Intimate Partner Violence, Loss of Control, and Adolescent Perception of Birth

Abstract

This secondary analysis used cross-sectional baseline data from a previous longitudinal study exploring the mental health of 303 postpartum adolescents to examine associations and predictors reflecting the perception of the birth experience among three race–ethnic groups. Analysis of two key variables, partner violence and loss of control (LOC) during labor, revealed no association. Race–ethnic differences were noted for demographic variables (marital status, birth mode, and stress level) and perception of the birth experience. Black ethnicity, multiparity, LOC, and vaginal birth were found to predict a negative perception of the birth experience. Health-care provider awareness of risk factors can guide perinatal assessments and supportive and educational interventions to promote a positive perception of birth.

INTRODUCTION

Intimate partner violence (IPV) has been recognized as robbing a woman of personal control (Stark & Hester, 2019). Furthermore, violence has the potential to affect how the birth experience is perceived by altering the amount of personal control perceived during labor (Mohd Arifin et al., 2014). Independently, both IPV and a loss of control (LOC, e.g., disallowing involvement/decision-making in one’s birth) during labor have been identified to influence the adult’s birth perception, while demographic risk factors including age, marital status, parity, race–ethnicity, birth mode, stress, unplanned pregnancy, and adverse neonatal outcome have been inconsistently noted as contributors (Ayers, 2004; Berman et al., 2021; Greenfield et al., 2019; Hollander et al., 2017). Despite the need for research, contribution of these risk factors to the adolescent’s perception of the birth experience is unexamined.

The term birth experience is a multidimensional phenomenon reflective of a woman’s subjective perception of labor and birth inclusive of emotional and physical distress and fulfilment (Chabbert et al., 2021). A recent systematic review reported the prevalence of a negative birth experience to range between 6.8% and 44% (Hosseini Tabaghdehi et al., 2020), signaling the importance of assessing and promoting a positive birth perception as a significant health-care provider goal. Available studies, however, focus on the adult’s perception of the birth experience, while it may be suggested that adolescents are more likely to report a negative perception of the birth experience due to higher occurrence of IPV, unintended pregnancies, and adverse pregnancy outcomes (Bekaert & SmithBattle, 2016; Ganchimeg et al., 2014; Marvin-Dowle et al., 2018; Sutherland, 2011). Furthermore, recognized race–ethnic differences may place the Black adolescent at additional risk for a negative birth perception. Published findings have shown a higher likelihood for Black women than White women to experience IPV, as well as cesarean births (Capaldi et al., 2012; Huesch & Doctor, 2015), a suggested associate to increased stress and a negative birth perception (Berman et al., 2021; Greenfield et al., 2019). However, only limited study has examined birth perception by race–ethnicity, especially among adolescents; therefore, the current study examined the following research questions: (a) Is there an association between IPV and LOC during labor among a diverse group of adolescents? (b) Do demographic risk factors or birth perceptions differ by race–ethnicity among adolescents? (c) What is the contribution of IPV, LOC during labor, and selected demographic risk factors to the adolescent’s birth perception?

LITERATURE REVIEW

Adolescent Violence

A systematic review of 19 studies among adolescent youth reflected a range of violence from the witnessing of a violent event to experiencing direct interpersonal violence, including sexual, emotional, verbal, and physical abuse perpetrated by parents, partners, and others (Fenimore et al., 2019). Worldwide, approximately 200,000 adolescents die by violence each year (World Health Organization [WHO], 2021), with most violent events (36.9%) perpetrated by acquaintances, such as a boyfriend (Stöckl et al., 2017). Adolescent dating violence ranges from 12% to 50% (Bekaert & SmithBattle, 2016). A systematic review of 228 studies including adults and adolescents further supported the frequency of IPV, especially among African Americans (Capaldi et al., 2012).

