Written on our Wombs.

By Rachael Ouwejan
Nov 2014

Anybody who has been witness to the sharing of birth stories in regular company knows there is no shortage of “war stories” to be told by birthing women. Almost without exception these stories are categorised by fear, pain and a loss of personal autonomy and power. This piece aims not to delve into the reasons why the mainstream narrative surrounding birth is often more in the horror genre rather than romance, nor to look into preventing birth trauma (that’s a story for another day, and begins and ends with honouring the spirit of true informed consent) but to explore the feelings of many birthing women after their own traumatic experience, debunk the victim blaming that often accompanies these feelings, and discuss the healing process after birth trauma.

NOTE: I have taken pains in this article to avoid describing incidents in childbirth that have led to birth trauma and PTSD in any detail. Such pains are not taken in many of the references, so please consider this a TRIGGER WARNING and do not delve into the readings, particularly the academic papers, if descriptions of traumatic childbirth experiences are likely to disturb you.

“Trauma after the birth of a baby is a ‘special’ kind of trauma. It’s a bittersweet kind of trauma. It’s a silent kind of trauma. It’s an invisible kind of trauma. And if your baby is healthy, it is usually considered an unjustified kind of trauma.” (Harshe, 2013)

After a healing homebirth following a traumatic hospital experience with her first a mother is sobbing an apology to her older daughter for the birth she missed out on. Image supplied by Kelly Barnes.

A mother experiences a wave of emotion at the beautiful home water birth of her second daughter after a previous (questionably ‘necessary’) caesarean and traumatic experience in her first birth. “This picture shows a beautiful and painful moment” she recalls, “where I am SO happy at what has just happened but grieving for what should have been with my first birth”.

“With my first child, the classic ‘cascade of interventions’ and ‘we know better’ led to an emergency caesarean section (which, when you look back on it, could have been avoided).

 Having had this second chance, I KNOW that had I been in New Zealand, with THIS midwife, in my own home – Kaiya would also have been born naturally, into the water.

Instead, before the birth of my 1st daughter, Kaiya – my husband and I looked into each other’s eyes and wept, not tears of joy and precious moments, but of despair and hopelessness. We were caught in the ‘machine’, stuck in the cogs of a hospital with the highest Caesarean rate in the UK and don’t be fooled; New Zealand is no haven from this. North Shore Hospital has one of the highest C Section rates in the country.

After Kaiya’s birth, I had a sense of detachment from her that had begun BEFORE she was born. I felt DEFEATED. I felt myself physically slump and give up. It was that point, that I felt I was no longer part of the birth of my daughter. I felt a sense of something being ‘done to me’, not being present to it, not being part of it.

Nothing prepared me for the years of grief and detachment I would feel, surrounding this ending to the beautiful and wholly enriching experience that my pregnancy was for me.  I couldn’t talk about the birth without crying… I hated hearing other people’s birth stories, both good and bad. I was suffering from PTSD but was unaware of it. When Kaiya was a year old, a Plunket Nurse gave me the contact details of a group dedicated to help mothers suffering from PTSD. They linked me to a retired Midwife, who was now a Psychotherapist, helping women come to terms with these types of birth trauma.”

For her second birth Kelly sought out a homebirth midwife and had an amazing water birth at home. Almost immediately after her daughter was born Kelly experienced a wave of emotion. “I sobbed, holding my daughter, and then I got it together and said “We went in under the wire, didn’t we, Elora? Not an obstetrician in the land knew we existed.”

Sheila Kitzinger, interviewed for an article in Prima Baby magazine in 2000, notes:

“A woman who has been through a difficult time in labour is initially in a numb emotional state, so relieved is she that it’s over. This can last weeks, months or even years. Then suddenly the floodgates open. But these feelings are complicated. The woman feels bound to be grateful to the professionals who helped her deliver her baby, especially if the baby was perceived to be at risk, and yet these are the very people you feel have violated you. A woman who has had an emergency caesarean can be very vulnerable to this.”

