Every day 385,000 babies are born; in Egypt, this number is about 8,000 live births per day, an average of 338 per hour (Our World in Data, 2020). Unfortunately, studies report alarming rates of women experiencing birth trauma, with higher prevalence in settings characterized by overmedicalization in intrapartum care (Reed et al., 2017; Olza Fernández, 2013). The overmedicalization of childbirth in Egypt, characterized by one of the highest C-section rates globally, sounds the alarm to investigate birth trauma and offer recommendations to remedy this growing silent epidemic (Giacomozzi et al., 2021; Khalil & Ronzoni, forthcoming).

Understanding trauma in birth

Birth trauma is a form of distress experienced by women during and after childbirth, which can be physical, emotional, or psychological (Taghizadeh et al., 2013; Birth Trauma Association, n.d.). A complex concept in medicine with varying definitions, causes, symptoms/manifestations and effects, some experts even consider birth trauma a form of post-traumatic stress disorder (PTSD) following childbirth (Reed et al., 2017; Patterson et al., 2019; Greenfield et al., 2016).

A systematic review and meta-analysis of 50 studies found that poor maternal mental health in pregnancy – including depression, fear and anxiety of childbirth, history of PTSD – and complications during childbirth increased women’s vulnerability to birth trauma and PTSD (Ayers, 2017). Furthermore, according to this same study, the strongest risk factors associated with birth trauma were those related to negative birth experiences, having an operative birth (e.g., C-Section), lacking support during birth and dissociating (Ayers, 2017). The Birth Trauma Association (n.d.) provides a non-comprehensive list of factors which likely attribute to birth trauma and PTSD following childbirth, with further research ongoing and needed to expand this list; these factors include:

Fear for baby's safety, lack of information or explanation,
High levels of medical interventions, such as inductions, emergency C-sections, immediate separation of mother and child as a result of keeping the infant in the nursery or neonatal intensive care unit,
Feelings of loss of control,
Impersonal treatment or problems with staff attitudes, not being listened to, insufficient pain relief, lack of privacy and dignity and poor postnatal care,
Previous traumas (e.g., miscarriages, stillbirths and various forms of gender-based violence).

Due to this broad spectrum of trauma and the varying experiences, symptoms and coping mechanisms, global findings have ranged from one third to as high as 45% of women finding childbirth traumatic (Patterson et al., 2019; Yildiz et al., 2017; Ayers, 2017). Notably, while these studies have indicated diversities in prevalences of birth trauma, several links are explicit: firstly, women’s experiences of childbirth are the most important risk factor, and secondly, the overmedicalization of childbirth increases the risk of birth trauma and PTSD (Reed et al., 2017; Taghizadeh et al., 2013).

Impacts of birth trauma on maternal and child health

While the medicalization of childbirth has saved millions of lives globally, overmedicalization has often resulted in more severe complications on both physical and mental health outcomes (Olza Fernández, 2013). Studies have confirmed that traumatic births are associated with high rates of postpartum mental health conditions including depression, anxiety and post-traumatic stress disorder, which can often extend for a prolonged period of time (Reed et al., 2017; Taghizadeh et al., 2013; Yildiz et al., 2017). Furthermore, according to Taghizadeh et al. (2013), such trauma can hurt relationships within the family, reduce the lactation period and thus adversely influence infant development, meaning that “in the long run, the children of these mothers [may] end up with emotional, cognitive and behavioral disorders.”

These findings are confirmed by several global systematic reviews which confirmed the impacts of postpartum depression (PPD) on the mother’s health, her child’s health, and their interactions and bonding (Slomian et al., 2019; Bluett-Duncan et al., 2021; Taghizadeh et al., 2013; Ertan et al., 2021). Women also reported exacerbated isolation, depression, resentment towards motherhood and feelings of inadequacy and guilt as a mother (Taghizadeh et al., 2013; Slomian et al., 2019; Bluett-Duncan et al., 2021).

Systemic factors affecting birth trauma and maternal mental health

The widespread stigma towards both mental health disorders and sexual and reproductive health and rights (SRHR) in Egyptian society are among the chief barriers to improving healthcare. Misinformation and lack of awareness further continue the toxic cycle of silencing trauma survivors and reducing their access to timely and adequate health services in the immediate postpartum period, increasing their sense of isolation and vulnerability to mental health disorders. The trend towards more nuclear family structures has reduced structures of social and familial support available to mothers (Okasha et al., 2012). Culturally, the narratives and traditions of celebration around birth may gaslight new mother’s experiences of birth trauma (Taghizadeh et al., 2013; Ertan et al., 2021).

Across the Eastern Mediterranean region, the two most common forms of obstetric violence included physical abuse (specifically the overuse of unconsented and routine interventions) and non-dignified care (such as verbal abuse, coercion, humiliation and belittling, dehumanization and disrespect in medical care) (Khalil, 2020). In Egypt particularly, the overmedicalization of maternal care, resulting in the rampant rates of unnecessary C-sections, other medical interventions (such as routine use of episiotomies and frequent inductions) and the immediate separation of newborns to the nursery leaves many women feelings dissatisfied, dehumanized and traumatized following their births (Khalil & Ronzoni, forthcoming).

