Iranian mothers' perception of the psychological birth trauma: A qualitative study.

OBJECTIVE: Childbirth is one of the most vulnerable moments and the most important and memorable events in the lives of women that despite of bringing happiness, it can be associated with psychological trauma and endanger the mother and neonate health. Mothers' perception of the psychological birth trauma is a highly subjective process that depends on the cultural, social and biological conditions of mothers that is not achievable except with examination of their views. This study aimed to understand psychological birth trauma from the perceptions of Iranian mothers.
METHODS: A qualitative research design using in-depth interviews of 23 Iranian mothers was conducted from Tehran and Isfahan health centers. The interviews were transcribed and analyzed using conventional content analysis.
RESULTS: Two themes were extracted from the data: impact of psychological birth trauma and trends of psychological birth trauma. Several categories and sub-categories also emerged from the data. Feelings of fear, anxiety, helplessness and sense of impending death (collapse) were reported by the mothers.
CONCLUSIONS: By considering the unforgettable experience of mothers from the psychological birth trauma, a plan for supportive care before, during and after birth is critical.

Childbirth is one of the most crucial moments of a woman’s life(1). Despite the fact that birth is a joyful event, it can be associated with physiological trauma and for some women, it can be a fearful experience (2), (3), (4). Some women regard birth as a violent incident for the mother or baby, a point between life and death that can lead to disorders in their emotions, feelings and behaviors (1), an event associated with trauma (5). Psychological birth trauma has a similar connotation with “suffering” (2). It emerges during the birth process when the mother feels that there is a serious threat and death risk for her or her baby.

The prevalence of psychological birth trauma has been reported at a rate between 20 to 30%. (2), (5), (3). And Creedyat el 2000, reported that one out of every three births can cause psychological birth trauma. Psychological birth trauma can also lead to women feeling out of control, depressed, anxious and diagnosed with post-traumatic stress disorders (6); (7). In one study, 34% of women perceived birth as traumatic and in 1.9% of cases that has progressed to post-traumatic stress disorder (3). Psychological birth trauma can also hurt family relationships (8), reduce lactation period (9) and in the long term, lead to emotional, cognitive and behavioral disorders in the children of these mothers (10); (11). Currently, the psychological trauma during the childbirth is not routinely assessed in most women and is not treated (6).

Birthing practices in Iran

Iran is located in Southwest Asia with a population of about 70 million, making it the second most populated country in the Middle East. The health status of Iranians has improved over the last two decades. As a result, child and maternal mortality rates have decreased dramatically, and life expectancy at birth has gone up significantly. In Iran, more than 95% of births take place in the hospital (12-14). Currently, about 1.5 million Iranian women are admitted in hospitals for child birthing annually (14). Almost all of the population in Iran is Muslim. As TorkZahrani is noted, ‘‘Islam honors and cherishes the women who give birth’’ (15).

Iranian cultural values view birth as ‘‘women’s events’’, men despite the women`s needs, do not attend labor and birth as a father or a male doctor. Usually, mothers arrive alone in the labor ward and stay with other mothers in the same room during labor. Midwives or other health-care providers are the women’s only source of support at labor and childbirth (15). In recent decades, continuous support during labor in Iranian hospitals has become the exception rather than the routine. Because in such crowded hospitals with limited personnel, mother`s support is not possible. So, Iranian mothers often experience excessive fear and anxiety during labor and birth. According to a study in a health care center in Tehran, 46.5%, 12.1% and 11.1% of mothers experience post-trauma stress disorders, anxiety, and depression respectively 4 to 6 weeks after a traumatic birth (16).

Need for the study

Despite the prevalence of psychological birth trauma, there is little evidence of its effects from the perspectives of mothers (17) especially in Iran. Psychological birth trauma as a concept varies in different cultural, social, economic and environmental contexts. In addition, the perception of the mothers of this phenomenon is completely subjective (4). Simply reviewing mothers’ medical records will not be helpful for recognizing mothers’ perception of psychological birth trauma. Exploring the mothers’ perception of psychological birth trauma will help health professional provide appropriate care needed by these mothers (4). For this reason, this qualitative study was conducted to explain the Iranian mothers' perception of the psychological birth trauma, a complex phenomenon that cannot be perform by a quantitative study.

