Maternal mental health

RESEARCH ARTICLE Open Access

Women’s descriptions of childbirth trauma relating to care provider actions and interactions Rachel Reed1* , Rachael Sharman1 and Christian Inglis2

Abstract

Background: Many women experience psychological trauma during birth. A traumatic birth can impact on postnatal mental health and family relationships. It is important to understand how interpersonal factors influence women’s experience 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 the question ‘describe the birth trauma experience, and what you found traumatising’. Data relating to care provider actions 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 embodied knowledge’; ‘lies and threats’; and ‘violation’. Women felt that care providers prioritised their own agendas over the needs of the woman. This could result in unnecessary intervention as care providers attempted to alter the birth process to meet their own preferences. In some cases, women became learning resources for hospital staff to observe or practice on. Women’s own embodied knowledge about labour progress and fetal wellbeing was disregarded in favour of care provider’s clinical assessments. Care providers used lies and threats to coerce women into complying with procedures. In particular, these lies and threats related to the wellbeing of the baby. Women also described actions 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 is necessary to address interpersonal birth trauma on both a macro and micro level. Maternity service development and provision needs to be underpinned by a paradigm and framework that prioritises both the physical and emotional needs of women. Care providers require training and support to minimise interpersonal birth trauma.

Keywords: Childbirth, Trauma, Maternity care

Background Around one third of women experience trauma whilst giving birth [1, 2]. A traumatic birth experience is asso- ciated with postpartum mental health problems, includ- ing depression and post traumatic stress disorder [PTSD] [1, 3–6]. Poor mental health in the postnatal period can alter a woman’s sense of self, and disrupt family relationships [7–10]. Difficulties with early mother-baby bonding can negatively influence a child’s social, emotional and mental development [11]. In

addition, the experience of a traumatic birth can influ- ence 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 repeating a traumatic hospital experience [14]. Jackson et al. [15] found that the decision to freebirth (give birth without a professional care provider) can be influenced by previous birth traumatic. Therefore, the consequences of a trau- matic birth experience can be substantial and wide- ranging for women and their families. Birth trauma has been associated with medical interven-

tion and type of birth [5, 16, 17]. It has been defined as a perception of ‘actual or threatened injury or death to the mother or her baby’ [18]. However, Beck [19] argues that

* Correspondence: [email protected] 1University of the Sunshine Coast, 90 Sippy Downs Drive, Sippy Downs, QLD 4556, Australia Full list of author information is available at the end of the article

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

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. Qualita- tive studies exploring women’s experiences of traumatic birth identify interactions with care providers as a more im- portant factor than medical intervention or type of birth [20–23]. For example, a perceived lack of control and in- volvement in decision-making can contribute to the experi- ence of trauma [21, 23]. A study by Thomson and Downe [20] found that trauma was related to ‘fractured interper- sonal relationships with caregivers’, and that women felt dis- connected, helpless and isolated during birth. Whilst not all traumatic birth experiences result in PTSD, two quantita- tive meta-analyses identified that negative care provider in- teractions are a significant risk factor for PTSD [5, 17]. A study by Harris and Ayers [24] also found that the strongest predictor of developing birth related PTSD was interper- sonal difficulties with care providers, in particular experien- cing a lack of support. A recent Cochrane Review [25] concluded that women

require improved emotional support during birth from their care providers to reduce the risk trauma. Health care professionals have an ethical, legal and professional obliga- tion to provide safe and respectful care [26–28]. In order to improve care, it is important to understand what interac- tions and actions are associated with trauma [20]. This paper focuses on traumatic care provider actions and inter- actions from the perspective of the women experiencing them. The findings contribute to the body of literature examining women’s experiences of traumatic birth; and to an understanding of how care providers influence women’s perceptions of trauma. This paper presents a subset of find- ings from a large mixed methods study that investigated parental mental health following traumatic birth. The quan- titative findings have not yet been published. The qualita- tive findings concerning paternal mental health are reported elsewhere [29]. This paper presents the qualitative findings relating to women’s descriptions of birth trauma involving care provider actions and interactions.

