Within the last decade, the perinatal period has rapidly become a high-priority area of research (Howard & Khalifeh, Reference Howard and Khalifeh2020). There is increasing awareness of vast and persistent maternal health disparities in the United States, as well as intergenerational consequences and economic costs of inadequate perinatal healthcare (Glazer & Howell, Reference Glazer and Howell2021). The transition from pregnancy to postpartum often is described as one of the most complicated, meaningful, and challenging developmental transitions in the human life span. Thus, it is ideal timing to apply a developmental psychopathology perspective to this life phase because this framework emphasizes longitudinal, multilevel investigations of both adaptive and maladaptive health (Cicchetti & Rogosch, Reference Cicchetti and Rogosch1996; Cicchetti & Toth, Reference Cicchetti and Toth2009). Indeed, there have been recent applications of this framework to the perinatal period (e.g., Davis & Narayan, Reference Davis and Narayan2020; Doyle & Cicchetti, Reference Doyle and Cicchetti2018; Glynn et al., Reference Glynn, Howland and Fox2018; Goodman & Dimidjian, Reference Goodman and Dimidjian2012), which hold promise for advancing research and healthcare practices during this critical life phase.
In spite of these conceptual and empirical advancements in perinatal research, childbirth – a critical component of the perinatal transition – has received limited attention in the developmental psychopathology literature (for a biopsychosocial perspective on pain and social support during childbirth, see Saxbe, Reference Saxbe2017). Although childbirth is only a fragment of the entire perinatal period, it is a momentous inflection point with the potential to drastically alter birthing parents’ postnatal health trajectories.Footnote 1 Typical childbirth is characterized by numerous biopsychosocial changes that influence birthing parents’ health, parenting behaviors, and interpersonal relationships. In the context of adverse or traumatic childbirth experiences, the consequences may become even more pervasive and enduring. Thus, childbirth cannot be neglected in developmental psychopathology research on the perinatal period.
In this paper, we present a multilevel developmental psychopathology model of childbirth and the perinatal transition (i.e., pregnancy to early postpartum). Our model is informed by pivotal research on neurobiological changes during the perinatal period (e.g., Davis & Narayan, Reference Davis and Narayan2020; Glynn & Sandman, Reference Glynn and Sandman2011), sociocultural influences on the birth experience (e.g., Cooper Owens & Fett, Reference Cooper Owens and Fett2019; Greenwood et al., Reference Greenwood, Hardeman, Huang and Sojourner2020), and the causes and consequences of childbirth trauma (e.g., Beck et al., Reference Beck, Driscoll and Watson2013). Separately, these literatures have illuminated the sensitive nature of the perinatal period, the transgenerational consequences of implicit and systemic racism, and the prevalence of childbirth trauma. We integrate these literatures within a developmental psychopathology framework in order to deepen scholars’ conceptualizations of childbirth as a pathway by which prenatal experiences may indirectly influence postnatal health outcomes.
A central tenet of developmental psychopathology is that development is dynamic across the life span – individuals fluctuate in continuous and discontinuous ways between adaptive and maladaptive functioning (Cicchetti, Reference Cicchetti2016). However, even during periods of maladaptive functioning, adaptive coping may be present. Thus, it is critical to study both typical and atypical developmental trajectories, as they are mutually informative. In line with this framework, we first outline typical biopsychosocial aspects of pregnancy and childbirth. Then, we explore ways in which these processes might deviate from normative development – in other words, when biological, psychological, and sociocultural processes interact to result in adverse or traumatic childbirth experiences. We acknowledge that many psychological conceptualizations of “typical” pregnancy and childbirth often reflect the experiences of White, well-educated, financially privileged samples. However, there is a burgeoning literature outside of psychology (e.g., in the fields of midwifery, nursing, public health, sociology) on perinatal and childbirth experiences among minoritized and marginalized populations. We integrate this literature throughout our review, consistent with multicultural perspectives and a developmental psychopathology framework for addressing perinatal health disparities (Causadias, Reference Causadias2013; Conradt et al., Reference Conradt, Carter and Crowell2020).
We illustrate these dynamic perinatal processes in a conceptual model (Figure 1). Our model highlights potential ways in which biological, psychological, and sociocultural factors interact during pregnancy and influence multilevel processes postpartum, both directly and indirectly, through effects on childbirth experiences. This model serves as an illustration of the biopsychosocial processes reviewed in this paper. We conclude with a brief description of early postnatal health trajectories, including those which are adaptive following childbirth trauma, as well as implications for research and healthcare practice.
Figure 1. A conceptual model of childbirth as a pathway by which prenatal experiences may indirectly influence postnatal health trajectories. Biological, psychological, and sociocultural factors interact dynamically during each of these developmental stages.
“Typical” biopsychosocial processes during pregnancy and childbirth
Neurobiology and sleep
Birthing parents undergo profound neurobiological and anatomical changes that are necessary for pregnancy, childbirth, and preparation for parenthood (for reviews on these changes, see Glynn & Sandman, Reference Glynn and Sandman2011; Schaffir, Reference Schaffir and Wenzel2016). In fact, hormone exposures during the perinatal period are unmatched compared to any other time in the female life span. Human chorionic gonadotropin levels rise rapidly during pregnancy and facilitate the production of progesterone. As a smooth muscle relaxant, progesterone helps to prevent premature birth, reduce hypertension risk, increase oxygen intake, and promote greater nutrient and energy yields (Edwards et al., Reference Edwards, Cunningham, Dunlop and Corwin2017; Schaffir, Reference Schaffir and Wenzel2016). Also, the conversion of progesterone to allopregnanolone (ALLO) – a neurosteroid implicated in physiologic homeostasis following stress – promotes dampened stress responsivity during late gestation, which protects the birthing parent and fetus from adverse effects of stress exposure (de Weerth & Buitelaar, Reference de Weerth and Buitelaar2005; Glynn et al., Reference Glynn, Wadhwa, Dunkel Schetter, Chicz-DeMet and Sandman2001; Schiller et al., Reference Schiller, Schmidt and Rubinow2014). These and other prenatal hormonal changes induce alterations in lipid metabolism and shift gut and vaginal microbial diversity to increase fat storage, prepare birthing parents for lactation, and promote bacterial growth that is associated with positive birth outcomes (Edwards et al., Reference Edwards, Cunningham, Dunlop and Corwin2017; Prince et al., Reference Prince, Chu, Seferovic, Antony, Ma and Aagaard2015). Placental corticotropin-releasing hormone triggers cortisol production during pregnancy, which supports fetal maturation and potentiates the onset of labor (Gangestad et al., Reference Gangestad, Caldwell Hooper and Eaton2012; Howland et al., Reference Howland, Sandman and Glynn2017). Then, during labor, endogenous opioids regulate oxytocin (a neuropeptide that promotes uterine contractions) and help to blunt pain (Saxbe, Reference Saxbe2017).
