International Journal of
Environmental Research
and Public Health
Commentary
“Women Friendly”: A Childbirth Preparation Intervention in
Israel for Women with Symptoms of Post-Traumatic
Stress Disorder
Rachel Bachner-Melman 1,2, * , Racheli Haim-Dahan 1 and Ada H. Zohar 1,3
Citation: Bachner-Melman, R.;
Haim-Dahan, R.; Zohar, A.H.
“Women Friendly”: A Childbirth
Preparation Intervention in Israel for
Women with Symptoms of
Post-Traumatic Stress Disorder. Int. J.
Environ. Res. Public Health 2023, 20,
6851. https://doi.org/10.3390/
ijerph20196851
Academic Editor: Avi Besser
Received: 16 August 2023
Revised: 24 September 2023
Accepted: 26 September 2023
Published: 28 September 2023
Copyright: © 2023 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
Int. J. Environ. Res. Public Health 2023, 20, 6851. https://doi.org/10.3390/ijerph20196851
1 Ruppin Academic Center, Emek Hefer 4025000, Israel
2 School of Social Work, Hebrew University of Jerusalem, Jerusalem 9190500, Israel
3 Lior Zfaty Suicide and Mental Pain Research Center, Ruppin Academic Center, Emek Hefer 4025000, Israel
* Correspondence: rachel.bachner@mail.huji.ac.il
Abstract: Pregnant women with symptoms of post-traumatic stress disorder (PTSD), who have
experienced traumatic events such as sexual abuse and traumatic births, are particularly vulnerable
to experiencing extreme fear of childbirth complications during labor and traumatic deliveries. In
this commentary, we review the literature on this group of women and their specific needs during
pregnancy and childbirth. We present a childbirth preparation intervention for pregnant women
with PTSD symptoms, “Women Friendly”, designed in Israel and gradually becoming available in
the community and Israeli hospitals. This intervention is intended for women with high levels of
fear of childbirth who are unmotivated or unable to undergo traditional psychotherapy that focuses
on exposure to and processing of past traumatic event(s). It is based on birth-oriented thinking,
principles of positive psychology, and trauma-informed care. In addition to the five sessions offered
to pregnant women, medical staff are provided with 19 training sessions on the “Women Friendly”
approach. Qualitative and quantitative research should examine the effectiveness of this intervention.
Should results be encouraging, this intervention could be more widely implemented in Israel and
abroad and applied in broader contexts, such as gynecological check-ups and medical examinations,
interventions, and surgery.
Keywords: childbirth preparation; pregnancy; childbirth; PTSD; fear of childbirth; labor; staff
training; midwives; secondary traumatic stress; “Women Friendly”
1. Introduction
Most women view pregnancy and childbirth as normative developments that bring
with them joy, new life, and meaning, as well as challenges and physical pain. Yet for
women who have experienced traumatic events, in particular those related to sexual
abuse [1] and previous pregnancies and deliveries [2], the perinatal period is often fraught
with tension, fear, and anxiety, and childbirth is an event that is dreaded. In this com-
mentary, we review the literature on this vulnerable group of women and their specific
difficulties and needs during pregnancy and childbirth. We then briefly describe an inter-
vention for this group of women that was developed in Israel and is currently implemented
there, “Women Friendly”. Finally, we suggest future research to evaluate the effectiveness
of this intervention and possible adaptations to broader medical and cultural contexts.
1.1. Fear of Childbirth
Since childbirth is a complex, sensitive, and unpredictable process over which the
mother has limited control, it is almost universal to be apprehensive about the event to
some extent. Fear of childbirth exists on a continuum, with many women experiencing
high levels of fear [3]. At its most severe, a specific fear of childbirth has been likened to a
phobic response called “tokophobia” (tokos = childbirth in Greek), a term coined by the
https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2023, 20, 6851 2 of 9

French psychiatrist Louis Victor Marcé [4], which can seriously affect quality of life [5].
Whether or not tokophobia can be considered a specific phobia, this term is commonly
used to describe a severe fear of childbirth [5].
Eriksson & Westman [6] analyzed the open-ended responses of 308 women to a ques-
tionnaire about the specific fears they experienced during pregnancy about the childbirth
process. The women reported fears about the labor and delivery process (e.g., pain, pro-
longed labor), the health and life of the baby (e.g., disease or handicap, death), their
capabilities and reactions (e.g., not performing “correctly”, losing control of their body),
their health and life (e.g., being injured, dying), and professionals’ competence and be-
havior (receiving inadequate medical care, being treated disrespectfully). Women’s other
childbirth-related fears include a lack of support [7], disempowerment and helplessness, a
caesarean section, the unknown, and/or the repetition of a traumatic or horrific experience
during a past delivery [8]. Fear of childbirth seems to be both a consequence of [9] and a
risk factor for [10] symptoms of trauma, and prevention interventions are limited [11].