The feelings surrounding a “difficult time in labour”, as Kitzinger puts in such understated fashion, are indeed highly complex and complicated. They are further confused by a woman’s hormonal response to fear – dubbed “tend-and-befriend”, a possibly peculiarly female stress response can be to “friend-make” with those around them, a trick designed to promote survival in difficult situations (McCarthy, 2005).

Similarly, the prevalent view that the baby is the single most important part of the birthing dyad colours the situation. If baby is healthy there is a tendency for those who might not recognise the value and importance of a good birth experience to dismiss the mother’s feelings with comments such as “at least you have a healthy baby”. On the flipside, if the baby did not arrive completely healthy then a focus on the mother’s experience can be seen by the outsider as an indulgence compared to the grief or intensity of focus on baby.

Grieving for the labour you might have had, then, can feel like a betrayal, not only of your baby but also of the birth professionals and support team who attended the birth. But birth, to paraphrase Barbara Katz Rothman, is not only the process of making babies, it is the process by which we become mothers too. If we start that journey in an uncertain way, mired in fear and pain, it is something that can continue to cause pain for some time. Birth trauma should not be dismissed or buried but needs to be worked through!

TRAUMA IS IN THE EYE OF THE BEHOLDER

“Beauty is not the only quality or phenomenon that lies in the eye of the beholder; birth trauma also does. What a mother perceives as birth trauma may be seen quite differently through the eyes of obstetric care providers, who may view it as a routine delivery and just another day at the hospital” (Beck, 2004).

That mainstream narrative of birthing war stories means that some birthing women seem perfectly content with an experience in which their power and dignity was stripped from them. It’s also possible that perhaps they never held any power or dignity for themselves in the first place. Birth trauma is also not necessarily related to outcomes – if a woman continues to be treated with respect throughout a birth experience, then she might not suffer from any traumatic feelings afterwards, even though it might have been the most intervention filled delivery.

Swalm notes a particular set of risk factors that contribute to birth trauma:

1. Poor support from partner, family and/or staff
2. Unplanned pregnancy
3. Previous stillbirth
4. Previous trauma (sexual abuse). Some aspects of labour and birth might remind her of previous sexual assault
5. High trait anxiety: some women are simply more prone to anxiety of all kinds.
6. Perceptions of not being in control during labour and/or not knowing what’s going on
7. Poor pain relief
8. Fear for the well-being of the baby or oneself

However, whether a mother’s experience qualifies as birth trauma is particular to that mother – there is no threshold of injustice or injury that must be crossed in order to qualify. If you suffer from grief or guilt for your experience after the fact, you suffered birth trauma.

According to Dr. Kalina Christoff of Vancouver Birth Trauma, two of the biggest reasons women experience childbirth-related-PTSD are unnecessary medical interventions and feeling mistreated by their care providers.

POST TRAUMATIC STRESS DISORDER?

The reported prevalence of Post-Traumatic Stress Disorder (PTSD) after childbirth ranges from 1.5 to 5.6 percent (Beck, 2004). This means that as many as 1 in 18 births result in lasting psychological effects for the mother that would benefit from professional help.

“Women with symptoms of PTSD were more likely to feel that they had little control during the labour, to have higher ratings of trait anxiety, and greater fear during the labour for their babies and their own wellbeing. Symptomatic women also felt less well supported by their partner and staff, and less informed about what was happening. In addition, women reporting PTSD symptoms were more likely to attribute blame to themselves and staff for any problems that occurred and were less able to cope with what was happening.” (Bailham & Joseph, 2003)

The original diagnostic criteria for PTSD, which was first recognised in veterans of the Vietnam War, dictated that it had to be in response to events outside of normal human experience. However, it was redefined in 1995 to more broadly include triggering events that involve actual or threatened death or serious injury. A personal response involving intense fear, helplessness or horror and continued symptoms in categories of intrusion, avoidance and hyper-arousal complete the PTSD picture. “For example, intrusion would include the persistent re-experiencing of the trauma through distressing recollections, dreams, or feeling like one is reliving the whole traumatic experience.” (Swalm, undated).

