April Research Update

Comorbid trajectories of postpartum depression and PTSD among mothers with childhood trauma history: Course, predictors, processes and child adjustment.

Oh W, Muzik M, McGinnis EW, Hamilton L, Menke RA, Rosenblum KL.

J Affect Disord. 2016 Apr 20;200:133-141. doi: 10.1016/j.jad.2016.04.037.



Both postpartum depression and posttraumatic stress disorder (PTSD) have been identified as unique risk factors for poor maternal psychopathology. Little is known, however, regarding the longitudinal processes of co-occurring depression and PTSD among mothers with childhood adversity. The present study addressed this research gap by examining co-occurring postpartum depression and PTSD trajectories among mothers with childhood trauma history.


177 mothers with childhood trauma history reported depression and PTSD symptoms at 4, 6, 12, 15 and 18 months postpartum, as well as individual (shame, posttraumatic cognitions, dissociation) and contextual (social support, childhood and postpartum trauma experiences) factors.


Growth mixture modeling (GMM) identified three comorbid change patterns: The Resilient group (64%) showed the lowest levels of depression and PTSD that remained stable over time; the Vulnerable group (23%) displayed moderately high levels of comorbid depression and PTSD; and the Chronic High-Risk group (14%) showed the highest level of comorbid depression and PTSD. Further, a path model revealed that postpartum dissociation, negative posttraumatic cognitions, shame, as well as social support, and childhood and postpartum trauma experiences differentiated membership in the Chronic High-Risk and Vulnerable. Finally, we found that children of mothers in the Vulnerable group were reported as having more externalizing and total problem behaviors.


Generalizability is limited, given this is a sample of mothers with childhood trauma history and demographic risk.


The results highlight the strong comorbidity of postpartum depression and PTSD among mothers with childhood trauma history, and also emphasize its aversive impact on the offspring.


Blame and guilt – a mixed methods study of obstetricians’ and midwives’ experiences and existential considerations after involvement in traumatic childbirth.

Schrøder K, Jørgensen JS, Lamont RF, Hvidt NC.

Acta Obstet Gynecol Scand. 2016 Apr 13. doi: 10.1111/aogs.12897.



When complications arise in the delivery room, midwives and obstetricians operate at the interface of life and death, and in rare cases the infant or the mother suffers severe and possibly fatal injuries related to the birth. This descriptive study investigated the numbers and proportions of obstetricians and midwives involved in such traumatic childbirth and explored their experiences with guilt, blame, shame and existential concerns.


A mixed methods study comprising a national survey of Danish obstetricians and midwives and a qualitative interview study with selected survey participants.


The response rate was 59% (1237/2098), of which 85% stated that they had been involved in a traumatic childbirth. We formed five categories during the comparative mixed methods analysis: the patient, clinical peers, official complaints, guilt, and existential considerations. Although blame from patients, peers or official authorities was feared (and sometimes experienced), the inner struggles with guilt and existential considerations were dominant. Feelings of guilt were reported by 36-49%, and 50% agreed that the traumatic childbirth had made them think more about the meaning of life. Sixty-five percent felt that they had become a better midwife or doctor due to the traumatic incident.


The results of this large, exploratory study suggest that obstetricians and midwives struggle with issues of blame, guilt and existential concerns in the aftermath of a traumatic childbirth.


[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

Encephale. 2016 Apr;42(2):191-6. doi: 10.1016/j.encep.2016.01.007. Epub 2016 Feb 26.



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.


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

Ayers S, Bond R, Bertullies S, Wijma K.
Psychol Med. 2016 Apr;46(6):1121-34. doi: 10.1017/S0033291715002706.


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.


Posttraumatic Stress Disorder After Birth: A Metaphor Analysis.

Beck CT.
MCN Am J Matern Child Nurs. 2016 Mar-Apr;41(2):76-83. doi: 10.1097/NMC.0000000000000211.



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.


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