Childbirth Outcomes and Postpartum Depression: Are They Linked?

childbirth, birth planSo many of you have asked about birth plans, your childbirth experience and postpartum depression, that I asked our fabulous Kate Kripke to write about how these things may or may not impact PPD or postpartum PTSD.

Oh, the pressure around childbirth!  Do we try for a natural, unmedicated birth or do we choose an epidural to relieve our pain when delivering our little ones?  Do we hire a doula to support us through our childbirth journey or do we rely on our doctor and nurses to support us throughout?  Do we choose to give birth in the comfort of our home with a trained home birth midwife, or do we plan to labor and deliver in a hospital surrounded by doctors and the option for pain medication?  Do we choose to attempt a VBAC or plan a second C-Section?  Do we lean towards waiting for natural contractions to begin, or do we get induced and, with that, have a clear idea of when that little face will enter this world?  Do we go forward towards childbirth with a birth plan, or do we enter the experience with an ease and flexibility about what the ultimate experience entails? These decisions can be endless, and I think it is fair to say that there is expectation, judgment, and pressure that come at us from every direction as we muddle through this laundry list of “choices.”

The woman and mother in me believe strongly that we should have a say in the process that is called birth.  I believe that each women should have the right to choose who her provider is, what positions she wants to labor in, and whether or not to receive pain relief.  Each one of us is, ultimately, the best judge of what our body needs under best-case scenarios.  However, the clinician in me also knows that sometimes deep hopes and expectations can lead to emotional challenges postpartum if and when they are not met as desired.  And the research buff, experienced therapist, and perinatal mood disorder expert in me knows that it is actually not the specifics of one’s birth that can lead to a postpartum mood disorder like postpartum depression, anxiety, or postpartum PTSD, but a mom’s perceptions of those experiences.

Let me explain with some examples:

I am talking about the mom whose birth, on paper was “perfect.”  She gave birth in a hospital with a nurse midwife.  Her labor was moderate in length and she delivered vaginally with no medication for pain relief.  Her baby was born with an Apgar score of nine.  Her husband was encouraging of her throughout.  And, still, this mom arrived in my office several weeks later in deep despair.  In her memory, her birth was “traumatic.” She remembers intense pain and little relief from this and, while her husband and midwife had cheered her on because they “knew” that she had wanted to give birth naturally, what she remembers wanting most desperately was for it all to just stop.  She cried when recalling that she felt unheard, torn apart, and vulnerable. She was terrified throughout her birth process and, despite the loving people around her, she felt alone.  Because it had all gone as planned, this mom felt ashamed for her despair and guilty for “not being happy” about all of it.  She had, until coming to my office, not talked to anyone about how she felt.

I am talking about the mom who wanted desperately to give birth “naturally” but who, after 30 hours of labor and six hours of pushing, was rushed into the operating room for an emergency C-Section.  A nurse held her hand all the way down the hall and explained to her what was happening.  She remembers her OB, masked and ready for surgery, talking to her over the curtain as he explained his process in removing her son from her body.  She remembers seeing her son whisked away after being born and being left, only momentarily, until a second nurse who she had never met before came and sat with her and described her baby in detail until her husband returned.  When asked about her birth experience, this mom smiled and became tearful with pride. “It was as it was meant to be,” she said.  “ My baby and I were surrounded by people who cared about us and I could not have asked for anything more.”

I am talking about the mom who is terrified of pain and who, leading up to her birth, knew that she wanted an epidural at the moment her contractions began.  Her friends all discouraged her from this as most of them had given birth naturally without intervention, but this mom knew what was best for her and remained committed to this.  Her epidural was followed by the typical cascade of interventions: pitocin, heart monitor, and an ultimate vacuum delivery.  She gave birth to a beautiful baby girl, with an OB who she had never met, and with nurses who she never got to know because of a shift change during her labor.  “It was amazing,” this mom says of her birth.  It was all that I hoped and expected.

There are such opinions, such camps of thought, and such differing ideas about what it means to give birth, so many, in fact, that it is unrealistic and unfair to assume that any of us know what the “right way to give birth” is.  What truly matters most in the connection between birth experience and whether or not a mom develops postpartum depression, postpartum PTSD or any other mood disorder is whether or not she felt heard, seen, and supported, and whether or not that mom had the chance to process her experience and talk about what it means to her, both empowering and difficult.  Truly.  Even a mom who is disappointed by the loss of expectation around a hoped childbirth may not develop symptoms of depression or anxiety if she is given the chance to discuss and mourn her losses.

There is no doubt, however, that every woman should have the chance to think about what she would like, ideally, and have the opportunity to express this to her care providers and her support people.  One OB who I work closely with here in Boulder (and who I trust, admire, and respect deeply) speaks openly about how, if a mom does not express a desire to give birth without intervention, she will assume that an epidural and pitocin will be part of the equation. And if a mom does not reject this, she will push on. Because, yes, in western medicine this seems to be the culture these days.  And so, I imagine that because of similar situations across the globe, we are led to believe that OB’s don’t care what a mom wants (sure, there may be those out there too, I know) and that a mom really has to fight for the kind of birth that she desires.

