Why are women traumatized during childbirth in such great numbers?  The reasons have a lot to do with the unnecessarily high rate of medical interventions during childbirth these days (1) (see Facts) and the inappropriate and sometimes even abusive behaviors of health care providers who follow hospital protocols developed to serve the hospital's interests, often to the detriment of the birthing woman's welfare.  

High rate of unnecessary medical interventions

Being subjected to a high number of medical interventions while giving birth is one of the main factors leading to maternal psychological trauma and PTSD (2).  There are many interventions, such as emergency C-section, forceps or vacuum delivery, induction of labour, and manual removal of the placenta, that are highly traumatic, both physiologically and psychologically.  In practice, they always go hand in hand with multiple other interventions, such as electronic fetal monitoring (EFM), intravenous drugs and catheters. The outcome is often a stunned, traumatized mother who feels that the baby was literally "yanked out of her", while she played little or no role in the actual birth.


The vast majority of interventions are not only unnecessary but can be harmful to the mother and the baby, although health care practitioners may not be aware of this (3). For example, membrane sweep is routinely done in pregnancy as the woman reaches or passes her due date.  Health care practitioners wrongly believe that it causes labour to begin by releasing prostaglandins.  Research, however, shows that it does not increase the chance of labour beginning spontaneously, but can lead to premature rupture of membranes, making it necessary for labor to be induced (4).


Membrane sweep is one example of an unnecessary, invasive procedure that can lead to harmful consequences (membrane rupture exposes the fetus to infections and labour induction is a major intervention that has adverse health consequences on both mother and baby).  But even those interventions that may appear to be necessary and "life-saving", such as an emergency C-section, are more often than not unnecessary in the sense that they are easily avoidable.  For example, in North America these days, including Canada, approximately one of every three babies (33%) is born by C-section.  Other countries, however, have a much lower C-section rate wtih the same maternal and fetal health outcomes.  For example, Norway has a 16% C-section rate, showing that the high rate of C-section performed in Canada is unnecessary (see Facts for more details).

Unsupportive or abusive birth environment

The other main factor that can lead to birth trauma is the mother's exposure to an unsupportive or abusive birthing environment (2).  The hospital staff may assume a hostile attitude towards the birthing mother, especially if she tries to decline any interventions they would like to perform on her.  Many health care practitioners, especially obstetricians, do not believe that a woman should play an active role in the birth of her own child (5).  In practice that translates into excluding the mother from medical decision making and performing procedures on her without explanation or consent, and sometimes even without her knowledge.  Concerns for the baby, whether they are real or not, are usually used to convince, and if necessary coerce, the mother and her partner into agreeing to procedures that are primarily for the hospital’s or the doctor's benefit.  

Unfortunately, this manipulative, disrespectful birth environment is the norm rather than the exception in modern hospitals.  In most cases, women and their partners are not aware of it because they trust medical authority beyond any doubt and because if they are compliant, the hospital staff's attitude is generally positive.  But for those mothers who want an active role in their birth and are informed enough to question or oppose interventions, the environment can turn outright abusive.  When a mother tries to question a procedure recommended by a doctor, especially if there are nurses and medical students present, the doctor's authority and ego can easily become threatened.  In an effort to assert his or her authority, and under the pretext that the mother does not understand the medical situation, the doctor may instruct those present in the room to hold her down while the "recommended" procedure is performed on her against her wishes and sometimes while she is physically struggling to prevent it.  Afterwards, such actions are almost always justified with the statement that they were necessary to save the baby or the mother herself.

There is practically nothing the mother can do to defend herself against the hospital through formal complaints or legal action.  The following film gives a good description of this through the traumatic birth story of one woman:

Babel: Voices of a Medical Trauma


Birth wars: The conflict between mothers and hospitals

There is a widening gap between the interests of birthing mothers and the interests of hospitals.  Women who try to oppose medical interventions are often pressured until they "surrender" to hospital protocol.  Those who do succeed in avoiding interventions during birth usually have to openly fight with their hospital health care providers to achieve this and often leave the hospital feeling as though they had to wage war with the hospital staff in order to give birth free of interventions.  The frequent occurrence of maternal trauma after childbirth is one of the signs that for the most part, it is women who are losing out in these birth wars.

