Anne Nicholson Weber: 00:00 Today I’m talking to Dr. Elizabeth Pearce, a clinical psychologist with advanced training in perinatal mental health. Dr. Pearce is also a doula and a childbirth educator, and the creator of the Birth Profile Assessment, which is a tool to help pregnant women guide their choices around birth. Welcome, Dr. Pearce.
Dr. Elizabeth Pearce: 00:19 Thank you so much. I’m really happy to be here with you.
Anne Nicholson Weber: 00:22 I appreciate your joining me. There seems to be an increasing awareness that for many women, the experience of birth is traumatic, while for others the birth experience can be empowering, very satisfying, even ecstatic. What would you say are some of the factors that can drive those differences in how a woman feels about her birth experience?
Dr. Elizabeth Pearce: 00:47 I’m so happy that you’re asking that question and that you led by acknowledging the prevalence of birth trauma. I was actually going to throw out a couple of numbers really quick here. As we talk about this, 25 to 34% of women have a birth that causes trauma symptoms later for the woman. That is a staggeringly high number. And so your question about what are the factors that can help a woman to have a good birth, you know, to avoid birth trauma — I think that’s setting the bar really low — but to have a good birth. And what we know about that is that a woman’s subjective sense of safety and support and autonomy during birth are some of the biggest predictors for how she will go on to feel about her birth later. So that really sets the stage for her postpartum wellbeing as she processes the birth. You know, whether your birth was great or difficult, women go on to really think a lot about their births and kind of process the memories of that. So you’re really setting the stage for postpartum wellness, um, bonding with your baby — so much about that early parenting journey is set up by how your birth experience goes.
Anne Nicholson Weber: 02:03 So to me, safety seems like — depending on how you define it — different from the other two. Support is clearly to do with the behavior of the people around you. And autonomy likewise, I would say, although that may also be driven by your own, um, personality and how able you are to assert yourself. But safety just on its face seems like an objective thing. Were you actually — did your birth go spin out of control? Did you have an emergency? Is that what you mean by that? Or is there more to it?
Dr. Elizabeth Pearce: 02:38 There is so much more to it. Safety, the way that I mean it — and I think the way that we understand it as a predictor of birth trauma — is very much more subjective. Uh, you know, I can think of examples. I’ve been in the birth room with a number of women. I’ve been in the therapy room postpartum with many women. And what stands out to me about their sense of safety, you know, and whether they go on to develop symptoms of trauma, has to do with how they experience their birth, how they experience the events of labor. And I can think of moms right off the top of my head who on paper looked like they had a very straightforward birth and there was nothing emergent that happened, it looked like their birth actually adhered pretty closely to their written birth plan. And yet their experience during birth was that they felt alone.
Dr. Elizabeth Pearce: 03:33 They felt that their birth team was not checking in with them. We know that the labor experience is stressful and it’s very intense <laugh>. And so subjectively going through an intense endurance marathon-type event where you are in discomfort and you are having to cope with a very challenging process, if you feel like you’re on your own with that . . . Again, depending on personality factors, some women will kind of center in and do very well, maybe turning inward and feeling they can sort of do that independently. But for many, many women, the subjective feeling of — Was my birth team attentive to me? Were they checking in with me? Were they helping me understand what was happening at each stage along the way? And then, especially if an intervention was being suggested to me, was that coming with an adequate amount of information and my team not only helping me make the decision, but supporting me in how I felt about that decision? — especially if it’s a departure from the birth plan. So there are very many, I would say, subjective elements that go into a feeling of safety. Were the people that were there to help me actually helping me and did I feel connected with them? Did I feel that my wellbeing was a priority to the people around me? And that goes much further into a mom’s sense of safety than just what the medical events were in the course of her labor.
Anne Nicholson Weber: 05:10 So thinking about the, as you say, rather staggering prevalence of trauma, what do you think . . . where is the failure happening in those three elements? What isn’t happening that women need most commonly?
