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A qualitative exploration of women’s and their partners’ experiences of birth trauma in Australia, utilising critical feminist theory

  • Author Footnotes
    1 @paige_tsakmakis
    Paige L. Tsakmakis
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    Correspondence to: 207 Bouverie St, Carlton, VIC 3053, Australia.
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    1 @paige_tsakmakis
    Affiliations
    Gender and Women’s Health Unit, Centre for Health Equity, School of Population and Global Health, University of Melbourne, Carlton, VIC, Australia

    Mercy Health, Victoria, Australia
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    2 @akter_shahinoor.
    Shahinoor Akter
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    2 @akter_shahinoor.
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    Gender and Women’s Health Unit, Centre for Health Equity, School of Population and Global Health, University of Melbourne, Carlton, VIC, Australia
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    3 @meghanbohren.
    Meghan A. Bohren
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    3 @meghanbohren.
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    Gender and Women’s Health Unit, Centre for Health Equity, School of Population and Global Health, University of Melbourne, Carlton, VIC, Australia
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    1 @paige_tsakmakis
    2 @akter_shahinoor.
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Open AccessPublished:December 24, 2022DOI:https://doi.org/10.1016/j.wombi.2022.12.004

      Abstract

      Background

      Many women in Australia emerge from childbirth describing their experience as traumatic. Birth trauma can be both physical and psychological, with long-lasting and intergenerational impacts.

      Aim

      To explore women’s and their partners’ experiences of birth trauma in Australia and consider the role of gender using a feminist theoretical lens.

      Methods

      We used a descriptive phenomenological and constructivist/interpretivist approach and two frameworks (WHO Quality of Care framework; socio-ecological model) to explore experiences of traumatic birth. Participants were recruited through social media using purposive sampling. Data were collected through online in-depth interviews. Data were analysed thematically, considering gender and power dynamics using critical feminist theory.

      Findings

      24 women and 4 male partners were interviewed. We identified 8 themes, including: Individual: birth grief and best laid plans; breastfeeding to regain identity after trauma. Interpersonal: impact of trauma on bonding with baby; partner trauma. Institutional: inadequate consent processes; to debrief or not to debrief. Community: more than a healthy baby. Policy: an augmented reality.

      Discussion

      Findings highlighted the impact of patriarchal maternity care systems and policies in undermining women’s sense of control during birth, evident in high levels of labour augmentation and inadequate consent processes. This study draws attention to how gender shapes how birth trauma is expressed within both women’s and their partners’ identities as parents, their relationships, and society.

      Conclusions

      Recommendations include the development of women-centred policies for obtaining informed consent and training in trauma-informed care in maternity services. Further research must include the voices of women from diverse backgrounds.

      Keywords

      Statement of significance
      Problem
      Birth trauma is common in Australia, impacting at least one in three women giving birth. The implications are multifaceted and intergenerational, impacting both physical and mental health and their child’s development.
      What is already known
      Contributing factors for birth trauma include physical injuries, obstetric interventions, a perceived lack of control and poor relationships with health care providers
      What this paper adds
      This study contributes a qualitative understanding about how birth trauma is experienced by women and families in Australia, offering a unique perspective of the impact of gender inequalities and structural patriarchy on these experiences.

      Introduction

      Birth trauma is an inclusive term that has emerged in the past 20 years in response to the growing awareness that many women live with the negative physical and psychological sequelae of a traumatic childbirth experience. It encompasses many different but related traumatic incidents, such as physical injury to the woman’s body and/or baby as well as psychological responses to specific birth events or to the care received during childbirth [
      • Greenfield M.
      • Jomeen J.
      • Glover L.
      What is traumatic birth? A concept analysis and literature review.
      ]. Research in Australia suggests that almost half (45.5 %) of women describe their childbirth experience as traumatic [
      • Alcorn K.L.
      • O'Donovan A.
      • Patrick J.C.
      • Creedy D.
      • Devilly G.J.
      A prospective longitudinal study of the prevalence of post-traumatic stress disorder resulting from childbirth events.
      ], while one in three women will display at least three trauma symptoms in the early postpartum period [
      • Creedy D.K.
      • Shochet I.M.
      • Horsfall J.
      Childbirth and the development of acute trauma symptoms: incidence and contributing factors.
      ]. This is consistent with data from the United States and other high-income countries, where the prevalence of birth trauma is estimated at around 34 % [
      • Soet J.E.
      • Brack G.A.
      • DiIorio C.
      Prevalence and predictors of women^s experience of psychological trauma during childbirth.
      ]. Reported rates of childbirth-related post-traumatic stress disorder (PTSD) in Australia range from 1 % to 6 % [
      • Creedy D.K.
      • Shochet I.M.
      • Horsfall J.
      Childbirth and the development of acute trauma symptoms: incidence and contributing factors.
      ]; however international data suggests this may be an underestimate, with some population groups (such as women with a past history of trauma, violence or abuse, or those with severe pregnancy complications such as hyperemesis or pre-eclampsia) in the United Kingdom experiencing a prevalence of up to 18 % [
      • Yildiz P.D.
      • Ayers S.
      • Phillips L.
      The prevalence of posttraumatic stress disorder in pregnancy and after birth: a systematic review and meta-analysis.
      ].
      The implications of birth trauma are multifaceted and intergenerational, impacting not only a woman’s mental and physical health but also her interpersonal relationships and her ability to bond with her new baby [
      • Fenech G.
      • Thomson G.
      Tormented by ghosts from their past’: a meta-synthesis to explore the psychosocial implications of a traumatic birth on maternal well-being.
      ,

      Ponti L., Smorti M., Ghinassi S., Mannella P., Simoncini T. Can a traumatic childbirth experience affect maternal psychopathology and postnatal attachment bond? Current Psychology. 2020.

      ], which in turn can have negative consequences for the child’s development [
      • Cook N.
      • Ayers S.
      • Horsch A.
      Maternal posttraumatic stress disorder during the perinatal period and child outcomes: A systematic review.
      ,
      • Garthus-Niegel S.
      • Ayers S.
      • Martini J.
      • von Soest T.
      • Eberhard-Gran M.
      The impact of postpartum post-traumatic stress disorder symptoms on child development: a population-based, 2-year follow-up study.
      ]. Recent research has also explored the effect that birth trauma has on fathers, with findings highlighting similar negative mental health outcomes [
      • Elmir R.
      • Schmied V.
      A qualitative study of the impact of adverse birth experiences on fathers.
      ,
      • Daniels E.
      • Arden-Close E.
      • Mayers A.
      Be quiet and man up: a qualitative questionnaire study into fathers who witnessed their Partner's birth trauma.
      ,
      • Inglis C.
      • Sharman R.
      • Reed R.
      Paternal mental health following perceived traumatic childbirth.
      ].
      Birth trauma refers to both physical and psychological trauma, which can occur in isolation or in combination with each other. So, while birth trauma can exist exclusive of physical injury, injuries such as significant perineal and anal sphincter tears and pelvic organ prolapse sustained during childbirth and their potential for lifelong morbidity, have also been shown to be associated with significant psychological symptoms such as PTSD, depression and anxiety [
      • Skinner E.M.
      • Barnett B.
      • Dietz H.P.
      Psychological consequences of pelvic floor trauma following vaginal birth: a qualitative study from two Australian tertiary maternity units.
      ]. In addition, high rates of obstetric interventions such as instrumental birth (e.g., vacuum or forceps) – commonly associated with birth injuries – and emergency caesarean birth are considered predictors of trauma [
      • Creedy D.K.
      • Shochet I.M.
      • Horsfall J.
      Childbirth and the development of acute trauma symptoms: incidence and contributing factors.
      ,
      • Boorman R.J.
      • Devilly G.J.
      • Gamble J.
      • Creedy D.K.
      • Fenwick J.
      Childbirth and criteria for traumatic events.
      ]. While the unpredictable and urgent nature of an emergency caesarean may lend itself to a traumatic experience for those involved, evidence suggests that the trauma is more likely to stem from a perceived lack of control and inadequate involvement in the decision-making surrounding this mode of birth [
      • Soet J.E.
      • Brack G.A.
      • DiIorio C.
      Prevalence and predictors of women^s experience of psychological trauma during childbirth.
      ,
      • Boorman R.J.
      • Devilly G.J.
      • Gamble J.
      • Creedy D.K.
      • Fenwick J.
      Childbirth and criteria for traumatic events.
      ].
      Research has shown that as interventions during labour and birth increase, women’s confidence in the competence of healthcare staff and the relationship between the healthcare worker and the woman deteriorates [
      • Creedy D.K.
      • Shochet I.M.
      • Horsfall J.
      Childbirth and the development of acute trauma symptoms: incidence and contributing factors.
      ,
      • Cook K.
      • Loomis C.
      The impact of choice and control on women's childbirth experiences.
      ,

      Watson K., White C., Hall H., Hewitt A. Women’s experiences of birth trauma: a scoping review. Women and Birth, 2020.

