This article begins Improving Birth's Summer 2014 campaign to Break the Silence around trauma and abuse in maternity care. It is one piece of several - including a toolkit for trauma survivors, "How to File a Complaint for Mistreatment in Childbirth," stories from women, and more - intended to open up the conversation on these issues. Please watch our Facebook page and sign up for our newsletter to be sure you don't miss anything.
“I looked fine because of the epidural, but I went to a very dark place in my mind, having flashbacks about being victimized in childhood. I was freaking out inside, feeling helpless about keeping my baby safe in that moment, but nobody knew it. It was horrible. Now that I’m pregnant again, I’m terrified of it happening a second time.”
This mother’s experience is far too common, as many women are left with feelings of numbness, grief, shame, guilt, or sadness, and experience nightmares or flashbacks after giving birth. The well-intentioned cheer “at least you have a healthy baby” can feel dismissive and even cruel to the women who feel shattered by their births.
According to Cheryl Beck, author of Traumatic Childbirth, birth trauma is defined 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. The birthing woman experiences intense fear, helplessness, loss of control and horror.” She also probably feels stripped of her dignity and autonomy.
This happens more than people realize. Up to 34% of women experienced a birth that they describe as traumatic and about 1/3 of those women may meet the diagnostic criteria for Postpartum Post Traumatic Stress Disorder. Think about these numbers for a moment! That’s almost 1 in 10 women who will come out of childbirth with a serious, sometimes debilitating, condition. This may be your sister, daughter, friend, co-worker, neighbor, or your wife . . . and it’s possible that you aren’t even aware of her situation.
Sometimes a birth that looks routine to the health care provider can leave a woman feeling traumatized by the experience. There are many reasons for this, including a woman’s personal history, unexpected events during labor, and how she is treated by her care providers.
When a woman gives birth to a live baby and doesn’t have visible injuries, it is often assumed that the birth was a “success.” Such a simplistic conclusion fails to account for the woman’s mental and emotional state as well as the stress of a new baby, and other non-permanent but uncomfortable birth-related complications that she must handle while caring for her newborn.
Thankfully, there are wonderfully supportive resources, such as Solace for Mothers, that provide information and networking opportunities for women. Increasing awareness of birth trauma is the first step in treating and reducing it.
To help raise that awareness, ImprovingBirth.org has created a toolkit and resource directory with helpful information designed for women, birth professionals, and care providers.
>> What causes birth trauma?
Between 25% and 40% of women have a history of childhood sexual abuse, 1 in 4 experience domestic violence, and 1 in 5 are sexually assaulted. Many of these women and their care providers don’t realize how a history of trauma can trigger emotions and behaviors during pregnancy, labor, and birth. Although birth trauma can also happen to women with no history of abuse or mental health concerns, it is less common. Treatment by the health care provider, the unpredictability of labor, and “routine” (one policy for all) procedures associated with standard maternity care can all impact the way a woman perceives her birth.
For example, it is standard policy in many hospitals to perform at least one vaginal exam during labor—frequently, several exams—by multiple strangers. Many women report that these exams are extremely painful and distracting, and that having to lie still on their backs for each exam interrupts the labor process.
Women have good reason to decline these exams. They also have the right to decline them, even though the procedure is usually presented as a requirement. Routine vaginal exams are medically unnecessary and increase the risk of infection. Even women who have said “no” to vaginal exams may be heavily pressured into having them, or, even, as many women have reported to Improving Birth, forced into having them against their will. Unwanted and painful vaginal exams could be traumatic for any woman, but may be more so for the 25 to 40% of women who have experienced prior sexual abuse or rape.
Another standard hospital policy is depriving women in labor of food or drink other than clear fluids or ice chips. This is an outdated policy that is no longer supported by evidence, but is still common practice (about 6 in 10 women today will have food and drink restricted in labor). There are many drawbacks to this policy, as Henci Goer explains: “dehydration and starvation caused by restricting food/drink intake during labor causes a woman not only considerable discomfort but can also lead to fever, prolonged labor, increased use of oxytocin (a.k.a. pitocin), instrumental delivery, and a non-reassuring fetal heart rate pattern/fetal distress. And what can all of these lead to? . . . That’s right, a cesarean section!”
When we think about how routine use of vaginal exams and food/drink deprivation affects women who have experienced abuse or neglect, it’s easy to see how these common policies could trigger flashbacks, intrusive thoughts, or dissociation. Women are often unaware of why they suddenly feel anxiety, hostility, or fear. When a person feels scared or threatened, the brain responds by releasing hormones that cause the “fight, flight, or freeze” reaction. This can slow and even stop labor, causing additional stress and feelings of failure, that also negatively impact labor progress. Often, this can cause a downward spiral of medical interventions to keep labor going artificially—with Cesarean section as the inevitable outcome if the body does not respond as expected or the fetus is sent into distress because of the drugs.
To add insult to injury, many women are told, “Thank goodness you were in the hospital since you needed a cesarean!” It is important to note that, today, Cesarean surgery is the most frequent operating room procedure in America, with 1 in 3 women giving birth surgically—a rate many times higher than what optimal care suggests is best.
