Post traumatic stress disorder (PTSD) is something we associate with soldiers and emergency workers.
It’s not something we think can happen after birth.
Giving birth is meant to be one of life’s most important events.
Yet for many, birth isn’t the wonderful experience it should be.
How Common Is PTSD After Birth?
Among those who have experienced (PTSD) related to birth are mothers, fathers and even birth workers such as midwives.
There’s something incredibly wrong with this situation.
Birth trauma and birth related PTSD are increasing problems for childbearing women, their families, and the people who support them during birth.
Birth related PTSD has the power to devastate the lives and emotional health of everyone affected.
What Is Birth Related PTSD?
Trauma is used to describe a serious injury or damage, which can be physical or psychological.
PTSD covers a number of symptoms or reactions that can develop after someone has experienced or witnessed a traumatic event.
In the case of birth related PTSD, the traumatic event centres upon something that happens during childbirth.
Birth trauma usually brings to mind the idea of physical injury following birth. This can indeed lead to a woman experiencing PTSD, as evidenced in recent Australian research. Many physical birth injuries are underdiagnosed and left untreated, leading women to live with devastating pelvic floor problems such as prolapse and urinary/fecal incontinence.
Psychological trauma can occur where there is a huge disparity between expectations and the reality of birth. It can result from feeling a lack of control or a loss of autonomy, from having no voice, from experiencing lack of support, or hostility, and from perceived threats of danger.
It’s very important to understand severe emotional distress can happen after a traumatic birth, whether or not there have been physical birth injuries. It is about each person’s experience and there is no checklist which must be ticked in order for birth trauma to be experienced.
Risk factors associated with developing PTSD include: previous trauma; having mental health problems, or relatives with mental health problems, such as depression; substance abuse; and working in an environment with exposure to trauma.
If you were to experience PTSD, you might:
- Be overly alert. This interferes with sleep, and can make you irritable or unable to concentrate. You might have an exaggerated ‘fight or flight’ response, being constantly aware of potential dangers, constantly worrying or feeling fearful.
- Relive the traumatic event. This could happen during nightmares, or in the form of unwanted or recurring memories, flashbacks, or talking about the experience. It can produce a physical and emotional response, such as heart racing, panic attacks, sweating or feeling physically sick.
- Display avoidance behaviour. You actively avoid any reminders – places, people or thoughts that are associated with the traumatic event.
- Feel numb. You are emotionally flat, and unable to engage with other people. You feel detached from your life, family and friends
Who Is Affected By Birth Related PTSD?
Until recently, birth trauma and related PTSD were not widely understood or studied. Research is now showing these are very real and growing problems. Birth related PTSD affects not only birthing mothers, but also their partners and even birth workers.
Birth trauma can affect anyone but not every person will develop PTSD after a traumatic birth event.
Those who experience PTSD are often completely unprepared for the possibility of trauma. Their brains are unable to process the event because it violates their expectations, and they are stuck in a state of fear and shock.
This can be explained using two contrasting situations.
A woman might discover, during pregnancy, there is a medical complication that means her baby needs to be taken to NICU straight after birth. She is prepared for what will happen. She has discussed it with her care providers, and has possibly even visited and met the staff who will care for her baby.
Although this event might be traumatic for her, she is not expecting anything else. She doesn’t develop PTSD.
On the other hand, a woman who plans for a normal, vaginal birth and ends up having multiple interventions resulting in a c-section might well feel traumatised. She might also experience PTSD. Her birth felt out of control, she had no voice, and she might have had multiple staff caring for her and felt unsupported. She was expecting one thing and her experience was completely unrelated to that expectation.
According to the charity Prevention and Treatment of Traumatic Childbirth (PATTCh), around 30% of US births are traumatic for mothers.
In the UK, the Birth Trauma Association estimates up to 20,000 women a year develop PTSD following a traumatic event.
Research from Australia suggests around 33% of women experience a traumatic birth and 6% develop PTSD as a result.
Men can also be affected by birth trauma. Partners often witness events for which they are simply unprepared. Staff might be too busy or unavailable to explain what has happened or is happening. Partners are often left to deal with their feelings without an understanding of what is happening, the support to deal with it, or recognition of how it has affected them.
Because of a lack of awareness in this area, most men simply try to carry on and rarely seek help for the anxiety, depression or anger they experience after witnessing a traumatic birth event. Our social expectation of men is that they bury their feelings and ‘get on with it’; this means they often don’t get the help they need.
We don’t really know how many men suffer from PTSD. According to the UK’s National Childbirth Trust, 1 in 3 new fathers said they were concerned about their mental health, with 1 in 10 getting a diagnosis.
A 2014 study of ten male partners who witnessed serious birth complications suggests men are very likely to develop PTSD after birth trauma.
Parents of premature babies are also at an increased risk for developing PTSD. Their baby’s early arrival might be completely unexpected, and the aftermath of uncertainty about their baby’s survival and health compounds the trauma.
The experience and the isolation involved in parenting a premature baby in an unfamiliar environment like a NICU are things no parent can be prepared for.
Birth workers can also feel traumatised by events that occur in the workplace. Research from Australia shows almost 20% of midwives meet the criteria for PTSD. The study found almost 70% of midwives reported witnessing traumatic birth events, including injury, death, abusive treatment by other care providers, or lack of sensitive care.
