{"paper_id":"43f71673-ef94-462b-8a7e-4d7fceda09ca","body_text":"How Did We Get Here? 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A Qualitative Study of Contributors to Traumatic Birth Experiences in NICU parents Roopa Gorur, Paris S. Ekeke This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6330376/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 07 Nov, 2025 Read the published version in Maternal Health, Neonatology and Perinatology → Version 1 posted 11 You are reading this latest preprint version Abstract Background: Birth trauma is a complex concept that encompasses various experiences related to events in the perinatal period, including prenatal care, delivery, and postpartum care. Despite NICU parents being a high-risk population, there are limited studies in this group and many studies reference the stress of the medical complexities, while the dynamics of interpersonal trauma remain poorly understood by the medical community. The purpose of our study was to explore perspectives of NICU families and staff on contributors to traumatic birth experiences. Methods: A mixed methods study was performed exploring the qualitative experience of postpartum mothers with infants currently admitted to a level IV NICU. A single semi-structured interview was conducted with each participant which included questions about their prenatal, delivery, and postnatal experiences. Interviews were audio-recorded and transcribed using HIPAA compliant transcription software then manually verified by principal investigators for accuracy. Thematic analysis using the constant comparative method was performed by each principal investigator until saturation and consensus was reached. Additionally, NICU Staff completed an anonymous Qualtrics survey soliciting baseline knowledge and attitudes regarding traumatic birth experiences. Perspectives from birthing parents and medical staff were compared to assess for concordance. Results: There were 3 salient themes among birthing parents that negatively contributed to the perception of a traumatic birth: 1) inadequate communication with the medical team 2) lack of support from trusted sources and 3) fear of the unknown of what would happen to them or their infants. While 96% of medical staff acknowledged they were aware that implicit bias and interpersonal trauma contributes negatively to healthcare disparities, when probed about real life examples, 50% of staff were unsure if they had personally witnessed such events. Conclusions and Relevancy: There seems to be a collective lack of provider awareness of the ways interpersonal trauma plays a role in potential short- and long-term consequences in birthing parents and their infants. It is imperative that we enhance education among medical staff to improve recognition of signs and symptoms of trauma responses and trauma-informed care to reduce re-traumatization of our patients throughout the entire perinatal experience. birth trauma NICU perinatal mental health Background Recent literature on disparities in perinatal outcomes suggests that the experience of the birthing person is not homogenous. 1 Severe maternal morbidity and mortality remains high in the U.S. compared to other high-income countries, which includes psychiatric disorders such as birth trauma and post-traumatic stress disorder (PTSD). 2 , 3 Birth trauma is a complex concept that is difficult to define and encompasses a wide range of experiences. 4 , 5 Traumatic birth experiences are described as overwhelming emotional distress directly related to interactions or events during childbirth. 6 , 7 Between 28–40% of birthing parents around the world are reporting their birth experiences as traumatic and 1–6% go on to develop PTSD within the first year of giving birth. 8 , 9 Minority populations, parents with previous history of mental health disorders, and those who experience medical complications such as unexpected Cesarean section or postpartum hemorrhage are at increased risk of birth trauma. 4 , 10 Causes of physical and emotional trauma are commonly referenced when describing birth trauma but interpersonal trauma is also a frequent contributor to traumatic birth experiences and remains poorly described. 5 , 6 , 11 , 12 The concepts of psychological trauma and mistreatment of birthing parents often overlap and both fundamentally derive from patients’ perception of medical teams’ behaviors meeting their stated and implied needs. 4 , 15 , 16 A systemic review by Bohren et al. described 7 different domains of medical maltreatment including: 1) verbal 2) physical or 3) sexual abuse 4) stigma and discrimination 5) failure to meet professional standards of care 6) poor rapport between women and providers and 7) health system conditions and constraints. 17 When asked about birth trauma, many patients described at least one experience that also fit into the maltreatment domains. 14 Similarly, clinicians when asked about birth trauma often described maltreatment even when not specifically asked about it further supporting these concepts are interconnected. 14 Trauma during pregnancy can have implications for subsequent interactions with their medical team but also their infant’s medical team. 18 Multiple studies have shown that neonatal complications and NICU admission can be a large contributor to birth trauma, and the overall NICU environment can add additional stress but there is sparse literature elucidating which elements of the NICU experience are highly associated with postpartum PTSD. 4 , 17 , 18 Sharp et al performed a mixed methods study which evaluated NICU-Specific Stress and its effect on the relationship between traumatic birth experience and post-traumatic stress symptoms and found that 42% of birth parents mentioned distressing maternal emotional experiences (e.g., feeling guilty, sad, and anxious), 42% mentioned NICU characteristics (e.g. restricted access, frequent staff changes, noise and lights), and 33% mentioned dissatisfaction with their infant’s medical care all as contributors to birth trauma. 17 Despite NICU parents being a high risk population, there are limited studies on this group and many studies merely reference the stress of the medical complexity of NICU admission, while the dynamics of interpersonal trauma remain understudied. 4 , 18 , 19 Because of the deeply personal nature of the birth experience, it is imperative to center the voice of the birthing parent, so our study set out to explore major contributors to negative perinatal experiences in NICU families from their own perspective. Comparing their perspectives with medical staff knowledge of birth trauma will allow identification of discordance between families and staff which can present opportunities for education in efforts to minimize re-traumatization. Methods We conducted a mixed methods study of postpartum mothers who had an infant currently admitted to our level IV NICU and staff in the NICU. This study was approved by our institutional IRB. Inclusion criteria included any birthing person with an infant < 12 months old who had an infant currently admitted in the level IV tertiary care neonatal intensive care unit (NICU). There were no exclusions. Recruitment flyers were placed around the unit and at each bedside with principal investigator contact information. If the birthing person was present at the infant's bedside, they were also approached. Once verbal interest was expressed, formal written informed consent was obtained, and an interview was conducted or scheduled later per participant preference. A single semi-structured interview was conducted with each participant which included asking questions about their prenatal, delivery, and postnatal experiences. Twenty-four interviews were conducted using an interview guide (see Appendix A) with open-ended questions and probes designed to assess the salient positive and negative elements of each period of their birth experience (prenatal, delivery, postpartum, and NICU). At the conclusion of the interview, a $ 15 gift card was distributed for their participation. Interviews were audio-recorded and transcribed using HIPAA compliant transcription software then manually verified by principal investigator for accuracy. Transcripts were subsequently independently analyzed by principal investigators for relevant themes using the constant comparative method until saturation was reached. After independent review, the investigators met to reconcile theme discrepancies and develop consensus on theme classification. The second portion of the study involved soliciting baseline knowledge and attitudes regarding traumatic birth experiences from medical staff working in the neonatal intensive care unit (NICU). An anonymous Qualtrics survey was sent to first line providers in the NICU, including registered nurses, neonatal nurse practitioners, neonatal physician assistants, and neonatology fellows. Results Table 1 depicts demographic information of the 24 parent participants. 