A woman's experience of childbirth can have a significant impact on her health after birth. Research has shown that childbirth experience is associated with mental health, such as postpartum depression (Bell and Andersson, 2016), post-traumatic stress disorder (Czarnocka and Slade, 2000; Dekel et al, 2017), and anxiety (Field, 2018), as well as marital and maternal-infant relationships (Parfitt and Ayers, 2009; Johansson et al, 2020) and number of future children (Gottvall and Waldenström, 2002).
How these birth experiences are remembered is still not fully understood, but it is known that disorganised memory of childbirth is related to postpartum mental health, as the memory process is likely to be affected by the experience of intense pain and emotions during birth (Ayers, 2007; Briddon et al, 2011). This indicates that the memory of childbirth is as important for women as the experience of childbirth itself.
Research on memory of childbirth has primarily focused on its content, accuracy and consistency. Memories of childbirth have been reported to be relatively accurate (Githens et al, 1993; Olson et al, 1997) and can be clearly remembered even 5 years later (Takehara et al, 2014). However, it has been shown that these memories may change over time and that there is great variation (Waldenström, 2003). Thus, it is difficult to definitively determine the accuracy of these memories. In relation to postpartum women's health, research has focused on the consequences of recall. The development of post-traumatic stress disorder as a result of intrusive recall of traumatic birth memories has been observed (Davies et al, 2008) and has the potential to have negative effects on women's physical wellbeing, mood, behaviour and social interactions (Ayers et al, 2006). In contrast, positive birth memory recall has been reported to improve women's self-confidence and self-esteem (Simkin, 1991; 1992). Research has shown that women experience both positive and negative involuntary memories, which are associated with symptoms of post-traumatic stress and wellbeing (Briddon et al, 2015).
Therefore, revealing how such memories of childbirth are recalled in daily life from women's perspectives would provide suggestions for better childbirth and postpartum care. However, few studies have explored the experience of memory recall. Beck (2004a; 2006) and Beck and Watson (2010) describe the experiences of women who suffer from intrusive recall of birth memories; however, these studies are limited to women who had traumatic births. Therefore, further research is needed.
Previous research has indicated that there is an involuntary memory experience in the recall of childbirth memories (Briddon et al, 2015). To examine this experience, the present study focused on memory as a phenomenon in which memories appear in consciousness regardless of intention (Kawaguchi, 2012) and explored the experience of recalling such memories. This study aimed to describe how women recall memories of childbirth in daily life.
Methods
Design
Husserl's (1936) descriptive phenomenology, which focuses on the description of human experience as it is (Polit and Beck, 2012), was chosen for this study. This philosophy states that experience, as perceived by human consciousness, is important and any lived experience has characteristics that are common to all persons who have that experience; this allows understanding of the essence of lived experience (Lopez and Willis, 2004). Specifically, Ricœur's (Kawaguchi, 2012) and Thomas and Pollio's (2002) approaches were used, which incorporate Husserl's philosophy. Ricœur (2004) applied Husserl's methodology of noesis-noema, and states that by treating the content of memory as noema (the object of intentionality), it can be used as a pivot to reflect on noesis (the activity of intentionality), which is the action of consciousness itself, and explore the phenomenon of memory from a philosophical perspective (Kawaguchi, 2012).
Recruitment
Primiparous and multiparous women with memories of childbirth were recruited using snowball sampling, through the researcher's social acquaintances. This technique is beneficial for phenomenological interviewing, as it produces trustworthy relationships with participants (Polit and Beck, 2012), thereby allowing them to describe their experiences freely (Thomas and Pollio, 2002).
Procedure
In descriptive phenomenology, ‘bracketing’ is an important step in listening to and reflecting on participants' experiences (Polit and Beck, 2012). Before conducting the interviews, the interviewer identified and held in abeyance any preconceived notions, beliefs, opinions or assumptions about the phenomenon under study (Thomas and Pollio, 2002). In phenomenological research, in-depth interviews are crucial. This process involves not only listening carefully but also understanding the person as they are (Munhall, 2012). Interviewers approached interviewees with an unknowing attitude and concentrated on listening to the participant's narrative, taking great care not to interrupt or lead the conversation.
