Subjective maternal experiences of childbirth have raised increasing social interest and research attention during recent years as they may have an impact on postpartum mental health adaptation, mother–child-caregiving, and even the longitudinal development of the child (1–4). The physical component of the subjective birth experience (SBE) is determined by pain and exhaustion, analgesic control, obstetric interventions, duration of labor, and others (3, 5). Psychologically, it is important how the mother attributes and understands what is happening to her and the child in the specific birth situation. On the negative side, the emotional component of SBE is determined by the experience of a perceived threat to the mother's and/or infant's physical health, loss of control, or guilt. Thus, it is partly a reaction to physical experiences (e.g., pain and obstetric interventions). On the other hand, the emotional component contains all the intense emotions of becoming a mother, such as seeing, touching, or hearing her baby for the first time (2, 6). Studies suggest that the maternal experience and satisfaction with the course of childbirth is predicted by the expectations regarding the upcoming delivery which may, in the case of multiparous women, in turn, be associated with the SBE in prior deliveries (7–10). Additionally, and very importantly, there is a strong impact of the quality of the care provider on SBE (e.g., emotional support, respect, privacy, communication, and being involved in decision-making) (1).

Depending on the method of measurement, time of assessment after birth, and case definition, prevalence rates of a negative SBE vary across studies and are not directly comparable. Large population-based Swedish, Dutch, and Canadian studies found that 7–17% of women recall a negative SBE 5–9 months (11) and 1 year (12) vs. 3 (13) years postpartum, with higher rates in primiparous compared to multiparous women (22.5 vs.11.6%) (13). A recent review found even higher rates of up to 34% of mothers reporting a negative or traumatic birth experience (14).

The birth of the baby can even be experienced as traumatic in the sense of posttraumatic stress. There are two ways to experience the birth as traumatic. On one hand, birth itself with its potential complications, anxiety, panic, loss of control, and helplessness may be experienced as traumatic. On the other hand, former traumatic experiences may be reactualized, leading to retraumatization (15). Approximately, 20% of mothers show an acute traumatic stress reaction during the first week after birth. According to a meta-analysis by Yildiz et al. (16), 4.0% (95% CI 2.77–5.71) of mothers from the general population develop a full-syndrome post traumatic stress disorder (PTSD) and 18.5% (95% CI 10.6–30.38) from high-risk groups develop it (16–21). In addition, other potentially trauma-related postpartum disorders are common in early motherhood with prevalence rates ranging from 10 to 20% for depression and 10% for postpartum anxiety disorders, depending on definition, time frame, and population (22). They often occur comorbidly (23), and in many cases are considered to be a sequela of postpartum PTSD (17, 19, 24).

A negative SBE has been shown to be a potential predictor for the development of posttraumatic stress symptoms, mediating the influence of predisposing factors such as antenatal anxiety and depression, especially fear of childbirth (3). Thus, fear of childbirth can not only be considered a risk factor for a negative SBE (25), but it may also be the result of a prior negative and a potentially traumatic experienced birth, thereby leading to future risks, e.g., increased incidence of caesarian section or postpartum psychopathology (11, 26, 27).

A negative SBE may be determined by unexpected medical problems, such as emergency caesarian section or vaginal operative deliveries, placental problems leading to heavy bleedings and/or infant transfer to neonatal care (12), and sensations and effects during labor related to pain, loss of control, and guilt (5). A prior study found the impact of such “objective” birth experiences [number of medical complications (MC)] to be to a large degree mediated by subjective appraisals during birth (3). Other factors related to a negative SBE are social issues of the women (e.g., unwanted/unplanned pregnancy, lack of social partner support) and the caregiving situation during birth (e.g., communication, empathy, joint decision making, etc.) (2, 12).

A negative SBE may not only affect the mother's wellbeing but also feelings and behavior toward the baby. About 60 years ago Newton and Newton (28) asked over 600 women about their feelings when they first saw their newborn. They found a more positive mother–infant bonding when the birth experience had been less painful, more relaxed, and actively controllable (28). The recent comprehensive literature review by Bell et al. (1) focused on quantitative and qualitative research regarding SBE and its impact on maternal caregiving (self-report and observational studies). The majority of the studies (11 of 15 included) reported the better the SBE, the more positive and sensitive the caregiving attitudes and behavior were (e.g., higher maternal self-esteem and parental self-efficacy, more positive mother–infant-bonding, and significantly more positive descriptions of the baby).

Results regarding the continuity of such dysfunctionalities were mixed in the previous studies. Although some studies found a transient effect after birth, which faded over time (29) or was only significant for younger women <30 yr (30), others reported a consistently impaired parental self-esteem throughout the first postnatal year if mothers had reported a negative SBE (31).

Finally, recent Japanese research suggests that aspects of a traumatic birth experience are associated with immediate mother–infant BD 1 month postpartum, but 4 months postpartum depressiveness seems to be the key variable predicting an impaired mother–infant bonding (32).