79.2%(N = 19) of participants were white while only 20.8% (N = 5) were non-White races including 2 Black, 1 Asian, 1 Hispanic, and 1 Native American participant. Majority of participants underwent Cesarean sections in our institution (Inborn) with average gestational age of 33.5 weeks. Table 1 Characteristics of Participants’ Birth Experience N = 24 N (%) Race White Black Other 19 (79.2) 2 (8.3) 3 (12.5) Mode of Delivery Vaginal Cesarean section 5 (20.8) 19 (79.2) Inborn Yes No 19 (79.2) 5 (20.8) Gestational age at birth < 28 weeks 28–31 weeks 32–36 weeks >= 37 weeks 2 (8.3) 7 (29.2) 10 (41.7) 5 (20.8) Theme 1: Communication with the medical team is inadequate and patient concerns are not being addressed The most common contributors to a negative birth experience centered around issues with communication between the parents and medical team. Parents reported conversations with providers often “felt rushed”, were unbalanced with overwhelmingly negative information, and contained too much information given at once. Many of the parents cited getting conflicting information from different medical providers as a major source of stress and anxiety during their birth experience. With the complexity of obstetric care, clear messaging from their local obstetricians and the Maternal Fetal Medicine team and congruence of their messaging remains important to patients. Lack of clarity regarding their care bred mistrust between patients and their medical team. “And so I just wish that I would have been, like, handled better because at that point, like, I was really to a point where I was like, “hey, if you guys can't figure out what's going on with me, but I'm supposed to trust you guys to take care of my child who's going to need services or surgeries, like, things, like, how is that going to work?” -Participant 1 Another salient feature parents recall that contributed to their negative birth experiences was the feeling that their concerns were not adequately addressed. Birthing parents reported “not feeling heard” when it came to their physical and mental concerns. Additionally, they reported their pain not being adequately controlled during delivery was particularly traumatic. Birthing parents noted that providers being dismissive of their physical symptoms or concerns about their symptoms made them feel alone and that the medical team didn’t have their best interest at heart. These events contributed to many patients’ feelings of loss of autonomy and gave the impression that their medical team was only interested in pushing their own agenda and not taking patients’ perspectives into consideration. Well, I got really upset, because, eventually, I felt different than I did the first time. I felt a pop in my back. I thought I was going to be paralyzed or something, 'cause it is your back, and I started panicking. She's like, \"Oh, this is normal,\" but it's not for me -Participant 14 Participants often didn’t feel validated by the medical team and noted there seemed to be a provider mistrust of patient experience. Whether it was a pain that felt different than normal or expected, a new symptom that patients felt were a part of bigger problem, or a provider ignoring a patient’s perception of medical therapies that have historically been successful or unsuccessful for them, such instances contributed to patients feeling dismissed and that their provider didn’t believe them about their own bodies. So they had me drive down here, and I was all prepared. Like, I got everything ready. Like, they said, you're going to have your baby. Like, we get down here. And the one doctor I saw, um, told me I was lying. “That’s a really nice story you’re telling me but you’re not ruptured. -Participant 1 Theme 2: Parents reporting a lack of support from familiar people triggered their anxiety Participants expressed worry about not having their support system involved in their pregnancy and delivery experience. Feeling alone when their spouse or family member was not able to be present led to immense pressure on the birthing parent that they were solely responsible for advocating for themselves and their infants. There were also reports of anxiety if women did not have a previously established relationship with their care team. They noted having to make important medical decisions in collaboration with providers that they just met and had not seen in previous encounters felt anxiety-provoking. Parents also noted feeling unsettled if their care team expressed their care was too complex or made statements about how “they had never seen this before”. When thinking about the instances where their care had to be transferred from their local obstetrician to a quaternary center, participants expressed appreciation for the transparency about the need for higher level of care, but also noted feelings of abandonment in losing their “medical home” resulting in not knowing who to contact when even the most basic obstetric concerns arose. \"Not through here, but once my regular OB knew that I was seeing the high-risk doctor here, they refused to see me. That was hard on me because then that meant all my care had to come from here and it's an hour drive here and an hour drive back. That was a negative experience.” -Participant 9 Theme 3: Fear of the Unknown Although parents acknowledge that pregnancy complications can be unexpected, there was often a feeling of being out of control when things came up that they felt unprepared for. Often there was a feeling of being overwhelmed with new information and some mentioned feeling like their medical team held back vital information about potential complications which led to resentment from losing the opportunity to mentally prepare themselves. The uncertainty of what would happen to them or their infants at times was described as “traumatizing” or “debilitating”. Participants often described their feeling of loss of control was often triggered well into the postpartum period and during their infant’s NICU stay. “It's stressful like when you don't know what it is...you don't know had to read it. I'm not a nurse. I just see that it goes up and down, up and down. And when it doesn't, I already know that that's not good. It means that it's either she's not breathing or her heart's not beating. And it, you know, sometimes there was like instances where they were like, oh, there's another like beat in there. And I was like, oh, no. Is something wrong with her heart? -Participant 5 Contributing factors to positive birth experiences: When considering the spectrum of themes, there were often counter positive contributors that were also identified. Generally, patients prefer communication that is bidirectional and allows time for them to digest information and get follow up questions answered. Prenatal counseling and anticipatory guidance were preferred compared to rushed explanations when complications occurred. Patients often commented that it was difficult to come up with questions in the moment and appreciated it when the medical team came back in subsequent encounters to address additional concerns. Counseling that was well-received was thorough, anticipatory, and checked for patient understanding throughout the conversation. \" I've set the tone now, like, so this is what we're doing today, and what's the big picture impact of that? I've started advocating for my understanding. That's what I need in these conversations. That has helped a lot. The folks who have been with us now, that are often with us multiple days, they're getting that that's the case. Now they're coming and prepared to talk about that and help to paint that picture better.” -Participant 23 Families also leaned into the elements of emotional and mental support that were provided by the medical team and identified that as a salient contributor to how they viewed their birth experience. Validating their emotional stress, \"feeling heard”, offering reassurance, or just being a familiar face and calm presence were cited as sources of decreasing anxiety. Parents often noted small gestures from the medical team such as holding their hand or walking with them often made them feel cared for as the birthing person and gave them the feeling the team had their best interests at heart. Offering mental support for birthing parents and encouragement from the medical team for birthing parent to also attend to their own needs gave parents a sense that the team wanted the best for the maternal-infant dyad as a family unit and gave them a sense of comfort. She was supposed to be the baby's nurse, but she came and held my hand when I was getting my spinal and just talked me through it. And even though she had stuff that she was supposed to be doing, she just sat there to make sure I was okay before my mom came in and it just made a difference that she went that extra step like “hey calm down”, you know, “you gotta arch your back more or do this and you know just kept me calm. It was really just kind of nice. -Participant 1 When considering the care for their baby, parents often expressed a desire to be very involved in the hands-on care of their infant. From basic care needs such as feeding and changing their infant’s diapers to more complex needs such as placing nasogastric tubes and ostomy care, being an active member of their infant’s care team put parents at ease. Although this sentiment was noted frequently, there seemed to be a delicate balance between hands on care and hypervigilance. Many parents reflected on early feelings of not being able to leave the bedside due to discomfort with the care and need for advocacy for competent care. These anxious feelings seemed to reduce greatly with continuity of care among the team. The nurses that have chosen him for primary have been—it’s a relief when they’re here. They know him. I know that if I have to run out, if I have to do anything, I don’t even have to worry about it ’cause they know him so well. -Participant 12 Perspectives from Staff Fifty members of the NICU medical team completed the anonymous survey via Qualtrics, and results were summarized in Table 2 . 