Birth trauma: characterization and thematic analysis of traumatic birth experiences revealed on social media

Abstract

Background

Although guidelines exist for the diagnosis and treatment of those who have endured traumatic birth, the term itself is poorly defined and has no clear identifying criteria. Birth trauma has profound long-term health and quality of life sequelae. This study assessed how birth trauma was described by women who had experienced it and were followers of a public social media platform interested in the topic to help better characterize the term.

Methods

We posted an invitation on the Birth and Trauma Facebook Support Group website to English speaking people over age 18 years with personal experience with birth trauma to participate in an anonymous, beta-tested, IRB-approved, 18-question survey.

The survey asked about demographic information, personal experiences with what the respondents perceived to be birth trauma, the settings in which it occurred and any longer-term impacts they may have noted. We calculated the percentage of participants' responses to objective questions and performed thematic analysis of the answers to the open-ended questions.

Results

From the approximately 6,000 online group followers, we received 1,362 responses (response rate = 22.7%). The average age of respondents was 25 years; 55% were multiparous, and half of those latter participants reported having suffered multiple episodes of traumatic birth. Most participants (73%) reported that trauma occurred during labor and delivery; 17% said it occurred at any time during pregnancy and 32.5% reported their trauma in the immediate postpartum period. Three major and two minor themes emerged to characterize their traumatic experiences. Physical trauma was the most common theme- pain, lacerations/incisions, surgical complications, hemorrhage, unplanned C-Sects. (41.4%), but emotional- fear/anxiety about death, complications, judgment, infection, and feelings of disempowerment (21%) and unexpected adverse outcomes- premature births, intensive care stays, complications due to pre-existing chronic illness/history of infertility (17.6%) were also prevalent.

Conclusion

Respondents generalized “birth trauma” to include experiences throughout pregnancy. Our results suggest that many women are entering pregnancy unprepared for experiences that can have significant long-term impacts. Even multiparous women reported unexpected outcomes that they found traumatic. The themes derived from this survey provide insight into how multifaceted and complex birth trauma is, and how challenging it may be to tailor individual trauma-informed care.

Background

Professional organizations such as the American College of Obstetrics and Gynecology (ACOG, 2015), the American Academy of Pediatrics (2010), and the United States Preventive Services Task Force (2016) have recognized the importance of screening for mental health conditions during pregnancy and postpartum [1–3], but they tend to focus on psychiatric pathologies. ACOG has also strongly advocated for trauma-informed care for obstetric and gynecologic settings, but again their focus has been more about providing trauma-informed care rather than characterizing specifics about birth trauma [4].

The terminology itself is ambiguous. Although many professionals exclusively use “traumatic birth” to describe a patient’s subjective experience of childbirth as having been traumatic, regardless of the medical outcomes for the mother and the newborn and reserve “birth trauma” to refer to both physical injuries and psychological consequences resulting from complications during birth, most patients and special interest groups use the terms interchangeably. The Cleveland Clinic describes birth trauma as “any physical or emotional pain you experience before, during, or after childbirth” [5]; the March of Dimes defines birth trauma as “any physical or emotional distress you may experience during or after childbirth” [6]. As evidenced by those descriptions, some restrict the concept to events and perception around the delivery process itself, and others include any experiences that occur during and following pregnancy itself. Whatever terminology is used, upward of 50% of women have reported that they felt they had suffered trauma during or following childbirth [7].

Linked to inconsistent terminology, the current definitions of what constitutes birth trauma are still evolving. Studies have highlighted the subjectivity of the definition of birth trauma, and that traumatic births perceived by the patient are often ones viewed as routine by clinicians [7]. Traumatic birth experiences can have significant adverse impacts for both the new mother and the infant; they can lead to mental health challenges, fear of future pregnancies and interference of mother-newborn bonding, which can be followed by future child health issues [8–11]. Many studies of birth trauma build on the foundation of post-traumatic stress disorder (PTSD) [8, 10, 12], which is defined by the DSMV-TR as the development of characteristic symptoms including intrusion, avoidance, negative alterations in mood and cognition, and alterations in arousal and reactivity for at least one month [13]. Froeliger et al. estimated that 1 in 11 women with Cesarean deliveries had PTSD symptoms at two months postpartum [14].

