A leaked letter shows how OBGYNs disregard emotional health in childbirth. Here is how this traumatizes birthing people

As a clinical psychologist specializing in birth trauma, I’m all-too-familiar with the many ways the medical experience of childbirth – which 33-45% of birthing people report as being a traumatic experience – can lead to poor mental health outcomes. My clients say, and research confirms, that the most profound components of birth trauma are the experiences of being stripped of dignity in the birthing process, feeling uncared for, and feeling like the birthing person wasn’t treated as an individual.

But I’ve never seen written evidence that some doctors practice in a way that directly causes these adverse outcomes – until now. Late last week, a letter addressed to “expectant mothers” (though not all birthing people identify as women) from a group of obstetricians affiliated with Weill Cornell Medical College of New York Presbyterian Hospital in New York caused outrage among parents and providers alike after being circulated online. The reach of online birth justice communities meant that, moments after being shared, the post ricocheted far beyond its origins.

But I’ve never seen written evidence that some doctors practice in a way that directly causes these adverse outcomes – until now.

In the letter, reportedly included in new-patient information packets, the doctors discouraged patients from creating birth plans, which expectant parents use to outline the experience they hope to have during labor and delivery, from whether they prefer epidurals to what sort of music should play in the birthing room.

The doctors wrote that, while they would love for their patients to have the “perfect birth,” they feel that “the use of birth plans too frequently sets up unrealistic expectations and conditions for potential conflict. We are your care givers and would like to use our knowledge and experience to act in the best interest of you and your baby.”

Weill Cornell has since disavowed the letter, writing in an instagram post that it was “erroneously” included in recent information packets to patients (some recent patients expressed doubt about that in the post’s comments).

"We are your care givers and would like to use our knowledge and experience to act in the best interest of you and your baby."

But it doesn’t much matter whether the letter was given out in error or the hospital is backtracking for PR. The fact that it exists at all is concrete evidence of the widespread trauma birthing people experience regularly at the hands of medical professionals: perinatal mood and anxiety disorders are the most common complications of childbirth. And it shows what my clients have been telling me for years: that medicalized birth is in crisis, and urgently needs reform.

The United States has the worst childbirth-related mortality and severe maternal morbidity (i.e. “near misses”) rates of any other developed nation, with higher adverse outcome rates in birthing people of color. This is related to a confluence of factors, including systemic oppression and racism in medicine, and the U.S.’s profit-driven healthcare system. But it’s also due to the way physicians are still trained to prioritize medical interventions ahead of the people on whom they perform them (Lown, 2014).

Medicalized birth is in crisis, and urgently needs reform.

This includes when doctors diminish patient birth plans, which in my clinical experience is a tool for empowerment and education for the birthing person. To discount patient priorities around labor and delivery is to look at them as bodies rather than people, which leaves emotional health out of the care equation.

This is a recipe for birth trauma in and of itself, but the letter goes even further.

The doctors write, “Some of you may have specific questions about episiotomies, labor induction or augmentation, forceps or vacuum delivery, fetal monitoring or anesthesia in labor. We believe in giving our patients the best of care. In modern obstetrics, this may still include the aforementioned procedures.” This is a scary series of sentences meant to frighten birthing parents into compliance, further silencing any person-centered dialogue in the medical relationship.

In a country where the future of reproductive rights hinges on the opinions of a small group of conservative judges, the medical system must do better.

This is the opposite of what should be happening to start lowering the numbers of people who experience trauma symptoms after childbirth. Given that many birthing people are also survivors of sexual trauma or assault, we need to be focusing on improving trauma-informed obstetric care to this population. Nixing birthing plans does not accomplish this. Doctors need to take time to get to know their patients as human beings to protect their physical and emotional health during the birthing process.

In a country where the future of reproductive rights hinges on the opinions of a small group of conservative judges, the medical system must do better. Obstetrics must do better. People have a right to agency and choices in childbirth. Life-threatening emergencies happen where swift intervention is necessary, but there is no need to shut down communication prematurely.

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We need to start talking about birth trauma

Imagine this: there are two people in labor at the same time at a hospital. Both of them planned vaginal childbirths. But their labors didn’t go smoothly, and the well-being of their babies dictated that both undergo emergency caesarean sections.

Both ultimately delivered healthy babies, but that’s where the similarity of experience ended.

Their postpartum journeys were drastically different: One parent healed from the surgery and went on to enjoy the child’s infancy; the other healed physically but started having flashbacks shortly after leaving the hospital. She couldn’t hold her baby without reliving how scared she felt moments before the baby was first handed to her, after a hastily assembled emergency surgery, where medical staff were so focused on the task at hand that the patient felt like an object rather than the vulnerable, terrified person she was in that moment.

