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!
I would like to cite some of the statistics in this article for a scholarship application. Does anyone have links or knowledge of the primary sources available ? ASAP ? (as in need today, 8/14/2015, because I’m a giant procrasinator and my essay is due at midnight) Thanks !!! 🙂
Thank you for coming forward with your powerful stories. As much as it saddens me to read about your experiences, I truly appreciate the bravery of women stepping forward and finding their voices. There is no place in maternity care for coercion, bullying, lies and abuse. It is important that the mainstream public understand what is happening and the reality and frequency of birth trauma. It is also important for women to get support because it IS out there. Our toolkit will be ready soon with lots of resources and information including; the need for immediate advocacy during labor, legal assistance, or emotional support for a traumatic birth and more. Meanwhile, please know that you are not alone. We have started a campaign called #breakthesilence where you can see many, many stories of real moms, dads and partners. https://www.facebook.com/media/set/?set=a.705655609507930.1073741854.255657527841076&type=1
I had a rough moment in my first childbirth .I decided for midwifery treatment .I thought of them as gentle caress professionals who prepare themselves in the arts of dealing with the profound emotions and intense experience of the childbearing process .Instead I got myself entangled in a severe psychological trauma I will never forget .Oh I regret the moment I decided to go for it.I had a very natural untouched delivery.As I had decided .Actually the baby came almost in my husband’s hands .But we did not sign for it that way .No we surely not .We wanted a fine approach ,a delicate refine individualized approach not a neglected assaulted one.I did not want screaming or a judgmental statement ” if you did not want the pain why did you get pregnant” ” there is always pain . pain before or pain after birth there is always pain” the pain will leave your body as soon as the baby gets out of it” Get yourself joined and do your best for your baby or he will get stuck there and believe me you don’t want your baby to suffer so do your job” such obstetrical violence who would forget ???..the last one words resound still in my mind..I had the bitterest person in the entire midwifery community for sure .We wrote a large testimony after all the ordeal we endured.The Hospital case Management got in contact with us .They sent letters ,they tried to smooth what had happened they wanted probably back clock the time so I would experience a different delivery but they were wasted we never replied .After all what the intention??? .My poor husband ,I recall painfully ,burst the moment our boy was born .But there were not tears of joy only there were : sadness ,regret,soreness,and unswallowed anger .I could see the sorrow in his eyes .We did not sign for it .Thankfully my boy came out unharmed.It was an expedited delivery .5 hours and done .God was assisting and probably decided it was the best way ….Post partum depression settled in for 5 years and When we got pregnant again we felt the veil would left off .The time was coming for us to heal and that happened .The Doctor I found could not be selected more exquisitely …He kissed and sang for my second baby boy as soon as he was born .He hugged us and cheered with us as it were his .I did well after my second birth .I enjoyed it as should be.That reminds me there is no pain that last forever and YES to recover from trauma after obstetric violence is harsh but possible.
It’s important to distinguish birth trauma…which is PTSD that occurs because of events during labour and childhood abuse which can affect how a woman experiences labour.
Healing form childhood trauma can be helped by having a safe birth with choices respected. Healing from birth trauma requires a different kind of support to heal.
Thank you thank you thank you! This is a such a beautifully written, intelligent piece shiNing light on a topic that has been hidden away for too long. I am so grateful for the work you and IB are doing.
