Postnatal Post-traumatic Stress Research Articles

An exploratory qualitative study exploring GPs' and psychiatrists' perceptions of post-traumatic stress disorder in postnatal women using a fictional case vignette.

Postnatal post-traumatic stress disorder (PTSD) affects 3%-4% of women who give birth. It is underdiagnosed and undertreated. Thus far, no studies have investigated doctors' perceptions of PTSD in postnatal women. We investigated whether GPs and psychiatrists perceive PTSD symptoms after birth to indicate pathology and what diagnosis and management they would offer. Semi-structured interviews were conducted with six GPs and seven psychiatrists using a fictional vignette featuring a woman experiencing PTSD following a traumatic birth. A framework analysis approach was used. Despite half the GPs recognizing trauma-related features in the vignette their most common diagnosis was postnatal depression whereas six of the seven psychiatrists identified PTSD. Management plans reflected this. Both GPs and psychiatrists lacked trust in timeliness of referrals to psychological services. Both suggested referral to specialist perinatal mental health teams. Results suggest women are unlikely to get a PTSD diagnosis during initial GP consultations, however the woman-centred care proposed by GPs means that a trauma-focussed diagnosis later in the care pathway was not ruled out. Further research is needed to confirm these findings, which suggest that an evidence base around best management for women with postnatal PTSD is sorely needed, especially to inform GP training.

Maternal Mental Health Disorders Following Very Preterm Birth at 5 Years Post-Birth.

Mothers of children born very preterm (VP) are at increased risk of developing postnatal depression, anxiety, and post-traumatic stress symptoms. However, mental health disorder rates are rarely assessed in this population compared with full-term peers, and it is unclear if postnatal distress symptoms precede higher rates of maternal mental health disorders at 5 years post-birth in both birth groups. Mothers of children born VP (n = 65; mean [SD] age at birth, 33.9 [5.0]; 72.1% tertiary educated) and full-term (n = 90; mean [SD] age at birth, 33.4 [4.0]; 88.2% tertiary educated) completed questionnaires assessing symptoms of depression, anxiety, and trauma within 4 weeks of birth. At 5 years post-birth, they participated in a structured diagnostic interview assessing mood, anxiety, and trauma-related mental health disorders, both current and over the lifetime. There was little evidence for differences between mothers in the VP and full-term groups in rates of any mental health disorder at 5 years (VP = 14%, full-term = 14%) or lifetime (VP = 41%, full-term = 37%). In mothers of children born VP, elevated postnatal post-traumatic stress symptoms were associated with higher rates of mental health disorders at 5 years (odds ratio = 21.5, 95% confidence interval = 1.35-342). Findings suggest that preterm birth may not lead to increased odds of later developing maternal mental health disorders, despite known risks of elevated postnatal distress following a VP birth. However, those with post-traumatic stress symptoms following a VP birth could be more vulnerable, and assessment and monitoring is recommended.

When birth is not as expected: a systematic review of the impact of a mismatch between expectations and experiences

BackgroundPregnancy and childbirth are significant events in women’s lives and most women have expectations or plans for how they hope their labour and birth will go. It is possible that strong expectations about labour and birth lead to dissatisfaction or other negative outcomes if these expectations are not met, but it is not clear if this is the case. The aim was therefore to synthesise prospective studies in order to understand whether unmet birth expectations are associated with adverse outcomes for women, their partners and their infants.MethodSearches were carried out in Academic Search Complete; CINAHL; Medline; PsycINFO, PsychArticles, PubMed, SCOPUS and Web of Science. Forward and backward searches were also completed. Studies were included if they reported prospective empirical research that examined the association between a mismatch in birth expectations/experience and postnatal outcomes in women, their children and/or their partners. Data were synthesised qualitatively using a narrative approach where study characteristics, context and methodological quality were extracted and summarised and then the differences and similarities among studies were used to draw conclusions.ResultsEleven quantitative studies were identified for inclusion from nine countries. A mismatch between birth expectations and experiences was associated with reduced birth satisfaction. Three studies found a link between a mismatch and the development of postnatal post-traumatic stress disorder (PTSD). The evidence was inconsistent for postnatal depression, and fear of childbirth. Only one study looked at physical outcomes in the form of health-related quality of life.ConclusionsA mismatch between birth expectations and experiences is associated with birth satisfaction and it may increase the risk of developing postnatal PTSD. However, it is not clear whether a mismatch is associated with other postnatal mental health conditions. Further prospective research is needed to examine gaps in knowledge and provide standardised methods of measuring childbirth expectations-experiences mismatch. To ensure women’s expectations are met, and therefore experience a satisfying birth experience, maternity providers should provide sensitive care, which acknowledges women’s needs and preferences, is based on open and clear communication, is delivered as early in pregnancy as possible, and enables women to make their own decisions about care.Trial registrationProtocol registration: PROSPERO CRD42020191081.

