By Kathleen Kendall-Tackett, Ph.D., IBCLC, RLC, FAPA
I first became interested in childbirth-related psychological trauma in 1990. Twenty-three years ago, it was not on researchers’ radar. I found only one study, and it reported that there was no relation between women’s birth experiences and their emotional health. Those results never rang true for me. There were just too many stories floating around with women describing their harrowing births. I was convinced that the researchers got it wrong.
To really understand this issue, I decided to immerse myself in the literature on posttraumatic stress disorder (PTSD). During the 1980s and 1990s, most trauma researchers were interested in the effects of combat, the Holocaust, or sexual assault. Not birth. But in Charles Figley’s classic book, Trauma and Its Wake, Vol. 2 (1986), I stumbled upon something that was quite helpful in understanding the possible impact of birth. In summarizing the state of trauma research in the mid-1980s, Charles stated that an event will be troubling to the extent that it is “sudden, dangerous, and overwhelming.” That was a perfect framework for me to begin to understand women’s experiences of birth. It focused on women’s subjective reactions, and I used it to describe birth trauma in my first book, Postpartum Depression (1992, Sage). {ed. note – this book is now in its 3rd edition and is titled Depression in New Mothers (Routledge, 2010).}
Photo by Tristan Wallace via Flickr Creative Commons
Since writing my first book, there has been an explosion of excellent research on the subject of birth trauma. The bad news is that what these researchers are finding is quite distressing:
High numbers of American women have posttraumatic stress symptoms (PTS) after birth.
Some even meet full criteria for posttraumatic stress disorder. For example, Lamaze International’s Listening to Mothers’ Survey II included a nationally representative sample of 1,573 mothers. They found that 9% met full-criteria for posttraumatic stress disorder following their births, and an additional 18% had posttraumatic symptoms (Beck, Gable, Sakala, & Declercq, 2011). These findings also varied by ethnic group: a whopping 26% of non-Hispanic black mothers had PTS. The authors noted that “the high percentage of mothers with elevated posttraumatic stress symptoms is a sobering statistic” (Beck, et al., 2011).
If the number of women meeting full-criteria does not seem very high to you, I invite you to compare it to another number. In the weeks following September 11th, 7.5% of residents of lower Manhattan met full criteria for PTSD (Galea et al., 2003).
Take a minute to absorb these statistics. In at least one large study, the rates of full-criteria PTSD in the U.S. following childbirth are now higher than those following a major terrorist attack.
In a meta-ethnography of 10 studies, women with PTSD were more likely to describe their births negatively if they felt “invisible and out of control” (Elmir, Schmied, Wilkes, & Jackson, 2010). The women used phrases, such as “barbaric,” “inhumane,” “intrusive,” “horrific,” and “degrading” to describe the mistreatment they received from healthcare professionals.
“Isn’t that just birth?” you might ask. “Birth is hard.” Yes, it certainly can be.
But see what happens to these rates in countries where birth is treated as a normal event, where there are fewer interventions, and where women have continuous labor support. For example, in a prospective study from Sweden (N=1,224), 1.3% of mothers had PTSD and 9% described their births as traumatic (Soderquist, Wijma, Thorbert, & Wijma, 2009). Similarly, a study of 907 women in the Netherlands found that 1.2% had PTSD and 9% identified their births as traumatic (Stramrood et al., 2011). Both of the countries reported considerably lower rates of PTS and PTSD than those found in the U.S.
How Does This Influence Breastfeeding?
Breastfeeding can be adversely impacted by traumatic birth experiences, as these
mothers in Beck and Watson’s study (Beck & Watson, 2008) describe:
“I hated breastfeeding because it hurt to try and sit to do it. I couldn’t seem to manage lying down. I was cheated out of breastfeeding. I feel that I have been cheated out of something exceptional.”
“The first five months of my baby’s life (before I got help) are a virtual blank. I dutifully nursed him every two to three hours on demand, but I rarely made eye contact with him and dumped him in his crib as soon as I was done. I thought that if it were not for breastfeeding, I could go the whole day without interacting with him at all.”
