February and March Research Update

Apologies for missing February’s update. To ensure no studies are missed I have decided to compile February’s and Marchs into one post:

[Reliability and Validity of the Korean Version of the Perinatal Post-Traumatic Stress Disorder Questionnaire].

[Article in Korean]


Park YK, Ju HO, Na H3.




The Perinatal Post-Traumatic Stress Disorder Questionnaire (PPQ) was designed to measure post-traumatic symptoms related to childbirth and symptoms during postnatal period. The purpose of this study was to develop a translated Korean version of the PPQ and to evaluate reliability and validity of the Korean PPQ.


Participants were 196 mothers at one to 18 months after giving childbirth and data were collected through e-mails. The PPQ was translated into Korean using translation guideline from World Health Organization. For this study Cronbach’s alpha and split-half reliability were used to evaluate the reliability of the PPQ. Exploratory Factor Analysis (EFA), Confirmatory Factor Analysis (CFA), and known-group validity were conducted to examine construct validity. Correlations of the PPQ with Impact of Event Scale (IES), Beck Depression Inventory II (BDI-II), and Beck Anxiety Inventory (BAI) were used to test a criterion validity of the PPQ.


Cronbach’s alpha and Spearman-Brown split-half correlation coefficient were 0.91 and 0.77, respectively. EFA identified a 3-factor solution including arousal, avoidance, and intrusion factors and CFA revealed the strongest support for the 3-factor model. The correlations of the PPQ with IES, BDI-II, and BAI were .99, .60, and .72, respectively, pointing to criterion validity of a high level.


The Korean version PPQ is a useful tool for screening and assessing mothers’ experiencing emotional distress related to child birth and during the postnatal period. The PPQ also reflects Post Traumatic Stress Disorder’s diagnostic standards well.




[Fear of childbirth among nulliparous women: Relations with pain during delivery, post-traumatic stress symptoms, and postpartum depressive symptoms].

[Article in French]


Gosselin P, Chabot K, Béland M, Goulet-Gervais L, Morin AJ.




Fear of childbirth is common in women who are pregnant with their first child and is associated with important consequences such as abortions and miscarriages. Twenty percent of nulliparous women seem to exhibit a mild or moderate fear, while 6% present an excessive and irrational fear known as tocophobia. Tocophobia is suggested to be associated with many negative consequences such as postpartum depression (PPD) and Post-traumatic stress (PTS). However, there is little empirical evidence to support these relationships. Recently, Fairbrother and Woody (2007) did not observe a link between the fear of childbirth and symptoms of PPD and PTS in nulliparous women. Some results, near the significance level, could be explained by a lack of statistical power. The present study focused on the link between the fear of childbirth and the process of delivery, the perception of pain, PPD and PTS. More specifically, it aimed to test three hypotheses: (i) fear of childbirth will be linked to the process of delivery, especially regarding the perception of pain, the use of anaesthesia and the use of Caesarean section; (ii) a high level of fear of childbirth will be associated with more negative postpartum consequences (namely PPD/PTS symptoms); (iii) the process of delivery and pain will also be related to post-delivery symptoms. Mediation effects were tested.


Data from a longitudinal study were used to meet the hypotheses. A total of 176 nulliparous pregnant women responded to questionnaires at two time measurements (during pregnancy and at 5weeks postpartum).


Fear of childbirth is related to the perception of pain at birth among women delivering vaginally, in the absence of anaesthesia. It is also linked to symptoms of PPD and PTS, regardless of whether or not anaesthesia was used. Fear of childbirth also appears to be strongly associated to symptoms of PTS in women who have experienced an unplanned caesarean section. Thus, symptoms of postpartum PTS could play a mediating role in the link between fear of childbirth and PPD.


These results support the relevance of taking into account the fear of childbirth and perception of pain in connection with symptoms of PTS and PPD in nulliparous women. The unplanned caesarean section (including emergency caesarean) also appears to be important in the study of the relationship between fear and symptoms of PTS. Fear of childbirth could render the experience of childbearing more negative and predispose to PTS and PPD. Enabling psychological vulnerabilities could also be an interesting avenue for understanding these links. Limitations are discussed.




Posttraumatic Stress Disorder After Birth: A Metaphor Analysis.


Beck CT1.




Nine percent of mothers screened positive for meeting the diagnostic criteria for posttraumatic stress disorder (PTSD) due to childbirth in a recent study of childbearing women in the United States. The purpose of this study was to analyze the language used by mothers experiencing PTSD after traumatic birth for metaphors as a rich source of insight into this mental illness for maternal-child nurses.


A secondary analysis was conducted of the corpus of 124 typed pages from the primary qualitative study of women’s experiences of PTSD following traumatic childbirth. The Pragglejaz Group’s metaphor identification procedure was the method used for identifying metaphorically used words in the mothers’ discourse.