Birth trauma is widespread but cloaked in a stigmatized silence that prevents people from seeking treatment.

For a significant minority of people who give birth, the experience ends up more like the second scenario than the first one: as many as 45% of parents who went through labor -- laboring parents are primarily mothers, but not all people who give birth identify as women -- report that the experience was traumatic (Alcorn, O’Donovan, Patrick, Creedy, & Devilly, 2010). And 9% of people who give birth will go on to develop symptoms of post-traumatic stress disorder (PTSD).

Birth trauma, as defined by Cheryl Tatano Beck DNSc, CNM, is caused by an event or series of events during labor and delivery that involves the birthing person experiencing an actual or perceived threat of injury or death to the parent or unborn child -- or by a birth experience that leaves them feeling stripped of their dignity. Beck writes that “birth trauma lies in the eye of the beholder,” meaning that the parent may experience terror, helplessness, powerlessness, or horror while, from the perspective of medical staff or partners, the labor was uneventful.

Like the physical effects of childbirth, which are regularly underdiagnosed and treated, leaving new parents to suffer for years with treatable injuries, birth trauma is widespread but cloaked in a stigmatized silence that prevents people from seeking treatment. And without treatment, it has the potential to destroy the joy of the postpartum period with shame and self-blame.

By the time patients seek my help, they have been dealing with full-blown PTSD or other mood symptoms for months, even years.

As a trauma therapist specializing in perinatal mood and anxiety disorders, I see this all the time. By the time patients seek my help, they have been dealing with full-blown PTSD or other mood symptoms for months, even years. They talk about feeling like they were assaulted in front of their entire family during nonconsensual cervical exams, or of doctors deploying forceps with such force that they were dragged down the hospital bed. Other experiences that can cause birth trauma include a prolapsed cord, a baby needing the NICU, severe postpartum injury, like tearing or hemorrhaging, and a prior history of trauma, like sexual assault/abuse.

In fact, birth trauma has major similarities to sexual assault: both involve women feeling objectified, violated, stripped of dignity, and unable to escape. And – no surprise – both come with a tragic societal stigma around talking about the experience, which makes millions of people suffering from a common experience feel isolated and alone.

We need to continually push to destigmatize birth trauma to create a culture of nonjudgement and acceptance...

This shame-based silence is a tragedy, because both types of trauma are treatable with trauma therapies, which are especially effective if the trauma event is addressed early. Trauma therapy helps undo the painful sense of aloneness, helping people feel connected, and providing a window for them to reclaim their vitality. When taking care of a newborn, sleep-deprived parents need all the vitality they can harness.

We need to continually push to destigmatize birth trauma to create a culture of nonjudgement and acceptance, allowing sufferers to feel empowered to reach out for help.

If a new parent is experiencing flashbacks, a feeling of numbness, hypervigilance, or detachment, remember: it’s not your fault, and it doesn’t have to be this way. Help is out there.

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How today’s trauma can affect future generations – and how to stop it

We are currently living through a confluence of mass trauma events: a global pandemic; oppressive forces of white supremacy; a dangerously partisan political environment; an escalating climate crisis. Mounting evidence suggests that once some of these disasters ebb, the trauma they have inflicted can have lingering effects, even on future generations.

In other words, the current and future offspring of people living through today’s panoply of horrors may well suffer from it even without their own memories of events.

In the United States alone, 23.2 million people have been diagnosed with COVID-19, and more than 385,000 people have died from it, making it the country with the highest number of deaths worldwide, growing daily.

On top of that, the past year has seen multiple killings of Black people by police, leading to historically large and widespread protests against the ongoing legacies of racism in America, generations of racism brought to bear.

Undergirding all this is an ever-escalating climate crisis that wreaked extreme storm damage across the gulf just as COVID made it dangerous to house climate refugees en masse.

The trauma risks to frontline workers, especially healthcare workers during COVID, have already been documented. But the effects 2020 will have on the rest of us are still playing out, and research suggests that those effects may echo far beyond the current generation.

Past studies have indicated an association between parental PTSD and secondary trauma in offspring of refugees, torture victims, and combat veterans, among others.

There is growing recognition in psychology of secondary trauma, where a person experiences post-traumatic stress disorder symptoms via proximity to someone else’s harrowing experience. That is, you don’t need to experience a potentially traumatic event directly to suffer psychological symptoms from it, because learning about terrible things happening to loved ones can trigger reactions akin to experiencing it first-hand. Past studies have indicated an association between parental PTSD and secondary trauma in offspring of refugees (Sangalang & Vang, 2017), torture victims (Daud et al., 2005), and combat veterans (Dekel & Goldblatt, 2008; O’Tool et al., 2016), among others.