Breastfeeding can also be enormously healing, and with gentle assistance can work even after the most difficult births.
“Breastfeeding became my focus for overcoming the birth and proving to everyone else, and mostly to me, that there was something that I could do right. It was part of my crusade, so to speak, to prove myself as a mother.”
“My body’s ability to produce milk, and so the sustenance to keep my baby alive, also helped to restore my faith in my body, which at some core level, I felt had really let me down, due to a terrible pregnancy, labor, and birth. It helped build my confidence in my body and as a mother. It helped me heal and feel connected to my baby.”
What You Can Do to Help
There are many things that lactation consultants can do to help mothers heal and have positive breastfeeding experiences in the wake of traumatic births. You really can make a difference for these mothers.
- Anticipate possible breastfeeding problems mothers might encounter. Severe stress during labor can delay lactogenesis II by as much as several days (Grajeda & Perez-Escamilla, 2002). Recognize that this can happen, and work with the mother to develop a plan to counter it. Some strategies for this include increasing skin-to-skin contact if she can tolerate it, and/or possibly beginning a pumping regimen until lactogenesis II has begun. She may also need to briefly supplement, but that will not be necessary in all cases.
- Recognize that breastfeeding can be quite healing for trauma survivors, but also respect the mothers’ boundaries. Some mothers may be too overwhelmed to initiate or continue breastfeeding. Sometimes, with gentle encouragement, a mother may be able to handle it. But if she can’t, we must respect that. Even if a mother decides not to breastfeed, we must gently encourage her to connect with her baby in other ways, such as skin-to-skin, babywearing, or infant massage.
- Refer her to resources for diagnosis and treatment. There are a number of short-term treatments for trauma that are effective and widely available. EMDR is a highly effective type of psychotherapy and is considered a frontline treatment for PTSD. Journaling about a traumatic experience is also helpful. The National Center for PTSD has many resources including a PTSD 101 course for providers and even a free app for patients called the PTSD Coach. In addition, the site HelpGuide.org also has many great resources including a summary of available treatments, lists of symptoms, and possible risk factors.
- Partner with other groups and organizations who want to reform birth in the U.S. Our rates of PTS and PTSD following birth are scandalously high. Organizations, such as Childbirth Connection (take the opportunity to view their reports on the important issues regarding birth in the US HERE) , are working to reform birth in the U.S. 2013 may be a banner year for recognizing and responding to childbirth-related trauma. The new PTSD diagnostic criteria will be released in May in the DSM-5, and more mothers may be identified as having PTS and PTSD.
There has also been a large upswing in U.S. in the number of hospitals starting the process to become Baby Friendly, which will encourage better birthing practices. I would also like to see our hospitals implementing practices recommended by the Mother-friendly Childbirth Initiative.
There is also a major push among organizations, such as March of Dimes, to discourage high-intervention procedures, such as elective inductions. And hospitals with high cesarean rates are under scrutiny. This could be the year when mothers and care providers stand together and say that the high rate of traumatic birth is not acceptable, and it’s time that we do something about it. Amy Romano, of Childbirth Connection, describes it this way:
As we begin 2013, it is clear from my vantage point at the Transforming
Maternity Care Partnership that the transformation is underway. In Childbirth Connection’s nearly century-long history, we’ve never seen so much political will from leaders, so much passion from grassroots advocates, and so much collaboration among clinicians and other stakeholders. This new landscape presents many new opportunities for educators and advocates.
There is much you can do to help mothers who have experienced birth-related trauma. Whether you join the effort to advocate for all mothers, or simply help one traumatized mother at a time, you are making a difference. Thank you for all you do for babies and new mothers.
