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Reed et al. BMC Pregnancy and Childbirth (2017) 17:21DOI 10.1186/s12884-016-1197-0RESEARCH ARTICLEOpen AccessWomen’s descriptions of childbirth traumarelating to care provider actions andinteractionsRachel Reed1* , Rachael Sharman1 and Christian Inglis2AbstractBackground: Many women experience psychological trauma during birth. A traumatic birth can impact on postnatalmental health and family relationships. It is important to understand how interpersonal factors influence women’sexperience of trauma in order to inform the development of care that promotes optimal psychosocial outcomes.Methods: As part of a large mixed methods study, 748 women completed an online survey and answered thequestion ‘describe the birth trauma experience, and what you found traumatising’. Data relating to care provideractions and interactions were analysed using a six-phase inductive thematic analysis process.Results: Four themes were identified in the data: ‘prioritising the care provider’s agenda’; ‘disregarding embodiedknowledge’; ‘lies and threats’; and ‘violation’. Women felt that care providers prioritised their own agendas over theneeds of the woman. This could result in unnecessary intervention as care providers attempted to alter the birthprocess to meet their own preferences. In some cases, women became learning resources for hospital staff to observeor practice on. Women’s own embodied knowledge about labour progress and fetal wellbeing was disregarded infavour of care provider’s clinical assessments. Care providers used lies and threats to coerce women into complyingwith procedures. In particular, these lies and threats related to the wellbeing of the baby. Women also describedactions that were abusive and violent. For some women these actions triggered memories of sexual assault.Conclusion: Care provider actions and interactions can influence women’s experience of trauma during birth. It isnecessary to address interpersonal birth trauma on both a macro and micro level. Maternity service development andprovision needs to be underpinned by a paradigm and framework that prioritises both the physical and emotionalneeds of women. Care providers require training and support to minimise interpersonal birth trauma.Keywords: Childbirth, Trauma, Maternity careBackgroundAround one third of women experience trauma whilstgiving birth [1, 2]. A traumatic birth experience is associated with postpartum mental health problems, including depression and post traumatic stress disorder[PTSD] [1, 3–6]. Poor mental health in the postnatalperiod can alter a woman’s sense of self, and disruptfamily relationships [7–10]. Difficulties with earlymother-baby bonding can negatively influence a child’ssocial, emotional and mental development [11]. In* Correspondence: [email protected] of the Sunshine Coast, 90 Sippy Downs Drive, Sippy Downs, QLD4556, AustraliaFull list of author information is available at the end of the articleaddition, the experience of a traumatic birth can influence a woman’s future decisions regarding where, how,and with whom she gives birth [12, 13]. For example,women may choose to birth at home to avoid repeatinga traumatic hospital experience [14]. Jackson et al. [15]found that the decision to freebirth (give birth without aprofessional care provider) can be influenced by previousbirth traumatic. Therefore, the consequences of a traumatic birth experience can be substantial and wideranging for women and their families.Birth trauma has been associated with medical intervention and type of birth [5, 16, 17]. It has been defined as aperception of ‘actual or threatened injury or death to themother or her baby’ [18]. However, Beck [19] argues that The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication o/1.0/) applies to the data made available in this article, unless otherwise stated.

