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Identifying post-traumatic stress disorder after childbirth

Linked practice.

It felt like my birth trauma had been forgotten

• Related content
• Peer review
• Pauline Slade , professor in clinical psychology , consultant clinical psychologist 1 ,
• Andrea Murphy , general practitioner and Liverpool Clinical Commissioning Group 2 ,
• Emma Hayden , expert by experience
• 1 Department of Primary Care and Mental Health, University of Liverpool, Liverpool, UK
• 2 Woolton House Medical Centre, Liverpool, UK
• Correspondence to P Slade pauline.slade{at}liverpool.ac.uk

What you need to know

One third of women experience giving birth as traumatic, and consequently 3-6% of all women giving birth develop postpartum post-traumatic stress disorder (PTSD), with many going undiagnosed

Healthcare providers should ask about birth trauma routinely. Recognising early responses to a traumatic birth and providing advice and support can reduce the risk of PTSD developing

PTSD is different from postpartum depression. Although both can occur simultaneously, they require different psychological treatments. Some cases of postpartum depression can be managed in primary care, but postpartum PTSD more commonly requires specialist maternal mental health referral

“My baby was in distress after a long labour, this resulted in a forceps delivery after which I haemorrhaged and sustained injury. As a new mother I felt frightened all the time, tearful and low, fearing danger around every corner. I was afraid to put my baby down to sleep, or to even walk down the stairs with my new son in my arms. I experienced nightmares and replayed the birth over in my head, wondering what could have happened differently and what I wish I could have changed. I had scary intrusive thoughts that I was concerned to disclose for fear of being judged a bad mother. I felt forever changed mentally and physically by the birth, and wondered if I would ever feel myself again. I loved being a mother and felt guilty that I was struggling. It was a very lonely time as there was no one to talk to who understood or could point me in the right direction for help. My husband knew I was struggling, but was at a loss to know what to do, so we both did our best to attempt to deal with things alone.”

One in three people will find giving birth a traumatic experience, with 3-6% going …

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• Research article
• Open access
• Published: 16 March 2021

Post-traumatic stress disorder following childbirth

• Deniz Ertan 1 , 2   na1 ,
• Coraline Hingray   ORCID: orcid.org/0000-0002-7665-3310 1 , 3   na1 ,
• Elena Burlacu 4 ,
• Aude Sterlé 4 &
• Wissam El-Hage   ORCID: orcid.org/0000-0003-3877-0855 4 , 5  

BMC Psychiatry volume  21 , Article number:  155 ( 2021 ) Cite this article

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Childbirth experience could be complicated and even traumatic. This study explored the possible risk factors for post-traumatic stress disorder following childbirth (PTSD-FC) in mothers and partners.

Through a cross-sectional online survey biographical, medical, psychological, obstetrical and trauma history data were collected. The PTSD-FC, postnatal depression, social support, and perceived mother-infant bond in 916 mothers and 64 partners were measured through self-reported psychometric assessments.

Our findings highlight the possible impact of several risk factors such as emergency childbirth, past traumatic experiences and distressing events during childbirth on PTSD-FC. The difficulties in mother-infant bond and the postpartum depression were highly associated with the total score of PTSD-FC symptoms for mothers. While for partners, post-partum depression was highly associated with the total score of PTSD-FC.

Conclusions

Our study demonstrated significant links between psychological, traumatic and birth-related risk factors as well as the perceived social support and the possible PTSD following childbirth in mothers and partners. Given that, a specific attention to PTSD-FC and psychological distress following childbirth should be given to mothers and their partners following childbirth.

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Introduction

Childbirth could be experienced as distressing or even traumatic for some women, which might produce undesirable marks on their lives. A traumatic childbirth could cause psychological distress, intense fear, or helplessness for the parturient and increases the risk of anxiety, depression and even post-traumatic stress disorder (PTSD) [ 1 , 2 ]. One study showed that about 45% of women experienced traumatic childbirth [ 3 ] and up to 4–6% of women developed PTSD following childbirth (PTSD-FC) [ 4 , 5 ]. Women who experience PTSD-FC might feel abandonment, guilt and helplessness. These feelings have direct impact on mother-child interactions and could cause important social isolation [ 6 ]. Moreover, couples relationships could be negatively affected by a traumatic childbirth experience and PTSD-FC symptoms [ 7 ]. During the postpartum, women could suffer from mental health disorders related to birth experience. The risk of postpartum depression, postpartum psychosis, and anxiety are increased after a complicated childbirth [ 8 , 9 , 10 ]. Moreover, postpartum is associated with increased risk of suicide, especially for women who suffer from post-partum depression [ 11 ]. One study showed that one of the non-medical leading causes of death for women during the postpartum is suicide [ 12 ]. In France, suicide is the second cause of post-partum death during 2013–2015 [ 13 ].

Several studies examined the risk factors for developing PTSD-FC [ 14 , 15 , 16 , 17 , 18 , 19 ]. Negative experiences and severe fear of childbirth [ 14 ], subjective distress [ 15 ], previous abortion [ 16 ], psychological difficulties in pregnancy (particularly depression in early pregnancy) [ 17 ], previous psychiatric problems [ 14 ], history of PTSD and trauma (particularly interpersonal violence) [ 14 ] are possible psychological risk factors for developing PTSD following childbirth. Several obstetric and birth-related factors such as pregnancy complications (e.g., labour and obstetrical emergencies) [ 15 , 19 ], modes of birth (e.g., emergency caesarean) [ 14 , 19 ] could also contribute to PTSD-FC in women. Additionally, different environmental factors like poor interaction between provider and mother [ 18 ], low social support during labour and birth [ 14 , 18 , 19 ] are associated with development of PTSD-FC.

The partners could also be affected by the childbirth experience. One recent study showed that unexpected events during pregnancy and the childbirth could cause a “rollercoaster of emotion” in partners [ 20 ]. On one hand, partners who feel more prepared for the possible complications during pregnancy and childbirth, who feel supported and included to the procedure have more positive experiences of childbirth [ 21 ]. On the other hand, partners who feel excluded, abandoned, unconfident during pregnancy and childbirth process, are more likely to develop distress and avoidance coping strategies [ 20 ]. Unplanned pregnancies, being less prepared, and higher trait anxiety are the possible risk factors for negative emotional experiences after childbirth in partners [ 20 , 22 ].

Birth trauma experiences do not affect only mothers but they also affect the relationship of mothers with their partners. Negative childbirth experiences have important short- and long-term consequences on the couples relationships and on the parent-child interactions [ 23 , 24 ]. Indeed, the state of well-being following childbirth both in mothers and their partners is critical for the child’s development [ 25 ]. Therefore, the mental health following childbirth constitute an important subject of research. Even though PTSD-FC is a very important topic, there is few research focusing on the possible PTSD following childbirth in mothers and also in partners. Our aim was to explore psychological, traumatic and birth-related factors for possible PTSD-FC in women and the partners. The purpose of this study was to examine the link between history of traumatic events, child loss, modes of birth, distressing childbirth, social support, perceived mother-infant bond, postnatal depression and symptoms of PTSD-FC. We expect to find differences between the modes of birth, the history of traumatic events, and that there is a relationship between postnatal depression, social support, perceived mother-infant bond and PTSD-FC.

We adopted a cross-sectional online questionnaire through a secure survey platform (Sphinx software), with a 9-month enrolment period. The study and consent procedures were approved by the ethics committee of the University (Comité d’Ethique de la Recherche Tours-Poitiers, n°2019-09-01). Online advertisement and snowballing were used to recruit participants. All participants endorsed an online informed consent and were subsequently directed to the online questionnaire. Measures were taken between 1-month to 12-months postpartum. Male or female participants completed the online survey assessing demographics, obstetric history, psychological history, birth experience, symptoms of anxiety, depression, PTSD, perceived parental bonding, and social support. Participants were instructed to answer about their experience during the birth of their most recent baby. They were asked about potential traumatic events during (or immediately after) the birth, and if they experienced post-traumatic symptoms related to this birth. The online procedure facilitated access to the study for a larger number of participants and also allowed participations based on the availability of subjects.

The exclusion criteria comprised: women who gave birth less than 1 month or more then 1 year ago; partners of women who gave birth less than 1 month or more than 1 year ago; persons under guardianship or curatorship; persons with difficulty to understand the informed consent form; participants who did not fill out the survey completely.

Biographical data were collected using sociodemographic questions, medical, psychological, obstetrical history, and traumatic life events. A self-reported psychometric assessment allowed to measure the PTSD-FC, postnatal depression, social support, and perceived mother-infant bond.

Sample description. The information regarding obstetric and birth-related history were collected through several questions such as the number of pregnancies, the number of children, the sex of the last child, the mode of the last birth – emergency caesarean, vaginal vacuum, vaginal (no instrument) and vaginal (forceps). We also investigated the experience of distressing events during childbirth by asking “Have you experienced particularly upsetting or traumatic event during childbirth?” We also asked if the participants have lost a child before (i.e., miscarriage, stillbirth, etc.). Moreover, we explored the history of other traumatic events by asking the participants if they have experienced a traumatic event in their lifetime (e.g., accident, natural disaster, illness, unexpected death, violent attack, or sexual abuse). If yes, they were asked to give a brief description of the traumatic event.

The City Birth Trauma Scale (CBTS) is a self-reported questionnaire developed by Ayers et al. (4) in response to the need for an instrument for assessing PTSD following childbirth [ 26 ]. This scale includes 31 items, 29 of which correspond to the diagnostic criteria for PTSD according to the DSM-5 (including intrusion, avoidance, negative cognition and mood, and hyperarousal), as well as additional questions to assess the subjective criterion and symptoms of emotional insensitivity [ 26 ]. Of the 31 items, 23 of them are based on a Likert-type scale (0 = not at all, to 3 = 5 or more times). The questionnaire has two subscales to evaluate general symptoms and birth-related symptoms (score range 0–69). The response scale for symptoms asks for frequency of symptoms over the last week. The highest score reveals a higher risk for PTSD. An additional questionnaire for partners was also developed. It helps identifying women and partners with PTSD-FC. The psychometric properties have been evaluated and validated by Ayers et al. (4) and replicated in Hebrew [ 27 ], Croatian [ 28 ] and Turkish [ 29 ]. The CBTS has shown good psychometric properties to detect symptoms of PTSD-FC. According to the study of Ayers et al., the reliability analyses of CBTS showed high internal consistency (Cronbach’s α = .92) [ 26 ]. In this study, a non-validated French version of CBTS was used. We also performed reliability analysis for CBTS total and subscales. Similar to previous studies, our results showed high internal consistency for CBTS total scale (α = .92), for CBTS birth related symptoms (α = .90) and CBTS global symptoms (α = .91).

The PTSD checklist for DSM-5 (PCL-5) is a questionnaire developed by Weathers et al., according to the diagnostic criteria of the DSM-5 [ 30 ]. The scale is composed of 20 items assessing the intensity of the 20 criteria for PTSD symptoms presented in the DSM-5. Responders were invited to respond a Likert-type scale (0 = not at all, to 4 = extremely) to evaluate the level of bother that they felt for each item during the past month [ 30 ]. This self-questionnaire was validated for the screening and monitoring of PTSD and validated in French [ 31 ]. Scores higher than 33 indicate provisional diagnosis of PTSD. High internal consistency was demonstrated for the French version of PCL-5 (Cronbach’s α = .94) [ 31 ] and in the present study (α = .94).

The Edinburgh Postnatal Depression Scale (EPDS) is a 10-item scale developed by Cox et al. [ 32 ] translated and validated in French [ 33 ]. Responders were invited to score each item from 0 to 3, which allows to assess depressive symptoms in the post-partum period. The scores range from 0 to 30. Score more than 10 indicates provisional diagnosis of depression. The Cronbach’s coefficient of .76 was demonstrated for the French version of EPDS [ 33 ]. Our results showed high internal consistency (α = .886).

The Medical Outcomes Study (MOS) is a 20 item-scale developed by Sherbourne & Stewart [ 34 ]. The items are divided into 4 categories to evaluate different types of support (emotional, tangible, affectionate and positive social interactions). Responders were invited to score (0 = none of the time, to 5 = all of the time) for each item in order to evaluate how often these different types of supports are available. The internal consistency was found high for MOS in the study of Sherbourne & Stewart (Cronbach’s α = .91) [ 34 ] and very high in our study (α = .958).

The Mother-to-Infant Bonding Scale (MIBS) is an eight item-questionnaire developed by Taylor et al. [ 35 ]. Each item refers to an adjective to evaluate the participants feelings towards their baby during the first week that follows childbirth. The items are based on Likert-type scale (0 = not at all, to 3 = very much). The scores range between 0 and 24. This scale assesses the perceived difficulties of the mother-child bond during the first weeks of the newborn’s life. It was validated in French [ 36 ]. The scale was also used with fathers to assess their bonding scores with their child [ 37 ]. The internal consistency was demonstrated for MIBS as acceptable in previous studies (Cronbach’s α = .71) [ 36 ] and high in the present study (α = .824).

Statistical analyses

Descriptive statistics were calculated for sociodemographic, medical, psychological, obstetrical characteristics as well as traumatic life events. The bivariate ANOVA tests were performed to test the group differences on the scores of CBTS total and subscales for mothers and for their partners separately (dependent variables). The tests were performed between groups who were either exposed to a potential risk factor or not (i.e., child loss, past traumatic experiences) or whether the different modes of birth differed (i.e., mode of birth, distressing childbirth). Regarding post hoc tests for ANOVA, we first performed multiple comparison between independent variables. We then performed the post hoc Tukey test when the Levene’s test for homogeneity of variances was non-significant, and the post hoc Games Howell test when the Levene’s test for homogeneity of variances was significant.

We also performed Bravais-Pearson correlations to calculate the bivariate associations between the MOS, the MIBS, the EPDS, the PCL-5, the CBTS total scale and subscales for mothers and for partners. The Bravais-Pearson correlations could allow us to explore the relationship between several biopsychosocial factors (i.e., depression, perceived social support, mother-infant bonding) and CBTS total and subscales (possible PTSD-FC). Descriptive and statistical analyses were performed using SPSS 24.0 software (IBM).

Of the 1093 entries, 980 participants completed the full questionnaire including all the assessments: 916 mothers and 64 partners were retained for analysis. Of the 916 mothers, 203 had a previous distressing childbirth, 465 had at least one traumatic event in their lives. Of the 64 partners, 7 had a previous distressing childbirth, and 23 had at least one traumatic event in their lives.

For the majority of the mothers, this was their first childbirth and majority of them had a vaginal birth. Postnatal depression measured using the EPDS revealed mean score for mothers above 10 points (below 10 for partners). The mothers to infant bond scale (MIBS) revealed low mean scores for mothers and for partners. The social support scale (MOS) mean score was found moderate in mothers and partners. The PTSD symptoms measured by the PCL-5 and the CBTS revealed mean scores below the cut-offs in both groups. The sample characteristics were presented in Table  1 .

For mothers

Correlation analyses.

We performed a correlation analysis on the study dimensions. We performed Bravais-Pearson correlations between the scores of the MOS, the MIBS, the EPDS, the PCL-5, the CBTS total scale and subscales for mothers. All correlations were significant. Low social support (MOS) was significantly correlated with higher scores at the CBTS total scale, the CBTS general symptoms subscale and the CBTS birth-related symptoms subscale. We found positive correlations between perceived mother-child bond and the CBTS total scale, the CBTS general symptoms subscale and CBTS birth-related symptoms subscale. Similarly, postnatal depression (EPDS) was significantly correlated with PTSD-FC as evaluated by the CBTS total scale, the CBTS general symptoms subscale and the CBTS birth-related symptoms subscale. Lastly, we found significant concordant results between the PCL-5 scores and the CBTS total scale, the CBTS general symptoms subscale and the CBTS birth-related symptoms subscale (Table  2 ).

One-way ANOVA tests

We performed bivariate ANOVAs to test the group differences between exposed and non-exposed mothers to a potential risk factor (i.e., trauma history, child loss), and whether the different modes of birth differed (i.e., mode of birth, distressing childbirth) on the scores of CBTS total and subscales. We found significant group differences for the mode of birth on CBTS birth-related symptoms (F (4,911) = 20.6, p  < .001, η 2  = .083), on CBTS general symptoms (F (4,911) = 4.1, p  < .005, η 2  = .018) and on CBTS total score (F (4,911) = 11.6, p < .001, η 2  = .049). Women who had an emergency caesarean had the highest scores on CBTS total score and on CBTS birth-related subscale. Women who had vaginal birth with vacuum and women who had vaginal birth with forceps had the second and the third highest scores on CBTS total and on CBTS birth-related symptoms subscale. In contrast, women who had vaginal birth without instrument had the lowest scores on CBTS total score and on CBTS birth-related symptoms. For general symptoms subscale, women who had emergency caesarean and vaginal vacuum had the highest scores. In contrast, women who had vaginal birth without instrument and forceps birth had the lowest scores in CBTS general symptoms subscale. In regard to the CBTS-BR scores, post hoc tests showed that women who had vaginal birth differed significantly from women who had emergency cesarean ( p  < .001, d = .791), vaginal vacuum ( p  < .002, d = .552), and forceps birth ( p  < .018, d = .477), while women who had emergency cesarean differed from women who had programmed cesarean ( p  < .001, d = .608). We found a medium effect size (η 2  = .083), so we can assume that 8.3% of the variance in CBTS-BR was a result of the type of birth. For the CBTS-GS scores, only women who had vaginal birth differed significantly from women who had emergency cesarean ( p  < .014, d = .297). There was a small effect size for the different modes of birth in regard to the CBTS-GS scores (η 2  = .018). Regarding the total score of CBTS, women who had vaginal birth differed significantly from women who had emergency cesarean ( p  < .001, d = .589) and vaginal vacuum ( p  < .011, d = .469). For this ANOVA test, we found a small effect size (η 2  = .049).

We also found a significant group differences for distressing events during childbirth on CBTS birth-related symptoms (F (1,914) = 106.5, p  < .001, η 2  = .104), on CBTS general symptoms (F (1,914) = 16.5, p  < .001, η 2  = .018) and on CBTS total scale (F (1,914) = 60.3, p  < .001, η 2  = .062). Women who had distressing events during childbirth had higher scores on CBTS total score and subscales compared to women who did not experience distressing events during childbirth. We found no significant group difference for history of child loss on the CBTS total scale and subscales. In contrast, we found a significant group differences for experiencing past traumatic events on CBTS general symptoms (F (1,914) = 6.8, p  < .01, η 2  = .007) and on CBTS total scale (F (1,914) = 8.4, p  < .005, η 2  = .009). Women who experienced past traumatic events had higher scores on CBTS general symptoms subscale and on CBTS total scale. However, no such difference was found for CBTS birth-related symptoms (F (1,914) = 5.636, p  = .018).

For partners

We also conducted the same correlation analysis on the study dimensions for partners. We found no significant correlation between social support (MOS) and CBTS total scale and subscales were found. In contrast, we found a positive correlation between perceived mother-child bond (MIB) and CBTS general symptoms as well as CBTS total symptoms. However, there were no significant correlation between MIB and CBTS birth-related symptoms. We found positive correlations between postnatal depression (EPDS) and CBTS total scale, CBTS birth-related symptoms and CBTS general symptoms. Consistently, PCL-5 symptoms were positively correlated to CBTS total scale, CBTS birth-related symptoms and CBTS general symptoms (Table  3 ).

