We are going to explore Birth Trauma today, and build a new framework to understand how birth can affect women and families, and how we can support them to make peace and move on.

We are going to start off by investigating a new definition of a bad birth experience

We tend to define births as being "good" or "bad", as in, if you ask someone, " How was your birth?"...women often tend to go, "Oh - pretty good. It was about 8 hours, after being induced, and then an epidural, and then he got foetal distress so they had to use forceps, but we're both fine."or, "Oh - not bad - I had a caesarean and it was all very civilised really." But these answers do not tell you much about how a woman felt about the birth. If she was disappointed, or felt empty. If she was scared for her life, or her baby's.If her husband can still not talk about it because of what he saw his wife endure.

We tend to think of a "good" birth as being one that ended up with a healthy baby, despite what may have happened to us, physically or emotionally. It is especially "good" if it is quick, with women envying openly those who have 5 hours or less labours. But all is not as it seems, as we will come to later.

Women tend to feel they got away pretty unscathed if it was a vaginal birth. Regardless of how they felt.

And a "bad" birth is generally looked upon as being one with obvious trauma, eg a premmie baby, or a massive haemorrhage. Some would classify any caesarean as a "bad" birth. Some would classify any vaginal birth as a "bad" birth.

But this categorisation of births robs women of their chance to identify their experience as being "bad", and results in them being seen as ungrateful when they voice their distress

So we would like to offer a new definiton of each of these, before we go any further. (It is vital as understanding it affects everything we learn 4 rest of day)

and we are gong to define the births in terms of Feelings and CONSEQUENCES because we want to make really certain that everyone leaves today knowing that birth has consequences.

NEW DEFINITION OF A BAD EXPERIENCE OF BIRTH
There are common feelings shared by women who have experienced a bad birth, no matter how it unfolded or what path the birth followed. That is, regardless of whether it was a caesarean after 30 hrs, or a freight train 3 hour labour and natural delivery, or an induction leading to epidural leading to foetal distress and vacuum delivery., or even a homebirth where the support wasn't appropriate...there are common feelings amongst women from all and any type of birth.

A BAD EXPERIENCE OF BIRTH
a birth where a woman (and/or her partner) felt:

DURING THE LABOUR & BIRTH
powerless, confused, fearful, isolation or abandonment, unacknowledged or unheard

CONSEQUENCES
these feelings can lead postnatally to:

disappointment or emptiness-a feeling that there was something missing from the birth

a lack of confidence with mothering and an unawareness or rejection of your mothering instincts

hypervigilance in your care of your baby

feelings of failure, which can impact upon your general confidence in life

anger with partner (especially if you felt he should have rescued you, whether or not he really could). (easy target)

feeling so constricted by the trauma of the birth that you cannot fully express your love for your baby.

We would like to reiterate that these feelings occur across the board. They are not dependant upon how the baby arrived, or how fast or slow, or how the birth unfolded at every step of the way.

And we have found ourselves that women echo the same responses as each other, regardless of their personal story of birth, time and again.

It seems the main factors affecting how a woman will feel postnatally are how she feels during the birth.

This can be seen illustrated with some quotes from Birthtalk women...

"Initially, I was too overwhelmed by a newborn baby to think much about the birth, in fact, I tried not to think about it. Six months later, I realised I was devestated by my birth experience. I had failed to give birth to my baby, instead, I was delivered of my baby. The first action in my new career as mother had failed dismally. This affected my relationship with both my baby and my husband in a negative way. "

"It always seems to come down to the fact that you should be grateful that you and your baby are alive, but it's so much more than that. I felt I was intruded upon and treated like an incompetent pelvis/uterus, rather than a real person with feelings. It makes you feel like you have no self-worth."

"After my first birth, I was depressed, self-doubting and chronically sleep deprived. My situation became so bad that I was constantly aggressive towards my partner, and couldnt refer to my baby by name."

"Before I had my baby I believed that birth was going to be exciting and a fantastic journey through pain and pleasure and meeting my baby. After birth I felt that this expectation was totally wrong and although I felt this confusion that I had been robbed of this beautiful experience but I should just be grateful that all the experts were there to tell me what I and my baby needed at every moment. I felt guilty that I wasnt just grateful to everyone and that my baby was safe and that I shouldnt feel any concern for myself and how the process made me feel."

We now need to look at the flipside of the same coin. What are the consequences of a good birth? And is there such a thing?