Reed et al. BMC Pregnancy and Childbirth (2017) 17:21the perception of trauma is in the ‘eye of the beholder’, andshould be defined by the woman experiencing it. Qualitative studies exploring women’s experiences of traumaticbirth identify interactions with care providers as a more important factor than medical intervention or type of birth[20–23]. For example, a perceived lack of control and involvement in decision-making can contribute to the experience of trauma [21, 23]. A study by Thomson and Downe[20] found that trauma was related to ‘fractured interpersonal relationships with caregivers’, and that women felt disconnected, helpless and isolated during birth. Whilst not alltraumatic birth experiences result in PTSD, two quantitative meta-analyses identified that negative care provider interactions are a significant risk factor for PTSD [5, 17]. Astudy by Harris and Ayers [24] also found that the strongestpredictor of developing birth related PTSD was interpersonal difficulties with care providers, in particular experiencing a lack of support.A recent Cochrane Review [25] concluded that womenrequire improved emotional support during birth fromtheir care providers to reduce the risk trauma. Health careprofessionals have an ethical, legal and professional obligation to provide safe and respectful care [26–28]. In order toimprove care, it is important to understand what interactions and actions are associated with trauma [20]. Thispaper focuses on traumatic care provider actions and interactions from the perspective of the women experiencingthem. The findings contribute to the body of literatureexamining women’s experiences of traumatic birth; and toan understanding of how care providers influence women’sperceptions of trauma. This paper presents a subset of findings from a large mixed methods study that investigatedparental mental health following traumatic birth. The quantitative findings have not yet been published. The qualitative findings concerning paternal mental health arereported elsewhere [29]. This paper presents the qualitativefindings relating to women’s descriptions of birth traumainvolving care provider actions and interactions.MethodsThe mixed methods study involved parents completingan online survey, and additional face-to-face interviewswith fathers [29]. The online survey included questionson demographics, descriptive birth assessments, parentinfant attachment, partner relationship quality, currentmental health, and coping strategies used after thetrauma. In addition, the survey incorporated a questionabout the experience of birth trauma with space for awritten response. A qualitative approach was taken toexplore women’s written descriptions of trauma. Thearea of interest in this aspect of the study was women’sexperiences of trauma, rather than outcomes associatedwith trauma. The majority of qualitative data related toPage 2 of 10care provider actions and interactions, and this paperpresents themes relating to this data.Participant recruitmentParticipants were recruited via online social media forumssuch as Facebook, Twitter and a midwife’s blog site. Inclusion criteria was that participants were over 18 and hadexperienced a traumatic birth. A definition of a traumaticbirth was not provided in order to capture what participants themselves considered’trauma’ [19]. There was noexclusion criterion for time since the birth, as women’smemories of childbirth remain strong over time [30]. Participant information detailing the research question andaims was provided on the first page of the online survey.In order to obtain consent, participants were required toread an online consent form and ‘click’ agree prior toaccessing the survey.Data collectionAfter consenting to participate, participants completed anonline survey administered through the program SurveyMonkey. The survey included demographics (eg. age, relationship status) and information such as type of birth (eg.caesarean, vaginal); place of birth (eg. public hospital,home); and admission of baby to special care (Table 1). Thequantitative element of the study comprised of a number ofpsychological assessment tools: Maternal Postnatal Attachment [31]; Quality of Marriage Index [32]; Depression Anxiety Stress Scale-21 [33]; Posttraumatic Stress DisorderChecklist-5 [34]; and The Brief Cope index [35]. The qualitative element of the study involved women responding intheir own words to the question ‘describe the birth traumaexperience, and what you found traumatising’. The meanlength of written responses was 69 words.Data analysisWomen’s descriptions of trauma were analysed using asix-phase inductive thematic analysis process describedby Braun and Clarke [36]. Phase one involved becomingfamiliar with the data by reading and re-reading; andnoting initial ideas. In phase two initial codes were generated and data relevant to each code was collated.Phase three of the process involved collating the codesinto potential themes. These themes were reviewed inphase four to ensure they were consistent in the codedextracts and across the entire data set. In phase fivethemes were defined and named using words andphrases. Phase six involved selecting extract examples toillustrate the themes, and relating the analysis to the research question and the literature. Three researchersparticipated in the thematic analysis process to ensureconsistency in analysis and findings.