And fighting is draining.  And heart wrenching.  And leaves us feeling angry and let down and vulnerable even if we end up with what we want.

So, write your birth plan if it’s something you’d like to do.  Interview providers and find someone to work with whom, ideally, supports your ultimate goals in childbirth if/whenever possible.  Make sure that if you are working with an OB in a practice with rotating providers that you meet each one and spread your hopes around so that those doctors know who you are and what your ultimate wishes are in delivery care.  Talk to your partner, your doula if you have one, and your doctor or midwife about your hopes and fears around childbirth and make sure that THEY know what kind of emotional support you desire.  If you plan on delivering in a hospital, request a nurse who has experience supporting moms through natural childbirth if this is a goal (yes, you can request this).   You can most certainly do your part ahead of time to set yourself up for the most supported experience possible.

And then, of course, know that it doesn’t always go as planned. Know that there are those times when your wishes won’t be granted and your goals won’t be met because birth tends to happen the way it happens both because of and despite our positive thinking, hard work, and determination.  Sometimes we are pleasantly surprised, and often we find that our expectations result in a bit of loss.  And if this is you, please find support- from your partner, family members, friends, doula, doctor, or therapist … wherever you can.

Our birth experiences tend to determine the lens from which we look into early motherhood, and if it doesn’t feel right — if this lens is dusted with anger, disappointment, sadness, loss, or fear — you might be at a higher risk for developing postpartum depression, anxiety or PTSD.  The sooner you get support around this, the sooner you will be able to look towards being a mom with clarity and understanding.

Updated Author’s Note:  

Please understand that my intention of this post is not to judge any one type of birth plan nor is it to criticize any one’s ultimate experience.  Although I did not include such an example here, there are certainly many many women out there who give birth naturally- without intervention- who leave that experience feeling fulfilled and empowered (and some of these women may NOT have intended to give birth this way).  These women, however, are also most likely those who felt supported, heard, and validated along the way.  The goal of this post is to bring light to that, particular, part of the birth process and to call attention to the fact that it is not the experience that brings the positive feelings about childbirth that we all hope for, but each mom’s feelings about her ultimate experience- did she feel heard?  Did she feel prepared?  Did she feel a sense of control?  So many folks out there in the blog world have written about ways in which they believe that “natural” childbirth is the only way to feel empowered and fulfilled, and this is simply a closer look at whether or not that is true.  Would love, as always, to hear thoughts around this…

~ Kate Kripke, LCSW

Photo credit: © iMAGINE – Fotolia.com

About Kate Kripke

Kate Kripke is a Licensed Clinical Social Worker (LCSW) specializing in the prevention and treatment of perinatal mood and anxiety disorders. She is also a Colorado state coordinator for Postpartum Support International. Kate lives in Boulder with her husband and two daughters and writes an eponymous blog.

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Comments

  1. phdinparenting says:

    With my first birth, my "plan" was get the epidural and follow the nurse/doctor's instructions. That was it. Sure, I'd read books, yada yada, but other than pain avoidance, I had no "plans". In the end, it was horrible. I was up all night, confined to a bed but unable to sleep, incredibly uncomfortable but unable to move, and I ended up with painful tears because I was pushing according to someone's instructions, instead of by listening to my body. I have so many regrets about that birth experience, but I can't go back and change my lack of preparation.

    For my second birth, I prepared. When the day came, I ate lunch at home and then went to the hospital. I had a juice and a snack in the cafeteria with my husband. Then I called my doula so she could meet us, went to L&D, handed out copies of my birth plan, walked around, used the jacuzzi tub, and when my body said it was ready, I pushed three times and delivered my baby a couple of hours after I'd left my house.

    Preparing, for me, took the fear out of it and allowed me to trust and listen to my own body. That, in my opinion, is never a bad thing.

    Here are my expanded thoughts on birth plans (including a copy of my plan): http://www.phdinparenting.com/2008/09/14/birth-pl

  2. Being a first time mom, I was only able to relax and not be fearful when I was fully educated about the birth process, I was the one on the hospital tour asking incessant questions (I was also the only one there not even showing while all the other moms were clearly in their 3rd trimesters). I wanted, no I NEEDED to be prepared. I needed to know what was going on and why. I wanted to know each step of the process, why certain interventions might be needed and why not, what the risks of each intervention might be, as well as benefits. I needed to know my baby would be with me when it was all done unless there was something wrong. My OB felt insulted and became rude when I asked her questions. When I did anything but be a "good patient", when I started learning and researching, she literally cut me off at one point and wouldn't answer me. I was asking about how often she did c-sections, episiotomies, how long past my due date would I be allowed to go, how long would I be allowed to labor naturally before pitocin or other actions were taken to speed my labor. I needed to know these things and after her reaction to being asked about how my labor would go I fired her. I couldn't use an OB who was rude and disrespectful to me just because I wanted to know how my labor might go, because I wouldn't trust in her as the almighty authority on all things labor related. It was my body, my baby, I had the right to know. So I interviewed new OB's and midwives and finally found a birthcenter an hour away from my home in Los Angeles. I met the most amazing midwife. And my labor was long, and it was hard and I've never experienced such an amazing euphoria when it was all over. I was madly in love with my baby and every ounce of my long, hard, and natural labor was worth it. I was never scared, I always knew what was going on and why. I trusted my midwives because I knew them. The second time around I tried to go the OB route again. Even though this time the OB was great, I still was stressed about my birthplan and all the things I had to dictate and specify regarding my labor and the care of my newborn. It was just too stressful, so midpregnancy I gave up and switched to a midwife and had a quick, less than 2 hours, homebirth. There were things that happened at the very end, with my sister, that had nothing to do with anything I could have included in a birthplan that caused me to be upset afterward. It took me a bit of extra time to bond with my son, but I did and I wouldn't have had it any other way. I cannot in any way, imagine being prepared and educated and desiring to go the most healthy route for you and your baby, being a bad thing. I find it curious that you only spoke of the natural birth as being the one resulting in an unhappy mother. I know of many mothers who've had beautiful natural births and who couldn't have been happier, and I know plenty who've had c-sections and epidurals and an unhappy result. I think in any group you are going to find both. Education is key, and discouraging it is wrong, in my opinion.

