By Elisabeth Kulze, Mom-osophy

On childbirth PTSD, obstetric violence, and the legacy of mechanistic philosophy.

While I was giving birth to my first child, my mother was having a panic attack. I’d never known my mother to have a pathological response to anything. Even when her younger sister was dying, she took it upon herself to remain strong for everyone else, and then the morning her sister died, my mother went home, shut her bedroom door, and wept until there were no more tears left. But when my husband informed her that I was experiencing some bleeding while giving birth to her first grandchild, something inside her came loose.

My sister was with her and says she’s never seen my mother, a physician and seasoned meditator, behave the way she did. “Suddenly, she wasn’t there,” my sister says. “I could tell something was terribly wrong.” According to my mother, those eight hours in which she waited for me to give birth were the most terrifying hours of her life. “I genuinely don’t know how I survived it,” she says. “The only thing I could do was try to focus on my breathing.” Several hours in, as they wandered the neighborhoods surrounding the birth center, my sister realized that my mother was experiencing a post-traumatic flashback. Thirty years earlier she’d had a traumatic birth following an elective induction, after which my brother spent two months in the NICU and nearly died multiple times. The experience profoundly impacted my brother’s life, and my family’s more broadly, but no one had ever stopped to consider what my mother had gone through the morning she gave birth—not even her.

“I realized no one had ever said to her, ‘I’m so sorry you had to experience that,’” my sister says. She put her hand on my mother’s shoulder and told her she was sorry for everything she’d gone through and that no one had ever bothered to acknowledge it. My mother promptly burst into tears and wept until my husband called to say that a healthy baby boy had been born.

Childbirth trauma is a major public health issue in the United States, as well as globally, with up to one third of mothers1 describing their birth experiences as traumatic, and up to 20 percent reporting clinically significant symptoms of PTSD, though the number is likely higher given the prevalence of underreporting, misdiagnosis, and an absence of routine screening protocols and any formal diagnosis. (Childbirth PTSD or “CB-PTSD” doesn’t currently appear in the DSM.) But regardless of its high incidence and its devastating short and long-term effects, which can include depression, hyperarousal, and other serious health concerns for the mother; impaired bonding and breastfeeding; reduced maternal affection; negative behavioral and developmental impacts on the baby; decreased relationship satisfaction; and decreased fertility; among other harms, you’d be hard pressed to find a comparable women’s issue that has received less attention, both publicly and in clinical and research settings.

The first research attempting to measure the mother’s psychological response to childbirth trauma didn’t emerge until the late 1990’s, with these early studies demonstrating that the birthing process itself could act as a traumatic stressor, thereby distinguishing post-traumatic responses from symptoms of postpartum depression. And it wasn’t until the early 2000’s that nurse-midwife Dr. Cheryl Tatano Beck began to formalize the field, with her research showing that it was the mother’s subjective experience of the birth, including feelings of helplessness and the experience of a loss of dignity, and not just objective stressors, like medical complications, that could result in clinical PTSD.Despite this early research, when Dr. Sharon Dekel, an Associate Professor of Psychology at Harvard Medical School and the founding director of the Postpartum Traumatic Stress Disorders Research Program at Massachusetts General Hospital, set out to begin studying PTSD resulting from childbirth in 2017, she was met with skepticism. There were those who thought the research would be a waste of time, and that if PTSD was discovered in birthing mothers, it would be the result of some preexisting mental impairment, an argument that eerily mirrors those made during the 18th and 19th centuries when hysteria still appeared in diagnostic manuals. But Dekel, who’d spent years studying trauma and PTSD in other contexts like war and terrorism, decided to charge ahead anyway.