A mother might “overreact” (in the eyes of an outsider) to internal or external cues that resemble some aspect of the traumatic event (a particular beeping sound, dramatic depictions of birth on television, even just mentions of birth in conversation). In terms of avoidance “there might be avoidance of thoughts, feelings, or conversations associated with the trauma. The person might avoid any kind of activities or places that arouse recollections of the trauma” (Swalm, undated). Hyper-arousal symptoms include things like sleep problems, irritability, poor concentration, and hyper-vigilance (notably all symptoms that can be masked by the standard fog of early motherhood!). If the duration of symptoms is in general longer than a month – no matter when it begins, which can be months after the birth – then PTSD should be considered.

TABS (2003) offer the following list of symptoms to alert mothers to possible PTSD:

• • Experienced an event perceived by the person experiencing it as traumatic.
  • Flashbacks of the event, vivid & sudden memories.
  • Nightmares of the event.
  • Inability to recall an important aspect of the event – psychogenic amnesia.
  • Exaggerated startle response, constantly living on edge.
  • Hyper-arousal, always on guard.
  • Hyper-vigilant, constantly looking around for trouble or stressors.
  • Avoidance of all reminders of the traumatic event.
  • Intense psychological stress at exposure to events that resemble the traumatic event.
  • Physiological reactivity on exposure to events resembling the traumatic event- panic attacks, sweating, palpitations.
  • Fantasies of retaliation.
  • Cynicism and distrust of authority figures and public institutions.
  • Hypersensitivity to injustice.

Elizabeth Ford (2011) points out, however, that “A woman who feels very angry is struggling with a valid emotional response to being discounted or not listened to during the birth, or even being mistreated or assaulted. Even when women don’t fit into the “PTSD box” (fulfilling all the symptom criteria), they may have a spectrum of subclinical trauma reactions which would benefit from support, counselling, or psychotherapy.”

BLAME

“Women… blame themselves when their bodies do what they have been designed to do and shut down when they feel unsafe.   Women blame themselves when they begin to ‘friend-make’ with the very carers who are undermining them, because they have no choice…they need them for their survival.” (Bruijn & Gould, 2010)

In the birth version of “victim blaming”, in processing birth trauma mothers often, at least initially, blame themselves for the turn events took, asking themselves what they did wrong and what they could do next time to avoid a recurrence. While this reflection can be helpful in processing the birth, it is often misguided.

Krista Arias illustrates the internal thought process: “…when I went into labour something happened. It was unexpected and it was bigger than me. It was NOT safe. It came from outside, a flurry of energies in my sacred birth space. It came from within, something deep, something old and unresolved. All I knew was that I could NOT have anything pass through my pelvis. I pushed with all my might, and I held back equally. I was alone in the underworld, and I was terrified. For years, I couldn’t think about my daughter’s birth without shuddering. And oh, the guilt. What was wrong with me that I didn’t have an ecstatic, orgasmic, A+ honours equivalent, birth?”

The victim blaming is not confined to mothers themselves. We often will hear messages like, “a woman is traumatised because she is prone to anxiety,”  “she has not recovered from her past traumatic history,” “she was not properly prepared for how unpredictable birth is and how quickly it can turn into an “emergency” situation.” A birth professional in a homebirth forum recently even suggested that a traumatic birth experience is purely the result of a mother’s poor birth skills education – or that she did not employ her birth education properly.

Jessica Austin (2012) puts it most succinctly: “The truth is, unnecessary medical interventions often lead to the dramatic birth situations which ultimately feel traumatic to women… Although studies consistently show that less intervention leads to better births, hospital practices often stay stuck in the status quo of heavy monitoring and attempts to control the very complex process of birth.

Not only that, but women who do know and understand the risks of medical intervention are often pressured by medical professionals to comply with their recommendations by being told that their lives or the lives of their babies are “in jeopardy”.