Prenatal sleep is intimately intertwined with these hormone changes (for a review, see Bazalakova et al., Reference Bazalakova, Bianchi, Stanic and Bianchi2014). Due to the soporific effects of rapidly increased progesterone levels, the 1st trimester of pregnancy often is characterized by longer sleep duration. However, with advancing gestational age, rising progesterone and cortisol levels contribute to declines in total overnight and REM sleep, more frequent and longer nighttime awakenings, and increased urinary frequency and heartburn. Oftentimes, sleep patterns during the 3rd trimester reflect clinically significant insomnia, which is endorsed by more than 50% of birthing parents (Facco et al., Reference Facco, Kramer, Ho, Zee and Grobman2010). Increased daytime napping may preserve total sleep time per 24 hr; however, it is unclear whether daytime sleep fully offsets the neurologic and metabolic consequences of poor nighttime sleep and overall poor sleep quality (Bazalakova et al., Reference Bazalakova, Bianchi, Stanic and Bianchi2014). In addition to disruption via hormonal changes, prenatal sleep is disrupted by experiences with physical discomfort and back pain, leg cramps and restlessness, shortness of breath, and fetal movements (Bazalakova et al., Reference Bazalakova, Bianchi, Stanic and Bianchi2014; Schaffir, Reference Schaffir and Wenzel2016).
Sociohistorical processes
Perceptions and practices surrounding childbirth and the perinatal transition have shifted over time with evolving societal beliefs and scientific developments. The rise of industrialization and modern medicine during the early 20th century instigated a transition in prenatal care and childbirth from the home – in the presence of female kin and midwives – to the hospital with predominantly White, male doctors (Saxbe, Reference Saxbe2017). This transition was accompanied by an increase in surgical births (e.g., Cesarean birth, use of forceps during vaginal birth) and use of anesthesia during labor (Declerq et al., Reference Declercq, Sakala, Corry, Applebaum and Herrlich2013; Hamilton et al., Reference Hamilton, Martin, Osterman and Curtin2015), although this latter phenomenon also has ebbed and flowed with shifting feminist perspectives, such as from championing non-medicalized births in the 1960s to supporting women’s rights to choose “pain-free” births in the 1990s (Skowronski, Reference Skowronski2015). Similarly, there have been shifts in the involvement of fathers during prenatal care and childbirth. Whereas, historically, fathers were excluded from pregnancy and childbirth matters, advocacy efforts in the 1960s prompted changes in these standards in the United States, and today, father presence at birth is highly valued (Longworth et al., Reference Longworth, Furber and Kirk2015; Saxbe, Reference Saxbe2017).
Western industrialization and scientific progress have been associated with advancements in perinatal healthcare and increased capacity to disseminate perinatal science (Lennon, Reference Lennon2016). However, these advancements have also incited increased perceptions of childbirth as a medically dangerous event (Bondas & Eriksson, Reference Bondas and Eriksson2001; Hunter, Reference Hunter2006; Lennon, Reference Lennon2016). Resultantly, there have been shifts in birthing parents’ experiences with pregnancy and childbirth, such as increased anxiety about adhering to medical recommendations and reduced agency in decision-making. These experiences have become increasingly normalized, and yet are often associated with perceptions of childbirth as traumatic.
Potentially traumatic childbirth
Expanding from this baseline, albeit non-exhaustive, understanding of biopsychosocial aspects of “typical” pregnancy and childbirth, we next examine what happens when these processes deviate from normative development. In other words, we describe the ways in which “atypical” developmental processes may result in adverse or traumatic childbirth experiences, which then impel multifinal postnatal health trajectories. It is estimated that 9-44% of birthing parents describe their childbirth as traumatic, and a wide range of childbirth experiences have fallen under this description (Alcorn et al., Reference Alcorn, O’Donovan, Patrick, Creedy and Devilly2010; de Graaff et al., Reference de Graff, Honig, van Pampus and Stramrood2018; Grekin & O’Hara, Reference Grekin and O’Hara2014; Yildiz et al., Reference Yildiz, Ayers and Phillips2017). These experiences include (but are not limited to) emergency surgical births, preterm birth, prolonged and painful childbirth, admission of the infant into the Neonatal Intensive Care Unit (NICU), and “degrading” healthcare experiences, such as medical staff making healthcare decisions without input or consent of the birthing parent (Beck, Reference Beck2004, p. 32). These broad examples highlight that “traumatic childbirth … lies in the eye of the beholder” (Beck, Reference Beck, Quatraro and Grussu2020, pp. 132). What may be perceived by obstetrical healthcare providers as routine, non-life-threatening delivery may be experienced as traumatic and life-altering by birthing parents. Specific rates of subjective traumatic experiences vary based on samples (e.g., community vs. high-risk), methodology (e.g., self-report vs. diagnostic interviews), and time period (e.g., early vs. later postpartum; Williams et al., Reference Williams, Strobino and Holliday2022; Yildiz et al., Reference Yildiz, Ayers and Phillips2017), but their prevalence underscores the importance of including childbirth in developmental psychopathology conceptualizations of the perinatal transition.