We performed bivariate ANOVAs to test for group differences between exposed and non-exposed partners to a potential risk factor (i.e., trauma history, child loss), and whether the different modes of birth differed (i.e., mode of birth, distressing childbirth) on the scores of CBTS total and subscales. We found no significative results regarding CBTS total score for child loss (F (1,62) = .101, p  = .757) or distressing childbirth (F (1,62) = 1.654, p  = .203), but the differences in past trauma scores were significant (F (1,62) = 5.149, p  = .027, η 2  = .077).

Our aim was to explore psychological, traumatic and birth-related factors for possible PTSD-FC in women and the partners. Our findings highlight group differences concerning several risk factors such as emergency childbirth, past traumatic experiences and distressing events during childbirth on the development of PTSD following childbirth in mothers. Likewise, our results shows that the PTSD-FC are correlated positively with difficulties in mother-infant bond, scores of depression and correlated negatively with perceived social support.

Traumatic factors

Similar to earlier studies [ 14 , 38 , 39 , 40 , 41 , 42 , 43 ], our results showed that PTSD-FC symptoms were higher in mothers who priorly experienced a traumatic event compared to mothers who did not. For instance, a systematic review of risk factors for childbirth induced PTSD showed that previous exposure to trauma is an important risk factor for developing PTSD following childbirth [ 14 ]. Experiencing two or more traumatic events [ 43 ], history of sexual trauma [ 40 , 41 ], traumatic experiences during childhood [ 38 ] or childhood maltreatment [ 42 ] could increase the likelihood of developing PTSD following childbirth. These results showed that previous traumatic experiences have multiple roles during postpartum period by increasing the odds of future PTSD for mothers. One study highlighted the importance of resilience as a protective factor against possible PTSD-FC [ 42 ]. Mothers who are at greater risk for developing PTSD-FC could benefit from resilience-enhancing interventions [ 42 ]. Our results also showed that partners who experienced past traumatic events have significantly higher scores in CBTS total scale compared to partners who did not experience past traumas. These results highlight the past traumatic events as a factor increasing the likelihood of possible PTSD following childbirth in partners. Mental health of both parents is crucial for child’s development. It is therefore important to be vigilant about the traumatic background of mothers but also of their partners, while preparing for childbirth.

Birth-related factors

According to our results women who experienced childbirth as distressing had higher scores in PTSD-FC. We also found a significant group difference for the mode of birth on the scores of PTSD-FC. We found that women who had emergency caesarean were more vulnerable for developing PTSD-FC. Our findings are consistent with literature. According to several studies, birth complications and mode of birth are the factors associated with potential PTSD-FC [ 44 , 45 , 46 ]. Women who had emergency caesarean had higher risk of developing PTSD-FC compared to women who had vaginal birth [ 45 , 46 ]. According to a recent systematic review [ 19 ] emergency caesarean and labour pain are identified risk factors for negative childbirth experiences for women. Similar to emergency caesarean, several studies highlighted the risk for developing PTSD after a major surgery in adults and in children [ 47 , 48 , 49 ]. It is therefore important to give a particular attention to patients for possible distress and PTSD after major or emergency surgeries, to identify those who test positive and refer them for treatment, such as trauma-focused psychotherapy.

Biopsychosocial factors

We also examined the relationship between PTSD-FC and social support, PTSD symptoms, the quality of child-mother bond and the postnatal depression by focusing on birth-related PTSD symptoms and general PTSD symptoms in mothers and in partners. Our results demonstrated that mothers who had higher score in PCL-5 had also higher scores in CBTS total and subscales. These results highlights that the general PTSD symptoms are correlated with PTSD following childbirth.

Our results demonstrated that the difficulties in perceived child-mother bond and the postpartum depression were highly associated with birth-related PTSD symptoms, general PTSD symptoms and total score of PTSD-FC symptoms for mothers. Several studies showed a negative impact of PTSD on mother-infant relationship [ 50 , 51 , 52 , 53 ]. According to Davies et al. [ 50 ], mothers with PTSD symptoms have more negative maternal representations and they describe their babies as less warm and more invasive. Similarly, Parfitt & Ayers [ 51 ] found that symptoms of PTSD and depression have a negative impact on couples relationships as well as parent-infant bond. According to a recent study [ 53 ], PTSD and depressive symptoms have negative impact on infant-mother bond. However, in contrast to our findings, the authors did not find a correlation between the birth-related PTSD symptoms with mother-infant bonding [ 53 ]. Although, the authors demonstrated an indirect effect of general PTSD symptoms on mother-infant bonding via depressive symptoms [ 53 ].

Our results showed a positive correlation between depression and PTSD-FC symptoms for mothers. Several studies showed a high comorbidity between postnatal depression and PTSD following childbirth [ 23 , 54 ] In this light, Söderquist et al. [ 17 ] suggested that depression and PTSD might share the common vulnerabilities and risk factors. In addition, several studies showed that the depression is a significant predictor for post-partum PTSD symptoms [ 55 ].

We found a negative correlation for the social support and the symptoms of PTSD-FC for mothers. These results showed the importance of social support during pre- and post-partum period for mothers. One meta-analysis found that poor social support is one of the risk factors associated with PTSD-FC [ 54 ]. According to this study, the lack of social support in general is a vulnerability factor for developing PTSD-FC while the lack of support from medical staff is one of the risk factors during birth for PTSD-FC. Likewise, several studies showed the absence of social support associated with higher risk for developing PTSD symptoms following childbirth [ 41 , 56 , 57 ]. A recent systematic review [ 19 ] found that perceived control during labour as well as the strong partner support are the important protective factors to have a positive childbirth experience for mothers. We did not find a relationship between social support and PTSD-FC for partners.

Similar to mothers, we found that post-partum depression was highly associated with birth-related PTSD symptoms, general PTSD symptoms and PTSD-FC for partners. Consistent with our results, one study found a significant relationship between depressive symptoms and symptoms of PTSD (avoidance, intrusion, hyperarousal) in partners of women who gave birth. Another study found a positive correlation between depression and PTSD scores for partners who experienced pregnancy complications caused by preterm preeclampsia or preterm premature rupture of membranes [ 58 ].

We also found that partners who had more difficulties in parent-child bonding, had also higher scores in general PTSD symptoms and in PTSD-FC. Several studies showed that higher symptoms of depression and anxiety caused a poorer parent-baby interaction [ 51 , 59 ]. Likewise, according to previous scientific literature, the symptoms of PTSD and depression associated with lower quality of parent-baby bond [ 23 , 51 ].

Limitations

The current study has several limitations. First, the data of this study was obtained from an online survey and therefore our results should be interpreted with caution. Second, our findings for partners were limited by our small sample size. For this reason, our study population might not be representative. Overall, these limitations reveal some concerns about the generalizability of our data. The correlation analysis gave an important overview to understand the positive and negative associations between several variables, however it did not provide a causal relationship. It is therefore important to complete this study with further researches. The CBTS is a promising questionnaire to assess the PTSD-FC; however, the French versions of the CBTS were not yet validated, therefore it is important to interpret our results cautiously although reliability analysis in this study was promising. The current research was based on a cross-sectional retrospective study, therefore we remain prudent in the interpretation of our results. Further and larger longitudinal studies are needed to confirm our results. Thus, further studies are required to validate the French versions of the CBTS for mothers and partners, replicate our findings in a different population sample of women and at different time points across the postpartum period, include a larger sample of partners, and use structured diagnostic interviews in order to confirm our results using different methodological approaches.

Our study demonstrated significant links between psychological and traumatic risk factors as well as the perceived social support and PTSD following childbirth in mothers and partners. Given that, we should pay specific attention to possible PTSD following childbirth in mothers but also in their partners. A systematic screening for possible risk factors for developing PTSD-FC might be a beneficial approach to identify the most vulnerable mothers. Moreover, it is also important to inform mothers and their partners sooner rather than later for the possible complications during pregnancy and delivery in order to prepare them for pregnancy and childbirth. Therefore, it is important to conduct further studies that focus on potential PTSD following childbirth with the ultimate goal of identifying early interventions to implement on maternal and paternal PTSD-FC.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

PTSD checklist for DSM-5

Edinburgh Postnatal Depression Scale

Medical Outcomes Study

Mother-to-Infant Bonding Scale

City Birth Trauma Scale

Birth-related symptoms

General symptoms

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Acknowledgements

We would like to thank the many people who have helped us disseminating the survey link, namely Alison Ly Passieux (Alliance francophone pour l’accouchement respecté, AFAR), Antje Horsch, Lamyae Benzakour, Marie-Gabrielle Evanno (Docctissimo), Vania Sandoz, … the TV program ‘La maison des maternelles’, and different radio stations.

This study did not benefit from any research funding.

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Université de Lorraine, CNRS, CRAN, UMR 7039, Nancy, France

Deniz Ertan & Coraline Hingray

La Teppe, Tain l’Hermitage, France

Deniz Ertan

Pôle Hospitalo-Universitaire de Psychiatrie d’Adultes du Grand Nancy, Centre Psychothérapique de Nancy, Laxou, France

Coraline Hingray

CHRU de Tours, Centre Régional de Psychotraumatologie CVL, Tours, France

Elena Burlacu, Aude Sterlé & Wissam El-Hage

UMR 1253, iBrain, Université de Tours, Inserm, Tours, France

Wissam El-Hage

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Conception or design of the work (CH, EB, WEH). Data collection (AS, CH, EB, WEH). Data analysis and interpretation (DE, EB, WEH). Drafting the article (DE, CH, WEH). Critical revision of the article (CH, WEH). Final approval of the version to be published (AS, CH, DE, EB, WEH).

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The experiment, information and consent procedures were approved by the ethics committee of the University (Comité d’Ethique de la Recherche Tours-Poitiers, n°2019-09-01). All methods were performed in accordance with the Declaration of Helsinki and the relevant guidelines and regulations. All participants read an online information sheet and gave informed consent to participate before responding to the questionnaires.

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WEH reports personal fees from Air Liquide, Chugai, EISAI, Janssen, Lundbeck, Otsuka, Roche and UCB. CH reports personal fees from EISAI, Janssen, Lundbeck, Otsuka, Sanofi and UCB. The other authors declare that they have no competing interests.

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Ertan, D., Hingray, C., Burlacu, E. et al. Post-traumatic stress disorder following childbirth. BMC Psychiatry 21 , 155 (2021). https://doi.org/10.1186/s12888-021-03158-6

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Women’s descriptions of childbirth trauma relating to care provider actions and interactions

• Rachel Reed   ORCID: orcid.org/0000-0003-0979-2895 1 ,
• Rachael Sharman 1 &
• Christian Inglis 2  

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Many women experience psychological trauma during birth. A traumatic birth can impact on postnatal mental health and family relationships. It is important to understand how interpersonal factors influence women’s experience of trauma in order to inform the development of care that promotes optimal psychosocial outcomes.

As part of a large mixed methods study, 748 women completed an online survey and answered the question ‘describe the birth trauma experience, and what you found traumatising’. Data relating to care provider actions and interactions were analysed using a six-phase inductive thematic analysis process.

Four themes were identified in the data: ‘prioritising the care provider’s agenda’; ‘disregarding embodied knowledge’; ‘lies and threats’; and ‘violation’. Women felt that care providers prioritised their own agendas over the needs of the woman. This could result in unnecessary intervention as care providers attempted to alter the birth process to meet their own preferences. In some cases, women became learning resources for hospital staff to observe or practice on. Women’s own embodied knowledge about labour progress and fetal wellbeing was disregarded in favour of care provider’s clinical assessments. Care providers used lies and threats to coerce women into complying with procedures. In particular, these lies and threats related to the wellbeing of the baby. Women also described actions that were abusive and violent. For some women these actions triggered memories of sexual assault.

Care provider actions and interactions can influence women’s experience of trauma during birth. It is necessary to address interpersonal birth trauma on both a macro and micro level. Maternity service development and provision needs to be underpinned by a paradigm and framework that prioritises both the physical and emotional needs of women. Care providers require training and support to minimise interpersonal birth trauma.

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Around one third of women experience trauma whilst giving birth [ 1 , 2 ]. A traumatic birth experience is associated with postpartum mental health problems, including depression and post traumatic stress disorder [PTSD] [ 1 , 3 – 6 ]. Poor mental health in the postnatal period can alter a woman’s sense of self, and disrupt family relationships [ 7 – 10 ]. Difficulties with early mother-baby bonding can negatively influence a child’s social, emotional and mental development [ 11 ]. In addition, the experience of a traumatic birth can influence a woman’s future decisions regarding where, how, and with whom she gives birth [ 12 , 13 ]. For example, women may choose to birth at home to avoid repeating a traumatic hospital experience [ 14 ]. Jackson et al. [ 15 ] found that the decision to freebirth (give birth without a professional care provider) can be influenced by previous birth traumatic. Therefore, the consequences of a traumatic birth experience can be substantial and wide-ranging for women and their families.

Birth trauma has been associated with medical intervention and type of birth [ 5 , 16 , 17 ]. It has been defined as a perception of ‘actual or threatened injury or death to the mother or her baby’ [ 18 ]. However, Beck [ 19 ] argues that the perception of trauma is in the ‘eye of the beholder’, and should be defined by the woman experiencing it. Qualitative studies exploring women’s experiences of traumatic birth identify interactions with care providers as a more important factor than medical intervention or type of birth [ 20 – 23 ]. For example, a perceived lack of control and involvement in decision-making can contribute to the experience of trauma [ 21 , 23 ]. A study by Thomson and Downe [ 20 ] found that trauma was related to ‘fractured interpersonal relationships with caregivers’, and that women felt disconnected, helpless and isolated during birth. Whilst not all traumatic birth experiences result in PTSD, two quantitative meta-analyses identified that negative care provider interactions are a significant risk factor for PTSD [ 5 , 17 ]. A study by Harris and Ayers [ 24 ] also found that the strongest predictor of developing birth related PTSD was interpersonal difficulties with care providers, in particular experiencing a lack of support.

A recent Cochrane Review [ 25 ] concluded that women require improved emotional support during birth from their care providers to reduce the risk trauma. Health care professionals have an ethical, legal and professional obligation to provide safe and respectful care [ 26 – 28 ]. In order to improve care, it is important to understand what interactions and actions are associated with trauma [ 20 ]. This paper focuses on traumatic care provider actions and interactions from the perspective of the women experiencing them. The findings contribute to the body of literature examining women’s experiences of traumatic birth; and to an understanding of how care providers influence women’s perceptions of trauma. This paper presents a subset of findings from a large mixed methods study that investigated parental mental health following traumatic birth. The quantitative findings have not yet been published. The qualitative findings concerning paternal mental health are reported elsewhere [ 29 ]. This paper presents the qualitative findings relating to women’s descriptions of birth trauma involving care provider actions and interactions.

The mixed methods study involved parents completing an online survey, and additional face-to-face interviews with fathers [ 29 ]. The online survey included questions on demographics, descriptive birth assessments, parent-infant attachment, partner relationship quality, current mental health, and coping strategies used after the trauma. In addition, the survey incorporated a question about the experience of birth trauma with space for a written response. A qualitative approach was taken to explore women’s written descriptions of trauma. The area of interest in this aspect of the study was women’s experiences of trauma, rather than outcomes associated with trauma. The majority of qualitative data related to care provider actions and interactions, and this paper presents themes relating to this data.

Participant recruitment

Participants were recruited via online social media forums such as Facebook, Twitter and a midwife’s blog site. Inclusion criteria was that participants were over 18 and had experienced a traumatic birth. A definition of a traumatic birth was not provided in order to capture what participants themselves considered’trauma’ [ 19 ]. There was no exclusion criterion for time since the birth, as women’s memories of childbirth remain strong over time [ 30 ]. Participant information detailing the research question and aims was provided on the first page of the online survey. In order to obtain consent, participants were required to read an online consent form and ‘click’ agree prior to accessing the survey.

Data collection

After consenting to participate, participants completed an online survey administered through the program Survey Monkey. The survey included demographics (eg. age, relationship status) and information such as type of birth (eg. caesarean, vaginal); place of birth (eg. public hospital, home); and admission of baby to special care (Table  1 ). The quantitative element of the study comprised of a number of psychological assessment tools: Maternal Postnatal Attachment [ 31 ]; Quality of Marriage Index [ 32 ]; Depression Anxiety Stress Scale-21 [ 33 ]; Posttraumatic Stress Disorder Checklist-5 [ 34 ]; and The Brief Cope index [ 35 ]. The qualitative element of the study involved women responding in their own words to the question ‘describe the birth trauma experience, and what you found traumatising’. The mean length of written responses was 69 words.

Data analysis

Women’s descriptions of trauma were analysed using a six-phase inductive thematic analysis process described by Braun and Clarke [ 36 ]. Phase one involved becoming familiar with the data by reading and re-reading; and noting initial ideas. In phase two initial codes were generated and data relevant to each code was collated. Phase three of the process involved collating the codes into potential themes. These themes were reviewed in phase four to ensure they were consistent in the coded extracts and across the entire data set. In phase five themes were defined and named using words and phrases. Phase six involved selecting extract examples to illustrate the themes, and relating the analysis to the research question and the literature. Three researchers participated in the thematic analysis process to ensure consistency in analysis and findings.

A total of 943 women completed the online survey from around the world. The majority of participants were from Australia and Oceania (36.8%), North America (34.2%) and Europe (25.5%). A small number of participants were from South America (2.1%), Asia (0.9%), South Africa (0.5%) and the Middle East (0.2%) (Table  1 ). The majority of participants gave birth in a public hospital (69%) and either had an unplanned caesarean (37%), or an unassisted vaginal birth (34.3%) (Table  1 ). In addition, 34.4% of participants reported that their baby was admitted to special care nursery.

Of the 943 participants, 748 (79%) responded to the qualitative question ‘describe the birth trauma and what you found traumatising’. A third of respondents described events such as premature labour, haemorrhage or concerns regarding their baby’s wellbeing. However, the majority (66.7%) described care provider actions and interactions as the traumatic element in their experience. From the data relating to interpersonal factors, four overarching themes were identified from the descriptions. The themes are presented below with illustrative data using the participants’ own words, therefore spelling and grammar varies. The term ‘care provider’ is used to refer to the professional responsible for the woman’s care. In the women’s accounts care providers included obstetricians, midwives and nurses.

Prioritising the care provider’s agenda

Women described how care providers prioritised their own agenda over the needs of the woman. In some cases it was made clear to women that their labour was keeping the care provider from something, or someplace they would rather be:

I found my OB’s lip service to my wishes and then his switch against them traumatic. I found the comment “let’s get this over and done with, I have a golf game to get to” traumatic… (045) … after an OB coming in and telling me that she would like me to deliver by 5 pm because she wanted to go home, I just burst in to tears… (549)

Women felt that they were subjected to unnecessary and unwanted medical interventions in order to meet the needs of their care providers:

I begged not to have a c section, neither I nor my baby were in distress or danger, but because the doctor was ready to go home, he did a terrible section that resulted in almost a year of recovery. (220) I was steamrolled with unnecessary intervention and didn’t get to speak with a doctor about my options, risks vs benefits… I feel like the nurses, doctors and hospital only did what was in their best interest, not mine… It was a nightmare. (381)

Some women described how they became a learning resource for the benefit of hospital staff. For example, care providers offered other staff the opportunity to practice without seeking women’s permission:

… the doctor asked a student nurse, first day on the job, if she wanted to suture my episiotomy incision. (644) … 20 people in theatre and half were sitting down on phones and chatting away while I had someone training with forceps on me… (867)

One woman described feeling like she “… was part of an experiment” (565) rather than a woman giving birth. In particular, women experiencing unusual births became a spectacle for others to watch:

… I was a looking point for students and anyone who hoped to witness a twin vaginal birth and a breech birth. (523)

One woman wrote about how the room filled with staff hoping to watch her give birth to her breech baby:

… and the amount of people that filled the room to watch a vaginal breech delivery, when I failed at this, everyone left. (662)

When she was unable to provide this learning opportunity she no longer warranted being an object of observation. The value of her birth experience for others appeared to be based on what she could provide in terms of a learning experience.

