The total number of questionnaires started was 2634. After removing doubles (based on IP address), participants who had given birth before 2005, participants with impossible answers (e.g., cesarean section at home), and participants who quit the questionnaire before the main question on the cause of the traumatic experience, 2192 responses remained for analysis. The characteristics of the participants are shown in Table
1. Comparison with maternal characteristics from the Dutch Perinatal Registry is shown in the last column (Brouwers
2014). The study population differs significantly in ethnicity, parity, gestational age at delivery, mode of delivery, and level of care during pregnancy and delivery compared to the general population.
Table 1
Characteristics of the participants (n = 2192) compared to the reference group
Age (n = 2192) |
At time of survey | 33.1 {5.5} | | |
At time of (traumatic) birth | 29.6 {4.4}*
| | 31.0 yr {4.9} |
Gestational age at time of traumatic childbirth |
16–32 weeks | 133 (6.1) | | >22 wks: 1.5b
|
32–37 weeks | 243 (11.1)*
| 9.8–12.4 | 6.1 |
37–42 weeks | 1688 (77.0)*
| 75.2–78.8 | 89.8 |
>42 weeks | 127 (5.8)*
| 4.8–6.8 | 1.3 |
Unknown | N/A | | 1.3 |
Years since traumatic childbirth |
<2 years | 999 (45.6) | | |
2–5 years | 684 (31.2) | | |
5–12 years | 509 (23.2) | | |
Ethnicity (n = 2192) |
Dutch | 2004 (91.4)*
| 90.2–92.6 | 74.3 |
Not Dutch | 188 (8.6)*
| 7.4–9.8 | 25.7 |
Parity at time of survey (n = 2178) |
Mean parity | 1.66 {0.8}*
| | 1.71c
|
Parity at time of traumatic birth experience (n = 2178) |
Primiparous | 1737 (79.8)*
| 78.1–81.5 | 45.2 |
Multiparous | 441 (20.2)*
| 18.5–21.9 | 54.8 |
Responsible caregiver during pregnancy (n = 2180) |
Midwife | 1146 (52.6) | 50.5–54.7 | 50.7 |
Obstetrician | 345 (15.8) | 14.3–17.3 | 14.6 |
Both (referral from primary to secondary care during pregnancy) | 677 (31.1)*
| 29.2–33.0 | 34.7 |
Mode of delivery (n = 2176) |
Spontaneous vaginal delivery | 919 (42.2)*
| 40.1–44.3 | 74.9 |
Operative vaginal delivery | 577 (26.5)*
| 24.6–28.4 | 8.7 |
Secondary cesarean section | 627 (28.8)*
| 26.9–30.7 | 8.6 |
Primary cesarean section | 53 (2.4)*
| 1.8–3.0 | 7.8 |
Responsible caregiver during delivery (n = 2147) |
Midwife (primary care) | 122 (5.7)*
| 4.7–6.7 | 27.4 |
Obstetrician-led (secondary care) | 1098 (51.1) | 49.0–53.2 | 49.4 |
Bothd (referral during labor or directly postpartum) | 927 (43.2)*
| 41.1–45.3 | 23.2 |
Attribution of trauma
Most frequently perceived causes of or contributions to the traumatic experience, were
Lack and/or loss of control (54.6% of participants),
Fear for baby’s health/life (49.9%),
High intensity of pain/physical discomfort (47.4%), and
Communication/explanation (43.7%). An overview of the answers is shown in Table
2 in descending order of frequency and extended with stratification by parity. This stratification shows that primiparous participants chose
High intensity of pain/physical discomfort,
Long duration of delivery, and
Discrepancy between expectations and reality more often and
Fear for own health/life,
A bad outcome, and
Delivery went too fast less often than multiparous participants.
