IBONE OLZA FERNANDEZ.M.D, Ph.D.

25th October 2014

13th Conference of the Federation of Spanish Midwifery Associations

Subjectivity of trauma

Balance of expectations and reality

Cultural and transcultural aspects

Perception of own birth varies with time

No consistent definition of traumatic birth and no sistematized way of measuring trauma (Elmir 2010)

Birth trauma: "injury or threat of injury or death for mother or baby in childbirth" (Beck 2008)

Women may consider their experience traumatic as a result of the interventions, the type of birth or the way they were treated (Allen 1998)

Even women who underwent an apparently normal birth (without interventions) may feel it as traumatic (Thompson 2008)

Childbirth may be stressful enough to cause PTSD(posttraumatic stress disorder).

1.5-6% women are estimated to suffer from postpartum PTSD.

Risk factors include: primiparous woman, prematurity, highlevel of obstetric intervention, Cesarean section, separationfrom newborn, perception of inadequate care or even abuse

PTSD due to childbirth involves an enormous psychologicalsuffering and affects the relationship of the mother with herbaby, her partner, her family and healthcare providers. Itssymptoms differ from those of postpartum depression,although some mothers suffer from both.

Symptoms may last for months or years

Bailham, 2003.

Amanda Greavette

Constantly remember and relive their traumaticexperience with flashbacks and nightmares (forweeks or months).

They feel disconnected or far from their babies andabsent from reality, as if they were not there or as ifthey were not the same person.

https://birthcut.wordpress.com/

The trauma makes women try to find an explanation to whathappened to them and constantly talking about it. They alsoobsessively search for obstetric information.

They feel angry with the healthcare professionals, their own familiesand themselves. They have symptoms of anxiety and depression.

Their experience of maternity is seriously affected. They often feeldetached from their children.

They have many difficulties to relate to other mothers, as they cannothelp compare their childbirth experience with theirs.

PTSD may trigger a rejection to sexuality, to having more children orto the decision of choosing a programmed C-section next time

Beck, 2004.

An apparently normal birth can quickly get complicated.

The individual perception of danger is key to the further development of PTSD.

There is no dose-dependent relationship between the seriousness of the circumstances and the

degree of the consequent PTSD.

Perceiving a lack of support is a risk factor for PTSD

Olde 2006

Total absence of care and communication increases feelings of helplessness, fear and horror.

BECK 2006.

... I perfectly recall the fear from overhearing

The level of obstetric intervention experienced during labour

and the perception of an inadequate intrapartum care were

consistently associated to the development of acute trauma

symptom.

Amanda Greavette

Leinweber & Rowe 2008

High level of reciprocity, even beyond empathy

High identification

Midwife's implication allows the woman to share her experience (Kennedy 2004)

Midwife must be open, ready for the woman's experience to affect her personally. Spirituality in midwifery = reciprocal relationship (Pembroke)

Lundgren 2002 (after interviewing Swedish midwives): need for identification with women and their experience of pain. Excess of empathy risk?

Frequent conflict for hospital midwives between "being with the woman" and "being with the institution" (Hunter 2004): frustration, helplessness, feeling of hurting women.(Kennedy, 2004 )

"IT IS THE MIDWIFE'S EMOTIONAL AVAILABILITY WHAT ENCOURAGES THE WOMAN TO LET HERSELF GO"

Amanda Greavette

Feeling helpless and out of control

Felt angry and powerless

Felt powerless because person in authority was causing unnecessary trauma

Felt frustrated and angry at physician for not listening

Why didn't physician listen to me?

Amanda Greavette

Did I do anything wrong?

Did I miss something?

Did I do everything I should have?

Could I have prevented this?

What could have been done differently?

Feel like I failed my patient

I let my patient down

I should have tried to stop the physician

My patient was counting on me to protect her

Nurses frequently used phrases such as “the physician violated her,” “a perfectdelivery turned violent,” “unnecessary roughness with her perineum,” “felt like anaccomplice to a crime.”

A description of the L&D of a grand multipara provided by one nurse illustratesthat risk factor: “The doctor treated her like a piece of dirt. After the birth of thebaby he proceeded to put his hand inside her practically halfway up his arm tostart pulling the placenta out. She screamed ‘something is not right. It never hurtlike this before.’

I felt like I was watching a rape.”

Beck 2012

This nurse admitted that one of her most traumatic births involved a 15-year-old who wanted a drug and epidural free birth:

She was petrified of everything, cried easily, and spent most of the time screaming.During the delivery the MD was very rough with her perineum and said she wasn’tpushing extremely effectively. After two pushes the MD cut a huge episiotomy andthe patient felt it. She screamed in a manner that will always give me chills. TheMD said, “This is what happens when you don’t get an epidural.” The young motherstarted crying. It was terrible. He traumatized her and assaulted her. That screamand the MD’s comment will always haunt me

The patient was wonderful, intelligent, and cooperative. She was easy to coach. Af-ter several hours in labor with good, normal progress, the doctor checked her. I wassur- prised when he said she was ready to go back to the delivery room. Once in theDR he checked her again and told her to start pushing, but he checked her soroughly she was unable to push because she started screaming. I figured out thatshe was only 6 cm dilated and he was trying to manually dilate her with eachcontraction. My only clear memory is that this beautiful, intelligent, cooperativewoman turned into a screaming, mindless animal under his torture. I’ve never feltso powerless, helpless, or useless in my life. I really feel that I failed her. She wascounting on me to help her and I let that man torture her. I feel as sick to mystomach thinking about it today as I did 40 years ago when it was fresh."

