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Women's perceptions and experiences of a traumatic birth: A meta-

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 JAN JOURNAL OF ADVANCED NURSING

REVIEW PAPER

Women’s perceptions and experiences of a traumatic birth:

a meta-ethnography
Rakime Elmir, Virginia Schmied, Lesley Wilkes & Debra Jackson

Accepted for publication 22 May 2010

Correspondence to R. Elmir: E L M I R R . , S C H M I E D V . , W I L K E S L . & J A C K S O N D . ( 2 0 1 0 ) Women’s perceptions

email [email protected] 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
Rakime Elmir RN RM
PhD Candidate
Family and Community Health Research
Abstract
Group (FaCH), School of Nursing and Aim. This study presents the findings a meta-ethnographic study reporting women’s
Midwifery, University of Western Sydney, perceptions and experiences of traumatic birth.
Australia Background. Childbirth is viewed by many as a life transition that can bring a sense
of accomplishment. However, for some women, birth is experienced as a traumatic
Virginia Schmied PhD RN RM event with a minority experiencing post-traumatic stress. A traumatic birth experi-
Associate Professor ence can have a significant impact on the physical and emotional well-being of a
Family and Community Health Research
woman, her infant and family.
Group (FaCH), School of Nursing and
Data source. The CINAHL, MEDLINE, Scopus and PubMed databases were sear-
Midwifery, University of Western Sydney,
Australia ched for the period January 1994 to October 2009 using the keywords birth trauma,
traumatic birth, qualitative research, birth narrative and birth stories.
Lesley Wilkes PhD RN Review methods. A meta-ethnographic approach was used. Quality appraisal was
Professor carried out. An index paper served as a guide in identifying particular findings and
Family and Community Health Research comparing them with other findings. This ‘reciprocal translation’ process started with
Group (FaCH), School of Nursing and a search for common themes, phrases and metaphors.
Midwifery, University of Western Sydney,
Results. Ten qualitative studies were included in the final sample. Six major themes
Australia
were identified: ‘feeling invisible and out of control’, ‘to be treated humanely’, ‘feeling
Debra Jackson, PhD RN trapped: the reoccurring nightmare of my childbirth experience’, ‘a rollercoaster of
Professor emotions’, ‘disrupted relationships’ and ‘strength of purpose: a way to succeed as a
Family and Community Health Research mother’.
Group (FaCH), School of Nursing and Conclusions. It is evident that a small percentage of women experience a traumatic
Midwifery, University of Western Sydney, birth. Although some women who experience a traumatic birth do not necessarily
Australia
have physical or psychological adverse outcomes, others identify a significant per-
sonal impact. Healthcare professionals must recognize women’s need to be involved
in decision-making and to be fully informed about all aspects of their labour and birth
to increase their sense of control.

Keywords: childbirth, meta-ethnography, midwifery, nursing, qualitative study,

traumatic birth

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JAN: REVIEW PAPER Women’s perceptions and experiences of a traumatic birth

