Maternal adjustment five months after birth: the impact of the subjective experience of childbirth and emotional support from the partner

: Recent research suggests that negative childbirth experiences may cause maternal maladjustment. The impact of intranatal emotional distress, intranatal physical discomfort and postnatal emotional evaluation of birth on symptoms of posttraumatic stress and depression is investigated with regard to the moderating role of emotional support from the partner.

Subjective childbirth experience measured with the German version of the Salmons Item List, obstetric characteristics and postnatal emotional support from the partner were assessed in 374 women six weeks after childbirth. Trauma symptoms and postnatal depression were measured five months after childbirth.

Postnatal emotional partner support acts as a moderator of the effect of the subjective childbirth experience on the development of symptoms of avoidance, intrusive thoughts and depression. The direct influence of emotional partner support is stronger regarding symptoms of depression and hyperarousal than regarding avoidance and intrusive thoughts. No direct association between intranatal physical discomfort/labour pain and later maternal adjustment could be found.

Women with a negative childbirth experience and poor emotional support from their partner are at increased risk for psychological maladjustment in the first five months after birth.     

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.     

Synthesis of Mixed Research on Posttraumatic Stress Related to Traumatic Birth

ObjectiveTo synthesize mixed-research results (quantitative and qualitative) on posttraumatic stress in women who experienced traumatic births.Data SourcesPubMed, Scopus, and PsycINFO databases.Study SelectionQuantitative and qualitative studies were included if they were published in English from January 1, 2009, through December 31, 2018, and focused on posttraumatic stress in the postpartum period related to traumatic childbirth.Data ExtractionThe final sample consisted of 59 studies: 4 qualitative and 55 quantitative. Both authors independently appraised each study using the Critical Appraisal Skills Programme. Quantitative studies were synthesized by narrative synthesis and vote counting, and qualitative studies were synthesized by content analysis.Data SynthesisIn the included studies, prevalence rates of elevated posttraumatic stress ranged from 0.8% to 26%. Significant predictors of posttraumatic stress that occurred before childbirth and those that were birth related were identified. Reports of six intervention studies to decrease posttraumatic stress symptoms after traumatic births were included. These interventions focused on postnatal debriefing, expressive writing, online cognitive behavioral therapy, a brief cognitive intervention, and the implementation of the nine instinctive stages of the infant during the first hour after birth. We created four themes from the findings of the qualitative studies: Distressing Symptoms, Detrimental Effect of Posttraumatic Stress on Women’s Relationships With Their Infants and Partners, Critical Influence of Support, and Debriefing.ConclusionWhen a woman experiences posttraumatic stress related to a traumatic birth, the entire family unit is vulnerable. Findings from quantitative predictor studies can be used to develop an instrument to screen women for risk factors for posttraumatic stress related to birth trauma. Primary interventions are needed to prevent women from experiencing traumatic births.     

Labour experience and postpartum stress and depression: a quantitative and qualitative examination

Objectives: The purpose of this study was to examine the relationship between qualitatively and quantitatively assessed birth experiences and rates of post-birth distress and depressive symptoms three to four weeks postpartum. Both the rates of post-birth distress and depressive symptoms represented risk factors for subsequent mental health problems in the later postpartum period. Background: Childbirth is accompanied by various stress factors. However, little is known about the relationship between stressors occurring during birth (intrapartum) and the ways women cope with them and women’s development of depressive symptoms or acute stress reactions postpartum. Methods: One hundred and twenty-seven women from two longitudinal studies were interviewed 48–96 h after childbirth. Thirty birth interviews from both samples were additionally examined for qualitative themes related to women’s reported experience in connection with mental health adaptation (i.e. without symptoms (n = 10), symptoms of depression (n = 10) and acute stress reactions (n = 10)) at three to four weeks postpartum. Results: Women with depressive symptoms reported less intimate and helpful contact with their partners and baby during labour compared with women without symptoms or with acute stress reactions. Women with acute stress reactions had less confidence in themselves, and reported disorientation during the birth process, compared with women without symptoms or with depressive symptoms. Conclusions: Recognition of how women cope with intrapartum factors during labour could help to identify psychological distress shortly after delivery, and inform the introduction of timely and appropriate psychological support for affected women.     