This study investigated the relevance of the SBE on mother–infant BD, considering MC, current psychopathology, and other potentially confounding variables. We used a clinical sample of women treated in our MBU for mental disorders.

Patients were characterized by high comorbidity and mean scores above the clinical cutoff on all psychopathological measures (anxiety, depression, and general psychopathology). Unipolar depression was the most frequent disorders, present in three-quarters of women, followed by personality disorders, anxiety disorders, PTSD, and obsessive–compulsive disorder. More than half of the sample reported distorted mother–child bonding, which is more than double the rate compared to healthy populations (52, 53).

Almost half of the women in our study recalled the SBE as negative. These rates are about three times higher than those from population-based studies (11–13). On average 1.4 maternal and/or infant medical birth complications from a list of 19 incidents were self-reported in our sample. Three-quarters of the patients experienced at least one event (about 40% two or more). MC have frequently been shown to be associated with posttraumatic stress symptoms and postpartum psychopathology (3, 18, 25), but less is known about their association with bonding.

The univariate analyses revealed highly significant differences on comparing patients with mental disorders and BD to those without BD. An impaired mother–infant bonding has frequently been shown to be associated with postpartum psychopathology, especially depressiveness (54–56). This was replicated in our sample regarding depressiveness, anxiety, and the general psychopathological burden. The majority of women scored above the clinical cutoff on the scales, but women with postpartum BD had even higher scores (small to moderate effects). Compared to postpartum psychopathology, the effect sizes were even higher for the SBE. More than twice as many mothers with BD than without scored above the clinical cutoff for a negative SBE, and patients with BD reported considerably lower total SIL-scores, on average, minus one standard deviation. This is in line with the results of previous epidemiological and clinical studies which found the SBE being associated with mother–child bonding and maternal caregiving (1, 3, 12).

Beyond a general evaluation of the birth experience, our study allows a deeper insight into its different domains. Women with BD reported significantly less postpartum fulfillment, more postpartum disappointment, and a worse intrapartum emotional adaptation. Interestingly, no significant differences were found regarding the intrapartum subscale pain/exhaustion, which refers to the physical dimension of the birth experience. Accordingly, the group difference of the mean number of “objective” MC was significant, but less pronounced (1.6 with BD vs. 1.1 without BD).

Finally, while in our study all the investigated variables (SBE, MC, psychopathology) were significant univariate predictors for BD, of the potentially confounding variables, neither the duration of the postpartum period until assessment (recall time for SBE) nor the number of previous birth experiences or the actual family situation were associated with BD in our sample. However, higher educated and older mothers had an increased risk of impaired mother–infant bonding in our clinical sample. It needs to be further investigated if education and/or maternal age play a systematic role for mother–infant bonding processes and the subjective perception and expectation of such.

Interestingly, within the multiple model, the SBE ruled out every other univariate predictor of BD included in our model, even current depressiveness, other psychopathology, and MC. A negative SBE remained the only significant predictor for BD with a high degree of explained variance of 27%.

The results of our study highlight the importance of the subjective emotional and mental processes during birth, as previously reported by others (1, 2, 12, 28). Neither pain, exhaustion, nor MC seem to be the most important for the process of engaging into a new relation with the infant. They are mediated by subjective appraisals (3). The experience of being in control during this extraordinary life event of childbirth and/or being able to cope with a very demanding and stressful birth situation seems to be crucial. Right after birth is the first time that the baby and the mother directly interact, and for both it is a fundamentally life-changing situation. It is intuitively comprehensible that it makes a difference for the whole bonding process if the mother feels confident, proud, and in her strength as compared to feeling disappointed, guilty, or weak. The postpartum period repeatedly goes along with new and challenging situations for mother and baby, such as (the initiation of) breast-feeding, growth spurts, excessive crying periods, infections, and disturbed maternal sleep (57, 58). It may be helpful to face these challenges with self-confidence and trust in one's self-efficacy as well as emotional and body capability. Accordingly, some recent studies found the SBE to be considerably associated with maternal self-esteem/self-efficacy and the descriptions of and feelings toward the child (31, 59).

Empirical data about the endurance of the impact of a negative SBE on motherhood are inconclusive so far (29, 31). Yet, in our study, the association of a negative SBE and BD was not associated with the time since birth, ranging broadly between 4 and 60 weeks (median 23 weeks). There was obviously no systematic fading-out effect during the first year postpartum in our clinical population. This highlights the probability that the SBE may be related to more general personal dispositions and vulnerabilities (e.g., anxiousness, need for personal control, self-esteem, problem- vs. emotion-focused coping style). In turn, it is also in line with the evidence from other studies which found a negative SBE to be a potent mediator between fear of childbirth and postpartum PTSD (3, 19).