Data were collected between December 2015 and July 2017. One-on-one interviews were conducted in either the participant's home or the interviewer's office, depending on the participant's preference. Each participant was interviewed once; however, in the case of ambiguity, a second interview was conducted, a situation that occurred with participants ‘Ms B’ and ‘Ms F’. During the interview, participants were asked to reflect on their experiences. The researcher informed them that they could interrupt the interview at any time and did not have to discuss anything that made them uncomfortable. The researcher also observed their expressions and behaviour to ensure that the interview did not have a negative effect on them.
The phenomenological description of memories can be carried out through analysis of intentionality (Kawaguchi, 2012). First is the description of the noema (the object of intentionality; in this case, the content of the childbirth memory). This is followed by the description of the noesis (the activity of intentionality; how the memory is experienced) (Kawaguchi, 2012). The first question was ‘please tell me what you remember about your childbirth’ followed by ‘please tell me how you recall these memories’. The interviews were recorded on a digital voice recorder with the interviewees' consent and transcribed verbatim.
Analysis
To analyse the data, the authors first focused on the noema and described and analysed the meaning of childbirth for each woman. Second, with a focus on the noesis, the authors analysed and described how a woman's consciousness moved toward her memories, examining its relationship with the meaning of childbirth. In each interview, units of meaning were identified, grouped into clusters of meaning and categorised according to themes. Next, the entirety of participants' experiences were scrutinised to identify common constructs. The main theme emerged from the subthemes generated from these common constructs. After repeatedly returning to the data to determine representativeness, the themes were structured and the results were described. The descriptions were publicly available in phenomenological research groups throughout the study period to ensure that the analysis and descriptions were not bound by the researcher's preconceptions and assumptions. After describing the results, the participants were asked to confirm whether these interpretations were valid.
Ethical considerations
A collaborator and researcher informed the participants about the study. Subsequently, the researcher explained the study to the women by telephone. The participants could decide whether to cooperate with or discontinue participation in the study. Interview appointments were arranged for women who provided verbal consent. During the first interview, the researcher explained the study again and obtained written consent for participation. This study was conducted with the approval of the ethical review committee of the author's university in August 2015 (approval number: No. M2000-2164).
Results
Participant characteristics
The participants were six Japanese women aged 30–39 years (mean: 34 years) who had experienced their first childbirth within the past 2–14 years (Table 1). The interviews lasted 43–136 minutes.
Table 1. Details of participants
| Participant | Births | Age of child(ren) (years), type of delivery, other information |
|---|---|---|
| A | 2 | First: 8, normal spontaneous vaginal deliverySecond: 5, normal spontaneous vaginal delivery |
| B | 3 | First: 5, normal spontaneous vaginal deliverySecond: 3, normal spontaneous vaginal deliveryThird 0, normal spontaneous vaginal delivery |
| C | 2 | First: 7, emergency caesarean section, fetal distressSecond: 5, emergency caesarean section, premature birth |
| D | 2 | First: 6, normal spontaneous vaginal deliverySecond: 2, normal spontaneous vaginal delivery |
| E | 1 | First: 2, normal spontaneous vaginal delivery, infertility treatment |
| F | 2 | First: 14, normal spontaneous vaginal delivery, uterine inversionSecond: 11, normal spontaneous vaginal delivery |
Themes
Analysis of the six women's stories describing their experience of memories of childbirth revealed three themes. These themes were ‘do not recall memories of childbirth often’, ‘try to remember memories of childbirth’ and ‘memories keep coming back and circling round in one's head’. The themes are presented in Table 2 with the various subthemes that were used as guides for analysis.
Table 2. Overview of main themes and subthemes
| Participant | Main theme | Subthemes |
|---|---|---|
| A | Do not recall memories of childbirth | One process |
| B | Old story | |
| C | A life-or-death (event), but it is over | |
| D | Try to remember the memories of childbirth | Starting point |
| E | Family restarted | |
| F | The memories keep coming back and circling around in one's head | Painful, terrifying and lonely |
Do not recall the memories of childbirth often
All the participants clearly remembered their childbirth; however, memories were usually recalled when someone asked about them. Ms A, who had a strong desire to work normally after pregnancy, took medication to suppress uterine contractions during her two pregnancies and continued to work until her maternity leave. Ms A stated that it was difficult, but overcoming this pregnancy experience and giving birth remained a positive memory; however, such memories were not often recalled.
