Published on Birth Trauma Ontario November 11, 2018
It Begins with a Mistrustful Client
Photo Martin Walls freeimages.com
It’s frustrating for care providers when their client comes armed with a 10-page birth plan, an army of doulas, and a mistrustful and hostile attitude. Care providers exist for the sole purpose of providing medical or midwifery services for pregnant, birthing, and postpartum clients and their goal is to help them emerge healthy and whole. Unfortunately, this creates friction before the relationship begins.
A mistrustful client has probably already had her trust broken by someone else long before they come armed with the minute details of how they need things to unfold. They may have already experienced abuse, neglect, sexual assault, victimisation, and trauma. Their trauma might have been the result of an abusive childhood, racial adversity, marginalisation, being the victim of a crime, or it might have been the result of a previous traumatic birth experience.
Birth Trauma Changes the Individual
Birth trauma doesn’t just happen. It’s not connected to an emergency or an unexpected outcome. These parents are not looking for someone to blame. Birth trauma is the result of clearly defined factors where the greatest indicator is a breakdown in the relationship between the care providers and the client (Harris & Ayers, 2012). The birthing mother felt disrespected, lied to, coerced, bullied, ignored, unsupported, and like she was just another cog in the wheel (Beck 2004; Reed, Reed, Sharman & Inglis, 2017). When this is partnered with pre-existing risk factors, this individual is at risk for developing postpartum post-traumatic stress disorder (Wu, Molteni, Ying, & Gomez-Pinilla, 2003; Faravelli, Giugni, Salvatori, & Ricca, 2004; Fromm, Heath, Vink, & Nimmo, 2004; Cortina &Kubiak, 2006; Eby & Eby, 2006; Sarandol et al., 2007; Lev-Wiesel, Chen, Daphna-Tekoah, & Hod, 2009; Roberts, Austin, Corliss, Vandermorris, & Koenen, 2010; Beck, Gable, Sakala, & Declercq, 2011; Cisternas et al., 2015; Matsumura et al., 2016; Du et al., 2016).
When parents have had a traumatic birth (about one third of all parents), they are much less likely to have another child, even if they wanted a larger family. In fact, they are twice as likely to not have another baby as someone who had a positive experience. If they choose to have another baby, the spacing between babies is twice as long as someone who had a positive experience. It takes them a much longer time to work up to doing it again (Gottvall & Waldenström, 2002).
Birthing after a traumatic experience is very different than preparing to birth a first child or another baby after a positive experience. These mothers are likely still dealing with the symptoms of trauma – flashbacks, sleep disturbances, terror, rage, difficulty forming new memories, hyperarousal always being on guard, and avoidance of triggers – including care providers and hospitals. These mothers are also more likely to be dealing with depression, anxiety, changes in their functional capacity, and suicidal thoughts than mothers without trauma. (DSM-5, 2013; Brady, Killeen, Brewerton, & Lucerini, 2000; Cook et al., 2004; Tavares et al., 2012).
When a Parent-of-Trauma Gets Pregnant Again
When a woman has had a traumatic birth and may still be suffering the effects of trauma, a new pregnancy can be a profoundly challenging time for her. She must now come face-to-face with the possibility that she will possibly endure the same horror in order to welcome this child into the world. Feelings of desperation, despair, fear, terror, and suicidal thoughts are not uncommon. Thoughts of running away and birthing alone in the woods are also common. This dread often interferes with bonding to her baby. (Beck & Watson, 2010)
The healthcare and birthing choices these parents make for subsequent births can be quite varied and diverse. Some might choose the same provider and location simply because it’s familiar and they know what’s coming. They know that they survived it the first time, and therefore can survive it again.
They might plan a caesarean section to gain the most control over the event. This way they can choose the surgeon, the day, and their support team. They won’t be facing the unknowns of whichever provider is on call.
If a mother chooses a vaginal birth, its very common for them to hire a doula as an advocate, to change providers, hospitals, plan a homebirth, or even birth in another city.
Unassisted Birth Choices
Freebirth, unassisted birth, or family birth, where there is no licensed medical attendant present, is a choice that is appearing more frequently in many developed countries (Holton & de Miranda, 2016). It’s a choice that is more common among parents who are birthing after trauma. Unassisted birth choices speak to the resistance that can be a response to the biomedical model of birth. Some families are finding that the obstetrical and midwifery model of risk-aversion and risk management removes their autonomy, and violates their culture, values, faith, or at times, their sexuality. If a mother has received disrespectful care, then they are more likely to avoid these services for subsequent pregnancies (UNPA, 2004). In an online survey of families that chose an unassisted birth, over half identified a previous negative hospital experience as the reason for their choice (O’Day, 2016). While there is no licensed medical attendant present, an unassisted birth may include the support of family members, doulas, traditional birth attendants, or other companions.