Frequently, women reporting IPV tend to misread, or underestimate, the threat of violence (Perizzolo Pointet et al., 2021). Pregnant adolescents have been found to normalize abuse and blame themselves for the violent event (Bekaert & SmithBattle, 2016). These adolescent beliefs may offer support for the recognized link between IPV and reproductive coercion and an unexpected, unplanned pregnancy (Samankasikorn et al., 2019). Unlike their adult counterparts, Cornell et al. (2015) found that 60% of adolescents reporting an unplanned pregnancy also reported having witnessed violence within the past 2 years. When considering all forms of violence and neglect among childbearing adolescents, rates may be as high as 50%–75% (Madigan et al., 2014; Meltzer-Brody et al., 2013).

Risk Factors and Birth Perception

Nearly 20 years ago, Leeners et al. (2006) noted that traumatized individuals could be confronted with memories and reminders of past violent events during their labor, thus, altering their birth experience. Recent researchers have revealed that reports of past violence and a LOC during labor have been found to correlate independently with a negative birth perception, as well as ultimately an increase in stress with subsequent pregnancies and a resulting fear of childbirth (Greenfield et al., 2019; Henriksen et al., 2017). Furthermore, unexpected hospital procedures and medical complications have been found to trigger perceived LOC leading to increased stress (Greenfield et al., 2019) and subsequently a negative birth perception (Berman et al., 2021). Consequently, some women who suffered violent events in the past may request an elective cesarean birth in an attempt to establish or maintain some personal control over the birth experience (Greenfield et al., 2019; Henriksen et al., 2014; Lukasse et al., 2010). Of note, while some women anticipate the choice of a cesarean birth as empowering, others report a cesarean birth as disappointing and a personal failure (Kjerulff & Brubaker, 2018). A connection between cesarean birth, a negative birth experience, and posttraumatic stress has been recognized (Dekel et al., 2017).

A recent systematic review revealed several additional demographic variables to be inconsistently linked to a woman’s subjective perception of the childbirth experience including age, parity, marital status, stress, and neonatal outcome (Chabbert et al., 2021). It might be suggested that the younger childbearing adolescent may face an increased likelihood to experience cesarean birth or adverse infant outcome or be without a partner or general support, thus more likely to report a negative birth experience than the older adolescent; however, very few studies exist for this population and many studies are not age adjusted (Vesel & Nickasch, 2015). Additional research is indicated.

METHODS

Research Design

Our cross-sectional study was a secondary analysis of data previously collected to explore the birth experience and mental health of adolescents over a 9-month postpartum period. The primary Institutional Review Board approved the study and provided data collected over four time periods. For the current study, we examined only the initial study data collected at 48–72 hours postpartum.

Study Setting

Data for the primary study were collected on two postpartum units at a large county hospital in Fort Worth, Texas, by multiple research assistants enrolled as either graduate or undergraduate nursing students over approximately 8 years. This hospital delivers approximately 5,000 babies per year serving primarily low-income and ethnically diverse patients, especially of Hispanic background.

Participants

The primary study (conducted by this primary investigator) used convenience sampling to recruit 303 postpartum adolescents. For the current study, complete data for the main variables to be examined yielded 284 adolescents. Inclusion criteria for the primary study included adolescents between the ages of 13 and 19 who spoke, read, and wrote in English or Spanish. The primary study sample consisted of adolescents who generally were single (83.7%) and Hispanic (63.3%), with a mean age of 17.8. The majority spoke English and completed surveys in English. Approximately 4% (12 adolescents) spoke minimal English and completed all surveys and consents in Spanish. Less than 1% of adolescents reported a fetal loss and were included in the study. Additional sample characteristics are shown in Table 1.

TABLE 1. Sample Characteristics.

