Listening to Women After Childbirth

Alison Brodrick, Emma Williamson

• Publisher: Routledge
• Year: 2020
• Print ISBN: 9780815360339
• eBook ISBN: 9781351118408
• Edition: 1
• Topic: Medicine
• Subtopic: Psychiatry & Mental Health

It is vital that healthcare practitioners understand the psychological impact of childbirth when caring for women. This accessible guide is designed to improve the care that women receive and, as a result, public health outcomes related to maternal and infant wellbeing.

This book outlines how clinicians can offer practical support to women after birth. It:

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• discusses what we know about how women adapt to motherhood and develop a post-childbirth identity;

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• outlines some of the causes and manifestations of post-traumatic stress following childbirth;

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• provides practical guidance for setting up postnatal pathways for women traumatised by birth and how to communicate effectively;

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• equips practitioners with the knowledge and skills to support pregnant women with a fear of birth;

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• incorporates narratives from women to demonstrate how their births and related events were perceived and processed, before discussing how women's views can be used to inform future practice;

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• highlights the importance of restorative supervision for healthcare professionals working in this area to promote staff resilience and sustainability.

Drawing together theoretical knowledge, evidence, practical skills and women's narratives to help clinicians understand the psychology of childbirth and support women, it is of significant value to all healthcare practitioners engaged in maternity services.

1Transition to motherhood

Introduction

For some women, the transition to motherhood is a time of joy and happiness. The general view of the post-partum period within Western society is one of celebration, where mothers are in a blissful state of sleep-deprived gratitude for their new bundle of joy. In contrast to the image of total love and contentment encompassed within the ‘Madonna myth’ of mothering and motherhood, we are getting better at acknowledging that the reality may be quite different. Women describe various challenges during this period as they recover physically and emotionally from childbirth, often juggling additional responsibilities and adjusting to changes in relationships and family dynamics. It is a period of transition often accompanied by stress and a feeling of vulnerability (Mazzeschi et al, 2015).

It is estimated that 15–20 per cent of women will experience anxiety and depression in the first year after childbirth (NICE, 2014). In the last Confidential Enquiry into Maternal Deaths, suicide remains the leading cause of direct deaths occurring within a year after the end of pregnancy (Knight et al, 2017). Over the past few decades, there has been continual progress in promoting the understanding, assessment and treatment of the mental health difficulties that can affect women during pregnancy and the post-partum period. As a result, midwives, health visitors and GPs are more aware of the potential for women to be experiencing mental health problems around the birth of a child. Women are therefore more likely now to receive screening and support, particularly for postnatal depression (PND).

Psychological assessment, understanding and treatment have not, however, received the same level of attention. Back in 1996, Lesley Barclay and Beverley Lloyd raised concerns that an increased awareness and focus on diagnosing and treating PND leads to a risk of clinical depression becoming confused with the unhappiness, anxiety and frustration that many women feel after the birth of a baby (particularly for first-time mothers). They suggest that this potential over-diagnosis of PND is unhelpful in pathologising distress, as clinical depression may not be the most appropriate explanation for an emotional response which may actually be considered quite normal after the birth of a baby. Barclay and Lloyd (1996) describe a range of research showing that increased distress and lowered quality of life is in fact common and normal following childbirth, but for the majority of women, does not usually progress to a clinically significant depression. They conclude that the emphasis on providing psychiatric explanations for women’s distress following childbirth ignores ‘the possibility that women may be manifesting an appropriate response to the immense social, emotional and physical changes which they face in a culture that neither acknowledges nor sufficiently supports the process of becoming a mother’ (1996, p. 138).

Within this context of normal elevations of distress, for women undergoing their first experience of birth, there is an additional psychological challenge: forming a new identity as a mother. As the philosopher Osho stated: ‘the moment a child is born, the mother is also born. She never existed before. The woman existed, but the mother, never. A mother is something absolutely new.’ For women having subsequent babies, the challenge may be different, but there will also be a period of emotional adjustment to being the mother of the new baby, as well as any existing children. Understanding these seismic changes in lifestyle, relationships, and even, or especially, sense of self is crucial to understanding how women recover from childbirth and to appreciate the additional effect and manifestation of birth trauma.

Becoming a mother: what happens

Back in 1967, Reva Rubin developed a theory of how women attain a sense of their ‘maternal role’. She argued that women go through progressive stages in this process, beginning in pregnancy, where they will seek out information and expert ‘role models’, and fantasise about themselves as a mother. When a maternal role has been accomplished, Rubin said women feel a sense of ‘being’ in the role, and a comfort about their present and future. Rubin (1984) developed this theory further to acknowledge that motherhood is more than a role that can be inhabited and left; instead it is incorporated within the entire personality. Rubin went on to explain that certain ‘tasks’ are important in this process, beginning in pregnancy and lasting through the post-partum. These tasks include ensuring ‘safe passage’ and seeking acceptance for themselves and their baby, as well as a process of ‘binding in’ to the baby and the woman ‘giving’ of herself. Rubin also described how the development of this new dimension to a woman’s personality is required with the birth not just of the woman’s first child, but also of every subsequent child. As each baby is unique, so is the mother at that particular point in her life, and these ‘tasks’ must therefore be carried out to get to know and incorporate each child into her own self and family system.