Disregarding embodied knowledge

Many of the descriptions involved women’s own embodied knowledge being disregarded in favour of their care provider’s assessment of events:

… I felt like I was being told I was silly for thinking I was in labour and that this awful pain was nothing to be worried about. My opinion was dismissed and ignored as I was just a first timer… (436)

In particular ‘being in labour’ was a contested area. Women’s perceptions of being in labour were based on their embodied experience, whereas care provider’s perceptions were based on clinical findings. For example, one woman was considered to ‘not be in labour’ because her cervix was not dilating according to care provider’s expectations:

Hospital staff did not listen to me, didn’t trust me to know my body. Dismissed me as a first time mother who was over reacting. In actual fact I dilated from 0 to 6 in just over an hour. The hospital midwives told me that I was just feeling the period pain associated with early labour and induction… (485)

Another woman described how her midwife determined she was not contracting, therefore not in labour, based on an abdominal palpation:

Was going into premature labour and midwife palpated during a contraction and stated I was not having them. Eventually went into labour as they ignored me… Although not traumatic in medical terms, felt completely disgruntled that my journey was not taken on own merits and was completely ignored as a woman during labour. (061)

Both of these women considered themselves to be in labour, and having their embodied knowledge disregarded was traumatic.

Embodied knowledge was also dismissed when women experienced an urge to push before care providers considered it appropriate. Women were instructed to ignore what was happening in their body and stop pushing:

Told to stop pushing and… being told what to do when my body was telling me differently. (248) Being told to stop pushing when baby was clearly on its way. Being told I had a long way to go when baby was on the way out. (436)

Care providers used clinical assessments (vaginal examinations) to determine whether pushing was appropriate. Based on the findings of these clinical assessments women were ordered to over-ride their own bodily urges:

… I had the strongest urge to push, the midwife on staff insisted on an internal examination to check dilation, she told me if I pushed now I would end up with an emergency caesarean due to my cervix swelling. She then spent the next hour yelling at me not to push and trying to talk me into an epidural (I was trying my hardest to not push but my body kept taking over). I was begging to be allowed to push…. (932)

In some cases women described feeling that the wellbeing of their baby was in danger. When they attempted to alert care providers their embodied knowledge was disregarded:

… I felt like everything was going wrong and found that distressing. I felt like people didn’t believe me when I said something didn’t feel right. (851) … My baby was in distress and had mec liquor and in all honesty probably should’ve been sectioned, at this stage I was begging for one as I knew something was wrong with my baby but they refused… (732)

In these descriptions women’s own assessment of labour progress and fetal wellbeing was not valued or acted on which caused trauma.

Lies and threats

Women perceived that they were being lied to by care providers to coerce them into agreeing to unnecessary interventions:

It was not the birth itself that I found traumatic, rather the way we were treated by the midwife. Being lied to in order to speed up my labour unnecessarily and putting me and my baby at risk. (015) All of this is avoidable and unnecessary, if only we had known… I was forced into interventions that I believed were unnecessary. I was also lied to many times by the doctors. (857)

They also described how care providers threatened them in order to coerce them into undergoing procedures:

My daughter was breech… I was told that if I didn’t consent to the cesarean before labor started then they would perform a cesarean without my consent under general anesthesia when I arrived (267).

In this case, the woman was threatened with surgery against her wishes. Other women were threatened with having their baby taken from them if they did not comply with proposed interventions:

Psychological coercion - ie “if you do not consent to syntocin OR a c-section then we can get our friend the psych registrar down here to section you - then we can do whatever we want to you but you may not be able to keep your baby” - All I wanted was to let my body go into labour naturally - my baby was not in distress… (186) I was bullied into an induction late on a Sunday night and then told I would be kept over night. I wasn’t aware when I finally agreed to be induced after quite some time of being threatened with DoCS [Department of Child Safety] etc. (400)

The most common threats described by women related to the wellbeing of the baby. Some women used the term ‘dead baby threat’ to describe how they were coerced, for example: “dead baby threats to gain consent…” (860); and “forced into c section with dead baby threat…” (223). Some care providers asked women if they wanted their baby to die when they declined an intervention:

…Being bullied into interventions with such wording the following: “Do you want a dead baby?”… (919)

Women felt that care providers were lying about the risks to the baby in order to pressure them into complying. They did not believe their babies were in danger, and in some cases had evidence that their care provider’s assessment was incorrect:

…I was basically told that if I didn’t have a c-section on their timetable I would kill my baby, even though they couldn’t tell me what exactly was “wrong” as to why I was not delivering vaginally… They broke me down gradually until they declared my baby was “in distress” (she wasn’t… I could see the screens). (559) … Lots of coercion and being told my baby would die if I didn’t consent to the c-section. She was born with apgars of 9 and 9. (194)

Being lied to and threatened contributed to the experience of trauma, particularly when it involved the wellbeing of the baby.

Many women described their birth experience as ‘violating’. A lack of control appeared to be associated with a sense of violation. For example, one woman described that she felt “…out of control and violated” (660). In these descriptions, care providers carried out actions against the explicit wishes of the woman:

…All in all, I felt very bullied, and even violated… It was the feeling of disempowerment and not having the right to do with my body what I wished - and that someone else could force me to do something against my will. (731) I felt violated, and angry that I should have to defend myself and my body while I was trying to push my baby out. (733)

The descriptions of what care providers did to women were, in many cases, graphic and violent. For example, one woman wrote “…couldn’t be tubed nurses manually choked me out” (490). Another wrote that she was “… assaulted vaginally by medical staff during crowning” (295). These descriptions focused on the manner in which the care provider acted, in addition to their actions:

… She was very rude and condescending, both to myself and to my midwife. She proceeded to dig out my uterus without any numbing medication. It was horrifying… (431) …The pain was not the traumatic bit, it was the way that I was treated during my labour. I was 20 years old. I had more midwives than I can count, attempt an internal examination and one yelled at me to ‘relax!’ because she couldn’t force her fingers in. She was a bloody bitch to put it lightly. (256)

One woman described how her obstetrician assaulted her to gain her compliance to induce labour:

She said she wanted to do one more cervical check. I consented and when she did it, she grabbed my cervix and pinched it. She would not let go until I consented to letting her break my water. I was in tears from the pain, screaming, begging and sobbing for her to let go and get her hand out of my vagina. She would not let go until I consented, which I finally did. (997)

A number of women described how they screamed ‘no’ as care providers carried out procedures. For example, one woman told her care provider “expressively” that she “didn’t want any vaginal examinations” (413). Her care provider persuaded her to have a vaginal examination telling her that they “would be very gentle and would stop if it was too much”. However her wishes were not respected during the examination:

I was crying and screaming in pain telling her no and to stop and she carried on, my husband shouted at her to leave me alone and she carried on. (413)

Another woman described how her doctor failed to respond to direct requests, and then to screams for her to stop:

The doctor would not get her fingers out of my vagina even when directly told. After it was discovered that I suffered tearing, I wanted the tearing to be healed on its own - no stitches, but she and another doctor stitched anyway, despite my screaming at them to stop. (445)

In addition, some women wrote about being ‘held down’ while care providers carried out procedures against their will:

…Being pinned down by 4 midwives (forcing an unnecessary oxygen mask on me just so my screams of ‘no’ were muffled) and my husband so the consultant could examine me against my will. (888) …At one point, 3 nurses physically held me down despite my protests that I couldn't breathe and needed a minute to catch my breath before the procedure (AROM). They held me down until the doctor was finished… (491)

Women described how equipment tethered or tied them to the bed during labour: “was tethered to the bed during an induction…” (328), and “I was tied to the bed, forced to lay on my back…” (418). Women experienced being forced into birth positions: “screaming, lots of people, nurses forcing me down and ripping my legs open…” (565). In particular, care providers made women lie on their backs:

During birth, multiple nurses screamed in my face “PUSH!!!” and flipped me onto my back and forced my legs open, holding me down… (414)

In describing their experiences women used words such as “humiliating” (561); “belittled” (520); “brutal and barbaric” (132). Some described “being treated like a piece of meat” (979), or an animal:

…I was treated like a cow having trouble calving, and felt abused and humiliated. (222)

A number of women used language associated with sexual assault and rape, writing that they felt: “…raped and mutilated” (376), “… violated and damaged” (119), “…violated and scared and disgusting” (423). Women who had previously experienced sexual abuse or rape described how the actions of care providers triggered distressing memories:

…my cervix was manually dilated forcefully after pleading for the Dr. to stop. This caused me to re-experience a previous rape. Later in my birth my Dr. performed a deep episiotomy after being told repeatedly that I did not want one… Images and fears from my past sexual abuse/assaults became constant in my mind after birth. (057) …the whole experience was made worse as it triggered my post traumatic stress that related to gang rape in my teens. (444)

One woman felt that her birth experience was more traumatising than her experience of sexual abuse as a child:

…The most terrifying part of whole ordeal was being held down by 4 people and my genitals being touched and probed repeatedly without permission and no say in the matter, this is called rape, except when you are giving birth. My daughter’s birth was more sexually traumatising than the childhood abuse I’d experienced… (201)

This study described women’s experiences of birth trauma. The data set was large, and women recounted similar experiences across different birth settings and cultural contexts. The findings contribute to an understanding of birth trauma from the perspective of women experiencing it. Whilst non-interpersonal factors contributed to trauma, the majority of descriptions involved care provider actions and interactions. These findings are consistent with other studies that identify the relationship between the care provider and the woman as critical to the birth experience [ 20 , 21 , 37 ]. Whilst care providers may consider their actions and interactions to be routine, some woman experience them as traumatic [ 19 ]. Therefore, it is vital that care providers understand how their practice influences the psychological and emotional experience of birth, in addition to the physical outcome of birth.

In this study women described how care providers priorised their own agendas over the needs of the woman. This approach to practice is contrary to global standards regarding woman-centred maternity services [ 26 , 38 ]. In addition, women felt that this resulted in unnecessary interventions, as care providers attempted to alter the birth process to fit their agenda. There is global concern regarding the increase in unnecessary medical intervention during birth [ 39 , 40 ]. Therefore, this phenomena needs to be further examined as a possible contributing factor. In some cases, women in the study described how hospital staff observed or practiced on them to facilitate their learning. Whilst clinical learning is an important element of professional development, further research is needed to examine women’s experience of participation in these activities.

Women reported that their embodied knowledge about labour onset, progress, and fetal wellbeing was disregarded in favour of their care provider’s clinical evaluation. The clinical diagnosis of labour onset usually involves the assessment of contraction pattern and cervical dilatation [ 41 ]. However, this evaluation can conflict with women’s own perceptions regarding the onset of their labour [ 42 , 43 ], causing distress [ 44 – 48 ]. Contradictory perceptions of progress can also occur during the expulsive phase of labour when women experience an uncontrollable urge to push [ 49 ]. Being instructed to resist the urge to push can be distressing for women [ 50 , 51 ]. In this study, instructions to stop pushing were based on assumptions regarding normal labour timeframes, and on vaginal examinations. However, there is increasing debate in the literature regarding the accuracy of prescribed timeframes [ 52 ]; the efficacy of vaginal examinations [ 53 ]; and how clinical assessments relate to women’s experience of birth [ 49 , 54 , 55 ]. Whilst further research is necessary to examine women’s embodied knowledge of fetal wellbeing during labour, dismissal of women’s concerns has been found to contribute to the experience of trauma [ 56 ].

Consent is an important legal and ethical principle in health care [ 57 ]. For consent to be valid it must be voluntarily and feely given; the person consenting must not be under any undue influence or coercion; and there must be no misrepresentation as to the nature or necessity of the procedure. However, women in the study described being lied to, and threatened in order to gain their agreement for procedures. In particular, lies and threats centred on the wellbeing of the baby, and some women referred to this as ‘the dead baby threat’. Bohren et al. [ 56 ] also found that care providers threatened women regarding the safety of their baby in order to ensure they complied during labour. In addition, women in this study were threatened with being reported to child safety services if they did not agree to proposed procedures. Other studies have identified that women choosing birth options outside of the norm, such as freebirth, or homebirth after a caesarean, can experience threats relating to the safety of their baby, and of being reported to child safety agencies [ 13 , 58 ].

Women’s accounts of birth trauma often included violence and physical abuse. Unfortunately these findings are not unique, and the World Health Organization [ 38 ] reports that many women worldwide experience disrespectful, abusive or neglectful treatment within maternity services. This phenomena has resulted in the introduction of the legal term ‘obstetric violence’ in some countries [ 59 ]. Women in the study used language associated with sexual assault and rape. Beck [ 19 ] also found that women likened the actions of care providers to rape; and Elmir et al. [ 21 ] noted that women used the term ‘birth rape’ to describe experiences of obstetric violence. Kitzinger [ 60 ] suggests that women who experience a traumatic birth display similar symptoms to rape survivors. In addition, women who have a history of sexual abuse or rape can have memories triggered by their care provider’s actions and interactions [ 19 ]. Montgomery et al. [ 61 ] carried out a study exploring the experience of birth for women with a history of childhood sexual abuse. They found it was not the intimate procedures themselves that triggered abuse memories. Instead, it was the manner in which the procedures were carried out. Actions and words that reduced a woman’s sense of control, and disempowered her could result in a ‘re-enactment of abuse’. These findings are consistent with this study, whereby descriptions of trauma focused on the manner in which actions were carried out, rather than on the physical procedures themselves.

A systematic review concluded that whilst the mistreatment of women in labour occurs at the level of care provider interactions, it is influenced by systematic failures at the health facility and health system level [ 56 ]. Current health systems are underpinned by a technocratic, biomedical paradigm in which the patient is considered passive, and authority and responsibility are inherent in the practitioner [ 62 ]. The power dynamics operating within this paradigm contribute to legitimising the control that care providers have over women, and subsequently to mistreatment [ 56 ]. Risk aversion and the avoidance of litigation is also a key component that influences care provider’s practice within the current technocratic maternity system [ 63 – 65 ]. However, concerns about litigation focus on perceived risks to physical outcomes for mothers and babies, rather than on psychosocial impacts of care [ 63 – 65 ].

Wagner [ 66 ] argues that dehumanising practices are so pervasive within maternity services, that care providers are unable to perceive them. He uses the analogy of fish being unable to see the water they swim in, to describe this phenomenon. This notion is supported by Bohern et al.’s [ 56 ] review that found some care providers consider the mistreatment of women to be normal. However, some care providers are cognisant of the paradigm in which they operate. In particular, research has demonstrated that midwives are often aware of an inherent conflict between woman-centred care, and the needs of the technocratic maternity system [ 67 – 69 ]. Midwives consciously adjust their practice to meet the cultural needs of the facilities in which they work in order to protect themselves professionally [ 67 – 69 ]. However, this results in what Hunter calls ‘emotional work’, as midwives practice in ways that are contradictory to their own woman-centred philosophy [ 68 ]. In addition, a recent study [ 70 ] found that midwives who witness interpersonal birth trauma can experience trauma themselves. The researchers suggest that witnessing this type of trauma may be perceived as a threat to their sense of personal and professional integrity.

Addressing interpersonal related birth trauma will require a multifold response on both a macro and micro level. Davis-Floyd [ 62 ] suggests that more effective woman-centred care can be delivered by combining humanism and holism with the current technocratic approach. However, this will require a cultural paradigm shift to support the evolution of such an approach. The World Health Organization recommends that five key actions should be taken to develop and sustain respectful maternity care for all women [ 38 ]. Firstly, greater support from governments and development partners for research and action on disrespect and abuse. Secondly, initiation and support of programs designed to improve the quality of maternal health care, with a strong focus on respectful care as an essential component of quality care. Thirdly, emphasising the rights of women to dignified, respectful care throughout their childbearing experience. Fourthly, the generation of data relating to respectful and disrespectful care practices, systems of accountability and meaningful professional support. Finally, the involvement of all stakeholders, including women, in efforts to improve quality care and eliminate disrespectful and abusive practices. In addition, it can be argued that the current risk discourse needs to be expanded to include psychosocial risk in addition to physical risk. On a micro level, Fenech and Thomson [ 7 ] suggest that care providers require training to develop their ability to prevent and identify trauma, and to respond sensitively to women’s emotional concerns.

Limitations

The study was a cross-sectional qualitative study, therefore cannot establish cause and effect. There was a lack of representation across many countries with participants mainly from Australia and Oceania, North America, and Europe, and findings cannot be generalised globally. In addition, the data consisted of short written descriptions within a larger quantitative survey. In-depth qualitative accounts elicited by participant interviews may have enriched theme development.

In this study women’s descriptions of childbirth trauma centred on the actions and interactions of care providers. Women described how care providers prioritised their own agendas; disregarded embodied knowledge; used lies and threats to gain compliance; and violated them. Findings contribute to the growing body of literature relating to women’s experiences of traumatic birth. Interpersonal birth trauma is becoming increasingly recognised as a global issue, and measures are required to address it. Recommendations include changing the current technocratic paradigm by including holistic and humanistic approaches to care delivery. Maternity service provision needs to be underpinned by the World Health Organization’s ‘five actions’ [ 38 ] to develop, promote and sustain respectful woman-centred care. Care providers require training and support to understand, value, and practice in ways that optimise psychological outcomes for women.

Abbreviations

Post traumatic stress disorder

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Acknowledgements

The women who shared their experiences in the study. Jessie Johnson-Cash (Lecturer) who assisted with the data analysis.

No funding was received for this study.

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Authors’ contributions

The contribution to authorship is as follows: CI designed the study and collected data supervised by RS and RR as part of an Honours study, and reviewed the analysis and the paper. RR analysed the data and drafted the initial paper. RS analysed the data and contributed to writing the paper. All authors read and approved the final manuscript.

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Ethical approval for the study was gained via the University of the Sunshine Coast Human Research Ethics Committee (USC Ethics Approval No. S/14/590). The consent form in the online survey included information and contact details for support groups, and mental health professionals. Data were de-identifed at the point of the online survey and participants were allocated a code.

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Reed, R., Sharman, R. & Inglis, C. Women’s descriptions of childbirth trauma relating to care provider actions and interactions. BMC Pregnancy Childbirth 17 , 21 (2017). https://doi.org/10.1186/s12884-016-1197-0

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Received : 12 March 2016

Accepted : 13 December 2016

Published : 10 January 2017

DOI : https://doi.org/10.1186/s12884-016-1197-0

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Women's experiences of birth trauma: A scoping review

Affiliations.

