Women's experience of psychological birth trauma in China: a qualitative study

Analysis of influencing factors of psychological birth trauma among postpartum women in China: A multicenter cross-sectional study based on the ABC-X model

BACKGROUND

Little is known about the influencing factors of psychological birth trauma (PBT) among postpartum women in China.

METHODS

A multicenter cross-sectional survey was conducted from April to June 2023 among 2230 women within one year postpartum by convenience sampling. The measurement tools were selected based on the classical ABC-X model. PBT (factor X) was assessed using the Psychological Birth Trauma Assessment Scale. Data on predictors were collected from three aspects, including birth events (factor A), women's coping resources (factor B), and perception of birth events (factor C). Univariate analysis, correlation analysis, and multivariate linear regression analysis were performed to identify the influencing factors of PBT.

RESULTS

Multivariate linear regression analysis results showed that induced labor onset (β' = 0.086, P < .001), preterm birth (β' = 0.049, P = .001), instrumental vaginal delivery (β' = 0.031, P = .039), neuroticism (β' = 0.229, P < .001), and negative cognitions of birth events (β' = 0.375, P < .001) were risk factors for PBT among postpartum women in China. Perceived social support (β' = -0.175, P < .001) and nursing support (β' = -0.117, P < .001) were protective factors. These factors accounted for 52.5 % of explained variances in PBT.

CONCLUSIONS

Multifaceted influencing factors of PBT were identified based on the ABC-X model. Such efforts seem to provide information for identifying women at high risk of PBT and formulating interventions aimed at preventing or reducing PBT and its associated adverse consequences. Additional well-designed studies are required to validate our findings and deepen the understanding of this topic.

Systematic Review and Meta-Analysis of Prevalence and Risk Factors for Psychological Birth Trauma

OBJECTIVE

The aim of this study was to determine the pooled prevalence of and risk factors for PBT.

METHODS

The Cochrane Library, Web of Science, PubMed, Embase, and Scopus databases were systematically searched between their inception and October 1, 2023. Pooled prevalence, odds ratio, and 95% confidence intervals were calculated using fixed- or random-effects models using Stata 15.0.

RESULT

The pooled prevalence rate of PBT was 19%. We performed subgroup analysis based on age, parity, region, and measurement tools. The results showed differences in the prevalence of PBT between these subgroups, suggesting the need for clinical personalization in different populations. The pooled odds ratio showed that fear of childbirth, cesarean section, operative vaginal birth, pain during labor, and dissatisfaction with support from midwives were significantly associated with PBT.

DISCUSSION

The study found that the pooled prevalence of PBT was 19%. PBT risk factors are diverse, and understanding the prevalence and risk factors for PBT has important implications for healthcare and social care systems.

The traumatic childbirth experience of mothers after emergency cesarean section(EmCS) in China: a descriptive qualitative study

BACKGROUND

Emergency cesarean section (EmCS) is an effective means to save the lives of the mother and fetus. Women who undergo EmCS experience sudden physiological changes and high level of psychological stress response due to its complexity, risks, and urgency. They may consider their delivery as traumatic childbirth. This study aims to understand the traumatic childbirth experience among women who underwent EmCS, as well as providing evidence for developing preventive measures in future.

METHODS

Sixteen women who underwent an EmCS in the past year and experienced traumatic childbirth in a tertiary hospital in Luoyang, Henan Province had participated in semi-structured, in-depth interviews between February and May 2023. Thematic analysis was used to analyze the data.

RESULTS

Four themes and ten sub-themes were extracted from the data: Theme 1: Journey from crisis to renewal: the psychological recovery process of women experienced traumatic childbirth after EmCS (stress phase, reaction phase, emotional processing and adjustment phase, and stabilization and reconstruction phase); Theme 2: Empowering mothers and families: addressing the multifaceted needs of comprehensive perinatal health education (insufficient individualized care: diversity and challenges of maternal needs, the gap in spousal involvement in perinatal health education); Theme 3: The barriers between patient-professional communication in healthcare (breaking the silence: needs to address the ineffective communication, beyond the diagnosis: needs for empathy in healthcare); and Theme 4: Limited family support (the forgotten mothers, husbands' emotional absence).

CONCLUSIONS

This study contributed to our understanding of the childbirth process for women undergoing EmCS. Women in this period experienced a range of negative emotions, they were lacking in sufficient health education, good communication between healthcare professionals and adequate family support. The research findings are valuable for us to identify their difficulties and needs, enabling us to provide assistance.