It has been suggested that birth trauma lies “in the eye of the beholder”, however women have expressed general feelings of betrayal and powerlessness in their birthing experiences [7]. Other studies have focused more on psychological birth trauma, developing a scale to assess this manifestation. The domain of this scale included themes to help characterize the experiences such as “being neglected”, “out of control”, “physiological emotional response”, and “cognitive behavioral response” [15]. This was supported by the Hollander study, which reinforced that women with traumatic birth experiences felt that the lack and/or loss of control, as well as the interaction around interventions (rather than the interventions themselves) were the most important contributing factors [16]. Another study that focused on Iranian women demonstrated that these mothers experienced feelings of fear, disappointment, and death during delivery [17], while mothers in China have reported that suffering caused by severe physical pain was a major influencing factor for psychological birth trauma [18]. The variety in findings amongst the studies reveal a multitude of factors that can contribute to the experience of birth trauma, as further revealed by De Schepper, whose study suggested that contextual factors such as religion, socio-economic status, and childbirth experience may be important factors to address [19]. In a literature review, Simpson et al. identified risk factors for psychological birth trauma, such as prior mental disorders, poor obstetrical outcomes and poor quality of provider interactions and recommended interventions that might show benefits [11].

Our study complements this previous literature in a unique way by surveying women on a social media platform dedicated to those with interest in this topic about their personal experiences with perceived traumatic birth in order to contribute to developing a more complete description of what constitutes a traumatic birth, both physically and emotionally. While we asked when in their pregnancy experiences women felt traumatized, we focused most of our questions about trauma on experiences that happened at the time of labor and delivery. We also attempted to gain a better understanding from the patients’ perspective if they felt there were shortcomings in their care during labor and delivery, as well as specifically what actions they believe could have been taken to minimize trauma. Furthermore, participants were asked to reflect on the long-term impacts of their experiences, including medical issues and changes in their reproductive life plans.

Methods

An anonymous 18-question survey with 15 closed-ended, 2 open-ended, and 1 Likert style question was developed, beta tested and approved by the Human Subjects Committee (Institutional Review Board) at Western University of Health Sciences. To identify potential subjects, a search of Facebook communities with the words “Birth Trauma” yielded the “Birth and Trauma Facebook Support Group”, with an estimated 6,000 followers. The website moderator agreed to let us post on their site an IRB-approved study invitation for women aged 18 and older, who had personally experienced what they perceived to be birth trauma, with a link to a detailed description of the purpose of the study and its risks and benefits. We asked potential candidates to refrain from participating if they were pregnant or if they anticipated that taking the survey might cause them any discomfort. If a follower felt she met these criteria and decided to participate, she clicked the link to the survey. The invitation was posted once in September 2023 and taken down in October 2023, once no further responses were received.

The survey included questions about demographic information in brackets to preserve participant privacy. It asked participants about how they would classify their traumatic experience using categories identified in the earlier mentioned studies, such as “Emotional”, “Physical”, “Loss of control over the birth experience”, “Loss of control over the experience”, and “Other” [9, 15, 16]. Participants were also asked at what point during the birth they experienced trauma, how they delivered the pregnancy, whether or not they felt they had support during their labor and delivery, and to describe in their own words what they thought it was about their pregnancy that was traumatic. Additionally, participants were asked about any medical problems that they or their babies experienced, and whether or not healthcare providers noticed their trauma, or if they thought the providers could have done anything different to improve their experiences. Long-term impacts were also explored, asking members if they thought their birth trauma explicitly caused any problems after the birth, or whether or not the perceived trauma affected future pregnancy plans. As an incentive, after they submitted their responses, participants were invited to enter a raffle to win one of five $25 Amazon gift cards.