Risk Factors for Fear of Childbirth and Traumatic Birth: History of Abuse and Traumatic
Childbirth Experiences
In terms of etiology, many sociodemographic, psychosocial, and personality factors
have been linked to an extreme fear of childbirth [12]. Two are worthy of special mention.
The first is a history of sexual, emotional, or physical abuse or violence [13–15]. Soet
et al. [16] found that women who had experienced past sexual trauma were 12 times more
likely than women who had not experienced sexual trauma to experience the childbirth
event as traumatic. Heimstad et al. [13] found that Norwegian women who reported having
been exposed to physical or sexual abuse during childhood scored significantly higher
on fear of childbirth than women who had not. Leeners et al. [17] compared the birth
experiences of 85 women with a history of child sexual abuse to those of women without
such a history. They found that for women who were abused as children, childbirth was
a significantly more negative and frightening experience. However, supportive factors
during pregnancy and labor, such as birth preparation classes, the presence of a trusted
person, and active participation in medical decisions, weakened this effect. Support and
empowerment during pregnancy and childhood therefore seem to be of particularly great
value to women who were abused as children and should therefore be a central element of
childbirth interventions for this population.
A second factor strongly predictive of an extreme fear of childbirth is a previous
distressing or traumatic birth experience [2] that may have involved prolonged labor, birth
complications, and/or emergency obstetric procedures [18], such as a caesarean section or
vacuum extraction [19]. Sexual abuse and traumatic childbirth experiences are also included
in the category of sudden and catastrophic events that can lead to the development of post-
traumatic stress disorder (PTSD) [20]. Childbirth leads to PTSD in an estimated 3–4% of
women, with 15–19% of women in high-risk groups developing postpartum PTSD [21,22].
Pre-existing post-traumatic symptoms may also be exacerbated following pregnancy and
childbirth [23,24]. Ertan et al. [25] identified social support as a protective factor for the
well-being of mothers with PTSD symptoms following childbirth, underscoring the impor-
tance of support in childbirth interventions. McKenzie-McHarg et al. [11] suggested the
prevention strategies of early identification of vulnerable women and additional midwifery
support to ensure compassionate care during labor.

1.2. Mistreatment of Women during Childbirth

Mistreatment of women and violence against them during childbirth are sadly not
uncommon [26–28]. Perrotte et al. [29] used the seven categories of Bowser and Hill’s [30]
seven categories of “disrespect and abuse” or “obstetric violence” (physical abuse, non-
consensual care, non-confidential care, non-dignified care, discrimination, inadequate care,
and detention in facilities) to review 22 relevant studies on disrespect and abuse of women
during childbirth and found this to occur throughout the world. Fear of a repetition of
Int. J. Environ. Res. Public Health 2023, 20, 6851 3 of 9

disrespect and abuse in subsequent births causes some women to avoid pregnancy [31],
plan unsafe home births, and avoid available obstetric care [32]. Since women often
describe experiences of violence in childbirth via metaphors of rape [33], those who have
past experience of sexual abuse, especially rape, are particularly prone to re-traumatization
when professionals use forceful behaviors during delivery. This tragic state of affairs has
led to definitions of and a call for respectful maternity care [34,35].
According to Shabot [33], one of the causes of obstetric violence during childbirth
is power imbalances between physicians and patients, in particular when the woman’s
choice differs from the decision of the physician. Patients often choose not to challenge
the system by reporting obstetric violence since they feel dependent on the medical team
for their ongoing and future care [36]. There is, therefore, a great need for change via
training and discussion among medical teams, to make them aware of the power they
have because of their professional and institutional status, and the need for them to listen
carefully to what women want when delivering their babies and to respect their wishes as
far as possible. Working conditions in obstetrical wards are often stressful because of low
resources, understaffing, and long shifts [37,38], so improving the working conditions of
professionals involved in giving birth also stands to contribute to the well-being of women
in childbirth.