Childbirth and the Development of Acute Trauma Symptoms: Incidence and Contributing Factors

Background: Little is known about the relationship between women's birthing experiences and the development of trauma symptoms. This study aimed to determine the incidence of acute trauma symptoms and posttraumatic stress disorder in women as a result of their labor and birth experiences, and to identify factors that contributed to the women's psychological distress. Method: Using a prospective, longitudinal design, women in their last trimester of pregnancy were recruited from four public hospital antenatal clinics. Telephone interviews with 499 participants were conducted at 4 to 6 weeks postpartum to explore the medical and midwifery management of the birth, perceptions of intrapartum care, and the presence of trauma symptoms. Results: One in three women (33%) identified a traumatic birthing event and reported the presence of at least three trauma symptoms. Twenty‐eight women (5.6%) met DSM‐IV criteria for acute posttraumatic stress disorder. Antenatal variables did not contribute to the development of acute or chronic trauma symptoms. The level of obstetric intervention experienced during childbirth (β= 0.351, p < 0.0001)and the perception of inadequate intrapartum care (β= 0.319, p < 0.0001) during labor were consistently associated with the development of acute trauma symptoms. Conclusions: Posttraumatic stress disorder after childbirth is a poorly recognized phenomenon. Women who experienced both a high level of obstetric intervention and dissatisfaction with their intrapartum care were more likely to develop trauma symptoms than women who received a high level of obstetric intervention or women who perceived their care to be inadequate. These findings should prompt a serious review of intrusive obstetric intervention during labor and delivery, and the care provided to birthing women.     

Maternal psychosocial outcome after early onset preeclampsia and preterm birth

Objective.?To evaluate the impact of severe, early onset preeclampsia on long-term maternal psychosocial outcome after preterm birth.

Methods.?Women with severe, early onset preeclampsia before 32 weeks’ gestation (cases) admitted in a tertiary university referral center between 1993 and 2004, and women with preterm delivery without preeclampsia (controls), matched for age, parity, gestational age at delivery, ethnicity, and year of delivery. Women who consented to participation received three questionnaires in 2008 concerning depression (Zung Depression Scale: score range 0–20; 20 items with 2-point frequency scale: no?=?0 and yes?=?1), posttraumatic stress symptoms (Impact of Event Scale: score range 0–75; 15 items with 4-point frequency scale: not at all?=?0, rarely?=?1, sometimes?=?3 and often?=?5. Scores?>?19 are regarded as high symptom levels), and social aspects (Social Readjustment Rating Scale: selection of six items concerning relational aspects with husband/partner, employer, or future family planning).

Results.?Included in the study were 104 cases and 78 controls (response rate 79% and 58%, respectively). There was no difference in depression scores between cases (5.4 ± 4.0) and controls (5.4 ± 4.3). Patients with severe, early onset preeclampsia had significantly higher scores of posttraumatic stress symptoms (28.7 ± 8.6 vs. 25.7 ± 7.9). The majority of women among both cases and controls had high-posttraumatic stress symptom levels (88% vs. 79%). No differences could be found in relational aspects.

Conclusion.?Women with preterm birth due to severe, early onset preeclampsia experience more often posttraumatic stress symptoms on average 7 years after the pregnancy compared to women with preterm birth without preeclampsia.     

