Trigger warning – some of the information in this article may be distressing for people who have experienced or witnessed obstetric violence and other forms of birth trauma.
Birthing is one of the most compelling life events for a woman, her family, and the generations to come. Birthing is an experience that women embody for life. This momentous life event may affect the woman positively or negatively, depending on her perceived experiences (Sandall et al, 2009).
Recently, there has been a growing interest in the psychological impact of violent obstetric childbirth, which some women and researchers are calling ‘birth rape’. There has also been a growing awareness of the impact of birth trauma on women, their partners and their children. In fact, a high number of women report experiencing traumatic birthing events, but despite high incidence and the potential for widespread and long-lasting effects, birth trauma is poorly recognized, often ignored and insufficiently treated. This article provides insight into the obstetric birthing trauma effects experienced by women and some of the common risk factors contributing to traumatic birthing, as well as protective considerations.
While older research on birth trauma had mostly focused on many physical or medical aspects of birth trauma, such as complications, injury or loss of life, more recent literature has focused on obstetric violence, broadly meaning the psychological, physical or sexual mistreatment of laboring and birthing women. Obstetric violence includes verbal abuse, intimidation, unwanted sexual touch, coercive control, failure to gain informed consent to interventions, as well as physical injury. Research is increasingly framing obstetric violence as a type of gendered violence, and a type of systemic violence, with birthing women, their children, and the predominately female midwifery workforce all being adversely affected. The most recent research is also using qualitative methods to give women a voice, often exploring birth through the lens of critical feminist theory or a reproductive justice framework. This changing emphasis on birth trauma may be due in part to the use of social media by women, since the #MeToo movement, to speak about their experiences of violence, including obstetric violence (Keedle et al., 2022; Simonovic, 2019).
Birth trauma is not rare. Between 20% and 48% of women around the world are reporting their birth experiences as traumatic (Simpson & Catling, 2016). Recorded international rates of posttraumatic stress disorder (PTSD) due to birth trauma range as high as 6% (Dekel et al, 2017). A recent meta-analysis of studies estimated the international prevalence of PTSD among new mothers to be 4% (Ayers et al, 2016). However, it is possible that PTSD is underdiagnosed and misdiagnosed as post-natal depression (Birth Trauma Association UK, n.d.). Sheila Kitzinger, childbirth advocate, researcher and author of Birth Crisis (Kitzinger, 2006) reported that she felt that in order to diagnose PTSD professionals need to realize birth can be a serious trauma. She added that ‘Without this recognition of women’s trauma, I think their doctors tend to over-diagnose post-natal depression’ (Kitzinger, 2003, personal communication with second author).
The links between birth trauma and obstetric violence are increasingly being identified. The term obstetric violence is relatively new, but it seems this issue is an international one, with studies across the world exploring similar experiences and issues. In Latin America, the term ‘Obstetric Violence’, where patients are subjected to painful gynecological procedures and invasive treatment without consent during pregnancy and birthing, was first used legally in Venezuela, when it was brought into legislation in 2007 to protect women giving birth. Within two years Argentina followed suit, with Mexico doing the same in 2014. Unfortunately, obstetric violence doesn’t just apply to childbirth. It can also occur during terminations or post-miscarriage procedures. Back in 2018, a Croatian mother publicly shared in an English newspaper her experience, revealing how medical staff tied up her arms and legs during an abortion and started the procedure of curettage without anesthesia. In the United States where obstetric violence is often controversially referred to as “birth rape”, an Alabama mother was awarded an unprecedented multi-million settlement through a civil case in August 2016 (O’Reilly, 2019).
In Australia, a number of recent studies have specifically explored women’s experiences of birth and the findings have been given significant media attention. Keedle et al (2022) surveyed over 8, 000 women and identified themes to explain obstetric violence. The key themes were feeling dehumanized, violated and powerless. Women spoke of ‘being seen as a number’ or an ‘object’ and keenly felt that the hospital system was more important in the birthing process than they were as mothers. Women reported being violated by internal examinations and episiotomies being done, not only without seeking consent, but being done to women who had explicitly said no. Women reported that health staff made negative comments about their age or bodies, telling them they were ‘too old’ or ‘too fat’. They also reported that they were forced to birth in positions that they did not want, or which did not feel right for their bodies. It was common to hear that their expressions of pain or emotional distress were not taken seriously, or were ridiculed. Similarly, Tsakmakis et al (2022) in a study of Australian births found that both women and their partners were traumatized by births in which they felt they lacked control and did not give informed consent. This birth experience was found to adversely affect both parents’ mental health as well as bonding with their baby.
