Midwives magazine: December 2009/January 2010
By Ghebremicael Andemicael (principal author), a registered midwife and nurse and a qualified midwife teacher at the College of Nursing and Health Technologies in Asmara, Eritrea, University of Dundee’s Distance Learning Centre academic lead for Eritrea Lorna Numbers, e-learning and research coordinator in the Distance Learning Centre (Nursing and Palliative Care) Linda Martindale.
Introduction
Adewuya et al (2006) define PTSD as a reaction to an event, either personally experienced or witnessed, which involves actual or threatened death or serious injury, or threat to physical integrity (of self or others). The experience is common in both natural and man-made situations, such as tsunami, earthquake, flood, war, terrorism, drought, or when there is individual violence such as rape.
Does traumatic childbirth feature in this list of causes of stress disorder?
This study will focus on traumatic childbirth and its consequences, therefore it is important to establish whether it features in the list of causes of stress disorder. According to McKenzie-McHarg (2004), supported by Olde et al (2006), childbirth was recognised as a cause of PTSD in 1994. Furthermore, Seng et al (2004: 605), citing the American Psychiatric Association’s criteria Demographic Statistics Manual for Mental Disorders No. 4 (DSM-4) includes anxiety, intrusive thoughts and flashbacks, nightmares, avoidance, numbness, vulnerability, and substance abuse as manifestation of PTSD. Childbirth was acknowledged within DSM-4 as early as 1980; some of the DSM-4 criteria are present in this analysis.
Although post-obstetric trauma is not well classified or even documented in the Eritrean context, a 2005 survey by Ghebrehiwet, building on earlier work from Ghebreab (2004), found maternal morbidity to be 30 times greater than mortality (which in itself is an issue: 752 deaths per 100,000 births). These women are significantly incapacitated in respect of daily living, raising fundamental postpartum questions, which must include psychological aspects of trauma. In addition to quality of life, quality of Eritrean midwifery practice is poorly reflected in these data.
This analysis addresses the principal author’s actual experience with an Eritrean family who were victims of psychologically traumatic childbirth. Reference is made to the 1950s Selye’s model of stress the General Adaptation Syndrome (GAS) (cited in Crompton, 2002: 107) – these authors identify that childbirth can be a stressor resulting in the mother’s ill health. The names given have been altered to maintain the family’s confidentiality.
Nejat, an 18-year-old pregnant woman, Islamic by religion, arrived in the maternity unit, accompanied by her parents. Her partner, Osman, was absent; this was not unusual because in Eritrean culture, a primigravid woman usually goes to her mother’s home for the delivery. The Eritrean Ministry of Health (MoH) (2002) protocol, which includes standards to guide safe practice, was observed during the admission process to ensure effective assessment.
Nejat had been unhappy and passive throughout her pregnancy, which by complete physical examination we knew to have reached 32 weeks’ gestation. There was a clear and normal fetal heart beat. However both Nejat’s feet were oedematous and her blood pressure was 140/100 mmHg. Laboratory tests found haemoglobin was 12g per decilitre and her blood group was O rhesus positive. Urinalysis was positive (++) for protein. Indicators of pre-eclampsia were therefore recognised.
Nejat was initially admitted for rest, helped with some sedation. Oral diazepam 5mg was given, then she was assisted into the left lateral position to reduce the risk of supine hypotension and enhance blood perfusion and placental circulation (Campbell and Lees, 2000). She was reassured that staff would monitor her carefully. However, she complained of persistent frontal headache, nausea, blurred vision, and epigastric pain, which, according to Lloyd, in Fraser and Cooper, (Lloyd, 2003) are indicators of severe pre-eclampsia or imminent eclampsia. Concurrently, Nejat’s blood pressure rose to 160/140 mmHg and her urine output was poor. Her deteriorating condition was further demonstrated when she had a convulsion.
Implementation of the MoH 2002 protocol (above) continued, with administration of intravenous hydralazine (an anti-hypertensive); magnesium sulphate (to reduce convulsions); diazepam (for sedation); and prophylactic amoxicillin (which the protocol specifically recommends; MoH audit data demonstrates a high risk of perinatal infection, especially with complicated deliveries).