For her first study, Dekel and her team employed the same physiological tools that were used to validate PTSD among Vietnam veterans in the 1980s, which paved the way for PTSD to be included in the DSM for the first time and which were also developed at Harvard, so they were easy for her team to replicate. Because of the number of institutions conducting research in the Boston area, it’s a notoriously difficult place to find study participants, but when Dekel and her team sent out their first posting looking for mothers who believed they were traumatized in childbirth, they received hundreds of respondents within the first few days. They initially only intended to study women who were up to a year postpartum, but because they heard from many women who were five and even ten years removed from the experience, they decided to study them too. The study, which was eventually published in the American Journal of Obstetrics and Gynecology in 2022, showed that physiological arousal, one of the hallmarks of PTSD, was present in women who had traumatic births, and that in some cases the physiological symptoms—including the pulse and breathing rates—of women who experienced CB-PTSD were even more severe than those measured in Vietnam veterans.

“We were able to give validation to these women who were actually experiencing PTSD,” many of whom had been suffering in silence for years, as Dekel told me in an interview las

Suffering in Silence

The issue of gender bias against female scientists, female-led studies, and research about women is a well-documented issue worth mentioning, but beyond gender bias, there is our societal level attitude toward childbirth, which much like our attitude toward motherhood, lacks critical nuance and wavers between two highly reductionist and seemingly incompatible conceptions, in which it’s either the happiest moment of one’s life or a high-stakes medical event defined by inherent suffering. The former narrative encourages silence as women who experience profound suffering and trauma while giving birth are often blindsided, and then left feeling guilty, ashamed, and as if there’s something wrong with them rather than with the circumstances of their births or the care they received. As Dekel has found in her work, many women who were actually brave enough to speak up about the symptoms they were experiencing, whether in the maternity ward or at a postnatal appointment, said that their experiences were minimized or dismissed by the attending providers who believed their birth experiences were objectively “successful,” while others were afraid to say anything because they worried they might be committed to a psychiatric ward or have their babies taken away. For many of these mothers, Dekel’s studies were the first time they’d spoken about their experiences and symptoms to anyone.

“In our studies, we have women who tell me that they are experiencing full-blown panic attacks or repeated nightmares about their childbirth experiences and nobody knows,” Dekel says. “Nobody is monitoring these symptoms. Nobody is educating them about these symptoms. And of course nobody is offering them any kind of intervention because it’s all silent. That has to change. Can you imagine having a heart attack, and no one bothering to acknowledge or observe it?”

The latter narrative, in which childbirth is conceived of as a high-stakes medical event defined by inherent suffering, has long been the dominant one pushed by the entertainment industry and is also the narrative providers often push in response to criticism for intervention overuse, accusations of mistreatment, or attempts by women to take back their agency or to shape their own experiences, whether by coming to childbirth with specific desires and plans, or by choosing to give birth outside of a hospital setting entirely. As I will explore more deeply in part II of this series, this narrative is especially pernicious because it encourages women to fear childbirth, rendering them more vulnerable to both complications and birth trauma. But in regard to our present purposes, the idea that suffering is standard when it comes to childbirth has the effect of normalizing the physical and psychological horrors that many women encounter, leading them to view their traumatic experiences with a sense of resignation.

In my anecdotal experience, there isn’t a single area of life in which women are more resigned to suffering and dehumanizing treatment than childbirth. It took my own mother, a woman with robust medical knowledge, thirty years to even begin to question whether or not the harm and suffering she and my brother endured during and after his birth could have been avoided. And it’s not uncommon that I find myself listening to other women as they one up each other with their dramatic childbirth stories, seemingly unaware that the treatment they were subjected to would be considered inhumane in any other context. As I listen to these stories, it’s often quite easy to imagine that they’re casually detailing their experiences of rape, which uncoincidentally is the most common analogy made by victims of childbirth trauma:2

“I strongly believe my PTSD was caused by feelings of powerlessness and loss of control of what people did to my body.”

“I am amazed that 3.5 hours in the labor and delivery room could cause such utter destruction in my life. It truly was like being the victim of a violent crime or rape.”

“I felt raped and my dignity was taken from me.”