74% of respondents were bedside nurses while the remaining 26% were advanced practice practitioners and physicians. Of all respondents, 96% agreed that unconscious bias could negatively impact patient care and 92% endorsed awareness of research that inequitable health care delivery contributes to disparities in perinatal outcomes, but when asked if they had personally witnessed an instance of inequitable treatment, only 34% of respondents could recall one while 50% of respondents were unsure. When asked more generally their thoughts on which factors contributed most to patients’ perception of negative birth experiences, 34% believed deviation from birth plans was most important to patients while only 20% of respondents believed provider-patient interactions were most common. Table 2 Staff Perspectives Questionnaire Results (N = 50) Q1. Role on the medical team n (%) Nurse APP/Physician 37 (74) 13 (26) Q2. Please indicate how much you agree with each statement below: Agree n (%) Unsure n (%) Disagree n (%) a. Unconscious Bias can negatively impact patient care and perpetuate systemic inequalities 48 (96) 0(0) 2(4) b. There is sufficient evidence in the literature that suggests inequitable health care delivery contributes to disparities in perinatal outcomes 46 (92) 3 (6) 1 (2) c. Within the last 5 years, I have witnessed a patient getting substandard medical care and believe implicit bias played a role 17 (34) 25 (50) 8 (16) Q3. In your opinion, what is the most common complaint from patients who reported a negative birth experience? n (%) Deviation from Birth Plan Prolonged Hospitalization of Mother or Infant Treatment Decisions Provider-patient interactions Lack of Social Support 17 (34) 12 (24) 10 (20) 10 (20) 1 (2) Discussion Birth trauma is highly prevalent among parents in the neonatal intensive care unit. Often, providers considered medical complications in birthing parents or their infants to be the major contributors to having negative feelings about the birth experience. However, our study highlights the rise of interpersonal trauma as a major cause of birthing parents’ negative experiences. When NICU birthing parents are reflecting on their experience, there appeared to be 3 major themes that came across: transparency, empathy, and mutual respect. Transparency equated to thorough, honest assessment of the clinical situation and taking the time to clearly communicate their medical reasoning while still remaining responsive to patient concerns. Families appreciated escalation to a higher level of care if a clinician was unsure. They often reported negative feelings if it appeared the medical team was holding back information for fear of upsetting them or not fully explaining the potential complications when medical decision making is required. This correlates with the feelings of loss of autonomy reported in previous studies. 14 , 15 , 20 When patients feel they are not given the opportunity to make a fully informed decision, they are robbed of the opportunity to make an autonomous decision free from clinician bias. Whether it is a decision about termination, resuscitation, delivery planning or vaccinations, it remains paramount that patients feel like they have a sense of control over their bodies and their infant’s bodies. 14 , 15 Empathy refers to the acts of kindness that allow birthing parents to feel that we are not only interested in taking care of their bodies but also their minds and emotions. Small gestures that make patients feel seen and heard were often reported and the most impactful. Lastly, mutual respect was described in many of the responses. Respect for patients' experience and their expertise in their own and their infant's health was frequently described. When contrasting parent experience with staff perception, there was a clear discordance. Although most staff recognized unconscious bias as a source of disparity in health outcomes in theory, many were unsure of specific examples of how this may present in their clinical practice. From staff perspectives, many believed that deviations from the parent’s birth plan was the major contributor to birth trauma which was not supported by the patient responses which heavily focused on interpersonal interactions. The dichotomy between patient and staff responses on the topic of traumatic birth experiences highlights a cognitive dissonance that remains pervasive. It seems the medical community often conceptualizes birth trauma by events that happen to the birthing parent without sincere acknowledgement of how interpersonal trauma with medical personnel contributes to this perception. This invalidation can have negative consequences to the maternal-infant dyad and their health. From a medical perspective, feeling dismissed by providers and experiencing medical trauma has the potential to impact how parents seek care in subsequent encounters. 16 Avoiding over-medicalization of subsequent birth experiences by delaying prenatal care, the use of lay midwives, and engaging in home births are often attempts by patients to regain control of their birth experiences. Traumatic birth experiences also impact maternal mental health with increased risk of subsequent development of PTSD, which can be characterized by flashbacks, poor sleep, and avoidance behaviors. A study by Harris and Ayers also found that the strongest predictor of developing birth-related PTSD was interpersonal difficulties with care providers, more specifically, experiencing a lack of support which is consistent with our results. 20 In addition to the previously described consequences on maternal mental and physical health, the effects of traumatic birth experiences often linger into their postpartum experience as well. Birthing parents often feel ill-equipped to process the negative feelings around their birth, and these feelings combined with the invalidation of their experiences from medical personnel leads to avoidant behaviors commonly seen in the NICU. To avoid dealing with their own emotional trauma, patients instead tend to become hypervigilant in their infant’s care. Although few parents in our study had insight into how their prenatal trauma reflected in their behaviors with their infant’s care team, many often reflected that being included in their infant’s care and being heard by their infant’s care team were anxiety-reducing behaviors. Dismissive communication and disrespect by the infant care team were noted to cause flashbacks of previous feelings of loss of control and not feeling heard which triggered parents’ “fight or flight” response and impacted their ability to calmly process their infant’s medical information. Labile, dysregulated behavior is often referred to in the literature as a “trauma response” and can present as extreme anxiety and hypervigilance often resulting in micromanaging of care, detachment from participating in infant care, and/or anger. These interactions are often difficult to navigate for the parents but also may expose medical providers to secondary trauma. Secondary trauma is a significant concern for maternity and neonatal staff with reports of rates as high as 25–30%. The moral injury from observing traumatic births and navigating challenging patient interactions as a result of the previous trauma they experienced contributes significantly to burn out in perinatal providers. 21 Overall, birth trauma is underdiagnosed and underrecognized among medical professionals. There seems to be a collective lack of provider awareness of the ways interpersonal trauma plays a role in serious potential short- and long-term consequences on the birthing parents and their infants. It is imperative that we enhance education among medical staff to improve recognition of signs and symptoms of trauma responses and trauma-informed care to reduce re-traumatization of our patients throughout the entire perinatal experience. Declarations Funding: University of Michigan Diversity Office of Health Equity & Inclusion Diversity Fund • Competing interest: None • Ethics approval: Study was approved by the IRB at University of Michigan • Consent to participate: Not applicable; exempt status • Consent for publication: All authors consent to publication; no other consents required • Availability of data and material: De-identified data available upon request • Authors' contributions: Each author made significant contributions to this manuscript, meeting the criteria for authorship. RG contributed to data collection, performing participant interviews, data analysis, and preparation of the manuscript. PE led study design, data analysis and manuscript preparation. References Howell EA, Zeitlin J. Quality of care and disparities in obstetrics. Obstetrics and Gynecology Clinics of North America. 2017 Mar;44(1):13. Hoyert DL, Miniño AM. 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Frontiers in Global Women's Health. 2022 May 4;3:835811. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 07 Nov, 2025 Read the published version in Maternal Health, Neonatology and Perinatology → Version 1 posted Editorial decision: Revision requested 19 Aug, 2025 Reviews received at journal 19 Aug, 2025 Reviews received at journal 11 Aug, 2025 Reviews received at journal 01 Aug, 2025 Reviewers agreed at journal 24 Jul, 2025 Reviewers agreed at journal 23 Jul, 2025 Reviewers agreed at journal 23 Jul, 2025 Reviewers invited by journal 20 Jul, 2025 Editor assigned by journal 31 Mar, 2025 Submission checks completed at journal 31 Mar, 2025 First submitted to journal 28 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-6330376\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":489412736,\"identity\":\"5c9507eb-90d9-4397-8c79-daecbc5091b2\",\"order_by\":0,\"name\":\"Roopa Gorur\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"University of Michigan School of Medicine\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Roopa\",\"middleName\":\"\",\"lastName\":\"Gorur\",\"suffix\":\"\"},{\"id\":489412737,\"identity\":\"7944f00d-1e79-4db2-a47d-fac58c59efff\",\"order_by\":1,\"name\":\"Paris S. Ekeke\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA20lEQVRIiWNgGAWjYFACNgbGBgYbICMBiA2gJBFa0kjXchiqhYEILebsbYkPZ1Scj+ZnT2CTulFgl8fA3rxNAp8Wy55jhw03nLmdO7PnAZt0jkFyMQPPsTK8WgxupLdJPmy7nbvhRgJIy4HEBokcM/xa7j9v//nw37nc/XAt8m8IaLnBdoxxY8OB3A0ScFt48Gux7ElLlpxxLDl3xpmHzdZAvyS28aQVW+DTYs5+zPBjT41dbn978sHbOX/sEvvZD2+8gddhCCYwekCADZ9yNC2jYBSMglEwCnAAAOMjTV+xeHXPAAAAAElFTkSuQmCC\",\"orcid\":\"\",\"institution\":\"University of Michigan School of Medicine\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Paris\",\"middleName\":\"S.