Methods The mixed methods study involved parents completing an online survey, and additional face-to-face interviews with fathers [29]. The online survey included questions on demographics, descriptive birth assessments, parent- infant attachment, partner relationship quality, current mental health, and coping strategies used after the trauma. In addition, the survey incorporated a question about the experience of birth trauma with space for a written response. A qualitative approach was taken to explore women’s written descriptions of trauma. The area of interest in this aspect of the study was women’s experiences of trauma, rather than outcomes associated with trauma. The majority of qualitative data related to

care provider actions and interactions, and this paper presents themes relating to this data.

Participant recruitment Participants were recruited via online social media forums such as Facebook, Twitter and a midwife’s blog site. Inclu- sion criteria was that participants were over 18 and had experienced a traumatic birth. A definition of a traumatic birth was not provided in order to capture what partici- pants themselves considered’trauma’ [19]. There was no exclusion criterion for time since the birth, as women’s memories of childbirth remain strong over time [30]. Par- ticipant information detailing the research question and aims was provided on the first page of the online survey. In order to obtain consent, participants were required to read an online consent form and ‘click’ agree prior to accessing the survey.

Data collection After consenting to participate, participants completed an online survey administered through the program Survey Monkey. The survey included demographics (eg. age, rela- tionship 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). The quantitative element of the study comprised of a number of psychological assessment tools: Maternal Postnatal Attach- ment [31]; Quality of Marriage Index [32]; Depression Anx- iety Stress Scale-21 [33]; Posttraumatic Stress Disorder Checklist-5 [34]; and The Brief Cope index [35]. The quali- tative element of the study involved women responding in their own words to the question ‘describe the birth trauma experience, and what you found traumatising’. The mean length of written responses was 69 words.

Data analysis Women’s descriptions of trauma were analysed using a six-phase inductive thematic analysis process described by Braun and Clarke [36]. Phase one involved becoming familiar with the data by reading and re-reading; and noting initial ideas. In phase two initial codes were gen- erated and data relevant to each code was collated. Phase three of the process involved collating the codes into potential themes. These themes were reviewed in phase four to ensure they were consistent in the coded extracts and across the entire data set. In phase five themes were defined and named using words and phrases. Phase six involved selecting extract examples to illustrate the themes, and relating the analysis to the re- search question and the literature. Three researchers participated in the thematic analysis process to ensure consistency in analysis and findings.

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Findings A total of 943 women completed the online survey from around the world. The majority of participants were from Australia and Oceania (36.8%), North America (34.2%) and Europe (25.5%). A small number of partici- pants 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 hos- pital (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 their baby was admitted to special care nursery. Of the 943 participants, 748 (79%) responded to the

qualitative question ‘describe the birth trauma and what you found traumatising’. A third of respondents de- scribed events such as premature labour, haemorrhage or concerns regarding their baby’s wellbeing. However, the majority (66.7%) described care provider actions and interactions as the traumatic element in their experience. From the data relating to interpersonal factors, four overarching themes were identified from the descrip- tions. The themes are presented below with illustrative data using the participants’ own words, therefore spell- ing and grammar varies. The term ‘care provider’ is used to refer to the professional responsible for the woman’s care. In the women’s accounts care providers included obstetricians, midwives and nurses.

Prioritising the care provider’s agenda Women described how care providers prioritised their own agenda over the needs of the woman. In some cases it was made clear to women that their labour was keep- ing the care provider from something, or someplace they would rather be:

I found my OB’s lip service to my wishes and then his switch against them traumatic. I found the comment “let’s get this over and done with, I have a golf game to get to” traumatic… (045)

… after an OB coming in and telling me that she would like me to deliver by 5 pm because she wanted to go home, I just burst in to tears… (549) Women felt that they were subjected to unnecessary

and unwanted medical interventions in order to meet the needs of their care providers:

Table 1 Demographics and type of birth

Age

Range = 18 to 77 years (Mean = 33.13)

N (%)

Marital status

Married 798 (77.5%)

De Facto 124 (12.5%)

Single 42 (4.1%)

Divorced 21 (2%)

Separated 23 (2.2%)

In a relationship but not living together 11 (1.2%)

Widowed 2 (0.2%)

Engaged 4 (0.3%)

Number of children

0 7 (0.7%)

1 409 (39.4%)

2 345 (34%)

3 159 (15.3%)

4 70 (6.8%)

5 23 (2.2%)

> 5 17 (1.5%)

Region of origin

Australia and Oceania 386 (36.8%)

North America 347 (34.2%)