experience is often accompanied by fear, helplessness and

Introduction
terror, and is subsequently associated with a range of
For many women, the birth of a child is a key life transition, thoughts including vivid memories of the event, flashbacks,
and when they are well supported, this can be described as a nightmares and irritability (Ayers 2004, Olde et al. 2006).
moment of triumph, satisfaction and reward (Nelson 2003). Unfortunately, the ambiguity of the definition of traumatic
There remain, however, a proportion of women who are birth and the criteria constituting PTSD result in delayed or
deeply distressed following birth. In a study of Swedish and missed diagnoses of PTSD.
Australian birthing women, Waldenstrom et al. (2004) found Despite the increasing knowledge of traumatic birth
that 5–7% continued to be dissatisfied with their birth experiences and PTSD, very few professional support services
experience after 2–4 months. Reports of dissatisfaction with are available to help women after the event and prior to a
the birth experience are frequently linked with descriptions subsequent birth (Thomson & Downe 2008). In order for
of complicated, negative or traumatic birth experiences healthcare professionals to provide greater support for
(Waldenstrom et al. 2004, Dahlen et al. 2010). Soet et al. women through birth and the transition to parenthood,
(2003) in the United Kingdom (UK) suggest that up to 34% of further research into women’s experiences of traumatic birth
women report the birth as traumatic, and an Australian study is necessary. This study contributes to knowledge of this
showed one in three women continued to experience trauma phenomenon by reporting the findings of a meta-ethno-
symptoms at 4–6 weeks after a traumatic birth (Creedy et al. graphic study of published studies about women’s percep-
2000). tions and experiences of a traumatic birth.
There is no consistent definition of traumatic birth and no A meta-ethnographic study is a rigorous and analytical
systematic way to assess birth trauma, and the terms birth process of synthesizing qualitative studies. The aim of the
trauma and traumatic birth are used frequently synony- approach is to make interpretations about the phenomenon
mously. Beck and Watson (2008) define birth trauma as from the translation of studies into each other (Noblit &
‘actual or threatened injury or death to the mother or her Hare 1988). Unlike a literature review, a meta-ethnographic
baby’ (p. 229). Women may also perceive their birthing study involves the comparison and interpretation of similar
experience to be traumatic as a result of intervention during contexts, studies and populations, thereby creating new
the process, the mode of birth (caesarean or vaginal) and the meanings in the translation process (Noblit & Hare 1988).
way they are treated by healthcare professionals (Allen In this meta-ethnographic study, we sought to understand the
1998). Thompson and Downe (2008) state that women commonalities and differences in the findings of studies with
who have an apparently normal birth with no interventions women who experience a traumatic birth.
may also perceive it as traumatic. This leads Beck (2004b,
p. 28) to comment that birth trauma is perceived in the ‘eye
The review
of the beholder’.
A traumatic birth experience can have a severe impact on
Aim
women and their families (Ayers 2004, Olde et al. 2006) and is
associated with negative outcomes, such psychological distress The aim of the study was to describe women’s perceptions
and ongoing physical pain (Creedy et al. 2000, Czarnocka & and experiences of a traumatic birth.
Slade 2000, Beck 2004b). Women who experience a traumatic
birth often report that they have not had the opportunity to
Design
voice their distress, and they fear that their concerns will be
dismissed (Reynolds 1997, Moyzakitis 2004). The synthesis of the literature presented in this study was
There is increasing recognition that, for some women, guided by the original work of Noblit and Hare (1988) on
traumatic birth can lead to post-traumatic stress disorder meta-ethnography. Although they outline processes to syn-
(PTSD) (Beck 2004b, Ayers 2007). Large population-based thesize ethnographic studies, they and others (Britten et al.
studies from Australia and the UK indicate that between 1% 2002, Campbell et al. 2003, Pound et al. 2005, Downe et al.
and 6% of women will develop symptoms of PTSD following 2009) have used these techniques when synthesizing studies
childbirth (Creedy et al. 2000, Ayers & Pickering 2001). that have used a range of qualitative methodologies in diverse
Women experiencing PTSD related to childbirth report that healthcare settings. The techniques described by Noblit and
they feared for their lives or the lives of their babies, or that Hare (1988) include reciprocal translation (looking for sim-
they would experience physical damage during the birth ilarities across studies), refutational investigation (identifying
(Anderson & McGuiness 2008). A traumatic birthing differences or challenges to the emerging concepts), and then

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R. Elmir et al.

development of a ‘line of argument’ that takes into account

Quality appraisal
both the similarities and differences found in the studies.
Quality appraisal was considered an important component to
prevent the inclusion of poorly conducted studies. Although
Search methods
the application of quality criteria has received much debate,
The search was conducted in February to March 2009 and currently there are no agreed criteria that should be applied
revised again in October 2009. It was limited to papers (Atkins et al. 2008). We chose to assess papers for quality in
published in English in peer-reviewed journals during January order to provide clarity and achieve consensus on which
1994 to October 2009. Studies were included if they focused papers were included in or excluded from the analysis.
on women’s perceptions and/or experiences of traumatic To validate the inclusion of papers, a set of criteria was
birth, birth trauma or PTSD, and used these terms in the title, adopted from Spencer et al. (2003). This ensured that the
abstract or keywords. Studies of women experiencing either findings were credible, and that knowledge gained from the
their first birth or subsequent birth as traumatic were study could be applied to the same population (transferable),
included. To be included, studies had to be primarily the sample was appropriate and reflected the inclusion criteria,
qualitative (including studies using grounded theory, phe- data collection was appropriate, findings were presented in a
nomenology, ethnography and other descriptive qualitative coherent and succinct way, and level of depth and understand-
approaches). We also included studies designed as large-scale ing were portrayed through the interpretation of the findings
cross-sectional surveys if the authors had conducted and (Spencer et al. 2003). The majority of studies reviewed
reported on in-depth interviews with a subgroup of the included a report of the philosophical basis that informed the
sample. research methodology, for example interpretive or descriptive
The MEDLINE, CINAHL, Scopus and PubMed databases phenomenology, and most made mention of ethics approval by
were searched using the Medical Subject Headings (MeSH an appropriate committee (Campbell et al. 2003). Three
headings) and keywords ‘birth trauma’, ‘traumatic birth’, papers were excluded at this point. One (Salter 2009) was
‘qualitative research’, ‘birth narratives’ and ‘birth stories’. excluded because it did not adequately describe the research
The terms were entered individually and in combination. methods and did not provide an audit trail of data analysis,
with limited presentation of qualitative data to support the
findings. Two further papers (Berg & Dahlberg 1998,
Search outcome
Goldbort 2009) were excluded because their focus was on
The search strategy identified 726 papers. The titles and complicated birth (Table 1 shows the papers selected for
abstracts of these papers were reviewed and they were review).
excluded if they were discussion or opinion papers or studies Eight studies included in the synthesis were designed as in-
reporting on birth experiences in general and not traumatic depth qualitative studies focusing on the experience of birth
birth or PTSD following birth. This resulted in 32 papers for trauma; two (Allen 1998, Ayers 2007) not only had a survey
inclusion that were then read in full by two authors to ensure design with a larger sample, but also incorporated a
their relevance to the meta-ethnography. Papers were elim- qualitative component using semi-structured interviews with
inated at this stage primarily because they did not report a subset of the sample and provided rich and authentic
primary research, focused on women’s perceptions of a descriptions of women’s experiences. All 10 researchers had
negative or complicated birth but did not describe this as a collected data from interviews with women; in a study by
traumatic experience, or were case studies or quantitative Nicholls and Ayers (2007), both women and their male
studies that did not have a significant qualitative component. partners were interviewed. Another study by Thompson and
This further reduced the number of papers to 11. Reference Downe (2008) focused in particular on the ‘redemptive’
lists of these papers were read to identify additional relevant experience of having a positive birth event after a traumatic
original research. This method is referred to as ‘backchaining’ birth. Two studies by the same author (Beck 2004a,b) had a
(Downe et al. 2009) and resulted in a further two papers. similar approach to data collection (Internet interviews), with
Three authors of retrieved papers were contacted to identify the same number of participants and location. The author
other relevant publications that might not have been was contacted by email to clarify information on these
retrieved, but no further papers were identified with this studies. Confirmation was obtained that the two papers
approach. The 13 papers considered relevant according to the reported separate studies, presenting different findings; how-
inclusion criteria were then assessed for methodological ever, some women had participated in both studies. Included
quality. studies had been conducted in a number of countries