\",\"lastName\":\"Ekeke\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2025-03-28 18:53:10\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-6330376/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-6330376/v1\",\"draftVersion\":[],\"editorialEvents\":[{\"content\":\"https://doi.org/10.1186/s40748-025-00236-5\",\"type\":\"published\",\"date\":\"2025-11-07T15:57:57+00:00\"}],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":95564081,\"identity\":\"1f4b58ca-d7b8-4ea0-b305-3124bc740d53\",\"added_by\":\"auto\",\"created_at\":\"2025-11-10 16:07:30\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":505462,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-6330376/v1/968c4d58-6e40-43e8-be67-33a8c3f7f2e3.pdf\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"How Did We Get Here? A Qualitative Study of Contributors to Traumatic Birth Experiences in NICU parents\",\"fulltext\":[{\"header\":\"Background\",\"content\":\"\\u003cp\\u003eRecent literature on disparities in perinatal outcomes suggests that the experience of the birthing person is not homogenous.\\u003csup\\u003e\\u003cspan citationid=\\\"CR25\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e\\u003c/sup\\u003e Severe maternal morbidity and mortality remains high in the U.S. compared to other high-income countries, which includes psychiatric disorders such as birth trauma and post-traumatic stress disorder (PTSD).\\u003csup\\u003e\\u003cspan citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR27\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e\\u003c/sup\\u003e Birth trauma is a complex concept that is difficult to define and encompasses a wide range of experiences.\\u003csup\\u003e\\u003cspan citationid=\\\"CR28\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR24\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e\\u003c/sup\\u003e Traumatic birth experiences are described as overwhelming emotional distress directly related to interactions or events during childbirth.\\u003csup\\u003e\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e\\u003c/sup\\u003e Between 28\\u0026ndash;40% of birthing parents around the world are reporting their birth experiences as traumatic and 1\\u0026ndash;6% go on to develop PTSD within the first year of giving birth.\\u003csup\\u003e\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e\\u003c/sup\\u003e Minority populations, parents with previous history of mental health disorders, and those who experience medical complications such as unexpected Cesarean section or postpartum hemorrhage are at increased risk of birth trauma.\\u003csup\\u003e\\u003cspan citationid=\\\"CR28\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e\\u003c/sup\\u003e Causes of physical and emotional trauma are commonly referenced when describing birth trauma but interpersonal trauma is also a frequent contributor to traumatic birth experiences and remains poorly described. \\u003csup\\u003e\\u003cspan citationid=\\\"CR24\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e\\u003c/sup\\u003e The concepts of psychological trauma and mistreatment of birthing parents often overlap and both fundamentally derive from patients\\u0026rsquo; perception of medical teams\\u0026rsquo; behaviors meeting their stated and implied needs.\\u003csup\\u003e\\u003cspan citationid=\\\"CR28\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e\\u003c/sup\\u003e A systemic review by Bohren et al. described 7 different domains of medical maltreatment including: 1) verbal 2) physical or 3) sexual abuse 4) stigma and discrimination 5) failure to meet professional standards of care 6) poor rapport between women and providers and 7) health system conditions and constraints.\\u003csup\\u003e\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e\\u003c/sup\\u003e When asked about birth trauma, many patients described at least one experience that also fit into the maltreatment domains.\\u003csup\\u003e\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e\\u003c/sup\\u003e Similarly, clinicians when asked about birth trauma often described maltreatment even when not specifically asked about it further supporting these concepts are interconnected.\\u003csup\\u003e\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e\\u003cp\\u003eTrauma during pregnancy can have implications for subsequent interactions with their medical team but also their infant\\u0026rsquo;s medical team.\\u003csup\\u003e\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e\\u003c/sup\\u003e Multiple studies have shown that neonatal complications and NICU admission can be a large contributor to birth trauma, and the overall NICU environment can add additional stress but there is sparse literature elucidating which elements of the NICU experience are highly associated with postpartum PTSD.\\u003csup\\u003e\\u003cspan citationid=\\\"CR28\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e\\u003c/sup\\u003e Sharp et al performed a mixed methods study which evaluated NICU-Specific Stress and its effect on the relationship between traumatic birth experience and post-traumatic stress symptoms and found that 42% of birth parents mentioned distressing maternal emotional experiences (e.g., feeling guilty, sad, and anxious), 42% mentioned NICU characteristics (e.g. restricted access, frequent staff changes, noise and lights), and 33% mentioned dissatisfaction with their infant\\u0026rsquo;s medical care all as contributors to birth trauma.\\u003csup\\u003e\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e\\u003c/sup\\u003e Despite NICU parents being a high risk population, there are limited studies on this group and many studies merely reference the stress of the medical complexity of NICU admission, while the dynamics of interpersonal trauma remain understudied.\\u003csup\\u003e\\u003cspan citationid=\\\"CR28\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e\\u003c/sup\\u003e Because of the deeply personal nature of the birth experience, it is imperative to center the voice of the birthing parent, so our study set out to explore major contributors to negative perinatal experiences in NICU families from their own perspective. Comparing their perspectives with medical staff knowledge of birth trauma will allow identification of discordance between families and staff which can present opportunities for education in efforts to minimize re-traumatization.\\u003c/p\\u003e\"},{\"header\":\"Methods\",\"content\":\"\\u003cp\\u003eWe conducted a mixed methods study of postpartum mothers who had an infant currently admitted to our level IV NICU and staff in the NICU. This study was approved by our institutional IRB. Inclusion criteria included any birthing person with an infant\\u0026thinsp;\\u0026lt;\\u0026thinsp;12 months old who had an infant currently admitted in the level IV tertiary care neonatal intensive care unit (NICU). There were no exclusions. Recruitment flyers were placed around the unit and at each bedside with principal investigator contact information. If the birthing person was present at the infant's bedside, they were also approached. Once verbal interest was expressed, formal written informed consent was obtained, and an interview was conducted or scheduled later per participant preference. A single semi-structured interview was conducted with each participant which included asking questions about their prenatal, delivery, and postnatal experiences. Twenty-four interviews were conducted using an interview guide (see Appendix A) with open-ended questions and probes designed to assess the salient positive and negative elements of each period of their birth experience (prenatal, delivery, postpartum, and NICU). At the conclusion of the interview, a \\u003cspan\\u003e$\\u003c/span\\u003e15 gift card was distributed for their participation. Interviews were audio-recorded and transcribed using HIPAA compliant transcription software then manually verified by principal investigator for accuracy. Transcripts were subsequently independently analyzed by principal investigators for relevant themes using the constant comparative method until saturation was reached. After independent review, the investigators met to reconcile theme discrepancies and develop consensus on theme classification.\\u003c/p\\u003e\\u003cp\\u003eThe second portion of the study involved soliciting baseline knowledge and attitudes regarding traumatic birth experiences from medical staff working in the neonatal intensive care unit (NICU). An anonymous Qualtrics survey was sent to first line providers in the NICU, including registered nurses, neonatal nurse practitioners, neonatal physician assistants, and neonatology fellows.\\u003c/p\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cp\\u003eTable \\u003cspan class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e depicts demographic information of the 24 parent participants. 79.2%(N\\u0026thinsp;=\\u0026thinsp;19) of participants were white while only 20.8% (N\\u0026thinsp;=\\u0026thinsp;5) were non-White races including 2 Black, 1 Asian, 1 Hispanic, and 1 Native American participant. Majority of participants underwent Cesarean sections in our institution (Inborn) with average gestational age of 33.5 weeks.