May and June Research Update

The co-existence of depression, anxiety and post-traumatic stress symptoms in the perinatal period: A systematic review.

Agius A, Xuereb RB, Carrick-Sen D, Sultana R, Rankin J.
Midwifery. 2016 May;36:70-9. doi: 10.1016/j.midw.2016.02.013.



to identify and appraise the current international evidence regarding the presence and prevalence of the co-existence of depression, anxiety and post-traumatic stress symptoms in the antenatal and post partum period.


using a list of keywords, Medline, CINHAL, Cochrane Library, EMBASE, PsychINFO, Web of Science and the Index of Theses and Conference Proceedings (Jan 1960 – Jan 2015) were systematically searched. Experts in the field were contacted to locate papers that were in progress or in press. Reference lists from relevant review articles were searched. Inclusion criteria included full papers published in English reporting concurrent depression, anxiety and post-traumatic stress symptoms in pregnant and post partum women. A validated data extraction review tool was used.


3424 citations were identified. Three studies met the full inclusion criteria. All reported findings in the postnatal period. No antenatal studies were identified. The prevalence of triple co-morbidity was relatively low ranging from 2% to 3%.


triple co-morbidity does occur, although the prevalence appears to be low. Due to the presentation of complex symptoms, women with triple co-morbidity are likely to be difficult to identify, diagnose and treat. Clinical staff should be aware of the potential of complex symptomatology.

Predictors of birth-related post-traumatic stress symptoms: secondary analysis of a cohort study.

Furuta M, Sandall J, Cooper D, Bick D.
Arch Womens Ment Health. 2016 May 13.


This study aimed to identify factors associated with birth-related post-traumatic stress symptoms during the early postnatal period. Secondary analysis was conducted using data from a prospective cohort study of 1824 women who gave birth in one large hospital in England. Post-traumatic stress symptoms were measured by the Impact of Event Scale at 6 to 8 weeks postpartum. Zero-inflated negative binomial regression models were developed for analyses. Results showed that post-traumatic stress symptoms were more frequently observed in black women and in women who had a higher pre-pregnancy BMI compared to those with a lower BMI. Women who have a history of mental illness as well as those who gave birth before arriving at the hospital, underwent an emergency caesarean section or experienced severe maternal morbidity or neonatal complications also showed symptoms. Women’s perceived control during labour and birth significantly reduced the effects of some risk factors. A higher level of perceived social support during the postnatal period also reduced the risk of post-traumatic stress symptoms. From the perspective of clinical practice, improving women’s sense of control during labour and birth appears to be important, as does providing social support following the birth.

Emotional Distress Following Childbirth: An Intervention to Buffer Depressive and PTSD Symptoms.

Di Blasio P, Miragoli S, Camisasca E, Di Vita AM, Pizzo R, Pipitone L.
Eur J Psychol. 2015 May 29;11(2):214-32. doi: 10.5964/ejop.v11i2.779.


Childbirth for some women is a negative experience associated with depressive and post-traumatic symptoms. The preventive actions focusing on helping mothers to cope with negative emotions experienced after childbirth are strongly recommended. It is also recommended both to intervene early and on all women to avoid the risk that these symptoms can worsen in the months after childbirth. The intervention described in the current study is focalized on the elaboration of post-partum negative thoughts and emotion through a writing task, with the purpose to help new mothers to reflect, understand, evaluate and, thus, reformulate the stressful situation with new beliefs and emotions. 176 women aged from 19 to 43 years (M = 31.55, SD = 4.58) were assessed for depression and PTSD in the prenatal phase (T1). In about 96 hours after childbirth they were randomly assigned to either “Making Sense condition” (MS: in which they wrote about the thoughts and emotions connected with delivery and childbirth) or “Control-Neutral condition” (NC: in which they wrote about the daily events in behavioural terms) and then reassessed for depression and PTSD (T2). A follow up was conducted 3 months later (T3) to verify depression and posttraumatic symptoms. The results showed that depressive symptoms decreased both at 96 hours and at 3 months as a result of making-sense task. Regarding the posttraumatic symptoms the positive effect emerged at three months and not at 96 hours after birth.

Internet-provided cognitive behaviour therapy of posttraumatic stress symptoms following childbirth-a randomized controlled trial.

Nieminen K1,2, Berg I3, Frankenstein K3, Viita L3, Larsson K3, Persson U3, Spånberger L3, Wretman A3, Silfvernagel K3, Andersson G3,4, Wijma K1.
Cogn Behav Ther. 2016 Jun;45(4):287-306. doi: 10.1080/16506073.2016.1169626.