Although getting to know one’s baby and transitioning into this new identity is a time of often joyful growth and transformation, Rubin acknowledged that grief is also a normal part of this process. Women have to ‘relinquish’ parts of their lives which are incompatible with motherhood, and the nature and focus of this grief can be wide and varied. Many women experience feelings of loss around not having time for themselves, or for their relationships or other roles that had been important for them, as the needs of a baby are so initially all-consuming. Women may experience a feeling of loss as their previously held fantasy about what motherhood would feel like, or what kind of mother they may be, proves to be different to the reality. For some women, who may have consciously or unconsciously expected to experience the famous ‘rush of love’ for their infant, there may be a feeling of grief as they let go of this idea and adjust to what is the reality for many women, which more resembles a gradual process of falling in love.

Mercer (2004) advocates the use of the term ‘Becoming a Mother’ to describe what is happening to women following the birth of their first child. During Mercer’s research, interviews and conversations with women about the experience of becoming a mother shed light on this process. Women talk about a sense of themselves needing to ‘break’ in order to remould their selves into a new identity that incorporates their baby, and their new caring role. For some women, this breaking process is experienced as painful, and is accompanied by a feeling of loss as women grieve for their previous selves and lives: amongst many others, women may miss their autonomy, their financial independence, spontaneity and time with their partner and friends.

Between 1943 and 1962, the influential paediatrician and psychoanalyst Donald Winnicott made approximately fifty BBC radio broadcasts on the subject of parenting. In these, he famously gave mothers compassionate and non-judgemental insights into parenting challenges and child behaviour. One of Winnicott’s many contributions to understanding the subjective experience of mothers was to raise awareness of the idea that alongside the intense love a mother feels for her child, she will also inevitably at times feel much more negative towards them, and understandably so, given that ‘he (the baby) is ruthless, treats her (the mother) as scum, an unpaid servant, a slave’ (Winnicott, 1949, pp. 72–73). Winnicott explained that mothers tolerate these feelings without expressing them to their babies, and he expressed admiration for how mothers absorb so much hurt from their babies without ‘paying the child out’. It is interesting that Winnicott not only saw these feelings of negativity as natural and inevitable, but he also believed they have a positive function in providing an environment where children can learn a full range and depth of emotional experience. Following on from this, psychotherapist and writer Rozsika Parker (1995) elaborated on the positive function of mothers experiencing both intense positive and negative feelings towards their babies in her book Torn in Two: The Experience of Maternal Ambivalence. Parker explained that when a mother can experience a full range of emotion in relation to her child, the child comes to learn that they have an impact on others, that they can hurt others but also repair relationships, and therefore they know themselves better. Seen through this lens, it is apparent that again, a rise in negative emotion and distress is a natural aspect of parenting, although one that many women find difficult and often shaming to become aware of, or own up to. This negative emotion, in conjunction with the potential for associated shame, becomes a further psychological challenge for women in the post-partum.

A woman’s sense of becoming a mother is thought to be competency based; it gradually develops as women do more for their babies, and their confidence in their ability to perform the tasks of motherhood grows. It is interesting to note that our culture uses the term ‘mother’ both as a noun and a verb. We talk about ‘mothering’ as a behaviour, reflecting how this role is expressed in action. We know that the main facilitator of this process of learning to become a mother is social support. Women need to learn the skills of motherhood in order to care for their babies, but the act of this caring also serves to develop their competence as a mother, and consequently, their sense of self as a mother. Some of this learning may have happened implicitly over their lifetime: for many women, the skills of demonstrating care and nurture begin as a young girl playing with a doll. From early toddlerhood, some girls show a keen interest in babies and enjoy play that centres around providing care for dolls, imitating the mothering acts they may have experienced with their own caregiver. And of course, it is a girl’s own mother (or mother-figure, if not the actual mother) who provides the first ‘blueprint’ or ‘schema’ of how to be a mother. It is through this mother, or mother-figure’s actions that a girl begins to form an idea of what mothering looks and feels like. Clearly, these influences can be helpful or unhelpful in developing a woman’s blueprint of motherhood. When unhelpful, these influences have been termed the ‘ghosts in the nursery’ (Fraiberg et al, 1975), referring to ‘visitors from the unremembered past of the parents … [who] take up residence and conduct the rehearsal of the family tragedy from a tattered script’ (pp. 387–388). A woman who grows up with a cold or critical mother may find herself unconsciously repeating this behaviour with her own children, or she may decide to reject this, banish the ghosts and give her own children a very different experience. A woman who, as a child, was made to eat everything, even food she detested, may overcompensate for this experience by deciding to take a very relaxed approach to food. She may also, however, not realise that she is passing on concerns about other aspects of her children’s behaviour that she has internalised. This learning is life-long and is influenced by the mothers a woman is exposed to, whether they are real life mothers in her circle of family, friends and acquaintances, or the fantasy mothers she may come across in the media, or in literature. All of these sources build up a schema of what a mother does, what she looks like, and how she conducts herself in the world. Upon entering the realm of motherhood herself, a woman therefore has to negotiate her way through all of these influences to decide how the role of mother, and the act of mothering, fits with her own sense of self.