The use of technology and interventions during childbirth is on the rise.  For example, during the last four decades, as technology in birth has become the norm, the cesarean rate has skyrocketed, going from less than 7% in 1970 to 30.2% in 2005 (6).  In many cases, technology is used for the benefit of the health care providers, despite its proven negative effect on the mother's health.  For example, continuous electronic fetal monitoring (EFM) is known to increase the incidence of emergency C-sections, forceps, and vacuum deliveries, without improving the health outcomes to the baby.  It also limits the mother's mobility during labour, which makes her labour more painful and more likely to require epidural analgesia, putting her at further risk.  Despite these adverse effects on maternal health, EFM is routinely used by hospitals because it allows nurses to attend to several patients simultaneously (i.e., the hospital can save money by hiring fewer nurses) and because it can be used to defend the medico-legal interests of hospital employees.

This excessive medicalization of childbirth (7) is one of the unfortunate consequences of our modern society’s unconditional belief in technology and simultaneous distrust of the body's natural processes.  Women in childbirth are treated like products on a factory conveyor belt; like machines that are at constant risk of breaking down (8).  It is not at all surprising that at the end of a birth, women often feel as though they were sucked into one end of a medical machine and spat out at the other end, with a “prize” -- a baby in their arms -- that is supposed to make up for any abuse and dehumanization they were subjected to in the process.

Misconceptions about birth trauma

Often people believe that women who have been traumatized by birth must have prior history of trauma (e.g., childhood sexual abuse) or some other mental health problems (e.g., depression or anxiety).  This is not true.  Research shows that the causes of maternal birth trauma are primarily situational (2), as are the causes of any trauma (9).  According to the official Diagnostic Statistical Manual DSM-IV-TR [9; p.466]: 

The severity, duration, and proximity of an individual's exposure to the tramatic event are the most important factors affecting the likelihood of developing PTSD.  Although there is evidence that factors such as social support, family history and childhood experiences may influence its development, PTSD can develop in individuals without any predisposing conditions, particularly if the stressor is especially extreme. 

Thus, the primary determinant of trauma and PTSD is the severity of the traumatic event, and not the history of prior trauma.  Any person, even the strongest, healthiest individual, can be traumatized by a sufficiently strong traumatic event.


References

1. Romano, A.M. and J.A. Lothian, Promoting, protecting, and supporting normal birth: a look at the evidence. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 2008. 37(1): p. 94-105.

2. Creedy, D.K., I.M. Shochet, and J. Horsfall, Childbirth and the development of acute trauma symptoms: incidence and contributing factors. Birth, 2000. 27(2): p. 104-11.

3. Klein, M.C., et al., The attitudes of Canadian maternity care practitioners towards labour and birth: many differences but important similarities. Journal of Obstetrics and Gynaecology Canada, 2009. 31(9): p. 827-40.

4. Hill, M.J., et al., The effect of membrane sweeping on prelabor rupture of membranes: a randomized controlled trial. Obstetrics and Gynecology, 2008. 111(6): p. 1313-9.

5. Klein, M.C., et al., The attitudes of Canadian maternity care practitioners towards labour and birth: many differences but important similarities. Journal of Obstetrics and Gynaecology Canada, 2009. 31(9): p. 827-40.

6. Hamilton, B.E., J.A. Martin, and S.J. Ventura, Births: preliminary data for 2005. National vital statistics reports : from the Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System, 2006. 55(11): p. 1-18.

7. Henley-Einion, A., The medicalisation of childbirth, in The Social Context of Birth, C. Squire, Editor. 2003, Radcliffe Publishing Ltd: Oxon, UK.

8. Kitzinger, S., Birth Crisis. 2006, New York, NY: Routledge.

9. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders IV- Text Revision. . 2000, Washington, D.C.: American Psychiatric Association.


Artwork:  
"The aftermath" Photograph in charcoal. Copyright © 2011 Kalina Christoff