Atypical neurobiology, stress responsivity, and sleep
Birthing parents who do not exhibit normative biological changes during pregnancy – namely, increasing hormone levels and dampened stress responsivity during the 3rd trimester – may be at heightened risk for adverse or traumatic childbirth experiences (Dickens et al., Reference Dickens, Pawluski and Romero2020). For instance, research has demonstrated that increases in perceived stress across gestation are associated with elevated risk for preterm birth even after controlling for obstetric risk, pregnancy-specific anxiety, and prenatal life events (Glynn et al., Reference Glynn, Dunkel Schetter, Hobel and Sandman2008). In addition, more pronounced cortisol awakening responsivity during the 3rd trimester has been associated with more subjectively negative childbirth experiences measured within the first few postpartum hours (Alder et al., Reference Alder, Breitinger, Granado, Fornaro, Bitzer, Hösli and Urech2011). Given the role that ALLO plays in restoring homeostasis and dampening stress responsivity, it is likely that atypically low levels of this neurosteroid facilitate the relation between prenatal stress and adverse childbirth outcomes. Excessively low levels of ALLO during 2nd trimester have been associated with postpartum depression (PPD) and anxiety (Osborne et al., Reference Osborne, Betz, Yenokyan, Standeven and Payne2019; Osborne et al., Reference Osborne, Gispen, Sanyal, Yenokyan, Meilman and Payne2017); however, direct relations between prenatal ALLO levels and childbirth outcomes have not been studied.
Also important to consider are individual differences in prenatal stress responsivity, particularly given that these may be heightened by experiences of racism and thus provide a mechanism to explain racial disparities in childbirth experiences and outcomes (Chaney et al., Reference Chaney, Lopez, Wiley, Meyer and Valeggia2019; Conradt et al., Reference Conradt, Carter and Crowell2020; Glynn & Sandman, Reference Glynn and Sandman2011; Kramer & Hogue, Reference Kramer and Hogue2009). Black birthing parents in the United States are two times more likely than White birthing parents to give birth preterm, and they are three times more likely to give birth very preterm (Kramer & Hogue, Reference Kramer and Hogue2009). Exposure to racism, ranging from interpersonal to structural, is experienced in the body like chronic stress in that it increases sympathetic nervous system activation, upregulates the HPA axis, and results in physiological wear-and-tear (for reviews on this topic, see Chaney et al., Reference Chaney, Lopez, Wiley, Meyer and Valeggia2019; Goosby et al., Reference Goosby, Cheadle and Mitchell2018). Indeed, research has shown that Black birthing parents who endorsed multiple experiences of direct and indirect childhood racism and exhibited excessive increases in diastolic blood pressure over the course of pregnancy were at heightened risk for delivering low birthweight infants (Hilmert et al., Reference Hilmert, Dominguez, Dunkel Schetter, Srinivas, Glynn, Hobel and Sandman2014).
An emerging body of research has begun exploring atypical vaginal and gut microbial communities during pregnancy as risk factors for traumatic childbirth experiences (Corwin et al., Reference Corwin, Hogue, Pearce, Hill, Read, Mulle and Dunlop2017). For instance, Black and Latinx birthing parents are less likely than are White birthing parents to exhibit Lactobacillus-dominated vaginal microbial profiles, which may partially explain higher rates of preterm birth among birthing parents of color (Fettweis et al., Reference Fettweis, Brooks, Serrano, Sheth, Girerd, Edwards, Strauss, Jefferson and Buck2014; Hickey et al., Reference Hickey, Zhou, Pierson, Ravel and Forney2012; Hyman et al., Reference Hyman, Fukushima, Jiang, Fung, Rand, Johnson, Vo, Caughey, Hilton, Davis and Giudice2014; Prince et al., Reference Prince, Chu, Seferovic, Antony, Ma and Aagaard2015). However, one recent longitudinal study found that increased risk for preterm birth was associated with a sudden decrease in vaginal richness and diversity between the 1st and 2nd trimesters, followed by continued microbial instability throughout gestation (Stout et al., Reference Stout, Zhou, Wylie, Tarr, Macones and Tuuli2017). Thus, risk for potentially traumatic childbirth may be related to sudden, early decreases and subsequent instability in vaginal microbiome diversity, which may occur more commonly among birthing parents who endure chronic stress and/or acute stress earlier in gestation. Similarly, atypical alterations in gut microbial composition over the course of gestation – specifically, premature shifts from anti- to pro-inflammatory states, which initiate labor – have been associated with preterm birth (for a review, see Bayar et al., Reference Bayar, Bennett, Chan, Sykes and MacIntyre2020).
Finally, atypical patterns in prenatal sleep may confer risk for adverse and traumatic childbirth experiences. Severe insomnia and sleep apnea during pregnancy have been associated with prolonged labor, emergency surgical births, and preterm birth (Felder et al., Reference Felder, Baer, Rand, Jelliffe-Pawlowski and Prather2017; Paavonen et al., Reference Paavonen, Saarenpää-Heikkilä, Pölkki, Kylliäinen, Porkka-Heiskanen and Paunio2017). Excessive sleep deprivation has been associated with high levels of pro-inflammatory serum cytokines among pregnant adults, which may explain the links between poor sleep and adverse childbirth outcomes (Okun et al., Reference Okun and Coussons-Read2007; for a review, see Chang et al., Reference Chang, Pien, Duntley and Macones2010). In addition, birthing parents who are especially sleep deprived have reported more pain and discomfort during labor (Chang et al., Reference Chang, Pien, Duntley and Macones2010). Sleep deprivation has been associated with increased pain sensitivity among non-pregnant adults (Schrimpf et al., Reference Schrimpf, Liegl, Boeckle, Leitner, Geisler and Pieh2015; Smith et al., Reference Smith, Edwards, Stonerock and McCann2005), and the association between sleep deprivation and elevated stress hormones may explain this association as it pertains to childbirth pain (Alehagen et al., Reference Alehagen, Wijma, Lundberg, Melin and Wijma2001; Besedovsky et al., Reference Besedovsky, Lange and Born2012).