In other words, the current and future offspring of people living through today’s panoply of horrors may well suffer from it even without their own memories of events.

A recent research paper published in Traumatology further supports the grim notion that traumas have the potential to affect the children of those who have survived them (Payne & Berle, 2020). The paper is a meta-analysis -- the study of multiple research papers at once, looking for larger trends across data sets -- of prior studies on PTSD in children and grandchildren of Holocaust survivors. The researchers found that children, but not grandchildren, of survivors are more likely than the general population to display trauma symptoms.

It’s unclear how trauma is passed from one generation to the next. Trauma could be hereditary, perhaps through stress hormones, or children may internalize their parents’ trauma through observing behavioral and emotional patterns. Trauma may even be passed down through how parents communicate or interact with their kids. The authors recommend that future studies parse these possibilities further. Regardless, the paper further strengthens the case that if parents suffer from PTSD, their children are more likely to have symptoms, too.

We can’t always stop terrible things from happening to us, but we can, with help, go from strength to strength.

This growing problem has a solution: As we navigate this historically troubling era, we must prioritize systematic screening for – and increasing access to – trauma treatment, notably for the people of color who have long been shut out of our current system. PTSD is treatable, and no one should have to suffer when there are evidence-based treatments that actually work and can prevent trauma’s passage to survivor offspring.

What’s more, working through trauma has additional benefits -- treatment opens a person up to experiencing posttraumatic growth, an experience of positive psychological change as a result of going through a challenging event. People I’ve worked with who have experienced this talk about having increased resilience, empathy, and improved relationships. We can’t always stop terrible things from happening to us, but we can, with help, go from strength to strength.

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Moral injury and COVID: how to protect our front-line healthcare workers

COVID-19 rates are soaring nationwide, setting new records nearly every day. Recent reports show that doctors have learned a lot about how COVID operates in the past eight months – leading to briefer hospitalizations and fewer deaths. But as hospitals reach and then exceed capacity, doctors, nurses and other healthcare workers are again facing situations where resources are dangerously stretched.

These conditions can lead to moral injury, a form of psychological distress that results when someone’s actions, or inactions, violate their ethical code, or when they feel unprepared to face decisions or situations before them. Moral injury was originally described vis-a-vis the military: think soldiers on the front lines, forced to make decisions that will cause civilian casualties.

Moral injury is not, in itself, a mental illness, but it can contribute to PTSD, depression, or anxiety.

Today, our front line is the healthcare profession, and COVID has forced an ongoing stream of Sophie’s choices, where the options get more dire as the pandemic worsens. Which of two equally sick patients gets the last available ventilator? Who gets admitted first when there aren’t enough beds for everyone? When does saving the life of a milder COVID case trump using resources on a severe one when there aren’t enough supplies to do both? All doctors take an oath to avoid doing harm, and the pandemic’s strain on medical resources has made that vow difficult to uphold.

Moral injury is not, in itself, a mental illness, but it can contribute to PTSD, depression, or anxiety. And since doctors already have a suicide rate twice that of the general population – one doctor commits suicide every day in the US – it’s vital that hospitals prioritize helping their staffs process pandemic treatment experiences before, during, and after each COVID spike.

Today, our front line is the healthcare profession, and COVID has forced an ongoing stream of Sophie’s choices, where the options get more dire as the pandemic worsens.

According to a recent paper published in the British Medical Journal, psychological support is key for ensuring that what researchers called potentially morally injurious events (PMIEs) become a foundation for increased psychological resilience rather than a risk factor.

A few studies that have come out recently looking at healthcare workers during COVID-19 point to strategies for supporting them through the pandemic, including:

Prepping healthcare workers for the moral quandaries they are going to face during the pandemic: We know that preparing staff for the job and its associated challenges reduces the risk of mental health problems later on.
Checking in with staff who are “too busy” or routinely “not available” to process experiences in a group setting, since avoidance is a core symptom of unresolved trauma.
Making time to reflect on the extraordinarily difficult experiences healthcare providers are facing to create a meaningful, rather than traumatic, narrative.
Taking practical steps to manage anxiety, such as limiting time spent consuming news.
Encouraging healthcare workers to seek support from trained peers and/or professionals when necessary.

Healthcare workers struggling with the hard emotional fallout of moral injury during COVID have the capacity to eventually experience post-traumatic growth...

