Category: Childbirth

Improving clinicians understanding of effects nutrition can have on maternal health and fetal and neonatal development can have a considerable impact on achieving a healthy pregnancy and reducing childhood morbidity (Symonds and Ramsay 3). It is the statement from the book Maternal-Fetal Nutrition During Pregnancy and Lactation by Symonds and Ramsay that reflects the authors main idea. This book is very useful for people who are somehow connected with pregnancy such as mothers, doctors, nurses, and others. In the book, the authors are concentrated on demonstrating that nutrition during pregnancy and lactation is extremely important with the focus on nutritional requirements, the physiology and phycology of pregnancy, and factors that affect the nutrition during pregnancy and lactation.

The book is divided into three sections. The first section refers to nutritional regulation and requirements for pregnancy and fetal growth. The second section is aimed at describing nutritional requirements for lactation and infant growth. The third section is called Specialized requirements, and it is devoted to such topics as teenage pregnancies, vegetarianism during pregnancy and lactation, and multiple pregnancies.

It can be said that the authors present the essence of main topics. For instance, Symonds and Ramsay state that nutrition is important even in the early stages of pregnancy, and they support this idea describing the process of the placenta formation and emphasizing the key role of nutrition during this process (4). In their book, Davies and Deery pay a lot of attention to micronutrients and macronutrients (33). Symonds and Ramsay also investigate this topic and underline that micronutrients and macronutrients contribute to supporting mothers vital activity and the development and growth of her baby (48). As it is described by the Healthline, micronutrients are dietary components, such as vitamins and minerals, which are only required by the body in small amounts; macronutrients, on the other hand, are nutrients that provide calories or energy (Nutritional needs during pregnancy par. 2). In the first section, Symonds and Ramsay support this definition and describe main macronutrients that should be included in a womans daily diet such as protein (for the proper growth of fetal tissue), calcium (for building fetal bones), iron (to supply enough oxygen to the fetus), folate (to reduce the risk of neural tube defects), and others (56).

It goes without saying that the authors follow their strategy to remark on the effects that nutrition have on maternal health and fetal. They analyze gathered information and make connections between the nutritional requirements and different stages of fetal development and growth. It is worth mentioning that the authors fulfill the following task and success with their objectives in the book. In the second section of their book, the authors consider breastfeeding and highlight key factors related to it. A lot of authors such as Aune et al, Kornides and Kitsantas, Victora et al argue that breastfeeding protects children from many diseases, and Symonds and Ramsay agree with them (67). Besides, in the last section of the book, Symonds and Ramsay analyze and pay a lot of attention to some specific problems that occur during pregnancy.

To sum up, in the book Maternal-Fetal Nutrition During Pregnancy and Lactation, the authors illustrate the idea of the connection between nutrition and pregnancy. They accentuate the idea of the importance of nutrition during pregnancy and lactation. This book is an excellent guideline for doctors, health-care workers, scientists, and pregnant women. The authors fulfill the following task and reveal why nutrition plays a vital role in the development and growth of the fetus.

Works Cited

Aune, Dagfinn, et al. Breastfeeding and the Maternal Risk of Type Two Diabetes: A Systematic Review and DoseResponse Meta-Analysis of Cohort Studies. Nutrition, Metabolism and Cardiovascular Diseases, vol. 24, no. 2, 2014, pp. 107-115.

Davies, Lorna, and Ruth Deery. Nutrition in Pregnancy and Childbirth: Food for Thought. Routledge, 2013.

Kornides, Melanie, and Panagiota Kitsantas. Evaluation of Breastfeeding Promotion, Support, and Knowledge of Benefits on Breastfeeding Outcomes. Journal of Child Health Care, vol. 17, no. 3, 2013, pp. 264-273.

Nutritional needs during pregnancy. Healthline: Medical Information & Trusted Health Advice, 2016, Web.

Symonds, Michael E., and Margaret M. Ramsay. Maternal-Fetal Nutrition during Pregnancy and Lactation. Cambridge University Press, 2010.

Victora, Cesar, et al. Breastfeeding in the 21st Century: Epidemiology, Mechanisms, and Lifelong Effect. The Lancet, vol. 387, no. 10017, 2016, pp. 475-490.

The technological advancement and expansion of biomedical knowledge may assist pregnant women in delivery and may help them avoid multiple birth complications. The medical and obstetric assistance are especially important when a womans health condition is unsatisfactory, and there are fewer chances for the positive pregnancy outcomes. However, many women in the USA prefer natural childbirth which implies minimum obstetric and medical assistance.

The choice of a particular birth option can be influenced by the cultural and social backgrounds of a woman, the availability of support resources, and potential health risks. The choice of an appropriate childbirth option is important because it can help to prevent birth complications that may threaten the psychological and physical well-being of a pregnant woman and affect infant development in a negative way.

Hospital birth is a common option for labor and delivery. Traditional hospital birth is associated with medical support and professional supervision during the gestation period. Many hospitals in the USA provide prenatal care practices such as parenting and childbirth training which help women to reduce stress and to feel more secure. Although hospital birthing is commonly perceived in close relation to medical interference and regarded as unnatural, many US medical settings give women an opportunity to have more natural delivery without medication yet with the assistance of a midwife (Miller & Shriver, 2012).

However, in the emergency situations, technological and obstetric interventions are needed for the maintenance of maternal health and infant survival. Nowadays, about 26% of births in the USA were supported by the surgical interference, and the researchers consider that many of such deliveries were unrelated to the factors of maternal health and childs survival (Crossley, 2007).

It is observed that the rates of caesarean deliveries have risen dramatically in a few decades, and it is considered that women may prefer medicated hospital childbirth because it is commonly associated with a high level of professional expertise and less painful experience (Miller & Shriver, 2012).

The natural home births became very popular. Many women prefer to reduce medical control and management in labor and delivery. Natural delivery often takes place at home among the family members, and because of the comfortable conditions and psychological support the woman may feel less stressed. Natural home childbirth is often idealized and regarded as the best option, but the lack of pregnancy monitoring may provoke adverse outcomes and birth complications. Therefore, at least a small amount of obstetric supervision is still important to ensure the positive pregnancy outcomes.

Factors of Childbirth Decisions

There are close interrelations between cultural contexts, social organization and influences, personal values and the selection of childbirth options. For example, it is observed that natural unassisted homebirth can be largely influenced by the religion-centered lifestyle (Miller & Shriver, 2012, p. 713). Natural delivery and mothering are also frequently preferred by the women who are attached to family and are primarily child-oriented.

At the same time, the women who prefer hospital childbirth associate the availability of midwives and the presence of physicians during delivery with safety (Miller & Shriver, 2012). It this way, cultural contexts, as well as the personal values and beliefs, play a decisive role in childbirth decision making. However, it is possible to say that the role of personal values and preferences in childbirth decision making is significant in case many options are available for a woman, and she does not have any strict financial or social constraints in following the personal interests.

The choice of the childbirth option can be motivated by the socioeconomic position of a pregnant woman. The costs of deliveries in the US hospitals may exceed $6000 (Miller & Shriver, 2012). The preparation training practices, prenatal care and monitoring, courses and other pregnancy management activities may become unavailable for many women from poor families who do not have medical insurance.

In some cases the assisted homebirth may be more expensive than a hospital delivery, and many women who cannot afford to have a homebirth but regard it as an ideal sense of safety are forced to give birth in less comfortable conditions due to the financial situation.

Birth Complications

Although a woman may have no health problems during the pregnancy, the complications during delivery still may arise. For example, the complications may be related to the abnormal position of the fetus in the uterus that may lead to the prolonging of labor, increase of pain and traumatic experience during delivery. The fetal malposition and the consequent prolonged labor often require the surgical intervention, and the severe cases can result in the mothers morbidity (Senecal, Xiong, & Fraser, 2005). It also increases the risks of the infant morbidity that may include the admission to the neonatal intensive care unit, and multiple traumas.

There is the risk of umbilical cord prolapse and umbilical cord compression as well. Umbilical cord provides the flow of blood to the fetus and its disposition during delivery provokes the emergency situations. Umbilical cord compression decreases the blood flow and may provoke the fetal heart rate drops (Ashington, 2009). The severe consequences of umbilical cord compression are uncommon and they usually require the caesarean section.

Umbilical cord prolapse is also a rare phenomenon, but the respond to this critical situation should be urgent. It occurs when the umbilical cord precedes the baby in the birth canal during the delivery (Maher & Heavey, 2015). When the fetal cord can be felt or seen on the perineum after the rupture of membranes it is defined as the overt prolapse, or when it is not seen but it moves alongside the fetus body, it is defined as the occult prolapse (Gabbay-Benziv et al., 2014). Cord prolapse may be spontaneous, or it can be developed as a consequence of the artificial and premature rupture of membranes (Maher & Heavey, 2015).

The frequency of the complication occurrence is low but it may lead to the infants death. Cord prolapse decreases the blood flow and leads to the deceleration of the fetal heart rate. The perinatal mortality associated with the cord abnormality is asphyxia, prematurity and low body weight (Gabbay-Benziv et al., 2014). The prolonged umbilical cord prolapse increases the chances of negative outcomes in both preterm and term deliveries. Thus, the quick medical respond to the emergency situation is a necessity.

The prolonged umbilical cord prolapse can result in the development of physical abnormalities in the infant. It is reported that about 15% of all neonates influenced by the prolapsed cord during delivery were referred to the intensive care units due to respiratory problems, such as transient tachypnea or respiratory distress syndrome, or hypoxic brain injury (Gabbay-Benziv et al., 2014). The fetal hypoxic brain injury caused by the reduction of blood flow influences the development of brain structure in a negative way and, as a result, the infants cognitive and motor development can be delayed (Macnab, 2012).

The intervention of cognitive and sensorimotor deficits should include the stimulation of the neurocognitive mechanisms in a child. The caregivers need to communicate and actively interact with the infant and create a favourable sociocultural and physical environment to facilitate the sound neonatal development.

The cord abnormality does not usually have a severe physiological negative impact on mother, and the physical distress can be caused only by the medical interventions. However, the critical health condition of a newborn child may create a significant psychological burden for the mother and her family. The post-delivery intervention that may include the admission to the intensive care unit does not guarantee the positive outcomes and implies large financial costs, and it thus can be unaffordable for the low-income families. Based on this, it is recommended to take the preliminary measures to ensure the medical intervention in case of emergency will be rapid.

The factors increasing the risk of cord prolapse include the fetal malpresentation, multiple pregnancy, congenital abnormalities, or prematurity (Maher & Heavey, 2015). These factors can be identified through prenatal screening. The early identification of risk factors allows the physicians and parents to make necessary preparations for a quick intervention. It is recommended for a woman who is at risk of umbilical cord prolapse to choose the supervised hospital as a childbirth option and increase medical control during labor.

The level of medical staff skilfulness and technological advancement in the setting is significant as well. The opportunity to communicate about the medical decisions and procedures included in the labor management can be an important factor for a woman because it can increase her confidence in the positive delivery outcome and develop the sense of safety.

The Role of Culture in Family and Birthing Decisions

Depending on the culture, the decisions individuals make about birthing and family can vary significantly. For example, Brazil is the country where the rate of cesarean sections comprises forty percent; furthermore, if to analyze private hospitals, the rate can even be higher than forty percent. This occurs due to the fact that the majority of women that give birth in private clinics come from high, and middle class thus can afford the procedure.

On the contrary, in Japan, there is a prevailing paternalistic pattern of approach towards childbirth  when the doctor makes all the decisions concerning the health of the mother and the fetus. Such an approach is used in countries like Australia only in specific emergency situations when there is little time for deliberations. Women in labor hospitalization in Ethiopia is acceptable if the cervical opening is more than three centimeters.

If the cervical opening is smaller than three centimeters, a woman is sent home until she surpasses the requirement. Another interesting differentiation in cultural decisions about childbirth can be found in India where it is illegal to determine the sex of the fetus during the prenatal screening tests (Queensland Health Multicultural Services, 2014).