• 1 School of Nursing and Midwifery, Monash University, Frankston, Victoria, Australia; Women's, Children's and Adolescent Health, Peninsula Health, Frankston, Victoria, Australia. Electronic address: [email protected].
• 2 Women's, Children's and Adolescent Health, Peninsula Health, Frankston, Victoria, Australia.
• 3 School of Nursing and Midwifery, Monash University, Frankston, Victoria, Australia; Australian Research Centre in Complementary and Integrative Medicine (ARCCIM), University of Technology Sydney, Sydney, NSW, Australia.
• 4 School of Primary and Allied Health Care, Monash University, Frankston, Victoria, Australia.
• PMID: 33020046
• DOI: 10.1016/j.wombi.2020.09.016

Background: A high number of Australian women report experiencing traumatic birth events. Despite high incidence and potential wide spread and long-lasting effects, birth trauma is poorly recognised and insufficiently treated. Birth trauma can trigger ongoing psychosocial symptoms for women, including anxiety, tokophobia, bonding difficulties, relationship issues and PTSD. Additionally, women's future fertility choices can be inhibited by birth trauma.

Aim: To summarize the existing literature to provide insight into women's experiences of birth trauma unrelated to a specific pre-existing obstetric or contextual factor.

Methods: The review follows 5 stages of Arksey and O'Malley's framework. 7 databases were searched using indexed terms and boolen operators. Data searching identified 1354 records, 5 studies met inclusion criteria.

Findings: Three key themes emerged; (1) health care providers and the maternity care system. (2) Women's sense of knowing and control. (3) Support.

Discussion: Continuity of carer creates the foundations for facilitative interactions between care provider and woman which increases the likelihood of a positive birth experience. Women are able to gain a sense of feeling informed and being in control when empowering and individualized care is offered. Functional social supports and forms of debriefing promotes psychological processing and can enable post traumatic growth.

Conclusion: Existing literature highlights how birth trauma is strongly influenced by negative health care provider interactions and dysfunctional operation of the maternity care system. A lack of education and support limited informed decision-making, resulting in feelings of losing control and powerlessness which contributes to women's trauma. Insufficient support further compounds women's experiences.

Keywords: Birth; Birth trauma; Post-traumatic stress disorders; Scoping review; Trauma; Women.

Copyright © 2020 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.

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Subsequent childbirth after previous traumatic birth experience: women's choices and evaluations

Annaleena Holopainen

PhD candidate, clinical child and family studies, Vrije Universiteit Amsterdam

View articles · Email Annaleena

Claire Stramrood

Post-doctoral researcher, department of obstetrics and gynaecology, OLVG, Amsterdam

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Mariëlle G van Pampus

Gynaecologist, department of obstetrics and gynaecology, OLVG, Amsterdam

Martine Hollander

Gynaecologist, department of obstetrics, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen

Carlo Schuengel

Full professor, clinical child and family studies, Vrije Universiteit Amsterdam

After a traumatic childbirth experience, women are often afraid of future pregnancies, and may be at risk for also experiencing their subsequent childbirth as traumatic.

Two questions were investigated regarding women's experience of their subsequent childbirth after a previous traumatic birth: (1) which factors in the previous traumatic birth are associated with the subsequent childbirth experience, and (2) fear of childbirth and coping behaviour during the subsequent pregnancy associated with the subsequent birth experience.

A total 474 Dutch women (mean age during traumatic childbirth=28.9 years; SD=3.9) answered an online survey about their previous traumatic and subsequent birth experience.

Making a birth plan, choosing a home birth in a high-risk pregnancy, and having a planned caesarean section emerged as statistically significant correlates of positive subsequent birth experience.

Experiencing control over the subsequent birth might underlie practices associated with more positive subsequent childbirth experience among women with a traumatic childbirth history.

A sizable minority (10%–20%) of women describe their childbirth as a traumatic experience and have long-lasting negative memories of it ( Olde et al, 2005 ; Bossano et al, 2017 ; Rijnders, 2011 ; Stramrood et al, 2011 ). Still, many women choose to give birth again. Previous research has aimed to understand what women actually mean by a traumatic childbirth experience. Answers include, for example, feeling neglected and experiencing loss of control during the birth, fear for their own or their baby's life, and a bad outcome ( Beck, 2004 ; Thomson and Downe, 2008 ; Elmir et al, 2010 ; Henriksen et al, 2017 ; Hollander et al, 2017b ). Traumatic birth experiences are therefore highly personal and subjective ( Beck, 2004 ; Stramrood and Slade, 2017 ), meaning that a birth that seems normal and straightforward to a provider may be experienced as traumatic by the woman ( Thomson and Downe, 2008 ).

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Birth trauma research

It is clear from a number of sources that traumatic birth experiences (which are experienced differently from person to person, of course) can significantly affect a mother’s experiences, well being and mental health.

This is the starting point taken by a number of groups of researchers. This blog post contains discussion of some of the key studies on this topic, which I have shared and discussed in my Birth Information Update . These papers contain links to many others for those who would like to explore birth trauma further.

Defining birth trauma

The most recent study that I have written about is an important discussion paper on the topic of developing a woman-centered, inclusive definition of traumatic childbirth experiences.

Published in Birth: Issues in Perinatal Care, Leinweber et al (2022) set out the problem:

“Many women experience giving birth as traumatic. Although women’s subjective experiences of trauma are considered the most important, currently there is no clear inclusive definition of a traumatic birth to help guide practice, education, and research.”

The issue of subjectivity

This lack of a clear definition is often an issue when we try to research subjective experiences. And birth is full of subjective experiences. The sensations of labour, our satisfaction (or otherwise) with the care that is offered, the way we feel about giving birth.

It’s important for individuals to be able to h ave their experiences respected and heard, and for us not to assume that things are the same for everyone. But researchers, service users and clinicians also all need to be able to use terms that we can define, so that we can write about such topics and know what each other are talking about.

This is especially the case with birth trauma, which is thought to be experienced by somewhere between 9% and 50% of women, depending on what research you look at ( Leinweber et al 2022 ). The rate is also variable according to country, care provider, types of birth and several other factors.

The aim of the conversation

So Leinweber et al (2022)  set out, “To formulate a woman-centered, inclusive definition of a traumatic childbirth experience.” To do that, they began a quick literatu re review, which helps get a sense of what is out there already, and they then undertook a five-step process.

“First, a draft definition was created based on interdisciplinary experts’ views. The definition was then discussed and reformulated with input from over 60 multidisciplinary clinicians and researchers during a perinatal mental health and birth trauma research meeting in Europe. A revised definition was then shared with consumer groups in eight countries to confirm its face validity and adjusted based on their feedback.” ( Leinweber et al 2022)

Unsurprisingly, their research confirmed that a woman-centered and inclusive definition was felt to be important to both the recipients and providers of maternity care.

The definition

Their final definition was: “A traumatic childbirth experience refers to a woman’s experience of interactions and/or events directly related to childbirth that caused overwhelming distressing emotions and reactions; leading to short and/ or long-term negative impacts on a woman’s health and wellbeing.” ( Leinweber et al 2022)

A few things are important about this definition. As the researchers note, it, “acknowledges that low-quality provider interactions and obstetric violence can traumatize individuals during childbirth.” ( Leinweber et al 2022)

But just naming something can help us to further the conversation. And, while we have been talking and writing about birth trauma for a while, we are still developing the language needed in order to deepen and widen our understanding of this. This paper, which is open access, will help with that. It contains an in-depth discussion of many aspects of birth trauma and reference to more than ninety papers for those who want to explore the issues further. You can read it here .

Women’s experiences of birth trauma

In another important paper, researchers undertook a qualitative study in which they interviewed ten mothers. They wanted to “explore maternal self-perceptions of bonding with their infants and parenting experiences following birth trauma.” ( Molloy et al 2020 ).

I won’t lie about the fact that reading some of these women’s words is harrowing. But this kind of honesty is what we seek in qualitative research. These women’s words remind us that trauma is complex. People experience things differently. There is much talk from some areas of the kind of trauma that derives from intervention or the words and actions of professionals, and that is certainly confirmed in this paper. But in talking about the sources of their feelings, the women also reference being upset by information from outside sources (childbirth education being one example), by their expectations of themselves, by societal pressure. It’s important not to focus only on one area when sources of trauma are multiple, and also individual.

Undermining knowledge

In Your Own Time was written to help parents and professionals better understand the issues and the evidence relating to the current induction epidemic. Looks at the evidence relating to due dates, ‘post-term’, older and larger women, suspected big babies, maternal race and more.

If you’ve heard me speak, either live or online , you might know that one of the things I refer to often is the way that our current approach to maternity care has served to undermine woman’s own knowledge. I’ve written about that as well, most recently in In Your Own Time: how western medicine controls the start of labour and why this needs to stop . When we insist that pregnancy length is fixed and not fluid, when we force women to follow due dates defined by machines and not their own bodies, when we constantly prioritise medical definitions over women’s own instincts, we undermine a vital source of information and a well of trust.

Sadly, this has been further confirmed by this study.

“Women saw the start of their parenting journey as contributing to this emotional disconnect from their infants where their self-knowledge and understanding of their own bodies was dismissed by professionals, which in turn led to them doubting further decision making and knowledge about parenting. They began to mistrust their own instincts. They also felt they couldn’t talk about what they really felt for fear of being branded ‘bad mothers’ or having children removed.” ( Molloy et al 2020 ).

Key findings

Sadly, the results of the study didn’t surprise those who are involved with birth, which seems these days to be managed and run on a commercial model :

“Women who experienced birth trauma often described disconnection to their infants and lacking confidence in their parental decision making. Many perceived themselves as being ‘not good enough’ mothers. For some women the trauma resulted in memory gaps of the immediate post-partum period which they found distressing, or physical recovery was so overwhelming that it impacted their capabilities to parent the way they had imagined they would. Some women developed health anxiety which resulted in an isolating experience of early parenthood.” ( Molloy et al 2020 ).

The knock-on effects

And the authors conclude that, “Women who have suffered birth trauma may be at risk of increased fear and anxiety around their child’s health and their parenting abilities. Some women may experience this as feeling a lower emotional attachment to their infant. Women who experience birth trauma should be offered support during early parenting. Mother-Infant relationships often improve after the first year.” ( Molloy et al 2020 ).

All studies have limitations. As Molloy et al (2020) acknowledge, the study population in this one were self-selected. All but one of the women described herself as ‘White British’, and the other as ‘Eastern European’. The researchers also acknowledge this, and the fact that this is a rather specific group. That’s especially important when one considers the experiences of Black and Brown women in maternity care and how badly we need to work out how to improve their experiences and outcomes. The authors note a plan to undertake further work to include more diverse populations.

Is there any hope?

The authors do express a bit of hope in their summary. “Other than anecdotally, little is understood or known about a mother’s experience of parenting through PNMH illness. Exploring mothers’ perceptions of their parenting experiences and capabilities may inform the development of services which are there to support parents with PMNH illnesses, and early parenting. This also goes some way to explore the link for women between their birth experience and how they feel able to parent. Those women who struggled to develop a relationship found that this improved over time. This may also give hope to mothers who are struggling with their parenting relationships.”

We can only hope that work like this will help make a difference to those experiencing birth trauma.

The studies in this post were previously featured as the ‘study of the month’ in my Birth Information Update, a monthly newsletter in which I share up-to-date birth-related research and thinking. If you’d like to hear about new research, make sure you’re subscribed to our free newsletter list, which means you’ll get Sara’s monthly Birth Information Update and details of our current projects .

Leinweber J, Fontein-Kuipers Y, Thomson G  et al  (2022). Developing a woman-centered, inclusive definition of traumatic childbirth experiences: A discussion paper.  Birth . doi: 10.1111/birt.12634 .

Molloy E, Biggerstaff DL, Sidebotham P (2020). A phenomenological exploration of parenting after birth trauma: Mothers perceptions of the first year. Women and Birth. In press. https://doi.org/10.1016/j.wombi.2020.03.004

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What Is Trauma, and How Common Is It?

What birth trauma is, how to know if you've experienced it, and the impacts..

Posted May 22, 2023 | Reviewed by Devon Frye

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• Birth trauma happens when the mother finds the events or care she received during birth deeply distressing.
• Whether or not your birth is “traumatic” is determined only by your own individual experience.
• Symptoms may include psychological distress related to birthing experience, and repetitive thoughts about it.
• Birth trauma has a “ripple effect”; it has long-term, wide-reaching impacts on many areas of a mother’s life.

Research finds that up to 45 percent of mothers report experiencing “birth trauma .” Yet, despite almost half of mothers experiencing birth trauma, it is rarely included as a part of labor and delivery preparation, screened for in the postpartum period, or even discussed. It seems to be something that birthing individuals are just expected to “get over,” particularly when everyone is physically healthy after the birth.

Birth trauma is poorly defined in the research and the terms “birth trauma” and “ traumatic birth” are often used interchangeably. A concept analysis based on previous research proposed the following definition of birth trauma (read the concept analysis here ):

"The emergence of a baby from the body of its mother, in a way which may or may not have caused physical injury. The mother finds either the events, injury, or the care she received deeply distressing or disturbing. The distress is of an enduring nature."

Birth trauma can also occur in birthing partners or any observers of the birth .

How Do You Know if You Experienced Birth Trauma?

Whether or not your birth is “traumatic” is determined only by your own individual experience. A doctor or nurse present at your birth may perceive the birth as entirely uncomplicated and typical—but based on your own experience of feeling unsupported or afraid, it may be a traumatic birth.

The DSM-5 defines trauma as the experience of “actual or threatened death, serious injury, or sexual violence.” It can involve experiencing the event yourself, witnessing others experience it, or even learning that it happened to a family member or close friend (or this in case, an infant).

It is important to note that birthing individuals are in such a vulnerable position that you may perceive the threat of an injury or death even when a medical professional may not. However, many clinicians and researchers think the definition of trauma should be broader —an individual can perceive an event as traumatic even if it does not involve threatened injury or death. Trauma may instead be defined as an event that disrupts foundational beliefs about yourself, others, or the world, and/or changes the direction of your life (for example, you think in terms of before and after the trauma).

On the other hand, a difficult birth or birth involving injury to you or the baby doesn’t necessarily lead to birth trauma. Regardless of what happens during the birthing experience, it is entirely up to the birthing individual to determine whether it was a traumatic experience or not.

Symptoms of Birth Trauma

Symptoms of birth trauma can include:

• Psychological distress related to your birthing experience.
• Repetitive and intrusive thoughts, flashbacks, or nightmares about your birthing experience or anything related to it.
• Avoiding people, places, and memories related to the birth.
• Being overly aware of potential threats to you or your baby.
• Feeling guilty or blaming yourself.
• Having difficulty remembering important parts of the birth.
• The birthing experience significantly and negatively changing your thoughts about yourself, others, or the world, or causing a significant and negative change in mood.

Examples of Birth Trauma

Birth trauma can include late miscarriages or stillbirths, medical complications for the birthing individual or baby, emergency C-sections, resuscitation of the infant, hemorrhaging during or after delivery, any type of birth injury, the infant being taken to the NICU, the baby being born with disability or illness, or feeling in extreme pain or out of control during labor. Birth trauma may also include obstetric violence, which is any medical procedures performed without consent, a lack of respect or information from medical professionals, or anything that dehumanizes or takes away the rights of the birthing individual .

What Are the Impacts of Birth Trauma?

Birth trauma has a “ripple effect,” meaning it has long-term and wide-reaching impacts on many areas of a mother’s life. Birth trauma may negatively impact breastfeeding experiences, increase anxiety related to later pregnancies or birth experiences , and negatively impact your relationship with a partner for up to two years .

Birth trauma may also disrupt bonding with your infant . When you experience a traumatic event, you often experience distress related to anything that reminds you of the trauma. In the case of birth trauma, your own infant can remind of the traumatic event. In one qualitative study, women reported an initial feeling of rejection toward their infant which faded over time.

Those who experience a traumatic birth may also experience an immense sense of loss about their birth experience, transition to motherhood, or sense of self . They may experience a fear of childbirth in the future, and/or make a decision to not have additional children or have an elective C-section in order to eliminate uncertainty about future births.

However, many people who experience traumatic birth are made to feel shameful or ungrateful if they discuss it as such. Many people are told that as long as they have a healthy baby that the birth doesn’t matter or are told that their birth complications could have been worse.

Birth Trauma and Mental Health

Birth trauma dramatically increases the risk for postpartum depression with some studies showing up a 4 to 5 times increase in the risk for postpartum depression in mothers reporting a high level of birth trauma . Birth trauma is also associated with an increased risk for postpartum depression in partners .

Birth trauma also increases the risk of postpartum anxiety and elevated stress during the postpartum period. Birth trauma may even increase the risk for postpartum psychosis .

Stay tuned for future articles about coping with birth trauma.

Cara Goodwin, Ph.D., is a licensed clinical psychologist who specializes in translating scientific research into information that is useful, accurate, and relevant for parents.

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CONCEPTUAL ANALYSIS article

Psychological birth trauma: a concept analysis.

• 1 School of Nursing, Nanjing Medical University, Jiangsu, China
• 2 Women’s Hospital of Nanjing Medical University (Nanjing Maternity and Child Health Care Hospital), Jiangsu, China
• 3 School of Nursing, Suzhou University, Jiangsu, China

Aim: To define and analyze the concept of psychological birth trauma.

Design: The concept analysis method of Walker and Avant was used.

Method: Eight databases (PubMed, CINAHL Complete, Cochrane Library, Web of Science, China National Knowledge Infrastructure, Wanfang, VIP Information Chinese Journal Service Platform, and Chinese BioMedicine Literature Database) were searched from inception to July 2022 for studies focused on psychological birth trauma.

Results: Of the 5,372 studies identified, 44 ultimately met the inclusion criteria. The attributes identified were (1) women’s subjective feelings, (2) intertwined painful emotional experiences, (3) originating in the birth process, and (4) lasting until postpartum. Antecedents were divided into two groups: pre-existing antecedents and birth-related antecedents. Consequences were identified as negative and positive.

Conclusion: Psychological birth trauma is a more complex and comprehensive concept than previously thought, and should be regarded as a separate postpartum mental health problem. This study deepens the understanding of psychological birth trauma through a comprehensive concept analysis and also puts forward some suggestions for the prevention, identification, and intervention of psychological birth trauma, which provides a basis for assisting in the identification of psychological birth trauma and provides a reference for the development of rigorous assessment tools and the design of appropriate interventions in the future. Further research is needed to update and refine this concept.

1. Introduction

Childbirth, a major event in a woman’s life, is of a profound and complex nature ( Shorey and Wong, 2022 ). Not only does it involve huge physical changes, but it is also accompanied by significant psychological fluctuations ( Fenech and Thomson, 2015 ; Shorey and Wong, 2022 ). Negative birth experiences can even cause terrible psychological trauma to women ( Fenech and Thomson, 2015 ; Shorey and Wong, 2022 ). Studies indicated that the incidence of traumatic birth ranges from 20 to 68.6 percent in different countries ( Uotila et al., 2005 ; Türkmen et al., 2020 ; Bay and Sayiner, 2021 ). Professor Beck used the word “ripple effect” to describe the negative impacts of psychological birth trauma ( Beck, 2015 ). These impacts appear to be centered on the poor mental health of women themselves ( Beck, 2006 ; Taghizadeh et al., 2013 ), and then expand like ripples, affecting mother-infant relationships ( Taghizadeh et al., 2013 ; Beck and Watson, 2019 ), breastfeeding behavior ( Beck and Watson, 2008 ; Fenech and Thomson, 2014 ), marital relationships ( Taghizadeh et al., 2013 ; Fenech and Thomson, 2014 ), and future reproductive decisions ( Gottvall and Waldenström, 2002 ; Taghizadeh et al., 2013 ; Holopainen et al., 2020 ), etc. The further impact of psychological birth trauma is associated with post-traumatic stress disorder (PTSD) ( Taghizadeh et al., 2013 ; Türkmen et al., 2020 ; McKelvin et al., 2021 ), a widely known term. According to DSM-IV criteria, PTSD is categorized as a disorder related to trauma and stress, which is mainly manifested in four symptom clusters: re-experience, avoidance, hyperarousal, and negative cognition and mood, and these symptoms should exist for more than a month ( American Psychiatric Association, 2000 ). These symptoms can appear directly after experiencing a traumatic event, but can also occur later in life ( American Psychiatric Association, 2000 ). A meta-analysis suggested that 4% of postpartum women in community samples developed PTSD following a traumatic birth experience, compared with 18.5% in high-risk samples (such as women with complications of pregnancy or childbirth) ( Yildiz et al., 2017 ). This means that more postpartum women who have experienced psychological trauma are not reaching the threshold of PTSD and are therefore unidentified, but they are struggling with the trauma.