It is important to note that most people who endure traumatic events like PMIEs will recover on their own and will not require professional support. Even most healthcare workers struggling with the hard emotional fallout of moral injury during COVID have the capacity to eventually experience “post-traumatic growth,” a strengthening of resilience, self-worth, and values after living through extraordinarily difficult circumstances. But making sure there are supports in place when healthcare workers need them will help ensure that PMIEs won’t contribute to wearing down exhausted front-line workers all the more.

The pandemic has dropped us all in largely uncharted waters, both medically and psychologically. But it’s becoming clear that current conditions, rife with potentially morally injurious events, are putting our healthcare providers at unprecedented risk. What we do know is how to help protect them, and it must become a top national priority.

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5 things moms can do postpartum to support their mental health

(This post was originally published to AfterThird)

The perinatal period – which lasts from pregnancy until a year after childbirth – is a time of great psychological vulnerability, which has only been heightened due to COVID-19.

Approximately one in seven perinatal women will experience depression, anxiety or another significant mood concern. Postpartum depression and anxiety can occur anytime within the first year after the baby is born, but many women who suffer from this condition experience symptoms earlier, during pregnancy. And even before COVID, few of them got help.

“Only 30% of people who should be treated are treated,” said Ann Smith, CNM, the New York City coordinator for Postpartum Support International, which helps parents struggling with perinatal mood and anxiety disorders.

Perinatal mood and anxiety disorders are the most common complication of childbirth in the US, and no one should have to go through it alone.

It’s too early to quantify if more new mothers are experiencing perinatal mood symptoms because of the pandemic, but doctors who work with them say that the increased stressors have taken a toll, even though the movement toward online services has given many of these women easier access to sources of support.

“The biggest anxiety that I’m hearing about from moms is that they know their babies are really fragile when they’re first born and want to make sure they don’t do anything that could expose them to getting COVID-19,” said Priyanka Rao, MD, a board-certified pediatrician and instructor at the C.S. Mott Children’s Hospital in Michigan. In these unprecedented times, we cannot ignore that the psychosocial stressors borne from the COVID-19 pandemic have the potential to heighten the intensity of perinatal mood and anxiety disorders.

While parents adjust to life with a new baby, they are also learning to tolerate uncertainty about the future, the loneliness of social distancing, parenting older children who are attending virtual school, and maintaining partner relationships. Many parents have missed out on the normal rituals after childbirth due to social distancing (like baptisms or brises) and are coping with feelings of loss. It’s normal to feel some level of anxiety about all of this.

But when anxiety becomes excessive, it can interfere with overall wellness and functioning. Some signs that’s happening include:

Worries that border irrationality and cannot be soothed
Intrusive thoughts – e.g., disturbing thoughts/images that repeat over and over in your mind and cannot be controlled
Hypervigilance and feelings of panic
Loss of pleasure, trouble concentrating, social isolation
Irritability, hopelessness, and crying spells
Unable to sleep when the baby is sleeping

And no matter how you’re feeling, know that it’s temporary, and that support is available.

When any of these things feel overwhelming, consider seeking professional help, anything from private therapy to support groups that you can now attend from home while maintaining social distancing. PSI, for example, holds support groups every weekday. Or, if those steps feel too overwhelming, talk to your child’s pediatrician, since you’re guaranteed to see them regularly.

“For a lot of families, the only reason they’re leaving the protection and bubble of their home is to come to the pediatric office,” Dr. Rao said. “I’m not a mental health professional or an OB-GYN, but I do know how to help moms connect to resources if I start to notice signs or symptoms that have me concerned.”

Besides reaching out for help, there are things postpartum mothers can do to help stave off depression and anxiety going forward. They include:

Self-care: rest, eat well, exercise
Limit isolation: find ways to interact with relatives/friends virtually or in a safe, socially distanced manner
Don’t consume disturbing social media or news. That might mean asking friends and family to not send you alarming messages, or opting out of groups that share them.
Find ways to relax: practice yoga or mindfulness, take a walk, binge-watch a new show, etc.

And no matter how you’re feeling, know that it’s temporary, and that support is available. Perinatal mood and anxiety disorders are the most common complication of childbirth in the US, and no one should have to go through it alone.

Other resources for new parents include:

How the just world hypothesis worsens the trauma of sexual assault survivors

People tend to mistake their own perceptions for universal reality. When it comes to politics, that tendency leads to our current hyper-partisan political environment, where people tapping into different media ecosystems may as well be living on different planets. When it comes to race, we see a cohort that cannot recognize the way white supremacy is structurally woven into the way society operates.

