Progress of PTSD symptoms following birth: a prospective study in mothers of high-risk infants.
To understand how postpartum posttraumatic stress disorder (PTSD) symptoms in mothers of high-risk infants progress and identify what factors predict postpartum PTSD.
We prospectively obtained self-reported psychological data from neonatal intensive care unit discharged infants’ mothers (NICU mothers) at the infants’ corrected ages of 1 (T0), 3 (T1) and 12 months (T2) and mothers of healthy infants (controls). Maternal sociodemographic and infant-related factors were also investigated.
PTSD was present in 25 and 9% of NICU mothers and controls, respectively. We identified four PTSD patterns: none, persistent, delayed and recovered. The postpartum PTSD course was associated with trait anxiety. Whether the infant was the first child who predicted PTSD at year 1 (adjusted odds ratio=7.62, 95% confidence interval=1.07 to 54.52).
Mothers of high-risk infants can develop early or late PTSD, and its course can be influenced by factors besides medical status. We therefore recommend regular screenings of postpartum PTSD.
Debriefing interventions for the prevention of psychological trauma in women following childbirth.
Childbirth is a complex life event that can be associated with both positive and negative psychological responses. When giving birthis experienced as particularly traumatic this can have a negative impact on a woman’s postnatal emotional well-being. There has been an increasing focus on women’s psychological trauma symptoms following childbirth, including the relatively rare phenomenon of post-traumatic stress disorder (PTSD), and the benefit of debriefing interventions to prevent this. In this review we examined the evidence for debriefing as a preventative intervention for psychological trauma following childbirth.
To assess the effects of debriefing interventions compared with standard postnatal care for the prevention of psychological trauma in women following childbirth.
The trials registers of the Cochrane Depression, Anxiety and Neurosis Group (CCDANCTR-References and CCDANCTR-Studies) and the Cochrane Pregnancy and Childbirth Group were searched up to 4 March 2015. These registers include relevant randomised controlled trials from the following bibliographic databases: the Cochrane Library (all years to date), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date). Additional searches were conducted in CENTRAL, MEDLINE, EMBASE, PsycINFO, and Maternity and Infant Care. The reference lists of all included studies were checked for additional published reports and citations of unpublished research. Experts in the field were contacted.
We included randomised controlled trials (RCTs) and quasi-randomised trials comparing postnatal debriefing interventions with standard postnatal care for the prevention of psychological trauma of women following childbirth. The intervention consisted of at least one debriefing intervention session, which had the purpose of allowing women to describe their experience and to normalise their emotional reaction to that experience.
DATA COLLECTION AND ANALYSIS:
Three authors independently assessed trial quality and extracted data. Meta-analysis was conducted where there were more than two trials examining the same outcomes.
We included seven trials (eight articles) from three countries (UK, Australia and Sweden) that fulfilled the inclusion criteria. The number of women contributing data to each outcome varied from 102 to 1745. Methodological quality was variable and most of the studies were of low quality. The quality of evidence for the prevalence of psychological trauma (primary outcome) and the prevalence of depression symptoms was rated low or very low, based on few studies (ranging from a single study to three studies) with high risk of bias in main domains such as performance bias, random sequence generation, allocation concealment and incomplete outcome data. The quality of evidence for the remaining outcomes (that is prevalence of anxiety, prevalence of fear of childbirth, prevalence of general psychological morbidity, health service utilization and attrition from treatment) was not assessed as data were not available.Among women who had a high level of obstetric intervention during labour and birth, we found no difference between standard postnatal care with debriefing and standard postnatal care without debriefing on psychological traumasymptoms within three months postpartum (RR 0.61; 95% CI 0.28 to 1.31; n = 425) or at three to six months postpartum (RR 0.62; 95% CI 0.27 to 1.42; n = 246). The results were based on two trials, respectively. Among women who experienced a distressing or traumatic birth, there was no evidence of an effect of psychological debriefing on the prevention of PTSD (measured by the MINI-PTSD) at four to six weeks postpartum (RR 1.15; 95% CI 0.66 to 2.01; n = 102) or at six months (RR 0.35; 95% CI 0.10 to 1.23; n = 103). The results were based on one small trial. One trial involving low-risk women who delivered healthy infants at or near term reported no significant difference between the intervention group and the control group in the proportion of women who met the diagnostic criteria for psychological trauma during the year following childbirth (RR 1.06; 95% CI 0.88 to 1.28; n = 1745). We did not find any information about attrition rates.
We did not find any high quality evidence to inform practice, with substantial heterogeneity being found between the studies conducted to date. There is little or no evidence to support either a positive or adverse effect of psychological debriefing for the prevention of psychological trauma in women following childbirth. There is no evidence to support routine debriefing for women who perceive giving birth as psychologically traumatic.Future research should provide greater detail of the outcome measures used, and with scales for measuring psychologicaltrauma validated against clinical diagnostic interviews. High rates of obstetric intervention in some birth settings may mean that women require improved emotional care from health professionals to reduce the risk of childbirth being experienced as traumatic. As all included trials excluded women unable to communicate in the native language of the study setting, there is no information on the response of these women to psychological debriefing. No included studies were conducted in low or middle-income countries.
Cognitive Predictors and Risk Factors of PTSD Following Stillbirth: A Short-Term Longitudinal Study.