Material and Methods

The study was performed with a descriptive qualitative approach, which was based on conventional content analysis method to uncover the attitudes, points of view, feelings and experiences of mother experiences (18) Using this method, categories were derived from the gathered data and by this approach; a researcher can reach to a deeper perception of a phenomenon (19). The participants were recruited from the academic health centers, public and private hospitals in Isfahan and Tehran, as well as the home and workplace of participants. The study was conducted from September 2011 to February 2012. Initial interviews were conducted with 94 women to determine their eligibility to be interviewed. This interview consisted of one self-designed questionnaire based on A criterion of PTSD in DSM-IV-R with 4 questions that shows a birth or pregnancy experience being as traumatic. A criterion of PTSD in DSM-IV-R has been used by Soet (2003), Gambel (2005) and Taghizadeh (2008) in order to recognize the mother who experience psychological birth trauma(3),(5),(20). The inclusion criteria included a history of psychological traumatic pregnancy or childbirth, ability to speak and understand Persian language.

To achieve maximum variation of participants, the age, number of pregnancies, educational level, economic, social and cultural status, employment status and mode of delivery were considered. Finally by purposive method, semi-structured interviews were conducted with 23 mothers, after obtaining an informed consent.

Data collection procedures

Approval to conduct the study was obtained from the institution’s ethics committee. The purpose and nature of the study were explained to the participants and a written informed consent was obtained for the taped recorded interview. They were assured of their privacy and also informed that they can withdraw from the study without this affecting their care. The interviews were conducted at a time and place convenient to the participants using an interview guideline. The average time of interviews was about 60 minutes. Interviews were conducted until saturation was achieved.

Data analysis

Taped recorded interviews were transcribed verbatim. The transcripts were read line by line to get a general sense of what the participants were saying. Content analysis was conducted to extract from the mother's expression the initial codes from the interviews (21). Codes were reviewed several times and categorized based on their similarity. Second level coding or data classification was conducted by this way. The groups were compared in the next stage with each other and those with similar characteristics were merged to form themes (22). This method of analysis was useful to obtain a deeper perception of a phenomenon under study (19). The data was managed using software MAXQDA Version 2010.

To ensure rigor and integrity of the data, member check was conducted through supervisor check and peer debriefing. Data credibility was established by face-to-face discussions with any participants and through prolonged engagement. Considering the long-term communication with the mothers, researcher made effort to better understanding of participants` perception. To ensure that no data were lost in analysis process, three academic staff took part as peer reviewers.

To ensure reliability, repeated interviews were conducted to clarify any ambiguity in the previous interviews. Using the purposive and maximum variation sampling covering a diverse range of participants in both Tehran and Isfahan cities provided the data transferability of these research findings.

Result

Demographic characteristics

Twenty three (n=23) participants aged between 18 and 50 years consented to be interviewed. Their educational status ranged from secondary school to the doctoral degree, housewives, employed, and different ethnicities. None had a history of psychiatric drug use or smoking. Experience of psychological birth trauma ranged between 72 hours to 32 years. Their reproductive characteristics are presented in the following Table 1.

Table 1

Characteristics patients with Juvenile Myoclonic Epilepsy (JME) and control cases; mean (SD) or n (%)

Themes	Categories	Sub-Categories
		apprehension
Mothers’ perception of the psychological birth trauma	Childbirth suffering	helplessness
		Collapse and sense of impeding death
	childbirth sequel	Onset of trauma
		Peak of trauma

Qualitative results

Figure 1 show the study results that the mothers perceived the psychological trauma in every point of time during their pregnancy and giving birth as apprehension, helplessness and collapse and sense of impeding death with these continuing feelings more evident at the time of childbearing.

Themes describing psychological birth trauma

The themes described the participant's perception of the psychological birth trauma in the two dimensions: childbirth suffering and childbirth sequel experience. All the obtained categories and subcategories from the mothers's perception of psychological birth trauma in birth transition are summarized in Table 2.

Table 2

Themes, categories and Sub-Categories of the mothers perception of the psychological birth trauma

Percent	Frequency	Classified	Reproductive variables
11	47/82	nulliparous	Parity
12	52/17	Multiparous
6	26/08	Vaginal delivery	Type of delivery
17	73/91	Caesarean section
12	52/17	yes	Has a history of infertility
11	47/28	no
14	60/86	yes	Complications in pregnancy
9	39/13	no
15	65/21	desirable	Wanted or unwanted pregnancy urged
8	34/78	Undesirable
19	82/60	desirable	Wanted or unwanted sex asked baby
4	17/39	Undesirable
17
6	73/91	state	Type of hospital

Childbirth suffering

Mothers’ perception of the feeling of psychological birth trauma was expressed in three subcategories: apprehension, helplessness and sense of impeding death Regardless of their education, knowledge, socio-economic status and place of delivery they expressed their fear as some of the mothers said:

"I was very scared, I thought I would die and couldn’t see my child, I repeatedly called my midwife, and I can’t express myself I just know I was crying and scared, maybe it was an intense stress, it was terrible ".

