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Natural Childbirth – A Major Cause Of Posttraumatic Stress Syndrome?

By Penny Simkin, PT, CCE, CD(DONA)

In a two part series examining the recent research that stated that natural childbirth is a major cause of  Posttraumatic Stress Disorder,  our guest bloggers, Penny Simkin and Dr. David White, look at how the media may be sensationalizing the topic and reviews the published article to help understand more about what the research revealed.  Enjoy this blog post and the second part on Tuesday, August 21 to gain great insight into the statements made by the researchers. – SM

It has happened again. Yet another study of a hot topic in maternity care – this time, “natural childbirth,” which the authors define as “childbirth without an analgesia or without an epidural” – has been picked up by online and print media, and passed on to their audiences, with twists sensationalizing the material and adding fuel to the belief that natural childbirth is traumatic. Such articles bear provocative titles or subtitles, such as “Natural Births a Major Cause of PTSD”; “Having a Baby Like Being in a Terror Attack”; and “Is Natural Birth Connected with Post-Traumatic Stress in New Moms?”  Additionally, social media sites have begun discussing these frightening reports, most of which do not accurately present the study findings.

photo licensed under creative commons by megyarsh

The study causing the stir is “Postpartum Post-Traumatic Stress Disorder symptoms:  The Uninvited Birth Companion” (1), which was published in the Israel Medical Association Journal in June, 2012 but was picked up and disseminated widely only in early August. There are two major problems with this study:

  1. The misinformation and selective reporting by the media (it was attention from the media that led to my seeking the original paper to confirm the accuracy of the media statements; and
  2. The quality of the study itself (from design to interpretation of the findings to its validity).

In today’s blog post (part one of a two part series on this research article,) I will try to clarify some of the misinformation published in the media and analyze the harm done by these reports.  In part two, to be published on Science & Sensibility next Tuesday, David White, MD, masterfully analyzes deficiencies with the study itself.

At the beginning of the study, 102 women (a convenience sample) volunteered to participate in two surveys – one given within the first two to four days after birth and another at one month after birth. 89 subjects completed both surveys and were included in the results. The purposes of the surveys were to detect the prevalence of Posttraumatic Stress Disorder(PTSD,) and to identify associated risk factors before, during, and after birth. Because of the small sample size inconsistency in both reported numbers and terminology, and other factors (to be discussed in Part Two), any conclusions should be viewed with skepticism about the study’s external validity and applicability beyond the group studied.

And yet, despite these issues, the big media push has thrust this study into the limelight, giving it much more visibility and influence than it deserves. Most of the media accounts that I have read emphasize the finding that natural childbirth (meaning vaginal birth without pain medications) was the major cause of PTSD. In this study, there was an extremely high rate of cesarean birth (53%). Another finding reported by the media was that being accompanied during labor had no impact on the rate of PTSD. Neither of these findings was accompanied by statistical evidence.  These and other findings of the Israeli study are contrary to those of numerous other studies and reviews of satisfaction with childbirth, PTSD after childbirth, and the role of pain vs suffering during labor (2-4). Close examination of the details of the Israeli study design and reporting is called for, even though the damage has already been done by the media. Please see Part Two of this blog on Tuesday for this careful analysis.

Participants were questioned about the prevalence of PTSD symptoms after birth, and also about the presence of pre-pregnancy, intrapartum, and postpartum factors that are known to be associated with post-birth PTSD. Natural birth was highlighted by the media because of the report that 80% of the 7 women who developed PTSD (5 women) did not receive pain medication. In fact, many media reports state that these women either chose or opted for natural childbirth without pain relief. On careful inspection of the original paper, nowhere does it state that the women chose natural birth, but rather that “… fewer women who developed PTSD symptoms received an epidural and there was a great incidence of PTSD symptoms in women who did not receive an epidural.” It is possible that an epidural was not available to the women (which could be traumatizing if they had wished to have one).