    • "Education is key, and discouraging it is wrong, in my opinion." LOVE THAT!

    • katekripke says:

      Thanks, Momo. I appreciate your comment and shared experience, and I do feel a need to clarify….
      The purpose of this post was to take note of the births that did not go as planned.. and to highlight that this shift in expectation can be both traumatic but also rewarding… often depending on the type of support that a mom received (both intended and, of course, unintended). You are absolutely right, there are many many many women to give birth "naturally"- without intervention- who feel empowered, blissful, strong, and extremely satisfied by their experiences… And, in referring back to the goal of this post, I also know that these are most likely the women who felt supported, heard, and validated along the way. Please know that this post is not intended to judge any ultimate childbirth experience nor is it to say that one way of approaching childbirth is better than another- in fact, my intention was the opposite of that. I think we are in agreement here that women deserve to be educated and to decide, for themselves, what type of birth they want and what choices make the most sense for them- as individuals.

    • With respect, momo, it seems that you were set up for a big fall if things had not gone well. Your desire to know evey detail in advance perhaps reflects a huge anxiety and need to be "in control."

      While I don't condone any health care provider being disrespectful, professionals can also feel distrespected by someone who feels they need to 'check" every detail of that professional's approach in advance. Perahps your questions were communicating a basic lack of trust – in which case, it was better that you didn;t continue the relationship.

      I would just suggest caution, though, in assuming that "reading up" in an area that we are not trained or experienced in allows us to make critical decisions with good judgment – whether it is childbirth, dental work, a court trial or a sea rescue.

      It might be best to communicate the issues that are most pressing or important for us, and then recognise that the clinical decisions are what the provider has expertise in.

  3. My most traumatic birth (of 3) was the one where I had no plan other than wanting my doula and husband there. I read many articles such as this one that essentially said "don't plan too much. you set yourself up for disappointment if things don't go according to the plan" and I believed it. For me? This couldn't have more wrong. I had no plan for when my labor stalled during an epidural I didn't want under the threat of an emergency c-section. I was scared, tired and with no plan to refer to I couldn't articulate what I wanted to happen. My son was vaginally delivered with a partially collapsed lung and was rushed to the NICU. I was separated from him for hours because of my own complications brought on by a bad reaction to the epidural and a placental abruption. For 3 years I suffered PPD and was treated. For 5 years afterward I had nightmares about his birth and back pain from the epidural. Now it's over 11 years later and although the trauma has mostly passed, you can bet I recommend a birth plan for expectant moms. I had one in place for my child after him and it was a gorgeous birth even though things didn't follow the plan to the letter.

    • katekripke says:

      Thank you for this comment, Kiki. And I truly appreciate your perspective…. Perhaps the more appropriate statement is to, as best as possible, plan for each scenario (although I also have seen moms "plan" for worst case and become exceptionally anxious leading up to birth because of this). When I work with pregnant moms leading up to birth, must of the work is around helping that mom to understand her strengths (both physically and emotionally) so that she has faith in her ability to be okay EVEN if she is scared, anxious, and uncertain… This does not mean that we work to limit her disappointment or challenging emotions (because, as you know so well, when there is a traumatic childbirth of any kind, these emotions will be there as we are all human), but rather to help her learn to tolerate them, care for herself when they are there, and not judge herself for feeling them…)… So, perhaps it is the intention of the birth plan rather than the plan itself that helps to limit debilitating distress…

  4. You are so biased against natural birth it's breathtaking. I had an OB who, even when I tried to refuse certain (unnecessary) interventions, told me I did not have a choice because I was in a hospital and "that's how we do things." There's quite a lot of that out there! You gave examples of how natural birth went wrong and managed births went well (by the woman's experience of PPD or not). Why didn't you give an example of a woman who had a managed birth and then had PPD? Why did you make it look like only those who have natural births are likely to suffer? Why do you defend the current climate of interventions? You've selected information that supports your perspective and opinion. Congratulations — you haven't really helped women or showed that you understand them at all.

    Next time, try being understanding of ALL women instead of basically saying, "Have your expectations, sure, but really — managed birth is pretty good." You just don't get it. You really don't.

