DEPRESSION AND ANXIETY IN ADULTHOOD AS A FUNCTION OF BIRTH TRAUMA IN PAKISTAN

AFSHAN AZIZ DAMJI

BAHRIA UNIVERSITY ISLAMABAD 2004

Depression and anxiety in adulthood as a function of birth trauma in Pakistan

Afshan Aziz Damji

Submitted in partial fulfillment of the requirement for the award of Ph.D. degree in professional Psychology with specialization in Clinical Psychology at the faculty of Professional Psychology, Bahria University, Islamabad.

Supervisor

October, 2004

I certify that I have read this Dissertation and that in my opinion it is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy.

___ Prof. Dr. Miss Farrukh Z Ahmad Hon. Surgeon Commodore Director Institute of Professional PsychologyKarachi Chairman Dissertation Committee

I certify that I have read this Dissertation and that in my opinion it is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy.

Dr. Mrs. Eva Hasan Visiting Professor Institute of Professional PsychologyKarachi Member Dissertation Committee I certify that I have read this Dissertation and that in my opinion it is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy.

Prof. Masood-Ul-Haq Visiting Professor Institute of Professional PsychologyKarachi Member Dissertation Committee

CONTENTS Page No.

List of Tables List of Graphs

vii

v vi

Acknowledgments Abstract Chapter 1 Introduction Chapter 2 Method Chapter 3 Results Chapter 4 Discussion Chapter 5 Conclusion References Appendix A Appendix B Appendix C

viii 01 64 72 104

123 126 139 141 142

(iv)

LIST OF TABLES Tables

Table No 1Comparison of Anxiety Between Individuals With Natural And Traumatic Births Table No 2Comparison of Depression Between Individuals With Natural And Traumatic Births Table No 3 Comparison of Depression Between Female Individuals With Natural And Cesarean Birth Comparison of Depression Between Male Individuals With Natural And Cesarean Birth Comparison of Anxiety Between Female Individuals With Natural And Cesarean Birth Comparison of Anxiety Between Male Individuals With Natural And Cesarean Birth Comparison of Depression Between Female Individuals With Natural And Forceps Birth Comparison of Depression Between Male Individuals With Natural And Forceps Birth Comparison of Anxiety Between Female Individuals With Natural And Forceps Birth Comparison of Anxiety Between Among Male Individuals With Natural And Forceps Birth 84

Page No

86

88

Table No 4

90

Table No 5

92

Table No 6

94

Table No 7

96

Table No 8

98

Table No 9

100

Table No 10

102

LIST OF GRAPHS Graphs Page No

(v)

Graph A

Level of Anxiety Among Individuals With Natural And Different Forms of Traumatic Birth Level of Depression Among Individuals With Natural And Different Forms of Traumatic Birth Level of Depression Among Female Individuals With Natural And Cesarean Birth Level of Depression Among Male Individuals With Natural And Cesarean Birth Level of Anxiety Among Female Individuals With Natural And Cesarean Birth Level of Anxiety Among Male Individuals With Natural And Cesarean Birth Level of Depression Among Female Individuals With Natural And Forceps Birth Level of Depression Among Male Individuals With Natural And Forceps Birth Level of Anxiety Among Female Individuals With Natural And Forceps Birth Level of Anxiety Among Male Individuals With Natural And Forceps Birth

85

Graph B

87

Graph C

89

Graph D

91

Graph E

93

Graph F

95

Graph G

97

Graph H

99

Graph I

101

Graph J

103

ACKNOWLEDGMENTS
I wish to to express the my profound gratitude of and the Z.

appreciation dissertation Ahmad under

Supervisor/Chairman Professor Dr. Miss.

committee whose

Farrukh has

guidance

this

research

been

(vi)

completed.

She

was

the

source

of

inspiration

and

motivation for me.

I would also like to extend my gratitude to the members of the Dissertation Committee, Dr. Eva Hasan and Prof. Masood-ul-Haq for their constant help and support.

I would deeply like to thank and honor my mother Mrs. Parveen Aziz Damji of who with her prayers was a

constant

source

encouragement

especially

during

difficult times of the dissertation period. I would also like to profoundly thank my aunts Mrs. Nargis Damji and Mrs. Yasmin Merchant for taking care of my children when I was busy studying and attending my classes.

Last but not the least, I thank my husband Mr. Amyn Hussain and my kids Ayra and Ayhan for all their love, support, patience and understanding without which the completion of this project would have been impossible.

ABSTRACT
A study was conducted on Depression and Anxiety in

adulthood as a function of Birth Trauma in Pakistan. The main aim of the study was to assess the impact of birth trauma and assess the level of anxiety and depression in adult population of Pakistan.

(vii)

For

the

purpose

of

this

study

Birth

Trauma

was

classified into 2 distinct groups: 500 participants were included in this study. 1. 100 Individuals of both sexes born under Cesarean Section. 2. 100 Individuals of both sexes born through Forceps or Vacuum Extraction 3. 300 individuals of both sexes were taken as a controlled group who were born through the normal birth procedure. It was hypothesized that individuals born through a traumatic birth procedure will be more vulnerable towards anxiety and depression in adulthood in Pakistan. Following Information measures Form, were used: Scale, Demographic Personality

IPAT-Anxiety

Assessment Questionnaire. Chi-Square test was computed in order to obtain the statistical significance of the data. The findings showed that individuals who knew they were born through traumatic birth procedures had high anxiety and depression sten scores on IPAT Anxiety and IPAT Depression scales as compared to individuals born through Normal Birth Procedure.

(viii)

CHAPTER 1

INTRODUCTION

Hurlock states the that of

(1953) life

developmental not begin that at is,

psychologist birth but at

does

time

conception,

approximately

nine months before birth. It is a fact that growth during the prenatal period is very fast, resulting in the development an of of an organism. in that the is Birth is

therefore development changes in

interruption the individual from

normal by to

caused body

environment

the

mothers

the world outside the mothers body. In Pakistan the birth of a child is considered a blessing. Therefore it is to in natural take this that of the the

family infant

immediately who has just

starts

care

arrived

world

after

going through a transitional birth procedure. In family along a Pakistani the culture, care of is because the taken that in of the born the of a joint child family need is

system, with the

new by

mother they

members care

because

feel A of son

both such

them

and

affection. the heir than

society is

considered more

the

family.

He

given gives

importance

the

daughter.

Family

more consideration and care to the daughter-in-law who has given birth to their heir. The birth of a daughter is seen as a calamity by many families

and

that

the

daughter-in-law

is

blamed

for

her

birth. Birth some can become a traumatic anxiety experience and for

individuals

inducing

depression

in adulthood. Many theorists have laid emphasis on the experience of birth procedure and its effects on later personality development. Otto Rank (1923) has based his entire personality theory on the

basis of birth trauma. Pakistan is a developing country and there is a dearth of facilities which are conducive to

health including mental health of the individuals. On top of it, most of the people are not educated, they live in the rural areas as Pakistan is an

agro-based country. Due problems to of difficulties, living in far both fledged financial areas, and

modern

health care facilities are unavailable and cannot be reached health easily. care The families to cannot afford and to the

give

attention

the

mother

child at the time of the birth. People seldom focus on the reasons and causes behind an absurd or a maladaptive behavior. The

moment one feels that an individual is behaving in a different manner, that family takes that member to the renowned Hakims, Shrines or Pirs for

eradicating the evil, which might have overpowered that person. It is not only the uneducated class

but also the educated sector who goes to the faith

healers and religious leaders for help to resolve their nature. In efforts Mannat. excessive order are By to save the patient, includes faith and many types of or problems that might be of psychological

made going

which to of the

offerings healers

where spent.

amount

money

time

is

Taking the sufferer to a doctor or a professional is the familys last hope and resort and this only happens when they fail to get substantial healing or benefits from these faith healers. A greater

number of the people term it as Black Magic when a person respond (1988). child strong does to A not the show appropriate treatment, can behavior & a or

given

Ahmad make and

Ismail healthy

strategic into in

approach a

develop person

physically It is

mentally to

adulthood.

important

know that all stages of development are linked and the best time to start ensuring a full life is as early become strong as possible. A healthy baby is likely to

physically child will more delay risk

and grow

mentally to be to defer

healthy. a

This

contributing with and

adolescent, education, avoid

liable marriage,

continue childbirth child

high-

pregnancies.

The

would

later lay a foundation for the next generation. A study was conducted by Inayatullah (2001)

that 9,000 children are born everyday in Pakistan. She concluded that out of 9,000 children, 83% of

these

children

are

delivered

at

home

without

any

trained and qualified help. It trained may be noted health all the the that now in and Pakistan midwives the are

local at

visitors stages trained of

appointed With the

local

government. decides

result

professional

as to whether the delivery should be conducted at home or the mother should be sent to the hospital for delivery. In study the above , it mentioned is a view of Inayatullahs situation and

(2001)

deplorable

can bring a lot of anxiety and depression to the future minimize population first we generation the of of Pakistan. of birth it is of In trauma order on to the that the

impact

Pakistan, the

imperative birth on

study of

effects and

population

Pakistan

then

give

appropriate

measures to policy makers to prevent the frequency and severity of birth trauma in Pakistani

children. In mental Pakistan, illness in it is very lack difficult of to detect and

because the it

awareness of

understanding disorder. individual illness, etiology,

symptomotology is from obvious mental

emotional when an

Hence

that and

suffers the

physical about of the the

family

should and

know

symptomotology

treatment

individuals problems.

Childhood given

problems in

are

not

considered and it

and is

importance

Pakistani

culture

believed that it can only coexist with an adult as he to has a the capacity who is to feel as and express contrary having no

child

viewed

innocent,

problems whatsoever. A Pakistani family seldom realizes that all of us are faced with different kinds of problems.

Providence does not differentiate between a child and an adult. It could theft be and a thunderstorm, fire. When an this

earthquake, situation labile,

robbery, occurs, a of

person

becomes

emotionally and These wounds

feelings

inadequacy, in some

insecurity

helplessness traumatic

persists cause

adulthood. psychological

events

that seldom heal. For a Clinical Psychologist, it is important to conduct this research in order to see the effect of the is process of birth to that can and

cause

trauma

that

vulnerable

anxiety

depression in adulthood. It is thus imperative in order to improve the mental health of the country to the by giving and full the and

qualified

assistance

mother

child

at the time of birth.

TRAUMA OF BIRTH:
Bhatia defines Birth trauma as: An attempt to

explain psychological disturbance that results from the trauma of being born.

Gale Encyclopedia of Psychology (2001) defines Birth Trauma as: first major event of severe

anxiety in the life of an individual (according to psychoanalytical concept). This feeling of anxiety and a state of discomfort is experienced at birth as the infant moves from of the the womb of gentle into a and new and

comfortable environment

environment outside that

comprises

harsh

unfamiliar stimuli that is very disturbing for the new born. According can also to be an to Gale Encyclopedia as: Any Birth trauma injury of

defined infant

physical

caused birth.

during

the

procedure

Rank

(1929)

defines

Birth

Trauma

as:

Birth

trauma creates a reservoir of anxiety, which is a disturbing suggested influence that because throughout event is so life. painful He for

the infant that this separation is the most feared and anxiety-provoking and the life experience. of the Personality is then

development

infant

seen as recurring attempts to obtain the security that was experienced that from from while in is the womb. He also with with of

reiterated separation separation effortless

anxiety the the

correlated specifically is the

mother, which The

womb,

source feels

gratification.

infant

very

secure and at peace inside the womb of his mother for nine months that is gestational period and

therefore painful and

when

separation

takes

place Thus

it

is

traumatized

feeling.

this

event

results in birth anxiety in adulthood that is very distressing development. birth anxiety and He in effects 1923 the to in personality investigate adult life

started

and

its

consequences

and culture. Rank, (1929) and Greenacre, (1945) elaborated the theory and found the importance of the theory of Birth Trauma. Freud, (1926) says that mental life begins at birth. The act of birth is the first experience of anxiety.

According to neo-psychoanalysts mental life begins after birth. Birth is the first danger experienced by the child therefore it provides the model for all later anxieties. Freud also mentioned that birth is a physiological shock for to the infant. that The he event needs is so astonishing time to

the

infant

sufficient

recover from this episode. Rank (1924) correlated the trauma of birth to anxiety. studied emphasis Hence by on the theory of Birth Trauma Rank was laid

various

psychologists. phase of

Pre-Oedipal

development

(birth to age 3). Oedipal phase is when the child develops sexual the is interest parent of the by in the parents sex. The of

particularly Oedipal innate within

opposite the

phase

determined drives and

strength by

biological the family

partly the

dynamics

environment,

attention,

guilt

and

anxiety by

resulting

from

it

are the

normally same sex and this

resolved parent in

identification of extra to by

within familial

favor

interest achieve as a a

activities. resolution conflict

Failure is seen psych

successfully psychoanalyst and as

nuclear decisive

in

neuroses

influence in adult sexuality.