On the other hand, some cultures, especially countries that practice Islam, resort to female genital mutilation (FGM) that has a long-term effect on the health of women and their pregnancy. FGM is usually conducted in childhood to preserve the culture heritage of a particular nation, a supposed initiation into womanhood, or other non-surgical reasons. FGM makes the pelvic examinations during pregnancy almost impossible, create a risk for the mother and the fetus without an opened birth canal, complicate the monitoring of the fetal distress.

Thus, the ability or inability of women to make decisions about family and childbirth are deeply rooted in cultural beliefs and traditions, no matter how specific or inexplicable they may be.

References

Ashington, G. (2009). Umbilical cord anomalies. Ultrasound, 17(2), 106-108.

Crossley, M. L. (2007). Childbirth, complications and the illusion of choice: A case study. Feminism & Psychology, 17(4), 543-563. Web.

Gabbay-Benziv, R., Maman, M., Wiznitzer, A., Linder, N., & Yogev, Y. (2014). Umbilical cord prolapse during delivery  risk factors and pregnancy outcome: A single center experience. Journal of Maternal-Fetal & Neonatal Medicine, 27(1), 14-17. Web.

Macnab, A. (2012). The etiology and evolution of fetal brain injury. Brain Damage  Bridging Between Basic Research and Clinics. Web.

Maher, M. D., & Heavey, E. (2015). When the cord comes first. Nursing, 45(7), 53-56. Web.

Miller, A. C., & Shriver, T. E. (2012). Womens childbirth preferences and practices in the United States. Social Science & Medicine, 75(4), 709-716. Web.

Queensland Health Multicultural Services. (2014). Cultural dimensions of pregnancy, birth and post-natal care. Web.

Senecal, J., Xiong, X., & Fraser, W. D. (2005). Effect of fetal position on second-stage duration and labor outcome. Obstetrics & Gynecology, 105(4), 763-772. Web.

Introduction

The birthing process alone makes delivery a significant life experience, in addition to the fact that birth represents the beginning of a new existence. Physical and psychological difficulties, including coping with pain, losing control, and potential medical procedures, are part of the birthing process, which frequently involves C-sections). Nevertheless, not much information is available about the long-term psychological and physiological aspects of delivery since studies on this subject have only started to gain traction. Both mental and physiological changes are present during the whole gestation period. However, it appears to be more prevalent in the first trimesters. Thus, birthing is a difficult, laborious procedure with lasting repercussions, which involves anxiety, postpartum depression, a high risk of developing diabetes, cardiovascular disease, hyperpigmentation, and spinal issues.

Physical Effects

The first physical issue women are exposed to after childbirth is gestational diabetes. As per the research, 36% of female patients with a record of gestational diabetes (GDM) who do the 75-gram glucose tolerance test six to twelve weeks after delivery are shown to have glucose resistance (Neiger). Meanwhile, 2-16% are confirmed with type 2 diabetes mellitus (Neiger). According on risk variables and the period of follow-up, women with past gestational diabetes mellitus had a 36-70% chance of subsequently acquiring type 2 diabetes (Neiger). It is critical for women who underwent GDM to receive the proper follow-up care since diabetes damages multiple organs over time, frequently before clients are evaluated. After childbirth, women at risk of GDM might be exposed to issues with the cardiovascular system, blood vessels, renal system, eyes, and nerves.

What is additionally noteworthy is that Prediabetes was liked to a greater likelihood of compound coronary heart disease, strokes, and all-cause death relative to normoglycemia. A potential risk for the emergence of endothelial dysfunction and coronary heart disease is GDM (Neiger). It is indeed likely that during or even before a birth that is affected by gestational diabetes mellitus, artery dysfunction that raises the risk of eventual cardiovascular disease accumulates.

Another long-term physiological effect of childbirth is the development of cardiovascular disease. The postpartum phase is marked by considerable structural and cardiovascular changes. During pregnancy, heart output rises; yet, in the first few hours after birth, due to uterine contractions and the relaxation of venous system restriction, there seems to be a growth in the circulating volume of blood, increasing pulse rate and heart function by 60 to 80% (Chauhan and Tadi). Even so, this upsurge in cardiac function quickly begins to decline to pre-labor levels in several hours and to pre-pregnancy levels two weeks after giving birth. Pregnancy-related complications, such as hypertension or premature birth, might reveal families who are vulnerable to cardiovascular issues later in life (Chauhan and Tadi). It is unknown if the prenatal problem causes heart illness or if the strain of pregnancy reveals an existing propensity (Chauhan and Tadi). Nevertheless, a rising cohort of people now has this elevated cardiovascular disease risk after childbirth, which might lead to issues for both the mother and, especially, the child.

Furthermore, hyperpigmentation and stretch marks are among the long-term effects of childbirth. The most often observed skin alteration during pregnancy and after childbirth, impacting 85% to 90% of women is hyperpigmentation (Chauhan and Tadi). The idea is that increased amounts of estrogen, progesterone, and endorphins throughout gestation and childbirth make melanocytes more vulnerable (Chauhan and Tadi). Tyrosine kinase is upregulated as a result of the bodys immune substances the placenta produces, which encourages the production of more pigment (Chauhan and Tadi). Melasma and linea nigra, two pigmentation alterations related to pregnancy, are often gone in six to eight weeks (Chauhan and Tadi). Additionally, telangiectasis and spider angiomata can result from increased estrogen levels.

However, it is often the case when hyperpigmentation does not leave after childbirth, which is can be a long-lasting physical effect. In addition to hyperpigmentation during pregnancy and childbirth, the torso muscles are pulled beyond their frequent range of motion (Chauhan and Tadi). As a result, they take longer to recover their normal tension and flexibility, reaching pre-pregnancy levels in two to three months. Still, the stretch marks that can be observed in the torso and leg regions can still be present in the patient due to divarication.

Finally, diastasis recti is frequently observed in women after childbirth. After birth, the musculature experiences diastasis recti, which causes them to lose strength by becoming lax. Diastasis recti can make it difficult to maintain good posture and can cause pelvic and lower spine discomfort aggravated. Research warns that diastasis recti could result in a variety of functional issues if it is not treated. Every muscle and region around the abdomen has to find ways of making up for overstretching. A lot of people have back discomfort, an active pelvic floor, and quite stiff hips and buttocks. Consequently, women experience issues with their spinal area.

Mental Effects

As for mental and spiritual effects, among the most frequent among young mothers is the depression that takes place after childbirth. In line with other studies linking postpartum depression to views of more challenging newborn behavior, maternal postnatal depression indicated the presence of disturbed, erratic, and impatient infant behavioral style (Power et al.). It is possible that a yelling, disturbed child will impact the mothers temperament, which will be made worse by lack of sleep, and a restless child will react negatively to a stressed-out mother (Power et al.). What is noteworthy is that research suggested that unfavorable childbirth experiences and postpartum psychological conditions play a part in depression since depression levels were associated with parental frustration (Power et al.). Consequently, it can be linked to physical and emotional birthing process (Power et al.). In this sense, spiritual changes of the mother are evident due to her changes in beliefs and desires, increasing frustration.

Additionally, a challenging or intrusive delivery may immediately result in an increase in unsettling newborn behavior, and prolonged newborn crying forecasts subsequent EPDS levels, especially if the mother does not feel capable of soothing the child (Power et al.). Oxytocin encourages connection and bonding between the infant and the mother (Power et al.). However, women who are depressed and have lower oxytocin levels seem to be more prone to disregard their childs messages (Power et al.). Therefore, even when parental attitude recovers, postnatal depression, and parental disengagement are linked to interactional challenges that impact mother-infant attachment and infant health.

Lastly, maternal anxiety is a mental alteration in female bodies following childbirth. It has been shown that more than 20% of young mothers have postpartum anxiety, which is a common issue that has negative effects on the family (Walker et al.). It is linked to distress on an individual level, psychological and organizational instability, and poor family dynamics and both circumstances have been demonstrated to have a detrimental impact on relationships between mothers and their infants. Following childbirth, the mother might be exposed to postpartum anxiety (Walker et al.). These uncontrollable, worrisome sensations frequently dominate their thinking. It is indeed normal to feel slightly anxious after childbirth.

However, if women experience postnatal anxiety, the fear may become overwhelming and lead to the insomnia in the new mothers. Insomnia after childbirth is the struggle to consistently fall asleep or remain asleep after the delivery (Naki Radoa et al.). Not many mothers have postnatal sleeplessness, yet they might experience it for a number of reasons, such as hormonal imbalances or lifestyle modification (Naki Radoa et al.). Nevertheless, patients ought to receive assistance if they have trouble going to sleep or staying asleep. Taking care of sleep issues immediately might lower the risk of postnatal depression.

Conclusion

Hence, birthing is a challenging, stressful process with long-lasting effects that involve spiritual, bodily, and mental changes that a large number of women experience. Gestational diabetes is the first physical condition that women experience after giving birth. According to the study, 36% of female patients exhibit glucose resistance. The onset of cardiovascular disease is another long-term physiological impact of delivery. Stretch marks and hyperpigmentation are two additional long-term impacts of delivery that are among the most often seen skin changes. Lastly, strain after delivery commonly results in diastasis recti in women. When it comes to psychological and spiritual impacts, depression following childbirth is one of the most common among young mothers. Finally, childbirth changes and stress in female bodies cause maternal anxiety. Most young mothers develop postpartum anxiety, which, if left untreated, might progress to depression.

Works Cited

Chauhan, Gaurav and Tadi, Prasanna. Physiology, Postpartum Changes. National Library of Medicine, 2021. Web.

Power, Carmen et al. Physical and Psychological Childbirth Experiences and Early Infant Temperament. Frontiers in Psychology, vol. 13, 2022, pp.1-9. doi:10.3389/fpsyg.2022.792392

Naki Radoa, Sandra et al. Anxiety During Pregnancy and Postpartum: Course, Predictors and Comorbidity with Postpartum Depression. Acta Clinica Croatica, vol. 57, no.1, 2018, pp.39-51. doi:10.20471/acc.2017.56.04.05

Neiger, Ran. Long-Term Effects of Pregnancy Complications on Maternal Health: A Review. Journal of Clinical Medicine, vol. 6, no. 8, 2017, pp.1-22. doi:10.3390/jcm6080076

Walker, Annika L., et al. The long-term impact of maternal anxiety and depression postpartum and in early childhood on child and paternal mental health at 1112 years follow-up. Frontiers in Psychiatry, vol. 11, 2020, pp.1-12. doi:10.3389/fpsyt.2020.562237

Introduction

This report aims to discuss the purpose of Public Health England (PHE) and the short- and long-term implications of smoking during pregnancy and childhood. Besides, it will explore the role of the midwife in health promotion, the parent-infant attachment in correlation to local and national guidelines and communication strategies that influences behavioural changes.

Government Agenda

Public Health England (PHE) is a government agency within the UK; the main purpose of PHE is to protect and improve the nation’s health and wellbeing. They thrive to reduce inequalities through working with the National Health Services (NHS) and local authorities to implement and deliver specialist services to improve the health of the general public (Public Health England, 2019).

The publication of Public Health Outcomes Framework (2013) put in place new direction for the health care system with an importance on ‘improving and protecting the nation’s health while improving the health of the poorest fastest this links with the NHS outcome framework who place great emphasis on preventing premature death and treating and caring for people in a safe environment and protecting them from avoidable harm. PHE uses indicators to examine trends within the public health through data collection, which is carried out every three years, these indicators divided into four domains.