Furthermore, these women had numerous other factors that are associated with PTSD. Before accepting natural birth as the major cause of PTSD after childbirth, please check the table below for these other factors, which were as prevalent, or nearly so, as lack of pain relief as a cause of PTSD. As you can see, for example, 80 percent of the women with PTSD also had discomfort with being undressed; previous mental health problems in previous pregnancy or postpartum; and complications, emotional crises, and high fear of childbirth in their current pregnancy.  All these factors have been reported in many studies to be instrumental in the development of PTSD (2-4).

Selected PTSD Risk Factors (with large differences in incidence between the two groups)

Existing before the study pregnancy P Value PTSD (n=7) No PTSD (n=82)
Psychiatric or psychological treatment P=0.157 60% (n=4) 29.8% (n=24)
Body image (uncomfortable in undressed state) P=0.014 80% (n=4) 27.7% (n= 22)
Existing in previous pregnancies      
Traumatic birth experience p=0.012 60% (n=4) 15.5% (n= 12)
Sadness, blues, or anxiety during or after pregnancy p=0.038 80% (n=4) 33% (n= 26)
Existing in current pregnancy      
Complications during p= 0.016 80% (n=4) 28.6% (n=25)
Emotional crises during p= 0.06 80% (n=4) 23.8% (n=21)
High fear of childbirth p= 0.021 80% (n=4) 30% (n= 27)
Delivery      
“A significantly smaller number of women who developed PTSD received analgesia during delivery compared to the control group” * p=0.000 No numbers or % given No numbers  or % given
Mothers’ Feelings in Labor & Birth     No PTSD (n=80)
Felt danger to their life or health p=0.001 71.4% (n=5) 20.7% (n=17)
Mild discomfort with undressed state p=0.029p=0.029 57.1% (n=4) 87.7% (n= 70)
Major discomfort with undressed state 42.9% (n=3) 12.3% (n= 10)
Support during labor      
No relationship between PTSD and being accompanied by someone or the extent of support received. No numbers or percentages were given.

*  This statement was all that was given to support “evidence” of natural birth as a cause for PTSD.

In spite of the flaws of this study, the authors offered some valuable conclusions, pointing out “the importance of inquiring about previous pregnancy and birthing experiences and the need to identify at-risk populations and increase awareness of the disorder.” Despite the shortcomings of their study, this advice is on target, as has been confirmed over and over again in the literature on traumatic birth.

In conclusion, this study was given much more publicity than it deserves, and as such has done more harm than good in understanding PTSD after childbirth. Our lesson: Recognize that many media outlets look for sensational and shocking material to attract readers, and will manufacture it if it doesn’t exist. Go to the source and think for yourself.

As educators and  birth professionals, how do you deal with students, clients and patients sharing what they read in the media, that may have been sensationalized?  What is your response?  Have you had to field questions about this recent study?  How do you respond?  Did you come to your own conclusions about this study?  Please come back on Tuesday to read a wonderful review of this research by Dr. David White and continue the discussion. – SM

Resources:

1. Polachek I, Harari L H, Baum M, Strous RD, (2012) Postpartum Post-Traumatic Stress Disorder symptoms: The Uninvited Birth Companion. Israel Medical Association Journal 14: 347-353

2. Alcorn K L,  O’Donovan A, Patrick J C, Creedy D and Devilly G J. (2010). A prospective longitudinal study of the prevalence of post-traumatic stress disorder resulting from childbirth events. Psychological Medicine, 40, pp 1849-1859 doi:10.1017/S0033291709992224

3. Alder J, Breitinger G, Granado C, Fornaro I, et al. 2011. Antenatal psychobiological predictors of psychological response to childbirth. Journal of the American Psychiatric Nurses Association 17(6): 417-425. doi: 10.1177/1078390311426454

4. Simkin P, Hull K. 2011 Pain, Suffering and Trauma in the Perinatal Period. Journal of Perinatal Education 20(3): 166-175.

For more information visit the PATTCh Resource Guide.

About Penny Simkin

Penny Simkin is a physical therapist, childbirth educator, doula, and birth counselor. She is author or co-author of many books and articles on maternity related topics for both professionals and the public. She is a co-founder of DONA International, and of PATTCh (Prevention and Treatment of Traumatic Childbirth), and is also a member of the Editorial Board of the journal, Birth.

