When a bad birth haunts you

An article in Prima Baby October/November 2000 called `When a bad birth haunts you' describes post traumatic stress disorder after childbirth. It quotes a paper in the British Journal of Clinical Psychology by Dr Pauline Slade which describes a major study of post-traumatic stress linked to birth. In the Prima Baby article Dr Slade says:

“This problem is distinct from postnatal depression and far more damaging than so called “baby blues”. But I am concerned less with misdiagnosis than the fact that it may not be picked up at all. So many women hide their difficulties.”

The article includes an interview with Sheila Kitzinger in which she says that she believes that a woman who has been through a difficult time in labour is initially in a numb emotional state, so relieved is she that it's over. This can last weeks, months or even years.

"Then suddenly the floodgates open. But these feelings are complicated. The woman feels bound to be grateful to the professionals who helped her deliver her baby, especially if the baby was perceived to be at risk, and yet these are the very people you feel have violated you. A woman who has had an emergency caesarean can be very vulnerable to this."

Sheila wants to see a full-scale study looking in detail at interventions following childbirth:

“This is not postnatal depression. These women have their birth experience going round and round in their heads like video on a loop. They can't switch it off. They are constantly reliving the trauma but rarely getting continuing support to deal with it. We need to find out what is most useful to women in this situation and what makes them feel worse. Then we can provide effective, individually-tailored support."

 

Post Traumatic Stress Disorder

After the Vietnam War soldiers on both sides who had not suffered any physical injury often became distressed. They had panic attacks and flashbacks to terrible events they had witnessed, but which they were unable to do anything about. The diagnosis “post traumatic stress disorder” was invented.

The same thing can happen after a birth in which a woman felt she had no control over what people did to her and was just a “body on the table”. She is alert, irritable and panic-stricken. She may feel as if she has been raped. And, as so often with rape, she believes that somehow it must have been her fault. The birth experience goes round and round in her head like a video set on “replay”. It cannot be switched off.

For these women birth was a kind of torture. They could not get the information they needed to make choices between alternatives, and felt that they had no control over what was done to them. They were disempowered in a very important event in their lives. They feel terribly alone. They may fear that they are going mad.

This can happen even with a so-called `normal' birth. But it occurs most often with high-tech births: when there are obstetric interventions like induction and revving up the uterus with drugs to speed labour. Electronic fetal monitoring often means that the woman is made to lie down and keep still instead of swinging and rocking her hips. There is bound to be more pain when she cannot move freely. An episiotomy (a cut), a forceps or ventouse (vacuum extraction) delivery, or an unplanned Caesarean section, may make a woman feel as if she is being treated like an object on a conveyor belt.

Post Traumatic Stress Disorder (PTSD for short) is different from depression. Anti-depressant drugs do not help, and can even make it worse. Many women who are haunted by what has to be done to them in childbirth are treated by GPs with anti-depressant drugs. What they really need is to be able to talk with someone who understands, a person who does not try to explain or justify the treatment they received, or to criticise them and the way they feel about what happened to them, and who knows how to listen reflectively.

Taking Action

  • Ask for your case notes from the hospital. If you get on well with your GP or with a midwife in the practice go through them with him or her, so that you find out what went wrong, and why these things were done to you. Some hospitals have a Birth Afterthoughts service and the midwife will come to your home to let you talk through the labour and link your experience with the notes.

  • Write your version of what happened, and how you felt about it. It will probably be very different from the hospital version. If it is hard to do this, write it as a story about someone else.
  • Contact Birth Crisis, who can put you in touch by phone with a member of its network who is there to listen, understand, and help you find the power within yourself to handle this distress.

 

Becoming a mother

The romantic image of a radiant mother, a beautiful baby in her arms, her golden hair lit by the sun’s rays, displayed on the jackets of many birth books is far removed from reality. New mothers are often unhappy. This major life transition is made incredibly difficult by poverty, poor housing, overcrowding, and social isolation. But one reason why many women have low self-esteem and cannot enjoy their babies is that care in childbirth often denies them honest information, the possibility of choice, and simple human respect.

As research by Green, Coupland and my daughter, Jenny Kitzinger, England,1 and Simkin’s research in Seattle2 reveals, women remember with acute clarity, often many years later, what midwives and doctors did and said. When they saw them as authoritarian or punitive and they did not offer information and choice, they feel they were degraded and abused.

Birth crisis

I started the Birth Crisis Network3 to offer women who had experienced a traumatic birth, an opportunity to talk on the phone with someone who validates what they say and helps them find within themselves the power to cope. As they talk they often describe how they were subjected to what some call "emotional blackmail". This starts during pregnancy. One woman told me that at the antenatal clinic, when she asked if it would be possible to have a VBAC, the midwife in charge said, "If I wanted to leave my children without a mother, and if I didn’t have a repeat Caesarean ‘you try for a natural labour!’ I came home in tears because I thought ‘I’ve got no choice. I’ve got to have a Caesarean. Otherwise I would kill myself.’"