The mediating role of coping style in the relationship between fear of childbirth and psychological birth trauma among natural childbirth women in China: a structural equation model analysis

BACKGROUND

Psychological birth trauma represents a significant global public health concern, with an estimated 45% of new mothers reporting such an experience. Researchers mostly focus on the impacts of postpartum mental health issues, such as postpartum post-traumatic stress disorder, minimal attention has been given to the antecedents of psychological birth trauma. This study seeks to investigate the correlation between fear of childbirth and psychological birth trauma among Chinese women who have undergone natural childbirth, as well as the mediating role of coping styles in the association between fear of childbirth and psychological birth trauma.

METHODS

This cross-sectional study was conducted among 420 women who underwent natural childbirth between June and December 2021 in Shandong Province, China. Data were gathered using the Wijma Delivery Experience Questionnaire, Trait Coping Style Questionnaire, and Impact of Event Scale-Revised. The structural equation model (SEM) was employed to examine the relationships between variables and to develop the final model.

RESULTS

The prevalence of psychological birth trauma among women who had experienced natural childbirth was recorded at 10.27%. The mean score and standard deviation of psychological birth trauma, fear of birth, positive coping (PC), and negative coping (NC) among these women were 19.7 ± 12.5, 76.9 ± 21.3, 35.66 ± 7.05, and 28.20 ± 7.99, respectively. Findings indicated that women's fear of childbirth was directly (B = 0.340, p = 0.001) and indirectly (B = 0.124, p = 0.001) linked to women's psychological birth trauma. Additionally, women's PC was negatively associated with psychological birth trauma (B= -0.352, p = 0.001), while NC was positively associated with psychological birth trauma (B = 0.199, p = 0.001).

CONCLUSIONS

Chinese women who experienced natural childbirth encountered a moderate level of psychological birth trauma. Women's coping style plays a pivotal mediating role in the connection between fear of childbirth and psychological birth trauma. Consequently, interventions aimed at diminishing women's fear of childbirth and enhancing PC skills should be devised and implemented to alleviate women's psychological birth trauma.

Empowering women with fetal malpositions: enhancing childbirth experience and empowerment through educational interventions: a randomized controlled clinical trial

BACKGROUND

This study aims to determine the impact of a childbirth educational intervention, based on empowerment theory, on childbirth experience and empowerment in women with fetal occiput posterior and occiput transverse malpositions.

METHODS

A randomized controlled trial was conducted from February 2022 to December 2022 involving pregnant women with fetal occiput posterior and occiput transverse malpositions. Eligible women were randomly assigned to either the control or study group. The control group received routine care during childbirth, while the study group received routine care and a childbirth-empowering educational intervention delivered by midwives. Primary outcomes assessed were childbirth experience and patient perceptions of patient-empowering nurse behaviors in pregnant women. Secondary outcomes included pregnancy outcomes, delivery support and control, maternal coping behavior during delivery, maternal participation in delivery decisions, and perception of empowerment.

RESULTS

A total of 137 pregnant women were enrolled, with 69 and 68 in the control and study groups, respectively. The study group showed significantly higher levels of childbirth experience and reported better patient perceptions of patient-empowering nurse behaviors than the control group. Additionally, the study group demonstrated higher levels of delivery support and control, maternal coping behavior, and specific aspects of perceived participation and patient perception of empowerment compared to the control group. There were no statistically significant differences in pregnancy outcomes between the two groups.

CONCLUSION

The childbirth empowering educational intervention effectively improved the childbirth experience and empowerment of women with fetal occiput posterior and occiput transverse malpositions. However, further studies are required to investigate its impact on pregnancy outcomes.

TRIAL REGISTRATION

The study protocol was approved by the hospital ethics committee (approval number:2020140A01) and registered at the Chinese Clinical Trial Registry (registration number: ChiCTR2300070915; date of first registration: 26/04/2023).

Contribution of the abbreviated CAVE-st questionnaire in Spanish: the attitudes toward childbirth experiences

There are several factors that influence women's childbirth experience, and personal interactions with health professionals are of particular significance. The main objective of this study was to present the validation of an abbreviated form of an existing questionnaire on attitudes about childbirth in medical and nursing students. We used a sample of 512 perinatal medicine and nursing students who received the original 52-item CAVE-st questionnaire to obtain a shorter version with proper psychometric properties. We used Cronbach's alpha coefficient to evaluate the new version's internal consistency. The Kaiser- Meyer-Olkin test and the Barlett sphericity test were performed to assess the suitability of exploratory factor analysis (EFA). Subsequently, confirmatory factor analysis (CFA) was performed using structural equation models in a second sample of 139 medical students. We obtained a 15-item version with a Cronbach's alpha of 0.82. The EFA revealed a four-dimensional structure, similar to the full 52-item version. In the CFA the adjustment indexes showed good model fitness, RMSEA= 0.046 [CI 0.00-0.07]; CFI = 0.978. We can conclude that the 15-item version is a valid tool for evaluating the attitude of students toward childbirth, pointing out the matters that should be improved in their training to avoid obstetric trauma by the promotion of a positive experience in women during childbirth.