‘I do not often think about the births…When my children ask me what their births were like, I look back and discuss it with them, but I do not usually recall it myself…I think that childbirth and pregnancy is one process…and it…does not affect my present’.
(Ms A)
Ms A described recalling childbirth as ‘looking back’. Childbirth was seen as a thing of the past, distinguished from the present. Ms B said that she had given birth to three children and that many friends and family happily visited her for every birth, which left positive memories. Even for Ms B, whose last childbirth was only a few months ago, the experience seemed to be in the past, distant and nostalgic. Their daily lives were occupied with taking care of their children.
‘Childbirth was a long time ago, and it feels nostalgic. It seems like an old story. It is in the past. H's [5 years], K's [3 years], and even M's [3 months] births are all in the past. They are all in the distant past now’.
(Ms B)
‘I am too busy trying to take care of my three children. I have been too busy, and time was dense with things to do. My youngest baby was also hospitalised…I do not know when I will recall [the births]. I have never thought of that’.
(Ms B)
The women had to not only adjust to the daily routines of the responsibilities that come with caring for a newborn but also cope with changes in their children's growth and health conditions. Ms B, who had three children, said that it was distressing to be unable to focus on taking care of her baby when he was hospitalised because she also had to take care of her older children. After birth, participants reported that they had to be aware of their children's lives and think about the present in order to fulfill their responsibilities.
‘I must protect my children…I think about my children's growth and the present more than the past. Rather than looking back and thinking about the past, I must think about what I am going to do. It seems that “what to do now or next” occupies a larger percentage of my mind’.
(Ms A)
Ms A's sense of duty was evident from the word ‘must’. Being conscious of the present was necessary to continue daily life with children. Ms C was also always thinking about the present and valued living in the present.
‘It is not a laughing matter that I had a hard time giving birth or that my mother has an incurable disease, but I am going to die anyway so I want to laugh and live my life. If I think about my regrets in the past, there is no end to it. However, I think I did my best at all times, so I am the happiest now’.
(Ms C)
Regarding her two emergency caesarian sections, Ms C described how she struggled to endure 3 days of labour pains and that her baby experienced fetal distress, as well as how she suffered when her child was ill after being born prematurely. Now, however, Ms C reported that she felt happy. Her happiness was based on her past experience of doing her best in each moment. It was connected to her motto of living happily now, no matter what the situation. Her concern was on the present.
‘I think I will never see my children covered in mud [playing soccer] and saying, “Mum, I got a shot in!” This is a treasure really. It is now that is priceless’.
(Ms C)
‘When my children ask me with great interest about their birth, [I recall the memories]. But when I talk about it, I cannot help turning it into an interesting story. At that time, it might have been a life-or-death [event], but now that it is over, I think everyone probably can make it into an interesting story’.
(Ms C)
Ms C described her experience of childbirth as being ‘over’, and distinguished it from ‘now’. Although it was a life or death experience of childbirth, now that it was over, it could be transformed into an ‘interesting story’ to suit an audience. When a woman's awareness was on their lives with their children, the memory of childbirth could be recalled if the woman was asked about it, but most of the time, it was forgotten.
Try to remember memories of childbirth
Some women tried not to forget their memories and consciously recalled them. For example, during childrearing, things did not always go as the participants expected, they sometimes felt angry or lost peace of mind. When this happened, Ms D deliberately directed her attention to her childbirth memories.
‘I do not recall the pain of labour, but I recall that I felt my children were adorable the moment they were born. I especially try to recall those memories when I feel like I have scolded my children too much. It makes me realise “I should show them more love”. It is like…I am making use of it well’.
(Ms D)
An important memory for Ms D was the moment of feeling love for her children at birth. That memory became the foundation of her love for her children in daily life.