Psychosocial risk factors
Psychological and sociocultural factors interact dynamically with birthing parents’ neurobiology and sleep to confer risk for traumatic childbirth experiences. For instance, when conceptualizing atypical stress responsivity as a biological risk, it is pertinent to recognize that birthing parents with histories of chronic life stress are likely to continue experiencing stress during pregnancy, which may compromise their bodies’ abilities to downregulate stress responsivity (Dickens et al., Reference Dickens, Pawluski and Romero2020). Unstable housing and food scarcity are two chronic stressors that have been associated with labor complications and preterm birth (Buultjens et al., Reference Buultjens, Murphy, Robinson and Milgrom2013; Clark et al., Reference Clark, Weinred, Flahive and Seifert2019; Pantell et al., Reference Pantell, Baer, Torres, Felder, Gomez, Chambers, Dunn, Parikh, Pacheco-Werner, Rogers, Feuer, Ryckman, Novak, Tabb, Fuchs, Rand and Jelliffe-Pawlowski2019). Moreover, birthing parents facing food scarcity are more likely to have limited education on and access to healthy prenatal diets, which increases their risk for unhealthy weight during pregnancy. High BMI and obesity during pregnancy are associated with elevated risks for insomnia and sleep apnea, and thus preterm and emergency Cesarean birth (Cnattingius et al., Reference Cnattingius, Villamor, Johansson, Edstedt Bonamy, Persson, Wikström and Granath2013; Dempsey et al., Reference Dempsey, Ashiny, Qiu, Miller, Sorensen and Williams2005; Loy et al., Reference Loy, KNS and JM2013; Swanson et al., Reference Swanson, Kalmbach, Raglan and O’Brien2020).
Daily experiences with racism and discrimination are additional chronic life stressors that have been associated with atypical prenatal sleep, including poorer sleep quality, more difficulties falling asleep, and more frequent nightmares (Feinstein et al., Reference Feinstein, McWhorter, Gaston, Troxel, Sharkey and Jackson2020; Kalmbach et al., Reference Kalmbach, Cheng, Sangha, O’Brien, Swanson, Palagini, Bazan, Roth and Drake2019). It has been theorized that the links between racism and sleep health may partially explain racial and ethnic disparities in adverse birth experiences, but more research on this topic is needed (Feinstein et al., Reference Feinstein, McWhorter, Gaston, Troxel, Sharkey and Jackson2020). One recent study found that pre-pregnancy sleep disturbances among non-Hispanic Black birthing parents predicted fetal growth restriction and preterm birth above and beyond prenatal sleep disturbances (White et al., Reference White, Dunietz, Pitts, Kalmbach, Lucchini and O’Brien2022). This finding highlights the need for developmental conceptualizations and longitudinal research on sleep health and childbirth.
Given bidirectional associations between poor sleep and difficulties with emotion regulation (Littlewood et al., Reference Littlewood, Kyle, Pratt, Peters and Gooding2017), it is likely that these factors interact to increase risk for traumatic childbirth experiences. Indeed, prenatal sleep deprivation has been associated with elevated fears of labor pain (Hall et al., Reference Hall, Hauck, Carty, Hutton, Fenwick and Stoll2009). Moreover, birthing parents’ experiences with depression and anxiety (both generalized and health-specific) have been found to exacerbate these fears, increase the likelihood of requesting Cesarean birth, and predict prolonged labor above and beyond prenatal substance use and health complications (Dencker et al., Reference Dencker, Nilsson, Begley, Jangsten, Mollberg, Patel, Wigert, Hessman, Sjöblom and Sparud-Lundin2019; Nilsson et al., Reference Nilsson, Hessman, Sjöblom, Dencker, Jangsten, Mollberg, Patel, Sparud-Lundin, Wigert and Begley2018; Orr et al., Reference Orr, James and Blackmore Prince2002; Polachek et al., Reference Polachek, Dulitzky, Margolis-Dorfman and Simchen2016; Türkmen et al., Reference Türkmen, Dilcen and Özçoban2020). Some research indicates that these psychological factors are more potent predictors of traumatic childbirth than the mode of birth itself (King et al., Reference King, McKenzie-McHarg and Horsch2017). Heightened psychological distress increases stress hormones, such as cortisol and epinephrine, that may slow labor and prolong discomfort, which would at least partially explain the link between psychological distress and traumatic childbirth experiences (Saxbe, Reference Saxbe2017).
Birthing parents who report adverse childhood experiences and interpersonal trauma histories are significantly more likely than those without trauma histories to endorse traumatic childbirth experiences (Choi & Sikkema, Reference Choi and Sikkema2016; Osofsky et al., Reference Osofsky, Osofsky, Frazer, Fields-Olivieri, Many, Selby, Holman and Conrad2021; Shamblaw et al., Reference Shamblaw, Sommer, Reynolds, Mota, Afifi and El-Gabalawy2021; Soet et al., Reference Soet, Brack and Dilorio2003). In fact, one study found that birthing parents’ interpersonal trauma histories predicted childbirth-related PTSD symptoms above and beyond prenatal psychopathology, lack of perceived social support, and labor pain (MacKinnon et al., Reference MacKinnon, Houazene, Robins, Feeley and Zelkowitz2018). This finding underscores the potency of preconception trauma histories as predictors of adverse and traumatic childbirth. There is a wealth of literature linking childhood maltreatment experiences – particularly, childhood sexual abuse – with traumatic childbirth, and the mechanisms facilitating these relations warrant further investigation (Lev-Wiesel et al., Reference Lev-Wiesel, Daphna-Tekoah and Hallak2009; Shamblaw et al., Reference Shamblaw, Sommer, Reynolds, Mota, Afifi and El-Gabalawy2021). Mechanisms that have been tested empirically include trauma-related schemas pertaining to helplessness and low perceived safety (Ayers, Reference Ayers2004; Iles & Pote, Reference Iles and Pote2015; King et al., Reference King, McKenzie-McHarg and Horsch2017; Soet et al., Reference Soet, Brack and Dilorio2003); intimate partner violence during pregnancy (Do et al., Reference Do, Vo, Murray, Baker, Murray, Valdenbenito, Eisner, Tran, Luong-Thanh, Nguyen and Dunne2022; Oliveira et al., Reference Oliveira, Reichenheim, Moraes, Howard and Lobato2017); maladaptive physiological stress responsivity during pregnancy (Yehuda & Meaney, Reference Yehuda and Meaney2018); re-traumatization, physical pain, and dissociation during childbirth (Choi & Seng et al., Reference Choi and Seng2016; Ford & Ayers, Reference Ford and Ayers2011; Goutaudier et al., Reference Goutaudier, Séjourné, Rousset, Lami and Chabrol2012; Reed et al., Reference Reed, Sharman and Inglis2017); and gut microbial communities that potentiate atypical inflammatory and glucocorticoid stress responses (Hantsoo et al., Reference Hantsoo, Jašarević, Criniti, McGeehan, Tanes, Sammel, Elovitz, Compher, Wu and Epperson2019). The multidimensionality of these mechanisms highlights the relevance of developmental psychopathology conceptualizations of childbirth.
