences.
Khalil, M., Carasso, K. B., & Kabakian-Khasholian, T. (2022). Exposing Obstetric Violence in the Eastern Mediterranean Region: A Review of Women’s Narratives of Disrespect and Abuse in Childbirth. Frontiers in global women’s health, 3, 850796. https://doi.org/10.3389/fgwh.2022.850796
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Abstract
Background: Obstetric violence (OV) threatens the provision of dignified, rights-based, high-quality, and respectful maternal care (RMC). The dearth of evidence on OV in the Eastern Mediterranean Region poses a knowledge gap requiring research to improve rights-based and respectful health practice and policy. While efforts to improve the quality of maternal health have long-existed, women’s experiences of childbirth and perceptions of dignity and respect are not adequately or systematically recorded, especially in the said region.
Aim: This study centered on the experiences of women’s mistreatment in childbirth to provide an overview of OV and offer recommendations to improve RMC.
Methods: A scoping review was conducted, and a total of 38 articles met the inclusion criteria and were analyzed using Bowser and Hill’s framework of the seven typologies of Disrespect and Abuse (D&A) in childbirth. D&A in childbirth (or violations to RMC) is a manifestation of OV and served as a proxy to analyze its prevalence in the EMR.
Findings and discussion: This study indicated that across the EMR, women experienced every type of D&A in childbirth. This happens regardless of health systems’ strength or country’s income, with 6 out of 7 types of D&A found in almost two-thirds of included countries. In the EMR, the most common types of D&A in childbirth are physical abuse (especially overused routine interventions) and non-dignified care (embedded in patriarchal socio-cultural norms). The intersections of these abuses enable the objectification of women’s bodies and overuse of unconsented routine interventions in a hierarchical and patriarchal system that regards the power and autonomy of doctors above birthing women. If unchecked, the implications include acceptance, continuation, and underreporting of D&A in childbirth, as well as passivity toward human-rights violations, which all further cause the continuing the cycle of OV.
Conclusion: In order to eliminate OV, a paradigm shift is required involving infrastructure changes, education, empowerment, advocacy, a women-centered and gender-sensitive approach to health system strengthening, and policy development. Recommendations are given at individual, community, health systems, and policy levels to ensure that every woman achieves her right to health and birth in a dignified, respectful, and empowered manner.
van der Pijl, M. S. G., Verhoeven, C. J. M., Verweij, R., van der Linden, T., Kingma, E., Hollander, M. H., & de Jonge, A. (2022). Disrespect and abuse during labour and birth amongst 12,239 women in the Netherlands: a national survey. Reproductive health, 19(1), 160. https://doi.org/10.1186/s12978-022-01460-4
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Abstract
Background: Women experience disrespect and abuse during labour and birth all over the world. While the gravity of many forms of disrespect and abuse is evident, some of its more subtle forms may not always be experienced as upsetting by women. This study examines (1) how often women experience disrespect and abuse during labour and birth in the Netherlands and (2) how frequently they consider such experiences upsetting. We also examine (3) which respondent characteristics (age, ethnicity, educational level and parity) are associated with those experiences of disrespect and abuse that are upsetting, and (4) the associations between upsetting experiences of disrespect and abuse, and women’s labour and birth experiences.
Methods: Women who gave birth up to five years ago were recruited through social media platforms to participate in an online survey. The survey consisted of 37 questions about experiences of disrespect and abuse divided into seven categories, dichotomised in (1) not experienced, or experienced but not considered upsetting (2) experienced and considered upsetting. A multivariable logistic regression analysis was performed to examine associated characteristics with upsetting experiences of disrespect and abuse. A Chi-square test was used to investigate the association between upsetting experiences of disrespect and abuse and overall birth experience.
Results: 13,359 respondents started the questionnaire, of whom 12,239 met the inclusion and exclusion criteria. Disrespect and abuse in terms of ‘lack of choices’ (39.8%) was reported most, followed by ‘lack of communication’ (29.9%), ‘lack of support’ (21.3%) and ‘harsh or rough treatment/physical violence’ (21.1%). Large variation was found in how frequently certain types of disrespect and abuse were considered upsetting, with 36.3% of women experiencing at least one situation of disrespect and abuse as upsetting. Primiparity and a migrant background were risk factors for experiencing upsetting disrespect and abuse in all categories. Experiencing more categories of upsetting disrespect and abuse was found to be associated with a more negative birth experience.
Conclusions: Disrespectful and abusive experiences during labour and birth are reported regularly in the Netherlands, and are often (but not always) experienced as upsetting. This emphasizes an urgent need to implement respectful maternity care, even in high income countries.