They feel they were processed through labour and delivery like factory goods on a conveyor belt. Debbie’s account is typical. When she rang me she found it difficult to speak, and there were long silences. Her baby was born 15 months ago. She went to hospital immediately when her membranes ruptured and was told she was 2cm dilated.
"After a couple of hours things had hardly changed at all. They told me I should have a drip to speed things up and recommended an epidural. I asked the midwife ‘What would you feel about an epidural?’ She said she would probably have one. They said ‘It will take away all your pain’. They didn’t mention any risks. They said it was fine. I wouldn’t feel a thing."……"Afterwards I was much more interested in the monitor, because that was the only way to know what was going on. The fetal heart was going down during contractions. I asked what the numbers were for. I was told the heart should stay between 140 and 120." It dipped to 70 during contractions, rose at the end of a contraction, but gradually became lower – down to 50 during contractions. "The doctor called in and said, ‘Don’t worry’. He got another doctor and he put like a tiny fish hook in her head." At 11.30am they topped up the epidural and the fetal heart dropped further.
"I was getting frightened. I was being rummaged around. My legs were held up by a nurse and my husband. I felt so embarrassed, humiliated and useless that I couldn’t even do this for myself, with the doctor’s face almost up inside me. They said the head was high. Everybody ran into action. People were dashing everywhere. I thought, ‘Oh my God, what’s happening?’" She had a Caesarean. "They had to knock me out. They took my husband away. And there I was. I’d had a baby".

Post traumatic stress


Women usually feel numb at first, simply relieved that it is all over. Later the floodgates open, and gratitude that they and their babies are alive is mixed with a sense that they have been violated: "I felt butchered, assaulted, raped." "I felt like an animal being slaughtered." Scenes from the labour and birth are played over and over again in their minds like a video on a loop that cannot be switched off. They suffer nightmares and flashbacks to the trauma. People who are trying to help often tell them, "You expected too much". They have little confidence in their bodies, and breastfeeding is turned into a struggle. These women suffer from post traumatic stress which may last months or even years, it may adversely affect their relationship with a child and with their partner.

The baby


Some women do not mention the baby, or do so only in passing. Others refer to the baby as "it". They often feel that the baby cannot really be theirs. They say that they "go through the motions of mothering". Or that it is as if they are on "auto-pilot".

A woman told me "When I saw her she was all clean and nice and in a babygro. I thought, ‘Have I got the right baby?’ After a normal birth I know they’re all gooey, but that’s how I wanted her. When I got home I started thinking, ‘God!’ I was blaming the baby. It was all her fault that everything had gone wrong…. my stitches and my sore nipples. I never actually hated her. But I went to my GP and cried and cried. He prescribed tablets. I was neutral towards her, I didn’t give her cuddles. I kept crying the whole time. I felt I was half asleep all the time". I tried to find out what sources of emotional support she had. She said: "I live on an Army base. I don’t know hardly any people. They’re constantly changing. My husband goes to work at 6.30 and he comes home 10 – 12 hours after."

These women often feel helpless and confused: "I didn’t know what to do with the baby on my own. My Mum took her home for the weekend. I can’t visit anyone. I can’t go out for a meal. My Mum and sisters are natural born mothers. They instinctively know what to do. I am inadequate. Every time I tried to say how I felt, the health visitor implied that I had a healthy baby, so what’s the problem?".

Of 150 consecutive calls to me by women who were traumatised by their birth experience sixteen percent made negative comments about their babies. As one woman put it: "Everyone says, ‘You’ve got a lovely, healthy baby.’ But I feel ripped off." Others say: "For six months I hated my baby. I’ve wanted to throw him downstairs. It wasn’t worth it."; "He just cried and cried inconsolably for hours and I carried him day and night. This all left me exhausted and even more depressed about my inability to cope with the whole childbirth and child care experience"; "I hated her afterwards. I looked at her and wished she was dead. I feel guilty for thinking it." One woman who said of her labour, seven years ago, "I felt totally powerless. I ended up with a blanket over my face. I wanted nothing to do with it," told me, " I had terrible problems bonding. At times I still don’t think she is mine."
A woman who wrote a very detailed account said: "My baby was next to me but I didn’t want to touch him or look at him. I was mourning the loss of a child who never came through me, I was unable to give birth. He was stripped from me. Eight hours after the operation, the nurse came and asked me if I had touched my son and I said ‘no.’ She was worried that he hadn’t had any milk and she put him straight away onto my breast, which I found a bit of a shock. It was like meeting a man for the first time and even when you do not fancy him people make you kiss him on the lips." "It was a real battle to breastfeed. I experienced so much frustration and pain at the same time when they put the baby on top of my tummy which was extremely sore. He was a hungry baby and was not satisfied with my early drops of milk. I didn’t want to give up because that was the only thing I wanted to do properly. But I failed again." The word "failure" recurs in many women’s accounts. "The feeling of failure was almost overwhelming. I couldn’t give birth to him properly and I couldn’t even feed him. I was totally useless."