Focus is on mother-

child relationship. Emphasis is on separation and individuation Oedipal result and its This birth is felt inevitable painful anxiety in prewould

period. in

separation

anxiety. during natal

Intrauterine and some minds prenatal lasting of the

consciousness events,

which and

leaves traces

behind in the

experiences neonate.

Rank,(1929), Ribble, from the (1944)

Freud, of the

(1936), psychic fetal

Sadger, trauma

(1941);

speak of

resulting with the

rupture

relations

mother. This causes the state of anxiety that can have a lasting effect on the pattern of an

individuals personality. Breuer and Freud, (1893) postulated that

hysterical states were the result of unmentalized traumatic and unbearable ideas that were primarily unacceptable sexual wishes leading back to actual experiences of childhood sexual abuse. It was

Freud who gradually replaced the theory of trauma with his new reality concept and of the unconscious universality fantasy, of the

psychic

Oedipal

conflict.

Influence within

of the

trauma

on

symtomotology

remained

psychoanalytic

theory even later. In another study Piontelli, (1987) studied

the possibility that mental life, ego functioning, and awareness on for exist in the fetus and of of it has its

effects Sample

the

mental

functioning consisted via

the twins

baby. and

observation fetuses

individual

monthly,

ultra

sound,

beginning in the fourth month of pregnancy. Follow up was done She on also two years weekly that early infant marks in

observation. of the

mentioned and in

individual womb and

temperament continued It was

behavior the same by

began

direction her that a

during very

infancy. sensual the

also

noted

fetus

who

continually the

licked

and cord,

stroked

placenta

and

umbilical

licked and stroked everything in sight during her first 2 years of postnatal life. there is a link between an She stated that mental

individuals

functioning and prenatal experience.

Another

study

was

done

on

year

old

psychotic child. This child had stopped moving in the womb at 5 months and was born with umbilical cord that was doubled tightly round her neck. This child was hospitalized in her first month of life. Due to this she underwent painful medical

procedures. Her actions reflected an autistic play

10

and

the

memories

of

her

past

entangled

life

that

was inside the womb. This was evident as she wore a huge, heavy, double knotted chain around her

neck and refused to part with it. The participant also constantly pressed an object horizontally across

her naval. She was also seen playing with a cord and curtain, wrapping herself like mummy. This

indicated her parting herself out from the rest of the world. Her actions also showed that she was

recreating her past life that was inside the womb. After this observation it is clear that adults who have undergone in trauma earlier may remember the his

process

their

unconscious

effecting

personality. Despert and that Pratt the (1946), Anderson that (1948), is Ruja an (1948)

(1954)

say

there is

evidence of the of a

newborn the

infant change or that that

capable occurs is in

understanding pattern of

his any

life

he

capable to have

experiencing

emotions

developed

lasting influence on his personality. Kaplan reconstruction et of al (1994) Oedipal suggests and that

post-Oedipal important. The

experience and psychic reality is

personality is divided into impulses, emotions and will. The childs As impulses impulses are seek immediate for

gratification. instance

mastered

in toilet training, the child begins the

11

process of will development. If it is carried too far, pathological traits such as stubbornness,

disobedience and inhibitions may develop. Bernstein & Blacher (1967), Anna Freud (1969), Rubinfine (1981), Fajardo (1987) and Arlow (1991)

did a research on infants. It was assumed by them that a neonates by a early vague phase and of life state is of

characterized mind. Discrete

amorphous though

experiences

even

traumatic

in nature could not be stored and retained as such by the infant. Phyllis experimental neurobiology that early (1941) stated child studies in

psychology, and

psychiatry, suggests and so

psychoanalytic system does

infant exist

memory

psychoanalytic and the

analyzing is

these

infantile There

events is a

experiences

possible.

possibility that events from the beginning of life can be reconstructed. talk about It was own reported birth the that

patients their

their

injuries, of

early

illness,

accidents,

attitude

their mother toward and during pregnancy, possible effects of reconstruction of their experiences is visible as a young child. Kris (1956) suggested that reconstruction of

childhood experiences and patterns are colored and modified by the present and the traumatic events

are infused with fantasy and consequents defenses

12

Bail communication. psychoanalytic

(1991) He

speaks says that

of

personal to is

according infant trauma

interpretation,

related to unconscious. He also talks about birth and infant experiences are stored saying in the that emotional that

experiences

unconscious

starts from the beginning of life till death. Blum (1976) states that sleep and dreams

symbolize the return to the womb. The dreams make it easy for the recovery of repressed childhood memories and

provide access to early infantile experiences. Therefore the birth memories are very important for assessing the impact of birth trauma on the personality of an adult. Evidences that a neonate in is our previous aware literature of what prove is

fully

ever

happening around him, inside and outside the womb. In a paper written by Winnicott (1949), it was proposed theory that that some the doctors do not believe in the are the

experiences seldom give

during

birth to

important.

They

importance

babys traumatic experience during birth and their relation not to emotional that development. experiences They can also lead did to

believe

these

anxiety in his adulthood. A study was conducted by Winnicott (1949) to see the variation amongst new born babies. It was also seen that prolonged labor could be traumatic that the to the fetus. was that in It some a was so

distressful were born

result that

babies of

paranoid

means

state

13

expecting that being at

persecution. there

It is

was

later a

concluded full human of

full-term, the

already human is

in

womb.

This

capable

experiencing and is able to grasp memories and is also with able any to organize defensive measures to deal shows

trauma

provoking

situation.

This

that a child is fully aware of whatever event is taking place because he has already developed his sense study, with organs he by the his time of delivery. In his deal used

made

child The

patients procedure

directly that was

birth

anxiety.

was he him to

made the child get down inside to was the his

sit

on his lap, and asked and would his turn legs. again. him This The

coat

upside

ground

between again

procedure

repeated

and

results of the study showed that memory traces of birth procedure do persist. He also mentioned that the client would relive the feeling of breathing on the

changes, head during from and

convulsive the fear

movements, of

pressure

annihilation to him the one can

experience also who see were

birth.

According of

the

experiences

patients

placed in this situation as of being born. In the light of the above studies it is obvious that

feelings and experiences during birth have a great influence on the development of the personality of an individual. In another study Winnicott (1949) states that traumatized infants were studied to see their

14

verbal

and

behavioral

memory.

20

children

were

studied under the age of 5 years. Main aim was to compare the memories with documentation of the

same event. The results showed that at the age of two and a half to three years, most children are able to retain and later able to retrieve verbal

material of memory of trauma. It was found that by this age, to children them can say in words The what had also

happened

significantly.

results

showed that birth trauma does have an impact from birth where till no of of the age of 2 years. This is the time

verbal this

memory group This

exists. more

Traumatized behavioral when they

children memories

showed was

traumas.

visible

reenacted in play or in other behaviours at least a part of their traumatic experiences. It was

shown that from birth out

a child who had been sexually abused to the 6 months in a of day her care setting (that were was

played was

exact in

details

abuse that she 11

verified

those the

photographs police) of 2 when years

confiscated interviewed

by at

the

age

months.

According to the researcher it is important to see that early how it literal comes their behavioral memory is, how the

into

operation,

how

accurate

details are and how long it continues. Engle, Reichsman, Harway and Wilson, (1985)

conducted a longitudinal study of a woman who was born with congenital artesian of the esophagus

(food line). Whenever she was fed, she used to lie

15

down flat on her back with a feeding tube called Fistula that was inserted to her stomach. She was never held physically or made contact with during her the feeding same time. Similarly making ever. them Even she lye after fed her dolls having years, in no she

manner, what so

flat, 30

contact

started to feed her girl infants in the identical manner and had no other method of doing it. If she held aches not a her or infants, the she complained heavy. for of having this found in arm was it

babies

were but

Though she

normal She

position only

her

natural. position.

felt else

comfortable seemed

this

Nothing

comfortable.

Although she had seen her other siblings being fed in an arms it folded was to position. seen feed that As the in research subjects the same

progressed, children

started

their

dolls

way as they were fed. the trauma had

It was then concluded that and unconsciously

somatically

passed through the next generation. Perris, study in Myers and Clifton It (1990) was conducted from verbal present. and a

Massachusetts. that that memories are

seen

the or An at

findings, behavioral early least

whether are

articulated is of active age, in

memory by 6

system months

infancy

mediate

long

term

memory. A study was conducted in the University of Massachusetts on 24 infants of six and a half

months old. These infants were put in a laboratory setting sounding them: where their Two task was to were reach for a to

rattle.

conditions

provided

16

1. Lighted

room:

When

the

room

was

lighted

the

infants were to reach for the rattle. 2. Darkened room: suddenly Once again when the room was This experiment was

darkened.

presented to the infants only once. After two and a half to years, the same It same infants along that were with the

reintroduced the control

setting was seen

group.

experienced infants were four times better to withstand being the slightly from the scary light experience into the of dark

plunged

than the According

children of the controlled group. to Lagercrantz & Slotkin (1986)

birth procedure produces stress on babies as well as mothers. the The baby, powerful usually muscles head of the uterus the

squeeze

first

through

birth canal. The infant also passes from its dark secure bright environment lights, say into the outside world and with

cool that

temperatures stress and nor

noises. large in the to and a

Researchers quantity babys flee of

produces adrenaline an

adrenaline These in

blood. or

hormones

prepare of

adult

fight The

situations in an

danger have

emergency.

hormones

infant

stimulating effect on breathing, heart action and all organs and cells of the body. Comparatively,

in cesarean section before labor begins there is a lack in these hormones and this is one reason why babies have problems breathing right after.

17

Menzies (1946) and Spitz (1949) say that there is a possibility that the mothers emotional

reactions would influence the infant, even though he does not comprehend their meanings. Infants who are separated from their mothers do not make good adjustments to their postnatal environments as

those who are with their mothers. Sontag suggest before (1941), Dunbar (1944), of Fries the (1944) mother over to the some his

that birth

emotional which has

tension

frequently been found

carries to and

postnatal infants extent, mother .

period

influence , to with

postnatal affect his

adjustments early

relationship

According to Wallin and Riley (1950), Levy and Hess baby this (1952) or is if if the the mother is is not of happy having a

baby

not

the

desired and

sex, will

bound

to

influence

her

behavior

be sensed, if not understood, by the infant. Carithers mothers confused shift (1951) says that the initially, baby is the often

attitude and

towards Her

unstable. day to

emotional even hour is

reactions to hour,

from

day, suspects

especially wrong with

if

she

there

something as the

the the

infant. mothers

Maternal

attitude with

reflected

in

relationship

infant is more important factor in the personality development of the infant than the psychic trauma

18

that the infant is supposed to experience when his life as a parasite ends and he must adjust to an independent life. Chamberlain et al: (1992) suggest that infancy is not a stress-free stage of life. A major source of stress and trauma during birth and infancy is

caused by (a) prenatal events and (b) during birth process. It is seen that and babies are sensitive, vulnerable

intelligent, before birth. Some itself

receptive

extremely

experts be

propose

the

idea

that

birth and

can

extremely

painful,

confusing

frightening experience for the infants. The major kinds being of birth trauma (b) can be resulted by from (a) (c)

drugged,

removed (d)

forceps,

cesarean

delivery,

experiencing

prolonged

labor and (e) oxygen deprivation. Once the baby is born, new it can be confusing he and terrifying sudden sounds for the

born

because rough

experiences harsh

coldness, or most These

brightness, importantly

handling, from

separation

the

mother.

feelings occur because the neonate is not prepared for all this shock. Medical interventions such as fetal monitoring, heel sticks, eye drops and

circumcisions can be distressing for the infant. According to a study conducted by Emerson

(2001), it was seen that fifty percent of a sample of two-hundred children showed signs of moderate

19

to severe birth trauma. Unfortunately birth trauma appears to be very common. Batchelor Roedding (1991) et say al., that (1991), Mednick births (1971), have a

traumatic

potential for causing lifelong problems. There is now seen a correlation and later between peri-natal to

complications emotional This also and

susceptibility in

behavioral

problems

adulthood. crime

includes

schizophrenia,

violent

and suicidal behavior. A survey was conducted by It was observed that babies Kitzinger in 1989. whose mothers have

experienced a difficult delivery tend to cry more than babies A whose survey whose mothers was have had it pleasant was seen were

delivery. that

conducted cried

and the

mothers

babies

most

significantly more likely to have had obstetrical interventions during birth. Bernal (1973) did another study related to babies. It was observed that babies who had problems at birth were more likely to wake up crying frequently at night during the first fourteen months. She further elaborated that if one sees the physiological correlation of pre-natal and peri-natal trauma, these children are in a state of or been made to feel powerless

tension that is a result of an overactive sympathetic nervous system and excess or of stress response hormones. may have This been

biological

fight

flight

adaptive in helping the infants survive the birth trauma

20

but

may

last

longer

than

needed,

thus

resulting

in

physiological problems. This increased sympathetic effect might be responsible for the sleep disorders that are commonly observed in birth-traumatized infants. In babies after result a traumatic of a birth, excessive crying could be a

biological

stress-release

mechanism

that

permits excess chemicals to excrete from the body either through sweat and eventually tears. This also provides a release of energy, thus completing the physiological

stress-relaxing cycle. It is imperative to know that if the birth trauma is severe then the infant may have long crying spells everyday for several months before trauma is completely resolved and homeostasis is attained.