Europe 253 (25.5%)

South America 23 (2.1%)

Asia 8 (0.9%)

South Africa 7 (0.5%)

Middle East 2 (0.2%)

Education

Did not finish high school 14 (1.4%)

Finished high school 196 (19.1%)

Trade or technical qualification 157 (14.1%)

Undergraduate degree 395 (39.1%)

Postgraduate degree 264 (26.4%)

Type of birth

Unassisted vaginal birth 271 (34.3%)

Assisted vaginal birth (ventouse or forceps) 176 (22.4%)

Planned caesarean 47 (6%)

Unplanned caesarean 290 (37%)

Place of birth / transfer

Public hospital 542 (69%)

Private hospital 115 (14.6%)

Birth centre 12 (1.5%)

Planned birth centre transfer to hospital 23 (2.9%)

Homebirth 29 (3.7%)

Table 1 Demographics and type of birth (Continued)

Planned homebirth transfer to hospital 63 (8%)

Unplanned out of hospital birth 1 (0.1%)

Admission of baby to special care nursery

Yes 269 (34.4%)

No 512 (65.6%)

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I begged not to have a c section, neither I nor my baby were in distress or danger, but because the doctor was ready to go home, he did a terrible section that resulted in almost a year of recovery. (220)

I was steamrolled with unnecessary intervention and didn’t get to speak with a doctor about my options, risks vs benefits… I feel like the nurses, doctors and hospital only did what was in their best interest, not mine… It was a nightmare. (381) Some women described how they became a learning

resource for the benefit of hospital staff. For example, care providers offered other staff the opportunity to practice without seeking women’s permission:

… the doctor asked a student nurse, first day on the job, if she wanted to suture my episiotomy incision. (644)

… 20 people in theatre and half were sitting down on phones and chatting away while I had someone training with forceps on me… (867) One woman described feeling like she “… was part of

an experiment” (565) rather than a woman giving birth. In particular, women experiencing unusual births be- came a spectacle for others to watch:

… I was a looking point for students and anyone who hoped to witness a twin vaginal birth and a breech birth. (523)

One woman wrote about how the room filled with staff hoping to watch her give birth to her breech baby:

… and the amount of people that filled the room to watch a vaginal breech delivery, when I failed at this, everyone left. (662)

When she was unable to provide this learning oppor- tunity she no longer warranted being an object of obser- vation. The value of her birth experience for others appeared to be based on what she could provide in terms of a learning experience.

Disregarding embodied knowledge Many of the descriptions involved women’s own em- bodied knowledge being disregarded in favour of their care provider’s assessment of events:

… I felt like I was being told I was silly for thinking I was in labour and that this awful pain was nothing to be worried about. My opinion was dismissed and ignored as I was just a first timer… (436)

In particular ‘being in labour’ was a contested area. Women’s perceptions of being in labour were based on their embodied experience, whereas care provider’s per- ceptions were based on clinical findings. For example, one woman was considered to ‘not be in labour’ because her cervix was not dilating according to care provider’s expectations:

Hospital staff did not listen to me, didn’t trust me to know my body. Dismissed me as a first time mother who was over reacting. In actual fact I dilated from 0 to 6 in just over an hour. The hospital midwives told me that I was just feeling the period pain associated with early labour and induction… (485)

Another woman described how her midwife deter- mined she was not contracting, therefore not in labour, based on an abdominal palpation:

Was going into premature labour and midwife palpated during a contraction and stated I was not having them. Eventually went into labour as they ignored me… Although not traumatic in medical terms, felt completely disgruntled that my journey was not taken on own merits and was completely ignored as a woman during labour. (061)

Both of these women considered themselves to be in labour, and having their embodied knowledge disre- garded was traumatic. Embodied knowledge was also dismissed when women

experienced an urge to push before care providers con- sidered it appropriate. Women were instructed to ignore what was happening in their body and stop pushing:

Told to stop pushing and… being told what to do when my body was telling me differently. (248)

Being told to stop pushing when baby was clearly on its way. Being told I had a long way to go when baby was on the way out. (436) Care providers used clinical assessments (vaginal exami-

nations) to determine whether pushing was appropriate. Based on the findings of these clinical assessments women were ordered to over-ride their own bodily urges:

