Does a traumatic birth experience have an impact on future reproduction?

Authors


*Mrs K. Gottvall, Department of Nursing, Karolinska Institutet, Box 286, SE-171 77 Stockholm, Sweden.

Abstract

Objective To investigate whether women's experiences of their first birth affects future reproduction.

Design Prospective cohort study.

Setting South Hospital, Stockholm, Sweden.

Population Six hundred and seventeen women who gave birth to their first child 1989–1992.

Methods A global measure of women's experiences of their first birth, assessed two months postpartum, was available from a birth centre trial, together with information on a range of background variables. This information was linked to the Swedish Medical Birth Register, which included information on the number of subsequent births during the following 8–10 years.

Main Outcome Measures Number of births (0 or ≥1) following the first birth.

Results Women with a negative experience of their first birth had fewer subsequent children and a longer interval to the second baby (RR 1.7, 95% CI 1.3–2.3). Being 35 years and older (RR 2.6, 95% CI 1.6–3.7), or single (RR 2.6, 95% CI 1.7–3.9) was also associated with subsequent infertility.

Conclusion A negative birth experience was associated with subsequent infertility, and women's experiences should therefore be considered seriously in the provision of maternity care.

Introduction

From clinical practice we know that some women who experience their first birth as traumatic decide not to have another baby. However, to our knowledge, the association between the birth experience and subsequent reproduction has not been studied systematically. The causal link between the two variables is not established, and many factors such as women's socio-demographic background, expectations about the birth, and personality traits may increase the risk in some women of having a negative birth experience, as well as influencing the decision to become pregnant again.

The Swedish National Birth Register, which is based on personal identity codes, made it possible to link data on women's birth experiences, collected in a randomised controlled trial of birth centre care in Stockholm 1989–1992, with the same women's subsequent births during the following eight to 10 years. The aim of the present study was to investigate whether a negative experience of the first birth, as assessed two months postpartum, had any impact on whether women had another baby within the following years or not.

Methods

Altogether, 1230 women were enrolled in the Stockholm Birth Centre Trial, which evaluated women's childbirth experience1. Inclusion criteria for the trial were an interest in participating in a birth centre trial, residence in the greater Stockholm area, low medical risk in early pregnancy, and ability to understand the Swedish language in order to fill in a questionnaire. For the purpose of the present study the experiment and control groups were collapsed and treated as one study group. Only the 681 primiparas were included, as we were interested in the effect of women's first experience of childbirth. Nine women had a miscarriage or fetal loss, and of the remaining 672 women, 629 (93.6%) returned the follow up questionnaire mailed two months after the birth, and 617 (91.8%) responded to the specific question about their overall birth experience.

The 617 women gave birth during the period October 1989 to February 1992 and birth register data were available for the following years until December 1999. The observation period for the first entered birth was 10.2 years and for the last 7.9 years.

The two-month follow up questionnaire included a wide range of questions, such as satisfaction with care, breastfeeding, maternal and infant health, and experience of labour and birth. Different aspects of the birth experience were explored, such as experience of pain, satisfaction with own achievement, involvement in the birth process, anxiety and support by partner and midwife. These questions were followed by a question asking about the overall assessment of labour and birth, expressed on a 7 point scale with the anchors verbally defined (1 = very negative, 7 = very positive). This overall measure was the independent variable in the present study. In order to limit the effect of other variables, which could confound the causal link between childbirth experience and future reproduction, we used data from the birth centre trial collected by means of a questionnaire before randomisation in early pregnancy. These were demographic background (age, marital status, education, ethnic background), attitudes to decision making, anxiety (when thinking of approaching birth, labour pain, and responsibility of taking care of the infant), and expectations (expected birth experience, expectations on competence as a mother). The background questionnaire also included two scales from the Karolinska Scales of Personality measuring trait anxiety, with 10 items focusing on somatic anxiety and ten on psychic anxiety. Somatic anxiety referred to physiological symptoms and somatic complaints such as palpitations and sweating as a predominating feature accompanied by feelings of vague discomfort amounting occasionally to panic. Psychic anxiety referred to anxiety expressed as a cognitive structure linked to awareness of problems, worrying, anticipatory anxiousness and prolonged post-stress reactions, low self-confidence, and discomfort in social situations2,3. A locus-of-control instrument4,5 measured the degree to which the individual felt able to control her own life (internal locus of control) versus the degree to which she felt controlled by extrinsic factors such as fate, chance, and other people (external locus of control). In this study, the responses on Karolinska Scales of Personality and the locus of control scales were divided into three categories, ‘low’ (≤25%), ‘medium’ (>25% and <75%) and ‘high’ (≥75%). The response rate to the background questionnaire was 100%1.