Nejat was nursed in the left lateral position; her airway was maintained with gentle oropharyngeal suction as necessary and oxygen was administered via nasal cannulae. Her bladder was catheterised. Meanwhile the fetal condition continued to be monitored and it was noted that the heartbeat had become unstable. The duty doctor performed an emergency caesarean section (CS) and Nejat delivered a stillborn infant. Post-operatively this young woman then died from overwhelming sepsis. It is likely that she already had some infection, or at least was developing infection in her weakened state in living accommodation that was less than ideal. Superimposed on that are traditional ‘obstetric’ practices, which would surely have been tried before seeking health service assistance.
Nejat’s parents were profoundly shocked and distressed in their response to her death. Her mother, Dahab, fainted; later she exclaimed: ‘Do not lie, she cannot die, let me see her first.’ Meanwhile, her father, Ali, stood motionless and was uncommunicative.
Approximately a year later, this bereaved mother, Dahab, who was 36 years old (gravida 7, para 6) and whose youngest baby was now two years old, was again pregnant and she arrived at the maternity unit in labour. She was very upset, tearful and non-communicative, because she had been admitted to the same delivery room as Nejat and her memories were very distressing.
Although this would be Dahab’s seventh baby, it was going to be her first hospital delivery. She explained this was because her traditional birth attendant had told her to give birth in the hospital. She was uncooperative, refusing all care offered because of the associations with her daughter’s situation. Progress of her labour was delayed; weak uterine contractions occurred every ten minutes, lasting between 20 to 40 seconds. Two consecutive vaginal examinations, at four hourly intervals, revealed no progress in respect of either fetal head descent or cervical dilatation. The advice of the doctor was sought and augmentation of labour by oxytocin was prescribed (one international unit (IU) in 500ml dextrose 5% solution infused accurately at 1ml per minute, with close monitoring of quality and quantity of uterine contractions and fetal heart). Dahab’s discomfort and anxiety increased; she did not understand what was happening and recognised her intravenous line as something Nejat had also experienced. In the meantime her husband, in the waiting area, became restless and worried; staff noticed he smelled of alcohol, which is unusual for a Muslim.
One and a half hours after the start of the oxytocin infusion, Dahab gave birth to a moderately asphyxiated female baby with an Apgar score of 5/10 and 6/10 at one and five minutes after birth. The delivery of the placenta was then delayed. Afterwards Dahab had a postpartum haemorrhage due to an atonic uterus. She was rapidly transfused two units of screened blood, but developed irreversible disseminated intra-vascular coagulopathy (DIC) and died. When he was told of Dahab’s death, her husband left the hospital without saying anything then came back later incapacitated by alcohol.
Mr Ali, now grieving the loss of two loved ones, wife and daughter, has become an alcohol abuser with problems of self-neglect. As alcohol is condemned by Islamic society, he has become an outcast from his community, from whom he could normally expect support. Meanwhile, relatives are urging him repeatedly to remarry according to Islamic law, but he remains reluctant to do so.
Discussion
There are identifiable risk factors for psychological crisis in this account. These include biological or functional issues integral to the process of two difficult births, as well as personal experience of trauma due to loss, and environmental factors relating to the health facility and care providers.
It is important to analyse both the impact of risk factors on each client’s psychological status and the outcomes, which not only severely impacted family integrity, but also affected care providers. Therefore, focusing on the circumstances in the aftermath of Nejat’s death, when the nuclear family was acutely traumatised, it appears to the author (who understands the culture of Dahab’s ethnic group) that she became pregnant and gave birth while still mourning Nejat. Eritrean women like Dahab are not independent or self-reliant and it is likely that the pregnancy increased her sense of vulnerability. Then after Dahab died, Mr Ali, now alone, had to re-visit the trauma of family death and responded by developing behaviour, which is regarded as anti-social. As a healthcare provider, the principal author reviewed and reflected on this critical episode where obstetric complications gave rise to such poor outcomes; to witness the death of two mothers, who were themselves mother and daughter, even in an Eritrean context of significant maternal mortality, is a unique event.
Nejat’s extended family had to face an unexpected and unacceptable death and suffered a serious psychological crisis. The experience of her death, at a young age, was traumatic, thereby impacting the parents’ grieving. The whole family’s quality of life deteriorated.