Frequency of responses was calculated for each of the closed-ended questions. Demographic and numerical style data were analyzed using descriptive statistics. Qualitative thematic analysis was conducted of the traumatic birth experiences that respondents reported in the open-ended questions; we analyzed those free response texts by using a content analysis approach for identification of recurring themes. NVivo Software was used to assist with qualitative content analysis. Although it does require training and may not be appropriate for all platforms, NVivo enabled us to organize, analyze and perform analysis of the unstructured data from the open-ended question answers. Responses were coded into categories suggested by NVivo that informed the themes that we extracted.

Results

From the estimated 6,000 members of the Facebook “Birth and Trauma Support Group”, 1,362 submitted surveys, for a response rate of 22.7%. Table 1 summarizes the demographic information of the respondents. Looking at both age and parity, nearly half of participants were aged 25–35, and more than half (55%) were multiparous.

Table 1.

Ages of Participants

Age in years (N = 1356)	Number of Response (%)a
18–24	277 (20.4)
25–35	661 (48.7)
36–45	292 (21.5)
> 45	126 (9.3)

^aPercentages total 99.9% due to rounding issues

Table 2 demonstrates that the majority of participants (71%) experienced perceived birth trauma during only one birth, although it should be noted that multiparous women reported perceiving birth trauma in more than one birth, with 2 participants citing birth trauma in as many as 8 pregnancies. When asked to report all categories of trauma they experienced, half of participants cited “Physical” trauma as part of their response, 47% cited “Emotional” trauma, 40% cited “Loss of control over body exposure” and 34.2% cited “Loss of control over birth experience”.

Table 2.

Total Deliveries vs Deliveries with Perceived Birth Traumas

# Deliveries (N = 1356)	Number of Responses (%)	# Traumatic Deliveries	Number of Responses (%)a
1	608 (44.8)	1	968 (71.4)
2	582 (42.9)	2	296 (21.8)
≥ 3	166 (12.2)	≥ 3	92 (6.8)

^aPercentage of responses exceeds 100% because multiple responses were allowed

The majority of participants delivered their pregnancy vaginally (76%), 18% had planned Cesarean deliveries; 6% had unplanned Cesarean delivery. “Emotional” trauma was cited at slightly higher rates than physical trauma by both planned and unplanned Cesarean groups, with 57.6% and 61.6% respectively, indicating potential emotional distress induced by the reasons for and/or the conduct of the procedure. In contrast, women who delivered vaginally (n = 1,022) most commonly cited “Physical” trauma (47.4%).

Table 3 demonstrates that while women experienced perceived birth trauma at any time during pregnancy, nearly half of participants reported that maximal trauma occurred during labor. A smaller portion (155) of participants indicated that maximal trauma happened only during prenatal care, however prenatal trauma was not always isolated, as shown by 75 individuals who mentioned they also had trauma at other times in their pregnancy, such as labor and delivery.

Table 3.

Timing during pregnancy of the worst traumatic experience

Timing of Worst Trauma	Number of Response (%)a
During Labor	666 (49)
During Delivery	319 (24)
After Delivery in the Hospital	293 (22)
During Prenatal Care	230 (17)
After Discharge	146 (11)

^aPercentage of responses exceeds 100% because multiple responses received

Themes

We identified 5 common themes (3 major and 2 minor ones) from the 1243 free responses to the open-ended optional prompt “Please describe what it was about your birthing experience that was traumatic”. We have displayed those themes, their frequencies, and illustrated examples in Table 4.

Table 4.

