The Anniversary of Birth Trauma: A Metaphor Analysis

ABSTRACT

The aim of this qualitative secondary data analysis was to identify the metaphors women used to describe their anniversary of their traumatic births. The existing data set that was reanalyzed was from a phenomenological study of the anniversary of birth trauma. Metaphor identification procedure was the method used to identify 8 different metaphors from the women’s descriptions that provided a rich source of insight into their yearly struggles. These metaphors characterized the anniversary of traumatic birth as a great pretender, a lottery, a trigger, a clock watcher, a giant rubber band, a guilt trip, a sea of sadness, and bottled up anger.

INTRODUCTION

As many as 43% of mothers view their births as traumatic (Alcorn, O’Donovan, Patrick, Creedy, & Devilly, 2010). In a meta-analysis of 78 studies, the prevalence of posttraumatic stress disorder (PTSD) because of traumatic childbirth was 3.1% in community samples and 15.7% in at-risk samples (Grekin & O’Hara, 2014). In addition to developing PTSD, traumatic childbirth can have other long-term consequences for maternal and infant health, relationships with partners, breastfeeding, and future reproductive choices. Metasyntheses of qualitative studies on traumatic childbirth revealed the multifaceted emotional impact on mothers such as seething anger, suffocating guilt, uncontrollable flashbacks, and numbing detachment (Beck, 2015; Fenech & Thomson, 2014). Impaired mother–infant relationships have been reported in the literature (Beck, Driscoll, & Watson, 2013; McKenzie-McHarg et al., 2015). The impact of postpartum PTSD symptoms on child development was recently assessed in a large population-based 2-year follow-up study (N = 1,472) in Norway (Garthus-Niegel, Ayers, Martini, von Soest, & Eberhard-Gran, 2017). Even when controlling for confounding variables such as infant temperament and mother’s depression and anxiety, PTSD symptoms were significantly related to poor child social-emotional development 2 years later.

As many as 43% of mothers view their births as traumatic.

Relationships with their partners also can be negatively impacted when women are struggling with the after effects of birth trauma (Beck et al., 2013). Elmir and Schmied (2016) conducted a meta-ethnography of qualitative studies on fathers’ experiences with their partners’ traumatic births. One of the themes discovered was “scarring the relationship.” Men revealed that their lack of empathy or understanding of the birth trauma negatively impacted their relationship with their partners. Men shared that the traumatic birth also impacted their sexual relationships as they or their partners felt physically and emotionally disconnected and did not desire sexual intimacy.

Traumatic childbirth can also have consequences for breastfeeding. In their qualitative study of the impact of birth trauma on breastfeeding, Beck and Watson (2008) found that it was a tale of two pathways. For some women their birth trauma helped to promote their breastfeeding as they felt it was mentally healing. Women who followed this path felt compelled to prove that they could succeed at something related to motherhood because they had failed at giving birth and also to atone to their infants for the traumatic way they had entered the world. Other women traveled down a different path that hindered their breastfeeding attempts. Intruding flashbacks of the traumatic birth when breastfeeding, disturbing detachment with their infants, insufficient milk supply, enduring physical pain, and feeling violated from their birth trauma all impeded their breastfeeding attempts.

Perinatal nurses and other clinicians, childbirth educators, and lactation consultants need to be vigilant about the possibility that mothers may be struggling with the aftermath of traumatic births. Only once identified can women be referred for any necessary follow-up care. Being attentive to metaphors mothers use can provide a unique approach in helping with this identification. In clinical practice, metaphors can be windows into how our patients are experiencing their physical or mental illness. Metaphors have the capability of enhancing patients’ communication with their health-care providers that is not captured by medical terminology. Metaphors give mothers a new and different voice and open up a space for them to explain what they experience each year with the anniversary of their traumatic births. The purpose of this qualitative secondary data analysis was to examine the language used by women to describe their experiences of the anniversary of their traumatic births for metaphors as a rich source of insight.

Perinatal nurses and other clinicians, childbirth educators, and lactation consultants need to be vigilant about the possibility that mothers may be struggling with the aftermath of traumatic births.