Psychologically, the neonate suffers following symptoms as a result of traumatic Developmental birth: Unfilled needs, Over pain,

stimulation,

frustrations,

Physical

Frightening experiences (that occur during the weeks and months after birth). Due to the traumatic birth and a painful episode, babies are extremely vulnerable because of the lack of information and skills and their total dependence on others to meet their needs. It is important to fulfill all the needs and prevent stress in babys lives. This cannot be guaranteed that no matter how loving parents are, some stress is inevitable and the baby would cry even if there is no prenatal or birth trauma. Watson (1925) say that at birth or shortly afterward, only three distinct emotional reactions occur and these may

be aroused by only a very few specific stimuli. It is

21

difficult to determine if an infant is capable of any emotional behavior that is fear, rage and love.

Bakwin (1947), says that an infants response to any disagreeable stimuli is expressed by crying and the newborn is ready with a well-developed set of emotional is responses. present in in Not infants only born emotional after full to

reactivity term but

also

premature

infants.

According

him these emotional responses are divided into two groups. The pleasant the or the positive or the responses. negative

Secondly, responses.

unpleasant

1. Pleasant responses were patting, rocking, warmth, snug, holding and allowing the infant to suck.

2. Unpleasant Responses were changing infants position abruptly, changing by loud noises, hampering the infants movements, applying cold object to the babys skin and using a wet diaper. Sherman and Sherman (1929), Irwin (1930), Pratt et al., (1930), Pratt (1932), Taylor (1934), Hunt et al., (1936), Hunt and Clarke (1937), Dennis (1940a) suggest that an infants behavior is characterized by generalized

activity, having no definite emotional pattern and lacking the stirred up state of the organism which is

characteristics of emotions. Spitz (1949) opposes the theory of pleasurable and unpleasuraeble responses. According to him there is no pleasurable emotion present, but there is only a state of calmness and serenity. Differences in personality like

22

differences in appearance are evident during the first few days of life. Some infants are good as gold, while

others are fussy and troublesome. These differences could be due to age (premature as compared to full term

infants), circumstances of delivery, or health conditions. Shirley babies from (1933) the studied the in personalities connection of

data

obtained

with

periodic tests. Personality tests found that over a period of time there was an assumption that a

nucleus of personality exists at birth and that a nucleus certain various persists degree traits. and the Some grows and determines of by to a

relative change

importance is produced

the the

environmental factors, but this change is limited in the original personality nucleus. Irritability was found to be greater during the first fourteen days of life than it was, as the baby grew older. This trait, according to Shirley is recognized

from birth on. According to Share (1994), a new born baby is not like Tabula Rasa but he does have the

capacity to understand emotional experience. There is a possibility in dream of that thought their and symbolic impact start

representation on the

their may

structuring

the

personality,

in utero. According to Meltzer (1988) there is an impact of interferences such as prematurity, of incubation,

early

separation,

failures

breastfeeding,

23

physical

illness

in

mother

or

baby

in

the

development of character and may have an effect on the early phases of development. From all the findings and studies above mentioned it can be seen that a newborn is conscious about his

environment. An infant is alert and knows what ever is going on within his surroundings. Infants behavior taking

indicates that he is stimulated by activities

place around him, he knows what is going on in his mind and what he perceives during the first days after birth. James According (1890) to him, describes baby is infant consciousness. by eyes,

overwhelmed

ears, nose, skin, and entrails all at once, feels it all at one great, blooming, buzzing confusion. In addition, in his analysis of sensations, he

says that organs, the

prior to all impressions of the sense brain is plunged in deep sleep and

consciousness is practically nonexistent. Even the first few weeks sleep from after by the birth are passed It to in almost a long this

unbroken message

human sense

infants. organs

takes

break

slumber. Birth experience is so traumatic that it leaves the child in a state of shock. The child

experiences the world as a big booming, confusing buzzing place. According to Stern (1930), the newborn infant is a creature of reflexes, and the first traces of consciousness states, all are that present are at birth. He also in

possibly

justified

24

assuming

is

the of

presence

of

dull in

undefined which are may states the so be or of

foreshadowing sensorial inextricably designated and

consciousness emotional

elements that they

intermingled as

either

sense-emotional states. or The comfort

emotional-perceptive the feelings of

presence is

discomfort

evident

from the very first day by the bodily habit , by the expression of the face, and by the active

expression of the screaming. Koffka experiences just as the (1925) the says that the newborn from a infant adults, symphony

world

differently person

unmusical

hears

differently from one who is musical. Some experts suggest that a traumatic delivery or birth occurs and age also It when the the mother has be small pelvic for

measurements gestational There could

infant with breach said

may

larger

(often be is

diabetic or that other

mothers). abnormal fetal

presentation.

after

monitoring, if fetal distress is seen an immediate cesarean section should be performed. Federal (formulated reports that Security in the Agency United is an Report of (1950), America) the human

States ordeal

birth

for

infant as well as for the mother. Not all new born infants are unable to make adjustment in the

postnatal environment, there fore not all new born survive in a healthy manner.

25

It is seen that the percentages of still born infants and the deaths after birth and during the adjustment period This is because field in in the U.S have been declining. techniques prenatal have improved in and

medical

care,

childbirth

postnatal care. Benda (1943), Usdin and Weil (1952) say that different on the types of births Whether none have it are different is a effects or

neonate.

natural

instrumental

birth,

without

problems.

Difficulties may start even before the birth takes place. used as Difficult an to than may aid births, to where the instruments baby, and have are been

deliver more

reported damage damage

produce

damage

more

severe The even

natural, be

spontaneous until

births. or

not

apparent

months

years after the birth and it may be temporary or permanent. Pratt, K. et al: (1954), palsy state and that low motor grade

difficulties,

cerebral

intelligence are frequently reported as aftermaths of difficult births. Boland et al: children. with aid It of was (1951) studied adolescents and seen that those who were born

instruments characteristics

revealed than

unfavorable those born were

personality

spontaneously(natural). apparent: speech hyperactivity,

Following

symptoms

restlessness, poor

anxiety,

problems,

stuttering,

concentration

26

etc.

These

symptoms

are

very

common

in

those

individuals born with the aid of the instrument. Fries cesarean babies (1941) born and Ruja They they (1948) report cry have that but studied these make

babies. quiet,

are

very

less

better adjustments to their post natal environment compared to natural delivered visible or spontaneous born baby or

instrumentseem to be

babies. in a

Following cesarean

symptoms baby: a)

Difficult After important born. The

respiration, b) Affects in the brain. reviewing to know as the to literature when thing the is it is not is the

individual the way

important

individual is born whether he had a natural birth or instrumental or a C-Section. How the baby

emerges into this world has a great impact on him physically as well as emotionally. The attitude in the and surrounding postnatal varies too. Prenatal, a very perinatal important

environment

play

role in the lives of an individual. For the purpose defined a of this study, as the author

operationally born through

birth

trauma Section

individuals and Forceps

Cesarean

delivery.

CESAREAN BIRTH PROCEDURE: History of Cesarean Birth:

There is a saying according to Cohen and Estner

(1983), Legend has it that Julius Caesar was born by

27

cesarean section and that the procedure was named after him. Surgical delivery has been a practice for many years in fact centuries. Originally this procedure was adopted to separate the infant from its dead mother so that a separate burial could take place. Later, this procedure was used to save the infant when its mother had passed away. Eventually in the 16
th

century,

the

cesarean

was

performed to save both the life of the mother and the child. Technically advanced mothers began to have their

babies in the hospital instead of homes where initially birthing took place. Like this cesarean became very

popular because women believed that they should be free from the pains of labor and childbirth. Margot and Waldorf (1984) inform that in the thirties and forties, women who knew about the controversy between natural childbirth and drugged childbirth, preferred

having drugged childbirth. Seeing these women, they did not want to suffer the way their grandmothers did. They thought that not having drugs and having a bay was crude and unscientific. Today the trend in Pakistani society is changing. In some sects of the population, where the expectant mother is a professional lady, they prefer to have the baby at a selected date and time. This normally ends up in a

cesarean delivery.

28

Jukelevies (2001) suggests that the way childbirth is conducted Evidences cesarean has tell follow long us a lasting that lot effects in his adulthood. elective by a

instrumental of

delivery,

complications.

Birth

cesarean can have a powerful psychological effects on the neonate problems. and the mother. They also have adjustment

Effects of Cesarean Birth on the Newborn:

Cohen and Estner (1983) suggest that following are the manifestations of an infant who is born through a surgical procedure: 1. Jaundice 2. Respiratory problems 3. Neonatal acidosis due to maternal hypo tension 4. Inadvertent infant-to-placenta transfusion 5. Neonatal death 6. Psychological distress

Physiological factors to the mother:

Pain, Depression, Gas, Blood transfusion Infection, Hemorrhage, Adhesions, Pneumonia, Anesthetic

complications,

accidents, Cardiac arrest and woman may feel a) lost

Death.

Psychologically the over her childbirth

control

experience, b) she may feel cheated, c) frustrated , e) helpless etc.

disappointed, d)

According to Cummings, (1988); Cranley, (1983); Marut and Mercer, (1979); Sheppard-McLain (1985) there are

various

factors associated with a mothers experience of

cesarean section.

29

Why

the

cesarean

was

performed?

Cultural

values,

beliefs social support and sense of control. Many cultures differ amongst their value system. In eastern cultures, more conventional mode of childbirth is accepted. Mutryn (1993) conducted a research and it was seen that negative psychological effects of cesareans can be

significant. Emerson. W. (2001) suggests after a

longitudinal study that that cesarean births cause considerable physical occur psyche: at and the trauma to babies. Following are the that

psychological unconscious crying,

effects level Feeding

observed of the

infant

Excessive

difficulties,

Sleep problems, Colic, Tactile defensiveness.

Long Term Psychological Effects:

Include: Inferiority complexes, Poor self-

esteem, Dysfunctional feelings and behaviors.

Factors For High Cesarean Birth Rate in the United States:

Cohen and Estner (1983) suggest that if an infant stubbornly refuses to budge from a transverse

presentation (it) must be delivered by cesarean. 1. It is seen that even though a vaginal delivery when possible, a C-sec is performed. 2. Doctors perfect are baby concerned or else about they delivering be a

would

charged

with a law suit. Therefore in order to avoid

30

any

mishaps,

C-section

is

performed

immediately. 3. Once a Cesarean, a norm always a a Cesarean. by This has

become

and

policy

obstetrical

practice. 4. Lack of proper training makes it difficult for the physicians to handle labor. According to

many physicians, they are not trained in labor practice, but in high technical equipments. 5. According deliveries seen that to lead there some to is physicians, outcome. cesarean It is in

superior no

significant

change

fetal mortality rate even after the advent of cesarean section. 6. Economic incentives are involved. There is

less time involved and more money seen. During cesarean delivery, physicians give in more

time, the mother has to stay in the hospital longer, as compared to normal birth. A longitudinal study conducted by (1985) feelings feelings, related had of to 3 main objectives: to Khamsi et al: elicit of the birth to the

the

subjects the

descriptions

relate

subjects

feelings to

psychological

literature,

generate

hypothesis for the investigations. subjects men). participated 27-55 in the study

A total of 13 (8 women, 5

Age:

years.