Nine metaphors emerged. These metaphors portray PTSD due to childbirth as a mechanical robot, a ticking time bomb, an invisible wall, a video on constant reply, enveloping darkness, a dangerous ocean, a thief in the night, a bottomless abyss, and suffocating layers of trauma.


Metaphors that mothers used to describe their experiences of PTSD following a traumatic birth provide rich insight for maternal-child nurses. These metaphors give a new voice to women’s experiences of PTSD and are a perfect match for a valuable source for nurses’ evidence-based practice.




Anxiety Sensitivity Among First-Time Fathers Moderates the Relationship Between Exposure to Stress During Birth and Posttraumatic Stress Symptoms.


Zerach G, Magal O.



This longitudinal study examined posttraumatic stress disorder (PTSD) and anxiety symptoms among men attending the birth of their first offspring. Furthermore, we examined the moderating role of anxiety sensitivity (AS) and intolerance of uncertainty in the association between exposure to stress during birth and PTSD and anxiety symptoms. Participants were Israeli men (n = 171) who were assessed with self-report questionnaires during the third trimester of pregnancy (T1) and approximately a month following birth (T2). Results show that the rates of postnatal PTSD and anxiety symptoms were relatively low. Subjective exposure to stress during birth and AS predicted PTSD in T2, above and beyond other negative life events and PTSD in T1. In addition, AS moderated the relations between subjective exposure to stress during birth and PTSD symptoms. Pregnancy and childbirth professionals may benefit from the insight that men with high levels of AS might experience childbirth as a highly stressful situation with possible posttraumatic stress symptoms.




Seeing Their Children in Pain: Symptoms of Posttraumatic Stress Disorder in Mothers of Children with an Anomaly Requiring Surgery at Birth.


Aite L, Bevilacqua F, Zaccara A, La Sala E, Gentile S, Bagolan P.



Objective Assess the presence of posttraumatic stress disorder (PTSD) symptoms in mothers of newborns requiring early surgery. Study Design Mothers of newborns operated on for a congenital anomaly underwent a semi-structured interview on their experience 6 months postpartum. Interviews were audiotaped, transcribed verbatim, and analyzed for symptoms of the three major criteria of PTSD: re-experiencing, avoidance, and heightened arousal. Results A total of 120 mothers took part in the study; their children were affected by one of the following congenital anomaly: esophageal atresia (n = 29); congenital diaphragmatic hernia (n = 38); midgut malformations (n = 38); and abdominal wall defects (n = 15). Two mothers did not show any symptoms; 12 mothers (10%) had one posttraumatic symptom, 77 (64.2%) had two, and 29 (24.2%) had three. Overall, 106 mothers (88.4%) presented at least two symptoms. Conclusion PTSD can be considered a useful model to describe and comprehend mothers’ reactions in this specific population. Preventive interventions and dedicated follow-up program should be offered to these families.




Psychological trauma and posttraumatic stress disorder: risk factors and associations with birth outcomes in the Drakenstein Child Health Study.


Koen N, Brittain K, Donald KA, Barnett W, Koopowitz S, Maré K, Zar HJ, Stein DJ.




Prenatal and peripartum trauma may be associated with poor maternal-fetal outcomes. However, relatively few data on these associations exist from low-middle income countries, and populations in transition.


We investigated the prevalence and risk factors for maternal trauma and posttraumatic stress disorder (PTSD), and their association with adverse birth outcomes in the Drakenstein Child Health Study, a South African birth cohort study.


Pregnant women were recruited from two clinics in a peri-urban community outside Cape Town. Trauma exposure and PTSD were assessed using diagnostic interviews; validated self-report questionnaires measured other psychosocial characteristics. Gestational age at delivery was calculated and birth outcomes were assessed by trained staff. Multiple logistic regression explored risk factors for trauma and PTSD; associations with birth outcomes were investigated using linear regression. Potential confounders included study site, socioeconomic status (SES), and depression.


A total of 544 mother-infant dyads were included. Lifetime trauma was reported in approximately two-thirds of mothers, with about a third exposed to past-year intimate partner violence (IPV). The prevalence of current/lifetime PTSD was 19%. In multiple logistic regression, recent life stressors were significantly associated with lifetime trauma, when controlling for SES, study site, and recent IPV. Childhood trauma and recent stressors were significantly associated with PTSD, controlling for SES and study site. While no association was observed between maternal PTSD and birth outcomes, maternal trauma was significantly associated with a 0.3 unit reduction (95% CI: 0.1; 0.5) in infant head-circumference-for-age z-scores (HCAZ scores) at birth in crude analysis, which remained significant when adjusted for study site and recent stressors in a multivariate regression model.