Around 75% of midwives felt horror and 65% felt guilt about what happened to women in a traumatic birth. Midwives who witnessed abusive treatment from other health professionals were significantly more likely to experience severe post traumatic stress than other types of trauma.
In the UK, ongoing research shows around 5% of midwives have PTSD – higher levels than those found in the UK armed forces who deployed to Afghanistan in 2010 and 2011. Researchers sent postal surveys to 2,800 midwives, asking whether they had experienced a traumatic birth event and what impact this had on their life and work.
Of the 464 respondents, 421 had experienced a traumatic event, with an average of seven events per career in midwifery. The impact on life and work was predominately negative, varying from ‘nightmares, hearing screaming in my sleep’, and ‘constantly worrying about my care’ to ‘practising more defensively, which sometimes obscured my own professional judgement’.
Midwives are trained in normal labour and birth, so they do not have the expectation that birth should be traumatic. How likely, then, are they to be traumatised when they experience such high rates of interventions and active management, especially of low risk women?
Obstetricians are specialists in high risk pregnancies and therefore are more likely to expect a medically traumatic birth and be more prepared for its occurrence.
Why Does PTSD Happen?
As discussed above, PTSD has a set of risk factors associated with it. Some people are more likely to develop PTSD because of those risk factors if they experience some kind of birth trauma.
But isn’t birth sort of traumatic anyway?
Modern society generally sees birth as a highly medicalised event – something to fear and definitely not something to look forward to or even to enjoy.
Women are encouraged to birth in hospitals with all the modern technology standing by ‘just in case’. Yet this very attitude leads to more women experiencing birth trauma and fewer women having a normal birth experience.
Birth in hospital became the norm last century, at about the time women started to have very medicalised births, thanks to the advent of pain-reducing childbirth anaesthesia. Midwifery took a backseat to obstetric care and during the next one hundred years, specialists in pregnancy and birth complications set the tone.
Birth isn’t risk free, and sometimes things will go wrong. But the risk is incredibly small, particularly when a woman has a known care provider through her pregnancy and birth.
A difficult birth should not lead to mental health problems. About one in every five women experiences mental health problems after birth; this study found 9% of new mothers experience suicidal thoughts.
Women who birth in obstetric settings (hospitals) are engaging in risk avoidance models of care. This approach to maternity care interferes with normal birth from the beginning, starting with fear and ending with trauma. There is little continuity of care and a higher risk of interventions.
Women are also not prepared to see birth as a normal, positive experience. Anxiety and fear play a huge part in the way a woman chooses her care provider, her expectations of birth and her active involvement in choices about her care.
Women are prepared either to believe interventions and trauma are part of the process of birth, or to believe ‘it won’t happen to me’.
It’s estimated 97% of women who birth in Australian hospitals have some form of intervention, ranging from an unnecessary vaginal exam to a c-section. Given less than 2% of babies are born out of hospital, that is a lot of interventions. That is a lot of normalised interventions.
Although vaginal exams don’t seem like a big deal, they aren’t a necessary part of birth care. Electronic fetal monitoring might seem completely harmless at the time, but research shows it significantly increases the risk of having a c-section while having no evidence base for its routine use. Different staff popping in and out during labour might not seem to be a problem, even though we know there are huge benefits of care in having a known support person.
Most women don’t believe it can happen to them, or think the cascade of interventions will happen. They don’t really understand how important continuity of care is until they don’t have it.
Why Is Birth Related PTSD So Hidden?
The main reason we don’t know much about birth trauma and PTSD is lack of awareness and resources.
Women might seek help from their local doctor, who is primarily geared toward postnatal blues and depression. In general, if both mother and baby are alive and healthy, most people assume the birth was ‘fine’ and unrelated to any mental health problems. This leads to women being misdiagnosed with postnatal depression, when PTSD is the more appropriate answer.
Partners, particularly men, are very reluctant to seek help for mental health problems. It’s not uncommon for them to avoid at all costs being seen as weak or not coping; this can have a huge impact on their ability to cope with the very real symptoms of PTSD.
Birth workers who experience PTSD due to traumatic events are reluctant to talk about their experiences for fear of being seen as incompetent or incapable of doing their job. It’s not surprising many midwives burn out and leave the profession, particularly given the disparity between their training and the real world experience of a busy maternity ward.
How Do We Reduce The Risk Of Birth Related PTSD?
Changing the fundamental way maternity care is provided is key. There is a great deal of research available showing the benefits of midwifery led models of care, but accessibility is very limited in many places.
Research shows women who have good care and support from their care providers are less likely to experience PTSD. Having a trusted support person, such as a doula, who understands you and what you want, can help you to feel listened to and validated.
We have to be realistic about birth in obstetric settings, whether that is the local public hospital maternity ward or the private hospital birth suite with the attached ensuite. Birth environment and birth attendants matter – they are key components in birth outcomes.
Believing it won’t happen to you won’t stop it from happening. We also need to change the culture of fear around birth. Believing it will happen to you leaves you open to fear-based decisions.
Educating yourself on everything about birth makes you a powerful driver of your birth outcome. If you and your partner are informed, you are more prepared to roll with the punches and take on the changes if they come. Having rigid expectations of what birth will be like leaves you at risk of trauma if things don’t go the way you expect.
Find a good quality birth education option such as BellyBelly’s Birth & Early Parenting Immersion, which can prepare you and your partner, showing you what to look for to maximise your chances of a positive birth experience and reduce the risk of a traumatic birth that might lead to PTSD.