Rates of C-sections and postpartum posttraumatic stress disorder on the rise

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      The birth of Helen Dunn’s first son didn’t go nearly as smoothly as she had envisioned. Induced two weeks early because of concerns about the baby’s health, the Vancouver clinical counsellor endured 17 hours of painful contractions before her baby went into distress. As nurses ran in and out of the room, a doctor yelled, “We have to get this baby out now.” She had an emergency caesarean section, the whole experience proving to be a traumatic one with terrible, lasting effects.

      “I immediately felt disconnected from him when they showed him to me,” Dunn says over a cup of tea at a Commercial Drive cafe. “I didn’t recognize him. I wasn’t attached to him; in fact, I had an aversion to him. I wanted them to take him away, which is hard to admit. After that it was very difficult for me, it was a long process of panic attacks, which I’ve never experienced before, and full-blown agoraphobia.

      “I didn’t want to tell people how I felt; I felt a tremendous amount of shame about how I felt toward my child, the difficulty I was having bonding with him,” she adds. “I was diagnosed with postpartum depression, but I had no idea about postpartum posttraumatic stress disorder.”

      Looking back now, she can see that those panic attacks were among the condition’s telltale signs. According to Mental Health America, PTSD after childbirth is characterized by two key elements: experiencing or witnessing an event involving actual or threatened danger to oneself or others and a response of intense fear, helplessness, or horror. Symptoms include obsessive thoughts about the birth; feelings of numbness, detachment, or panic; disturbing memories of the birth experience; nightmares; flashbacks; and sadness, fearfulness, anxiety, or irritability.

      According to a study published in the journal Nursing Research in 2004, the reported prevalence of postpartum PTSD ranges from 1.5 percent to 6 percent—a wide enough margin, the journal noted, to provide “the impetus for increased research efforts in this neglected area”.

      Dunn was even more struck by the effects of her traumatic birth following the delivery of her second son six years later. She laboured for 17 hours again, but this time delivered vaginally with the assistance of a midwife in hospital and went home soon after.

      “I didn’t have any problems,” Dunn says. “He immediately looked familiar to me—he looked like my sister—I felt bonded to him, attached to him.” The stark differences between her two childbirth experiences prompted her to explore other women’s feelings of attachment to their newborns among those who delivered via emergency C-section as well as vaginally in her Master’s thesis. Now she wants to raise awareness among health professionals and the public alike of two pressing issues: postpartum PTSD—in particular signs, early intervention, and effects on maternal-infant attachment—and the high rates of C-sections in this country.

      Although C-sections clearly play a vital role in maternal health and can be life-saving, about 26 percent of deliveries in Canada take place this way, which is nearly double the rate recommended by the World Health Organization.

      Then there is the way postpartum PTSD is so widely misunderstood and overlooked, in Dunn’s view.

      “When I did reach out for help, people would say, ‘You’ve got a healthy baby; what do you have to complain about?’ or ‘This was so long ago; why is it still bothering you?’

      “I would love for doctors and nurses and therapists and mental health professionals to recognize the signs,” Dunn adds. “When someone says, ‘I don’t want to see my child… I really wish someone would have said to me at that point, ‘Can we help you?’ When I told a nurse I was feeling strange, having panic attacks, she said it was because of the medication. Even one gesture of support or kindness from somebody on the front lines can go a long way to help a woman gain a sense of control of what’s happening to her. I think it could have been handled a lot better in my case. I think I would have benefitted from more support had there been more knowledge around it.”

      Maternal-health expert Michael Klein, emeritus professor of family practice and pediatrics at UBC and senior scientist emeritus at the Child and Family Research Institute’s Centre for Developmental Neurosciences and Child Health, says that in general, women who have emergency C-sections without adequate support or communication from their caregivers suffer from posttraumatic stress disorder far more frequently than those who don’t.

      “What we know about the psychological experiences of women is that women who have a sudden, unexpected, emergency caesarean section without any chance to really adapt to it are the most likely to suffer psychological distress,” Klein says in a phone interview. “Posttraumatic stress disorder is much, much, much neglected.”

      However, Klein emphasizes that the primary determinant of whether a woman will suffer PTSD after child birth is not the mode of delivery. Rather, it’s how she’s cared for. In other words, the condition can occur in women who have vaginal births, deliveries that require forceps, midwife-assisted labours, and in other situations. The crucial factor throughout is how her care team responds to her needs.

      Other factors come into play as well, such as prior psychological and psychiatric disorders and the woman’s prepregnancy mental state.

      When women do end up requiring an emergency C-section, Klein adds, it would be helpful for health-care workers to acknowledge their feelings and arrange for support and counselling after the fact if they need it and to follow up on that offer.

      “We know that women never forget their childbirth experiences,” says Klein. “They can be transformative in a positive way or transformative in a negative way. Talk to any 50- or 60-year old woman and she can tell you every minute of their childbirth experience.” (Klein is father to journalist Naomi Klein and Seth Klein, director of the B.C. branch of the Canadian Centre for Policy Alternatives.)

      Dunn, meanwhile, who hopes to build on her thesis research and write a book, is brainstorming with other health-care workers to come up with concrete ways to raise awareness and make a positive change in the way women are cared for during birth, particularly in instances where their dream of delivering vaginally disappears only for the operating-room lights to flash on.

      “I want therapists and doctors to understand what a woman may have gone through,” she says. “I hope women themselves who’ve gone through this will reach out and get help, and if they don’t get help the first time to keep looking for it and not get discouraged. I want to advocate for change, to say what happened to me wasn’t right. I want to push for change.

      “Not feeling attached to your child is just heartbreaking,” she adds. “There’s isolation and this really deep sense of failure. And I wonder who’s in their home right now, alone, keeping this shame to herself.”