Here are some helpful links to share with mothers:
- Prevention and Treatment of Traumatic Childbirth
- Midwifery Today’s Resource for Healing Birth Trauma
- Trauma and Birth Stress
- Posttraumatic Stress After Childbirth
- Birth Trauma Association
Kathleen Kendall-Tackett, Ph.D., IBCLC, FAPA is a health psychologist and board-certified lactation consultant. Dr. Kendall-Tackett is Owner and Editor-in-Chief of Praeclarus Press. She is a research associate at the Crimes against Children Research Center at the University of New Hampshire and a clinical associate professor of pediatrics at Texas Tech University School of Medicine in Amarillo, Texas. She is Editor-in-Chief of the journal, Clinical Lactation, a Fellow of the American Psychological Association, and is president elect of the APA Division of Trauma Psychology. This post is a preview of her editorial in the Vol 3-4 of Clinical Lactation. You can read more about Kathy at www.KathleenKendall-Tackett.com.
I am so, so very happy that this area is being researched and talked about. The one thing missing from this article is some discussion on how traumatic birth can affect the baby, and in turn, affect breastfeeding from that angle as well. Things such as forceps, vacuum extraction, shoulder dystocia, acynclitic presentation, etc. can cause tightness in baby’s neck, shoulders and jaw, as well as misalignment that can affect tongue & jaw function. Mothers are so quick to believe that any problems with breastfeeding rest on their own shoulders – that they are doing something wrong. Acknowledging that baby has experienced trauma too and may have issues that are also affecting the breastfeeding relationship is so important.
Yes, I agree. Two people have been potentially traumatized and this can impact breastfeeding on both sides. Understanding, compassion and support are essential. I experienced a traumatic childbirth with my first child — it took me a long time to get over. My second birth was very healing. As a childbirth and lactation educator, I find much that makes me sad and angry about our current maternity care system. “First Do No Harm,” seems lost in the medical field of obstetrics.
I think a compounding issue in trauma experienced in childbirth is that not only may the birth experience have been traumatizing, but it is layered upon other possibly traumatic experiences that have been locked in the mother’s body. This can make it overwhelming. This can possibly explain the difference of why some mom’s are able to find solace in the breastfeeding experience and for others it is simply too much to bear. Unresolved trauma stored in our bodies can exacerbate a traumatizing birth experience. Finding healing takes time and is expensive. Finding the support and resources to overcome this kind of experience is beyond many mothers abilities. An ounce of prevention would be a much better course of action.
I am glad this is being addressed. Our first son came 8 wks early & I had to have a c/s. I was devastated. He was born early due to my severe pre-eclampsia. I pumped & through support from a lactation consultant, LLL & my husband, we were finally able to breastfeed!
Then, when we were expecting our second, I read up & prepared myself for a vbac, only to find out that I couldn’t have one. I fell into a deep depression & by the time I was trying to find out more resources for a new doctor who might let me try, I started having gall bladder attacks & was in extreme pain. When our second was born, he did take straight to the breast. He refused a bottle & was nursing around the clock, 1.5-2 hrs. All day, all night. I had 18 mos of broken sleep.
He is now 2 & a half. Things are better now, but whenever a friend is pregnant & gives birth, I sometimes relapse in the pain I had from not having the births I wanted. I understand that I have two healthy boys, etc. But the feelings come out of nowhere & I have come to terms that I am still healing.
I am so happy to read this, and also to know that I’m not alone! While I had a relatively calm *birth* (med-free, birthing center, no interventions), at some point during my delivery I contracted an invasive group A strep infection that nearly took my life. After being released from the hospital with a clean bill of health 2 days post-partum, I started spiking very high fevers and ended up back in the hospital on the 4th day post-partum. After they discovered what it was, I was admitted and put on very high doses of antibiotics to get it under control. I was very aware that I could die, leaving my husband and newborn daughter with no wife/mother (and no life insurance policy). It was a horrible experience. On top of that, because I was admitted right at the start of a holiday weekend, no one was around to help me figure out if I could breastfeed while on the medications I was on. I got the worst advice you can imagine (don’t pump, just give her formula, we’ll address this when the LC comes back three days from now, etc. etc.). By some miracle, not only was I able to recover from the infection, but ultimately I was also able to exclusively breastfeed my daughter, against all odds.
