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By Aviva Romm, MD
I gave birth to the first of my four children, at home, 39 years ago. During labor I ate and rested as needed, walked outdoors—squatting between contractions supported by my partner, and by mid-afternoon, feeling ready to push, I took to my bed. Comfortably semi-sitting against my pillows, my midwife whispering encouragement, telling me I could do it, I gently breathed as my baby emerged into my hands. At the end of the day I remember thinking, “I did it.” My memories of that day are so vivid it feels like yesterday. And no, this is neither a fantasy story nor a false memory; it is how my birth actually happened.
Unfortunately, the reality is that for far too many women giving birth in the United States today, the journey into motherhood is not a happy memory. It’s stressful at best, frequently harrowing, and too often traumatic. A ‘good birth’ by medical definition is, for mothers, often, not good enough. It typically means that there were no complications; labor and birth resulted in a ‘healthy mother and a healthy baby,’ the gold standard of what obstetricians consider ‘a good birth.’ And of course, who doesn’t want that?
Reframing the Narrative: Birth is Never “Uneventful” for Mothers
The problem is that this definition of a ‘good birth' disregards the important fact that giving birth is never ‘uneventful,’ the term used for a birth without complications. It is a major life event that imprints itself in our memories, in our muscles, and can, for better or worse, profoundly impact our postpartum mental health and our experience of motherhood—both in the short and long term.
In my many years of birth work my over 40 years of work as both a home birth midwife and a Yale-trained MD and Family Physician who practices obstetrics, and more so recently as I’ve been gathering birth stories from my large online community in a project called Gathering the Storm: Healing Birth Trauma Through Story, I’ve heard from many women for whom their birth was an event that has left a lasting impression of disempowerment—and even trauma.
Birth Trauma: In the Eye of the Beholder
In recent years, we’ve seen growing attention paid to the US’s maternal health crisis. Despite our access to hospitals and life-saving technologies, maternal mortality rates, already higher than in most Western nations, have been increasing. The medical model is also failing new mothers abysmally when it comes to their mental health. Postpartum depression alone has increased by 70 percent in the past two years, now affecting 1 in 8 women in the US.
The bar for what is considered a “healthy mother” is depressingly low. It’s based on limited medical parameters that require little more than that the mother is alive and, ideally, not in the ICU. It is assumed that all new mothers should simply be grateful that they made it through to the other side with a healthy baby, regardless of her experience along the way.
An under acknowledged cause of postpartum distress and depression for a shocking number of women is a phenomenon known as birth trauma. First identified by researchers in the early 2000s, birth trauma is defined as psychological or emotional distress experienced by a mother at any point during or after labor and childbirth. Symptoms may include flashbacks, nightmares, severe anxiety, anger, isolation, and avoidance of reminders of the birth, all signs of hypervigilance in the nervous system. Women may delay subsequent pregnancy due to fear of recurrence of the trauma.
It is now known that birth trauma is not rare. Nurse researcher Cheryl Tatano Beck and her team set out to find out how big of a problem it was. They found that from 1 in 3 to as many as 45 percent of women who give birth in the United States experience birth trauma. And for 1 in 6 women, their symptoms are severe enough that they qualify medically for a diagnosis of PTSD.
It should be noted that birth trauma is distinct from disappointment with how one’s birth unfolded—for example, if someone was transferred from a home to hospital birth or had an unplanned and undesired cesarean section. However, as pioneering birth trauma researcher Cheryl Tatano Beck states, birth trauma is “in the eye of the beholder.” It is the woman’s perception of her experience that determines the diagnosis, whether or not clinical staff or caregivers agree.
When Mothers Are Ignored: The Consequences of Birth Trauma
Kaitlyn’s Story: Kaitlyn was unexpectedly told she had to have a cesarean because her baby was breech. Kaitlyn was sent home from the hospital two days later, but her daughter needed help breathing and had to remain in the NICU for 9 days, during which time this 34-year-old first-time mother was told she could not hold her baby. “It took me a long time to bond with my baby. I felt like a failure. I cried all of the time and was emotionally exhausted.” The only help or support she was offered during this time was an antidepressant.
Kaitlyn also experienced ambivalence toward her much-wanted baby. “I'm taken to recovery once everything is in order and am in unbearable pain from my emergency cesarean. I can't open my eyes and I didn't care about my baby. I was in so much pain. My husband kept trying to show her to me, and I didn't have the ability to care or to even physically open my eyes. I was mad at her. This is the part I still struggle with.”
Birth trauma can have dramatic and devastating impacts on mothering. While birth trauma is its own unique condition, mothers who experience birth trauma are six times more likely to have postpartum depression, as well as postpartum anxiety. Rates of postpartum anxiety are also significantly higher among those with birth trauma.
It is very common for women to become triggered by memories of their birth experience; sadly, for some women, the baby may be a trigger. Thus, many women who have experienced birth trauma report difficulty bonding with their baby and tremendous regret and guilt as a result.
