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Childbirth is an emotional and intense experience for most women. For some, it is deeply traumatic, and for a smaller subset, it can lead to post-traumatic stress disorder (PTSD).
Understanding who is most likely to suffer and how to identify them so they can receive support is a continuing challenge.
Defining birth trauma and those women affected by it can be difficult. A 2018 article in the Journal of Perinatal Education determined that up to 45 percent of new mothers reported experiencing birth trauma and it classified the condition as an international public health problem.
More recently, an article in the British Medical Journal found that one third of women experienced giving birth as traumatic, while 3-6 percent of all women giving birth went on to develop PTSD. Many others go undiagnosed, the authors of the article said. The U.S.-based organization Postpartum Support International, suggests that up to 9 percent of women experience postpartum PTSD.
"We don't know why it occurs," Dr. Iffath Hoskins, president of the American College of Obstetricians and Gynecologists (ACOG) tells Newsweek. "Two different individuals could experience the same incident and only one experiences PTSD." She adds that ACOG estimated that between 10 percent and 20 percent of the four million births that take place annually in the U.S. result in PTSD.
PTSD is characterized by intense, heightened fear and is often diagnosed according to a number of symptoms; people with PTSD often experience nightmares or flashbacks about the triggering event and avoid experiences that remind them of it. In the case of postpartum PTSD, women often avoid talking about the birth and may even avoid meeting up with other new parents or other occasions that are likely to cause them to relive their own birth experience.
In the case of Naomi Norris, a dental nurse in the U.K., a normal, slowly progressing labor turned into a category one emergency when midwives were about to give her a spinal anesthetic to enable her to get some sleep, and then were unable to find her baby's heartbeat.
The next thing she knew, she was having an emergency C-section to deliver her baby as soon as possible.
"I remember being run down a corridor with lights flashing and a lady saying, we have to get the baby out and we need to put you to sleep, with no spinal," she tells Newsweek. Her next memory came when she awoke and a midwife assured her that her baby, a boy, was fine.
"I said, 'I don't care.' I had been in hospital only around eight hours. When my partner came in and said, 'have you held him or touched him,' I said, 'I don't really want to.'" Norris still struggles to bond fully with her son three years after his birth, and says she feels that only the experience of having another child to "fix" her previous birth would help her to gain closure.
What causes PTSD after birth?
Although postpartum PTSD usually results from the birth itself, it can be connected with events in pregnancy as well, Hoskins says. Symptoms can appear immediately or many months (or years) after the birth, and in some cases, those who have suffered opt not to have any more children.
The precipitating causes of PTSD, like those for birth trauma more generally, are as diverse as the people who experience them. For many women, the catalyst can be an emergency during childbirth—a baby in distress, an unplanned cesarean section or a severe hemorrhage.
Norris believes the general anesthetic she received was a major factor in her postpartum PTSD. The lack of skin-to-skin contact immediately after her son's birth, the fact that her partner wasn't able to be present, were key aspects of her difficulty bonding with her son, she says.
"I've mentioned having a DNA test on the baby," she says. "It's this tiny niggly thing—maybe helping me see that he's 100 percent mine." Two of the birthing team who delivered Norris's son did reach out in the days and months after his birth, she said. The doctor who spoke to her before she was discharged told her the type of emergency delivery she experienced was extremely rare, and the midwife who was present rang Norris when she was off-duty and emphasized how uncommon her birth experience was.
After she continued to struggle to connect with her infant several months after the birth, Norris was granted a debriefing at the hospital and a referral to a group support program through the UK National Health Service. Because the support was brief, and she found it difficult to find a psychotherapist with experience in birth trauma, Norris still has panic attacks and finds herself avoiding gatherings with other women who have recently given birth or have had easier births.
Better preparation in antenatal classes for the small possibility of giving birth under general anesthetic might have helped her process the birth more easily, Norris said. "The [doctor] said this hardly ever happens, but it happened to me," she says.
Some women can be traumatized by what is considered to be an uncomplicated birth, due to factors such as levels of blood loss and pain that they have not anticipated and which set off other emotional triggers.
"The blood flow at a normal, uncomplicated delivery can be around half of a one-liter coke bottle," Hoskins says, adding that blood loss in a scheduled C-section can be twice that amount. Postpartum PTSD can also have a genetic component, with women more likely to experience it if their mothers and sisters have.
Recognition is key to treating symptoms
Many women who feel traumatized after childbirth are not necessarily recognized or even heard by healthcare providers, making it more likely that traumatic feelings will remain unresolved and undermine their mental health.
"PTSD is very subjective, but we should accept that it occurs and give it its full respect," Hoskins says.
It is essential that women ask questions of their obstetrician, Hoskins says, especially if they feel they have had insufficient information about information that emerges from an examination or ultrasound, or if they are upset about their birth experience. Yet, the authors of the BMJ article advise that doctors and midwives should also ask women about their birth experiences as standard policy, with their postpartum check-up a particularly appropriate time to do so.
Women with better support systems available, from both family and the medical system, are more likely to be treated successfully, Hoskins says. Professional counsellers can also help teach resilience and coping skills.
Experts point out that PTSD should not be confused with postpartum depression, although both can occur simultaneously. The two conditions demand different treatments, according to the authors of the BMJ article, noting that some cases of postpartum depression can be managed in primary care, while postpartum PTSD often requires a specialist maternal mental health referral.
Ultimately, Hoskins says, the intensity of trauma that can lead to postpartum PTSD reflects the significance of childbirth for a family as opposed to the clinicians who treat them.
"One of my professors taught us, for you it's just another day at work, for patients it's a life event," Hoskins says.