The Venezuelan law defines obstetricviolence as:

"the appropriation of the body andreproductive processes of women byhealth personnel, which isexpressed as dehumanizedtreatment, an abuse of medication,and to convert the natural processesinto pathological ones, bringing withit loss of autonomy and the ability todecide freely about their bodies andsexuality, negatively impacting thequality of life of women.”

According to article 51 of the Venezuelan law, "the following acts executed by healthcare providers are considered obstetric violence:

1. Untimely and ineffective attention of obstetric emergencies;

2. Forcing the woman to give birth in a supine position, with legs raised, when the necessary means to perform a vertical delivery are available;

3. Impeding early attachment of the child with his/her mother without a medical cause thus preventing the early attachment and blocking the possibility of holding, nursing or breast-feeding immediately after birth;

4. Altering the natural process of low-risk delivery by using acceleration techniques, without obtaining voluntary, expressed and informed consent of the woman;

5. Performing delivery via cesarean section, when natural childbirth is possible, without obtaining voluntary, expressed, and informed consent from the woman."

She criesHe smiles and says it will be nothingShe is naked, feels fragile and vulnerableHe puts his hand inside her despite her negativeHe doesn't listen to herHe goes on while she criesIt hurtsShe asks him not to touch herto leave her aloneto take his hand out of her vaginaShe begs himHe doesn't listen and tells her to be quietThen another person comes in and repeats the actionAnd then another one...They finishThey leave her on her ownShe criesIt is not rapeShe is in labourIs it not rape?

Clara.

From: http://www.elpartoesnuestro.es/blog/2011/01/11/en-mi-pueblo-se-llama-violacion

Obstetric violence report form of the

Argentinian Ministry of Justice and Human Rights

Researching knowledge of the concept of obstetric violence among birth professionals

Studying in depth how obstetric violence praxis are taught and transmitted

Investigating the impact of obstetric violence in the career of birth professionals

Investigating the impact of obstetric violence in the personal life and in the mental health of such professionals

Detecting possible strategies and factors which may the encourage eradication of obstetric violence

Pilot study: online questionnaire, self-administered, 11 items, anonymous "Obstetric violence survey for professionals“

Later quantitative and qualitative inquiry among professionals of the Madrid region. 74 questionnaires answered: 69 women, 5 men. Profession:63 midwives6 Midwifery students1 gynaecologist1 auxiliary nurse in the delivery room2 nurses in the delivery room2 others

Average age: 37.7 years old (23-67) Average experience: 11.4 years

Preliminary findings

Have you witnessed obstetric violence in your training?94% yes

During your training: do you feel you were taught to execute or be an accomplice to obstetric violence?80% yes

In your work in the delivery room: have you felt compelled or pressured to execute actions you considered violent?78% yes

Women that are sedated just to be quiet and not a bother, births which areinstrumentalised so that the student practices, shouts at women telling them thatthey are doing it wrong or that they are going to kill their babies..

Unnecessary vaginal explorations, Ph measurement for statistics, unnecessaryforceps because it was dinner time.

Performing a C-section for the only reason of finishing at a certain time.

Sentences such as: “Do not explain so much to women… The less they know, thebetter. Some midwives do not know how to make women give birth”.

They teach us we have to protect each other, so if we see a case of violence, wealways excuse ourselves saying that what happened is the right thing and wenever tell the woman the truth or support her.

Denying women water or getting up and walking. Doing an episiotomy becausethe midwife says so, but there is no indication for it.

Putting a hand on a woman´s mouth so that she doesn´t yell.

A midwife told me once: “You have to dominate childbirth, otherwise the womanloses control”.

Accusing the woman of not knowing how to give birth. Telling her she is not ableto push. Refusing to give her an epidural because when they offered it to her, shesaid no (it was possible to administer it, but the specialist refused to do it).

Women who are explored by up to 6 different people and with no privacy duringthe procedure. Births with over 15 people in the delivery room, each one doingone´s thing, paying no attention to the woman, except to her perineum and hervagina. Kristeller manoeuvres that make me shiver. Episiotomies: random, bigand inappropriate (without making the perineum convex in most occasions).

I have had depression symptoms and have left the deliveryroom crying due to the trauma. A gynaecologist slappedme when I gently and politely touched his arm and lookedinto his eyes to ask her to stop doing a terrible minutes-long Kristeller manoeuvre on a woman in labour. She keptasking him to stop and he went on and on. It looked likerape. I still feel like crying and have nightmares.

I came home crying many times and dreaming of births I had seen. Above all, I have felt deep guilt for having been an indirect accomplice of such violence.

Thinking that many of the complications that happen in labour are our fault. And I know I am right, because more births get complicated due to the unnecessary actions we do.