Kaleidoscope of emotions in hospital childbirth: A phenomenological study

The childbirth process represents a moment of transition in the life of each woman, and is a source of complex and dynamic emotions. The aim of this study was to describe the emotions women experience during hospital childbirth and to determine the conditioning factors. A qualitative prospective study with a phenomenological approach was conducted using semi-structured interviews with 42 women. The negative emotions the women highlighted were fear, anguish, suffering, concern and nervousness, and they were related to factors such as: the evolution of childbirth, the appearance of complications, pain, the doubt about the ability to give birth and poor communication. The positive emotions highlighted were joy, satisfaction, security, confidence and tranquillity, and they were related to the first skin-to-skin contact, effective communication, partner support and participation in decisions. The findings may contribute to the development of policies aimed at achieving the women and newborns' maximum health and life potential.

Predictors of pregnancy stress and psychological birth trauma in women undergoing vaginal delivery: a cross-sectional study in China

BACKGROUND

Psychological birth trauma exhibits a high incidence worldwide, resulting in a wide range of negative impacts on mothers, infants, couples, families and society at large through the maternal-centered ripple effect. However, there is currently limited research on psychological birth trauma in China. Social support and pregnancy stress are important influencing factors of psychological birth trauma. Consequently, this study aimed to explore predictors of pregnancy stress and psychological birth trauma in women undergoing vaginal delivery in China.

METHODS

This cross-sectional study was performed at a single medical center between December 2021 and May 2022 in Hangzhou, China. Participants were selected using a convenience sampling technique. A total of 351 postpartum women within one week after vaginal delivery were included. Questionnaires were used to collect sociodemographic and obstetric characteristics and scores on the Pregnancy Stress Rating Scale (PSRS), City Birth Trauma Scale (City BiTS), Social Support Rating Scale (SSRS) and Family Adaptation Partnership Growth Affection and Resolve index (Family APGAR). Both univariate analysis and multiple linear regression analysis were conducted to assess predictors of pregnancy stress and psychological birth trauma.

RESULTS

The median (IQR) of PSRS and City BiTS scores were 10.00 (14.00) and 3.00 (9.00), respectively. The incidence of postpartum posttraumatic stress disorder was 4.0% (14/351). Parity, social support, family support and level of education were predictors of pregnancy stress. Delivery complications, psychological traumatic event, pregnancy stress and family support were predictors of psychological birth trauma (P < 0.05).

CONCLUSION

Pregnancy stress is related to social support, family support and some sociodemographic and obstetric characteristics. Psychological birth trauma is correlated with delivery complications, psychological traumatic event, pregnancy stress and family support. Consequently, enhancing social support, especially family support, for pregnant women as a means of reducing pregnancy stress can effectively prevent psychological birth trauma.

Geographic and urban-rural disparities in dietary energy and macronutrient composition among women of childbearing age: findings from the China health and nutrition survey,1991-2015

BACKGROUND

Understanding nutritional status among women of childbearing age (WCA) is of increasing concern, as nutrient intakes may affect the health of WCA and well-being of their offspring. This study aimed to investigate secular trends of dietary energy and macronutrients intakes and access longitudinally the urban-rural and geographic disparities among Chinese WCA.

METHODS

A total of 10,219 participants were involved in three rounds of the Chinese Health and Nutrition Survey (CHNS:1991, 2004, and 2015). Average macronutrients intakes were compared against the Chinese Dietary Reference Intakes Standard (DRIs) to better assess adequacy. Mixed effect models were used to estimate the secular trends of dietary intake.

RESULTS

A total of 10,219 participants were involved. Dietary fat, the percentage of energy (%E) from fat, and the proportion with more than 30% of energy from fat and less than 50% from carbohydrates increased notably over time (p < 0.001). In 2015, urban western WCA had the most dietary fat (89.5 g/d), %E from fat (41.4%), with the highest proportion of energy from fat (81.7%) and carbohydrate (72.1%) out the range of DRIs. From 1991 to 2015, the average urban-rural differences in dietary fat decreased from 15.7 g/d to 3.2 g/d among eastern WCA. However, it increased to 16.4 g/d and 6.3 g/d among central and western WCA, respectively.