Baseline characteristic	Primary study total samplea	Adolescents reporting IPV	Adolescents reporting LOC during labor
	N = 284	n = 11 (3.9%)	n = 116 (40.8%)
Age, mean/SD	17.86 (1.38)	18.55 (.522)	17.85 (1.33)
Unplanned pregnancy	187 (65.4)	10 (90.9)	73 (63.5)
Cesarean birth	65 (22.2)	3 (30.0)	20 (17.2)
IPV	11 (3.9)	11 (3.9)	2 (1.78)
LOC–labor	116 (40.8)	2 (20.0)	116 (40.8)
Single status	247 (83.7)	10 (90.9)	97 (83.6)
Race–ethnicity
White	31 (10.7)	3 (27.3)	5 (4.5)
Black	75 (26.0)	3 (27.3)	25 (22.3)
Hispanic	183 (63.3)	5 (45.5)	82 (73.2)
Adverse neonatal outcome	92 (30.6)	4 (36.4)	34 (29.6)
Parity (1)	280 (78.5)	8 (72.7)	98 (84.5)
IES, mean/SD	18.34 (15.54)	33.67 (17.74)	19.86 (15.62)
0–25	193 (69.1)	3 (33.3)	75 (67.6)
26+	89 (30.9)	6 (66.6)	36 (32.4)
Childbirth rating: Md	5.00	5.50	6.00

Note. IES = Impact of Event Scale; IPV = intimate partner violence; LOC = loss of control; SD = standard deviation.

^aSome missing data in total sample (N = 284) and group data.

Procedures

For the primary study, unit secretaries provided data collectors with names of adolescents meeting the inclusion/exclusion criteria. Data collectors introduced themselves to potential study participants (and family if present) and provided study details. Following consent, surveys were completed privately by data collectors in the adolescent’s room without parents or partners present when possible. Adolescents 18 years of age and older consented for themselves; teens under the age of 18 assented and either a parent or a guardian provided written consent. Completion of surveys created no reported mental anguish. Over 90% of adolescents approached for study participation consented to the initial data collection.

Measures

Data in the primary study were collected via single-item questions, the Impact of Event Scale (IES; Horowitz et al., 1979), and a researcher-developed childbirth rating scale and demographic sheet. Violence was originally measured by three survey questions: Is there a personal history of child abuse? Is there a history of or current report of abuse by a partner? Are there any past life experiences that were very traumatic to you? The current study focused on IPV only which may have been considered by the adolescent as physical, sexual, or emotional. The variable LOC was measured via one question: Were you ever afraid you would lose control during labor and birth? Demographic risk factors, including age, parity, race–ethnicity, marital status, birth mode (vaginal or cesarean), unplanned pregnancy, and adverse neonatal outcomes, were assessed via single questions listed on the demographic sheet.

The total 15-item IES measured stress (Horowitz et al., 1979). The Likert scale question format of the IES comprises two subscales, intrusion and avoidance, which assesses information related to these two concepts via responses of “not at all,” “rarely,” “sometimes,” or “often.” The scoring for the IES indicates subclinical stress (0–8), mild stress (9–25), moderate stress (26–43), and severe stress (44+). The IES has been regarded as a reliable and valid measurement as a screen for acute stress, as well as posttraumatic stress and posttraumatic stress disorder (PTSD) following childbirth (Furuta et al., 2016; Horowitz et al., 1979). For the current study, reliability of the IES was established at .87 (Cronbach’s alpha). For the 12 Spanish speakers, a copy of the IES was translated by a bilingual English–Spanish speaking research team member and back translated by the primary investigator; however, reliability is unknown. Previous studies using a Spanish version of the IES for childbearing adolescents are unknown.

The dependent variable, perception of the birth experience, was measured via a single rating scale with 1 being “great” to 10 being “awful/traumatic.” Single-item rating scales have been suggested to be reliable and capable of providing important highlights (Youngblut & Casper, 1993). Furthermore, previous researchers have used a single-item rating scale to assess birth perception as traumatic (Nagle et al., 2022; Sorenson & Tschetter, 2010). For the current study, 6–7 and above defined a negative birth perception as used by Sorenson and Tschetter.

