Journal of Reproductive and Infant Psychology Special Issue: PTSD After Birth

The Journal of Reproductive and Infant Psychology have published a special issue on PTSD following childbirth. Here are a list of the titles and abstracts that can be found in this special issue:

Post-traumatic stress disorder after birth

Susan Ayers, Kirstie McKenzie-McHarg, & Pauline Slade


Post-traumatic stress disorder following childbirth: an update of current issues and recommendations for future research

Kirstie McKenzie-McHarg, Susan Ayers, Elizabeth Ford, Antje Horsch, Julie Jomeen, Alexandra Sawyer, Claire Stramrood, Gill Thomson & Pauline Slade


Objective: This paper aimed to report the current status of research in the field of post-traumatic stress disorder following childbirth (PTSD FC), and to update the findings of an earlier 2008 paper. Background: A group of international researchers, clinicians and service users met in 2006 to establish the state of clinical and academic knowledge relating to PTSD FC. A paper identified four key areas of research knowledge at that time.Methods: Fourteen clinicians and researchers met in Oxford, UK to update the previously published paper relating to PTSD FC. The first part of the meeting focused on updating the four key areas identified previously, and the second part on discussing new and emerging areas of research within the field. Results: A number of advances have been made in research within the area of PTSD FC. Prevalence is well established within mothers, several intervention studies have been published, and there is growing interest in new areas: staff and pathways; prevention and early intervention; impact on families and children; special populations; and post-traumatic growth. Conclusion: Despite progress, significant gaps remain within the PTSD FC knowledge base. Further research continues to be needed across all areas identified in 2006, and five areas were identified which can be seen as ‘new and emerging’. All of these new areas require further extensive research. Relatively little is still known about PTSD FC.

Postnatal posttraumatic stress: A grounded theory model of first-time mothers’ experiences


Objective: To develop a grounded theory model of first-time mothers’ experiences of postnatal posttraumatic stress, with the aim of aiding understanding, formulation and treatment of new mothers. Background: Research into postnatal posttraumatic stress is growing, yet evidence-based treatment models have yet to be fully developed. It is unknown whether existing models of posttraumatic stress are directly applicable to postnatal posttraumatic stress, or whether other factors are particularly relevant for symptoms occurring in this context. Methods: A qualitative design explored first-time mothers’ experiences of pregnancy, labour, birth and the postpartum, following a subjectively identified traumatic labour and/ or childbirth. Eleven mothers were interviewed individually, either reporting full symptoms of posttraumatic stress (n = 6), or partial symptoms (n = 5). Grounded theory methodology was used to code the data and develop a theoretical model of maternal postnatal posttraumatic stress based on these accounts. Results: Factors emerged specific to postnatal experiences, including: antenatal expectations and anxieties, constructions of the experience, perceptions of other people’s views, social support (from specific sources) and adaptive and maladaptive coping strategies. Limitations: The study was based on a small sample of first-time mothers’ accounts, and therefore may not be applicable to mothers with previous children, or a wider maternal population. Conclusions: The new model highlights important areas for development in clinical practice at various stages of maternal healthcare provision: in the antenatal period, during labour and birth, and into the postpartum. The model can inform formulation and treatment of mothers experiencing postnatal trauma symptoms, providing specific areas of focus for intervention.

A longitudinal study exploring the role of adult attachment in relation to perceptions of pain in labour, childbirth memory and acute traumatic stress responses

Kate Quinn, Helen Spiby & Pauline Slade

Objective: To investigate if adult attachment patterns, measured before childbirth, are predisposing factors for the experiences of childbirth pain and disorganised memory patterns. In addition, we aimed to investigate relationships between these variables and acute symptoms of traumatic stress following childbirth. Background: In 2006, Slade proposed a model for understanding the development of post-traumatic symptoms following childbirth, suggesting consideration of predisposing, precipitating and maintaining internal, external and interactional factors. This study investigated whether adult attachment patterns are a potential predisposing factor by examining associations with other factors in the Slade model: perceived pain and support during birth, and memory processing after birth. Method: Eighty-one nulliparous women were recruited in late pregnancy and completed a questionnaire, including an adult attachment measure. Shortly after childbirth, participants reported on their childbirth experience, concerning perceived pain, perceived staff support memory variables and symptoms of acute traumatic stress. Results: Higher scores on anxious adult attachment were associated with higher pain severity ratings. Higher scores on avoidant attachment were related to participants reporting feeling less respected by staff. However, no relationships between attachment and memory disorganisation were found. Less secure adult attachment was associated with greater acute traumatic stress symptoms of hyperarousal. Conclusion: The findings indicate a possible association between adult attachment and the experience of pain in childbirth. It partially supports previous work demonstrating links between attachment and acute stress symptoms postpartum.