CONCLUSION

WCA was experiencing a rapid transformation to a high-fat diet. Temporal variation with obvious urban-rural and geographic disparities in dietary. energy and macronutrient composition persistently existed among Chinese WCA.These findings have implications of future public strategies to strengthen the nutrition propaganda and education of balanced diet for WCA to help them to improve their nutritional status, especially for those living in western China.

Perceived Birth Trauma in Macedonian Women

Although the childbearing is perceived as a normal and happy event, new research shows that psychological birth trauma is, however, a universal and not so rare phenomenon. Traumatic birth experiences can cause postnatal mental health disturbances, fear of childbirth in subsequent pregnancies and disruption to mother-infant bonding, leading to possible impaired child development. The purpose of this research was to evaluate collected data from several obstetric clinics, as well as from primary paediatric settings related to 'Birth Trauma' in order to review women with symptoms of post-traumatic stress disorder (PTSD) following childbirth. The study is prospective, starting from January 2021 and ending in December 2022. The psychological instrument used in this research is the Intersect Questionnaire, composed of 59 questions grouped in 8 parts. The obtained results from our study confirmed that birth trauma is not a rare phenomenon in our country. Symptoms correlated with PTSD were present as follows: unpleasant memories (2.7%), anxiety (38.54%), panic (6.47%), trying not to remember the delivery (4.04%), self-accusation (2.16%), negative emotions (1.89%), alienation (4.31%), irritation/aggression (1.89%), self-destruction (1.89%), impulsiveness (4.31%), problems with concentration (3.23%), and sleeping problems (21.88%). These results are alarming. It is imperative to better understand this vulnerable period in a woman's life. As a general conclusion, we must highlight the importance of perceived birth trauma in women, phenomena which has been confirmed worldwide and which must be overcome as quickly and as successfully as possible.

Development and psychometric testing of a scale for assessing the psychological birth trauma

Background

Psychological birth trauma is widespread in postpartum women, and its harms are serious to mothers' health. Existing tools rely on posttraumatic stress disorder to evaluate, which cannot effectively evaluate its connotation. The aim of this study was to develop a new instrument for use to comprehensively assess the psychological birth trauma level of women after birth and test the scale's psychometric properties.

Methods

The scale was developed and evaluated through item generation, expert consultation, pre-survey, and psychometric evaluation. A literature review, focus group, and individual deep semi-structured interviews were utilized to identify the scale items. The expert consultation evaluated the content validity. Psychometric testing was conducted in a convenience sample of 712 mothers within the first 72 h postpartum who were recruited from three hospitals in China.

Results

The total Cronbach alpha coefficient of the scale was 0.874. Exploratory factor analysis supported that the final scale consisted of four dimensions and fifteen items. The explanatory variance of the four factors was 66.724%. The four dimensions are named "being neglected," "out of control," "physiological emotional response," and "cognitive behavioral response." The results of the confirmatory factor analysis showed that the fit indices were all at acceptable and good levels.

Conclusion

The 15-item Birth Trauma Scale is a valid and reliable tool to evaluate the psychological trauma of mothers who experienced spontaneous childbirth. The scale is a maternal self-assessment scale that can help women understand their mental health. Healthcare providers can identify key populations and intervene with them.

Psychological birth trauma: A concept analysis

Aim

To define and analyze the concept of psychological birth trauma.

Design

The concept analysis method of Walker and Avant was used.

Method

Eight databases (PubMed, CINAHL Complete, Cochrane Library, Web of Science, China National Knowledge Infrastructure, Wanfang, VIP Information Chinese Journal Service Platform, and Chinese BioMedicine Literature Database) were searched from inception to July 2022 for studies focused on psychological birth trauma.

Results

Of the 5,372 studies identified, 44 ultimately met the inclusion criteria. The attributes identified were (1) women's subjective feelings, (2) intertwined painful emotional experiences, (3) originating in the birth process, and (4) lasting until postpartum. Antecedents were divided into two groups: pre-existing antecedents and birth-related antecedents. Consequences were identified as negative and positive.

Conclusion

Psychological birth trauma is a more complex and comprehensive concept than previously thought, and should be regarded as a separate postpartum mental health problem. This study deepens the understanding of psychological birth trauma through a comprehensive concept analysis and also puts forward some suggestions for the prevention, identification, and intervention of psychological birth trauma, which provides a basis for assisting in the identification of psychological birth trauma and provides a reference for the development of rigorous assessment tools and the design of appropriate interventions in the future. Further research is needed to update and refine this concept.

