Originally posted April 22, 2019.
In my work as a perinatal psychotherapist, I have had the honor of hearing many women’s oral histories about their childbirth. I often see women who have nearly died in childbirth, usually due to hemorrhaging.
**Due to the confidential and personal nature of my work, I never share personal information about my clients here**
Today I wanted to share the confluence of factors gleaned from multiple disciplines intertwining maternal mortality and post-traumatic stress after childbirth (PTSD CB Onset). The issues are intertwined. The roots are in how US family policies and healthcare coverage lags behind other industrialized countries, racism and how healthcare is actually delivered prenatally and in the birthing room.
There is a large body of both quantitative and qualitative research that provides the foundation of what influences birth outcomes and birth trauma.
In fact, research across academic disciplines intersect to bring evidence-based data that informs the multiple biopsychosocial determinants of the occurrence of birth outcome and birth trauma in the individual.
What are some of the factors that influence birth outcome and the development of trauma during childbirth?
Research shows that the following factors influence birth outcome and are the causation of post-traumatic stress after childbirth. They are an intersection of micro (personal) and macro (societal) factors.
Public health research informs us that macro (societal) reasons underpin whether or not a woman is physically safe in her life, if she has been consistently discriminated against across her lifetime (regardless of socio-economic status) and even how she is treated by healthcare professionals.
The micro (personal) reasons have traditionally been studied as physical and mental health on an individual level. Physical and mental health vary on an individual level but are influenced by socio-economic strata.
These are some of the main factors for poor birth outcome and PTSD CB Onset:
Unsafe living conditions
History of childhood sexual abuse and history of adult sexual abuse
Lack of personal social support
Lack of compassionate support during the birth itself
About the Research in the Multiple Areas of Intersection
Research about intersection of toxic stress during pregnancy on physical and mental health
Trauma Informed Care in the Perinatal Period, edited by Julia Seng, Ph.D. and Ms. Julie Taylor, is one of the seminal books pulling together the intersecting evidence from multiple research disciplines on improving perinatal outcomes and prevention of birth trauma.
Dr. Seng’s thesis is that in order to improve perinatal outcomes for the majority, perinatal healthcare professionals must also recognize the load that toxic societal stress, ie, racism, poverty, childhood abuse, exert on the individual and use this information to inform their care. In addition, Ms. Seng finds that national family policies must be updated with evidence-based information in order to support a family based society.
Research About Pregnancy and Stress and Birth Outcomes
According to the March of Dimes, 1 in 10 babies are born pre-term in the United States. In 2016, the rate of preterm birth among African-American women (14%) was about 50 percent higher than the rate of preterm birth among white women (9%).
Paula Bravman, MD, MPH, Tyan Parker Dominguez, Ph.D, and Christine Dunkell-Schetter , Ph.D. are three leading researchers in the area of racial and socioeconomic disparities in adverse birth outcomes. Their research includes multiple factors that influence stress and lack of support during pregnancy and birth, inclusive of influences of poverty, abuse and systemic racism across all socioeconomic strata in society.
Their collective work shows that toxic stress derived from experiences of systemic racism has a profound effect on birth outcome, regardless of socioeconomic status.
Dr. Bravman and her colleagues’ (including Dr. Dominguez) 2015 research on 10,000 subjects found that socioeconomic factors influenced preterm birth (PTB) rates in White but not Black women. This suggests that social factors, such as racism related stress, contributes to the PTB among Black and White women.
Dr. Dunkell-Schetter (2008), in her research contributes to the body of literature around birth outcome and brith trauma. She discusses the different types of stress encountered in a woman’s lifetime and the different types of effects on the body during pregnancy. She brings in information about the pathways stress affects in the body, specifically the action on the HPA Axis, as being affected by high levels of toxic stress. For example, life events, such as divorce and familial deaths, will have an impact on pregnancy. However, this stress is different than the effects of lifelong systemic racism.
Research about the necessity for woman-centered childbirth
Penny Simkin, PT, is one of the pioneers who recognized that women’s voices needed to be brought into the birthing room. That women’s voices needed to be heard in order to change how we as a society view and put value on caring for pregnant and birthing women.