      ]. This can result in women’s perceived lack of control, choice and respect and an increased likelihood of a negative birth experience [
      • Creedy D.K.
      • Shochet I.M.
      • Horsfall J.
      Childbirth and the development of acute trauma symptoms: incidence and contributing factors.
      ,
      • Cook K.
      • Loomis C.
      The impact of choice and control on women's childbirth experiences.
      ,

      Watson K., White C., Hall H., Hewitt A. Women’s experiences of birth trauma: a scoping review. Women and Birth, 2020.

      ]. Birth trauma that includes accounts of a lack of or insufficient informed consent before interventions, disrespectful care and unnecessary restrictions placed on the woman constitute a specific form of violence against women, leading to the creation of the legal term ‘obstetric violence’ in several South American countries [
      • D'Gregorio R.P.
      Obstetric violence: a new legal term introduced in Venezuela.
      ]. However, ‘obstetric violence’ is currently not recognised in any Australian legislation.
      The issue of the mistreatment of women during childbirth has gained burgeoning attention in the public health and human rights sphere over the past ten years, with the World Health Organisation (WHO) issuing a statement calling for greater action, research and advocacy for this important topic that threatens a women’s basic human rights [
      • WHO
      The Prevention and Elimination of Disrespect and Abuse during Facility-based Childbirth: WHO Statement.
      ]. Mistreatment can vary from physical abuse such as slapping, pinching and physical restraint, verbal abuse, non-consented care or discrimination by healthcare workers [

      Bowser D., Hill K. Exploring Evidence for Disrespect and Abuse in Facility-Based Childbirth: Report of a Landscape Analysis. Harvard School of Public Health, 2010.

      ]. Like other forms of violence against women, the hegemonic power relations in the maternity setting mirrors that of society at large, where structural gender inequality sees women holding a subordinate position compared to men [
      • Jewkes R.
      • Penn-Kekana L.
      Mistreatment of Women in Childbirth: Time for Action on This Important Dimension of Violence against Women.
      ]. The United Nations Special Rapporteur on Violence Against Women recently stressed that the mistreatment of women receiving reproductive health services is part of a continuum of violations that occur within the broader context of structural inequality, discrimination and patriarchy, resulting in the degradation of women’s social status and access to basic human rights such as health, bodily integrity, privacy and autonomy [

      Simonovic D. A human rights-based approach to mistreatment and violence against women in reproductive health services with a focus on childbirth and obstetric violence: note / by the Secretary-General. United Nations, 2019. Contract No.: A/74/137.

      ].
      While birth trauma can occur as a result of a significant physical injury or threat to the life of the woman giving birth or baby, it can equally arise as a response to threats to psychological safety via interactions with healthcare providers and the maternity care system. Previous qualitative explorations of birth trauma show that it “lies in the eye of the beholder” [
      • Beck C.T.
      Birth trauma: in the eye of the beholder.
      ] (e.g., the woman), therefore it is important not to make assumptions about a woman’s trauma experience based solely on the characteristics or outcomes related to her birth. Rather, there is substantial evidence to suggest that the mistreatment of women during labour contributes to and may result in experiences of birth trauma [
      • Beck C.T.
      Birth trauma: in the eye of the beholder.
      ,
      • Thomson G.
      • Downe S.
      Widening the trauma discourse: the link between childbirth and experiences of abuse.
      ,
      • Reed R.
      • Sharman R.
      • Inglis C.
      Women's descriptions of childbirth trauma relating to care provider actions and interactions.
      ]. This trauma can be further driven by structural determinants such as systemic failures at the level of health systems, including policies and power dynamics that act to disempower women [
      • Bohren M.A.
      • Vogel J.P.
      • Hunter E.C.
      • Lutsiv O.
      • Makh S.K.
      • Souza J.P.
      • et al.
      The Mistreatment of women during childbirth in health facilities globally: a mixed-methods systematic review.
      ]. Furthermore, historically the technocratic model of obstetric care can be incompatible with the physiological process of childbirth [
      • Davis-Floyd R.
      The technocratic, humanistic, and holistic paradigms of childbirth.
      ], creating a patriarchal environment where coercion, control and the disempowerment of women is commonplace [
      • Reed R.
      • Sharman R.
      • Inglis C.
      Women's descriptions of childbirth trauma relating to care provider actions and interactions.
      ,
      • Keedle H.
      • Schmied V.
      • Burns E.
      • Dahlen H.G.
      A narrative analysis of women's experiences of planning a vaginal birth after caesarean (VBAC) in Australia using critical feminist theory.
      ].
      To our knowledge, there is currently no in-depth qualitative research that combines both women’s and their partner’s experiences of birth trauma in Australia. This research aims to address this critical gap in Australia by conducting qualitative semi-structured interviews and exploring the common themes of birth trauma using a multi-level, socio-ecological framework. In order to bring a focus to the proposed influence that gender inequalities and structural patriarchy have on women’s experiences and interactions with caregivers during their birth, a critical feminist theory lens was employed. The overall aim of this research was to develop a richer understanding of how traumatic birth is experienced by women and their partners in Australia, and in presenting these findings, explore to what extent gender influences and often exacerbates birth trauma at each level of their interactions with the maternity care system.

      Methods

      Qualitative approach, paradigm and conceptual frameworks

      We used a descriptive phenomenological approach using a constructivist/interpretivist paradigm, in order to explore socially-constructed realities and lived experiences of women and their partners who self-describe as experiencing birth trauma [
      • Allsop J.
      Competing paradigms and health research: design and process.
      ]. The benefit of a qualitative approach and specifically in-depth interviewing in this context allows the researchers to explore the topic of birth trauma in greater depth by allowing for follow-up questions, encouraging greater reflection on a participant’s feelings and emotions [
      • Coombes L.
      • Allen D.
      • Humphrey D.
      • Neale J.
      In-depth interviews.
      ]. This study is reported in accordance with the Standards for Reporting Qualitative Research (SRQR; Appendix 1) [
      • O'Brien B.C.
      • Harris I.B.
      • Beckman T.J.
      • Reed D.A.
      • Cook D.A.
      Standards for reporting qualitative research: a synthesis of recommendations.
      ].
      We used two conceptual frameworks to inform the design and analysis of this research: the socio-ecological model and the World Health Organization (WHO) Quality of Care framework for maternal and newborn health [
      • Tuncalp O.
      • Were W.M.
      • MacLennan C.
      • Oladapo O.T.
      • Gulmezoglu A.M.
      • Bahl R.
      • et al.
      Quality of care for pregnant women and newborns-the WHO vision.
      ]. The socio-ecological model is a widely used framework that places the individual at the centre of a number of systems that expand to encompass the main contributors to health, namely interpersonal and community factors, and the broader environment, including social and political influences [
      • Kilanowski J.F.
      Breadth of the socio-ecological model.
      ,
      • McLaren L.
      • Hawe P.
      Ecological perspectives in health research.
      ]. By utilising this framework, we were able to explore how broader social structures such as patriarchy manifests itself within healthcare settings and through interpersonal relationships during childbirth.
      The WHO Quality of Care framework for maternal and newborn health conceptualises the domains of care that health systems should address in order to provide quality care and end preventable maternal and infant morbidity and mortality [
      • Tuncalp O.
      • Were W.M.
      • MacLennan C.
      • Oladapo O.T.
      • Gulmezoglu A.M.
      • Bahl R.
      • et al.
      Quality of care for pregnant women and newborns-the WHO vision.
      ]. A key component of this framework pertains to a woman’s experience of care, which includes providing effective communication – including understanding her rights - and receiving care with respect and dignity [
      • Tuncalp O.
      • Were W.M.
      • MacLennan C.
      • Oladapo O.T.
      • Gulmezoglu A.M.
      • Bahl R.
      • et al.
      Quality of care for pregnant women and newborns-the WHO vision.
      ]. The importance that this framework places on the woman’s experience during childbirth as a key component of quality care, made it a useful tool to apply in this research while considering the system level drivers of birth trauma.
      The quality of care framework was used in the development of the interview guide, ensuring that questions elicited responses regarding the participant’s experiences of care in all their interactions with the maternity care system. Both frameworks were used during data analysis phase in order to undertake a multi-level analysis using the socio-ecological model to specifically explore the experience of care domain as it sits within the context of the health system in the quality of care framework.