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JAN: REVIEW PAPER Women’s perceptions and experiences of a traumatic birth

Table 1 Flow chart of search strategy paper). This index paper served as a guide in identifying
particular findings and comparing them with other findings.
726 papers retrieved The process commences with a search for common themes,
phrases and metaphors described by Noblit and Hare (1988)
as ‘reciprocal translation’. This process of comparing findings
continued across the 10 studies to highlight similarities in
findings. Once themes became apparent, we then undertook a
Excluded quantitative studies,
epidemiological studies, discussion papers, process of refutational inquiry (refutational translation),
opinion papers and papers reporting birth looking for differences across studies to ensure findings were
experience in general rigorously presented and to ensure that the authors did not
miss anything that may add or disprove the findings. Very
few differences were uncovered during this process. Common
themes were then summarized in a statement or ‘line of
32 papers
argument synthesis’ (Noblit & Hare 1988). Direct quotations
from participants were used to illustrate their experiences.

Findings
Excluded quantitative studies that did not
have a substantial qualitative component, The five themes developed through the processes of reciprocal
were focused on complicated or negative translation and refutation investigation are outlined in
birth experiences, were not primary research Table 2. These themes will be presented using the original
source of women’s narratives and the original authors’
interpretations. Table 3 presents the common themes,
phrases, ideas and concepts across the 10 included papers.
11 papers

Hand search of reference lists Feeling invisible and out of control

Women described having no control over their birthing

experiences (Allen 1998, Beck 2004b, Ayers 2007, Nicholls
& Ayers 2007). They had expected, and indeed considered it
13 papers
essential, that healthcare professionals would communicate
Application of Spencer et al. (2003) information to them about the labour process, including
quality appraisal regular updates on its status. Participants considered this
pivotal to being actively involved in decisions about labour
and birth, and many women reported that they were not
included in the decision-making process. They often became
10 papers included in synthesis distressed when recalling conversations with healthcare
professionals present during their labour and birth. Research-
ers reported that women’s opinions were ignored and that
they were subjected to authoritarian decision-making. Infor-
mation from healthcare professionals was not forthcoming,
including New Zealand, the United States of America (USA), and women felt as though these people were ‘faceless’
the UK and Australia. The 10 studies represented a combined (Thompson & Downe 2008, p. 271) or invisible, indicating
sample of approximately 398 women. healthcare professionals’ failure to consider them as individ-
uals with a right to make informed decisions: ‘The hospital
staff discussed my baby’s possible death in front of me and
Data abstraction and synthesis
argued in front of me just as if I weren’t there’ (Beck 2004b,
Data abstraction and synthesis was guided by the work of p. 33). Some women perceived staff to be ‘too busy’ to
Noblit and Hare (1988) and others (Walsh & Downe 2005, explain procedures and what was happening during the birth
Downe et al. 2009) and we began with one study (an index (Allen 1998, p. 117), creating feelings of anxiety and unease.

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2146
Table 2 Qualitative studies of women’s experiences and perceptions of traumatic birth
Author/location Methodology Method Aim Sample Inclusion criteria
R. Elmir et al.