Birth trauma: the mediating effects of perceived support

Background Many women experience their childbirth as traumatic, and 4-6% of mothers present with postnatal post-traumatic stress disorder. Aims To measure the relationship between obstetric intervention, perceived support in childbirth and mothers' experiences of postnatal trauma, and to identify salient aspects of the birth experience that are considered traumatic. Methods A total of 222 women in their first year postpartum were recruited between October and December 2018 via local mother and baby groups in southwest England (UK) and online social media pages. They completed an online survey regarding their birth experience. Further insight into mother's birth experiences was garnered through free-text responses in the survey. Results Overall, 29% of mothers experienced a traumatic birth and 15% met full or partial criteria for post-traumatic stress disorder. Feeling supported mediated the relationship between obstetric intervention and postnatal trauma symptoms. Conclusions This study reinforces the value of supportive healthcare professionals and the power of a nurturing environment, which can buffer the potentially negative effects of an obstetrically complicated birth on postnatal trauma symptoms.

Improving mental health and physiological stress responses in mothers following traumatic childbirth and in their infants: study protocol for the Swiss TrAumatic biRth Trial (START)

IntroductionEmergency caesarean section (ECS) qualifies as a psychological trauma, which may result in postnatal post-traumatic stress disorder (PTSD). Maternal PTSD may not only have a significant negative impact on mother–infant...

Postnatal post-traumatic stress: An integrative review.

Post-traumatic stress disorder and post-traumatic stress symptoms following birth occur amongst a small proportion of women but can lead to poor maternal mental health, impairment in mother-infant bonding and relationship stress. This integrative review aims to examine the associated risk factors and women's own experiences of postnatal post-traumatic stress in order to better understand this phenomenon. Fifty three articles were included and critically reviewed using the relevant Critical Appraisal Skills Program checklists or Strengthening the Reporting of Observational studies in Epidemiology assessment tool. Risk factors for postnatal post-traumatic stress symptoms and disorder include factors arising before pregnancy, during the antenatal period, in labour and birth and in the postnatal period. Potential protective factors against postnatal post-traumatic stress have been identified in a few studies. The development of postnatal post-traumatic stress can lead to negative outcomes for women, infants and families. Risk factors for post-traumatic stress symptoms and disorder are potentially identifiable pre-pregnancy and during the antenatal, intrapartum and postnatal periods. Potential protective factors have been identified however they are presently under researched. Predictive models for postnatal post-traumatic stress disorder development have been proposed, however further investigation is required to test such models in a variety of settings. Postnatal post-traumatic stress symptoms and disorder have been shown to negatively impact the lives of childbearing women. Further investigation into methods and models for identifying women at risk of developing postnatal post-traumatic stress following childbirth is required in order to improve outcomes for this population of women.