\\u003c/p\\u003e\\n\\u003cdiv class=\\\"gridtable\\\"\\u003e\\n \\u003ctable id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e\\n \\u003ccaption\\u003e\\n \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e\\n \\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\n \\u003cp\\u003eCharacteristics of Participants\\u0026rsquo; Birth Experience\\u003c/p\\u003e\\n \\u003c/div\\u003e\\n \\u003c/caption\\u003e\\n \\u003cthead\\u003e\\n \\u003ctr\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eN\\u0026thinsp;=\\u0026thinsp;24\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eN (%)\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/thead\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eRace\\u003c/p\\u003e\\n \\u003cp\\u003eWhite\\u003c/p\\u003e\\n \\u003cp\\u003eBlack\\u003c/p\\u003e\\n \\u003cp\\u003eOther\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e19 (79.2)\\u003c/p\\u003e\\n \\u003cp\\u003e2 (8.3)\\u003c/p\\u003e\\n \\u003cp\\u003e3 (12.5)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eMode of Delivery\\u003c/p\\u003e\\n \\u003cp\\u003eVaginal\\u003c/p\\u003e\\n \\u003cp\\u003eCesarean section\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e5 (20.8)\\u003c/p\\u003e\\n \\u003cp\\u003e19 (79.2)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eInborn\\u003c/p\\u003e\\n \\u003cp\\u003eYes\\u003c/p\\u003e\\n \\u003cp\\u003eNo\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e19 (79.2)\\u003c/p\\u003e\\n \\u003cp\\u003e5 (20.8)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eGestational age at birth\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026lt;\\u0026thinsp;28 weeks\\u003c/p\\u003e\\n \\u003cp\\u003e28\\u0026ndash;31 weeks\\u003c/p\\u003e\\n \\u003cp\\u003e32\\u0026ndash;36 weeks\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026gt;= 37 weeks\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e2 (8.3)\\u003c/p\\u003e\\n \\u003cp\\u003e7 (29.2)\\u003c/p\\u003e\\n \\u003cp\\u003e10 (41.7)\\u003c/p\\u003e\\n \\u003cp\\u003e5 (20.8)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n \\u003c/table\\u003e\\n\\u003c/div\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eTheme 1: Communication with the medical team is inadequate and patient concerns are not being addressed\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe most common contributors to a negative birth experience centered around issues with communication between the parents and medical team. Parents reported conversations with providers often \\u0026ldquo;felt rushed\\u0026rdquo;, were unbalanced with overwhelmingly negative information, and contained too much information given at once. Many of the parents cited getting conflicting information from different medical providers as a major source of stress and anxiety during their birth experience. With the complexity of obstetric care, clear messaging from their local obstetricians and the Maternal Fetal Medicine team and congruence of their messaging remains important to patients. Lack of clarity regarding their care bred mistrust between patients and their medical team.\\u003c/p\\u003e\\n\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\n \\u003cp\\u003e\\u003cem\\u003e\\u0026ldquo;And so I just wish that I would have been, like, handled better because at that point, like, I was really to a point where I was like, \\u0026ldquo;hey, if you guys can\\u0026apos;t figure out what\\u0026apos;s going on with me, but I\\u0026apos;m supposed to trust you guys to take care of my child who\\u0026apos;s going to need services or surgeries, like, things, like, how is that going to work?\\u0026rdquo;\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e-Participant 1\\u003c/p\\u003e\\n\\u003c/div\\u003e\\n\\u003cp\\u003eAnother salient feature parents recall that contributed to their negative birth experiences was the feeling that their concerns were not adequately addressed. Birthing parents reported \\u0026ldquo;not feeling heard\\u0026rdquo; when it came to their physical and mental concerns. Additionally, they reported their pain not being adequately controlled during delivery was particularly traumatic. Birthing parents noted that providers being dismissive of their physical symptoms or concerns about their symptoms made them feel alone and that the medical team didn\\u0026rsquo;t have their best interest at heart. These events contributed to many patients\\u0026rsquo; feelings of loss of autonomy and gave the impression that their medical team was only interested in pushing their own agenda and not taking patients\\u0026rsquo; perspectives into consideration.\\u003c/p\\u003e\\n\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\n \\u003cp\\u003eWell, I got really upset, because, eventually, I felt different than I did the first time. I felt a pop in my back. I thought I was going to be paralyzed or something, \\u0026apos;cause it is your back, and I started panicking. She\\u0026apos;s like, \\u0026quot;Oh, this is normal,\\u0026quot; but it\\u0026apos;s not for me\\u003c/p\\u003e\\n \\u003cp\\u003e-Participant 14\\u003c/p\\u003e\\n\\u003c/div\\u003e\\n\\u003cp\\u003eParticipants often didn\\u0026rsquo;t feel validated by the medical team and noted there seemed to be a provider mistrust of patient experience. Whether it was a pain that felt different than normal or expected, a new symptom that patients felt were a part of bigger problem, or a provider ignoring a patient\\u0026rsquo;s perception of medical therapies that have historically been successful or unsuccessful for them, such instances contributed to patients feeling dismissed and that their provider didn\\u0026rsquo;t believe them about their own bodies.\\u003c/p\\u003e\\n\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\n \\u003cp\\u003eSo they had me drive down here, and I was all prepared. Like, I got everything ready. Like, they said, you\\u0026apos;re going to have your baby. Like, we get down here. And the one doctor I saw, um, told me I was lying. \\u0026ldquo;That\\u0026rsquo;s a really nice story you\\u0026rsquo;re telling me but you\\u0026rsquo;re not ruptured.\\u003c/p\\u003e\\n \\u003cp\\u003e-Participant 1\\u003c/p\\u003e\\n\\u003c/div\\u003e\\n\\u003cdiv id=\\\"Sec7\\\" class=\\\"Section2\\\"\\u003e\\n \\u003ch2\\u003eTheme 2: Parents reporting a lack of support from familiar people triggered their anxiety\\u003c/h2\\u003e\\n \\u003cp\\u003eParticipants expressed worry about not having their support system involved in their pregnancy and delivery experience. Feeling alone when their spouse or family member was not able to be present led to immense pressure on the birthing parent that they were solely responsible for advocating for themselves and their infants. There were also reports of anxiety if women did not have a previously established relationship with their care team. They noted having to make important medical decisions in collaboration with providers that they just met and had not seen in previous encounters felt anxiety-provoking. Parents also noted feeling unsettled if their care team expressed their care was too complex or made statements about how \\u0026ldquo;they had never seen this before\\u0026rdquo;. When thinking about the instances where their care had to be transferred from their local obstetrician to a quaternary center, participants expressed appreciation for the transparency about the need for higher level of care, but also noted feelings of abandonment in losing their \\u0026ldquo;medical home\\u0026rdquo; resulting in not knowing who to contact when even the most basic obstetric concerns arose.\\u003c/p\\u003e\\n \\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\n \\u003cp\\u003e\\u003cem\\u003e\\u0026quot;Not through here, but once my regular OB knew that I was seeing the high-risk doctor here, they refused to see me. That was hard on me because then that meant all my care had to come from here and it\\u0026apos;s an hour drive here and an hour drive back. That was a negative experience.\\u0026rdquo;\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e-Participant 9\\u003c/p\\u003e\\n \\u003c/div\\u003e\\n\\u003c/div\\u003e\\n\\u003cdiv id=\\\"Sec8\\\" class=\\\"Section2\\\"\\u003e\\n \\u003cdiv id=\\\"Sec9\\\" class=\\\"Section3\\\"\\u003e\\n \\u003ch2\\u003eTheme 3: Fear of the Unknown\\u003c/h2\\u003e\\n \\u003cp\\u003eAlthough parents acknowledge that pregnancy complications can be unexpected, there was often a feeling of being out of control when things came up that they felt unprepared for. Often there was a feeling of being overwhelmed with new information and some mentioned feeling like their medical team held back vital information about potential complications which led to resentment from losing the opportunity to mentally prepare themselves. The uncertainty of what would happen to them or their infants at times was described as \\u0026ldquo;traumatizing\\u0026rdquo; or \\u0026ldquo;debilitating\\u0026rdquo;. Participants often described their feeling of loss of control was often triggered well into the postpartum period and during their infant\\u0026rsquo;s NICU stay.\\u003c/p\\u003e\\n \\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\n \\u003cp\\u003e\\u003cem\\u003e\\u0026ldquo;It\\u0026apos;s stressful like when you don\\u0026apos;t know what it is...you don\\u0026apos;t know had to read it. I\\u0026apos;m not a nurse. I just see that it goes up and down, up and down. And when it doesn\\u0026apos;t, I already know that that\\u0026apos;s not good. It means that it\\u0026apos;s either she\\u0026apos;s not breathing or her heart\\u0026apos;s not beating. And it, you know, sometimes there was like instances where they were like, oh, there\\u0026apos;s another like beat in there. And I was like, oh, no. Is something wrong with her heart?