In this exploratory study, maternal trauma and PTSD were found to be highly prevalent, and preliminary evidence suggested that trauma may adversely affect fetal growth, as measured by birth head circumference. However, these findings are limited by a number of methodological weaknesses, and further studies are required to extend findings and delineate causal links and mechanisms of association.




The aetiology of post-traumatic stress following childbirth: a meta-analysis and theoretical framework.


Ayers S, Bond R, Bertullies S, Wijma K.



There is evidence that 3.17% of women report post-traumatic stress disorder (PTSD) after childbirth. This meta-analysis synthesizes research on vulnerability and risk factors for birth-related PTSD and refines a diathesis-stress model of its aetiology. Systematic searches were carried out on PsycINFO, PubMed, Scopus and Web of Science using PTSD terms crossed with childbirth terms. Studies were included if they reported primary research that examined factors associated with birth-related PTSD measured at least 1 month after birth. In all, 50 studies (n = 21 429) from 15 countries fulfilled inclusion criteria. Pre-birth vulnerability factors most strongly associated with PTSD were depression in pregnancy (r = 0.51), fear of childbirth (r = 0.41), poor health or complications in pregnancy (r = 0.38), and a history of PTSD (r = 0.39) and counselling for pregnancy or birth (r = 0.32). Risk factors in birth most strongly associated with PTSD were negative subjective birth experiences (r = 0.59), having an operative birth (assisted vaginal or caesarean, r = 0.48), lack of support (r = -0.38) and dissociation (r = 0.32). After birth, PTSD was associated with poor coping and stress (r = 0.30), and was highly co-morbid with depression (r = 0.60). Moderator analyses showed that the effect of poor health or complications in pregnancy was more apparent in high-risk samples. The results of this meta-analysis are used to update a diathesis-stress model of the aetiology of postpartum PTSD and can be used to inform screening, prevention and intervention in maternity care.




Does abortion increase women’s risk for post-traumatic stress? Findings from a prospective longitudinal cohort study.


Biggs MA, Rowland B, McCulloch CE, Foster DG.




To prospectively assess women’s risk for post-traumatic stress disorder (PTSD) and of experiencing post-traumatic stress symptoms (PTSS) over 4 years after seeking an abortion, and to assess whether symptoms are attributed to the pregnancy, abortion or birth, or other events in women’s lives.


Prospective longitudinal cohort study which followed women from approximately 1 week after receiving or being denied an abortion (baseline), then every 6 months for 4 years (9 interview waves).


30 abortion facilities located throughout the USA.


Among 956 women presenting for abortion care, some of whom received an abortion and some of whom were denied due to advanced gestational age; 863 women are included in the longitudinal analyses.


PTSS and PTSD risk were measured using the Primary Care PTSD Screen (PC-PTSD). Index pregnancy-related PTSS was measured by coding the event(s) described by women as the cause of their symptoms.


We used unadjusted and adjusted logistic mixed-effects regression analyses to assess whether PTSS, PTSD risk and pregnancy-related PTSS trajectories of women obtaining abortions differed from those who were denied one.


At baseline, 39% of participants reported any PTSS and 16% reported three or more symptoms. Among women with symptoms 1-week post-abortion seeking (n=338), 30% said their symptoms were due to experiences of sexual, physical or emotional abuse or violence; 20% attributed their symptoms to non-violent relationship issues; and 19% said they were due to the index pregnancy. Baseline levels of PTSS, PTSD risk and pregnancy-related PTSS outcomes did not differ significantly between women who received and women who were denied an abortion. PTSS, PTSD risk and pregnancy-related PTSS declined over time for all study groups.


Women who received an abortion were at no higher risk of PTSD than women denied an abortion.




Factors Associated with Post-Traumatic Symptoms in Mothers of Preterm Infants.


Chang HP, Chen JY, Huang YH, Yeh CJ, Huang JY, Su PH, Chen VC.




Symptoms of post-traumatic distress in mothers of preterm infants have been a subject of mental health research. The aim of this study was to assess the prevalence of and risk factors associated with such symptoms in mothers of preterm infants in Taiwan.


This was a cross-sectional study performed between January 1, 2010 and June 30, 2011. One hundred and two mothers of preterm infants born at less than 37weeks gestation and with a subsequent neonatal intensive care unit (NICU) stay between 2005 and 2009 were recruited. Participants completed a demographic questionnaire, the Impact of Event Scale-Revised (IES-R), the Center for Epidemiologic Studies Depression Scale (CES-D) and the neuroticism subscale of the Maudsley Personality Inventory (MPI). The preterm infants’ data were taken from medical records.


The prevalence of symptoms of distress was 25.5% (26/102) in the participants. These symptoms were associated with previous miscarriages, preterm premature rupture of membranes, neurotic personality and depression.