Reed et al. BMC Pregnancy and Childbirth (2017) 17:21Page 3 of 10Table 1 Demographics and type of birthTable 1 Demographics and type of birth (Continued)AgeRange 18 to 77 years (Mean 33.13)N (%)Marital statusPlanned homebirth transfer to hospital63 (8%)Unplanned out of hospital birth1 (0.1%)Admission of baby to special care nurseryYes269 (34.4%)No512 (65.6%)Married798 (77.5%)De Facto124 (12.5%)Single42 (4.1%)FindingsDivorced21 (2%)Separated23 (2.2%)A total of 943 women completed the online survey fromaround the world. The majority of participants werefrom Australia and Oceania (36.8%), North America(34.2%) and Europe (25.5%). A small number of participants were from South America (2.1%), Asia (0.9%),South Africa (0.5%) and the Middle East (0.2%) (Table 1).The majority of participants gave birth in a public hospital (69%) and either had an unplanned caesarean(37%), or an unassisted vaginal birth (34.3%) (Table 1).In addition, 34.4% of participants reported that theirbaby was admitted to special care nursery.Of the 943 participants, 748 (79%) responded to thequalitative question ‘describe the birth trauma and whatyou found traumatising’. A third of respondents described events such as premature labour, haemorrhageor concerns regarding their baby’s wellbeing. However,the majority (66.7%) described care provider actions andinteractions as the traumatic element in their experience.From the data relating to interpersonal factors, fouroverarching themes were identified from the descriptions. The themes are presented below with illustrativedata using the participants’ own words, therefore spelling and grammar varies. The term ‘care provider’ is usedto refer to the professional responsible for the woman’scare. In the women’s accounts care providers includedobstetricians, midwives and nurses.In a relationship but not living together11 (1.2%)Widowed2 (0.2%)Engaged4 (0.3%)Number of children07 (0.7%)1409 (39.4%)2345 (34%)3159 (15.3%)470 (6.8%)523 (2.2%) 517 (1.5%)Region of originAustralia and Oceania386 (36.8%)North America347 (34.2%)Europe253 (25.5%)South America23 (2.1%)Asia8 (0.9%)South Africa7 (0.5%)Middle East2 (0.2%)EducationDid not finish high school14 (1.4%)Finished high school196 (19.1%)Prioritising the care provider’s agendaTrade or technical qualification157 (14.1%)Undergraduate degree395 (39.1%)Postgraduate degree264 (26.4%)Women described how care providers prioritised theirown agenda over the needs of the woman. In some casesit was made clear to women that their labour was keeping the care provider from something, or someplace theywould rather be:Type of birthUnassisted vaginal birth271 (34.3%)Assisted vaginal birth (ventouse or forceps)176 (22.4%)Planned caesarean47 (6%)Unplanned caesarean290 (37%)Place of birth / transferPublic hospital542 (69%)Private hospital115 (14.6%)Birth centre12 (1.5%)Planned birth centre transfer to hospital23 (2.9%)Homebirth29 (3.7%)I found my OB’s lip service to my wishes and then hisswitch against them traumatic. I found the comment“let’s get this over and done with, I have a golf gameto get to” traumatic (045) after an OB coming in and telling me that shewould like me to deliver by 5 pm because she wantedto go home, I just burst in to tears (549)Women felt that they were subjected to unnecessaryand unwanted medical interventions in order to meetthe needs of their care providers:

Reed et al. BMC Pregnancy and Childbirth (2017) 17:21I begged not to have a c section, neither I nor mybaby were in distress or danger, but because thedoctor was ready to go home, he did a terrible sectionthat resulted in almost a year of recovery. (220)I was steamrolled with unnecessary interventionand didn’t get to speak with a doctor about myoptions, risks vs benefits I feel like the nurses,doctors and hospital only did what was in theirbest interest, not mine It was a nightmare.(381)Some women described how they became a learningresource for the benefit of hospital staff. For example,care providers offered other staff the opportunity topractice without seeking women’s permission: the doctor asked a student nurse, first day onthe job, if she wanted to suture my episiotomyincision. (644) 20 people in theatre and half were sitting down onphones and chatting away while I had someonetraining with forceps on me (867)One woman described feeling like she “ was part ofan experiment” (565) rather than a woman giving birth.In particular, women experiencing unusual births became a spectacle for others to watch: I was a looking point for students and anyone whohoped to witness a twin vaginal birth and a breechbirth. (523)One woman wrote about how the room filled withstaff hoping to watch her give birth to her breech baby: and the amount of people that filled the room towatch a vaginal breech delivery, when I failed at this,everyone left. (662)When she was unable to provide this learning opportunity she no longer warranted being an object of observation. The value of her birth experience for othersappeared to be based on what she could provide interms of a learning experience.Page 4 of 10In particular ‘being