Data on pain relief (epidural, pethidine and nitrous oxide), duration of labour, augmentation of labour, mode of delivery (vaginal, vacuum extraction, caesarean section), and infant outcome (birthweight, Apgar score <7 at 5 minutes, admission to neonatal care), were extracted from the medical records.

The Swedish Medical Birth Register held by the National Board of Health and Welfare gave information on each woman's subsequent birth and the time interval between the first and second birth. The registration is based on a medical birth registration form, which is part of a standardised record system for maternal and child health care. The register includes data on more than 99% of all births in Sweden since 19736. Personal identifiers were removed from data files before analysis.

The Research and Ethics Committee at Karolinska Institutet gave approval for the study (102/00).

Analysis

The association between women's birth experience and subsequent reproduction was studied by means of Kaplan Meier curves, which take into account not only whether a woman has one more baby or not, but also the time interval to the next birth. Kaplan Meier curves estimate the time to an event as survival time, which in this context corresponds to the interval between the first and second birth. Women who did not have another baby during the observation period were censored observations.

Women who did not have another baby were also compared with those who had at least one more baby regarding all the background variables extracted from the pregnancy questionnaire. Differences between the two groups were tested by the χ2 test including all response alternatives for the respective item.

All background variables, including ‘overall birth experience’, were then included in a Cox regression analysis, and then excluded one by one if they did not contribute to the model. The final model included only those variables which differed statistically between the two groups in the univariate analysis. The method of including all variables combined with backward selection thus gave the same result as if only the statistically significant variables had been included.

The variable ‘overall birth experience’ was dichotomised in advance in a way that would make it possible to study the subgroup of women with the most negative experiences. Previous studies by Waldenström et al.1,7,8 have shown that approximately 10% of women assessed labour and birth in negative terms. In the present study of primiparous women, 12% scored 1 or 2 on the seven point scale, and we chose to compare this group with women who scored 3–7. The background variables were divided into two or three subgroups (see Table 1) based on analyses by Kaplan Meier curves which take women's responses into account, for instance by collapsing response alternatives with few observations. In Cox regression the hazard ratio corresponds to the risk ratio.

Table 1.  Characteristics of women who had 0 or ≥1 birth during a 8–10 year period following their first birth.
 Total: n (n= 617)0 birth: (%) (n= 122)≥1 births: (%) (n= 495)P (2-sided)
  1. Categorisation of scales based on analyses by Kaplan Meier curves for the purpose of the regression analysis.

  2. 1Questionnaire two months postpartum.

  3. 2Questionnaire at onset of first pregnancy.

  4. 3Hospital records.