NEW DEFINITION OF A GOOD EXPERIENCE OF BIRTH

A birth where a woman (and/or her partner) felt:

DURING THE LABOUR & BIRTH
empowered (ie that she was central to the experience, and was “doing? birth, not having birth “done? to her), safe, supported by those around her
respected, nurtured, able to ask Qs, that her expert knowledge about herself and her baby was acknowledged & respected

CONSEQUENCES
these feelings can lead postnatally to:
sense of completeness & fulfillment
high levels of confidence with mothering: the most capable person
to make decisions regarding her gorgeous little ones.
feelings of strength & capability
increased connection with partner
fulfilling bonding and relationship with baby

Here are some quotes from Birthtalk women who have moved on after a previous challenging birth and birthed again :

"All in all, I feel totally ...empowered by Clancy's birth. I feel like a woman again, and a mother too - as strange as that actually sounds!"

"We both felt blanketed in the warmest, most complete sense of peace and joy that I have ever experienced. .. A surreal combination of peace and joyful elation welcomed me to motherhood for the second time and carried me and my family through the first weeks of her life."

"I felt power I have never known. I felt strong, capable, loved and supported. Afterwards, I felt amazing and in awe of the little one who just flew out into the world as well as in awe of what my body could do. I am forever changed and have found my roaring voice"

So this then may challenge everything you may have thought about what defines a traumatic birth. Yes some births ARE clearly traumatic, with life-and-death situations arising. But even these can be dealt with in a way that couples can emerge stronger and surer of themselves, and ready for whatever lies ahead.

But it becomes clear that a challenging birth, a disturbing birth, a traumatic birth cannot be defined just by “what happened?. It must also be defined by “how the woman feels about what happened?. And that cannot be voiced by anyone but the woman herself.

This has impact for Health Professionals - we can’t look at a woman’s birth and tell how she feels about it. As Cheryl Beck says, in her article presented in Nursing Research journal, “Birth trauma lies in the eye of the beholder?.

And the same goes for partners who have been on their own road throughout the birth. It can be extremely difficult for a partner, especially if he himself is feeling fear, unacknowledgement & confusion during the event. And his perhaps completely different experience is likely to be as invalidated as the woman’s.

Of great concern is a study by Dr Debra Creedy, where it was found that 1 in 3 women identified a traumatic birthing event, and reported the presence of at least 3 trauma symptoms. That is at least 1 in 3 women are having abnormal births.

*As we have said earlier: the feelings of disappointment, grief, and trauma, are NOT part of what birth is designed to be. Experiencing birth as such is not normal, & actually largely avoidable.

I’ll say that again: not normal and it is largely avoidable.

Two of this afternoon's workshops will look at ways to try and avoid a bad experience of birth - by women having certain information and skills and by looking at achievable changes in the provision of care in our health system.

It is important to stress that a traumatic birth does not have to have any obvious dramatic situations in it. This ties in with our definition of a bad birth earlier, where we defined a bad birth as being one in which a woman feels certain things, which can occur over a vast array of birthing paths.

So why are so many women having traumatic or disturbing births? Especially if it is avoidable?

There are two answers to this question that we will focus on today. But to be able to answer them, we do need to look at a definition of a traumatic event, and what response warrants a diagnosis of PTSD, according to the Diagnostic and Statistical Manual of Mental Disorders.

The stressor or event that causes PTSD should involve actual or threatened death or serious injury, or damage to self or others. And the person’s response should involve intense fear, helplessness or horror.

So even if everything seems completely ok to an outsider during the birth, if a woman perceives that she or her baby is threatened with damage; or feels horror, fear and helplessness at a procedure that is routine to medical staff; she can experience that as a traumatic event. This is regardless of her level of pain relief at the time. It is regardless of the fact that she and her baby leave the hospital alive and physically healthy.

So the answer to the question: ‘why are so many women having traumatic or disturbing births? Is firstly this:

There is a great lack of emotional support for women and their partners as they negotiate the path to their child’s birth.

A supported woman who is feeling horror or fear can voice this, and have her fears acknowledged and processed with real information about what is happening. A supported woman perceiving danger can ask for more information, knowing she is in a trusting relationship with the person supporting her. An aware support person can also watch for any concerns and if she knows the couple more easily identify these concerns if they arise, knowing what the woman is like outside of labour. This person needs to be someone outside of her partner, as he himself may find he is in need of support too. This support needs to be ‘truly with woman’.