Dr. Elizabeth Pearce: 05:26 Women need to be the center of their care. And, you know, I think a couple of things that happen with regard to women’s birth choices — and how that can unintentionally set them up to not have the safety and support that they would want to have — a couple of those pitfalls are, “I really like my OB, I’m just gonna stick with that person and I’ll have my baby at the hospital where they have privileges. This is a relationship that’s been working for me.” And what breaks down there is, you know, not realizing that when you become pregnant, you have a need for a different type of service at that point. So, you know, thinking critically, taking that step back and saying, “I’m essentially shopping for a new type of service here, now that I need pregnancy care and I need birth care.”
Dr. Elizabeth Pearce: 06:17 So I think that gives you a different lens as you ask questions in your appointments with your provider, and as you think about what you’re looking for in a provider, in a setting, a birth setting, to help you feel safe and supported. And the other mindset that I’ve encountered is, “I just wanna have my bases covered.” So, you know, this is a mom who says, “I think I would like to be in a hospital so that all those medical interventions are close by if I need them. And I think I’m gonna work with a doctor, an OB, in that setting because they would be ready at a moment’s notice to offer a medical intervention if I need it. And then, because I want a low intervention birth, I’m gonna hire a doula and I’m gonna take a really good childbirth class”, right?
Dr. Elizabeth Pearce: 07:06 And so that can feel like, wow, I’ve covered my bases. However, in reality, and speaking as a someone who’s been a doula, in those kinds of settings it can end up feeling like there’s a lot of tension, a lot of disparity between these different parts of your birth plan. So you’re in a setting that typically does birth a certain way, and now you’re adding into that a doula and your own birth knowledge and training that you’ve done to try to have maybe a different kind of birth than what is routinely offered there. And that tension, I think, can really lead to a sense for a mom of not feeling as safe and in harmony with her birth setting and team as she would like to be.
So I think those are a couple places that the breakdown can enter in as a mom starts to think about, you know, “where should I give birth?
Dr. Elizabeth Pearce: 08:05 Who do I want to work with?”
And then we’ve got, you know, individual factors as well, you know, personality, history, you know, what each mom brings to the table. Because what makes you feel safe is going to be different from what makes me feel safe. And there are going to be a lot of similarities probably, but there are also going to be differences based on the fact that you and I have different lived experiences, and we have different histories in our relationships with authority figures and caregivers in our lives. And that comes into play when you’re right in labor. So there are a lot of those individual differences as well that I don’t know that women have been encouraged to think about
Anne Nicholson Weber: 08:46 Your description of the tension in the labor room when a woman is — I mean, most commonly the situation is she wants to have a physiologic natural birth in a setting that really isn’t geared to that. And it seems to me there are really two pitfalls there. One is that it’s just harder for the people who are providing care to do something that isn’t really what they do. I mean, they have their ways of doing things. Institutions are set up with routines, and maybe most importantly, a culture — a culture of attitudes towards birth and a culture of attitudes towards whether birth is safe and how to make it safe and so forth. So they’re bringing their ideas of safety into the room.
But the other thing is that if there is that tension, that difference, and your idea is, “ well that’s fine. I’m just going to say no to the things I don’t want. I’m gonna navigate it,” you’re putting yourself in a place where you need to use a different part of your brain than is the part that births. Do you agree with that? And would you say more about that?
Dr. Elizabeth Pearce: 09:49 I agree completely. I love that we’re kind of shifting into this idea of what parts of a woman are involved in birth. And it’s a very instinctual, sort of primall part of you, where you are really needing to surrender and relax and get out of the way in a lot of ways, um, for labor to unfold. And when it comes to needing to advocate for yourself, that involves a lot more of your prefrontal cortex and getting involved in information and, um, maybe stepping outside of what’s really comfortable for you. And your brain cannot be both in a relaxed state and in a state of self-preservation, advocate for myself, potentially have even a mild confrontation with a team that’s recommending something I don’t want — those are very different parts of your nervous system that would be in play.