Childbirth Education, Depression, Guest Posts, Maternal Mental Health, Perinatal Mood Disorders, Postpartum Depression, PTSD, Research, Social Media, Uncategorized , , , , , , , , , , , ,

  1. August 16th, 2012 at 10:38 | #1

    Thank you so much for writing this piece. It’s a great reminder to always check the source and that just because it’s published, doesn’t mean it’s applicable. The spin people in the media and blogs have been taking on all sorts of topics is amazing. Asking questions is always a great way to figure out if a study pertains to you and/or if it’s really saying what the media claims it’s saying.

  2. August 16th, 2012 at 11:06 | #2

    Hi, Robin,
    Thanks for your comment. It occurs to me that the Polachek paper would be excellent to use in an epidemiology course or a course in critical reading of the scientific literature. Readers will see why on Tuesday when they see the deconstruction of this paper that is Part 2 of this Blog. Post.
    Sadly, the paper has already had its impact. Our pushback is “too little too late,” but, on the other hand, “Better late then never!”
    Penny

    a href=”#comment-12971″>@Robin Elise Weiss

  3. August 16th, 2012 at 12:46 | #3

    Natural birth causes PTSD?! Seriously?! Um, let me review my births and see which one caused me PTSD… nope, not the natural ones.

  4. August 16th, 2012 at 13:43 | #4

    @Penny Simkin

    There have been a lot of things out of control this week, it seems. Like the vaginal birth = smarter babies, etc. There is a good piece by Diana Cassar-Uhl, IBCLC on the Spinning of the Biological Norm:
    http://dianaibclc.com/2012/08/14/when-the-media-spins-the-biological-norm/

  5. avatar
    Meghan
    August 16th, 2012 at 13:45 | #5

    What this paper says is, essentially, what we already know: that some women perceive birth as traumatic, and of people who experience a trauma, some will develop PTSD. I think what we need to do is examine what it is about how we do birth in this culture that would be traumatizing.

    One thing epidurals do that is not an option in unmedicated births is allow the woman to separate from the experience and from her body, which may be comforting, but I think the bigger question is what are we doing and what are we teaching women about birth? What are the differences by provider, by location? What would be the responses from a prospective randomly-selected trial, instead of convenience sampling? Psychologic comorbidity and emotional crises in pregnancy are not significant in this study at the 95% confidence level, but what were the definitions used? I also didn’t see prior abuse as a factor in the analysis, which is an interesting omission.

    This study raises more questions than it answers, and the media have extrapolated a causative relationship where one has not been shown by this study. It’s another example of very poor science reporting, and of the need for women to empower themselves with the ability to critically read scientific writing.

  6. avatar
    Annie
    August 16th, 2012 at 13:50 | #6

    It is important to have reliable sources of analysis when considering any new study, whether it fits into our current belief system or not. Doubly so for a study whose findings are so removed from previous studies on the same subject. This is sadly not the first time such misinformation is promoted but luckily has some great pushback (Thanks Penny!).
    It does seem like an important question is being asked, which is, what makes a birth truamatic. Another important question is how can we minimize these? Overwhelmingly, the answer is: care, support, listening to the mom’s needs and choices, respect and shared decision making, regardless of place or method of birth.

  7. August 16th, 2012 at 14:33 | #7

    I think this also brings to mind the need to educate doulas and childbirth educators about perinatal mental health. If we knew more, we could do more.

  8. August 16th, 2012 at 15:50 | #8

    I’m really not surprised. As soon as I saw the abstract of that study I figured it wasn’t worth all the media attention it was getting. However, media are notorious for blowing study findings out of proportion. They do this in all aspects of healthcare– not just with OB research. Take, for example, the claim that chocolate reduces the risk of heart disease. This is everyone’s favorite excuse for eating chocolate. But when you go look at the actual studies–most of the studies have ridiculously small sample sizes, and all are of poor quality.

