September Research Update

Here is an update that has been published during late August and September.

Induced Abortions and Posttraumatic Stress – Is there any relation?

Lundell, I. W. (2014)

Introduction: Induced abortion is a common medical intervention. Whether psychological sequelae might follow induced abortion has long been a subject of concern among researchers, and there is lack of knowledge about the relationship between posttraumatic disorder (PTSD) and induced abortion. Aims: To study and compare PTSD, posttraumatic stress symptoms (PTSS) and anxiety- and depressive symptoms among women seeking abortion, allowing for demographic variables. Further aims were to assess risk factors and to assess PTSD and PTSS following induced abortion in relation to experienced care at the clinic. Methods: This was a multi-centre cohort study targeting women who requested an induced abortion at the outpatient clinics of the gynaecology and obstetrics departments of six public hospitals in Sweden. All women who requested an induced abortion before the end of gestational week 12 were approached for participation. PTSD, PTSS, anxiety- and depressive symptoms, personality traits and women’s perceptions of abortion care were measured by means of questionnaires. Measurements were made at the first visit before the abortion as well as three- and six-months thereafter. Data collection was performed from September 2009 to January 2011. Results: 1,514 women filled out the questionnaire before the abortion. Abortion-seeking women did not suffer from PTSD to a greater extent than the general Swedish female population. Few women (51/720) developed PTSD or PTSS after the abortion, 11 did so due to trauma experience related to the abortion. Women at risk of posttraumatic stress were more likely to be young, having anxiety- or depressive symptoms and personality traits related to neuroticism. Furthermore, women with PTSD or PTSS were more likely to perceive certain aspects of the abortion care as deficient. Conclusions: The vast majority of women coped well with the induced abortion. Few developed posttraumatic stress post abortion. The majority did so because of trauma experiences unrelated to the induced abortion. Young women and women with mental distress are vulnerable groups that need to be paid attention to in abortion care. These women are at risk for negative experiences of the abortion care, and may be at risk of PTSD or PTSS post abortion

Think pink! A sticker alert system for psychological distress or vulnerability during pregnancy

McKenzie-McHarg, K., Crockeet, M., Olander, E. K., & Ayers. (2014)

The importance of good clinical communication to women during pregnancy and birth is clear. Poor communication in labour is associated with general dissatisfaction, more complaints and a range of perinatal mental health problems including post-traumatic stress disorder (PTSD) and postnatal depression. To communicate effectively, maternity staff need information about which women are vulnerable and require extra support. To address this, a pink sticker communication system to alert midwifery and obstetric staff to potential psychological difficulties experienced by some women was implemented and evaluated. Evaluation showed this system was viewed positively by women and midwifery staff. Audit of referrals to the perinatal psychology service during this period suggests no woman with a pink sticker developed birth trauma as a direct result of perceived poor care. In addition, the proportion of referrals to perinatal psychology for birth trauma significantly reduced during this period.

Mental health of women who suffer intimate partner violence during pregnancy

Fonseca-Machado, O., Alves, L. S., Freitas, P. S., dos Santos Monteiro, J. C., & Gomes-Sponholz. (2014).

Objective: To identify the relationship between intimate partner violence (IPV) during pregnancy and mental disorders in women in the pregnancy-puerperal cycle. Method: A review was conducted of papers published in Portuguese, English and Spanish regarding the study theme. The databases explored were PubMed, CINAHL, LILACS and PsycINFO. Results: The 17 included papers studied the relationship between IPV and: pre- and postpartum depression (41%); pregnancy anxiety (23%) and pregnancy posttraumatic stress disorder (12%). None of the studies investigated the association between IPV and suicidal ideation. Conclusion: IPV against women during the pregnancy-puerperal cycle causes negative impacts on mental health. Concrete actions shall be proposed regarding the prevention, identification and treatment of women exposed to IPV during their pregnancy period.

Posttraumatic stress disorder, smoking, and cortisol in a community sample of pregnant women.