in labour’ was a contested area.Women’s perceptions of being in labour were based ontheir embodied experience, whereas care provider’s perceptions were based on clinical findings. For example,one woman was considered to ‘not be in labour’ becauseher cervix was not dilating according to care provider’sexpectations:Hospital staff did not listen to me, didn’t trust me toknow my body. Dismissed me as a first time motherwho was over reacting. In actual fact I dilated from 0to 6 in just over an hour. The hospital midwives toldme that I was just feeling the period pain associatedwith early labour and induction (485)Another woman described how her midwife determined she was not contracting, therefore not in labour,based on an abdominal palpation:Was going into premature labour and midwifepalpated during a contraction and stated I was nothaving them. Eventually went into labour as theyignored me Although not traumatic in medicalterms, felt completely disgruntled that my journeywas not taken on own merits and was completelyignored as a woman during labour. (061)Both of these women considered themselves to be inlabour, and having their embodied knowledge disregarded was traumatic.Embodied knowledge was also dismissed when womenexperienced an urge to push before care providers considered it appropriate. Women were instructed to ignorewhat was happening in their body and stop pushing:Told to stop pushing and being told what to dowhen my body was telling me differently. (248)Being told to stop pushing when baby was clearly onits way. Being told I had a long way to go when babywas on the way out. (436)Care providers used clinical assessments (vaginal examinations) to determine whether pushing was appropriate.Based on the findings of these clinical assessments womenwere ordered to over-ride their own bodily urges:Disregarding embodied knowledgeMany of the descriptions involved women’s own embodied knowledge being disregarded in favour of theircare provider’s assessment of events: I felt like I was being told I was silly for thinking Iwas in labour and that this awful pain was nothing tobe worried about. My opinion was dismissed andignored as I was just a first timer (436) I had the strongest urge to push, the midwife on staffinsisted on an internal examination to check dilation,she told me if I pushed now I would end up with anemergency caesarean due to my cervix swelling. Shethen spent the next hour yelling at me not to push andtrying to talk me into an epidural (I was trying myhardest to not push but my body kept taking over). Iwas begging to be allowed to push . (932)

Reed et al. BMC Pregnancy and Childbirth (2017) 17:21In some cases women described feeling that the wellbeingof their baby was in danger. When they attempted to alertcare providers their embodied knowledge was disregarded: I felt like everything was going wrong and foundthat distressing. I felt like people didn’t believe mewhen I said something didn’t feel right. (851) My baby was in distress and had mec liquor and inall honesty probably should’ve been sectioned, at thisstage I was begging for one as I knew something waswrong with my baby but they refused (732)In these descriptions women’s own assessment oflabour progress and fetal wellbeing was not valued oracted on which caused trauma.Lies and threatsWomen perceived that they were being lied to by careproviders to coerce them into agreeing to unnecessaryinterventions:It was not the birth itself that I found traumatic,rather the way we were treated by the midwife. Beinglied to in order to speed up my labour unnecessarilyand putting me and my baby at risk. (015)All of this is avoidable and unnecessary, if only wehad known I was forced into interventions that Ibelieved were unnecessary. I was also lied to manytimes by the doctors. (857)They also described how care providers threatened themin order to coerce them into undergoing procedures:My daughter was breech I was told that if I didn’tconsent to the cesarean before labor started then theywould perform a cesarean without my consent undergeneral anesthesia when I arrived (267).In this case, the woman was threatened with surgeryagainst her wishes. Other women were threatened withhaving their baby taken from them if they did not comply with proposed interventions:Psychological coercion - ie “if you do not consent tosyntocin OR a c-section then we can get our friendthe psych registrar down here to section you - thenwe can do whatever we want to you but you may notbe able to keep your baby” - All I wanted was to letmy body go into labour naturally - my baby was notin distress (186)I was bullied into an induction late on a Sunday nightand then told I would be kept over night. I wasn’taware when I finally agreed to be induced after quitePage 5 of 10some time of being threatened with DoCS[Department of Child Safety] etc. (400)The most common threats described by women related to the wellbeing of the baby. Some women usedthe term ‘dead baby threat’ to describe how they werecoerced, for example: “dead baby threats to gain consent ” (860); and “forced into c section