Kari had her first baby via Cesarean section in 2011 and it was all fairly routine. Her doctors believed it was necessary. The baby was healthy. She was healthy. Though she had some sadness about the birth experience, ultimately everyone was fine.
But when she got pregnant again two years later, Kari, 36, decided to try for a vaginal birth after cesarean (VBAC). She found a doctor who was supportive and whom she adored. He assured her that the other obstetricians in his practice were also on board with the procedure if she happened to go into labor when he wasn't on call. She hired a doula to help support her through her birth.
At 39 weeks, Kari's water broke. When she arrived at the hospital, she was told her regular doctor was not there and because it was nighttime, it was policy not to contact him. Hours later, her labor had not progressed, so she was induced. Shifts changed, and another doctor came on. It was clear to Kari, almost immediately, that it was a bad fit.
"First, [the doctor] kept pushing me to get an epidural. She said, 'If something catastrophic happens, it'll be horrible, they'll have to knock you out and your husband won't be able to come in,'" explained Kari, who wanted to at least try and labor without pain medication. She also made it obvious to Kari that she would have opted for a C-section right away, rather than inducing her.
The doctor was irritated that Kari got up to use the bathroom several times, which meant removing the fetal monitoring strip, again urging her to get an epidural so she could be catheterized and stay in the bed. Once Kari came out of the bathroom to find a nurse waiting right outside the door. "The doctor said if you go to the bathroom again and take [the fetal monitoring strip] off, you're having a C-section," she warned. At another point, the doctor came in to discuss Kari's progress in the middle of an intense contraction. Kari couldn't speak, so her doula answered. The doctor held her hand in the woman's face and told her she refused to speak with anyone but the patient, effectively silencing her. Then there were the frequent cervical checks, which at the hands of a woman she didn't trust, felt rough. Physically, Kari felt violated.
Kari was beside herself. "I just kept thinking, 'I'm terrified of this woman,'" she said. "I was in disbelief about how she was acting, and I just kept thinking, 'If she performs surgery, she's going to hurt me. She's going to punish me.' I was not in a logical space, clearly, but she just seemed so angry with me.'" At one point, her husband spoke with the doctor in the hallway, reminding her that his wife was doing the best that she could and that the doctor needed to be more respectful.
Eventually, Kari got an epidural, at which point she immediately began vomiting. The baby's heart rate dipped. Kari had only dilated four centimeters, so the doctor said it was time to have a C-section. Kari was wheeled into the OR. She remembers someone asking, "Where is the husband?" and someone else answering, "I forgot to get him." Under the bright lights, Kari alternated between passing out and violently throwing up. Vomit ran down her face, into her hair. When her husband finally came into the room, he was horrified by what he saw. After, he tearfully confessed to the doula -- who was not allowed in the OR -- that when he saw his wife like that, he thought she might die.
In the end, both Kari and the baby were physically healthy, and for that she is deeply grateful. But emotionally, she was devastated by the birth. A month postpartum, she received a diagnosis of post-traumatic stress disorder (PTSD).
"I'm not upset that I had a C-section," said Kari, who saw a counselor once a week for a full year to get her postpartum PTSD and depression under control. "It's how I was treated."
What one woman perceives as a "normal" birth experience may be deeply, psychologically troubling for another -- but that doesn't make the trauma any less real.
Postpartum Support International, an advocacy and support group, estimates that approximately 9 percent of new mothers experience PTSD, a disorder that is often associated with war veterans, but that can be triggered by a trauma of any kind. Fear sets off the body's fight-or-flight reflex, which takes time to settle back down -- though most people do recover. With PTSD, however, the body gets stuck in that hyper-vigilant state, leading to flashbacks, extreme avoidance, insomnia, detachment and more. A woman with postpartum PTSD won't just be upset by remembering her birth; she will have a physiological, bodily response to it.