      Study setting and participants

      Potential participants were eligible if they were women of reproductive age (18–49 years), who had given birth anywhere in Australia in the past five years, who identified as having had a traumatic birth experience and were willing to articulate it. Birth trauma is a highly subjective phenomena that is perceived differently by each woman who has given birth [
      • Beck C.T.
      Birth trauma: in the eye of the beholder.
      ], therefore no definition of birth trauma was provided in order to capture what participants themselves considered to be ‘trauma’. Women who suffered a neonatal loss or foetal death in utero were excluded from participating, as the multidimensional nature of their trauma experience is outside the scope of this research project. We acknowledge that gender is a social construct [
      • Hammarstrom A.
      • Johansson K.
      • Annandale E.
      • Ahlgren C.
      • Alex L.
      • Christianson M.
      • et al.
      Central gender theoretical concepts in health research: the state of the art.
      ], but for the purposes of this research, people who identified as women were included, as they represent the majority of people giving birth in Australia, and people who are non-binary or transgender may have additional or unique needs during childbirth worthy of more in-depth exploration. Non-English-speaking participants were also excluded as the resources required to facilitate their inclusion was not feasible within the scope of this research. However, participants born outside Australia themselves were eligible for inclusion. Participants who had a partner were offered the opportunity to have their partners contribute to the interview, although the non-participation of a partner did not exclude the participation of a woman if she preferred to be interviewed alone or not have her partner interviewed.
      A passive social media recruitment strategy was employed, which involved placing a recruitment advertisement on the members-only Facebook group of The Australasian Birth Trauma Association (ABTA) and an Instagram story post on Core + Floor Restore, an Australian maternal health and wellness resource. The first author was familiar with these organisations through her professional experience as a physiotherapist and approached the founders individually to request assistance with recruitment for this study.
      A purposive sampling method was used, with an initial estimated sample size of approximately 10–20 women (with or without their partners) considered appropriate to reach saturation, so data collection continued until no new themes were forthcoming [
      • Bowen G.A.
      Naturalistic inquiry and the saturation concept: a research note.
      ].

      Data collection and management

      Interested participants contacted the first author via email, text message or direct message through the Instagram account created solely for this project (@birth.trauma.study). If they were eligible to participate, obtaining informed consent was navigated through the provision of a written Plain Language Statement outlining important information about the research project, including the possible risks and benefits to the individual while informing them of their right to withdraw from the study at any time. The PLS and the consent form were provided via email to all participants and written consent was obtained prior to their interview. No authors had any prior relationship with any of the participants before the study commenced.
      The subject of birth trauma understandably brings with it the potential for emotional distress for both participants and researchers, requiring additional ethical considerations. A distress protocol was created to address and support any participant who experienced any emotional or psychological discomfort during an interview and all participants were provided with a list of appropriate mental health support services, including services specific to birth trauma and perinatal mental health, to access. In order to protect participants’ privacy and ensure the confidentiality of the data, participants have been reported anonymously in this article with the use of pseudonyms.
      Data were collected by the first author via semi-structured interviews with participants over the period of July and August 2021. Half of the partner interviews were conducted simultaneously alongside the female participant, the other half chose to provide their experiences separately, immediately following the female participant’s interview. Participants chose their preferred interview method, either via Zoom or phone call, at a time convenient to all. Few interruptions pertained to babies and children requiring care and had minimal impact on the flow of the interview. In-person interviews were not possible due to COVID-19 restrictions, but the utilisation of this technology enabled participants from across Australia to take part. Evidence suggests that virtual qualitative interviewing is both an acceptable alternative and often preferred method in these unprecedented times [
      • Sah L.K.
      • Singh D.R.
      • Sah R.K.
      Conducting qualitative interviews using virtual communication tools amid COVID-19 Pandemic: a learning opportunity for future research.
      ]. Each interview lasted for approximately an hour (range 35–105 min) and participants were given a $40 Coles Myer gift card, mailed to them after the interview was completed, to compensate for their time. The interviews were audio-recorded, with the permission of the participants.
      After each interview, the audio files were transcribed verbatim using Otter.ai software, which converts voice conversations to written data and complies with the General Data Protection Regulation (GDPR) [

      Otter.ai. Otter.ai 2021 [Available from: 〈https://otter.ai/〉.

      ]. Member checking or participant validation of transcripts was then undertaken with only small corrections made, contributing further to the credibility and in turn the rigour of the study [
      • Liamputtong P.
      ]. Study data consisted of interview audio files, verbatim interview transcripts, researcher field journal and the master list to link participants identifiers to their identification number to maintain confidentiality. These files were uploaded and stored on a cloud drive account at The University of Melbourne, accessible only by the research team.

      Study instrument

      A semi-structured interview guide (Appendix 2) was developed, pre-tested and refined through piloting with the assistance of a fellow researcher independent to this study, to ensure optimal phrasing and ethicality of the questions. The interview included the following domains and covered these themes:
      • The antenatal period: birth preparation, expectations, interactions with healthcare providers, autonomy and decision-making.
      • Labour and birth: choice, informed consent, autonomy, interactions with healthcare providers, physical injuries.
      • Early postnatal phase (first 6 weeks): support network, opportunities to debrief, infant bonding.
      • Period from early postnatal phase to today: Ongoing impacts on relationships with child, partner and family, ongoing physical impact if any, impact on future/subsequent pregnancies/births, path to healing.
      • Partner-specific questions: trauma witness or shared experience, impact on relationship with partner and baby after birth, supports utilised or offered.

      Data analysis

      The process of data collection and analysis commenced simultaneously. The data were analysed through the process of inductive thematic analysis. Thematic analysis is a foundational and widely used method of qualitative data analysis, which involves identifying and analysing themes or patterns within the data [
      • Braun V.
      • Clarke V.
      Successful Qualitative Research: A Practical Guide for Beginners.
      ,
      • Liamputtong P.
      • Serry T.
      Making sense of qualitative data.
      ]. The suggested process for thematic analysis as outlined by Braun and Clarke [
      • Braun V.
      • Clarke V.
      Successful Qualitative Research: A Practical Guide for Beginners.
      ] was followed, including data familiarisation, creation of both data-driven and researcher driven codes, then looking for emerging themes and collating codes accordingly. A combined inductive and deductive approach was used to identify themes emerging from the participants voices (inductive) and based on the frameworks and interview guide (deductive). This process was supported through the use of NVivo data management software [] and the codebook (Appendix 3) was developed independently by the first and second authors, with the final coding framework discussed and agreed upon by all researchers. Data analysis continued alongside data collection until the themes derived addressed the research questions.
      Critical feminist theory provides a foundation that informs all aspects of this research, from the development of the research questions to the data collection, analysis and interpretation methods. Both critical theory and feminist theory have a shared foundation in social and economic inequalities, with an aim to produce systematic change [
      • Martin J.
      Feminist theory and critical theory: unexplored synergies.
      ]. However, critical theory focuses primarily on issues relating to social class, while feminist theory places sex and gender at the forefront, analysing the role that hegemony and patriarchy play in inequalities [
      • Martin J.
      Feminist theory and critical theory: unexplored synergies.
      ]. Critical feminist theory combines the two to highlight gender as a focus for analysis whilst also challenging the existing distributions of power within a society or social structure [
      • Rhode D.L.
      Feminist critical theories.
      ]. While the quality of care framework guided the development of the study instrument and formed the structure of the analysis, critical feminist theory was utilised as an overarching lens, guiding us to consider the way that gender and the balance of power is expressed in relationships and interactions at every level and as a possible contributing factor to women’s experiences of birth trauma.

      Ethics and reflexivity statement

      This study received ethics approval from The University of Melbourne, (reference no: 2021–21846–18459–3).
      An important element of qualitative research and one that is essential to the concept of reflexivity is to define a researcher’s positionality in relation to their research topic [
      • Holmes A.G.D.
      Researcher positionality -- a consideration of its influence and place in qualitative research -- a new researcher guide.
      ]. Author 1 is a health professional with 10 years of experience working within the maternity care system, primarily as a physiotherapist. Having witnessed and treated women suffering from birth trauma over her career, she has a strong interest in this research topic. She is also a white woman, born in Australia and of childbearing age, but has not experienced childbirth personally. She had no previous contact with any of the participants, although one did give birth at the hospital where she is employed, which became apparent during the interview. Given that her background is in clinical rather than qualitative research, her innate perspective is to focus on the physical manifestations of trauma. Although this was mitigated through regular reflection, the use of a field journal and debriefing discussions with the research team, it is important to acknowledge the possibility of researcher bias that exists and positioning in relation to the analysis and interpretation. Authors 2 and 3 are social scientists with training in medical anthropology, public health, and epidemiology. Author 3 has worked extensively on improving the understanding and measurement of women’s experiences of pregnancy and childbirth, and how this relates to their health, well-being, and future care-seeking behaviours.

