Please make 4 slides to propose a project on maternal mental health. Using the article: please state on the slide: 
1. What is the problem: 
2. Why is it a problem
3. What can you do to improve or prevent birth trauma 
4. How would you change it

RESEARCH ARTICLE Open Access

Women’s descriptions of childbirth trauma
relating to care provider actions and
interactions
Rachel Reed1* , Rachael Sharman1 and Christian Inglis2

Abstract

Background: Many women experience psychological trauma during birth. A traumatic birth can impact on postnatal
mental health and family relationships. It is important to understand how interpersonal factors influence women’s
experience of trauma in order to inform the development of care that promotes optimal psychosocial outcomes.

Methods: As part of a large mixed methods study, 748 women completed an online survey and answered the
question ‘describe the birth trauma experience, and what you found traumatising’. Data relating to care provider
actions and interactions were analysed using a six-phase inductive thematic analysis process.

Results: Four themes were identified in the data: ‘prioritising the care provider’s agenda’; ‘disregarding embodied
knowledge’; ‘lies and threats’; and ‘violation’. Women felt that care providers prioritised their own agendas over the
needs of the woman. This could result in unnecessary intervention as care providers attempted to alter the birth
process to meet their own preferences. In some cases, women became learning resources for hospital staff to observe
or practice on. Women’s own embodied knowledge about labour progress and fetal wellbeing was disregarded in
favour of care provider’s clinical assessments. Care providers used lies and threats to coerce women into complying
with procedures. In particular, these lies and threats related to the wellbeing of the baby. Women also described
actions that were abusive and violent. For some women these actions triggered memories of sexual assault.

Conclusion: Care provider actions and interactions can influence women’s experience of trauma during birth. It is
necessary to address interpersonal birth trauma on both a macro and micro level. Maternity service development and
provision needs to be underpinned by a paradigm and framework that prioritises both the physical and emotional
needs of women. Care providers require training and support to minimise interpersonal birth trauma.

Keywords: Childbirth, Trauma, Maternity care

Background
Around one third of women experience trauma whilst
giving birth [1, 2]. A traumatic birth experience is asso-
ciated with postpartum mental health problems, includ-
ing depression and post traumatic stress disorder
[PTSD] [1, 3–6]. Poor mental health in the postnatal
period can alter a woman’s sense of self, and disrupt
family relationships [7–10]. Difficulties with early
mother-baby bonding can negatively influence a child’s
social, emotional and mental development [11]. In

addition, the experience of a traumatic birth can influ-
ence a woman’s future decisions regarding where, how,
and with whom she gives birth [12, 13]. For example,
women may choose to birth at home to avoid repeating
a traumatic hospital experience [14]. Jackson et al. [15]
found that the decision to freebirth (give birth without a
professional care provider) can be influenced by previous
birth traumatic. Therefore, the consequences of a trau-
matic birth experience can be substantial and wide-
ranging for women and their families.
Birth trauma has been associated with medical interven-

tion and type of birth [5, 16, 17]. It has been defined as a
perception of ‘actual or threatened injury or death to the
mother or her baby’ [18]. However, Beck [19] argues that

* Correspondence: [email protected]
1University of the Sunshine Coast, 90 Sippy Downs Drive, Sippy Downs, QLD
4556, Australia
Full list of author information is available at the end of the article

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Reed et al. BMC Pregnancy and Childbirth (2017) 17:21
DOI 10.1186/s12884-016-1197-0

http://crossmark.crossref.org/dialog/?doi=10.1186/s12884-016-1197-0&domain=pdf

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the perception of trauma is in the ‘eye of the beholder’, and
should be defined by the woman experiencing it. Qualita-
tive studies exploring women’s experiences of traumatic
birth identify interactions with care providers as a more im-
portant factor than medical intervention or type of birth
[20–23]. For example, a perceived lack of control and in-
volvement in decision-making can contribute to the experi-
ence of trauma [21, 23]. A study by Thomson and Downe
[20] found that trauma was related to ‘fractured interper-
sonal relationships with caregivers’, and that women felt dis-
connected, helpless and isolated during birth. Whilst not all
traumatic birth experiences result in PTSD, two quantita-
tive meta-analyses identified that negative care provider in-
teractions are a significant risk factor for PTSD [5, 17]. A
study by Harris and Ayers [24] also found that the strongest
predictor of developing birth related PTSD was interper-
sonal difficulties with care providers, in particular experien-
cing a lack of support.
A recent Cochrane Review [25] concluded that women

