Research Update – December 2018 & January 2019

The impact of parental posttraumatic stress disorder on parenting: a systematic review.

Eur J Psychotraumatol. 2019 Jan 14;10(1):1550345. doi: 10.1080/20008198.2018.1550345. eCollection 2019.

Christie H1Hamilton-Giachritsis C1Alves-Costa F1,2Tomlinson M3Halligan SL1.


Background: Posttraumatic stress disorder (PTSD) is a serious and debilitating disorder that can develop following exposure to a traumatic event. Where parents develop PTSD, it may have an impact on their parenting role. Objective: The objective was to review the existing evidence base on parental PTSD, examining whether parental PTSD has an impact on key parenting domains. Method: A comprehensive web-based search identified 27 quantitative studies that examined parental PTSD in relation to parenting domains. Results: Several parenting domains were investigated including: parenting satisfaction, parenting stress, the parent-child relationship, and specific parenting practices. Sample sizes ranged from 19 to 3931 parents. A range of parental traumas were investigated, including traumatic birth experiences, military trauma, and intimate partner violence. Findings indicated associations between parental PTSD and several domains of parenting, but there were inconsistencies across studies. Conclusions: Findings suggested that parental PTSD is associated with impaired functioning across a number of parenting domains, including increased levels of parenting stress, lower parenting satisfaction, less optimal parent-child relationships, and more frequent use of negative parenting practices, such as overt hostility and controlling behaviours. However, methodological limitations across the literature as a whole limited the potential to infer causal impacts of PTSD on parenting. Further study is also needed to advance our current understanding around the impact of different trauma types on parenting domains.


Afterbirth support provision for women following a traumatic/distressing birth: Survey of NHS hospital trusts in England.

Midwifery. 2019 Jan 15;71:63-70. doi: 10.1016/j.midw.2019.01.004. [Epub ahead of print]

Thomson G1Garrett C2.

Foundation Trust, Preston, Lancashire PR2 9HT, UK.


OBJECTIVE:Despite recommendations within postnatal care guidelines, many National Health Service (NHS) hospital trusts in the UK provide an afterbirth, debriefing type service for women who have had a traumatic/distressing birth. Currently there are a lack of insights into what, how, and when this support is provided. The aim of this study was to explore afterbirth provision for women who have had a traumatic/distressing birth in NHS hospital trusts in England.

DESIGN: An online survey comprising forced choice and open text comments was disseminated via direct email and social media to NHS hospital trusts in England. Questions explored the types of support provided, when the support was offered, how and when the service was promoted to women, funding issues, and the role/training of service providers.

PARTICIPANTS: Fifty-nine respondents completed the survey, with responses from 54 different NHS hospital trusts from all geographic regions in England (40% of all trusts) included.

FINDINGS: While the numbers of women accessing afterbirth services varied, this was often associated with a lack of dedicated funding (∼52%), and poor recording mechanisms. Some 83.3% of services had evolved based on women’s needs rather than wider research/literature. Midwives are commonly the sole provider of afterbirth services (59.3%) and in 40.7% of cases the professionals who provide afterbirth support had received no specific training. In only 51.9% of trusts were ‘all’ women routinely given information about the service, and women were more likely to self-refer (79.6%) rather than be referred via routine screening (11.1%) or obstetric criteria (27.8%). Almost all services offered flexible access (92.6%) and many offered multiple contacts (70.3%). While most services enabled women to discuss and review their birth, only 55.6% furnished women with information on birth trauma. Approximately 89% of services referred women to specialist provision (i.e. mental health) as needed, although directing support within personal (63%) or wider support (55.6%) networks was less evident.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE: While women want, and value opportunities to discuss the birth with a maternity professional following a traumatic/difficult birth, evidence suggests that resource provision is insufficient, hampered by a lack of funding, publicity, and recording systems. While further research is needed, funds to establish a well-resourced, evidence-based and well-promoted service should be prioritised.


[Perinatal and postnatal treatment of traumatized parents with mental disorders: impact on parents and their children].

Nervenarzt. 2019 Jan 14. doi: 10.1007/s00115-018-0660-8. [Epub ahead of print]

[Article in German]

Klinger-König J1Grabe HJ2,3.


BACKGROUND: In traumatized parents with mental disorders, pregnancy and related medical examinations can lead to high emotional distress and flashbacks and increase the already tense emotional situation. Besides psychiatric burdens, parental insecurity concerning dealing with and reduced sensitivity for the child often exist. The children themselves have a higher risk of being neglected or abused and to also develop mental disorders.

OBJECTIVE: How does interventional research take the special needs of traumatized parents with mental disorders into account? What kind of interventions predominate and what impact do they have on parents and children?

MATERIAL AND METHODS: Publications on perinatal and postnatal interventions for traumatized and mentally disordered parents were included in the review if at least one intervention was explicitly described, a parental trauma was discussed and the impact of the intervention on the parents and children was analyzed.

RESULTS: A total of 2 reviews and 10 interventional studies were included. Interventions were primarily based on professional educational counseling, psychoeducation, nurse home visits, individual and group therapies and inpatient mother-baby units. The interventions led to reduced psychiatric symptoms, enhanced parental sensitivity for the child’s needs, enhanced quality of nurturing and care and an improved mother-child bonding.

CONCLUSION: Although only few studies focused on the special needs of traumatized, mentally disordered parents, the described interventions show promising effect sizes, especially in combination with several kinds of interventions. Nevertheless, an adequate integration of fathers into the therapies has so far been neglected.


Midwives’ practices and knowledge about fear of childbirth and postpartum posttraumatic stress disorder.