Ms E turned her attention to memories of childbirth when she experienced difficulties raising her children.
‘I sometimes think “Oh my god!” when I am raising my children. But in those moments, I try to recall the memories that were the hard times during childbirth and before pregnancy, but that he was born… My husband and I were just grateful that he was born. We had a lot of fights through infertility treatment, so I do not think there is any hardship that can surpass that tragedy. Even if my son is stirring the toilet bowl with his hands, I think it is cute’.
(Ms E)
Pregnancy and childbirth brought many challenges. Ms E emphasised the fact that her child had been born despite difficult circumstances. The memory that he was born after overcoming difficulties Ms E had experienced with her husband led to a feeling of gratitude for the birth of her son, and she regained her peace of mind. It also gave her the strength to face current difficulties.
For some participants, childbirth had been a special moment in their lives.
‘Until giving birth, I had always feared that I could not love my own child because I had never felt the general sense of mother-child relationship with my own mother. I thought my mother did not feel affection for me. When I gave birth, I felt they were adorable. I was relieved…A baseline was established that made me feel like this child is important to me…I thought my life had changed. I think childbirth gave me confidence. I had always been afraid that I would be like my mother. But I felt like I became a normal person. Childbirth was a turning point that changed me’.
(Ms D)
Ms D thought that a mother who could not love her own child was not normal. For a long time, the fear of not being normal haunted her, threatening her confidence. During childbirth, feeling affection for her child countered these feelings. The memory of feeling love for her child was the basis for what she felt was the process of becoming a normal mother. Whenever her ‘baseline’ of loving her child was threatened, she would return to the memory of childbirth, as it was a starting point of being a normal mother for her.
‘It is like returning to the starting point. I should remember it and never forget. After that, however, I would scold my children again’.
(Ms D)
Ms E had been experiencing difficulties with her husband because of disagreements they had during several years of infertility treatments. Ms. E had felt that she might not be able to get along with her husband until the fetal heartrate dropped during childbirth.
‘After my pregnancy, my husband and I had different view and thoughts, just as we did during infertility treatment. I felt my family fall apart. However, my mind changed during childbirth. When the fetal heart rate dropped, I suddenly realised that I wanted my husband. I asked the midwife to call him. That was the first time I wanted to count on my husband… The moment he arrived, I thought “Thank God!” and felt like I was okay. As soon as I saw him, I knew he was filled with anxiety and doing what was best for me. I thought we were finally on the same wavelength. I felt that my husband, doctors and midwives were all united…In our case, our family restarted with childbirth…After I gave birth, and I overcame infertility treatment, so I feel happier now’.
(Ms E)
It was only after relying on her husband through the birth process that Ms E realised how much he supported her. Childbirth had brought an opportunity to mend family ties and the memories were something she felt should not be forgotten.
‘I have decorated my room with some photos of my son as a baby and used a digital photo frame, so I do not forget’.
(Ms E)
The memories keep coming back and circling around in one's head
In daily life, memories of childbirth were usually forgotten unless the participants were reminded by someone or unless they tried to remember it themselves. However, participants reported that at some point, the memories had begun to intrude into their consciousness.
After childbirth, Ms F was immersed in taking care of her children.
‘I do not think I recalled the memories in that way for some time after childbirth. I think my mind was so occupied with what I should do at that time’.
(Ms F)
Years later, while driving a car on a long-distance trip, the memories of childbirth suddenly started recurring.
‘After entering university [6 years after the first birth], the memories started coming back and circling around every day during…drive to university. Often, I used to suddenly realise that I had no idea where I had driven. The road used to be familiar, so maybe I was driving unconsciously and automatically. Many times, I used to suddenly realise that I had already reached my destination. It was dangerous’.
(Ms F)
Once her concentration on driving was disrupted, the memories had quickly begun to intrude on her consciousness. Ms F said that this happened even though her children were in the car. Time and her surroundings stopped entering her consciousness, putting them in danger.
‘The memories used to keep coming back and circling around in my head, things like what happened after giving birth, what was said to me during the birth, and so on’.
(Ms F)
For Ms F, childbirth had been lonely, as no-one responded to her call for help.