require improved emotional support during birth from
their care providers to reduce the risk trauma. Health care
professionals have an ethical, legal and professional obliga-
tion to provide safe and respectful care [26–28]. In order to
improve care, it is important to understand what interac-
tions and actions are associated with trauma [20]. This
paper focuses on traumatic care provider actions and inter-
actions from the perspective of the women experiencing
them. The findings contribute to the body of literature
examining women’s experiences of traumatic birth; and to
an understanding of how care providers influence women’s
perceptions of trauma. This paper presents a subset of find-
ings from a large mixed methods study that investigated
parental mental health following traumatic birth. The quan-
titative findings have not yet been published. The qualita-
tive findings concerning paternal mental health are
reported elsewhere [29]. This paper presents the qualitative
findings relating to women’s descriptions of birth trauma
involving care provider actions and interactions.

Methods
The mixed methods study involved parents completing
an online survey, and additional face-to-face interviews
with fathers [29]. The online survey included questions
on demographics, descriptive birth assessments, parent-
infant attachment, partner relationship quality, current
mental health, and coping strategies used after the
trauma. In addition, the survey incorporated a question
about the experience of birth trauma with space for a
written response. A qualitative approach was taken to
explore women’s written descriptions of trauma. The
area of interest in this aspect of the study was women’s
experiences of trauma, rather than outcomes associated
with trauma. The majority of qualitative data related to

care provider actions and interactions, and this paper
presents themes relating to this data.

Participant recruitment
Participants were recruited via online social media forums
such as Facebook, Twitter and a midwife’s blog site. Inclu-
sion criteria was that participants were over 18 and had
experienced a traumatic birth. A definition of a traumatic
birth was not provided in order to capture what partici-
pants themselves considered’trauma’ [19]. There was no
exclusion criterion for time since the birth, as women’s
memories of childbirth remain strong over time [30]. Par-
ticipant information detailing the research question and
aims was provided on the first page of the online survey.
In order to obtain consent, participants were required to
read an online consent form and ‘click’ agree prior to
accessing the survey.

Data collection
After consenting to participate, participants completed an
online survey administered through the program Survey
Monkey. The survey included demographics (eg. age, rela-
tionship status) and information such as type of birth (eg.
caesarean, vaginal); place of birth (eg. public hospital,
home); and admission of baby to special care (Table 1). The
quantitative element of the study comprised of a number of
psychological assessment tools: Maternal Postnatal Attach-
ment [31]; Quality of Marriage Index [32]; Depression Anx-
iety Stress Scale-21 [33]; Posttraumatic Stress Disorder
Checklist-5 [34]; and The Brief Cope index [35]. The quali-
tative element of the study involved women responding in
their own words to the question ‘describe the birth trauma
experience, and what you found traumatising’. The mean
length of written responses was 69 words.

Data analysis
Women’s descriptions of trauma were analysed using a
six-phase inductive thematic analysis process described
by Braun and Clarke [36]. Phase one involved becoming
familiar with the data by reading and re-reading; and
noting initial ideas. In phase two initial codes were gen-
erated and data relevant to each code was collated.
Phase three of the process involved collating the codes
into potential themes. These themes were reviewed in
phase four to ensure they were consistent in the coded
extracts and across the entire data set. In phase five
themes were defined and named using words and
phrases. Phase six involved selecting extract examples to
illustrate the themes, and relating the analysis to the re-
search question and the literature. Three researchers
participated in the thematic analysis process to ensure
consistency in analysis and findings.