Beyond this very personal level of influence, women are also influenced by cultural ideas of how women ought to mother their children, and indeed, how mothers should behave in general. This can even influence a woman’s feelings around how she ought to dress or wear her hair, in order to conform to, or again, reject the notion of what is culturally expected of her to do as a mother. This can feel like a tightrope for some women, not wanting to expose themselves to negative judgement from others for daring to dress in a way deemed to be sexy now they are mothers, but similarly, not wanting to attract the judgement of being ‘mumsy’, with all the negative connotations carried by that adjective. In her book, Pretty Honest, the writer Sali Hughes (2014) describes being visited by a friend when her eldest son was four weeks old. She reports picking what she felt was an appropriate outfit for the occasion, to demonstrate that she was coping well. Her friend, however, saw right through it, and it was Sali’s choice of a pastel-coloured jumper after ‘decades in heels, skinny jeans and killer make-up’ that indicated to her friend that Sali was not feeling well, despite her efforts to ‘look like a proper mum’ (p. 239).

Even for women with much experience caring for babies within their own families and friendship circles, or professional experience if employed within a childcare setting, there is a significant difference between this and the continuous provision of care and feeling of ultimate responsibility for their own child. Much of the learning, therefore, must happen ‘on the job’, as women look to older, more experienced mothers, or health professionals, for guidance and tutoring in how to care for their babies. There is a general acknowledgement that the nature of this learning has changed in modern times. Previously, women would have received their informal tutoring in mothering skills from older female relatives, neighbours and friends. In our technology-savvy age, women increasingly turn to online resources and forums for their learning and advice and to maintain social connections with other mothers (Lupton, 2016). At the time of writing this chapter, entering ‘how to’ in the search bar of the Mumsnet generated 530,000 results, with topics as varied as how to unlatch a breastfeeding baby with teeth, how to keep laminate floors free of dust and how to update a CV after having children. Women continue to search for their answers of ‘how to’ perform the endlessly myriad tasks of motherhood as their identity as a mother continuously develops and evolves.

This idea of the self developing from a feeling of competency is important and relevant when considering women for whom birth has felt traumatic. For those women who feel let down and angry by those who were meant to care for them, their trust in their support system (both personal and/or professional) may have been broken to the extent that social support feels like a threat, rather than a source of strength and development. These women may then avoid seeking support because they have such limited trust that if they reach out, they will not find the support they need. For the many women who describe feeling that they have ‘failed’ if they were unable to have the labour and birth they had hoped for and planned, their journey into motherhood begins from a position of perceived inadequacy. Borrowing from Rubin’s (1967) language, women may feel they were unable to provide the ‘safe passage’ for their baby which is one of the tasks of developing a maternal identity. Often, this starting point can be the beginning of a vicious cycle of perceived failures which only confirms a woman’s beliefs that either professionals, or her very self, are not to be trusted. This process is illustrated in Dee’s experience (see Case Study 1.1).

Case Study 1.1 Dee’s experience

Dee was in established labour when it was realised that her baby was in a breech position, and a decision was made to deliver the baby by emergency caesarean section at 11 o’clock at night. Dee had already been unwell with a chest infection when she went into labour, so during surgery she was placed on oxygen. This was left on until the following morning. Dee felt physically weak and overwhelmed by her physical symptoms and didn’t have the energy to think about feeding her baby, which made her feel ashamed when she remembered this. That afternoon, a midwife on the ward suggested feeding the baby who struggled with latching on and became increasingly restless. Dee was also feeling unwell, and throughout the next night her screaming baby was taken away several times by the midwives and brought back calm and settled. Dee was confused and upset by this: why could they settle her baby and not her? Were they feeding her formula? The midwives denied giving the baby top-up feeds, but Dee began to feel that she could not trust them, and they must be lying. Dee found it hard to sleep because of her discomfort and coughing fits. Two other women in the bay began to complain that they couldn’t get any rest ‘with her making all that noise’. Dee felt angry and ashamed at this memory. She focused on being discharged from hospital, hoping that everything would resolve itself once she was at home with her baby in familiar surroundings, but to her dismay, the struggles with feeding continued once at home.

Despite seeking help from the community midwives and a local breastfeeding support group, the baby had lost 17 per cent of her birth weight by day ten, and the midwife worried she was becoming unresponsive. Again, this memory was full of shame for Dee. She and the baby were readmitted to the hospital, which recommended a regime of expressing milk and introduced regular ...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Contents
• Boxes
• Case studies
• About the authors
• Foreword
• Preface
• 1 Transition to motherhood
• 2 Post-traumatic stress disorder: Understanding the iceberg
• 3 Communication skills: How to listen
• 4 Birth afterthoughts: A stepped care model
• 5 Therapeutic interventions: The next step
• 6 Supporting women in their next pregnancy
• 7 Promoting staff resilience
• 8 Using narratives to inform practice
• Index