A qualitative analysis of the process, mediating variables and impact of traumatic childbirth

The processes occurring during traumatic childbirth experiences, factors mediating development of PTSD symptoms and the impact on post-partum adaptation were explored in a cohort of 20 women 10 months post childbirth. Pain, past experiences and beliefs that their baby would be harmed led to feeling out of control which was maintained by failed attempts to elicit practical and emotional support from staff and partners. Following childbirth, coping strategies relating to successfully accessing more than one source of social support, positive reinterpretation of traumatic events and making time for own interests were associated with reduced distress. Avoidance of thinking about events and a belief that one should not admit to not coping maintained distress. Consequences of continued distress related to an impact on self, relationships with others and fear of future childbirth. The Revised Impact of Event Scale (Horowitz et al., 1979) was used as a measure of PTSD symptoms. Six women reported scores above the cut-off point indicating clinically significant scores and two women had borderline scores. The present findings therefore support the evidence from the PTSD and childbirth literature that some women do report clinically significant levels of PTSD symptoms following childbirth. Introduction Previous research on psychological factors relating to childbirth mainly concentrates on women's overall satisfaction with their childbirth or on postnatal depression, with relatively little focus on how women's subjective experiences of labour are relevant to their post-partum psychological state. However, recently there has been a burgeoning literature reporting that some women experience PTSD symptoms following childbirth, e.g. Beech and Robinson (1985); Kitzinger (1992); Moleman et al., (1992); Niven (1992); Ryding (1993); Ralph and Alexander (1994); Ballard et al. (1995); Crompton (1996a, b); Lyons (1998); Alien, North and Elliott (submitted). PTSD can involve a person persistently re-experiencing the traumatic event, avoiding stimuli associated with the trauma, experiencing numbing of general responsiveness and persistent symptoms of increased arousal. The DSM IV (American Psychiatric Association, 1994) defines the stressor criterion for PTSD as occurring when a person has experienced, witnessed or was confronted with, a traumatic event that involved actual or threatened death or serious injury, © Society for Reproductive and Infant Psychology Analysis of traumatic childbirth 108 a threat to their or another's physical integrity and the stressed person's response involved intense fear, helplessness or horror. Childbirth can be frightening for some women, and they may fear for their own or for their infant's life and physical wellbeing. Medical procedures during labour can also be invasive and associated with feelings of lack of control. Furthermore, the emergency nature of some events can leave professionals little time to prepare women for the procedures. PTSD has been recognized as occurring after stressful medical and surgical procedures involving intense pain (Fisch and Tadmore, 1989), invasive medical procedures (Shalev et ai, 1993) and obstetric and gynecological procedures (Menage, 1993), suggesting that it is relevant to consider traumatic labour experiences as potential stressors for PTSD symptoms. The general postnatal and PTSD literature suggests that mediating factors concerning social support and coping style may increase vulnerability in the development of PTSD following childbirth. Quine etal. (1993) found that women who felt supported prior to labour reported less pain and greater satisfaction with the birth experience. Beech and Robinson (1985), Niven (1992), Menage (1993) and Ballard etal. (1995) all reported that women with PTSD symptoms following labour experienced lack of a supportive relationship with carers. Lyons (1998) found an association between higher scores for perceived social support from families and lower numbers of reported PTSD symptoms. Several studies focusing on PTSD as a consequence of other traumatic experiences have shown social support to be involved in the etiology, maintenance and development of PTSD (Jones and Barlow, 1990). Solomon etal. (1988) reported that more intense PTSD symptoms were not only associated with insufficient perceived social support but also emotion-focused coping style and Gotlib etal. (1991) found a greater use of escape-avoidance coping strategies in women who became depressed postnatally. Psychological and sociological literature has shown the importance of psychological functioning and social context in relation to post-partum distress. Oakley (1980) suggests that it is normal to experience difficulties following Analysis of traumatic childbirth 109 childbirth due to factors relating to the birth management, feelings of control and current life situations. Socialization, and cultural stereotypes relating to motherhood being only a positive experience, also influence feelings of failure and distress when expectations are not met. Oakley's (1980) study is important in showing that stress and patterns of coping are linked to typical experiences of motherhood, therefore PTSD symptoms may be the extreme end of a continuum. Oakley and Rajan (1991) warn that identifying postnatal distress can lead to pathologizing women. Kitzinger (1992) suggests that to give a woman a psychiatric label following an overwhelmingly stressful labour locates the problem away from her care to a problem with her mind, especially given that childbirth has been medicalized to the extent that there is more reliance on technology and procedures, often to the detriment of addressing the needs and fears of the mother. The psychosocial model of PTSD (Green et al, 1985) argues that there is a complex interaction between stressors, individuals' characteristics (coping strategies, prior stressful experiences) and their social/cultural environment, indicating that a study of the experience of traumatic childbirth should investigate the role of these factors as well as the events leading to the traumatic experience. To the author's knowledge, there has not been a study specifically investigating the impact significant PTSD symptoms have on post-partum adaptation. However, there have been a small number of short discussions of impact identified in the course of related areas of research or in clinical practice relating to the following areas. Affonso (1987) found that negative feelings towards infants were associated with mothers' reports of post-partum adaptation difficulties and Ballard et al. '(1995) presented case reports of four women with PTSD and found that three reported the need to avoid contact with their infants following a traumatic birth. Stewart (1982) and O'Driscoll (1994) also suggest that marital and sexual relationships suffer following traumatic births and Niven (1992), Ryding (1993) and Lyons (1998) report that previous distressing labours lead to fear and avoidance of future childbirth. Analysis of traumatic childbirth 110 Research concerning PTSD symptoms following childbirth is a growing area of interest in the postnatal field but the literature review indicates that there is a paucity of studies that do not rely on case study or anecdotal evidence. The majority of studies also limit their focus to describing the existence of PTSD symptoms without consideration of triggering factors or mediating variables deemed to be pertinent by the general PTSD literature. The present study therefore aims to identify the prevalence of clinically significant PTSD symptoms within a cohort of mothers who had given birth within a 4-week period 8 months prior to the investigation. By enlisting the assistance of health visitors, questionnaires could be given to all willing participants attending their baby's 8-month check-up, enabling a larger-scale study of PTSD symptoms following childbirth than previously reported in the literature. This method also enabled the identification of women who considered their labour to be extremely distressing with varying numbers of PTSD symptoms, with the aim of investigating the processes occurring during distressing labours, the mediating variables that affect psychological state and the impact that PTSD symptoms have on women's post-partum adaptation. Researching the nature of PTSD symptoms may lead to clearer identification of women who show PTSD reactions following childbirth and provide greater awareness of the effect of experiencing PTSD symptoms. This research therefore aims to identify whether women do experience significant PTSD symptoms following childbirth and to provide data that will facilitate prevention of PTSD symptoms and guide psychological intervention with women who have experienced traumatic labour experiences rather than just labelling the experience. This study describes the qualitative data analysis that was utilized because it is a useful means of generating a coding system for looking at data when a predetermined set of categories is not available (Dey, 1993). Due to the paucity of research on the effect of experiencing PTSD symptoms following a distressing labour, an exploratory framework was necessary. Analysis of traumatic childbirth 111 The present research project also used quantitative research methods to investigate the relationship between scores on the Revised Impact of Event Scale (Horowitz et al., 1979) (PTSD symptoms), Edinburgh Postnatal Depression Scale (Cox et al., 1987) (postnatal depression), Perceived Social Support Scales (Procidano and Heller, 1983) (social support from family and friends) and the COPE (Carver et al., 1989) (coping strategies) and these results are reported in Alien et al. (submitted).