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.
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:
- 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
- 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)|
|“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
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.