Although not exclusively relevant for the further development of the mother–child bond, the SBE is a very important factor at the early beginning of postpartum mother–child relation, which in turn is associated with child development later on. Delayed or distorted mother–child bonding as well as parental mental disorders are considered adverse childhood experiences (ACE), which in turn are associated with somatic, cognitive, mental, and psychopathological risks over the life span of the child (60, 61). The earlier and stronger their impact is, the more neurobiological and epigenetic change may take place in the developing brain of the infant, with all the shaping consequences for the emotional and behavioral regulation of the offspring (4, 62–67).

Consequently, it is highly important to break this vicious cycle. It should be a routine to focus on women with a high risk for a negative SBE during pregnancy itself. Longitudinal epidemiological studies should furthermore examine whether women with a higher pre-conceptional or antenatal psychopathological burden or certain personality traits are specifically prone to a negative SBE. A recent study by Asselmann et al. suggest that less emotionally stable, less conscientious, and less open women tend to experience their delivery as worse, particularly in case of unexpected incidents (i.e., preterm delivery, emergency cesarean section, and necessity of anesthetics), and might thus profit from early targeted interventions (68). Further risk factors are, for instance, women with preexisting depression, fear of childbirth, exposure to current or prior domestic violence, or those with a history of trauma (17, 19, 69).

Women at risk for a negative birth experience may benefit from an adapted birth preparation, which focusses on strengthening self-esteem and building flexibility and realistic expectations of birth. Psychological individual or group treatment of underlying mental disorders may be warranted prior to birth. A recent Dutch study could show that trait-mindfulness is associated with a more positive perception of childbirth (70). An RCT-study applying online mindfulness training during pregnancy is underway (71). This could be a helpful low-threshold means of prevention.

Beyond these individual interventions during pregnancy, the sensitive management of birth in the obstetric wards is crucial, especially for women at risk. This includes good communication, transparency, and social support during delivery. The negative SBE can be in contrast to the “objective” course of delivery, as perceived by the obstetric staff. As the somatic health of mother and baby is the main focus, the maternal psychological reaction may be easily neglected, especially if apparently everything went “fine”. Many of the women might not speak about their feelings of loss of control, shame, or guilt because of perceived weakness. Offering them the opportunity to re-evaluate the emotional and bodily experiences by directly addressing these issues and potential negative feelings may support the timely adaptation to early motherhood and the development of a healthy mother–infant bonding [see (72, 73)]. This can be facilitated by also involving psychological and/or psychosomatic staff. Even though debriefing after childbirth is not recommended routinely (74), in women with preexisting mental disorders a psychosocial debriefing seems to be beneficial as a diagnostic and preventive measure.

This study has the following strengths: data come from a MBU with a large sample size (high ecological validity). Patients' mental status at admission and discharge was routinely examined using a diagnostic interview (SCID I) and well-established questionnaires with solid psychometric properties (e.g., EPDS, BSI, and PBQ). We used multiple modeling controlling for shared variance of the SBE, current psychopathology, and recall-time effects in the prediction of mother–infant BD. Addressing these issues, our data clearly add additional insight to the existing literature.

Nevertheless, the present study has also some limitations which have to be considered when interpreting the results. We used cross-sectional data from a clinical sample of women. Birth-related data were retrospective and may have been biased by the current psychopathological burden. Furthermore, medical data were obtained by self-report because we had no access to the obstetric charts. The quality and nature of obstetric care could therefore not be evaluated but may have contributed to the SBE (6). Our sample consisted of women with mental disorders, so we cannot draw any conclusions for the general population from our data.

Our results highlight the importance of both, good obstetric as well as psychological care prior, during, and after birth, especially for vulnerable women. Considering the psychosomatic perspective as routine obstetric care may make a huge difference for the mother–child relation, thereby potentially the life-long maternal and offspring mental and somatic health. Thus, it offers a highly sensitive window for low threshold preventive interventions. Primary prevention should start as early as in pregnancy and not only with the treatment of the postpartum depression with manifest mother–infant BD during a subjectively failed postpartum period. Nevertheless, the treatment of postpartum mental disorders, including mother–infant BD, focusing on the mother–infant dyad is possible and effective for both the mother and child. It should explicitly include the processing of the birth experience (55, 75–77).

Future research should focus on risk factors for a negative SBE and means of effective preventive interventions as well as integrated psychological treatment for mental disorders within a longitudinal approach. As approaches may differ depending on the respective target groups, clinical and non-clinical studies are relevant for future investigations.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving human participants were reviewed and approved by Ethics Committee, Technische Universität Dresden. The patients/participants provided their written informed consent to participate in this study.

JJ-H, KW, and AB: study design and conduction of the scientific evaluation of the Dresden MBU. JJ-H, KW, AB, and SG-N: concept of paper. JJ-H and AB: data analysis. JJ-H and KW: draft of manuscript. JJ-H, KW, SG-N, AB, MG, and JM: revision and editing of paper. All authors contributed to the article and approved the submitted version.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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