After 28 hours of labor with my first child, I struggled to breathe. In the hospital, a nurse strapped an oxygen mask to my face. A sea of people stood around me, screaming for me to breathe. Breathing, something we're born knowing how to do, escaped me.I had no idea this moment would later bring about weeks of enervating postpartum post-traumatic stress disorder (PTSD) symptoms. Researchers estimate postpartum PTSD, often triggered by birth trauma, impacts anywhere from 4% to up to 17% of birthing people—but I didn't even know it existed.
Symptoms of Postpartum PTSD
PTSD, well-known and well-researched among veterans, has common symptoms including:
Flashbacks or nightmaresIntrusive reimagining of past eventsPanic attacksA sense of detachmentAvoidance of reminders of the traumatic birth experienceSleep issuesIrritability
Why Postpartum PTSD Is Often Undiagnosed
Many patients with postpartum PTSD go undiagnosed. Myself included.
My lower-income status didn't help. My husband was in graduate school and we had just moved to a new city. I was juggling three low-paying jobs with no benefits, which placed me on Medi-Cal, California's Medicaid health care program, through a clinic east of Los Angeles. The payout for Medi-Cal patients is lower, so doctors who take it may slot these appointments back-to-back to compensate. The first OB-GYN I saw said, "You shouldn't care how you're treated. You don't work. You aren't paying." I told her I had been paying government taxes since I started working at 16 years old, and still was. I walked out of her office and never looked back.
It's no wonder my symptoms went undiagnosed. Poverty is a leading factor in maternal vulnerability in the U.S., according to 2021 data released by Surgo Ventures. Beyond the physical impact of health care disparity for birthing people, maternal depression rates are an estimated 40 to 60% higher for low-income people, according to the Georgetown University Health Policy Institute.
As a white woman who did not grow up in poverty, I have much more privilege than some. There is staggering racial disparity in maternal health care: Black, American Indian, and Alaska Native women are two to three times more likely to die from pregnancy-related causes than white women, according to the Centers for Disease Control and Prevention (CDC). When birthing people of color live in low-income communities, the inequities increase even more.
The OB-GYN whom I ultimately stayed with never got to know me. He sped through each appointment; I barely got a question in. When he told me he wouldn't be in the delivery room, I shouldn't have been caught off guard, but I still was.
Another issue is lack of awareness for postpartum PTSD. This leaves many to suffer in silence.
Postpartum PTSD vs. Postpartum Depression
While you may experience both conditions at the same time, postpartum PTSD is not the same as postpartum depression. The latter is often marked by symptoms including:
Persistent sadness or hopelessnessCrying a lotFeeling empty or numbLoss of interest in once enjoyable activities and withdrawalAppetite changes and sleep issuesSuicidal thoughtsDifficultly bonding with the babyThoughts of harming the baby
Both postpartum PTSD and depression are serious conditions that need to be treated.
Causes of Postpartum PTSD
Traumatic birthing experiences like mine can lead to postpartum PTSD. This birth trauma—whether real or perceived—can vary and may include:
Long and painful laborA health crisis during labor impacting the baby or parentEmergency C-sectionConditions like postpartum hemorrhage, perineal tearing, or hysterectomyLack of support during delivery
And research confirms severe or life-threatening trauma increases the risk for developing psychiatric disorders, including PTSD.
In the hospital delivery room, my body had entered a panic. I arrived the day before on an instinct of fear—I couldn't feel the baby kick. Over the next 28 hours I was pumped with Pitocin, Demerol (or possibly Fentanyl), antibiotics, and a failed epidural. My water was broken without my consent. I could not move my body but I could feel substantial pain. I forgot how to breathe.
In the final moments before my baby's birth, I yearned for comfort from a familiar face at the other end of the hospital bed. Instead, the on-call doctor, whom I'd never seen before, took out a knife and sliced me without warning—a violent, bloody episiotomy. He pulled out my baby and the NICU team swooped my son away for examination. My body shook in shock as I cried.
