Some Keys to Unlocking the Birth Trauma Puzzle
According to recent sources the incidence of birth trauma in Australia is currently estimated at somewhere between 30% and 50%. This quite likely represents the tip of the iceberg. The actual figures could well be higher given that the signs and symptoms of trauma are often insidious and the extent of self-reporting highly variable.
This is a staggering statistic and an indictment of our birth culture in 2017.
We cannot even begin to estimate the physical, psycho-emotional and social fallout from birth trauma in our society if we consider these epidemic levels.
So what is trauma, how does it develop and why is it so rife in relation to birth?
As humans we all experience overwhelming situations in our lives. When this occurs, our autonomic nervous system sets off a defensive response of flight, fight or freeze to varying degrees. This is our primal survival system which keeps us safe and alive when we feel exposed to real or perceived threat. A healthy nervous system will naturally return to regulation if we don’t inhibit its innate capacity to re-set itself and allow flow between the states of settling and activation..
Trauma on the other hand is described as the feelings of physical and psychological overwhelm which remain as a lasting response to a threat that is no longer present in time. It is a result of a stimulus that is outside of our normal range of resiliency and approaches too fast for us to process and integrate. Our nervous system remains stuck ON or OFF and cannot return to flow and coherence.
Symptoms of trauma may include anxiety, panic attacks, depression, hyper- or hypo-sensitivity, sleep disturbances, hyper-vigilance, numbness and a sense of being disconnected from our bodies and feelings, chronic fatigue, chronic or mysterious pain patterns, addictions of any kind, cognitive dysfunction, sexual dysfunction, auto-immune disorders, gastro-intestinal disorders and other debilitating states. Behavioural patterns can also emerge that impact our interpersonal relating such as avoidance, hyper-reactivity, shame, guilt, helplessness, overriding our limits, boundaries or awareness of potential danger.
The key to understanding why these symptoms occur lies in our mammalian biology. Neuro-scientsit Stephen Porges proposed that our primitive neural circuits operate involuntarily to evaluate risk in the environment, below the level of our conscious awareness. When confronted, humans and other mammals experience autonomic responses such as an increase in heart rate and sweating hands accompanied by a rise in adrenaline levels to deal with potential threat (Porges, 2011).
Dr Peter Levine, renowned for his pioneering work in the field of trauma, found that even though animals in the wild are routinely exposed to potentially traumatic events, they rarely suffer from symptoms of trauma. If a fleeing animal manages to escape from its predator while being chased, it literally shakes off the adrenaline spike from the event and re-joins its herd. We humans on the other hand have learned to inhibit or override these instinctual responses of our bodies, often for reasons of sociability or shame. By doing so we thwart the natural physiological conclusion of the threat response which may have taken the form of shaking, trembling, hitting, running, stomping, crying, shouting or other physical actions.
An animal that does not escape after fleeing from a predator may fall to the ground immobile at the moment of capture. This is known as the freeze response and is a kind of endorphinised altered state which minimises the animal’s suffering at the time of death. But it also has survival value: if the predator does not kill its prey immediately, it may still rouse from its trance and escape (Levine, 1997).
When we as humans are unable to physically complete the fight or flight response, our nervous system defaults to the freeze response. The frozen, immobilised state may look calm on the outside but can internally be likened to what happens when we step on the brake and accelerator of a car at the same time: a huge amount of energy is generated, usually below our conscious awareness. When powerful survival energies are not discharged they remain bound in the nervous system.
Fuelled by our cognitive and somatic memories of events, the charge of these incomplete threat responses may over time lead to entrenched symptoms of trauma. The body effectively remembers the original overwhelming experience and the person remains stuck in a particular way of reacting as a residue from that experience, no matter how much the feelings are rationalised or willed away. Choice and resilience become compromised and the person’s world becomes constricted.
The nervous system is thus said to have become dysregulated or lacking in its healthy range of response options between activation and settling. In order to heal and recover this resilience, it is found that we have to work with the residual charge from the events which triggered the survival responses of flight, flight or freeze at the level of the nervous system. (Levine, 2010). Since these instinctual responses are generated in the most primitive part of the nervous system, symptoms of trauma tend to be related to the functions regulated by those aspects of the brain: breathing, heart rate and blood pressure, appetite and digestion, sex and sleep.
Trauma is therefore not so much about the precipitating event or “story” but rather about the physiological imprint of the perceived threat as undischarged energy of the fight, flight or freeze response which remains in the nervous system.
What one person finds threatening may be insignificant to another, and the impact of major and minor threats is found to be cumulative. The likely triggers of trauma are wide-ranging and the more obvious ones include natural disasters, exposure to violence, accidents, falls, serious illness, sudden loss of a loved one, anaesthesia, medical, dental and surgical procedures, childhood neglect or abuse, misattunement of caregivers to our emotional needs, difficult births, and high levels of stress and toxicity during gestation. But that in fact is not the whole story.