      Findings

      Recruitment commenced in June 2021 1 and we received an overwhelming response in the first 24-hours following the recruitment flyer posting on Facebook and Instagram, with 48 women making contact by text message, email, and Instagram direct message. This response required recruitment to be paused and no further recruitment was needed after this point. All 48 women were provided with the plain language statement and consent form, and 45 out of 48 women met the inclusion criteria. Twenty-four of these women consented to participate, and 21 chose not to participate by not engaging any further after the initial contact phase or providing any reason for this choice (Fig. 1).
      Twenty-four women and four male partners completed interviews in July and August 2021, with two of the male partners being interviewed alongside their partners, adding their contribution throughout the interview as well as responding to the partner-specific questions listed in the interview guide (Appendix 2). The other two partners participated separately, directly following the interview with their female partner. Socio-demographic data of the final sample are provided in Table 1. Most women were between 25 and 34 years old, were born in Australia, gave birth in Victoria and have one child. The most common modes of birth were emergency caesarean section and forceps assisted vaginal birth.
      Table 1Socio-demographic characteristics of participants.
      Participant characteristics and birth demographicsN ( %)
      Female Age (Median= 31 years)



       20–242 (8.4 %)
       25–296 (25.0 %)
       30–3412 (50.0 %)
       35–392 (8.4 %)
       40–442 (8.4 %)
      Male Age (Median= 31 years)
       25–291 (25.0 %)
       30–342 (50.0 %)
       35–391 (25.0 %)
      Number of children



       119 (79.2 %)
       25 (20.8 %)
      Country of birth (Female)

       Australia22 (91.6 %)
       New Zealand1 (4.2 %)
       South Africa1 (4.2 %)
      Country of birth (Male)
       Australia4 (100.0 %)
      State of birth of baby

       Victoria13 (54.2 %)
       New South Wales6 (25.0 %)
       Queensland3 (12.5 %)
       South Australia1 (4.2 %)
       Western Australia1 (4.2 %)
      Place of birth of baby



       Public hospital21 (87.5 %)
       Private hospital3 (12.5 %)
      Type of birth (assoc. with trauma)

       Unassisted vaginal5 (20.8 %)
       Forceps assisted vaginal8 (33.3 %)
       Vacuum assisted vaginal2 (8.4 %)
       Emergency caesarean section9 (37.5 %)
      The themes that emerged during analysis have been structured in relation to the socio-ecological model, whilst considering the overarching role that gender plays within and across all levels of an individual’s interactions with the healthcare system. These key themes are presented in Fig. 2 and will be outlined in detail below with illustrative data using the participants’ own words.
      Fig. 2
      Fig. 2Main themes mapped to the socio-ecological model.

      Individual

      Birth grief and best laid plans

      A common thread woven through women’s descriptions of their birth trauma related to the concept of ‘birth grief’, where a woman is essentially grieving the birth that she had prepared for and envisaged but for many reasons was unable to obtain. Chloe, who experienced a failed induction and emergency caesarean describes this disconnect between expectation and reality:“And (my partner) said to me ‘but you've just given birth.’ And I wanted - I didn't - but I wanted to jump down his throat and to stop him from saying that. Because I felt like I hadn't given birth. She'd been delivered by someone else. … I guess, it's just a grief for the thing that I, that I knew I wanted but probably didn't understand how much I wanted it.” -Chloe, Victoria
      Almost all participants had a high level of literacy in regards to physiological vaginal birth, having read books, completed classes and birth courses and sought out information from social media and podcasts. However, they had varied approaches to birth plans, opting more for birth wishes and preferences with most acknowledging the issues associated with going into birth with an inflexible plan:“So, I did end up filling out the birth preferences sheet, they call them preferences in New South Wales. I was not to have a plan because I knew that you didn't, you know, you don't get to choose how birth goes.” -Kellie, New South Wales
      But however flexible a birth plan proved to be, this did not diminish the sense of powerlessness and disempowerment that can occur when one’s experience differs so far from their expected path:“I felt a bit out of control of the whole thing, was just kind of panicking a little bit in general because it had gone so not to plan, like everything I planned for up until that point I'd not been able to do. Up to that point it was like, well what even is the point?” -Kate, Queensland
      This concept of disempowerment and a perceived lack of control within a healthcare setting is a highly gendered concept that spans across multiple levels of the socio-ecological model, impacting not just the individual, and will be expanded upon in the discussion.

      Breastfeeding to regain identity after trauma

      Women frequently expressed their determination to succeed with their breastfeeding journey, often overcoming significant challenges to do so, in order to rebuild their identity as a mother following a traumatic birth experience. Bree describes her experience:“Oh, yeah, I was really intent on breastfeeding. And then it kind of, you know, I wanted to have this natural birth, I wanted to breastfeed. And then I thought, right, if I can't have the natural birth, I'm going to breastfeed. And I'm like, I'm going to do it like, hell or high water.” -Bree, Victoria
      They often saw breastfeeding and/or feeding with expressed breast milk as a way to provide for their child and achieve the connection that was taken away from them at the time of birth, therefore re-affirming their role as a mother:“Still breastfeeding, yeah. Yeah, I feel I'm, I'm very attached to that. Even though it frustrates me sometimes, but I feel like it's the only thing that I, that wasn't taken away from me. And, you know, whilst it was hard to actually get up and running. I feel like it's the only thing that makes me a mum sometimes. You know, if that wasn't there, anyone could look after him, I guess, in a way, so I'm very attached to that.” -Amy, South Australia
      Breastfeeding was highlighted by several women as a significant component of how they valued themselves as a mother, through their ability to provide for their child. This inherent belief only taking on greater importance following a traumatic birth, where some women described feeling like they failed in this initial rite of passage into motherhood.

      Interpersonal

      Impact of trauma on bonding with baby

      Having a traumatic birth experience can have a profound impact on the ability of the mother to bond with her child, particularly in situations where mother and baby are separated for extended periods of time immediately following birth. One woman who underwent an emergency caesarean under general anaesthetic, unable to witness her child’s birth, expressed a deep disconnect with her child in the early post-natal period:“I had this overwhelming sensation when we got home, that (the baby) wasn't mine. And I, I'm a very visual person, and I didn't have a vision of him leaving my body, I just was wheeled into a room and pointed to a corner where this crib was, and there was more than one baby in there and told "that's your baby over there." And I was, you know, how do I even know that? How am I ever going to prove that really is my baby? It was really awful.” -Amy, South Australia
      Other women described how their physical trauma following childbirth impacted their postnatal recovery and therefore their ability to form a relationship with their baby:“I would love to say that I had that overwhelming love and that feeling initially. Weeks, months, like I cared for her and I did everything I had to do for her. But I didn't feel that deep, undying, unconditional love. Like yes, I did love her, but it wasn't that overwhelming, or I didn't really feel that. I was just sort of going through the steps, I guess. …I just remember being like, that six weeks being so consumed with how miserable I felt. I couldn't sit comfortably. I couldn't stand comfortably. Like, had this huge gaping hole, a fractured tailbone. I could feel my organs falling out.” -Zoe, New South Wales
      Another common impact on the mother-child relationship following birth trauma was one of hypervigilance. Women described being in a state of increased arousal in relation to their newborn’s health, triggered from their own experience of trauma, resulting in often irrational thoughts and behaviours:“And my anxiety, which was sort of a symptom of the trauma really started focusing in on what if I lose (my baby)? Like, you know, in my head, I kind of was like, you know how they say like when you get vicarious trauma… you start to see the world as an unsafe place, instead of a safe place where sometimes unsafe things happen. I started sort of seeing it as like there’s no, what's to say that she won't die of SIDS because I can't convince myself that's rare, it won't happen. Something I thought was rare and wouldn't happen, happened, like I had this inability to sort of talk myself down. So, I was like, hypervigilant around her breathing.” -Kellie, New South Wales
      Interestingly, the impact of birth trauma on the relationship between a parent and their child appears to be gendered, as the male partners interviewed did not describe experiencing challenges around bonding with their baby. In contrast, male partners described the time they spent alone with their child in the early period following the birth as an opportunity to create a special bond of their own that they perhaps would not have had if the mother was available:“It sounds weird to say but I did quite like having that alone time with (my child) to begin with even though I was so shit-scared really. And I didn't know what was going on and was super worried about (my partner). It was just nice to sort of just have that special moment with her. Yeah, I feel like that was sort of, you know, our first bond.” -Adam, New South Wales