Taghizadeh et al (2013) noted that many Iranian women lacked adequate preparation for birth, and were psychologically distressed by hospitalization and midwifery procedures. They found that lack of control and trauma during birth was linked to poorer maternal mental health, relationship stress and poorer mother-infant attachment.
Khalil et al (2022) studied eastern Mediterranean women to learn about their experiences of birth trauma. They found that while great gains had been made in many areas of maternal physical care, the psychological and relationship aspects of birth care had not been well attended to, with women often reporting verbal abuse and disrespect. Women also reported physical abuse such as having their face slapped and being restrained with such physical force to cause bruises. There was a lack of informed consent and procedures being forced upon non-consenting women. They framed such processes as a product of patriarchal societal norms which disrespect women.
The Effects of Birth Trauma
Women diagnosed with post-birth PTSD may suffer either an acute form, with symptoms resolving up to 2 years post birthing, or a chronic form with symptoms maintaining or even worsening for two years or longer (Dahlberg et al, 2016; Hollander et al, 2017). Trauma associated with violent obstetric birthing practices is frequently absent in clinical discussions, conferences, or the literature of women’s trauma. However, this is not the case among the birthing women. The international birthing community is experiencing childbirth as an event so traumatic that women are developing symptoms of post-traumatic stress at a rate of almost 30% (Ford et al 2010) and are coining strong terminology such as “birth rape” and “obstetric violence” (Ehlers et al, 2000). Prenatal obstetric teams need to be educated about ways to reduce traumatic birthing experiences and how to manage posttraumatic stress (PTS) symptoms timely and properly as their effects can have a lifetime psychological outcome for women.
Women who are traumatized by birthing have an increased incidence of developing several psychosocial difficulties in the postpartum period. These may include, anxiety, PTS, PTSD (i.e. flashbacks, nightmares, avoidance, somatic reactivity) (Milosavljevic et al, 2016), tokophobia, attachment difficulties, familial issues, relationship breakdown, parenting stress, isolation, anger and a loss of self-identity (Dahlberg et al 2013). Often women report avoiding reminders of their traumatic birth experiences, this may begin with avoiding psychotherapy and other conversations about birth, and sometimes avoiding a future pregnancy entirely (Yildiz et al, 2017). Additionally, a lack of obstetric trauma informed care (TIC) can precipitously activate pre-existing psychosocial conditions, and traumatic or dissociated somatic memories of sexual abuse, rape, and other relational issues (Cortizo, 2021). In a recent study, Watson et al (2021) concluded that maternal birthing trauma is strongly influenced by, 1) negative health care provider interactions and dysfunctional operation of the maternity care system, 2) lack of prenatal education, 3) insufficient support, 4) limited informed decision-making, resulting in feelings of losing control and powerlessness which contributes to women’s trauma.
In addition to psychological effects birth trauma affects both the woman and the baby physically. Firstly, it can adversely impact breast feeding. This can be due to drugs, procedures and trauma impacting milk production, but additionally women report that it can hurt to sit or lay down to breastfeed (Beck & Watson, 2008). Furthermore, after traumatic birth women are more likely to have pelvic floor trauma, urinary and fecal incontinence, and pelvic organ prolapse. These have extensive personal and financial costs for the woman (Freeman et al, 2021). Finally, it is possible that obstetric violence, as a systemic, gendered violence, is leading to an increase in caesarean rates. More research is needed to investigate this, but one study in America has indeed suggested that the rise of low-risk caesareans may be partially due to gendered violence and structural sexism which manifests as obstetric violence (Nagle & Samari 2022).
Risk Factors for Birth Trauma
As the studies above indicate risk factors for birth trauma include negative and disempowering health care provider interactions and loss of control and decision-making power in prenatal care and labor (Keedle et al, 2022; Taghizadeh et al, 2013; Tsakmakis et al, 2022). Other risks include having had a previous traumatic birth experience (Dekel et al, 2017), unmatched birth expectations (Watson et al, 2020), having a pre-existing mood disorder, anxiety disorder or PTSD (Fors et al, 2010). In addition, being a survivor of sexual abuse is a risk factor, particularly if dissociated sexual abuse and rape memories are activated (Reed et al, 2017).