Table 2
Women’s attributions of the traumatic birth experience in descending order of frequency and stratified by parity. Participants could choose multiple answers; there was no maximum number of answers
Lack and/or loss of control | 1196 | 54.6% | 961 (55.3%) | 226 (51.2%) | 0.13 |
Fear for baby’s health/life | 1093 | 49.9% | 846 (48.7%) | 235 (53.3%) | 0.09 |
High intensity of pain/physical discomfort | 1039 | 47.4% | 850 (48.9%) | 184 (41.7%) | 0.01 * |
Communication/explanation | 957 | 43.7% | 773 (44.5%) | 178 (40.4%) | 0.12 |
Long duration of delivery | 830 | 37.9% | 746 (42.9%) | 78 (17.7%) | 0.00 * |
Lack of emotional and/or practical support from caregivers | 781 | 35.6% | 620 (35.7%) | 154 (34.9%) | 0.76 |
A certain action/intervention was done | 758 | 34.6% | 608 (35.0%) | 145 (32.9%) | 0.40 |
Discrepancy of expectations | 751 | 34.3% | 617 (35.5%) | 133 (30.2%) | 0.03 * |
(Lack of) autonomy/involvement in decision-making process | 664 | 30.3% | 513 (29.5%) | 146 (33.1%) | 0.15 |
Fear for own health/life | 633 | 28.9% | 476 (27.4%) | 155 (35.1%) | 0.00 * |
Respect/taken seriously/way they were treated | 487 | 22.2% | 375 (21.6%) | 106 (24.0%) | 0.27 |
Bad outcome (impactful maternal/infant complications) | 444 | 20.3% | 334 (19.2%) | 108 (24.5%) | 0.01 * |
A certain intervention was not done, while the woman would have wanted it to be | 382 | 17.4% | 293 (16.9%) | 87 (19.7%) | 0.16 |
Lack of emotional support from partner | 178 | 8.1% | 134 (7.7%) | 42 (9.5%) | 0.21 |
Other |
Separated from baby after delivery | 36 | 1.6% | 32 (1.8%) | 4 (0.9%) | 0.17 |
Delivery went too fast | 34 | 1.6% | 21 (1.2%) | 13 (2.9%) | 0.01 * |
Have not experienced the delivery consciously (due to general anesthesia or other medication) | 25 | 1.1% | 22 (1.3%) | 3 (0.7%) | 0.30 |
Other reasons | 93 | 4.2% | 34 (4.9%) | 7 (3.9%) | 0.57 |
In the category “Other,” many answers fit into three extra topics: Separated from baby after delivery, Delivery went too fast, and Have not experienced the delivery consciously (due to general anesthesia or other medication).
Of the 51 participants whose baby had died, 62.7% appointed A bad outcome as one of the causes of their traumatic experience. The remaining 37.3% mainly reported Lack and/or loss of control, Communication/explanation, Respect/taken seriously/way they were treated, and Lack of emotional and/or practical support from caregivers.
The answer Discrepancy between expectations and reality was chosen significantly more often as cause of trauma when the preparation methods Hypnobirthing and/or Reading in books or on the internet were used, than when these preparation methods were not used (51.7 vs. 33.8%, p = 0.004, and 36.4 vs. 31.1%, p = 0.010). For other preparation methods, there were no significant differences in how often Discrepancy between expectations and reality was perceived as cause of trauma.
Improvement in caregiver management
Participants were asked what their caregiver could have done to prevent the traumatic birth experience. A minority of 12.4% indicated that the caregiver could have done
nothing to prevent the trauma.
Communicate/explain (39.1%) and
Listen to me (
more) (36.1%) were the most frequently chosen answers, followed by
Support me (
more/better)
emotionally/practically (29.8%), as shown in Table
3. Examples of lack of emotional or practical support given by women in the free text fields included not being taken seriously in their perception of the speed of labor progression, being left alone during labor, no continuity of care, and a midwife or gynecologist who was too busy to spend time with them. The answers most often ranked as the most important in this category were
Listen to me (
more) (20.6%) and
Communicate/explain (19.7%). Stratification by parity showed that primiparous women listed
Discuss expectations/birth plan,
Communicate/explain, and
Do certain actions/interventions later/not at all significantly more often than multiparous women. Multiparous women chose the options
Nothing and
Listen to me (
more) significantly more often than primiparous women. Examples of commentaries of women in reference to the answer
Discuss expectations/birth plan were that their birth plan was not taken seriously, that they had not been realistically informed about the likelihood of certain interventions or outcomes, and that their antenatal course downplayed the actual pain involved (“painting a rosy picture”).