    • katekripke says:

      Wow- I am sorry that you misread my points here, Kate. Truth be told, I am very much in support of natural childbirth if, and when, it feels important to the women who choose it. You are right, my post would have benefited from an example such as this:
      I am talking about the mom who learned all she could about childbirth. The mom who interviewed both obs and midwives until she found someone who listened, asked her about her fears and hopes around childbirth, and who made a commitment to her to do her best to work with these wishes. This mom gave birth, in a hospital, with a rained nurse midwife, without the need for pain relief, and without intervention of any kind. This mom says that her experience was empowering because she felt prepared, listened to her body, and was surrounded by people who she loved. And, yet, despite this rewarding experience, this mom developed postpartum anxiety that led her to my office for support and treatment.
      And, yet, my post is really touching on folks who suffer from PPD after an unexpected result and the intent was to discuss birth outcomes that were not in line with hopes and expectations. I apologize if your experience felt missed.
      I am a proud mother of two birth experiences: one with medical intervention in which I received an epidural and one without in which my daughter was born without pain medication or medical support. I am in awe of both of my experiences and, as I mentioned in my post, feel blessed to have felt seen, heard, and empowered in both. I suffered from PPA after my first birth and not after my second. Experiences vary. For everyone. What I may be biased against is the belief that there is only one right way to birth. Please let me clarify that I am in full support and wonderfully proud of myself and all of the other women out there who desire, attempt, and succeed at birthing babies naturally, with medication, through trauma, and/or without unexpected results. We are all on the same team here.

    • I had three hospital births and never believe these stories about forced interventions. I think that is just your perception of what happened.

  5. As I told Katherine on Twitter, as a doula, childbirth educator, and former ICAN Chapter Leader, I work first-hand with moms who've experienced birth trauma. I am also a mom who experienced severe birth trauma from an unexpected cesarean. In my first birth, my "plan" was to go to the hospital and do what they say because everybody told me there's no point in planning. That was one of the worst decisions I've ever made in my life. By not planning or educating myself, I had NO control over what was done to me and by the time it was over, I was recovering from a totally unnecessary major abdominal surgery. Nobody mentioned that was even a possibility. If I'd taken more time to figure out what I wanted, I would have avoided that. I know that because I did take the time for my second and third baby, and was able to have the births I wanted – no scalpel required. Of course, we cannot script birth and we cannot control everything. But telling moms not to bother educating themselves or having expectations means a mom is at the mercy of the provider's preferences and choices for how her labor should go. Women should be taught to trust their instincts, especially when it comes to labor, and those choices need to be more respected by the people around them. That may have been what you were trying to say, but it just came off very anti-birth-plan, anti-informed decision-making, and anti-natural birth in general.

    • katekripke says:

      Thanks for this- and I am unsure of where all of the perceived anti-elements came from in my post. I don't think of myself as much of an anti-anything… At the same time, I have seen way to many women in my psychotherapy practice who have been told that the only real way to birth a baby is naturally and without pain medication, who have not succeeded at this, and who then feel terrible about themselves and their experiences…. And I feel it is important to speak for them, as well.
      What is more clear than anything here is that the whole topic of birth is held with immense amounts of passion and importance. We all hold that because we are all mothers. And when it comes to this very meaningful right of passage, we all want to feel that we have been respected and heard.

    • Well, I guess it would seem like that to a person with a teenaged mentality, but to us adults it was a wonderful article full of compassion that said nothing anti-anything.

      • "Dr." Amy Tuteur…your response is garbage and based on nothing evidence based. The c-section rate is over 30% so it's obviously all our faults for having such faulty bodies that don't allow us to birth our babies and surrender to the every whim of a physician. Their reasoning and skills are just too much for us simpletons to understand, I guess? You make me sick. Stop calling yourself a doctor, and stop lunging at any chance to endorse a c-section. Do they PAY YOU or something????? Mom0f3..you're obviously her little surrogate. Go away. TFB haters always flock together….

        • Tina was that really necessary? Because a person replied that happened to disagree they need to go away from a site that isn't related in the slightest? Do my opinions not matter either because I happen to read a blog by someone with whom you disagree?
          Dr. Amy didn't link to it so it has nothing to do with her or the blogs that the any of us read. Could their opinions have been worded better? yes. But disagree with people who are here and commenting instead of accusing people of being minions because they have a different opinion.

  6. Walker Karraa says:

    Dear Kate,
    Thank you for this important discussion. The prevention of traumatic childbirth for women and their partners is of the utmost importance in addressing the prevalence of PTSD secondary to childbirth which is around 9% based on LTMII (2009).

    PATTCh, is a new collection of professionals addressing this very topic. This month we have launched a Traumatic Birth Prevention and Resource Guide at Giving Birth With Confidence, hosted by Lamaze International. There are some of the leaders in the field sharing insights and opening the conversation, just as you have here, about the relationship between childbirth and perinatal mental health.

    As we build our organization, we will be sharing resources, research, and professional information inviting a multidisciplinary discussion to address PTSD, and traumatic stress symptoms following birth.

    I can't thank you enough for your wonderful post.