Dr. Elizabeth Pearce: 10:43 And so going into a birth setting and working with a provider where you think you may need to do a lot of that advocating to try to stand up for the birth choices that you want — I mean, I think that’s very likely to work against the natural flow of labor. You may run into problems with the hormones of labor kind of dwindling in your body and labor progress stalling out. Which, you know, then we get into kind of a cyclical need for more interventions, because you’re not feeling relaxed, you know, that synergy isn’t happening with oxytocin and the endorphins. So absolutely, that creates kind of a tension even within the woman: relax and allow labor to unfold, but also be on guard <laugh>. And those two things are very difficult to coexist with each other. So, I actually think in some cases the medical team ends up looking like the hero for saving a woman from a situation they sort of contributed to.
But one of the things that we assess in our birth profiler tool is, what do you believe about birth?
Dr. Elizabeth Pearce: 11:49 Do you believe it’s unpredictable? Do you believe it’s scary? Do you believe it’s a medical — emergency might be too strong of a word, but is it something that you really must have a medical team to guide and help and rescue you along the way? Or do you view it as a normal natural event? It does reflect some beliefs. And we want women to know and reflect on what their beliefs are about birth prior to going into the labor room, and to be in a place who believes similarly to them about birth, so that those beliefs, that approach is in harmony, and we hopefully can decrease the tension that may arise in the birth room.
Anne Nicholson Weber: 12:29 So I think that you are saying something which is essentially the premise of BirthGuideChicago.com, which is that a good fit with your provider is one of the very best ways to increase your chances of having a satisfying birth experience. So maybe we should go now to the Birth Profile Assessment and talk about what are some of the elements of my personality as a birthing woman that could impact the type of provider I should be looking for?
Dr. Elizabeth Pearce: 13:02 Yes, there is so much. We’ve really tried to create a pretty detailed tool that asks a number of questions in a few key areas and helps really maximize a woman’s chances of finding that good fit with a provider and also with the setting. So we ask questions related to personality — about half of the assessment tools relate to personality. We ask about three key areas. We ask about assertiveness. We wanna help women identify, you know, how assertive am I normally, how assertive am I under pressure? And to tap into that and to draw out an example in this scale of the tool, a woman who scores lower on assertiveness — meaning she maybe tends to be quieter about her needs, maybe she has a harder time speaking up, particularly with an authority figure like a medical doctor or even a nurse.
Dr. Elizabeth Pearce: 13:57 There can be a power differential felt in the room with the medical provider. So she’s going to want to be very careful about her choice of provider, and choose somebody whose normal routine approach to birth is very closely aligned with her own, so that she doesn’t feel like she needs to step out of that relaxed, comfortable space that she needs to be in and kind of be someone she’s not or really tax her energy to do that. She’s most likely gonna want a provider who spends a lot of time with her prenatally in her appointments so that she feels that provider really knows her. And then also a provider who spends a lot of time with her during labor so that she has a sense of connection. This provider is attuned to me, they are seeing what I’m going through, and they care and they’re offering help.
Dr. Elizabeth Pearce: 14:48 That’s gonna tend to be a midwife <laugh>, I believe, in terms of the time spent. You know, then we do offer that feedback that we recommend you consider a midwife and interview some midwives and look for those key elements in a provider.
Now there are OBs that also practice, I think, closer to a midwifery model. It’s maybe less common. So we do recommend asking a lot of questions, and we give specific questions for those moms to be asking. But that would be one example. So that’s just the assertiveness scale. So we also ask about the personality trait of control. How much control do I like to have? How active do I tend to be in taking control, advocating for what I want, or do I tend to be passive and accept what is happening to me?
Dr. Elizabeth Pearce: 15:38 So this is a little more of the internal component where assertiveness is that outward — you know, how readily do I convey and express those things. And then we also ask about flexibility. As you know, the process of labor is such a balance, <laugh>, it’s a balancing act between standing up for what you want and advocating, but also being flexible because it’s a process that does not unfold with perfect predictability. And so a balance between control and flexibility is ideal. And we want women to know, What is my sort of inherent balance to those traits? What do I want to consider if I’m a very intentional person and I like things to go according to plan, and I’ve got a birth plan I’m really invested in? What do I need to be thinking about with regard to choosing a birth setting, choosing a birth provider that will maximize those odds so that I don’t feel really thrown off and potentially traumatized by my birth going very differently than that? And then we do encourage women to think about, in their birth preparation, skills and mindset that will help them maybe increase their flexibility or increase their assertiveness, giving them skills and tools to be able to work with their team in a way that most leverages their natural personality.