‘My first childbirth was painful, terrifying and lonely. I asked midwives to let my husband stay with me because I was afraid of the pain, but they immediately sent him back to the waiting room and left me alone. I told them I feared the internal examination, but they said that it was dangerous to move…I do not remember the moment when my child was born. I think the doctor pulled the placenta and my uterus turned over…It was a terrible pain. But everyone was in such a hurry, they ignored me completely’.
(Ms F)
This recollection had not changed over time. Her memories were described as still causing difficulty, and this did not change as it had with Ms C, who said she made her experiences into an ‘interesting story’.
‘When my eldest daughter asks me what her birth was like, I still have difficulty. I cannot come up with anything positive at all. It is just painful, terrifying, and lonely’.
(Ms F)
About 10 years after her first childbirth, when she had graduated from university and no longer needed to concentrate as much on raising her children and studying, the memories began intruding into her consciousness more often.
‘I had time while my children were at school. Then, [memories] used to come more. Once it started, it just kept coming out. Even things like being hurt by my parents and being shocked by my husband, and so on…I had been so depressed. Probably, I had not realised before. It started to become clear. The things were whenever I asked for help, but I had been always cut off…I could not even sleep’.
(Ms F)
The memories of her lonely childbirth triggered similar memories, with the common denominator being ‘asking for help but being cut off’, and entering her consciousness. The feelings of loneliness and disconnection during childbirth affected her familial relationships with her husband and her parents. Ms F re-lived these experiences; they led her to realise her loneliness. The memories made it difficult to live in the present.
Discussion
The experiences of childbirth memories were narrated against the background of women attempting to live their lives in the present while coping with changes in their lives that accompanied the birth of a child. Most women described childbirth as ‘the past’ or a ‘starting point’ and as something that was distinct from the present. The memory of childbirth was thought of as part of the past. This was consistent with Aristotle's statement that ‘the memory is of the past’, an essential feature of memory (Kawaguchi, 2012). To recall a memory, recognising the temporal interval is important (Ricœur, 2004). Having a memory of childbirth as ‘the past’ means distinguishing between time intervals, and this is likely one of the abilities that enables recall (Kawaguchi, 2012).
The memory of childbirth as the past was usually forgotten when women's consciousness turned to the present in their daily childrearing activities, but some tried to recall their memories. These women had experienced difficulties in relationships with family members such as their mothers or husbands during childbirth and the birth was seen as a ‘starting point’ or a moment when ‘family restarted’. Because these memories of childbirth had become a source of support or confidence for them, they did not wish to forget them, making the memory not only a thing of the past but a new starting point. This confirms the findings of previous studies that memory contributes to increasing women's confidence and self-efficacy (Simkin, 1991; 1992). Midwives must understand that the meaning of childbirth is situated in the context of the woman who experiences it, including their interpersonal relationships. Such relationships include midwives, who are involved in and may influence the meaning-making of childbirth.
However, some memories of childbirth were not experienced as a thing of the past. For example, one woman had a birth that was ‘painful, terrifying and lonely’. She described her experience as ‘alone’ and ‘ignored’. She was deeply hurt by the fact that no-one responded to her. Similarly, previous studies have reported this type of suffering in childbirth, as women may feel they are not being understood, not being taken seriously or being reduced to an object (Beck, 2004a; Nilsson and Lundgren, 2009). The reciprocal relationship between the caregiver and caretaker is the foundation of caring (Mayeroff, 1971); however, medical care lacking this reciprocity may harm the woman. For Ms F, her memories of childbirth were not expressed in terms that signified the past. Such memories could not be changed to be more positive, as in the case of other participants, who stated that although their birth had been difficult at the time, now it was an interesting story to tell; rather, they were experienced as something that was merely ‘coming’ to the present. Recalling difficult experiences with childbirth could trigger other hurtful memories that repeatedly entered a woman's consciousness, making it difficult for her to forget them and to live in the present. The psychiatrist Nakai (2004) argued that memory is what we can recall if we want to but that we usually forget most of it; if all of our memories were to appear in our consciousness, it would collapse. Memory of childbirth being in the past and distinct from the present is necessary for forgetting and is considered an important factor in enabling people to focus on and live in the present (Nakai, 2004). Midwives are in a unique position to provide care in a reciprocal relationship during childbirth, building relationships from the beginning of pregnancy and being able to attend to women's emotions during birth. This can prevent women from feeling hurt or alone during this process, as some of the participants reported feeling in the present study.