Some studies have focused on investigating the risk factors of psychological birth trauma, and multiple factors have been found, including some objective factors, such as preterm delivery ( Chabbert et al., 2021 ; Sommerlad et al., 2021 ), as well as some subjective factors, such as women feeling disrespected by healthcare professionals during birth ( Zhang et al., 2020 ; McKelvin et al., 2021 ; Watson et al., 2021 ; Liu et al., 2022 ). Notably, the ongoing COVID-19 seems to have made this phenomenon more complicated. A study conducted in the United States confirmed that women who gave birth during the outbreak of COVID-19 experienced more traumatic births and subsequent mother-infant bonding problems than those who gave birth before the pandemic ( Mayopoulos et al., 2021 ). Another study investigated the impact of unaccompanied birth caused by COVID-19-related visiting bans on mothers’ mental health, and found that mothers who gave birth unaccompanied had higher psychological distress than those who gave birth accompanied ( Oddo-Sommerfeld et al., 2022 ).

Regrettably, not enough attention has been paid to the psychological birth trauma itself, and more attention seems to be focused on the diagnosable postpartum psychological problems, such as postpartum PTSD mentioned above. An international knowledge mapping exercise aimed at examining policies, services, and training provisions for women following traumatic birth showed that of the 18 European countries that participated, only the Netherlands has national policies on screening, treatment, and prevention of traumatic birth experiences ( Thomson et al., 2021 ). Adding to the dilemma is the fact that there is no consistent definition, terminology, or detailed description of this concept in the literature. Instead, various terms such as “birth/childbirth trauma,” “traumatic birth/childbirth,” “traumatic birth/childbirth experience,” or “psychological birth/childbirth trauma” are used, with almost the same meaning. Additionally, widely validated tools to assess psychological birth trauma are lacking. In conclusion, there is a long way to go in the management of psychological birth trauma.

A clear concept is the first key step to fully understanding this phenomenon and the basis for theoretical development ( Walker and Avant, 2019 ). Therefore, this study aims to provide a comprehensive analysis of the concept of psychological birth trauma, in order to clarify this definition and provide a basis for the development of rigorous assessment tools, and then provide a reference for subsequent screening and interventional research and practice. We hope this work can make some contribution to the promotion of women’s health and well-being and social development.

2. Materials and methods

2.1. concept analysis.

Concept analysis is a systematic process of developing, clarifying, and refining the phenomenon under analysis ( Walker and Avant, 2019 ). This study adopted the concept analysis method of Walker and Avant (2019) , which has been widely used in the field of nursing. It consists of eight steps intended to guide the process ( Table 1 ). Of these, the first and second steps have been described in the introduction section of this study.

Table 1. Process of concept analysis.

2.2. Data sources

A comprehensive search of PubMed, CINAHL Complete, Cochrane Library, Web of Science, China National Knowledge Infrastructure, Wanfang, VIP Information Chinese Journal Service Platform, and Chinese BioMedicine Literature Database was conducted from inception to July 2022. The following medical subject heading (MeSH) terms and text words were used: “traumatic childbirth,” “traumatic birth,” “traumatic labor,” “traumatic delivery,” “childbirth trauma,” “birth trauma,” “labor trauma,” “labor trauma,” “delivery trauma,” “psychological trauma” AND (“parturition” OR “delivery, obstetric” OR “childbirth” OR “labor” OR “birth-giving” OR “birth” OR “delivery” OR “deliver” OR “partus” OR “labor”). The search was limited to studies published in English or Chinese. Specific details of the retrieval strategy are shown in Supplementary material .

Studies that explicitly investigated or discussed psychological trauma following birth from the perspective of postpartum women were included in this concept analysis. The following studies would be excluded: (1) investigating the intervention effects of certain measures on psychological birth trauma; (2) examining physical birth trauma only; (3) only exploring psychological trauma of bystanders during the birthing process, primarily women’s partners and healthcare professionals; (4) only testing the reliability and validity of the scale. Furthermore, to improve the precision of the concept of psychological birth trauma, we excluded studies that aimed to explore postpartum PTSD and its similar themes, including postpartum post-traumatic stress symptoms and post-traumatic stress. Studies on broader topics such as negative birth experiences were also excluded.

A total of 5,372 studies were identified, then 1,675 duplicated studies were excluded. After screening the titles and abstracts of the remaining studies, 3,558 studies were further excluded. After reading the full texts of 139 studies, 95 studies were excluded for a variety of reasons. Finally, a total of 44 studies were included in the concept analysis. The search process is presented in Figure 1 . The specific characteristics of the included studies are presented in Table 2 . The years of publication ranged from 2002 to 2022. Of the 44 studies, 10 were from the USA, nine from the UK, five from Iran, four from China, four from Australia, three from the Netherlands, three from Turkey, and one from each of the following countries: Sweden, Singapore, Germany, France, Spain, and Finland. In terms of article type, qualitative studies ( n = 25) were the most, followed by quantitative studies ( n = 9), and the remaining included systematic reviews ( n = 5), mixed methods study ( n = 1), scope review ( n = 1), concept analysis ( n = 1), discussion paper ( n = 1), and middle range theory ( n = 1).

Figure 1. Flowchart of the study selection process of the concept analysis.

Table 2. Studies included in concept analysis.

3.1. Uses of the concept

Walker and Avant’s (2019) method involves identifying defining attributes used to describe the concept. This means that as many concept examples as possible need to be evaluated, and repeated features need to be recorded ( Walker and Avant, 2019 ). Results of the literature showed that earlier birth trauma almost exclusively refers to maternal or neonatal physical trauma during birth, i.e., tissue and organ damage, such as maternal damaged pelvic floor function, neonatal cephalohematoma, clavicular fracture, and brachial plexus injury ( Perlow et al., 1996 ; Meyer et al., 2000 ). The term further covers the long-term adverse effects of neonatal brain or skull injuries, which are usually presented in cognition ( Geirsson, 1988 ). With the deepening of research, there is increasing evidence that childbirth can cause not only physical trauma but also psychological disturbances ( Pantlen and Rohde, 2001 ). Professor Beck defined birth trauma in 2004 as an event that occurs during the labor and delivery process involving actual or threatened serious injury or death to the mother or her baby, in which women experience intense feelings of fear, helplessness, loss of control, and horror ( Beck, 2004 ). This definition emphasizes the psychological experience of birth. In 2015, professor Beck integrated a series of studies on the topic of birth trauma into a whole, thereby establishing a higher and more abstract middle range theory of birth trauma, in which he clearly proposed that birth trauma can be both psychological and physical ( Beck, 2015 ). Greenfield et al. (2016) conducted a concept analysis of traumatic birth, stating that the term can be defined as: the emergence of a baby from the mother in a way that involves events or care that cause psychological disturbance or deep distress, which may or may not involve physical injury, but leading to enduring psychological distress. A recent discussion paper developed an inclusive and woman-centered definition of the traumatic childbirth experience, which refers to a woman’s experience of interactions and/or events directly related to childbirth that caused overwhelming distressing emotions and reactions; leading to short and/or long-term negative impacts on a woman’s health and wellbeing ( Leinweber et al., 2022 ). Apart from the three definitions above, there is no further conceptual or operational understanding.

3.2. Defining attributes

Defining attributes can be used to identify, understand, and differentiate a concept from other concepts ( Walker and Avant, 2019 ). Analysis of the literature led to the identification of the most common features related to psychological birth trauma. After identifying these features, it was possible to identify key defining attributes. Thus, the attributes of psychological birth trauma are summarized as follows:

(1) Women’s subjective feelings

(2) Intertwined painful emotional experiences

(3) Originate in the birth process

(4) Last until postpartum.

3.2.1. Women’s subjective feeling

Women’s perception of psychological birth trauma is highly subjective ( Taghizadeh et al., 2014 ). Each birth experience is unique to every woman, indeed, even the same events that occur during birth are perceived differently by every woman ( Shorey and Wong, 2022 ). Studies showed that childbirth that appears normal and straightforward to healthcare professionals and is medically uneventful can be perceived as traumatic by the woman ( Holopainen et al., 2020 ; Leinweber et al., 2022 ). Conversely, not all women with complications will have traumatic experiences ( Leinweber et al., 2022 ). Notably, many studies used self-perceived psychological trauma during birth as the criteria for the recruitment and selection of research subjects ( Thomson and Downe, 2008 ; Beck and Watson, 2019 ; Dai, 2019 ; Zhang et al., 2020 ). In conclusion, psychological birth trauma emphasizes the subjective feeling of women rather than objective aspects of the birth process.

3.2.2. Intertwined painful emotional experiences

3.2.2.1. fear and anxiety.

Faced with an unfamiliar environment and care providers, as well as an unknown birth process, women don’t know if an event will occur that threatens their own or their baby’s safety, which makes them fearful and anxious ( Taghizadeh et al., 2014 ; Hollander et al., 2017 ; Dai, 2019 ; Holopainen et al., 2020 ; Zhang et al., 2020 ; Shorey and Wong, 2022 ).

3.2.2.2. Helplessness and despair

During birth, women have to bear severe labor pain and face all the actual or potential risks, they do not know what to do, and the cruel reality makes them feel helpless or even despairing ( Beck, 2004 ; Thomson and Downe, 2008 ; Taghizadeh et al., 2014 ; Dai, 2019 ; Zhang et al., 2020 ).

3.2.2.3. Deprivation of dignity

Women feel verbally and physically abused and discriminated against by care providers and their privacy is violated, which deprives them of their dignity ( Beck, 2015 , 2018 ; Taghizadeh et al., 2015 ; Reed et al., 2017 ; Abdollahpour and Motaghi, 2019 ; Dai, 2019 ; Holopainen et al., 2020 ; Chabbert et al., 2021 ; Shorey and Wong, 2022 ).

3.2.2.4. Neglected and abandoned

Women feel that they are not receiving adequate communication, explanation, emotional and practical support, and attention, they lose the power to express their thoughts and feelings as if they are a machine rather than a human, which makes them feel neglected and abandoned ( Beck, 2004 , 2015 , 2018 ; Uotila et al., 2005 ; Elmir et al., 2010 ; Hollander et al., 2017 ; Murphy and Strong, 2018 ; Priddis et al., 2018 ; Abdollahpour and Motaghi, 2019 ; Dai, 2019 ; Rodríguez-Almagro et al., 2019 ; Holopainen et al., 2020 ; Koster et al., 2020 ; Zhang et al., 2020 ; Chabbert et al., 2021 ).

3.2.2.5. Loss of control

Women feel deprived of decision-making and informed consent, their birth process is completely in the hands of care providers, and reality is not moving toward their expectations, which makes them feel out of control ( Beck, 2004 , 2015 ; Elmir et al., 2010 ; Taghizadeh et al., 2015 ; Hollander et al., 2017 ; Abdollahpour and Motaghi, 2019 ; Holopainen et al., 2020 ; Koster et al., 2020 ; Zhang et al., 2020 ; Chabbert et al., 2021 ; Watson et al., 2021 ; Liu et al., 2022 ).

3.2.3. Originate in the birth process

Childbirth is a complex process involving medical acts and during which events that endanger the safety of the mother and baby may occur, which can be traumatic for women, especially when they believe that these events could have been avoided ( Leinweber et al., 2022 ). In addition, the quality of women’s interactions with healthcare professionals during birth was highlighted as a major factor influencing women’s feelings about childbirth, as women used emotional language to describe their negative interaction experiences, including feeling like they were at the “bottom of the hierarch,” “persecuted,” etc. ( Greenfield et al., 2019 ; Leinweber et al., 2022 ). Furthermore, psychological birth trauma may stem from events that occurred during birth that triggered women’s traumatic memories, such as sexual abuse ( Watson et al., 2021 ).

3.2.4. Last until postpartum

Persistence is a key attribute of psychological birth trauma ( Greenfield et al., 2016 ). However, it is not entirely clear how long it lasts postpartum. In fact, many studies investigated the prevalence or effects of psychological birth trauma at 5 days ( Uotila et al., 2005 ), 3–6 weeks ( Türkmen et al., 2021 ), 1 month ( Bay and Sayiner, 2021 ), and 1–4 months postpartum ( Ghanbari-Homayi et al., 2019 ), etc., while only a few studies conducted longitudinal surveys ( Türkmen et al., 2020 ). One study investigated the incidence of psychological birth trauma at 4 weeks, 3 months, and 6 months postpartum, unfortunately, there was no further longitudinal extension ( Türkmen et al., 2020 ). Studies have vividly described the horrific torment of birth anniversaries that women experienced at least once ( Beck, 2006 , 2011 , 2015 ). One study reported that women were formally diagnosed with postpartum PTSD 5 months to 19 years after experiencing psychological birth trauma ( Beck and Watson, 2016 ). And even without being diagnosed with PTSD, these women are still tormented by ghosts from psychological birth trauma ( Fenech and Thomson, 2014 ). It was indicated that there are women who still define the birth experience as psychologically traumatic even 32 years after giving birth ( Taghizadeh et al., 2015 ).

3.3. Model case

A model case is designed to demonstrate all defining attributes of the concept ( Walker and Avant, 2019 ). The model case in this study was adapted from a qualitative study aimed at investigating women’s experiences of psychological birth trauma ( Beck, 2004 ).

Mrs. M has been having regular uterine contractions for over 5 h. A midwife asked Mrs. M to take off the pants and she would do a vaginal examination to determine the extent of cervical dilation. At this time, several students suddenly entered the room. Mrs. M tried to cover her bottom with her gown, but a midwife took her hand away from the gown. The students also performed vaginal examinations without Mrs. M’s permission, and no explanation was given afterward. Mrs. M immediately recalled the scene of being sexually assaulted when she was a child. She felt that she had been raped again, which brought her overwhelming pain. Everything seemed to be normal during the whole birth process, and finally, Mrs. M gave birth to the baby successfully, which made the midwife satisfied. All the family members surrounded the baby, leaving Mrs. M in bed alone, no one asked how she was feeling. In the days that followed, Mrs. M still felt very distressed. She was reluctant to interact with her husband and baby, refused to breastfeed, and did not trust medical staff. When the child was 3 years old, Mrs. M became pregnant again. During the pregnancy, she was surrounded by fear that this birth would repeat the previous one, and she visited a psychotherapist several times.

3.4. Borderline case

The authors constructed the borderline case to provide an example that embraces most of the attributes of psychological birth trauma. Mrs. N longed for a vaginal delivery and believed she could do it. Unfortunately, signs of fetal distress appeared at the beginning of the first stage of labor. Doctors told her that the prolonged labor process was dangerous to the fetus and that a cesarean section was needed as soon as possible. Mrs. N had never thought about a cesarean section, she was very scared. The doctor and midwife patiently explained to her again and gave her support and encouragement, which made Mrs. N relax. Subsequently, Mrs. N underwent an emergency cesarean section, and both mother and baby were safe. Although failed to achieve delivery vaginally as expected, Mrs. N was satisfied with the outcomes. When looking back on her birth experience, she feels supported by the healthcare providers and that she was doing the right thing.

3.5. Antecedents

Antecedents are those events or incidents that must occur before or be in place prior to the occurrence of the concept ( Walker and Avant, 2019 ). Hence, in this concept analysis, antecedents refer to the precursive elements of psychological birth trauma. After reviewing the literature, considering the complexity of psychological birth trauma, antecedents are grouped according to either pre-existing or birth-related antecedents. Pre-existing antecedents refer to factors that exist prior to childbirth. These mainly include women’s demographic characteristics, personality traits, and medical and traumatic experiences. Specifically, demographic characteristics include single ( Chabbert et al., 2021 ), low income ( Bay and Sayiner, 2021 ), primipara ( Türkmen et al., 2020 ; Chabbert et al., 2021 ), and living in the city center ( Türkmen et al., 2020 ). Personality traits encompass insecure attachment style ( Chabbert et al., 2021 ), high health anxiety ( Türkmen et al., 2021 ), fear of childbirth ( Ghanbari-Homayi et al., 2019 ; Chabbert et al., 2021 ), and disbelief in one’s ability to cope with labor pain ( Türkmen et al., 2021 ). Medical and traumatic experiences encompass a history of sexual trauma ( Chabbert et al., 2021 ), previous mental or physical health problems ( Priddis et al., 2018 ), existing symptoms of depression or anxiety ( Chabbert et al., 2021 ), fertility or complex pregnancy issues ( Priddis et al., 2018 ) and a family history of labor difficulty ( Türkmen et al., 2020 ). Furthermore, several studies reported unplanned pregnancy ( Bay and Sayiner, 2021 ), insufficient prenatal care and training ( Uotila et al., 2005 ; Bay and Sayiner, 2021 ; Chabbert et al., 2021 ), society stereotyped pressure on motherhood ( Zhang et al., 2020 ), and lack of exercise during pregnancy ( Ghanbari-Homayi et al., 2019 ) are related to psychological birth trauma.

Birth-related antecedents are key contributors to the occurrence of psychological birth trauma. These include obstetric factors and factors related to healthcare professionals. Specifically, obstetric factors encompass severe pain or physical discomfort ( Uotila et al., 2005 ; Hollander et al., 2017 ; Murphy and Strong, 2018 ; Abdollahpour and Motaghi, 2019 ; Dai, 2019 ; Zhang et al., 2020 ; Chabbert et al., 2021 ), long duration of labor ( Hollander et al., 2017 ; Holopainen et al., 2020 ; Chabbert et al., 2021 ), too rapid birth process ( Hollander et al., 2017 ; Holopainen et al., 2020 ), unnecessary medical intervention ( Reed et al., 2017 ; Priddis et al., 2018 ; Watson et al., 2021 ), physical restraint during birth ( Shorey and Wong, 2022 ), cesarean section ( Bay and Sayiner, 2021 ) or emergency cesarean section ( Rodríguez-Almagro et al., 2019 ; Chabbert et al., 2021 ; Shorey and Wong, 2022 ), instrumental vaginal delivery ( Priddis et al., 2018 ; Rodríguez-Almagro et al., 2019 ; Chabbert et al., 2021 ; Shorey and Wong, 2022 ), separation from the baby ( Priddis et al., 2018 ; Abdollahpour and Motaghi, 2019 ; Dai, 2019 ), medical complications in infant ( Holopainen et al., 2020 ; Liu et al., 2022 ) or mother ( Priddis et al., 2018 ; Holopainen et al., 2020 ; Chabbert et al., 2021 ), dissatisfied neonatal gender ( Zhang et al., 2020 ), preterm delivery ( Chabbert et al., 2021 ), neonatal admission to neonatal intensive care unit ( Priddis et al., 2018 ; Chabbert et al., 2021 ), neonatal death ( Murphy and Strong, 2018 ; Dai, 2019 ), partner’s absence and lack of support ( Holopainen et al., 2020 ; Chabbert et al., 2021 ), unpleasant birthing physical environment, equipment and rules ( Taghizadeh et al., 2015 ; Beck, 2018 ; Abdollahpour and Motaghi, 2019 ; Watson et al., 2021 ; Liu et al., 2022 ; Shorey and Wong, 2022 ), and tense atmosphere during birth ( Zhang et al., 2020 ). As for factors associated with healthcare professionals, studies have documented that the following factors are linked to psychological birth trauma: poor communication and explanation ( Taghizadeh et al., 2015 ; Hollander et al., 2017 ; Beck, 2018 ; Priddis et al., 2018 ; Chabbert et al., 2021 ; Watson et al., 2021 ; Liu et al., 2022 ; Shorey and Wong, 2022 ), insufficient medical clinical competence ( Taghizadeh et al., 2015 ; Abdollahpour and Motaghi, 2019 ; Rodríguez-Almagro et al., 2019 ), negative attitudes and words ( Priddis et al., 2018 ), using mothers as learning resources for hospital staff ( Reed et al., 2017 ; Watson et al., 2021 ), and prioritizing work agendas rather than the thoughts of women in childbirth ( Reed et al., 2017 ; Watson et al., 2021 ).