• Domain 1: Improving the wider determinants of health
• Domain 2: Health improvement
• Domain 3: Health protection
• Domain 4: Healthcare, public health and preventing premature mortality

Domains 2 and 4 are indicative in the implementation and provision to influence and combat smoking in pregnancy. Domain 2 place great emphasis on supporting people to make a healthy lifestyle choice to reduce inequalities such as low birth weight of term babies, breastfeeding, smoking prevalence and smoking status at the time of delivery. While domain 4 aims to reduce people living with preventable ill health and premature deaths by improving the health outcome of babies first year of life through antenatal and neonatal intervention service delivered by local authorities support mothers with socioeconomic background and health behaviour that can impact the infant health. The national ambition by 2020 is for a smoke-free generation where the prevalence of smoking to 5% or below and that all pregnancy is smoke-free (Department of Health, 2017). The public health strategy 2020-2025 seen in (appendix 1) aim to promote a smoke-free society and a healthy start in life. According to better births care bundle( Cumberlege (2016), early intervention is key the reducing incidence of smoking in pregnancy and gap inequality to improve health outcome by reduction stillbirth caused by smoking in pregnancy. Public health England aims to reduce smoking in pregnancy 6% by 2030, through collaborative working on a national and local level to renovate and improve maternity care and bring about safe equity of care for all and provide more opportunities to access services. (Department of Health, 2017; NHS Improvements, 2017; Public Health England, 2019a; The Royal College of Paediatrics and Child Health, 2017).

Smoking is defined as the act of inhaling and exhaling the fumes from tobacco products (Rose & Hilton, 2020). Smoking is seen as a major contributor in ill health and death, it is reported that smoking contributes to an estimated 489,300 hospital admissions and an estimated 77,900 deaths per year (Office for National Statistics, 2019).

Smoking is also linked to inequality and poor health outcomes and yet 10.4% of women smoke at the time of delivery (Office for National Statistics, 2019). Smoking and inequalities are codependent as smoking is more common in people from a low socioeconomic background World Health Organisation (2014), people who suffer from mental health are more likely to smoke Mental Health Task Force (2016) and that children are likely to smoke if their parents smoke (National Health Service, 2017). Smoking harms health as smoking is associated with increased risk in heart attacks, it’s the leading cause of lung, stomach, mouth and throat cancers, causes fertility issues in men and women, causes brittle bone and osteoporosis in women and increases the chance of having a stroke by 50% this can be seen in (appendix 4) (National Institue for Health and Care Excellence, 2014) . Smoking in pregnancy is said to cause 2200 premature births, 5000 miscarriages and 300 perinatal death each year (Smokefree Action, 2017). Additionally, it is contagious behaviour and are often seen higher amongst those from deprived socio-economic background.

Smoking during pregnancy and childbirth and its effects

It is well evident that smoking in pregnancy negatively impacts maternal and foetal health, as smoking is associated with increased risk of stillbirth, placental abruption, miscarriages, ectopic pregnancies, low birth weight and preterm birth (Royal College of Physicians, 2013). It has been found that mothers who smoke were likely to experience deep vein thrombosis, stroke, pulmonary embolism, myocardial infarction and are 15 times likely to have bronchitis. (Roelands et al,. 2009).

Maternal smoking is found to increase the risk of paediatric cardiovascular mortality to the offspring Leybovitz-Haleluya (2018), having a child with cleft lip and pallet Barbosa (2015), poorer outcomes in children and higher risk for neurological related hospitalisation and attention deficit hyperactivity disorder (ADHA) (Gutvirtza et al. 2019). Animal studies conducted by Xiao (2007) demonstrated that nicotine increase vascular resistance and decrease uterine blood flow and that prolonged exposure to nicotine can disturb brain development. Other studies have identified that smoking during pregnancy is linked with sudden infant death syndrome Shah (2006), childhood obesity von Kries (2002) and childhood asthma (Neuman et al. 2012). According to the Royal College of Obstetricians and Gynaecologists (2015), maternal smoking attributes to 1/3 of stillbirth and neonatal deaths.

The role of the midwife in promoting Health, parent-infant attachment and how communication strategies can elicit change in behaviour

Midwife role

Pregnancy is regarded as a teachable period and during this period midwives and maternity services play an important role in the health and social care of the pregnant woman and her family. Midwives are the first point of contact for the woman and her family during pregnancy and research suggest that women are more receptive in behavioural changes (Murin et al. 2011). Its is therefore essential that midwives provide evidence-based information to educate and support women to make informed choices about their healthcare and wellbeing. such as smoking cessation. It is the duty of all health professional from preconception to motherhood to promote effective healthcare (PHE, 2019b). However, there are specific guidelines detailed in the PHOF (2013) that outlines the midwife involvement in the reduction of health inequalities by helping people to make healthy choices, the prevention of premature mortality and reducing the gap between communities.

According to the NMC (2018), the midwife’s role is to provide person centre evidence-based care, to act as advocates to the woman and her family and cater to her physical, social and psychological wellbeing. Therefore midwives should be knowledgeable about the health and social care need of the local community, have a good understanding of the local health and social care system and be vigilant in the identification of women at risk and act quickly and appropriately in supporting her and her family to access the necessary services (Chief Nursing Officers of England, Northern Ireland, Scotland and Wales, 2010). The midwife’s role is therefore embedded in Public Health as they aid in addressing inequalities by working in a multidisciplinary team to provide education, awareness and wellbeing to the woman and her family. It is therefore vital that the midwife can identify women at risk of smoking during pregnancy and refer promptly, according to NICE (2010) every woman should be offered CO2 testing at booking and every subsequent appointment and a referral made when necessary. Also, she should be provided with information on the benefits of stop smoking as well as the effect smoking has on herself and unborn child in a person-centred approach.

The current approach in supporting women to stop smoking in pregnancy depicted in (appendix 6); NICE (2019) explains the importance pregnancy women smoking status via CO2 testing; referring made to stop smoking service; where clear consistent person-centred care is provided by trained stop smoking advisor to women and her family to assess and address social care need and provide the right avenue to stop smoking whether non-pharmacological or pharmacological ie the use of Nicotine replacement therapy or cognitive behavioural therapies. Data obtained by non-stop smoking service reports that 44% of pregnant women who set a quit date done so successfully and that 63% of all pregnant women who quit smoking were confirmed via CO2 monitoring (NHS Digital, 2020). There is no specific guideline on smoking in pregnancy at Trust A, however, they do follow NICE (2010) in CO2 and refer women to non-stop smoking service where appropriate but CO2 testing is not routinely carried out at every appointment.

It is well evident that the quality of care women receive from maternity service during pregnancy and the perinatal period greatly influences the life chances of babies, especially those with complex needs like smoking (Zeitlin et al., 2009). However, maternity services are struggling and incapable of providing the level of care needed due to lack of funding, workforce and pay caps resulting in many women having little or no access to the support they need; according to a survey conducted by The Royal College of Midwives ( 2018), there is a shortage of 3500 midwives in England and some maternity unit report closure for 10 or more times on occasions.

Anderson (2018) reports that about 40% of local authorities in England are cutting stop smoking services, underfunding in these services reduces the support midwives has in encouraging safe pregnancies as there is little or no services to refer women. This can be observed in areas where access to stop smoking services are limited compared to those that are not. There are over 300 non-stop smoking services in Hertfordshire and Hertfordshire health improvement service (2019) offer pregnant women the chance to quit smoking from 12 weeks and if they attend the full programme and quit smoking they receive £300 shopping vouches compared to Norfolk where there is no incentive and non-stop service are not easily accessible in all areas see (appendix 2). This can be observed in smoking status at delivery which 6.3% in Hertfordshire compared to 13.4% in Norfolk see (appendix 3). This was echoed in a meta-analysis which concluded that financial incentives decrease the number of women smoking in late pregnancy (Chamberlain et al. 2017).

Communication strategies

Evidence has shown that women are more receptive to change in behaviour if midwives take a non-judgemental approach (Grice & Baston, 2011). The midwife should utilise every encounter were possible to build a trusting professional relationship through effective and sensitive communication to influence the quality of interaction between self and woman (Allison, 2012). Making every contact count (MECC) is an evidence-based method introduced by public health to improve people health and wellbeing by encouraging a change in behaviour through competent and confident healthcare worker, MECC engage people in conversation about addressing risk factor such as smoking ( (PHE, 2018)). This approach is a requirement of NHS contracts and is embedded in NHS long term plan (2019) which places great importance on increasing available support to enable people to manage and improve their health whilst enabling that behavioural intervention is accessible to all.

Piper (2005) behaviour change agent suggest change through education, where the midwife uses health education to empower the individual to be more motivated and responsive to change. Other evidence suggested that motivational interviewing, cognitive behavioural support and structured self-help and support from evidence-based stop-smoking services support pregnant women to quit smoking (NICE, 2010; NICE 2018a; NICE 2018b). However, it has also been established that Stigma from friends, family, strangers and health professionals may lead to hidden smoking habits (Grant et al. 2018). Therefore conducting CO2 testing for all women ensure that everyone is screened, smoking status confirmed and appropriate support is provided. This posses a barrier to women obtaining evidence-based support to stop smoking. McAndrew (2012) found that women from a deprived area and low socioeconomic background are more likely to smoke in pregnancy compare to people of less deprived. This coincides with (Grant et al. 2018; Mental Health Task Force, 2016; NHS England, 2019).

Parent infant attachment

The midwife plays a vital role in infant feeding choices and close relationship building as they are the initial point of contact for pregnant women and their families (Murin et al. 2011). Midwives must adhere NMC (2018) which dictates that the woman and her family first must be supported with evidence-based information enabling her to make informed choices about herself and her baby’s health. Midwives are encouraged to comply to the BFI standards with regards to skin to skin contact, relationship building, encouraging a close and loving relationship and having structured programmed to encourage and support breastfeeding (UNICEF, 2013). Having a meaningful conversation antenatally and postnatally encourages a parent to create a bond with their baby; antenatally stroking and talking to bump aid in fetal brain development and postnatally being close and responding to cues and cuddling provides comfort and calmness to baby and parent (NICE 2018a; NICE 2017;UNICEF, 2013 ).

There has been a wealth of evidence that suggests keeping baby close and provide skin to skin contact is essential in initiation of breastfeeding and maintaining of breastfeeding, keeping mother and baby calm, it aids in having and maintaining a close relationship (Moore et al. 2016). This was reiterated by Crenshaw (2014) who suggests it best practice to keep mother and baby close. It is evident that having a close mother-baby relationship aid in neurological, emotional and physical development as evidence suggests that early and often interaction between parent and child provide has a positive impact on their development Gerhadt (2014) while Moore (2017) found that children who had less physical contact were more distress as an infant and underdeveloped for their age. This stresses that 1001 critical days (2015) is essential as the initial experience in a baby’s life shape the social and emotional development.

Breastfeeding is known to provide beneficial health outcomes for the infant and their mothers and it vital that midwives inform the mother about the benefits as the component of breast milk protects the infant as it contains growth factor that aid in growth and development of the baby’s gut, it has enzymes that aid in digestion and destroys bacteria, it contains viral fragments that help to develop the infant immune system, it contains antibodies of mother pass infections and hormones that support baby’s immature immune system (UNICEF,2013). In the mothers breastfeeding for less than 12 months significantly reduce the risk of breast and ovarian cancer (Chowdhury et al. 2015; UNICEF UK, 2012). Also, the longer and greater number of children and breastfeeding for a little at 3 months is associated with a reduction in the risk of ovarian cancer (Li et al. 2014; Luan et al. 2014; Modugno et al. 2019).

Maternal smoking is also associated with asthmas incidence in children and adolescence Thacher (2014), however, breastfeeding for as little a four months is known to reduce the risk of asthma (Scholtens et al . 2009). This has been observed in (Appendix 6) as hospital admission due to asthma was higher in areas that were worst off or more deprived highlighted in red. It is recommended that mother continue breastfeeding if they smoke as the level of nicotine that in breastmilk decline significantly after 30 mins of smoking (Calvaresi et al. 2016). Stopping smoking before or during pregnancy decreases the risk of infant mortality, stopping early attributes to the greatest benefits for the child and stopping at any period results in health improvements (The Royal College of Paediatrics and Child Health, 2017). Interestingly, breastfeeding alone could save the NHS £21 million and eliminate illness (UNICEF UK, 2012).