Finally, birthing parents’ perceptions of being insufficiently cared for or ignored by healthcare staff and inadequately educated or consulted about childbirth procedures are also associated with appraisals of childbirth as traumatic (Ayers, Reference Ayers2004; De Schepper et al., Reference De Schepper, Vercauteren, Tersago, Jacquemyn, Raes and Franck2016; Soet et al., Reference Soet, Brack and Dilorio2003). One qualitative study found that birthing parents reported feeling coerced to comply with unwanted childbirth procedures in order to satisfy hospital staff’s needs over their own (Reed et al., Reference Reed, Sharman and Inglis2017). Some of these birthing parents described themselves as dehumanized objects of learning for healthcare staff. This latter point has been communicated powerfully by the Black birthing parent community, given that enslaved Black birthing parents often served as “experimental subjects in the development of the [reproductive healthcare] field” (Cooper Owens & Fett, Reference Cooper Owens and Fett2019, p. 1342). Indeed, limited access to culturally responsive healthcare has been theorized as a contributor to adverse childbirth experiences (Dunkel Schetter, Reference Dunkel Schetter2011). For example, among pregnant Latinx adolescents, low levels of acculturation have been associated with more subjectively traumatic childbirth experiences, and this association may result in part from barriers to culturally responsive healthcare (Anderson & Strickland, Reference Anderson and Strickland2017). Among Black birthing parents, experiences with racism during prenatal care have been associated with preterm birth above and beyond depressive symptoms (Dole et al., Reference Dole, Savitz, Siega-Riz, Hertz-Picciotto, McMahon and Buekens2004). Moreover, a recent large-scale longitudinal study found that risk for preterm birth was especially heightened among Black sexual minority birthing parents, even after accounting for preconception and prenatal risk factors and socioeconomic indicators (Everett et al., Reference Everett, Limburg, Charlton, Downing and Matthews2021). This study found that identifying as bisexual or lesbian was protective among White birthing parents, which highlights the importance of considering intersectional identities in reproductive health inequities and discriminatory healthcare practices.
Multifinal postnatal health trajectories following childbirth
Following childbirth, hormone levels plummet (Schaffir, Reference Schaffir and Wenzel2016). Oxytocin and prolactin are two hormones that do not exhibit sudden reductions, as they have been found to play critical roles in facilitating positive mother–infant bonding and inducing milk letdown for breastfeeding. However, birthing parents who endured adverse and traumatic childbirth experiences, such as prolonged labor or emergency Cesarean birth, are more likely to exhibit elevated stress hormones, abnormal oxytocin release patterns, and lower levels of prolactin (Beck & Watson, Reference Beck and Watson2008). Atypical hormone changes and stress responsivity can impede milk letdown and hinder birthing parents’ abilities to breastfeed (Beck & Watson, Reference Beck and Watson2008; Schaffir, Reference Schaffir and Wenzel2016). Given that prolactin and oxytocin promote estrogen suppression, which reduces corticotropin-releasing hormone production, birthing parents’ difficulties with breastfeeding may further increase physiological stress responsivity and propel a maladaptive neurobiological cycle.
It has been theorized that birthing parents who are particularly sensitive to atypical hormone changes following childbirth may also be more vulnerable to postpartum psychopathology, such as depression, anxiety, and posttraumatic stress disorder (Osborne et al., Reference Osborne, Betz, Yenokyan, Standeven and Payne2019; Schiller et al., Reference Schiller, Meltzer-Brody and Rubinow2015), which has bidirectional associations with breastfeeding challenges and pain (Iles & Pote, Reference Iles and Pote2015). Breastfeeding-related pain and postnatal psychopathology have been found to elicit feelings of shame and guilt, impede birthing parents’ bonding with their infants, and increase fear of future childbirth (Iles & Pote, Reference Iles and Pote2015; James, Reference James2015). Some birthing parents have reported that they persist through breastfeeding challenges due to strong desires to “prove” themselves as capable mothers and escape from ruminative thoughts and emotional pain (Ayers, Reference Ayers2004; Beck & Watson, Reference Beck and Watson2008). Other birthing parents describe breastfeeding following childbirth trauma as another form of physical violation (Beck & Watson, Reference Beck and Watson2008). Birthing parents with interpersonal trauma histories may be especially vulnerable to flashbacks and dissociation while breastfeeding, which may further challenge their abilities to bond with their infants (Haagen et al., Reference Haagen, Moerbeek, Olde, van der Hart and Kleber2015; Iles & Pote, Reference Iles and Pote2015).
