The aim of the study was to bring to light the types of subjective adverse incidents women experience during childbirth in Germany and in what frequency of occurrence. We further investigated which persons involved were responsible for the subjectively perceived adverse incidents as well as at what time point these incidents occurred. Finally, we considered whether there is a link between these subjectively adverse incidents and symptoms of postnatal depression or posttraumatic stress disorder.
The present study finds that approximately half of the women who participated experienced adverse incidents during childbirth; of those approx. 31% experienced physical incidents, 30% experienced neglect, and approx. 23% experienced psychological or verbal abuse (multiple responses were possible). According to the responses provided by the participants, the incidents were suffered at the hands of either a doctor (19.2%) or a midwife (22.4%), and the majority of the incidents occurred during delivery (24.2%). These statistics exceed the estimates given by the German Midwifery Association (between 10 and 25%; 2019) and liken the findings of Reed et al. (66%; 2017) and Mundlos (40–50%; 2017). It is possible that these results are due to the sort of survey used or other methodological aspects. The statistics of the German Midwifery Association are based on estimates of participation in the Roses Revolution Day, and the figures that Mundlos (2017) uses stem from surveys of women via social media. Moreover, it must be reiterated that there exists still to this day no uniform, objectifiable definition of what the adverse incidents exactly are in this context, which is why the numbers are based on the subjective experiences of the women surveyed.
The main categories of subjectively experienced incidents (Physical, Psychological, Neglect) were accompanied by the existence of mental stress during the survey period. This is consistent with a contemporary German study by Junge-Hoffmeister et al. (2022), which could possibly show that negative birth experiences are associated with elevated anxiety and depression scores as well as elevated posttraumatic stress disorder scores. The results of the present study also speak in favor of a (correlative) relationship between the number of adverse incidents experienced during childbirth and existing symptoms of depression and symptoms of PTSD within the first 12 months postpartum. Alongside the study’s absolute approach, the number of adverse incidents the women experienced during childbirth seems additionally relevant. The present study indicates that women who reported multiple adverse incidents consequently suffered more intensely under symptoms of posttraumatic stress disorder. The tendency of the correlation between the adverse experienced and psychological stress should more closely be examined in follow-up longitudinal studies. It is conceivable that individuals with preexisting symptoms of depression and symptoms of PTSD would be more likely to report of their adverse experiences or be able to recall these incidents more clearly or even more intensely. Moreover, interactional difficulties may also contribute to the rate of occurrence of adverse incidents. Intrapersonal characteristics or specific personality traits of the expectant mothers could increase or decrease the probability of an adverse childbirth experience. Aspects that could play a role in this include for example, social competency, a less-pronounced ability for setting boundaries, performance anxiety or high expectations of the birthing situation, as well as social and family support (presence of other people during the birth, emotional and practical social support during and after delivery). The additional adverse incidents described in the present study could lead to limitations in the women’s general coping mechanisms and coping behaviors according to the stress-vulnerability model (Zubin & Spring, 1977). According to this, women would tend to be more vulnerable due to the stress of childbirth right from the start and also more receptive to experiencing incidents as adverse, and the mothers who did experience such events were consequently at risk of developing depressive or traumatic symptoms.
Moreover, external influences should be taken into consideration in evaluating the responses given regarding adverse childbirth-related experiences. Media attention on this topic markedly increased at the beginning of the “Roses Revolution” movement of 2011, so that awareness and the willingness to problematize potentially adverse childbirth experiences dramatically increased within society. At the same time, it’s possible this is the reason the sensitivity threshold for tolerating such adverse events has declined. Thus, this may also have resulted in survey questionnaires allowing for more detailed responses regarding adverse incidents than in the past.
Studies show that adverse birth experiences are, among other things, also associated with a disrupted mother-child relationship (Nicholls & Ayers, 2007). In this study, 19.1% of the women reported experiencing a subjectively perceived disruption of the mother-child relationship directly related to the birth. The present survey did not ascertain the construct of the mother-child relationship by established means, but rather divided it up into the following categories: a) Baby was placed on the mother’s chest/abdomen without consent, b) Coerced into breastfeeding and c) Separated from the baby without consent (see Table 2, Category 4). As such, we can only hypothesize as to the quality of the disruption to the mother-child relationship through adverse childbirth-related experiences. Certainly, the subjective perception of disruption to the mother-child relationship is not a monocausal predictor for the quality of attachment in the future, nevertheless a delayed or disrupted mother-child bond as well as mental health conditions in the parents are seen as adverse childhood experiences (Adverse Childhood Experience, or ACE), which in turn are connected to somatic, cognitive, mental, and psychopathological risks throughout the child’s entire lifespan (de Cock et al., 2017; Fuchs et al., 2016). These risks particularly include neurobiological and epigenetic changes (Stein et al., 2014; Pearson et al., 2013). Additionally, the timing component plays a deciding factor, because the earlier the disruptions manifest themselves, the more serious the consequences are (Glover et al. 2017; Gress et al., 2012; Martini et al., 2010; van den Bergh, 2006). The results of a cross-sectional study (Lukasse et al., 2015) shows that “the experience of being powerless” during childbirth as well as experiencing “abuse in healthcare […] was significantly associated to a fear of birth.” Particularly with regard to the risk of a potentially adverse childbirth experience and the psychological stress associated with a vulnerable situation like giving birth, the initial results showcased here ought to be a catalyst for further research. Multi-factor analyses that include varying predictors would be conceivable. This way, epidemiological longitudinal studies could examine whether women with a higher level of pre-conception or pre-natal psychopathological stress or who possess certain personality traits are especially prone to experiencing adverse childbirth related incidents.