Overall birth experience1, (n= 122; 495) (1 = very negative; 7 = very positive)0.001
135(49)(51) 
238(29)(71) 
325(16)(84) 
466(18)(82) 
577(17)(83) 
6125(15)(85) 
7251(18)(82) 
Age2, years (n= 122; 495)<0.001
<2586(20)(80) 
25–35486(17)(83) 
>3545(51)(49) 
Marital status2, (n= 120; 495)<0.001
Married/cohabiting571(17)(83) 
Single44(50)(50) 
Education2, years (n= 118; 493)0.29
≤12162(23)(77) 
>12–15239(18)(82) 
>15210(18)(82) 
Country of birth2, (n= 119; 492)0.27
Sweden532(19)(81) 
Other countries79(24)(76) 
Somatic anxiety (KSP)2, (n= 119; 494)0.77
Low (≤25%)181(18)(82) 
Medium (>25%<75%)279(20)(80) 
High (≥75%)153(20)(80) 
Psychic anxiety (KSP)2, (n= 119; 494)0.35
Low (≤25%)169(19)(81) 
Medium (>25%<75%)304(18)(82) 
High (≥75%)140(24)(76) 
Locus of control2, (n= 119; 494)0.41
Low (≤25%)158(22)(78) 
Medium (>25%<75%)311(17)(83) 
High (≥75%)144(21)(79) 
Participation in decisions about pregnancy care2, (n= 119; 494) (1 = not at all important; 7 = very important)0.64
13(33)(67) 
24(0)(100) 
39(22)(78) 
440(23)(77) 
581(25)(75) 
6179(16)(84) 
7297(20)(80) 
Anxiety when thinking of approaching birth2, (n= 119; 492) (1 = not at all anxious; 7 = very anxious)0.28
165(22)(78) 
2153(20)(80) 
3116(17)(83) 
4117(20)(80) 
5113(14)(86) 
639(31)(69) 
78(38)(62) 
Anxiety when thinking of labour pain2, (n= 119; 492) (1 = not at all anxious; 7 = very anxious)0.5
136(25)(75) 
2134(16)(84) 
3112(15)(85) 
4177(20)(80) 
5103(23)(77) 
637(22)(78) 
712(33)(67) 
Anxiety when thinking of the responsibility of taking care of the infant2, (n= 119; 494) (1 = not at all anxious; 7 = very anxious)0.29
1125(20)(80) 
2232(17)(83) 
3107(16)(84) 
483(23)(77) 
543(30)(70) 
621(29)(71) 
72(0)(100) 
Expectations on approaching birth2, (n= 119; 491) (1 = very negative; 7 = very positive)0.02
10   
23(33)(67) 
34(25)(75) 
455(33)(67) 
596(16)(84) 
6215(14)(86) 
7237(23)(77) 
Expectations on becoming a good mother compared with Swedish women in general2, (n= 116; 491) (1 = much easier; 7 = much more difficult)0.7
137(32)(68) 
2120(18)(82) 
3145(21)(79) 
4298(16)(84) 
56(50)(50) 
61(0)(100) 
70   
Epidural3, (n= 117; 491)0.80
Yes130(20)(80) 
No478(19)(81) 
Pethidine3, (n= 116; 491)0.41
Yes71(15)(85) 
No536(20)(80) 
Nitrous oxide3, (n= 116; 490)0.49
Yes247(18)(82) 
No359(20)(80) 
Duration of labour3, hours (118; 475)0.23
≤18 h438(19)(81) 
>18 h155(23)(77) 
Augmentation of labour3, (n= 118; 490)0.38
Yes180(17)(83) 
No428(20)(80) 
Caesarean section3, (n= 122; 495)0.24
Yes63(25)(75) 
No554(19)(81) 
Vacuum extraction3, (n= 122; 495)0.71
Yes40(18)(82) 
No577(20)(80) 
Birth weight3, g (n= 121; 493)0.19
<250019(32)(68) 
≥2500595(19)(81) 
Apgar score<7 at 5 min3, (n= 122; 495)0.16
Yes11(36)(64) 
No606(19)(81) 
Neonatal transfer3, (n= 122; 495)0.16
Yes87(25)(75) 
No530(19)(81) 

Results

Fig. 1 shows that the majority of the 617 women had a positive overall experience of their first birth, and that woman with a negative experience were less likely to have a second child. Of women with a negative birth experience (scores 1 and 2), 38% had no more babies compared with 17% of women scoring 3–7 on the scale (RR 2.22, 95% CI 1.6–3.1).