Black birthing parents’ endorsements of breastfeeding pain and other physical injuries following traumatic childbirth are significantly more likely to be overlooked or minimized by healthcare staff than are those of White parents (Cooper Owens & Fett, Reference Cooper Owens and Fett2019; Greenwood et al., Reference Greenwood, Hardeman, Huang and Sojourner2020). Black, Latinx, and low-income birthing parents also are significantly less likely to receive breastfeeding education and support in the face of those challenges, which increases their risk for postpartum psychopathology (Anstey et al., Reference Anstey, Shoemaker, Barrera, O’Neil, Verma and Holman2017; Lara-Cinisomo et al., Reference Lara-Cinisomo, Girdler, Grewen and Meltzer-Brody2016). These disparities in support following childbirth are concerning because these individuals are significantly less likely than are White, affluent birthing parents to be screened for PPD, despite their increased risk (Rich-Edwards et al., Reference Rich-Edwards, Kleinman, Abrams, Harlow, McLaughlin, Joffe and Gillman2006; Sidebottom et al., Reference Sidebottom, Vacquier, LaRusso, Erickson and Hardeman2021). Even when birthing parents of marginalized identities are screened and referred for PPD treatment, they often face substantial instrumental barriers to care (Abrams et al., Reference Abrams, Dornig and Curran2009; Davis & Narayan, Reference Davis and Narayan2020; Lara-Cinisomo et al., Reference Lara-Cinisomo, Girdler, Grewen and Meltzer-Brody2016).
Protective factors and adaptive coping: the role of social support
In the face of adverse and traumatic childbirth experiences, birthing parents can exhibit profound coping and adaptive health trajectories. Research has focused most extensively on the protective effects of social support from family members and partners (Saxbe, Reference Saxbe2017). Indeed, social support is “one of the most robust correlates of better maternal mental health” and is associated with lower depressive and anxiety symptoms among birthing parents across racial, ethnic, and income groups (Atzl et al., Reference Atzl, Grande, Davis and Narayan2019; Davis & Narayan, Reference Davis and Narayan2020, p. 1632). Perceived social support also has been found to influence birthing parents’ health at 3 months postpartum more strongly than negative self-perceptions and traumatic appraisals of the childbirth experience (Ford et al., Reference Ford, Ayers and Bradley2010). Social support reduces cortisol levels and perceptions of pain, which is critical for birthing parents who endured physically traumatic childbirth and/or are experiencing breastfeeding challenges (Heinrichs et al., Reference Heinrichs, Baumgartner, Kirschbaum and Ehlert2003; Jewell et al., Reference Jewell, Luecken, Gress-Smith, Crnic and Gonzales2015; Moyer et al., Reference Moyer, Rounds and Hannum2004). Social support also facilitates opportunities for sleep among birthing parents. Infant care needs and hormone changes substantially disrupt sleep during the first few postpartum months, but consolidated, high quality sleep is possible and vital for lowering cortisol levels, alleviating pain perceptions, and promoting emotion regulation (Bazalakova et al., Reference Bazalakova, Bianchi, Stanic and Bianchi2014; Lillis et al., Reference Lillis, Hamilton, Pressman, Ziadni, Khou, Boddy and Wagner2018; Owais et al., Reference Owais, Chow, Furtado, Frey and Van Lieshout2018; Sivertsen et al., Reference Sivertsen, Petrie, Skogen, Hysing and Eberhard-Gran2017). Research indicates that breastfeeding may facilitate more restorative sleep, as well, because of the positive association between prolactin and slow wave sleep (Bazalakova et al., Reference Bazalakova, Bianchi, Stanic and Bianchi2014). Thus, there are interactive relations among these protective factors (i.e., social support, breastfeeding, and sleep) that warrant further investigation.
Although invalidating interactions with healthcare staff can increase risk for traumatic childbirth, supportive interactions during and following childbirth can be protective. For instance, providers who facilitate skin-to-skin contact between birthing parents and their infants – no matter how brief – help to promote bonding and breastfeeding and reduce anxiety and depressive symptoms (Bystrova et al., Reference Bystrova, Ivanova, Edhborg, Matthlesen, Mukhamedrakhlmov, Uvnas-Moberg and Widstrom2009). Comprehensive, compassionate, and personalized infant feeding education from providers also enables these adaptive outcomes (Beck & Watson, Reference Beck and Watson2008; Cricco-Lizza, Reference Cricco-Lizza2005). Supportive obstetric teams who invite birthing parents and partners to ask questions and participate in decision-making promote perceptions of control during and following childbirth, even in the face of unexpected medical complications. Birthing parents’ perceptions of control have been associated with higher ratings of fulfillment, satisfaction, and emotional well-being following childbirth, which has long-term implications for their and their infants’ health (Ayers, Reference Ayers2004; King et al., Reference King, McKenzie-McHarg and Horsch2017). Notably, White and high-income birthing parents often experience more control and decision-making privileges during childbirth (Bakhtari et al., Reference Bakhtari, Nadrian, Matlabi, Sarbakhsh and Bidar2019). These healthcare inequities have prompted more research on the benefits of working with doulas and community health workers for reducing birth-related pain, lowering rates of Cesarean births, and rectifying disparities in maternal morbidity and mortality rates (Hodnett et al., Reference Hodnett, Gates, Hofmeyr and Sakala2013; McCloskey et al., Reference McCloskey, Bernstein, Amutah-Onukagha, Anthony, Barger, Belanoff, Bennett, Bird, Bolds, Brenna, Carter, Celi, Chachere, Crear-Perry, Crossno, Cruz-Davis, Damus, Dangel and Lachance2021; McGrath & Kennell, Reference McGrath and Kennell2008).
Implications for research and clinical practice
Research
The conceptual model presented in Figure 1 illustrates relations across multiple levels of analysis that can inform testable hypotheses of childbirth as a mediator of the perinatal transition. We hope that this model not only illuminates the importance of including childbirth in perinatal research, but aids scholars in conceptualizing childbirth and the perinatal transition from a truly biopsychosocial perspective versus one that characterizes White, well-educated, and middle-class experiences as “typical” (and all others as “atypical”). Furthermore, we hope that presenting this model within a developmental psychopathology framework underscores the significance of a developmental perspective on childbirth and perinatal health (for a similar developmental perspective on pregnancy-related morbidity and mortality among Black US birthing parents, see Lin & Appleton, Reference Lin and Appleton2022).