Feeling of helplessness was reported at a time when they most needed help. One mother said:

"I felt helpless and alone at the time of my pregnancy and birth.” Another mother said:

“At this moment, you feel helpless, you feel you are not able to face it alone, neither your knowledge nor your feelings can help you, you feel that you have reached a dead end".

The mothers expressed that they are directly responsible for the health of their infants, but have no power to change anything, against all the unknowns and potential hazards. One of the mothers said:

“I felt that I must do something but I couldn’t, it was the time that I really couldn’t help myself and my infant, I felt my helplessness is progressing and I couldn’t resist against it”.

With having feelings of anxiety, fear and helplessness, mothers reported that they have reached a state of collapse. They felt a sense of loss of existence and death. One of the mothers said:

“I was crying; I had lost my control, the fear that I had in operation room demolished me moral, my sense of control, and my sense of existence.”

Another mother who has a cesarean section said: “I was scared from childbearing, always thought that I would die if I give birth, the feeling of death is always in my mind.”

Childbirth sequel

The second theme included three categories: onset of psychological birth trauma, peak of psychological trauma and its persistence. The onset of psychological trauma begins on the day of receiving a positive pregnancy test or after a physical problem in the pregnancy before being admitted to the hospital.

For some mothers, it also was reported to begin during labor (labor pains) and especially in the onset of birth as one mothers said:

“Before entering to hospital I was scared, I was scared from pain and anxiety that got more and more by the passing of time.” The peak of psychological birth trauma was pronounced when mothers were admitted to the hospital, especially when they had to have an operation. Most of mothers reported anxiety and fear after being admitted to the hospital as one mother who had to have surgery said:

“I was very afraid when I am being wheeled into the operating room. It was a lifeless atmosphere, not like the one that I had imagined. It didn’t give me any spirit rather it weakened my moral”.

Almost all the mothers affirmed that hospitals are not a friendly and suitable place for childbirth. Physical and human environment of the hospital is a factor for aggravating the occurrence of anxiety and fear in the mothers. Another mother said:

“The worst moment was the time when I entered the operation room. There was a concrete bed with tiled walls. They transferred me to a bed that felt like a concrete slab, like a place that the dead persons are placed to be washed, it was like a death house”.

The continuity or persistence of psychological birth trauma was expressed differently by the mothers. One of the mothers said:

“4 years after birth, still I think that a part of my body has been damaged and there is something that always disturbs me”.

Some of the mothers reported that although they know that fear is completely subjective, they did not the power to deal with the fear and that it has affected their lives that they did not want to get pregnant again as one of the mothers said:

“After 8 years, I still remember the fear, it is always in my mind, it is one of the reasons that I don’t want to be get pregnant again”.

The experience also affected the mothers because they could not get rid of it from their minds that it was like a tape recording that repeatedly played in their minds even though they wanted to forget about the unpleasant experience. One of the mothers said:

“I felt psychologically tired, I tried to go sleep but everything kept on repeating in my mind like a film”.

Discussion

Our study explored the perceptions of mothers who experienced psychological birth trauma as two themes: childbirth suffering and childbirth sequel. The overall results of our study revealed that Iranian mothers like the mothers of other countries experienced psychological birth trauma during their pregnancy and childbirth period. Nilsson and Lundgren (2009) reported that it is completely logical that the birth as an incident associated with life and existence could result in uncontrollable fear. Indeed it is time to pay more attention to understanding the mothers` perceptions related to psychological birth trauma (23).

The mothers` feelings of psychological birth trauma were reported as apprehension, and helplessness leading to a feeling of collapse and sense of impeding death. Results of a study on 8000 Swiss woman showed that despite the progress in medical science and reduction of maternal and neonatal mortality and morbidity, the women still fear about (24).