In her 1991 research, Just Another Day in a Woman’s Life? Women’s Long term Perceptions of Their First Birth Experience, (Part I and II) she asked women how they perceived their birth experiences and then how these experience affected their emotional and psychological life over their lifespan.
In Part 1, Ms. Simkin found that women were deeply affected by their childbirth experiences. They were most satisfied when they felt they had control and that the healthcare providers were compassionate, listened to them and treated then with dignity and respect. In Part II, conduced 15 years later, Ms. Simkin found that positive feelings about the birth affected the women long term, influencing feelings of self -esteem and pride. Ms. Simkin found that the women had vivid memories of the healthcare providers, their actions and words. Ms. Simkin found that the memory of childbirth has lasting influence on well being.
As Ms. Simkin says, “If it was discovered that the birth experience has an impact on mental health or psychological well being, then it would make sense to seek and use interventions that exert positive influences.” (Simkin, 1991, p. 230)
Cheryl Beck, Ph.D. is another pioneering researcher in the field of the woman-centered childbirth movement.
Cheryl Beck, Ph.D., has developed an extensive body of qualitative research about women’s perceptions of traumatic birth that helped us see how women perceived childbirth.
She showed us that there is a mismatch of perception between what healthcare providers believe is a routine birth and what is actually perceived as traumatic to the mother.
The now famous questions gleaned from her research from women asking about their obstetrical care:
“…To care for me: Was that too much to ask? To communicate with me: Why was this neglected? To provide safe care: You betrayed my trust and I felt powerless, and The end justifies the means: At whose expense? At what price….? (Beck, p. 30, 2004).
What is being done?
This was meant to be a brief overview of the confluence of issues in mental and physical health surrounding childbirth. The challenges are many and there are many ways to support women and families to start a productive life. Researchers, doulas, midwives, obstetricians, hospital administrators, mental health professionals, public health officials, Congressional leaders…can all contribute to improving birth outcomes.
It is a deeply satisfying field in which to work.
There are many programs that addressing both the physical and emotional side of childbirth that promote resiliency and community:
The State of California has successfully studied and taken steps to reduce there maternal mortality great in their state and it is a blueprint for the rest of the United States. Read about the California Maternal Quality Care Collaborative
The State of New Jersey has announced its Nurture NJ Campaign, to improve maternal and infant health.
Braveman, P.A., MD, MPH, Heck, K., MPH, Egerter, S., Marchi, K.S., MPH, Dominguez, T.P. et al. (2015), The role of socioeconomic factors in Black-White disparities in preterm birth. American Journal of Public Health, April 2015. Retrieved April 22, 2019 fromhttps://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2014.302008
Beck, C., Dricsoll, J. & Watson, S. (2013). Traumatic childbirth. Abingdon, United Kingdom: Routledge.
Beck C. T. (2004a). Birth trauma: In the eye of the beholder. Nursing Research, 53, 28–35. Retrieved April 22, 2019 from Google Scholar
Dunkell-Shetter (2008). Stress processes in pregnancy and preterm birth. Retrieved April 22, 2019 from https://cds.psych.ucla.edu/pubs/2009%20DunkelSchetter_Stress%20Proceses%20in%20Pregnancy%20and%20Preterm%20Birth.pdf
Karlstrom, A., Nystedt, A., and Hildingsson, I. (2015). The meaning of a very positive birth experience: focus groups discussions with women. BMS pregnancy and childbirth, 15, 251. Retrieved April 22, 1019 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4600272/
Simkin. P (1991). Just another day in a woman’s life? Part 1., Birth, 18, 4, 203-210. Retrieved April 22, 2019 from https://onlinelibrary.wiley.com/doi/epdf/10.1111/j.1523-536X.1991.tb00103.x
Simkin. P (1992). Just another day in a woman’s life? Part II., Birth, 19, 2, 64-81. Retrieved April 22, 2019 from https://www.ncbi.nlm.nih.gov/pubmed/1388434