The aim of this study was to analyse the effects of trauma-focused guided Internet-based cognitive behaviour therapy for relieving posttraumatic stress disorder (PTSD) symptoms following childbirth, a problem that about 3% women encounter postpartum. Following inclusion, 56 traumatized women were randomized to either treatment or to a waiting list control group. Primary outcome measures were the Traumatic Event Scale (TES) and Impact of Event Scale-Reversed (IES-R). Secondary measures were Beck depression inventory II, Patient Health Questionnaire (PHQ-9), Beck Anxiety Inventory, Quality Of Life Inventory and the EuroQol 5 Dimensions. The treatment was guided by a clinician and lasted eight weeks and comprised eight modules of written text. The between-group effect size (ES) was d = .82 (p < .0001) for the IES-R. The ES for the TES was small (d = .36) and not statistically significant (p = .09). A small between-group ES (d = .20; p = .02) was found for the PHQ-9. The results from pre- to post-treatment showed large within-group ESs for PTSD symptoms in the treatment group both on the TES (d = 1.42) and the IES-R (d = 1.30), but smaller ESs in the control group from inclusion to after deferred treatment (TES, d = .80; IES-R d = .45). In both groups, the treatment had positive effects on comorbid depression and anxiety, and in the treatment group also on quality of life. The results need to be verified in larger trials. Further studies are also needed to examine long-term effects.

Posttraumatic Stress Disorder Following Stillbirth: Trauma Characteristics, Locus of Control, Posttraumatic Cognitions.

Chung MC, Reed J.
Psychiatr Q. 2016 Jun 23.


This study examined the incidence of PTSD and psychiatric co-morbidity among women who experienced stillbirth and investigated the relationship between locus of control, trauma characteristics of stillbirth, posttraumatic cognitions, PTSD and co-morbid psychiatric symptoms following stillbirth. Fifty women recorded information on stillbirth experiences, and completed the Posttraumatic Stress Diagnostic Scale, General Health Questionnaire-28, Edinburgh Post-natal Depression Scale, Rotter’s Locus of Control Scale and the Posttraumatic Cognitions Inventory. 60, 28 and 12 % met the diagnostic criteria for probable full-PTSD, partial and no-PTSD respectively. Sixty-two percent and 54 % scored at or above the cutoff of the General Health Questionnaire-28 and postnatal depression respectively. Women who experienced stillbirth reported significantly more psychiatric co-morbid and post-natal depressive symptoms than the comparison group. Both groups were similar in locus of control. Women who experienced stillbirth reported negative cognitions about the self the most. After adjusting for postnatal depression, trauma characteristics were significantly correlated with Posttraumatic cognitions which, in turn, were significantly correlated with PTSD and psychiatric co-morbidity. Locus of control was not significantly correlated with psychological outcomes. Mediational analyses showed that negative cognitions about self mediated the relationship between trauma characteristics and psychiatric co-morbidity only. Women reported a high incidence of probable PTSD and co-morbid psychiatric symptoms following stillbirth. Stillbirth trauma characteristics influenced how they negatively perceived themselves. This then specifically influenced general psychological problems rather than PTSD symptoms.

The Effects of Trauma History and Prenatal Affective Symptoms on Obstetric Outcomes.

Blackmore ER, Putnam FW, Pressman EK, Rubinow DR, Putnam KT, Matthieu MM, Gilchrist MA, Jones I, O’Connor TG.
J Trauma Stress. 2016 Jun;29(3):245-52. doi: 10.1002/jts.22095.


Prenatal maternal mood may inform the adverse obstetric outcomes seen in disadvantaged populations. The contribution of having a trauma history is not well studied. We examined the impact of trauma exposure and mood symptoms on obstetric outcomes in 358 women. Women with antecedent trauma were more likely to have a history of depression, odds ratio = 2.83, 95% confidence interval [1.81, 4.42], were younger at their first pregnancy, 18.86 years versus 20.10 years, and had a higher number of previous pregnancies, 2.01 versus 1.54, compared to those with no trauma exposure. Women with prenatal anxiety had significantly smaller babies than nonanxious women, 3,313.17 g, (SD = 441.58) versus 3,429.27 g, (SD = 437.82) Trauma history magnified the effects of maternal prenatal mood on birthweight; the moderating effect was limited to those who first experienced a trauma under 18 years of age. Childhood trauma exposure increased vulnerability for low birthweight delivery associated with prenatal mood disturbance. Screening pregnant women for trauma history and current mood symptoms is indicated.