Our model offers numerous, exciting avenues for future inquiry. For instance, researchers may consider examining how prenatal changes in the vaginal microbiome influence childbirth experiences and subsequent postpartum mood and stress responsivity, as well as how daily experiences with racism moderate those associations. Similarly, researchers may consider investigating the influences of lifetime and healthcare-related discrimination on childbirth experiences and postnatal sleep health. Including childbirth in perinatal research warrants systematic measurement across studies, so more research is needed on valid measurement of the birth experience (e.g., City Birth Trauma Scale [Ayers et al., Reference Ayers, Wright and Thornton2018]; Birth Experiences Questionnaire [Saxbe et al., Reference Saxbe, Horton and Tsai2018]; see also Berger et al., Reference Berger, Strobino, Mehrtash, Bohren, Adu-Bonsaffoh, Leslie, Irinyenikan, Maung, Balde and Tunçalp2021). Rigorous measurement is especially important for accurately assessing the prevalence of childbirth-related postnatal psychopathology, such as PTSD (Williams et al., Reference Williams, Strobino and Holliday2022). More research also is needed on multilevel protective factors and adaptive health trajectories following traumatic childbirth (for a systematic review on perinatal protective factors and guidance for future research, see Atzl et al., Reference Atzl, Grande, Davis and Narayan2019). Finally, given what psychological science has illuminated about biosocial coregulation among romantic dyads (e.g., Butler & Randall, Reference Butler and Randall2013; Helm et al., Reference Helm, Sbarra and Ferrer2014; Saxbe & Repetti, Reference Saxbe and Repetti2010), more research is needed on partners’ childbirth experiences (Saxbe, Reference Saxbe2017). This area of research may advance our limited understanding of partners’ risk for postnatal psychopathology (Paulson & Bazemore, Reference Paulson and Bazemore2010).
Ideally, research addressing the interacting systems presented in our model will comprise longitudinal data sets that can account for idiosyncratic, nonlinear, and bidirectional relations (Suls & Rothman, Reference Suls and Rothman2004; for a recent longitudinal investigation of maternal depressive symptoms following preterm birth, see Roubinov et al., Reference Roubinov, Musci, Hipwell, Wu, Santos, Felder, Faleschini, Conradt, McEvoy, Lester, Buss, Elliott, Cordero, Stoustrup and Bush2022). Indeed, developmental psychopathology evolved from “dissatisfaction with static models of pathology” (Mascolo et al., Reference Mascolo, Van Geert, Steenbeek, Fischer and Cicchetti2016, pp. 665). Dynamic systems (DS) models offer one promising approach for handling data sets needed for multilevel developmental psychopathology research on childbirth and the perinatal transition. DS theory is a meta-theoretical framework that accounts for complex relations among variables over time (Granic, Reference Granic2005; Mascolo et al., Reference Mascolo, Van Geert, Steenbeek, Fischer and Cicchetti2016). DS models are well suited for illustrating how adaptive and maladaptive psychological functioning emerges and changes in response to lower-order biological, psychological, and sociocultural processes (Mascolo et al., Reference Mascolo, Van Geert, Steenbeek, Fischer and Cicchetti2016). In addition, DS models are ideal for examining transactional relations during developmental periods of heightened neurobiological plasticity because of their attention to rapid and enduring reorganization of states of functioning (Kaliush et al., Reference Kaliush, Gao, Vlisides-Henry, Thomas, Butner, Conradt and Crowell2021). Ambulatory assessment (e.g., Lazarides et al., Reference Lazarides, Moog, Verner, Voelkle, Henrich, Heim, Braun, Wadhwa, Buss and Entringer2021; Mendez et al., Reference Mendez, Sanders, Karimi, Gharani, Rathbun, Gary-Webb, Wallace, Gianakas, Burke and Davis2019; Sanjuan et al., Reference Sanjuan, Pearson, Poremba, de Los Angeles Amaro and Leeman2019), digital phenotyping (e.g., Vlisides-Henry et al., Reference Vlisides-Henry, Gao, Thomas, Kaliush, Conradt and Crowell2021), and natural language processing (e.g., De Choudhury et al., Reference De Choudhury, Counts and Horvitz2013; Gonzalez-Hernandez et al., Reference Gonzalez-Hernandez, Sarker, O’Connor and Savova2017) are just a few methodological techniques that could advance dynamic research on childbirth and the perinatal transition.
Clinical practice
Heightened neurobiological plasticity during the perinatal period may exacerbate birthing parents’ risk for psychopathology following childbirth. However, this developmental sensitivity also presents a window of possibility for promoting resilience and long-term adaptive health (Davis & Narayan, Reference Davis and Narayan2020; Kim, Reference Kim2021; Saxbe et al., Reference Saxbe, Rossin-Slater and Goldenberg2018). Moreover, the perinatal period is unlike any other life stage in terms of frequent contact with the healthcare system and increased motivation for change (Davis & Narayan, Reference Davis and Narayan2020). Developmental psychopathology models are ideal for this time period because they shed light on ways to alleviate the emergence of maladaptation while simultaneously promoting adaptation (Cicchetti, Reference Cicchetti2016). Thus, in addition to offering numerous research directions, our model implies biopsychosocial avenues for preventative intervention that may foster adaptive postnatal health trajectories. This multilevel developmental psychopathology approach is critical to advancing childbirth and perinatal healthcare beyond its predominant focus on pathologizing birthing parents and neglecting broader systemic factors.
MOMCare (Davis et al., Reference Davis, Hankin, Swales and Hoffman2018), Perinatal Child-Parent Psychotherapy (P-CPP; Narayan et al., Reference Narayan, Bucio, Rivera and Lieberman2016), and the Perinatal Mental Health Promotion Model (Fahey & Shenassa, Reference Fahey and Shenassa2013) are a few examples of promising multilevel preventative interventions during the transition to parenthood. MOMCare is a brief interpersonal psychotherapy designed to treat prenatal depressive symptoms among low-income birthing parents of color (Davis et al., Reference Davis, Hankin, Swales and Hoffman2018; Davis & Narayan, Reference Davis and Narayan2020). This intervention is innovative in that it targets marginalized birthing parents and engages them in conversations about barriers to treatment (Davis & Narayan, Reference Davis and Narayan2020). P-CPP is adapted from evidence-based CPP and aims to improve mother–child emotional attunement among trauma-exposed birthing parents, specifically (Narayan et al., Reference Narayan, Bucio, Rivera and Lieberman2016). The Perinatal Mental Health Promotion Model is not an intervention, per se, but rather a transdiagnostic framework for postpartum health promotion (Fahey & Shenassa, Reference Fahey and Shenassa2013). This model aligns closely with the multilevel nature of our model and asserts that adaptive postpartum health “goes beyond merely the absence of medical complications;” rather, it implies that birthing parents are equipped with individual, social, and community resources to successfully transition into motherhood (Fahey & Shenassa, Reference Fahey and Shenassa2013, p. 613). Given that social support may be one of the strongest protective factors for birthing parents during this life transition (Atzl et al., Reference Atzl, Grande, Davis and Narayan2019), interventions that align with this model are critical to preserve relationship quality (e.g., Schulz et al., Reference Schulz, Cowan and Cowan2006).