I have seen a father ask, “What might happen if we don’t induce today?”, and instead of giving appropriate information on the risks and benefits of induction, the doctor simply replied, “Your baby might die.”  Yes, your baby, always “might die”. But what are the actual statistics? What are the risks of induction (fetal compromise, uterine rupture, increased risk of caesarean birth) as compared to the risks of not inducing? Why wasn’t this couple offered this information, as required by Informed Consent law, in order to make an informed choice about their birth?”

Birth advocates around the world are working to raise awareness of the unnecessary medical interventions which lead to more challenging birth circumstances and pointing to the responsibility of medical professionals to provide accurate information and honour a woman’s right to make an informed choice about her health without pressure or scare-tactics.

Bruijn and Gould (2010) point out: “women cannot feel their strength unless they feel safe and supported and nurtured, and trusting of their body’s ability. So how do they get these things?  Firstly, it is hard for women to feel safe and supported and nurtured unless their support people understand the importance of this for labour progression and emotional health, so great communication and education is vital.  And how do women gain trust in their body?  Not just by blindly ‘trusting’, but by being given appropriate evidence-based information and the sharing of knowledge that enables birth to earn their trust.”

“Many natural birth advocates talk of the amazing hormones of childbirth.  They are right – they are amazing. But they are not available if the woman is scared out of her brain or left alone in a room to labour when she is needing support or given antenatal education that does not enable her to trust her body’s ability or talked down to & patted on the head with a ‘don’t worry your pretty head’ attitude, or not had her questions answered.  Yet this is how many, many women go into birth.

And these women who are birthing in this way have not failed. Really, they have been failed…by our system, our antenatal education, and even our culture in its attitudes to birth.   If she is well-supported by her carers and her knowledge, a woman does have access to those amazing hormones.”

Even more deeply, Krista Arias (2011) notes “As modern women, through no fault of our own, we have been deeply imprinted by birth fear. Not just from movies, and birth fear and doctors, but from the way we ourselves were born, the way our mothers and their mothers were born. Nearly ALL of our mothers were subjected to inhumane treatment and we, in our most vulnerable moments as newborns, were manhandled and abused. It’s no wonder we are a generation of women seeking a shortcut around the intensity of birth.

If we accept the evidence that the way we are born imprints us for our entire lives then we must also accept that modern women are host to a lineage and legacy of pain and fear written on our wombs, our throats, our breath, breasts, and being.”

MOVING ON

The healing process for birth trauma is as individual as the trauma itself.

“Birthing From Within” author Pam England describes herself as a “Birth Story Listener” and offers training for others in this process. She refers to nine “gates” or levels of processing that women can move through over the years as they tell and retell their birth stories to others or to themselves. It is important to note that not everyone works through – or needs to work through – all these levels (which can be followed in more detail at her blog http://birthpeeps.blogspot.com or in her upcoming book “Birth as a Hero’s Journey”).

It is also important to be mindful of how a birth is processed and with whom. In part the mainstream negative narrative surrounding childbirth is caused by the need for catharsis of those who have had a bad experience. For your own healing, process with someone who will validate your feelings and listen without judgement – including your own inner critic. For others’ benefit, please, try not to share birth trauma stories with those yet to birth themselves! England points out: “Not being heard, understood, or validated, while telling our story… can be hurtful, and cause secondary trauma. [A birth story] is not just “social” chit chat, it is an underestimated, powerful force in creating the collective story of birth. Because it is a story told quickly, often to half-listening listeners who are swapping their own stories… all listeners potentially leave with their own meaning, inferences, even distortions… then pass them on to others, like the rippling rock creating endless waves in the collective story of birth in our culture.”

Image generously gifted for use by Capturing Life Photography

The first level of a birth story is no story at all. Immediately after a birth the new mother is immersed in living the birth. The family is “still spinning, stunned open in love or stunned by the intensity of what they have lived”. Other people who witnessed the birth or who visit shortly after may have their own versions of what happened and begin to tell the mother their own opinions of her birth story, which inevitably influences what her story will become.