Allen (1998), UK Qualitative Questionnaire The process occurring during 145 Women first stage 3 Stage 1: women who experienced labour which
Semi-structured traumatic childbirth experiences, (Questionnaire) they perceived to be traumatic
interviews factors mediating development of 20 women second 3Stage 2: involved including women who rated
post-traumatic stress disorder stage (interviews) their labour as extremely distressing and
(PTSD) symptoms and the impact Ages not specified traumatic
on post-partum adaptation
10 months following childbirth
Ayers (2007), UK Qualitative Interviews Examine thoughts and emotions 50 Women 3 Post-traumatic stress group – scoring above the
Questionnaire during birth, cognitive processing PSTD symptoms cut-off for severe PSTD
after birth, and memories of birth mean age 29. 3 Control group – birth experience similar to
that might be important in the With PTSD symptoms women selected for the PSTD group
development of postnatal depression mean age 32
Ayers et al. Qualitative Semi-structured Study the effect of traumatic birth on 6 Women 3 Aged over 18 years
(2006), UK interviews women, their relationship with their (22–37 years) 3 Able to reads and speak English fluently
child and their relationship with their 3 Psychological problems as a result of a traumatic
partner birth experience
Beck (2004a), Qualitative Internet Describe the essence of mothers’ 38 Women 3 Experienced PTSD attributable to birth trauma
New Zealand, phenomenology interviews experiences of PTSD after childbirth representing 3 Willing to articulate her experience
USA, UK 4 countries
(25–44 years)
Beck and Watson Qualitative Internet To explore the impact of birth trauma 52 Women 3 Mother perceived the childbirth to be traumatic
(2008), phenomenology interviews on mothers’ breastfeeding (31 primiparas, 3 Her birth trauma had in some way had impacted
New Zealand experiences 21 multiparas) her decision to breastfeed. Her breastfeeding
(>18 years) experience or both
3 At least 18 years
3 Able to articulate her breastfeeding experience
Beck (2004b), Descriptive Internet stories To describe the meaning of women’s 38 Women 3 Experienced birth trauma
New Zealand, phenomenology birth trauma experiences (25–44 years) 3 Willing to articulate her experience
USA, Australia, UK 3 Able to read and write English
Beck (2006), Qualitative Internet Determine the essence of mother’s 37 Women 3 Perceived her childbirth as traumatic
New Zealand, interviews experience regarding the anniversary (19 primiparas, 3 She had experienced at least one anniversary of
USA, Australia, of their birth trauma 14 multiparas) that birth trauma
UK, Canada (24–54 years) 3 18 years of age or older
3 Able to articulate her experience
Moyzakitis Qualitative Semi-structured To explore women’s experience of 6 Women 3 Personally identified themselves as having
(2004), UK feminist interviews distress and/or trauma in childbirth (23–39 years) experienced distress and/or trauma in childbirth
and to consider the depth and
meaning of birth that was ‘awful’,
birth that ‘changed women forever’

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JAN: REVIEW PAPER Women’s perceptions and experiences of a traumatic birth

3 Phase 1. Participants who had experienced both a

Feeling out of control led to a sense of powerlessness,

3 One member of the couple had to fulfil DSM-IV

3 Phase 2. women who had a traumatic birth and

diagnostic criteria for childbirth related PTSD in
vulnerability and inability to make informed decisions about

self-defined traumatic and positive birth were

3 If they or their partner had experienced a
their care. They felt betrayed, and some indicated that they

3 Able to read and speak English fluently

who were pregnant with a further child

agreed to procedures such as epidural analgesia and vacuum
extractions in an attempt to end the trauma they were

traumatic birth over 3 months ago

experiencing (Goldbort 2009). Women believed that the lack
of control and involvement in decision-making was primarily
3 Willing to be interviewed due to the fragmented care and lack of continuity in care,

the first year after birth

3 Over 18 years of age

resulting in disconnection and lack of knowledge (Thompson

& Downe 2008).
Inclusion criteria

selected
To be treated humanely

The theme ‘invisible and out of control’ is closely connected

with women’s experiences of labour and birth care as
inhumane and degrading. They used phrases such as ‘barbaric’,
6 Couples (6 men
and 6 women)
(26–50 years)

(27–40 years)

‘intrusive’, ‘horrific’ and ‘degrading’ to describe the mistreat-

14 Women

ment they received from healthcare professionals (Thompson

Sample

& Downe 2008, p. 271). It was also distressing for them when
large numbers of people were invited to watch the birth
without their consent: ‘nobody said to me…do you mind five or
six complete strangers having a look at the most intimate parts
PTSD in couples and the perceived
Explore the experience of postnatal

of your body?’ (Nicholls & Ayers 2007, p. 496).

and personal meanings attributed
To explore the lived experience of
impact of postnatal PTSD on the
couple’s relationship and their

Other participants talked of feeling like a ‘lump of meat’ or

relationship with their baby

a ‘slab on a table’ when describing the dehumanizing way in

which they were treated during birth, and described a total
to a traumatic birth

lack of acknowledgement of them as people, as though they

were non-existent (Beck 2004b, Thompson & Downe 2008,
p. 271). One woman described her experience as being
treated ‘like nothing, just someone to get data from’ (Beck
2004b, p. 32). They wanted the ordeal of birth to end, with
Aim

thoughts of death as a way to escape from the intense pain

and trauma (Thompson & Downe 2008). Others reported
Semi-structured

feeling ‘like being a victim of a violent crime or rape’ (Beck

interviews

interviews

2004b, p. 32).
In-depth
Method

Feeling trapped: the recurring nightmare of my childbirth

experience
phenomenology

In the months or even years after birth, women felt trapped

Methodology

Interpretive
Qualitative

and experience vivid memories of their traumatic birth,

commonly reporting flashbacks and nightmares (Beck 2004a,
2006, Moyzakitis 2004, Ayers 2007, Beck & Watson 2008).
One stated:
Table 2 (Continued)