The experience of preterm birth and NICU hospitalization can be traumatic to mothers. Early support for mothers during the preterm infants’ NICU stay and transition to home care are recommended.




Mother’s Emotional and Posttraumatic Reactions after a Preterm Birth: The Mother-Infant Interaction Is at Stake 12 Months after Birth.


Petit AC, Eutrope J, Thierry A, Bednarek N, Aupetit L, Saad S, Vulliez L, Sibertin-Blanc D, Nezelof S, Rolland AC.



Objectives: Very preterm infants are known to be at risk of developmental disabilities and behavioural disorders. This condition is supposed to alter mother-infant interactions. Here we hypothesize that the parental coping with the very preterm birth may greatly influence mother-infant interactions. Methods: 100 dyads were included in 3 university hospitals in France. Preterm babies at higher risk of neurodevelopmental sequelae (PRI>10) were excluded to target the maternal determinants of mother-infant interaction. We report the follow-up of this cohort during 1 year after very preterm birth, with regular assessment of infant somatic state, mother psychological state and the assessment of mother-infant interaction at 12 months by validated scales (mPPQ, HADS, EPDS, PRI, DDST and PIPE). Results: We show that the intensity of post-traumatic reaction of the mother 6 months after birth is negatively correlated with the quality of mother-infant interaction at 12 months. Moreover, the anxious and depressive symptoms of the mother 6 and 12 months after birth are also correlated with the quality of mother-infant interaction at 12 months. By contrast, this interaction is not influenced by the initial affective state of the mother in the 2 weeks following birth. In this particular population of infants at low risk of sequelae, we also show that the quality of mother-infant interaction is not correlated with the assessment of the infant in the neonatal period but is correlated with the fine motor skills of the baby 12 months after birth. Conclusions: This study suggests that mothers’ psychological condition has to be monitored during the first year of very preterm infants’ follow-up. It also suggests that parental interventions have to be proposed when a post-traumatic, anxious or depressive reaction is suspected.



Computer- or web-based interventions for perinatal mental health: A systematic review.


Ashford MT, Olander EK, Ayers S



Background: Treating prenatal mental health issues is of great importance, but access to treatment is often poor. One way of accessing treatment is through computer- or web-based interventions. Reviews have shown that these interventions can be effective for a variety of mental health disorder across different populations. However, their effectiveness for women in the perinatal period has not been reviewed. This review therefore aimed to provide a first overview of computer- or web-based interventions for women’s perinatal mental health issues by systematically identifying and reviewing their characteristics and efficacy. Methods: Twelve electronic databases were searched for published and unpublished literature using keywords, supplemented by hand searches. Data were extracted for characteristics of the intervention and the study, study findings and the methodological quality was assessed. Results: The majority of the eleven eligible studies were randomized controlled trials. Interventions were targeted at depression, stress, and complicated grief during the antenatal or postpartum period or the time after pregnancy loss. Findings suggest that computer- or web-based interventions targeted at improving mental health, especially depression and complicated grief, may be effective. Limitations: Findings and their generalizability is limited by the heterogeneity of reviewed interventions and study designs, as well as methodological limitations. Conclusions: This systematic review constitutes the first synthesis of research on computer- or web-based interventions for perinatal mental health issues and provides preliminary support that this could be a promising form of treatment during this period. However, there are significant gaps in the current evidence-base so further research is needed.

Mindfulness and perinatal mental health: A systematic review.


Hall HG, Beattie J, East C, Anne Biro M



Background: Perinatal stress is associated with adverse maternal and infant outcomes. Mindfulness training may offer a safe and acceptable strategy to support perinatal mental health. Aim: To critically appraise and synthesise the best available evidence regarding the effectiveness of mindfulness training during pregnancy to support perinatal mental health. Methods: The search for relevant studies was conducted in six electronic databases and in the grey literature. Eligible studies were assessed for methodological quality according to standardised critical appraisal instruments. Data were extracted and recorded on a pre-designed form and then entered into Review Manager. Findings: Nine studies were included in the data synthesis. It was not appropriate to combine the study results because of the variation in methodologies and the interventions tested. Statistically significant improvements were found in small studies of women undertaking mindfulness awareness training in one study for stress (mean difference (MD) -5.28, 95% confidence intervals (CI) -10.4 to -0.42, n=22), two for depression (for example MD -5.48, 95% CI -8.96 to -2.0, n=46) and four for anxiety (for example, MD -6.50, 95% CI -10.95 to -2.05, n=32). However the findings of this review are limited by significant methodological issues within the current research studies. Conclusion: There is insufficient evidence from high quality research on which to base recommendations about the effectiveness of mindfulness to promote perinatal mental health. The limited positive findings support the design and conduct of adequately powered, longitudinal randomised controlled trials, with active controls.



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