      Partner trauma

      Although only four partners were interviewed, many women made reference to their partner also identifying the birth of their child as a traumatic experience. The partners that were involved provided a unique view of what elements of the birth they found traumatic, which often differed from those of their partner. Their trauma understandably centred around threats to the life of their partner and child, often in relation to observed physical trauma. Michael illustrates this well in relation to being removed from the operating theatre during his wife’s emergency caesarean:“So as soon as I got asked to leave, I just thought that was it. Like, I didn't think I was gonna see (my wife) again. I didn't think I was ever gonna meet …our child.” -Michael, South Australia
      Partners were more likely to describe their trauma in relation to what they saw, such as their partner in severe pain, a significant blood loss or undergoing a procedure. But James expressed more trauma in relation to his complete exclusion from the process, leaving him feeling powerless within his role as partner and father:“I sort of, like I was asleep on the couch, next to (my partner), and then all of a sudden, like, within about 15 seconds, the room was just full of people. And they're all sort of talking to her and getting her to sign stuff. And like, I didn't know what was going on. And nobody really spoke to me until they'd already like, whisked her out of the room. And one of the doctors said, you know, ‘we're prepping her for an emergency c-section.’ Then that was about it. They didn't give me any details on why or how long it would take or, you know, any possible risks.” -James, Victoria
      This again highlights the role that power plays within maternity care settings and how easily that imbalance of power can result in a traumatic experience for both the birthing woman and her partner.

      Institutional

      Inadequate consent processes

      Obtaining informed consent before exams or procedures is a core component of providing quality maternity care. Given the high number of interventions reported during the births in this study, the theme of inadequate consent processes was commonly reported across all states and maternity care settings. Women vividly described having consent forms shoved in their faces, scrawling something vaguely resembling their name across the page without the time or consciousness level to understand the contents of the document. Bree describes her experience:“And this is where a lot of my issue lies. I sort of went from being like, literally, my partner and I were asleep, laying on the bed and the couch to having a form shoved under my nose and being told to sign this. That's literally how it happened. It was like, sign this. And I was like, well, I don't even know what this is. Let alone like, I don't have time to, sort of made out like I had no time to read it. They put a pen in my hand. I looked at my partner and it was my first baby, I was petrified. And I just scribbled my name. I've since got a copy of my medical records and my signature, you should see it, it's very indicative of the emotional space that I was in. It just goes… completely diagonally. So, I signed this piece of paper and then they wheeled me off into theatre.” -Bree, Victoria
      In many cases women were able to recall some form of consent process occurring prior to more invasive procedures such as caesarean section, instrumental birth and vaginal examinations. However, they felt that they were very rarely provided with risks, benefits and alternatives to such procedures, thus seriously undermining the fidelity of the consent process. In one specific situation, a procedure was performed by an obstetrician not just without consent but in direct violation of the wishes of the participant. Zoe describes:“39 weeks, we went in and she brought up the stretch and sweep [of the cervix]. And I'd said, ‘look, I've spoken to [the obstetrician] last week about it. I'm not, I don't really want to do it.’ And then she goes, ‘well I need to check the cervix.’ And I said, ‘well, you can check the cervix only,’ and she did the stretch and sweep then. And I nearly flopped off the table. It was the worst experience of my life. I felt violated. It was just awful. And then at the end, she just holds up bloody fingers and goes ‘thanks for letting me do that.’ It was the worst experience. I will never ever let anyone touch me again after that. It was just horrible. And I felt sick straight away.” -Zoe, New South Wales
      Contention exists around when is the correct timing for gaining informed consent within the maternity care setting, as it is not always feasible to outline all the potential risks, benefits and alternatives in a potentially time-sensitive environment. Nevertheless, Chelsea had a positive experience, outlining how the process can be done well in this setting:“I do remember them expressly seeking my consent for an episiotomy. So, they didn't just do it. They did say to me, ‘this is what we need to do to get the baby out quickly because of x, y, z. This is what it involves. Do you consent to that?’ I think I had to even sign something on the bed as well. I remember that. And I just said yes, that's fine. I do remember that conversation quite clearly in the middle of all of that. So yeah, …I did feel like it was collaborative to a point but I also was happy to take direction from them based on what they thought was the best, for the best outcome.” -Chelsea, Western Australia
      While time is often of the essence in relation to the wellbeing of the mother or child, the benefit of taking an extra moment or two to undertake the informed consent process can prevent significant trauma for a woman.

      To debrief or not to debrief?

      The practice of birth debriefing is currently performed differently (if offered at all) in maternity services across Australia. For the few participants that were offered or requested a debrief, they described encounters that ranged from supportive and therapeutic to psychologically harmful and combative. Fiona describes her experience in seeking a debrief:“An obstetrician who I didn't know and had no involvement with the birth came to my bed, in the shared room where the other person was still sitting there. I said, like, I was hoping to have a bit of a debrief. And she said, ‘we tend to only do a formal debrief if the birth has been particularly traumatic, …you know, a lot of blood loss, or the baby is really unwell, or the baby dies, or whatever. And so, in your case, your birth was actually very normal.’ So, she basically was like, ‘don't worry about this and don't feel like you're feeling because you shouldn't be feeling like that.’ And I suspect …she was doing her best to alleviate my concerns and to make me feel better. But …now knowing a little bit more about trauma, I can say that telling someone what they went through wasn't traumatic is not how you help someone.” -Fiona, Victoria
      Many women mentioned their motivations for a debrief session with their healthcare provider as an opportunity to access their medical records and fill in the gaps in their memory of how things unfolded. Often in the pursuit of the elusive ‘why’ and ‘how’ explanations for their trauma. However, several women described this process as quite antagonistic, feeling that their requests evoked a litigious response. Emma elaborates on her experience:“Yes, I got offered a debrief several times, which I initially kept declining ‘cause I didn't want to go back there at the start. I didn't want to see any of them. I didn't want to set foot in there. But then I read my discharge report and saw that the information on there, there was information missing. So, I ended up organizing the debrief, because I wanted those things fixed up, at least. And the reason I avoided it for so long is because I sort of knew how it was going to go. That I would just sort of get excuses as to why it was the way it was. And that's exactly what happened. It just felt like they were reading off a script of things that they have to say.” -Emma, New South Wales
      The most successful debrief experiences tended to happen in the community and exclusive of the treating hospital, through independent agencies such as Perinatal Anxiety and Depression Australia (PANDA) or private psychologists and birth trauma specialists. But the waitlists and costs to access such services can be very restrictive for many women in need of more timely support:“So, they're (PANDA) inundated. My intake call took a month, but normally apparently takes about a week. And the next available appointment is about October (3 months away). So, I haven't really even started that.” -Steph, Victoria

      Community

      More than a healthy baby

      Women seeking support in the community and amongst their social circles following a traumatic birth are often met with the “health baby” rhetoric. The notion that if a woman and her baby have emerged from their birth appearing physically well from the outside and therefore, they should be grateful and happy for this outcome, is a common response that parents suffering from birth trauma are met with. Kellie describes the impact of navigating these discussions:“And then people visited and I found that really jarring because everybody was so excited and happy, which of course they were but, in my head, I still hadn't slept. I was like, do you have any idea what just happened? And they were like ‘yeah, but don't worry about that, (your baby’s) really healthy, like you're really lucky. At least you've got, it's worth it because you've got a healthy baby.’ When I couldn't see that. I was like, I don't know that it was worth it.” -Kellie, New South Wales
      This concept that the end result of a healthy baby justifies the means by which it was achieved, belittles a woman’s trauma response and the subjugation of her psychological safety that it infers is an issue that speaks to a broader and highly gendered social norm.

      Policy

      An augmented reality?