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      15 Comments

      Kalina Christoff

      Nov 30, 2011 at 3:40pm

      This is an excellent and a much needed article. Kudos to Helen for her courage and strength in stepping up and going public about the suffering she went through.

      A clarification: even though the picture caption says that Helen suffered from post-partum depression, this is inaccurate; Helen suffered from post-partum PTSD, not depression (the article itself is clear on that; I also know that from Helen herself, who is my friend). Depression is one of the symptoms of PTSD, but it is only a consequence. Post-partum depression is a distinct condition and should be treated completely differently.

      It is tragic that so many health care providers are unable to distinguish between post-natal depression and post-natal PTSD. It is even more tragic that many women every year in Vancouver must be diagnosed with depression, when what they are really experiencing is the symptoms of trauma.

      I went through post-natal PTSD after the highly abusive treatment I received from two obstetricians during the birth of my child at BC Women's Hospital last year. As a psychologist, it took me several months after the birth to realize that what I was really struggling with was PTSD, not depression. I happened to have the DSM-IV on my bookshelf. My self-diagnosis, according to the list of symptoms, was a "severe form of PTSD".

      I spent the next several months trying to find a support group in Vancouver that helps women with post-partum PTSD, finally realizing there isn't one. So I decided to put together one. Information on how to become part of this group, as well as other information about post-partum PTSD, is now available at:

      http://www.vancouverbirthtrauma.ca

      To the women out there who may go to their doctor with symptoms of trauma, just to be pressured to start anti-depressants: keep in mind that anti-depressants may or may not be right for you, and that your doctor or whoever is pressuring you to take them may or may not be aware of post-natal PTSD. If you're suffering from childbirth trauma, there is likely a specific external cause to your suffering -- it is probably not caused by a "chemical imbalance" and so it may be wrong to treat it as such. In some situations, anti-depressants might make some of your PTSD symptoms worse. And they are likely to make you even more emotionally numb (a side effects of anti-depressants). This could damage further the connection with your baby.

      The best treatment for PTSD is cognitive behavioral therapy (especially therapy involving "imagery exposure and re-scripting") and connecting with other women who have gone through a similar experience.

      CM

      Dec 1, 2011 at 10:24am

      I too had a terrible experience at B.C. Women's. I was shocked to receive such poor, inattentive care; to be stuck in a tiny room after an emergency C-section with nowhere for my husband to sleep; to be desperate for rest only to be interrupted constantly in my room by people wanting to sell me things (baby photos, insurance, onesies, pyjamas). It was absolutely awful in every possible way. Saddens me to this day, years later. Went to St. Paul's for baby #2 and had a much, much better experience.

      amy robertson

      Dec 1, 2011 at 10:27pm

      I am a doula here in Vancouver and have supported women at both St Pauls and BCWH. The challenge I see with hospitals is continuity of care. With shift changes and doctors on call meeting women for the first time during their second stage of labour then having another doctor check in the next day, it's no wonder women go undiagnosed for posnatal PTSD. Doulas provide support before, during and after labour. And while they aren't necessarily medically trained, they can help raise the red flag and encourage their clients to seek help. Douglas College has a great program as well as Doulas of North America, and I think this topic should be highlighted in the training of these valuable supporters of women's maternal health.

      monty/that'sme

      Dec 2, 2011 at 6:29am

      "We know that women never forget their child birthing experiences"--what rubbish and hogwash. Spoken by a man, of course. While one may remember the colour of the walls, or the doctor's moustache, it is unlikely that women remember any pain of childbirth. If they did, they would stop having children.

      What midwives should be paying attention to is the over use of baby aspirin during pregnancy. Consult mayo clinic pregnancy and baby aspirin and one learns it is dangerous and may kill the fetus.

      Stepanie

      Dec 3, 2011 at 8:13am

      Great article! I am myself writing a book about this. I also suffer from PP PTSD. I wrote a research paper for nursing school about PP PTSD and I will include it in my book, along with my own story and lots of resources for parent's and health care providers.

      Helen B

      Dec 3, 2011 at 10:29am

      Monty, your statement is completely ridiculous. Of course women remember childbirth, unless they are so drugged up that it's all a blur, and they certainly remember the pain they experience. Women who are so elderly and demented that they can't tell you what they had for breakfast may be able to describe their births in detail. I have had four children, unmedicated childbirth all four times, and believe you me I can remember the pain. As Ina May Gaskin says, the contractions can command your whole attention. Fortunately, for me the pain was part of a "climbing Mount Everest" or "running a marathon" kind of experience, not hours of agony from a pit drip. I agree with the author that the emotional and physical support that women receive during childbirth certainly informs their framing of the childbirth experience.

      DB

      Dec 3, 2011 at 3:25pm

      Great article. I also had similar issues. My first child was born by forceps and I had PND and terrible issues bonding with her. My second child was born vaginally and I couldn't believe the amazing bond I had with him - it brought back the guilt of not bonding very well with the first. So yes, its not just CS but any instrumental birth.

      tkoala26

      Dec 3, 2011 at 3:37pm

      Whoever said women dont remember childbirth is stupid whether its natural or c-section. And the hurting subsides after you see that baby. Women are far more tougher than men in that area, no doubt. Most women are caregivers and if they wanted more children, god given they'll have them

      Gentleman Jack

      Dec 3, 2011 at 7:44pm

      How about research into what happens to a baby born by c-section? First nonverbal memory, being grabbed, covered in blood, etc. etc. Hard on the mom? At least her nervous system isn't about as impressionable as it'll ever be.

      Patrice Allen

      Dec 4, 2011 at 9:18pm

      What about the baby?
      What about the baby's PTSD after such a traumatic journey from womb to world?
      How much do we know about the effect on the BABY of the stresses it endures while being born???