Anne Nicholson Weber: 17:05 Are there — the attributes you ascribed to midwifery sounded kind of all good. <laugh>, for whom wouldn’t those be good? Are there personalities for whom the culture of a hospital with an OB might actually be better?
Dr. Elizabeth Pearce: 17:20 To me, personality-wise, I don’t think that there are very many women who would just inherently do better with that. Now, I think that there are personality types that may be more resilient, who I think would be higher in assertiveness, higher in control, and probably higher in flexibility. Those are women who may feel like they could be adaptable to a variety of birth settings. To me the deciding factor though is really more about your risk level and your pregnancy and what level of medical intervention is needed. And that might guide that decision to birth in a hospital, work with an ob. And then within that we want to look at leveraging your personality, your history. Some of the other scales that we look at include your confidence, your beliefs about birth, which I had mentioned earlier — you know, leveraging all these other pieces so that if your medical setting is — if your birth setting is sort of decided for you based on your risk level and your medical need, then how can you best work within that based on who you are and what you’re bringing to the table.
Anne Nicholson Weber: 18:25 What would you see as some red flags that a provider or a setting that you’ve chosen is less likely to give you those three elements — you talked about the feeling of safety, of support and autonomy — and that might be reasons to reconsider your choice?
Dr. Elizabeth Pearce: 18:46 Number one that comes to mind for me is how do you feel when you’re in that setting? I think it’s so important to visit the birth setting that you plan to give birth in. And also pay attention to how you feel in appointments with your provider. Because how you’re feeling your nervous system is going to tell you, do I feel safe? Do I feel heard? And do I feel at ease? Can my system relax here? So I think getting there to the birth setting to be able to pay attention to that and notice how your system responds to it. It is an important component and it could be a red flag if you walk in and it tenses up <laugh> in that setting.
Anne Nicholson Weber: 19:22 So you’re saying really trust your antennae, listen to your antennae, and believe that that matters.
Dr. Elizabeth Pearce: 19:27 Yes. You know, I think you have to be intentional in looking for the red flags. They’re not going to come to you. So others that come to mind are, what are the rates of C-section? What are the rates of interventions? What are the rates of things that are done that aren’t really what I’m looking for? Snything over like an eight to 10% C-section rate is setting yourself up for too high odds for a surgical birth.
Anne Nicholson Weber: 19:54 You’re talking about a primary C-section rate, not overall?
Dr. Elizabeth Pearce: 19:57 Primary C-section. Correct. Thank you. And so thinking about it in terms of that c-section rate being your odds of having a c-section in that setting. If that place has a 20% or a 30% C-section rate, that’s incredibly high. And you’re kind of saying, okay, I’m fine with having a one-in-three or a one-in-five chance of having a surgical birth, in essence. And if half their patients have epidurals and you’re hoping not to have one, you deserve to know that. Find out if you’re walking up to McDonald’s and trying to order a pizza. <laugh> We want to know, am I going to the place that does what I’m looking for? Am I embarking on a path that I’m gonna be sort of fighting against to get what I want out of my birth experience?
Anne Nicholson Weber: 20:42 We’ve talked a lot about women who instinctively want less interventions in their birth, which isn’t everybody. Plenty of women feel from the outset that they would like to just have an epidural. They’re not really aiming for a physiologic birth, the term that we’ve been using. Is there anything different in anything that you’ve said for someone in that category?