Themes categorized: “Please describe what it was about your birthing experience that was traumatic”

Category	Number Responded (%)	Examples
Unexpected experience of pain and physical injury	515 (41.4%)	Unbearable pain
		Tears, lacerations, and incisions causing pain and difficulty in healing
		Surgical complications, hemorrhage, unplanned c-sections
		Complication leading to physical injury (i.e. physical injuries such as infection or incontinence)
Negative emotional and psychological impact	265 (21%)	Fear/anxiety about death, complications, judgment, and infection
		Feelings of disempowerment and being overwhelmed
		Fear of birth complications in low resource settings
Unexpected adverse outcomes unrelated to pain	219(17.6%)	Premature births
		Complications due to pre-existing conditions/chronic illnesses/history of infertility
		Complications for baby
		Intensive Care Unit or Neonatal Intensive Care Unit stays
		Postpartum depression or lack of postpartum support
Issues with healthcare providers, informed consent, and autonomy	16 (13%)	Trauma from medical errors, neglect, or lack of communications
		Cultural insensitivity
		Lack of informed consent for medical procedures
		Loss of bodily autonomy, privacy, or desired birth plan
Social, financial and relationship factors	82 (7%)	Partner related stress and domestic/sexual abuse
		Lack of family support during labor
		Trauma for single parents, adoptive parents, surrogates, and members of LGBTQ + community
		Trauma for parents with disabilities, addiction, mental health issues

Themes are not mutually exclusive; individual responses could include more than one theme simultaneously

Participants were also asked to rank the relevance of previously identified themes from current literature to their own experiences on a Likert scale of 1–5, where 1 was defined as “strongly disagree” and 5 was defined as “strongly agree” [15–18]. For the theme “I lacked all control/felt as though I had no control over my birth experience”, 69% reported the score as 3 or more. For the theme “I was disturbed by the fact that I had no control over the exposure of my body” 63% answered 3 or more. Finally, for the questions “I was asked about my preference of the gender of my caregiver” the percentage that were neutral or agreed was 63%.

Support during labor and delivery

In addition to asking participants to describe their perceived trauma, questions were also aimed at determining the quality of support they received from social groups and healthcare workers. 90% of participants responded “Yes” to the question “Do you feel you had support during that (the most traumatic) labor and delivery?” (n = 1,350). Of this group, the most commonly cited sources of support were family (52%) and nursing staff (50%). Each participant was able to cite more than one source of support. Other sources of support that were mentioned were friends (45%), doctors (42%), and doulas (31%). Midwives were mentioned as a main source of support in three separate responses.

When asked if healthcare staff seemed to be aware that they were suffering, 93% (1,158/1,248) of respondents indicated “Yes”. Of these individuals, only 13% (140) felt that healthcare providers could have done more; their most cited type of trauma being"emotional"(76.5%). Those who wouldn’t have changed the care they received mostly cited"physical"pain (48%) as the cause of their trauma. For both groups, their most commonly cited medical problem was"heavy bleeding".

The participants, who cited that healthcare providers could have done something different to improve their experience, were further asked to specify in free response text what exactly they wished was done differently (n = 138). Nearly one-third (30%) talked about improving comfort in the delivery room, citing factors such as positive reinforcement, encouragement, psychological comfort, breathing exercises and distractions. One quarter (26%) of this group wished that their concerns had been taken more seriously, and that their wishes had been better respected, whether that was respecting bodily autonomy/privacy, improved informed consent, validating emotional experiences, active listening, and not being dismissive of pain. In addition, 22% wished for better pain management and minimized interventions (smaller incisions); 10% felt that they were not properly educated or communicated with regarding prenatal education, birthing options, or complications/interventions; and 12% also wished that healthcare providers had acted sooner, citing lack of mental health screening and preventative care.