Defence against trauma: women’s use of defence mechanisms following childbirth-related trauma


Objective: To explore and identify women’s use of defence mechanisms in the aftermath of a traumatic birth. Background: Following childbirth-related trauma, women adopt a range of unconsciously mediated functional and dysfunctional responses in their attempts to ‘cope’ with their complex emotions. Methods: A secondary analysis was undertaken on existing qualitative research (n = 13) that considered women’s psychosocial responses following a traumatic birth, using Valliant’s (1992) framework of Freudian defence mechanisms as a conceptual lens. Extracted findings from the studies were mapped against the framework until saturation and consensual validation occurred. Results: Ten defence mechanisms were identified to resonate with women’s trauma-related responses. Women tried to ‘repress’ and ‘supress’ their memories of childbirth and used ‘avoidance’ to protect themselves from reminders. ‘Sublimation’ and ‘undoing’ were adopted in attempts to convert their negative emotions into more constructive responses and to present themselves as good mothers. However, the pervasive impact of a traumatic birth was evident through ‘displacement’, ‘somatisation’, ‘reaction formation’, ‘turning against the self’ and ‘regression’, with women expressing anger and hostility towards themselves, their infants, partners and others. Conclusion: Training and context-related screening processes to identify defence-related responses are needed. Raising awareness of defence mechanisms could provide reassurance of the ‘normality’ of women’s psychological responses in the short term. Recognition of how long-term adoption is indicative of undesirable and unhealthy behaviours may also promote and encourage access to suitable psychological support.

Hyperarousal symptoms after traumatic and nontraumatic births


Background: Measurement is critical in postnatal posttraumatic stress disorder (PTSD) because symptoms may be influenced by normal postnatal phenomena such as physiological changes and fatigue. Objective: This study examined: (1) whether hyperarousal symptoms differ between women who have traumatic or nontraumatic births; (2) whether the construct of hyperarousal is coherent in postnatal women; and (3) whether hyperarousal symptoms are useful for identifying women who have traumatic births or PTSD. Methods: A survey of PTSD symptoms in 1,078 women recruited via the community or Internet who completed an online or paper questionnaire measuring childbirth-related PTSD symptoms between 1 and 36 months after birth. Women who had a traumatic birth as defined by DSM-IV criterion A (n = 458) were compared with women who did not have a traumatic birth (n = 591). Results: A one-factor dimension of hyperarousal was identified that included all five hyperarousal items. Diagnostic criteria of two or more hyperarousal symptoms in the previous week were reported by 75.3% of women with traumatic birth and 50.5% of women with nontraumatic births. The difference in mean hyperarousal symptoms between groups was substantial at 0.76 of a standard deviation (Hedge’s g, CI = 0.64, 0.89). A larger difference was observed between women with and without diagnostic PTSD (g = 1.64, CI 1.46, 1.81). However, receiver operating characteristic analyses showed hyperarousal symptoms have poor specificity and alternative ways of calculating symptoms did not improve this. Comparison with other PTSD symptoms found re-experiencing symptoms were most accurate at identifying women with traumatic births. Conclusions: Results suggest hyperarousal symptoms are associated with traumatic birth and are a coherent construct in postnatal women. However, they have poor specificity and should only be used as part of diagnostic criteria, not as a sole indicator.

