For many women childbirth is a happy, fulfilling and
empowering experience. For others it can be one of the most traumatic events of
their lives. It can bring them a sense of accomplishment or failure, joy or
trauma.
Emotional reactions and adjustments to a cesarean birth vary
widely. Some women recover quickly from a cesarean and see it as just one more
step in their journey as a mother. Other women can experience sadness,
disappointment, loss of self-esteem, guilt, and anger, especially in the cases
of emergency C-sections or after a long and painful labor, had general
anesthesia, or were separated from their newborns after the birth. Some common
perceptions are that they were not involved in the decision-making process
regarding their care, were submitted to unwanted, invasive and painful
interventions, perceived care as inadequate or unnecessary. A lot of women
even see it as physical assault and a form of institutional violence (or
“obstetric violence”): a form of violation against women’s rights,
appropriation of the body and reproductive processes of women by health
personnel, which is expressed as dehumanized treatment, an abuse of medication,
and to convert the natural processes into pathological ones, bringing with it.
A negative experience of a primary cesarean birth may last
years and affect a woman’s future pregnancies. It can be so terrifying that
some women choose to have a cesarean in
a future pregnancy rather than experience labor again or even to avoid future
children altogether.
A U.S. survey of women’s first births in 2005 revealed that
women who had a cesarean birth were more likely to feel frightened, helpless,
and overwhelmed and less likely to feel capable, confident, powerful, and
unafraid while giving birth. “Assaulted, violated, voiceless, out of control”
are some of the things they report.
Several women experience a feeling of loss, grief, personal
failure, distress, anger, powerlessness, negative impact on self-esteem and
self-confidence as a mother. There is at times a delay in bonding and
attachment, the mother is still recovering from anesthesia or is in physical
pain, or is taking a lot of pain medications; sometimes breastfeeding can be
more challenging for the first few hours or days. And today we see an
overwhelming pressure to breastfeed (which is cyclical, a few decades ago there
was not that social expectation or pressure to breastfeed). There can be
long term effects on spousal relationship and the new mother’s ability to take
care of the baby.
C-section is considered a risk factor for PTSD and it is
said to be a consequence from a high level of anxiety about a situation which
she has no control of. Increased anxiety during the third trimester greatly
contributes to increase the risk.
They experience childbirth as a traumatic event, 6%
meeting criteria for PTSD in the PP period (their psychological distress is
similar to those experienced by war victims and natural disasters, for
example). The stress response symptoms include:
- Intrusive
thoughts and re-experiencing of the event in flashbacks or nightmares.
- Avoidance
of places or people that might trigger a reminder of the event. Symbolic
or real reminders of the event bring out intense feelings of distress.
- Numbing
of emotions and general responsiveness.
- A
sense of hyper vigilance or increased arousal.
- Disturbed
sleep, anxiety, lack of concentration, feeling irritable or angry.
- Nightmares
and flashbacks
- Difficulties
with bonding and attachment
- Sexual
issues with partner
- Depression
PTSD as a consequence
of childbirth is vastly understudied and all the data we have are from case
reports.
We’re seeing an increasing trend North America, where the
c-section rates increased from 10% to 30% in the past 25 years. (As a
reference, the WHO recommends between 10-15 C-sections per 100 live births).
It is important to notice that traumatic experiences related
to childbirth can happen both ways, with vaginal and cesarean deliveries, but
we have evidence that vaginal deliveries typically imply superior physical
health, which leads to better quality of life in general.
Elective C-sections are culturally accepted and are actually
the norm in a lot of places and there is a reverse phenomenon in Latin America,
for example, where we see rates of up to 50% of C-sections, and numbers close
to 70% among higher socioeconomic women with higher educational level and
private insurance who opt for an elective CS.
A lot of those women fear complications from a vaginal
delivery, like limb fractures, hypoxia leading to speech delays and paralysis
etc. Elective cesarean section exemplifies the avoidance behavior typical of
PTSD. A lot of them have a higher need to be in control and chose an elective
procedure, sometimes influenced by bad experiences reported by their mothers or
sisters or friends.
There are several factors to consider that will shape a
woman’s feelings about childbirth: the reason for which the cesarean was
performed; her cultural values; her beliefs and expectations of her birth
experience; prior traumatic events in her life (like sexual trauma or domestic
violence); the social support available to her during pregnancy and childbirth;
her own perception of how she was treated by her caregivers; her involvement in
making decisions regarding her care; and her personal sense of control of her
birth.
So it is really no one’s job to judge the woman’s choice and
her rights over her body, or the way she experiences childbirth one way or
another. This is one of the most important moments in a woman’s life and each
decision and outcome should be individualized and should take into account the
woman's prior experiences and perceptions, expectations, control issues, cognitive
biases, medical comorbidities, psychological factors and support systems.
What to do?
First of all, it is important to help the woman
understand that a normal delivery is not a synonym of vaginal delivery.
A good childbirth outcome is a healthy mom and a healthy
baby and everything else is secondary. Some things will be out of our
control and that is fine. A delivery may last a few hours, sometimes a little
over a day. Motherhood is a lot more than giving birth. It starts with a
nine-month experience and it lasts for the rest of your life.
Support groups or new mothers groups can help healing and
change perceptions and cognitions.
Promote bonding time and skin to skin contact immediately
following the procedure. There’s a movement for humanized C-sections, which
limits drug exposure and procedures to the minimum necessary and promotes
bonding/ attachment and encourages breastfeeding almost immediately after a C-section.
Lastly, recognize the tremendous power that exists on a C-section
scar. If anything, it should be empowering and a source of pride.