\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e-Participant 5\\u003c/p\\u003e\\n \\u003c/div\\u003e\\n \\u003c/div\\u003e\\n\\u003c/div\\u003e\\n\\u003cdiv id=\\\"Sec11\\\" class=\\\"Section2\\\"\\u003e\\n \\u003ch2\\u003eContributing factors to positive birth experiences:\\u003c/h2\\u003e\\n \\u003cp\\u003eWhen considering the spectrum of themes, there were often counter positive contributors that were also identified. Generally, patients prefer communication that is bidirectional and allows time for them to digest information and get follow up questions answered. Prenatal counseling and anticipatory guidance were preferred compared to rushed explanations when complications occurred. Patients often commented that it was difficult to come up with questions in the moment and appreciated it when the medical team came back in subsequent encounters to address additional concerns. Counseling that was well-received was thorough, anticipatory, and checked for patient understanding throughout the conversation.\\u003c/p\\u003e\\n \\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\n \\u003cp\\u003e\\u003cem\\u003e\\u0026quot; I\\u0026apos;ve set the tone now, like, so this is what we\\u0026apos;re doing today, and what\\u0026apos;s the big picture impact of that? I\\u0026apos;ve started advocating for my understanding. That\\u0026apos;s what I need in these conversations. That has helped a lot. The folks who have been with us now, that are often with us multiple days, they\\u0026apos;re getting that that\\u0026apos;s the case. Now they\\u0026apos;re coming and prepared to talk about that and help to paint that picture better.\\u0026rdquo;\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e-Participant 23\\u003c/p\\u003e\\n \\u003c/div\\u003e\\n\\u003c/div\\u003e\\n\\u003cdiv id=\\\"Sec12\\\" class=\\\"Section2\\\"\\u003e\\n \\u003cp\\u003eFamilies also leaned into the elements of emotional and mental support that were provided by the medical team and identified that as a salient contributor to how they viewed their birth experience. Validating their emotional stress, \\u0026quot;feeling heard\\u0026rdquo;, offering reassurance, or just being a familiar face and calm presence were cited as sources of decreasing anxiety. Parents often noted small gestures from the medical team such as holding their hand or walking with them often made them feel cared for as the birthing person and gave them the feeling the team had their best interests at heart. Offering mental support for birthing parents and encouragement from the medical team for birthing parent to also attend to their own needs gave parents a sense that the team wanted the best for the maternal-infant dyad as a family unit and gave them a sense of comfort.\\u003c/p\\u003e\\n \\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\n \\u003cp\\u003eShe was supposed to be the baby\\u0026apos;s nurse, but she came and held my hand when I was getting my spinal and just talked me through it. And even though she had stuff that she was supposed to be doing, she just sat there to make sure I was okay before my mom came in and it just made a difference that she went that extra step like \\u0026ldquo;hey calm down\\u0026rdquo;, you know, \\u0026ldquo;you gotta arch your back more or do this and you know just kept me calm. It was really just kind of nice.\\u003c/p\\u003e\\n \\u003cp\\u003e-Participant 1\\u003c/p\\u003e\\n \\u003c/div\\u003e\\n\\u003c/div\\u003e\\n\\u003cdiv id=\\\"Sec13\\\" class=\\\"Section2\\\"\\u003e\\n \\u003cp\\u003eWhen considering the care for their baby, parents often expressed a desire to be very involved in the hands-on care of their infant. From basic care needs such as feeding and changing their infant\\u0026rsquo;s diapers to more complex needs such as placing nasogastric tubes and ostomy care, being an active member of their infant\\u0026rsquo;s care team put parents at ease. Although this sentiment was noted frequently, there seemed to be a delicate balance between hands on care and hypervigilance. Many parents reflected on early feelings of not being able to leave the bedside due to discomfort with the care and need for advocacy for competent care. These anxious feelings seemed to reduce greatly with continuity of care among the team.\\u003c/p\\u003e\\n \\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\n \\u003cp\\u003e\\u003cem\\u003eThe nurses that have chosen him for primary have been\\u0026mdash;it\\u0026rsquo;s a relief when they\\u0026rsquo;re here. They know him. I know that if I have to run out, if I have to do anything, I don\\u0026rsquo;t even have to worry about it \\u0026rsquo;cause they know him so well.\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e-Participant 12\\u003c/p\\u003e\\n \\u003c/div\\u003e\\n\\u003c/div\\u003e\\n\\u003cdiv id=\\\"Sec14\\\" class=\\\"Section2\\\"\\u003e\\n \\u003cdiv id=\\\"Sec15\\\" class=\\\"Section3\\\"\\u003e\\n \\u003ch2\\u003ePerspectives from Staff\\u003c/h2\\u003e\\n \\u003cp\\u003eFifty members of the NICU medical team completed the anonymous survey via Qualtrics, and results were summarized in Table\\u0026nbsp;\\u003cspan class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e. 74% of respondents were bedside nurses while the remaining 26% were advanced practice practitioners and physicians. Of all respondents, 96% agreed that unconscious bias could negatively impact patient care and 92% endorsed awareness of research that inequitable health care delivery contributes to disparities in perinatal outcomes, but when asked if they had personally witnessed an instance of inequitable treatment, only 34% of respondents could recall one while 50% of respondents were unsure. When asked more generally their thoughts on which factors contributed most to patients\\u0026rsquo; perception of negative birth experiences, 34% believed deviation from birth plans was most important to patients while only 20% of respondents believed provider-patient interactions were most common.\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cdiv class=\\\"gridtable\\\"\\u003e\\n \\u003ctable id=\\\"Tab2\\\" border=\\\"1\\\"\\u003e\\n \\u003ccaption\\u003e\\n \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 2\\u003c/div\\u003e\\n \\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\n \\u003cp\\u003eStaff Perspectives Questionnaire Results (N\\u0026thinsp;=\\u0026thinsp;50)\\u003c/p\\u003e\\n \\u003c/div\\u003e\\n \\u003c/caption\\u003e\\n \\u003cthead\\u003e\\n \\u003ctr\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eQ1. Role on the medical team\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth colspan=\\\"3\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003en (%)\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/thead\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eNurse\\u003c/p\\u003e\\n \\u003cp\\u003eAPP/Physician\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"3\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e37 (74)\\u003c/p\\u003e\\n \\u003cp\\u003e13 (26)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eQ2. Please indicate how much you agree with each statement below:\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eAgree\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003en (%)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eUnsure\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003en (%)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eDisagree\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003en (%)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003ea. Unconscious Bias can negatively impact patient care and perpetuate systemic inequalities\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e48 (96)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0(0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e2(4)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eb. There is sufficient evidence in the literature that suggests inequitable health care delivery contributes to disparities in perinatal outcomes\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e46 (92)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e3 (6)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e1 (2)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003ec. Within the last 5 years, I have witnessed a patient getting substandard medical care and believe implicit bias played a role\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e17 (34)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e25 (50)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e8 (16)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eQ3. In your opinion, what is the most common complaint from patients who reported a negative birth experience?\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"3\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003en (%)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eDeviation from Birth Plan\\u003c/p\\u003e\\n \\u003cp\\u003eProlonged Hospitalization of Mother or Infant\\u003c/p\\u003e\\n \\u003cp\\u003eTreatment Decisions\\u003c/p\\u003e\\n \\u003cp\\u003eProvider-patient interactions\\u003c/p\\u003e\\n \\u003cp\\u003eLack of Social Support\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"3\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e17 (34)\\u003c/p\\u003e\\n \\u003cp\\u003e12 (24)\\u003c/p\\u003e\\n \\u003cp\\u003e10 (20)\\u003c/p\\u003e\\n \\u003cp\\u003e10 (20)\\u003c/p\\u003e\\n \\u003cp\\u003e1 (2)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n \\u003c/table\\u003e\\n \\u003c/div\\u003e\\n \\u003c/div\\u003e\\n\\u003c/div\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eBirth trauma is highly prevalent among parents in the neonatal intensive care unit. Often, providers considered medical complications in birthing parents or their infants to be the major contributors to having negative feelings about the birth experience. However, our study highlights the rise of interpersonal trauma as a major cause of birthing parents\\u0026rsquo; negative experiences.