Posttraumatic Growth after Birth Trauma: “I Was Broken, Now I Am Unbreakable”.

Beck CT, Watson S.
MCN Am J Matern Child Nurs. 2016 Jun 7.



The aim of this study was to investigate women’s experiences of posttraumatic growth following traumatic childbirth.


A descriptive phenomenological study was conducted using Colaizzi’s data analysis method. The Internet sample of 15 mothers was recruited from the Trauma and Birth Stress Web site. Women were asked to describe in as much detail as they could remember, their experiences of any positive changes in their beliefs or life as a result of their traumatic childbirth.


Using Calhoun and Tedeschi’s metaphor of an earthquake to help explain posttraumatic growth, the seismic waves of birth trauma had enough power to lead to four themes of posttraumatic growth revealed in this phenomenological study: (1) Opening oneself up to a new present, (2) Achieving a new level of relationship nakedness, (3) Fortifying spiritual-mindedness, and (4) Forging new paths.


Mothers’ experiences of their personal growth after birth trauma can help inform future research that can promote posttraumatic growth in mothers. Clinicians can share results of this study with their patients to provide some hope to mothers struggling with the aftermath of a traumatic birth that some women have reported positive growth. Healthcare providers need to respect trauma survivors’ struggles while at the same time permitting mothers to explore possibilities for growth. Clinicians must not, however, create the false expectation that posttraumatic growth will happen in most trauma survivors.

Posttraumatic Stress Disorder after Vaginal Delivery at Primiparous Women.

Milosavljevic M, Lecic Tosevski D, Soldatovic I, Vukovic O, Miljevic C, Peljto A, Kostic M, Olff M.
Sci Rep. 2016 Jun 8;6:27554. doi: 10.1038/srep27554.


Although severe gynaecological pathology during delivery and negative outcome have been shown to be related with posttraumatic stress disorder (PTSD) little is known about traumatic experiences following regular delivery, at the expected time and with a healthy child. The objective of our study was to determine the prevalence of PTSD during postpartum period after vaginal delivery and its risk factors. The sample included 126 primiparous women. Monthly, for the next three months, the women were assessed for PTSD using the gold standard interview for PTSD, Clinician-Administered PTSD Scale (CAPS). Risk factors were assessed including sociodemographic variables, personal medical history and clinical variables. After the first month, 2.4% women had acute full PTSD and another 9.5% had clinically significant level of PTSD symptoms. Following the second and the third month, partial PTSD was found in 5.9% and 1.3% of the women, respectively, and none of participants had full PTSD. Obstetrical interventions were the only significant risk factor for the development of PTSD. Symptoms of postpartum PTSD are not rare after a traumatic delivery, and associated with specific obstetrical risk factors. Awareness of these risk factors may stimulate interventions to prevent this important and neglected postpartum disorder.

Cumulative Trauma and Partner Conflict Predict Posttraumatic Stress Disorder in Postpartum African-American Women.

Hauff NJ1, Fry-McComish J1, Chiodo LM2.
Clin Nurs. 2016 Jun 6. doi: 10.1111/jocn.13421.



To describe relationships between cumulative trauma, partner conflict, and posttraumatic stress in African-American postpartum women.


Cumulative trauma exposure estimates for women in the United States range from 51%-69%. During pregnancy, most trauma research has focused on physical injury to the mother. Posttraumatic stress disorder (PTSD) is associated with trauma and more prevalent in African-American women than women of other groups. Knowledge about both the rate and impact of cumulative trauma on pregnancy may contribute to our understanding of women seeking prenatal care, and disparities in infant morbidity and mortality.


This retrospective, correlational, cross-sectional study took place on postpartum units of two Detroit hospitals. Participants were 150 African-American women ages 18-45 who had given birth.


Mothers completed the Cumulative Trauma Scale, Conflict Tactics Scale, Clinician Administered Posttraumatic Stress Scale, Edinburgh Postnatal Depression Scale, and a Demographic Data form. Descriptive statistics, correlations, and multiple regressions were used for data analysis.


All participants reported at least one traumatic event in their lifetime. Cumulative trauma and partner conflict predicted PTSD, with the trauma of a life threatening event for a loved one reported by 60% of the sample. Nearly one fourth of the women screened were at risk for PTSD. Increased cumulative trauma, increased partner conflict, and lower level of education were related to higher rates of PTSD symptoms.


Both cumulative trauma and partner conflict in the past year predict PTSD. Reasoning was used most often for partner conflict resolution. This article is protected by copyright. All rights reserved.



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