By Dr Alexandra Sawyer, University of Sussex
The preterm birth rate for live births ranges from about 5% to 10% in Europe (Euro-Peristat Project, 2013). Preterm birth is the most important determinant of adverse outcome in terms of survival, quality of life, psychosocial and emotional impact on the family and costs for health services.
Most studies looking at psychological outcomes following preterm birth have focused on depression and anxiety. However, only recently has the birth of a preterm baby been explored as a traumatic experience. The birth of a preterm baby can occur suddenly and the parents are often not prepared physically or emotionally (Lindberg & Ohrling, 2008). Parents can be overwhelmed with the concern of whether or not their child will survive and of future health problems (Lohr, Von Gontard, & Roth, 2000). Preterm babies are often taken away from their mother immediately so they can be stabilised and transferred to the neonatal unit. It is not surprising therefore that the emotional distress of the birth combined with early separation from the baby may contribute to a posttraumatic stress response. Below are two quotes from women we have interviewed about their experiences of giving birth to a very preterm baby (Sawyer, Rabe, Abbott, Gyte, Duley, & Ayers, 2013):
“It’s daunting going in a room when you’ve never been in. All your bits are going to be on show. And you’re worried about your children. Are they gonna survive? Are they gonna be born stillborn?” (Twins born at 30 weeks gestation)
“… I hadn’t seen anything of him, and I just saw this like incubator whisked off and off he went. So none of this bonding ‘you’ve got a baby boy, here he is’ or ‘have a look at him’. Didn’t give me that opportunity. Nothing. I hadn’t seen him from coming out to after I’d recovered in recovery. I hadn’t.. I didn’t see any of that. He was gone. It was like ‘have I had baby?’ ” (Baby born at 27 weeks gestation)
Studies report high prevalence rates of posttraumatic stress disorder (PTSD) following preterm birth: 7% (Kersting et al., 2009), 17% (Stramrood et al., 2011), 23% (Misund, Nerdrum, Braten, Pripp, & Diseth, 2013), and 41% (Pierrehumbert, Nicole, Muller-Nix, Forcada-Guex, & Ansermet, 2003). The research also suggests that posttraumatic stress symptoms persist beyond one year after birth. For example, Ahlund, Clarke, Hill, & Thalange (2009) found that 2-3 years after preterm birth mothers still reported relatively high symptoms of posttraumatic stress compared to mothers of healthy term babies. Several review papers have also identified preterm birth as a strong predictor of the development of PTSD following childbirth (e.g. Anderson, Melvaer, Videbech, Lamont, & Joergensen, 2012; Olde, van der Hart, Leber, & van Son, 2006). Therefore, early indications are that women who give birth to a preterm baby report more posttraumatic stress symptoms which last for a considerably longer time, compared to women who give birth to a term baby.
A number of studies have reported that PTSD following childbirth can negatively impact parent-infant relationships (Nicholls & Ayers, 2007). For example, Feeley et al. (2011) found that mothers of preterm babies who displayed high levels of posttraumatic symptoms were less sensitive and less effective at structuring the interaction when playing with their baby. Another study found that mothers of preterm babies who had high levels of posttraumatic stress symptoms were more likely to display a controlling type of interaction with their baby, which was characterised by hostility (Forcada-Guex, Borghini, Pierrehumbert, Ansermet, & Muller-Nix, 2011). This type of attachment dyad has been associated with eating problems, hearing and speech difficulties and poorer social/personal development in the infant (Shaw et al., 2013).
Of course not all parents who give birth to a preterm baby will display posttraumatic stress symptoms, and many parents adjust well. However, these early research studies suggest that we do need to identify women at risk of developing posttraumatic stress symptoms in order to optimise the health of mothers and their babies. Routine screening for perinatal PTSD in mothers who have given birth to a preterm infant is recommended (Feeley et al., 2011). This would help plan supportive interventions in the neonatal period, particularly for those most at risk. However, as with the general perinatal PTSD research, two key questions need to be considered first: 1) What is the best way to screen for perinatal PTSD, and 2) How do we treat vulnerable women once identified? But, what is most critical is that healthcare professionals are aware that the birth of a preterm baby and subsequent hospitalisation may lead to a posttraumatic stress response in some parents.