(these

subjects

were

referred by their primal therapist and the author of this report). Criteria for selecting these

31

subjects:

Two

conditions

were

put

forward

by

the

author to select the subjects for the study: 1. Those who had experienced birth feelings

during the coarse of primal therapy. 2. If they were able to articulate their

experiences. An intensive, semi-structured diagonal interviews

individually. Interviews were open-ended lasting from 1-2 hours. These interviews were audio-recorded for later

verbatim transcription. Two-interviewers were used. One male and the other female. These interviewers had

experienced primal therapy and were informed about the birth psychology literature and about qualitative interviewing. A long list of statements were asked to the

subjects comprising of specific data base, question like what is the quality of experience of birth feelings? Results were based on the central themes, the answers were categorized, content analyses was done. It was concluded that some subjects could not verbalize their feelings of birth. Some of them found it extremely difficult to state their thoughts about birth feelings. Breathing played a pivotal role in this experience. According to the

subjects, when breathing was easy, they felt ecstatic, they felt that the world was a safe, nurturing place. If breathing became problematic, they sensed danger, and

believed in struggling for life without help. One subject who was a twin, reported that birth feelings in this

situation was like having no space that was similar to having space in the womb that was limited and scarce. This feeling was, as if being pushed around and crowed a lot

32

as if her twin sister was pushing her around. Physical feelings that were reported by the subjects were: Feeling of being choked, of being crunched, crushed, or squished. Inability to stretch. Some experienced physical pain. Some reported reported a of sense of being bright in darkness. Some Two did subjects not get

extremely

light.

enough air to breath, for some breathing was painful. Emotional feelings that were reported by the subjects

were: Fear of death, Lack of control, Sense of danger, Anger , Frustration , irritability , Anxiety ,

Depression/Desperation, Discomfort, Helplessness, Sadness, Vulnerability, Unwanted and Unloved. The subject during the investigation reported all these emotional and

physical feelings. In the light of above investigation, it is apparent that these feelings are similar to what an infant goes through during birth process. Feelings of

anxiety, frustration and sadness give rise to birth trauma and personality development. It was summarized that birth feelings characterizes by the subjects as ineffable and all-encompassing experiences of birth and before birth. Common feelings like difficulty in breathing, pushing, and sense of struggling to get out or to get somewhere were common. It is important to note that one of the subjects was a cesarean born. It was reported that she had felt no pain during birth experience. Thus it can be proved that caesarean born children do not go through the same

experience as normal born child. According to Nandor Fodor et al (1949) patients tend to relive trauma in therapy situations. This helps to remove major emotional blocks in their lives. Calvin (1967) reports that feelings of being

33

trapped, of being crushed, pressure on head and cardiac distress, of being sucked into the whirlpool or being swallowed by terrible monsters, death-rebirth struggles appear in 60 percent of the dreams. These dreams are said to have pre-and peri-natal images.

FORCEPS BIRTH:
This procedure takes place when the fetus is too large and the head When of the baby birth does not come out

spontaneously.

normal

procedure

becomes

impossible, then a vacuum extractor called Silastic that is a plastic suction cup is used over the babys head. The baby is pulled or sucked out through the birth canal with the use of Forceps. Forceps is a metal device and is placed around the infants head. A vacuum extractor can also be used which is a plastic suction cup called Silastic. This fits over the top of the babys head. In this method of delivery there is a danger to the baby. Either there could be a rupturing of blood vessels or may even cause brain damage. Forceps are not used unless the cervix is completely dilated and the head is 2 inches away from the vagina. In Medical Search Engine, delivery by forceps applied to the fetal head when it has reached the perineal floor and is visible between contractions.

History of Forceps Delivery:

Forceps birth was earliest mentioned in Vedic era, called Ankush, Panda, S.N (2002). According to the researcher, Albucasis described forceps with teeth on the inner surface for dead fetus.

34

According

to

William

Chamberlain,

as

researcher

reports, he fled from France in 1569 and practiced forceps delivery as a family secret in Southampton. This was kept a secret in the family for over 100 years and 4

generations.

Classification of Forceps Application:

Panda, (2002) gave the following classification of forceps delivery:

1. Low Outlet Forceps:

In this forceps is applied when fetal head has reached the pelvic floor.

2. Mid Forceps:
Forceps is applied when head is engaged but criteria for low forceps not reached.

3. High Forceps:
Forceps is applied when head is not engaged.

Types of Forceps according to Panda, (2002): Panda(2002) says that : Classical Instrument:
Originally designed by

James Young Simpson, Wrigley and George L. Elliot Jr. in mid 19th century. It was commonly used for outlet and low pelvic rotational delivery.

Modified

Classical

Instrument:

It

is

an

overlapping solid blades with extended shanks like Tucker-Melane Forceps. Elliot type are commonly used as mid pelvic rotators or outlet blades.

35

Specialized Instruments: Designed for specific

indications.

Dangers of Forceps Delivery:

1. Maternal Injury (vaginal and cervical tear). 2. Postpartum hemorrhage (due to trauma or anesthesia). 3. Shock (due to blood loss, dehydration, prolonged

labor). Some experts can suggest cause that forces of labor to and the

delivery

physical

injuries

infant. This is visible from the head molding that follows vertex deliveries. It is said that severe molding can also cause problems and may need to be treated. difficult Incidence or of neonatal deliveries injury is from

traumatic

decreasing.

This is because of the improved prenatal diagnosis and monitoring during labor that has helped

prevent neurological and other injuries.

NATURAL BIRTH:
Birth has been described as the most

significant event in a womans life. The nature of womans labor and birth can affect her profoundly. No two human beings have experienced same kind of prenatal varies environment. from one The experience to an of birth It on is the

also

infant have of

another. affect

expected postnatal

that

birth

will

development than it would

one the

individual postnatal

differently

affect

development of another individual.

36

Psychological out are of this

and

medical

studies to

have them

borne there for

phenomenon. conditions

According that are

certain

responsible

the effects of birth on postnatal development. The first condition associated with the birth that has an affect on postnatal development is the type of birth. It is said that infants born spontaneously

usually adjust to their new

more quickly and more successfully environment long and than those who have where

experienced

difficult

labor

instruments or surgical delivery have to be used. Not all mothers give birth in hospitals and

not all births follow the major

a traditional course. Among to traditional birthing

alternatives

practices are following :

LAMAZE BIRTHING TECHNIQUE:

Lamaze (1970) says that natural birth is also called spontaneous birth because it occurs without outside or external aid. It is that type of birth where minimum or no medication is given to the

mother. In this type of birth the position of the

fetus in the mothers uterus and the size of the fetus make it possible the for the one fetus shoulder to emerge then

headfirst.

After

head,

and

the other appear as the fetal body rotates slowly in the birth canal. Next the arm emerges, one at a time and then finally the legs.

37

THE LABOYER METHOD:

Laboyer transition (1975) faced by a considered neonate. the abrupt to

Accustomed

floating in a pool of warm water (amniotic fluid) for nine months, hearing only muffled sounds and

seeing light only dimly, the new born is violently thrusted into a variety of different world outside the mother. to This French transition Physician approach be facilitated Leboyer. the

according The

Frederick to

optimal

maintain

environment of the womb as long as possible after birth. softly Under his method a delivery rooms are kept

lighted

and

hushed

atmosphere

prevails.

As soon as the baby is born, it is placed on the mothers warm stomach The and then floated cord in is a pool not of cut

water.

umbilical

immediately after birth, as is traditionally done to compel the baby to breathe on its own. Instead, the cord is left intact, allowing the neonate to

acclimate gradually to an air- breathing world. Maternal satisfaction with the experience of

childbirth was investigated in 1000 women having a vaginal delivery. It was seen that when pain

relief was administered to these women, it did not ensure block a satisfactory more birth experience. analgesia Epidural but more

produced

effective

women showed dissatisfaction among those who took epidural than among those who did not (p less than

38

0.05). Bad experienced scores were evaluated after one year and were clearly related to forceps

delivery, long labor, both of which were common in the epidural group, (Morgan; Bulpitt; Clifton;

Lewis).

BENEFITS OF NORMAL BIRTH ON: A) RECOVERY:

BirthChoiceUK.com reports that: Women who have normal birth are less likely to suffer post-natal pain and recovery. They recover more quickly than those who have had interventions such as: Forceps delivery Episiotomies feel bruised after normal birth and If

POST-NATAL

PAIN

AND

PHYSICAL

Women

could be due to stretching up of birth canal. perineal tear has been repaired, this

discomfort

no longer continues. On the contrary, after an episiotomy, perineal pain is felt for weeks after delivery. Apart from this, instrumental delivery also has a significant impact and causes trauma to the birth canal along with perineal pain. It can be concluded that recovery from Forceps delivery birth birth. and Cesarean takes Operation longer that time may than cause normal

injury,

much

39

The

length has

of

time

it

takes for

to

recover areas of

physically

implications

other

postnatal life.

B) SELF ESTEEM:
It is natural that when labor and birth are

positive experiences, a woman is likely to feel an overwhelming well being. This increase in self-esteem affects other sense of achievement and emotional

areas of post-natal life.

C) BONDING AND BREASTFEEDING:

The way a woman gives birth also affects the way she mothers. It effects her level of

confidence and ability as to how she takes care of her baby. A normal birth can boost self-esteem and give woman the confidence of her natural abilities. Having a successful normal birth helps motherchild bonding and increases the likely hood of

breastfeeding. Psychologically the mother establishes good

relationship with her infant.

FAMILY BIRTHING CENTERS:

According to Eakins (1986) the decision of

using birthing centers is becoming common. In the majority of cases permitting relaxed, In labor and to delivery occur the in are a

uneventful, relatively center

births

homelike the

setting of

birthing

provides.

event

complications,

40

equipment centers

is

at

hand. that

Supporters they can

of

birthing more a may

suggest less

provide

comfortable, hospital

stressful offering a

environment setting

than

room,

that

facilitate labor and delivery. DeClerq (1992) proposes that this philosophy also has implications In place who of a for the choice of care

provider. (a

traditional in

obstetrician delivering

physician

specializes

babies), some parents are turning to midwives ( a childbirth throughout nurses attendant labor and who stays with the mother

delivery). in

Midwives-often are which of used no

specializing for are

childbirth, in use

primarily

pregnancies expected. The

complications

midwives

are increasing in USA, they are employed only in a minority of births . Treffers et al (1990) suggests that in

contrast midwives help deliver some 80% of babies in other parts of the world. Moreover in countries at all levels of economic developments, many

births successfully take place at home. More than one third of all births in Netherlands occur at

home. Rusting(1990) does not make says a that in deal care and majority of cases it

great for

difference. be made

Naturally

arrangements and in

should back up

thoughtfully

advance

medical

care should be on call. If a birth is to occur in

41

traditional

hospitals,

such

hospital

should

be

no more than 5 or 10 minutes away. For pregnancies that stand a high risk of complications such as

those of women whose previous deliveries have been difficult, a hospital setting is preferable. In the United States of America, in the 19 t h

century, about 95% of the babies were born at home Gordon & Haire(1981). is Some well Some feel that hospital and see and

environment convenient. hospital

equipped, parents

clean still

expectant to be

practices

rigid,

impersonal,

expensive. They object to the separation of family members birth and want more Some control parents over seek the childs to

process.

midwives

perform home deliveries. A student of nurse midwifery practice, past

and present show delivery out comes as good as or better than those with physicians. Birth through

nurse midwives result in fewer forceps deliveries, cesarean low birth section, weight episiotomies, babies (Boston stillbirths Womens and

Health

Book Collective, 1984). Mehl paired & Peterson of (1981) conducted and a study of

samples

1,146

home

hospital

births

revealed no difference in infant mortality rates, but lower rates and diseases and birth injuries in home births. A research done by Jaffri, S (2001), concluded that womens health suffers due to Dayees or

42

midwives.

Approximately

40

Lac

children

are

born

per year. Out of these 40 lac, 80 percent are born at home without Children 60 any proper facility and medical is

aid.

born

through Due

midwives to it to of

approximately knowledge, that women every

percent. and

inadequate was 30 noted

education year die

training 25

approximately or are

thousand health

either

victims

major

complications. In mentioned Pakistan survey, 80 according to 85 to of the above

percent

localities

are without doctors. One births reason in for high success of rate is be of home a

United

States for must

America must 10

that,

prospective carefully. hospital

candidate The women

home live to go

screened from case the of

miles in

and

be

willing must birth

there

complications. learn to

She

be and

educated labor

about

birth,

identify

complications.

Moreover, agree to prepare her home for delivery. She must also locate a pediatrician who will see

the infant soon after birth. (National Association of Parents and Professionals for safe alternatives in Childbirth, NAPSAC). Unlike Pakistan where

there are no proper medical assistance and aid to provide to the expectant mother are at home. Here,

non-certified

midwives

who

called

Dayees

perform the duty. This leads to a lot of mishaps and accidents.

ANXIETY

43

Definition of Anxiety: Chaplan, J.P. Dictionary of Psychology defines anxiety future fear. as not It a feeling of apprehension specific fear cause is about for of the the mild

knowing is a

the

chronic

that

degree. Hurlock, mental Following state are E says that anxiety is an uneasy

concerning the

impending of

illness. anxiety:

manifestations

apprehension and uneasiness. According to Dr. Savitri Ramaiah reaction lived. Anxiety according to various researchers is an emotional attitude involving a feeling of to a stressful situation anxiety is a and is short

anticipated future danger accompanied by a somatic symptom of apprehension and tension. The form of

anticipated danger may be internal or external. Freud (1926) differentiates between two forms of anxiety:

Primary Anxiety:
It is more primitive and is related to traumatic experience possibly flooded by of to total disintegration thats leads being

annihilation,

consequently of

overwhelming

quantities

instinctual

tension.