Table 3
What women believe caregivers could have done to prevent the traumatic birth experience in descending order of frequency and stratified by parity. Participants could choose and rank multiple answers, with a maximum of three
Communicate/explain | 718 | 39.1% | 587 (40.2%) | 126 (33.2%) | 0.01 * |
Listen to me (more) | 678 | 36.9% | 515 (35.3%) | 160 (42.2%) | 0.01 * |
Support me (more/better) emotionally/practically | 547 | 29.8% | 445 (30.5%) | 97 (25.6%) | 0.06 |
Do certain actions/interventions sooner | 454 | 24.7% | 367 (25.1%) | 86 (22.7%) | 0.33 |
Discuss expectations/birth plan | 311 | 16.9% | 271 (18.6%) | 39 (10.3%) | 0.00 * |
Do certain actions/interventions later/not at all | 286 | 15.6% | 242 (16.6%) | 43 (11.3%) | 0.01 * |
Don’t do anything without my permission | 252 | 13.7% | 207 (14.2%) | 44 (11.6%) | 0.19 |
Nothing | 228 | 12.4% | 164 (11.2%) | 61 (16.1%) | 0.01 * |
Remain calm | 228 | 12.4% | 175 (12.0%) | 53 (14.0%) | 0.29 |
Other | 54 | 2.9% | 22 (3.2%) | 7 (3.9%) | 0.63 |
Other results
After the traumatic childbirth experience, 48.1% of women had a postpartum check-up with the caregiver who attended the delivery, 36.9% with another caregiver, and 15.0% did not have a check-up at all. Of those who did not have a check-up, 4 out of 5 indicated they were not invited and 1 out of 5 chose not to go. Of the women who did have a check-up, 42.0% were asked by the caregiver how they had experienced the delivery and 31.6% brought up the subject themselves. In the remaining 26.4%, the experience of the delivery was not discussed. When the traumatic experience was mentioned by the woman herself, 23% of the caregivers did nothing with this information and some participants added in the free text field that they felt their experience was downplayed (2.3%). According to participants, caregivers might have helped them better if they would have evaluated the experience more thoroughly (62.0%) or if they would have referred them for treatment of the trauma (28.7%).
Almost half of the participants (41.0%) considered filing a complaint against their caregiver, and 7.2% actually did. Of those participants who had a postpartum check-up with the same caregiver who assisted in their delivery, 39.5% considered filing a complaint versus 54.1% who had the check-up with a different caregiver. This difference was significant (p = <0.001).
Within the group of participants who had a postpartum check-up without discussing the traumatic experience, 21.3% reported that this was due to the check-up being too soon after the delivery. They explained they could not talk about it yet or they did not yet realize that it was a trauma.
Finally, outcome was compared for level of care during delivery. Participants were stratified into one of three categories: those who received only primary (midwife-led) care (A), those who started their delivery in primary care but were transferred to secondary (obstetrician-led) care during the delivery or immediately postpartum (B), and those who started their delivery in secondary care (C). Concerning perceived cause of the trauma, eight answers showed significant differences between the groups: Communication/explanation (A = 32.0%, B = 44.6%, C = 44.3%; AvsB p = 0.02; AvsC p = 0.02; BvsC p = 0.99) and A certain intervention was done (A = 23.0%, B = 35.4%, C = 35.7%; AvsB p = 0.01; AvsC p = 0.01; BvsC p = 0.99) were chosen significantly less often in the primary care group (A) than in the other two groups. Women who were transferred during labor (B) reported A long duration of delivery (A = 22.1%, B = 48.7%, C = 30.8%; AvsB p = 0.00; AvsC p = 0.08; BvsC p = 0.00) significantly more often than those who received solely primary or secondary care. The secondary care receivers (C) reported Fear for own health/life (A = 18.0%, B = 25.4%, C = 33.1%; AvsB p = 0.13; AvsC p = 0.00; BvsC p = 0.00) significantly more often and High intensity of pain/physical discomfort (A = 59.0%, B = 49.6%, C = 44.4%; AvsB p = 0.12; AvsC p = 0.01; BvsC p = 0.05) significantly less often than the other two groups. Fear for baby’s health/life (A = 35.2%, B = 47.0%, C = 54.1%; AvsB p = 0.03; AvsC p = 0.00; BvsC p = 0.00), the Delivery went too fast (A = 7.0%, B = 0.0%, C = 2.0%; AvsB p = 0.01; AvsC p = 0.04; BvsC p = 0.01), and A bad outcome (A = 9.0%, B = 18.4%, C = 22.8%; AvsB p = 0.00; AvsC p = 0.00; BvsC p = 0.04) significantly differed between all three groups separately.
Regarding advice to caregivers in order to prevent traumatic delivery experiences, participants who received solely primary care (A) answered Communicate/explain significantly less often than those who received solely secondary care (A = 27.6%, B = 38.9%, C = 40.7%; AvsB p = 0.054; AvsC p = 0.02; BvsC p = 0.74). With respect to what participants could have done to prevent the traumatic experience, two significant differences were found between participants who received solely secondary care (C) and those who were referred during labor (B): referred participants chose Remain calm/accept (A = 14.0%, B = 17.1%, C = 12.8%; AvsB p = 0.77; AvsC p = 0.90; BvsC p = 0.04) more often and less often reported Nothing (A = 33.0%, B = 33.2%, C = 40.3%; AvsB p = 1.00; AvsC p = 0.32; BvsC p = 0.01).