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I first became interested in childbirth-related psychological trauma in 1990. Twenty-three years ago, it was not something researchers were interested in studying. I found only one study, and it reported that there was norelation between women's birth experiences and their emotional health. Those results never rang true for me. There were just too many stories floating around with women describing their harrowing births. I was convinced that the researchers got it wrong,

To really understand this issue, I decided to immerse myself in the literature on posttraumatic stress disorder (PTSD). During the 1980s and 1990s, most trauma researchers were interested in the effects of combat, the Holocaust, or sexual assault. Not birth. But in Charles Figley's classic book, Trauma and Its Wake, Vol. 2 (1986), I stumbled upon something that was quite helpful in understanding the possible impact of birth. In summarizing the state of trauma research in the mid-1980s, Charles stated that an event will be troubling to the extent that it is "sudden, dangerous, and overwhelming." That was a perfect framework for me to begin to understand women's experiences of birth. It focused on women's subjective reactions, and I used it to describe birth trauma in my first book, Postpartum depression (1992, Sage).

Since writing Postpartum Depression, there has been an explosion of excellent research on the subject of birth trauma. The bad news is that what these researchers are finding is quite distressing: high numbers of American women, as well as women in other countries, have posttraumatic stress symptoms (PTS) after birth. Some even meet full criteria for posttraumatic stress disorder. For example, Childbirth Connection's Listening to Mothers' Survey II included a nationally representative sample of 1,573 mothers. They found that 9% met full-criteria for posttraumatic stress disorder following their births, and an additional 18% had posttraumatic symptoms (Beck, Gable, Sakala, & Declercq, 2011). These findings also varied by ethnic group: a whopping 26% of non-Hispanic black mothers had PTS. The authors noted that "the high percentage of mothers with elevated posttraumatic stress symptoms is a sobering statistic" (Beck, et al., 2011).

If the number of women meeting full-criteria does not seem very high to you, I invite you to compare it to another number. In the weeks following September 11th, 7.5% of residents of lower Manhattan met full criteria for PTSD (Galea et al., 2003).

Take a minute to absorb these statistics. In at least one large study, the rates of full-criteria PTSD in the U.S. following childbirth are now higher than those following a major terrorist attack.

In a meta-ethnography of 10 studies, women with PTSD were more likely to describe their births negatively if they felt "invisible and out of control" (Elmir, Schmied, Wilkes, & Jackson, 2010). The women used phrases, such as "barbaric," "inhumane," "intrusive," "horrific," and "degrading" to describe the mistreatment they received from healthcare professionals.

"Isn't that just birth?," you might ask. "Birth is hard." Yes, it certainly can be.

But see what happens to these rates in countries where birth is treated as a normal event, where there are fewer interventions, and where women have continuous labor support. For example, in a prospective study from Sweden (N=1,224), 1.3% of mothers had PTSD and 9% described their births as traumatic (Soderquist, Wijma, Thorbert, & Wijma, 2009). Similarly, a study of 907 women in the Netherlands found that 1.2% had PTSD and 9% identified their births as traumatic (Stramrood et al., 2011). Both of the countries reported considerably lower rates of PTS and PTSD than those found in the U.S.

How Does this Influence Breastfeeding?

Breastfeeding can be adversely impacted by traumatic birth experiences, as these mothers in Beck and Watson's study (Beck & Watson, 2008) describe:

• I hated breastfeeding because it hurt to try and sit to do it. I couldn't seem to manage lying down. I was cheated out of breastfeeding. I feel that I have been cheated out of something exceptional.
• The first five months of my baby's life (before I got help) are a virtual blank. I dutifully nursed him every two to three hours on demand, but I rarely made eye contact with him and dumped him in his crib as soon as I was done. I thought that if it were not for breastfeeding, I could go the whole day without interacting with him at all.
• Breastfeeding can also be enormously healing, and with gentle assistance can work even after the most difficult births.
• Breastfeeding became my focus for overcoming the birth and proving to everyone else, and mostly to me, that there was something that I could do right. It was part of my crusade, so to speak, to prove myself as a mother.
• My body's ability to produce milk, and so the sustenance to keep my baby alive, also helped to restore my faith in my body, which at some core level, I felt had really let me down, due to a terrible pregnancy, labor, and birth. It helped build my confidence in my body and as a mother. It helped me heal and feel connected to my baby.

What You Can Do to Help

There are many things that nurses, doulas, childbirth educators, and lactation consultants can do to help mothers heal and have positive breastfeeding experiences in the wake of traumatic births. Youreally can make a difference for these mothers.

• Recognize symptoms.

Although it is not within many of our scope of practice to diagnose PTSD, you can listen to a mother's story. That, by itself, can be healing. If you believe she has PTS or PTSD, or other sequelae of trauma, such as depression or anxiety, you can refer her to specialists or provide information about resources that are available (see below). Trauma survivors often believe that they are going "crazy." Knowing that posttraumatic symptoms are both predictable and quite treatable can reassure them.

• Refer her to resources for diagnosis and treatment.

There are a number of short-term treatments for trauma that are effective and widely available. EMDR, is a highly effective type of psychotherapy and is considered a frontline treatment for PTSD. Journaling about a traumatic experience is also helpful. The National Center for PTSD has many resources including a PTSD 101 course for providers, and even a free app for patients called the PTSD Coach.

The site HelpGuide.org also has many great resources including a summary of available treatments, lists of symptoms, and possible risk factors.

• Anticipate possible breastfeeding problems mothers might encounter.