Thank you for this post. I thought I was ‘over it’. I can see that I am not. The anxiety, numbness, pit-of-the-stomach terror is right THERE as I read your post, and It has been almost 30 years since the traumatic birth of my wonderful, beautiful, brilliant daughter. At the time, I tried to get someone to listen to me about what happened. I kept hearing “At least you have a healthy baby!” and many other words meant to comfort me, but they only served to enrage me and THAT was not acceptable, especially from someone with such an adorable baby! To add to my trauma, I woke during the ’emergency’ c-section, yet I was paralyzed and could not alert anyone to the fact that I was, in fact, PRESENT in the room. It wasn’t until a nurse saw my eyes trying to open despite being taped and my face flushed red (she asked if that was ‘normal for someone who was out’. I clearly remember those words.) that anyone knew I was distressed. Then I was given a huge dose of something that stopped my heart and ‘killed’ me. I woke to shouting, feeling like I had been body slammed. In the recovery room they told my husband that “the medication we gave her can make her believe those things happened, but she had a very normal, uneventful birth.” Who is he going to believe, the medical team or a traumatized weeping hospital patient? I went on to have a ‘failed VBAC’ and never dared to get pregnant again, even though it had always been my desire to have a big family. I was on the founding board of an ICAN – International Cesarean Awareness Network in the county I lived in after my son was born. I had to do SOMETHING to safeguard other women from becoming victims of the C-Section culture in hospitals in the late 80s. Please keep up this important work to Educate women that they are not sick, that they don’t need a doctor to give birth, they are Pregnant and their bodies know exactly what to do. Only by talking about our experiences, Woman to Woman, can we ever hope to bring about change.
As a childbirth educator, I see this scenario all too often. Too many women come out of birth less than they were before. They feel defeated and out of control. This should not be the case. Much of this trauma is preventable.
Thank you for also highlighting the secondary trauma suffered by doulas and nurses. We also need to remember that fathers and partners can experience trauma as well.
I had a very rude midwife with my first (I’m in UK so midwives are standard in hospitals). She at first refused to admit me to the hospital… Instead told me to “walk it off”. How do you walk off labour???
Next she left me in the wards (only seperate delivery rooms in that hospital) for 12 hours. She was incredibly rough when checking dialation (she wouldn’t put me in a delivery room without it.) Said I was 8cm and why didnt I get her earlier. She still dragged her feet moving me, that by the time I got into my delivery room I was ready to push. When my son didn’t come out within 15 minutes she took out those giant scissors to make an epsitomy (my birth plan said I wanted to tear naturally) and freaked me out so much my son was out in one push. I was later told I only tore as I rushed it.
Once my son was born, I had maybe 30 seconds of skin to skin before she used her freezing hands to grab my naked son causing him to scream. My husband tore her a new one and took him from her causing my son to have the initial bond with daddy and I think a reason as to why breastfeeding failed. (And to this day 20months on prefers daddy). As we were waiting for the placenta she was getting a needle ready. I asked what it was. “Oh nothing”. I was in my just had a baby stupor so didn’t really think. Turns out it was a injection to speed up the placenta which she knew I didn’t want. I worked it out when she jabbed me in the leg and said “there we go, should be out in a minute.”
Once everything was done we were shoved out of the delivery room. Had to find our own way to the post baby ward (well we did ask another midwife who escorted us there) I was only 20mimutes post baby. And couldn’t stand. Also I forgot to mention she kept trying to shove painkillers. And gas and air which I knew I had a bad reaction to but she didn’t care.
When I fell pregnant 2ish months postbaby I cried. I had a full out panic attack. Even my husband reacted badly. Our daughter was much better however as I laboured at home for 4hours and I was only at the hospital for 6 minutes and one push, and much nicer midwife. Got to stay in delivery room for 2 hours after having her. They are 10months 3 weeks apart and they are amazing kids. But our sons birth still effects me. “At least you didn’t have a c sec” has been said to me… Probably would have been less traumatic if I did! Only downside to daughters birth was my husband wasn’t there as he had to look after our son.
Apologies for the novel.
also CES certified per direct Penny Simkin classes!
L/D nurse for 50 years that believes in families having wonderful birth experieces
Thank you SO much for posting this. I spent roughly three years in therapy dealing with PTSD due to being severely neglected while I was in labor, then, had a very traumatic birth and aftermath. I lived for fifteen months with an obstetric fistula, and genuinely saw no end to my pain, mentally and emotionally. I’ve never felt more alone, hopeless, and alienated than I did during what should’ve been the happiest time in my life.
