Presentation about traumatic childbirth and obstetric violence impact on midwives. By Ibone Olza Fernandez, MD, PhD, perinatal psychiatrist and childbirth activist.

1. IBONE OLZA FERNANDEZ.M.D, Ph.D.
25th October 2014
13th Conference of the Federation of Spanish Midwifery
Associations

2.  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)

3.  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, high
level of obstetric intervention, Cesarean section, separation
from newborn, perception of inadequate care or even abuse
 PTSD due to childbirth involves an enormous psychological
suffering and affects the relationship of the mother with her
baby, her partner, her family and healthcare providers. Its
symptoms differ from those of postpartum depression,
although some mothers suffer from both.
 Symptoms may last for months or years
Bailham, 2003.

4. Amanda Greavette

5.  Constantly remember and relive their traumatic
experience with flashbacks and nightmares (for
weeks or months).
 They feel disconnected or far from their babies and
absent from reality, as if they were not there or as if
they were not the same person.

https://birthcut.wordpress.com/

6.  The trauma makes women try to find an explanation to what
happened to them and constantly talking about it. They also
obsessively search for obstetric information.
 They feel angry with the healthcare professionals, their own families
and themselves. They have symptoms of anxiety and depression.
 Their experience of maternity is seriously affected. They often feel
detached from their children.
 They have many difficulties to relate to other mothers, as they cannot
help compare their childbirth experience with theirs.
 PTSD may trigger a rejection to sexuality, to having more children or
to the decision of choosing a programmed C-section next time
Beck, 2004.

7.  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.

8. ... I perfectly recall the fear from overhearing

9. 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.

10. Amanda Greavette

11. Leinweber & Rowe 2008

12.  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 )

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

15.  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

16.  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?

17.  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

18.  Nurses frequently used phrases such as “the physician violated her,” “a perfect
delivery turned violent,” “unnecessary roughness with her perineum,” “felt like an
accomplice to a crime.”
 A description of the L&D of a grand multipara provided by one nurse illustrates
that risk factor: “The doctor treated her like a piece of dirt. After the birth of the
baby he proceeded to put his hand inside her practically halfway up his arm to
start pulling the placenta out. She screamed ‘something is not right. It never hurt
like this before.’
 I felt like I was watching a rape.”
Beck 2012

19.  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’t
pushing extremely effectively. After two pushes the MD cut a huge episiotomy and
the patient felt it. She screamed in a manner that will always give me chills. The
MD said, “This is what happens when you don’t get an epidural.” The young mother
started crying. It was terrible. He traumatized her and assaulted her. That scream
and the MD’s comment will always haunt me

20. 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 was
sur- prised when he said she was ready to go back to the delivery room. Once in the
DR he checked her again and told her to start pushing, but he checked her so
roughly she was unable to push because she started screaming. I figured out that
she was only 6 cm dilated and he was trying to manually dilate her with each
contraction. My only clear memory is that this beautiful, intelligent, cooperative
woman turned into a screaming, mindless animal under his torture. I’ve never felt
so powerless, helpless, or useless in my life. I really feel that I failed her. She was
counting on me to help her and I let that man torture her. I feel as sick to my
stomach thinking about it today as I did 40 years ago when it was fresh."

22. The Venezuelan law defines obstetric
violence as:
"the appropriation of the body and
reproductive processes of women by
health personnel, which is
expressed as dehumanized
treatment, an abuse of medication,
and to convert the natural processes
into pathological ones, bringing with
it loss of autonomy and the ability to
decide freely about their bodies and
sexuality, negatively impacting the
quality of life of women.”

23.  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."

25. She cries
He smiles and says it will be nothing
She is naked, feels fragile and vulnerable
He puts his hand inside her despite her negative
He doesn't listen to her
He goes on while she cries
It hurts
She asks him not to touch her
to leave her alone
to take his hand out of her vagina
She begs him
He doesn't listen and tells her to be quiet
Then another person comes in and repeats the action
And then another one...
They finish
They leave her on her own
She cries
It is not rape
She is in labour
Is it not rape?
Clara.
From: http://www.elpartoesnuestro.es/blog/2011/01/11/en-mi-pueblo-se-llama-violacion

26. Obstetric violence report form of the
Argentinian Ministry of Justice and Human Rights

29.  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

30.  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 midwives
6 Midwifery students
1 gynaecologist
1 auxiliary nurse in the delivery room
2 nurses in the delivery room
2 others
 Average age: 37.7 years old (23-67) Average experience: 11.4 years
 Preliminary findings

31. 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

32.  Women that are sedated just to be quiet and not a bother, births which are
instrumentalised so that the student practices, shouts at women telling them that
they are doing it wrong or that they are going to kill their babies..
 Unnecessary vaginal explorations, Ph measurement for statistics, unnecessary
forceps 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, the
better. 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, we
always excuse ourselves saying that what happened is the right thing and we
never tell the woman the truth or support her.

33.  Denying women water or getting up and walking. Doing an episiotomy because
the 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 woman
loses control”.
 Accusing the woman of not knowing how to give birth. Telling her she is not able
to push. Refusing to give her an epidural because when they offered it to her, she
said 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 during
the procedure. Births with over 15 people in the delivery room, each one doing
one´s thing, paying no attention to the woman, except to her perineum and her
vagina. Kristeller manoeuvres that make me shiver. Episiotomies: random, big
and inappropriate (without making the perineum convex in most occasions).

34. I have had depression symptoms and have left the delivery
room crying due to the trauma. A gynaecologist slapped
me when I gently and politely touched his arm and looked
into his eyes to ask her to stop doing a terrible minutes-
long Kristeller manoeuvre on a woman in labour. She kept
asking him to stop and he went on and on. It looked like
rape. I still feel like crying and have nightmares.

35.  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..

36.  It made me look for other ways of care and alternatives outside hospitals. I now
attend 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 in
the ass”. Besides women don´t fight for this or see the effort I make for them. I feel
frustrated.
 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 I
wouldn´t work in that hospital any more.
 I had to get out. Terrible relationship with the gynaecologists.

37.  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

38.  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…

39.  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.

40.  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.

41. 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.

42. Training
Guidance
Empowerment
Recognition
Gratitude

44.  Elmir, R., Schmied, V., Wilkes, L., & Jackson, D. (2010). Women's perceptions and experiences of a traumatic birth: A meta-ethnography. Journal of Advanced
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 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
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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
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