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Acute and post-traumatic stress disorders in an African maternity unit. Part 2: effects on clinicians and lessons for practice

10 February, 2010

Acute and post-traumatic stress disorders in an African maternity unit. Part 2: effects on clinicians and lessons for practice

This is the second paper by Ghebremicael Andemicael Kahsay, Lorna Numbers, Linda Martindale and Janet Dalzell and is a personal reflection from the principal author on the role of prevention in reducing the impact of acute and post-traumatic stress disorder.

This is the second paper by Ghebremicael Andemicael Kahsay, Lorna Numbers, Linda Martindale and Janet Dalzell and is a personal reflection from the principal author on the role of prevention in reducing the impact of acute and post-traumatic stress disorder.

Midwives magazine: February/March 2010


Introduction

The first paper of this study focused on traumatic childbirth and its sequelae, through discussion of one Eritrean family’s experience, which resulted in two maternal deaths and one stillbirth. Closer consideration of key points, from the parents’ response, through the psychological crises they experienced and their sequelae, to professional implications, has the potential to enhance understanding and extend knowledge for midwives on post-traumatic stress disorder (PTSD) in the Eritrean setting.

Professional perspectives of childbirth 

Everly, Flannery and Eyler (2002) discuss psychological morbidity in firefighters, policemen, nurses and doctors, ambulance drivers and other volunteer individuals directly involved in the US September 11 rescue following terrorist attacks. They report symptoms of acute stress such as nightmares and disturbed sleeping patterns. Contributory psychological risk factors for PTSD can also be identified for clinicians who experience distressing obstetric complications in their patients.

Midwives are directly involved with challenging obstetric complications (such as prolonged labour, caesarean section, haemorrhage, postpartum psychosis, and maternal or neonatal death, or fetal abnormality). The impact of a birth’s psychological trauma not only affects the functional, social, personal, and psychological situations of the immediate victims but also of the community and healthcare providers involved.

On personal reflection, I can clearly recollect meeting with Dahab in the admission room awaiting examination. As I remembered the events of her daughter’s delivery and subsequent death, I worried about my role and how I could build an effective rapport. After Dahab died, I found it hard to reflect on the challenges and could not readily reconcile myself with the outcomes. As a senior midwife in the maternity unit, I have experienced diverse obstetric and neonatal complications, but none gripped me as much as the intense loss of this family. I was overwhelmed with grief, giving way to weeping and self-blame and acknowledging guilt. Even now, in writing this account, I can still hear Dehab’s voice, intruding my peace of mind.

Nursing intervention

From this case study, and supported by relevant literature, it is clear that birth trauma can cause acute stress disorder (ASD) and PTSD in individuals and groups of people, who are directly involved, including care providers. Intervention to address this issue needs a multi-professional approach encompassing midwives, nurses, obstetricians, social workers, counsellors, spiritual therapists and health educators. Hood and Leddy (2003) suggest this strategy to enhance sharing of care responsibilities by focusing on common goals and objectives to maximise quality of care, and improve quality of life.

It appears that such a strategy is essential in the Eritrean context, where midwives play a significant role in the reduction of mortality and morbidity not only by attendance at delivery, but also taking on the roles of counsellors, health educators and professional educators (of nurses, associate nurses, traditional birth attendants (TBAs) and community members engaging in care) in such matters as, for example, emergency obstetric intervention, family planning and infection prevention. A study by Ghebrehiwet (2005), which reported reduced maternal mortality and morbidity in Eritrea when there is health facility involvement or skilled delivery assistance, is well supported by evidence from Ministry of Health (MoH) audit trails nationwide. Annual maternal mortality reduced from 998 per 100,000 in 1995 to 752 in 2002; concurrently in-facility delivery of 21% in 1995 has risen to 28%. From a practical point of view, in the decade reviewed by Ghebrehiwet, many midwives, nurses, associate nurses and TBAs were trained and deployed in remote areas. Ghebrehiwet’s work also suggests that midwifery care providers have contributed significantly to reduction in post-obstetric trauma stress disorders.

It is well reported (Marshall and Buffington, 1998; Ghebrehiwet, 2005) that skilled early intervention can impact positively on obstetric complications such as eclampsia, post-delivery bleeding and postpartum psychosis; effective intervention can minimise adverse effects on individuals, the community at large, and healthcare practitioners. Therefore implementation of effective preventive obstetric care can significantly reduce adverse physical and psychological outcomes of birth trauma, and is a positive contributor to quality of life for the individual, family and community. This approach complies with the core philosophy and strategies of the Eritrean MoH, which are rooted in primary health care; preventive objectives take precedence and have proved their effectiveness in many aspects of health care.

Primary prevention: before health problems occur

In the context of this study, it is therefore evident that the nurse-midwife’s intervention should focus on preventive aspects of obstetric care, such as recognising early cues and taking action before the health problem occurs, hence reducing incidence, as suggested by Ayers and Pickering (2001).

Prevention of complications appears to be the key to minimising trauma in childbirth. Early recognition of danger signs and symptoms of obstetric-related health difficulty can, through appropriate intervention, prevent trauma and its consequences (Ewles and Simnett, 2003; Eritrea Ministry of Health, 2002; Naidoo and Wills, 2000).