Data Analysis

Descriptive statistics defined participant characteristics. Pearson Product Moment Correlation provided report of association between IPV and LOC during labor. Differences among race–ethnic groups by demographic risk factors and perception of birth were examined via χ² or analysis of variance. Ordinal regression was used to estimate the contribution by main variables of IPV and LOC during labor and demographic risk factors on perception of birth. All analyses were conducted in SPSS version 29. Odds ratios were determined using the URL: allmath.com/ePowerxcalculator.php. A level of significance was set at .05.

RESULTS

An association between IPV and LOC during labor was not significant, r = −.081, p = .181. However, two demographic risk factors differed significantly by the race–ethnic group in the reporting of IPV or LOC during labor: unplanned pregnancy, p = .007, and single status, p = .001. While not significant, adolescents reporting violence reported a higher mean age, higher percentage of cesarean births, more adverse neonatal outcomes, and higher stress levels than non-disclosing adolescents. Hispanic adolescents were more likely to state exposure to violence (45.5%) or LOC during labor (73.2%). Adolescents reporting LOC during labor indicated higher parity and higher median childbirth ratings. Table 1 provides sample comparisons between the total sample of adolescents and subsamples of adolescents disclosing violence (n = 11, 3.9%) and reporting LOC during labor (n = 116, 40.8%).

Examination of research question number two revealed three significant race–ethnic differences for demographic risk factors. Black adolescents were found to be more likely single, X² = 16.285(4), p = .003, experience a cesarean birth, X² = 8.833(2), p = .012, and report higher stress levels (IES scores), F = 12.270(2), p = .001, than either Caucasian or Hispanic adolescents. Regarding marital status, 26.3% of Hispanics were married compared with 20% of White adolescents and 1% of Black adolescents. Thirty-two percent of Black adolescents reported a cesarean birth compared with 29% of White adolescents and 16.2% of Hispanic adolescents. The mean IES score for Black adolescents was 25.38 as compared with 18.8 for White adolescents and 15.09 for Hispanic adolescents. Parity, age, unplanned pregnancy, adverse newborn outcome, IPV, and LOC during labor did not significantly differ by race–ethnicity.

Race–ethnicity (Black), parity (>1), birth mode (vaginal birth), and LOC during labor were found to predict perception of a negative birth experience (Table 2). Moreover, a side analysis revealed a birth rating of 1 and 2 on the birth rating measurement tool to significantly predict perception of a positive birth experience, whereas a birth rating of 8 and 9 significantly predicted a perception of a negative birth experience. A median birth rating of 7.00 for Black adolescents compared with 5.00 for the Hispanic adolescents and 3.00 for the White adolescents was observed. A manual calculation of odds ratios indicated that White adolescents had 74% lower odds {B [95% confidence interval (CI) = −1.343 (−2.139 to −.547)]; p = .001} to report a negative perception of the birth experience than Black adolescents. A Hispanic adolescent had 52.5% lower odds {B [95% CI = −.743 (−1.281 to −.205); p = .007]} to report a negative perception of the birth experience than the Black adolescent.

TABLE 2. Predictors of Adolescent Negative Birth Experience.

Variable	Estimate	SE	95% CI		p
			LL	UL
Stress	.348	.338	−.314	1.010	.303
Age	−.020	.268	−.544	.505	.941
Marital status	−.356	.336	−1.015	.302	.289
Unplanned pregnancy	−.039	.234	−.497	.420	.869
Type of birth	−.734	.276	−1.275	−.193	.008
Partner violence	−.394	.647	−.814	1.662	.543
Neonatal complications	.334	.247	−.150	.818	.176
LOC	.879	.240	.408	1.350	<.001
Caucasian	−1.343	.406	−2.139	−.547	<.001
Hispanic	−.743	.274	−1.281	−.205	.007
Parity	.456	.216	.033	.880	.035
Rating scale
(1) “Great”	−2.173	.573	−3.295	−1.051	<001
(2)	−1.556	.561	−2.656	−.456	.006
(8)	1.781	.566	.671	2.891	.002
(9) “Traumatic”	2.146	.575	1.020	3.273	<.001

Note. CI = confidence interval; LL = lower limit; LOC = loss of control; SE = standard error; UL = upper limit.