Traumatic Birth Experience and Breastfeeding Ineffectiveness - a Literature Review

Background

A traumatic birth experience can affect the breastfeeding process and make it ineffective. The aim of this study was to identify the factors associated with breastfeeding ineffectiveness after birth trauma, through the world literature. There are several factors responsible for a traumatic birth experience, such as obstetric violence, postpartum complications and complications induced by doctors, invasive vaginal deliveries, emergency caesarean sections, admission of a neonate to the Neonatal Intensive Unit, past traumatic life events and mental health problems.

Objective

The aim of this study was to identify the factors associated with breastfeeding ineffectiveness after birth trauma, through the world literature.

Methods

An extended search was conducted to identify relevant for breastfeeding and traumatic birth experiences manuscripts for this study. Databases including PubMed, PsycINFO and Google Scholar. The search was limited to articles published in English the last decade.

Results

Factors that contribute to the ineffectiveness of breastfeeding after a traumatic birth are hormonal, medication, insufficient support from the partner, reliving the traumatic birth experience, past traumatic experiences in the woman's life and her mental state.

Conclusion

The mental trauma during childbirth is complex and multifactorial. Therefore, it is necessary to take measures on the one hand to prevent mental trauma during childbirth and on the other hand to make interventions to deal with the consequences of the trauma on the mental health of the mother and on breastfeeding which is directly affected.

Maternal experiences of care following a stillbirth at Steve Biko Academic Hospital, Pretoria, South Africa

Background. Despite improvements in obstetrics and neonatal care, the stillbirth rate remains high (23 per 1 000 births) in South Africa (SA). The occurrence of a stillbirth is a dramatic and often life-changing event for the family involved. The potential consequences include adverse effects on the health of the mother, strain on the relationship of the parents, and strain on the relationship between the parents and their other children. The standard of care in SA follows the Royal College of Obstetricians and Gynaecologists Green-top guidelines.Objectives. To explore maternal experiences of in-patient care received in cases of stillbirth.Methods. A descriptive phenomenological approach was performed in the obstetrics unit at Steve Biko Academic Hospital, Pretoria, SA. Post-discharge interviews were conducted with women who experienced a stillbirth. The healthcare workers in the obstetric unit were also interviewed on the care provided to these patients. Data analysis was performed using the Colaizzi’s method.Results. Data from the interviews with the 30 patients resulted in five themes relating to the maternal experience of stillbirth: ‘broken heart', ‘helping hand’, ‘searching brain’, ‘soul of service’ and ‘fractured system’. Healthcare worker participants emphasised the importance of medical care (the clinical guidelines) rather than maternal care (the psychosocial guidelines).Conclusion. While the medical aspects of the guidelines are adhered to, the psychosocial aspects are not. Consequently, the guidelines require adaptation, especially taking into consideration African cultural practices, and the inclusion of allocated responsibility regarding the application of the psychosocial guidelines, as this is the humanitarian umbilical cord between healthcare workers and those in their care.

Childbirth-Related Psychological Trauma

Traumatic childbirth is an international public health problem because it is supposed that currently up to 45% of new mothers have reported such an experience. International rates of PTSD due to birth trauma range between 1.5 and 9 percent of all births. Birth trauma is defined as an event occurring during the labour and delivery process that involves actual or threatened serious injury or death of the mother or her infant. A traumatic event or situation creates psychological trauma when it overwhelms the individual's ability to cope, and leaves that person fearing death, annihilation, mutilation, or psychosis. The individual may feel emotionally, cognitively, and physically overwhelmed. The aim of this article is to present a review of published data for childbirth trauma over various periods of time, as well as in different regions of the world. Studies were identified through a comprehensive search of PubMed, PsycInfo, ProQuest and PILOTS (Published International Literature of Traumatic Stress) over the last 20 years. More than 8000 articles were found. In this article we present and discuss some important findings.

Development and Validity Testing of the Workplace Parent Index: Assessment of Family-Friendly Practice

OBJECTIVE

We aimed to develop the Workplace Parent Index (WPI) as an assessment tool of family-friendly practice in the workplace and validate its psychometric properties.

METHODS

The development of the WPI included three phases: item generation, scale construction, and field testing. Participants were 1000 parents, aged 18 or more years old, who completed the WPI online and measures of competency of parentship, life satisfaction, and positive growth after experiencing a traumatic event.

RESULTS

The WPI comprised 80 items and five domains: Governance and Infrastructure, Planning and Communications, Action-Pregnancy and Childbirth, Action-Childrearing, and Monitoring and Feedback. All subscales of the WPI demonstrated high internal consistency reliability and correlated with other scales as expected in support of concurrent and predictive validity.

CONCLUSIONS

The WPI demonstrated excellent psychometric properties that can be used to assess comprehensive family-friendly practices in the workplace when addressing the need and prioritizing the allocation of resources for workplace parentship program initiatives.