Signal Anxiety:

44

It

is

not but a

directly signal

conflicted in the

instinctual ego of an

tension

occurring

anticipated instinctual tension. Laplanche anxiety as: The himself subjects in a reaction each time that he is finds each and Pontalis (1985) define automatic

traumatic

situation,

time he is confronted by an inflow of excitations, whether of external or internal origin, which he

is unable to master. Psychoanalytic really views If signal anxiety is something about to

overwhelming.

something

happen, something must be done quickly in order to survive mentally or physically. According experience function of is to Freud (1926) to this overwhelming The signally to

connected is

birth.

anxiety

biologically

adapted

warn an individual of some danger or a threat to its equilibrium. The anxiety according to Freud is felt as an increase bodily or mental tension and the signal

that the individual receives allows him to defend himself towards perceived danger. According to Rycroft (1968) it is defined as

an inwardly directed form of vigilance. Freud of (1926) that suggested is that and both these forms are

anxiety

signal

automatic,

derived from infants mental helplessness which is a counterpart of his biological helplessness.

45

Freuds fact of

notion that

of

anxiety

derives are

from

the

life

human

infants

helpless

creatures and utterly dependent for longer periods of time for survival function than is any to other species, this on

parenting,

reduce

inner

tension arising from hunger, thirst, danger, cold etc. This experience of helplessness is seen as

the prototype of any situation of trauma. Anxiety, which cannot It be dealt effectively the person is to said a to be of

traumatic.

reduces

state

infantile helplessness. Freud, ( 1936 ) says that Birth Trauma is also said to be the prototype of all later anxiety. The neonate for is bombarded he is not The his with stimuli from to a a the world he

which

prepared baby ego when

and

which

cannot

adopt. until the

needs has it had can

sheltered chance to

environment develop to

point

master

strong

stimulus from the environment. When the ego cannot cope fall with back anxiety upon by rational ones, methods these it has the to so-

realistic

are

called defense mechanisms of the ego. Anxiety is the theory most for important the More concept in of is

psychoanalytic personality

development over it

functioning.

centralized in Freuds theory of the neuroses and psychosis and the treatment of these pathological conditions.

46

Freud prototype defined

used of the

the

birth

experience of of

as

the He

experience as a state

anxiety.

anxiety

unpleasure

experience when the individual is confronted with the influx of new and painful stimuli. This is said to be similar to what happened

at birth when the fetus is suddenly thrushed into a new and strange environment. According to Freud being born is a painful experience, where there is suffocation that is unavoidable brings the infant into extreme danger and that is a prototype of all later attacks of fear. According experts it was to some experiments anxiety conducted tends to by

found

that

raise

in the first few days after childbirth. Many traumatic experiences in childhood,

though highly upsetting at that time are probably of less significance in their long-term

consequences. Some children are less vulnerable to others and show more negligence and recoverability from hurt that has occurred. A child who is exposed to traumatic experience is likely to show a In disruption addition, have of in even normal though

personality subsequent influence,

development. experiences the

may

corrective such early

detrimental

effects

traumas can never be completely eliminated. Lubin, Gardner & Roth (1975) tested 92 women

during each trimester of pregnancy. Pattern showed

47

that

anxiety

decreased

during

the

second

trimester and increased during the last trimester of pregnancy. Vogel & Vernberg (1933) identified the most

salient features of childrens responses following disasters. Specific fears were included in their

study that is fear of recurrence of the disaster, separation children, nightmares, images. difficulties, and especially for younger such as and more

post-traumatic and

symptoms

flashbacks concluded

intrusive

thoughts were

They

that

children

likely to show high levels of distress if, during the disaster, or had they has perceived bizarre strong scenes life of

threat

witnessed

destruction, had been seriously injured to where a family member had been injured or died, or if a

companion during the disaster had died. Vogel where levels data of and were Vernberg (1933) girls but also noted that higher further

available, than

reported made no

distress

boys

comments on this findings. Yule the role (1994) of stated as to that a be there risk more is conflict but in in to

gender seem

factor,

general

females

vulnerable

anxiety than males. Ahmad (1992) suggests that to develop a

healthy personality, the individual should be free from nature all of stresses and emotional problems. between The the

affectionate

relationship

48

parents the

and

children of

are

also

very If

important the

in

development

personality.

parents

love their children, the children tend to be more normal than the children of parents whose attitude is predominating, irritating with hostile and who and find who do the not they

children enjoy

burdensome or feel

being

them

tension

when

are around. It is also seen that if mothers are educated and interactive to of with their a infants, healthy found it helps the A

child study the

develop

into

personality. that the

Guatemalan of

women

longer will

schooling

the

mother,

the

more

she

talk with her toddler, and she will more likely to take a role of a teacher for her child. According environment and to some attention experts, or lack parental of it,

pervasively affects the personality of the growing child. He compared 1200 adolescents with 900

Italian orphan girls on ASQ that is Anxiety Scale Questionnaire. broken than family It are was much concluded more of that girls and from

insecure age who

anxious in a

their

companions

same

live

regular and orderly family nucleus. Ahmad, practices of the (1992) have an suggests influence and may that on the child mental in a rearing health of

individual

result

lack

adjustment or pathology.

49

Some

experts

also

state

that

the

first

reaction to physical punishment includes emotional shock symptoms such and as numbness and feelings of

vulnerability

helplessness.

Following

somatic

symptoms were also identified as Tightness in the throat, Choking, Shortness of breath, Feelings in the abdomen, Lack of muscle power, Sleep

disturbance and Loss of appetite. According psychoneurosis achievement. suffer but or to psychoanalytic neurosis also is have a the theory,

developmental capacity to

Infants are not

sufficiently

sophisticated

psychologically to have a classical neurosis until middle adulthood. According neurosis infantile to Freud mainly and (1929) the concept of

concerns sexuality

unconscious the

motivation, between

relationship

adult psychopathology and childhood trauma. According neurosis, to the psychoanalytic in the theory of of the

conflict

lies

heart

psychoanalytic theory of neurosis-conflict between what infants, toddlers, and preschoolers want to

do and what socializing adults require them to do. According to Freud another component of the

theory of neurosis is anxiety. It is the threat of parental love that to punishment provides lead and withdrawal charges of parental

affective to

sufficiently of socially

strong

inhibition

unacceptable behavior.

50

Anxiety sufficiently

is

not ,

a it

deterrent is

but

only

strong

exceedingly

painful

and can set into motion a whole array of maneuvers (defense and mechanisms) are repression, that are projection to

reaction the

formation from

designed the

protect

child

experiencing

distress

extreme anxiety produces. Neurosis also has symbolic meaning that

differs from manifest content of the behavior. Why does normal behavior become deviant:

according to psychoanalytic theory there might be two too reasons: much or classical too psychoanalysis libidinal states that

little

gratification

tends to fixate a child at a particular stage and makes him or her vulnerable to regression. Along with this theory Freud, (1965) added the concept progress similar of or to the balance of The forces concept one making itself that for is a

regression. the

now-familiar is the

stating of the

developmental

path

result

balance

between vulnerabilities and protective factors. It is said ional that in some vulnerability infants and rage by are have than their

constituent more intense and

that of

certain anxiety

reactions are

others

persistently

disrupted are

effects.

Other

vulnerabilities

experiential

with failure to receive sensitive care in infancy being particular important.

51

Certain resilient,

infants either

are

innately less

rugged anxiety

and or

experiencing

readily taking it in stride. Growthsensitive promoting in experiences infancy; in are legion: of

mothering

development

friendships; relations models. Freud can itself with

achievement teachers,

school; and

positive adult

coaches

other

(1965) become

that a

even

neurotic force

conflict in the

constructive

childs developing personality: a boy who handles his hostility toward a younger sibling by reaction formation of being especially concerned with the

plight of relatively weak and helpless youngsters can eventually have a successful vocation in one

of the helping professions. Nagera (1996) and Shapiro (1973) conducted a

presentation where it was stated that the specific content of the conflict is determined by the

psychosexual stages of development.

DEPRESSION
There are times when every one of us

experience low spirits, feel down or having blues. At times we also feel dejected or despair in

response to loss of a loved one or other painful events. These feelings are called depression that is a symptom relatively common and normal to all.

52

Depression symptoms sadness

as

syndrome

is

constellation including as

of

that and

often

co-occur, as

feeling and

loneliness

well

worry

nervousness. Peterson et al., (1993) defines depression as a disorder often refers has key a to referred profound to as clinical of these and of

depression symptoms outcome symptoms

levels

and The is

specific is that

etiology, the to

course

combination cause

significant

enough

distress

or to interfere with functioning. According to Hammen & Compas (1994) in the

past it was believed that depression did not exist in childhood because it was thought that children did not have for the cognitive complexity often that tend was to

required show such

depression.

Children to

non-depressive as

reactions

traumatic and

losses somatic these

rebelliousness, It was

restlessness thought

complaints. symptoms

initially an

that

were

masking who have

underlying studied that

depression. in

Investigators infants of and

depression

children depression can be

confirm and seen

characteristics depression ages. in are

adult

child at all

similar rather behavior

and than

Therefore childhood,

masking

depression

problems

actually

accompany

the

symptoms

of depression. Depression state or is also defined as a an emotional of

attitude

involving

feeling

53

inadequacy

and

hopelessness

accompanied

by

general lowering of psychophysical activity. Signs of depression in very young children include delays or losses or developmental accomplishments, such as toilet training, good sleeping habits and intellectual

growth. A sad facial expression and gaze may be seen too. Self-harming behavior such as head banging and self-biting occurs, as well as self-soothing behavior such as rocking or thumb sucking. Clinging and demanding behavior may

alternate with apathy and listlessness. A lot of overlapping is seen between the symptoms of anxiety and depression. Alloy et al. (1990) has given the summary of symptoms that a unique to both anxiety and depression.

SUMMARY OF SYMPTOMS UNIQUE AND COMMON TO DEPRESSION AND ANXIETY

Type of Symptoms Affective Unique to Depression Severe sadness and despair Low positive affect Psychomotor retardation Unique to Overlap both Anxiety Symptoms Severe fear and Negative affect tension Crying Irritability Increased activity Behavioral Decreased activity Lowered initiation

Behavioral

54

Anhedonia agitation Loss of interest Suicidal acts (and ideation)

of responses Decreased energy Behavioral disorganization and performance deficits Increased dependency Poor social skills Restless sleep Initial insomnia Panic attack

Somatic

Decreased Increased sympathetic sympathetic arousal arousal Decreased appetite Reduced sexual desire Hopelessness Perceived loss Perceived danger and threat Uncertainty Hyper vigilance (watchfulness)

Cognitive

Helplessness Rumination and obsessions Worry Low self confidence Negative self evaluation Self-criticism Selfpreoccupation Indecisiveness Poor concentration

SOURCE: Adapted from Alloy, Clements (1990), P. 507.

Kelly,

Mineka

&

PROBLEM:
There has been a dearth of research in the field of emotional health in Pakistan, therefore this research can be a land mark in the barren area of investigation and is most needed in order to educate the health policy makers and the population of Pakistan. The present study is being conducted in Pakistan to find out the vulnerability to depression and anxiety in

55

males and females in relation to the type of birth they have undergone. While framing the hypothesis cultural

patterns and various other factors prevalent in Pakistan were also kept in mind. Keeping in view the theoretical and literature review the following hypotheses were

formulated.

HYPOTHESES:
1. Individuals of both sexes born under different forms of traumatic birth will show higher level of Anxiety than Individuals born under Natural Birth. 2. Individuals of both sexes born under different forms of traumatic birth will show higher level of Depression than Individuals born under Natural Birth. 3. Females level born of under Cesareanthan Section females will born show under

higher

depression

Natural Birth. 4. Males born under Cesarean- Section will show higher level Birth. 5. Females born of under Cesareanthan Section females will born show under of depression than males born under Natural

higher

level

anxiety

Natural Birth. 6. Males born under Cesarean- Section will show higher level of anxiety than males born under Natural Birth. 7. Females born under Forceps Delivery will show higher level of depression than females born under Natural birth.

56

8. Males born under Forceps Delivery will show higher level Birth. 9. Females born under Forceps Delivery will show higher level of anxiety than females born under Natural Birth. 10. Males born under Forceps Delivery will show higher level of anxiety than males born under Natural Birth. of depression than males born under Natural

CHAPTER 2 METHOD PARTICIPANTS:

This study was conducted to assess the level of depression and the level of anxiety of 500 participants. The participants were selected from business communities, banks and educational institutions which included the

Institute of Professional Psychology, Defence Authority College for Men and Women and Home Economics College were also included.

AGE:
The age range of the participants was 16 years and above. This included both males and females. The following numbers and types of participants were

selected: 1. 300 participants with Natural Birth 150 males 150 females 2. 100 individuals with Cesarean Section 50 males 50 females 3. 100 individuals with Forceps Birth 50 males 50 females

PROCEDURE:
Questionnaire having demographic information was

given to each participant. Each participant was requested

65

to inquire about the procedure of birth from their parents for the purpose of the study. The IPAT Anxiety and IPAT Depression scales were then administered on the same

participants in order to assess the level of anxiety and depression with effect to the type of birth they had. The set of papers consisted of the following: a. Questionnaire having demographic information. b. IPAT Anxiety Scale c. IPAT Depression Questionnaire

MEASURES:
IPAT Anxiety and IPAT Depression were used to find out the level of anxiety and depression. Both these scales have been validated (Ahmad, 1972) for Pakistani population and can be administered with fair amount of predictability. Prior to starting the test, subjects were brought into a quiet room and seated comfortably. Rapport was created as

the author had to undergo various problems owing to the nature of organizational procedures and set-up.