I was so distraught after finally being released from the hospital, some two weeks after I had my daughter. I cried constantly, replayed the horrible experiences in my head, and did exhaustive research on post-partum invasive group A strep infections. I thought about it constantly. Finally when my daughter was four months old, I sought counseling for PTSD and it was one of the best decisions I’ve ever made, for myself, for my daughter, and for my family in general.
Eventually I felt comfortable enough to have another baby, and I am happy to report that I had a wonderful experience the second time around: a med-free, intervention-free water birth and a healthy 9 and a half pound baby boy, with no post-partum complications.
I never met anyone who experienced post-partum PTSD, and I didn’t find anything about it in my research; I thought I was the only one! It’s good to know that I’m not alone, and that other people are bringing this important issue to light.
I had heard horror stories of women who were badgered into doing things during birth (unwanted episiotomies, pressured into caesarians, etc.). So I decided not only to work with a midwife during my pregnancy who supported my birth plan, but I also hired a doula. I knew that while giving birth, a time when I wasn’t going to be a) knowledgeable enough to argue my case for any given course of action and b) in any position, physically or emotionally, to dispute something that a hospital wanted to do, I would need some knowledgeable people on my side.
When my natural childbirth turned into a caesarian (after 19 hours of labor), it was recommended by the informed agreement of both my midwife and my doula, and I felt that I made the best decisions possible, even though it didn’t go the way I wanted it to go.
I was very lucky. I know there are women whose opinions are belittled or simply ignored during one of the most difficult times of their lives. The sense of rage and resentment this must create is probably staggering. To be ignored by the community that you have been turning to for *support* must feel like a horrible betrayal.
I hope this research results in more sensitive action by healthcare providers, and more support for new mothers from hospitals. I’m so glad they’re looking into it.
I know people don’t want to talk about it, but trauma happens in non-intervention cases too. When my first came with an emergency c/s I thought I was traumatized by realized later i was just disappointed. I had true PTSD with my second, a home birth gone horribly wrong. No successful breast feeding in either case. Still an advocate for non intervention but in my case…what would have been worse?
Thank you. I am glad this is being brought to light. I also find it healing to know I’m not the only one who doesn’t have all warm and fuzzy memories concerning my child’s birth. I had a complicated pregnancy coupled with emotional stress from my personal life(it became necessary for me to leave my husband when I was six months pregnant). Even though I had to be induced, I still tried for a natural labor. After 16 hours of labor and 14 hours of being stalled at 5cm I opted for an epidural. Upon entering my room, the anesthesiologist told me that no one had forced me into this position, I had chosen to be there, and it was all my own doing. He also told me that he didn’t care if I was in pain or if the epi helped me at all. On his second attempt to place the epidural I tried to tell the doctor that something was wrong. He refused to listen and kept going. Next thing I knew I was completely paralyzed from the chest down. Instead of trying to reassure me that everything would be ok, the doctor started telling me it wasn’t his fault and “things like this can happen sometimes”. No one could tell me how long it would last. No one knew if I would be able to push her out on my own,since I was now fully dilated. The effects of the mediication eventually wore off, and early the next morning I gave birth to my beautiful little angel. Within afew hours I had developed a severe headache-worse than any migraine I had ever had. The pain became nearly unbearable when I sat upright or tried to stand. The anesthesiologist was called down to consult about the headache. I was propped up trying to eat some breakfast when he came in. He said the headache wasn’t from the botched epidural because I wouldn’t be able to sit up if it was. I tried to explain that as a breastfeeding mom I had to do my best to eat. Again, he refused to listen. I got no help for the headache, which continued to worsen throughout the day. Eventually my own doctor showed up and realized how bad off i was and that I was indeed suffering from a spinal headache, but it was too late. A simple blood patch could have fixed the problem. However, the doctors wouldn’t risk putting another needle in my back now that the original had already been removed and I was back on heparin injections. My already complicated recovery was now worse. It took ten days for the pain to subside. The first week and a half of my daughter’s life is a painful blur. All because a doctor didn’t care enough to listen.
i think a big part is that women are expected to be happy with the outcome. if they have a healthy baby, then it doesn’t matter how it arrived. even if that baby is now struggling to breastfeed or mom is depressed. moms need to feel that they can express their feelings regarding what they just experienced and everyone needs to be ok with that.