Reed et al. BMC Pregnancy and Childbirth (2017) 17:21 Page 2 of 10

Findings
A total of 943 women completed the online survey from
around the world. The majority of participants were
from Australia and Oceania (36.8%), North America
(34.2%) and Europe (25.5%). A small number of partici-
pants were from South America (2.1%), Asia (0.9%),
South Africa (0.5%) and the Middle East (0.2%) (Table 1).
The majority of participants gave birth in a public hos-
pital (69%) and either had an unplanned caesarean
(37%), or an unassisted vaginal birth (34.3%) (Table 1).
In addition, 34.4% of participants reported that their
baby was admitted to special care nursery.
Of the 943 participants, 748 (79%) responded to the

qualitative question ‘describe the birth trauma and what
you found traumatising’. A third of respondents de-
scribed events such as premature labour, haemorrhage
or concerns regarding their baby’s wellbeing. However,
the majority (66.7%) described care provider actions and
interactions as the traumatic element in their experience.
From the data relating to interpersonal factors, four
overarching themes were identified from the descrip-
tions. The themes are presented below with illustrative
data using the participants’ own words, therefore spell-
ing and grammar varies. The term ‘care provider’ is used
to refer to the professional responsible for the woman’s
care. In the women’s accounts care providers included
obstetricians, midwives and nurses.

Prioritising the care provider’s agenda
Women described how care providers prioritised their
own agenda over the needs of the woman. In some cases
it was made clear to women that their labour was keep-
ing the care provider from something, or someplace they
would rather be:

I found my OB’s lip service to my wishes and then his
switch against them traumatic. I found the comment
“let’s get this over and done with, I have a golf game
to get to” traumatic… (045)

… after an OB coming in and telling me that she
would like me to deliver by 5 pm because she wanted
to go home, I just burst in to tears… (549)
Women felt that they were subjected to unnecessary

and unwanted medical interventions in order to meet
the needs of their care providers:

Table 1 Demographics and type of birth

Age

Range = 18 to 77 years (Mean = 33.13)

N (%)

Marital status

Married 798 (77.5%)

De Facto 124 (12.5%)

Single 42 (4.1%)

Divorced 21 (2%)

Separated 23 (2.2%)

In a relationship but not living together 11 (1.2%)

Widowed 2 (0.2%)

Engaged 4 (0.3%)

Number of children

0 7 (0.7%)

1 409 (39.4%)

2 345 (34%)

3 159 (15.3%)

4 70 (6.8%)

5 23 (2.2%)

> 5 17 (1.5%)

Region of origin

Australia and Oceania 386 (36.8%)

North America 347 (34.2%)

Europe 253 (25.5%)

South America 23 (2.1%)

Asia 8 (0.9%)

South Africa 7 (0.5%)

Middle East 2 (0.2%)

Education

Did not finish high school 14 (1.4%)

Finished high school 196 (19.1%)

Trade or technical qualification 157 (14.1%)

Undergraduate degree 395 (39.1%)

Postgraduate degree 264 (26.4%)

Type of birth

Unassisted vaginal birth 271 (34.3%)

Assisted vaginal birth (ventouse or forceps) 176 (22.4%)

Planned caesarean 47 (6%)

Unplanned caesarean 290 (37%)

Place of birth / transfer

Public hospital 542 (69%)

Private hospital 115 (14.6%)

Birth centre 12 (1.5%)

Planned birth centre transfer to hospital 23 (2.9%)

Homebirth 29 (3.7%)

Table 1 Demographics and type of birth (Continued)

Planned homebirth transfer to hospital 63 (8%)

Unplanned out of hospital birth 1 (0.1%)

Admission of baby to special care nursery

Yes 269 (34.4%)

No 512 (65.6%)

Reed et al. BMC Pregnancy and Childbirth (2017) 17:21 Page 3 of 10

I begged not to have a c section, neither I nor my
baby were in distress or danger, but because the
doctor was ready to go home, he did a terrible section
that resulted in almost a year of recovery. (220)

