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Wednesday, 15 April 2020

Birth trauma (Things We Don’t Know about Pregnancy Series #17)

PTSD (post-traumatic stress disorder) is still a condition associated with soldiers. Men. But every year, estimates suggest 4% of births cause maternal PTSD [1]. We call this birth trauma.

Birth trauma was first recognised in the 1990s, when the American Psychiatry Association modified its definition of a traumatic event. It’s now thought that it may affect fathers who were present at the birth as well as mothers.

I recently visited the Oxford Spires – a midwife-led unit where mothers with no complications can give birth in a relaxed environment. It sits conveniently a few floors above the main hospital, so emergency treatment is only a lift journey away. But amongst the pools and mood lighting, the giant squashy birth aid balls and the ergonomic beds, I was struck by how much could go wrong during birth.

And I don’t just mean physically.



Obstetric forceps. Killian 1842 via Wikipedia Commons.

Birth trauma isn’t triggered only by intense physical ordeals, such as very slow/fast labour, over- or under-medication or gruelling interventions. Any stressful event can cause PTSD, including assault, accident, or witnessing a traumatic event; and likewise, birth trauma is highly subjective, some women will find an event traumatic that does not affect others. Overwhelmingly, the factors that women reported involved the way they were treated during the birth, including feeling lost control or dignity, not being heard, having medical things done to them they didn’t consent to or didn’t have explained to them, or not having information about the health of their baby. When in a vulnerable position, like giving birth, we are especially sensitive to these feelings because there’s not much we can do to assert ourselves. In this podcast, Dr Rebecca Moore, a postnatal psychologist, talks about birth trauma. Notice how the host interrupts her as she talks about women feeling they were not being listened to to jump in and explain that sometimes the medical professionals simply didn’t have time.

Or, in other words, mental health is still an afterthought. Even when medical staff attitudes may cause it.

Many researchers think that the subject may be under-researched because of pain bias: a gender bias against believing in women’s pain that leads to longer suffering times, misdiagnoses, and sometimes death. There may be differences in how men and women experience pain, but we also lack information about women’s pain: many female-only conditions are under-researched, and general medical conditions are often researched only in men, and based on male physiology, and treatments and drugs trialled on men – who may react differently. Many women’s conditions such as complicated births are treated physically, but the mental aspect is under-researched and rarely addressed, including birth trauma, postnatal depression, and grief following a miscarriage.

Baby entering the birth canal. William Smellie via Wikipedia Commons.
The midwives at the Spires put me at ease, explaining how they advocate for the labouring women (such as not letting her pushy American mother in on the birth, without letting on that this was at the labouring woman’s request!), and just being in a midwife-led unit reduces your chances of interventions, compared to being on the hospital floor.

I’ve said and said again that I don’t want an epidural because I have a previous spinal injury and don’t want an injection in my spine. This isn’t an idealistic preference: I have a genuine medical reason to be concerned about this intervention. But I’m still struggling to ensure this is registered and other options are in place.

Symptoms


Symptoms of birth trauma, like PTSD, include flashbacks, high anxiety, low mood and avoidant behaviours. It can affect sex lives, further childbearing, attendance at smear tests, bonding with their baby, and breastfeeding.

Treatment

Birth trauma is under-reported, and many who report it won’t be treated or will be misdiagnosed with and treated for postnatal depression. The primary treatment is talking therapy, which is still being explored.

Researchers have suggested taking a preventative approach: screening women to identify who is most at risk of birth trauma.

Initial findings suggest there could be structural indicators in the brain as well as social indicators or a history of other trauma. The amygdala may be 6% larger in soldiers with PTSD than those without, although it’s unclear whether this is caused by PTSD or makes you susceptible to it, and whether this is also true for birth trauma. Some researchers are looking into whether existing PTSD theories are applicable to birth trauma or not, and whether research into childbirth could help us understand more about PTSD.

Birth trauma and the brain


MRI brain scan. Novaksean via Wikipedia Commons.
Other research is exploring the validity of birth memories. Hormones released after birth may help a woman gradually forget the pain of labour, although the literature suggests memories are still extensive[3]
. Due to extensive methodological problems, more research is needed to confirm findings. Others are looking into the unconscious brain or “the shadow” are affected by birth traumas.

There are many unknowns when it comes to pregnancy, and over the next few months, I’ll be exploring more of them with you. Look out for my next blog post, which will be about depression during and after pregnancy.

You can also read our full article on the things we don't know about pregnancy, which is updated as we add posts across the coming months.



References
why don't all references have links?

[1] Yildiz, Pelin Dikmen, Susan Ayers, and Louise Phillips. The prevalence of posttraumatic stress disorder in pregnancy and after birth: A systematic review and meta-analysis. Journal of affective disorders 208 (2017): 634-645.
[2] Niven, Catherine A., and Tricia Murphy‐Black. "Memory for labor pain: a review of the literature." Birth 27.4 (2000): 244-253.
[3] Waldenström, Ulla, and Erica Schytt. A longitudinal study of women’s memory of labour pain—from 2 months to 5 years after the birth. BJOG: An International Journal of Obstetrics & Gynaecology 116.4 (2009): 577-583.

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