Lopez, W. D., Seng, J. S. (2014)

Background: The prevalence of posttraumatic stress disorder (PTSD) in the United States is higher among pregnant women than women generally. PTSD is related to adverse birth outcomes via physiological and behavioral alterations, such as smoking. Methods: We utilize salivary cortisol measures to examine how traumatic stress, smoking and the hypothalamic-pituitary-adrenal axis interact. Pregnant women (n=395) gave cortisol specimens as part of a cohort study of PTSD and pregnancy at three health systems in the Midwestern United States. Women were divided into three groups: nonsmokers, quitters (who stopped smoking during pregnancy), and pregnancy smokers. Mean cortisol values at three points, sociodemographics, trauma history, and PTSD were compared across groups. We assessed the association of smoking group and PTSD with late afternoon cortisol levels. Results: Smokers, quitters, and nonsmokers differed on demographic risk factors and PTSD symptom load. Late afternoon and bedtime cortisol measures were significantly positively correlated with smoking in pregnancy, with smokers with PTSD presenting the highest cortisol levels. Regression analysis showed that smoking in pregnancy was associated with higher late afternoon cortisol in an additive manner with PTSD symptoms. Conclusions: Smoking appears to have a different relationship with cortisol level for those with and without PTSD. This is the first study to show additive effects of smoking and PTSD on cortisol levels in pregnant women. Since high cortisol, smoking, and PTSD have been shown to adversely affect perinatal outcomes, and since those continuing to smoke in pregnancy had the highest PTSD symptom load, PTSD-specific smoking cessation programs in maternity settings are warranted.

Pregnant women with posttraumatic stress disorder and risk of preterm birth

Yonkers, K. A., Smith, M. V., Forray, A., Epperson, C. N., Costello, D., Lin, H., & Belanger,  K. (2014)

Importance: Posttraumatic stress disorder (PTSD) occurs in about 8% of pregnant women. Stressful conditions, including PTSD, are inconsistently linked to preterm birth. Psychotropic treatment has been frequently associated with preterm birth. Identifying whether the psychiatric illness or its treatment is independently associated with preterm birth may help clinicians and patients when making management decisions. Objective:  To determine whether a likely diagnosis of PTSD or antidepressant and benzodiazepine treatment during pregnancy is associated with risk of preterm birth. We hypothesized that pregnant women who likely had PTSD and women receiving antidepressant or anxiolytic treatment would be more likely to experience preterm birth. Design, Setting and Participants: Longitudinal, prospective cohort study of 2654 women who were recruited before 17 completed weeks of pregnancy from 137 obstetrical practices in Connecticut and Western Massachusetts. Exposures: Posttraumatic stress disorder, major depressive episode, and use of antidepressant and benzodiazepine medications. Main Outcomes and Measures: Preterm birth, operationalized as delivery prior to 37 completed weeks of pregnancy. Likely psychiatric diagnoses were generated through administration of the Composite International Diagnostic Interview and the Modified PTSD Symptom Scale. Data on medication use were gathered at each participant interview. Results: Recursive partitioning analysis showed elevated rates of preterm birth among women with PTSD. A further split of the PTSD node showed high rates for women who met criteria for a major depressive episode, which suggests an interaction between these 2 exposures. Logistic regression analysis confirmed risk for women who likely had both conditions (odds ratio [OR], 4.08 [95% CI, 1.27-13.15]). For each point increase on the Modified PTSD Symptom Scale (range, 0-110), the risk of preterm birth increased by 1% to 2%. The odds of preterm birth are high for women who used a serotonin reuptake inhibitor (OR, 1.55 [95% CI, 1.02-2.36]) and women who used a benzodiazepine medication (OR, 1.99 [95% CI, 0.98-4.03]).Conclusions and Relevance: Women with likely diagnoses of both PTSD and a major depressive episode are at a 4-fold increased risk of preterm birth; this risk is greater than, and independent of, antidepressant and benzodiazepine use and is not simply a function of mood or anxiety symptoms.