Once they begin to formulate their own version of the birth story, most mothers are overwhelmingly feeling relief and gratitude. “This is usually a short, repeating, litany of praise for anyone and everyone who helped in anyway; it is probably fuelled by endorphins and adrenalin, as well as genuine and overwhelming relief and joy. In addition, in the early weeks of postpartum, a new mother is falling in love with her baby; her attention is naturally directed toward learning to care for her baby, getting enough sleep, and hosting a flurry of visitors. There isn’t time for reflection, yet.”

Slowly but surely, however, the mother-storyteller begins to examine the relationships involved in the birth experience. She begins to look at “who was there, who wasn’t; who showed up in unexpected ways; who, if anyone, abandoned her”. She may also begin to ponder how her relationships may have changed, “with her own mother, family, husband/partner, friends, birth peeps, the new baby or older children, other mothers, and most importantly—to herself”.

Around the same time, a social birth story, the “sharing over the teacups” version of the story, starts being told. This story is not fixed but the emphasis, emotional meaning, and even what is included and left out, changes depending on the audience.

The medical birth story is often considered the dominant, most valid and validated birth story in our culture. This story can be emotionally charged, or it can be detached and objective, justifying, explaining, and debating the way the labour was managed. At this level of processing the birth story a mother assembles what happened (which can initially be fragmented and muddled in her mind) into linear sequential order. She will begin to ask others who were present what happened when (and why) in order to “get her facts straight”. England describes it as such: “When a birth story is emotionally traumatic, the storyteller can become attached to the meaning she has given the story and to herself because it happened to her. As a result, many get stuck at this Gate, which means that this version becomes their final version. If a woman never progresses beyond the Fifth Story Gate, something will always be missing for her.  If she stops here, she may never know a deeper, more spiritual meaning—or story–that is waiting up ahead.”

The Revolving Door of the Victim and Judge comes next. The mother swings between blaming someone else, remembering feelings of helplessness and powerlessness, and judging herself, telling herself she should be different, or should have done it differently, or what to do to get it right next time. Neither is right, and neither is wrong; both elements can be present in reflections of a traumatic birth experience. Many women seek to answer their internal victim and judge with a subsequent “healing birth” (and interestingly, many seek home birth as the answer). However, while a good birth experience can help move a mother on from this level of processing the previous birth trauma and allow a mother to let go of any feelings of inadequacy she might have harboured, often it does not “heal” the trauma itself – and in fact can drive a deeper anger or grief around birth issues in general.

As this dialogue is heard deeply by the mother herself (and possibly by a counsellor, therapist, or others who act as “story listener”) her mind experiences a pause in the process of thinking and searching. The deeper feelings, images, bodily sensations, and poetic metaphors that capture the heart of the story rise to the surface in a story that becomes more poetry than simple retelling. The pause is often filled with a new question, particular to the mother, which England describes as “her Heart’s Question”.

This Heart’s Question is answered by a Huntress: “The Huntress is looking out, looking far and wide, to see patterns and the whole picture, to “see” and to understand her story in the context of her past and future, how it relates to stories from seven generations past, and within the context of birth in her culture. She has moved from her personal story to her story within a collective story.” This stage is driven by a hunger to know who the mother is at her core, and how her birth experience relates to her past, her future, and in general to the larger picture of birth in our culture. “As the story-teller approaches this Gate, her questions move away from “Why did this happen to me?” or “What should I have done differently?” or “What should I do differently next time to prevent or avoid [fill in the blank]?”.” Many advocates across the birth spectrum (whether they have suffered birth trauma or not) are at this level of processing their own births.

By the final stage of processing birth, a mother has shared with many listeners, read authors, and been inspired by poetry and art. Her story has been deconstructed and reconstructed, given new meaning and digested. “Finally, no longer identified with the story, it no longer needs to be told or healed… [the mother] never tells her whole story to anyone. She keeps in her heart, knowing what and when to share a specific bit of her story—as Medicine. She doesn’t tell her story, or even a part of it, to get something back from the listener (e.g., sympathy, advice, assurance, praise, bonding). She may draw from her story-experience, without having to refer directly to it; Story Medicine comes in the form of a mirroring, validation, metaphor, or myth.”