A study by Menage has indicated that it may not only be obstetric and gynaecological procedures that contribute to the experience of trauma, but also the roles of health professionals. The right support, then, can possibly greatly enhance how a couple experiences the birth of their child.

In fact, we want to point out here that the effect of birth trauma on the male partner is often not considered in the literature. But, as Dr Debra Creedy says partners may be particularly at risk of secondary traumatic stress. According to Figley, in an article titled, ‘Trauma and its Wake: Traumatic Stress Theory Research and Intervention’, when an individual observes another person suffering they may experience emotional responses parallel to that person's actual emotions. Secondary traumatic stress disorder is produced by exposure to, and out of concern for, a person experiencing primary traumatic stress.

But without the right support, it can be very hard for our partners to deduce what is happening to their wife and baby. Especially if he has to try and figure it out by, say, looking at the expression on the medical staff’s faces. His interpretation may be completely wrong...but if he has no one to check things out with, his own sense of powerlessness and intense fear may soar.

So support by a third party can be a vital part of having a better experience of birth.

So, we said we had two answers today to our initial question of why are so many women having traumatic or disturbing births.

For our second answer, we need to explore the very nature of childbirth itself. A woman in labour is extremely vulnerable, and reliant to a great part on those around her to keep her safe. It is not as if women can easily just get up and say, ‘No thanks, I am not happy with this situation. I think I’ll come back another day.’

Once a woman is in labour, she is exposed, open and vulnerable. And unable to remove herself from the situation. Many women express their birth trauma as akin to being raped, and you can see why, when put in this context. Feeling high levels of fear, feeling unacknowledged and disempowered, feeling as though things are being ‘done to’ her...and in some cases having things being done to her body without her consent..., and being unable to leave the situation...many women report to feeling ‘violated’ in their births.

Understanding this possible interpretation of the events unfolding is really important for us as women, partners, and health professionals.

And quite conflicting as well, as we have been taught to put our trust in the medical profession. As partners, in particular, it can be a struggle...do I just stand back and watch them do that to my wife? I am not a doctor, I know nothing about birth. I don’t want to risk her life, or my baby’s. I’d better just stand back.' A completely understandable response.

So again here compassionate support can be a real boon to the birthing woman and her partner.

Now of course, sometimes trauma occurs due to unforeseen dramatic circumstances, e.g. an unexpected situation like a haemorrhage resulting in a premature birth, or a baby that is definitely unwell and not coping with labour, which are frightening situations

Also, for some women the actual process of having caesarean surgery is traumatic - just the fact of being awake while someone is cutting you open is too confronting for many women to be able to process without support.

These situations are very real, and need acknowledging. But they can be processed. We will talk about this shortly.

However there are certain steps that can be taken to minimalise the feelings of helplessness and isolation from such an experience, allowing for it to be processed far more easily. And one of these is by having the appropriate support in the first place, so when a situation arises, the trauma will be greatly reduced due to the couple having correct information and understanding.

So we cannot reiterate enough, that support support support is what women need. From people who know the real definition of a good vs. bad experience of birth. From people who understand that birth has a purpose, and that there may be a lot that this woman has to grieve. And that partners may have an equal need to debrief and grieve as well.

And support is only one of the aspects that a woman can put in place to actively reduce the likelihood of a traumatic experience. Other aspects include the nature of the knowledge she has gathered about birth and our maternal health system, as well as her understanding of her needs and her ability to communicate them to her support people before and during the birth. Birthtalk offers education in all these aspects in our "Path to a Better Birth" meetings, ad we have seen many women learn, and grow, and then move on to wonderfully empowering experiences. It is possible - in any birthing situation - to emerge empowered, strong and ready for the next set of challenges and joys awaiting in parenthood.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington DC:Author, 1994

Menage, J. (1993) Post-Traumatic Stress Disorder in Women Who Have Undergone Obstetric and/or Gynaecological Procedures. Journal of Reproductive and Infant Psychology. 11: 221-228

Figley CR. Trauma and Its Wake : Traumatic Stress Theory Research and Intervention. New York:Bruner Mazel, 1986:39-54

Creedy, D. K (2000) Childbirth and the Development of Acute Trauma Symptoms: Incidence and Contributing Factors.
Birth. 27(2): 104 – 111