What about PTSD in mothers who were forced to surrender their babies during the Baby Scoop Era (post WWII through 1972)? Consider reading my article “Adoption Induced Post Traumatic Stress Disorder in Mothers of the Baby Scoop Era” on Yahoo. This is a subject that the mental health community has NOT explored but absolutely should. Thank you. Karen Wilson-Buterbaugh babyscoopera.com
This adds yet another dimension to the lifelong trauma suffered by women who have surrendered their newborn babies for adoption. I’m one of those mothers, and I have been in a state of trauma for over fifty years. I belong to a vast international support network of mothers who also were denied the most basic instinctual interaction with their babies following the birthing process. Even the newer “open adoption” mothers are struggling to deal with the loss of their babies, and see no end in sight. Some have let their grief destroy them, turning to alcohol and drugs. Some have taken their own lives. Many were given a synthetic estrogen drug called diethylstilbestrol (DES) to suppress lactation and now worry about delayed effects. But worst of all, they were were told to “go on with your life” and “forget.” No sympathy or even empathy for their tremendous losses, and in fact, they are, to this day, encouraged to stay in their prisons of guilt and shame by maintaining sealed adoption records, making it difficult for their lost children to contact them.
I remember the first time I heard a (married) mother talk about having post-partum depression and I wanted to shout at her, “What do you have to complain about? You left the hospital with your baby, didn’t you? You don’t know depression until you return home with empty arms and a broken heart.”
So I’ve always known our PTSD was socially inflicted on us; now I know it was physiologically inflicted on us, as well.
I’m having a hard time sympathizing with many of these women. I’m afraid I had three childbirth experiences, all induced labour. I had PTSD after the first one because my babies were stillborn. Yes, that’s right. Both were dead. And until you’ve had that, I’m sorry, but PTSD for needing an episiotomy just doesn’t earn you any sympathy from me. Birth doesn’t go as planned. Sometimes things happen beyond your control. Why are women being taught that birth is this beautiful, nirvana-inducing spiritual bliss, and anything that falls short of that means you are a horrible failure?
Please note, I have huge sympathy for the very real experience of postpartum depression. And I do not think, ever, it is a woman’s “fault”, she has PTSD/depression. But rather, I think women are being set up for failure. The very real possibility that things can go wrong, that you won’t get the perfect birth you hoped for and that you are not a bad mother or a bad person for inducing, or having an epidural, or whatever. That you might have to make decisions while not having either the time or the energy to think them through and that you may rely on a professional (obstetrician, midwife, nurse, doula) or non-professional (your partner) to help you make them in the heat of the moment that you might not have made otherwise.
I think a couple of you have already expressed this better than I have. Women are pressured to be happy, and sometimes life isn’t perfect.