Dr. Elizabeth Pearce: 21:09 I would say no. I think if you know from the outset that pain management is important to you and you would like to be able to have an epidural when you want it, all of the same considerations are going to come up. You want to know what is routinely done, how will I be cared for, how will I be managed? There are gonna be some additional questions if you know that you want an epidural. How will you care for me? How will you make sure that I’m still getting enough movement to encourage labor progress and encourage my baby to be in a good position, a favorable position for descent? You know, I think that does direct your choice because an epidural is going to be available in a hospital. It’s not going to be available in a freestanding birth center. So you may want to have a medical intervention like an epidural, and still have very woman-centered, one-to-one care, and say, well, I’d really like to have a midwife and a doula. So we’re still looking at similar factors and preferences and what’s gonna be the best fit for me.
Anne Nicholson Weber: 22:11 Let’s talk just a little bit — first of all, what are some of the most common stories that result in feelings of trauma? Can you give some specifics or typical scenarios?
Dr. Elizabeth Pearce: 22:26 Absolutely. Some of the most common things that I hear that result in trauma, where a woman really struggles with her relationship with her birth, are feeling alone, right? Feeling disconnected from her team. And I’ve heard that from women whose birth was progressing normally. They felt like they were alone with the sensations and the intensity of labor. They felt unprepared for that, which I think could be identified as a separate element there — your birth knowledge and understanding when I feel the sensation of a contraction what’s happening, and knowing that that intensity is not harming me and it’s not harming my baby. And so the understanding of that. I think having good birth knowledge is a real predictor because a woman who has an understanding of what’s happening may be likely to feel less traumatized by even just the normal sensations and unfolding of labor.
Dr. Elizabeth Pearce: 23:20 So birth knowledge, sense of connection with her team. I’ve talked to women — and I’ve been in the labor room for this kind of event as well — where the intensity of the moment of delivery can be quite something. And so the baby is born, and the birth team’s focus — all the focus– is on the baby in that moment, very often. And for a mom who’s just given birth, and especially if she’s a first time mom, she doesn’t know if all that attention on baby means that something’s really wrong, or if everything’s okay. And that is something I think, mom feeling kind of hung out to dry. “I don’t know what’s happening. Everyone’s focused on my baby, standing around my baby, and I am like an outsider at my own birth all of a sudden in that moment of delivery.” And that detachment — if there’s not somebody checking in with mom, whether it’s the partner or the doula or a nurse or midwife or doctor thinking to pop their head up and let mom know, “babies looking fine, you know, this is what we’re doing, how are you?” — that in itself can really lead to a sense of trauma. Again, even if everything is fine. I’ve heard that through I think a number of birth stories, in processing births with women. Again, like just going back to that subjective feeling of like, I had no idea what was going on. And if a woman — if you feel out of control and you feel like you don’t know what’s going on, you’re more likely to feel traumatized by that event.
Anne Nicholson Weber: 24:48 So that makes me think of two things. One is I think a lot of women are — and well, couples are — unprepared for how little time their provider is going to spend with them in the birth room during labor. So if you’re expecting that you’re going to have kind of consistent support from hospital staff, you’re very likely to be surprised and concerned to find that you’re much more on your own. And for some women, that’s probably fine. You’ve talked about differences in how particular personalities are going to respond to that. But it is something to be prepared for.
But this other scenario you described right after delivery, that’s so interesting to me and it really resonates. And I’m thinking immediately of — there are a number of hospitals, at least in the Chicago area, where immediate skin-to-skin contact is part of the normal routine, iIs fully supported. The baby exam is delayed while mother and baby kind of get a moment together, or even half an hour or several hours if there are no signs that anything’s wrong. And that makes me think that that could be an important marker, not just because that immediate skin-to-skin is so helpful for bonding, but that it’s avoiding this scenario, as you describe it. I can understand why that is traumatic, could be traumatic. So that’s very interesting to me.
Dr. Elizabeth Pearce: 26:11 And that’s sort of a marker, you know, thinking about the baby friendly designations, you know, looking at hospitals that routinely practice those kinds of things like immediate skin-to-skin, encouraging breastfeeding, delayed baby exams or doing that at the bedside. Very glad that you brought all of that out. Because those are some of those things to look for in a hospital setting that may be more favorable. They understand the importance of keeping you together and affirming that initial bonding.