Posttraumatic Stress Disorder in New Mothers: Results from a Two‐Stage U.S. National Survey

Abstract: Background: Prevalence rates of women in community samples who screened positive for meeting the DSM‐IV criteria for posttraumatic stress disorder after childbirth range from 1.7 to 9 percent. A positive screen indicates a high likelihood of this postpartum anxiety disorder. The objective of this analysis was to examine the results that focus on the posttraumatic stress disorder data obtained from a two‐stage United States national survey conducted by Childbirth Connection: Listening to Mothers II (LTM II) and Listening to Mothers II Postpartum Survey (LTM II/PP). Methods: In the LTM II study, 1,373 women completed the survey online, and 200 mothers were interviewed by telephone. The same mothers were recontacted and asked to complete a second questionnaire 6 months later and of those, 859 women completed the online survey and 44 a telephone interview. Data obtained from three instruments are reported in this article: Posttraumatic Stress Disorder Symptom Scale‐Self Report (PSS‐SR), Postpartum Depression Screening Scale (PDSS), and the Patient Health Questionnaire‐2 (PHQ‐2). Results: Nine percent of the sample screened positive for meeting the diagnostic criteria of posttraumatic stress disorder after childbirth as determined by responses on the PSS‐SR. A total of 18 percent of women scored above the cutoff score on the PSS‐SR, which indicated that they were experiencing elevated levels of posttraumatic stress symptoms. The following variables were significantly related to elevated posttraumatic stress symptoms levels: low partner support, elevated postpartum depressive symptoms, more physical problems since birth, and less health‐promoting behaviors. In addition, eight variables significantly differentiated women who had elevated posttraumatic stress symptom levels from those who did not: no private health insurance, unplanned pregnancy, pressure to have an induction and epidural analgesia, planned cesarean birth, not breastfeeding as long as wanted, not exclusively breastfeeding at 1 month, and consulting with a clinician about mental well‐being since birth. A stepwise multiple regression revealed that two predictor variables significantly explained 55 percent of the variance in posttraumatic stress symptom scores: depressive symptom scores on the PHQ‐2 and total number of physical symptoms women were experiencing at the time they completed the LTM II/PP survey. Conclusion: In this two‐stage national survey the high percentage of mothers who screened positive for meeting all the DSM‐IV criteria for a posttraumatic stress disorder diagnosis is a sobering statistic. (BIRTH 38:3 September 2011)     

Not identifying with postnatal depression: a qualitative study of women’s postnatal symptoms of distress and need for support

Abstract

Introduction: Diagnoses and symptoms of postnatal mental health problems are associated with adverse outcomes for women and their families. Current classification and assessment of postnatal mental health problems may not adequately address the range or combination of emotional distress experienced by mothers. This study aims to explore symptoms of mental health problems reported by new mothers and their experiences of being assessed for these.

Methods: In-depth interviews with 17 women in southeast England with a baby under 1-year old who experienced a postnatal mental health problem. Data were analyzed using inductive thematic analysis.

Results: Women described a lack of identification with the concept of postnatal depression and felt that other forms of emotional distress were not recognized by the healthcare system. Women felt that support seeking for postnatal mental health problems needed to be normalized and that support should be available whether or not women were diagnosed. Assessment needs to be well timed and caringly implemented.

Discussion: Identification and recognition of symptoms and disorders other than postnatal depression need to be improved. Awareness of multiple types of distress needs to be raised both for women experiencing such distress, and for healthcare professionals, to enable them to support women at this time. Different approaches to assessment that include the range of symptoms reported should be piloted.     

Group Counseling for Mothers After Emergency Cesarean Section: A Randomized Controlled Trial of Intervention

Abstract: Background : An emergency cesarean section is often a traumatic experience for women, and can be associated with postnatal depression and posttraumatic stress. Various types of interventions have been tested to prevent such consequences. The purpose of this study was to test a model of group counseling for mothers after emergency cesarean section, and to examine its possible effects. Method : After undergoing an emergency cesarean section, 162 Swedish‐speaking women were randomized to group counseling or the control group. The participation rate was 75 percent. The counseling consisted of 2 sessions, conducted at about 2 months postpartum; 72 percent of the women randomized to the counseling group actually attended the sessions. At 6 months postpartum, all study participants completed a postal questionnaire (response rates were 92% in the counseling group and 89% in the control group). Results : No difference between the groups was found in terms of the level of fear after childbirth, symptoms of posttraumatic stress, or postnatal depression at 6 months after the emergency cesarean. The group counseling was much appreciated by the participating women, some of whose experiences are reported in this paper. Conclusion : Group counseling for mothers after emergency cesarean section did not influence their views on the recent delivery or prevent symptoms of posttraumatic stress or postnatal depression. It was, however, appreciated and did no harm. In future studies, other outcomes should be measured.     