After the APGAR score confirmed that the baby was healthy, he was passed to my husband for skin-to-skin. I was told I could not hold my child until I stopped shaking. I clenched my teeth, but I continued to scream and shake for what felt like hours. The stranger called “doctor” sat at the foot of my bed as I watched the thread pull up and down, yanking nearly 50 stitches through my raw skin. I yearned to hold my baby.
That loss of autonomy is one of many kinds of mistreatment in childbirth. Researchers found that in the U.S. one in six people reported experiencing mistreatment during labor or delivery. Based on The Giving Voice to Mothers survey, I was one of the about 18% of low-income white patients in the U.S. who report a mismanaged birth. The rates among low-income patients of color are starkly higher, at about 27%.
All Birth Trauma is Valid: How to Get the Support You Need
Struggling With Postpartum PTSD
In the weeks that followed, I felt stuck, voiceless, and unsure of how to make peace with what happened. Once home, I was unable to exclusively breastfeed. I bled for months. I couldn't sleep. My physical pain was enormous, as were the hauntings. I would dip further back in time to when I cared for my only brother, an infant in hospice care. He would wail from a rare disease electrifying him, damaging his brain. These traumas would replay in my mind, and I'd feel my whole body shudder.
I suffered from insomnia, nights spent staring at the ceiling as the past rewound in my mind. At my six-week check-up, I filled out a form—the Edinburgh Postnatal Depression Scale—that could possibly diagnose me with postpartum depression or anxiety. I did not feel like myself, but I didn't feel like I had either of those completely. I hoped the nurse would see something I could not vocalize.
During my visit, I was pushed through a system I felt was not meant to support me. I tried to explain to the nurse that I was experiencing feelings of reliving my birthing experience that would keep me up at night.
"You may have a slight case of depression—you can see someone or not. Up to you," she said, hand already on the doorknob. No one checked on my postpartum health again. I was never formally diagnosed. It wouldn't be until three years later, during my PhD program, when I would learn from a psychology professor doing research in the field that postpartum PTSD even existed.
Lyra Matin, a psychotherapist specializing in healing trauma
Trauma-informed care needs to be institutionalized and become required education for all medical professionals, not just mental health ones.
— Lyra Matin, a psychotherapist specializing in healing trauma
The Cost of a Failing System
People who experience traumatic childbirth and postpartum PTSD may feel isolated without appropriate care. Stephanie Bernard, 36, from Atlanta, wasn't able to see her OB-GYN at the typical six-week checkup. She was suffering from severe postpartum bleeding that left her unable to walk. She was also uninsured at the time.
“My husband lost his job shortly after I gave birth, which meant that we no longer had medical insurance,” says Bernard, who is African American. Her doctor's office did not accept Medicaid, and it wasn't until a full year later that she learned she was suffering from diastasis recti. “Had I received the care I needed, my recovery process would have been much smoother,” she says. “I had no idea about the dangers of postpartum hemorrhaging, fevers, infections, pulmonary embolisms, and heart-related issues that are common.” She says she was heartbroken during those first two years when she couldn't even pick up her child and feels lucky to even be alive to share her story now.
Her experience also highlights the medical bias and racism Black women experience during pregnancy, childbirth, and postpartum. “I was alarmed to learn the rate at which maternal mortality affects Black women due to not being listened to by medical professionals, staff, medical bias, and medical racism.” She calls for increased education for health care professionals, especially non-Black health care professionals, on institutional racism, racial biases, especially how to identify and address both within patient care.
The national cost of perinatal mood and anxiety disorders (PMADs), such as postpartum PTSD, from pregnancy through five years postpartum registers at $14.2 billion, or an average of $32,000, for those affected but not treated. These costs break down to health consequences for mothers and children, maternal productivity loss, and increased costs for social services. For parents like me who could barely afford groceries because we lacked paid parental leave, finding, navigating, and affording such treatment felt impossible.