      Twenty of 24 women reported having labour augmentation, with more than half via induction to commence labour, and the remaining with intravenous augmentation to speed up labour once it was established. Similarly, almost half of women reported having an instrumental vaginal birth. The flow on effect of this being a high prevalence of severe perineal injury – obstetric anal sphincter injury - in our study, reported by 5 participants. Kellie likened her experience with the syntocinon drip to a form of torture:“And it went from zero to 100. Like I was not in labour, and then I was in labour. So, no time to …get my head in the game. (My baby) was posterior, so it was like somebody was chain-sawing through my spine instantly. It was pretty painful, pretty intense. They started it at 6 am and they cranked it right up. It was cranked as high as the machine would go without damaging my uterus. I started to become terrified, there was no gap in the contractions, maybe four seconds. I had no time to collect myself and so I started to just become really crazy and really frightened.” -Kellie, New South Wales
      Several women shared this experience with syntocinon use in labour, often justified to women and their partners as a necessary tool to speed up labour progression, primarily due to a perceived concern for the baby’s wellbeing. Women often described this panicked state following syntocinon, perceived as a loss of control over their labour. Rebecca describes it as ‘losing herself’:“I was in so much pain, they tried decreasing the syntocinon, they stopped it. Even after like 40 minutes of it being turned off, it was still just really intense, contractions that I sort of couldn't have a breath in between. And then that's when I just …really sort of lost it. I just lost myself.” -Rebecca, Victoria
      Women’s descriptions of labour augmentation, namely the disempowerment and disembodiment it induced, coupled with the frequency in which it was reported by the participants, point towards a more systemic issue caused by a patriarchal and technocratic approach to obstetric care that has been normalised in Australia.

      Discussion

      The findings of this study provide a unique insight into women’s and their partners’ experiences of birth trauma in Australia. By structuring the common themes in relation to the socio-ecological model and applying a feminist lens, the influence of gender – and specifically the power imbalance it evokes - throughout each level of the socio-ecological model becomes highly apparent.
      At the individual level, women reported their intrinsic drive to restore their identity as a mother through their ability to breastfeed their child. This powerful function of the female body has been described in feminist discourse as a means for women to regain power over their bodies in the face of medical hegemony [
      • Wall G.
      Moral constructions of motherhood in breastfeeding discourse.
      ]. While at the institutional level, the failure to obtain truly informed consent is not only a violation of a woman’s healthcare rights and national standards for quality care [
      • COAG Health Council
      Woman-centred Care: Strategic Directions for Australian Maternity Services.
      ,

      Australian Commission on Safety and Quality in Health Care. Informed consent 2019 [Available from: 〈https://www.safetyandquality.gov.au/our-work/partnering-consumers/informed-consent〉.

      ], but reflects how such abuses are normalised within maternity care, actively infantilizing women and assuming agency over their bodies [

      Chadwick R.. Bodies that birth: vitalizing birth politics: Routledge, Taylor & Francis Group; 2018.

      ,
      • Borges M.T.R.
      A violent birth: reframing coerced procedures during childbirth as obstetric violence.
      ]. This narrative is also reflected at the policy level, where the high rates of labour induction and augmentation in our sample - almost double the Australian average [
      • Australian Institute of Health and Welfare
      Australia's Mothers and Babies 2017 - in Brief.
      ] – is aligned with international research, declaring the excessive or inappropriate use of interventions during childbirth as a public health problem and threat to maternal and newborn health and wellbeing [
      • Miller S.
      • Abalos E.
      • Chamillard M.
      • Ciapponi A.
      • Colaci D.
      • Comande D.
      • et al.
      Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide.
      ]. This desire to dominate and control the female body is common throughout history, but the persistence of the patriarchal medical model is most apparent in obstetric care, where a woman’s vulnerability is particularly heightened [
      • Cohen Shabot S.
      Making loud bodies "feminine": a feminist-phenomenological analysis of obstetric violence.
      ].
      The gender differences that exist between women and their male partners in relation to how they experienced traumatic birth, as well as society’s response to birth trauma as remedied by a healthy baby, emphasises the social gender order. While male partners also reported a sense of powerlessness as a trigger for their trauma, the impact of this manifested as an affront to their masculinity and undermined their role as protector [
      • Daniels E.
      • Arden-Close E.
      • Mayers A.
      Be quiet and man up: a qualitative questionnaire study into fathers who witnessed their Partner's birth trauma.
      ]. This gender norm was reinforced through the non-participation of most male partners in this study, with the most cited reason being their unwillingness to discuss their emotions despite identifying as having experienced birth trauma. Socialised gender roles are often cited as a significant barrier to men sharing emotional experiences and engaging in therapy for mental health issues [
      • Vogel D.L.
      • Wester S.R.
      • Hammer J.H.
      • Downing-Matibag T.M.
      Referring men to seek help: the influence of gender role conflict and stigma.
      ]. While society’s response to birth trauma as remedied by the arrival of a healthy baby is not a new concept [
      • Beck C.T.
      Birth trauma: in the eye of the beholder.
      ,
      • Cohen Shabot S.
      Making loud bodies "feminine": a feminist-phenomenological analysis of obstetric violence.
      ], it further highlights the subjugation of women in the social order and minimises the validity of their trauma.
      There are mixed opinions in the research sphere regarding the benefits of offering postnatal birth debrief sessions to women who have experienced birth trauma, compounded by the inconsistencies in how it is implemented and by whom [
      • Bastos M.H.
      • Furuta M.
      • Small R.
      • McKenzie-McHarg K.
      • Bick D.
      Debriefing interventions for the prevention of psychological trauma in women following childbirth.
      ,
      • Asadzadeh L.
      • Jafari E.
      • Kharaghani R.
      • Taremian F.
      Effectiveness of midwife-led brief counseling intervention on post-traumatic stress disorder, depression, and anxiety symptoms of women experiencing a traumatic childbirth: a randomized controlled trial.
      ,
      • Skibniewski-Woods D.
      A review of postnatal debriefing of mothers following traumatic delivery.
      ]. A 2015 Cochrane Review [
      • Bastos M.H.
      • Furuta M.
      • Small R.
      • McKenzie-McHarg K.
      • Bick D.
      Debriefing interventions for the prevention of psychological trauma in women following childbirth.
      ] found little to no evidence to support either a positive or negative effect of psychological debriefing in preventing psychological trauma after birth, echoing the experiences of our participants. The women in our study who sought a debrief from their caregivers did so in order to regain control and an understanding of their experience. Women were often met with a defensive response to their information-seeking, further compounding their sense of powerlessness within this technocratic system. While a recent study set in Iran suggests that midwife-led counselling sessions may be effective [
      • Asadzadeh L.
      • Jafari E.
      • Kharaghani R.
      • Taremian F.
      Effectiveness of midwife-led brief counseling intervention on post-traumatic stress disorder, depression, and anxiety symptoms of women experiencing a traumatic childbirth: a randomized controlled trial.
      ], we found that the most effective debriefs were those conducted external to the birthing hospital, suggesting the need for separation from the facility in order to achieve psychological safety in an independent setting.

      Strengths and limitations

      The strength of this study lies in its methodology and the richness of the data it permitted, as the first qualitative study conducted within Australia to utilise in-depth interviews to explore women’s experiences of birth trauma alongside those of their partners’. The issue of birth trauma in Australia is currently experiencing increased attention thanks in part to increased awareness in the media [

      K.P. Taguchi. Giving Birth Better (Season 2021, Episode 6). Insight: SBS; 2021.

      ]. Therefore, the timing of this study is optimal for influencing the social narrative around birth trauma.
      The potential for sampling bias is a limitation of this study, impacting the transferability of the findings. By recruiting through the ABTA, we are likely to have recruited participants who have a deeper understanding of their trauma, are further along in their healing journey and/or demonstrate greater help-seeking behaviour. The impact of this being that those people who are less likely to interact with a trauma organisation for whatever reason are underrepresented in our sample. Additionally, the ABTA is an organisation that has a strong focus on physical perineal trauma and birth injuries, therefore members of this group may be more likely to emphasis this aspect of their trauma and may also account for the higher rate of injury-causing birth interventions in our sample. In summary, while participants may have been more inclined to discuss physical trauma given our recruitment strategy, participants still spoke of their psychological harms despite this limitation.
      A possible limitation of our study was conducting the interviews on Zoom, particularly given the traumatic experiences discussed with participants. Despite potential limitations of the online interview environment, we found that participants spoke freely and openly about their experiences of traumatic birth, which may be due to their increased exposure to and use of the telehealth modality in their healthcare journey. In addition to this, their eagerness to share their experiences may again reflect their more advanced progress with processing their trauma at the time of recruitment.
      Existing Australian research has pointed towards the presence of inequalities in obstetric practice in relation to the ethnicity and socio-economic status of the mother [
      • Fox H.
      • Callander E.
      • Lindsay D.
      • Topp S.
      Evidence of overuse? Patterns of obstetric interventions during labour and birth among Australian mothers.
      ]. Additionally, evidence from the United States has found women of colour are far more likely to experience mistreatment during childbirth [
      • Vedam S.
      • Stoll K.
      • Taiwo T.K.
      • Rubashkin N.
      • Cheyney M.
      • Strauss N.
      • et al.
      The Giving Voice to Mothers study: inequity and mistreatment during pregnancy and childbirth in the United States.
      ]. The absence of non-English-speaking, Indigenous and migrant women’s voices in this study and in Australian birth trauma research in general, is a critical gap that needs to be addressed in order to draw such a link between the themes discussed here and factors like ethnicity, Indigeneity and socio-economic status. Also, greater partner participation in this study would have enriched the available first-hand knowledge of partner trauma and provided a deeper understanding of the gender dynamics at play.