Childbirth pain, perinatal dissociation and perinatal distress as predictors of posttraumatic stress symptoms

OBJECTIVE: This prospective, longitudinal study investigated the contributive role of childbirth pain, perinatal distress and perinatal dissociation to the development of PTSD symptoms following childbirth. PATIENTS AND METHODS: One hundred and seventeen women participated at the study. The first day after delivery they completed a questionnaire to evaluate pain, the peritraumatic distress inventory (PDI) and the peritraumatic dissociative experience questionnaire (PDEQ). Six weeks after birth, they completed the impact of event scale-revised (IES-R) to measure posttraumatic stress symptoms and the Edinburgh Postnatal Depression Scale (EPDS) to assess maternal depression. RESULTS: A multiple regression analysis revealed that only both components of perinatal distress, life-threat perception and dysphoric emotions were significant predictors of posttraumatic stress symptoms. In another multiple regression analysis predicting dysphoric emotions, affective dimension of pain was the only significant predictor. DISCUSSION AND CONCLUSION: Perinatal distress was the best predictor of posttraumatic stress symptoms. Dysphoric emotions were associated with affective dimension of pain, suggesting that women distressed by the childbirth pain would have higher risk to develop posttraumatic stress symptoms.     

Do Women Get Posttraumatic Stress Disorder as a Result of Childbirth? A Prospective Study of Incidence

Background: Recent research suggests that a proportion of women may develop posttraumatic stress disorder after birth. Research has not yet addressed the possibility that postpartum symptoms could be a continuation of the disorder in pregnancy. This study aimed to test the idea that some women develop posttraumatic stress disorder as a result of childbirth, and to provide an estimate of the incidence using a prospective design, which controls for the disorder in pregnancy. Method: This prospective study assessed 289 women at three time points: 36 weeks gestation and 6 weeks and 6 months postpartum. The prevalence of posttraumatic stress disorder was assessed by questionnaire at each time point, and the incidence was examined after removing women who had severe symptoms of posttraumatic stress disorder or clinical depression in pregnancy. Results: After removing women at the first time point, 2.8 percent of women fulfilled criteria for the disorder at 6 weeks postpartum and this decreased to 1.5 percent at 6 months postpartum. Conclusions: The results suggest that at least 1.5 percent of women may develop chronic posttraumatic stress disorder as a result of childbirth. It is important to increase awareness about the disorder and to give health professionals access to simple screening tools. Intervention is possible at several levels, but further research is needed to guide this intervention.     

Experiences of Emergency Cesarean Section: A Phenomenological Study of 53 Women

Background: Childbirth by emergency cesarean section can be a traumatic experience, but since the result is often a healthy mother and baby, its seriousness is open to doubt. Method: Fifty-three women were interviewed approximately two days after emergency cesarean section to ascertain whether or not the trauma met the stressor criterion of posttraumatic stress disorder. A time-spatial model from disaster psychiatry was used to chart the women's thoughts and feelings during consecutive phases of the delivery process. The women's causal attributions of the event were also assessed. Results: Generally speaking, the feeling of the women after they had arrived at the delivery ward changed from one of confidence and safety to one of fear. The decision to undertake a cesarean section brought a feeling of relief, but this was again replaced by fear as the operation approached. The women's thoughts centered around the impending delivery and operation until after the event, when the newborn baby occupied their attention and happiness predominated. In retrospect, 55 percent of the women experienced intense fear for their own life or that of their baby. Eight percent felt very badly treated by the delivery staff and were angry. Almost all the women had adequate knowledge of the reasons for the emergency cesarean section. One in four blamed themselves to some extent for the event. Conclusions: The stressor criterion of DSM IV is applicable to the trauma of emergency cesarean section. Even if and when a new mother is happy to meet her baby, negative feelings, such as fear, guilt, or anger, may dominate her memories of the birth. (BIRTH 25:4 December 1998)     

