PPD or PTSD?

Now back to our regularly scheduled Birth Bitch:

I’ve been doing some research for a psychology class I’m taking. I chose to look at the impact of birthing practice on postpartum depression/post-traumatic stress disorder (PDD/PTSD). My reasoning is thus: if we know the perception of trauma in birth increases postpartum mental health issues, and we know how to make birth not just less traumatic, but actually an ecstatic experience, we can reduce the rate of maternal adjustment issues that impact not just mothers, but babies, families and society.

I made this decision because I had just watched Monty Python’s Miracle of Birth from the Meaning of Life.



It struck me (as it has every time I watch this) how odd it is that comedians in 1983 could plainly see that inserting routine, useless and potentially harmful technology into the birth process, while disengaging the mother because she’s ‘not qualified’ to participate, could contribute to ‘PND’ (Post Natal Depression-British for Postpartum Depression). I wanted to see if an idea commonsensical enough to be present in satirical humor 25 years ago had been seriously examined.

One would think that if there was research to suggest certain procedures were unnecessary or harmful, they would be discontinued. Unfortunately, one would be wrong. We already know that invasive, routine birth interventions disrupt bonding and breastfeeding. (The Impact of Birthing Practices on Breastfeeding; Delivery Self-Attachment; What Babies Want) Yet, practices persist. It would stand to reason if the processes of birth and bonding were disrupted, the mother and baby would be affected as we know other mammalian mother-babies are.

Prevalence and Predictors of Women’s Experience of Psychological Trauma During Childbirth (Soet, Brack & Dilorio, 2003; Birth 30:1) examined how often women experienced trauma during birth, what caused the trauma, and to look for ways to prevent such things.

Of the 103 women in the study, 34% felt traumatized by their birth experience. 1.9% of those met the criteria for PTSD diagnosis.

A PTSD reaction included “…nightmares, intrusive memories, depression, anxiety, difficulty bonding with the infant, fear of sexual intimacy and avoidance of future childbearing…” and possible “…long-term bonding problems.” Other studies were cited that put the rate of a PTSD reaction as high as 6%.

There were three pre-existing factors contributing to trauma were lack of social support, previous sexual assault and the expectation of pain.

Other predictive factors were pain (although 74.8% had epidurals), feelings of powerlessness (Monty Python nailed it) “expectations, medical intervention and interaction with medical personal”.

I was confused by the part that said, “A sick (n=15) or stillborn infant (n=1) was delivered in 17.4 percent of the cases. By the time of the follow-up interview, all [emphasis mine] babies who had initial complications were at home and were described as healthy by the mothers.” I get that a sick or stillborn infant would be a significant factor in a negative perception of the experience, but how is a stillborn infant then described as healthy?

The title of the next one, Psychological trauma symptoms of operative birth(Gamble & Creedy, 2005; British Journal of Midwifery, April) is pretty self-explanatory. At the time of publication, US cesarean rates would have been around 24%. They are now at 32%, even though as the article correctly states, the World Health Organization recommends no more than a 10-15% rate.

The study of 400 women found that those who had emergency cesareans or “operative vaginal delivery” (most likely referring to episiotomy, but perhaps forceps or vacuum extraction as well…unless I missed it, it was not specified) to be more likely to suffer PTSD, with cesareans being 6 times more likely.

The conclusion? “Results of this study provide evidence that the use of obstetric procedures during childbirth significantly contribute to the presence of acute trauma reactions in the postpartum.” It goes on to cite other studies that have come to the same conclusion as far back as 1979. In fact, studies done in 1979, 1980, 1991, 1992, 1993, 1997 and 2000. And yet here we are in 2008 with rates of intervention just as high, and operative deliveries even higher…with NO improvement in outcomes. Hm.

Two others, Post-traumatic symptoms after childbirth: What should we offer?(Slder, Stadlmayr, Tschudin & Bitzer, 2006; Journal of Psychosomatic Obsterics & Gynecology 27:2) and Post-traumatic stress following childbirth: A review of the emerging literature and directions for research and practice(Bailham & Joseph, 2003; Psychology, Health & Medicine 8:2) came to similar conclusions, but this is depressing the hell out of me so I’m not going to comment on them. It’s not just that we’ve known all this for so long and haven’t acted on it, thus dooming millions of women, babies and families to suffer needlessly. That’s disgraceful, of course. But I find it appalling that the US doesn’t even seem to considering these studies worthwhile enough to look into the possibility that routine obstetrical interventions applied with such a cavalier attitude are harming our most vulnerable. All of these studies were from Europe. One more reason to seriously consider the life of an ex-pat.

Finally, Shelia Kitzinger commented on PSTD in birth in her commentary, “Birth as rape: There must be an end to ‘just in case’ obstetrics.” In it, she compares the descriptors rape victims and PTSD victims use. Sadly they are nearly identical. She also notes that it is unnecessary routine obstetrical intervention that is causative in the perceived trauma in birth, and notes that while we know which routine interventions are harmful or useless, in obstetrics it takes an average of 15 years before evidence changes practice. Though, the Monty Python bit was done 25 years ago. The research began 30 years ago. Why are women still being brutalized in birth?