Research into postpartum PTSD began around 2006 and awareness has expanded since then, but the lack of patient education persists. Much about postpartum PTSD is published in journals focused on psychiatry, psychology, and nursing, a 2020 report explains, allowing for a lack of awareness for obstetricians.
Lyra Matin, 37, who is of Filipina descent and lives in Los Angeles, experienced a traumatic birth, which included a blood transfusion and episiotomy that developed an infection. When she tried to discuss her trauma with her OB-GYN, he misdiagnosed her. “He tried to normalize it as baby blues because of ‘hormones fluctuating.' He referred me to a therapist for postpartum issues, but the therapist did not take my insurance,” says Matin. She had government-funded health insurance.
The experience motivated Matin to become a psychotherapist specializing in healing trauma. After seeing the obstacles so many people face—from misdiagnoses to insurance hurdles and steep costs—she believes the entire system needs to be overhauled. "Trauma-informed care needs to be institutionalized and become required education for all medical professionals, not just mental health ones," she says.
Courtney Lund O'Neil
I was told I could not hold my child until I stopped shaking. I clenched my teeth, but I continued to scream and shake for what felt like hours.
— Courtney Lund O'Neil
There are regional trauma-informed care programs trying to address this, like the California-based BEBA: A Center for Family Healing, which offers families early intervention and care. But national programs like these must have a larger presence during the perinatal and postnatal periods. Some families may be able to afford out-of-pocket therapy, night nurses, and postpartum doulas, but many are not in the economic position to do so. We need a system that doesn't shut out low-income patients or Black patients and patients of color. We need humans treating humans in every appointment, in every room. Those with fewer economic resources bear the brunt of our maternal health crisis; it's costing birthing people their physical health, their mental health, and their lives.
We also need improved education for our doctors and health care professionals. In 2021, the American Psychiatric Association published the first comprehensive educational textbook for understanding, diagnosing, and supporting reproductive and maternal mental health for use in medical education. At least that's a start.
My Journey Toward Healing
In the fall of 2020, I was pregnant again. This time, as a PhD student, my OB-GYN visits were covered by my insurance. I also qualified for secondary coverage under my husband. During this pregnancy, I became vocal in my prenatal doctor appointments. I was physically and mentally able to self-advocate, but the responsibility should not be on the birthing person. We are negotiating with a systemic problem.
Six weeks after I delivered my second child, I went to my postpartum appointment. When the Edinburgh Postnatal Depression Scale form was handed to me, I asked how diagnosis happens. The nurse told me that they only intervene if the patient is in crisis during the time of visit, but this designation is left to a clinician's own judgment.
“There has yet to be a measure created that does [appropriately test for PMADs], unfortunately,” says Stephanie Freiburg, a licensed therapist certified in perinatal mental health. “Better assessment of postpartum PTSD starts with awareness and training within our health care system. This would mean OB-GYNs, perinatologists, lactation consultants, and nurse practitioners, would all need to take part in a training on perinatal mood and anxiety disorders.”
How To Manage Postpartum PTSD
Postpartum PTSD is a serious condition that can impact a person's daily life. But it is treatable. Therapy and support groups can be helpful and medication may be needed.Speak with a health care provider you trust or use trusted resources like the Substance Abuse and Mental Health Services Administration (SAMHSA) for help.
Where To Go From Here
I'm optimistic we will see change in this country, where we currently face an undersupply of providers and postpartum support. But to begin our journey toward change, we need to voice our concerns in health care offices. We need to call our congressperson, to speak up about better support in the postpartum period. We need to advocate for ourselves and the generations to come. If you're a patient experiencing mistreatment, find a new health care provider who makes you feel heard—there are organizations that can help you advocate for your care. It's not just people who are pregnant that must do this work, but collectively, we must engage in actively pursuing better care for parents after birth. The changes will be slow, but they must begin.
This story was supported by the journalism non-profit the Economic Hardship Reporting Project.
Updated byAnna Halkidis
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