Postpartum depression also can have devastating consequences. In fact, it is responsible for more maternal deaths (due to suicide) than any other postpartum condition. Yet, because of the widely held medical and cultural belief that the primary important birth outcomes are a healthy baby and a physically healthy mother, this widespread and escalating problem remains under-studied and is not adequately addressed in medical training.
Health professionals are largely unaware of this issue, and even those who are, are under-equipped with the knowledge or screening tools to diagnose it, let alone treat it. And because many of the symptoms of birth trauma are similar to the common symptoms experienced by new mothers—sleepless nights, anxieties about the baby, irritability, “baby blues,” and more—birth trauma and accompanying mental health conditions like depression and anxiety are often chalked up to being normal for a new mother.
It’s Not Just About the Birth: The Root Causes of Birth Trauma
While one might assume birth trauma may be the consequence of an especially difficult labor, or one in which there were complications or an emergency, these are not necessary for birth trauma to occur. Birth trauma can arise any time a birthing woman or new mother felt that she or her baby were in danger of injury or death, or when a woman was treated in a way that led her to feel helpless, victimized, or alone.
In fact, the research in this emerging field shows us that the most consistent factor in whether birth trauma develops is not the events of the birth itself, but how a woman felt she was treated by her care providers and support team during labor, birth, or in the postpartum period.
Traumatic birth experiences typically include feelings of betrayal, abandonment, mistreatment, neglect, and helplessness to change how one is being treated. While there may have been an actual complication that led to these perceptions, these feelings may equally or more frequently arise due to a situation in which the laboring woman was not consented for an intervention, so felt her right to autonomous decision-making or her physical person, or both, were violated. This is often in the form of a vaginal exam or rupturing the bag of waters (which may be done surreptitiously while doing the vaginal exam).
Hayley’s Story: Hayley, 21 when her daughter was born, shared the following story with me: “After starting me on Pitocin, my body was not handling it well. I went into a uterine hyperstimulation which also caused my baby’s heart rate to plummet. My concerns were pushed aside and I was assured everything was fine. The on-call OB entered the room for a cervical check and ignored my verbal wish to NOT have a membrane sweep. As she started performing the membrane sweep, I was screaming for her to stop. But she wouldn’t. She told me ‘she needed to do this so the next doctor wouldn’t have to.’ I was utterly violated and felt unsafe. I was invalidated by the next on-call doctor and was told ‘this is what happens in labor.’” Her baby was born 39 hours later and suffered complications related to the birth. Hayley said, “This experience had significant effects on my postpartum experience. I loved the baby that was in front of me, but I feel disconnected. I was stuck in a period of grief.” While her family was supportive, she said they found it hard to understand why she “was struggling so hard over her birthing experience.” She is working through trauma on her own journey to become a doula to prevent other women from having to go through a traumatic birth.
Kept in the Dark: Disempowerment and Birth Trauma
Birth trauma also frequently arises from situations where a woman was kept uninformed about what was occurring, felt out of control, or feared for her own or her baby’s safety. This can happen to any woman, but it is more common in women who had cesareans, whether or not those were emergencies, and in women who have had labor inductions, particularly when they were not adequately informed of what would happen during a procedure, felt bullied into having the procedure, when they felt left out of decision-making in the process, or when they were physically or verbally mistreated along the way. This feeling of loss of autonomous decision-making is a commonly cited source of birth trauma.
The Problem of Medical Coersion
Further, it is not uncommon for medical providers to use coercive language, wielding the threat of risk to the baby as a weapon to bully women into complying with interventions, such as labor induction or cesarean sections. Women who go against their doctor’s recommendation, even if that recommendation is not evidence-based, or who simply question an obstetrician’s recommendation, may then be accused of essentially being ‘a bad mother.’ The combination of feelings—having been coerced and thus feeling victimized, threatened, and powerless, along with fear for their baby’s well-being—leaves many women with a pervasive feeling of trauma.
Obstetric Violence: A Pernicious Reality
There are also forms of mistreatment to which some women are subjected during their perinatal experience that are shocking. In 2019, the Giving Voice to Mothers Study, which surveyed over two thousand women who’d given birth in the US, found that 1 in 6 reported experiencing one or more types of mistreatment during labor and delivery. This included loss of autonomy; being shouted at, scolded, or threatened; and being ignored, refused, or receiving no response to requests for help.
While one might assume that these forms of coercion, verbal, and even physical mistreatment are rare, they are prevalent enough that in 2016 the American College of Obstetricians and Gynecologists (ACOG) issued a formal committee opinion called “Refusal of Medically Recommended Treatment During Pregnancy” in which it is stated that “Obstetrician–gynecologists are discouraged in the strongest possible terms from the use of duress, manipulation, coercion, physical force, or threats, including threats to involve the courts or child protective services, to motivate women toward a specific clinical decision.”