Uddin, N., Ayers, S., Khine, R., & Webb, R. (2022). The perceived impact of birth trauma witnessed by maternity health professionals: A systematic review. Midwifery, 114, 103460. https://doi.org/10.1016/j.midw.2022.103460
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Abstract
Objectives: Maternity health professionals (MHPs) caring for women may witness or be involved in traumatic births. This can be associated with MHPs experiencing secondary traumatic stress (STS) or probable post-traumatic stress disorder (PTSD), which may impact MHPs emotionally and physically. The aims of this review were therefore to determine: (i) the prevalence of STS and PTSD in maternity health professionals; and (ii) the impact of witnessing birth trauma on maternity health professionals.
Methods: A mixed-methods systematic review was carried out by conducting literature searches on CINAHL, MEDLINE, PsychARTICLES, PsychINFO and PsychTESTS databases. Searches were conducted from the inception of databases up to February 2022 using search terms on MHPs and birth trauma combined. Methodological quality and bias were assessed. Data were synthesised using thematic synthesis.
Results: A total of 18 studies were included in the review. Sample size ranged from 9 to 2,165 (total N = 8,630). Participants included midwives, nurses and obstetricians aged 18-77 years. Many MHPs had witnessed a traumatic birth event (45% – 96.9%) with the prevalence of STS ranging from 12.6%-38.7% and the proportion of participants meeting diagnostic criteria for PTSD ranging from 3.1%-46%. MHPs reported positive and negative effects associated with witnessing traumatic birth events. Synthesis of quantitative and qualitative papers identified five themes: Negative emotions and symptoms; Responsibility and regret; Impact on practice and care; Challenging professional identity; and Team support being essential.
Discussion: Witnessing traumatic birth events is associated with profound emotional and physical impacts on MHPs, signifying the importance of acknowledging and addressing this in the maternity workforce. It is important to raise awareness of the impact of birth trauma on MHPs. Effective education and training guidelines, a supervisory network, ways to change practice and policy, and support and treatment should be provided to assist and improve the outcomes and work-life of MHPs’ who witness traumatic births.
Nagle, U., Naughton, S., Ayers, S., Cooley, S., Duffy, R. M., & Dikmen-Yildiz, P. (2022). A survey of perceived traumatic birth experiences in an Irish maternity sample – prevalence, risk factors and follow up. Midwifery, 113, 103419. https://doi.org/10.1016/j.midw.2022.10341
Abstract
Objectives: To establish the prevalence and correlates of a subjectively traumatic birth experience in an Irish maternity sample.
Design: A questionnaire routinely provided to all women prior to hospital discharge post-birth was amended for data collection for this study. Two additional questions seeking information about women’s perceptions of their birth were added and analysed. Women who described their birth as traumatic and agreed to follow-up, received a City Birth Trauma Scale (Ayers et al., 2018) at subsequent follow-up (6 to 12 weeks postpartum). Demographic, obstetric, neonatal variables and factors associated with birth trauma were collected from electronic maternity records retrospectively.
Setting: A postnatal ward in an Irish maternity hospital which provides postnatal care for public maternity patients.
Participants: Postpartum women (N=1154) between 1 and 5 days postpartum.
Measurements & findings: Participants completed the Edinburgh Postnatal Depression Scale (EPDS) (Cox et al., 1987) with two additional questions about birth trauma. Eighteen percent (n=209) of women reported their birth as traumatic. Factors associated with reporting birth as traumatic included a history of depression, raised EPDS scores (>12), induction of labour, combined ventouse/forceps birth, and postpartum haemorrhage. Of these 209 women, 134 went on to complete the City Birth Trauma Scale (Ayers et al., 2018). The average score was 3.84 and 6 of this sample (4%) reached the threshold for postpartum post-traumatic stress disorder (PTSD).
Key conclusions: This study identified a prevalence of 18% of women experiencing birth as traumatic and the potentially important role of a current and past history of depression, postpartum haemorrhage, induction of labour and operative vaginal birth in defining a traumatic birth experience. The majority of women were resilient to birth trauma, few developed PTSD , but a larger cohort had significant functional impairment associated with sub-clinical postpartum PTSD symptoms.
Implications for practice: Maternity care providers should be aware of the risk factors for traumatic birth. Introducing a trauma-informed approach amongst midwives and maternity care providers in the postnatal period may help to detect emerging or established persisting trauma-related symptoms. For women with sub-clinical postpartum PTSD symptoms a detailed enquiry may be more effective in identifying postpartum PTSD at a later postnatal stage e.g., at six weeks postpartum. Maternity services should provide ongoing supports for women who have experienced birth trauma.