      Implications for policy and future research

      This study highlights the important role that a woman’s sense of control has in minimising the likelihood of describing her birth as traumatic. It also stresses the critical need within the maternity care system for the development of women-centred policies in relation to obtaining informed consent, decision-making processes for interventions during labour and providing referral to debriefing services that are trauma-informed and accessible to both women and their partners.
      Trauma-informed care refers to a framework that takes into account the impact of past traumas on a person’s current behaviours and their ability to cope when interacting with the healthcare system, and acts to reduce the risk of re-traumatisation [
      • Hall S.
      • White A.
      • Ballas J.
      • Saxton S.N.
      • Dempsey A.
      • Saxer K.
      Education in trauma-informed care in maternity settings can promote mental health during the COVID-19 pandemic.
      ]. Our study highlights the need for all healthcare professionals involved in the care of women and their families, wherever they may meet in their childbirth journey, to receive training in trauma-informed care and adopt this approach. For example, a physiotherapist must consider not only the physical injury that a woman may present with after her birth, but also the possible psychological trauma that may impact her participation in therapy or even increase her trauma further. Keedle et al. draw similar conclusions, highlighting that women who experienced respectful and supportive care from their maternity care team reported increased satisfaction with their birth experience [
      • Keedle H.
      • Schmied V.
      • Burns E.
      • Dahlen H.G.
      A narrative analysis of women's experiences of planning a vaginal birth after caesarean (VBAC) in Australia using critical feminist theory.
      ]. However, it is important to note that for healthcare professionals to provide this level of support to their clients, they in turn require the backing of healthcare systems that embrace such evidence-based models of care and training [
      • Keedle H.
      • Schmied V.
      • Burns E.
      • Dahlen H.G.
      A narrative analysis of women's experiences of planning a vaginal birth after caesarean (VBAC) in Australia using critical feminist theory.
      ].
      Future research on the topic of birth trauma in Australia must engage with women from more diverse backgrounds, in order to further explore how factors such as race and/or ethnicity, disability and socio-economic status intersects with gender in relation to how women experience birth trauma. This could be addressed through a mixed-methods study design to also gain important prevalence data. Intervention studies aimed at exploring appropriate informed consent processes for emergency maternity care and effective birth debriefing services will assist in the development of maternity care services that are truly women-centred and trauma-informed.

      Conclusion

      Our study enriches the growing body of evidence surrounding birth trauma in Australia, adding a unique perspective through the application of a critical feminist theory lens and including partners’ voices. They highlight the impact of patriarchal maternity care systems and policies in undermining women’s sense of control over their birth experience, evident in the high levels of labour augmentation and inadequate consent processes. This study also draws attention to the many ways in which gender shapes how birth trauma is expressed within both women’s and men’s identities as parents, their relationships and society at large. Recommendations from this research include the development of women-centred and gender-informed policies to address informed consent processes and the use of interventions in labour within maternity care services, as well as the referral to appropriate birth debriefing programs. Further mixed-methods research would improve the applicability of the current data by including women from diverse backgrounds, with the aim being to inform future directions for more equitable and acceptable maternity care services in Australia.

      Funding statement

      Support for this study is from a University of Melbourne Establishment Grant (MAB). MAB is supported by an Australian Research Council Discovery Early Career Researcher Award (DE200100264) and a Dame Kate Campbell Fellowship (University of Melbourne Faculty of Medicine, Dentistry, and Health Sciences).

      Author contributions

      This study was conceptualized and designed by PLT with the supervision of MAB and SA. PLT performed the data collection, and SA checked the accuracy and completeness of interview transcriptions and the coding framework. The analysis was conducted by PLT, and interpretations were discussed by all authors. PLT also drafted the manuscript with input from all.

      Ethical statement

      Ethics approval for this research was granted by the Human Ethics Team at the Office of Research Ethics and Integrity at The University of Melbourne (reference no: 2021–21846–18459–3).

      Conflicts of interest

      None declared.

      Acknowledgements

      The authors would like to acknowledge the bravery and strength of the participants, who entrusted us with their stories so selflessly – the good, the bad and the ugly – in the hope that no one else should suffer as they did in the future.

      Appendix A. Supplementary material

      References

        • Greenfield M.
        • Jomeen J.
        • Glover L.
        What is traumatic birth? A concept analysis and literature review.
        Br. J. Midwifery. 2016; 24: 254-267
        • Alcorn K.L.
        • O'Donovan A.
        • Patrick J.C.
        • Creedy D.
        • Devilly G.J.
        A prospective longitudinal study of the prevalence of post-traumatic stress disorder resulting from childbirth events.
        Psychol. Med. 2010; 40: 1849-1859
        • Creedy D.K.
        • Shochet I.M.
        • Horsfall J.
        Childbirth and the development of acute trauma symptoms: incidence and contributing factors.
        Birth. 2000; 27: 104-111
        • Soet J.E.
        • Brack G.A.
        • DiIorio C.
        Prevalence and predictors of women^s experience of psychological trauma during childbirth.
        Birth. 2003; 30: 36-46
        • Yildiz P.D.
        • Ayers S.
        • Phillips L.
        The prevalence of posttraumatic stress disorder in pregnancy and after birth: a systematic review and meta-analysis.
        J. Affect. Disord. 2017; 208: 634-645
        • Fenech G.
        • Thomson G.
        Tormented by ghosts from their past’: a meta-synthesis to explore the psychosocial implications of a traumatic birth on maternal well-being.
        Midwifery. 2014; 30: 185-193
      1. Ponti L., Smorti M., Ghinassi S., Mannella P., Simoncini T. Can a traumatic childbirth experience affect maternal psychopathology and postnatal attachment bond? Current Psychology. 2020.

        • Cook N.
        • Ayers S.
        • Horsch A.
        Maternal posttraumatic stress disorder during the perinatal period and child outcomes: A systematic review.
        J. Affect. Disord. 2018; 225: 18-31
        • Garthus-Niegel S.
        • Ayers S.
        • Martini J.
        • von Soest T.
        • Eberhard-Gran M.
        The impact of postpartum post-traumatic stress disorder symptoms on child development: a population-based, 2-year follow-up study.
        Psychol. Med. 2017; 47: 161-170
        • Elmir R.
        • Schmied V.
        A qualitative study of the impact of adverse birth experiences on fathers.
        Women Birth. 2021;
        • Daniels E.
        • Arden-Close E.
        • Mayers A.
        Be quiet and man up: a qualitative questionnaire study into fathers who witnessed their Partner's birth trauma.
        BMC Pregnancy Childbirth. 2020; 20: 1-12
        • Inglis C.
        • Sharman R.
        • Reed R.
        Paternal mental health following perceived traumatic childbirth.
        Midwifery. 2016; 41: 125-131
        • Skinner E.M.
        • Barnett B.
        • Dietz H.P.
        Psychological consequences of pelvic floor trauma following vaginal birth: a qualitative study from two Australian tertiary maternity units.
        Arch. Women's Ment. Health. 2018; 21: 341-351
        • Boorman R.J.
        • Devilly G.J.
        • Gamble J.
        • Creedy D.K.
        • Fenwick J.
        Childbirth and criteria for traumatic events.
        Midwifery. 2014; 30: 255-261
        • Cook K.
        • Loomis C.
        The impact of choice and control on women's childbirth experiences.
        J. Perinat. Educ. 2012; 21: 158-168
      2. Watson K., White C., Hall H., Hewitt A. Women’s experiences of birth trauma: a scoping review. Women and Birth, 2020.