3.6. Consequences

Consequences are those events or incidents that appear as results of the concept ( Walker and Avant, 2019 ). Thus, in this concept analysis, consequences refer to the negative or positive effects of psychological birth trauma on women’s well-being. Firstly, there is a definite relationship between psychological birth trauma and consequences that directly affect the mental health of the mother. Following the psychological birth trauma, mothers experience heightened levels of panic, grief, anger, anxiety ( Elmir et al., 2010 ; Fenech and Thomson, 2014 ), and even suicidal thoughts ( Elmir et al., 2010 ). They are trapped in memories of the traumatic birth ( Elmir et al., 2010 ; Shorey and Wong, 2022 ) and bombarded with flashbacks and nightmares ( Elmir et al., 2010 ; Fenech and Thomson, 2014 ). These symptoms can last for years ( Fenech and Thomson, 2014 ). A study described in detail their painful experiences during the subsequent birth anniversary ( Beck, 2006 ). Additionally, these women are more likely to suffer from postpartum depression ( Taghizadeh et al., 2013 ; Bay and Sayiner, 2021 ; McKelvin et al., 2021 ; Türkmen et al., 2021 ; Chen et al., 2022 ), anxiety ( Taghizadeh et al., 2013 ; McKelvin et al., 2021 ; Türkmen et al., 2021 ), PTSD ( Taghizadeh et al., 2013 ; Türkmen et al., 2020 ; McKelvin et al., 2021 ), and even psychosis ( Taghizadeh et al., 2013 ).

Secondly, psychological birth trauma leads to changes in the mother’s roles. Several studies reported negative mother-infant interactions, with women expressing feelings of disengagement or feeble attachment to their children ( Beck, 2011 ; Taghizadeh et al., 2013 ; Fenech and Thomson, 2014 ; Molloy et al., 2021 ), and feelings of incompetence as mothers ( Taghizadeh et al., 2013 ; Fenech and Thomson, 2014 ; Priddis et al., 2018 ; Molloy et al., 2021 ), such as low breastfeeding self-efficacy ( Türkmen et al., 2020 ). Mothers may experience excessive fear and anxiety about the health of their children ( Molloy et al., 2021 ). While others described the overprotection of their children ( Fenech and Thomson, 2014 ). Some studies reported that women experience distress while breastfeeding and therefore refuse to continue ( Beck and Watson, 2008 ; Taghizadeh et al., 2013 ). Other mothers, however, insist on breastfeeding to prove that they are a mother, to help their spiritual recovery, or to atone for the baby ( Beck and Watson, 2008 ). In addition, several studies suggested that psychological birth trauma can lead to difficulties or disruptions in couples’ emotional and sexual relationships ( Taghizadeh et al., 2013 ; Fenech and Thomson, 2014 ). Moreover, some mothers display social conflicts, such as blame and aggression toward others ( Taghizadeh et al., 2013 ; Fenech and Thomson, 2014 ; Watson et al., 2021 ), distrust and anger toward healthcare professionals ( Fenech and Thomson, 2014 ), and a preference to remain shy and isolated ( Taghizadeh et al., 2013 ; Fenech and Thomson, 2014 ).

Thirdly, psychological birth trauma affects the subsequent reproductive decisions, experiences, and coping behaviors. Women who have experienced psychological birth trauma are often fearful of future pregnancies ( Fenech and Thomson, 2014 ; Greenfield et al., 2019 ; Holopainen et al., 2020 ; McKelvin et al., 2021 ), and some refuse to be pregnant again ( Taghizadeh et al., 2013 ; Fenech and Thomson, 2014 ; Dai, 2019 ). In fact, findings suggested that women with psychological birth trauma have fewer subsequent children, as well as a longer interval to their second child ( Gottvall and Waldenström, 2002 ). Additionally, some women who become pregnant again are surrounded by fearful thoughts that subsequent childbirth will be a repeated traumatic experience ( Beck and Watson, 2010 ; Taghizadeh et al., 2013 ; Greenfield et al., 2019 ). And, they tend to choose a planned cesarean section ( Greenfield et al., 2019 ; Holopainen et al., 2020 ), a home delivery ( Holopainen et al., 2020 ), or a freebirth ( Greenfield et al., 2019 ).

Fourthly, psychological birth trauma leads to more health services utilization. Women with psychological birth trauma have longer postpartum hospital stays ( Turkstra et al., 2015 ). In addition, studies showed that they have more general practitioner visits and additional services utilization, such as psychological treatment, lactation support, child health clinic visits, and midwife home visits ( Turkstra et al., 2015 ).

While most of the consequences of psychological birth trauma found in the literature are negative, it can also have positive outcomes. One study explored how women who have experienced psychological birth trauma rely on external and internal resources to move toward resilience ( Brown et al., 2022 ). Moreover, several studies confirmed post-traumatic growth following psychological birth trauma ( Beck and Watson, 2016 ; Ketley et al., 2022 ), including increased self-confidence and pride ( Beck and Watson, 2016 ; Ketley et al., 2022 ), better relationship with partners, friends, children, and others ( Beck and Watson, 2016 ; Ketley et al., 2022 ), stronger faith and a better understanding of spiritual and religious matters ( Beck and Watson, 2016 ). Some women also established new professional and personal goals, such as completing a university degree ( Beck and Watson, 2016 ), and actively participating in volunteer work aimed at preventing other women from psychological birth trauma ( Beck and Watson, 2016 ; Ketley et al., 2022 ).

3.7. Empirical referents

According to Walker and Avant’s (2019) concept analysis method, the final step is to determine empirical referents of psychological birth trauma, which permits us to know how to measure or identify the defining attributes of a concept.

The Traumatic Childbirth Perception Scale (STCP) ( Türkmen et al., 2021 ) was developed by Yalnız et al. (2016) as a self-report scale to assess women’s perception of traumatic childbirth. The STCP contains information on physical, emotional, and mental trauma associated with childbirth. It includes 13 items. Each item is scored between 0 (positive) and 10 (negative), and the total scale score ranges between 0 and 130. The total mean scores of 0–26, 27–52, 53–78, 79–104, and 105–130 correspond to very low, low, moderate, high, and very high levels of traumatic childbirth perception, respectively. In the study of Yalnız et al. (2016) , the Cronbach’s alpha internal consistency coefficient of STCP was 0.895.

The Psychological Birth Trauma Questionnaire (QPBT) ( Hajarian Abhari et al., 2022 ) was developed by Taghizadeh et al. (2013) to assess the level of psychological birth trauma. It includes 30 items and five constructs, namely: anxiety and eternal suffering of birth/labor, psychological manifestations, helplessness, collapse and sensation of death, and somatic manifestations. Each item is scored from 1 to 5 points, with a total score of 30–150 points. A higher score indicates a higher level of psychological birth trauma. The validity and reliability of QPBT have been confirmed in the study by Taghizadeh et al. (2013) , the Cronbach’s alpha internal consistency coefficient was 0.949.

Notably, these two scales have not been used in studies in other countries, their English versions have not been identified yet.

3.8. Definition of the concept

Based on an analysis of the literature, the concept of psychological birth trauma is clearly defined as follows:

Psychological birth trauma refers to the woman’s subjective feeling caused by events directly or indirectly related to childbirth, which is manifested as intertwined painful emotional experiences that originate in the birth process and last until postpartum. It has a wide range of negative and, in some cases, positive effects on women. The conceptual model including the antecedents, attributes, and consequences of psychological birth trauma is shown in Figure 2 .

Figure 2. The concept of psychological birth trauma.

4. Discussion

Based on a systematic search of the literature and the method of Walker and Avant (2019) , we provided a comprehensive analysis of the concept of psychological birth trauma. Four defining attributes were identified: women’s subjective feelings; intertwined painful emotional experiences; originate in the birth process and last until postpartum. Currently, maternal and neonatal safety is often regarded as the bottom line for successful and satisfying childbirth ( Beck, 2004 ), while the subjective feeling of the mother appears to be ignored. It is worth highlighting whether women in childbirth are experiencing intertwined painful emotional experiences. Additionally, researchers and healthcare professionals should be aware that a proportion of women who have experienced psychological birth trauma are concerned by being diagnosed with postpartum PTSD, while more women who do not meet the diagnostic threshold are still in “dire straits.” Therefore, it is time to raise awareness of psychological birth trauma. Specifically, psychological birth trauma should be considered as a separate postpartum mental health problem.

Antecedents in this concept analysis suggest that women in childbirth are vulnerable to a range of pre-existing factors that may contribute to psychological trauma. Identification of these factors, including demographic characteristics, personality traits, and medical and trauma experiences can help healthcare professionals to be more vigilant and thus aid in prevention. However, the prevention of birth-related antecedents appears to be more promising. The first is to emphasize professional management of labor, such as avoiding unnecessary medical intervention, adequately relieving labor pain, and improving medical clinical competence to reduce maternal and neonatal complications. In addition, obstetric management should aim to reduce psychological birth trauma, including creating a comfortable environment and allowing the woman’s partner to accompany her during birth, etc. Furthermore, it is imperative to improve the quality of women’s interactions with healthcare professionals during birth, which may be achieved by adequately communicating and explaining what happens, listening to women, and seeking to meet their expectations. Notably, further studies are needed to systematically assess these antecedents and to determine their magnitude and interrelationships.

After examining the consequences of included studies, this concept analysis identified the profound negative effects of psychological birth trauma on women, including poor mental health, poor role of the mother, subsequent reproductive challenges, and increased health services utilization. Therefore, early identification and intervention of these women is crucial. In terms of identification, during the postpartum hospital stay, healthcare professionals are advised to be wary of symptoms that may indicate a woman has suffered psychological birth trauma, such as a dazed appearance, withdrawal, temporary amnesia, and detachment from the baby ( Church and Scanlan, 2002 ; Beck and Watson, 2008 ). If a mother has experienced complex childbirth, such as maternal and neonatal complications, she should be alerted to any psychological trauma as well ( Hayden, 2022 ). Before discharge, healthcare professionals should proactively discuss with mothers whether they perceive their childbirth to be traumatic ( Beck and Watson, 2008 ), as new mothers may not voluntarily express their feelings about the birth experience for fear that doctors will judge their parenting or involve social services ( Hayden, 2022 ). Try asking open-ended questions to get more information about what women might be saying ( Hayden, 2022 ). Beck and Watson (2016) and Beck et al. (2018) recommend that healthcare professionals be wary of the metaphors women use to help describe their experiences of post-traumatic stress. In addition, at infants’ well-baby checkups and yearly physical exams, healthcare professionals are recommended to ask mothers how they are doing and how they evaluate their birth experiences ( Beck, 2015 ). Pediatric clinicians may be in an ideal position to identify women with elevated posttraumatic stress symptoms and to make those critical referrals for mental health care ( Beck, 2015 ).

Furthermore, a limited number of studies have discussed interventions to reduce the negative effects of psychological birth trauma. A recent systematic review examined interventions to prevent women with recent traumatic birth from developing postpartum PTSD, including debriefing, encouraging skin-to-skin contact with healthy babies directly postpartum, structured psychological interventions, expressive writing, and seeing or holding the baby after stillbirth ( de Graaff et al., 2018 ). The results showed that there was great heterogeneity in the study characteristics, and the effectiveness of interventions was different. Possible effective interventions were encouraging skin-to-skin contact with healthy babies directly postpartum, structured psychological interventions, and expressive writing, but the evidence was insufficient ( de Graaff et al., 2018 ). A discussion article detailed how to use an emotion-focused approach to prevent psychological birth trauma ( Gökçe İsbir et al., 2022 ). However, this approach has not yet been applied in clinical practice. A recent study ( Hajarian Abhari et al., 2022 ) supported the effectiveness of counseling based on Gamble’s approach, originally proposed by Gamble et al. (2005) , in preventing psychological birth trauma in primiparas. The counseling approach is cost-effective, easy to implement, and can be implemented by midwives, thus it could be valuable to integrate it into healthcare programs. However, due to the huge differences among existing interventions, we cannot make wise recommendations on specific implementation programs. However, some considerations seem to be meaningful. Firstly, it is necessary to strengthen the knowledge and skills training of the interveners, which is the premise to ensure the effectiveness of the intervention. Secondly, the content, duration, frequency and timing of intervention are the key factors affecting the effectiveness, and further studies are needed to determine the optimal programs. Finally, women’s personal preferences should also be considered. Notably, the effectiveness of these interventions is mainly focused on the mental health status of women. Future studies should also examine the effectiveness of interventions on other negative effects of psychological birth trauma, such as mother-infant and marital relationships.

Reassuringly, this concept analysis found that while some women experienced some negative effects of psychological birth trauma, they gained some positive aspects that had not been mentioned in previous related concepts. Studies showed that some mothers who have experienced psychological birth trauma build resilience by using both external resources (such as faith and supportive relationships) and internal resources (such as recognizing the power of their own motherhood) ( Brown et al., 2022 ). And, some women are able to use their inner resources to develop the resilience they need as mothers, which empowers them and allows them to experience post-traumatic growth such as an increased sense of self-worth and competence ( Brown et al., 2022 ; Ketley et al., 2022 ). Thus, healthcare professionals may play an important role in facilitating this by encouraging mothers to explore their faith and use their social support networks, and informing mothers about organizations and resources that provide niche support after traumatic birth ( Brown et al., 2022 ). In addition, healthcare professionals can provide some hope to women who have experienced psychological birth trauma by sharing the possibility of post-traumatic growth ( Beck and Watson, 2016 ; Beck et al., 2018 ). Notably, the possibility of positive effects does not diminish the importance of preventing psychological birth trauma ( Ketley et al., 2022 ).

5. Limitations

Some limitations exist in this concept analysis. Firstly, studies were limited to English or Chinese, which restricts the scope of the review. Secondly, the studies included in this concept analysis were mostly qualitative, and quantitative studies were lacking due to the lack of widely validated tools for assessing psychological birth trauma. Thirdly, we excluded studies on postpartum PTSD, postpartum post-traumatic stress symptoms, postpartum post-traumatic stress, and negative birth experiences, which may contain content related to psychological birth trauma. Finally, we excluded studies that explored the feelings of bystanders (especially healthcare professionals and women’s partners) who may also experience psychological trauma as a result of witnessing the birth process. We, therefore, recognize that this definition may be subject to further development and adjustment.

6. Conclusion

This concept analysis provides a comprehensive insight into psychological birth trauma, which is a more complex and comprehensive phenomenon than previously thought and should be considered as a separate postpartum mental health problem. Given the high incidence and far-reaching effects of psychological birth trauma, its prevention, identification and intervention are crucial, but relevant studies are insufficient and need to be further explored. This study provides a starting point for future theory and research, and provides researchers and healthcare professionals with information that can serve as the foundation for assisting in the identification of psychological birth trauma, and as the reference for developing rigorous assessment tools as well as designing appropriate interventions. In addition, further research is needed to expand the definition of psychological birth trauma from the perspective of bystanders during birth. We expect that this concept will continue to be updated and refined as knowledge on the subject develops.

Author contributions

XS, XF, SC, RW, LS, HX, JH, ZZ, and AZ designed the study, critically revised the manuscript, and approved the final version. XS and XF conducted the literature retrieval, literature selection, data extraction, data analysis, and drafted the manuscript. All authors contributed to the article and approved the submitted version.

This work was supported by the National Natural Science Foundation of China Youth Program (grant number: 72204123) and the Nanjing Health Science and Technology Development Special Fund Project (grant number: YKK21162).

Acknowledgments

We acknowledge the support of the National Natural Science Foundation of China and the Nanjing Health Commission.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Supplementary material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyg.2022.1065612/full#supplementary-material

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Keywords : birth, psychological birth trauma, concept analysis, perinatal mental health, obstetric, psychological, trauma

Citation: Sun X, Fan X, Cong S, Wang R, Sha L, Xie H, Han J, Zhu Z and Zhang A (2023) Psychological birth trauma: A concept analysis. Front. Psychol. 13:1065612. doi: 10.3389/fpsyg.2022.1065612

Received: 10 October 2022; Accepted: 28 December 2022; Published: 13 January 2023.

Reviewed by:

Copyright © 2023 Sun, Fan, Cong, Wang, Sha, Xie, Han, Zhu and Zhang. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

† These authors have contributed equally to this work and share first authorship

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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Oregon news menu, oregon news, adoption study links child behavior issues with mother’s trauma.

Mothers’ childhood experiences of trauma can predict their children’s behavior problems, even when the mothers did not raise their children, who were placed for adoption as newborns, a new University of Oregon study shows.

The research team, led by Leslie Leve , a professor in the UO College of Education and scientist with the Prevention Science Institute , found a link between birth mothers who had experienced stressful childhood events, such as abuse, neglect, violence or poverty, and their children’s behavior problems. This was true even though the children were raised by their adoptive parents and were never directly exposed to the stresses their birth mothers had experienced.

If a child’s adoptive mother also experienced stressful events as a child, then the child’s behavior issues were even more pronounced, the researchers found.      

The paper in the journal Development and Psychopathology was recently published online.

This research underscores the importance of efforts to prevent child neglect, poverty, and sexual and physical abuse, and to intervene with help and support when children experience them.

“We can’t always prevent bad things from happening to young children,” Leve said. “But we can provide behavioral health supports to individuals who have been exposed to childhood trauma or neglect to help them develop coping skills and support networks, so that difficult childhood experiences are less likely to negatively impact them — or the next generation.”

Leve is the Lorry Lokey Chair in Education and head of the counseling psychology and human services department. 

In the only study of its kind, Leve and other researchers have followed 561 adopted children, their birth parents and adoptive parents for more than a decade. Participants were recruited through 45 adoption agencies in 15 states nationwide. The researchers collected data from the birth parents when children in the study were infants and from the adoptive parents when the children were age 6-7 and again at age 11.

The researchers found when birth mothers reported more adverse childhood experiences and other life stress when they were young, their children showed less “effortful control” at age 7. Examples of “effortful control” include the child being able to wait before initiating new activities when asked and being able to easily stop an activity when told “No.”

At age 11, the children of these same mothers showed more “externalizing behavior,” such as rule-breaking and aggressive behavior.

The study also points the way for additional inquiry. For example, exactly how does stress in one generation become associated with behavior in the next generation? 