… I had the strongest urge to push, the midwife on staff insisted on an internal examination to check dilation, she told me if I pushed now I would end up with an emergency caesarean due to my cervix swelling. She then spent the next hour yelling at me not to push and trying to talk me into an epidural (I was trying my hardest to not push but my body kept taking over). I was begging to be allowed to push…. (932)

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In some cases women described feeling that the wellbeing of their baby was in danger. When they attempted to alert care providers their embodied knowledge was disregarded:

… I felt like everything was going wrong and found that distressing. I felt like people didn’t believe me when I said something didn’t feel right. (851)

… My baby was in distress and had mec liquor and in all honesty probably should’ve been sectioned, at this stage I was begging for one as I knew something was wrong with my baby but they refused… (732) In these descriptions women’s own assessment of

labour progress and fetal wellbeing was not valued or acted on which caused trauma.

Lies and threats Women perceived that they were being lied to by care providers to coerce them into agreeing to unnecessary interventions:

It was not the birth itself that I found traumatic, rather the way we were treated by the midwife. Being lied to in order to speed up my labour unnecessarily and putting me and my baby at risk. (015)

All of this is avoidable and unnecessary, if only we had known… I was forced into interventions that I believed were unnecessary. I was also lied to many times by the doctors. (857) They also described how care providers threatened them

in order to coerce them into undergoing procedures:

My daughter was breech… I was told that if I didn’t consent to the cesarean before labor started then they would perform a cesarean without my consent under general anesthesia when I arrived (267).

In this case, the woman was threatened with surgery against her wishes. Other women were threatened with having their baby taken from them if they did not com- ply with proposed interventions:

Psychological coercion - ie “if you do not consent to syntocin OR a c-section then we can get our friend the psych registrar down here to section you - then we can do whatever we want to you but you may not be able to keep your baby” - All I wanted was to let my body go into labour naturally - my baby was not in distress… (186)

I was bullied into an induction late on a Sunday night and then told I would be kept over night. I wasn’t aware when I finally agreed to be induced after quite

some time of being threatened with DoCS [Department of Child Safety] etc. (400) The most common threats described by women re-

lated to the wellbeing of the baby. Some women used the term ‘dead baby threat’ to describe how they were coerced, for example: “dead baby threats to gain con- sent…” (860); and “forced into c section with dead baby threat…” (223). Some care providers asked women if they wanted their baby to die when they declined an intervention:

…Being bullied into interventions with such wording the following: “Do you want a dead baby?”… (919)

Women felt that care providers were lying about the risks to the baby in order to pressure them into comply- ing. They did not believe their babies were in danger, and in some cases had evidence that their care provider’s assessment was incorrect:

…I was basically told that if I didn’t have a c-section on their timetable I would kill my baby, even though they couldn’t tell me what exactly was “wrong” as to why I was not delivering vaginally… They broke me down gradually until they declared my baby was “in distress” (she wasn’t… I could see the screens). (559)

… Lots of coercion and being told my baby would die if I didn’t consent to the c-section. She was born with apgars of 9 and 9. (194) Being lied to and threatened contributed to the experi-

ence of trauma, particularly when it involved the well- being of the baby.

Violation Many women described their birth experience as ‘violat- ing’. A lack of control appeared to be associated with a sense of violation. For example, one woman described that she felt “…out of control and violated” (660). In these descriptions, care providers carried out actions against the explicit wishes of the woman:

…All in all, I felt very bullied, and even violated… It was the feeling of disempowerment and not having the right to do with my body what I wished - and that someone else could force me to do something against my will. (731)

I felt violated, and angry that I should have to defend myself and my body while I was trying to push my baby out. (733) The descriptions of what care providers did to women

were, in many cases, graphic and violent. For example, one woman wrote “…couldn’t be tubed nurses manually choked

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me out” (490). Another wrote that she was “… assaulted va- ginally by medical staff during crowning” (295). These de- scriptions focused on the manner in which the care provider acted, in addition to their actions:

… She was very rude and condescending, both to myself and to my midwife. She proceeded to dig out my uterus without any numbing medication. It was horrifying… (431)

…The pain was not the traumatic bit, it was the way that I was treated during my labour. I was 20 years old. I had more midwives than I can count, attempt an internal examination and one yelled at me to ‘relax!’ because she couldn’t force her fingers in. She was a bloody bitch to put it lightly. (256) One woman described how her obstetrician assaulted

her to gain her compliance to induce labour:

She said she wanted to do one more cervical check. I consented and when she did it, she grabbed my cervix and pinched it. She would not let go until I consented to letting her break my water. I was in tears from the pain, screaming, begging and sobbing for her to let go and get her hand out of my vagina. She would not let go until I consented, which I finally did. (997)

A number of women described how they screamed ‘no’ as care providers carried out procedures. For ex- ample, 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 exam- ination telling her that they “would be very gentle and would stop if it was too much”. However her wishes were not respected during the examination:

I was crying and screaming in pain telling her no and to stop and she carried on, my husband shouted at her to leave me alone and she carried on. (413)

Another woman described how her doctor failed to respond to direct requests, and then to screams for her to stop:

The doctor would not get her fingers out of my vagina even when directly told. After it was discovered that I suffered tearing, I wanted the tearing to be healed on its own - no stitches, but she and another doctor stitched anyway, despite my screaming at them to stop. (445)

In addition, some women wrote about being ‘held down’ while care providers carried out procedures against their will:

…Being pinned down by 4 midwives (forcing an unnecessary oxygen mask on me just so my screams of ‘no’ were muffled) and my husband so the consultant could examine me against my will. (888)

…At one point, 3 nurses physically held me down despite my protests that I couldn't breathe and needed a minute to catch my breath before the procedure (AROM). They held me down until the doctor was finished… (491) Women described how equipment tethered or tied them

to the bed during labour: “was tethered to the bed during an induction…” (328), and “I was tied to the bed, forced to lay on my back…” (418). Women experienced being forced into birth positions: “screaming, lots of people, nurses for- cing me down and ripping my legs open…” (565). In par- ticular, care providers made women lie on their backs:

During birth, multiple nurses screamed in my face “PUSH!!!” and flipped me onto my back and forced my legs open, holding me down… (414)

In describing their experiences women used words such as “humiliating” (561); “belittled” (520); “brutal and barbaric” (132). Some described “being treated like a piece of meat” (979), or an animal:

…I was treated like a cow having trouble calving, and felt abused and humiliated. (222)

A number of women used language associated with sexual assault and rape, writing that they felt: “…raped and mutilated” (376), “… violated and damaged” (119), “…violated and scared and disgusting” (423). Women who had previously experienced sexual abuse or rape de- scribed how the actions of care providers triggered dis- tressing memories:

…my cervix was manually dilated forcefully after pleading for the Dr. to stop. This caused me to re- experience a previous rape. Later in my birth my Dr. performed a deep episiotomy after being told repeat- edly that I did not want one… Images and fears from my past sexual abuse/assaults became constant in my mind after birth. (057)

…the whole experience was made worse as it triggered my post traumatic stress that related to gang rape in my teens. (444) One woman felt that her birth experience was more trau-

matising than her experience of sexual abuse as a child:

…The most terrifying part of whole ordeal was being held down by 4 people and my genitals being touched

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and probed repeatedly without permission and no say in the matter, this is called rape, except when you are giving birth. My daughter’s birth was more sexually traumatising than the childhood abuse I’d experienced… (201)

Discussion This study described women’s experiences of birth trauma. The data set was large, and women recounted similar experiences across different birth settings and cultural contexts. The findings contribute to an under- standing of birth trauma from the perspective of women experiencing it. Whilst non-interpersonal factors con- tributed to trauma, the majority of descriptions involved care provider actions and interactions. These findings are consistent with other studies that identify the rela- tionship between the care provider and the woman as critical to the birth experience [20, 21, 37]. Whilst care providers may consider their actions and interactions to be routine, some woman experience them as traumatic [19]. Therefore, it is vital that care providers understand how their practice influences the psychological and emo- tional experience of birth, in addition to the physical outcome of birth. In this study women described how care providers

priorised their own agendas over the needs of the woman. This approach to practice is contrary to global standards regarding woman-centred maternity services [26, 38]. In addition, women felt that this resulted in un- necessary interventions, as care providers attempted to alter the birth process to fit their agenda. There is global concern regarding the increase in unnecessary medical intervention during birth [39, 40]. Therefore, this phe- nomena needs to be further examined as a possible con- tributing factor. In some cases, women in the study described how hospital staff observed or practiced on them to facilitate their learning. Whilst clinical learning is an important element of professional development, further research is needed to examine women’s experi- ence of participation in these activities. Women reported that their embodied knowledge about