Personal growth in UK and Croatian women following childbirth: A preliminary study

Alexandra Sawyer, Sandra Nakić Radoš, Susan Ayers & Erin Burn


Objective: The aim of this study was to examine growth in UK and Croatian women following childbirth and to identify correlates of personal growth after birth, specifically focusing on sociodemographic, obstetric and coping variables. Background: Childbirth is a significant and challenging life event for many women with the potential for both positive and negative psychological changes. Research is increasingly exploring growth in different cultures. No studies have explored growth in Croatian women following childbirth.Methods: UK (N = 193) and Croatian (N = 160) women who had given birth within the last two years completed online questionnaires measuring growth, depression, posttraumatic stress symptoms and coping strategies. Results: Approximately 44% and 35% of UK and Croatian women, respectively, reported a moderate level of growth after childbirth. Hierarchical multiple regression analyses showed that younger women in both countries reported more growth. In the UK sample, coping strategies were related to higher growth. In the Croatian sample, higher posttraumatic stress symptoms and the avoidant coping strategy of denial were associated with higher levels of growth. Conclusion: This study suggests that many women report positive changes as a result of their birth experience. Further research is needed to explore how cultural elements are manifested in the experience of growth.

The efficacy of ‘debriefing’ after childbirth: Is there a case for targeted intervention?


Objective: To review the efficacy of debriefing interventions for reducing posttraumatic stress (PTS) and/ or depressive symptoms in postnatal women. Background: Techniques referred to as debriefing have been adapted for use within maternity care settings to prevent the development of PTS symptoms or depression. There is a requirement to disaggregate methods and approaches used by existing studies, rather than review the research as a whole, to identify elements that may contribute to an efficacious intervention and to clarify what is currently a confused position. Methods: Papers assessing the utility of providing a brief psychological intervention involving discussion of a birth with the mother and a professional, to reduce symptoms of PTS or depression, were reviewed. Discussions could be structured or unstructured, and involve any aspect of discussing the birth, responses and coping strategies. Results: Nine papers (eight studies) were reviewed. While the majority of studies reported findings indicating that debriefing was ineffective for reducing PTS or depressive symptoms, there was evidence indicating that targeted interventions (for women who experienced a traumatic birth) were efficacious. Conclusion: There may be potential utility in providing a debriefing intervention for women who perceive their childbirth experience to have been traumatic. A diversity of approaches termed ‘debriefing’ highlight a requirement to consider alternative terminology; the term ‘childbirth review’ is suggested as a useful alternative. Further research evaluating the efficacy of debriefing using a targeted approach for trauma perception is recommended.

June Research Update

The Influence of Childbirth Experiences on Women’s Post-Partum Traumatic Stress Symptoms: A Comparison Between Israeli Jewish and Arab Women

Halperin, O., Sarid, O., & Cwikel, J.’s_Post-Partum_Traumatic_Stress_Symptoms_A_Comparison_Between_Israeli_Jewish_and_Arab_Women

ABSTRACT childbirth is a positive experience for most women yet some women express distress after birth. Traumatic experience can sometimes cause post-traumatic stress disorder (PTSD) in relation to childbirth. Prevalence of traumatic birth experience and PTSD after childbirth differs between cultures.
to examine the subjective recall of childbirth experiences and PTSD symptoms of Israeli Jewish and Arab women; to examine comparatively the prevalence of PTSD symptoms six to eight weeks after childbirth and to establish the factors that predict PTSD symptoms.
a prospective study was conducted in a region characterised by wide variations in ethnocultural groups. The study was comprised of two time points: Time 1 (T1) interviews were conducted at the bedside of the women in the maternity ward of each hospital 24-48 hours after childbirth. Time 2 (T2), all 171 women participating in T1 were interviewed by phone six to eight weeks after childbirth. 34 women (19.9%) reported their labour as traumatic 24-48 hours after birth (T1), and six to eight weeks later (T2) 67 women (39.2%) assessed their experience as traumatic. More Arab women (69.6%) than Jewish women (56.5%) had a positive memory of childbirth, but this difference only approached statistical significance (p=.09). Results showed rather low frequencies of PTSD symptoms, and no ethnic difference. PTSD symptoms were significantly and positively predicted by subjective recollection of childbirth experience (Time 2). PTSD symptoms were higher for women who did not have a vaginal birth, and more women with PTSD symptoms were not breast feeding. We found more similarities than differences between Arab and Jewish women’s experience of their births and no differences between them on the prevalence of PTSD symptoms after birth. The results suggest that non-vaginal birth (instrumental or caesarean section) and negative recollection of the childbirth experience are important factors related to the development of PTSD symptoms after birth, and that women with PTSD symptoms are less likely to breast feed.