From a legal perspective, medical or physician-led interventions performed without the patient having been informed prior as to the potential necessity and side-effects as well as without the patient’s explicit permission, can be seen as bodily injury or violence. In Germany, in accordance with the German Civil Code (BGB), the doctor is obligated to inform the patient in advance of performing medical procedures and to obtain the patient’s consent. “This includes in particular the nature, extent, implementation, anticipated consequences and risks involved in the measure, as well as its necessity, urgency, suitability and prospects for success” (§ 630e BGB). In this context, it must also be emphasized that medically necessary steps cannot always be foreseen. For that reason, certain interventions can unexpectedly become necessary, often without opportunity for obtaining the patient’s permission (for example, when their life is in acute danger). The timing of the disclosure therefore needs to be as early as possible, i.e., as soon as the cause for intervention is recognized during childbirth (Bryan, 2019) Often, the patients are provided with basic information during the pregnancy (Hilpert, 2009). However, the disclosure of information should be provided by the acting physician at the latest when the patient is still capable of understanding any problematic issues that may arise and to weigh the risks so they can give their “informed consent” to the procedure (Bryan, 2019; Ulsenheimer, 1998).
The focus of the subjective analysis of the woman can in some cases stand in stark contrast to the medical benefits in the context of obstetric care. The procedures listed in the subcategory of physical incidents of this study included some that may possibly have been unavoidable or medically directed. Some of these procedures that were subjectively perceived as adverse may have been medically necessary in order to prevent further complications. If such procedures had not been performed, it may have resulted in potentially worse complications, which in turn could have led to an even stronger perception of an adverse childbirth experience. The aim of this study was not to evaluate the various measures taken in the obstetric care, but rather to observe the difference between the woman’s perception and her needs as opposed to the specialized medical staff in a sort of expert vs. lay person communication conflict.
Adequate information and communication with the expectant mother can give her the opportunity to make a balanced decision regarding any possible medical interventions. Studies have shown that this can have a ripple effect on her sense of control and on her overall childbirth experience (McKenzie-Harg et al., 2015). According to Guittier, Cedraschi, Jamei, Boulvain, and Guillemin (2014) among other things, an internal locus of control (in this case, retaining influence and control during childbirth) can have a positive effect on a woman’s subjective experience during childbirth. Several additional studies have shown that a lack of control and agency can, in contrast, be identified as the important factors associated with an adverse or traumatic birthing experience (e.g., Ayers et al., 2016). It cannot be concluded from the results of this study as to whether the type of information disclosed to the individuals studied differed (or if it was received differently by the women during labor who, due to stress, pain, etc., were no longer in a position to adequately understand and comprehend the information). Further, we did not examine whether the type of information disclosure provided had any influence on the women’s overall childbirth experience. A closer look at this connection is planned for future publications within the scope of the LABOR project.
Limitations
To interpret the results of the present paper, its strengths and limitations must be taken into consideration. This study consisted of a survey on adverse childbirth experiences with a large random sampling (n = 1076). To date, there are very few similar surveys in the literature. One aspect that must be considered a limitation is the fact that no validated instrument was used for collecting the perceived adverse experiences due to a lack of availability. The survey was conducted using qualitatively developed categories in order to empirically display the initial data situation of a German sample. Furthermore, the online survey asked about subjectively perceived adverse experiences, which does not allow for any direct objective statements regarding the actual circumstances. Also, the study did not question the attitude of the subjects regarding their adverse physical incidents (e.g., “I understood the medical procedure” or “I gave my consent”). The survey focused on the women’s subjectively perceived experience as this experience demonstrates a strong connection to the development of postpartum psychological stress. Further, the survey was also conducted within the first 12 months postpartum, which means that the births (and possibly its continued effects) were of varying lengths of time in the past and the retrospective responses could have been confounded by the effects of forgetting or distortion (potential recall bias), especially in the case of psychopathological stress. However, for medical or psychotherapeutic treatment representing formative events, a 12-month limit is recommended as a suitable time frame (Bhandari & Wagner, 2006).