    As the editor of the Journal of the American College of Cardiology asks everyone who reviews articles for his journal– Are the conclusions drawn justified by the results? http://content.onlinejacc.org/article.aspx?articleid=1132652

    It’s a great question to ask yourself about any study. Do the actual statistical results justify the conclusions that are offered? If the author makes claims that are above and beyond what was actually found, that is not good–it should not have made it through the peer review process. But it happens. Consumers and clinicians, beware.

  9. avatar
    Leah
    August 16th, 2012 at 16:32 | #9

    Thank you for this article, b/c the idea that natural births cause PTSD definitely needs to be debunked!

    Knowing that they didn’t factor in people who wanted an epidural but couldn’t get one and now have PTSD, that sort of throws the whole study out, I would think. Choosing to opt out of an epidural is vastly different from wanting one and not being able to get one. The difference should be considered in the study.

    Feeling like your choices and options are respected during your labor is empowering. It’s the loss of choice and ability to control the interventions that would cause a problem for me. My second child was born without any pain medication, and it was incredibly empowering for me. My first child was born after 24 hours of medication free labor, and then I transferred to the hospital b/c of an emergency, and she was born via emergency c-section. I felt respected by my caregivers in both situations. That makes all the difference.

  10. August 16th, 2012 at 17:41 | #10

    Thank you, Penny for working on the first part of this series! The crazy media loves to grab attention with a snazzy headline, and unfortunately the public runs with it, without really peeling back the facts. I appreciate your time and effort on this topic.

  11. avatar
    Penny Simkin
    August 16th, 2012 at 18:23 | #11

    @Vanessa
    Hard to believe, right, Vanessa? That’s because it’s not true!

  12. avatar
    Penny Simkin
    August 16th, 2012 at 18:32 | #12

    @Meghan
    Meghan,
    Watch for David White’s analysis of that study next Tues. He’ll reinforce your criticisms and give a lesson in deconstruction that will be valuable for all of us.

  13. avatar
    Penny Simkin
    August 16th, 2012 at 18:33 | #13

    @Annie
    Right on, Annie!

  14. avatar
    Penny Simkin
    August 16th, 2012 at 18:35 | #14

    @Walker Karraa
    I agree, Walker, and believe childbirth education and doulas can be a major force in the prevention of PTSD after birth.

  15. August 16th, 2012 at 19:44 | #15

    I am distinctly not a fan of over-sensationalized, mediocre studies. The media gloms onto a headline, but I feel the journalists(?) don’t do *any* background or research themselves. They lose integrity by reporting in the way they do. It’s reporting for readership numbers, not for facts or truth.

    I do wade through this in my CBE classes. I get a lot of “well, I heard/read/saw…” So, I end up doing a reality check in class. Sometimes I bring it up before they do if I feel it’s important enough to note. Often I’ll bring it up in my Prenatal Yoga classes because I’ve developed a relationship to those mothers. It’s important to build their confidence any time we can.

  16. August 16th, 2012 at 20:32 | #16

    Your comments are appropriate, though we could argue some. But your title is misleading, and here you show your bias. The study does not suggest that “Natural Childbirth – A Major Cause Of Posttraumatic Stress Syndrome?”. The study only finds that 80% of women who go through natural childbirth may have a greater risk of developing the Posttraumatic Syndrome. Not the same as your title , is it? Someone’s point of view does not need to be faced with revenge just because it is not our own. That’s how wars start. It has no place in science.

  17. avatar
    Linda Middlekauff, RN, LCCE
    August 17th, 2012 at 13:21 | #17

    Good point, Walker Karraa! I agree w educators learning about & even gently screening for mental health issues. To that end, PESI has a mental health track among their CEU choices, & their conferences are all over the country, even close enough to me (in rural OR) so I don’t even have to spend the night in a hotel. Many of these are apropos for nurses & CBE’s.

    The study description mentions a control group at the end, but nowhere else in the report do I see a description of such or how they were matched (or not) to the experimental group. This is another earmark of a poor study. I’d also have like to know what type of birth education the subjects did or did not receive & how that related to PTSD.