No matter what the mother-of-trauma chooses, she is disadvantaged because she can’t control for the behaviour of others in the medical system that don’t understand or respect her trauma or her perspective. Even the mother who chooses an unassisted birth may still be persecuted by hostile services if she transfers to the hospital for medical care (Vedam et al., 2017). Many a mother seeking medical support is “welcomed” by a harassing call to child protective services to investigate whether she is “conforming” to conventional medical services (Diaz-Tello, 2016). Online forums are filled with discussions on how to manage a possible trip to the hospital or doctor and how to prepare for a potentially harassing call to Childrens Aid Society (CAS), including sharing contact information for advocates and legal services. Indeed, misinformed providers are participating in this spiraling disconnect between clients and needed healthcare services.
Inappropriate Responses to Unconventional Choices
Providers will note that some of their clients decline the usual suite of obstetrical or midwifery services. For some clients, it’s an evidence-based decision. And for others, they are trying to avoid triggering their symptoms of trauma (Beck & Watson, 2010). Again, ill-equipped providers have been known to report these mothers to CAS, thinking that their health care choices are dangerous to the fetus. These are potentially well-meaning individuals, but have violated their professional ethics, as they cannot induce duress, bullying, or coercion to gain compliance (Health Care Consent Act, 1996). Further, the fetus has no citizenship and investigation by CAS regarding a fetus would be tantamount to harassment. However, this is one more obstacle that mothers-of-trauma often must navigate as they disentangle themselves from disrespectful care.
The consequence of these inappropriate actions from care providers is that mothers-of trauma will often decline further medical services for their babies once they are born, or to seek follow-up care or breastfeeding support (Finlayson & Downe, 2013; Moyer, Adongo, Aborigo, Hodgson, & Engmann, 2014). While pregnant, they may lie about their plans, their health, and other pertinent information, thereby missing an opportunity to form a collaborative relationship that could build lifetime wellness and resilience. They may choose to birth their babies without assistance and then tell their care provider that it just happened “too quickly”. This is ongoing evidence of the breakdown in the relationship between client and clinician.
Where Doulas Can Help
Doulas are the client’s and the clinician’s greatest ally as they generally develop the trust of the pregnant family and offer to serve as their advocate. Doulas can have a significant impact on the client’s outcome by reducing the need for surgery, assisted delivery, analgesia, and contributing to the reduction in low Apgars for the baby, and postpartum depression for the mother (Bohren, Hofmeyr, Sakala, Fukuzawa, & Cuthbert, 2017). Without the risk of reporting a non-compliant client, it is the doula that is privy to the client’s previous traumatic experience, the client’s coping strategies, and the wellbeing of the family. The doula has the opportunity to connect the client to resources in their community or to serve as a companion at medical visits. The rise of the doula to support families is indicative of a system that routinely denies birthing individuals informed choice, dignified care, and trauma-informed care (Dahlen, Jackson, & Stevens, 2011). Unfortunately, the burnout rate for doulas is very high due to vicarious trauma and institutional hostility (Naiman-Sessions, Henley, & Roth, 2017), meaning that experienced doulas are hard to find and it’s nearly impossible to foster their growth within the current medical paradigm.
© Billie Harrigan Consulting
Preparing to Birth After Trauma
When preparing to birth after trauma, the pregnant mother will often engage in a number of strategies that might seem excessive to someone who had a positive experience or to the provider who is not trauma-informed (Beck & Watson, 2010; Harrigan, 2017). These strategies can include:
Detailed, extensive, and lengthy birth plans
Hiring a doula
Doing extensive research into providers, locations, routines, and unassisted birth
Avoiding the usual suite of maternity services, such as ultrasound or scheduled prenatal visits
Doing birth art
Writing positive affirmations
Choosing complementary medicine to address health issues
Joining with other parents to learn more about birth, including how to have a breech baby, neonatal resuscitation, pre-eclampsia, etc.
Birth Plans – A Trauma Narrative in Disguise
Lengthy birth plans are generally the client’s attempt at communicating with their care team. It often represents their trauma narrative and is the care provider’s window into their client’s suffering that has brought them to this place. As a form of communication, however, it’s quite ineffective as far too many institutional cultures regard the birth plan as a joke where the longer the birth plan, the sooner she’s booked into the OR for a caesarean. Further, it has no impact on the care provider’s behaviour towards the client and may increase the client’s negative feelings about their birth (Berg, Lundgren, & Lindmark, 2003).