I was steamrolled with unnecessary intervention
and didn’t get to speak with a doctor about my
options, risks vs benefits… I feel like the nurses,
doctors and hospital only did what was in their
best interest, not mine… It was a nightmare.
(381)
Some women described how they became a learning

resource for the benefit of hospital staff. For example,
care providers offered other staff the opportunity to
practice without seeking women’s permission:

… the doctor asked a student nurse, first day on
the job, if she wanted to suture my episiotomy
incision. (644)

… 20 people in theatre and half were sitting down on
phones and chatting away while I had someone
training with forceps on me… (867)
One woman described feeling like she “… was part of

an experiment” (565) rather than a woman giving birth.
In particular, women experiencing unusual births be-
came a spectacle for others to watch:

… I was a looking point for students and anyone who
hoped to witness a twin vaginal birth and a breech
birth. (523)

One woman wrote about how the room filled with
staff hoping to watch her give birth to her breech baby:

… and the amount of people that filled the room to
watch a vaginal breech delivery, when I failed at this,
everyone left. (662)

When she was unable to provide this learning oppor-
tunity she no longer warranted being an object of obser-
vation. The value of her birth experience for others
appeared to be based on what she could provide in
terms of a learning experience.

Disregarding embodied knowledge
Many of the descriptions involved women’s own em-
bodied knowledge being disregarded in favour of their
care provider’s assessment of events:

… I felt like I was being told I was silly for thinking I
was in labour and that this awful pain was nothing to
be worried about. My opinion was dismissed and
ignored as I was just a first timer… (436)

In particular ‘being in labour’ was a contested area.
Women’s perceptions of being in labour were based on
their embodied experience, whereas care provider’s per-
ceptions were based on clinical findings. For example,
one woman was considered to ‘not be in labour’ because
her cervix was not dilating according to care provider’s
expectations:

Hospital staff did not listen to me, didn’t trust me to
know my body. Dismissed me as a first time mother
who was over reacting. In actual fact I dilated from 0
to 6 in just over an hour. The hospital midwives told
me that I was just feeling the period pain associated
with early labour and induction… (485)

Another woman described how her midwife deter-
mined she was not contracting, therefore not in labour,
based on an abdominal palpation:

Was going into premature labour and midwife
palpated during a contraction and stated I was not
having them. Eventually went into labour as they
ignored me… Although not traumatic in medical
terms, felt completely disgruntled that my journey
was not taken on own merits and was completely
ignored as a woman during labour. (061)

Both of these women considered themselves to be in
labour, and having their embodied knowledge disre-
garded was traumatic.
Embodied knowledge was also dismissed when women

experienced an urge to push before care providers con-
sidered it appropriate. Women were instructed to ignore
what was happening in their body and stop pushing:

Told to stop pushing and… being told what to do
when my body was telling me differently. (248)

Being told to stop pushing when baby was clearly on
its way. Being told I had a long way to go when baby
was on the way out. (436)
Care providers used clinical assessments (vaginal exami-

nations) to determine whether pushing was appropriate.
Based on the findings of these clinical assessments women
were ordered to over-ride their own bodily urges:

… I had the strongest urge to push, the midwife on staff
insisted on an internal examination to check dilation,
she told me if I pushed now I would end up with an
emergency caesarean due to my cervix swelling. She
then spent the next hour yelling at me not to push and
trying to talk me into an epidural (I was trying my
hardest to not push but my body kept taking over). I
was begging to be allowed to push…. (932)

Reed et al. BMC Pregnancy and Childbirth (2017) 17:21 Page 4 of 10

In some cases women described feeling that the wellbeing
of their baby was in danger. When they attempted to alert
care providers their embodied knowledge was disregarded:

… I felt like everything was going wrong and found
that distressing. I felt like people didn’t believe me
when I said something didn’t feel right. (851)

… My baby was in distress and had mec liquor and in
all honesty probably should’ve been sectioned, at this
stage I was begging for one as I knew something was
wrong with my baby but they refused… (732)
In these descriptions women’s own assessment of

labour progress and fetal wellbeing was not valued or
acted on which caused trauma.