Introduction

Many people would refer to the birth of a child as a joyous experience, but for some women, it can be traumatic and lead to post-traumatic stress disorder. Much of the research has shown that there are many different things that can cause a woman to perceive their childbirth experience as traumatic. However, 54.6 % of women reported that it was related to lack and or loss of control (Hollander et al., 2017). Some other factors that make birth trauma more likely include lengthy labor or short and very painful labor, stillbirths, poor postnatal care, or lack of privacy and dignity. In addition, the type of birth, as well as the type of interventions that may or may not have been applied, have an impact on the perception of one’s birth experience (Aktas, 2018). In turn, this affects the mother’s attachment to her newborn and can pose for an even higher risk of depression (Dekel et al., 2019).

Method

For the purpose of this literature review, we will be looking at the factors that influence a traumatic birth experience in women ages 18-35. Databases used include CHINL, EBSCOhost, ScienceDirect, and PubMed Central. We excluded dissertations from our search. Key search terms were traumatic birth, trauma, PTSD, depression and impaired bonding, and support.

Results

We found 16 articles relating to traumatic birth experiences, PTSD, and postpartum bonding issues from 2015-2019. Four were about possible ways to decrease PTSD in traumatic birth experiences. Five were about perception of a traumatic birth. Three talked about impaired bonding and negative effects of relationships. Four talked about predictive factors for traumatic birth and PTSD.

Risk Factors for a Traumatic Birth

Upon review of the literature, it was found that women who had a history of two or more previous traumatic life events or who had depression before or during pregnancy (Polachek I, Dulitzky et al., 2016) had a higher prevalence of birth trauma and symptoms of postpartum PTSD (Brittain et al., 2015). Levey (2018) had similar findings and also went on to say that having a history of abuse, or having experienced a sexual assault, are all risk factors for the development of antenatal anxiety, depression, and post-traumatic stress symptoms after birth. Weinreb (2018) supported these findings and also determined that women who had a lack of social support were also more at risk.

Events During Prior and During Labor that May Lead to Trauma

Many women would expect pregnancy to be life-changing and encouraging but due to constant bodily changes and hormonal spikes, a woman’s pregnancy period can take a multitude of directions. Not every woman gets a joyous birth experience due to an inexplicable number of factors. Ghanbari-Homayi (2019) identifies predictive factors involved in traumatic birth experiences. Results found that the independent predictors of the traumatic birth experience were related to antenatal factors including lack of exercise during pregnancy and intrapartum factors including the absence of pain relief during labour and birth (Ghanbari-Homayi et al., 2019). Atkas (2017) had similar findings. Could this be decreased if women were more actively involved in their care and decisions during pregnancy and labour? The answer is yes, allowing involvement from the mother during antepartum and intrapartum can have greater results during the postpartum period. Perception of pain, limitations during labour such as choice of delivery position, prenatal care, and health insurance are all issues discussed. Socio-demographic factors such maternal obesity, marital status adolescent pregnancies, etc. can lead to traumatic birth.

Poor Relationship with Medical Staff

Interaction with personnel. The subject of interactions, relationships, and care from medical staff was common among the literature. It was found that negative experiences with medical staff, insufficient support, lack of communication, and feeling ignored/rushed were noted as some influences of a women’s perception of a traumatic birth experience (Reed et al., 2017; Rodríguez-Almagro et al., 2019). Huang (2019) identified a perceived lack of support, communication, and poor service from medical staff as an influencing factors for traumatic birth as well. Some women even stated that they felt manipulated by their providers (Greenfield et al., 2019). Birth is supposed to be a beautiful experience but how can it be when women feel like what they want is being ignored or pushed to the side? Many women believe that having better communication and support from their care providers could help decrease the instances of traumatic birth experiences (Hollander et al., 2017). Women need to be able to have a quality relationship with their providers in which trust, communication, and mutual respect can be established and maintained.

Control. Lack of control was another theme identified in the literature as an influencing factor in the perception of a traumatic birth experience. According to Hollander (2017), 56% of women attributed their traumatic birth experience to a loss or a lock of control. When asked what they thought could have been done differently in order to reduce or prevent the trauma many believe that they could have asked for more or less actions and interventions. Imagine being a woman and your midwife is pushing an intervention on you that you don’t want but your concerns did not matter. Now, what if you wanted a specific intervention performed but because it was time-consuming it was thrown to the wayside. I believe that this would make anyone not have a good experience, especially one as intense as childbirth.

Postpartum Concerns After a Traumatic Birth Experience

Postpartum Depression. Birth and the birthing process itself are already a cause of concern for mothers-to-be. There are so many stages and steps that occur and are needed in order for a birth to be successful. Along with these stages come different moods and experiences. Antepartum usually brings about joy, excitement, and worry. Intrapartum experience all depends on the perspective of the mother and her experience. However, postpartum usually has a negative label attached. Postpartum blues and/or depression is something that many mothers experience. Each case is different depending on the person, however, having a traumatic birth experience can take postpartum depression to a whole new level. Abdollah (2016) found that Traumatic childbirth with disturbing memories can have negative impacts on the mental health of postpartum mothers

Impaired Bonding. The effects can vary from the state of mentality the mother is in, to the behavior the mother exhibits. For example, many researchers have included in their reviews that the mother and newborn relationship and well-being suffer following a traumatic birth experience (Furuta et al., 2018; Hairston et al., 2018). Dekel (2018) had similar findings. Impaired bonding between mom and newborn can occur, which can pose a huge threat to the newborn as bonding has shown to be crucial to the development of the newborn. Mothers may not have the motivation or the strength to care for their babies after such a traumatic event. The baby may go unfed, unchanged, and also may suffer neglect or abuse. In addition, a mother could not be caring for herself, her other children, or her significant other. This causes couples to experience negative emotions towards each other as well as a loss of intimacy (Delicate et al., 2017). It is a vicious cycle that needs to be broken in order to ensure that a mother can have the best possible chance at healthy, functioning relationships with not only her child(ren) but also her partner.

Conclusion

It is our belief that the factors that influence a traumatic birth experience need to be addressed prior to birth in order to prevent the negative effects. Trauma is a subjective experience however, there were many similarities in the feeling and emotions for the women in these studies. There needs to be a focus on the quality of provider interactions and education for care providers in maternity wards ensuring that they are striving for positive interactions with women. This means providing support, therapeutic communication, validation, acknowledgment, and respect. Although further research is needed, with this added support throughout all stages of pregnancy including postpartum, we believe it could help reduce instances of traumatic birth experiences. As well as decreasing the likelihood of mental health issues and strain on the family following birth.

References

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8. Greenfield, M., Jomeen, J., & Glover, L. (2019). “It Can’t Be Like Last Time” – Choices Made in Early Pregnancy by Women Who Have Previously Experienced a Traumatic Birth. Frontiers in Psychology, 10, 56. https://www.frontiersin.org/article/10.3389/fpsyg.2019.00056
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In a post-child-birth exit survey of 641 women, Abuya, et al. (2015a) found that D&A is perpetuated by health workers and other facility staff. Further, a systematic review of fourteen studies conducted in Nigeria by Ishola, Owolabi, and Filippi (2017) corroborates this and suggests that D&A was mostly reported as perpetrated by facility staff in their systematic review of fourteen studies conducted in Nigeria. Sadler et al. (2016) also report that D&A can occur when women interact with the providers or simply by the systemic failures at the facilities. The evidence, therefore, confirms that D&A is very likely to occur during any stage of pregnancy, including childbirth and ANC services, and a typology for D&A during ANC services should be looked into. However, even though the typology by Bohren et al.(2015) is based on evidence synthesis from a study conducted on women during childbirth, it has aspects which can be applied to women during ANC services.

Misago et al. (2001) noted that the 1970s and 1980s saw the inception of the humanization of childbirth movement in Brazil which was aimed at promoting respectful maternity care. Ratcliffe (2013) further suggests that the movement only lost its spotlight in the late 1990s and early 2000s having realized many of the principles of the movement and the concept of respectful care. Regarding the history of quality of care as a human rights need, Miller and Lalonde (2015) acknowledge that it was after the 1994 International Conference on Population and Development in Cairo, Egypt, that the quality of care was first framed in a human rights perspective and the rights of girls and women were strengthened in the context of reproductive health and health care. This human rights lens was, however, perceived to have failed not only to focus on D&A during childbirth but also to establish a link between adverse maternal health outcomes to abusive practices and the poor quality of care (Miller & Lalonde, 2015). The authors further note that it was not until the year 2000 that women’s rights to dignity and respect in childbirth became acknowledged in Latin America where, following a Birth Humanization Conference in Brazil, the Latin American and Caribbean Network for the Humanization of Childbirth (RELACAHUPAN) was founded.

The term D&A was introduced and conceptualized in the year 2010 (Ishola et al. 2017). The same study, however, suggests that research related to this subject has been going on for many years and supports the assertion that although D&A has been in existence for a while, it had not, until recently, received much attention (Ishola et al., 2017).

Hodges (2009) suggests that despite the presence of many caring and supportive physicians and hospital staff in the USA, anyone involved with birthing women had come across a form of abuse directed at women giving birth in hospitals, hence D&A. In 2012, it was reported that a woman sued the Southern General Hospital in Glasgow, United Kingdom, where she had gone to deliver her third baby and the hospital admitted to bullying her into taking precautionary antibiotics that she did not want or need (The Guardian, 2012). Vedam et al. (2017) cite a qualitative study of women’s experiences of hospital-based birth by Baker et al. (2005) that reported that over half of British women interviewed commented on the negative attitudes and behaviors of mid-wives.

Patel (2013) confirms that the prevalence of D&A in India is better illustrated by a young doctor, who on finishing his internship in a hospital, equated giving birth in a public hospital in India to third-degree torture in jails (Patel, 2013). In Pakistan, D&A is reported to be highly prevalent although under-recognized by women (Azhar, et al., 2017)

A systematic review (Ishola et al., 2017) suggests that D&A during childbirth occurs frequently in Nigeria and takes many forms with non-dignified care being the most common. Kruk, Paczkowski, Mbaruku, Pinho, and Galea (2009) conducted a discrete choice experiment in two hospitals in rural Tanzania where previously only a third of women would deliver in health facilities to find out the preferred place of delivery. Of the six facility attributes looked into such as distance from hospital, cost, type of provider, provider attitude, drugs and equipment, availability of free transport, the study revealed that the most important attribute to the patients was respectful attitude and availability of drugs and medical equipment, an indication of the presence of D&A.

Abuya et al.(2015b) in a baseline study measured the effect of a package of interventions to reduce D&A by women during facility childbirth in 13 hospitals using an exit survey. The findings revealed that 20% of the women reported a form of D&A within the 13 hospitals studied. Ratcliffe (2013) notes that even though D&A is a global issue affecting both developed and developing countries, there is no accurate estimate of its global prevalence

All this evidence suggests that D&A is prevalent and could be one of the major contributing factors to low facility-based delivery. However, all the literature indicates that even the history and prevalence of D&A mostly cover the problem during childbirth.

McMahon et al.(2014) report that women view D&A as being caused by overworked providers who are, as a result, unable to provide the required ideal care. Reader and Gillespie (2013) in a review of literature around neglect of patients in hospital, found that both proximal (mostly high workload) and distal (mostly organizational management) were responsible for the prevalence of D&A. This could be attributed to structural violence and perhaps the reasons for D&A in many Kenyan hospitals where the patient/provider ratio is very high.

