Looking at childbirth as a traumatic event for attendant fathers through the lens of cognitive models of PTSD: The association of negative cognitions of labor and the development of posttraumatic symptoms

Introduction

Fathers’ attendance during labor has become conventional in recent decades. However, their role in the delivery room lacks definition. To this day, very little is known about the impact of this presence on their mental state. Some studies have shown positive effects of the father's presence during labor on parental relationships and father-infant relationships (Bowen & Miller, 1980), as well as on the general well-being of the mother (Gungor & Beji, 2007; Somers-Smith, 1999). Other studies focused on the possible negative effects of labor attendance on the mental state of the new fathers. For example, research shows that men who were less satisfied with the labor reported more symptoms of depression than men who expressed more satisfaction with it (Greenhalgh, Slade & Spiby, 2000).

It is well known that depression after a traumatic event is highly comorbid with posttraumatic stress disorder (PTSD) (Stander, Thomsen & Highfill-McRoy, 2014). It has been found that relative to levels of stress during and after pregnancy, fathers experience the highest levels of stress during labor (Johnson, 2002). In the only study of posttraumatic symptoms in men who accompanied their partners during labor, 12% reported a high level of avoidance or arousal, or intrusive symptoms (Bradley, Slade & Leviston, 2008). In addition, this study found that presence exactly at the moment of birth was one of the predictors of posttraumatic symptoms among these men.

Several studies suggest that there may be a connection between the subjective perceptions of the father's birth event and negative feelings after the event. A cognitive model of posttraumatic stress disorder developed by Ehlers & Clark (2000) provides a possible explanation for this relationship. According to this model, the traumatic event is not perceived by PTSD sufferers as time-limited, but as  having global negative implication for their future (Ehlers & Clark, 2000). Catastrophizing the future creates negative beliefs about the self, such as ``I attract disaster'' or ``bad things always happen to me''. Such negative cognitive appraisals create fear and avoidance.

 Studies indicate that many men experience a wide range of negative emotional responses during and after birth resulting from negative appraisals of various aspects of the event, such as perceptions of self-functioning, the degree of support of the medical staff, and fear of birth. In a study that examined the levels of stress experienced by fathers during pregnancy, those who said they could not support their partner during labor experienced a higher level of stress than men who felt they had succeeded in supporting roles (Johnson, 2002). In another study, the lack of support from the medical staff affected the father's emotional state and increased his sense of alienation and despair during the birth (Elmir & Schmied, 2015). In a study of prospective fathers, 13.6% of the participants showed a fear of childbirth, which was correlated with being a first-time parent. High levels of fear were associated with a negative perception of pregnancy and approaching labor and the preference for cesarean section (Hildingsson et al., 2014).

In conclusion, the present study sought to examine the prevalence of post-traumatic stress disorder symptoms and fear of birth among Israeli fathers, who attended labor. In addition, the aim of this study was to examine how objective characteristics (labor type during which the father was present) and subjective appraisals of labor (negative perceptions of the self and the world, level of fear of childbirth, involvement of the father in labor and extent of information shared by the medical staff) were related to the severity of posttraumatic symptoms.

Hypotheses

It was hypothesized there would be a certain prevalence of men who suffer from posttraumatic symptoms and fear of childbirth after labor attendance, while there would be differences in the severity of posttraumatic symptoms and the level of fear of birth among the following groups: men who attended an emergent cesarean section, men who attended planned cesarean section, and men who were present during regular labor. The other hypotheses were that there would be a correlation between subjective characteristics of the labor event, such as negative cognitions, fear of childbirth, father’s involvement and extent of information shared by the medical staff, and the severity of post-traumatic symptoms. In addition, it was hypothesized that there would be correlation between the level of fear of childbirth and the extent of information shared by the medical staff.

Method

The data were collected using an online self- administered questionnaire, which was published in groups on social networks and on web forums targeted to mothers, fathers or both parents. The final sample included 224 men who attended the birth of one of their children no less than two months and no more than a year before participating in the study. The study variables were measured using a demographic questionnaire, delivery experience questionnaire (W-DEQ B), posttraumatic stress disorder check-up (PCL-5), and posttraumatic cognitions inventory (PTCI).

Results

The results confirm the hypothesis that there would be a certain prevalence of men who suffer from a clinical level of postpartum posttraumatic symptoms (7.9%) and the hypothesis that there would be a certain prevalence of men who have a clinical fear of childbirth (6.33%). In addition, the results confirm the hypotheses that there would be differences in the severity of posttraumatic symptoms and the level of fear according to the type of labor which the father attended. Thus, the most severe posttraumatic symptoms were found among men who attended a planned cesarean section. On the other hand, the highest level of fear of childbirth was found among men who attended emergent cesarean section. In addition, research hypotheses regarding the association between the severity of posttraumatic symptoms and negative cognitions and between the level of fear of birth and the extent of information shared by the medical staff were confirmed. However, research hypotheses regarding the association between the severity of posttraumatic symptoms and the level of fear of birth, the degree of father’s involvement during the labor, and the extent of information shared by the medical staff were not confirmed.

Conclusions

The findings suggest that there are fathers who suffer from post-traumatic symptoms and fear of childbirth after attending labor, while the severity of post-traumatic symptoms and level of fear of childbirth may be related to the type of labor which the father attended. These findings may have important implications at the practical level, with one option for change being the formulation of a clear, formal policy regarding the role of the father in the delivery room and the attitude of the staff to his presence. The findings of this study highlight the importance of sharing information about the condition of the mother and the fetus by the medical staff. Many men feel confused about their role during labor, which may later affect their mental state and their relationship with their partner and the newborn. Obtaining reliable information from the medical staff about the condition of their loved ones may reduce the level of fear.