Lies and threats
Women perceived that they were being lied to by care
providers to coerce them into agreeing to unnecessary
interventions:

It was not the birth itself that I found traumatic,
rather the way we were treated by the midwife. Being
lied to in order to speed up my labour unnecessarily
and putting me and my baby at risk. (015)

All of this is avoidable and unnecessary, if only we
had known… I was forced into interventions that I
believed were unnecessary. I was also lied to many
times by the doctors. (857)
They also described how care providers threatened them

in order to coerce them into undergoing procedures:

My daughter was breech… I was told that if I didn’t
consent to the cesarean before labor started then they
would perform a cesarean without my consent under
general anesthesia when I arrived (267).

In this case, the woman was threatened with surgery
against her wishes. Other women were threatened with
having their baby taken from them if they did not com-
ply with proposed interventions:

Psychological coercion – ie “if you do not consent to
syntocin OR a c-section then we can get our friend
the psych registrar down here to section you – then
we can do whatever we want to you but you may not
be able to keep your baby” – All I wanted was to let
my body go into labour naturally – my baby was not
in distress… (186)

I was bullied into an induction late on a Sunday night
and then told I would be kept over night. I wasn’t
aware when I finally agreed to be induced after quite

some time of being threatened with DoCS
[Department of Child Safety] etc. (400)
The most common threats described by women re-

lated to the wellbeing of the baby. Some women used
the term ‘dead baby threat’ to describe how they were
coerced, for example: “dead baby threats to gain con-
sent…” (860); and “forced into c section with dead baby
threat…” (223). Some care providers asked women if
they wanted their baby to die when they declined an
intervention:

…Being bullied into interventions with such wording
the following: “Do you want a dead baby?”… (919)

Women felt that care providers were lying about the
risks to the baby in order to pressure them into comply-
ing. They did not believe their babies were in danger,
and in some cases had evidence that their care provider’s
assessment was incorrect:

…I was basically told that if I didn’t have a c-section
on their timetable I would kill my baby, even though
they couldn’t tell me what exactly was “wrong” as to
why I was not delivering vaginally… They broke me
down gradually until they declared my baby was “in
distress” (she wasn’t… I could see the screens). (559)

… Lots of coercion and being told my baby would die
if I didn’t consent to the c-section. She was born with
apgars of 9 and 9. (194)
Being lied to and threatened contributed to the experi-

ence of trauma, particularly when it involved the well-
being of the baby.

Violation
Many women described their birth experience as ‘violat-
ing’. A lack of control appeared to be associated with a
sense of violation. For example, one woman described
that she felt “…out of control and violated” (660). In
these descriptions, care providers carried out actions
against the explicit wishes of the woman:

…All in all, I felt very bullied, and even violated… It
was the feeling of disempowerment and not having
the right to do with my body what I wished – and that
someone else could force me to do something against
my will. (731)

I felt violated, and angry that I should have to defend
myself and my body while I was trying to push my
baby out. (733)
The descriptions of what care providers did to women

were, in many cases, graphic and violent. For example, one
woman wrote “…couldn’t be tubed nurses manually choked

Reed et al. BMC Pregnancy and Childbirth (2017) 17:21 Page 5 of 10

me out” (490). Another wrote that she was “… assaulted va-
ginally by medical staff during crowning” (295). These de-
scriptions focused on the manner in which the care
provider acted, in addition to their actions:

… She was very rude and condescending, both to
myself and to my midwife. She proceeded to dig out
my uterus without any numbing medication. It was
horrifying… (431)

…The pain was not the traumatic bit, it was the way
that I was treated during my labour. I was 20 years
old. I had more midwives than I can count, attempt
an internal examination and one yelled at me to
‘relax!’ because she couldn’t force her fingers in. She
was a bloody bitch to put it lightly. (256)
One woman described how her obstetrician assaulted

her to gain her compliance to induce labour:

She said she wanted to do one more cervical check. I
consented and when she did it, she grabbed my cervix
and pinched it. She would not let go until I consented
to letting her break my water. I was in tears from the
pain, screaming, begging and sobbing for her to let go
and get her hand out of my vagina. She would not let
go until I consented, which I finally did. (997)