“The labor care has hurt deep in my soul, and I have no words to describe the hurt.”

“I was treated like nothing.”

And while the mainstream, progressive wing of the feminist movement has long been vocal about women’s mistreatment in both the workplace and in intimate relationships, as well as our right to bodily autonomy and reproductive justice, its silence about the suffering3 and and loss of basic human rights women continue to experience while giving birth, particularly in hospital settings, is especially deafening. And even more condemningly, when mainstream feminist voices do speak up about childbirth, it’s often to rally to the defense of the medical establishment4 and shame women who took control over their own experiences in an effort to safeguard their and their babies’ dignity and human rights, and avoid being traumatized and/or physically harmed.

Substandard Standards of Care

In most instances, this is almost certainly true. Providers who are perceived as having mistreated patients are largely acting in accordance with their training (or lack thereof) and hospital policy, as was highlighted in a recent malpractice case5 in which a mother who now suffers from PTSD, chronic back pain, and nerve damage stemming from a 2019 birth sued a hospital for violating her right to informed consent by forcing her to have a c-section when her baby presented as breech. Breech babies were historically delivered vaginally until the late 20th century, but as c-sections became increasingly common, vaginal breech delivery, which requires specific training and increases neonatal mortality and morbidity by an absolute risk of 3.4%,6 is no longer a standard part of the training obstetricians receive in medical school. As a result and as the hospital defense team argued in response to the mother’s suit, c-sections for breech babies are now the “standard of care,” though such a standard, as the mother’s lawyer pointed out, violates both the law of informed consent and obstetricians’ own ethical guidelines when made compulsory.

The problem is that it’s precisely these standards of care—which privilege efficiency, reduced liability, and a hospital’s bottom line over the rights, needs, desires, and wellbeing of mothers and their babies—that are inflicting serious physical and psychological harm, as the prevalence of CB-PTSD is merely one example of. Of course, some degree of birth trauma may be unavoidable. Childbirth does come with inherent risks, and objective stressors, such as unforeseen medical complications for both the mother and baby, can increase a mother’s risk for CB-PTSD, but even in those cases there is a great deal providers can do to ensure a more positive experience for birthing mothers.

As Dekel and other researchers have consistently shown in their work, a confluence of both objective and contextual stressors increase a mother’s risk for incurring trauma and developing CB-PTSD. In the case of objective stressors, Dekel and her team have published multiple papers that show that women who have unscheduled cesareans, whether or not they’re considered medical emergencies, are four times more likely to experience acute psychological stress than women who deliver vaginally. Per her study published earlier this year in Pregnancy, “Stress levels among patients undergoing unscheduled cesareans were persistently elevated over time, while vaginal delivery was associated with a significant symptom reduction. Acute responses strongly predicted subsequent posttraumatic stress disorder and depressive symptoms and maternal-infant bonding difficulties.”

Given this increased risk for PTSD, depression, and maternal-infant bonding difficulties, providers should be ethically obliged to take these potential harms into account, especially when an estimated half a million unnecessary c-sections are performed in the U.S. alone each year, with the obsolete and scientifically dubious diagnosis of “failure to progress” accounting for 25 to 50% of all surgical births, while also being the leading cause of unplanned first-time cesareans. And in the event that a cesarean is medically indicated, which public health experts estimate to be around 10% of cases, mothers should be routinely screened and assessed for CB-PTSD during their hospital stay, so as to be provided with early interventions should they demonstrate symptoms. Other studies have also found that operative vaginal delivery, including the use of forceps, vacuums, and other interventions are associated with higher rates of trauma.