2.3 Prevalence of Disrespect and Abuse

2.3.1 Experiences of Women with Disrespect and Abuse

McMahon et al.(2014) in their study in Tanzania narrate how a woman experienced neglect that exposed her child to danger. A woman in Nyeri Level 5 Hospital experienced neglect, making her deliver her baby while standing (Daily Nation, 2016). CRR & FIDA (2007) reported in their study that a woman reported that the provider used on her an unsterilized pair of scissors previously used on another patient. In the same study, a woman experienced neglect after the doctor left for the day and the available nurse told her she would not help her until the head of the baby came out and had to be helped to deliver her baby by a fellow patient CRR & FIDA (2007) after which the nurse asked the woman who had just delivered to get off the bed and clean the bed herself. Some women are neglected while about to deliver and end up delivering their babies on the floor (McMahon et al., 2014). A woman in Bungoma, Kenya, was physically assaulted by a nurse after calling for help in vain, causing her to deliver on the floor (Centre for Reproductive Rights, 2018).

McMahon et al. (2014 report that some women experience discrimination at the hands of the health care providers just because of their refusal to bribe or due to their economic status. They report in their study of cases where healthcare providers solicited for bribes from the women in order for them to be treated with speed as their situation demanded. Another case is seen where a woman had been informed of the required amount for the service provided but the cost was increased by the cashier and the woman was further threatened with detainment if she did not pay the amount (McMahon et al., 2014). Medicalization of childbirth including some unnecessary interventions is also experienced by women (Manning & Schaaf, n.d.).

2.3.2 Normalization of Disrespect and Abuse

Extant studies suggest that D&A has been normalized and accepted by both women and the providers. For example, a study by the Kenya Ministry of Health in March 2017 revealed that women justify D&A as a necessity in enhancing the safety of the mothers with the facility providers in the same study also agreeing that D&A is necessary, justified and that it guarantees women cooperation and focus on the birth process. For example, the providers alleged that slapping the women encourages them to push when they have to (The Standard, 2017). This is the same case in South Africa where patients perceived the poor treatment as an inseparable part of the procedure in clinics (Jewkes, Abraham & Mvo, 1998). The said normalization is evident and was manifested during their study in the manner women apologetically confessed to having been treated with care (Jewkes et al., 1998). The authors note that even though women reported neglect as one of the most distressing parts of their hospital experience, few women, including those who delivered without the help of a nurse saw the neglect for what it truly is. Manning and Schaaf (n.d.) suggest that in many cases, the reason women view D&A as normal is because D&A is so common that the women often expect it to happen. Freedman et al. (2014) corroborate this and add that even in cases where some behavior is viewed by the women as disrespectful, the providers would not agree to view it as disrespectful.

McMahon et al.(2014) suggest that a majority of women, but not their partners rationalize that workers were not giving ideal care due to the workload. This suggests that the men are more knowledgeable on what to expect in terms of quality care. Additionally, the authors reported that a woman who participated in their study said she delivered alone but rather than feel frustrated or angry she could only empathize with the working conditions of the workers. Moronkola et al. (2007) suggest that women who were unaware of their rights and had never been treated respectfully during maternity care often see D&A as the norm. Even though some women and providers agree on the necessity for slapping to save the baby’s life hence normalization, Warren et al. (2017) stress the need to call abuse for what it is.

Sadler et al. (2016) suggest that it is wrong to assume that women fully understand their options and are always able to make a choice regarding their health, hence the little knowledge on D&A. Perhaps the lack of knowledge calls for awareness creation among women on the need to understand their options and their healthcare rights. This normalization of D&A could be an indication of high prevalence downplayed by the lack of knowledge. D&A is not just as a violation of women’s rights but also as a phenomenon that should be nonexistent. The lack of knowledge on the part of the women is a clear impediment to the fight against D&A and a contributing factor to the perpetuation of this form of violence against women.

2.4 Effects of Disrespect and Abuse

Miller and Lalonde (2015) investigated the global epidemic of D&A and found that there is a link between D&A and negative birth outcomes whether directly or indirectly.

2.4.2.1 Direct Effects

Disrespect and Abuse affects birth outcomes, for example, when a woman is ignored or abandoned while in labor or during delivery leading to negative birth outcomes(Miller & Lalonde, 2015). In their study conducted in the Dominican Republic a woman went through neglect in a facility where she was for over 24 before any check-up was done on her and thereafter was found to have a ruptured uterus and her baby’s heartbeats were missing (Miller & Lalonde, 2015). World Health Organization (2016) agrees that neglecting women could make women suffer life-threatening and yet avoidable complications and constitutes a violation of trust between patients and the health care providers. In their study in Tanzania, a nurse neglected a patient, responded late, and consequently had to hold the baby without the help of gloves which is potential health hazard for the baby (McMahon et al., 2014). Neglect is recognized to have the possibility of negatively impacting the health of either the mother, her newborn or both by preventing timely or proper diagnosis and/or treatment of complications (Asefa & Bekele, 2015; Manning & Schaaf, 2017). Over-medicalization of childbirth including some unnecessary interventions contributes to morbidity and mortality (Manning and Schaaf, 2017). Raj et al., (2017) reported that women who reported D&A during pregnancy were likely to have complications during childbirth and in the postpartum period. A study by Center for Reproductive Rights ; Federation of Women Lawyers–Kenya (2007) reported that a woman reported to have tested HIV positive after delivery while the husband was negative, attributing her new status to the use of unsterilized scissors which had been used on another patient during her last delivery.

Additionally, there are other health outcomes of concern like adverse mental health effects over and above other poor physical outcomes (Manning & Schaaf, n.d.). Such mental effects can result in fear of childbirth, influence sexuality and the desire to have children, generate lifelong feelings of guilt and grief, and even trigger memories of sexual assault, if any, in some women (Manning & Schaaf, n.d.). Other forms of D&A such as lack of autonomy during childbirth has also been reported to disempower women reducing them to a state of passivity hence disabling them from being active participants in the birthing process (Warren et al., 2017).

In a study where 98% of the study participants had delivered in a facility and were attended to by skilled health care personnel, Miller and Lalonde (2015) found that maternal mortality was still high, a factor that was attributed to D&A. This is further explained by (Warren et al., 2017: 12) who noted that treatments of discrimination in a particular facility often led to the stigmatized and discriminated women bypassing the nearest facilities leading to potential morbidities and mortalities associated with delays during self-referrals. Moreover, cases, where a woman’s identification card is withheld until the bill is settled, indicates the woman in question is unable to seek further care or other social services where necessary.

The effects of D&A can only be underscored. Poor ANC care could lead to complications and even death and the ripple effect is that the lack of trust arising from D&A during ANC services could dissuade women from seeking skilled attendance. In order to address [maternal and] neo-natal mortality it is extremely important to increase ANC coverage and attendance (Doku et al., 2012). This perhaps is achievable if the matter of D&A is conclusively addressed.

Most of this evidence derived from studies conducted during childbirth point to the fact that D&A directly affects women negatively and therefore a hindrance to the effort of reducing maternal mortality. There was need, therefore, to look into the likely effects of D&A during ANC services.

2.4.2.2. Indirect effects of Disrespect and Abuse

While examining the global epidemic of D&A during childbirth, Miller and Lalonde (2015) reported that indirect effects may occur in cases where women who have previously experienced D&A in past deliveries, avoid future use of facilities, even if they suspect complications. Asefa et al. (2018) confirm this in their study of service providers, with most of the respondents (79.6%) agreeing that lack of respectful care discourages pregnant women from coming to health facilities for delivery. As corroborated by Kipronoh (2009), despite high utilization of ANC in Kenya, ANC has not adequately influenced the use of skilled personnel at delivery.

Indirect effect is also reported in cases of inadequate facility infrastructure by McMahon et al.(2014) while exploring the experiences of, and responses to disrespectful maternity care and abuse during childbirth as likely to foster demoralizing atmosphere for both providers and patients. The authors further report that D&A could not only make patients lack the necessary trust in a facility but also view health facilities as inhospitable. Similarly, patients who perceive interrogations on their cultural practices and use of herbal medications as criticism of their social status by providers, are likely to be demoralized to use facility services in their present or subsequent deliveries, thus increasing the number of births by non-skilled personnel (Ishola et al., 2017; Manning and Schaaf n.d.; McMahon et al., 2014). Women’s experiences at the health facilities and their perceptions of quality of care in health facilities also influence their care-seeking tendencies for their expected newborns and children (Manning and Schaaf, n.d.). CRR; FIDA (2007) study confirms this and adds that the negative effects may have long-lasting effects. In a study on the violations of women’s human rights in Kenya health facilities, a woman narrated how her experience made her resolve to never bear another child, and that when she ‘accidentally’ got pregnant later, she chose to deliver at home (CRR; FIDA, 2007). It is no wonder that the same study reports that TBAs still deliver 28% of babies while relatives and friends assist in 22% of births at home and only 42% of deliveries happen in the care of a health professional.

WHO (2015) also recognizes that D&A constitutes a violation of trust between women and their health care providers hence a powerful disincentive for women to seek and use maternal health care services. This is not good for the health of any nation and is likely to contribute to the high morbidity and mortality rate in both the infants/children and their mothers.

The birth of a baby is a powerful life event that has implications for a woman’s well-being and future health. But less attention is paid to interventions for the safety, and comfort of the antenatal mother and makes her feel positive about her experience during childbirth. A positive birth experience promotes a sense of achievement, enhances feeling of self-worth, and facilitates confidence—all of which are important for a healthy adaptation to motherhood and psychological growth. Childbirth classes help them to cope- not just with pain, but with the entire childbirth process.

Need for the study:

“Make every mother and child count” reflects the need for today. In India, as per 2016 statistics, the maternal mortality is 130 per 100000 live births1. At present around 5, 85,000 women die from complications due to pregnancy and childbirth globally each year2. Between 11% and 17% maternal death occurs during first 24 hrs and more than 2/3 during first weeks and average infant mortality rate is 49.4%. Female education is a strong predictor of the use of reproductive health care services but the extent and nature of relation between the two is not uniform across social settings. Every woman has the right to get best possible care during pregnancy, delivery, and postpartum periods without any distinction of race, religion and political belief, economic or social condition. The basic strategy of Birth Preparedness and Complication Readiness (BPACR) in Safe motherhood is the women’s empowerment, which facilitates her to take appropriate decisions on time3.

In India, practices relating to pregnancy and childbirth have been rooted in cultural beliefs and traditions that are based on knowledge contained in ancient Indian texts. Pondicherry is in the southernmost part of India, has female literacy rate of 71%, 99.9% institutional birth, 33.6% cesarean deliveries and ranks third in having lesser IMR 22.0 per 10000 live births. Childbirth is not a topic openly discussed in this region of India. No one talks about what will happen during childbirth other than it will be painful. The researcher, in her earlier survey, identified that 33% of the rural antenatal mothers attending antenatal clinics in a tertiary care hospital had inadequate level of knowledge regarding childbirth, 63% had moderate knowledge and only 3.3 % had adequate knowledge4.

If a mother is truly informed on childbirth, she is aware of the whole process of childbirth, and what is expected of her at each stage. She approaches labor with confidence, she is armed with coping strategies and therefore it gives her a satisfying approach, rather finding themselves going into it with full of anxiety, fear, and apprehensions. But that information needs to be complete and obtained from a reliable source. Midwives and doctors are in a unique position to develop a trusting insightful relationship with the women they encounter by providing clear, evidence-based information, reassurance, and one-to-one support.

Hence the investigator would like to evaluate the effects of a Child Birth Education programme on selected outcomes of labour.