    Do you remember Deborah Tanzer’s book Why Natural Childbirth? Now that was a study!

    After getting to know the basics about my new students during the intake interview on the phone, I ask health history questions both about their general health and any previous pregnancies including the current one. This includes any surgeries, any meds they’ve had to take for long periods of time, or any which they’ve had to DC due to the current pregnancy. By this point in the interview, most clients are pretty honest. It seems to help them approach me about other issues as they arise.

  18. August 17th, 2012 at 18:17 | #18

    @Linda Middlekauff, RN, LCCE
    Thank you Linda. How do you see organizations such as Lamaze, DONA,and CAPPA integrating something like the PESI model? Wouldn’t it be wonderful?

    As it stands now, there is no public position in our childbirth organizations regarding perinatal mental health, and I so hope that changes. CBEs and consumers also need access to good information regarding PTSD, and ALL perinatal mood and anxiety disorders. Even something as simple as links to Suicide Prevention Hotline, or Postpartum Support International would be a start.

    Fingers crossed.

  19. August 18th, 2012 at 01:45 | #19

    It is so hard to believe that anybody would attempt to report such misintrepretations of a natural birth. As a birth doula I have personally experienced many natural childbirths with healthly mothers in both body and spirit. Women that are surrounded by loved ones and that are nurtured through their pregnancies will in many instances thrive in the postpartum phase of life. I am fortunate to share this moment in a womans life and help her to see that birth is a natural process that should be honored, it is a place where women can find strength and courage that will last their whole life long. We should see this as an opportunity to support and cherish her through this process as she brings a new life into the world instead of masking it with drugs. The Dalai Lama in his book The Art of Happiness speaks about the impact of technology on our lives and how by taking away any physical discomfort and making pain or suffering less visible, it is no longer seen as part of the fundamental nature of human beings-but rather as a “failure” if we experience difficulties. The mother should feel like a victor through her labor and delivery, never a victim.

  20. avatar
    Penny Simkin
    August 18th, 2012 at 10:14 | #20

    @Meghan
    You mentioned that you would have expected a history of sexual abuse to be a cause of PTSD. They did ask about that but found both groups had similar rates of abuse.But, of course there were only 7 women in the “control” group. We can’t really draw any conclusions from this study, I think.

  21. avatar
    Penny Simkin
    August 18th, 2012 at 10:16 | #21

    @Deena Blumenfeld RYT, RPYT, LCCE
    It’s a challenge, isn’t it, Deena to keep up with the media reports that our student in childbirth class bring in? Keep up the good work?

  22. avatar
    Penny Simkin
    August 18th, 2012 at 10:31 | #22

    @Silvio Aladjem MD
    You’re correct that the study did not find that natural birth is a major cause of PTSD. That was one of my points: The media publicized that as a finding of the study and then it spread like wildfire. I think you misunderstood that I was describing how the media warp information in order to sensationalize it or get readers’ attention.
    I have to say that your comment, “Someone’s point of view does not need to be faced with revenge just because it is not our own. That’s how wars start. It has no place in science,” stings a bit. All papers that are published in medical journals are not necessarily of good scientific quality. With due respect. I suggest that you read the study and decide for yourself whether it is worthy of the term, “science.” Also read Tuesday’s blog by David White, MD. He will deconstruct the study and show its many glaring flaws. I look forward to a comment from you after his blog post is published.

  23. August 19th, 2012 at 00:06 | #23

    Merry,
    I think it is very possible that the women in the study did not have continuous support from anyone. The authors stated that being accompanied did not make a difference in the incidence of PTSD. They did not describe what that means. As you say, women who are surrounded by loved ones and nurtured during pregnancy and birth are likely to thrive in post partum. We have much work to do. Thanks for your comment.

  24. August 26th, 2012 at 16:21 | #24

    A young woman in Israel, a blogger that I follow, is familiar with the hospital where this study was done. She has posted a response to this study. It is interesting to read. Here is the url:
    http://ccostello.blogspot.com/2012/08/unmedicated-birth-leads-to-ptsd.html

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