GETTING HELP FOR YOUR OWN TRAUMA

“It is important to remember that a traumatic birth experience is NOT your fault. In working with women who have experienced a birth trauma, there is often a great deal of self-blame. The fact of the matter is, you did the very best you could at that moment in time. You looked at the information that was given to you, weighed the pros and cons of each choice and made the very best choice that you could. Any reasonable person, in your shoes, knowing what you knew, being told what you were told, probably would have made the same choices. That is NOT your fault. From here, it is important to find some way to process through the birth experience” (Treat, 2012).

If you have had a traumatic birth and don’t know how to get help, there are a number of resources both online and in person that may be helpful.  There are many options to process the experience including support groups, journaling, and therapy.

Obtaining a copy of your birth notes may help you to understand what happened during the birth and why events proceeded as they did. Sometimes in long and difficult labours the details and timeline get confused and the birth notes – if accurate! – can help with this.

Many women find writing their birth story, either for sharing with others or purely for their own eyes as a simple cathartic experience, may help to externalise the trauma and reduce flashbacks and constant revisiting of the events surrounding the birth, to work through Pam England’s nine levels of birth storytelling. For others, mandala painting or crafting is another way to process.

The Trauma And Birth Stress (TABS) website (http://tabs.org.nz) is a valuable source of NZ based information – some of the information is now a little out of date as the website is no longer being actively updated but there is a great collection of articles and links and also a listing of fee-charging counsellors and practitioners with experience in birth trauma. You can contact a counsellor directly or you can ask your GP for a referral.

The UK-based Birth Trauma Association (www.birthtraumaassociation.org.uk)also have an extensive website with information and support.

Time alone does not heal all wounds; but birth trauma wounds do heal with a little tender loving care. The final word goes to Krista Arias in her essay “Trust Love” (2011).

“Women who plan natural births, but don’t get them, aren’t failures.

They are the martyrs of our traumatic age. They are birth warriors extraordinaire. Honour them.”

Image supplied by Sian Hannagan

References

Arias, K. (2011). Trust Love. Available online at  http://www.kristaarias.com/trust-love/

Austin, J. (2012). What REALLY causes birth trauma? Available online at  http://www.birthtakesavillage.com/causes-of-birth-trauma/

Bailham, D & Joseph, S (2003). Post-traumatic stress following childbirth: a review of the emerging literature and directions for research and practice. Psychology, Health & Medicine, Vol. 8, No. 2, 2003. Available online at  http://tabs.org.nz/pdfdocs/159-168.pdf

Beck, C.T. (2004). Birth Trauma: In the eye of the beholder. Nursing Research, 53 (1), 28-35. Available online at  http://tabs.org.nz/pdfdocs/eyebeholder.pdf

Bruijn, M and Gould, D (2010), There is asecret in our culture, but it is not that women are strong. Why some birth quotes may be damaging to women. Birthtalk, June 2010.Available online at  http://birthtraumatruths.wordpress.com/2010/06/03/there-is-a-secret-in-our-culture-but-it-is-not-that-women-are-strong-why-some-birth-quotes-may-be-damaging-to-women/

Ford, E. (2011). When birth is trauma. Available online at  http://midwifethinking.com/2011/05/13/guest-post-when-birth-is-trauma/

Harshe, J (2013). Grief and Guilt {The Birth Trauma Experience}.  http://birthwithoutfearblog.com/2013/11/22/grief-and-guilt-the-birth-trauma-experience/

McCarthy, L. (2005). “Evolutionary and Biochemical Explanations for a Unique Female Stress Response: Tend-and-Befriend,” Personality Research, available online at http://www.personalityresearch.org/papers/mccarthy.html

Swalm, D. (undated). Childbirth and Emotional Trauma: Why it’s Important to Talk Talk Talk. Available online at  http://tabs.org.nz/pdfdocs/important2talk.pdf

TABS (Trauma and Birth Stress) (2003). Could this be PTSD? Available online at  http://tabs.org.nz/diagnostic.htm