1.3. Vicarious Traumatization and Needs of Medical Staff

Obstetric medical staff members often experience emotionally complex events be-
cause of their central and critical role in childbirth. This role can expose them to loss and
trauma during pregnancy and childbirth, for which they are ill-prepared and unable to
process adequately [39]. Midwives, in particular, are at high risk for symptoms of PTSD
for these reasons [40,41]. Secondary traumatic stress resulting from indirect traumatic
exposure in a professional context is sadly common in all professionals who help women
deliver their babies [42–44]. Beck & Gable [45] collected both quantitative and qualitative
data from 464 labor and delivery nurses in the US, of whom 35% reported moderate to
severe levels of secondary traumatic stress. Content analyses of participants’ descrip-
tions yielded six themes: (a) facing situations that intensify exposure to traumatic births;
(b) struggling to maintain a professional front; (c) agonizing over what should have been
done; (d) mitigating the aftermath of exposure to traumatic births; (e) secondary traumatic
stress symptoms; and (f) considering a change in career. It is therefore of great impor-
tance for medical professionals involved in childbirth to receive information, training, and
emotional support related to the traumatic aspects of pregnancy and delivery.
De Vries [46] found that midwives generally hold positive attitudes towards women
with PTSD but feel that, in general, they lack the knowledge necessary to help them
adequately. It is important to offer relevant training to midwives and to all professionals
who come into contact with women during pregnancy and childbirth.

1.4. The Need for Interventions for Women with Severe Fear of Childbirth
Little is known about how pregnant women with severe fear of childbirth can be best
supported and how appropriate support can be best organized within healthcare systems.
Respect and joint decision-making seem essential to a positive emotional environment
for women giving birth [47–49]. As suggested by Reynolds [50] and by Gelaye et al. [51],
thorough and discreet screening for past traumatic experiences, particularly sexual trauma
and traumatic birth, is important.
Psychoeducation can be effective in reducing the fear of childbirth, preventing re-
traumatization, and reducing the use of caesarean sections [19,48,52,53]. Eye Movement
Desensitization and Reprocessing (EMDR) is not more effective than care-as-usual in
treating fear of childbirth [54]. Hosseini et al. [55] examined the effectiveness of the
interventions evaluated in eight studies that used education and two that used hypnosis
to reduce fear of childbirth and concluded that educational interventions may be twice as
effective as hypnosis. Newham et al. [56] found that 29 women randomized to receive eight
Int. J. Environ. Res. Public Health 2023, 20, 6851 4 of 9

weeks of antenatal Hatha yoga reported lower levels of fear of childbirth than 28 women
who received treatment as usual, although the effect size was small. Other interventions that
may be effective include supportive midwifery [57] and cognitive behavioral approaches,
which are effective treatments for anxiety disorders [58]. It is unclear how effective birth
plans are in reducing fear of childbirth [59], although Thomson & Downe [60] found
that those that help prepare women for multiple realities were perceived as helpful. A
Cochrane review synthesizing empirical evidence for non-pharmacological interventions
to treat fear of childbirth, including tocophobia, included seven trials with a total of
1357 participants [61]. The authors concluded that the effect of such interventions is
uncertain, although there may be a reduction in caesarean section delivery.
There is a growing awareness in Israel of the need to address the emotional as well
as medical needs of women in pregnancy and labor, which has given rise to a field coined
“Birth-oriented Thinking” (see https://www.bot.co.il/english-bot, accessed on 15 August
2023). This field focuses on the emotional aspects of the pre- and post-partum period and of
labor itself. Its overarching aim is to promote mindful communication about birth between
women giving birth and the medical team. This is done via education and training programs
for professionals involved in childbirth, such as physicians, midwives, psychotherapists,
nurses, doulas, and social workers, so as to address the needs of all involved. The “Women
Friendly” intervention, described below, is one example of how “Birth-oriented Thinking”
programs help women to cope successfully with the perinatal period and labor.
Psychotherapy, including hypnotism, biofeedback, emotional freedom techniques and
breathing awareness, group psychotherapy, EMDR, psycho-education intensive therapy,
mindfulness, cognitive group therapy, relaxation and directed images, and reality therapy,
can, in fact, be helpful for women with fear of childbirth, according to a recent systematic
review [53]. However, pregnant women with symptoms of PTSD may not be motivated or
emotionally available for psychotherapy that addresses sensitive issues from the past that
affect their pregnancy and delivery. In-depth therapy that aims to process past abuse or
other traumatic events often lasts longer than nine months and requires inner emotional
resources that may not always be available. For these reasons, pregnant women may
therefore decide not to engage in therapy during pregnancy to address PTSD symptoms,
yet they may experience distress as childbirth approaches, which they would like to be able
to manage.