Metaphor

A metaphor is “a way of conceiving one thing in terms of another, and its primary function is understanding abstract, emotional or other experiences” (Lakoff & Johnson, 1980, p. 36). Instead of metaphor being seen as of peripheral interest, it is now viewed as central to providing understanding (Lakoff & Johnson, 1980). Metaphors help us make sense of our experiences especially when they are emotional and complex. A metaphor may be the best way to coherently organize aspects of one’s experience. Something new is created when a metaphor is understood (Ortony, 1993). Different metaphors can structure different aspects of a single experience or concept. Martin and Lueckenhausen (2005) explained that persons may not just use a single metaphor but several different metaphors to communicate their feelings or ideas.

A metaphor is “a way of conceiving one thing in terms of another, and its primary function is understanding abstract, emotional or other experiences.”

Lakoff and Johnson (1980) developed the cognitive linguistic view of metaphors. Metaphor is a powerful cognitive tool humans have to permit an association between two disparate ideas or facts. Cognitive linguists view metaphor as understanding one conceptual domain in terms of another conceptual domain. Source and target domains are the names given to these two domains of a conceptual metaphor. The conceptual domain, where the metaphorical expressions come from to aid in understanding the target domain, is the source domain. Lakoff and Johnson provided the formula of A is B to describe a metaphor. A is the target domain and B is the source domain. A is helped to be understood in terms of B.

There is not just one type of metaphor but several different types (Lakoff & Johnson, 1980). In a personification metaphor, we make sense of a phenomenon in the world in human terms. We see something that is not human as human as physical objects are specified as being a person. In structural metaphors, the source domain provides a rich source of concrete structure to the target domain. Structural metaphors allow us “to use one highly structured and clearly delineated concept to structure another” (Lakoff & Johnson, 1980, p. 61). A third type of metaphor is the container metaphor where

Even when there is no natural physical boundary that can be viewed as defining a container, we impose boundaries—marking off territory so that it has an inside and a bounding surface—whether a wall, a fence, or an abstract line or plane. (Lakoff & Johnson, 1980, p. 29)

Mental health disorders where metaphor analysis has been fruitful include autism (Olofson et al., 2014), schizophrenia (Mossaheb et al., 2014), young-onset dementia (Johannessen, Möller, Haugen, & Biong, 2014), depression (Charteris-Black, 2012), anorexia (Bates, 2015), and substance abuse (Redden, Tracy, & Shafer, 2013). Only one metaphorical analysis of perinatal mood or anxiety disorders has been conducted to date. This metaphor analysis focused on PTSD after birth and identified nine metaphors that are a rich source of insight into this anxiety disorder that can plague new mothers (Beck, 2016). These metaphors characterize PTSD following traumatic childbirth as a mechanical robot, a ticking time bomb, an invisible wall, a video on constant replay, enveloping darkness, a dangerous ocean, a thief in the night, a bottomless abyss, and suffocating layers of trauma.

METHOD

Research Design

Secondary Qualitative Analysis

Thorne (2013) identified five different approaches that can be used to conduct a secondary qualitative data analysis. This metaphorical study used the analytic expansion approach wherein a researcher makes additional use of a primary data set to ask new questions that were not investigated in the primary analysis. In this secondary qualitative data analysis, an existing data set was used to investigate a different research question than the one in the primary study of the anniversary of birth trauma (Beck, 2006). The primary study was a phenomenological study whose research question was “What is the essence of women’s experiences regarding the anniversary of their traumatic childbirth?”

Research Question

The new research question investigated was “What are the metaphorical expressions used by women to describe the anniversary of their traumatic childbirth?”

Primary Study

As Thorne (2013) stressed, a secondary study must provide the readers with sufficient information about the primary study to lay the foundation for the trustworthiness of its findings. Critical to achieving this is the ability of the secondary researcher to examine in depth the primary data set. In this case of the metaphor analysis of the anniversary of birth trauma, the primary and secondary researchers are one in the same person giving the advantage of being privy to the intimate details of the data set.

Approval for the conduct of the primary study (Beck, 2006) was obtained from the university’s institutional review board. The sample was recruited over the Internet from a recruitment notice place on the Trauma and Birth Stress’s website (http://www.tabs.org.nz). Criteria for inclusion in this study were that the woman was at least 18 years of age, perceived she had a traumatic birth, and experienced at least one anniversary of that birth trauma. Thirty-seven women participated in the study from five countries: the United States, New Zealand, Australia, the United Kingdom, and Canada. Mothers were asked to describe in depth their experiences surrounding the anniversary of their birth trauma. Sending their narratives by attachment to the researcher implied their consent.