Additionally, adolescents reporting a second or additional birth were 36.7% more likely {B [95% CI = .456 (.033 to .880)]; p = .035} to experience a negative birth perception. Over 21% of study adolescents reported 2–4 children. Most infants were delivered vaginally (77.8%), and experiencing a cesarean birth reduced the odds of reporting a negative birth perception by 52% {B [95% CI = −.734 (−1.275 to −.193)]; p = .008}. Finally, adolescents reporting LOC during labor were 58.5% more likely {B [95% CI = .879 (.408 to 1.350)]; p = .001} to experience a negative birth perception. Risk factors of age, stress, marital status, unplanned pregnancy, adverse neonatal outcomes, and IPV failed to significantly contribute to the adolescent’s birth perception.

DISCUSSION

An association between IPV and LOC during labor was not found, but findings were possibly limited by the small disclosure rate of IPV (3.9%). Other researchers have reported that the severity of violence in an adolescent’s partner relationship is frequently minimized, normalized, and considered to be nonserious with a belief held by some adolescents that “men show their love through hitting” (Bekaert & SmithBattle, 2016; Herrman, 2013, p. 466). When compared with other studies, Thomas et al. (2019) revealed that 38% of New York city adolescents (N = 930) experienced IPV during their third trimester of pregnancy. Yet, a wide prevalence range between 6% and 55% has been noted for adolescents at high risk to experience dating violence during pregnancy and postpartum (Herrman, 2013).

While 40.8% of adolescents reported LOC during labor, more than half of adolescents did not, possibly because of increased attention and support during labor by health-care providers, family, and/or friends. Furthermore, younger adolescents may have felt more comfortable if health-care providers, or mothers, assumed control over necessary decisions. Seminal work by Low et al. (2003) reported that a sense of control or being in control was important among a population of hypothetical adults, yet dialog regarding control was absent among adolescents. Comparison studies between adolescents and adults are rare; however, Hollander et al. (2017) noted that 54.6% of adult women (mean age 30) ranked LOC during labor as a top concern.

The second research question examined in the current study sought to determine differences in both demographic risk factors and perception of birth by race–ethnicity. Several significant demographic differences emerged between Black, Hispanic, and White adolescents, with Black adolescents more often reporting single status at birth, cesarean births, and higher stress levels. Numerous studies have expounded upon an increased number of risk factors and poorer maternal–infant outcomes for Black versus Hispanic and White women. When compared with other race–ethnic groups, the vulnerability of the Black childbearing woman for pregnancy complications and stressful events during birth, such as a cesarean birth, has been recognized (Huesch & Doctor, 2015). Furthermore, Blebu et al. (2022) noted that the odds of a preterm birth were found to differ by race (Black, White, and Mixed), socioeconomic, pre-pregnancy, and gestational factors, with White woman least likely to experience an early birth.

Regarding the third research question, predictors of a negative birth perception included Black race–ethnicity, LOC, vaginal birth, and multiparity. While Black adolescents significantly differed by several demographic risk factors, none of these significant differences were associated with a negative birth perception by the Black adolescent, suggesting other factors to be at play. It has been noted that at the root of reproductive issues among Black women is an ongoing experience of racism and discrimination that have been suggested to increase across adolescence (Bossick et al., 2022; Rosenthal et al., 2015).

Somewhat contrary, Hispanic adolescents reported higher IPV, LOC during labor, and more cesarean births but not generally a negative perception of birth. Protective factors related to family or partner presence and less reported stress may have contributed to the positive perception of birth. Hispanic culture emphasizes the extended family, wherein connections to family and homeland culture are sources of needed strength and support (Robledo-Gil et al., 2022a). Additional work is needed to explore the connection between race–ethnicity and birth perception for adolescents and adults.