Women's experiences of living with postnatal PTSD

the mental health of new mothers is a public health concern as it is likely to have an impact on the mother herself, her close relationships and the behavioural and emotional health of her children. Post-traumatic stress disorder affects some women after childbirth. Objectivethe aim of this study was to explore how women were affected by the memories of a birth that they perceived as traumatic. Designin this paper the authors report the qualitative analysis of interview data from seven postnatal women reporting symptoms of PTSD. Participants were recruited from a large NHS Trust in the South West of England. Thematic analysis was used to analyse interview data collected from the seven women reporting symptoms of postnatal PTSD. Findingscomplicating factors such as relationship difficulties and pre-existing health problems appeared to contribute to postnatal post-traumatic stress disorder and some women reported difficulty expressing emotions. The study findings confirm that women value good relationships with midwives during labour. Key conclusions and implications for practiceantenatal screening for personality traits such as alexithymia (difficulty expressing emotions) may be useful and midwives should be alert to current life events that may increase women's vulnerability to post-traumatic stress disorder.

Reducing intrusive traumatic memories after emergency caesarean section: A proof-of-principle randomized controlled study

Preventative psychological interventions to aid women after traumatic childbirth are needed. This proof-of-principle randomized controlled study evaluated whether the number of intrusive traumatic memories mothers experience after emergency caesarean section (ECS) could be reduced by a brief cognitive intervention. 56 women after ECS were randomized to one of two parallel groups in a 1:1 ratio: intervention (usual care plus cognitive task procedure) or control (usual care). The intervention group engaged in a visuospatial task (computer-game ‘Tetris’ via a handheld gaming device) for 15 min within six hours following their ECS. The primary outcome was the number of intrusive traumatic memories related to the ECS recorded in a diary for the week post-ECS. As predicted, compared with controls, the intervention group reported fewer intrusive traumatic memories (M = 4.77, SD = 10.71 vs. M = 9.22, SD = 10.69, d = 0.647 [95% CI: 0.106, 1.182]) over 1 week (intention-to-treat analyses, primary outcome). There was a trend towards reduced acute stress re-experiencing symptoms (d = 0.503 [95% CI: −0.032, 1.033]) after 1 week (intention-to-treat analyses). Times series analysis on daily intrusions data confirmed the predicted difference between groups. 72% of women rated the intervention “rather” to “extremely” acceptable. This represents a first step in the development of an early (and potentially universal) intervention to prevent postnatal posttraumatic stress symptoms that may benefit both mother and child. Clinical trial registrationClinicalTrials.gov, www.clinicaltrials.gov, NCT02502513.

The Validity and Reliability of a Scale on Postnatal Posttraumatic Stress Symptoms Related to Childbirth among Japanese Women: Evaluation of the Japanese-language Version of the Impact of Event Scale-revised

Objective: The aim of this study was to examine the validity and reliability of the Postnatal Women Version of Japanese-language version of the Impact of Event Scale-Revised (IES-R-J-PWV) at one month after childbirth among Japanese women. Methods: Data were collected at two general hospital maternity wards and one obstetric clinic in Aichi Prefecture from July to December 2013. A total of 260 postnatal Japanese women participated in this study. The women completed anonymous self-report questionnaires at one month postpartum. To examine the construct validity of the IES-R-J-PWV, we conducted exploratory factor analysis with promax rotation. We evaluated the criterion-related validity of the IES-R-J-PWV using Spearman’s correlation coefficients between IES-R-J scores and scale scores from the Japanese Edinburgh Postpartum Depression Scale (JEPDS), the Visual Analog Scale (VAS), and the Sense of Coherence-13 (SOC-13) instrument. Results: Exploratory factor analysis revealed that the IES-R-J-PWV was composed of four factors. The total subscale scores for the four factors significantly correlated with each subscale score. The IES-R-J-PWV was positively correlated with the JEPDS (rs = 0.40, p < 0.01) and the VAS (rs = 0.47, p < 0.01) and negatively correlated with the SOC-13 (rs = -0.33, p < 0.01). The IES-R-J-PWV had good internal consistency, with a Cronbach’s α coefficient of 0.92. Conclusions: The results of this study indicated that the IES-R-J-PWV was a valid and acceptable instrument for measuring and evaluating postnatal posttraumatic stress symptoms related to childbirth among Japanese women at one month after childbirth.