A number of women described how they screamed
‘no’ as care providers carried out procedures. For ex-
ample, one woman told her care provider “expressively”
that she “didn’t want any vaginal examinations” (413).
Her care provider persuaded her to have a vaginal exam-
ination telling her that they “would be very gentle and
would stop if it was too much”. However her wishes
were not respected during the examination:

I was crying and screaming in pain telling her no and
to stop and she carried on, my husband shouted at
her to leave me alone and she carried on. (413)

Another woman described how her doctor failed to
respond to direct requests, and then to screams for
her to stop:

The doctor would not get her fingers out of my
vagina even when directly told. After it was
discovered that I suffered tearing, I wanted the tearing
to be healed on its own – no stitches, but she and
another doctor stitched anyway, despite my screaming
at them to stop. (445)

In addition, some women wrote about being ‘held
down’ while care providers carried out procedures
against their will:

…Being pinned down by 4 midwives (forcing an
unnecessary oxygen mask on me just so my screams
of ‘no’ were muffled) and my husband so the
consultant could examine me against my will. (888)

…At one point, 3 nurses physically held me down
despite my protests that I couldn’t breathe and
needed a minute to catch my breath before the
procedure (AROM). They held me down until the
doctor was finished… (491)
Women described how equipment tethered or tied them

to the bed during labour: “was tethered to the bed during
an induction…” (328), and “I was tied to the bed, forced to
lay on my back…” (418). Women experienced being forced
into birth positions: “screaming, lots of people, nurses for-
cing me down and ripping my legs open…” (565). In par-
ticular, care providers made women lie on their backs:

During birth, multiple nurses screamed in my face
“PUSH!!!” and flipped me onto my back and forced
my legs open, holding me down… (414)

In describing their experiences women used words
such as “humiliating” (561); “belittled” (520); “brutal and
barbaric” (132). Some described “being treated like a
piece of meat” (979), or an animal:

…I was treated like a cow having trouble calving, and
felt abused and humiliated. (222)

A number of women used language associated with
sexual assault and rape, writing that they felt: “…raped
and mutilated” (376), “… violated and damaged” (119),
“…violated and scared and disgusting” (423). Women
who had previously experienced sexual abuse or rape de-
scribed how the actions of care providers triggered dis-
tressing memories:

…my cervix was manually dilated forcefully after
pleading for the Dr. to stop. This caused me to re-
experience a previous rape. Later in my birth my Dr.
performed a deep episiotomy after being told repeat-
edly that I did not want one… Images and fears from
my past sexual abuse/assaults became constant in my
mind after birth. (057)

…the whole experience was made worse as it
triggered my post traumatic stress that related to gang
rape in my teens. (444)
One woman felt that her birth experience was more trau-

matising than her experience of sexual abuse as a child:

…The most terrifying part of whole ordeal was being
held down by 4 people and my genitals being touched

Reed et al. BMC Pregnancy and Childbirth (2017) 17:21 Page 6 of 10

and probed repeatedly without permission and no say
in the matter, this is called rape, except when you are
giving birth. My daughter’s birth was more sexually
traumatising than the childhood abuse I’d
experienced… (201)

Discussion
This study described women’s experiences of birth
trauma. The data set was large, and women recounted
similar experiences across different birth settings and
cultural contexts. The findings contribute to an under-
standing of birth trauma from the perspective of women
experiencing it. Whilst non-interpersonal factors con-
tributed to trauma, the majority of descriptions involved
care provider actions and interactions. These findings
are consistent with other studies that identify the rela-
tionship between the care provider and the woman as
critical to the birth experience [20, 21, 37]. Whilst care
providers may consider their actions and interactions to
be routine, some woman experience them as traumatic
[19]. Therefore, it is vital that care providers understand
how their practice influences the psychological and emo-
tional experience of birth, in addition to the physical
outcome of birth.
In this study women described how care providers

priorised their own agendas over the needs of the
woman. This …