In this primary Internet sample, 18 mothers (58%) had vaginal births and 13 (42%) had cesarean births. Nineteen women (58%) were primiparas, whereas 14 (42%) were multiparas. Thirty-one women (94%) were married, 1 (3%) was single, and 1 (3%) was divorced. Of the 29 women who included their highest education level, 7 (25%) had high school diplomas, 1 (3%) some college, 2 (7%) associate degrees, 12 (41%) college degrees, 6 (21%) masters degrees, and 1 (3%) a PhD. The age range of the sample was 24–54 years with a mean of 32 years. The range of time since women had experienced their birth trauma was 1–23 years. Eighteen mothers (49%) reported they had been diagnosed with PTSD because of their birth trauma, and of those women, 12 were currently in treatment for this disorder. Examples of some of the birth traumas shared most frequently by the participants were premature birth, shoulder dystocia, and emergency cesarean births.

The researcher in the primary study found that data saturation was achieved much earlier than the final sample of 37 women. In order not to put any undue pressure on the participants, the researcher did not specify a deadline when the narratives needed to be sent. Consequently, some of the mothers sent their stories after data saturation had been reached. The researcher had promised the participants she would use their words to the best of her ability to help educate clinicians. Therefore, the researcher felt that ethically she needed to include all the narratives in her analysis.

As a step to help increase the trustworthiness of the primary study, the findings were validated by two of the mothers as the following quote illustrated: “This is superb and I love every word of it” (Beck, 2006, p. 384). Using Colaizzi’s (1978) data analysis method for phenomenological studies, four themes emerged in the primary study: (a) “the prologue: an agonizing time,” (b) “the actual day: a celebration of a birthday or the torment of an anniversary,” (c) “the epilogue: a fragile state,” and (d) “subsequent anniversaries: for better or worse.”

Secondary Study

In this secondary study, the unit of analysis, metaphors, was different than that in the primary study. A corpus is a large collection of texts that are derived from natural language used and not from texts that were specifically developed for illustrating a point about language (Charteris-Black, 2004). For this metaphorical analysis, the initial corpus consisted of 162 single-typed pages from the primary study. Individual narratives provided by the 37 participants ranged from 1 to 19 pages in length. Out of this initial corpus of 37 narratives, 33 of them included metaphors that helped describe the mothers’ experiences of the anniversary of their birth trauma. These 33 narratives were selected as the corpus for this secondary analysis.

Data Analysis

One researcher analyzed the 33 narratives for metaphors used by the women. She was the researcher of the primary study and had the benefit of knowing firsthand the insider’s details of the corpus. The metaphor identification procedure (MIP) was the method used to analyze the data. The Pragglejaz Group (2007) developed the MIP as a method for identifying metaphorically used words in discourse. Pitcher (2013) supports use of the MIP as a more valid and repeatable method of identifying metaphors. The following MIP steps list the process that was used to identify metaphors used by mothers to describe the anniversary of their traumatic births:

1. Read the entire text-discourse to establish a general understanding of the meaning.

2. Determine the lexical units in the text-discourse.

3. 1. For each lexical unit in the text, establish its meaning in context, that is, how it applies to an entity, relation, or attribute in the situation evoked by the text (contextual meaning). Take into account what comes before and after the lexical unit.

   2. For each lexical unit, determine if it has a more basic contemporary meaning in other contexts than the one in the given context. For our purposes, basic meanings tend to be more concrete (what they evoke is easier to imagine, see, hear, feel, smell, and taste); related to bodily action; more precise; and historically older;

   3. If the lexical unit has a more basic current-contemporary meaning in other contexts than the given context, decide whether the contextual meaning contrasts with the basic meaning but can be understood in comparison with it.

4. If yes, mark the lexical unit as metaphorical. (Pragglejaz Group, 2007, p. 3)

The following is an example of MIP in this analysis of metaphors used in women’s descriptions of their experiences of the anniversary of their traumatic childbirth.

“Ten/years/later/I/still/remember/feeling/like/an/imposter/with/my/smile/and/feigned/excitement/. I/kind/of/dragged/through/the/day/feeling/like/a/total/faker/.”

Out of the 28 lexical units in these two sentences, two lexical units were judged as being used metaphorically: “imposter” and “total faker.” Once all the lexical units were identified in the corpus, they were sorted into the metaphors most often used by mothers to describe their anniversaries of birth trauma. Counts for each of these metaphors were done to identify their order of frequency.

