The Psychological Consequences of Obstetric Negligence
Obstetrics is the branch of medicine that deals with pregnancy, childbirth, and the time immediately following a birth. These are known as the prenatal, perinatal, and postnatal (or postpartum) periods. Obstetricians are responsible for managing any risks or complications that might occur during or after pregnancy. They work alongside midwives, who are tasked with handling normal pregnancies and providing care for healthy mothers and children.
For many people, the experience of pregnancy and childbirth is overwhelmingly positive. Normal childbirth is, however, associated with psychological distress. Up to 50% of mothers report a transient form of distress known as “baby blues,” more than 1 in 10 experience postnatal depression, and approximately 0.2% experience a full-blown psychosis.
In certain circumstances, these long-lasting psychological effects can be the result of obstetric negligence. This occurs when the effects were foreseeable and preventable in advance. In this post, we look at some of the major mental health risks associated with pregnancies and childbirth and consider what needs to be established to demonstrate psychiatric injury from obstetric negligence.
Traumatic births
In general, pregnancies or births that have a negative psychological impact on the mother are referred to as “traumatic.” There is no single definition of what constitutes a traumatic birth. Broadly speaking, it is any physical or psychological harm caused by an “actual or threatened injury to the mother or her baby.”
There is no objective way of measuring traumatic births. On the one hand, women who undergo interventions due to complications in the birthing process, or who feel that they have been poorly cared for, often describe their birthing experience as traumatic. On the other hand, even women who experience seemingly straightforward pregnancies may still experience birth trauma. For this reason, it has been argued that birth trauma is largely “in the eye of the beholder.”
The experience of birth trauma is more common than one might think. A 2003 survey of more than a hundred British women found that 34% of them described their birth experience as traumatic. This survey also identified several antecedent factors that correlated with traumatic births, such as a history of sexual trauma and lack of social support. Moreover, during pregnancy itself, the following factors were identified as predictors of birth trauma: pain during the early stages of labour; negative interactions with medical personnel; invasive medical procedures; and feelings of powerlessness.
What are the mental health risks posed by traumatic births?
Psychological disorders that arise as a result of traumatic births include depression and post-traumatic stress disorder (PTSD), and this article will focus on these. Depression is an ongoing and persistent feeling of sadness or hopelessness. PTSD involves reliving the traumatic event or feeling haunted by it.
In a survey conducted in 2008, researchers found that 22% of women had depressive symptoms six weeks after having undergone a traumatic birth. This figure did not decrease much over time, with 21.3% of women reporting depressive symptoms six months later. Meanwhile, the same study showed that the percentage of women with clinically significant PTSD symptoms increased over time. 6% of women showed signs of postnatal PTSD at six weeks, whereas 14.9% showed signs of postnatal PTSD after six months. The most significant predictors for both depressive and post-traumatic stress symptoms were “anxiety in late pregnancy,” “psychiatric symptoms in late pregnancy,” “critical life events,” and “negative experiences of the delivery.”
These findings were backed up by a more recent study, published in 2016, which found a significant correlation between traumatic birth experiences and PTSD. Among the factors most likely to lead to postnatal PTSD, a negative birth experience was again found to be the most common. Women who had to undergo an operation or who did not feel supported during the birthing process were also likely to develop PTSD. In all cases, women who suffered PTSD were far more likely to develop depression as well.
What are the causes of postnatal PTSD and depression?
There is a small risk of PTSD in the wake of any birth. As mentioned, women who undergo seemingly straightforward pregnancies may experience birth trauma and thereby run the risk of developing depression or PTSD. Nevertheless, studies have shown that there is a significantly higher prevalence of PTSD among women who experience severe obstetric adverse events. It applies, for example, to women who experience prolonged painful labour, emergency c-sections, or who are admitted to an intensive care unit.
Furthermore, as is to be expected, perinatal loss is a significant predictor of depression and PTSD. Perinatal loss is defined as either a stillbirth or an infant death within 28 days of the birth. In a survey that received responses from more than 600 women, those who suffered a bereavement of this kind were seven times as likely to screen positive for PTSD symptoms and four times as likely to screen positive for depression. The heartbreaking effects of this kind of loss meant that, nine months after the birth, the bereaved women showed “high levels of distress with limited rates of treatment.”
What are the symptoms of PTSD and postnatal depression?
While the symptoms of PTSD and depression in the wake of traumatic births are often grouped together, they can present in various different ways, and studies have suggested that some might be more prevalent than others. The most common markers of PTSD are intrusion and avoidance.
Intrusion
Intrusion is the reappearance of painful or unwanted memories of the traumatic event. Some people who suffer from PTSD experience flashbacks and feel as if the event is happening to them all over again. They may suffer from nightmares or experience intense distress whenever something reminds them of the trauma. In severe cases of postpartum PTSD, this can be anything that makes the mother think about the birth, even her child.