This last factor, having a history of sexual abuse is an incredibly important factor, as experiencing sexual abuse prior to birthing age is very common. Kitzinger, in her book Birth Crisis (Kitzinger, 2006) devotes an entire chapter to the topic of sexual abuse and birth. She notes that many common birth experiences may inadvertently replicate earlier sexual abuse experiences such as being forced into positions, being told to undress, having legs tethered into stirrups, loss of control, and having to engage with authority figures. In truth, birth is ripe with triggers for a sexual abuse survivor, but it can also be an opportunity to be cared for and supported through the development of birth procedures that accommodate the inevitable high percentage of sexual abuse survivors who will, at some stage of their lives, give birth. These birth procedures can, at their best, restore dignity, choice and control to women.
It is worth noting that some women who report experiencing birth trauma may have no predictable risk factors. It is important to make sure that researchers and clinicians do not exclusively focus on the personal risk factors of mothers, when mothers themselves are repeatedly stating that the problems they encounter are external to them. While it is important to explore such intrapsychic or personal risk factors, it is also obvious, when hearing women’s personal stories of extreme violation, threats, and abuse (Kahlil et al, 2022, Keedle et al, 2022; Taghizadeh et al, 2013; Tsakmakis et al, 2022), that looking to the survivor’s personal traits could be missing a very important chance to highlight real systemic and gender-based problems which enable obstetric violence to continue. Additionally focusing only on the personal risk factors of the birthing mother may increase shame and self-blame.
What can we do to prevent obstetric violence and birth trauma?
Reducing the risk of women experiencing their birth as a traumatic event should be a priority for maternity care providers as the ill effects can have long-term negative implications for women and their families. However, within the health care system childbirth services tend to be separated from ongoing health services in the rest of that woman’s life. This means that childbirth services are disconnected from and unaware of the impact of birth trauma in a woman’s life and her family’s life months or years later. A ‘whole of woman’ approach to health service design is needed.
Clearly there needs to be systemic changes to birth systems to allow for women-centered birth, where women are respected and cared for. Obstetric services need to seriously and repeatedly examine their practices for signs of systemic or gendered power imbalance and violence (Kahlil et al 2022; Keedle et al, 2022; Taghizadeh et al, 2013). Because of potential harmful effects of obstetric procedures, medical interventions should be limited to medically high-risk births rather than all pregnancies and childbirths (Verny, 1992).
Although birth is increasingly technocratic and systemized, it remains an intensely personal experience, requiring a woman to listen to her own body. Many women report that their requests, feedback about positions, and intuitive birth preferences have been ignored in labor (Keedle et al, 2022). Developing systems and protocols that recognize the expertise of both birth attendants and birthing women is important.
Increasingly wealthier women are paying for services such as private doulas, midwives and doctors to support them as they navigate, or even side-step, the problems of systemic violence in maternity services. While such actions may help a well-informed and affluent minority, they do not solve the problem. It is important that all maternity services are trauma informed and woman-centered, with policies and practices that are free from obstetric violence.
Having birth plans that are respected is an important step, but so too is empathic care when birth plans cannot be followed for medical reasons. A woman in such a position is not just in a medical emergency and potentially facing traumatic medical procedures, she is also facing a loss of her ideal birth and will need to grieve the loss of her dreams for one of the most special, meaningful, and powerful events of her life.
Additionally, there is a need for pre-existing risk factors for birth trauma to be assessed and addressed prior to birth (Cortizo, 2020b, 2021; Simpson & Catling, 2016) with a need for trauma informed care at the prenatal, birth and postnatal periods (Cortizo, 2019; 2020a). For women with pre-identified risk factors the Calming Womb model may be appropriate (Cortizo, 2020a; 2021).
After a difficult birth, some factors can reduce the chance of prolonged trauma. These include having skin to skin contact between mother and baby immediately following birth (Widström et al, 2019) and being able to breastfeed (Tsakmakis et al, 2022). While breastfeeding may not be desired or possible for all women, Tsakmakis et al (2022) found that breastfeeding was an important way for women to regain their identity and confidence after a traumatic birth, that it was very important to most of them, and that they appreciated support in establishing feeding, even in the adverse circumstances of traumatic birth.