Women's experiences of symptoms of posttraumatic stress disorder (PTSD) after traumatic childbirth: a review and critical appraisal.

This paper critically analyses nine studies on postnatal posttraumatic stress disorder (PTSD) following traumatic childbirth, in order to find common themes of PTSD symptoms, using the cognitive model of PTSD as a guide; it critically appraised one of the studies in depth and it attempted to explain the lived experience of women suffering from postnatal PTSD following traumatic childbirth and the suitability of cognitive behavioural therapy (CBT) for postnatal PTSD. This paper found that women following traumatic childbirth do experience postnatal PTSD; postnatal PTSD symptoms are similar to PTSD symptoms of other events and that CBT for PTSD of other events is just as effective for postnatal PTSD. Future recommendations include more qualitative studies with interpretative phenomenological approach in order to establish evidence-based CBT treatment for this client group, and more referrals need to be sent to the psychological services for CBT intervention.

Postnatal posttraumatic stress: A grounded theory model of first-time mothers’ experiences

Objective: To develop a grounded theory model of first-time mothers’ experiences of postnatal posttraumatic stress, with the aim of aiding understanding, formulation and treatment of new mothers. Background: Research into postnatal posttraumatic stress is growing, yet evidence-based treatment models have yet to be fully developed. It is unknown whether existing models of posttraumatic stress are directly applicable to postnatal posttraumatic stress, or whether other factors are particularly relevant for symptoms occurring in this context. Methods: A qualitative design explored first-time mothers’ experiences of pregnancy, labour, birth and the postpartum, following a subjectively identified traumatic labour and/ or childbirth. Eleven mothers were interviewed individually, either reporting full symptoms of posttraumatic stress (n = 6), or partial symptoms (n = 5). Grounded theory methodology was used to code the data and develop a theoretical model of maternal postnatal posttraumatic stress based on these accounts. Results: Factors emerged specific to postnatal experiences, including: antenatal expectations and anxieties, constructions of the experience, perceptions of other people’s views, social support (from specific sources) and adaptive and maladaptive coping strategies. Limitations: The study was based on a small sample of first-time mothers’ accounts, and therefore may not be applicable to mothers with previous children, or a wider maternal population. Conclusions: The new model highlights important areas for development in clinical practice at various stages of maternal healthcare provision: in the antenatal period, during labour and birth, and into the postpartum. The model can inform formulation and treatment of mothers experiencing postnatal trauma symptoms, providing specific areas of focus for intervention.

Hyperarousal symptoms after traumatic and nontraumatic births

Background: Measurement is critical in postnatal posttraumatic stress disorder (PTSD) because symptoms may be influenced by normal postnatal phenomena such as physiological changes and fatigue. Objective: This study examined: (1) whether hyperarousal symptoms differ between women who have traumatic or nontraumatic births; (2) whether the construct of hyperarousal is coherent in postnatal women; and (3) whether hyperarousal symptoms are useful for identifying women who have traumatic births or PTSD. Methods: A survey of PTSD symptoms in 1,078 women recruited via the community or Internet who completed an online or paper questionnaire measuring childbirth-related PTSD symptoms between 1 and 36 months after birth. Women who had a traumatic birth as defined by DSM-IV criterion A (n = 458) were compared with women who did not have a traumatic birth (n = 591). Results: A one-factor dimension of hyperarousal was identified that included all five hyperarousal items. Diagnostic criteria of two or more hyperarousal symptoms in the previous week were reported by 75.3% of women with traumatic birth and 50.5% of women with nontraumatic births. The difference in mean hyperarousal symptoms between groups was substantial at 0.76 of a standard deviation (Hedge’s g, CI = 0.64, 0.89). A larger difference was observed between women with and without diagnostic PTSD (g = 1.64, CI 1.46, 1.81). However, receiver operating characteristic analyses showed hyperarousal symptoms have poor specificity and alternative ways of calculating symptoms did not improve this. Comparison with other PTSD symptoms found re-experiencing symptoms were most accurate at identifying women with traumatic births. Conclusions: Results suggest hyperarousal symptoms are associated with traumatic birth and are a coherent construct in postnatal women. However, they have poor specificity and should only be used as part of diagnostic criteria, not as a sole indicator.