Sense of Coherence and Childbearing: A Scoping Review of the Literature

Ferguson, S., Davis, D., Browne, J., & Taylor, J. (2014).

Objective: To undertake a scoping review of the literature to understand how a woman’s sense of coherence (SOC) score affects her childbearing. Method: Ovid MEDLINE, CINAHL, Cochrane, and Web of Science databases were searched to identify articles published in English from 2000 to 2014 using combinations of specified search terms. Included articles were assessed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and the Critical Appraisal Skills Programme. Findings: This scoping review identified 15 studies focusing on SOC scores and childbearing. Childbearing women with strong SOC were less likely to smoke and more likely to seek out useful support compared to women with low SOC. Women with strong SOC demonstrated increased emotional health, experiencing less depression, anxiety, stress, and posttraumatic stress disorder. Women with strong SOC were more likely to experience uncomplicated birth and birth at home, identify normal birth as their preferred birth option in pregnancy and identify a desire to avoid epidural anesthesia in labor compared to women with low SOC. Conclusion: This scoping review of the literature identified significant associations between strong SOC and positive childbearing, including increased emotional health, improved health behaviors, and increased normal birth choices and outcomes.

Exploring Some Swedish Women’s Experiences of Support During Childbirth

Nysted, A., Kristiansen, L., Ehrenstrale, K., & Hildingsson, I. (2014)

Background: Caregivers need to better understand women’s experiences of support during childbirth because research suggests that social support positively influences childbirth. Aim: This study describes women’s experiences of support given by caregivers during pregnancy and childbirth. Method: The study design was inspired by grounded theory. Seven interviews of women were analyzed with an open coding, and different time-related categories related to the childbirth process emerged. The categories were marked by fear and a negative birth experience, being guided on own terms, feel supported, and transformation into courage to give birth. The analysis continued with a selective coding, reflecting the process of mistrust to trust in caregivers. Findings: The mistrust in caregivers began with feelings of fear of birth and a negative birth experience. Through being guided on own terms and feeling supported by the caregivers, a trusting relationship could be established. If the trusting relationship continued during labor, then a woman could transform the fear of birth into the courage to give birth. Conclusions: Women’s experience of support can be seen as a product of earlier experiences from interactions with caregivers. Therefore, caregivers must be sensitive to the potential power and far-reaching consequences their actions can have.

Parents bereaved by infant death: sex differences and moderation in PTSD, attachment, coping and social support.

Christiansen, D. M., Olff, M., Elklit, A. (2014)

OBJECTIVE: Parents bereaved by infant death experience a wide range of symptomatology, including posttraumatic stress disorder (PTSD) that may persist for years after the loss. Little research has been conducted on PTSD in fathers who have lost an infant. Mothers report most symptoms to a greater extent than fathers, but not much is known about other sex differences following infant death. METHOD: The present cross-sectional study examined sex differences in PTSD and sex differences in the relationship between PTSD severity and related variables. Subjects were 361 mothers and 273 fathers who had lost an infant either late in pregnancy, during birth or in the first year of life. Participants filled out questionnaires between 1.2 months and 18 years after the loss (M=3.4 years). RESULTS:  Mothers reported significantly more PTSD symptoms, attachment anxiety, emotion-focused coping and feeling let down, but significantly lower levels of attachment avoidance than fathers. Attachment anxiety, attachment avoidance and emotion-focused coping were significantly more strongly associated with PTSD severity in mothers than fathers, but only when examined alone. When all variables and time since the loss were examined together, there were no longer any significant moderation effects of sex. CONCLUSIONS: Persistent posttraumatic symptomatology exists in both mothers and fathers long after the loss. There are several sex differences in severity and correlates of PTSD, and a few moderation effects were identified for attachment and emotion-focused coping. Overall, more similarities than differences were found between mothers and fathers in the associations between PTSD and covariates.