“We know from nonhuman animal studies that stress can change the expression of genes by essentially changing which genes are turned “on” or “off” when passed on to the next generation,” Leve said. “That could be a plausible pathway.”

Further, what is the effect of the environment in which the child was raised?

“Can we find something positive in the rearing environment, perhaps parents’ warmth or sensitivity, that can help offset the child’s genetic or biologic risk for impulsive or externalizing behavior?” Leve asked. That is the next question the research team is asking.

Along with Leve, the study’s authors include Veronica Oro and David DeGarmo with the UO’s Prevention Science Institute; Misaki Natsuaki with University of California, Riverside; Gordon Harold, University of Cambridge; Jenae Neiderhiser, The Pennsylvania State University; Jody Ganiban, George Washington University; and Daniel Shaw, University of Pittsburgh.

— By Sherri Buri McDonald, University Communications

This research was supported by grants from the Eunice Kennedy Shriver National Institute of Child Health & Human Development; the National Institute on Drug Abuse; National Institutes of Health Office of Behavioral and Social Sciences Research; National Institute of Mental Health; National Institute of Diabetes and Digestive and Kidney Disease; National Institute of Health’s Office of the Director; and the Andrew and Virginia Rudd Family Foundation.

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The PROMOTE Network: Improving Access to Mental Health Care for Older Adult Trauma Survivors

This project is focused on improving mental health care for older adults with trauma.

1 March 2024

Grant: Grand Challenges Mental Health and Wellbeing Network Building Year awarded:  2023-24 Amount awarded:  £2,471.13 

Dr Vasiliki Orgeta, Brain Sciences  Dr Jean Stafford, MRC Unit for Lifelong Health & Ageing, Population Science & Experimental Medicine, Population Health Sciences 

Older adult trauma survivors face significant health challenges, including higher rates of PTSD, cardiovascular disease, and cognitive decline, yet they often receive misdiagnoses and inadequate treatment. Our systematic review highlights a lack of large-scale clinical trials focused on this population, particularly outside veteran groups, with women and low- to middle-income countries notably underrepresented. This project aims to unite global experts to develop effective, evidence-based interventions and create a community dedicated to improving care for older adults exposed to trauma. 

Outputs and Impact

Progress to date and milestones: 1. Research assistant for the project has been employed International collaborations. 2. We have had an introductory Symposium meeting with international experts on psychological trauma in late life (via the Global Collaboration on trauma and ageing workgroup https://www.global-psychotrauma.net/ageing ) and introduced the network; all experts expressed interest in being part of PROMOTE and contributing their expertise - In this meeting major future important research projects were discussed, and particularly emerging evidence of how psychological trauma could contribute to metabolic disease in late life and the importance of identifying key pathophysiological mechanisms that could influence physical health for this group - Our second International Symposium will take place in July 2024 and will primarily be aimed at identifying interventions ready to be evaluated/urgently needed (pharmacological and psychological treatments). 3. We have reviewed evidence of both pharmacological and psychological interventions to inform our Symposium of the State-of-the-Art evidence; overall we find under-representation of the general population of older people; with most trials of treatments to date focusing on war veterans, and male populations. We have identified no evidence-base for pharmacological therapies for treating PTSD symptoms for people 65+. 4. Our first symposium of international experts addressing clinical guidelines for treating traumarelated symptoms identified a major gap; there are currently no clinical guidelines specifically for this group. A major finding of this early symposium was that first choice of treatments varies by country; for example, some European countries use Eye Movement Desensitization and Reprocessing (EMDR) Therapy, whereas other countries use anti-depressants as a first line of treatment; we have now identified no evidence-base to support clinical effectiveness of neither of these interventions.

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Watch CBS News

Trump rally shooter identified as Thomas Matthew Crooks, 20-year-old Pennsylvania man. Here's what we know so far.

By Nicole Sganga , Emily Mae Czachor , Pat Milton , Allison Elyse Gualtieri , Michael Kaplan , Madeleine May

Updated on: July 17, 2024 / 1:25 PM EDT / CBS News

The gunman who fired shots at former President Donald Trump in an assassination attempt at a campaign rally in Butler, Pennsylvania, Saturday night has been identified by the FBI as 20-year-old Thomas Matthew Crooks. He  was killed  by a Secret Service sniper, officials said. 

One audience member at the rally, Pennsylvania firefighter  Corey Comperatore , was killed in the shooting, and two other men are in critical condition, officials said. A spokesperson for Allegheny General Hospital said the injured victims were stable, although still in critical condition, on Sunday night.

Who was the shooter?

In a statement, the FBI said: 

"The FBI has identified Thomas Matthew Crooks, 20, of Bethel Park, Pennsylvania, as the subject involved in the assassination attempt of former President Donald Trump on July 13, in Butler, Pennsylvania. This remains an active and ongoing investigation, and anyone with information that may assist with the investigation is encouraged to submit photos or videos online at  FBI.gov/butler  or call 1-800-CALL-FBI."

Federal investigators said the gunman was not carrying identification, so they analyzed his DNA to provide a biometric confirmation of his identity. 

Crooks was from Bethel Park, Pennsylvania, a Pittsburgh suburb about an hour south of Butler. The town in Allegheny County is home to about 30,000 people and has one high school with about 1,300 students.

He graduated from the Community College of Allegheny County in May with an associate in science degree in engineering science, a spokesperson for the college confirmed to CBS News. He was expected to enroll in Robert Morris University in the fall, a spokesperson for the private university in the Pittsburgh area confirmed Monday to CBS News, and had not yet attended classes there.

Bethel Park School District confirmed to CBS Pittsburgh station KDKA that Crooks was a 2022 graduate of Bethel Park High School. School officials pledged to work with law enforcement investigating the shooting, and offered condolences to those affected by the attack. 

Some Bethel Park residents recalled interactions with the gunman and his family in interviews with CBS News Pittsburgh after the shooting.

"I had a really pleasant conversation with them," said Alleghany County councilman Dan Grzybek, who lives on the same street as the shooter and visited the home while campaigning. "I got the perception they were nice people." 

Grzybek said he fears the shooter's actions will "result in further political violence." 

Former high school classmate Jameson Myers, a member of the school's varsity rifle team, told CBS News that Crooks had tried out for the team freshman year but did not make the junior varsity roster and did not return to try out for the team in subsequent years.

He called Crooks a "nice kid who never talked poorly of anyone," and he said, "I never have thought him capable of anything I've seen him do in the last few days."

Fellow classmate Summer Barkley told CBS Pittsburgh reporter Megan Schiller that although Crooks wasn't popular, he still had a group of friends and was a good student beloved by teachers. She said she didn't see any red flags that would lead her to believe he would do something like this.

Mark Sigafoos, who graduated with Crooks and sat near him in class, told CBS News that while it was possible Crooks was bullied in school, he never personally saw it happen. Sigafoos described him as smart, friendly and frequently engaged during class, "definitely nerdy for sure," but said he "never gave off that he was creepy or like a school shooter."

"He seemed like he wouldn't hurt a fly," he said.

Another classmate, Jason Koehler, had a somewhat different view, telling Schiller that Crooks was a loner who was bullied relentlessly for his appearance and wore camo/hunting outfits in class. He said Crooks would often sit in the cafeteria alone before class. He also said Crooks was very COVID-conscious and wore a surgical mask long after they were required.

Crooks also worked at Bethel Park Skilled Nursing and Rehabilitation Center as a dietary aide, according to the facility's administrator. The University of Pittsburgh confirmed Monday that Crooks had been admitted for the fall semester to study mechanical engineering, but according to a statement from the school, he informed the university in March he had decided not to attend.

Crooks also had a membership at a nearby gun club for at least a year. Bill Sellitto, the president of the Clairton Sportsmen's Club in Clairton, Pennsylvania, told CBS News that Crooks was a member.

"We can confirm that Mr. Crooks was a member of the Clairton Sportsmen's Club. Beyond that, the club is unable to make any additional commentary in relation to this matter in light of pending law enforcement investigations," Sellitto said in a statement. "Obviously, the Club fully admonishes the senseless act of violence that occurred yesterday."

A law enforcement source noted that at the time of the shooting, the gunman was wearing a shirt that apparently read "DemolitionRanch," a popular gun-related YouTube channel with over 11 million subscribers. 

What was his motive?

Federal authorities are still investigating what may have prompted the gunman to carry out the shooting, but so far, they say it appears he acted alone.

The FBI is investigating whether the shooter was "motivated by a violent extremist ideology or had any association with additional plotters or co-conspirators," according to an FBI and Department of Homeland Security bulletin sent to law enforcement Monday and obtained by CBS News.

"We do not currently have an identified motive," said Kevin Rojek, FBI Pittsburgh special agent in charge, at a briefing late Saturday, and President Biden said the shooter's motives were still unclear in an address from the Oval Office the following night.

"There is no place in America for this kind of violence, for any violence, ever. Period. No exceptions. We can't allow this violence to become normalized," Mr. Biden said. "The political rhetoric in this country has gotten very heated. It's time to cool it down. We all have a responsibility to do that."

A law enforcement official said early Sunday that no foreign terrorism ties were known at the time and the suspect was not on the radar of law enforcement.

There was also no indication that Crooks ever had a connection to any military branch, officials confirmed to CBS News.

Crooks' political leanings were not immediately clear. He was registered as a Republican voter in Pennsylvania but Federal Election Commission  records show he made a $15 donation to a Democratic-aligned group.

An FBI official said the family of the shooter is cooperating with investigators. 

FBI officials told reporters during a press call Sunday afternoon that determining the motive is the primary objective of the agency's investigation. Officials also said there was no indication of Crooks having mental health issues. 

Crooks did have a social media presence, the FBI officials said Sunday. Agents are combing through his posts and emails but have found nothing so far that reveals a motive or anything threatening. 

In a Monday statement, the FBI confirmed they were able to access the shooter's phone and continue to analyze his electronic devices. Sources told CBS News the phone has so far not yielded any information about his beliefs or a potential motive.

Meanwhile, the public has submitted over 2,000 tips to the FBI for examination.

What weapon did he have?

The gunman was armed with a semiautomatic AR-style rifle, multiple law enforcement sources said. He had purchased a box of ammunition with 50 rounds on the day of the shooting, a law enforcement source confirmed to CBS News on Monday.

Law enforcement sources told CBS News the gun was legally purchased in 2013 and was registered to the shooter's father, Matthew Crooks. 

Investigators found three suspected improvised explosive devices, according to an FBI/DHS bulletin. Two were found in the shooter's car and another was found at his residence.

A source confirmed on Tuesday that authorities found rudimentary bomb-making materials at the gunman's residence and inside his vehicle, which were being analyzed by the FBI. 

What protections were there for Trump?

Trump said  in a social media post that a bullet pierced the upper part of his right ear. He was checked at a local hospital before leaving the area under Secret Service protection and flying to New Jersey late Saturday night. Hi son, Eric Trump, told CBS News on Wednesday that his father didn't have stitches, but had a "nice flesh wound."

Trump's Secret Service detail was given additional assets that are part of the protocol for the presumptive nominee due to his heavy campaigning, which includes additional manpower, counter-sniper, drones and robotic dogs, a law enforcement official said. On Saturday, there were four counter-sniper teams on site, the official said. At least a dozen additional police officers and sheriff's deputies were assisting the Secret Service and Pennsylvania State Police with rally security, the Associated Press reported.

Additionally, Trump's teleprompter is protective and the flag and podium banners are made of steel, the law enforcement official said.

In a statement Sunday morning, U.S. Secret Service spokesperson Anthony Guglielmi said the agency recently "added protective resources and capabilities to the former President's security detail," and said any suggestion that they had rebuffed a request for more security "is absolutely false."  

"The U. S. Secret Service takes threats seriously, and it takes actions based on those threats as warranted," he said. "The U.S. Secret Service is constantly evaluating the very dynamic threat environment and responding to it in the fulfillment of its responsibilities."

What did witnesses see?

Cellphone video  taken at the rally shows attendees pointing toward the gunman and trying to inform authorities that he was there. The video was taken two minutes before the shooter fired at Trump. In it, people are seen running away from the area less than 15 seconds before shots were fired. Moments after that, some people in the crowd start shouting that a man on the roof has a gun.

One man who was at the rally said that soon after Trump started speaking,  he saw a man  "bear crawling" up a building.

"We're pointing at the guy," said the witness, named Greg. "He had a rifle — you could literally see him with a rifle." He told the BBC that he and others told the police and were pointing him out to U.S. Secret Service agents. He estimated that the man was on the roof for "three or four minutes" before shots were heard.

Other witnesses  told CBS Pittsburgh station KDKA  that they also saw the gunman and tried to alert officers before the shooting.

Sequence of events

Details continued to emerge  on Tuesday about the sequence of events leading up to the shooting. In addition to the ammunition that he purchased, the gunman also bought a ladder at Home Depot before the rally on Saturday, two law enforcement sources told CBS News, after it was first reported by  CNN . Home Depot condemned the violence in a statement.

It was unclear whether the shooter brought that ladder to Trump's event, where he ultimately ended up on the roof of a building about 410 feet from the main stage and just outside the bounds of a security perimeter established on the property, according to law enforcement sources and video analyzed by CBS News. 

Along with witnesses who recalled seeing the gunman, multiple law enforcement officers were aware of his presence on the roof just before the shooting happened.

Three snipers from local tactical teams had been deployed to assist Secret Service agents at the rally and were stationed inside the building that the shooter used in the attack, a local law enforcement officer with direct knowledge of the events  told CBS News . The security operations plan had them stationed inside in order to face the rally and scan the crowd through the windows. Local news outlet BeaverCountain.com initially reported details about the three snipers.

One of those snipers saw the gunman outside of the building, looking up at the roof and observing the building before disappearing, according to the officer who spoke to CBS News. The sniper saw the gunman as he returned to the building, sat down and looked at his phone. 

That's when one of the snipers took a picture of the gunman, and then saw the shooter looking through a rangefinder minutes before he tried to assassinate the former president, the officer said. The sniper radioed to the command post right away and tried to send the photo that he'd taken of the gunman up the chain of command.

As this was happening, a local police officer was hoisted up onto the roof of the building by another officer to check the premises, after receiving reports from bystanders who spotted the gunman,  the sheriff of Butler County told  CBS News Pittsburgh . The officer saw the shooter, who pointed the rifle at him. The officer then let go and fell from the roof, the sheriff said.

At that point, the gunman turned to face the rally and fired between six and eight rounds.

-Jessica Kegu, Clare Hymes, Robert Legare, Pat Milton, Andres Triay, Megan Schiller, Anna Schecter, Nicole Sganga, Adam Yamaguchi and other CBS News staff contributed to this report. 

• Pennsylvania
• Donald Trump

Nicole Sganga is a CBS News reporter covering homeland security and justice.

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Breaking news, pillowcases can be ‘dirtier than the toilet’ during summer, experts warn.

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The extreme summer heat has many people drenched in sweat outdoors, indoors and even in their sleep.

Experts revealed how a sweaty night’s sleep could harbor bacteria in your pillowcase, making it more gross than a certain bathroom fixture.

“Your pillowcases could be considered dirtier than the toilet. The good news is these bacteria are very likely to be from you to begin with and, therefore, aren’t harmful,” Dr. Gareth Nye, a program lead for medical science, confessed to Wales Online.

The medical expert encourages people to wash their pillowcases and bedsheets once a week to avoid the buildup of germs and bacteria growth lingering on them — even if they are their own.

“In terms of bacteria, some studies have shown that there were 17,000 more bacteria colonies on a pillow case after a week when compared to a toilet seat,” Nye added.

Real Simple also reported that “after one week without washing, their pillowcases carried an average of 3 million colony forming units (CFU) of bacteria per square inch.”

Most people can lose between 500 millimeters and 700 millimeters of sweat on an average night. However, at least 200 millimeters of the water gets soaked into the bedsheets or pajamas, according to Nye’s studies.

“The body is replacing skin cells leading to skin cell shedding. With people losing an average of 500 million skin cells a day (most of which come off at night), the body is ALSO producing other body secretions and then you have the added fluid loss through drool/saliva,” Nye shared.

If ignored, other issues can arise, such as fungi or dust mites, which thrive off dead skin cells and can leave droppings that trigger allergies and asthma.

“One study found that a typical pillow has as many as 16 different species of fungus and literally millions of fungal spores,” he continued.

The Post previously reported how making your bed immediately after you get rise can increase bacteria growth.

“By  being in a hurry to make your bed , you run the risk of trapping damp air under the covers, which helps the nasty creepy-crawlies to breed,” the anonymous domestic diva behind  Mrs. D’s Cleaning Reviews said.

Experts admit that people should allow their bed to breathe during the summer season and change their sheets frequently.

Nye suggests avoiding polyester bedding and considering “cotton or linen sheets or put the duvet away and utilize sheets alone.”

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• v.15(10); 2013 Oct

Mothers' Response to Psychological Birth Trauma: A Qualitative Study

Ziba taghizadeh.

1 School of Nursing and Midwifery, Isfahan University of Medical Sciences. Faculty Member of Nursing and Midwifery Care Research Center, Nursing and Midwifery School, Tehran University of Medical Sciences

Alireza Irajpour

2 Nursing and midwifery Care Research Center, Isfahan University of Medical Sciences, Isfahan, IR Iran

Mohammad Arbabi

3 Psychiatry and psychology research center, Roozbeh hospital Department of Psychiatry,Tehran University of Medical Sciences, Tehran, IR Iran

Psychologically traumatic events can affect anybody, but consequences of psychological birth trauma for the mother are very profound, extensive and unforgettable. Furthermore, the mother’s response not only touches the mother, but also affects the child, the father and the society. The objective of this study was to explore the mothers’ response to psychological birth trauma.

Psychological birth trauma is a complex matter as the length of a women`s life and mother`s responds can be present through different psychological and physical ways. In this regard, the mothers suffer from its consequences, but they do not know what is going on? Mothers are getting worse every day by “the silent effects of the psychological phenomena”.

Materials & Methods

This qualitative study was conducted on 23 mothers with psychological birth trauma experience, who were recruited from health centers of the capital and one of the metropolises of Iran. Their interviews were transcribed verbatim and analyzed by the content analysis method.

Three themes were extracted from the data: impact on health, changes in mother`s roles, and changes decision making ability. Several categories and sub-categories also emerged from the data (physical and psychological problems, bonding with the child, relationship with husband, social role, cesarean request and psychological inability to have another child).

Conclusions

By considering the mothers` responses to traumatic labor, which endangers the health of the child as well as that of the mother and impairs their familial and social relationships, midwives should notice the consequences of psychological birth trauma in order to plan supportive and timely interventions.

1. Background

Pregnancy and childbirth can lead women down two strikingly different paths. One path can get off to a very good start to motherhood, whereas in case of traumatic labor, the other path can lead them to a very poor start in their relationship with the child and husband, as well as to psychological problems ( 1 ). It may also cause some problems in mothers` social lives. Whereas birth is a powerful experience, when it is traumatic, its impacts can be considerable and unforgettable ( 2 ). Psychological birth trauma (PBT), also referred to as traumatic childbirth (TB), is a situation in which the woman has suffered distress as a result of injury to herself and her baby, or pain or sorrow, which is in such a magnitude that it may prone the mother to a traumatic condition, with a prolonged psychological and/or physical effect ( 3 ).