Downe (2008), UK
Ayers (2007), UK

I can’t believe five years later that I feel such strong emotions and that
Author/location

Thompson and

my body responds physically. It is like birthing trauma and the

Nicholls and

anxiety, loss and pain associated with it seems to reside in every cell
of my being, with a memory capacity that serves to never let me
forget. (Beck 2006, p. 388)

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 Table 3 Common metaphors and phrases

2148
Feeling trapped: the reoccur- Strength of purpose:
Feeling invisible To be treated ring nightmares of my child- A rollercoaster Disrupted a way to succeed
and out of control humanely birth experience of emotions relationships as a mother
R. Elmir et al.

Allen (1998) Pain from contractions, Medical Avoidant behaviour, Anger, tearfulness, Lack of understanding from Detached and
feeling out of control interventions and intrusive imagery, guilt, panic partners; unable to cope overprotective
internal self-blame, inability to and feeling with other children of child
examinations cope distressed
Ayers (2007) Out of control, Not coping, lack Intrusive memories, Panicky, angry,
frightened of choice and flashbacks. aggressive, annoyed,
autonomy irritable
Ayers et al. Perceived self as Depression, anger, Avoidant and rejecting Over-protective
(2006) ‘mutilated’. Suicidal physically drained baby, child blame. behaviour
Avoiding sexual
encounters, strain on
relationship with partner
Beck (2004a) Lack of understanding Difficulties in sexual Numbness and detach from Anger, depressed, Avoidance, being isolated
from health providers encounters. Lack of former self, flashbacks. anxiety, panic from baby
understanding from Suicidal, nightmares attacks
friends. Fear of
pregnancy
Beck and Feeling distressed, Anguish, Detached, distant. Breastfeeding to
Watson (2008) flashbacks, hallucinations physical pain Breastfeeding an act overcome trauma
of violation
Beck (2004b) Lack of communication, Loss of dignity Panicked,
lack of care, powerless, frightened
feeling out of control
Beck (2006) Out of control, drugged Experiencing flashbacks Tearful, angry, Lack of emotional bond
up, strapped to the bed and nightmares. upset between mother and child
Distressing thoughts
(suicidal)
Nicholls and Pain, out of control, Violated, Flashbacks, vivid memories Blame, feelings Anxious, hyper-vigilance Over-protective
Ayers (2007) feeling, continuity of humiliated, of despair avoidant/rejecting bonds. bonds to
care, environment helpless, Avoiding sex and compensate
dehumanized, lack intimacy. Fear of being for trauma
of information pregnant
Thompson and Power imbalance among Faceless, tortured, Intrusive memories. Empty Upset, anger,
Downe (2008) healthcare abused, felt body and devoid of blaming self
professionals, lack of ‘robbed’ personal identity
knowledge and
communication and
decision-making
Moyzakitis (2004) Flashbacks, nightmares and Depression ‘Felt nothing for baby’ lack
intrusive memories. of emotional support and
Detached from self sexual difficulties No help
or support and lack of
opportunity to talk

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JAN: REVIEW PAPER Women’s perceptions and experiences of a traumatic birth