Any situation which places an individual’s nervous system on high alert has the potential to precipitate trauma.
We understand from the hormonal physiology of childbirth (Buckley, 2014) that conditions conducive to normal physiological birth include a calm, supportive environment, warmth, dim lighting and a lack of direct surveillance, and feelings of safety – in other words, the very conditions that keep the human nervous system from becoming highly activated and vigilant for the presence of threats.
Consider then our modern birthing environment: clinical setting with bright lights, medical equipment, alarms, code blue announcements, odours which may trigger negative memories of previous hospital visits, hospital bed, surgical gown, not to mention the complexities that anaesthesia and surgery bring to the mix. Add to this authoritarian birth practices, the full medicalisation of birth itself, poor continuity of care or emotional attunement for the birthing mother, separation of mother and baby, and a birth culture dominated by fear and politics.
Then stir into the boiling pot the already heightened sensitivity of the birthing woman, the belief she may have internalised that birth is dangerous unless proven otherwise, and her lack of trust and confidence in birth on a visceral level. Human mammals especially females often resort to social engagement or befriending the “perpertrator” or source of threat as a first line of defence. This often translates to acquiescence to minimise harm to themselves or their children. As she hands over her inner authority to the experts in medicalised birth who surround her, her ability to access primal birthing states where oxytocin, beta-endorphins and other favourable birth hormones are flowing freely, is highly compromised. She is naturally on guard, scanning her surroundings for threats which she already anticipates. She cannot safely drop into the instinctual realm of birth where the outside world disappears and she is left alone with the compelling power of her birthing body.
It is no wonder then that this territory is ripe for alerting a woman in birth to potential threats, and this in turn has a snowballing effect on her already vulnerable nervous system.
Given that fleeing or fighting from perceived threats is not usually a viable option in birth, the labouring woman is akin to captured prey. The only way to deal with the threat then is to freeze, dissociate or collapse – to disconnect from her body and her emotions. If anaesthetics of any kind are part of the cocktail, there will be a further dis-embodying and dissociating effect. And if traumatised in this way, the symptoms may be even less visible to the onlooker in the weeks, months and years of holding the memory of the traumatic events in her body.
If one assumes the absolute sentience of newborn babies and the strong limbic resonance between mother and baby, the impact of traumatic birth on women and therefore their babies and whole families is far-reaching and frightening to contemplate.
All of this seems insurmountable.
But regardless whether birthworker or birthing mother, we all have a voice.
The thing is, how will we use it?
How can we as a society change this situation urgently?
What are the birth practices and institutions that require a radical overhaul to facilitate true woman-centred care?
What can we each do within our power to create birth environments which mitigate the triggering of threat responses?
What are the qualities of our own presence and behaviour as birth workers that will support the resilience of the women we serve in birth?
Is it possible to educate women and their partners to become less pervious to their outer reality in birth – to create an oxytocin buffer of embodied trust in order to access their primal birthing abilities, and to neutralise the impact of their birth environment?
Can we encourage birthing parents to clear the imprints of their own birth trauma or that resulting from previous birth experiences in a timely way?
When and how do mothers need to be supported post-natally to reduce their distress?
And there trauma first aid measures that might reduce the likelihood of an entrenched trauma response?
These are among the questions that fuel my work with birthing women and sometimes keep me awake at night. I suspect that I’m not alone. If the prevalence of birth trauma is of concern to you as a birth worker, I invite you to share your thoughts & ideas in the comments section below.
Alcorn, K., O’Donovan, A., Patrick, J., Creedy, D., Devilly, G. (2010). A prospective longitudinal study
of the prevalence of post-traumatic stress disorder resulting from childbirth events. (p 1849-
1859). Psychological Medicine. (40). Cambridge University Press.
Boorman, R., Devilly, G., Gamble, J., Creedy, D., Fenwick, J. (2014). Childbirth and criteria for
traumatic events. Midwifery. 30, 255-261.
Buckley, Sarah J (2014) The Hormonal Physiology of Childbearing Report
Fernandez, O. (2013). PTSD and obstetric violence. Midwifery Today. 48(3), 105-109.
Levine, Peter A (2008) Healing Trauma
Levine, Peter A (1997) Waking The Tiger
Levine, Peter A (2010) In An Unspoken Voice
PATTCh (Prevention and Treatment of Traumatic Birth). 2012. PATTCh Resource Guide on PTSD After Childbirth. Available at PATTCh.org.
Porges, Stephen W (2011) The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication & Self-regulation
Yates, A. 2017 Women’s experiences of emotionally and psychologically traumatic birth; hegemony and authoritarianism in Victorian public maternity settings. Masters by Research, Health and Biomedical Sciences, RMIT University.
Nisha Gill is the founder of Feminine Instincts ~ Melbourne Holistic Wellbeing & Birth Services. She works holistically in the fields of childbirth education, bodywork, counselling, Somatic Experiencing® (body-centered trauma therapy), pre- and post-natal yoga & supporting women in birth as a doula.