Figure 1.

Women's future reproduction in relation to overall birth experience assessed two months after the first birth.

The Kaplan Meier curve (Fig. 2) illustrates that a very negative birth experience (scores 1 and 2) was associated with a longer interval to the next birth, but no major differences were found between women scoring 3–7. The estimated median time to the second birth was 4.2 years for women scoring 1 and 2 on the childbirth experience scale, and 2.4 years for women scoring 3–7 (Log Rank 16.0, P <0.001).

Figure 2.

Time to the second birth in relation to overall birth experience. Scores of birth experience 1–7 as above (1 = very negative, 7 = very positive).

Table 1 shows statistically significant differences between women who had no subsequent births and those who had one or more, regarding overall birth experience, age, marital status and expectations on approaching birth. No statistical differences were observed regarding education, country of birth, somatic and psychic anxiety, locus of control, attitudes to decision making, anxieties when thinking of approaching birth, labour pain and the responsibility of parenthood. Obstetric analgesia, duration of labour, augmentation of labour, mode of delivery and infant outcomes such as birthweight, Apgar score and transfer to neonatal unit were not associated with future reproduction.

In the regression analysis, only three of the variables in Table 1 contributed to the explanation of future reproduction: negative experience of the first birth, being ≥35 years and being single (Table 2). Women with an average to good birth experience (scores 3–7) had a 1.7 times higher probability of having a second birth during the eight to 10 years following their first birth, compared with women with a negative childbirth experience.

Table 2.  Factors associated with having a second birth during a period of 8–10 years following the first birth. HR = hazard ratio, corresponding to the risk ratio (RR).
 BHR95% CIP
Birth experience
Positive (3–7)0.531.731.25–2.320.001
Negative (1–2) 1.0  
Age (years)
<350.872.551.56–3.69<0.001
≥35 1.0  
Marital status
Married/Cohabiting0.942.571.67–3.94<0.001
Single 1.0  
Expectations on approaching birth
Positive (5–7)0.221.250.91–1.720.17
Negative (1–4) 1.0  

When including only women who were married or cohabiting or who were younger than 35 years of age, a negative birth experience was associated with a similar risk of not having a second baby (RR 1.76, 95% CI 1.27–2.45) (P < 0.001).

Discussion

The most significant finding of this study was that women with a negative experience of their first birth had fewer subsequent children and a longer interval to the second birth. Being older or single was, for understandable reasons, also associated with future reproduction.

Although this study controlled for a wide range of variables that could impact on whether women have a second child or not, such as sociodemographic background, outcome of first labour and birth, expectations on birth and parenthood, attitudes to decision making, and anxiety, we cannot exclude other important confounders that may have been overlooked.

It is well established that personality variables may affect health, aetiology and progression of disorder, health-related behaviour as well as psychosocial responses to illness9. Of five major personality dimensions related to health outcomes, described by John and Srivastava10 as agreeableness, conscientiousness, extraversion, openness and neuroticism, it is probably the last one which is most commonly associated with health complaints and negative outcomes11. Theoretically, the personality trait of neuroticism could affect women's experience of their first birth as well as their willingness to have a second baby. In the present study, neuroticism-related personality scales, such as the somatic and psychic anxiety scales in the Karolinska Scales of Personality, were used to control for the confounding impact of personality on the association between ratings of childbirth experience and future reproduction. It has previously been demonstrated that these scales are good markers of the neuroticism construct12.

A limitation of this study is that the women were drawn from a birth centre trial. These women have a stronger focus on psychological aspects of childbirth, including more positive expectations on the approaching birth than other women13. It cannot be excluded that the childbirth experience was more important to these women compared with the general population.

Conclusion

In spite of the limitations, the study provides data that strongly suggests that women's experiences of the first birth has consequences for future reproductive behaviour. The finding elucidates the importance of taking women's experiences into account when providing intrapartum care, and to pay attention to their birth experiences during postpartum follow up.

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