        • D'Gregorio R.P.
        Obstetric violence: a new legal term introduced in Venezuela.
        Int. J. Gynaecol. Obstet.: Off. Organ Int. Fed. Gynaecol. Obstet. 2010; 111: 201-202
        • WHO
        The Prevention and Elimination of Disrespect and Abuse during Facility-based Childbirth: WHO Statement.
        World Health Organization, Geneva2015
      3. Bowser D., Hill K. Exploring Evidence for Disrespect and Abuse in Facility-Based Childbirth: Report of a Landscape Analysis. Harvard School of Public Health, 2010.

        • Jewkes R.
        • Penn-Kekana L.
        Mistreatment of Women in Childbirth: Time for Action on This Important Dimension of Violence against Women.
        PLoS Med. 2015; 12: 1-4
      4. Simonovic D. A human rights-based approach to mistreatment and violence against women in reproductive health services with a focus on childbirth and obstetric violence: note / by the Secretary-General. United Nations, 2019. Contract No.: A/74/137.

        • Beck C.T.
        Birth trauma: in the eye of the beholder.
        Nurs. Res. 2004; 53: 28-35
        • Thomson G.
        • Downe S.
        Widening the trauma discourse: the link between childbirth and experiences of abuse.
        J. Psychosom. Obstet. Gynecol. 2008; 29: 268-273
        • Reed R.
        • Sharman R.
        • Inglis C.
        Women's descriptions of childbirth trauma relating to care provider actions and interactions.
        BMC Pregnancy Childbirth. 2017; : 17
        • Bohren M.A.
        • Vogel J.P.
        • Hunter E.C.
        • Lutsiv O.
        • Makh S.K.
        • Souza J.P.
        • et al.
        The Mistreatment of women during childbirth in health facilities globally: a mixed-methods systematic review.
        Plos Med. 2015; 12e1001847
        • Davis-Floyd R.
        The technocratic, humanistic, and holistic paradigms of childbirth.
        Int. J. Gynaecol. Obstet. 2001; 75: S5-S23
        • Keedle H.
        • Schmied V.
        • Burns E.
        • Dahlen H.G.
        A narrative analysis of women's experiences of planning a vaginal birth after caesarean (VBAC) in Australia using critical feminist theory.
        BMC Pregnancy Childbirth. 2019; : 19
        • Allsop J.
        Competing paradigms and health research: design and process.
        in: Saks M. Allsop J. Researching Health: Qualitative, Quantitative and Mixed Methods. 2 ed. SAGE, London2013
        • Coombes L.
        • Allen D.
        • Humphrey D.
        • Neale J.
        In-depth interviews.
        in: Neale J. Research Methods for Health and Social Care. Palgrave Macmillan, London2009
        • O'Brien B.C.
        • Harris I.B.
        • Beckman T.J.
        • Reed D.A.
        • Cook D.A.
        Standards for reporting qualitative research: a synthesis of recommendations.
        Acad. Med. 2014; 89: 1245-1251
        • Tuncalp O.
        • Were W.M.
        • MacLennan C.
        • Oladapo O.T.
        • Gulmezoglu A.M.
        • Bahl R.
        • et al.
        Quality of care for pregnant women and newborns-the WHO vision.
        BJOG: Int. J. Obstet. Gynaecol. 2015; 122: 1045
        • Kilanowski J.F.
        Breadth of the socio-ecological model.
        J. Agromed. 2017; 22: 295-297
        • McLaren L.
        • Hawe P.
        Ecological perspectives in health research.
        J. Epidemiol. Community Health (1979-). 2005; 59: 6-14
        • Hammarstrom A.
        • Johansson K.
        • Annandale E.
        • Ahlgren C.
        • Alex L.
        • Christianson M.
        • et al.
        Central gender theoretical concepts in health research: the state of the art.
        J. Epidemiol. Community Health. 2014; 68: 185-190
        • Bowen G.A.
        Naturalistic inquiry and the saturation concept: a research note.
        Qual. Res. 2008; 8: 137-152
        • Sah L.K.
        • Singh D.R.
        • Sah R.K.
        Conducting qualitative interviews using virtual communication tools amid COVID-19 Pandemic: a learning opportunity for future research.
        JNMA J. Nepal Med Assoc. 2020; 58: 1103-1106
      5. Otter.ai. Otter.ai 2021 [Available from: 〈https://otter.ai/〉.

        • Liamputtong P.
        Qualitative Research Methods. Fourth ed. Oxford University Press, 2013
        • Braun V.
        • Clarke V.
        Successful Qualitative Research: A Practical Guide for Beginners.
        SAGE, 2013
        • Liamputtong P.
        • Serry T.
        Making sense of qualitative data.
        in: Liamputtong P. Research methods in health: foundations for evidence-based practice. 3 ed..,. Oxford University Press, South Melbourne2017
      6. QSR International Pty Ltd. NVivo 2020 [Available from: 〈https://www.qsrinternational.com/nvivo-qualitative-data-analysis-software/home?_ga=2.184315813.262555890.1635822772–1112990085.1632787066〉.

        • Martin J.
        Feminist theory and critical theory: unexplored synergies.
        in: Alvesson M. Willmott H. Studying Management Critically. SAGE Publications, 2003
        • Rhode D.L.
        Feminist critical theories.
        Stanf. Law Rev. 1990; 42: 617-638
        • Holmes A.G.D.
        Researcher positionality -- a consideration of its influence and place in qualitative research -- a new researcher guide.
        Shanlax Int. J. Educ. 2020; 8: 1-10
        • Wall G.
        Moral constructions of motherhood in breastfeeding discourse.
        Gend. Soc. 2001; 15: 592-610
        • COAG Health Council
        Woman-centred Care: Strategic Directions for Australian Maternity Services.
        Department of Health, Canberra2019
      7. Australian Commission on Safety and Quality in Health Care. Informed consent 2019 [Available from: 〈https://www.safetyandquality.gov.au/our-work/partnering-consumers/informed-consent〉.

      8. Chadwick R.. Bodies that birth: vitalizing birth politics: Routledge, Taylor & Francis Group; 2018.

        • Borges M.T.R.
        A violent birth: reframing coerced procedures during childbirth as obstetric violence.
        Duke Law J. 2018; 67: 827-862
        • Australian Institute of Health and Welfare
        Australia's Mothers and Babies 2017 - in Brief.
        AIHW, Canberra2019
        • Miller S.
        • Abalos E.
        • Chamillard M.
        • Ciapponi A.
        • Colaci D.
        • Comande D.
        • et al.
        Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide.
        Lancet. 2016; 388: 2176-2192
        • Cohen Shabot S.
        Making loud bodies "feminine": a feminist-phenomenological analysis of obstetric violence.
        Hum. Stud. 2016; 39: 231-247
        • Vogel D.L.
        • Wester S.R.
        • Hammer J.H.
        • Downing-Matibag T.M.
        Referring men to seek help: the influence of gender role conflict and stigma.
        Psychol. Men. Masc. 2014; 15: 60-67
        • Bastos M.H.
        • Furuta M.
        • Small R.
        • McKenzie-McHarg K.
        • Bick D.
        Debriefing interventions for the prevention of psychological trauma in women following childbirth.
        Cochrane Database Syst. Rev. 2015; CD007194
        • Asadzadeh L.
        • Jafari E.
        • Kharaghani R.
        • Taremian F.
        Effectiveness of midwife-led brief counseling intervention on post-traumatic stress disorder, depression, and anxiety symptoms of women experiencing a traumatic childbirth: a randomized controlled trial.
        BMC Pregnancy Childbirth. 2020; 20: 1-9
        • Skibniewski-Woods D.
        A review of postnatal debriefing of mothers following traumatic delivery.
        Community Pract. 2011; 84: 29-32
        • Fox H.
        • Callander E.
        • Lindsay D.
        • Topp S.
        Evidence of overuse? Patterns of obstetric interventions during labour and birth among Australian mothers.
        BMC Pregnancy Childbirth. 2019; 19: 1-8
        • Vedam S.
        • Stoll K.
        • Taiwo T.K.
        • Rubashkin N.
        • Cheyney M.
        • Strauss N.
        • et al.
        The Giving Voice to Mothers study: inequity and mistreatment during pregnancy and childbirth in the United States.
        Reprod. Health. 2019; 16: 1-18
        • Hall S.
        • White A.
        • Ballas J.
        • Saxton S.N.
        • Dempsey A.
        • Saxer K.
        Education in trauma-informed care in maternity settings can promote mental health during the COVID-19 pandemic.
        JOGNN-J. Obstetric Gynecologic Neonatal Nurs. 2021; 50: 340-351
      9. K.P. Taguchi. Giving Birth Better (Season 2021, Episode 6). Insight: SBS; 2021.