with dead babythreat ” (223). Some care providers asked women ifthey wanted their baby to die when they declined anintervention: Being bullied into interventions with such wordingthe following: “Do you want a dead baby?” (919)Women felt that care providers were lying about therisks to the baby in order to pressure them into complying. They did not believe their babies were in danger,and in some cases had evidence that their care provider’sassessment was incorrect: I was basically told that if I didn’t have a c-sectionon their timetable I would kill my baby, even thoughthey couldn’t tell me what exactly was “wrong” as towhy I was not delivering vaginally They broke medown gradually until they declared my baby was “indistress” (she wasn’t I could see the screens). (559) Lots of coercion and being told my baby would dieif I didn’t consent to the c-section. She was born withapgars of 9 and 9. (194)Being lied to and threatened contributed to the experience of trauma, particularly when it involved the wellbeing of the baby.ViolationMany women described their birth experience as ‘violating’. A lack of control appeared to be associated with asense of violation. For example, one woman describedthat she felt “ out of control and violated” (660). Inthese descriptions, care providers carried out actionsagainst the explicit wishes of the woman: All in all, I felt very bullied, and even violated Itwas the feeling of disempowerment and not havingthe right to do with my body what I wished - and thatsomeone else could force me to do something againstmy will. (731)I felt violated, and angry that I should have to defendmyself and my body while I was trying to push mybaby out. (733)The descriptions of what care providers did to womenwere, in many cases, graphic and violent. For example, onewoman wrote “ couldn’t be tubed nurses manually choked

Reed et al. BMC Pregnancy and Childbirth (2017) 17:21Page 6 of 10me out” (490). Another wrote that she was “ assaulted vaginally by medical staff during crowning” (295). These descriptions focused on the manner in which the careprovider acted, in addition to their actions: Being pinned down by 4 midwives (forcing anunnecessary oxygen mask on me just so my screamsof ‘no’ were muffled) and my husband so theconsultant could examine me against my will. (888) She was very rude and condescending, both tomyself and to my midwife. She proceeded to dig outmy uterus without any numbing medication. It washorrifying (431) At one point, 3 nurses physically held me downdespite my protests that I couldn't breathe andneeded a minute to catch my breath before theprocedure (AROM). They held me down until thedoctor was finished (491)Women described how equipment tethered or tied themto the bed during labour: “was tethered to the bed duringan induction ” (328), and “I was tied to the bed, forced tolay on my back ” (418). Women experienced being forcedinto birth positions: “screaming, lots of people, nurses forcing me down and ripping my legs open ” (565). In particular, care providers made women lie on their backs: The pain was not the traumatic bit, it was the waythat I was treated during my labour. I was 20 yearsold. I had more midwives than I can count, attemptan internal examination and one yelled at me to‘relax!’ because she couldn’t force her fingers in. Shewas a bloody bitch to put it lightly. (256)One woman described how her obstetrician assaultedher to gain her compliance to induce labour:She said she wanted to do one more cervical check. Iconsented and when she did it, she grabbed my cervixand pinched it. She would not let go until I consentedto letting her break my water. I was in tears from thepain, screaming, begging and sobbing for her to let goand get her hand out of my vagina. She would not letgo until I consented, which I finally did. (997)A number of women described how they screamed‘no’ as care providers carried out procedures. For example, one woman told her care provider “expressively”that she “didn’t want any vaginal examinations” (413).Her care provider persuaded her to have a vaginal examination telling her that they “would be very gentle andwould stop if it was too much”. However her wisheswere not respected during the examination:I was crying and screaming in pain telling her no andto stop and she carried on, my husband shouted ather to leave me alone and she carried on. (413)Another woman described how her doctor failed torespond to direct requests, and then to screams forher to stop:The doctor would not get her fingers out of myvagina even when directly told. After it wasdiscovered that I suffered tearing, I wanted the tearingto be healed on its own - no stitches, but she andanother doctor stitched anyway, despite my screamingat them to stop. (445)In addition, some women wrote about being ‘helddown’ while care providers carried out proceduresagainst their will:During birth, multiple nurses screamed in my face“PUSH!!!” and flipped me onto my back and forcedmy legs open, holding me down (414)In describing their experiences women used wordssuch as “humiliating” (561); “belittled” (520); “brutal