Objectives:

1. To assess the level of Knowledge of childbirthrth among antenatal mothers in the experimental and control group
2. To compare the level of knowledge of antenatal mothers on Childbirth before and after childbirth education among antenatal mothers in the experimental group.
3. To determine the difference in the level of Anxiety on childbirth among antenatal mothers between the experimental group and control group
4. To compare the labor outcomes among antenatal mothers between the experimental and control group which includes, Duration of Labor, type of delivery, coping during labor, birth experience and Maternal-Infant Bonding.
5. To associate the labor outcomes with selected demographic and clinical variables in the experimental group and control group

Conceptual framework:

The researcher has adopted the model of “Modified version of the Negotiating the journey- preparing for childbirth through education by Mary Koehn”5. The concept of a journey to a destination is the culmination of the women’s phases of physical and emotional transition into a mother. Knowledge decreases the anxiety and fosters a sense of confidence. The tension and a sense of discomfort are associated with not knowing what was going to happen to them exist prior to the classes. At the end of the classes, a sense of serenity emerges in them which increases the confidence in them to face the labor, facilitates control, decision making, and thereby lesser interventions and a positive experience of childbirth. It also enhances the bonding between the mother and the unborn child. Thus this theory fits with the present study on preparation of women for childbirth

Materials and methods

True Experimental- Post-test only- control group design was adopted. Ethical clearance from the Institutional Review Board was obtained. 248 primipara women attending antenatal clinic at PIMS Hospital with 32- 34 weeks of gestation who had planned to have delivery at PIMS and willing to participate in the study were registered as participants. Antenatal mothers who have absolute contraindication for vaginal delivery and who opted for epidural analgesia were excluded. After getting informed consent, the Antenatal mothers were assigned into either experimental (n=120) or control group (n=128) using double-blinded computer-assisted randomization. The experimental group had 3 sessions of video-assisted Childbirth education while the control group had followed routine care. Before shifting to labour room their level of anxiety on childbirth was assessed using a modified shortened anxiety questionnaire for both the groups. Throughout labour and delivery, they were observed by the Research Assistants(midwives) using a Structured Observation Checklist on level of coping. When the mother and the baby were shifted to the postnatal ward, the participants were assessed for their childbirth experience using a semi-structured interview Questionnaire within 24 hours of delivery. Maternal infant bonding was assessed using a likert scale on the 3rd postnatal day in both the groups. Data regarding Duration of labor, type of delivery, and complications arose during labour and delivery were gathered using a semi-structured observation checklist.

Statistical analysis

The data was analyzed using Descriptive Statistics: Frequency, Percentage, Mean, Standard error of mean and standard deviation to describe the socio demographic and clinical variables. The effect of child birth education on the labor outcomes was analyzed using t test, Fishers exact test, Mann Whitney U test. Chi-square test was used to determine the association between the demographic and clinical variables and the labour outcomes and Spearman correlation coefficient to determine the correlation between the labour outcomes.

The study findings revealed that the mean post test knowledge scoresof the antenatal mothers on childbirth education was significantly greater than the mean pretest knowledge score (t=70.63 p=0.000 ) This increase in knowledge is attributed to the child birth education. The child birth education was effective in increasing the level of knowledge of antenatal mothers.

Bendangaro (2016) in his study to evaluate the effectiveness of video assisted teaching on knowledge and attitude regarding childbirth preparation among 60primi mothers in selected hospitals at Dindigul district also got similar findings( t=19.023 at p < 0.01)6.

The present study findings showed that level of anxiety among the antenatal mothers in the experimental group was significantly lower than the level of anxiety among the antenatal mothers in the control group (Mann Whitney U= 13.65) at p=0.05. The findings of the present study can be compared with the quasi-experimental study conducted by Devilata and Swarna to assess the Effectiveness of pre-delivery preparation on anxiety among 60 Primigravida mothers at maternal child healthcentre, Tirupati, AP, India. The post-assessment mean anxiety value 46.233(SD=8.156) of the experimental group was lower than the pre-assessment mean anxiety value 71.767 (SD=10.782). The obtained “t” value was 19.023 which was significant at 0.01 level7.

The Study findings proved that the childbirth education improved the level of coping, reduced the duration of labor, improved the standard of experience, reduced the no. of cesarean section, and improved the level of coping. The findings can be compared with the following studies

Madhavan Prabhakaran, Girija& Dsouza, Melba &Nairy, Subrahmanya. (2016) did a randomized controlled trial with a two-group pretest/ posttest design was used among hundred nulliparous third-trimester pregnant women in major maternity hospital in Kerala, India. The experimental group (n = 50) received three sessions of childbirth education. The experimental group demonstrated a significantly high mean knowledge scores of (54.30 ± 3.86, P < 0.001) childbirth preparation than the control group (31.08 ± 1.96). Significant reductions of caesarean birth (50%) among nulliparous women along with a 12% increase in newborn’s birth weights were the main positive birth outcomes8.

Adams S, Eberhard‐Gran M, Eskild (2012), did a prospective study to assess the association between fear of childbirth and duration of labour among 2206 pregnant women with a singleton pregnancy and intended vaginal delivery during the period 2008–10at Akershus University Hospital, Norway also got similar findings. Labour duration was significantly longer in women with fear of childbirth compared with women with no such fear using a linear regression model (crude unstandardized coefficient 1.54; 95% confidence interval 0.87–2.22, corresponding to a difference of 1 hour and 32 minute, until delivery of the child9

A descriptive study was done to determine the effect of childbirth preparation classes on self-efficacy in coping with labor pain among sixty Thai primiparas selected by nonprobability convenience sampling assigned to either a control or an experimental group (thirty in each group). The control group participants received standard care and education. Self-efficacy expectancy in the experimental group was significantly different than that of the control group, F(1, 54) = 14.66, p < .001. Control group outcome expectancy decreased dramatically across three data points while the experimental group self-efficacy increased after the class and then decreased after the birth but was higher than baseline. The groups did not differ in duration of labor and type of delivery. These findings indicate partial effect of childbirth preparation classes on self-efficacy in coping with labor pain10.

A randomized controlled trial to test the effectiveness of an efficacy‐enhancing educational intervention to promote women’s self‐efficacy for childbirth and coping ability in reducing anxiety and pain during labour. The experimental group received two 90‐minute sessions of the educational programme in between the 33rd–35th weeks of pregnancy. The experimental group was significantly more likely than the control group to demonstrate higher levels of self‐efficacy for childbirth (p NazikEvsen (2016) did a descriptive casecontrol study to determine the effect of childbirth education classes on prenatal attachment among 246 pregnant women, The mean Prenatal Attachment score of the case group was 38.30 ± 9.64 and the control group was 34.10 ± 10.52, and the difference was statistically significant (p = 0.001). It was determined that the prenatal attachment levels of the mothers participating in the childbirth education class were higher12.

The above study findings correlate with the present study findings and the hypothesis that there is a significant difference in the labour outcomes among women in the experimental group and control group was supported.

Chi-square analysis was done to determine the association between the labor outcomes and gestational age of the mothers in the experimental and control group. It was found that gestational age has a significant association with Level of coping( X²=0.781 at p=0.05) and Standard of Experience (X²=1.053 at p=0.05).

A similar kind of study was done by Maryam et al.,(2014) among 100 primiparous women, referring to the selected heath care centers of Mashhad. Pregnant women with a gestational age of 35-41 weeks, who met the inclusion criteria, completed Cranley’s questionnaire, as well as the demographic/obstetric questionnaire. There was a direct positive relationship between maternal-fetal attachment and mothers’ emotional behaviors toward infants four and eight weeks after delivery. The gestational age of the mother had positive correlation with the Maternal infant bonding.( R = -170.0 p= 0.211)13

Paridhi Et.al,.did a survey to assess the woman’s satisfaction with childbirth services and its significant impact on her mental health and ability to bond with her neonate in Chattisgarh, India. In logistic regression analysis, Period of gestation in current pregnancy is associated with the childbirth satisfaction at p= 0.00014

Chi-square analysis was done to determine the association between the Weight of the mothers and the Mode of Delivery of the mothers in the experimental and control group.

Similar study findings were identified with Ingegerd and Ian in their survey among 919 pregnant women to identify the propotion of pregnant women with high BMI(>30) and compare the pregnancy outcomes. Prevalence of obesity was 15.2%. High BMI was associated with labor induction and operative delivery. No difference in Birth complications, birth experience or satisfaction with the care during labor and delivery 15

The infant’s sex and mother-infant bonding was analyzed to determine any association between them using Chi-square analysis. It was identified that there was highly significant association between the infant’s sex and the maternal-infant bonding (X2=3.283, p 0.070). Even in this 21st century, where men and women are equally educated and enjoy equal status in the society, male children are looked upon than the female children by the mothers themselves. This brings about the deep-rooted cultural influence inspite of all the education, status, and the advancement of the society prevailing in the region.Rizk (2012 ) and Abbas (2018 ) concluded from their study thatthe positive attachment between mother and child was more inclined toward boys and girls respectively, that might be attributed to the effect of social and cultural differences16.

Limitations

• The data was collected by the research assistants.
• The effect of all potential sources of information on childbirth, such as family and friends, books, and the Internet, was not assessed.

Implications for nursing practice:

The findings of the present study are an important contribution to the evidence-based strategies in making child birth a positive experience through childbirth preparation courses.

• It is recommended to extend childbirth preparation classes as in developed countries and support the participation of both antenatal mothers and the spouse to provide a more positive experience of pregnancy and childbirth.
• An assessment of maternal confidence and fear of childbirth be incorporated into existing pregnancy care guidelines for third trimester.
• Training and education to antenatal care providers in the hospital and community on childbirth education based on adult learning principles can be included as a project in the curriculum for post graduate midwifery program.
• Encourage the students for effective utilization of research-based practices in antenatal, intranatal, and post-natal care.
• Nurse administrators can develop strategies to move from medicalization of childbirth to a more humanistic and low-intervention midwife-led care that empowers women.
• Collaborate with the obstetric team to formulate standard policies and protocols to emphasize evidence-based intranatal care with minimum interventions to bring about a positive childbirth experience for all women

How and why the childbirth in Heian and Tokugawa period were so different than today’s childbirth?

In the words of Marco Gottardo, “Pregnancy and childbirth in early-modern Japan within a religious framework, as they were charged with religious meaning at the popular level”[footnoteRef:1] represents one of the best angles to analyze this phenomenon. By this quote, we can understand that women’s role in medieval Japan had several faces. Their positions were linked to religious assessments-Buddhism and Shinto, but other social spheres could interact. [1: GOTTARDO Marco, Pregnancy and infanticide in early-modern Japan: the role of the midwife as a medium, Bulletin of Tamagawa University Faculty of Letters, n°54, 2013, 214.]

The key ideas must first of all be defined. The context of the analysis goes through the medieval and classical periods mainly the Heian and Tokugawa periods, until the modern era which begins with the Meiji Period. The Heian Period (794-1185) corresponds to the formation of an independent Japanese State around the Emperor. One of its principal characteristics was its autonomy from the Asian continent by hybridization of norms. By a lack of record, we will show for this period the elite practice of childbirth, near the imperial power, thanks to aristocratic diaries. This social group had peculiar practices different from the countryside. The Tokugawa Period (1600-1868) was based on a shogunate and a strict separation between social classes. Hence, we some middle-class records, we could know some commons practice about childbirth that we will explain. In the end, the Meiji era corresponds to the return of the Emperor of the throne, which rises reforms in all areas at the end of the 19th century and had still consequences today.

Moreover, the pregnancy is the period when a woman carries a child for nine months and childbirth represents the moment of the delivery of the baby. These reflections fall in the context of the course “Gender and Family in Premodern Japan”. The term gender deals with how society and individuals define masculinity or femininity thanks to cultural traits, and not by biological ones (sex). About the word family, it represents the social connection between people who had blood and biological links.

We can see that the social and economic contexts were totally different through the centuries. Putting the light on one of the key moments of the life-childbirth by finding some anthropological aspects in premodern Japanese society could be another manner to watch the evolution of Japanese society. Consequently, this paper will focus on the meanings of childbirth and pregnancy in Heian and Tokugawa periods and of its posterity in modern times.

The main questions addressed in this paper are- How and why the childbirth in Heian and Tokugawa period were so different than today’s childbirth? Why we don’t have lots of records about it even if it represents the beginning of individual life? What were the rites and myths concerning Mother’s health? How can we define the role of midwives through the centuries? Could we see some Heian and Tokugawa heritage in today’s practice? How can we explain the radical change about childbirth in societies awareness?

This essay has been divided into three parts, the first part deals with the explanation of childbirth and pregnancy in Early Modern Japan, from different points of view. The second part will put the light on modern childbirth practice and links which remain between past and present. To end, the last part will explain why I have chosen this topic.