labour onset, progress, and fetal wellbeing was disregarded in favour of their care provider’s clinical evaluation. The clinical diagnosis of labour onset usually involves the as- sessment of contraction pattern and cervical dilatation [41]. However, this evaluation can conflict with women’s own perceptions regarding the onset of their labour [42, 43], causing distress [44–48]. Contradictory perceptions of pro- gress can also occur during the expulsive phase of labour when women experience an uncontrollable urge to push [49]. Being instructed to resist the urge to push can be dis- tressing for women [50, 51]. In this study, instructions to stop pushing were based on assumptions regarding normal labour timeframes, and on vaginal examinations. However,

there is increasing debate in the literature regarding the ac- curacy of prescribed timeframes [52]; the efficacy of vaginal examinations [53]; and how clinical assessments relate to women’s experience of birth [49, 54, 55]. Whilst further re- search is necessary to examine women’s embodied know- ledge of fetal wellbeing during labour, dismissal of women’s concerns has been found to contribute to the experience of trauma [56]. Consent is an important legal and ethical principle in

health care [57]. For consent to be valid it must be vol- untarily and feely given; the person consenting must not be under any undue influence or coercion; and there must be no misrepresentation as to the nature or neces- sity of the procedure. However, women in the study de- scribed being lied to, and threatened in order to gain their agreement for procedures. In particular, lies and threats centred on the wellbeing of the baby, and some women referred to this as ‘the dead baby threat’. Bohren et al. [56] also found that care providers threatened women regarding the safety of their baby in order to en- sure they complied during labour. In addition, women in this study were threatened with being reported to child safety services if they did not agree to proposed proce- dures. Other studies have identified that women choos- ing birth options outside of the norm, such as freebirth, or homebirth after a caesarean, can experience threats relating to the safety of their baby, and of being reported to child safety agencies [13, 58]. Women’s accounts of birth trauma often included vio-

lence and physical abuse. Unfortunately these findings are not unique, and the World Health Organization [38] reports that many women worldwide experience disres- pectful, abusive or neglectful treatment within maternity services. This phenomena has resulted in the introduc- tion of the legal term ‘obstetric violence’ in some coun- tries [59]. Women in the study used language associated with sexual assault and rape. Beck [19] also found that women likened the actions of care providers to rape; and Elmir et al. [21] noted that women used the term ‘birth rape’ to describe experiences of obstetric violence. Kitzinger [60] suggests that women who experience a traumatic birth display similar symptoms to rape survi- vors. In addition, women who have a history of sexual abuse or rape can have memories triggered by their care provider’s actions and interactions [19]. Montgomery et al. [61] carried out a study exploring the experience of birth for women with a history of childhood sexual abuse. They found it was not the intimate procedures themselves that triggered abuse memories. Instead, it was the manner in which the procedures were carried out. Actions and words that reduced a woman’s sense of control, and disempowered her could result in a ‘re-en- actment of abuse’. These findings are consistent with this study, whereby descriptions of trauma focused on

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the manner in which actions were carried out, rather than on the physical procedures themselves. A systematic review concluded that whilst the mis-

treatment of women in labour occurs at the level of care provider interactions, it is influenced by system- atic failures at the health facility and health system level [56]. Current health systems are underpinned by a technocratic, biomedical paradigm in which the pa- tient is considered passive, and authority and respon- sibility are inherent in the practitioner [62]. The power dynamics operating within this paradigm con- tribute to legitimising the control that care providers have over women, and subsequently to mistreatment [56]. Risk aversion and the avoidance of litigation is also a key component that influences care provider’s practice within the current technocratic maternity system [63–65]. However, concerns about litigation focus on perceived risks to physical outcomes for mothers and babies, rather than on psychosocial im- pacts of care [63–65]. Wagner [66] argues that dehumanising practices are