What makes postpartum PTSD easy to overlook, and to minimize, is that while some triggers are obviously traumatic -- say, the near-death of an infant, or searing, unimaginable pain -- others are far more subjective, even invisible. What one woman perceives as a completely normal birth experience may be deeply psychologically troubling for another -- but that doesn't make the sense of trauma, or its consequences, any less real.
"Say you have a mom who, on paper, had a very normal, low-intervention vaginal birth. She had no tearing. She had her OB there. She didn't have too much pain," said Kate Kripke, a clinical social worker and founder of the Postpartum Wellness Center of Boulder. "On paper, it looks textbook. But if at any point during her experience her sense of safety and security felt truly threatened, she can come out of it being traumatized."
Several grassroots organizations are attempting to bring greater consumer attention to the problem, including Improving Birth, an advocacy group that began in California in 2011. Though it wasn't necessarily its initial aim, Improving Birth has drawn a great deal of attention to the concept of "obstetric violence" through social media campaigns and rallies, according to Dawn Thompson, a doula and the organization's founder. That violence can be physical (as in the case of a provider performing an unwanted episiotomy, or restraining a mother on a bed). But often it takes the form of emotional harm, the kind that is all too easy for outsiders to dismiss with a pithy, "all that matters is that you're all healthy."
"Most of the women [we speak to] are experiencing a form of obstetric violence that is coercive and disrespectful communication by nurses, and doctors and midwives," Thompson said.
Currently, there is no legally recognized definition for "obstetric violence" in the United States, though some countries have embraced it as a legal term, and the World Health Organization has called for increased scrutiny of disrespectful childbirth practices around the world. "In America, this would be an offshoot of a battery claim, or an informed consent claim, or informed refusal claim," said Eric Frisch, a Georgia-based attorney who represents physician practices and hospitals in health care liability cases, and who explored the idea of obstetric violence in a piece for Law Journal Newsletters. "There just aren't a whole heck of a lot of cases out there," he added.
Which means that for now, at least, questions about what obstetric violence is -- and how much it contributes to postpartum PTSD -- are largely left to play out in individual labor and delivery units across the country, each with its own culture and rules. Under those circumstances, it is unclear to what extent the issue is actually being addressed. Maternity care in the United States has many problems. It is incredibly expensive. It is plagued by increasing maternal mortality and high C-section rates. In the face of all that, the psychological outcomes of mothers can seem like a secondary concern.
A crucial piece of preventing birth-related trauma is making sure women don't feel they've been stripped of their voices during childbirth, even though (or perhaps because) so much of what happens during birth is simply beyond their control.
And for some critics, charges of widespread birth trauma and obstetric violence are an off-shoot of what they perceive as a cult of natural childbirth -- the desire to have a vaginal, drug-free birth above all else. But others see obvious room for improvement in the culture of many maternity wards across the United States.
"I think there are many things [during birth] that are perceived as life threatening or emergencies, and the way you're trained as a physician is you just gotta do what you gotta do ... it's your responsibility to make sure they come out OK no matter what," said Dr. Emiliano Chavira, a Los Angeles-based OB-GYN.
"It sounds very rational and beneficent, and I don't think there are any obstetricians who are out there to traumatize women and cause PTSD," he continued. "But I do think sometimes we get trained with this ethos to such a degree, and you can carry it so far, that it's at the expense of other ethical values, like patient autonomy and compassion." The fear of malpractice litigation also forces some doctors to favor C-sections, he believes.
Chavira thinks of childbirth as a dance. A mother may have to concede that she cannot stick to the birth plan of her dreams because circumstances simply do not allow for it. And her physician should be able to communicate with her respectfully and recognize that for many women, birth is an emotional and spiritual event, not simply a medical one, Chavira said.
Ultimately, experts seem to agree that a crucial piece of preventing birth-related trauma is making sure women don't feel they've been stripped of their voices during childbirth, even though (or perhaps because) so much of what happens during birth is simply beyond their control. It can be as simple as a doctor or midwife asking how a mother is doing, and explaining clearly and kindly what is about to take place, Kripke said. In rushed moments, even eye contact can make a difference.