The client-of-trauma is again disadvantaged in trying to garner empathetic care in light of institutional hostility towards various modes of communication, including a birth plan, the use of a doula, self-advocacy, or the inclusion of other advocates. Attempts on the part of the client to change institutional culture are wholly ineffective if the entire facility isn’t addressing entrenched biases (Betrán et al., 2018).
It Begins with an Empathetic Trauma-Informed Care Provider
Photo credit: http://www.thefirsthelloproject.com
Birthing after trauma sometimes feels like a herculean feat for the mother where she is taken on a roller coaster of fear, despair, opposition, obstacles, institutional hostility, ill-equipped care providers, and unfortunately thoughts of suicide.
Yet, there is great hope. As more care providers become trauma-informed and institutions develop appropriate practices to support the client-of-trauma and develop a collaborative and respectful culture, the client can emerge with greater wellness, increased resilience, and growing trust. When a woman has a subsequent birth that fuels her post-traumatic growth, she credits the caring support of her care providers as a crucial element (Beck, 2010)
Nothing compares to the gift of a healing care provider.
Much love,
Mother Billie
References:
Beck, C. T. (2004). Birth trauma: in the eye of the beholder. Nursing Research, 53(1), 28-35.
Beck, C. T., & Watson, S. (2010). Subsequent childbirth after a previous traumatic birth. Nursing research, 59(4), 241-249.
Beck, C. T., Gable, R. K., Sakala, C., & Declercq, E. R. (2011). Posttraumatic stress disorder in new mothers: Results from a two‐stage US National Survey. Birth, 38(3), 216-227.
Berg, M., Lundgren, I., Lindmark G. (2003). Childbirth experience in women at risk: Is it improved by a birth plan? Journal of Perinatal Education. 12(2):1–15.
Betrán, A. P., Temmerman, M., Kingdon, C., Mohiddin, A., Opiyo, N., Torloni, M. R., ... & Downe, S. (2018). Interventions to reduce unnecessary caesarean sections in healthy women and babies. The Lancet, 392(10155), 1358-1368.
Bohren, M. A., Hofmeyr, G. J., Sakala, C., Fukuzawa, R. K., & Cuthbert, A. (2017). Continuous support for women during childbirth. The Cochrane Library.
Brady, K. T., Killeen, T. K., Brewerton, T., & Lucerini, S. (2000). Comorbidity of psychiatric disorders and posttraumatic stress disorder. Journal of Clinical Psychiatry,61, 22-32.
Cisternas, P., Salazar, P., Serrano, F. G., Montecinos-Oliva, C., Arredondo, S. B., Varela-Nallar, L., ... & Inestrosa, N. C. (2015). Fructose consumption reduces hippocampal synaptic plasticity underlying cognitive performance. Biochimica et Biophysica Acta (BBA)-Molecular Basis of Disease,1852(11), 2379-2390.
Cortina, L. M., & Kubiak, S. P. (2006). Gender and posttraumatic stress: sexual violence as an explanation for women's increased risk. Journal of abnormal psychology, 115(4), 753.
Cook, C. A. L., Flick, L. H., Homan, S. M., Campbell, C., McSweeney, M., & Gallagher, M. E. (2004). Posttraumatic stress disorder in pregnancy: prevalence, risk factors, and treatment. Obstetrics & Gynecology, 103(4), 710-717.
Coxon, K., Homer, C., Bisits, A., Sandall, J., & Bick, D. (2016). Reconceptualising risk in childbirth. Midwifery, 38, 1-5.
Dahlen, H. G., Jackson, M., & Stevens, J. (2011). Homebirth, freebirth and doulas: casualty and consequences of a broken maternity system. Women and Birth, 24(1), 47-50.
Diagnostic and Statistical Manual of Mental Disorders (DSM-5) American Psychiatric Assoc Pub; 5 edition(May 22 2013).
Diaz-Tello, F. (2016). Invisible wounds: obstetric violence in the United States. Reproductive Health Matters.
Du, J., Zhu, M., Bao, H., Li, B., Dong, Y., Xiao, C., ... & Vitiello, B. (2016). The role of nutrients in protecting mitochondrial function and neurotransmitter signaling: implications for the treatment of depression, PTSD, and suicidal behaviors. Critical reviews in food science and nutrition, 56(15), 2560-2578.
Eby, G. A., & Eby, K. L. (2006). Rapid recovery from major depression using magnesium treatment. Medical hypotheses, 67(2), 362-370.