This problem is so pernicious that it recently made its way into pop culture: In the television dramatization of Taffy Brodesser-Akner’s novel Fleishman is in Trouble, we watch (for me, in horror but also with an unsettling familiarity, having trained in obstetrics) as Rachel, played by Claire Danes, undergoes significant discomfort and a sense of physical violation, as her amniotic sac is ruptured without her permission during a vaginal exam in labor. When she asks the obstetrician what he’s doing and tells him to stop, he condescendingly asks Rachel, “Are you planning on being a baby or delivering a baby?” and suggests a psych consult might be in order. This moment marks the beginning of a later unraveling for this character, whose birth trauma had not been diagnosed, despite obvious symptoms that something was very wrong as she attempted to adjust to life as a new mother.
Disparities in Birth Trauma: Who is Most Affected?
Birth trauma occurs across all ethnic and socioeconomic groups. However, Black and Brown women, LGBTQ+ people, individuals with physical or intellectual disabilities, immigrant and undocumented people, and young mothers, especially young mothers from any of the above demographics, are two to three times more likely to experience mistreatment during birth. They are also more likely to report having been ignored, insulted, yelled at, and even slapped or otherwise physically mistreated, giving rise to the term obstetric violence, a reported and observed problem.
Women whose babies require special medical care, and women who have transferred from home to hospital birth are also more likely to receive interventions that may feel coercive or disrespectful. Women who disagree with—or even question—an obstetric care provider’s medical recommendations are also at greater risk of being berated, coerced, ignored, and treated as being ‘difficult’ or ‘defiant.’
The Silence Surrounding Birth Trauma
The topic also remains taboo amongst mothers, who may be ashamed to admit their feelings, or don’t want to appear “ungrateful” or “complaining.” As one mother told me, “I felt like as a new mom I was supposed to be grateful….” So women too often struggle with their feelings in isolation. Further, many women express a sense of guilt or responsibility for how their birth unfolded, particularly if there were complications with the baby after birth. Kaitlyn, who was 34 when she gave birth to her daughter who required a 9-day NICU stay for breathing difficulties after birth said, over a year after her birth, “I’ll always regret the events in my labor. I feel like it’s my fault and that I did something wrong even though my daughter is healthy and thriving.”
In the aftermath of a traumatic birth, well-intentioned family members, friends, and medical practitioners often make statements like: “Thank goodness for modern medicine,” “Well, it’s not too bad, it's just one day in your life, and you can always have another baby,” and the most commonly repeated: “At least you have a healthy baby.”
Reimagining Birth: A Matrifocal Approach
In my decades of midwifery and obstetric practice, I’ve seen countless instances in which obstetric norms prioritized the health of the baby over that of the mother. Traumatic birth experiences are frequently rooted in a fundamental problem: a medical culture that treats the mother as if she's just a container for her baby. As Alison Stuebe, MD, a maternal-fetal medicine physician and professor of obstetrics and gynecology at the University of North Carolina, has stated, “We have to stop treating the baby as the candy and the mom as the wrapper.”
So what’s needed to shift the status quo?
First and foremost, we need to expand our definition of “a healthy mother” to center the mother’s mental and emotional well-being. Birth in our culture needs to be reimagined as a matrifocal, or mother-centered, experience that leaves each woman feeling emotionally supported and empowered. We must ensure that every provider caring for pregnant and birthing people and new mothers is “trauma-informed,” compassionate, respectful, and works in partnership with women, not wielding power over them.
A Global Perspective: Learning from the Midwifery Model
Obstetrics could benefit from borrowing elements of the midwifery model, which focuses on the mother’s psychoemotional needs while being less interventionist. In the US, the reported rate of birth trauma is 5.1 percent for women who gave birth at home, compared to 28.1 percent for women who gave birth in the hospital.
Centering the mother’s well-being during birth is not at odds with providing quality medical care. On the contrary, according to a 2020 study in the European Journal of Midwifery, in countries where midwifery is the norm, not only are women more likely to report greater satisfaction with their birth and early new motherhood experience, but they have maternal and infant mortality rates that are dramatically lower than in the US, and higher breastfeeding rates. Doulas and midwives in the US have also been shown to improve birth outcomes, reduce postpartum depression and anxiety, and increase breastfeeding success.
A Vision for the Future of Birth Care
I don’t expect all births to be like mine; I know, as a midwife and medical doctor, that even in ideal settings, some women and babies will still experience medical complications. Yet even during a complicated birth, when the mother stays informed, her decision-making is respected, her autonomy honored, and she is spoken to as the authority she is on her own lived experience, it’s much less likely that she’ll feel the psychological or emotional disconnect that leads to her birth having felt traumatic. Trauma due to medical mistreatment is entirely preventable, and should be a priority as part of our commitment to preventing postpartum depression and the needless maternal suffering and even deaths that result.
Global health experts agree that the well-being of the mother is intrinsic to the well-being of her baby, her family, and to society. But I believe the well-being of mothers should also be a priority simply because it is the right of every woman to come through her birth feeling safe, respected, cared for, and empowered as she enters into the demanding and important role of motherhood.
The way we care for the total well-being of birthing women may be the single most important factor as she starts this journey.