Furthermore, community and professional response to birth trauma can also be helpful to prevent further traumatization. Tsakmakis et al (2022) found that women were distressed by the dismissal of their birth traumas, not just by professionals but by family and community members. They termed this the ‘Healthy Baby Rhetoric” where women’s stories of distress, abuse, violence and trauma were dismissed and subjugated with responses that implied ‘don’t worry about it, you’ve got a healthy baby’. Both professional and community education is needed to better support mothers, so their feelings can be listened to and responded to in a manner that is not re-traumatising.
Treating Birth Trauma
It is important that women who have experienced all forms of birth trauma are assessed and treated for postnatal depression and anxiety and PSTD. Women who have experienced coercive control, verbal abuse, disrespect and psychological abuse, even in the absence of significant physical trauma, are still at risk of developing these psychological problems.
Research suggests there is a very real risk that maternity staff are not fully aware of the difference between PTSD and PND and there is a risk of misdiagnosis. This is very important as the evidence-based treatments for PSTD and PND are quite different (Bromley et al, 2017). Women report that debriefing with hospital staff often results in psychological distress being minimized or distressed, and such debriefing can also be antagonistic and defensive (Tsakmakis, 2022). In fact, a Cochrane review suggests there is little evidence that early debriefing of birth trauma prevents or treats PTSD (Bastos et al, 2105).
However experienced and trained trauma therapists are in a unique position to provide quality interventions, more appropriate than routine ‘debriefing’. As therapists we can provide a validating and empathic response to women who have had birth trauma. In addition, our independence from the labor itself may facilitate a more supportive and open discussion of the experience and the resultant impacts.
Trauma therapists are uniquely positioned to understand obstetric violence which can be coercive, gendered and sexual. We are also trained to respond to any trauma from previous sexual assaults that may be reactivated. Therapists can also empathically respond to bonding problems that can occur after traumatic birth, while encouraging attuned parent-infant interactions.
Recommended treatments for birth trauma include trauma-focused CBT, exposure therapy and EMDR, but making firm conclusions about the outcomes of treatments is limited as studies are very heterogenous and can include early intervention, later intervention and interventions by people who are not mental health professionals such as obstetric doctors and midwives. However, there is some evidence that early interventions are helpful (Miller et al., 2021).
EMDR is emerging as a useful technique and one that most trauma therapists are already familiar with. An EMDR Recent Birth Trauma protocol has been developed and an RCT has indicated it is more effective than treatment as usual in reducing PTSD symptoms (Chiorino et al 2020). The EMDR Standard Protocol has also been used with sustained results (Cortizo, 2020a). Given the high rates of childhood sexual abuse that women experience, it is important that EMDR treatment is dissociation-informed. Early trauma may be dissociated, but come out in the body in the form of somatic flashbacks or may manifest as shame and phobias (Cortizo, 2020).
Finally, it is important that women planning to have another baby after a traumatic birth are supported by their birthing team and their therapist to make informed choices about the next birth. Women may vary a great deal in what they want to do, and non-directive, non-judgmental counselling is important. For some women an elective caesarean may be preferred, as a way to avoid another violent vaginal birth, while other women will feel strongly that they wish to have a VBAC (Vaginal Birth after Caesarean). Even women who have some restricted choice due to medical reasons, or lack of services in remote areas or developing countries, can still benefit from exploring elements of their birth over which they can have choice and control. This process in itself can help heal birth trauma.
Birth Trauma can be caused by many factors and an emerging factor is obstetric violence. As women increasingly speak out about their experiences of traumatic birth and obstetric violence, pressure is being placed on maternity systems to take greater consideration of psychological health, as well as to implement respectful practices which are free of gendered and systemic violence. Trauma therapists are uniquely placed to understand and respond to the multifaceted causes of birth trauma. However more research is needed into effective ways to respond to birth trauma immediately after birth, as well as treat disorders that later emerge as a result of birth trauma and obstetric violence.
Photos courtesy of Shutterstock
The authors wish to thank Lynette Danylchuk for her review and comments on the manuscript. Additionally, the authors are indebted to L, a woman with lived experience of obstetric violence and birth trauma, whose comments also helped shape this manuscript.
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