Modification and preliminary use of the five-minute speech sample in the postpartum: associations with postnatal depression and posttraumatic stress

Little is known about what constitutes key components of partner support during the childbirth experience. This study modified the five minute speech sample, a measure of expressed emotion (EE), for use with new parents in the immediate postpartum. A coding framework was developed to rate the speech samples on dimensions of couple support. Associations were explored between these codes and subsequent symptoms of postnatal depression and posttraumatic stress. 372 couples were recruited in the early postpartum and individually provided short speech samples. Posttraumatic stress and postnatal depression symptoms were assessed via questionnaire measures at six and thirteen weeks. Two hundred and twelve couples completed all time-points. Key elements of supportive interactions were identified and reliably categorised. Mothers' posttraumatic stress was associated with criticisms of the partner during childbirth, general relationship criticisms and men's perception of helplessness. Postnatal depression was associated with absence of partner empathy and any positive comments regarding the partner's support. The content of new parents' descriptions of labour and childbirth, their partner during labour and birth and their relationship within the immediate postpartum may have significant implications for later psychological functioning. Interventions to enhance specific supportive elements between couples during the antenatal period merit development and evaluation.

Infant Developmental Outcomes: A Family Systems Perspective

The aim of the current study was to examine whether parental mental health, parent–infant relationship, infant characteristics and couple's relationship factors were associated with the infant's development. Forty-two families took part at three time points. The first, at 3 months postpartum, involved a video recorded observation (CARE-index) of parent–infant interactions. At 5 months postpartum, in-depth clinical interviews (the Birmingham Interview of Maternal Mental Health) assessed parental mental health and parental perceptions of their relationship with their infant, their partner and their infant's characteristics. Finally, the Bayley Scales III was carried out 17 months postpartum to assess the infants' cognitive, language and motor development. A higher mother–infant relationship quality was significantly associated with more optimal language development, whilst a higher father–infant relationship quality was associated with more advanced motor development. Additionally, maternal postnatal post-traumatic stress disorder had a negative impact on the infant's cognitive development, whilst maternal prenatal depression was associated with a less optimal infant's language development. The largest prediction was afforded by parental perceptions of their infant's characteristics. The findings indicate that such perceptions may be crucial for the infant's development and imply that negative internal parental perceptions should be considered when assessing risk factors or designing interventions to prevent negative child outcomes.

A review assessing the current treatment strategies for postnatal psychological morbidity with a focus on post-traumatic stress disorder

Objectiveto conduct a systematic review of randomised controlled trials investigating the efficacy of treatments used to manage postnatal psychological morbidity. Designa systematic review was conducted of studies in English published from 1995 to 2011. Studies were included in the review if they were randomised controlled trials and had extractable data on symptoms of psychological morbidity after an intervention designed to manage the disorders in postnatal women. Eight studies met the criteria and were included in the review. Findingsthe number of participants ranged from 58 to 1745. The interventions included group and individual counselling, debriefing and expressive writing. Authors of only three studies reported fewer symptoms of PTSD after the intervention. Those that appeared to be helpful were counselling and expressive writing. However most authors did not assess pre-existing PTSD. Key conclusions and implications for practicethe review revealed that there was no standardised scale used for diagnosis of post-traumatic stress disorder across the studies and no single efficacious treatment. A universal instrument for diagnosis of postnatal post-traumatic stress disorder is required. The intrapartum relationship with midwives appears to be an important contributor to prevention of PTSD and this requires further investigation.

