Natural childbirth advocates have been caught, proverbially, with their pants down. After making the specter of posttraumatic stress disorder a centerpiece of their efforts to promote natural childbirth, they are shocked to discover that it is natural childbirth itself that may cause post traumatic stress disorder (PTSD) after birth.
Hypocrites take your mark! Set! Go!
The first hypocrite around the bend is Penny Simkin, physical therapist, childbirth educator and all around popularizer of the notion that modern obstetrics causes PTSD and natural childbirth prevents it.
Not surprisingly, she is now struggling mightily to discredit a new study that claims that unmedicated childbirth is a cause of posttraumatic stress disorder after birth. Step 1: discredit the paper.
The paper is Postpartum Post-Traumatic Stress Disorder symptoms: The Uninvited Birth Companion. The impact of pain on symptoms of posttraumatic stress disorder is just one of many findings noted in the study:
The prevalence of post-partum PTSD was 3.4% (complete PTSD), 7.9% nearly complete PTSD, and 25.9% significant partial disorder. Women who developed PTSD symptoms had a higher prevalence of “traumatic” previous childbirth, with subsequent depression and anxiety. They also reported more medical complications and “mental crises” during pregnancy as well as anticipating more childbirth pain and fear. Instrumental or cesarean deliveries were not associated with PTSD. Most of the women who developed PTSD symptoms delivered vaginally, but received fewer analgesics with stronger reported pain. Women with PTSD reported more discomfort with the undressed state, stronger feelings of danger, and higher rates of not wanting additional children.
None of these findings is unexpected. Indeed, there is a substantial amount of research suggesting that labor pain can be a source of trauma:
It has been suggested that the intense experience of pain can lead to an event perceived as traumatic. In their study of individuals injured in traumatic events, Schreiber and Galai found that the sensation of pain rather than the injury
itself caused the perception of a traumatic event. Melzack reported that the experience of pain in childbirth is associated with traumatic memories long after the birth itself, with others reporting that many prefer to have the next birth by cesarean
section due to the memory of painful childbirth even 3 years after the birth . In a survey of 28 women requesting cesarean section, all had memories of a traumatic birth, including 50% who had an emergency cesarean section. The repercussions of post-traumatic symptoms after childbirth are varied, with some reporting avoidance of sex and fear of having further children.
Simkin is already on record insisting that it is “suffering” not pain that leads to PTSD.
She discounts the benefit of pain relief in labor:
An enormous industry exists in North America to manufacture and safely deliver pain relieving medications for labor. Hospital maternity departments are designed with elimination of pain as a primary consideration, complete with numerous interventions and protocols to keep the pain management medications from causing serious harm. When staff believe that labor pain equals suffering, they convey that belief to the woman and her partner, and, instead of offering support and guidance for comfort, they offer pain medication…
What an amazing coincidence that Simkin disparages the service that she is incapable of providing (pharmacologic pain relief) and instead offers the service that she can charge money for (doula services).
For Simkin, the implication is straight forward. Pain does not cause PTSD. Therefore, anesthesiologists cannot prevent PTSD. It is “suffering” that causes PTSD and doulas can relieve “suffering.”
And what is suffering?
Simkin insists that it is “suffering” that leads to PTSD and suffering is whatever the sufferer says it is:
One’s perception of the event is what defines it as traumatic or not. As it pertains to childbirth, “Birth trauma is in the eye of the beholder”, and whether others would agree is irrelevant to the diagnosis.
Unless, of course, the beholder says it is unrelieved pain that is traumatic.
That’s why Simkin is trying to discredit the new paper. The study found that untreated pain is among a variety of factors associated with PTSD after childbirth:
There were more natural births (noninterventional) in the PTSD group than in the control group. A significantly smaller number of women who developed PTSD symptoms received analgesia during delivery compared to the control group (chi-square P = 0.000).
Moreover, the extent to which women were supported during labor made no difference:
No relationship was found between the development of PTSD symptoms after childbirth and being accompanied by someone during labor or the extent to which the accompanying person gave support.
But, but, but … these results are unacceptable. Simkin insists that the paper actually showed that the etiology of PTSD after childbirth is complex and multi-factorial:
Furthermore, these women had numerous other factors that are associated with PTSD. Before accepting natural birth as the major cause of PTSD after childbirth, please check the … other factors, which were as prevalent, or nearly so, as lack of pain relief as a cause of PTSD… [F]or example, 80 percent of the women with PTSD also had discomfort with being undressed; previous mental health problems in previous pregnancy or postpartum; and complications, emotional crises, and high fear of childbirth in their current pregnancy. All these factors have been reported in many studies to be instrumental in the development of PTSD.
Yes, all these factors have been reported to be involved in the development of PTSD, suggesting that characteristics of the women who develop PTSD are more important than their actual experience in labor or their perception of what caused the trauma. Trauma isn’t in the eyes of the beholder, it’s in the psychological disposition of the beholder.
Hence the hypocrisy. The papers that Simkin has cited for years in her assertion that it is the modern obstetric experience that leads to PTSD found exactly the same thing that this new paper found: that PTSD reflects the predisposition of the patient, not her experience. Simkin ignored those findings and insisted that childbirth educators and doulas could prevent PTSD by changing a woman’s experience by:
- Recommend that the woman/couple learn about labor, maternity care practices, and master coping techniques for labor…
- Recommend a Birth Plan…
- [A] process in which she was respected, nurtured, and aided…
- [N]o supportive person wants a woman to have pain medication that she had hoped to avoid. A previously agreed-upon “code word” provides a safety net for a woman who is highly motivated to have an unmedicated birth.
Simkin can’t have it both ways. Either the etiology of PTSD after childbirth is complex, multi-factorial, and affected by psychological predisposition or it isn’t.
I happen to think she is right that this is precisely what the new paper shows, but it is also precisely what everything else she has been citing in support of her own theories shows. PTSD after childbirth has more to do with the patient than her experience. Hence we cannot conclude that unmedicated childbirth leads to PTSD, but we also cannot conclude that a poor childbirth experience leads to PTSD or that childbirth educators and doulas can prevent it.