andbarbaric” (132). Some described “being treated like apiece of meat” (979), or an animal: I was treated like a cow having trouble calving, andfelt abused and humiliated. (222)A number of women used language associated withsexual assault and rape, writing that they felt: “ rapedand mutilated” (376), “ violated and damaged” (119),“ violated and scared and disgusting” (423). Womenwho had previously experienced sexual abuse or rape described how the actions of care providers triggered distressing memories: my cervix was manually dilated forcefully afterpleading for the Dr. to stop. This caused me to reexperience a previous rape. Later in my birth my Dr.performed a deep episiotomy after being told repeatedly that I did not want one Images and fears frommy past sexual abuse/assaults became constant in mymind after birth. (057) the whole experience was made worse as ittriggered my post traumatic stress that related to gangrape in my teens. (444)One woman felt that her birth experience was more traumatising than her experience of sexual abuse as a child: The most terrifying part of whole ordeal was beingheld down by 4 people and my genitals being touched

Reed et al. BMC Pregnancy and Childbirth (2017) 17:21and probed repeatedly without permission and no sayin the matter, this is called rape, except when you aregiving birth. My daughter’s birth was more sexuallytraumatising than the childhood abuse I’dexperienced (201)DiscussionThis study described women’s experiences of birthtrauma. The data set was large, and women recountedsimilar experiences across different birth settings andcultural contexts. The findings contribute to an understanding of birth trauma from the perspective of womenexperiencing it. Whilst non-interpersonal factors contributed to trauma, the majority of descriptions involvedcare provider actions and interactions. These findingsare consistent with other studies that identify the relationship between the care provider and the woman ascritical to the birth experience [20, 21, 37]. Whilst careproviders may consider their actions and interactions tobe routine, some woman experience them as traumatic[19]. Therefore, it is vital that care providers understandhow their practice influences the psychological and emotional experience of birth, in addition to the physicaloutcome of birth.In this study women described how care providerspriorised their own agendas over the needs of thewoman. This approach to practice is contrary to globalstandards regarding woman-centred maternity services[26, 38]. In addition, women felt that this resulted in unnecessary interventions, as care providers attempted toalter the birth process to fit their agenda. There is globalconcern regarding the increase in unnecessary medicalintervention during birth [39, 40]. Therefore, this phenomena needs to be further examined as a possible contributing factor. In some cases, women in the studydescribed how hospital staff observed or practiced onthem to facilitate their learning. Whilst clinical learningis an important element of professional development,further research is needed to examine women’s experience of participation in these activities.Women reported that their embodied knowledge aboutlabour onset, progress, and fetal wellbeing was disregardedin favour of their care provider’s clinical evaluation. Theclinical diagnosis of labour onset usually involves the assessment of contraction pattern and cervical dilatation [41].However, this evaluation can conflict with women’s ownperceptions regarding the onset of their labour [42, 43],causing distress [44–48]. Contradictory perceptions of progress can also occur during the expulsive phase of labourwhen women experience an uncontrollable urge to push[49]. Being instructed to resist the urge to push can be distressing for women [50, 51]. In this study, instructions tostop pushing were based on assumptions regarding normallabour timeframes, and on vaginal examinations. However,Page 7 of 10there is increasing debate in the literature regarding the accuracy of prescribed timeframes [52]; the efficacy of vaginalexaminations [53]; and how clinical assessments relate towomen’s experience of birth [49, 54, 55]. Whilst further research is necessary to examine women’s embodied knowledge of fetal wellbeing during labour, dismissal of women’sconcerns has been found to contribute to the experience oftrauma [56].Consent is an important legal and ethical principle inhealth care [57]. For consent to be valid it must be voluntarily and feely given; the person consenting must notbe under any undue influence or coercion; and theremust be no misrepresentation as to the nature or necessity of the procedure. However, women in the study described being lied to, and threatened in order to gaintheir agreement for procedures. In particular, lies andthreats centred on the wellbeing of the baby, and

Reed et al. BMC Pregnancy and Childbirth (2017) 17:21 DOI 10.1186/s12884-016-1197-0. the perception of trauma is in the ‘eye of the beholder’,and should be defined by the woman experiencing it. Qualit