Support during birth interacts with prior trauma and birth intervention to predict postnatal post-traumatic stress symptoms

Background: Many women experience childbirth as traumatic and 2% develop post-traumatic stress disorder. This study examined the role of health practitioner support and personal control during birth as predictors of post-traumatic stress (PTS) symptoms, adjusting for vulnerability factors of prior trauma, depression, control beliefs and birth intervention. It also investigated interactions between support, prior trauma and birth intervention and their association with PTS symptoms. Methods: A prospective longitudinal survey of 138 women recruited from UK NHS maternity clinics. Measures were taken in pregnancy, 3 weeks and 3 months after the birth. Results: Support and control during birth were not predictive of postnatal PTS symptoms. However, support was predictive of PTS symptoms in a subset of women with prior trauma (β = −0.41, R 2 = 16%) at both 3-weeks and 3-months postpartum. The interaction of birth intervention and support was associated with PTS symptoms 3 months after birth, the relationship between support and PTS symptoms was stronger in women experiencing more intervention. Conclusions: Low support from health practitioners is predictive of postnatal PTS symptoms in women who have a history of trauma. Longer term effects of low support on postnatal PTS symptoms are also found in women who had more intervention during birth.

Thoughts and Emotions During Traumatic Birth: A Qualitative Study

Previous research shows that 1 to 6 percent of women will develop symptoms of posttraumatic stress disorder after childbirth. The objective of this study was to examine thoughts and emotions during birth, cognitive processing after birth, and memories of birth that might be important in the development of postnatal posttraumatic stress symptoms. In a qualitative study, women with posttraumatic stress symptoms (n= 25) and without (n = 25) were matched for obstetric events to examine the nonmedical aspects of birth that made it traumatic. Women were interviewed 3 months after birth. The following themes emerged for all women: thoughts during birth included mental coping strategies, wanting labor to end, poor understanding of what was going on, and mental defeat. More negative than positive emotions were described during birth, primarily feeling scared, frightened, and upset. Postnatal cognitive processing included retrospective appraisal of birth, such as taking a fatalistic view and focusing on the present, for example, concentrating on the baby. Memories of birth included not remembering parts of the birth and forgetting how bad it was. Women with posttraumatic stress symptoms reported more panic, anger, thoughts of death, mental defeat, and dissociation during birth; after birth, they reported fewer strategies that focused on the present, more painful memories, intrusive memories, and rumination, than women without symptoms. The results provide a useful first step toward identifying aspects of birth and postnatal processing that might determine whether women develop postnatal posttraumatic stress symptoms. Further research is needed to broaden knowledge of posttraumatic stress disorder before drawing definite conclusions.

Cognitive behaviour therapy for postnatal post-traumatic stress disorder: case studies

Background. Approximately 1–2% of women suffer from postnatal post-traumatic stress disorder (PTSD) with wide ranging consequences for these women and their families . Appropriate treatment of women who have difficult or traumatic births is not yet established. Evidence in other populations shows that cognitive behavior therapy (CBT) is effective for PTSD and it is therefore the recommended treatment . However, a recent review of treatments for postnatal distress concluded that descriptions of postnatal counseling are largely generalized and non-specific, which makes them difficult to assess or replicate .Aims and method. The current paper therefore aims to describe the use of CBT interventions to treat postnatal distress, and to illustrate common themes or issues that occur in postnatal PTSD. This paper reports two case studies of women with postnatal PTSD and their treatment using CBT.Conclusions. In these cases, CBT was an effective treatment for postnatal PTSD. A number of implications are explored for the management of pregnancy and labor.

Delivery as a traumatic event: prevalence, risk factors, and treatment for postnatal posttraumatic stress disorder.

Department of Psychology, University of Sussex, Brighton, United Kingdom Correspondence: Susan Ayers, PhD, C.Psychol., Psychology Department, University of Sussex, Brighton, BN1 9QH, UK. E-mail: [email protected]

When delivery is torture — postnatal PTSD

The cases that worry us most are those where the mother has postnatal post traumatic stress disorder (PTSD). Often when she calls us, months or years after the birth, she does not know that is what she has, because it has not been diagnosed. Her GP and health visitor see her as a case of postnatal depression and she has been on anti-depressants, with or without tranquilizers, for a long time with little benefit.