IPAT ANXIETY SCALE:

Anxiety is a very common factor in the personality of the individual. To make it more scientific the standardized, reliable and valid, questionnaires and scales were constructed for the measurement of various factors of personality. IPAT anxiety scale was evolved in 1957 by the Institute for Personality and Ability Testing.

66

The

scale

is

brief

and

applicable

to

the

lowest

educational levels. It can be given to people who belong to age 15 years and above. It gives accurate estimate of anxiety level and supplement clinical diagnosis. Moreover the scale facilitates all kinds of screening operations and research. The central features of scale are worry, tension, low self These control, are suspiciousness known as the and trait

emotionality.

features

components of anxiety. The scores derived from the scale are reliable enough for research purposes and group comparison. Each question in the scale has three possible answers, YES, NO &

Uncertain. A further division of pattern is made as covert and overt anxiety which can be easily obtained from the scores.

IPAT DEPRESSION SCALE:

Depression faced by the is one of the most confusing and problems clinical any

physicians, It is

psychiatrists to

psychologists.

difficult

identify

precipitating factor in the persons immediate surrounding which is responsible for depressive reactions. To the practitioners, accurate diagnosis is very

essential for the treatment procedures. In depression and anxiety most of the symptoms and complaints are common like sleep disturbance etc. It is this confusion of anxiety and depression

symptoms which creates one of the significant problems in the treatment of depression. Ayd (1973) reports on 500 patients later on diagnosed as depressive-who were

admitted to a general hospital with a variety of somatic

67

complaints. On the average, each patient was seen by three physicians and had four diagnostic tests performed in

addition to the usual given upon admission before being referred for psychiatric evaluation. Consequently an

instrument was introduced in 1976 to measure depression. The main aim was to produce psychometrically sophisticated instrument which could easily be used to estimate

depression in a reliable and valid manner.

STEN SCORES: The Scores obtained on IPAT Anxiety Scale and IPAT Depression These Questionnaire scores are are called Sten

Scores.

sten

called

Standard

Scores by the author of the IPAT Anxiety and IPAT Depression scales. The Standard Scores are used in order to find out how an individual stands in relationship for the to a defined population, Handbook for

IPAT

anxiety

scale,

Institute

Personality and Ability testing ( 1963). High Sten Scores: Sten scores falling between 8 to 10 are

considered high in anxiety and depression. Low Sten Scores: Sten scores falling between 1 to 3 are

considered low in anxiety and depression. STATISTICAL ANALYSIS:

Chi square test was computed to investigate whether

68

or

not

there

was

significant

difference

between

the

vulnerability to depression and anxiety in the individuals who underwent natural birth procedure and who underwent Traumatic variables Birth. used in The reason was the were fact not that the

this

research

continuous.

Therefore only non-parametric test was used.

DEFINITIONS OF DIFFERENT VARIABLES

There are several definitions of Birth Trauma that are given in the introduction but one of the most

comprehensive is given by Amethyst Resource (1982) who defines Birth Trauma as the anxiety, thought to be the prototype of all later anxiety, experienced by the infant upon being born and flooded with the stimuli.

History of the Theory of Birth Trauma:

From the 1920s a lot of work was being done by European researchers. They wrote on the Effects of Pre and Perinatal experiences on human growth and development. Some of the first indications that babies are conscious came from the pioneer of psychology and the work of

Sigmund Freud. Initially he was skeptical about how the infant mind worked but gradually client information linked their anxieties and fears to events surrounding their

birth. Freud theorized that birth might be the original trauma upon which later anxiety was based. This concept was initially acknowledged by Freud but then Otto Rank assigned it a major role. He wrote a book in 1923 called Trauma of Birth. Birth Trauma is defined as an anxiety provoking experience and feelings of

69

insecurity take place as a neonate comes out of his/her mothers womb. This separation according to Otto Rank is traumatic because the child now feels that he might not get that much security as he did in the womb where he was all alone. A lot of focus is laid on mother and child

relationship. This painful separation according to Otto Rank would result in birth anxiety. In this present study, birth trauma is also defined in the type of 2 birth states an of individual birth may go through. have been

Therefore

procedures

considered, that is, Cesarean Section and Forceps Delivery According to Rank (1923), intra uterine consciousness is felt during natal and prenatal events, which leaves behind some lasting experiences. Because of this

distancing the child is faced with birth trauma and its effects are later seen in his/her adulthood.

Cesarean Section:
According to Hyper Dictionary-Word net Dictionary: Cesarean is the delivery of a fetus by surgical incision through the abdominal wall and the uterus. In this procedure the baby is removed surgically from the uterus rather than traveling through the birth canal. This is done through abdominal incision.

Forceps Delivery:
Hyper dictionary defines Forceps birth as the

delivery in which forceps are inserted through the vagina and used to grasp the head of the fetus and pull it through the birth canal.

Natural Birth:

70

The World Health Organization has stated that normal birth is: spontaneous in onset, low risk at the start of labor and remaining so throughout labor and delivery. The infant is born spontaneously (without help) in the vertex position (head down) between 37 and 42 completed weeks of pregnancy. After birth, mother and the baby are in good condition The Association of Improvements in maternity Services (AIMS) defines normal birth by extending WHOs definition. It states that to exclude any births where labor has been altered by technological intervention. The above mentioned definitions of normal birth does not include where labor has been induced, accelerated by drugs, epidural or episiotomies. According to AIMS it is a birth without interference. It is also called by them physiological birth or straightforward vaginal birth. This type of birth occurs without any outside aid or with minimum or no medication at all to the mother. In this procedure, the position of the fetus in the mothers uterus and the size of the fetus make it possible for the head of the fetus to come out first from the birth canal naturally.

CHAPTER 3 RESULTS

The aim of the study is to assess the vulnerability of males and females in relation to the type of birth to depression and anxiety. The IPAT anxiety scale and IPAT depression scale were administered on 500 individuals out of which there were 100 males and 100 females who were assessed as a experimental group and 300 were the

controlled group. The results that are obtained show that the HYPOTHESIS are statistically significant.

HYPOTHESIS NO 1:- STATES THAT:

Individuals of both sexes born under different birth of forms will anxiety of show than

traumatic higher

level

individuals born under natural birth . The results of the Statistical analysis are shown in Table No 1 and Graph A. The chi square x2= 37.84, df= 2, p < 0.001 level of significance. The result indicates that there is a

significant difference in the two groups.

The traumatic

birth group and the control group, both males and females show a lot of difference in the level of anxiety in

adulthood. Individuals both males and females have high sten scores in anxiety scale questionnaire as compared to individuals of control group.

78

HYPOTHESIS NO 2:- STATES THAT:

Individuals of both sexes born under different birth forms will of show

traumatic

higher level of depression than individuals born under natural birth. The results of the Statistical analysis are shown in Table No 2 and Graph B. The chi square x2 = 35.64, df= 2, p < 0.001 level of significance. The result indicates that there is a

significant difference in the two groups. The traumatic birth group and the control group, males and females show a lot of difference in the level of depression in

adulthood. Individuals both males and females have high sten scores in depression self-assessment questionnaire as compared to individuals of control group.

HYPOTHESIS NO 3:- STATES THAT:

Females born under Cesarean section will show higher level of depression than females born

under Normal procedure. The results of the Statistical analysis are shown in Table No 3 and Graph C. The chi square x2 = 14.83 , df= 1, significant at

p < 0.001 level of significance. The result indicates that there is a high correlation between individuals (females)

79

born through cesarean section with the level of depression in adulthood. There is a significant difference in the two groups. Females sten in traumatic as birth group to have high in

depression

scores

compared

individuals

control group.

HYPOTHESIS NO 4:- STATES THAT:

Males section level Males of born born will under show Cesarean higher than Normal

depression under

procedure. The results of the Statistical analysis are shown in Table No 4 and Graph D. The chi square x2 = 11.81, df= 1, significant at

p < 0.001 level of significance. Results indicate high relationship in the males born through Cesarean section with the level of depression in adulthood. Male

individuals born through cesarean section

have a high

score in depression questionnaire than males born through normal birth procedure.

HYPOTHESIS NO 5:- STATES THAT:

Females born under Cesarean

section will show higher level of anxiety than females born

under Normal procedure. The results of the Statistical analysis are shown in Table No 5 and Graph E.

80

The

chi

square

13.54,

df=

1,

significant

at

p < 0.001 level of significance. The result indicates that there is a significant

difference in the two groups. Level of anxiety is very high in females of the experimental group as compared to control group where the anxiety sten scores are not very noticeable. The results show that the two groups have significant difference.

HYPOTHESIS NO 6:- STATES THAT:

Males section born will under show Cesarean higher

level of anxiety

than Males

born under Normal procedure.

The results of the Statistical analysis are shown in Table No 6 and Graph F. The chi square
2 x=

11.76,

df=

1,

significant

at

p < 0.001 level of significance. The hypothesis has been proved as males show a profound correlation of birth and its relation to anxiety in to the type adulthood as

compared to males who were born through a normal birth.

HYPOTHESIS NO 7:- STATES THAT:

Females Delivery level females of born will under show Forceps higher than Normal

depression under

born

procedure.

81

The results of the Statistical analysis are shown in Table No 7 and Graph G. The chi square x2 p < 0.001 = 13.09, df= 1, significant at

level of significance. in

The result indicates that there is a major difference

the two modes of birth that is forceps and natural birth. Females show a high degree of correlation with forceps birth and the level of depression which is noticeably high. Whereas females who were born through a natural process do not show high sten scores in depression

questionnaire. Thus proving the hypothesis.

HYPOTHESIS NO 8:- STATES THAT:

Males born under Forceps Delivery will show higher level of

Depression than Males born under Normal procedure. The results of the Statistical analysis are shown in Table No 8 and Graph H. The chi square x2 of significance. The result indicates that there is a significant = 16.81, df= 1, p < 0.001 level

difference in the two groups of males.

HYPOTHESIS NO 9:- STATES THAT:

Females born under Forceps

Delivery will show higher level of anxiety than females born under Normal procedure.

82

The results of the Statistical analysis are shown in Table No 9 and Graph I. The chi square
2 x=

11.8,

df=

1,

significant

at

p < 0.001 level of significance. The result indicates that there is a significant

difference

in the Anxiety sten scores of the two groups

that were studied.

HYPOTHESIS NO 10:-

STATES THAT:
Males born under Forceps Delivery will show higher level of anxiety than males born under Normal

procedure. The results of the Statistical analysis are shown in Table No 10 and Graph J. The p < 0.001 The chi square x2= 10, df= 1, significant at

level of significance. results indicate that there is a noteworthy

difference

in the groups. Males born under forceps or

through vacuum extraction show a high level of anxiety as compared to males born through normal procedure of birth.