    Walker Karraa, MFA, MA, CD(DONA).
    President, PATTCh http://www.pattch.net

    • Addie Devant says:

      Walker, I could support the Pattch agenda more wholeheartedly if you weren't associated with Lamaze. I'm concerned about a bias being built in, right from the start, since Lamaze has a clear agenda of "normal" birth, whatever that is. Why must you associate such an important topic with an organization that is clearly biased?

      • Walker Karraa says:

        Wow. Really good feedback. thanks. PATTCh is a separate entity, we are our own organization, and Lamaze merely posted our Traumatic Resource Guide. Check us out at http://www.pattch.net. We are multidisciplinary collection of professionals and we leave our other orgs at the door. I really appreciate your perspective, and will definitely share with other PATTCh board members. Thanks, Addie!

    • katekripke says:

      Fabulous, Walker. Thank you for all of YOUR hard work out there!

  7. Walker Karraa says:

    I just had to offer that while some heavy hitters have chimed in here, Kate, I am in full support of your questioning the nature of natural birth. I too have been a doula, until I realized that the agenda of my colleagues was so rigidly fixed on natural birth, for a profit nonetheless, that the women and partners' choices were disregarded.

    As with feminist groups, lactivists, anti-vax, etc., there is a breathtaking willingness to vilify anything from evidence based research as products of the evil white coats. Women need inclusive, well-informed advocates who set their own agendas aside. Period.

    The vast majority of writing on this topic is by Cheryl Tatano Beck, and I encourage the folks labeling you anti-birth plan to do some serious homework on the topic.

    Lastly, it is a sociological phenomenon to me that the same women who demonize male-based Western medicine in birth as corporate callousness, have no problem making money on natural birth products, videos, workshops, certifications, etc.

    Truth be told, the founder of Natural Birth in this country, Grantly Dick-Read, was a British expat, ultra conservative, Christian, sexist OB who had lost his license in England so moved to South Africa. Just sayin'. Who else is there promoting natural childbirth?? Oh yea…Odent (man), Sears (man), Lamaze (man…even though Elizabeth Bing brought it here and got an epidural herself). And then the experts on 'natural attachment parenting'…Sears, Bowlby, Odent, hmmm…seems we feel validated if a man tells us it's ok.

    I probably just pissed a few off, but it is the truth, Ruth. Hang in there, kate

    • katekripke says:

      What we are all saying here is that being told WHAT to do feels disempowering. Unfortunately, when we hold tight to opinions about right vs wrong when it comes to childbirth, we miss the important reality that each women is different, each has different needs and desires, and each will interpret experiences differently. There is so much emotion behind this topic and, while we each will bring our reactions, insight, and experience to the table, it feels necessary to pay close attention to research and fact, in all directions when it comes to the realities of mental health and mental illness. What we are all supporting here is the wellness of mothers.

  8. katekripke says:

    Dear Readers-
    I must say, that I am confused by the responses here… I am not biased against birth plans, education, or natural childbirth. In any way. The goal of this post is to encourage the exploration of options and the importance of listening to ones' own fears, hopes, and desires. Birth plans are wonderfully important pieces of childbirth planning, but they are not the end all be all. Support, validation, encouragement, and true listening are what matter in the prevention of a PMAD like postpartum PTSD.

    • The problem for me is that your original post makes it sound like everything is the mother's true decisions, made without influence. If by default, the medical staff available give everyone the interventions, how are the mother's choices truly hers? If she hasn't tried to plan ahead and instead just takes what she gets because "that's what will happen anyway", any decisions will most likely actually be the medical staff's decisions, and NOT truly the mother's. Fixating on the plan can be harmful, because it's unlikely to actually happen 100%, but going with whatever means instead you can learn later that the medical staff lied/misinformed/messed with your choices, and maybe if you'd known more you could have done something. Maybe instead of focusing on birth plans, this piece should talk about how to tell if your medical support will actually listen to you during labor, and how medical staff that doesn't is a risk factor for postpartum problems.

      • katekripke says:

        I think we are actually saying the same things here… We want women to know that there are options, to be allowed to voice their preferences, and to feel supported during their process… I appreciate your interest in a follow up piece and will consider this. I also bet that many women reading this blog have thoughts on that and can share great insight into what worked or did not work for them in finding the medical staff who listens and supports as we would hope….

      • I think that is what she was saying. Did you read the article?

  9. Excellent post. Although my birth experience was considered "traumatic" by everyone there (family, doctor, nurses, etc), it still blows me away how my perception of what happened is different from others'. I absolutely believe that a mother's perception of her birth experience has an impact on her post partum mental health, regardless of what those around her perceived to be happening. Thank you for sharing.

  10. What a beautifully written piece. I thought it was very effective that you used birth examples that were the opposite of what one would expect to illustrate your point. (i.e. One mother's unmedicated birth is disappointing but another's emergency c-section is not.) It is truly not the type of birth, but the mother's perception of it that can cause emotional pain. I hope those who commented here and didn't understand this will go back and read this piece again. It is very important for women who are hurting from PPD or PTSD.

  11. anonOmom says:

    I always believed in natural childbirth, and I had 3 wonderful doula-attended natural births with CNMs, 2 in hospital and one at a birth center. However, listening to other mothers' stories and learning what can go wrong in childbirth, I am very grateful to the medical profession for doing their best to minimize risks.