In the first part, I will put the light on the meaning of childbirth and pregnancy in terms of Buddhism and describe the specificities in the Medieval-Classic Era. During Premodern Japan, the influence of Buddhism and its principles conducted human life. One of the best things that Buddhism promoted were “the impermanence of human existence that passed through the nature of transmigration”[footnoteRef:2], a passage from one state to other thanks to rebirth. Hence, childbirth constitutes a key moment for the realization of Buddhist ethics, but which appears to be contradictory. Thus, “it allows one to advance through the karmic cycle, but it is also negative, as it is seen as the origin of suffering”[footnoteRef:3]. It is in this permanent tension that we can understand the signification of pregnancy and childbirth. [2: ANDREEVA Anna, Childbirth in aristocratic households of Heian Japan, Dynamis, 34 (2), 2014, 358.] [3: LAFLEUR, William R. Liquid Life, Princeton, Princeton University Press, 1992, 115.]

Moreover, Buddhism sees women inferior to men, be on earth just to distract the attention of men, and couldn’t access karma without rebirth in men. Thanks to the analysis of A. Andreeva of the Kitano Tenjin emaki (“The Picture Scroll of the Kitano Shrine Deity”) and Gaki zôshi (“The Scroll of Hungry Ghosts”)[footnoteRef:4], published in the 12th century, we can have some information about Heian childbirth and how it works? Above all, the title of the books revealed myths/deities’ presences, as a shadow lingers on. The act of delivery is a carrier of dirtiness, accompanied by Mother Evil. Bad spirits were described as an “emaciated hungry ghost, with its red hair standing on end, a distended stomach and a large tongue protruding from its open mouth, extending its bone-thin fingers and arms towards the infant and the pool of blood into which the baby has just descended”[footnoteRef:5]. This is a good illustration of the society’s fear about this phenomenon, lead women to exclusion by the rejection of kegare. This expression refers to the pollution that childbirth concentrated: “those of birth, of death, and of blood”[footnoteRef:6]. [4: ANDREEVA Anna, Ibid, 358.] [5: ANDREEVA Anna, Ibid, 359.] [6: GOTTARDO Marco, Ibid, 213. ]

In Heian period concerning the noble Court, childbirth took place in a separate room in the palace, which needs to be located “in the northernmost quarter of the mansion”[footnoteRef:7], in a matter to respect deities’ volunteer and avoid all taboos. It was necessary that all things were white from the room decoration to women’s clothes. Rites happened through the use of incense, and oils. Nonetheless, the atmosphere was absolutely neither quiet nor silent and much more stressed and tenser. Furthermore, in the noble court, we could observe the presence of religious figures to sing sutras for the successful completion of the childbirth and to ward off the bad spirit. We can mention Miko, a women medium which had to catch evil ghosts. She was a “ritual receptacle” and “monks chanting the scriptures, usually the Lotus Sutra or The Five Great Wisdom Kings”, as A. Andreeva pointed out[footnoteRef:8]. These people did their work in a closer place to the delivery room because this one was reserved for women’s cohort. Again, there was the “strict absence of men”[footnoteRef:9], inside the room, as a phenomenon of “female pollution/male antidote”[footnoteRef:10]. On top of that, childbirth in aristocratic and royal sphere had a political dimension for the country, as protecting the state and the nation[footnoteRef:11]. [7: ANDREEVA Anna, Ibid, 362.] [8: ANDREEVA Anna, Ibid, 360-362-364.] [9: HARDACRE, Helen, Marketing the Menacing Fetus in Japan, Berkeley, University of California Press, 1997, 24.] [10: GOTTARDO Marco, Ibid, 217.] [11: ANDREEVA Anna, Ibid, 365.]

Accordingly, all was done to separate women from the community and especially from men. In the countryside, we can also find the procedure of isolation of pregnant by ubuya[footnoteRef:12]. The term ubuya refers to a little hut built outside the house, where pregnant were confined when childbirth arrived or at menstruation time. Moreover, Hitomi Tonomura analyzes this place as a “desire for privacy in the hours of contraction and pain” [footnoteRef:13] for women, nuanced the simple view of pollution. [12: TONOMURA Hitomi, Birth-giving and Avoidance Taboo: Women’s Body versus the Historiography of Ubuya, Japan Review, 19, 2007, 3.] [13: TONOMURA Hitomi, Ibid, 10.]

Nonetheless, the withdrawal of the society was codified by norms and laws, as the Engishiki, 10th-century collection pointed out[footnoteRef:14]. A woman had to be recluse from the month of delivery to seven days after childbirth, sometimes even leading to thirty days. [14: GOTTARDO Marco, Ibid, 215.]

To avoid bad omen, rituals were the norm in a matter to protect and salve women and babies. These practices were mainly given by the midwives (toriagebaasan)[footnoteRef:15], which represent a shamanic and intercessor figure during pregnancy and delivery. Doing habits was a manner to drive away death, an end which was part of childbirth. As Hisako Kamata pointed out “the midwife was no less than a psychopomp, a conductor of souls, and master of their transition from the liminal state within the womb to a full-fledged member of the human community”[footnoteRef:16]. [15: HARDACRE Helen, The Role of the Japanese State in Ritual and Ritualization, 1868-1945, Bulletin de l’Ecole française d’Extrême-Orient, volume 84, 1997, 139.] [16: KAMATA Hisako, ‘Sanba-sono fujoteki seikaku ni tsuite’ Seijo bungei 42, 1966, 47-60, in HARDACRE Helen, The Role of the Japanese State in Ritual and Ritualization, 1868-1945, Bulletin de l’Ecole française d’Extrême-Orient, volume 84, 1997, 131.]

For instance, we can mention the use of Iwata obi, a little fabric strip that the midwife will put near the pregnant‘s tummy[footnoteRef:17]. This action will be accompanied by a party to integrate the community to the event and officialize woman’s status, becoming “a source of social power”[footnoteRef:18]. Hence, be pregnant “constituted a rite of passage into the community of fully adult women”[footnoteRef:19]. It represents also the outset of social restrictions like going to shrines or food taboos. Consequently, we can observe that “pollution beliefs can provide grounds for solidarity among women” [footnoteRef:20] in the words of Michelle Zimbalist Rosaldo. [17: HARDACRE Helen, Ibid, 131.] [18: GERHART Karen M, Women, Rites, and Ritual Objects in Premodern Japan, Koninklijke Brill NV, Leiden, the Netherlands, 2018.] [19: MATSUOKA Etsuko, Shussan no bunka jinruigaku, Tokyo, Kaimeisha 1985, 23. ] [20: ROSALDO ZIMBALIST Michelle, “Woman, Culture and Society: A Theoretical Overview”, Woman Culture and Society, eds. Michelle Zimbalist Rosaldo and Louise Lamphere, Stanford, Stanford University Press, 1974, 38-39.]

Despite the huge place of religion, medical practice and physicians began to help the imperial court, by small steps. The publication of the Ishinpô (Essentials of Medicine), at the end of the 10th century, constituted the first Japanese medical book. And we can find inside a whole part dedicated to pregnancy and childbirth. We can find pictures about the development of the pregnancy and the acupuncture points. The physicians (Jp Kukushi) tried to imply medicine and trained to educate women physicians (nyoi) in obstetrics and gynecological fields[footnoteRef:21]. Hence, midwives had a key role in Japanese society, even if they were marginal. At the same time, they had an intellectual knowledge, practice competencies, and controlled kegare. They really “assumes the novel religious and social function of medium or mediating figure”[footnoteRef:22]. [21: ANDREEVA Anna, Ibid, 371.] [22: GOTTARDO Marco, Ibid, 214. ]

In the second part, we will emphasize the mutation of childbirth in modern era, from the notion of pollution to hygiene.

The first change marks could be seen at the end of the Tokugawa Period thanks to the diary of Watanabe Katsunosuke (1802–1864)[footnoteRef:23]. Moreover, with the intensification of the urbanization in the 19th century, pregnant mothers were in labor in their house, with their family. But why leads to this shift? [23: TONOMURA Hitomi, Ibid, 25.]

The framework and the social norms had changed, by a complexification of relations and the advent of scientism as a power rule. With the Meiji Restoration in 1868 and its volunteer to modernize the State, hospitals and clinics were promoted. Rely on science and medicine were more rational and could secure the issue of birth. However, births became a political tool for the new regime because it found a population, thus the nation. Incited families to give birth at the hospital had been a manner to control and registered the growth of the population through public hospitals which were created. The aim changed by the stranglehold of the Empire on birth control. This new organization allows the Tennō to “claim property of the life and health of each newborn as Japanese subjects”[footnoteRef:24]. Having children became a duty for families, who want to be great citizens. Widen the population “increased the number of potential workers and soldiers”[footnoteRef:25] and allows to solidify the State in front of other powers. Furthermore, midwives became more recognized by the creation of diplomas, licenses. Knowledge became a safety sign and individual rights ethic was implemented. Midwives gave pieces of advice and done medical examines throughout the pregnancy- “they conducted prenatal physical examinations, as well as using rolls of waxed paper, white cotton cloth, and disinfectant at the birth itself”.[footnoteRef:26] [24: GOTTARDO Marco, Ibid, 232.] [25: LAFLEUR, Ibid, 108-111.] [26: HARDACRE, Helen, Ibid, 140.]

From pollution rejected by all the society, especially male family members, we moved to the research of the absolute cleanliness. The aim is to avoid all corpse intrusions by pathogens. The idea has remained the same-the fear of contamination. It is more the terms used which changed in more intellectual one but not the concept. Moreover, the place where you give childbirth was replaced by the hospital. It is no longer in the family environment but in a dedicated place, sterilized and free of pollution. Could we not see a kind of modern ubuya? Maternity wards are places dedicated solely to this act, but which are more opened to the family, especially men. Childbirth today is a moment where men and women, father and mother are together, in communion and not a strict separation.

I would like to explain the reasons which led me to choose this topic. First, we do not speak a lot of this subject during the course and I find interesting to put the light on a particular moment that each woman could live. I was curious to understand the links of religion, especially Buddhism in childbirth because this event represents a key point in the life of a person. Furthermore, the term birth could have different meanings, depending on your socialization and the norms that prevail in society at one moment. By the study and the comparison of one mechanism through periods, I realize that some ancestral concepts are still available today, by an adaptation to today’s values. At last, the role of midwives has always drawn my attention and I wanted to make a career. Besides, I did an internship in a maternity hospital and examine in detail the origins of this function in another country than France makes sense.

What conclusions can be reached from this essay? First, we can say that Childbirth and Pregnancy in Japan are a great part of the social life by the respect of traditions, rites, and customs in early modern Japan, transformed by the arrival and progress of medicine in the 19th century. By a process of isolation of women by the fear of kegare for religious matter and physicians’ precautions, we moved to an individual system regulated by the State, doctors, and professional midwives. However, we can say that the role of midwives had always played a key role, being the cornerstone through eras. Magic or fear moment, childbirth constitutes the beginning of Humanity, transcending all the societies. It is the cultural interpretation of what is birth and gender which confers specificities to communities. Hence, the social, economic, and cultural context gives sense and depth to daily life practices.

Bibliography

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A topic I chose for this project is Postpartum Depression in mothers after labor and how it affects the bond with their baby. This topic is a personal topic to me because I experienced postpartum depression after giving birth to my first daughter in 2018. I felt lonely for the first three weeks after birth and could not cope with my emotions and bond with my daughter. After three weeks, I went back to my normal routine and back to myself. In some cultures, people are not aware and are not educated about PPD and do not consider that it could be an issue. But a majority in general, people are uneducated about Postpartum depression and do not know what actions to take to help the mother with PPD, which can lead the mother to feel even more isolated and do things that she has not carefully thought through. For example, mothers with PPD can do dangerous activities with their babies without realizing it or doing damage to themselves. Most importantly, it is critical to always support mothers after birth and be there for them just in case they might be diagnosed with PPD or baby blues.