Effects of perinatal stress and maternal traumatic stress on the cortisol regulation of preterm infants

Habersaat, S., Borghini, A., Nessi, J., Forcada-Guex, M., Müller-Nix, C., Pierrehumbert, B., & Ansermet, F. (2014)

Preterm infants experience intense stress during the perinatal period because they endure painful and intense medical procedures. Repeated activation of the hypothalamic-pituitary-adrenal (HPA) axis during this period may have long-term effects on subsequent cortisol regulation. A premature delivery may also be intensely stressful for the parents, and they may develop symptoms of posttraumatic stress disorder (PTSD). Usable saliva samples were collected (4 times per day over 2 days, in the morning at awakening, at midday, in the afternoon, and in the evening before going to bed) to assess the diurnal cortisol regulation from 46 preterm infants when the infants were 12 months of corrected age (∼ 14 months after birth). Mothers reported their level of PTSD symptoms. The results showed an interaction between perinatal stress and maternal traumatic stress on the diurnal cortisol slope of preterm infants (R(2) = .32). This suggests that the HPA axis of preterm infants exposed to high perinatal stress may be more sensitive to subsequent environmental stress

Effects of an early intervention on maternal post-traumatic stress symptoms and the quality of mother-infant interaction: The case of preterm birth.

Borghini, A., Habersaat. S., Forcada-Guex, M., Nessi, J., Pierrehumbert, B., Ansermet, F., Müller-Nix, C.(2014)

Preterm birth may represent a traumatic situation for both parents and a stressful situation for the infant, potentially leading to difficulties in mother-infant relationships. This study aimed to investigate the impact of an early intervention on maternal posttraumatic stress symptoms, and on the quality of mother-infant interactions, in a sample of very preterm infants and their mothers. Half of the very preterm infants involved in the study (n=26) were randomly assigned to a 3-step early intervention program (at 33 and 42 weeks after conception and at 4 months’ corrected age). Both groups of preterm infants (with and without intervention) were compared to a group of full-term infants. The impact of the intervention on maternal posttraumatic stress symptoms was assessed 42 weeks after conception and when the infants were 4 and 12 months of age. The impact of the intervention on the quality of mother-infant interactions was assessed when the infants were 4 months old. Results showed a lowering of mothers’ posttraumatic stress symptoms between 42 weeks and 12 months in the group of preterm infants who received the intervention. Moreover, an enhancement in maternal sensitivity and infant cooperation during interactions was found at 4 months in the group with intervention. In the case of a preterm birth, an early intervention aimed at enhancing the quality of the mother-infant relationship can help to alleviate maternal post-traumatic stress symptoms and may have a positive impact on the quality of mother-infant interactions

Designing an on-line course on traumatic childbirth: considerations for rural nurse educators

A project draft submitted in partial fulfillment of the requirements for the degree of Masters in Nursing in the School of Nursing, Faculty of Human and Social Development, University of Victoria

Onlock, S. (2014).

Designing educational courses for professional nurses is a complex and in-depth process that requires extensive research and planning. The purpose of this project is to explore the process of course development for an on-line course designed for rural nurses, entitled Traumatic stress and childbirth: Promoting a safe workplace. The aims of this project include making the pedagogical considerations of course design explicit and providing a range of learning activities and strategies that can be adapted for on-line learning. Rural nurses face unique professional and educational challenges related to accessing education that is relevant to isolated settings, having a wider scope of responsibilities than their urban counterparts, and the nature of uncertainty in rural nursing contexts. Theoretical influences that inform the design of this course include Barnett’s (2012) discussion on teaching for an uncertain future wherein he proposes a pedagogy of risk; and Garrison’s (2011) Community of Inquiry framework, which is a constructivist model designed to maximize the benefits of on-line learning. Domains of knowledge, taxonomy, and constructivist alignment are incorporated into the design of learning outcomes, strategies, and assessments in order to involve the affective domain in providing meaningful, complex learning. Particular attention is paid to promoting comfort with uncertainty by engaging learners in such a way that they develop a way of being rather than teaching specific knowledge or skills.