RESULTS

Eight different metaphors were identified from the mothers’ descriptions of the anniversaries of their traumatic childbirths. “Metaphors are like a series of brush-strokes so that no single metaphor adequately expresses the state” (Charteris-Black, 2012, p. 213). The series of brush strokes of the eight metaphors paints a vivid picture of what mothers have to contend with at anniversary time: anger, guilt, sadness, anxiety, dread, and fear while putting on their “mask of happiness” (Figure 1).

Figure 1. Eight metaphors of the anniversary of birth trauma.

The number of metaphors that mothers used in their descriptions ranged from one metaphor (n = 14 women) to seven metaphors (n = 1 woman) with a median of three metaphors per participant. Each of these eight metaphors is described now in their order of frequency. The metaphor with the highest frequency count was the great pretender, and bottled up anger had the lowest frequency count. Metaphors encompass a large amount of information into a compact package. In the descriptions in the following section, these metaphors women used are unpacked.

Anniversary of Birth Trauma Is the Great Pretender

This is the first personification metaphor that gave a human quality to anniversaries, that of being an imposter or pretender. Repeatedly, women recalled that during the actual day of the anniversary, which always was supposed to be a day of celebration for their child’s birthday, they threw on their “mask of happiness.” Mothers did not want to spoil their child’s birthday so they feigned how excited and happy they were. As one woman who had experienced four anniversaries explained,

I could win an Oscar for my performances. I find that each birthday for my daughter is a real trial for me. I know I should seem happy and bouncy and so that’s the front I put on but inside I feel like I’m coming to pieces.

Women also pretended that they were not filled with anxiety and fear as the following quote captures: “As my son’s first birthday approached, the fear got stronger and stronger. On his birthday, I was a nervous wreck, but I managed to hide it very well though.”

Women often used the phrase “a total faker” to describe themselves.

I was woken up on Monday morning with my son running into my room all excited saying it’s his birthday. I, of course, squeezed him with a big smile on my face, telling him how great being four is going to be! But I kind of dragged through the day feeling like a total faker.

Another mother recalled, “I felt like an outside to the birthday celebration. I put on a brave, happy face but spent most of the day walking around in a daze, feeling numb to the whole celebration.”

At anniversary time, women’s use of some metaphors, such as an imposter or pretender, is concerning regarding mother–infant/child attachment:

As I approached my son’s first birthday, I felt nothing for him and found it hard to celebrate the joy of this child that meant so little to me. I took excellent care of him, but it was if I was babysitting. I was an imposter. The emotional bond just wasn’t there.

Anniversary of Birth Trauma Is a Lottery

A lottery was the metaphor women used who reflected back on more than one anniversary. As women compared one anniversary against another one, phrases such as “a game of chance” and “spinning a roulette wheel” described how they felt. Unpredictability was the name of the game. There was no consistent pattern to successive anniversaries as to whether they were easier, more difficult, or the same. The mother who had the largest number of anniversaries reflected back on all 23 of them. She concluded that “on my son’s birthdays, I would always feel a bit ‘funny’ trying not to remember. My stress and panic attacks would be worse.”

Another woman shared that “it hasn’t gotten better as time has gone by. Actually, I had a meltdown at about his second birthday.” For other women, the second birthday “was a lot easier than the first one. I had a few flashbacks but no longer so filled with fear.”

The unpredictability of each anniversary is illustrated in the following two excerpts from mothers’ narratives:

“This year’s anniversary, which will be my 12th, is approaching and so I will wait and see. PTSD can be like an octopus and its tentacles can take hold at any time.”

“Each anniversary is a lottery. One is at the mercy of one’s emotions, one’s memories and of course other people and daily life, which of course are the undefinable triggers, the worst of all.”

Anniversary of Birth Trauma Is a Trigger

With this structural metaphor, the target concept is the anniversary of women’s traumatic childbirth and the trigger is the source domain. Women repeatedly explained that as their anniversary loomed in the near future, it triggered the surfacing of painful memories of their birth trauma. Anniversary time sparked an increase in their PTSD symptoms, such as flashbacks and nightmares and also physical symptoms. It sets in motion a trio of distressing emotions: fear, dread, and anxiety. These disturbing memories and emotions and PTSD symptoms had mostly been held in check all year long till anniversary time when flare-ups began to plague mothers. An example of this was provided by a mother who described her first anniversary:

As my daughter’s birthday approached, it triggered my becoming very anxious, very jumpy and fearful, forgetful, preoccupied, trying to avoid any thoughts surrounding the month of her birthday. My PTSD symptoms would come to the forefront, and my nightmares were more ferocious.