An additional limitation is the high dropout rate of 42.6%. A current meta-analysis by Wu, Zhao, and Fils-Aime (2022) indicates that the average response rate of online surveys is generally lower and the average response rate is 44.1%. One possible reason for the participants to drop out of the survey prematurely is that answering the questions stirred up negative memories and the stress of reliving these memories was too great. An alternative explanation of the high drop-out rate is the amount of time involved, the average duration being 48 minutes to complete. This demanded concentration as well as a willingness from the women, and were probably interrupted. Furthermore, it is possible that especially among the women who finished the survey, it was important to them to tell their story. This may indicate that the women who took part in the survey were especially encumbered by their experience or that the topic is particularly important to them. As such, a skewing of the results is possible.
Implications
Although the subjective perception and experiences of the women during childbirth are considered important, at the moment there is no clear and comprehensive definition of a subjectively perceived adverse childbirth experience to serve as a guideline for use in practice, educational instruction, or research. Establishing a conventional definition of the concept would be a first step in continuing to develop and empirically test valid survey methods. For use in clinics and birthing centers, it is recommended to introduce the international S3 guidelines on “Vaginal Birth at Term (German Society for Gynecology and Obstetrics and the German Society of Midwifery) as a basic set of guidelines. The findings mentioned in the discussion pose further causes for concern. In light of the fact that negative interaction with the medical staff appears to be a significant risk factor in developing posttraumatic stress disorder (meta-analyses: Ayers et al., 2016; Grekin et al., 2014; qualitative study: Reed et al., 2017), it is of great importance to educate the psychological and medical personnel (doctors, midwives) of the crucial role such interaction and communication (interpersonal influences) play during childbirth. This includes above all being empathetic toward the women’s emotional needs as well as maintaining the patients’ freedom of agency. One good solution would be to offer “communication training in medical school, residency training, and continuing medical education would be desirable so that physicians can better exploit the power of words to patients' benefit, rather than their detriment” (Häuser, Hansen, Enck, 2012). For more precise and causal conclusions on the relationship between adverse childbirth experiences and the stress, as well as further consequences, more evidence-based studies are urgently needed, ideally longitudinal studies or clinical samples.
Moreover, opportunities for preventative care for pregnant women need to be developed to explain the potential side effects of childbirth and to counteract overly high expectations. One type of preventative measure would be for the medical personnel to provide standardized, detailed informative discussions before the birth to explain commonly obstetric methods and specific interventions in the case of emergency. The result of this would be that the woman and her labor companions would be better able to accept the procedures during labor, and in case of a life-or-death situation, would still retain the patient’s autonomy due to having been informed in advance (Hansen, 2014). On the other hand, a birth plan that is too deficit-oriented or that calls up the need for a conversation on the risks can lead to negative expectations or reinforce anxiety and, as happens with a nocebo effect, will evoke negative implications during childbirth. Furthermore, alongside clarifying the risks there stands an additional risk of prematurely rejected necessary intervention or treatments (Hansen, 2014). Particularly in cases where some interventions are medically necessary, but no such informative discussion can occur during the procedure so that the procedure must go on without the patient’s consent, preventative measures need to be developed that will prevent subsequent psychological stress. One possible opportunity for prevention could be follow-up conversations between the gynecological department and the patients explaining the procedures, with everyone present who was involved in the birth. According to S3 guidelines, this approach is already routinely recommended in psychiatric facilities as a follow-up to coercive measures (German Society for Psychiatry, Psychotherapy and Psychosomatics, DGPPN, 2018). Good communication of medical information is known to be positively connected to better coping with illnesses and the patient’s own self-efficacy (Hansen, 2018); it also reduces emotional stress as well as the need to bring up negative emotions.
If, despite all efforts of disclosure and improved communication, patients still have an adverse birth experience, further attempts at offering low-threshold counseling services (e.g., in the postpartum recovery ward) should be implemented for affected women and families. This would provide a place to go for more information and could offer concrete advice on what to do and who to contact. Especially during the early postpartum phase, women are often physically limited and overwhelmed by this new situation which can hamper their ability to contact a counseling center or utilize the help system. Many women receive regular visits from a midwife during this time period as part of their aftercare. These midwives could be trained to recognize psychological stress stemming from an adverse birth experience and further refer the women accordingly. If a mental illness develops, specific long-term interventions for the affected women need to be developed. Furthermore, preventative as well as therapy services need to take into consideration the specificities of the postpartum period and the initial time with the baby in order to professionally address the effects of adverse childbirth experiences. Future studies should especially focus on the potential causal relationship between adverse childbirth experiences, high levels of stress, and the postpartum mental illnesses that can arise as a result.