Within the community, Nejat’s death caused mass grief and significant psychological impact. The events were outside their understanding; as lay people, the community perceives pregnancy, labour and delivery as a natural process, which should cause none of these problems.
Parents’ responses
Eritreans, who have prolonged experience of armed conflict, are no strangers to suffering and death. In a country that is almost equally divided between Islam and Christianity, there are robust cultural and religious practices in all communities to support and care for the bereaved. Despite this, Nejat’s family, probably because they were completely unprepared for her death, were devastated. Their knowledge of childbirth and other aspects of health care was very basic. They did not understand the possibility of complications or the significance of antenatal care. This experience was therefore far beyond their own resources for coping.
Dahab’s response to the death of her daughter was characterised by disbelief, avoidance, loss of control and numbness. Her husband also displayed signs of numbness and was unresponsive; he lost control. These signs, based on the discussion of Crompton (2002) and Ayers and Pickering (2001) suggest psychological trauma; both parents appeared to experience acute stress disorder (ASD) related to psychological crisis. These responses are congruent with phenomena or the signs and symptoms discussed by Seng et al (2004: 205) by referring to DSM-4.
Dahab’s late pregnancy naturally in itself caused stress (Raynor and Oates, 2003), arising from pregnancy-induced physiological and emotional changes and accompanying anxiety. Furthermore, in the principal author’s own professional experience, pregnant mothers are often additionally concerned about their self-image and can be apprehensive; curiosity and fear of the unknown challenge any mother.
Dahab became pregnant during a situation of overwhelmingly sad memories of Nejat; as discussed above, it is likely that Dahab’s quality of life during her last pregnancy was poor, especially because of the close association with Nejat’s pregnancy. There is strong evidence (de Bruyn, 2003; Campbell and Lees, 2000) that stressful life situations before and during pregnancy not only influence the progress of the pregnancy itself, but can also affect labour and delivery. Furthermore, psychological crisis during pregnancy has been linked to both pre-term and prolonged labour, adversely affecting both mother and baby (Raynor and Oates, 2003; Teixeira et al, 1999).
Pain is always an important issue during childbirth. There is evidence of significant variance in the perception of pain between mothers, influenced by psychological, socio-cultural, cognitive and behavioural factors (Wittink and Michel, 2002; DeCherney and Nathan, 2003; Morse, 2004). For example, within the multi-ethnic Eritrean context, Kunama women in labour accept and tolerate the pain, because in their culture expression of labour pain is humiliating to their mothers and brings shame on the family. However, Dahab was from the Islamic Tigregna ethnic group; for her, labour pain was terrible and unbearable, further complicating her experience of psychological trauma.
With hindsight, the care providers recognised the serious impact of Dahab labouring in the same place where her daughter had died. Creedy et al (2000) explain that an environment where traumatic events took place is a stressor to individuals. Inevitably she had flashbacks, panic and anxiety attacks, and an acute lack of confidence. For her, the environment was hostile and she must have felt helpless and hopeless. Childbirth is universally agreed to be a life crisis and may increase anxiety, irritability and stress levels. Dahab’s background therefore potentiated risk factors of labour creating major physiological stress as described by Selye (1956, as cited by Crompton, 2002: 107). The physiological adaptive mechanisms of stress would exaggerate the physiological pain of uterine contraction, further demoralising and debilitating her.
These effects of PTSD are well supported in recent literature, in addition to Selye’s original work on stress, as cited by Crompton (2002: 107). For example, Decherney and Nathan (2003) agree on the negative consequences of acute and chronic stress on the course of labour. Stress hormones such as beta-endorphin, adrenocorticotrophic hormone, cortisol and adrenaline interfere with uterine function and cervical dilatation. There have been a number of studies exploring the prevalence of PTSD, where women present with symptoms of flashbacks, anxiety, and nightmares. Nigeria has one of the highest rates of obstetric PTSD, where 5.9% of women experience these distressing symptoms (Adewuya et al, 2006). This compares with much lower rates in Sweden (Wijma et al, 1997) and Italy (Maggioni et al, 2006).