Another woman described the 2 months leading up to her son’s first birthday: “It set off my suffering from frequent flashbacks of the birth that would come without any warning at any time and would be extremely vivid like I was watching a movie of what happened.”

Anniversary time also triggered flare-ups of physical symptoms for some mothers as illustrated by the following quote: “My asthma and psoriasis flared up; my digestive problems became debilitating. This starts I would estimate at least 3 weeks before my daughter’s birthday.”

Holidays, seasons of the year, and the weather when the traumatic birth occurred all could be triggers at anniversary time. For instances, one mother who gave birth in October recalled, “Feeling the briskness and smelling the fall air triggered a lot of fear. I always loved Halloween, but now when I see decorations for this holiday around town or in the newspaper ads, fear rushes through my body.”

Anniversary time was extremely difficult for women who described having felt raped during the birth as this woman did:

My daughter’s birthday was not an enjoyable event and I was very emotional. It triggered the whole experience flooding back; the sense of extreme violation by a rough, arrogant male doctor who invade[d] my space and made me feel disgusting and ruined my inner self.

Anniversary of Birth Trauma Is a Clock Watcher

In this second personification metaphor, the anniversary of birth trauma was given a human quality by some women as they referred to the anniversary as being a clock watcher. At anniversary time, women shared how they relived every moment of the birth day synchronized to the clock. As this mother who experienced four anniversaries explained, “I watched the clock all day as again I follow the events of the day she was born.” Another woman, who had 10 anniversaries, recalled, “As the day of the anniversary dawned, I was instantly aware of the time and what was happening 10 years earlier. I watched the clock continually and plotted out what was happening minute by minute.”

“Time was definitely a traumatic concept during the anniversary. I found myself linking the time of day to what happened. I retraced the number of dilatation to the minute. A clock reading 9:51 will turn my stomach upside down.” For some women, clock watching could extend for a period prior to the actual day of the anniversary. As this mother revealed,

The entire 2 days before the anniversary, I watched the clock and relived all the hell I know that, a year or 2 or 3 years ago now, for the first 30 plus hours of labor I was hanging in there suffering but dealing with the pain virtually alone.

For 1 month prior to her anniversary, this mother who had given birth prematurely shared that she clock watched.

There is a 4-week time span from when my waters broke at 33 weeks’ gestation to when my daughter was allowed home from the hospital at 37 weeks. As each date arrives, I go back over and over the events and sync what happened with the clock.

Remembering her 52-hour labor, this mother admitted,

Two days before my son’s first and second birthdays, I am recalling exactly what I was doing and how I was feeling. I tried to fast for 52 hours and retrace and rescript every humiliating, dehumanizing, torturous detail of the trauma in an attempt to reclaim some semblance of personal power but I made it for only 36 hours into the fast before I was sick. (Beck, 2006, p. 386)

Anniversary of Birth Trauma Is a Giant Rubber Band

No matter how much progress women had made all year long with healing from and coping with the aftermath of their birth trauma, at anniversary time, they felt like they had regressed back to where they were right after the birth. This excerpt from one mother’s narrative sums this up.

At anniversary time, I find myself in the same kind of state that I was in just after my daughter’s birth. As hard as I try to move away from the trauma, at birthday anniversary time, I am pulled straight back as if on a giant rubber band into the midst of it all and spend months after trying to pull myself away from it again. (Beck, 2006, p. 387)

After her first anniversary, this woman explained,

I thought that maybe I had the thing beat, but once the birthday was over, all hell broke loose: crying jags, shaking, insomnia, and repetitive thoughts. I felt as if all the work I had done all year to overcome the trauma had been for naught. (Beck, 2006, p. 387)

Mothers were so discouraged and felt that perhaps they would never overcome their traumatic births. One mother, who experienced five anniversaries, described the impact in this way:

I can’t believe almost 5 years later that I feel such strong emotions and that my body responds physically. It is like the birthing experience, and the anxiety, loss, and pain associated with it seem to reside in every cell of my being, with a memory capacity that serves to never let me forget. (Beck, 2006, p. 388)

Being pulled back like a giant rubber band at anniversary time left mothers feeling very fragile and emotionally and physically exhausted. During the post-anniversary period, their nerves were raw and needed time to heal.