This is incredibly offensive. Someone does not need for their baby to die for them to be ranging from a bit to incredibly traumatized by a birth experience… and not necessarily due to expectations she holds but because of trauma from A. nearly dying, like a friend of mine that an ER doctor yanked her entire uterus out of her body (yes, her uterus) and she was rushed to OR and bled to death but was brought back and spent a month in hospital. B. extreme physical trauma during/after the delivery on the part of the mom or baby.. like a friend of mine whose baby they brain damaged with the vacuum.. or an acquaintance whose baby got a staph infection in his leg from an IV and ended up having his leg amputated at only 7 days old. Another woman in a group I am in had the nurses and the midwife all throw themselves onto her abdomen during a shoulder dystocia, and she had a post-partum bleed that required her to be knocked out and brought to surgery and the baby had such severe bruising his eyes were swollen shut. C. rights violated or sexually assaulted during the delivery. You seriously think that an epsiotomy against a woman’s consent and for non-emergency purposes is not a form of sexual assault and a form of mutilation? Or if a woman says “take your hands off of my labia.. “out of my vagina” or “stop touching me”, and they do not comply, that is not sexual assault? How is it not sexual assault? How is it okay because it is cloaked in “standard of care” or “most women don’t complain” or “we know better than you” ? It is clearly them touching a woman’s privates against her consent.. this is illegal and traumatizing. Or, other examples of this are giving her medications against her consent, or performing surgery or an extraction against her consent.. those are crimes! They are criminal. These women are traumatized because they are assaulted! This could also apply to any case where they do something non-emergency related against the mothers consent to the baby. D. The woman had untreated severe pain. The epidural fails and she isn’t provided other coping measures. Stitches performed upon feeling tissues, cesareans performed with not working epidurals/spinals, very painful procedures like a placenta being scraped out manually, without anesthesia. E. The woman did not have the privacy she needed, traumatized by feeling like a spectacle. Medical students, bustling employees during shift changes, many many people witnessing her nudity or her birth that she did not consent to being there and should have been introduced to earlier. This is particularly true for many abuse survivors or extremely religious women who are very shy and punitive towards themselves about their bodies and it can be extremely traumatic for them to be a “spectacle”, particularly if many young students are in the room, men are in the room, or the woman did not authorize it or revoked consent and was ignored. This is not silly , this is human rights. F. An extended hospital stay for baby.. due to prematurity, defects, or illness. This often causes PTSD, and it’s because of witnessing the baby experience multiple painful procedures and due to the fear and feelings of helplessness and sometimes guilt or poor treatment involved. Sometimes the trauma is worsened by losing the baby… G. Being forced/brow-beaten/lied to into having surgery. H. Something terrible happens during the birth/after and her children witness it and are traumatized. Women feel great guilt over this scenario.. I. Baby loss, as you experienced, is often very traumatizing.. And, often made worse by our ways. And yes.. of course.. There are cases where women are traumatized by birth due to her expectations about it.. but these are not the rule but the exception. Usually, if women are traumatized, there is something rather severe surrounding this trauma. You don’t get to invalidate everyone else’s trauma just because you lost your children. That’s like a rape victim who was almost beaten to death and left for dead in a trash bag telling a woman who was held at knifepoint and raped but otherwise unharmed that she shouldn’t feel traumatized because it was so much worse for her. Yes, we know you had a bad go of it but that doesn’t invalidate anyone else’s pain or trauma..
Thank you, eljafima.
I’m not going to engage in an “I had it harder than you” discussion, which we women love to have. It’s good to have that perspective that it could have been worse. But PTSD isn’t chosen. I did not see it coming. My experience was hard, but I had no idea PTSD was on its way. And in the throes of it, I could not function or care for my children, and that was terrifying. Not because I was just disappointed, but because I had a clinical mental illness that I didn’t know how to treat.
Let’s just have sympathy for each other, that birth is hard for many of us, regardless of what we went through. And figure out the best way to help mothers in this situation.
I agree with Oneika’s comment above about how hard it is when friends or relatives have a baby. It always sends me back into a deep depression. Then i feel guilty that i can’t even be happy for my own sister when she had an easy delivery and quick recovery. And the feelings DO come out of nowhere. Just when you think you’re over it, it hits you again.
What’s nice about this article is that we have found other people that we can relate to. That there are people who do understand. My SIL is pregnant with her 4th child. She’s never had any issues & even though I am happy for her, (I don’t think anyone should have to go through what any of us had), I am glad that she lives in another state so that it’s not a constant reminder for me.
Wonderful article! Thanks! The only thing I miss is: respect the mother’s boundaries when she does not feel comfortable with the idea of another spontaneous birth any more after surviving a traumatic birth. Or with a spontaneous birth at all (even if it is her first birth).
Reblogged this on For Henry and commented:
Definitely something women should talk more about. Both my births were traumatic. Henry, because we didn’t take him home. And Corin, because I could have died.