At first: awful, helpless, clueless, weak… Later: empowered, growing, waking up… In the right way.

Midwife training was the period of my life I have cried the most, too often because I felt like an accomplice of violence..

It made me look for other ways of care and alternatives outside hospitals. I nowattend homebirths.

I am tired of fighting. It was hard being the black sheep, I have suffered mobbing.But the worst part was hearing “We will not stop until we fire him with a kick inthe ass”. Besides women don´t fight for this or see the effort I make for them. I feelfrustrated.

This has simply pushed me to escape from a system I do not believe in.

I left the delivery room and told Human resources that by the end of the month Iwouldn´t work in that hospital any more.

I had to get out. Terrible relationship with the gynaecologists.

I quit working as a midwife.

Lack of motivation, feelings of guilt.

Helplessness, deep sadness.

Aggressivity.

Pressure and constant mobbing until I started working at a different hospital.

I stopped working at a hospital. I didn´t want to be an accomplice

I think it has been a painful process, but today I can admit that the conflicts a

part of me guided have revealed the pain disguised as fake power that my work as

a midwife hid. I have discovered the self-deception believing that as a midwife I

was some sort of saviour… arrogance towards life and death… Seeing such deceit

has made me more humble and confident in life, without ignoring death…

I became edgy, stressed, too reactive (in a negative way) to any request. It affected

my family life: it made my partner unstable, my daughters were scared of me, as

they saw me so angry with the world.

I am scared of childbirth. That is why I haven´t become a mother yet.

Most professionals taking part in the study recognize obstetric violence.

Most of them state having witnessed obstetric violence and having been trained to execute it.

The practices they describe are clear examples of a serious institutionalized violence towards women in labour and their babies.

The level of personal suffering is high. Many have to leave the workplace or even the profession.

Need for emotional support, not included in the curriculum.

More attention to posttraumatic stress in midwives.

Increasing conscience of the psychological dimension of midwifery may help protect and care for midwives´ mental health

Secondary trauma among midwives has a high economic cost and can cause abandonment of profession.

Training

Guidance

Empowerment

Recognition

Gratitude

Elmir, R., Schmied, V., Wilkes, L., & Jackson, D. (2010). Women's perceptions and experiences of a traumatic birth: A meta-ethnography. Journal of Advanced Nursing, 66(10), 2142-2153. doi:10.1111/j.1365-2648.2010.05391.x; 10.1111/j.1365-2648.2010.05391.x

Beck, C. T., Gable, R. K., Sakala, C., & Declercq, E. R. (2011). Posttraumatic stress disorder in new mothers: Results from a two-stage U.S. national survey. Birth (Berkeley, Calif.), 38(3), 216-227. doi:10.1111/j.1523-536X.2011.00475.x; 10.1111/j.1523-536X.2011.00475.x

Olde, E., van der Hart, O., Kleber, R., & van Son, M. (2006). Posttraumatic stress following childbirth: A review. Clinical Psychology Review, 26(1), 1-16. doi:10.1016/j.cpr.2005.07.002

Creedy, D. K., Shochet, I. M., & Horsfall, J. (2000). Childbirth and the development of acute trauma symptoms: Incidence and contributing factors. Birth (Berkeley, Calif.), 27(2), 104-111.

Leinweber, J., & Rowe, H. J. (2010). The costs of 'being with the woman': Secondary traumatic stress in midwifery. Midwifery, 26(1), 76-87. doi:10.1016/j.midw.2008.04.003

Olza Fernández I., Marín Gabriel MA., Gil-Sanchez A; Garcia-Segura LM; Arevalo MA. Neuroendocrinology of childbirth: the basis of an etiopathogenic model of perinatal neurobiological disorders”. Frontiers in Neuroendocrinology accepted ISSN: 0091-3022 Indice de impacto 2012: 7,985 2014 doi: 10.1016/j.yfrne.2014.03.007. [Epub ahead of print]

Olza Fernández I . PTSD and obstetric violence”.. Midwifery Today, Midwifery Today Int Midwife. 2013 Spring;(105):48-9, 68. ISSN: 1551-8892

Perez D'Gregorio, R. (2010). Obstetric violence: A new legal term introduced in venezuela. International Journal of Gynaecology and Obstetrics: The Official Organ of the International Federation of Gynaecology and Obstetrics, 111(3), 201-202. doi:10.1016/j.ijgo.2010.09.002

Hunter,B.,2004.Conflicting ideologies as a source of emotion work in midwifery. Midwifery 20,261–272.

Hunter,B.,2006.The importance of reciprocity in relationships between community-based midwives and mothers.Midwifery 22, 308–322.

Hunter,B.,Deery,R.,2005.Building our knowledge about emotion work in midwifery: combining and comparing findings from two different research studies. Evidence Based Midwifery 3,10–15.

Kennedy, H.P., Shannon,M.T., Chuahorm, U.,et al.,2004.The landscape of caring for women: a narrative study of midwifery practice.Journal of Midwifery and Women’s Health 49,14–23.

Lundgren, I.,Berg,M.,2007.Central concepts in themidwife– woman relationship.ScandinavianJournalofCaringScience 21, 220–228.