Anniversary of Birth Trauma Is a Guilt Trip

Guilt was pervasive for mothers because the anniversary of their traumatic birth took them on an unwanted guilt trip. Women felt guilty for not being able to give their child a joyous birthday celebration; that they were cheating their child of something. The following quote illustrates this:

I carried a lot of guilt around my son’s first birthday because I didn’t feel the joy and celebration I expected to have as a new mom. I looked at his birthday as a loss and with guilt because I wasn’t truly “there”—mind, body, or spirit.

Another woman admitted, “I felt terrible guilt that I could not make my son a birthday cake and let him eat it for a video opportunity.”

As painful memories of their birth trauma resurfaced at anniversary time, women also felt guilty remembering the way their child entered the world. One mother who had given birth prematurely struggled with guilt because her body had failed her carrying her baby to full term, and as a result, her daughter suffered so much in the neonatal intensive care unit (NICU).

Anniversary of Birth Trauma Is a Sea of Sadness

With this structural metaphor, the source domain of a sea of sadness provided a richer, more concrete description of what it was like for women to experience the anniversary of their traumatic birth. Waves of sadness and grief would wash over them during the day as they tried to celebrate their child’s birthday. As this mother described,

It breaks my heart because the very time I should be honoring the precious life of my child and truly enjoying his birthday, I often feel I am drowning in sadness and grief over the loss we all endured, and all that was taken from him.

The following excerpt from one woman’s narrative provides a glimpse into the second anniversary of her traumatic birth and her need to mourn.

Yesterday was my daughter’s second birthday. We did our best to make her feel very special, and it was fun watching her open presents and blow out her candles. But underneath that I felt a need to “mourn” something. After everyone had gone to bed, I lit a candle and read my doula’s write-up about the birth. I couldn’t get through it without crying. Imagine, it’s been 2 years! (Beck, 2006, p. 387)

Tears flowed for some women on their child’s birthday but only when they were not in the presence of their children. This woman recalled her premature birth 4 years earlier:

Right before I went to bed, I went into my son’s room and knelt down beside his bed. I watched him sleep and breathe. Then, I put my face in his hair just to smell it. I stayed like this for at least 5 minutes. I thanked God again for my little son’s life. He woke up then and hugged me in his half-sleep state. Then, he gently ran his hands down both sides of my face. I said, “Go to sleep, birthday boy,” and he said, “Ok, Mom.” I walked out of his room and into my own. I took out the little album with the NICU photos and got through about five of them. Then, I started to cry. Not just a little but big sobs (I rarely do this). I cried for about 5 minutes or so before my husband walked into the room and put his arm around me. I kept crying. I was trying to figure out why I was crying and all I could feel was grief. Like someone had died.

Anniversary of Birth Trauma Is Bottled Up Anger

A container metaphor was used by some women to describe how they felt at anniversary time, that being, bottled up with anger. Mothers were filled with anger at the labor and delivery staff who were supposed to have been caring for them and angry at their family and friends. Mothers repressed their anger, however, keeping it inside themselves. The following quote captures what they were keeping a lid on:

This should be a happy family day, but I feel such anger at the selfish labor and delivery staff who stole the birth of my daughter from me and manage now to steal the fun of her birthday from me each year.

Another woman shared,

It makes me really angry that I can’t enjoy my son’s birthday and that I can’t think back to my son’s birth and see it as the wondrous event that it was supposed to be. It seems like it was a magical moment for everyone but me.

When this mother’s child turned 1 year old, she recalled,

I was emotionally numb until the rage hit at his birthday. I wished I had not survived his birth. Of course, I kept my feelings bottled up inside not to ruin my son’s special day. I still feel the same way even now as the third anniversary approaches.

Family and friends also were targets of mothers’ hidden anger as this excerpt for one narrative reveals; “On my daughter’s first birthday, I was so angry when my family and friends didn’t mention the birth or hospital experience at all. How could they not acknowledge the trauma I went through and its effect on me?”