Sara, 30, is a testament to the role that respectful communication plays in determining a woman's outcome. Going in to her first birth three years ago, she didn't have much in the way of a birth plan, although she was very clear that she didn't want to have a Cesarean delivery unless it was necessary. The idea of major surgery just "freaked her out." Sara's doctor reassured her that of course they would not perform a C-section unless it was truly needed.
Then three days after her due date, Sara was induced with Pitocin. A few hours in, the IV fell out, causing her labor to stop. Relatively soon after nurses fixed the IV, and Sara's contractions re-started, her doctor came in. "She said, 'We're going to do a section in 30 minutes,' and I freaked out," Sara recalled. "She said, 'Well, you know me. I'm your doctor and I need to leave soon. If I'm not here there's going to be another doctor that has to do C-section ... there were no indications that anything was wrong with my son, or with me, it was like, 'I need to go home, so let's do a C-section.'"
At that point, Sara became unglued. The thought of being awake while in surgery was too much for her to handle, and she begged the doctor and anesthesiologist to put her under. Ultimately, they convinced her that she'd want to be awake for the birth of her son, and the nursing staff and Sara's husband attempted to distract her while her OB-GYN worked away on the other side of the curtain. The anesthesiologist gave her extra drugs to try and keep her calm. "I know [that surgery] is very common," Sara said. "But it freaked me out. You don't feel pain, but you feel a lot of pressure and, oh my god, I could not get my head around it." It took all of her mental strength to keep still on the table and not be a hassle to the OR staff, but she was sobbing. "I have never been that scared in my life."
When her son was born, Sara remembers her husband saying "He has so much black hair!" ... then nothing. Because she continued to cry unconsolably, Sara's doctor and anesthesiologist decided at that point to put her under, while they stitched her back up. "It's basically because I was loud," she said ruefully. When she woke up a little over an hour later, she was not allowed to hold her son.
"When your baby is born, you have that moment when you're like, there's this person who I've been carrying around for nine months and then they're here," she said, pausing to collect herself. "I didn't have that at all. I don't remember seeing him. When I woke up, there was no one in my belly anymore, and it felt like I had this child that I was babysitting. It took me several weeks to feel any connection with my son, and that made me feel like just the worst mother in the world."
Sara put the birth entirely out of her mind for about six months, until she and her husband had their first serious conversation about maybe trying to get pregnant again. At that point, memories of the birth flooded back, threatening to pull her under. One afternoon, her son smiled up at her and Sara thought to herself, OK, I can do this. I can smile back at him. But physically, she couldn't make the muscles in her face obey. Eventually, she saw a counselor and was diagnosed with PTSD.
Once again she had a C-section, but this time it was wonderful.
A year ago, Sara gave birth to another baby and the difference with her earlier birth experience was stark. Once again, her labor didn't progress and once again she had a C-section, but this time it was wonderful. She had a doula who knew about her previous trauma. The doctors and nurses were kind and patient, Sara said. They did simple things that helped her feel connected to the birth process, and to her baby. As soon as the baby was born, doctors lifted her up over the curtain so Sara could see her daughter. They helped bring her skin-to-skin.
After, in the recovery room, Sara pulled her doula aside and asked her, "What did they put in my IV? Because I feel champagne wasted," she laughed. "She was like, 'Um, nothing. Those are just the happy birth hormones!'"
"At my first birth, it felt like no one cared about me aside from 'Let's make sure that everyone is alive,' which is of course the most important thing," she said. "But when they don't leave [you] emotionally intact, it's impossible to be the kind of mother you want to be."
By speaking out about their traumatic birth experiences Sara, and women like her, have begun to heal their psychological wounds. At the same time, they are using their painful experiences to empower others to advocate for their own rights in the delivery room.
Correction: An earlier version of this article misidentified Postpartum Support International.