    I am ashamed of how annoyed I used to be at the medicalization of childbirth, when I now realize that many of those interventions are there because they save lives. We can't know if a caesarean was unnecessary until after the fact, and who wants to err on the side of not doing one when it was needed? OBs, CNMs, and OB nurses are doing their best (minus the few bad apples that every profession contains), and we are incredibly lucky that people don't usually die in childbirth anymore.

  12. Amy Tuteur, MD says:

    Thanks for this terrific piece.

    Although there is not a great deal of research on the impact of birthplans and childbirth experiences, all the existing research suggestss:

    1. Mode of delivery has no impact on postpartum depression

    2. Birthplans have no impact on childbirth outcomes

    3. Reactions to C-section are determined in large part by culture. Natural childbirth advocates are part of a subculture of Western, white, relatively well off women, who have created a variety of arbitrary expectations around the "performance" of women at birth. Members of that subculture may feel disaappointed and guilty about failing to live up to the expectations of other natural childbirth advocates, but the vast majority of women view birth as a way to meet their baby, not a competition with other mothers.

    PPD is a serious medical illness with biochemical as well as psychologocial causes. It has nothing to do with mode of birth.

    • katekripke says:

      Thank you, Amy, for this clear and concise explanation…

      • I developed PPD after a VBAC. Even though I had an unscheduled emergency c-section birth for my first child, I had a normal recovery. I was talked through the process and had a sympathetic nurse and physician. My choice to have a VBAC for my second child was supported by my physician however the delivery was horrific and I felt rushed by the doctor on call and abandoned right afterwards. I was then left in the hands of a resident who was unable to handle repairing my injury. I had months of physical recovery, more surgery and physiotherapy. It was this birth that I developed PPD after. I think there is a link between birth experience and developing PPD, not necessarily causality, but a link for sure.

        • katekripke says:

          Thank you so much, Lisa, for sharing this difficult experience. I am hopeful that you have received support along the way.

  13. katekripke says:

    Thank you for sharing your experiences… such a lovely example of when having a birth plan, feeling supported, and making choices around birthing positions helps lead to a wonderfully fulfilling experience. I appreciate your insight.

  14. I had a full explanation typed out but apparently it was too long so I will get to the point and say that my birth was definitely the start of my PPD. After almost 24 hours of labor, 5 hours of pushing, and an unexpected c-section I was left exhausted and drugged up and feeling like a failure. Looking back now asking my doctor after her "birth" if it was my fault, if I wasn't pushing good enough, or if it was because I got the epidural , was the start of my PPD. It was failure #1 as a mom, in my mind. Switching to formula was failure #2 and my breaking point. So yes, I strongly believe birth is one of the first influences on PPD.

    • katekripke says:

      There is so much pressure to feel guilt and failure when women can't do things the way they imagine that they should "naturally"- birth without intervention, breast feed without problems etc.. and so then when they don't succeed at this, they feel inadequate and undeserving to mother at all… and THIS is where we have somehow gone wrong as a society. Yes… birthing without intervention is what women have done for centuries and breast feeding has nourished trillions of babies and provides our young with health and bonding. However…. what matters most is that babies have their moms… regardless of the way that they were birthed or fed. And every mom that gives birth and raises a baby is heroic just as they are. Please remind yourself of this And know that you are not alone.

  15. By the way, I had gone to birth class, watched shows, read up on babycenter, and talked to other women. My only birth plan was to go into labor and see how well I tolerated the pain. Needing to be induced started me off wrong right away. With a c-section you are ripped off of the special moment where they lay the baby on you after birth like you see on tv. Instead you can't even touch your baby 'cuz you're arms are spread out and numb. Sorry if this post wasn't meant to discuss our own experiences but I like to share so hopefully it can help figure out PPD somehow, if it's even possible.

    • katekripke says:

      I am glad that you have given voice here, Amanda. You describe a feeling that so many others who have had unexpected C-Sections describe- the missed opportunity for what we all believe "should" be the introduction to motherhood (baby on chest etc). It sounds like this was really difficult for you and I am hopeful that you have been able to get some support around this. Thanks for sharing.

  16. parentingforpeaceprof says:

    Thank you, Kate, for opening this important discussion. In her brilliant "Birth in Four Cultures" Brigitte Jordan chronicled relative differences in such things as prenatal care, attendants and support systems, birth territory, technologies, birth positions and cultural attitudes toward pregnancy and birth in Sweden, Holland, the U.S. and Yucatan. What emerged as perhaps the most important difference was *locus of decision-making.* Swedish women utilized plenty of drugs and technology, yet didn't seem as undone by it as U.S. women. So yes, as you wisely point out, it's about "Am I being heard, and do I have a voice — the *central* voice — in this process??"

    While I do believe there tends to be more of an "upside of empowerment" to be found in natural birth over a regimented / routinized / medicalized birth, those things you bring up can indeed get in the way. Our plans, our perfectionism, our comparison-ism. A white-knuckle death grip on our birth plans. Disconnection from our bodies.