\\u003c/p\\u003e\\u003cp\\u003e When NICU birthing parents are reflecting on their experience, there appeared to be 3 major themes that came across: transparency, empathy, and mutual respect. Transparency equated to thorough, honest assessment of the clinical situation and taking the time to clearly communicate their medical reasoning while still remaining responsive to patient concerns. Families appreciated escalation to a higher level of care if a clinician was unsure. They often reported negative feelings if it appeared the medical team was holding back information for fear of upsetting them or not fully explaining the potential complications when medical decision making is required. This correlates with the feelings of loss of autonomy reported in previous studies.\\u003csup\\u003e\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e\\u003c/sup\\u003e When patients feel they are not given the opportunity to make a fully informed decision, they are robbed of the opportunity to make an autonomous decision free from clinician bias. Whether it is a decision about termination, resuscitation, delivery planning or vaccinations, it remains paramount that patients feel like they have a sense of control over their bodies and their infant\\u0026rsquo;s bodies.\\u003csup\\u003e\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e\\u003c/sup\\u003e Empathy refers to the acts of kindness that allow birthing parents to feel that we are not only interested in taking care of their bodies but also their minds and emotions. Small gestures that make patients feel seen and heard were often reported and the most impactful. Lastly, mutual respect was described in many of the responses. Respect for patients' experience and their expertise in their own and their infant's health was frequently described.\\u003c/p\\u003e\\u003cp\\u003eWhen contrasting parent experience with staff perception, there was a clear discordance. Although most staff recognized unconscious bias as a source of disparity in health outcomes in theory, many were unsure of specific examples of how this may present in their clinical practice. From staff perspectives, many believed that deviations from the parent\\u0026rsquo;s birth plan was the major contributor to birth trauma which was not supported by the patient responses which heavily focused on interpersonal interactions. The dichotomy between patient and staff responses on the topic of traumatic birth experiences highlights a cognitive dissonance that remains pervasive. It seems the medical community often conceptualizes birth trauma by events that happen to the birthing parent without sincere acknowledgement of how interpersonal trauma with medical personnel contributes to this perception. This invalidation can have negative consequences to the maternal-infant dyad and their health. From a medical perspective, feeling dismissed by providers and experiencing medical trauma has the potential to impact how parents seek care in subsequent encounters.\\u003csup\\u003e\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e\\u003c/sup\\u003e Avoiding over-medicalization of subsequent birth experiences by delaying prenatal care, the use of lay midwives, and engaging in home births are often attempts by patients to regain control of their birth experiences. Traumatic birth experiences also impact maternal mental health with increased risk of subsequent development of PTSD, which can be characterized by flashbacks, poor sleep, and avoidance behaviors. A study by Harris and Ayers also found that the strongest predictor of developing birth-related PTSD was interpersonal difficulties with care providers, more specifically, experiencing a lack of support which is consistent with our results.\\u003csup\\u003e\\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e\\u003cp\\u003eIn addition to the previously described consequences on maternal mental and physical health, the effects of traumatic birth experiences often linger into their postpartum experience as well. Birthing parents often feel ill-equipped to process the negative feelings around their birth, and these feelings combined with the invalidation of their experiences from medical personnel leads to avoidant behaviors commonly seen in the NICU. To avoid dealing with their own emotional trauma, patients instead tend to become hypervigilant in their infant\\u0026rsquo;s care. Although few parents in our study had insight into how their prenatal trauma reflected in their behaviors with their infant\\u0026rsquo;s care team, many often reflected that being included in their infant\\u0026rsquo;s care and being heard by their infant\\u0026rsquo;s care team were anxiety-reducing behaviors. Dismissive communication and disrespect by the infant care team were noted to cause flashbacks of previous feelings of loss of control and not feeling heard which triggered parents\\u0026rsquo; \\u0026ldquo;fight or flight\\u0026rdquo; response and impacted their ability to calmly process their infant\\u0026rsquo;s medical information. Labile, dysregulated behavior is often referred to in the literature as a \\u0026ldquo;trauma response\\u0026rdquo; and can present as extreme anxiety and hypervigilance often resulting in micromanaging of care, detachment from participating in infant care, and/or anger. These interactions are often difficult to navigate for the parents but also may expose medical providers to secondary trauma. Secondary trauma is a significant concern for maternity and neonatal staff with reports of rates as high as 25\\u0026ndash;30%. The moral injury from observing traumatic births and navigating challenging patient interactions as a result of the previous trauma they experienced contributes significantly to burn out in perinatal providers.\\u003csup\\u003e\\u003cspan citationid=\\\"CR21\\\" class=\\\"CitationRef\\\"\\u003e21\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e\\u003cp\\u003eOverall, birth trauma is underdiagnosed and underrecognized among medical professionals. There seems to be a collective lack of provider awareness of the ways interpersonal trauma plays a role in serious potential short- and long-term consequences on the birthing parents and their infants. It is imperative that we enhance education among medical staff to improve recognition of signs and symptoms of trauma responses and trauma-informed care to reduce re-traumatization of our patients throughout the entire perinatal experience.\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003eFunding: University of Michigan Diversity Office of Health Equity \\u0026amp; Inclusion Diversity Fund\\u003c/p\\u003e\\n\\u003cp\\u003e• Competing interest: None\\u003c/p\\u003e\\n\\u003cp\\u003e• Ethics approval: Study was approved by the IRB at University of Michigan\\u003c/p\\u003e\\n\\u003cp\\u003e• Consent to participate: Not applicable; exempt status\\u003c/p\\u003e\\n\\u003cp\\u003e• Consent for publication: All authors consent to publication; no other consents required\\u003c/p\\u003e\\n\\u003cp\\u003e• Availability of data and material: De-identified data available upon request\\u003c/p\\u003e\\n\\u003cp\\u003e• Authors' contributions: Each author made significant contributions to this manuscript, meeting the criteria for authorship. RG contributed to data collection, performing participant interviews, data analysis, and preparation of the manuscript. PE led study design, data analysis and manuscript preparation. \\u0026nbsp;\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\n\\u003cli\\u003eHowell EA, Zeitlin J. Quality of care and disparities in obstetrics. Obstetrics and Gynecology Clinics of North America. 2017 Mar;44(1):13.\\u003c/li\\u003e\\n\\u003cli\\u003eHoyert DL, Mini\\u0026ntilde;o AM. Maternal mortality in the United States: changes in coding, publication, and data release, 2018.\\u003c/li\\u003e\\n\\u003cli\\u003eTikkanen R, Gunja MZ, FitzGerald M, Zephyrin L. Maternal mortality and maternity care in the United States compared to 10 other developed countries. The Commonwealth Fund. 2020 Nov 18;10:22.\\u003c/li\\u003e\\n\\u003cli\\u003eSimpson M, Catling C. Understanding psychological traumatic birth experiences: A literature review. Women and Birth. 2016 Jun 1;29(3):203-7.\\u003c/li\\u003e\\n\\u003cli\\u003eBeck CT. Birth trauma: in the eye of the beholder. Nursing research. 2004 Jan 1;53(1):28-35.\\u003c/li\\u003e\\n\\u003cli\\u003eSoet JE, Brack GA, DiIorio C. Prevalence and predictors of women's experience of psychological trauma during childbirth. Birth. 2003 Mar;30(1):36-46.\\u003c/li\\u003e\\n\\u003cli\\u003eAlcorn KL, O'Donovan A, Patrick JC, Creedy D, Devilly GJ. A prospective longitudinal study of the prevalence of post-traumatic stress disorder resulting from childbirth events. Psychological medicine. 2010 Nov;40(11):1849-59.\\u003c/li\\u003e\\n\\u003cli\\u003eFord E, Ayers S. Support during birth interacts with prior trauma and birth intervention to predict postnatal post-traumatic stress symptoms. Psychology \\u0026amp; health. 2011 Dec 1;26(12):1553-70.