Re-experiencing the event affected their lives and ability to feeling love’ for their infant were short-lived, but for others
function on a daily basis; they felt trapped, with no way of they continued until the baby reached the toddler years
escaping from their ordeal, as they experienced the constant (Nicholls & Ayers 2007). Some women, despite having had
reminder of the event (Moyzakitis 2004, Beck 2006, Ayers previous children, explained that they felt distant from their
2007, Beck & Watson 2008): ‘I just kept thinking about it all infant or child and reported feeling very little emotion and
the time and I felt I had some sort of car crash or something, I physical connection with their baby. Irrespective of the time
kept getting flashbacks all the time and I found it really that had elapsed, they continued to feel a sense of ‘numbness’
upsetting’ (Ayers 2007, p. 261). Often they would avoid (Beck 2004a, p. 222) and were unable to feel a real closeness
situations that would remind them of the original trauma, for to their children, particularly while breastfeeding. Women
example, watching a woman giving birth on television, sometimes ‘hated’ the thought of offering their breast to a
entering a labour room or hospital (Moyzakitis 2004), stranger (referring to the baby) (Beck & Watson 2008,
celebrating the anniversary of the birth (Beck 2006) or while p. 234). They felt empty and demonstrated little emotion or
breastfeeding (Beck & Watson 2008). Women avoided these feelings towards their baby during breastfeeding sessions;
situations and tried to push intrusive thoughts away (Ayers some would rarely make eye contact and interact with their
2007) in an attempt to get closer to their ‘normal self again’ babies (Beck & Watson 2008). In a few cases, breastfeeding
(Beck & Watson 2008, p. 234). For some, this meant ceasing was linked with the violation experienced during birth (Beck
to breastfeed. 2004a).
Recognizing these feelings, women spoke of working hard
to establish a strong bond with their babies. They felt that
A rollercoaster of emotions
they had ‘failed’ them and wanted to compensate them for
The theme ‘a rollercoaster of emotions’ describes the mixed the trauma experienced (Ayers et al. 2006, p. 395, Beck
emotions women felt in response to their birth experiences. & Watson 2008). Some reports described women using
They described heightened levels of anxiety, panic attacks, ‘over-protective behaviours’ (Allen 1998, Ayers et al. 2006,
depression and suicidal thoughts (Beck 2004a, 2006, Nicholls & Ayers 2007) or being hyper-vigilant towards their
Moyzakitis 2004, Ayers et al. 2006). This had an impact infants. For example, they reported favouring the baby to
on their mental health, and they doubted their ability to cope other siblings and excluding their partners from caring and
with day-to-day events and interactions. Some suffered long- attending to their babies: ‘It’s made me so over-protective of
term physical and psychological repercussions from the birth, her…I don’t like other people touching her’ (Nicholls &
including depression, and some contemplated ending their Ayers 2007, p. 503).
lives: ‘I was hugely depressed, I was suicidal’ (Ayers et al.
2006, p. 393). Women also expressed feeling ‘angry’ at Never wanting to be touched: a constant reminder
themselves for not speaking up and voicing their concerns Women’s traumatic birth experiences affected relationships
during their birthing experiences, particularly in relation to with their partners, particularly when there was a lack of
certain procedures being performed, such as having their understanding in relation to the ordeal and the partner was
membranes artificially ruptured (Beck 2004a, Ayers et al. not considerate to their needs. They emphasized a need for
2006, p. 393). They needed their birth trauma to be empathy and to feel supported by their partners when
acknowledged, and some felt quite angry if this need was relaying their concerns about their birthing experiences
not met (Allen 1998, Beck 2004a). (Allen 1998, Ayers et al. 2006, Nicholls & Ayers 2007).
Women felt that their traumatic birth experiences were not
acknowledged or felt by their partner (Ayers et al. 2006).
Disrupted relationships
Some received practical support to care for the baby
For many women the experience of a traumatic birth results from their partners, but emotional support and time to talk
in some disruption in their relationships, both with their about their feelings and emotions were lacking (Moyzakitis
infants and partners. 2004). Conversely, other women spoke of receiving emo-
tional support; however, this fell short of their expectations
Disconnected from the baby and needs.
The impact of birth trauma on the woman and her baby can For many women, sexual intimacy was a constant
be so detrimental that it affects the maternal–infant rela- reminder of the birth event. They often reported avoiding
tionship and induces negative feelings and emotions towards sex for fear of becoming pregnant, and this led to difficulties
the baby. For some women, feelings of disconnection or ‘not in their relationships. Some found it difficult to engage in

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R. Elmir et al.