    It's why *PRESENCE* is one of my guiding principles. One of the major causes of parental misery is our impulse to be somewhere other than where we are right now (or to wish our *kids* were somewhere else), whether right now is with a colicky baby who is crying for her twenty-seventh straight evening, or a toddler who has again missed getting to the potty (recalling that bumper sticker, Shit Happens). Much of our distress lies in the very resistance to giving ourselves over to what *is*. And paradoxically, when we let go of our idea of what *should* be in this moment, and instead receive this moment as it is, any moment can become perfection.

    Including a birth that doesn't go as we had perfectly envisioned. (And yes, it helps a great deal if those participating in the birth can be similarly present and can remain connected and respectful of the birthing mother.)

    Bliss Happens.

    Marcy Axness, PhD
    author, "Parenting for Peace: Raising the Next Generation of Peacemakers"
    (and years-long sufferer of "CCPD" — Chronic Covert Postpartum Depression) about which I wrote a blog post that I only just realized includes a link to Kate Kripke! http://marcyaxness.com/parenting-for-peace/covert

  17. Holly Cline Adelman says:

    Thank you for this discussion, Kate. I have experienced PPD myself with all three of my children. I have experienced (in this order) an unplanned c-section, a homebirth (VBAC) without any pain medication and a hospital birth (VBAC) with an epidural. The experience where I felt least listened to was my homebirth, ironically. I was in immense pain and no one seemed to care. I had continual support from three people (my husband, my midwife and her assistant) and yet I felt like no one was listening to me. This traumatic experience of natural childbirth led me to choose an epidural in a hospital with my third birth. It was a wonderful experience and my only birth so far where I felt like someone was paying attention to me, as a person. It was remarkably humanizing. It was also a birth that I went into with absolutely no birth plan.

    Birth plans do not do much of anything, and I say that as a health care provider myself. You can not predict birth. You can not plan for birth. The best "birth plan" is one where you allow yourself to be carried through the experience by the experience, rolling with the punches, adapting your "plan" to the situation. Trauma is not correlated with mode of delivery. PPD is not correlated to mode of delivery. Women need to stop blaming themselves and others for their PPD, and they do this by claiming that NCB results in less PPD, when we know that that data just does not exist.

    Thank you for the work that you do and I look forward to reading future posts.

  18. Great synopsis on this important topic, Kate!

  19. What many are tip-toeing politely around here is that natural birth at all costs has become a prized accolade among relatively affluent Western white women — if you don't have a natural birth, you are disparaged in many circles and you become a pariah, which is emotionally traumatic for women.  If you do have a natural birth, you are placed on a pedestal.  It's not the interventions themselves that result in emotional scars, it's the artificially created feeling of failure that comes courtesy of the natural childbirth movement and its silly birth plans etc.  Women who have uncomplicated births and happen to have no need for intervention are lucky — this is not an accomplishment in the same way that, say, getting a degree or running a marathon is.  This natural birth stuff would be harmless if it weren't (a) convincing women to take unnecessary risks with their lives and their babies lives by eschewing life-saving interventions and even birthing at home or unassisted, and (b) causing women to develop postpartum mood disorders because they feel guilty that they weren't "mom enough" (hah) to birth naturally.  Of course those are extreme cases, but the social influences of the natural childbirth movement and the ridiculous expectations it places on women are becoming insidious.

    • Thank you for this input. I am not trying to blame anyone but I do believe my birth situation was an influence on me. In my mom's group the two other moms who had PPD, admitedly, also had c-sections. One thing you forget about with a c-section is that you are recovering from surgery while being sleep deprived and caring for a newborn. Not saying everyone who has a c-section will get PPD or natural births won't get it but I am just saying what I have seen and felt with my experience. Nobody can say for sure that the type of birth does not influence PPD.

      • katekripke says:

        I have seen this a lot in my practice, Amanda. The recovery from a C-Section can most certainly make caring for a newborn all the more difficult. Thanks for your input.

    • Well said!

  20. (…sorry…first line "bending over backwards"…)

  21. My childbirth experience was traumatic to me. In my case I went to the hospital looking for mainstream care and was forced into a natural model of care. So I ended up with the triumphant natural birth that everyone thinks is the best possible outcome and spent the next two years an absolutely wreck. I have never been able to forget the severe pain, which no one would acknowledge or attempt to relieve, combined with the humiliation, severe fear (for my baby and myself), and my inability to do anything but lie there and scream in pain and horror while midwives and nurses manipulated my genitals without my consent, then feeling myself being ripped apart and permanently damaged in the most humiliating and intimate way.
    Then there was the physical recovery afterward. Dealing with a severe tear, incontinence, and an altered body. I was horrified and ashamed at the way I'd been left. I went to physical therapy which was further humiliation and ultimately unhelpful. Eventually, after many embarrassing exams and procedures with specialists, I had surgery to repair the damage.
    For a long time I was a wreck. I cried and was on edge and angry and completely eaten up by shame. I didn't want to be alive anymore. I didn't want to go to sleep at night because I knew I would dream about it again–either the birth itself, the humiliating exams, or the surgery.
    It' s been a couple of years and I'm better now. I'll never feel physically normal or ok again, but things are better than they were. I can sleep without nightmares most of the time, though tv shows, movies, and other reminders can still upset me.