This short-term longitudinal study investigated cognitive predictors and risk factors of posttraumatic stress disorder (PTSD) in mothers followingstillbirth. After a stillbirth at ≥ 24 weeks gestational age, 65 women completed structured clinical interviews and questionnaires assessing PTSDsymptoms, cognitive predictors (appraisals, dysfunctional strategies), and risk factors (perceived social support, trauma history, obstetric history) at 3 and 6 months. PTSD symptoms decreased between 3 and 6 months (Cohen’s d ranged .34-.52). Regression analyses also revealed a specific positive relationship between Rumination and concurrent frequency of PTSD symptoms (β = .45). Negative Self-View and Negative World-View related positively and Self-Blame related negatively to concurrent number of PTSD symptoms (β = .48, .44, -.45, respectively). Suppression and Distraction predicted a decrease and Numbing predicted an increase in time-lagged number of PTSD symptoms (β = -.33, -.28, .30, respectively). Risk factors for PTSD symptoms were younger age (β = -.25), lower income (β = -.29), fewer previous pregnancies (β = -.31), and poorer perceived social support (β = -.26). Interventions addressing negative appraisals, dysfunctional strategies, and social support are recommended for mothers with PTSD following stillbirth. Knowledge of cognitive predictors and risk factors of PTSD may inform the development of a screening instrument.
Trauma and traumatic loss in pregnant adolescents: the impact of Trauma-Focused Cognitive Behavior Therapy on maternal unresolved states of mind and Posttraumatic Stress Disorder
Madigan, S., Vaillancourt, K., McKibbon, A.,& Benoit, D.
Pregnant adolescents are a group at high risk for exposure to traumatic experiences. The present study aimed to examine if Trauma-Focused Cognitive Behavior Therapy (TF-CBT) typically applied to Posttraumatic Stress Disorder (PTSD), could also be applied to unresolved states of mind in a sample of socially at-risk pregnant adolescents. Forty-three adolescents who were in their second trimester of pregnancy and who also had positive indices of unresolved states of mind or symptoms of PTSD were randomly assigned to either the treatment as usual (parenting classes) or intervention (parenting classes + TF-CBT) group. Adolescent mother–infant dyads were then re-assessed at infant ages 6 and 12 months on a broad range of measures, including those specific to attachment, as well as to PTSD, and adolescent behavioral adjustment. Twenty-six of the 43 (60%) recruited subjects completed all components of the study protocol. Although there were no significant effects of the TF-CBT intervention on maternal attachment, infant attachment, PTSD diagnosis and adolescent behavioral adjustment, several study limitations restrict our ability to draw firm conclusions about the efficacy of TF-CBT for use in pregnant adolescents with complex trauma. The discussion offers insight and guidance for clinical work and future intervention research efforts with this vulnerable population.
Effectiveness of hospital-based video interaction guidance on parental interactive behavior, bonding, and stress after preterm birth: A randomized controlled trial.
Hoffenkamp, H. N., Tooten, A., Hall, R. A. S., Braeken, J., Eliëns, M. P. J., Vingerhoets, A. J. J. M., & van Bakel, H. J. A.
This study examined the effectiveness of hospital-based Video Interaction Guidance (VIG; Eliëns, 2010; Kennedy, Landor, & Todd, 2011) for mothers and fathers of infants born preterm (25–37 weeks of gestation).
VIG is a preventive video-feedback intervention to support the parent–infant relationship. One hundred fifty families (150 infants, 150 mothers, 144 fathers) participated in a pragmatic randomized controlled trial to evaluate the effects of VIG as adjunct to standard hospital care. Primary outcome was parental interactive behavior (sensitivity, intrusiveness, and withdrawal) as observed in videotaped dyadic parent–infant interaction. Secondary outcomes comprised parental bonding, stress responses, and psychological well-being based on self-report. The intervention effects were assessed at baseline, mid-intervention, 3-week, 3-month, and 6-month follow-ups. Data were analyzed on an intention-to-treat basis, using multilevel modeling and analyses of covariance.
VIG proved to be effective in enhancing sensitive behavior and diminishing withdrawn behavior in mothers (Cohen’s d range = .24–.44) and in fathers (d range: .54–.60). The positive effects of VIG were particularly found in mothers who experienced the preterm birth as very traumatic (d range = .80–1.04). The intervention, however, did not change parents’ intrusive behavior. Analyses additionally revealed positive effects on parental bonding, especially for fathers, yet no significant effects on stress and well-being were detected.
The results indicate that VIG is a useful addition to standard hospital care, reducing the possible negative impact of preterm birth on the parent–infant relationship. VIG appeared particularly beneficial for fathers, and for mothers with traumatic birth experiences. High levels of parental intrusiveness, however, need complementary intervention.
Post-natal psychopathology and bonding with the infant among first-time mothers undergoing a cesarean section and vaginal delivery: Sense of coherence and social support as moderators.
Noyman-Veksler, G., Herishanu-Gilutz, S., Kofman, O., Holchberg, G., & Shahar, G.
To investigate the protective role of sense of coherence (SOC) and perceived social support in the effect of emergency/elective caesarian section on post-natal psychological symptoms and impairment in mother–infant bonding.
Thirty-seven women delivering via an emergency C-section, 21 via elective C-section and 38 through a vaginal delivery were assessed six weeks post-partum (Time 1) as to their post-traumatic stress disorder (PTSD) and depressive symptoms, impairment in bonding and SOC and social support. Symptoms and bonding difficulties were assessed again six weeks later (Time 2). Main and interactive effects of mode of delivery and the protective factors were examined.
Main Outcome Measures:
Post-natal depressive and PTSD symptoms and mother–infant bonding.
An emergency C-section mode of delivery predicted an increase in PTSD symptoms in Time 2, but only among women with low levels of Time-1 social support. Time-1 SOC predicted a decrease in post-natal PTSD and depression.
Social support might buffer against the potentially traumatic effect of an emergency C-section. SOC appears to constitute a powerful dimension of post-natal resilience.