Apprehension

The study results of Beck and Watson (2010) like our result showed that women experience an intense fear following a traumatic birth. Eleven percent (11%) of Swedish women (25), 5.3% of Swiss women (23), and 78% of Finnish women (26)also were reported to suffer from an intense fear of childbirth. Most of mothers in our study reported fear and anxiety that it affected them from having another pregnancy in the future. (27) Also reported that intense fear has complicated 6 to 10% of childbirths and women opted to cesarean section in order to escape from the fear of childbirth pain. This is similarly reported in the study in Finland, Sweden and England that 7 to 22% of women requested cesarean delivery. The study results of Thomson and Downe (2008), like our result, showed that there was no significant relation between the methods of delivery and incidence of psychological trauma in mothers. It confirms that the delivery process, despite its method, can cause psychological trauma in the mother(28).

Helplessness

Feelings of helplessness in the face with labor, inability in controlling circumstances and inability to change the conditions and environment in the delivery suites caused the mothers to feel that they have lost their sense of existence. Ballard, Stanley and Brockington (1995) in his study discovered that mothers experience feelings of loss of control and helplessness in addition to intense fear (29). Thomson and Downe (2008) also reported that 14 mothers in his phenomenological study reported feelings of helplessness, isolation and a sense of disconnection (28). Such intense negative emotion and fear of childbirth as reported by Nilsson and Lundgren caused the mothers to lose their confidence about their ability to complete the birthing process (23).

Collapse and sense of impeding death

Results of our study showed that the moments and events associated with the birth or being in the operating room caused most mothers to further feel helpless and feeling on a death bed, due to the atmosphere of the operating room being tiled and concrete-like operating table. Thomson and Downe (2008) stated that Swedish mothers also expressed their lived experience of childbirth as a loss of individual existence and being alone in the childbirth experience (28). Nilson and Laundgren (2009) reported that feeling of being alone also increased their fear of childbirth (23). In a qualitative study Essen, Johnsdotter, Hovelius, and Gudmundsson (2000) found that Somali women describe their birth as a point between life and death and bad memories (30).

The mothers also reported that their experience was unforgettable and memorable experience, that last longer than expected. They suffered from lack of communication, insecurity and helplessness. Perhaps the lack of information in Iranian women about their rights and their lack of familiarity with the birth process was a reason of onset of the psychological birth trauma experience.

Onset and peak of trauma

Accordingly the result, the mothers described their experiences of psychological birth trauma as a trend from onset to continuity. This concurs with the study by Beck (2008) who emphasized that birth trauma is an event that occurs during any stage of the childbearing time, and involves mother with an actual or threatened serious injury or death for her or her baby (31). In a phenomenological study, mothers experience of psychological birth trauma was intensified at the birth time, because they did not received caring, feeling of security, and communicating with them have been forgotten by health professionals (31). Even the positive pregnancy test in some mothers caused the onset of psychological birth trauma. Pregnancy disorders also were reasons for the onset or aggravation of psychological birth trauma. With approaching birth, mothers’ anxiety and fear became greater. Inappropriate physical structure and atmosphere of the hospital and carelessness of staff also intensified the psychological birth trauma. Nilsson and Lundgren, 2009, discussed “knowledge limitation about women’s experiences of fear of childbirth” (23). Mention to the result related to onset of trauma, it is clear that medical team should improve their practices in order to decrease their contribution to a childbirth experience being traumatic (31).

Trauma persistence

In this study the mothers` experiences of trauma have been continued. This concurs with the study by Beck (2009) when she reported that psychological birth trauma was experienced by mother’s repeatability and continuously. The experiences impacted the rest of mothers’ lives. The mothers expressed that they felt ill for weeks or months kept on recalling and remembering the experience (32).

Limitations

Although the mothers in this study were not representative of all Iranian mothers, the results of this study provided evidence of the impact of psychological birth trauma that may be experienced by mothers for a long time. However, further research is needed to compare this result with the experience of other women without psychological birth traumatic (31).

Conclusion

The present study adds to the literature “the Iranian mothers` experiences about psychological birth trauma”, that can happened in any stage of pregnancy and childbirth as an unforgettable matter at different stages of the pregnancy and birth, like the mothers of other countries. By considering the success of Iran and many other countries in achieving the two health indicators of the Millennium Development Goals and the International Conference on Population and Development Goals, in reducing maternal morbidity and mortality and increasing the number of births supervised by skilled practitioners, perhaps more attention should be paid for proper planning to protect mothers against psychological birth trauma and preserve their psychological health by designing proper programs to support them throughout the birth process.

Therefore, early assessment of mothers who may be at risk of psychological birth trauma needs to be conducted, and also appropriate interventions can be provided to them as early as possible and should continue long after birth. So training maternity caregivers, especially midwives, to improve their ability to provide emotional support for mother in their childbearing process through counseling with mothers, is very important (5).