Reported intrapartum and neonatal outcomes

Of the 1,320 respondents who reported having what they consider to be medical problems during their birth experience, painful contractions (43.6%) and heavy bleeding (33.3%) were the most cited problems. Also of note, 22% of participants mentioned suffering an infection, and 21.5% noted high blood pressure as a concerning medical problem. Problems dilating (19.5%), and problems pushing (15.3%) were also cited. The participants who reported here that they did not experience medical problems during their birth experience (6.3%) most commonly fell in the “Negative Emotional and Psychological Impact” theme in the thematic analysis. Sixteen participants elected to write in other medical problems they experienced that did not fall into the previously mentioned categories, citing a variety of conditions such as spleen aneurysm, breech birth, blood transfusions, bladder and heart complications, placenta abruption, uterine inversion, placenta accreta, and postpartum hemorrhage.

In terms of neonatal outcomes, nearly one-third (30%) reported their babies had no medical problem during delivery. However, 29.6% of participants noted that their infants experienced trouble breathing; 20.8% noted an infectious complication; and 18.6% noted prematurity as a major health complication for their baby. Only 12 participants (0.9%) selected that their babies experienced complications that lay outside of the previously mentioned conditions.

Longer lasting impacts

Out of the 1,320 responses to the question, “Do you think this birth trauma caused you any problems after the birth?”, 21% (n = 237) indicated that their birth trauma caused them problems after their birth. PTSD or psychological impact were most commonly cited (44%), with women discussing fear of childbirth and intimacy, postpartum depression, and frequent nightmares and trouble sleeping. Almost one-third (32%) of those reporting any problems claimed they had longer term health complications, such as GI problems, high blood pressure, infertility, pelvic organ prolapse, heart failure, and lasting physical weakness. Persistent pelvic pain was specifically noted by 40 participants. Additional associated problems included bladder damage and urinary incontinence, infections, and a loss in trust of physicians. In a subanalysis of participants, who had specifically cited experiencing “Emotional” trauma (n = 623), 33% indicated the presence of long-term impacts.

Ten percent (n = 137) of all respondents to these questions also indicated that their birth trauma affected their future pregnancy plans, with the majority of those declaring that they no longer want another child after their perceived traumatic birth experience. In addition, women discussed being unable to have more children (infertility and financial reasons), delaying family plans, fears of loss, and finding new locations and birthing teams.

Discussion

The findings from this study provide insights into the multifaceted nature of perceived birth trauma, emphasizing its physical, emotional, and relational dimensions. The use of social media to collect data enabled input from a motivated group of patients with a wide range of traumatic childbirth experiences. Several key themes emerged from the analysis, highlighting both commonalities and unique aspects of perceived trauma.

This study corroborates prior research asserting that birth trauma is highly subjective, often differing from medical perspectives that often classify such births as routine. Consistent with Bech et al.'s assertion that birth trauma lies “in the eye of the beholder” as well as Hollander’s main conclusion, our results showed that participants cited a combination of physical injuries, emotional distress, and a perceived lack of control as primary contributors to their trauma [9, 16].

Our analysis reveals that physical trauma, such as severe pain, lacerations, and surgical complications, was the most commonly reported factor (41.4%). However, emotional and psychological impacts, including feelings of fear, disempowerment, and anxiety about death, were also frequently cited (21%). These findings align with Taghizadeh et al., who emphasized emotional responses such as fear and disappointment [17]. Importantly, emotional trauma often co-occurred with physical injuries, illustrating the interconnectedness of these dimensions.

While less frequently cited, social and relational factors, including partner-related stress and lack of family support, were significant for a few participants (7%). This corresponds with existing literature indicating that the presence of supportive individuals and post-natal counselling can buffer against the adverse effects of traumatic births [11, 12]. Interestingly, some of our participants reported trauma linked to societal pressures or systemic issues, such as cultural insensitivity and bias against marginalized groups.