so pervasive within maternity services, that care pro- viders are unable to perceive them. He uses the ana- logy of fish being unable to see the water they swim in, to describe this phenomenon. This notion is sup- ported by Bohern et al.’s [56] review that found some care providers consider the mistreatment of women to be normal. However, some care providers are cog- nisant of the paradigm in which they operate. In par- ticular, research has demonstrated that midwives are often aware of an inherent conflict between woman- centred care, and the needs of the technocratic ma- ternity system [67–69]. Midwives consciously adjust their practice to meet the cultural needs of the facil- ities in which they work in order to protect them- selves professionally [67–69]. However, this results in what Hunter calls ‘emotional work’, as midwives prac- tice in ways that are contradictory to their own woman-centred philosophy [68]. In addition, a recent study [70] found that midwives who witness interper- sonal birth trauma can experience trauma themselves. The researchers suggest that witnessing this type of trauma may be perceived as a threat to their sense of personal and professional integrity. Addressing interpersonal related birth trauma will

require a multifold response on both a macro and micro level. Davis-Floyd [62] suggests that more ef- fective woman-centred care can be delivered by com- bining humanism and holism with the current technocratic approach. However, this will require a cultural paradigm shift to support the evolution of such an approach. The World Health Organization recommends that five key actions should be taken to develop and sustain respectful maternity care for all

women [38]. Firstly, greater support from govern- ments and development partners for research and ac- tion on disrespect and abuse. Secondly, initiation and support of programs designed to improve the quality of maternal health care, with a strong focus on re- spectful care as an essential component of quality care. Thirdly, emphasising the rights of women to dignified, respectful care throughout their childbearing experience. Fourthly, the generation of data relating to respectful and disrespectful care practices, systems of accountability and meaningful professional support. Finally, the involvement of all stakeholders, including women, in efforts to improve quality care and elimin- ate disrespectful and abusive practices. In addition, it can be argued that the current risk discourse needs to be expanded to include psychosocial risk in addition to physical risk. On a micro level, Fenech and Thomson [7] suggest that care providers require training to develop their ability to prevent and iden- tify trauma, and to respond sensitively to women’s emotional concerns.

Limitations The study was a cross-sectional qualitative study, there- fore cannot establish cause and effect. There was a lack of representation across many countries with partici- pants mainly from Australia and Oceania, North America, and Europe, and findings cannot be generalised globally. In addition, the data consisted of short written descriptions within a larger quantitative survey. In-depth qualitative accounts elicited by participant interviews may have enriched theme development.

Conclusion In this study women’s descriptions of childbirth trauma centred on the actions and interactions of care pro- viders. Women described how care providers prioritised their own agendas; disregarded embodied knowledge; used lies and threats to gain compliance; and violated them. Findings contribute to the growing body of litera- ture relating to women’s experiences of traumatic birth. Interpersonal birth trauma is becoming increasingly recognised as a global issue, and measures are required to address it. Recommendations include changing the current technocratic paradigm by including holistic and humanistic approaches to care delivery. Maternity ser- vice provision needs to be underpinned by the World Health Organization’s ‘five actions’ [38] to develop, pro- mote and sustain respectful woman-centred care. Care providers require training and support to understand, value, and practice in ways that optimise psychological outcomes for women.

Reed et al. BMC Pregnancy and Childbirth (2017) 17:21 Page 8 of 10

Abbreviations PTSD: Post traumatic stress disorder

Acknowledgements The women who shared their experiences in the study. Jessie Johnson-Cash (Lecturer) who assisted with the data analysis.

Funding No funding was received for this study.

Availability of data and materials Not applicable – data presented in article.

Authors’ contributions The contribution to authorship is as follows: CI designed the study and collected data supervised by RS and RR as part of an Honours study, and reviewed the analysis and the paper. RR analysed the data and drafted the initial paper. RS analysed the data and contributed to writing the paper. All authors read and approved the final manuscript.

Competing interests The authors declare that they have no competing interests.

Consent for publication Not applicable.

Ethics approval and consent to participate Ethical approval for the study was gained via the University of the Sunshine Coast Human Research Ethics Committee (USC Ethics Approval No. S/14/ 590). The consent form in the online survey included information and contact details for support groups, and mental health professionals. Data were de-identifed at the point of the online survey and participants were allocated a code.

Author details 1University of the Sunshine Coast, 90 Sippy Downs Drive, Sippy Downs, QLD 4556, Australia. 2The University of Notre Dame, 160 Oxford St, Sydney, NSW 2010, Australia.

Received: 12 March 2016 Accepted: 13 December 2016

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