Based on this evidence, the Eritrea Ministry of Health (2002) advises that pregnant Eritrean women should visit and be examined in the antenatal clinic at least four times during pregnancy. This enables both education and identification of anticipated complications. For example, in Eritrea, hyperemesis gravidarum, characterised by severe persistent vomiting which causes starvation, weight loss, dehydration, tiredness, lethargy and discomfort, is common in the first 12 to 14 weeks of pregnancy. If left untreated, clients can develop frustration, hopelessness, and fear of loss of the pregnancy, inducing stress. Therefore, the prevention and management of nausea and vomiting during early pregnancy, before it progresses to hyperemesis, has been identified as the most effective means of preventing chronic vomiting and its negative impacts. In the Eritrean context, where the importance of appropriate maternal nutrition is not widely understood (especially in rural areas), midwives should ideally educate and counsel clients before, or as early as possible in pregnancy.

Secondary prevention: intervention to reduce prevalence

Clients may arrive in the labour ward with established health problems such as PTSD. Dahab’s situation exemplifies this situation: she already had PTSD and the circumstances and context of the delivery then induced ASD.

The case for a holistic approach to obstetric care is beyond argument. Holistic assessment, no matter how brief, would have prompted the midwife to recognise and address the cues that this mother was acutely stressed, even if time did not permit inquiry into the reasons. A birth plan would utilise concepts and practices to enable stress alleviation. This might include encouraging the mother to walk around, and to eat and drink, also talking with her, and allowing the family to stay with her. Intervention should be directed at reducing or stopping the release of stress hormone, recognising that there can be a negative impact on the physiology of uterine contraction to control bleeding. Ideally, the shorter the duration of labour the greater the mother’s satisfaction: blood loss is minimised, client/care provider interaction is optimised, and it is easy to promote maternal/neonatal bonding.

As the father, according to Eritrean cultural norms, Mr Ali would not have volunteered to go into the labour ward to interact with his wife, because Dahab would not have accepted him. However, keeping him informed and letting her walk out to talk to him could have been helpful. A partner’s interaction and communication during stressful events can help both of them to build up hope, courage, and confidence and to think positively; in contrast, lack of partner and family support, potentiates stress.

Therefore, the role of midwives in secondary prevention should include assessment and insight with regard to the thoughts and perceptions of the client and partner and applying simple cognitive-behavioral therapeutics. For example, Dahab felt hopeless and had signs of psychological stress, because of intrusive memories. Her midwives should have had an awareness of her thoughts and anxieties in order to help her distinguish between Nejat’s situation and her own to help reduce stress.

Tertiary prevention: intervention to prevent recurrence of health problems and rehabilitation


Principles of cultural and religious practice are relevant in situations of psychological crisis. In the Eritrean situation, this is illustrated by the practice of allowing remarriage following death of a spouse. A new partner would have cared for Mr Ali and his children, including his newborn baby, thereby minimising his stressors. Another Eritrean cultural practice that contributes to reducing stress is closure of mourning within a timeframe, which is the expected norm (12 days), setting a date for a wake after 40 days, and repeating the wake after one year, accompanied by the appropriate religious liturgy. This is compatible with psycho-spiritual therapy, discussed by Sahle (2005). Religious rites can be beneficial in healing psychosocial problems. In addition to cultural and psycho-spiritual therapy, healthcare providers’ intervention in tertiary prevention should include education on the signs, symptoms and complications of psychological crisis.

Paradoxically, Mr Ali’s complicated grief reaction prevented him from taking advantage of cultural and traditional support resources, to help him resume normal activities of life, return to work, join with friends and develop positive thinking to displace negative thoughts, such as suicide.

Conclusion

Analysis of this family’s experience identifies factors, which may lead to psychological crisis resulting from traumatic childbirth, impacting on the mother, her partner, their family, and community and also on care-providers. Therefore, midwifery practice in Eritrea should encompass psychological support, mass and individual health education on family planning, and active involvement of partners in women’s reproductive health issues. Apart from early identification, timely intervention in controlling complications, and supportive education to increase public awareness on critical factors of birth trauma, which might cause episodes of stress for the mother, could be very important.

Lastly, the importance of accurate and comprehensive documentation with special emphasis on predictors of ASD and PTSD is strongly emphasised. This should be recognised as a critical element of best midwifery practice, promoting communication between the care providers and healthcare facilities to ensure optimum obstetric decision-making.


References

Ayers S, Pickering AD. (2001) Do women get post-traumatic stress disorder as a result of childbirth? A prospective study of incidence. Birth 28: 111-8.

Eritrea Ministry of Health. (2002) Safe motherhood protocol. Sabur Printing Press: Asmara, Eritrea.

Everly GJ, Flannery RJ, Eyler V. (2002) Crisis intervention stress management (CISM): a statistical review of the literature. Psychiatric Quarterly 73: 171-83.

Ewles L, Simnett I. (2003) Promoting health: a practical guide. Baillière Tindall: London.

Ghebrehiwet M. (2005) Maternal health services in Eritrea: availability, utilization and quality. Sabur Printing Press: Asmara, Eritrea.

Hood L, Leddy S. (2003) Leddy and Pepper’s conceptual bases of professional nursing. Lippincott: Philadelphia.

Marshall M, Buffington S. (1998) Life-saving skills manual for midwives. American College of Nurse-Midwives: Washington DC.

Naidoo J, Wills J. (2000) Health promotion: foundations for practice. Baillière Tindall (in association with the RCN): Edinburgh.

Sahle A. (2005) Traditional psychiatry: lying on the community couch. Eritrean Profile 11.







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