Moreover, the hierarchical and patriarchal socio-cultural norms which influence the medical systems limit women’s decision-making power, silence the space for their informed consent and normalize the use of intimidation tactics in maternal healthcare (Kabakian-Khasholian et al., 2017). Reed et al. (2017) found that almost two-thirds of women who experience birth trauma attribute this to negative interactions with their healthcare providers. Furthermore, in many public hospitals, the lack of privacy, overcrowding, limited pain relief, forced supine position for birth, discrimination against poor and illiterate women and their denial of birth companion exacerbate women’s feelings of helplessness and underpin rampant birth trauma occurring in Egyptian hospitals (Giacomozzi et al., 2021; Khalil & Ronzoni, forthcoming).

In the Egyptian health system, the lack of women-centered care inhibits the delivery of high-quality and trauma-informed service delivery (Khalil & Ronzoni, forthcoming). This is especially exacerbated by the shortages of mental health specialists. Furthermore, while many women blame their health providers for these violations, it is important to note that birth trauma and obstetric violence are embedded at the intersection of the health system and our socio-cultural norms. Many of these health workers are often traumatized by the system they work in, and in many cases, are overwhelmed due to lack of staffing and work without the basic resources to provide quality care (Khalil, 2020).

In addition to this, despite the evidence of the impact of maternal mental health on women and children, mental health prevention programs are neglected nationally. In Egypt, most mental health services are centrally provided in mental health hospitals where almost all mental health providers are concentrated (World Health Organization Regional Office for the Eastern Mediterranean [WHO-EMRO], 2015). There are few maternal mental health services provided at the primary care level. Moreover, the lack of integration of mental health in postnatal care and maternal and child health programs is another major challenge. Despite the ongoing and historic efforts to improve maternal and child health, the political, economic and public health commitment to mental health is insufficient.

Solutions and recommendations at the community, health system, and policy levels

At the community level, ending the stigma on SRHR and maternal mental health is the first and most urgent step. Multi-level and multi-stakeholder initiatives are needed which engage communities and their gatekeepers (such as male heads of households along with religious and political leaders) to create safe spaces for mothers in the intrapartum period, and raise awareness to normalize SRHR, perinatal mental health and postpartum care. Additionally, efforts must be made to promote gender equality, improve family and social support in the postpartum period, increase positive parenting models and reduce family violence.

Integrating women-centered approaches to the Egyptian health system is critical for providing trauma-informed care and improving health maternal and child health outcomes. Improving maternal mental health service delivery can be achieved by the following mix of short, medium, and long-term interventions. Introducing early screening for postpartum depression and increasing mental health services through multidisciplinary care teams throughout the postpartum period are necessary and immediate interventions. In addressing its shortages of mental health specialists, Egypt could benefit from task-sharing and training health workers on mh-GAP, the Mental Health Gap Action Programme recommended by WHO. Health managers can also introduce community-based interventions such as Thinking Healthy, a manual for psychological management of perinatal depression, and optimize psychological support provided by non-specialized professionals at the primary care level (WHO, 2015). Accountability mechanisms must be instituted at both the facility and national-levels to allow patients to report complaints or abuses, monitor the use of unnecessary routine interventions and ensure the implementation of evidence-based practices such as the 56 WHO recommendations on intrapartum care for a positive childbirth experience (WHO, 2018).

At the policy level, a rights-based approach to formulating mental health legislation, policies and plans that applies to all people is crucial. An equity perspective should be utilized to prioritize specific populations who are discriminated against due to their sex, age, race, ethnicity, sexual orientation, disability, or beliefs. Tackling birth trauma also requires revising mental health legislation, which should include the following actions:

Strengthening the role of patients by including women with lived experience in the process of legislation development and amendment, particularly that pertaining to amendments to the Code of Practice of the Mental Health Act.
Amending the mental health law to clearly stipulate the provision of accessible and quality mental health services to mothers, to enshrine the right to receive quality antenatal, natal and postnatal care and establish an entity for the protection of reproductive rights. Such amendments should entail provisions to guarantee that women know their maternal medical rights.
Including specified priority mental health conditions common during the postpartum period into basic packages of public and private health insurance schemes.
Enhancing budget allocations to achieve maternal mental health service delivery targets.

Finally, improving the situation of birth trauma and maternal and child health nationally requires scaling up available evidence to enable informed policymaking. This requires collecting sex-disaggregated national data on mental health outcomes and conducting more rigorous and gender-sensitive research.

References:

Ayers, S. (2017). Birth trauma and post-traumatic stress disorder: the importance of risk and resilience. Journal of reproductive and infant psychology, 35(5), 427–430. https://doi.org/10.1080/02646838.2017.1386874
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Bluett-Duncan, M., Kishore, M.T., Patil, D.M., Satyanarayana, V.A., & Sharp, H. (2021). A systematic review of the association between perinatal depression and cognitive development in infancy in low and middle-income countries. PLoS ONE, 16(6), e0253790. https://doi.org/10.1371/journal.pone.0253790
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