Regarding LOC during labor as a predictor of a negative birth perception, Hollander et al. (2017) noted that the most frequent response by adult women in connection to a perceived traumatic childbirth was LOC during labor. Among women of 18–35 years of age, Fair and Morrison (2012) examined three types of control among primiparous women including prenatal control, expectations, and experienced control during birth for an association with birth satisfaction. Findings revealed only experienced control to be of significance, in which perceived control during birth predicted birth satisfaction. In a more recent publication, a systematic review by Chabbert et al. (2021) supported perceived control as a major predictor for the subjective experience of childbirth, revealing that the higher the perceived control, the more positive the birth perception.

Vaginal birth was also found to be a predictor of a negative birth perception for adolescents; yet, cesarean birth has more often been debated as a contributing factor to a woman’s (negative) birth experience (Carquillat et al., 2016). As a potentially life-threatening event, a cesarean birth can cause intrusive memories (Horsch et al., 2017), and connections between cesarean birth, a negative birth experience, and posttraumatic stress have been recognized (Dekel et al., 2017). Moreover, a cesarean birth may have been necessary with an adverse neonatal outcome, which has been suggested to associate with increased stress and a negative birth perception among adults (Berman et al., 2021; Greenfield et al., 2019).

However, Fair and Morrison (2012) found that cesarean birth did not significantly affect birth satisfaction. Low et al. (2003) revealed that birth by cesarean surgery was less of an issue to adolescents than adult women, who viewed cesarean birth as a personal failure. The current study supports the finding that adolescents appear to be more distressed with a vaginal birth. Young Canadian university students (mean age 22) raised concerns over physical changes to their body with a vaginal birth leading them to frequently request a cesarean birth (Stoll et al., 2014). In the current study, however, fear of vaginal complications or the reason for a cesarean birth (emergency, repeat, or elective) was unknown, which may have impacted this finding.

In a study among multiparous Turkish adult women (mean age 28), Aktas (2018) revealed that women planning for a vaginal birth more likely perceived a traumatic birth to come than women planning a cesarean birth. In a follow-up qualitative study by Aktaş and Aydın (2019) with the same dataset of women, reports of a negative birth experience were associated with four general themes: challenges/difficulties–inability to cope with pain; inability to push, birth interventions, and hunger; embarrassment/privacy and inadequate communication; and hospital facilities.

In the current study, having had a previous birth was also a predictor of a negative birth experience. While most of the adolescents (78.5%) were primigravids, the remaining percentage of teens reported two to four children. Parity has had more research attention than other demographics but has failed to show consistent support as a contributor to a negative birth perception. In her landmark literature review, Ayers (2004) noted studies that revealed parity as related to traumatic birth stress but also indicated that the effect of parity appeared to be mediated by the type of birth. A recent systematic review of 28 studies by Chabbert et al. (2021) noted seven studies that related inconsistent findings examining parity (age unclear across studies). The connection between multiparity and a negative birth perception found in the current study may reflect the increased emotional and financial stress that additional children to an adolescent’s household may produce, especially if lacking support of a family or partner.

Unexpectedly, IPV was not identified as a predictor for a negative birth perception for this adolescent sample; however, this finding does not downplay the importance of IPV, or violence in general, as a significant influence on the perception of birth and consequent mental health issues, such as depression. Studies have shown the negative impact of a history of violence on the birth experience (Henriksen et al., 2017). A Canadian study (n = 6421) conducted among adolescents and adults revealed that experiencing violence within the past 2 years was found to be predictive of a negative birth experience (Smarandache et al., 2016). In the current study, a larger sample of adolescents disclosing violence may have revealed a different finding.

In summary, IPV and LOC during labor did not associate, and IPV was not found to influence one’s perception of birth. Black adolescents reported several risk factors; yet, no identified risk factor was directly found to be a significant predictor of a perceived negative birth. Independently, race–ethnicity was, however, found to be a predictor of a perceived negative birth along with vaginal birth, multiparity, and LOC during labor. These predictors can help identify adolescents most vulnerable to perceiving their birth as negative and direct guided assessments and interventions throughout pregnancy and postpartum. Additional research is needed in this population including adult–adolescent comparison studies and more targeted research related to race–ethnic differences including potential racial discrimination and societal discrimination as factors impacting the birth experience for minority adolescents, as well as protective factors seemingly present among Hispanic childbearing adolescents.