Faravelli, C., Giugni, A., Salvatori, S., & Ricca, V. (2004). Psychopathology after rape. American Journal of Psychiatry, 161(8), 1483-1485.
Finlayson, K., & Downe, S. (2013). Why do women not use antenatal services in low-and middle-income countries? A meta-synthesis of qualitative studies. PLoS medicine, 10(1), e1001373.
Fromm, L., Heath, D. L., Vink, R., & Nimmo, A. J. (2004). Magnesium attenuates post-traumatic depression/anxiety following diffuse traumatic brain injury in rats. Journal of the American College of Nutrition, 23(5), 529S-533S.
Gottvall, K., & Waldenström, U. (2002). Does a traumatic birth experience have an impact on future reproduction?. BJOG: An International Journal of Obstetrics & Gynaecology,109(3), 254-260.
Harrigan, Billie. (2017). The Epic Failure of the Evidence-Based Movement. https://www.billieharrigan.com/blog/2017/1/16/the-epic-failure-of-the-evidence-based-movement.
Harris, R., & Ayers, S. (2012). What makes labour and birth traumatic? A survey of intrapartum ‘hotspots’. Psychology & Health, 27(10), 1166-1177.
Health Care Consent Act, 1996, S.O. 1996, c. 2, Sched. A
Holten, L., & de Miranda, E. (2016). Women׳s motivations for having unassisted childbirth or high-risk homebirth: An exploration of the literature on ‘birthing outside the system’. Midwifery.
Lev-Wiesel, R., Chen, R., Daphna-Tekoah, S., & Hod, M. (2009). Past traumatic events: are they a risk factor for high-risk pregnancy, delivery complications, and postpartum posttraumatic symptoms?. Journal of Women's Health, 18(1), 119-125.
Matsumura, K., Noguchi, H., Nishi, D., Hamazaki, K., Hamazaki, T., & Matsuoka, Y. J. (2016). Effects of omega-3 polyunsaturated fatty acids on psychophysiological symptoms of post-traumatic stress disorder in accident survivors: a randomized, double-blind, placebo-controlled trial. Journal of affective disorders.
Moyer, C. A., Adongo, P. B., Aborigo, R. A., Hodgson, A., & Engmann, C. M. (2014). ‘They treat you like you are not a human being’: maltreatment during labour and delivery in rural northern Ghana. Midwifery, 30(2), 262-268.
Naiman-Sessions, M., Henley, M. M., & Roth, L. M. (2017). Bearing the Burden of Care: Emotional Burnout Among Maternity Support Workers. In Health and Health Care Concerns Among Women and Racial and Ethnic Minorities (pp. 99-125). Emerald Publishing Limited.
O’Day, Katharine, L, "Outside the System": Motivations and Outcomes of Unassisted Childbirth. Transitions Midwifery Institute, Published online November 19, 2016.
Reed, R., Sharman, R., & Inglis, C. (2017). Women’s descriptions of childbirth trauma relating to care provider actions and interactions. BMC pregnancy and childbirth, 17(1), 21.
Roberts, A. L., Austin, S. B., Corliss, H. L., Vandermorris, A. K., & Koenen, K. C. (2010). Pervasive trauma exposure among US sexual orientation minority adults and risk of posttraumatic stress disorder. American Journal of Public Health, 100(12), 2433-2441.
Sarandol, A., Sarandol, E., Eker, S. S., Erdinc, S., Vatansever, E., & Kirli, S. (2007). Major depressive disorder is accompanied with oxidative stress: short‐term antidepressant treatment does not alter oxidative–antioxidative systems. Human Psychopharmacology: Clinical and Experimental, 22(2), 67-73.
Tavares, D., Quevedo, L., Jansen, K., Souza, L., Pinheiro, R., & Silva, R. (2012). Prevalence of suicide risk and comorbidities in postpartum women in Pelotas. Revista Brasileira de Psiquiatria, 34(3), 270-276.
United Nations Population Fund. (2004) in: UNFPA (Ed.) State of the World Population 2004. UNFPA, New York.
Vedam, S., Stoll, K., Rubashkin, N., Martin, K., Miller-Vedam, Z., Hayes-Klein, H., & Jolicoeur, G. (2017). The mothers on respect (MOR) index: measuring quality, safety, and human rights in childbirth. SSM-population health, 3, 201-210.
Wu, A., Molteni, R., Ying, Z., & Gomez-Pinilla, F. (2003). A saturated-fat diet aggravates the outcome of traumatic brain injury on hippocampal plasticity and cognitive function by reducing brain-derived neurotrophic factor. Neuroscience, 119(2), 365-375.