University of Nevada, Reno Traumatic Birth Experiences within the Family Context: The Role of Adverse Childhood Experiences, Postpartum Mental Health, Bonding and Infant Emotion Identification A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy in Education By Alexandra Shrake Dr. Brenda Freeman, Dissertation Advisor August 2020 Copyright by Alexandra Shrake 2018 All Rights Reserved i ABSTRACT Obstetric complications and emergencies are an increasing concern in the United States with over fifty thousand women experiencing severe life-threatening emergencies annually (CDC, 2020). Beyond the stark realities of increasing rates of serious complications and death during childbirth are reports that up to one third of women would describe the birth of their child as “traumatic” and indicate that they feared that they or their child would die or be seriously injured (Soet, Brack & DiLorio, 2003). Research indicates that these traumatic experiences have negative physical, emotional and social sequalae for the women involved (Ayers et al., 2008; Skinner et al., 2018). Despite increasing awareness of the ramifications of traumatic childbirth, the relationship between these experiences and parent-child bonding is not well understood. More specifically, there is a lack of understanding of how overall parental adverse childhood experience scores, specific forms of traumatic birth experiences, and infant emotion identification may relate to the development of healthy parent-child bonding. This dissertation examined three research questions: Are there significant differences between low history of trauma and high history of trauma as measured by the ACE checklist in post-natal depression, post-birth PTSD, and bonding, in those who experienced birth trauma? Are there significant differences between types of birth trauma in post-natal depression, post-birth post-traumatic stress disorder, and bonding in those who have experienced birth trauma? In those who have experienced traumatic birth experiences, are there significant differences in frequencies of infant emotions identified in those who report high and low birth-related trauma and bonding? ii Three-hundred and nineteen participants responded to an online survey and were asked to respond to questions about adverse childhood experiences, types of birth trauma, postpartum mental illness, parent-infant bonding and infant emotion identification. The results of the study indicated that those who experience birth trauma report much higher rates of postpartum depression, postpartum post-traumatic stress disorder and parent-infant bonding disorders than rates reported by the general population (Gavin et al., 2005; Muzik, Bockneck, Broderick, Richardson, Rosenblum, Thelen, & Seng, 2013; O’Hara & Wisner, 2014; Postpartum Support International, 2020; Reck, Klier, Pabst, Stehle, Steffenelli, Struben, Backenstrass, 2006). In this study, parental adverse childhood experiences did not appear to be related to rates of postpartum depression, postpartum posttraumatic stress disorder or disorders of parent-child bonding. Although prior adversity was not associated with birth trauma outcomes, some physical, psychological and relational aspects of traumatic birth experiences were associated with higher levels of postpartum depression, post-natal post-traumatic stress disorder and bonding disorders. Experiencing traumatic birth as interpersonal in nature and differences in attributions of responsibility demonstrated differing outcomes for postpartum PTSD and bonding. Finally, parents who identified higher rates of identification of passivity, unusual “other” responses and lower rates of interest in images of infants expressing ambiguous and mixed emotions endorsed more difficulty in parent-child bonding in this sample. The findings of this study highlight concerning rates of postpartum mental illness and disorders of parent-child bond in those experiencing birth trauma. Moreover, this study speaks to the possible negative ramifications that interpersonal forms of birth iii trauma may have for postpartum individuals and their families. Further research may continue to examine the role of parents’ identification of infants’ emotions as a precursor to healthy bonding in those experiencing traumatic birth. Keywords: adverse childhood experiences, attachment theory, birth trauma, infant emotion identification, interpersonal trauma, parent-infant bond, postpartum depression, postpartum post-traumatic stress disorder iv DEDICATION To My Daughter You are my greatest adventure and my greatest joy. “Your children are not your children. They are the sons and daughters of Life’s longing for itself. They come through you but not from you, And though they are with you, yet they belong not to you. You may give them your love but not your thoughts, For they have their own thoughts. You may house their bodies but not their souls, For their souls dwell in the house of tomorrow, which you cannot visit, not even in your dreams. You may strive to be like them, but seek not to make them like you. For life goes not backward nor tarries with yesterday. You are the bows from which your children as living arrows are sent fourth.” Kahlil Gibran v ACKNOWLEDGEMENTS To my husband, there is no one I’d rather have by my side on our journey. Thank you for stretching me to be more courageous, more adventurous and more compassionate. This dissertation journey is just as much yours as it has been mine. Thank you for all the sacrifices that you have made to get us here. To my mother and my father, who has always been there with unconditional love, empathy, hard work and encouragement. Thank you for instilling in me curiosity, the confidence to pursue my dreams and a love of learning that sustains me during even the hardest times. To my in laws, without you, none of this would be possible. You have been ever willing to lend a hand, an ear to listen and more than a few delicious meals. I am honored to be part of your family. To Brenda Freeman, my sincerest gratitude for being a guiding force behind this dissertation particularly as I established my family, moved across states, and now through a global pandemic. To my committee, your insight has been valuable. I am so thankful for your willingness to share your expertise, guidance and most of all, your time with me. Thank you. vi TABLE OF CONTENTS ABSTRACT .........................................................................................................................2 DEDICATION .....................................................................................................................5 ACKNOWLEDGEMENTS .................................................................................................6 CHAPTER I: INTRODUCTION………………………………………………………………………...1 Brief Introduction to Birth Trauma ..........................................................................1 Statement of the Problem ........................................................................... ….……2 Adverse Childhood Experiences ..................................................................3 Types of Birth Trauma .................................................................................3 Postpartum Mental Illness ............................................................................4 Infant Emotional Identification ....................................................................5 Research Questions ........................................................................... ……..………6 Theoretical Background .......................................................................................... 6 Attachment Theory .................................................................................... 6 Attachment Theory and Trauma………………………………………..…7 Attachment Theory and Postpartum Mental Illness………………………8 Attachment Theory and Infant Emotion Identification……………………8 Definitions…………………………………………………………………………9 CHAPTER II: LITERATURE REVIEW…………………………………………………………...…………………….10 vii Birth Trauma ......................................................................................................... 11 Definition of Birth Trauma ........................................................................11 Prevalence ..................................................................................................14 Types of Birth Trauma……………………………………………….…..15 Physical Types of Trauma .............................................................15 Psychological Birth Trauma ..........................................................15 Relational Nature of Birth Trauma………………………..…..…16 Betrayal Trauma…………………………………………17 Cultural Narratives in Birth Trauma…………………………………..…23 Risks for Birth Trauma…………………………………………………24 Impact of Birth Trauma (Postpartum Mental Health)……………………27 Birth Trauma and Family Context……………………………………….29 Birth Trauma and Partners………………………………………………29 Birth and Infant Factors…………………………………………………30 Attachment Theory ...................................................................... …….…………32 Attachment Definition……………………………………….………………………..32 Development of Attachment Theory .........................................................33 Classification of Infant's Attachment .........................................................34 Attachment and Caring for Infants ................................................ ……...37 Infant Cues and Responsiveness ................................................................38 Birth Trauma