In addition to cesareans and operative vaginal births, there is also the rising use of inductions, which account for 34.5% of births in the US and have increased nearly 39% since 2016 alone. And while the controversial ARRIVE trial showed that an induction at 39 weeks can reduce the risk of a c-section for first-time mothers who give birth in a hospital by 3.6%,7 inductions can also lead to fetal distress, unintended iatrogenic preterm delivery (as happened in my brother’s case), uterine rupture (especially if you’ve had a previous c-section), serious bleeding, infection (if an amniotomy is performed), and even c-sections (in the case of a “failed induction”). And as the midwife Ann Ledbetter highlighted in a recent essay, “It’s an open secret that inductions can be miserable,” as they can prolong labor and make contractions significantly more painful, which is why women who have inductions are more likely to be unsatisfied with their birth experience. And while there are of course valid medical reasons where the benefits of an induction may outweigh the risks, all of these stressors could increase a mother’s risk for CB-PTSD, which should be assessed as a relevant factor. Several studies have also found that 1 in 6 women feel pressured or coerced into having inductions by providers, and coercion itself can act as a contextual stressor that is often seen in cases where mothers develop CB-PTSD.

Some of the most interesting findings in both Tatano Beck and Dekel’s research is that CB-PTSD can occur even in cases where the birth is considered objectively successful by the provider. In these cases, the mother’s mental health and trauma history can play a role, including pre-existing anxiety, sexual trauma, medical trauma, and even intergenerational trauma, none of which is routinely screened for in the context of childbirth. However, even mothers who have no history of trauma or other mental health conditions and who also experience “successful” births by provider standards can develop CB-PTSD. In these cases, contextual stressors, including provider actions and interactions, can create an environment in which birth trauma may occur. These stressors include feeling disrespected and unsupported by the providers; feeling abandoned, rushed, coerced, or pressured; feeling like one’s embodied knowledge was ignored; poor communication; being yelled at or threatened; experiencing a loss of agency or a lack of participation in decision making; and being treated like an object.

“In our studies, people say that they felt like providers were talking about them without engaging them in the conversations and treating them like a body instead of a real person,” Dekel says.

Studies have also shown that Black mothers, who are more likely to experience birth complications, maternal and neonatal mortality and morbidity, as well as mistreatment, are more vulnerable to birth trauma, and similar disparities have been found in indigenous and Latina mothers. One of Dekel’s studies found that Black and Latina mothers were twice as likely to experience acute stress during childbirth, even when controlling for obstetric complications and socioeconomics, suggesting that psychosocial stressors, like racism and other forms of mistreatment, could be a key factor here.

Given the relationship between these stressors and the incidence of childbirth trauma, it shouldn’t surprise us that the rates of birth center births, which follow a midwifery model of care, and intended home births have risen substantially in recent years, with the greatest increases being seen amongst Black and Hispanic patients, and a desire for fewer interventions and more personalized, human-centered care being cited as primary reasons for choosing to opt out of a standard hospital birth. According to a first-of-its-kind study that examined mistreatment in the context of childbirth in the US, birthing mothers are nearly six times as likely to experience forms of mistreatment in a hospital vs. at home, and are also less likely to experience mistreatment with a midwife or at a birth center. According to the study, mistreatment by providers fell into four major themes: “prioritizing the care provider’s agenda; disregarding embodied knowledge; lies and threats; and violation,” all of which were associated with birth trauma and constitute “ a violation of basic human rights.” And while I don’t think it would be fair to attribute the incidence of childbirth trauma (the event) and CB-PTSD (the resulting psychopathology) to hospital providers themselves, it seems clear that the system in which providers are made to operate is directly contributing to birth trauma and is almost certainly 100% responsible for the failure to adequately address it.