DISCUSSION

Perinatal nurses, childbirth educators, lactation consultants, and other clinicians have unique opportunities to gain the trust of mothers and provide a safe environment where the women can open up to the struggles they may be having because of a traumatic childbirth. The metaphorical expressions used by mothers to describe their birth trauma can provide rich insight. We need to be proactive and vigilant in quickly identifying signs that a mother may be struggling during the postpartum period. Such signs can include a dazed look, acting withdrawn, or experiencing temporary amnesia regarding parts of the labor and delivery. Perinatal clinicians need to keep in mind that birth trauma lies in the eyes of the beholder (Beck, 2004). What labor and delivery staff would consider a routine, successful birth may be perceived as traumatic by a mother.

We need to be proactive and vigilant in quickly identifying signs that a mother may be struggling during the postpartum period.

Before women are discharged from the hospital or birthing center, a perinatal clinician should explore with mothers if they have perceived their labor and delivery as traumatic to identify as soon as possible women who may need follow-up care. Traumatic childbirth also has implications for lactation consultants. Intensive one-on-one support for traumatized women may be needed to help them establish and maintain breastfeeding. There are instruments available that can also be used to screen women for posttraumatic stress symptoms such as the PTSD Symptom Scale—Self-Report (PSS-SR; Foa, Riggs, Dancu, & Rothbaum, 1993). If women are referred for mental health follow-up and are diagnosed with PTSD, cognitive-behavioral therapy and eye movement desensitization reprocessing (EMDR) treatments are two options available.

Support groups for women who are experiencing elevated posttraumatic stress symptoms because of birth trauma or who are diagnosed with PTSD can be started. Also, more specific support groups can target multiparas who are having a subsequent pregnancy following a previous traumatic birth. Pregnancy is an ideal time for perinatal clinicians to help women deal with unresolved or traumatic issues surrounding prior traumatic births. In Table 1, some valuable websites on traumatic childbirth that can be helpful to both perinatal clinicians and to mothers and their families are listed.

TABLE 1. Birth Trauma Websites.

Trauma and Birth Stress: http://www.tabs.org.nz Postpartum Support International: http://www.postpartum.net Birth Trauma Association of United Kingdom: http://www.birthtraumaassociation.org.uk The Australian Birth Trauma and PTSD Treatment Centre: http://www.birthtraumaaustralia.com Birth Trauma of Canada: http://www.birthtraumacanada.org Solace for Mothers Healing After Traumatic Childbirth: http://www.solaceformothers.org

Note. PTSD = posttraumatic stress disorder.

There are several implications for clinicians specifically directed at anniversary time that are based on the identified metaphors. For example, the metaphor of the great pretender, which was the metaphor mothers used most frequently, is very troubling. As women are hiding what they are plagued with as they try their best to celebrate their child’s birthday, clinicians are unaware that we are failing to rescue these mothers who have suffered traumatic births. The anniversary of traumatic childbirth is an invisible phenomenon that metaphors can help to bring it visibility.

The metaphor of a giant rubber band alerts health-care providers to how discouraged women can become at anniversary time. All the progress they have made through the year regarding healing from their traumatic childbirth seems to be undone at anniversary time. Women are burdened with the possibility that they may never overcome their birth trauma and that for anniversaries to come, they may be haunted by the memories. Mothers need the support not only of their families but also of their clinicians, as women shared that their wounds had been reopened and were raw.

Many of the metaphors have troubling implications for maternal–child attachment and child development. Women shared they were imposters as they took excellent physical care of their children but felt that the emotional bond was missing. Anniversary time is a golden opportunity to identify these vulnerable mother–child dyads.

Metaphor analysis also has fruitful implications for future research. A benefit of qualitative secondary data analysis of clinical studies is the ability of researchers to continue to fulfill their promise to their participants to use what data have been shared about their experiences to improve care given to other patients. Also, researchers know all too well the tremendous amount of time, effort, and resources that goes into conducting a qualitative study. To be given the opportunity to use their original qualitative data set to extract and discover new knowledge is exciting. A decade ago, Sandelowski (1997, p. 129) stressed that qualitative researchers can do more with what we already possess. She astutely claimed, “We have become inveterate data collectors, having been imbued with the idea that research means collecting new data.” If a primary qualitative data set lends itself to analysis of metaphorical expressions, let’s not let this valuable opportunity go to waste. It can provide valuable information for perinatal nurses, childbirth educators, Lamaze International instructors, and all clinicians caring for childbearing women.

Biography

CHERYL TATANO BECK is a distinguished professor at the University of Connecticut School of Nursing. She also holds a joint appointment in the School of Medicine in the Department of Obstetrics & Gynecology.