84

TABLE NO. 01 COMPARISON OF ANXIETY BETWEEN INDIVIDUALS OF BOTH SEXES (MALES AND FEMALES) WITH NATURAL AND TRAUMATIC BIRTH

CATEGORY NATURAL BIRTH CESAREAN SECTION FORCEPS DELIVERY TOTAL

ANXIOUS 123

NORMAL 177

TOTAL 300

70

30

100

68

32

100

261

239

500

CHI SQUARE VALUE= x 2 = 37.84 DEGREE OF FREEDOM= 2 LEVEL OF SIGNIFICANCE= p < 0.001

85

LEVEL OF ANXIETY BETWEEN ADULTS (MALES AND FEMALES) WITH NATURAL AND TRAUMATIC BIRTHS

80 70 P e r c e n ta g e o f A n x e i ty L e v e l 60 50 40 30 20 10 0
Cesarean Section Forceps Delivery Natural Birth

Graph A

86

TABLE NO. 02 COMPARISON OF DEPRESSION BETWEEN INDIVIDUALS OF BOTH SEXES (MALES AND FEMALES) WITH NATURAL AND TRAUMATIC BIRTH

CATEGORY NATURAL BIRTH CESAREAN SECTION FORCEPS DELIVERY TOTAL

DEPRESSED 105

NORMAL 195

TOTAL 300

67

33

100

55

45

100

227

273

500

CHI SQUARE VALUE= x 2 = 35.64 DEGREE OF FREEDOM= 2 LEVEL OF SIGNIFICANCE= p < 0.001

87

LEVEL OF DEPRESSION BETWEEN INDIVIDUALS OF BOTH SEXES (MALES AND FEMALES) WITH NATURAL AND TRAUMATIC BIRTHS

80 P e r c e n ta g e o f D e p r e s s i o n L e v e l 70 60 50 40 30 20 10 0
Cesarean Section Forceps Delivery Natural Birth

Graph B

88

TABLE NO. 03

COMPARISON OF DEPRESSION BETWEEN FEMALE INDIVIDUALS WITH NATURAL AND CESAREAN BIRTH

Type of Birth Natural Birth Cesarean Section Total

DEPRESSED 55 34 89

NORMAL 95 16 111

Total 150 50 200

Chi Square Value= x 2 = 14.83 Degree of Freedom= 1 Level of Significance= p > 0.001

89

LEVEL OF DEPRESSION BETWEEN FEMALE INDIVIDUALS WITH NATURAL AND CESAREAN BIRTH

80 P e r c e n ta g e o f D e p r e s s i o n L e v e l 70 60 50 40 30 20 10 0
Cesarean Section Natural Birth

Graph C

90

TABLE NO. 04

COMPARISON OF DEPRESSION BETWEEN MALE INDIVIDUALS WITH NATURAL AND CESAREAN BIRTH

Type of Birth Natural Birth Caesarean Birth Total

DEPRESSED 50 33 83

NORMAL 100 17 117

Total 150 50 200

Chi Square Value= x 2 = 16.81 Degree of Freedom= 1 Level of Significance= p < 0.001

LEVEL OF DEPRESSION BETWEEN MALE INDIVIDUALS WITH NATURAL AND CESAREAN BIRTH

91

70 60 50 40 30 20 10 0
Cesarean Section Natural Birth

P e r c e n ta g e o f D e p r e s s i o n L e v e l

Graph D

92

TABLE NO. 05

COMPARISON OF ANXIETY BETWEEN FEMALE INDIVIDUALS WITH NATURAL AND CESAREAN BIRTH

Type of Birth Natural Birth Caesarean Birth Total

ANXIOUS 60 35 95

NORMAL 90 15 105

Total 150 50 200

Chi Square Value= x 2 = 13.54 Degree of Freedom= 1 Level of Significance= p < 0.001

LEVEL OF ANXIETY BETWEEN FEMALE INDIVIDUALS WITH NATURAL AND CESAREAN BIRTH

93

80 70 P e r c e n ta g e o f A n x e i ty L e v e l 60 50 40 30 20 10 0
Cesarean Section Natural Birth

Graph E

TABLE NO. 06

94

COMPARISON OF ANXIETY BETWEEN MALE INDIVIDUALS WITH NATURAL AND CESAREAN BIRTH

Type of Birth Natural Birth Cesarean Section Total

ANXIOUS 63 35 98

NORMAL 87 15 102

Total 150 50 200

Chi Square Value=X 2 = 11.76 Degree of Freedom= 1 Level of Significance= p < 0.001

LEVEL OF ANXIETY BETWEEN MALE INDIVIDUALS WITH NATURAL AND CESAREAN BIRTH

95

80 70 P e r c e n ta g e o f A n x e i ty L e v e l 60 50 40 30 20 10 0
Cesarean Section Natural Birth

Graph F

96

TABLE NO. 07

COMPARISON OF DEPRESSION BETWEEN FEMALE INDIVIDUALS WITH NATURAL AND FORCEPS BIRTH

Type of Birth Natural Birth Forceps Birth Total

DEPRESSED 55 33 88

NORMAL 95 17 112

Total 150 50 200

Chi Square Value=X 2 =13.09 Degree of Freedom= 1 Level of Significance= p < 0.001

LEVEL OF DEPRESSION BETWEEN FEMALE INDIVIDUALS WITH NATURAL AND FORCEPS BIRTH

97

70 60 50 40 30 20 10 0

P e r c e n ta g e o f D e p e s s i o n L e v e l

Forceps Birth

Natural Birth

Graph G

98

TABLE NO. 08

COMPARISON OF DEPRESSION BETWEEN MALE INDIVIDUALS WITH NATURAL AND FORCEPS BIRTH

Type of Birth Natural Birth Forceps Birth Total

DEPRESSED 50 33 83

NORMAL 100 17 117

Total 150 50 200

Chi Square Value= X 2 =16.81 Degree of Freedom= 1 Level of Significance= p < 0.001

LEVEL OF DEPRESSION BETWEEN MALE INDIVIDUALS WITH NATURAL AND FORCEPS BIRTH

P e r c e n ta g e o f D e p r e s s i o n L e v e l 20 30 40 50 60 70

10

0
Forceps Birth Natural Birth

Graph H

99

100

TABLE NO. 09

COMPARISON OF ANXIETY BETWEEN FEMALE INDIVIDUALS WITH NATURAL AND FORCEPS BIRTH

Type of Birth Natural Birth Forceps Birth Total

ANXIOUS 60 34 94

NORMAL 90 16 106

Total 150 50 200

Chi Square Value= X 2 = 11.8 Degree of Freedom= 1 Level of Significance= p > 0.001

LEVEL OF ANXIETY BETWEEN FEMALE INDIVIDUALS WITH NATURAL AND FORCEPS BIRTH

101

80 70 P e r c e n ta g e o f A n x e ity L e v e l 60 50 40 30 20 10 0
Forceps Birth Natural Birth

Graph I

102

TABLE NO. 10

COMPARISON OF ANXIETY BETWEEN MALE INDIVIDUALS WITH NATURAL AND FORCEPS BIRTH

Type of Birth Natural Birth Forceps Birth Total

ANXIOUS 63 34 97

NORMAL 87 16 103

Total 150 50 200

Chi Square Value= X 2 = 10 Degree of Freedom= 1 Level of Significance= p < 0.001

LEVEL OF ANXIETY BETWEEN MALE INDIVIDUALS WITH NATURAL AND FORCEPS BIRTH

103

80 70 P e r c e n ta g e o f A n x e i ty L e v e l 60 50 40 30 20 10 0
Forceps Birth Natural Birth

Graph J

CHAPTER 4 DISCUSSION

The theoretical and practical observations make it evident that individuals who have undergone Birth Trauma that is level of Cesarean Section and Forceps Delivery, their anxiety who and have depression experienced will be greater procedure than of

individuals birth.

Normal

The fact remains that Birth traumatized individuals have experienced and felt this painful mode of birth and emotional crises. In the light of literature review and theoretical constructs it has now become clear that the type of child birth has a definite effect on the adult life of an individual. These effects are manifested in the shape of anxiety and depression. It is known; that whatever research and literature review is available So far no has been conducted has been in developed in

countries.

research

conducted

Pakistan to explore the factors that contribute towards depression and anxiety in adulthood due to birth trauma. In the previous chapter the statistical results of the various hypotheses have been demonstrated and this chapter will elaborate on the discussion of these

hypotheses in the light of the results obtained in this research. Like many other countries in the developing world, mental health remains perhaps the most neglected sector of

105

health and health care services in Pakistan. The country gives a low priority to its public health services in general, and among those services mental health is given a still lower priority.

HYPOTHESIS NO 1:- STATES THAT:

Individuals of both sexes born under different birth of forms will anxiety of show than

traumatic higher

level

individuals born under natural birth.

The results of the Statistical analysis are shown in Table No 1 and Graph A. The chi square x2= 37.84, df= 2, p < 0.001 level of significance. The result indicates that there is a

significant difference in the two groups. The traumatic birth group and the control group that is individuals both males and females show a lot of difference in the level of anxiety in adulthood. Individuals both males and females have high sten scores in anxiety scale questionnaire as compared to individuals of control group. Individuals born under c-sec have high level in

anxiety as compared to individuals born through normal procedure. There is a profound correlation between instrumental and drugged birth in comparison to natural birth. Literature review and statistical results support this fact that such individuals are more susceptible towards anxiety in

106

adulthood. The hypothesis has been proved by evidence in the literature review and now the statistical analysis confirms this fact. Instrumental or drugged birth of an individual, as discussed earlier, is a traumatic procedure by itself. Cesarean section further makes the birth of a child

difficult as the child who is prepared to come out in this world through a systematic procedure via birth canal, is now threshed upon through surgery, or instrumental birth that he was never prepared for. This procedure is very

shocking for the child and its effects are long lasting. It is evident from the literature review, that

instrumental births, elective cesarean and prolonged birth have long lasting effects in the personality of the

adults. A lot of physical problems are also associated with vacuum extraction. Problems arise when the suction pulls the scalp from the underlying tissue, creating a space into which the baby may bleed. It was suggested by Dr. Dena Tower, an ob-gyn at the University of California at Davis Medical Center, that one needs to be careful not to twist the babys head with the device or leave the device on for more than 20 seconds. Dangers of forceps include injuring the soft tissue of the head, face and neck. Where ever the baby is clamped may cause nerve damage. In the western world, a lot of care is taken in any medical or health related issues. In our eastern world, due to paucity of funds, lack of awareness, lack of

adequate knowledge, all these factors may be overlooked.

107

If not overlooked, then not much importance is placed on these procedures. One developed mishap more and differentiation under-developed during is prominent between if the any

countries prenatal

that, or

occurs

peri-natal,

postnatal

care, the individual has full authority to question the department overlooked treatment concerned. by or some In Pakistan, this system If any is ill

medical

practitioners. takes place,

malpractice

the

final

responsibility is kept on nature. Cesarean birth is also at high risk for depression and anxiety in both the infant and the mother. The results calculated prove this phenomenon that such type of birth deliveries will definitely have an impact on the adult life. One needs to be extremely careful as how a child birth takes place. A lot of mishaps or traumatic birth of prolonged labor practice of midwifery especially in those areas where there is lack of education and health

facilities. A lot of emphases are laid on natural delivery and thus many a times it gives rise to prolonged labor or unassisted instrumental labor that in turn traumatizes the infant and is one of the major causes of mother and child mortality. These are the factors that are vulnerable towards depression and anxiety in adulthood in Pakistan.

HYPOTHESIS NO 2:- STATES THAT:

Individuals of both sexes born under different forms of

108

The results of the Statistical analysis are shown in Table No 2 and Graph B. The chi square x2 = 35.64, df= 2, p < 0.001 level of significance. The result indicates that there is a

significant difference in the two groups. The traumatic birth group and the control group that is individuals both males and females show a lot of difference in the level of depression females in adulthood. high sten Individuals scores as in both males and selfof

have

depression to

assessment

questionnaire

compared

individuals

control group. There is a high correlation between the type of birth an individual goes through with the features of depression and anxiety they will manifest in adulthood as discussed earlier. It is clear from the evidences and data calculated that feelings of apprehension, low-self esteem, crying

episodes and uneasiness are the symptoms of depression and are present in individuals who are born through traumatic procedure. Theoretical perspective gives rich information

as to how an infant psyche works before and after his birth. The infant is susceptible to psychic trauma due to these birth procedures that leave a strong impression in his mind in the form of birth memories.

109

Chaos.com, Birth Trauma reports, that when an infant is in the womb it is a very peaceful place for him. It is sacred because he is all alone. The infant floats in a warm liquid that is surrounded by dim red lights with a rhythm of his mothers heart beat. This is an environment where an infant experiences the natural state of existence that is there is no feeling of hunger, no cold or hot but only comfort that is auto regulated by the mothers body. It is a state of bliss for the neonate. Birth time becomes chaotic for the child. He starts looking for his way out trying to find a tight squeeze. Suddenly after a thrust he is in a situation with hustle bustle around him. If it is a normal birth, the infant would be handled normally and immediately handed over to the mother for bonding. But, if, instead, the infant is operated or any metal or plastic device is used, this event becomes very traumatic and hurtful. What he expected did not happen. It is also reported that when the infant comes out from his mothers womb, he is surrounded by big people in gowns who are tousling with the childs helpless body. Feelings of child immediately after birth: Feelings of being tossed and turned Poking Cutting

110

Scrubbing Infants psyche of Now and Then Environment: It was peaceful before Dim Red lights in the womb Frigid air space now replaces the comfortable warm liquid of the womb.

Gradually the child has to adapt to the new environment for food water and basic needs, which was formerly

provided by the mothers umbilical cord. These feelings are torturous for a neonate. It becomes imperative to note that instrumental or drugged delivery have marked

impression on the childs psyche as compared to normal birth which is a more stable and accepted form of

childbirth.

HYPOTHESIS NO 3:-

STATES THAT:
Females section born will under show Cesarean level

higher

of depression than females born under Normal procedure.

The results of the Statistical analysis are shown in Table No 3 and Graph C.

