years researchers have largely focused on the technical aspects and
�appropriate� rate of
cesarean section: the surgical procedure. However, birth by cesarean can
have powerful psychological effects on women and their ability to adjust
woman�s experience of her cesarean birth and her perceptions of the
event, are influenced by
multiple complex factors: The reason for which the cesarean was
performed, her cultural values, her beliefs and anticipations of the
birth, possible traumatic events in her life, available social support,
and her personal sense of control, are only a few (Cummings, 1988;
Cranley, 1983; Marut and Mercer, 1979; Sheppard-McLain1985).
women recover fully physically and emotionally from a cesarean birth,
others do not. Little
attention has been paid to the psychological impact that a surgical
birth may have on women�s emotional well being. Their personal
experiences have been at times trivialized, misunderstood, or ignored by
the medical community.
birth by cesarean can have an adverse psychological impact on some
mothers was already a concern in the early 1980�s as the cesarean rate
in the United States was climbing rapidly (Lipson and Tilden, 1980).
Anecdotal reports and personal testimonies
have helped to increase awareness of the
negative psychological repercussions that some women experience
following a cesarean birth. (Baptisti-Richards 1988; Madsen,
1994;Pertson and Mehl, 1985; Wainer-Cohen and Estner 1983).
suggests that the negative psychosocial effects of cesareans can be
significant and far-reaching for some women (Mutryn, 1993).
Several reports also indicate that a cesarean birth, especially
one that was not anticipated, can put some women at increased risk for
depression and post-traumatic stress.
Birth and Postpartum Depression
Erlichman, LCSW a faculty member in the Obstetrics and Gynecology
Department at the University of San Francisco works with women who have
had a difficult pregnancy or a traumatic birth. In her presentations to
medical professionals working with birthing women, she tries to convey
an important message- that birth by cesarean is an emotional experience,
not just a medical procedure. (Erlichman, 1999). Women�s experience
and perceptions of their birth may have very negative consequences
despite good medical outcomes.
British study screened expectant mothers for emotional well being at 30
and 36 weeks gestation and again at 6 weeks after they gave birth.
Results indicated that a disproportionately large number of women who
had a cesarean birth reported symptoms of clinical depression. Women who
felt they were �not in control� of the events or felt they received
medical interventions that were not necessary were at higher risk for
depressed mood (Green, 1990).
researchers looked at risk factors for postpartum depression in women
expecting their first child during the first trimester, and at one
month, 3 months and at 6 months postpartum. Compared to women who had a
spontaneous vaginal delivery and women who had a forceps delivery, 46%
of the women who had an emergency cesarean were more than six times more
likely to develop symptoms of depression at three months postpartum. The
increased risk for postpartum depression could not be attributed to
personality dysfunction. Had the pain of the physical recovery been the
cause of the depression, the authors speculated,
one would have been more likely to see a difference at one month
rather than at 3 months after the cesarean.
The women�s perceptions of the emergency cesarean had lowered
their self-esteem, left them with a sense of failure, loss of control
and disappointment. (Boyce and Todd, 1992).
800 women who gave birth in Victoria, Australia were screened for
multiple factors associated with postpartum depression eight to nine
months after birth researchers discovered significant results. A careful
analysis established a significant association between obstetric
procedure and subsequent depression. Women who gave birth with forceps
or by cesarean were more likely to exhibit symptoms of clinical
depression. When examining the relationship between perinatal
complications in a previous pregnancy and depression following the
current birth, a prior cesarean delivery was identified as a significant
factor. Women who had a prior cesarean were 2 � times more likely to
suffer from depression after a subsequent birth. (Brown et al 1994).
Cesarean Birth as Trauma
who experience problems with infertility treatments, miscarriage,
abortion or an ectopic pregnancy sometimes suffer from depression and/or
post traumatic stress.