\\u003c/li\\u003e\\n\\u003cli\\u003eFawcett EJ, Fairbrother N, Cox ML, White IR, Fawcett JM. The prevalence of anxiety disorders during pregnancy and the postpartum period: a multivariate Bayesian meta-analysis. The Journal of clinical psychiatry. 2019 Jul 23;80(4):1181.\\u003c/li\\u003e\\n\\u003cli\\u003eBeck CT, Gable RK, Sakala C, Declercq ER. Posttraumatic stress disorder in new mothers: Results from a two‐stage US national survey. Birth. 2011 Sep;38(3):216-27.\\u003c/li\\u003e\\n\\u003cli\\u003eMoczygemba CK, Paramsothy P, Meikle S, Kourtis AP, Barfield WD, Kuklina E, Posner SF, Whiteman MK, Jamieson DJ. Route of delivery and neonatal birth trauma. American journal of obstetrics and gynecology. 2010 Apr 1;202(4):361-e1.\\u003c/li\\u003e\\n\\u003cli\\u003eDumpa V, Kamity R. Birth Trauma. [Updated 2023 Aug 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK539831/\\u003c/li\\u003e\\n\\u003cli\\u003eSorenson DS, Tschetter L. Prevalence of negative birth perception, disaffirmation, perinatal trauma symptoms, and depression among postpartum women. Perspectives in psychiatric care. 2010 Jan;46(1):14-25.\\u003c/li\\u003e\\n\\u003cli\\u003eSalter C, Wint K, Burke J, Chang JC, Documet P, Kaselitz E, Mendez D. Overlap between birth trauma and mistreatment: a qualitative analysis exploring American clinician perspectives on patient birth experiences. Reproductive Health. 2023 Apr 21;20(1):63.\\u003c/li\\u003e\\n\\u003cli\\u003eBohren MA, Vogel JP, Hunter EC, Lutsiv O, Makh SK, Souza JP, Aguiar C, Coneglian FS, Diniz AL, Tun\\u0026ccedil;alp \\u0026Ouml;, Javadi D. The mistreatment of women during childbirth in health facilities globally: a mixed-methods systematic review. PLoS medicine. 2015 Jun 30;12(6):e1001847.\\u003c/li\\u003e\\n\\u003cli\\u003eBeck CT, Driscoll JW, Watson S. Subsequent childbirth after a previous traumatic birth. InTraumatic childbirth 2013 Jul 18 (pp. 151-168). Routledge.\\u003c/li\\u003e\\n\\u003cli\\u003eSarfo JO, Segalo P. Mothers\\u0026rsquo; Psychological Trauma Experiences Associated With Preterm Pregnancy, Birth, and Care: A Qualitative Study. Indian Journal of Psychological Medicine. 2024 Sep 7:02537176241275560.\\u003c/li\\u003e\\n\\u003cli\\u003eSharp M, Huber N, Ward LG, Dolbier C. NICU-specific stress following traumatic childbirth and its relationship with posttraumatic stress. The Journal of perinatal \\u0026amp; neonatal nursing. 2021 Jan 1;35(1):57-67.\\u003c/li\\u003e\\n\\u003cli\\u003eHorsch A, Garthus-Niegel S, Ayers S, Chandra P, Hartmann K, Vaisbuch E, Lalor J. Childbirth-related posttraumatic stress disorder: definition, risk factors, pathophysiology, diagnosis, prevention, and treatment. American journal of obstetrics and gynecology. 2024 Mar 1;230(3):S1116-27.\\u003c/li\\u003e\\n\\u003cli\\u003eHarris R, Ayers S. What makes labour and birth traumatic? A survey of intrapartum \\u0026lsquo;hotspots\\u0026rsquo;. Psychology \\u0026amp; health. 2012 Oct 1;27(10):1166-77.\\u003c/li\\u003e\\n\\u003cli\\u003eKendall-Tackett K, Beck CT. Secondary traumatic stress and moral injury in maternity care providers: a narrative and exploratory review. Frontiers in Global Women's Health. 2022 May 4;3:835811.\\u003c/li\\u003e\\n\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":true,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"maternal-health-neonatology-and-perinatology\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"mhnp\",\"sideBox\":\"Learn more about [Maternal Health, Neonatology and Perinatology](http://mhnpjournal.biomedcentral.com)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/mhnp/default.aspx\",\"title\":\"Maternal Health, Neonatology and Perinatology\",\"twitterHandle\":\"@BioMedCentral\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC/SO AJ\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true},\"keywords\":\"birth trauma, NICU, perinatal mental health\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-6330376/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-6330376/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003e\\u003cstrong\\u003eBackground: \\u003c/strong\\u003eBirth trauma is a complex concept that encompasses various experiences related to events in the perinatal period, including prenatal care, delivery, and postpartum care. Despite NICU parents being a high-risk population, there are limited studies in this group and many studies reference the stress of the medical complexities, while the dynamics of interpersonal trauma remain poorly understood by the medical community. The purpose of our study was to explore perspectives of NICU families and staff on contributors to traumatic birth experiences.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eMethods: \\u003c/strong\\u003eA mixed methods study was performed exploring the qualitative experience of postpartum mothers with infants currently admitted to a level IV NICU. A single semi-structured interview was conducted with each participant which included questions about their prenatal, delivery, and postnatal experiences. Interviews were audio-recorded and transcribed using HIPAA compliant transcription software then manually verified by principal investigators for accuracy. Thematic analysis using the constant comparative method was performed by each principal investigator until saturation and consensus was reached.\\u003c/p\\u003e\\n\\u003cp\\u003eAdditionally, NICU Staff completed an anonymous Qualtrics survey soliciting baseline knowledge and attitudes regarding traumatic birth experiences. Perspectives from birthing parents and medical staff were compared to assess for concordance.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eResults: \\u003c/strong\\u003eThere were 3 salient themes among birthing parents that negatively contributed to the perception of a traumatic birth: 1) inadequate communication with the medical team 2) lack of support from trusted sources and 3) fear of the unknown of what would happen to them or their infants.\\u003c/p\\u003e\\n\\u003cp\\u003eWhile 96% of medical staff acknowledged they were aware that implicit bias and interpersonal trauma contributes negatively to healthcare disparities, when probed about real life examples, 50% of staff were unsure if they had personally witnessed such events.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConclusions and Relevancy: \\u003c/strong\\u003eThere seems to be a collective lack of provider awareness of the ways interpersonal trauma plays a role in potential short- and long-term consequences in birthing parents and their infants. It is imperative that we enhance education among medical staff to improve recognition of signs and symptoms of trauma responses and trauma-informed care to reduce re-traumatization of our patients throughout the entire perinatal experience.\\u003c/p\\u003e\",\"manuscriptTitle\":\"How Did We Get Here? A Qualitative Study of Contributors to Traumatic Birth Experiences in NICU parents\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2025-07-23 07:27:18\",\"doi\":\"10.21203/rs.3.rs-6330376/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"decision\",\"content\":\"Revision requested\",\"date\":\"2025-08-19T22:39:24+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2025-08-19T09:59:21+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2025-08-11T15:37:10+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2025-08-01T19:19:36+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"36996473531116079961583289336872776406\",\"date\":\"2025-07-24T17:47:24+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"234554526271782051890650545453436376673\",\"date\":\"2025-07-23T13:02:29+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"119087640917068179041957388684235742610\",\"date\":\"2025-07-23T11:28:40+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2025-07-20T21:51:50+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2025-03-31T07:55:41+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2025-03-31T07:54:54+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"Maternal Health, Neonatology and Perinatology\",\"date\":\"2025-03-28T18:43:20+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"maternal-health-neonatology-and-perinatology\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"mhnp\",\"sideBox\":\"Learn more about [Maternal Health, Neonatology and Perinatology](http://mhnpjournal.biomedcentral.com)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/mhnp/default.aspx\",\"title\":\"Maternal Health, Neonatology and Perinatology\",\"twitterHandle\":\"@BioMedCentral\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC/SO AJ\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"39bae1cf-e310-4ad0-8bbe-15fb61dd19cd\",\"owner\":[],\"postedDate\":\"July 23rd, 2025\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"published-in-journal\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2025-11-10T16:02:54+00:00\",\"versionOfRecord\":{\"articleIdentity\":\"rs-6330376\",\"link\":\"https://doi.org/10.1186/s40748-025-00236-5\",\"journal\":{\"identity\":\"maternal-health-neonatology-and-perinatology\",\"isVorOnly\":false,\"title\":\"Maternal Health, Neonatology and Perinatology\"},\"publishedOn\":\"2025-11-07 15:57:57\",\"publishedOnDateReadable\":\"November 7th, 2025\"},\"versionCreatedAt\":\"2025-07-23 07:27:18\",\"video\":\"\",\"vorDoi\":\"10.1186/s40748-025-00236-5\",\"vorDoiUrl\":\"https://doi.org/10.1186/s40748-025-00236-5\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-6330376\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-6330376\",\"identity\":\"rs-6330376\",\"version\":[\"v1\"]},\"buildId\":\"8U1c8b4HqxoKbykW_rLl7\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}