Attachment

Attachment is the assumption that children must develop an attachment to their caregiver to fully develop and have a secure relationship in the future. John Bowlby’s (1982) attachment theory is based on the idea that the early relationship that develops between the infant and caregiver provides the foundation for later development (Lefkovics, Baji, & Rigo, 2014). A mother’s emotions should be analyzed along with how she develops her feelings of attachment to her infant, which brings the closeness of the mother and infant together. Bowlby (1973); Weinfield, Sroufe, Egeland, & Carlson, (1999) as cited in Mason, Briggs, and Silver (2011) state “with the reciprocal interaction between infant and caregiver, the infant learns not only who his or her caregiver is but can also learn how to anticipate the caregiver’s behaviors. From these expectations, the infant forms a model of how to relate to and interact with others, and this model will be used as a guide for future behaviors and relationships throughout life (p.382).” The infant must form this model because it forms a secure attachment that will benefit that infant in later life with other adults and help the infant developmentally grow. The internal working model shapes an infant’s development thinking of attachment based on his caregiver’s attachment to him (Borelli et al., 2017).

Research in general shows the differences between secure and insecure attachment. Huang et. al (2012) explain the difference between secure and insecure attachment. Huang et. al (2012) state when there is a secure attachment in children, children develop positive developmental outcomes, such as “emotional regulation, social competence and peer relationships, problem-solving, and understanding of emotion (p.41). However, an insecure attachment is the opposite of a secure attachment. Insecure attachment is associated with “negative developmental outcomes such as anxious and depressive mood, behavioral problems, and poor peer relation (Huang et. al, 2012, pg. 41)”. Insecure attachment can interfere with the quality of mother-child interactions, leading the child to have a developmental issue as he grows. Attachment theory evaluates the mother’s understanding of her infant’s distress and signals (Ainsworth et al., 1978 cited in Santona et. al, 2015). Tronick (2005) as quoted in Santona et. al, 2015 states when depressed mothers fail to understand their children’s needs, it affects the child and causes the child to have a negative relationship with the mother and the child will most likely express negative emotion. Mothers with PPD can lack the ability to respond to their child’s needs with the stress level, she may have and forget her surroundings.

Attachment theory can lead to the understanding that mothers with PPD can affect the attachment and closeness of the mother and infant relations. This causes insecure bonds, which then cause the infant to lose the ability in the future to build a secure bond with other people. “Conflicting strategies of approach and avoidance towards the newborn might result in less coordinated and effectively matched interactional processes between mother and infant, which in turn harm positive experiences in the maternal role and thus impair the developing mother-infant bond by creating or increasing emotional barriers (Nonnenmacher et al, 2016, p. 932). Mason, Briggs, and Silver (2011) note that maternal feelings are a moderator between maternal PPD and the infant’s outcome, which is to support the closeness and build a strong attachment between the mother and infant, However, partner support can help mothers with PPD to improve attachment and relation. Partner support can “mediate the effects of mothers’ interpersonal security and relationship satisfaction on maternal and infant outcomes” (Lefkovics, Baji, &Rigo,2014, p.360). Attachment theory can be examined through the importance of building a secure attachment after the mother gives birth to her infant and the damage PPD can do if the mother is diagnosed with PPD. The next theory, Temperament, will discuss how an infant can become difficult and have issues in their development due to the lack of response from the mother.

Temperament

The second theory, Temperament, is used to assess an infant’s characteristics. There are three types of temperament: easy, slow to warm up, and difficult. “Alongside interest in relations between temperament and children’s outcomes, there also is considerable interest in how children’s temperament characteristics may affect the contexts in which they are raised, including the parenting that they receive” (Nolvi et al, 2016, p.14). Distressed mothers will not respond to their child’s needs, which causes unmet needs of the child and the disengagement between the infant and mother. The distress can cause the child to become difficult and arousal to the child’s environment.

Temperament has been used to explain developmental phenomena in this topic of postpartum depression of how mothers with PPD distress can lead an infant to have difficult adjusting to their environment. “maternal depression, which has been associated with increased emotional unavailability and negativity, has been consistently linked with disruptions in parent-child interactions and parenting behaviors beginning in infancy and extending through adolescence” (Cummings & Davies, 1994; Downey & Coyne, 1990; Field et al., 1988; Stanley, Murray, & Stein, 2004 as cited in Bridgett et al.,2009, p.106). Mothers with PPD, when in a vulnerable state, lose how to interact with their child and to provide the emotions that are needed to bond with the child. For example, when an infant cries and throws a fit and the mother does not respond, will cause the infant to become more stressed and difficult later. Edhborg et al. (2005) as cited in Nolvi et. al (2016) found that infant fussiness and negative affect were related to the lower quality of bonding between mothers and their infants (p.14).

Temperament theory shows the correlation between temperament and PPD. Also, understanding the how important mother’s relationship with the infant during PPD may affect the child’s temperament. “Mother-reported infant temperament traits were associated with bonding in regression analyses (Nolvi et. al, 2016, p.20)”. However, some researchers mentioned mothers who were distressed during pregnancy can contribute to the infant’s temperament and it could be possibly worse when the mother has PPD. “Infants of prenatally depressed mothers may be at risk for biological contributions to a difficult temperament. Infants of mothers with postpartum depression may be at risk for inadequate emotional and physical caregiving, again contributing to a difficult infant temperament” (Rode & Kiel, 2016, p.135). Mothers with postpartum depression cannot give emotional and physical caregiving because they are in a state where they are too depressed to feel any emotions and know how to respond to any distress they hear. Temperament and attachment theories both give a different perspective on Child Development and assess the results differently according to the purpose of their theory.

What I learned from postpartum depression and how it affects the newborn is that if the mother is not getting support from her significant and close families, more damage can happen to her mental self and the newborn. I want more new mothers to be aware of the depression that may occur after birth and how to seek help. Also, educate their significant ones on how they can help her if she has postpartum depression. My purpose of this project is to spread awareness and to be aware of the changes that may occur after birth. After my postpartum, I have become more aware of postpartum and the signs to look for. Postpartum depression affects mothers and their newborns if the mother does not get proper help and seek medical help.  

When people discuss pregnancy, it is easy to believe that it is a safe process. While it is easy to notice physical changes throughout a woman’s pregnancy, it is not easy to realize the mental changes that pregnancy can drown a new mother in. What people do not see is a new mother going through a range of intensified emotions after birth, such as postpartum depression. Changes such as mood swings, negative thoughts, and sleep pattern changes are just a few of the changes women experience. What is the harm in having these changes? It not only affects the safety of a mother but also how the newborn will progress and grow. If the baby does not grow or progress as he or she should, it could potentially affect the safety of the baby. This illness can put a mother and baby in a life-or-death scenario. Therefore, the mothers must reach out for help and for them to realize that what they are going through is ok. Pregnancy is a beautiful experience in life and unfortunately, the mothers who are diagnosed with this illness sometimes view it as anything less than beautiful. With the many different treatment options, it can allow the mother to experience the beautiful side of birth. Postpartum depression is a very treatable illness if the proper prevention, education, and treatment measures are used.

Women have the opportunity to take part in a miracle that keeps humans in existence around the world. That miracle is known as pregnancy and birth. Although it is a magical opportunity it also comes with risks, one which is known as postpartum depression. Postpartum depression is not a rare diagnosis during the postpartum period after birth. In fact, “around one in seven women can develop postpartum depression” (Mughal, 2021, p.1). After childbirth, a mother can experience a range of emotions from anger, sadness, and irritability with varying degrees of intensity. These emotions can lead to a long-term effect for mothers which interferes with the mother’s ability to get back to their pre-pregnancy normality. Furthermore, these feelings are accompanied by many different risk factors, signs and symptoms, and treatment options that will be discussed throughout this paper. Postpartum depression is a very treatable illness if the proper prevention, education, and treatment measures are used.

Postpartum depression does not discriminate and could potentially affect any mother after giving birth. It can stem from psychological, obstetric, social, and lifestyle issues. Women with a previous history of current depression, anxiety, and mood disorders are precursors to an increased risk for postpartum depression. Another example is lifestyle issues which can range from diet, sleep cycle, and exercise. A mother not getting enough sleep can push them into a depressive state and can cause many different mood swings. Also, “vitamin B6 has been known to be involved in postpartum depression via its conversion of tryptophan and later on serotonin, which, in turn, affects mood” (Mughal, 2021, p. 2). Lastly, exercise plays a huge role in affecting a person’s self-esteem. It is known that “exercise increases endogenous endorphins opioids, which brings positive effects on mental illness” (Mughal, 2021, p. 2) So essentially when a person is not exercising enough, it can potentially decrease one’s self-esteem which in turn can cause a person to be sent into a depressive state. These are just a few among many risk factors that can place a woman at risk for developing postpartum depression, which has the potential to lead to very dangerous symptoms and outcomes for both mother and baby.

Women experience many different emotions and thoughts with a diagnosis of postpartum depression. They are overwhelmed with symptoms such as “a depressed mood, loss of interest, changes in sleep patterns, change in appetite, feelings of worthlessness, inability to concentrate, suicidal ideations, and even delusions or hallucinations” (Mughal, 2021, p. 4). Specifically, women can feel a sense of loss of interest in the newborn or life in general. These feelings and symptoms can overpower a mother’s ability to want or allow bonding between the newborn and the mother. The bond that a mother has with the newborn can affect an infant throughout their whole life by playing a role in the child’s physical and psychological development. Furthermore, this puts the newborn at risk for failure to thrive which can cause very dangerous outcomes such as the death of an infant. With symptoms ranging anywhere from mild to severe, mothers need to reach out for treatment. It is also important for the healthcare team to stay vigilant throughout the pregnancy to ensure that action is taken if the patient starts to show signs and symptoms of this illness.

Women who are suffering from postpartum depression must reach out to receive the needed treatment. Due to many mothers going undiagnosed due to fear of judgment and lack of support, the medical team must identify patients who are at higher risk for developing postpartum depression in the early stages of pregnancy. This can be done by observing risk factors and assessing mothers’ emotions and actions pre- and post-birth, whether that be in the hospital or follow-up visits. Doing so will allow for prevention by educating the mother and providing different options of support before the depression worsens. Typically, the mother is treated with psychotherapy and antidepressants. The severity of the depression will determine how the mother is treated. Psychotherapy will be offered first which involves more of a talking aspect when a mother is experiencing only mild to moderate symptoms. This is mostly used in a counseling atmosphere. This is also used when the mother does not feel comfortable taking medications due to different reasons including breastfeeding. When a mother is experiencing severe symptoms, it is recommended that she begins taking an antidepressant medication. Medications such are serotonin reuptake inhibitors or serotonin-norepinephrine reuptake inhibitors are the common medications used. It could also be effective for both psychotherapy and medications to be used together if needed. While many women believe they are doing much better within a couple of months, treatment needs to be continued typically a year after pregnancy. This will help to ensure no symptoms reappear in the future. After all, it is important to ensure a relapse of this illness does not occur as it negatively affects the mother, newborns, and even families.

Postpartum depression is a very treatable illness if the proper prevention, education, and treatment measures are used. Having a baby most of the time is viewed as something beautiful, but it does not always start or end as a beautiful experience for the mother due to the risks of life after the baby. It is a common illness that can potentially affect many different women. This illness can shatter a mother’s expectations of life after delivery. Postpartum depression comes with many different emotions and feelings which can make a mother feel incapable of caring for a newborn. Feelings can make a mother feel unhappy in life and can intensify to idea of harming not only oneself but the baby as well. While symptoms can be mild to severe mothers need to seek treatment as this illness is very much treatable. With many different risk factors, it is very much possible for the health care team to identify mothers who may suffer from this depression illness. Identifying these women early on allows room for education on the illness as well as education on treatment options that could potentially be used if needed. Identifying mothers who may develop this illness, will allow the healthcare team to prevent it from getting severe and resulting in worse-case outcomes.