IMPLICATIONS FOR POLICY AND PRACTICE

Existing data to date suggest that the perception of birth associates with many variables that form a woman’s thinking. Given the prevalence of a reported negative birth experience for many women, increased awareness by health-care providers of both risk and protective factors can support development and implementation of routine screening strategies and clinical targeted interventions. Current study findings suggest the importance of comprehensive assessments to identify the at-risk adolescent throughout pregnancy, labor, and postpartum, which can offer preparation for birth and direct immediate and long-term health-care and social needs interventions. Essential interventions may be educational/informational and supportive directed. Preparation for birth, education related to the labor process, and screening for risk and protective factors, with interventions for modifiable risks, should begin prenatally and highlight the need to encourage adolescents to receive prenatal care throughout pregnancy.

Prenatally, health-care providers can educate women as to how awareness during childbirth, participation in decision-making, sharing expectations and worries, and good communication with staff can help one to feel more positive about the birth experience (Chabbert et al., 2021). If the adolescent exhibits an extreme fear of childbirth, health-care providers should assess for past traumas including past or current abuse, as well as a previous traumatic birth, and provide interventions and/or offer counseling prior to birth. During labor, assessing supports and making special efforts to allow the adolescent as much control/decision-making as possible are important actions. Effectively communicating the changes that may occur to the original birth plan can help maintain some personal control and, hence, lower stress and hopefully generate a more positive perception of birth. Good communication is beneficial in making the woman feel more in control of her birth experience even when changes are unexpected (Cook & Loomis, 2012). If unexpected fetal complications arise requiring an emergency cesarean birth or a complicated vaginal birth, additional support and education and interventions postpartum, including ideally a follow-up contact after hospital discharge, are essential.

Before being discharged to home, an evaluation of adolescents at risk for a negative birth experience may be beneficial to protect mental health (Aktaş & Aydın, 2019). At immediate postpartum, however, the joy of a healthy baby may obscure negative emotions and lead the actual birth experience to be overlooked (Muslu et al., 2022). Thus, it is suggested that the childbirth experience be evaluated specifically with both short- and long-term assessments. These actions can aid in improving the perception of birth of all women and prevent future mental health issues associated with a negative and traumatic birth experience, such as postpartum depression and posttraumatic stress, or posttraumatic stress disorder (Bay & Sayiner, 2021; Dekel et al., 2017). Swift et al. (2020) noted that younger women with ages 15–19 were more vulnerable to the mental health effects of childbirth including depression and anxiety than older women, thereby highlighting the importance of assessments, interventions, and follow-up for this population.

Limitations

Several strengths and limitations of the study exist. The current study is one of only a few published articles examining the perception of birth among adolescents which also offers a comparison between three race–ethnic groups. Limitations largely stem from the use of a secondary analysis design which restricts available data for future studies. Samples, procedures, and measurement tools, for instance, could not be changed for the current study. The overall sample size was adequate except for smaller subsamples, especially of White adolescents. Furthermore, only a small percentage of adolescents reported violence. Witnessing of violence was unknown and can impact the perception of numerous life events, including potentially the perception of one’s birth experience. A fetal loss was noted for three women (1% of study) which may also impact their perception of birth. Twelve adolescents spoke limited English; therefore, study materials were translated into Spanish by a bilingual member of our research team. The reliability and validity of the Spanish version IES for the current study are unknown.

Funding Statement

FUNDING The authors received no specific grant or financial support for the research, authorship, and/or publication of this article.

DISCLOSURE

The authors have no relevant financial interest or affiliations with any commercial interests related to the subjects discussed within this article.