And when it comes to sexual assault, it means that onlookers overlook the gender inequality that pervades our socio-political system and instead blame the survivor for enduring a traumatic event that happened beyond their control.

This is the Just World Hypothesis in action -- the flawed idea that people get what they deserve.

“In a rape case, the Just World Hypothesis states that people can’t handle the cognitive lift of the fact that something unjust happened to the rape victim,” wrote Culda , Opre, and Dobrin in a 2018 paper published in Cognition, Brain, Behavior. They went on to say, “So to preserve the ‘you get what you deserve’ mentality, it’s necessary to view the victim as flawed in some way.”

Sound familiar? Her skirt was too short. She drank too much. She was asking for it.

This is the Just World Hypothesis in action -- the flawed idea that people get what they deserve.

The Just World Hypothesis is another shade of the prosperity gospel - that people become wealthy because they deserve to, never mind that most of those people are white, male, and cisgender. It allows lucky people to look at the world and divine that their lives are fortunate because they deserve what they get, not because they are at the top of a racist, sexist hierarchy designed to keep them up and everyone else down.

In American culture, it might be even more pronounced, as our milieu idealizes the American Dream and the concept of controlling our future. As a general rule, Americans have a hard time with the idea that bad things happen to good people (white Americans definitely struggle with this concept).

No matter what we want to believe, the world is not a just place, and sometimes terrible things happen to people. And nobody, no matter how they operate, ever deserves that plight.

Victim blaming: doubling down on harm

Though people engage in victim blaming to psychologically distance themselves from the idea that they are vulnerable to becoming victims themselves, it ends up compounding the trauma of sexual assault survivors.

The problem is, victim blaming takes the focus and responsibility off of the perpetrator and shifts it onto the survivor, thus silencing her – 90% of adult rape victims are women – and increasing her feelings of isolation. Victim blaming can also be experienced as a "second assault" by the survivor, complicating the trauma.

Believe the survivor. People rarely make up stories of abuse.

In my clinical practice, I have seen how victim blaming deepens the shame, self-blame, and confusion that revolves around the trauma of sexual assault. This detrimental form of secondary gaslighting deceives the survivor into believing fallacies like “I’m worthless,” “It was my fault,” or “I’m making this up in my head.”

Changing the status quo

We must all do our part to push against victim blaming in society, starting with educating ourselves about rape-culture and the myths that perpetuate it.

Some common myths and realities around sexual assault include:

She's lying.

Very few people lie about being sexually assaulted. Research has found that approximately 2-10% of rapes are false reports (Lisak, Gardinier, Nicksa, and Cote, 2010). What’s more, there are countless examples of alleged sexual assault where victim blaming led to little or insufficient punishment for the perpetrator. The #MeToo movement is virtually built on that traumatic disparity.

She wanted it.

No one wants to be sexually assaulted. This myth conflates sexual assault with sexual desire. Sexual assault is a violent act motivated by the urge to dominate and humiliate. Additionally, sexual assault is NOT caused by the survivors’ drinking or drug use, clothing or makeup, flirting, or consensual past sexual encounters with the perpetrator.

Sexual assault by an acquaintance is less traumatic than assault by a stranger.

Sexual assault is traumatic whether perpetrated by a stranger or someone known to the survivor. An acquaintance assault can have devastating long-term consequences because the survivor may doubt their ability to judge who they can trust.

Each one of us must take responsibility for making sure that victim blaming becomes an unacceptable response to sexual assault and gender-based misconduct.

Beyond educating ourselves about victim blaming and rape culture, we must practice responding appropriately when someone close to us discloses they have experienced sexual assault, breaking the cycle of victim blaming and allowing survivors to start healing.

Here is what you can do:

Believe the survivor. People rarely make up stories of abuse.
Express compassion. If you feel outraged, sad, or shocked by the survivor's pain, share it with them. There is nothing more validating than a genuine human response. Make sure your feelings don't overwhelm the survivor’s.
Inform them of appropriate resources and options. Encourage them to get help to heal.
Respect the survivor’s timeline for healing. Trauma integration is a process that cannot be hurried.

Though victim blaming can be charitably understood as a self-protective impulse, allowing people to avoid the reality that something just as horrific could happen to them, that magical thinking does nothing, in reality, to protect those using it. But it does inflict tangible harm on assault survivors. Each one of us must take responsibility for making sure that victim blaming becomes an unacceptable response to sexual assault and gender-based misconduct.

Resources for survivors of sexual assault:

RAINN

The Safe Helpline

The Voices and Faces Project

It’s On Us

It Happen ed to Alexa Foundation