Trauma and the Effects on the Midwife

Calvert. I., & Benn, C.


BACKGROUND: When practicing as a lead maternity carer, the first author (IC) found that following a traumatic practice experience, there appeared to be very little emotional support for the midwife unless provided by colleagues or family. Midwives were expected to continue as if nothing had happened and they had not been affected in any way by the event.

AIM: To explore the effects of a traumatic practice experience on the midwifery practitioner.

RESEARCH METHODOLOGY AND METHOD: A qualitative study using a narrative research method was implemented. Data were collected using an adapted biographical narrative interview method. An eclectic approach was used to analyze the data for content and form based on identity and ontology.

FINDINGS: The study demonstrated that partnership and autonomous midwifery practice are key drivers that make New Zealand midwives more likely to be blamed for unfortunate outcomes, and their competence in practice challenged. The study identified that a breach of relational trust exacerbates or prolongs the initial physiological and/or psychological symptoms experienced by the participating midwives following a traumatic practice event. The perpetrators of this betrayal of trust were organizational and clinical managers, medical and midwifery colleagues, women, and their families.

CONCLUSION: The participants’ stories have drawn attention to the effects of counterproductive behaviors that occur in dysfunctional health organizations and the need for professional emotional support.

Mixed expectations: Effects of goal ambivalence during pregnancy on maternal well‐being, stress, and coping.

Background: We hypothesised that experiencing ambivalence toward the childbearing goal would be related to indicators of well‐being, stress, and coping among women with planned pregnancies. Methods: Study 1 (N = 208) tested cross‐sectional associations between goal ambivalence and measures of well‐being, stress, and coping. It also included a postpartum measurement point (N = 71) to examine prospective effects of goal ambivalence. Study 2 (N = 109) extended the investigation to within‐person effects in a three‐week daily diary assessment. Results: In Study 1, goal ambivalence in pregnant women was positively associated with depressive symptoms, perceived stress, and pregnancy‐specific avoidance‐oriented coping, and negatively associated with coping self‐efficacy. Goal ambivalence also predicted changes in life satisfaction, depressive symptoms, perceived stress, and coping self‐efficacy postpartum. Study 2 revealed within‐person effects of daily fluctuations in goal ambivalence on day‐to‐day changes in positive emotions, negative activation, and avoidance‐oriented coping. Conclusions: Ambivalence towards the childbearing goal is a source of significant distress to pregnant women with planned pregnancies and its effects seem to extend into the postpartum period. These findings may have important clinical implications for maternal and child well‐being. Future studies should examine whether goal ambivalence during pregnancy affects the maternal–child relationship in the long term.


Exposure to violence among women with unwanted pregnancies and the association with post-traumatic stressdisorder, symptoms of anxiety and depression.

Tinglöf,S., Högberg, U., Lundell IW., & Svanberg, A.S.



The objective was to examine lifetime exposure to violence, physical and sexual, among women seeking termination of pregnancy (TOP) and its association with socio-demographic factors, PTSD, symptoms of anxiety and depression.


The design of the study was a Swedish multi-centre study targeting women requesting TOP.


All women requesting TOP with a gestational length less than 12 pregnancy weeks were approached for participation in the study. The questionnaire comprised the following research instruments: Screen Questionnaire-Post traumatic Stress Disorder (SQ-PTSD) and Hospital Anxiety and Depression Scale (HADS). The response rate was 57% and the final sample was 1514 women. Descriptive and analytic statistics were applied.


Lifetime exposure to violence was common among women seeking abortion. Exposure to violence was associated with low education, single marital status, smoking and high alcohol consumption. Exposure to violence was associated with the occurrence of signs of PTSD and symptoms of anxiety and depression. Among those having PTSD, all had been exposed to sexual violence and almost all had been exposed to physical violence, while for those with symptoms of anxiety and depression almost half had been exposed to either physical or sexual violence.


Exposure to physical and sexual abuse was common among women requesting TOP, and was strongly associated with the occurrence of PTSD, symptoms of anxiety and depression. This underscores the importance for health professionals to recognize and offer support to those women exposed to violence.

Should Perinatal Mental Health be Everyone’s Business?

Ayers, A., & Shakespeare, J.