“I’m much stronger than I thought” – Posttraumatic growth following childbirth

by Alexandra Sawyer, Research Fellow, University of Sussex

There are many examples in religion, philosophy, and literature of individuals who have been transformed positively by their experience and struggle with challenging and traumatic events. However, only in the last few decades have researchers begun to research positive changes that individuals report following challenging life events. Positive changes have been documented in a range of individuals following a variety of stressful events, including sexual assault, heart disease, breast cancer, HIV/AIDS, arthritis, terrorist attacks, bereavement, immigration, infertility and natural disasters (see Linley & Joseph, 2004, for a review).

Many different terms have been used in the literature to describe these positive changes but the most commonly used term is posttraumatic growth (PTG). A simple definition of PTG is “positive psychological change as a result of the struggle with life crises or traumatic life events” (Tedeschi & Calhoun, 1996). However, stressful events, which are not necessarily traumatic, like some illnesses, work-related stress, and immigration have been shown to facilitate PTG. Therefore we prefer to use ‘growth’ to describe the experience of positive change following a challenging event. Three broad areas of growth have been reported in the literature: changes in interpersonal relationships, changes in self-perception, and changes in life-philosophy (Tedeschi, Park, & Calhoun, 1998).

Most research looking at psychological adjustment following childbirth has focused on negative psychological outcomes, whilst positive psychological outcomes have been relatively ignored. However, researchers are beginning to recognise the need to explore a range of possible responses (Allan, Carrick-Sen, & Martin, 2013, Ayers, Joseph, McKenzie-McHarg, Slade, & Wijma, 2009). Aldwin and Levenson (2004) were amongst the first researchers to suggest that developmental events have the potential to promote growth, and it is only in the last few years that research has begun to explore childbirth as one of these events. One qualitative study explored women’s accounts of a subsequent childbirth after a previous traumatic birth and found evidence of one of the domains of growth: a sense of personal strength (Beck & Watson, 2010). Women felt that their previous experience of birth had provided them with a sense of strength and empowerment when dealing with the subsequent birth. Only two studies have looked specifically at growth following childbirth in the UK. In a cross-sectional Internet study (Sawyer & Ayers, 2009) 219 women who had given birth within the previous three years completed the Posttraumatic Growth Inventory; a 21-item questionnaire assessing five areas of positive change (PTGI; Tedeschi & Calhoun, 1996). Approximately 50% of women reported at least moderate levels of growth and growth scores were comparable to other samples (e.g. victims of assault, accidents) using the PTGI. This study also explored how coping strategies related to growth. Approach coping strategies (e.g. seeking guidance and support) were significantly associated with higher levels of growth. Another study explored growth in a longitudinal, prospective study of women recruited from hospital clinics (Sawyer, Ayers, Bradley, Young, & Smith, 2012). Posttraumatic stress symptoms during pregnancy and type of delivery (elective or emergency caesarean section) significantly predicted higher levels of growth after childbirth. In both of these studies women reported most growth in the Appreciation of Life domain of the PTGI, and the least amount of growth in the Spiritual Change domain.

In my view, assessment of growth following childbirth is important for a number of reasons. Firstly, as mentioned earlier there is an increasing awareness for a broader focus on psychological adjustment following childbirth. If we examine positive and negative psychological outcomes together, a more comprehensive account of adjustment can be developed. Secondly, longitudinal studies in other populations suggest that growth following a challenging event may be associated with better adjustment in the long term. Findings from such studies suggest that growth may be a useful clinical target in clinical and healthcare settings and there are promising studies that demonstrate that growth may be integrated into clinical interventions (see Antoni et al., 2001, Stanton et al., 2002). Therefore the promotion of growth may be a possible option for therapists working with traumatised women.  However, until the potential effectiveness of interventions aimed at developing growth has been further explored, caution should be taken when using them clinically with postnatal women. Thirdly, there is a lack of longitudinal, prospective studies of growth. From a theoretical viewpoint childbirth is a naturally occurring and predictable event, which allows the role of different variables in the development of growth to be considered prospectively. Childbirth provides a valuable opportunity to explore how pre-event variables (for example mental health, social support, coping) influences experiences of growth, which can in turn inform current theories of growth.

In this short overview I hope I have illustrated why I think it is important and interesting to widen our focus of psychological adjustment following childbirth to include growth. For those who would like to read further about growth, including theories and measurement, I recommend the papers by Joseph & Linley (2006), Tedeschi & Calhoun (2004), and Zoellner & Maercker (2006).

Perinatal PTSD on the internet

By Donna Moore, PhD student, Centre for Maternal and Child Health, City University London

If you enter the search term “PTSD birth” into Google it yields approximately 692,000 results. There is a growing “voice” on the WWW concerning birth trauma. There are professional websites such as the Birth Trauma Association and sites run by survivors. There are pages dedicated to PTSD and childbirth on popular parenting sites such as Netmums. There are perinatal PTSD forums, discussion boards, Twitter feeds, yahoo groups, web logs (blogs), YouTube videos, chat rooms, Google+ and facebook pages. People are hashtagging, tweeting, pinning, liking and sharing…and I’m blogging about it!

In my research I have reviewed websites for postnatal mental illness; postnatal depression, anxiety, PTSD, and psychosis. I reviewed resources on the world wide web (WWW) to identify the top websites for healthcare professionals and women with postnatal illness to use. The WWW provides information on symptoms, risk factors and treatment options and this could have implications for screening and prevention. There are also a range of resources for women including self-help tools (i.e. letters to healthcare professionals, prevention and stories), support (i.e. forums, email and personal messaging) and additional resources (i.e. leaflets, podcasts and audio/visual).

The internet offers continuous access with information just a click away (or a press of the app on a mobile phone). Women can utilise the WWW’s features without worrying about what others may think of them as they can search and participate anonymously. Birth stories feature regularly on perinatal PTSD websites which could also indicate some cathartic effects of sharing ones experience of trauma. There are growing and vibrant virtual communities offering women the space to have an online “voice”. Healthcare professionals could gain valuable insight into women’s experiences of birth trauma and suggest online resources to their clients.

Furthermore, healthcare professionals working in this area can benefit from using the internet in many ways. Academic online networking sites such as LinkedIn and ResearchGate can assist in collaboration with other researchers, exchanging ideas and disseminating research (no need to rely solely on networking at conferences). Indeed, this website is run by a network of researchers and clinicians who are working together to reduce birth trauma and perinatal PTSD across the world. There are many possibilities to expand and promote perinatal PTSD research globally.

Healthcare professionals could suggest quality websites to their clients to provide education and additional support. After all, it is crucial to increase public and professional awareness of perinatal PTSD and continue to help women who suffer and their families. I look forward to hearing this virtual voice get louder and louder.

Some useful websites
The Birth Trauma Association
PaTTCh – Prevention and Treatment of Traumatic Childbirth

Trauma After Birth (TABS)
Birth Trauma Association Canada   

Online support groups
Babycentre traumatic birth support group
PNI.ORG – active and supportive forum for all postnatal mental illnesses
SANDS – forum for stillbirth and neonatal death
Solace for Mothers – support for women who had a traumatic birth

Facebook groups
Birth Talk
Birth Trauma Association

The Truth About Traumatic Birth
My Postpartum Voice