Nothing rakes my grates more than hearing, “at least you have a healthy baby.” Of course I was thrilled my daughter was healthy! I was thankful she was healthy. I wasn’t. I was falling apart. I had flashbacks that paralyzed me with fear. I was terrified to leave my house, for fear of having an “accident” with my fistula. There were no resources for help for women living in the developed world with fistulas, because everywhere you turned seeking support or help, all you found was “obstetric fistula has been eradicated in the developed world due to proper obstetric care such as cesarean sections.” Bullshit.
In April of 2010 I founded a support group for women in the developed world living with obstetric fistula, knowing I couldn’t be the only one out there. I wasn’t. In four years, we’ve had over 400 women in our group. I hate to think how many more of us there are that aren’t able to find us, needing help and support.
Having an obstetric fistula is the ULTIMATE in birth trauma. As if it’s not bad enough going through what many of us do, with neglect, and traumatic deliveries, the fistula is the icing on the cake. The daily reminder of the birth gone wrong. As long as you have that fistula, you can’t let go of the trauma. Even with therapy. Even with your coping skills, reading your therapy books, doing your “homework”, and power of positive thinking, it doesn’t go away. It’s there with you.
I’ve been healed four years this year on May 12th. Just yesterday, in the nail salon, I was triggered. Had I not had my feet soaking in a pedicure “tub”, I would’ve RUN outside to light up a cigarette. An older woman was asking one of the manicurist about her baby, and birth experience. She made a comment about how “you forget the pain of childbirth”, and “once you look down at that little baby, it all goes away”. No. Not for some people. For some of us, it never goes away. For some of us, we learned how to cope. For some of us, we’ll never, EVER forget that pain. We’ll never forget how we truly believed we and our child were going to die. We’ll never forget that our babies weren’t breathing, and that they were jerked from our arms to be taken immediately to the NICU.
We will never forget. We simply cope.
This is a link to my story. I will warn those who are sensitive, this is graphic, and may be very emotional. EDITED: Link to story < http://rebornin2010.blogspot.com/>
Thank you very much for this very true and necessary article! I experienced abuse in the pregnancy and birth of my first child. I received mis-information and was stripped of my dignity and autonomy, just as described in your article. Nobody listened to me. The birth was an unnecessary c-section that I was bullied into and the hospital stay after the birth, with my son and I being separated from each other, me in the maternity ward, he in the children’s clinic, was very traumatic, too.
I later became a midwife myself and during the three years of training in a hospital setting experienced the secondary traumatic stress you described, because of watching abuse and feeling so very helpless about it. In addition to that I was bullied by midwives, nurses and doctors who were supposed to train me. These were the worst three years of my whole life.
Since then I have helped many women give birth peacefully, with respect, dignity, autonomy and love in their own homes. Whenever I have to transfer somebody to a hospital, it depends, though, what kind of care they will receive. Sometimes they are treated well and respectfully, but more often not and there is only so and so much I can do about it, because in case of a transfer the woman needs medical help. But why does the medical help so often come as part of an inseparable package married with misinformation, disrespect, abuse? We really need to change this!!!
My own second birth was a homebirth VBAC. I made sure the midwife knew not to touch me or do anything to me. She just stayed in the background in case I needed her, which I did not. I just wanted to and did give birth on my own, in peace, autonomously, and all was fine.
Thank you Penny! Your compassion and tireless advocacy in this area is such an inspiration! We will be releasing a birth trauma tool kit soon and PATTCh is highly referenced there, as it is such a valuable resource. We will definitely let you know when it is published.
Thank you for this valuable article, and for Improving Birth’s Summer 2014 Campaign to Break the Silence surrounding traumatic birth and its often devastating aftermath. I’d like to invite readers to visit http://www.PATTCh.org, the website for Prevention and Treatment of Traumatic Childbirth. Please note the two letters Ts in PATTCh. There are valuable articles there, and more to come.
Approximately one million women per year (and countless numbers of their partners) are traumatized during birth. I welcome this spotlight on a devastating public health issue.