Dr. J. Laurence Reynolds, a faculty member in the Department of
Family Medicine, University of Western Ontario, Canada explains
that because childbirth can be an extremely painful experience,
often associated with feelings of being out of control. It is
understandable that some women may experience the birth itself as a
psychological trauma. (Reynolds, 1997).
stress disorder is currently defined as a psychiatric disorder that may
develop from being exposed to an actual injury or death or from the
perceived threat of injury or death. Individuals with
post-traumatic stress experience
feelings of intense fear, helplessness, or horror in response to the
traumatic event. Emotional reactions can have significant and
long-lasting effects. Stress response symptoms include:
intrusive thoughts and re-experiencing of the event,
avoidance of places or people that might trigger a reminder of the
numbing of emotions and general
a sense of hypervigilance
or increased arousal.
suggest that post-traumatic stress is a much more common psychological
response to an unexpected cesarean than expected.
Women�s feelings of confidence and security on arriving at the
hospital quickly change to ones of fear and anxiety when they learn they
are going to have a cesarean. Almost one half of the 53 women who gave
birth by emergency cesarean in a Swedish hospital were afraid of
injuries their baby might sustain or afraid their baby might not
survive. About one quarter of the women feared for their life or were
convinced they would be seriously harmed. Some were afraid they would
not wake up from the general anesthesia, and thirteen per percent
experienced a frightening loss of contact with reality. Most of the
mothers experienced a deep sense of loss and grief. (Ryding, et al
comparing women�s reactions following uncomplicated vaginal birth,
instrumental delivery, and elective cesarean, women who had an emergency
reported more symptoms of post traumatic stress both within the first
few days after birth and at one month postpartum (Ryding, et al
women experience significant adverse reactions to their cesarean birth
as long as five years later A British study compared a group of women
who had a primary cesarean delivery with women who had an uncomplicated
vaginal birth and a group of women who had an assisted delivery with the
use of forceps or vacuum extractor. Women who had multiple pregnancies,
stillbirths, neonatal deaths, and home births were excluded from the
group of women who gave birth with forceps or a vacuum extractor and
women who gave birth by cesarean were more likely to have had a negative
birth experience. Of the women who gave birth by cesarean 82.2% were
recorded as an emergency and 17.8% as an elective operation. Over 80%
had general anesthesia for the cesarean. The women who had an assisted
delivery and those who gave birth by cesarean were much more
disappointed. Although five years had passed since they gave birth,
these mothers expressed dominant feelings of fear and anxiety about
their experience and were more reluctant to become pregnant again
(Jolly, J. et al 1999).
cesarean can be a life saving procedure, but recent data shows that a
first cesarean puts women at increased risk for medical complications in
a subsequent pregnancy and birth (Rageth, 1999). Given the evidence that
a cesarean may also put
some women at increased psychological risk, women should be encouraged
and supported in their efforts to avoid a cesarean.
SIDEBAR-Some Women�s Feelings
about Cesarean Birth
daughter�s birth was two years ago, it was extremely traumatic. I have
been trying to process these feelings that come up, and I thought I had,
but recently I have been having nightmares about the cesarean
reoccurring with this new baby. I am afraid the medical staff will just
intervene and I will be powerless to say anything."
was in such pain and terror that I didn�t care that I was having a
baby. I just didn�t care. I couldn�t find a way to attach myself to
my son. It was horrible, I was so detached that I didn�t even care
that my husband decided on the name. I had no desire to even think about
I need another cesarean, I don�t want to be awake this time. I don�t
want to know that they are slicing me open with a knife, I don�t want
to hear that suction noise, the cold clinking of the surgical
was awake during my cesarean, but I really didn�t feel like I 'was
there.' The doctor brought
my baby to me, but I really didn�t have any connection to this baby.
It�s been twelve weeks, but it�s still difficult to associate
him with the cesarean. I
had no euphoria, didn�t feel much joy. For many weeks after I kept
dreaming that I was on my way to the hospital to give birth to him."
I had a previous
c-section�a c-section was arranged�As I was wheeled away�I felt
like I was an animal led to the slaughter with no mind of my own and
doing as I was told�No real consideration was given to how I felt. I
was lying there having the epidural inserted, screaming out inside, why,
why, I don�t want this."
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