Severe stress during labor can delay lactogenesis II by as much as several days (Grajeda & Perez-Escamilla, 2002). Recognize that this can happen, and work with the mother to develop a plan to counter it. Some strategies for this include increasing skin-to-skin contact if she can tolerate it, and/or possibly beginning a pumping regimen until lactogenesis II has begun. She may also need to briefly supplement, but that will not be necessary in all cases.

• Recognize that breastfeeding can be quite healing for trauma survivors, but also respect the mothers' boundaries.

Some mothers may be too overwhelmed to initiate or continue breastfeeding. Sometimes, with gentle encouragement, a mother may be able handle it. But if she can't, we must respect that. Even if a mother decides not to breastfeed, we must gently encourage her to connect with her baby in other ways, such as skin to skin, babywearing or infant massage.

• Partner with other groups and organizations who want to reform birth in the U.S.

Our rates of PTS and PTSD following birth are scandalously high. Organizations, such as Childbirth Connection, are working to reform birth in the U.S.

2013 may be a banner year for recognizing and responding to childbirth-related trauma. The new PTSD diagnostic criteria were released in May in the DSM-5, and more mothers may be identified as having PTS and PTSD.

There has also been a large upswing in U.S. in the number of hospitals starting the process to become Baby Friendly, which will encourage better birthing practices.

I would also like to see our hospitals implementing practices recommended by the Mother-friendly Childbirth Initiative.

There is also a major push to among organizations, such as March of Dimes, to discourage high-intervention procedures, such as elective inductions.

And hospitals with high cesarean rates are under scrutiny. This could be the year when mothers are care providers stand together, and say that the high rate of traumatic birth is not acceptable, and it's time that we do something about it. Amy Romano describes it this way.

As we begin 2013, it is clear from my vantage point at the Transforming Maternity Care Partnership that the transformation is underway. In Childbirth Connection's nearly century-long history, we've never seen so much political will from leaders, so much passion from grassroots advocates, and so much collaboration among clinicians and other stakeholders. This new landscape presents many new opportunities for educators and advocates.

There is much you can do to help mothers who have experienced birth-related trauma. Whether you join the effort to advocate for all mothers, or simply help one traumatized mother at a time, you are making a difference. Thank you for all you do for babies and new mothers.

This article originally appeared as an editorial in the journal Clinical Lactation: Kendall-Tackett, K.A. (2013). Childbirth-related psychological trauma: An issue whose time has come.Clinical Lactation, 4(1), 9-11

References

Beck, C. T., Gable, R. K., Sakala, C., & Declercq, E. R. (2011). Posttraumatic stress disorder in new mothers: Results from a two-stage U.S. national survey. Birth, 38(3), 216-227.

Beck, C. T., & Watson, S. (2008). Impact of birth trauma on breast-feeding. Nursing Research, 57(4), 228-236.

Elmir, R., Schmied, V., Wilkes, L., & Jackson, D. (2010). Women's perceptions and experiences of a traumatic birth: A meta-ethnography. Journal of Advanced Nursing, 66(10), 2142-2153.

Galea, S., Vlahov, D., Resnick, H., Ahern, J., Susser, E., Gold, J., . . . Kilpatrick, D. (2003). Trends of probable post-traumatic stress disorder in New York City after the September 11 terrorist attacks.American Journal of Epidemiology, 158, 514-524.

Grajeda, R., & Perez-Escamilla, R. (2002). Stress during labor and delivery is associated with delayed onset of lactation among urban Guatemalan women. Journal of Nutrition, 132, 3055-3060.

Soderquist, I., Wijma, B., Thorbert, G., & Wijma, K. (2009). Risk factors in pregnancy for post-traumatic stress and depression after childbirth. British Journal of Obstetrics & Gynecology, 116, 672-680.

Stramrood, C. A., Paarlberg, K. M., Huis in ' - T Veld, E. M., Berger, L. W. A. R., Vingerhoets, A. J. J. M., Schultz, W. C. M. W., & Van Pampus, M. G. (2011). Posttraumatic stress following childbirth in homelike- and hospital settings. Journal of Psychosomatic Obstetrics & Gynecology, 32(2), 88-97.

Reports from Childbirth Connection on Important Issues Regarding Birth in the U.S.

Helpful Links to Share with Mothers

• Prevention and Treatment of Traumatic Childbirth
• Midwifery Today
• Trauma and Birth Stress
• Posttraumatic Stress After Childbirth
• Birth Trauma Association

About Kathleen Kendall-Tackett, Ph.D., IBCLC, RLC, FAPA

Kathleen Kendall-Tackett is a health psychologist and an International Board Certified Lactation Consultant. She is the Owner and Editor-in-Chief of Praeclarus Press, a small press specializing in women's health. Dr. Kendall-Tackett is a Fellow of the American Psychological Association in both the Divisions of Health and Trauma Psychology, Editor-in-Chief of U.S. Lactation Consultant Association's journal, Clinical Lactation, and is President-Elect of the American Psychological Association's Division of Trauma Psychology. Dr. Kendall-Tackett is author of more than 320 journal articles, book chapters and other publications, and author or editor of 22 books in the fields of trauma, women's health, depression, and breastfeeding, including Treating the Lifetime Health Effects of Childhood Victimization, 2nd Edition (2013, Civic Research Institute),Depression in New Mothers, 2nd Edition (2010, Routledge), and Breastfeeding Made Simple, 2nd Edition (co-authored with Nancy Mohrbacher, 2010).

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