111

The chi square x

= 14.83, df= 1, significant at

p < 0.001 level of significance. The result indicates that there is a high correlation between individuals (females) born through cesarean section with the level of depression in adulthood. There is a significant difference in the two groups. Females in traumatic birth group have high anxiety sten scores as compared to individuals in control group. It is very clear from the results that females in the traumatic birth group show a very high level of depression as compared to females born through a normal birth

procedure. In our eastern culture, women are thought to be pacifiers and caretakers. This role to them is perceived automatically as a good lady of our society. Therefore for them to express their needs and desires in front of the family members is tough. Whether it is a husband or

father, she is not permitted to voice her feelings openly and share her desires. Birth through C-Sec is a procedure significant enough to cause hurt and pain to the neonate and the mother. The

statistical analyses prove the hypotheses, that it will have a long lasting impression on females later. There is a general trend seen that women who come from a stronger financial environment and who have strong family support, independence, and use these factors to sublimate and

displace these unpleasant manifestations. These symptoms do not create a hurdle in their lives. On the other hand women who come from low economic conditions, due to paucity of funds, manifestations are

112

felt overtly or covertly depending upon the nature of their surroundings. They tend to have mood swings, low self-esteem and crying spells. Some reasons are evident that could be familial background but the underlying cause at times is unknown. Due to these causes, women from low socio-economic poverty and background are unable get to into a vicious this cycle of for

break

chain

generations. After conducting this research, it can be said that the features and manifestations of depression in women, the causes are multi dimensional and birth trauma is one of them.

HYPOTHESIS NO 4:-

STATES THAT:
Males born under show Cesarean higher than Normal

section level Males of

will

depression under

born

procedure.

The results of the Statistical analysis are shown in Table No 4 and Graph D. The chi square x2 = 16.81, df= 1, significant at

p < 0.001 level of significance. Results indicate high relationship in the males of traumatic birth and level of depression. Male individuals born through cesarean section have a high score in depression questionnaire than males born through normal birth procedure.

113

Traumatic birth of C-Section does not rule out any gender difference. Males are also if not equally affected by the painful procedure of birth like females. No infant is prepared to come out in this world through a traumatic process. Therefore, when this abruption in the normal

birth process takes place, where the individual is in a state of shock and bewilderment. He is now brought out from the womb through a surgical cut. As seen previously, this process shakes the infants psyche. It is seen that infants who are born through C-Sec do not cry instantly after they are taken out from the womb as compared to children who are born naturally and come out through the birth canal. Therefore the practionars try to make the baby cry once out through a surgical cut. It is a painful period for the neonate and these painful impressions are carried throughout in his

personality in his adulthood. In Pakistan although men are believed to be strong, the results show that even though lower than females, but they too suffer this emotional crises in adulthood due to unnatural birth.

HYPOTHESIS NO 5:- STATES THAT:

Females section of born will under show than Cesarean level born

higher females

anxiety

under Normal procedure.

114

The results of the Statistical analysis are shown in Table No 5 and Graph E. The chi square x2 = 13.54, df= 1, significant at p < 0.001 level of significance. The result indicates that there is a significant

difference in the two groups. Level of anxiety is very high in females of the experimented group as compared to control group where the anxiety sten scores are not very noticeable. The results show that the two groups have significant difference. The result indicates that there is a higher level of anxiety features in females who were born through C-Sec as compared to females who were born out of normal procedure. Anxiety manifestations are a part and parcel of female personality in our eastern society. Before this research, vague. the A origins lot of of these unpleasant were held

feelings

were

factors

responsible for a female for feeling low and anxious. Now, after conducting the research, the researcher can safely say that birth trauma also has an effect on the

personality development of the woman and thus feelings of anxiety are predisposed to the the type roots of of birth she has are

experienced.

Predominantly

anxiety

ingrained in birth trauma and this is carried on for the rest of the life of the individual.

HYPOTHESIS NO 6:-

STATES THAT:
Males born under Cesarean section will show higher level Males of born anxiety under than Normal

procedure.

115

The results of the Statistical analysis are shown in Table No 6 and Graph F. The chi square
2 x=

11.7,

df=

1,

significant

at

p < 0.001 level of significance. The hypothesis has been proved as males born under cesarean section show a

profound relation to anxiety in adulthood as compared to males who were born through a normal birth. The result indicates that there is a significant

difference in the way a female copes with her traumatic experience and the male of a Pakistani society. Here men are perceived to be tough, and it is considered bad and a taboo for a man to exhibit his emotional needs. Therefore, the result does show a significant

difference between the c-sec birth males and normal birth males but is comparatively low as compared to females who are born under c-sec and who have anxiety features. Men are called the role models especially in the uneducated class where a lot of distinction is made

between a man and a woman and the level of independence and responsibilities. Male persona is of being tough and that he can handle anything even though it might be beyond his control. This is the reason why we see a difference in the anxiety level of males and females in a Pakistani society.

HYPOTHESIS NO 7:- STATES THAT:

Females Delivery born will under show Forceps higher

116

The results of the Statistical analysis are shown in Table No 7 and Graph G. The chi square x2 = 13.09, df= 1, significant at

p < 0.001 level of significance. The result indicates that there is a major difference in the two modes of birth that is forceps and natural birth. Females show a high degree of correlation with forceps birth and the level of depression which is

noticeably high. Whereas females who were born through a natural process do not show high sten scores in depression questionnaire. Thus proving the hypothesis. Here we see that females born through forceps show a general high level of depression as compared to females born under normal procedure. Literature information of review suggests types and of gives forceps us that the a

different

practionars can use. Forceps show a high rate in fetal damage, mothers cervical or uterus tear can take place. One has to be extremely careful when using these

instruments. This method is a high risk procedure and doctors need to be well trained and experienced before conducting this surgery. If by chance a mishap occurs due

117

to some sort of negligence, it leaves a mark of trauma throughout an individuals life. Here, females show higher level of depression as compared to males.

HYPOTHESIS NO 8:- STATES THAT:

Males born under Forceps Delivery will of show higher Males level born

Depression

than

under Normal procedure. The results of the Statistical analysis are shown in Table No 8 and Graph H. The chi square x2 of significance. The result indicates that there is a significant = 16.81, df= 1, p < 0.001 level

difference in the two groups of males. Forceps Delivery causes physical and emotional damage to the neonate as well as the mother. Teng and Sayre (1997), report that Vacuum or forceps extraction can be traumatic. factors: 1. Improperly applied location or pressure. 2. Practitioner inexperience 3. Any other sort of error Difficulty is seen once application is employed. Trauma can be caused due to the following

Peripheral, phrenic and brachial plexus, dural tears and traction injuries are also reported. It is evident that

emotional dilemma is associated with vacuum extraction. Males are also prone to depression like females. Therefore

118

we can see a correlation between the mode of birth and how it affects an individual later in his adulthood. The

gender roles a Pakistani culture gives to a man and a woman plays a significant role as to what extent a man suffers from emotional trauma as compared to women. In our eastern culture, women can express her emotions openly and easily and it is also seen that this becomes a tool in the hands for security and protection for a female in front of the society and her family. Men, comparatively feel

threatened by the labels that the society or the family may attach if they even show a crying or a weak facial expression.

HYPOTHESIS NO 9:- STATES THAT:

Females born under Forceps

Delivery will show higher level of anxiety than females born

under Normal procedure. The results of the Statistical analysis are shown in Table No 9 and Graph I.
2 The chi square x = 11.8, df= 1, significant at p < 0.001

level of significance. The result indicates that there is a significant

difference in the Anxiety sten scores of the two groups that were taken for the study. The results are proved and there is a significant effect of the type of birth with development of adult personality. Birth is estimated to be the 6th to 10th leading cause of infant mortality in the U.S.

119

In Pakistan there is no providence and therefore this research makers. Whether it is Vacuum extraction or cesarean birth, an individual will be affected by the forces used by outside aids or instruments. Therefore it can be concluded that will serve as a rich source for the policy

Forceps birth will significantly affect the females of Pakistan and anxiety will be found in their personalities. Sometimes irreversible damage is caused due to forceps where an individuals facial or head injury is inflicted. These women forever suffer from low self-esteem, anxiety, bouts of crying spells and most importantly, their chances of getting married becomes dim especially in a developing country where marriage is given a lot of importance to a woman.

HYPOTHESIS NO 10:-

STATES THAT:
Males born under Forceps Delivery will Anxiety show than higher level males born of under

Normal procedure. The results of the Statistical analysis are shown in Table No 10 and Graph J. The chi square x2= 10, df= 1, significant at p < 0.001 level of significance. The results indicate that there is a noteworthy

difference in the groups. Males born under forceps or through vacuum extraction show a high level of anxiety as compared to males born through normal procedure of birth.

120

Results

prove

that

birth

by

forceps

will

have

significant impact on males. Literature review suggests that the use of vacuum is a painful process for an infant along with his mother. One has to be really trained in order to perform this procedure. It was reported by a medical health practitioner that they are trained only in vaginal birth but were regularly

performing instrumental birth with minimal or no practice at all. It is suggested by a researcher that use of forceps is safe and should be practiced in order to save the life of an infant. This is true that when the critical time comes to take a decision for the delivery procedure, the doctor is the best judge to decide what to do. Although at times in Pakistan even though childbirth goes on smoothly,

practitioners tend to adopt these traumatic means. It is evident that forceps delivery can cause cervical and

uterus tear to the mother and its impact can be long lasting. In Pakistan use of Forceps is performed when the practitioner feels that natural birth is impossible or when the baby is in breech position.

CHAPTER 5

CONCLUSION

In the light of the research conducted, we can safely conclude that Traumatic Birth will have an impact on the individual in adulthood. Thus it is clear that anxiety and Depression will be prominent in their personality. Distress procedure. is inevitable itself in is any kind of for birth the

Childbirth

challenging

neonate as well as the mother. Once successful childbirth takes place and the mother is done with the various stages of labor, the neonate is free from all the disturbing elements child co-occurring to forget in the uterine the environment. he was The

seems

about

torture

going

through and mother-child bonding takes place after long hours of waiting period. On the contrary, Cesarean birth is an abrupt mode of childbirth as discussed earlier. The child was never

prepared for a thrusted feeling and thus creates a shock in his life, in retrospect inducing anxiety and

depression. Forceps Delivery also creates unpleasant emotional feelings in adulthood. It is an agonizing feeling for the child where he is sucked up by various odd instruments in order to come out from the birth canal. It is painful and can leave scars and marks on the child, emotional as well as physical.

124

It

is

suggested

that

policy

health

makers

should

notice the severity of these birth procedures. There is a dogma amongst the practionars that birth procedures do not affect the child neither the mother if good antenatal care is taken. It should be highlighted that however a woman takes preemptive measures; no one can predict the last minute decision as everything depends on the health care practionars. An interesting article was published in a Pakistani newspaper The Doctor Fortnightly. Effective Intervention on Perinatal The topic was Cost Health. Prof. Z.A

Bhutta reported that the study was undertaken in urban areas of Pakistan. It was seen that there was no community data regarding prenatal and neonatal care. Another

national survey too, that was conducted by PMRC had no data in this regard. Prof. Bhutta mentioned that vast majority of births were not registered, deliveries took place by the assistance of Dais (midwives) without proper aids. Since 1060s when neonatal studies took a toll, incidences have risen in neonatal mortality. This is the reason as a Clinical psychologist, policy health makers and officials need to be made aware of the trauma that is increasing day by day. It is concluded that traumatic events during perineal phase does leave a mark on later personality and have a potential for causing life long problems.

RECOMMENDATIONS FOR FURTHER RESEARCH

125

In the light of present research work on Depression and Anxiety in Adulthood As a Function of Birth Trauma In Pakistan, the author suggests few recommendations for

future research program: 1. There is a possibility that for the next research, number of participants could be increased. 2. Socio-Economic factor should be taken as one of the key variables. 3. For the next study, mothers of these individuals should also be taken as subjects. 4. Information regarding the decision of the delivery process should also be taken from the mothers. 5. Fathers can be included in order to find out their level of approval in the form of delivery.

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139

APPENDIX A DEMOGRAPHIC INFORMATION FORM

140

INSTRUCTIONS:

PLEASE FILL UP THE QUESTIONNAIRE. THE DATA WILL BE KEPT CONFIDENTIAL. YOUR COOPERATION WILL BE HIGHLY APPRECIATED. THIS RESEARCH IS BEING DONE FOR THE BENEFIT OF ALL CONCERNED IN THE COUNTRY.

1. SEX

MALE/FEMALE

2. AGE

____________

3. TYPE OF BIRTH

NATURAL DELIVERY CESAREAN BIRTH FORCEPS LABOR PROLONGED LABOR

4. PLACE OF BIRTH

HOME HOSPITAL OTHER ____________ (CLINIC, NURSING HOME, HEALTH CARE CENTER, ETC.)

5.MONTHLY PER CAPITA INCOME APPROXIMATELY (NUMBER OF PEOPLE LIVING IN THE FAMILY AND INCOME OF EARNING MEMBERS).

IT

MAY

BE

NOTED

THAT

EACH

PARTICIPANT

WAS

ASKED

TO

CONFIRM

THE

PROCEDURE OF BIRTH FROM THEIR PARENTS.

142

APPENDIX B SELF ANALYSIS FORM

143

APPENDIX C PERSONAL ASSESSMENT INVENTORY