Guest post submitted by Natalie Short of ICAN of Birmingham, AL.

Sadness, anger, disappointment, anxiety – sometimes our emotions postpartum are unexpectedly heavy. A lot more has been written in recent times about the legitimacy of birth grief and birth trauma, and, increasingly, women dealing with these emotions postpartum don’t have to suffer alone. But how does disappointment differ from trauma, and how might it matter?

Imagine these two scenarios – Katie was planning a home birth, but she ended up transferring to the hospital for an epidural. A couple hours later she gave birth vaginally to a healthy baby girl. In another state her sister, Dana, also transferred for an epidural and gave birth to a healthy boy. When they spoke on the phone later that week Katie expressed some disappointment about her birth but seemed otherwise pretty happy about her situation. However Dana seemed rather disjointed and upset on the phone. In the following weeks Dana would rehash her experience several times and seemed to be having some trouble coping with the stresses of new motherhood whereas Katie who, although tired and occasionally moody, seemed to be coping well. Despite their close bond, both sisters were having trouble understanding each other. What happened?

Despite their close bond, both sisters were having trouble understanding each other. What happened?

Here’s one possible scenario: Because midwifery is legal in her state, Katie’s midwife accompanied her to the hospital to provide continuous care, and hospital staff respected that Katie had wanted to birth out of the hospital and only came to the hospital because it offered something she couldn’t get at home – spinal pain relief. Despite her midwife’s support, Katie ended up feeling disappointed in herself for not having her daughter at home where she could curl up in her own bed instead of dealing with IVs and people constantly coming in and out. She occasionally second guesses her decision and cried after seeing pictures of her best friend’s home birth but otherwise appreciates that she was supported and encouraged throughout her labor.

Contrast this with Dana’s story: In Dana’s state, home birth midwifery is illegal, so her midwife wasn’t able to support her in the hospital. Despite having a healthy baby and labor, the doctors and nurses pushed a highly interventionist protocol on her, and the anesthesiologist made disparaging remarks about the women who decide they “don’t want to be a hero.” In the end, Dana felt bullied into accepting several unwanted and unnecessary interventions and had to talk her way out of the OR when her doctor tried to call for a cesarean after only two hours of pushing. Post birth her wishes were again ignored when her son was whisked away for “routine checks.” Now Dana finds herself spending a lot of emotional energy going over what happened and what she or her midwife could have done differently. When talking with Katie she struggles to express her frustrations and wonders if there’s something wrong with her since Katie seems pretty okay with her own hospital transfer.

You could imagine a variety of other possibilities – perhaps one mom had been sexually abused or suffered from anxiety. Maybe she had an emergency transfer for cord prolapse. It’s even possible that one of them experienced obstetric violence. Multiple factors go into making a birth peaceful, disappointing, or traumatic and those factors include the woman’s history, temperament, birth process and outcomes, her support network, and how she’s treated by her medical team.

As a general rule grief or disappointment in birth comes up when our experiences didn’t match up with our expectations, or our expectations were otherwise thwarted. Maybe you had to transfer. Maybe your VBAC wasn’t the peaceful, smooth birth you’d envisioned. Perhaps your doctor wasn’t on-call, or your husband/mother/doula didn’t make the birth. You either got the epidural, or you got there too late for it. In some respect, the birth you anticipated didn’t happen, and you’re sad about it.

Sometimes moms need to hear that no one is at fault and that their less than ideal birth doesn’t reflect on their preparation, choice of care provider, or expectations. In a normal birth it’s okay to have moments where you feel overwhelmed or scared or frustrated.

We need to remember that birth reflects life, and minor disappointments aren’t something to fear. When the ice cream shop is out of rocky road you might well discover how much you enjoy strawberry. Now, if they lied about having rocky road or if you’re allergic to strawberries that’s a much bigger deal, but in birth as in life we should be prepared to encounter and navigate minor disappointments. Sometimes moms need to hear that no one is at fault and that their less than ideal birth doesn’t reflect on their preparation, choice of care provider, or expectations. In a normal birth it’s okay to have moments where you feel overwhelmed or scared or frustrated. For many moms this won’t be a problem, and they can expect to handle these emotions if and when they occur.

Trauma, on the other hand, comes largely from outside ourselves. You were bullied in birth or ignored or had medical procedures done on you without our informed consent. An emergency arose that had you flying down the halls towards a swift and certain surgery. You hemorrhaged or tore badly. Perhaps your baby required immediate and extensive medical care. Your birth story suddenly became one of those stories no one wants to hear, and it has affected you deeply and inescapably. Of course, many women come out of traumatic birth incidences with a healthy mental outlook because they were respected, involved, and nurtured, and women with otherwise healthy deliveries can be traumatized simply by being bullied and ignored. There isn’t a hard line between the two experiences, but it’s valuable to make some sort of distinction even if we acknowledge that it’s partly artificial.

For instance, when speaking within the birth advocacy community many of us understand that emotions around birth can flow in very interconnected and complex ways, and we are comfortable just sitting with those emotions and not trying to categorize them too specifically. However, when we’re speaking to medical professional or people outside the birth community it’s crucial that we hammer again and again that birth trauma largely comes from a truly scary birth incidence or from disrespectful and callous birth care. As has been pointed out repeatedly – if birth is so scary and dangerous that it has to be closely managed in the most medical and restrictive of settings, no one should be surprised if women are traumatized by it. People who do scary and hard things do occasionally get scared and worn out, and people who have to put up with bullies or hostile experiences are often traumatized. It’s that simple.

When speaking to birth trauma skeptics, it’s important to make plain how those experiences are truly traumatic, arising from circumstances outside our control and not attributable, falsely or not, to us creating some “fantasy” about “how birth should be.” A medical provider bullying or coercing a laboring woman is something that is wrong no matter your birth philosophy. A cord prolapse is a scary medical emergency even if it occurs while driving to the hospital for an elective cesarean. In other words, it’s not about her. It’s about the care she receives and/or the statistically rare events that can make birth a difficult or even heartbreaking experience. When we group traumatic experiences with disappointing one we can lose this very important distinction.

By focusing on the human elements of compassion, respect, and informed consent we highlight the one thing we can give all women regardless of how or where they birth or any other circumstances – respectful, compassionate care.

The human element in maternity care can have a dramatic impact on whether a mother feels traumatized. To return to our original scenarios – the primary difference between Katie and Dana is that one woman received compassionate care based on evidence and informed consent, and the other one did not. By focusing on the human elements of compassion, respect, and informed consent we highlight the one thing we can give all women regardless of how or where they birth or any other circumstances – respectful, compassionate care.

Sifting out the exact differences between disappointment and trauma isn’t as important in communities that routinely validate, support, and comfort birthing women, but it is important when speaking into communities that dismiss women’s voices in and around birth. So long as women are scolded and shamed for having negative feelings after birth, there will exist the need to confront people with the realities of birth trauma in a very plain and bald manner. Birth trauma isn’t something confined to hypothetical over-privileged, ungrateful birth hippies and can affect women of various birth philosophies across the socioeconomic spectrum and impact their mothering and mental health for months or years, and our stories should reflect this.

Natalie Short is a wife and mother of two – her first born via a traumatic emergency cesarean and her second via a peaceful cesarean after a long trial of labor. She’s also chapter leader for ICAN of Birmingham, Alabama. When she’s not volunteering in her community, she enjoys knitting, photography, and not cleaning until the kids are in bed.