Anne Nicholson Weber: 26:41 So one more topic, if we could just spend another few minutes on — we’ve talked a lot about trying to avoid birth trauma by making good choices, by preparing yourself, but inevitably some women will have births that are traumatic, whether they could have been avoided or not. And the question is then, what do you do about that? Like, what are the signs of trauma? What should you, if you’re experiencing that, look for in the way of support?
Dr. Elizabeth Pearce: 27:09 Yes. So if I could speak first to mitigating trauma in the birth room. If a partner or a support person has any sense that mom just looks really disconnected, detached, she’s got a look on her face like she’s a million miles away, in that moment you may be able to mitigate some of that trauma by connecting with her, right? Trying to make eye contact. “Hey, just checking in. How are you doing? Here’s what’s happening with you and your baby.” Um, you may be able to, to mitigate what may already be going on — if mom seems, again, a million miles away or a look of fear on her face, that there is intervention possible even in the birth room. But let’s say, you know, birth has happened, it’s been challenging and it’s brought with it some elements of trauma.
Dr. Elizabeth Pearce: 28:01 Mom felt unsafe or disconnected from her team, and has now developed some real struggle related to that trauma. I would be looking for intrusive memories of the birth, whether that comes in the form of — it can be nightmares, it can be waking, you know, flashbacks, intrusive memories where, just at unwanted times, images and memories of your birth are coming back and really feeling haunted by that. And like it’s going on repeat in your brain, that’s a hallmark of trauma.
Feeling detached from your baby. If you are struggling to bond and you almost have a sense of like, this doesn’t even feel like my baby. I know I’m holding a baby, but I don’t feel a sense of connection or bonding. That’s something to pay attention to. That can be an indicator of birth trauma or postpartum depression, which are two different things.
Dr. Elizabeth Pearce: 28:57 But we know that bonding with babies can be compromised in both those cases. And to women who find themselves struggling to bond I would say, don’t lose hope. That bond will come. Always, at some point. But it’s worth noticing that, because it may be a sign that you need to reach out for some help to get over that hump and be able to resolve trauma, deal with other postpartum mental health issues that may be there.
So, intrusive memories, a lack of bonding with your baby, a feeling of numbness overall, trying to avoid anything that reminds you of your birth, which might include your baby, which can kind of then feed back into that lack of bonding. But if you are really trying to avoid anything that reminds you, right, like you don’t even want to drive past your doctor’s office, you don’t want to go to that postpartum checkup, you don’t want to see the hospital, you don’t want to to talk about birth.
Dr. Elizabeth Pearce: 29:50 That avoidance can also be a hallmark of trauma.
And the help that is available: you know, I would just encourage moms to be letting their partners know, I’m not sure I’m okay, I’m really struggling. That can be a first step, you know, when it feels difficult to reach out beyond that, just let your partner know, someone you trust that’s in your circle already. Um, I’m not, okay. I’m having a really hard time and it scares me, you know. And for a lot of women, they fear that it means they’re a bad mom. There can be a lot of irrational thoughts that wrap up into this. I’m a bad mom, they’re gonna take my baby away if they think there’s something wrong with me. None of that’s true, but ccan contribute to women being reluctant to let somebody know that they’re struggling with trauma or another postpartum mental health struggle.
Dr. Elizabeth Pearce: 30:39 So let your partner know. And, you know, I think that we could be doing better culturally in terms of postpartum follow-up with our providers, but everybody has at least one appointment, and the ability to call. I would say if that postpartum appointment has passed and you’re still struggling or you’re starting to notice red flags related to trauma, reach out because help is available. Connect with support groups. I would actually recommend, you know, postpartum.net is just another resource. They have many support groups and local providers listed, if you are in need of help for you, for your mental health postpartum. So just to give a mention to that. I want women to feel like they know where to turn to start to process that trauma. There is help and healing to be able to make peace with your birth experience.