The partner


Women are often aware that their partners are traumatised too. One response is for a man to fling himself into his work. A woman described how her husband stood by during a violent delivery in which she felt emotionally and physically abused: "I feel he cheated my son." She added: We haven’t made love after seven months."

Men are often frustrated and irritated when a partner feels the need to discuss the birth over and over again. A woman who talked compulsively about her distressing birth experience told me, "My husband says, "You’re not going on about that again! He completely shuts me out." This couple were on the point of separation. There are often sexual problems. Episiotomy and suturing that has damaged the perineum may mean that sex is painful or impossible. "He has been very understanding", they say. I have come to realise that this means, "He doesn’t force me to have sex." The woman is often terrified of another pregnancy. She also feels alienated from and hates her body – the body that cheated her: "I felt David was surgically removed from my body and that I hadn’t been able to give birth to him. I felt I had failed as a woman, as a wife, as a mother." "My scar was very depressing to see. I hated my body and felt sick and an intense dislike when I went into the bath. My scar looked like a smiling monster laughing about me, all purple, sore and swollen"….

A birth experience in which a woman feels, "I didn’t give birth. I had an operation", that she was "like meat on a table", or that "it was like a rape", is not over and done with. It intrudes in a destructive way on the relationship with a partner, and for some women who talked to me the relationship ended in break-down.

This unhappiness after birth is not an emotional miasma that envelops a new mother because of her hormones, experiences in early childhood, or even because of poverty and social disadvantage. It is a direct result of the aggressive management of birth typical of the contemporary hospital, a predominantly mechanistic approach to the human body, and childbirth that is governed by the clock.

Our medicalised culture of birth is one reason why it is important that there is a home birth alternative.

Home birth


A woman’s emotional state after a home birth tends to be very different. She is positive, self-confident – and often exultant. Birth is something she has achieved, rather than something that has been done to her. She starts labour in her own time, eats and drinks when she wishes, carries on with activities around the house and perhaps in the garden, learns to adapt to the gradually mounting strength and length of contractions, moves freely using familiar furniture to give support as she kneels or squats, and decides herself what she wants to do and when she wants to do it. She pushes as and when she wants to, does not feel under pressure to beat the clock, and is unlikely to have an episiotomy. Afterwards she cuddles the baby in her own bed. A woman who controls the space in which she gives birth, and who can therefore risk losing her self-control and can surrender to the overwhelming feelings welling up inside her, is much more likely to look back on birth as a positive experience. Childbirth is an adventure in which she has discovered her inner strength, joy in her body, and grown in self-awareness and self confidence. Birth is empowering.

Home birth offers a model of how all birth should be, a model on which hospitals should base practice, and which enables midwives to learn how to keep birth normal. Yet for many women getting a home birth is an obstacle race. GPs are the gatekeepers, and on the whole they distrust home birth and do not want to get involved in it, but are not prepared to refer their patients on to midwives, or to refer them to other GPs who support home birth.

We need to change the system so that women can go straight to midwives and to create the conditions in which it is simple and straightforward for women to have home births. I propose a campaign to promote home birth as an unexceptionable, reasonable choice.

For this to happen, on realising she is pregnant, a woman should be able to go direct to a midwife.

A healthy woman booked for hospital should be able to switch to home birth, without hassle, at any stage of pregnancy, even if in labour, and be supported in doing so.

Access to information about home birth must be made easier. One way of doing this would be to set up on the NHS website a special section on home birth. Designed together with major birth organisations, it should tell women exactly how to get a home birth, and giving them the information they need for a smooth path.

A new kind of midwifery education is urgently needed. The UKKC and RCM should work together to introduce training for midwives so that they know how to create the conditions for physiological, rather than medical, childbirth.

Every midwife should be capable of assisting at home birth, and all midwifery students should have experience of home births. This should be a required element in midwifery training. Yet if this is to happen there must be more home births.

In Wiltshire a midwife can specialise in performing ventouse deliveries.4 We need to acknowledge the skills of midwives who understand women’s bodies and enable women in their care to experience childbirth without any intervention. At present home birth midwives are under-valued and marginalised. We should consider creating a new post-registration qualification: the home birth midwife specialist.

References


1 Green JM, Coupland VA, Kitzinger, JV. Expectations, experiences and psychological outcomes of childbirth: A prospective study of 825 women. Birth 1990;17(1):15-24.

2 Simkin P. Just another day in a woman's life? Women's long-term perceptions of their first birth experience. Part 1. Birth 1991;18(4):203-10.

3 The Birth Crisis Network

4 Tinsley V. Rethinking the role of the midwife: midwife ventouse practitioners in community maternity units. MIDIRS Midwifery Digest 2001;11(3 suppl 2):S6-S9.

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