It has long been recognized that some women, following a traumatic childbirth, go on to develop some psychological disorders ( 4 ). In this connection, Hofberg and Ward believed although pregnancy and childbirth are often desired by women, it is not uncommon to experience some degree of anxiety ( 5 ). Gamble also found a high prevalence of postpartum depression and trauma symptoms occurring after childbirth ( 6 ). The prevalence of psychological birth trauma at a rate between 20 to 30% has been reported by different authors in different countries ( 6 - 8 ). Creedy et al. also reported that one out of every three births can lead mothers to psychological birth trauma. Feeling out of control, depressed, anxious and post-traumatic stress disorders are the consequences of psychological birth trauma ( 9 , 10 ). In one study, 1.9% of women perceived birth as traumatic and progressed to post-traumatic stress disorder (8). In addition, about 13% of all women will experience an episode of postnatal depression ( 1 ).

Psychological birth trauma can also hurt family relationships ( 11 ), reduce the lactation period ( 12 ) and, in the long run, the children of these mothers end up with emotional, cognitive and behavioral disorders ( 13 , 14 ). Postnatal depression may adversely influence infant and child development, as well as having potential negative consequences on women and their families ( 1 , 15 ). Moreover physical disorders such as those accompanied by excessive fatigue, vital exhaustion, and reduction in functional capacity can be caused by depression following psychological birth trauma ( 15 ). Four women in one study suffered from long-term physical consequences from their birth, such as severe pain ( 16 ). Furthermore, requesting an elective cesarean birth implies a high level of anxiety about childbirth. However, elective cesarean section does not ‘‘cure’’ the fear of childbirth. Thus, when a pregnant woman requests an elective cesarean section that is not medically endorsed and counseling is recommended ( 2 ).

Regarding psychological inability to have another child, the most significant finding of one study was that women with a negative experience from their first birth decided not to have another child or considered a longer interval before the second birth ( 17 ). Turning to the mother`s roles, different bonding styles with the child were reported by Nicholls and Ayers which seemed split between “overprotective/anxious bonds and avoidant/rejecting bonds”; in the former, some women reported acting out the mothering role (delayed onset of emotional attachment) ( 18 ). Also, in one study, initial feelings of rejecting their neonate were reported by the majority of the participants ( 16 ). In some cases, women believed that their ability to bond with their children had been affected by the negative childbirth experiences ( 19 ). With respect to the relationship with their husband, there is some evidence around sexual avoidance and fear of childbirth. During the first year, following childbirth, some women could not have a sexual relationship with their partners and had a cold and distant sexual behavior with them ( 4 ). In addition, some men and women perceived difficulty with intimacy due to birth ( 18 ). In one study all women were under pressure from their relationship with their partners due to the traumatic birth experience ( 16 ).

2. Objectives

Psychological birth trauma is a complex matter as the length of a women`s life and mother`s responds can be present through different psychological and physical ways. In this regard, the mothers suffer from its consequences, but they do not know what is going on? Mothers are getting worse every day by “the silent effects of the psychological phenomena”. However, true figure of psychological birth trauma is unknown, as many women do not seek help. Women suffer more than men according to surveys in Iran and other countries ( 20 , 21 ). Misdiagnosis, delay, non-specific treatments and lack of follow up have constituted a typical care pathway for depressed people throughout the world. One reason may be that the explanatory models of clinicians differ from those of patients in their own culture ( 22 ). Furthermore, in many countries the cost of psychological treatment is very high, not only in terms of social but also economic issues. For example referring to a psychologist is a “social stigma” for the mothers and it costs them a lot of money. Knowledge about psychological birth trauma is restricted; moreover the mother`s response as an ambiguous concept varies in different cultural, social, economic and environmental contexts, so this qualitative study tries to describe the mothers' response to psychological birth trauma.

3. Materials and Methods

In order to understand mother`s response to traumatic birth, a qualitative study with content analysis approach was adopted. Content analysis as a research method is a systematic and objective means to describe phenomena ( 23 ). Krippendorff believed that content analysis is a research method for making replicable and valid inferences from data to the context of the data, with the purpose of contributing knowledge, new insights and a representation of facts: to achieve a condensed and broad description of the phenomenon ( 23 , 24 ). In this study, inclusion criteria comprised of an experience of psychological birth trauma assessed using the revised fourth edition of the standard psychiatric questionnaire DSM, ability to speak and understand the Persian language, and exclusion criteria consisted of any proven post-trauma stress or psychotic disorders. We did not exclude any mothers during sampling. In order to achieve maximum variation of participants and to allow transferability of research findings, age, number of pregnancies, educational level, economic, social and cultural status, employment status and mode of delivery were considered in the process of purposive sampling.

3.1. Data Collection Procedures

Approval to conduct the study was obtained from the institution’s ethics committee. The participants were informed about the aim of the study and signed a written informed consent for the taped recorded interview. They were assured of their privacy and also informed that they could withdraw from the study without consequences. The interviews were conducted at a convenient time and place for the participants. The mean time of interviews was about 60 minutes. Interviews were conducted until saturation was achieved.

3.2. Data analysis

The participants were the mothers from Tehran and Isfahan health centers, who experienced traumatic childbirth, recruited from September 2011 to February 2012. Participants were aged between 18 to 50 years and their educational statuses ranged from secondary school to doctoral degree and were mostly housewives. The Reproductive characteristics of participants are shown in Table 1 .

Initial interviews were conducted with 94 mothers to determine their eligibility; any mother, who was suspected to have experienced PBT, underwent a semi-structured interview. After each interview verbatim transcriptions were used to illustrate each finding. Thereby, twenty-three mothers were identified to be eligible. Next, responses were coded using content analysis into three major categories.

3.3. Mothers’ Responses to Psychological Birth Trauma

The result of the interview with mothers showed that, if childbirth makes maternal psychological trauma, it would vitiate their social rapport, leading them to live an isolated life and ultimately a manifestation of their psychological disorders. Likewise, mother’s decision-making power for her future reproductive life would be affected by this trauma. Interpersonal communication problems and uncertainty in decision-making about her reproductive life thus constituted the theme, “mothers’ responses to psychological birth trauma”. There was a widespread disrupt relationship between the mother and her husband, children and relatives. The participant mothers, who suffer from psychological birth trauma, demonstrated similar reactions through different ways. The relationship gulf between mother and her child, challenging marital life, and social conflict are incorporated in the subcategory of communicative problems as the failure to a subsequent pregnancy; if the subsequent pregnancy takes place, resorting to caesarean section is incorporated to sub-category of uncertainty in decision-making. Table 2 , represent the theme, “mothers’ responses to psychological birth trauma”, categories, sub-categories and the contracted meaning unit. The responses of participating mothers in this psychological birth trauma study were as follows.

3.3.1. Relationship Gulf Between Mother and her Child

The sub-category of relationship gulf was constituted by the two concepts; mother’s feeble attachment to her baby and inability to fulfill the maternal role. The communicative gulf between the mother and her child, which is due to psychological trauma, did not go away, even with time. One of the mothers said about her relationship with her child; “I didn’t love my baby during the first three to four months as everybody came to kiss her and treated her with a sense of love, and the only person who didn’t have these feelings for her was me, I never thought she was my child, I don’t know why, I could only feed her my breast milk and there was no other feeling that I could have for her. When she was inside my belly, I liked her but this feeling went away once I gave birth to her. Since the childbirth, I don’t look like a normal human being”. A mother who had experienced pregnancy 8 months ago said “I wasn’t happy at all as evident in the video filmed in the delivery ward of the hospital, I didn’t feel anything special when my baby was brought close to my face. I felt nothing so I pulled my face away from her, it meant that I didn’t have any pleasant feeling about this, at this point I don’t have any feelings for my baby, I have no idea, maybe it will be fine when she grows up, and she can walk or talk to me”.

In case there was no attachment between the mother and the child, the mother’s role would be ruined. A young mother, after 3 years from her delivery, said about her first and only child: “such hollow feeling drove me to offer my child to my aunt. My husband, asked: Are you sure yet that you really want to give our child to your aunt ? And I replied to him, “No, I can’t”. But this was a lie, because I wanted to do so. I wanted to fix this relationship, really; but I couldn’t. I’m trying but it doesn’t work. I am experiencing hollow feelings about my child. I couldn’t take care of her. Such relationship gulf would disrupt the breastfeeding process, too. One of the mothers said about her first pregnancy (at the time of this interview, she had two kids): “at this point, I wish my first child could go back to infancy and I could feed her my breast-milk, kindly. How hard it was to breastfed her.”

3.3.2. Demanding Marital Life

Sensitive and emotional apathy along with a reluctance to have sexual relationship constitutes the “demanding marital life” class. Emotional and sexual relationships of most mothers are subject to be ruined by the psychological birth trauma. One mother, regarding this matter, said: “my anxiety affected my marital relationship. We became apart; our love decreased. It affected our life directly.” One of the mothers said: “our emotional relationship decreased after childbirth. I lost my sex drive. I don’t know what is my problem? I was damaged. It’s been four months since I have no interest to have sex with him. After this period, our relationship was interrupted. There was no pattern. At this point in time, I think we are going to reach that pattern, it’s been three years since I have had the delivery, and we are going back to the previous pattern, little by little”.

3.3.3. Social Conflict

The mothers’ relationships with their relatives were summed up based on two battling and struggling perspectives under the sub-category of social conflict. Following the psychological birth trauma, some mothers displayed aggressive behaviors towards their relatives, as others preferred to remain shy and isolated. The response, which make up the theme of social escape was as follows; “my husband knows, it means that he realized the change in my demeanor, I used to laugh a lot, happy, funny, but I spoke less and slept much, I hardly made an effort to do anything”. Another mother said “I was much into staying under the duvet. People’s chatter annoyed me. Baby’s voice vexed me, other’s voice made me sick”. The titles, wall and submissive lamb, which represent an inactive person, were used by two mothers as metaphors for their feelings and responses after the psychological birth trauma. A participant mother said “I had forgotten everybody, nobody mattered to me, when I was in a normal state, I cared about the person who came to see me, I especially liked guests, and I had a lot of things to do. However, I had never welcomed any guest coming to my house after the delivery, what else I can say! I looked as if I was a wall and I didn’t have the same feelings I had before”. Another mother said “I felt as if I was a little lamb, when I went to the delivery ward, it seemed to me that I had handed everything over to them so that they could make any decision they wanted. As far as I didn’t realize anything, I had to give in to what they wanted; I couldn’t take it any longer”. Some mother participants sought to get into a fight. One of them said: “I didn’t allow doctors to examine me as they insisted to do so. I said I don’t like to be touched, I felt weaker in spirit than before because I couldn’t stand it”. Another one said: “once they intended to do something for me, I didn’t let them go ahead. It wasn’t my fault. I was scared to death”.

3.3.4. Uncertainty of Decision-Making

The failure to have a later pregnancy and resorting to caesarean section in case of a later pregnancy, which in turn constituted the sub-category of uncertainty in decision-making, were manifested in the other mothers’ responses to the psychological trauma; these consequences embody in the maternal future reproductive life. One of the mother participants, who expressed her lack of interest in having the second child, said: “I don’t think of having another baby; I don’t, because I don’t want the hard time I had gone through to recur”, another participant said: “the one thing that has always annoyed me and put an obstacle on my way forward. Due to this, pregnancy process annoyed me. Even though it gave me a good result and I have a healthy kid and he is alive, it made me upset a lot. Such psychic harassment is with me and that's why I prefer to have only one kid". Another mother, who had only one child and went through the delivery eight years ago, said: "that kind of fear is lingering in my head. This is a reason that made me refuse a later pregnancy, as the same procedure would happen to me, things that I’m really afraid of, why do I have to go through it again?” Some mothers desperately used caesarean in order to run away from the delivery. One of the mothers said: “this delivery made me feel frightened, otherwise I would like to have another baby, I can’t stand seeing the delivery ward again, its pains, I don’t want it. If the situation allows for an easy delivery, I wouldn’t dislike having another baby. But when it comes to the delivery ward, I would say no. By the way, if I once again get pregnant, I would definitely have a caesarean”. Another one also said that “what I can say about the delivery!? It was horrible. People told me it is literally difficult to the extent that you feel you are dying. That’s way I preferred not to give birth to my child naturally, instead I chose to have a caesarean. This was the very reason that drove me to have a caesarean, that’s why I got frightened. Now, as I went through the delivery by myself, I will never ever have a normal delivery.”

Three themes were extracted from the data: impact on health, changes in mother’s roles, and changes decision making ability. Several categories and sub-categories also emerged from the data (physical and psychological problems, bonding with the child, relationship with husband, social role, cesarean request and psychological inability to have another child).

5. Discussion

This study explored the mothers' response to psychological birth trauma. On the whole, results of our study revealed that psychological birth trauma as an umbrella can shadow on the mother`s life through changing the mother`s roles, ability of their decision making and also impact on their health. All dimensions are discussed as followed.

5.1. Impact on Mother`s Health

In the developing world, women often do not have adequate antenatal care and may be psychologically unprepared to face hospitalization and procedures related to labor ( 25 ). So although the vast majority of women recover quickly after childbirth, for some of them prolonged suffering remains, that impacts on their lives and on the family members` lives ( 26 ). In our study, the responses of the mothers to psychological birth trauma consist of some psychological disorders such as mood disorders, thought disorder, perception and also physiological disorders. Majority of the participants cried even from thinking about the birth process. They had a profound grief and suffered from depression, anxiety, PTSD and even one of them suffered from psychosis. Beck and Ayers believed that psychological morbidity is common during women`s childbearing periods and some women perceived childbirth as a traumatic event which led them to experience posttraumatic stress reaction ( 27 - 29 ), anxiety and depression ( 30 ) and forced the mother to have an extra visit after physical symptoms ( 31 ). Some studies from Australia showed that 26% of pregnant women had fatigue and sleep deprivation due to strong fear of childbirth ( 32 , 33 ).

5.2. Changes in Mother`s Roles

Mother’s interaction in this study was affected by the fear of childbirth. Nonetheless, experiencing psychological trauma during childbirth, irrespective of development to posttraumatic stress disorder, can have a negative impact on the mother’s psychological functioning ( 8 ), such as difficulty in relationship with the husband and bonding and long-term attachment problems with the child ( 31 , 34 , 35 ) and led the mothers to a painful isolation from the world of motherhood ( 36 ). Women’s sexuality complications are an other outcome from fear of childbirth ( 34 ). In this regard, three women reported a lack of understanding from their partners ( 16 ). Our study`s results were supported by previous findings that experiencing a traumatic birth can end to some problems in bonding with the child or in relationship with the husband. Allen found an impact of psychological birth trauma on the mother`s relationship with others ( 37 ). In our study, some of the participants could not follow their health care providers` order and also they could not have sociability with their families or their friends whereas other studies did not support these findings.

5.3. Changes in Ability of Decision Making

In this study due to fear of childbirth, mothers had lost their decision-making power. In agreement to this finding, several studies showed that when the fear of childbirth, manifested as stress symptoms, it affected mother`s everyday life and resulted in a wish to avoid pregnancy and childbirth ( 5 , 37 - 39 ). Results of a recent Swedish study by Skari at el. showed that a negative birth experience is related to a reduced probability of having a subsequent child ( 1 ). Unfortunately research about psychological birth trauma is scant, and most has focused on the development of posttraumatic stress disorder after childbirth, which appears to be a relatively rare phenomenon; however, the experience of trauma may be much more prevalent ( 8 ). Beck and Watson (2010) stated that women experience an intense fear following a traumatic birth ( 7 ). Sever fear of childbirth affects the daily life of 6% of pregnant women and approximately 10% of Swedish pregnant women suffer from extraordinarily fear of childbirth (37). Eleven percent (11%) of Swedish women ( 40 ), 5.3% of Swiss women ( 41 ), and 78% of Finnish women ( 42 ) suffered from childbirth due to the impact of intense fear. In this regard twenty-two women believed that their whole care during childbirth had been mismanaged ( 19 ).

In order to cover the whole spectrum of psychological and behavioral responses, Skari believed that social role functioning, and psychological distress, such as anxiety and depressive symptoms, should be measured ( 1 ). Hall believed that we should find the way to diminish anxiety followed by traumatic birth ( 33 ). Regarding the results the authors believed that attention to the mental health of women in childbirth and its consequences is the main strong point of this study. Also, interview with families, especially with the husband could be useful, but in this study, interviews were conducted only with the mothers. This is the weak point of the study. It can be explored in further researches.

Results of the study showed that all aspects of women’s health are endangered due to traumatic childbirth. According to the matter that women's health not only forms half of the population's health, but also effects the health of the whole society, it seems necessary to psychologically prepare mothers to face hospitalization and procedures related to childbirth by designing innovative approaches and establishing friendly centers for protection of mothers` health in physical, psychological and social aspects.

Acknowledgments

This study was funded and supported by the Isfahan University of Medical sciences in 2011; grant no.389293. The authors wish to thank all the mothers who participated in this study. It was their willingness to share their experiences and insights that made this study achievable.

Implication for health policy/practice/research/medical education: Psychological birth trauma is a complex matter as the length of a women’s life and mother’s responds can be present through different psychological and physical ways.

Authors’ Contribution: None declared.

Financial Disclosure: None declared.

Funding/Support: This study was supported by the Isfahan University of Medical Sciences.

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J.D. Vance Was Not Always His Name. But It’s the One That Felt Closest to Home.

James David Vance has had a number of names in his life, a function of an upbringing marked by domestic instability.

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By Rebecca Davis O’Brien

• July 15, 2024

In May 2022, when J.D. Vance was a primary candidate vying for a U.S. Senate seat in Ohio, former President Donald J. Trump referred to him — or, seemed to refer to him — in passing at a rally in Nebraska.

“We’ve endorsed J.P. — right? J.D. Mandel, and he’s doing great,” Mr. Trump told the crowd. “And let’s see what happens.”

Mr. Trump had apparently confused Mr. Vance, whom he had just given a major boost with an endorsement the previous month, with his opponent in the Ohio Republican primary, Josh Mandel.

In Mr. Trump’s defense, James David Vance has had a number of names in his life, a function of an upbringing marked by domestic instability and a revolving door of father figures, as chronicled in his best-selling 2016 memoir, “Hillbilly Elegy.”

At birth, Mr. Vance was named James Donald Bowman, after his father, Donald Bowman. Mr. Bowman was Mr. Vance’s mother’s second husband — Mr. Vance wrote that they split up when he was a toddler, and that Mr. Bowman gave him up for adoption when he was 6.

After the divorce, Mr. Vance’s mother married Bob Hamel, who became J.D.’s legal father, and she changed her son’s name. James Donald Bowman became James David Hamel, swapping out her ex-husband’s first name for her uncle’s name, David, to preserve the “J.D.” — which by then was Mr. Vance’s established nickname. (“This seemed a bit of a stretch even when I was six,” Mr. Vance wrote. “Any old D name would have done, so long as it wasn’t Donald.”)

A few years later, Mr. Hamel and J.D.’s mother split up. “One of the worst parts, honestly, was that Bob’s departure would further complicate the tangled web of last names in our family.” His mother, he wrote, took the last name of “whatever husband she was married to.” Her own parents (“Mamaw” and “Papaw”) were Vances.

When J.D. got to Yale Law School, he began to tell his friends about his childhood and his identity. His legal father, whose name was on his birth certificate, was a “total stranger.”

After he graduated from law school, J.D. married a former classmate, Usha Chilukuri , and they both changed their last name to Vance — “giving me, finally, the same name as the family to which I belonged.”

Rebecca Davis O’Brien covers campaign finance and money in U.S. elections. She previously covered federal law enforcement, courts and criminal justice. More about Rebecca Davis O’Brien