Avoidance
People with postnatal PTSD may consistently avoid activities, situations, or people that remind them of the birth. This can include physical avoidance, such as refusing to visit hospitals or engage with clinicians. But it can also include psychological or emotional avoidance. Mothers with postnatal PTSD may be emotionally detached or unable to express affection. They may refuse to talk about what happened or use drugs and alcohol as an escape.
Depression
Postnatal depression is thought to affect more than 1 in every 10 women. It may be measured using the Edinburgh Postnatal Depression Scale, which involves ten questions that help to identify a mother’s level of risk. This screening questionnaire checks for symptoms such as increased anxiety, trouble sleeping, feelings of hopelessness, thoughts of self-harm, excessive crying, lack of energy, social isolation, feelings of sadness, and frightening thoughts (such as harming the baby).
Postnatal depression is different from the baby blues, which can affect both mothers and fathers and typically only lasts for a few weeks after birth. Not only does postnatal depression last considerably longer than the baby blues but it may also not develop until much later on. In some cases, symptoms may not present themselves until up to a year after the birth.
Ongoing “torment”
One of the largest systematic reviews of research concerning the ongoing psychological effects of traumatic births found that women demonstrated a general tendency to be “tormented” by the ghosts of their experience. These women describe being “consumed by demons” and suffering from “intense negative emotions.” They also feel a genuinely “embodied sense of loss,” which can occur not only in cases of perinatal mortality but also when the mother experiences a loss about her sense of self or her family ideals. Women who suffer traumatic births may feel like they have failed as a mother, and the pressure and anticipation around the pregnancy may only increase the effects of this. Women may feel devastated that the birth did not go as hoped. As such, traumatic births can lead to “shattered relationships” between mothers, their infants, and their partners. The UK mental health charity Mind points to the spiraling impacts of difficult births, citing the experience of one woman who said:
I had a traumatic birth. I was so petrified that my son would die that in my head it was easier not to love him just in case.
Establishing negligence
Though traumatic births can be extremely psychologically damaging, they are not always caused by medical negligence. In many cases, there is nothing that a medical practitioner could have done to foresee or change the outcome of a difficult pregnancy. If a traumatic birth and its ensuing effects are found to have been preventable, however, then a plaintiff may be able to make a claim for obstetric negligence.
As outlined in our earlier posts, there are two tests that are used to establish negligence in any medico-legal claim. These are known as the Bolam Test and the Bolitho Test. The Bolam Test, which was introduced in 1957, states that if a doctor or medical practitioner “acts in accordance with a responsible body of medical opinion, he or she will not be negligent.” The Bolitho Test updated this by clarifying that the medical opinion followed by the doctor must also be logical. For more information on this, see our posts on Bolam and Bolitho.
In the case of traumatic births, some of the reasons why a medical practitioner might be found guilty of obstetric negligence are as follows:
Misinterpreting scans or signs that should have predicted abnormalities in the foetus or potential harm to the mother.
Advising an inappropriate delivery method that leads to a painful or traumatic birth experience.
Failing to manage high risk pregnancies appropriately.
Causing unnecessary damage during a vaginal delivery or caesarean section, particularly to the patient’s uterus, bowels, or bladder.
In some cases, obstetric negligence can also cause damage to the baby during birth. For example, children may be born with cerebral palsy or Erb’s palsy (a kind of paralysis caused by injury to the nerves in the arm). In the most severe cases, obstetric negligence can cause unnecessary infant death.
Any of these devastating circumstances could conceivably lead to depressive or PTSD symptoms in the mother and would potentially be grounds for a claim of obstetric negligence.
Summary
Obstetric negligence refers to the failure to prevent foreseeable harm to a mother or her infant during a pregnancy or birth. Pregnancies or births that cause ongoing psychological damage to the mother are often referred to as “traumatic.” 34% of women report suffering from traumatic births. The most common psychological disorders that result from traumatic births are PTSD and postnatal depression. Even if a person does develop these symptoms, though, that does not necessarily mean that they would be able to make a successful claim for obstetric negligence. Any negligence claim would have to pass the Bolitho and Bolam tests, demonstrating that the medical practitioners responsible for handling the pregnancy and its aftermath did not act logically and in accordance with a responsible body of medical opinion.
This post is provided for general information purposes and is not intended to cover every aspect of the topics with which it deals. It does not constitute medical, legal, or professional advice, nor is it necessarily an endorsement of the views of Professor Elliott, the U.K. Centre for Medico-Legal Studies, its employees, or its affiliates. Though we aim to ensure that all information is accurate at the time of posting, we make no representations, warranties or guarantees, whether express or implied, that the content in the post is complete or up to date.