In recent years, reflective discussions, an opportunity for women to talk about their child's birth, ask questions, and get information they need, have been offered by midwives in Europe (Baxter et al, 2014). Although evidence regarding the effectiveness of this type of intervention is not consistent (Bastos et al, 2015; Graaff et al, 2018), the results of the present study provide some evidence of the need for long-term care, such as birth reflection services, for women with distressing childbirth memories.
The results of the present study suggest that intrusive recall of memories might occur several years after birth, after childrearing has settled down. This involuntary recall of memories closely resembles one of the major symptoms of post-traumatic stress disorder (Herman, 1992). Previous quantitative studies on post-traumatic stress disorder following childbirth were conducted within the first 6 months postpartum (Dekel et al, 2017; Yildiz et al, 2017). As suggested by the results of this study, post-traumatic stress disorder following childbirth may occur later than this. Herman (1992) argued that the memory of trauma always returns at some point and forces attention. Thus, future studies should explore delayed post-traumatic stress disorder associated with childbirth.
Limitations
The sample size of participants was small and limited to Japanese women; thus, cross-country differences regarding many aspects of childbirth were not explored. For example, as a result of social and cultural influences, the use of pain relief medications is low in Japan; the epidural delivery rate is approximately 6% (Japan Association of Obstetricians and Gynecologists, 2017), limiting the options for childbirth. Recently, emphasis has been placed on high-risk pregnant women and the development of services for normal delivery has been delayed in Japan (Ministry of Health, Labour and Welfare, 2019). Compared to the UK, where midwife-led maternity care is recommended from pregnancy to postpartum (Edmonds et al, 2020), Japan does not provide the same care (Kamiya et al, 2015). The above differences may influence individual women's experience of childbirth and its meaning. However, recalling and forgetting are a universal human issue. This study, which aims to describe this experience, could also be useful for understanding the experiences of non-Japanese women. It enables readers to compare their own experiences and to consider similarities and differences. This will provide further insight into the experience of remembering childbirth.
In this study, participant recruitment was conducted through snowball sampling, which resulted in the participants belonging to a similar age group. As the experience of memories can be influenced by the life circumstances related to the mother's life cycle, future studies should include women of various ages. Additionally, the interview data were analysed and described at a single point in time; future research on experiences of childbirth memories should be conducted over time.
Conclusions
The memory of childbirth being in the past and distinct from the present was an essential factor for women to be able to live in the present. Women also gained meaning from childbirth, which supported them in the present context of their lives. Midwives should recognise that they are allowed to be present when such memories are created. Memories of a hurtful birth may continue to be recalled, even 10 years after the birth, evoking other unresolved issues and amplifying suffering. Midwives must be attentive to each woman's context and give her the care she needs through a reciprocal relationship. It is also necessary to build a system to provide long-term support.
Key points
- After giving birth, women raising their children often focus on the present. The memories of childbirth usually do not enter their consciousness in daily life.
- The meaning women gain from childbirth is positioned in their individual contexts. Midwives need to understand this to provide better care.
- To ensure that women are not harmed by care, midwives must be attentive to each woman's context and provide the care that they require through reciprocal interactions.
- Unresolved memories of suffering during childbirth could suddenly intrude into the present when women are not focusing their attention on something else; therefore, long-term care is needed throughout women's lives.
CPD reflective questions
- In your clinical practice, do you have opportunities to reflect on how women experience the care you provide?
- Have you ever talked to women who were distressed regarding childbirth and asked about the aspects of childbirth that they struggled with?
- Do your facilities and communities offer any forms of long-term support for women who are suffering after childbirth?
- Do you provide continuous support from childbirth until after birth? If not, how can you collaborate with other organizations to provide this support?