It is concluded that stress hormones slowed down the progress of Dahab’s labour, increasing its duration by weakening the intensity of the uterine contraction and slowing the dilatation of the cervix. The resultant infrequent uterine contraction of poor intensity prolonged labour and the resulting complications were fatal. Other contributing factors for Dahab’s situation were multiparity and, at least in Eritrean terms, her relatively advanced age. Uterine muscle of poor tone is less able to contract postpartum, prolonging bleeding.
Saisto et al (2001) found evidence that prolonged labour (and also emergency Caesarean Section) can be related to a mother’s anxiety about the outcome of the labour. In the Eritrean tradition birth interventions, even a hospital delivery – arguably less intrusive than caesarean section (CS) – is unacceptable to the majority of women; when they are necessary, they contribute significantly to stress. The stressful events before and during her pregnancy and labour not only impacted on Dahab’s condition, but also affected the baby who was born asphyxiated. This assertion is supported by recent findings from DeCherney and Nathan (2003) and WHO (2003), on the stress engendered in utero from maternal psychological crisis during labour. Neonatal quality of life is adversely affected. Above all, maternal psychological trauma delays bonding and initiation of breastmilk production, both essential components of warmth and affection.
Dahab died from postpartum haemorrhage; her elderly, tired and exhausted uterus was too weak to control bleeding after the delivery of the placenta. However, as suggested by DeCherney and Nathan (2003) this exhausting, prolonged labour can be attributed to her psychological crisis, stressful events, and the grief and loss she had experienced. Physiologically this is explained in the work by McCormick (2003) – anxiety can increase the production of adrenaline, which inhibits uterine activity, and may in turn prolong the labour. This analysis relates closely to the discussion by Selye (1956, as cited by Crompton, 2002) on the interplay between the disturbances at molecular and cellular level due to stress. For Dahab, the biochemical changes associated with stress and anxiety during labour further affected the uterine muscle; the outcome was fatal.
Mr Ali’s response
Mr Ali was at the hospital during both unexpected deaths. Analysis of his response is an important aspect of this study. It was evident that he experienced loss, grief, bereavement and shock. These are signs and symptoms of acute and chronic psychological trauma as identified by Seng (2004: 605), and discussed by Ayers and Pickering (2001). In addition to the bereavement, he was the father of Dahab’s motherless newborn child. In Eritrean culture childcare and rearing are women’s work; the majority of Eritrean men see it as untouchable and difficult. Mr Ali’s background suggests that he would be no exception. Experience indicates that in Eritrea motherless babies appear to cause more psychological trauma to the sole parent than those who are fatherless.
The circumstances of his wife’s death would have made it particularly difficult for Mr Ali to deal with her loss. Muslims believe that the human being is in a state of total submission to the will of Allah (God). But neither his daughter, nor his wife were able to experience the normal Muslim preparation for death; physically they were abruptly and critically ill, in what they would have regarded as an alien environment. Normally when death is imminent, family members and devout friends should be with the dying person to encourage them spiritually; they should never leave them.
Once the death is confirmed, as with many faiths, there are certain rituals, which should be performed for the body. While the hospital staff would have helped with these arrangements, the strangeness of the environment would have had a negative impact on Mr. Ali’s ability to fulfil the requirements. However, the funeral would have taken place very quickly, giving little time to come to terms with events.
Mr Ali was already showing signs of hopelessness, worry, and irritability before he was told of Dahab’s death. He had been afraid she might die, and had already become vulnerable, showing signs and symptoms of stress. Leaving the hospital to find solace in alcohol indicates avoidance, vulnerability and substance abuse as indicated in the DSM-4 criteria of acute and PTSD. As time went on, it became clear that Mr Ali could not adapt to his situation as a lone survivor; he responded with continuous alcohol abuse, which is unacceptable in Islam. He was subsequently alienated from the community. He started quarrelling with people in public places, and his dirty and unkempt dress reflected his self-neglect.
Conclusion
These traumatic birth events demonstrate the negative impact and outcome for this family in the form of ASD and PTSD. The outcomes reinforce findings in the literature of PTSD, discussed in this study, that secondary psychological birth trauma can produce unacceptable socio-cultural and personal interactions, associated with health problems, and cognitive and behavioural changes.
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