Fear of childbirth; PTSD: New publications

The latest issue of Midwifery, containing an editorial by Professor Susan Ayers and articles from several of our collaborators, focuses on fear of childbirth and post-traumatic stress disorder.

The importance of addressing maternal mental health needs has been increasingly recognised in recent years.  The commentaries published on this web-site have cited the evidence relating to the impact of maternal psychological distress upon gestational age, infant outcomes and cognitive, behavioural and emotional development of young children, and upon the wellbeing and relationships of the woman and child.  The World Health Organisation has underlined the importance of ensuring adequate perinatal care for women experiencing psychological difficulties, but also recognises the lack of empirically evaluated care pathways.

There is a need to increase our knowledge of the mechanisms involved in perinatal mental health, not least to inform our understanding of the wider issue and to facilitate intervention aimed at prevention and treatment.  This special issue of Midwifery makes a contribution to this process through its focus upon fear of childbirth and postnatal PTSD.  It includes articles specifically on perinatal PTSD together with original research relating to fear of childbirth, women’s perceptions of morbidity, parental stress, the role of support, the impact on women midwives’ views on antenatal care, and treatment.  Contributions have been included from around the globe.

This special issue is published online on the Midwifery website and is fully accessible until the end of March 2014.


Attentional Biases in Birth-Related PTSD

by Rebecca Webb, Centre for Maternal & Child Health Research, City University London

While birth can be a positive experience for many women, up to one third of women describe their birth as traumatic (Olde et al, 2006). The role of cognitive processes and biases in postpartum PTSD is unclear. Ehlers and Clark (2000) suggest that PTSD develops through an interaction between previous experiences, beliefs and coping strategies and the actual event itself. This interaction influences the ongoing appraisal of the event, which creates and maintains the PTSD symptoms. There is some support for this theory in postpartum PTSD (Ford et al 2010).

One of the cognitive processes thought to influence the development of PTSD is selective attention towards threatening stimuli. This phenomenon can be measured in a number of ways but is commonly assessed using an emotional Stroop task.  In the classic Stroop task, participants name the colour of words presented to them.  Some of the words are consistent with their colour e.g. ‘Blue’, whilst others are not (‘Blue’).  Participants are slower to name the inconsistent words. This paradigm has subsequently been used to compare response times to colour-naming of emotional words compared to neutral words, with emotional words exhibiting slower response times. Cisler et al., (2011) conducted a meta-analysis of the emotional Stroop paradigm undertaken with participants with PTSD. They found that people with PTSD were slower to name the colour of trauma related words, which is thought to represent captured attention, i.e. the trauma related word held the attention of the participant, slowing them down. The results from these studies suggest PTSD is associated with hyper-vigilance towards threat-relevant information. This, however, may lead to the person avoiding threat, which can maintain anxiety as the individual never gains counter information about the threat.

It is not clear whether this attentional bias is the same in birth-related PTSD. Only one study has used an emotional Stroop paradigm to investigate whether women with birth-related PTSD have similar attentional biases to threat related stimuli as those with PTSD arising from non-childbirth-related events. Dale-Hewitt et al, (2012) conducted a labour related emotional Stroop task with women who were either categorised as having PTSD, or having experienced their birth as traumatic on one of three dimensions of PTSD (avoidance, intrusion, hyper-vigilance). Contrary to the evidence from non-birth-related PTSD, women who scored high on avoidance and intrusion, but not hyper-vigilance, were faster at performing the emotional Stroop task. The authors argue that the mechanisms in birth-related PTSD may differ from non-birth-related PTSD because the baby is constantly there in the form of a reminder. Therefore, rather than avoiding the trauma, as in other event related PTSD, labour related words may be continuously activated in memory (Foa et al, 1989), meaning the mothers need less time to identify these words as threatening and can apply ignoring strategies more quickly.

Dale-Hewitt et al’s findings suggest that attentional biases in birth-related PTSD and other event related PTSD may differ in terms of causal and maintaining factors. However, the lack of birth-related PTSD Stroop data makes it hard to draw any conclusions since it is impossible to generalise from a single study.  Furthermore, the use of the Stroop paradigm to measure attentional biases in PTSD has been widely questioned. Kimble et al. (2004) found that only 44% of all studies (including unpublished dissertations) identified a Stroop effect for trauma related words in people with PTSD.

Despite the difficulty in drawing a conclusion from these results, one thing is clear; the cognitive processes behind birth-related PTSD need to be examined further. This may provide key clues to the aetiology and maintaining factors, which could therefore lead to more effective treatments in the future.