    One of the worst things about it all is that there is simply silence. Everyone is there with open arms if you've had a c-section and are upset about it. No one acknowledges that natural birth can be traumatic and it's too embarrassing to talk about. The only places I've found supportive and honest have been specific to people suffering birth injuries and who've gone through the subsequent surgeries and treatments.

    • katekripke says:

      Ahh,.. you share SUCH an important perspective here, and you are not alone in this, I am certain. You are right, we so soften assume that a woman who deliver without intervention is contented by this, and so little time may be spent in really allowing for the opportunity to process the negative feelings that may exist there. Your input is valuable. thank you.

  22. katstone1 says:

    My two cents. I know Kate and I know how balanced Kate is. When I read her piece I didn't see bias the way others did. And no, I'm not arguing with you as to whether you should have seen it or not – it's just that I didn't. As I've read the feedback here in the comments section, on Twitter and on Facebook, one thing has become clear to me: There is NO single right answer.

    Some of you did not have much information or use a birth plan for your childbirth. Within that group, for some of you the birth was just fine and for others it was a nightmare. You experienced interventions or pain or experiences that were traumatizing.

    Some of you did have a lot of information, a clear idea of what you wanted, a birth plan and an active role in making sure your preferred experience was carried out. Within that group, many of you felt empowered and are very pleased with the outcome. Others of you felt disappointed and traumatized when all the expectations you had and planning you did fell through.

    I think any of these situations can potentially lead to a problem: not having any say or being ignored or dismissed during the birth process, or believing and expecting to have much more control and not getting it because of circumstance. I can tell you that I did inform myself, I did have a very clear plan and took a very active role, and when it couldn't be met, my anxiety went through the roof.

    I hope we can all respect each other's perspectives.

    ~ K

  23. I wish all of this information and treatment would have been available when I delivered my son, by c-section, 25 years ago after a very tramatic labor. I did not feel like a failure and other than having to wait for my epidural too long, I felt my care was great. And PPD was right there a few days later, so severe I was hospitalized for it 4 months later. It has taken until recent years for me to see the message of PTSD after birth and to know in my heart that is what happened to me. I never even considered having more children and will wonder if with better help, I could have gotten through it more completely.

    • katekripke says:

      Thanks, Becky…. the current move to reduce stigma and increase awareness is certainly helping with this, and I know that for women like you this can feel both hopeful and frustrating as your generation of mothers suffered in silence frequently. I am glad that you are here and sharing with us.

  24. "At the same time, I have seen way to many women in my psychotherapy practice who have been told that the only real way to birth a baby is naturally and without pain medication, who have not succeeded at this, and who then feel terrible about themselves and their experiences…. And I feel it is important to speak for them, as well."__Bravo!!! My close friend was incredibly traumatized by her medically necessary C-Section because of exactly this…and in my opinion, I believe that she was given overly paranoid information by the natural childbirth movement. I think that some of them are taking offense to your post because they know where the logic leads itself. They KNOW that they are subtly and sometimes overtly pressuring people that a natural birth is super-super-good and anything else is "less than". They KNOW that they are subtly and more often overtly criticizing OBGYNs for everything from morality to information, even though most of them have far, far, far less education.

  25. And…As a Marriage and Family Therapist who grew up in a cult-like church, I am very sensitive to picking up on group dynamics and ways that people try to control other people. I have seen many very controlling type actions that were done in the name of "freedom", ironically. Personally, I think that you are right on. Birth is NOT something that can always be planned, and women need to stop being told that a natural birth is better! Of COURSE it should be an option for women – but hello, when has it not been? Only when the baby's health is at stake, in which case, unfortunately many midwives' grasp of science seems to get a bit slippery… But back to your topic, I think that women have the right to know the pros and cons of rigid thinking and how it might affect them psychologically after the birth. Sometimes when you're being criticized (as in some of the reviews on this case), you know you've hit a nerve. But/and… You are RIGHT ON!!

  26. I had my first baby naturally, and it was my own personal hell in the end- after hours of breathing exercises with my wonderful husband, transition completely took me by surprise, and I can’t ever remember feeling so completely out of control- and I HATED it! When my beautiful daughter was born, I was completely exhausted and out of it- I literally don’t remember anything of the next one to two hours. It’s so hard when moms talk about that instant bond- I still feel like I have to work hard to bond with my oldest, and it makes me feel horrible! I had PPD for about 7 months after she was born.
    With my second, I opted for a an epidural once the labor was really going, and it made a whole world of difference- I relaxed for the last 45 mins, pushed a couple times, and enjoyed a wonderful moment with my husband when we could both see her out, and I have wonderful memories and pictures of the first time I held her, and how perfect she was.
    I’m on my third, and, quite possibly, last pregnancy and third girl, and we are ecstatic! We love our girls so much!! I’m planning on an epidural again. Hopefully I can have another beautiful experience!

  27. Phoenix Fourleaf says:

    I think birth is almost always traumatic. I had to deal with trauma recovery issues with both of my births, even though the 2nd one was “easy”.

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  3. […] of her birth experience? Which may often lead into Post Traumatic stress Disorder. (See here and here and here ). Coupled with that, their general ability to better adapt to their new life as a mother […]