any form of physical contact with their partners: ‘You just tioning, physical, psychosocial, emotional and behavioural
don’t want to be touched by anybody ever again’ (Nicholls problems (McCain & Mustard 2002, Murray et al. 2003).
& Ayers 2007, p. 499). Some women blamed themselves for Guided by Noblit and Hare (1988), we developed a ‘line of
falling short of their expectations as wives (Ayers et al. argument’ to summarize the key findings of this meta-
2006). The study by Allen (1998) included partners, and synthesis. Women participants in the studies reviewed felt
these men also reported feeling rejected and were frustrated overwhelmed by the experience of a traumatic birth. They
by the loss of intimacy and sexual contact. The tension in demonstrated feelings of disappointment, anger and loss, and
relationships was felt by both partners, and for some many held vivid memories of the experience of a traumatic
couples it resulted in relationship breakdown (Ayers et al. birth for many years. These feelings and experiences at times
2006). affected their ability to care for their babies, and their
capacity to establish a close bond or connection with their
infants and fulfil the expectations of the mother role. The
Strength of purpose: a way to succeed as a mother
support of their partners was considered paramount while
Breastfeeding provided an opportunity for some women to they attempted to reconcile their feelings. Women’s traumatic
overcome the trauma of their birth experiences and prove birth experiences sometimes created strain in relationships, as
their ‘success’ as mothers. They described having ‘strength of lacked interest in physical and sexual contact. Some felt
purpose’; for example, some talked of their determination to depressed, and spoke of feelings of despair and occasionally
succeed at breastfeeding. Some believed that they had suicidal ideations. Women’s perceptions of dehumanizing
committed a ‘sin’ (Beck & Watson 2008, p. 233) by ‘failing’ treatment during labour and birth by healthcare professionals
to have a normal birth, and practices such as breastfeeding may result in feelings of lack of control and a sense of
were seen as a way of compensating for the birth and giving inadequacy. The findings of the studies were overall very
their babies a good start in life: ‘I breastfed her for similar and refutational analysis only identified one area of
27 months’ (Beck & Watson 2008, p. 233). Breastfeeding difference. This related to whether women experienced
and the close proximity of the baby assisted women to heal breastfeeding as a positive and ‘redeeming’ experience or
and recover from their ordeals; more importantly, it resulted whether it was experienced as another burden or trauma
in greater levels of personal satisfaction and confidence (Berg (Beck & Watson 2008).
& Dahlberg 1998, Beck & Watson 2008). Our findings indicate that women are often traumatized as
a result of the actions or inactions of midwives, nurses and
doctors. The care received was sometimes experienced as
Discussion
dehumanizing, disrespectful and uncaring. This is supported
more generally by research reporting negative birth experi-
Review limitations
ences (Fraser 1999, Goldbort 2009). Women who report high
A limitation of this meta-ethnography is that all relevant levels of dissatisfaction with labour and birth care commonly
studies may not have been retrieved. This may have occurred describe midwives and other professionals as unhelpful,
because the keywords selected may not have been compre- insensitive, abrupt and rude (Fraser 1999). Magill-Cuerden
hensive, and because the search strategy was limited to four (2007) state that being sensitive to women’s needs during
databases. However, every effort was made to ensure that a labour and birth is the ‘hallmark of respect’ (p. 126), and that
thorough and extensive database search was undertaken. In respect goes beyond continuity, choice and control.
addition, only studies published in English were included, Healthcare professionals’ demeanour and interactions with
and all the studies had been conducted in developed or women in labour have a major influence on women’s feelings
resource-rich countries. of control of their birth experience (Salter 2009). Research by
Mozingo et al. (2002) and (Eliasson et al. 2008) also iden-
tified feelings of powerlessness experienced by women who
Consequence of traumatic birth
felt that they had no say in what happened during birth when
This meta-ethnographic study has demonstrated that trau- explanations were withheld women were not able to make
matic birth has profound consequences for women and their informed decisions. Goodall et al. (2009) identified that
partners. Further, the impact of a traumatic birth on a woman choice, information and the ability to make decisions may
can also result in poor outcomes for infants and children. facilitate a positive rather than traumatic birth experience.
Infants of women with poor mental health demonstrate Kitzinger (2006) has previously highlighted that for some
poorer cognitive functioning, impairments in language func- women birth is experienced as rape. The term ‘birth rape’ has

2150  2010 Blackwell Publishing Ltd

JAN: REVIEW PAPER Women’s perceptions and experiences of a traumatic birth

be traumatic during their childbirth experience. The literature

What is already known about this topic suggests that many healthcare professionals ignore or do not
• Traumatic birth can have debilitating consequences for recognize the signs of psychological and emotional trauma,
women and is associated with poor psychological and due to their perception that birth trauma is a physical injury
emotional outcomes. (Beck 2004a).
• However, women’s distress following a traumatic birth Some participants in these studies emphasized the impor-
is often not addressed by professionals or in the social tance of continuity of caregiver during pregnancy, labour and
context. birth, particularly in relation to choice, increasing their sense
• A small number of qualitative studies with women who of control and having a satisfying birth experience. Recent
experienced traumatic birth have shown that they have evidence from a systematic review indicates that women
not had the opportunity to voice their concerns. experiencing midwife-led models of care are less likely to
experience attendance at birth by an unknown midwife, have
less intervention in labour and birth and feel more satisfied
What this paper adds with their birthing experiences (Hatem et al. 2009).
• Many healthcare professionals are not communicating
effectively with women during labour and birth, causing Counselling and debriefing following traumatic birth
distress for women. The findings highlight the need for women to have support
• Support from healthcare professionals and continuity of following a traumatic birth. The opportunity to talk about
care during birth are imperative to help women achieve the experience is viewed by some women as cathartic
a more positive birth experience. (Gamble & Creedy 2009). When individuals are able to tell
• Support from partners and greater understanding of their story, this indicates that people are willing to listen.
birth experiences can assist women to reconcile their Pennebaker (2000) suggests that a woman who has the
feelings associated with their birth experience. opportunity to talk about her experience with an active and
engaged listener may also give additional details about her
life, including ‘her view of herself in relationships, her sense
Implications for practice and/or policy of power and her strivings to reach some sort of ideal self’
• Women need to be given the opportunity to talk about (Jack 1999, p. 92). However, there is a debate in the literature
their birth experiences and should be assessed in the as to whether debriefing sessions improve long-term out-
postnatal period for signs of psychological distress. comes for women (Small et al. 2000, Rose et al. 2003). The
• Healthcare providers should work towards midwifery/maternity literature often wrongly uses the terms
implementing continuity of care models as part of ‘talking’ and ‘debriefing’ interchangeably. Gamble and
organizational change and care that is woman-centred. Creedy (2009) argue that most debriefing interventions have
• Further research is needed on the efficacy of debriefing not been specifically designed for use in the immediate
and counselling interventions to support women who postbirth period, and they emphasize the need to design
experience traumatic birth. counselling interventions for this context. They also highlight
that the difference between debriefing and a counselling
intervention where women can share their stories and have
been used by women who feel that their bodies have been midwives help them work through and understand what has
violated, and that they have been coerced into consenting to happened and then offer a positive way forward. When
procedures without being informed of their details and psychological morbidity is not addressed, such as feelings of
accompanying risks. Kitzinger (2006) also identified that hopelessness and helplessness, women are more susceptible to
many women suffering from traumatic birth display similar recurrent episodes of trauma (Gamble & Creedy 2009).
symptoms to rape survivors.
It is sometimes difficult for healthcare professionals to
Conclusion
understand how a ‘natural’ event such as of childbirth can be
traumatic for women. What women perceive to be a Traumatic birth can have debilitating consequences for
traumatic birth experience may be viewed by healthcare women and is associated with poor psychological and
professionals as merely routine procedures (Beck 2004a). As emotional outcomes. However, women’s distress following
Beck (2004b) states, ‘birth trauma lies in the eye of the a traumatic birth is often not addressed by professionals or in
beholder’, implying that birth trauma is what women view to the social context. Participants in these studies indicate that