Participants frequently highlighted the role of healthcare providers in shaping their experiences. Approximately 13% of respondents described trauma linked to perceived medical errors, neglect, or lack of informed consent, consistent with prior studies on patient-provider communication [11, 20]. Notably, participants who felt their trauma could have been mitigated by different provider actions often emphasized the need for greater respect for bodily autonomy and emotional validation. Furthermore, participants provided several recommendations for improving childbirth experience. Key suggestions included enhancing pain management, providing more comprehensive prenatal education, fostering open communication, and ensuring informed consent. These correlate with Zhang et al.'s call for a patient-centered approach to care, which emphasizes understanding and addressing women's unique needs and preferences during childbirth [15]. Guidelines for screening suggested by Bydlowski, and for prevention of postpartum PTSD by Canfield and the prevention strategies separately offered by Horsch and Yildiz are all helpful in addressing the issue [21–24].

In addition, the study further underscores the long-term impacts of perceived birth trauma. Psychological sequelae such as PTSD, postpartum depression, and sleep disturbances were commonly reported, affecting participants'mental health and future pregnancy plans. Physical consequences, including pelvic pain and organ prolapse, were also reported, reflecting the lasting toll of traumatic childbirth experiences. These findings align with research indicating that unresolved birth trauma can adversely affect both maternal and child health [11, 16].

While this study provides rich qualitative data, several limitations should be noted. The use of this particular social media platform may have introduced selection bias, as participants with stronger emotional responses may have been more inclined to be followers of the site and to share their experiences. Additionally, the survey relied on self-reported data, which may be subject to recall bias.

Once birth trauma has been more completely defined, it may be more feasible to design interventions to reduce the incidence of perceived birth trauma, particularly those focused on enhancing provider communication, increasing patient autonomy, and improving emotional support during labor and delivery.

Conclusions

Women are not entering pregnancy prepared for the experience, which can have significant long-term impacts; even multiparous women face unexpected outcomes that resulted in perceived trauma. Without women knowing about the challenges posed by pregnancy, they are often surprised and alarmed when they develop them and consequently suffer a loss of control, which contributes strongly to their perception of trauma. Postpartum debriefing and counselling can help mitigate the adverse long-term impacts, but it cannot replace basic understanding and their frames of reference. The themes derived from the survey provide insight into how multifaceted and complex birth trauma is, and how important patient perspectives are in defining and addressing traumatic childbirth experiences. The findings emphasize the need for holistic, patient-centered approaches to maternity care that address both the physical and emotional aspects of childbirth and encourage timely communication, to help mitigate traumatic impact for mothers and their families.

Authors' contributions

JC submitted for IRB approval, obtained social media site moderator approval, prepared and posted the survey, analyzed and interpreted the respondent’s data via NVivo, and was a major contributor to preparing tables 1–4 and writing the manuscript. AN was a major contributor in ensuring the final quality of the survey and the dataset, as well as reading and approving the final manuscript. AN was a major contributor in ensuring the final quality of the survey and the dataset, as well as reading and approving the final manuscript.

Authors’ information

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Screening for Perinatal Depression- ACOG. (2018, October 29). From https://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Screening-for-Perinatal-Depression

Daniels, E., Arden-Close, E., & Mayers, A. (2020). Be quiet and man up: a qualitative questionnaire study into fathers who witnessed their Partner’s birth trauma. BMC pregnancy and childbirth, 20, 1–12.

- “birth trauma” is defined as physical and emotional suffering during birth that resulted from either complications, physical injury or negative reactions during the birthing experience.

Funding

Funding for this project was through the Western University Research Grant (2023). The funder had no specific role in conceptualization, design, data collection, analysis, decision to publish, or preparation of the manuscript. Additional funding for the raffle incentive came from an anonymous donor.

Western University Research Grant (2023)

Data availability

The data from the responses to the survey were downloaded as an Excel document from Qualtrics, and then converted into a Google Sheets document for easy sharing. Data can be viewed at the following link: https://docs.google.com/spreadsheets/d/1WYItQ0OKGGSybBwq0p7-RdcNvj0UsV4GB5OsvvSsOVo/edit?usp = sharing.

Declarations

Ethics committee approval and consent to participate

This survey had IRB approval by the Human Subjects Committee at Western University of Health Sciences. The project specific reference number is P23/IRB/054.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.