>> Trauma by Surgery – Again
A woman who becomes pregnant after having a previous cesarean section faces another obstacle, deciding on a repeat cesarean for her second child, or the difficult task of finding a provider who will fully support her in having a VBAC (vaginal birth after cesarean). Despite the fact that best evidence shows VBAC to be a safe and appropriate choice for most women, over 40% of hospitals in America ban VBAC. In other words, they force the woman to have surgery even when there is no medical reason other than a previous cesarean. Even ACOG has stated that, “Attempting a vaginal birth after cesarean (VBAC) is a safe and appropriate choice for most women who have had a prior cesarean delivery, including for some women who have had two previous cesareans.” The main concern is for laboring in women with a previous cesarean is uterine rupture along the previous scar line. However, according to VBAC Facts, “The risk of maternal mortality is very low whether a woman plans a VBAC (0.0038%) or an elective repeat cesarean (0.0134%).”
Providers and hospitals claim that VBAC bans are for the safety of mothers and babies. However women who have a repeat cesarean are actually 3 times more likely to die, and are much more likely to experience complications. Despite the commonly held belief that uterine rupture happens frequently and results in the death of the baby, the actual uterine rupture rate is 0.4% - 1%, and, if uterine rupture occurs, the fetal mortality rate is 6% or less.
Consider this: Is there any other field of medicine where a person is forced to have a medically unnecessary surgical procedure, despite the known risks?
Some people may find it easy to assume that women can use a different hospital that doesn’t have a VBAC ban. However, for many women, especially those in rural areas, it is financially or logistically impossible to include a long drive and indefinite hotel stay with her childbirth plans. Although some women overcome these obstacles, they shouldn’t have to!
When we look at this state of events from the perspective of women who have been assaulted or abused, this violation of basic human rights becomes even more disturbing. During the procedure, a woman’s arms are often restrained—a potential trigger for extreme emotions and reactions. There are so many ways that forced surgery is traumatizing, there’s no way to list them all.
>> Treatment by Care Providers
While there are amazing, wonderful and compassionate care providers who give women accurate information so they can make informed choices and who support women in those choices, there are providers who don’t. At Improving Birth, we frequently hear from women who report that their care providers gave them inaccurate information and were unsupportive of their decisions. Many also report being bullied, coerced, and abused.
Susan Hodges states in "Abuse in Hospital-Based Birth Settings?" (2009, the Perinatal Journal of Education):
“Abuse in the hospital-based birth setting may not seem the same as domestic abuse and violence, but it is no less harmful. Verbal abuse includes behaviors such as threatening, scolding, ridiculing, shaming, coercing, yelling, belittling, lying, manipulating, mocking, dismissing, and refusing to acknowledge—behaviors that undermine the recipient's self-esteem while enhancing the abuser's sense of power, typical of bullying. Most of us would recognize these as abusive behaviors in just about any other setting. However, because we are socialized to both expect trustworthy and professional behavior in the hospital setting and to be ‘compliant’ with medical directives, these behaviors are seldom recognized and interpreted as abuse. Furthermore, staff and doctors are the authorities in the hospital, while the pregnant and laboring woman is merely a ‘patient.’ Such a huge power imbalance allows, even encourages, bullying and abuse. We tend to feel helpless, so we rationalize and accept these behaviors while denying our experience of them. Abuse also includes actions such as medical treatment without informed consent, omission of information, overriding one's refusal of a treatment, and misrepresentation of medical situations and the need for interventions.”
>> Larger Implications
Society at large has a major stake in the reduction of birth trauma. The ripple effect continues far beyond mothers. Fathers or partners may also feel trauma from a difficult birth. As one father shared with Improving Birth readers, “The emotional impact of what happened drastically affected our lives for years and very nearly ended our marriage.”
Studies have also shown that labor and delivery nurses who support women in birth can have secondary traumatic stress. Doulas overwhelmingly report to Improving Birth the secondary trauma that results in feeling helpless while watching women being mistreated on a regular basis. And recently, we’ve begun to learn that women can transfer trauma to their babies in the womb. When women have untreated postpartum mood disorders, the ongoing effects on babies can delay development and cause problems with school and personal relationships that may continue into their adult lives… and the cycle continues.
A “healthy mom and healthy baby” means more than mere survival. Support and respect in birth is vital not only for the emotional health and happiness of the woman, but also for her family – the building block of the larger community.
Author Amy Meister-Stetson is ImprovingBirth.org's Trauma Care Coordinator. Her undergraduate degree is in psychology and human and family development. Prior to her career as a birth professional, she spent 12 years in the social service field, primarily mental health and women’s health care. The birth of her son in 2004 was so powerful that she changed careers and became a Certified Childbirth Educator in 2009. Two years later, the profound experience of the workshop “When Survivors Give Birth” led her to additional training, including education on Postpartum Mood Disorders and certification in Body-Centered Hypnosis for Birth (ideal for women with trauma). She is currently enrolled in the Trauma-Informed Clinical Foundation Certificate Program through the University at Buffalo School of Social Work, and has been a volunteer with ImprovingBirth.org since 2012 as a Seattle Rally to Improve Birth coordinator and participant on the IB Strategic Planning Task Force Committee.
Have you seen what Improving Birth is up to? We’re supporting women all over the country, as well as working with mothers, providers, and policy makers to lead change in various communities. We need your support today! Please give here and plan to attend or organize a gathering for the 2014 Rally to Improve Birth this Labor Day, September 1–the only national event of its kind, where consumers come together to raise awareness about the maternity care crisis and demand change. We’ll see you there!