 2010 Blackwell Publishing Ltd 2151

R. Elmir et al.

they have not had the opportunity to voice their concerns. Ayers S. & Pickering D.A. (2001) Do women get posttraumatic stress
Healthcare professionals also need to be aware of the needs disorder as a result of childbirth? A prospective study of incidence.
Birth 28(2), 111–118.
of women during labour and birth. Recommendations
Ayers S., Eagle A. & Waring H. (2006) The effects of childbirth-
include educating healthcare professionals to support women related post-traumatic stress disorder on women and their rela-
appropriately during labour and birth to have a more positive tionships: a qualitative study. Psychology, Health and Medicine
birth experience. 11(4), 389–398.
Models of midwifery-led care can potentially increase the Beck T.C. (2004a) Post-Traumatic Stress Disorder due to childbirth.
continuity of care and facilitate women’s active participation Nursing Research 53(4), 216–224.
Beck T.C. (2004b) Birth trauma: in the eye of the beholder. Nursing
in their birth experiences. Follow-up counselling and encour-
Research 53(1), 28–35.
aging them to talk about their birth are the first steps in Beck T.C. (2006) The anniversary of birth trauma: failure to rescue.
helping women to recover from such experiences. Findings Nursing Research 55(6), 381–390.
also suggest that women who wish to breastfeed following a Beck T.C. & Watson S. (2008) Impact of birth trauma on
traumatic birth may benefit from additional support to ensure breastfeeding: a tale of two pathways. Nursing Research 57(4),
228–236.
that this is successful. Further research should be directed
Berg M. & Dahlberg K. (1998) A phenomenological study of women’s
towards identifying ways in which women feel supported and experiences of complicated childbirth. Midwifery 14, 23–29.
empowered during their birth experience and to instigating Britten N., Campbell R., Pope C., Donovan J., Morgan M. & Pill R.
support services. (2002) Using meta-ethnography to synthesise qualitative research:
a worked example. Journal of Health Services Research and Policy
7(4), 209–215.
Funding Campbell R., Pound P., Pope C., Britten N., Pill R., Morgan M. &
Donovan J. (2003) Evaluating meta-ethnography: a synthesis of
This research received no specific grant from any funding qualitative research on lay experiences of diabetes and diabetes
agency in the public, commercial or not-for-profit sectors. care. Social Science and Medicine 56, 671–684.
Creedy K.D., Sochet M.I. & Horsfall J. (2000) Childbirth and the
development of acute trauma symptoms: incidence and contribut-
Conflicts of interest ing factors. Birth 27(2), 105–111.
Czarnocka J. & Slade P. (2000) Prevalence and predictors of post-
No conflict of interest has been declared by the authors. traumatic stress symptoms following childbirth. British Journal of
Clinical Psychology 39(1), 35–51.
Dahlen H.G., Barclay L.M. & Homer C.S.E. (2010) The novice
Author contributions birthing: theorising first-time mothers’ experiences of birth at
RE, VS, LW and DJ were responsible for the study conception home and in hospital in. Australia Midwifery 26(1), 53–63.
Downe S., Finlayson K., Walsh D. & Lavender T. (2009) ‘Weighing
and design. RE, VS, LW and DJ performed the data collection.
up and balancing out’: a meta-synthesis of barriers to antenatal
RE, VS, LW and DJ performed the data analysis. RE, VS, LW care fore marginalised women in high-income countries. An
and DJ were responsible for the drafting of the work. RE, VS, International Journal of Obstetrics and Gynaecology 116, 518–
LW and DJ made critical revisions to the study for important 529.
intellectual content. VS, LW and DJ supervised the study. Eliasson M., Kainz G. & von Post I. (2008) Uncaring midwives.
Nursing Ethics 15(4), 501–511.
Fraser M.D. (1999) Women’s perceptions of midwifery care: a
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