Effectiveness of a Counseling Intervention after a Traumatic Childbirth: A Randomized Controlled Trial

Abstract: Adverse childbirth experiences can evoke fear and overwhelming anxiety for some women and precipitate posttraumatic stress disorder. The objective of this study was to assess a midwife‐led brief counseling intervention for postpartum women at risk of developing psychological trauma symptoms. Method : Of 348 women screened for trauma symptoms, 103 met inclusion criteria and were randomized into an intervention (n = 50) or a control (n = 53) group. The intervention group received face‐to‐face counseling within 72 hours of birth and again via telephone at 4 to 6 weeks postpartum. Main outcome measures were posttraumatic stress symptoms, depression, self‐blame, and confidence about a future pregnancy. Results : At 3‐month follow‐up, intervention group women reported decreased trauma symptoms, low relative risk of depression, low relative risk of stress, and low feelings of self‐blame. Confidence about a future pregnancy was higher for these women than for control group women. Three intervention group women compared with 9 control group women met the diagnostic criteria for posttraumatic stress disorder at 3 months postpartum, but this result was not statistically significant. Discussion : A high prevalence of postpartum depression and trauma symptoms occurred after childbirth. Although most women improved over time, the intervention markedly affected participants’ trajectory toward recovery compared with women who did not receive counseling. Conclusions : A brief, midwife‐led counseling intervention for women who report a distressing birth experience was effective in reducing symptoms of trauma, depression, stress, and feelings of self‐blame. The intervention is within the scope of midwifery practice, caused no harm to participants, was perceived as helpful, and enhanced women's confidence about a future pregnancy.     

Negative emotions,childbirth pain,perinatal dissociation and self-efficacy as predictors of postpartum posttraumatic stress symptoms

Objective: The aim of the study was to assess the contribution of negative emotions, childbirth pain, perinatal dissociation, and feelings of self-efficacy to the development of posttraumatic stress disorder (PTSD) symptoms following childbirth. Patients and methods: A prospective longitudinal study was carried out on 98 women from the south of France area. Four questionnaires were completed at 2–3 days postpartum: the Peritraumatic Emotions List (PEL), the French version of the McGill Pain Questionnaire, the Peritraumatic Dissociative Experience Questionnaire (PDEQ) and the Childbirth Self-efficacy Inventory (CBSEI). The Impact of Event Scale-Revised (IES-R) assessing posttraumatic stress symptoms was also completed 6 weeks after delivery. Results: Pain and negative emotions were significant predictors of the intensity of posttraumatic stress symptoms at 6 weeks postpartum. Although higher levels of pain contribute to increased PSTD symptoms, and higher negative emotion also contributes to PTSD symptoms, the effect of pain on PSTD is stronger when there are high levels of negative emotion. Discussion and conclusion: Our findings highlight that pain, negative emotions and their interaction were significant predictors of posttraumatic stress symptoms and confirm the importance of developing more specific treatments focusing on support and prevention.     

Domestic violence, lifetime trauma and psychological health of childbearing women

OBJECTIVE: Although histories of abuse are associated with psychiatric illness in women, health professionals rarely enquire directly about such experiences. This study examined the association between physical and sexual violence and lifetime trauma and depressive and posttraumatic stress symptoms in women receiving maternity care. DESIGN: Cross sectional study. SETTING: South London Hospital maternity services. POPULATION: Two hundred women receiving postnatal or antenatal care. METHODS: Two hundred women receiving postnatal or antenatal care at a South London maternity service were screened for lifetime experiences of trauma and domestic violence. Information was obtained about self-harming behaviour, suicidal thoughts and attempts and psychiatric history. Women completed the Edinburgh Postnatal Depression Scale (EPDS) and the Posttraumatic Diagnostic Scale (PTDS). MAIN OUTCOME MEASURES: RESULTS: One hundred and twenty-one (60.5%) women reported at least one traumatic event and two-thirds of these had experienced multiple traumatic events. The most frequent (34%) was witnessing or experiencing physical assault by a family member. Forty-seven (23.5%) women had experienced domestic violence. Physical and sexual abuse commonly co-occurred. Thirteen (10.7%) women with a trauma history had current posttraumatic stress disorder. Severe posttraumatic symptoms were associated with physical and sexual abuse histories and repeat victimisation. Adult and childhood physical and sexual abuse histories were also associated with more severe depressive symptomatology. Significant social factors associated with depression were being single, separated or in a non-cohabiting relationship. CONCLUSION: Traumatic events are under-recognised risk factors in the development of depressive and posttraumatic stress symptoms in childbearing women. Childhood abuse creates a vulnerability to re-traumatisation in adulthood. Awareness of the impact of trauma and abuse on psychological health may enable more appropriate targeting of clinical services and support for women receiving maternity care.     