The Mother as Machine

Despite what governing bodies would like us to think, this reliance on metrics, data analysis, proceduralism, and standardization (all forms of machine logic) doesn’t holistically improve care, but instead decreases patient satisfaction and undermines real clinical expertise, which is a form of embodied, experiential knowledge (or “phronesis”) that is developed and strengthened through repeated use, and which does a far better job of attending to the immeasurable, and thus the whole. The intrusion of technology into medicine also serves to exacerbate this analytical detachment, not only between providers and their own wisdom, but between provider and patient, and even between the patient and their own body, so that in all instances the relationship becomes one defined by fear and distrust, which in turn feeds metric-reliance because “the demand for measured accountability and transparency waxes as trust wanes.”9

The legacy of mechanistic philosophy impacts all areas of medicine, but in childbirth, an event in which subjective experience is primary and functions in a reciprocal relationship with objective outcomes, the violence it inflicts is especially apparent. The reduction of childbirth from a complex physiological, emotional, and psycho-spiritual event that unfolds independent of human involvement to a mechanical process that requires metrics-informed management is ultimately an attempt to cope with our own fears and distrust by rendering childbirth legible in the context of our limited knowledge, so as to create opportunities for exploitation and control. And while reductionism has allowed for many biomedical advancements in a research context, in a care context it fosters a form of neglect that is experienced as violence, and childbirth trauma and CB-PTSD should be understood as responses to this violence.

Childbirth is not mechanical or even pathological, but a human experience as multi-dimensional as human beings are themselves, and unless all of these dimensions are being actively attended to and considered as part of every decision-making process, then we are not attending to mothers and infants as whole persons. And when people are not treated as whole, the likelihood that they will emerge from such an experience profoundly wounded is significantly greater.

Proposed solutions for the prevention and treatment of childbirth trauma and CB-PTSD include limiting unnecessary interventions, providing more personalized care, incorporating standard screening protocols, much like those already used for postpartum depression, and providing personalized, early therapeutic interventions for mothers exhibiting symptoms, though as Dekel notes in her systematic review of prevention and treatment interventions, “Presently, there is a critical gap in knowledge to inform recommendations to prevent and treat CB-PTSD.” And while I believe all such solutions are warranted, what is really needed is a society-wide transformation of how we view and treat childbirth, so that women might emerge from the experience with a deeper sense of love and respect for their bodies, and more confidence in their own strength and ability to trust in what they cannot control, all of which offer a tremendous advantage when navigating the complex terrain of early motherhood. To be sure, perhaps the greatest tragedy of childbirth trauma is the loss of these advantages and the experience of their opposite, which Dekel describes as “a violation of the mother’s psychic integrity.”

As I will argue in part II of this series, which will outline my approach to childbirth on both a philosophical and practical level, childbirth is a critical part of the intelligent design of the motherhood continuum. It’s a crucible in which a mother can encounter stores of strength and trust that far exceed her previously limited sense of self. And this can be true, even in cases where trauma occurs. As Dekel has highlighted in her research about posttraumatic growth, some mothers experience positive psychological changes as a consequence of overcoming trauma, growing in ways that exceed their pre-trauma selves, especially when provided with the proper support. These positive changes can include a greater appreciation for life and a sense of personal strength, both of which are positively associated with mother-infant bonding.

When I asked Dekel, who’s heard thousands of women recount the story of their traumatic births and their aftermath, what a decade of research in this area has taught her, she told me that the first word that came to her mind was “resilience.” “Women have an incredible ability to be resilient in the face of adversity,” she told me. “Women like your mom.”

My mother alternated between the same dissociative and panicked states when my brother’s wife, the brother who nearly died multiple times during his two-month NICU stay, gave birth to her second grandchild a year and half after me. But when my sister decided to give birth at home, my mom was entirely supportive and even had the opportunity to attend. It was the first birth my mother had been present for since her own children were born decades earlier. She was nervous at first and made the decision to leave the room so as not to disrupt my sister. She sat on the stairs outside the bedroom door, and it was during those hours that the bitter seed of her trauma began to dislodge itself. She listened to the way the midwife spoke to my sister and the way my sister responded, and the sense of calm and trust embodied by their exchanges let her know that everything was ok. “All the fear and panic I’d been carrying around for all those years just melted away,” she says. “And then I started to feel excited, like a kid on Christmas morning. It was magical.”

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