In Postpartum Issues

In this month’s issue of Birth, investigators examine the relationship between mode of delivery, negative feelings, and whether negative feelings have more substantive effects than the feelings alone. Most studies of the connection between perception of the birth experience and mode of delivery are small, qualitative studies with no adjustments for potential confounding factors. This study, by contrast, is large (3006 1st-time mothers), quantitative, and accounts for multiple factors that could influence feelings about the birth experience apart from mode of delivery. Let’s take a look.

The Setup

Women completed a baseline interview at 30 weeks or more of pregnancy and were re-interviewed at 1 month postpartum. The baseline interview included the Edinburgh Depression Scale and a social support scale. At the 1-month interview, women answered the question: “Thinking back to right after you had your baby, please tell me how you felt using the following scale—extremely, quite a bit, moderately, a little bit and not at all.” They were then presented with 16 feelings, a list developed from focus groups and qualitative studies of women shortly after childbirth and validated to ensure that the test measured what it was designed to measure. Total scores could range from 16 to 80 with higher scores indicating a more positive experience. The 1-month interview also included the Edinburgh Postnatal Depression Scale (12 points or more indicates probable depression) and a questionnaire evaluating attachment to the infant. In addition, women were asked whether, looking ahead, they would want to have another baby.

The analysis of the association between mode of delivery and perception of the birth experience controlled for maternal age, race/ethnicity, education, insurance, pregnancy intention, depression during pregnancy, social support, and maternal or newborn complications. The analyses of the associations between birth experience scores and postpartum depression, bonding with the infant, and plans for future children controlled for the same list of factors plus mode of delivery.

The Findings

Looking at the raw birth experience scores, mode of delivery, education, pregnancy intention, depression during pregnancy, social support, maternal complications, and newborn complications significantly influenced scores while maternal age, race/ethnicity, insurance, and marital status did not. Spontaneous vaginal birth produced the highest scores followed by planned cesarean, instrumental vaginal delivery, and unplanned cesarean.

Looking at specific feelings and their relationship to mode of delivery, 82% of women having spontaneous vaginal birth, 72% having instrumental vaginal delivery, 67% of woman having planned cesareans, and only 65% of women having unplanned cesareans reported feeling proud. Turning to negative feelings, women having unplanned cesareans were consistently more likely to report the negative feelings on the list, instrumental vaginal delivery and planned cesarean fell in the middle, and women having spontaneous vaginal birth were least likely to do so. Differences between unplanned cesarean and spontaneous vaginal birth were stark. Compared with women having spontaneous vaginal birth, women having unplanned cesarean were more likely to feel disappointed (23% vs. 5%), sad (24% vs. 12%), upset (27% vs. 11%), traumatized (22% vs. 13%), sick (32% vs. 15%), like a failure (16% vs. 3%), or angry (7% vs. 3%). After controlling for confounding factors, women having unplanned cesarean were 6 times more likely to feel disappointed and 5 times more likely to feel like a failure than women having spontaneous vaginal birth, and women having spontaneous birth were 3 times more likely to feel proud. Moreover, while investigators focused on unplanned cesarean, instrumental vaginal delivery also had adverse effects on perception of birth experience. In particular, 23% of women having instrumental vaginal delivery reported feeling traumatized, similar to the percentage having unplanned cesarean.

Of even greater concern, the harms of unplanned cesarean extended beyond feelings. For every point higher on the birth experience score, the likelihood of scoring 12 or higher on the Edinburgh Depression Scale decreased by 9%, the likelihood of scoring at the median or above on the postpartum bonding questionnaire increased by 12%, and women were 5% more likely to report wanting to have additional children.

The Take-Away

Often dismissed as being of minor—if any—importance, a negative birth experience can have far-reaching effects. Feeling inadequate, depressed, and less connected to the baby, extending even to not wanting more children, can have adverse long-term impacts on women’s lives, relationships, and especially on their ability to mother their children. The high percentage of women reporting feeling traumatized after unplanned cesareans and instrumental vaginal deliveries also raises concern. Investigators didn’t screen for posttraumatic distress. A large U.S. survey that did reported that 18% of women reported symptoms of childbirth-related posttraumatic stress and 9% met criteria for full-blown PTSD (Beck 2011).

The study’s authors think the solution is for doctors to listen sympathetically, explain why the cesarean or instrumental delivery was necessary, and help women feel proud of themselves regardless of mode of delivery. This should certainly be done, but it evades dealing with the root causes. In point of fact, roughly half the cesareans in U.S. 1st-time mothers, at least, are not necessary, as a study of physiologic care attests (Jolles 2017). Instrumental deliveries, too, could be minimized by avoiding epidurals and with better management of second stage. One wonders, as well, how many negative birth experiences in women having spontaneous vaginal births might have been avoided had all laboring women been treated kindly and respectfully and participated fully in decisions about their care (Reed 2017). Some women will have negative birth experiences even with optimal care, and those women should be treated with compassion and, when needed, should have access to professional help. Nonetheless, an ounce of prevention is worth a pound of cure.

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References

Beck CT, Gable RK, Sakala C, et al. Posttraumatic stress disorder in new mothers: results from a two-stage U.S. national survey. Birth 2011;38(3):216-27.

Jolles DR, Langford R, Stapleton S, et al. Outcomes of childbearing Medicaid beneficiaries engaged in care at Strong Start birth center sites between 2012 and 2014. Birth 2017;44(4):298-305.

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