The Importance of Mode of Birth After Previous Cesarean: Success,Satisfaction, and Postnatal Health

Introduction: The recent National Institutes of Health consensus conference on vaginal birth after cesarean (VBAC) recommended a focus on strategies that increase women's opportunities to make informed choices about VBAC. This study aimed to expand knowledge of women's experiences of planned VBAC by focusing on postnatal experiences of women who participated in an Australian birth‐after‐cesarean study. Methods: At 6 to 8 weeks after birth, 165 women who experienced childbirth after a previous cesarean rated satisfaction with their birth experiences using a 10‐point visual analogue scale, reported on postnatal health problems, and indicated whether they would make the same birth choice again. Results: Significant differences were found in satisfaction scores by mode of birth. Mean scores out of a possible score of 10 ranged from 8.86 for spontaneous vaginal birth, 7.86 for elective repeat cesarean delivery, 6.71 for emergency cesarean delivery, to 6.15 for instrumental vaginal birth (F= 5.33; P= .002). Mean satisfaction scores for spontaneous vaginal birth and elective repeat cesarean delivery were statistically higher than for instrumental vaginal birth and emergency cesarean birth. Women who experienced instrumental vaginal birth and emergency cesarean birth also reported a higher number of postnatal health‐related problems and were least likely to agree that they would make the same birth choice again. Discussion: Mode of birth was the most important determinant of postnatal satisfaction, postnatal health, and whether women felt they would make the same birth choice again. Clinicians, researchers, and policymakers should identify effective labor management practices that enhance women's opportunities to achieve spontaneous vaginal birth during planned VBAC.     

Childhood Abuse History,Posttraumatic Stress Disorder,Postpartum Mental Health,and Bonding: A Prospective Cohort Study

Introduction: Research is needed that prospectively characterizes the intergenerational pattern of effects of childhood maltreatment and lifetime posttraumatic stress disorder (PTSD) on women's mental health in pregnancy and on postpartum mental health and bonding outcomes. This prospective study included 566 nulliparous women in 3 cohorts: PTSD‐positive, trauma‐exposed resilient, and not exposed to trauma. Methods: Trauma history, PTSD diagnosis, and depression diagnosis were ascertained using standardized telephone interviews with women who were pregnant at less than 28 gestational weeks. A 6‐week‐postpartum interview reassessed interim trauma, labor experience, PTSD, depression, and bonding outcomes. Results: Regression modeling indicates that posttraumatic stress in pregnancy, alone, or comorbid with depression is associated with postpartum depression (R²= .204; P < .001). Postpartum depression alone or comorbid with posttraumatic stress was associated with impaired bonding (R²= .195; P < .001). In both models, higher quality of life ratings in pregnancy were associated with better outcomes, while reported dissociation in labor was a risk for worse outcomes. The effect of a history of childhood maltreatment on both postpartum mental health and bonding outcomes was mediated by preexisting mental health status. Discussion: Pregnancy represents an opportune time to interrupt the pattern of intergenerational transmission of abuse and psychiatric vulnerability. Further dyadic research is warranted beyond 6 weeks postpartum. Trauma‐informed interventions for women who enter care with abuse‐related PTSD or depression should be developed and tested.