Why Birth Trauma Needs To Be Part of Black Maternal Health Conversations

Zahara Johnson says she'll never forget the day she gave birth to her son, but it's not for reasons one might expect. Despite having what she felt was a straightforward pregnancy, Johnson learned that she required an emergency cesarean section after four agonizing hours of labor. By the time she was wheeled into an operating room, the epidural had worn off significantly. "They just started cutting me open," she says. "I could feel everything."

Johnson says she screamed and told providers about the pain; however, her pleas went unanswered. While Johnson recognizes that her son was in danger, she says nobody communicated with her. "I made a scene," Johnson says. That was what it took to be heard. Eventually, her birthing team put a mask over her face, and she fell asleep. "It makes me angry," Johnson says. "I could have died of shock from the pain."

"[Birth trauma] can look so different across different birthing people and the intersections of their identities." —Rachel Hardeman, PhD, MPH

Johnson's case may be unique (though there are other instances where people received c-sections without proper anesthesia), but 45 percent of birthing people have experienced birthing trauma or an event that's considered deeply distressing. Birth trauma can involve things like experiencing life-saving measures, receiving inadequate pain management, navigating language barriers during labor, or having your partner ejected from a hospital room. "[Birth trauma] can look so different across different birthing people and the intersections of their identities," says Rachel Hardeman, PhD, MPH, associate professor in the Division of Health Policy & Management at the University of Minnesota. She adds that these experiences are subjective and data is hard to quantify.

However, it's well-documented that Black women are two to three times more likely to die of complications related to pregnancy and childbirth, according to the Centers for Disease Control and Prevention (CDC). The leading causes—hemorrhage, cardiomyopathy, and thrombotic pulmonary embolism–are largely preventable. If Black maternal mortality is higher, given social determinants of health and implicit bias within the healthcare system, trauma rates are likely higher for Black birthing people.

Black birth trauma is multifaceted

After a personal traumatic birth experience, Saleemah McNeil, CLC, MS, MFT, went from being a doula to counseling individuals who've faced traumatic birth. Like Johnson, McNeil says that lack of communication contributed to her distress. During labor McNeil says procedures happened without explanation, and ultimately she needed an emergency c-section. "It was very traumatic because I didn't know much of what was going on," she says, adding that she didn't realize "this experience fucking sucked" until she was leaving the hospital.

Physicians can significantly impact a person's birthing experience, McNeil says. "Explain why something, like pulling out the placenta, needs to happen," she says. "Supporting [patients] through the journey, and being able to sit with them in the aftermath...is a world of difference versus just tugging and pulling and stitching and poking."

Informed consent and clear communication are essential for healthier birth outcomes, McNeil says. However, those factors are even more instrumental for survivors of sexual violence. According to the American Psychological Association (APA), one in four Black girls will be sexually assaulted before they turn 18, and one in five Black women has experienced rape. During labor—when birthing people may feel less control over their bodies—McNeil says survivors are often retraumatized and triggered. This can happen before and during the delivery; however, it can also occur postpartum. If, for instance, a nurse or lactation consultant touches someone's breasts without being mindful, it can bring up past abuse, McNeil says. Making sure providers are trauma-informed can help reduce added risk.

Additionally, Dr. Hardemen explains that trauma can be inherited through the stories and even the habits of elders. "There is intergenerational trauma of being a Black birthing person in America," she says, adding that knowing stories from family members and older generations can impact the birth experience.

Ultimately, residual effects of birth trauma impact the postpartum period overall. Around four percent of births lead to postpartum post-traumatic stress disorder (PTSD), and 15-19 percent of individuals with high-risk pregnancies are at risk for PTSD and depression. For many birthing people, having more children may depend on healing childbirth wounds and fears around seeking medical care. Compassion and informed consent help patients feel safe and supported throughout their process, McNeil says." And that's what can change a very traumatic experience so that it doesn't leave residual effects."

There are Black-led birth equity resources and solutions

Even though the onus shouldn't be on individuals to save themselves from a harmful medical institution, Dr. Hardemen says that Black pregnant people do need to find ways to navigate these experiences. "We have to ask ourselves: How do I, as a Black pregnant person, protect myself?" she says. "That's always such a frustrating question…because you shouldn't have to be worrying about protecting yourself from a systemic failure."

Dr. Hardeman says that there are organizations that are striving for birth equity. She recommends following the work of Black Mamas Matter Alliance and the National Birth Equity Collaborative, both organizations providing resources for birthing people and advocating for research and policy changes. Sister Song is another organization with a similar mission and structure, including leadership training and education. Additionally, maternal health advocate, Kimberly Seals Allers, created the Irth App, which helps Black birthing people read reviews of doctors and pediatricians. Allers launched the app to help eradicate disparities and give Black birthing people vital information they need to navigate the healthcare system.

Birthing centers have also emerged as an alternative to hospital settings, including Roots Birthing Center in Minneapolis, one of five Black-owned birthing centers in the US. Birth trauma-focused therapy is offered at quite a few birthing centers, including Oshun Family Center in Philadelphia, where McNeil is the CEO. Additionally, birth workers can help mitigate complications and trauma both in birthing centers and traditional hospital settings. Research published in the Journal of Perinatal Education in 2013 found that when people use doulas during their birthing journey, they are two times less likely to experience birth complications for themselves or their infant.

Policy changes are also afoot: The Black Maternal Health MOMNIBUS Act of 2021, which was put forth by the congressional Black Maternal Health Caucus, includes 12 bills designed to create equity and eliminate disparities that influence adverse outcomes for marginalized birthing people and their babies. These include extending insurance past birth, funding community-based initiatives that tackle disparities early on, and supporting pre and postnatal mental health and substance abuse concerns. Several bills explicitly state that there will be federal funding for programs that reduce and prevent bias, racism, and discrimination while facilitating trauma-informed care.

As for Johnson, she says her traumatic experience has made her reluctant to give birth again. However, she hasn't ruled it out completely. Johnson says with an advocate, like a doula, by her side, she could have a more positive deliver and experience the birthing joy that her mother always described.


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