These broader themes of cultural responsivity, community engagement, and client-centered care are vital to alleviating potentially traumatic childbirth and promoting adaptive postnatal health. For example, research has shown that even when birthing parents of color are screened for depressive symptoms, they are less likely than White birthing parents to endorse mental health concerns due to previous invalidating healthcare experiences (e.g., providers diminishing their spiritual and self-care practices; Abrams et al., Reference Abrams, Dornig and Curran2009). One solution for effective perinatal healthcare may include moving beyond training for PPD screening and simultaneously include cultural responsivity training (Clayton et al., Reference Clayton, Horrillo and Sniderman2020; FitzGerald & Hurst, Reference FitzGerald and Hurst2017; Moreland-Capuia, Reference Moreland-Capuia and Moreland-Capuia2019). Also, dimensionally screening for additional forms of psychopathology risk besides depression, such as emotion dysregulation (Lin et al., Reference Lin, Kaliush, Conradt, Terrell, Neff, Allen, Smid, Monk and Crowell2019) or posttraumatic stress symptoms (e.g., LeBeau et al., Reference LeBeau, Mischel, Resnick, Kilpatrick, Friedman and Craske2014), is critical given that over one-third of birthing parents describe their birth experiences as traumatic but do not necessarily meet full diagnostic criteria for PTSD or depression (Beck et al., Reference Beck, Driscoll and Watson2013; de Graaff et al., Reference de Graff, Honig, van Pampus and Stramrood2018; Yildiz et al., Reference Yildiz, Ayers and Phillips2017). Without consistent, dimensional, comprehensive, and culturally responsive screening and follow-up, these birthing parents will never receive adequate perinatal healthcare.
In addition to increasing cultural responsivity and improving mental health screening, outcomes for birthing parents will be enhanced by a shift toward more comprehensive, communicative, and trauma-informed models of “caring” versus biomedical models of “curing” (Hunter, Reference Hunter2006; Sperlich et al., Reference Sperlich, Seng, Li, Taylor and Bradbury-Jones2017). This paradigm shift is especially important among birthing parents with trauma histories and ongoing psychopathology who are more likely than those without trauma histories to experience modern-day, Westernized childbirth practices as victimizing, violating, and disenfranchising (Choi & Seng, Reference Choi and Seng2014; Ford & Ayers, Reference Ford and Ayers2011). This paradigm shift could empower and engage birthing parents by including more client-centered language (e.g., infants are “borne” by the mother versus “delivered” by the provider; Hunter, Reference Hunter2006); increasing perceptions of safety, autonomy, trustworthiness, transparency, and respect (Choi & Seng, Reference Choi and Seng2014; Seng, Reference Seng2015; Sperlich et al., Reference Sperlich, Seng, Li, Taylor and Bradbury-Jones2017; Stanton & Gogoi, Reference Stanton and Gogoi2022); and building collaborative, multidisciplinary healthcare teams (e.g., obstetricians, midwives, doulas, psychologists, and social workers; Ickovics et al., Reference Ickovics, Lewis, Cunningham, Thomas and Magriples2019). This latter point about multidisciplinary teams is vital for effectively delegating birthing parents’ healthcare needs and has been presented as one component of a solution for reducing racial disparities in perinatal health (Essien et al., Reference Essien, Molina and Lasser2019).
Conclusions
Childbirth may be only a fragment of the perinatal period – let alone the life span – but it is a powerful point of change. Biological, psychological, and sociocultural aspects of childbirth have the potential to alter the health course of the entire family, and yet the birth experience is sorely neglected in developmental psychopathology models of the perinatal transition. To address this limitation, we presented a conceptual model that illustrates childbirth as a bridge between birthing parents’ prenatal and postnatal health. Biopsychosocial processes during pregnancy interact to shape the birth experience, which then propels multifinal postnatal health trajectories. We described this model within a developmental psychopathology framework in order to highlight multilevel, dynamic processes across the life span and emphasize the fluid interplay between adaptive and maladaptive functioning. It is incumbent on perinatal scientists to include childbirth in their investigations of maternal, offspring, and family health. Furthermore, prevention and intervention efforts are critical during this life phase and also must address multiple levels of influence. Research and healthcare advancements should occur simultaneously and inform each other, as translational efforts will more effectively prevent traumatic childbirth experiences and promote health and well-being among birthing parents and their children.
Acknowledgments
We thank all of the families who generously offer their time to our research.
Author contributions
Parisa R. Kaliush: Conceptualization, Writing-original draft, Writing-review & editing; Elisabeth Conradt: Writing-review & editing; Patricia K. Kerig: Writing-review & editing; Paula G. Williams: Writing-review & editing; Sheila E. Crowell: Supervision, Writing-review & editing.
Funding statement
This manuscript was supported by the NIMH under Awards R21MH109777 (PI Crowell, Co-I Conradt), R01MH119070 (MPIs Crowell & Conradt), and F31MH124275 (PI Kaliush), as well as a Career Development Award from the National Institute on Drug Abuse 7K08DA038959-02 (PI: Conradt) and grants from the University of Utah Consortium for Families and Health Research and Interdisciplinary Research Pilot Program. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIMH, National Institute on Drug Abuse, or the NIH.
Conflicts of interest
None.
Ethical standards
This article was written and published in accordance with Cambridge University Press' publishing ethics guidelines.
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