2. The “Women Friendly” Intervention

The “Women Friendly” intervention program is an example of birth-related thinking
that focuses on women who have experienced traumatic events. It is a childbirth prepa-
ration program for pregnant women with symptoms of PTSD, founded in Israel in 2017
by Hila Lev-Ran. This program aims to improve communication between mothers with
complex emotional backgrounds and the medical staff during childbirth so as to facilitate
as positive an experience as possible all around and prevent the resurgence or exacerbation
of traumatic memories in the mothers. The needs of both mothers and the medical staff
in the labor wards are therefore targeted. The overall goals are consistent with positive
psychology interventions: An emphasis on strengths and sources of support and the em-
powerment of the pregnant woman to deal with the challenges posed by her traumatic
past and the potential triggers of childbirth. The goals of the “Women Friendly” childbirth
intervention are also consistent with the principles of trauma-informed care [62–64], which
aim to integrate an understanding of trauma and trauma-related symptoms into routine
practice so as to create a safe and healing environment. The intervention also strives to
break the vicious cycles of aggression that can develop during childbirth toward women
who have experienced traumatic events. It is offered either as a stand-alone intervention or
in combination with medications.
Int. J. Environ. Res. Public Health 2023, 20, 6851 5 of 9

2.1. Training for Medical Staff

Since the “Women Friendly” childbirth preparation intervention is delivered by health-
care professionals who accept joint responsibility for the well-being of the women giving
birth, they are provided with suitable training.
The “Women Friendly” intervention includes 19 four-hour training sessions over the
course of six months, covering theoretical and practical aspects of the intervention for med-
ical staff. This training is offered to midwives, doctors, nurses, technicians, psychologists,
social workers, doulas, lactation consultants, and pelvic floor physiotherapists. During the
training, professionals are taught skills to be used in checkups, medical procedures, and
childbirth, and how to adapt them when needed, based on the personal history presented
by each woman.
The skills imparted during the training include how to:
• identify women with post-traumatic symptoms and their needs, including women
who have experienced sexual abuse or previous birth trauma.
• engage in conversations in which women relate their past traumatic experiences.
• conduct an initial meeting at the Women Friendly Clinic with women who have had
traumatic experiences.
• facilitate the preparation of a personalized birth plan (“Women Friendly” document).
• support women briefly and effectively when they are fearful and anxious during labor.
• speak sensitively to women at all stages of childbirth, e.g., while waiting for an
epidural, after giving birth.
• use first aid tools and emotional support in the delivery room.
• self-regulate in emergency situations, such as the need to move from a delivery room
to an operating theater, or the need to resuscitate a newborn.
• accompany women during and after complex and traumatic emotional experiences
such as stillbirths.
Medical staff in hospitals, who are at the highest risk for vicarious traumatization,
are offered a more intensive intervention that takes 130 h, spread over six months. The
topics in this intensive course include in vitro fertilization (IVF) units, high-risk pregnan-
cies, labor, and premature deliveries. Specific techniques are imparted for self-regulation
in high-arousal emergency situations, for contending with the symptoms of secondary
traumatization, for supporting women who have experienced sexual abuse, pregnancy loss,
and other acute distress situations, and for mutually supportive communication between
staff members.

2.2. Childbirth Preparation Intervention for Pregnant Women

Five one-hour, individual sessions over approximately two months are included in
the “Women Friendly” intervention for pregnant women with fear of childbirth. They
are spread over approximately two months, although this varies according to the stage
of pregnancy at the time of the first session and the individual circumstances of each
woman. Facilitators are midwives, doctors, nurses, technicians, psychologists, social
workers, doulas, lactation consultants, and pelvic floor physiotherapists who successfully
completed the training described above.
The first session focuses on psychoeducation about childbirth and teaches cognitive-
behavioral techniques that can be used to desensitize the potential PTSD triggers anticipated
in the process of childbirth. For example, a woman who previously experienced a traumatic
experience during delivery may be encouraged to visit the hospital and, if possible, enter a
labor ward to decrease levels of anxiety when exposed to these specific settings.
The second session is devoted to the identification and processing of fears and anxieties
associated with the birth process. The group facilitator asks each participant to identify
her fears and anxieties and reflect on them, to increase awareness of the challenges that
lie ahead.
During the third session, participants delve further into potential specific situations
that could lead to stress, distress, and/or re-traumatization during childbirth. The women
Int. J. Environ. Res. Public Health 2023, 20, 6851 6 of 9

are encouraged to think of scenarios that might trigger the emergence of post-traumatic
symptoms, and troubleshoot and envisage coping strategies.
During the fourth and fifth sessions, participants put in writing, in collaboration
with the group facilitator, their “Women Friendly” document. This is a record of personal
background and requests that the women would like to convey to the medical team when
they arrive at the hospital to give birth; no separate birth plan is prepared. The purpose of
the document is to give the women a voice and allow them to communicate their genuine
wishes for how they are treated during childbirth, to help them assert themselves rather
than be passive and dependent on the hospital staff. Personal information and background
about emotional history are presented, although each woman determines the level of
self-disclosure with which she feels comfortable. The document describes the potential
anxiety- or distress-provoking scenarios identified during the “Women Friendly” sessions
and suggests possible strategies for the medical staff to help overcome them and minimize
distress. For example, a woman who has identified a vaginal examination by a male doctor
or nurse as a potential stressor might request to be examined by women only.

2.3. Implementation
To date, 75 female “Women Friendly” facilitators have been trained in Israel. Four
hospitals in Israel have established official “Women Friendly” clinics, headed by midwives
trained in the “Women Friendly” approach. Women who have participated in a “Women
Friendly” childbirth preparation intervention with a professional in the community during
pregnancy can prepare and take along a “Women Friendly” document when they give birth
in any Israeli hospital. More professionals should be trained in the approach to ensure a
positive and supportive response to the “Women Friendly” document across birth settings.
The “Women Friendly” approach is gradually expanding beyond labor wards to include
other medical contexts. For example, a “Women Friendly” intervention is now available for
women who need to undergo invasive medical treatments.

3. Suggestions for Research

The feasibility and effectiveness of the “Women Friendly” intervention should be
addressed in future research. The experiences of women participating in the intervention
could be explored in both qualitative and quantitative research. In a qualitative study,
for example, the birth experience of women who participate in the intervention could
be explored via face-to-face interviews to investigate its personal benefits and possible
drawbacks. The perspectives of partners, other family members, and the medical team
would also be of interest.
A quantitative study could compare symptoms of PTSD in women with a history of
traumatic experiences who participated in the intervention with women with a history of
traumatic experiences who did not. In initial quantitative research evaluating the effective-
ness of the “Women Friendly” intervention, it may be advantageous to include only women
not taking psychiatric medication, to rule out medication as a possible confounding factor.
Future studies should also compare the symptoms of PTSD in medical staff before
and after their participation in the intervention. The health outcomes of the offspring of
women with PTSD who participated in the intervention could also be compared to those of
the offspring of women with PTSD who did not participate in the intervention. Finally, it
should be examined whether “Women Friendly” is appropriate for use across cultures.
Should research provide evidence for the effectiveness of this intervention, the pro-
gram could be expanded to more hospitals and therapists, encouraged by gynecologists,
nurses, and other professionals during pregnancy, and implemented in other countries and
cultures. The principles of this childbirth intervention could also be applied in broader con-
texts, such as gynecological check-ups, medical examinations, interventions, and surgery.
It could also be used in additional medical contexts and settings, such as maternity wards
following birth, routine gynecological examinations, and other medical examinations.
Int. J. Environ. Res. Public Health 2023, 20, 6851 7 of 9

Author Contributions: R.B.-M. wrote the paper with the active help of R.H.-D. and A.H.Z. revised
and added to it. All authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.
Acknowledgments: The authors would like to thank Hila Lev-Ran, founder of the “Women Friendly”
intervention, for her wisdom and support.
Conflicts of Interest: The authors declare no conflict of interest.

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