Women Birth. 2018 Dec 19. pii: S1871-5192(18)30084-2. doi: 10.1016/j.wombi.2018.11.014. [Epub ahead of print]

de Vries, Stramrood, Sligter, Sluijs, van Pampus.


BACKGROUND: Women suffering from fear of childbirth and postpartum posttraumatic stress disorder are often not recognised by health care professionals.

AIM: To evaluate practices, knowledge and the attitudes of midwives towards women with fear of childbirth and postpartum posttraumatic stress disorder.

METHODS: A cross-sectional study was performed amongst midwives who work in community practices and hospitals in the Netherlands with the use of a questionnaire purposefully designed for this research aim.

FINDINGS: 257 midwives participated in the study, of whom 217 completed all items in the questionnaire. Midwives were better equipped to answer knowledge questions concerning fear of childbirth than posttraumatic stress disorder (regarding symptomatology, risk factors, consequences and treatment). When tending to women with fear of childbirth or (suspected) postpartum posttraumatic stress disorder, most midwives referred to another caregiver (e.g. psychologist). Most midwives expressed a positive and compassionate attitude towards women with fear of childbirth and postpartum posttraumatic stress disorder.

DISCUSSION: The majority of midwives are well informed with respect to fear of childbirth, but knowledge of important aspects of postpartum posttraumatic stress disorder is often lacking. Midwives report no crucial issues related to their attitudes towards women with fear of childbirth and posttraumatic stress disorder. Most midwives provide adequate organisation of care and support.


CONCLUSION: Midwives should acquire more in depth knowledge of fear of childbirth and postpartum posttraumatic stress disorder. This can be achieved by including the two conditions in the program of midwifery education.


Screening for trauma and anxiety recognition: knowledge, management and attitudes amongst gynecologists regarding women with fear of childbirth and postpartum posttraumatic stress disorder.

van Dinter-Douma EE1de Vries NE2Aarts-Greven M1Stramrood CAI3van Pampus MG1.

J Matern Fetal Neonatal Med. 2018 Dec 18:1-281. doi: 10.1080/14767058.2018.1560409. [Epub ahead of print]


OBJECTIVE: Fear of childbirth (FoC) and postpartum posttraumatic stress disorder (PP-PTSD) are often less well recognized by healthcare professionals than other peripartum mental health disorders. This study aims to evaluate knowledge, management and attitudes of gynecologists and gynecology residents regarding women with FoC and PP-PTSD.

STUDY DESIGN: A cross-sectional study was conducted among gynecologists and gynecology residents using an online questionnaire. An invitation was sent to all 1401 members of the Dutch Society of Obstetrics and Gynecology.

RESULTS: Two hundred forty-four respondents completed the online multiple-choice and open question survey. More respondents were able to answer the questions about risk factors, signs/symptoms and consequences of FoC in comparison with similar questions about PP-PTSD. When asked about performing a cesarean section on maternal request, 74% of respondents would grant this request if fear would persist despite adequate psychological treatment. During labor, providing good explanations and obtaining informed consent were most frequently named to reduce fear or the likelihood of a traumatic birth experience. Caregivers’ attitudes towards women with FoC or suspected PP-PTSD were mainly positive.

CONCLUSIONS: Further knowledge, in particular about PP-PTSD, is desirable for appropriate recognition of women with FoC and PP-PTSD. Gynecologists should be made more aware of how their communication is perceived by patients, given the discrepancy between patients’ experiences and the attitudes gynecologists report themselves. For optimizing the organization of care, we would recommend the use of a clear (inter)national policy regarding maternal requests for cesarean section (CS).


Pregnancy and Childbirth After Sexual Trauma: Patient Perspectives and Care Preferences.

Obstet Gynecol. 2018 Dec;132(6):1461-1468. doi: 10.1097/AOG.0000000000002956.

Sobel L1OʼRourke-Suchoff DHolland ERemis KResnick KPerkins RBell S.


OBJECTIVE: To explore the pregnancy and childbirth experiences and preferences of women with a history of sexual trauma in order to identify trauma-informed care practices that health care providers may use to improve obstetric care.

METHODS: We conducted a qualitative study consisting of semistructured interviews with women who either self-identified as having a history of sexual trauma or did not. Participants were recruited from a tertiary care ambulatory clinic and had at least one birth experience within the past 3 years. Interviews were audio-recorded and transcribed verbatim. Grounded theory was used to derive themes using the participants’ own words.

RESULTS: From 2015 to 2017, we interviewed 20 women with a history of sexual trauma and 10 without. Women with a history of sexual trauma desired clear communication about their history between prenatal care providers and the labor and delivery team. In the intrapartum period, they desired control over who was present in the labor room at the time of cervical examinations and for health care providers to avoid language that served as a stressing reminder of prior sexual trauma. They wanted control over the exposure of their bodies during labor and to be asked about their preference for a male health care provider. In the postpartum period, some women with a history of sexual trauma found breastfeeding healing and empowering.

CONCLUSION: Women with a history of sexual trauma have clear needs, preferences, and recommendations for obstetric care providers regarding disclosure, cervical examinations, health care provider language, body exposure, and male health care providers. They offer insight into unique breastfeeding challenges and benefits. /30563384


Fear of Childbirth, Postpartum Depression, and Birth-Related Variables as Predictors of Posttraumatic Stress Disorder After Childbirth.

Worldviews Evid Based Nurs. 2018 Dec;15(6):455-463. doi: 10.1111/wvn.12326. Epub 2018 Oct 3.

Çapik A1Durmaz H2.

of Psychiatric Nursing, Faculty of Nursing, Ataturk University, Erzurum, Turkey.


BACKGROUND: Childbirth may be a significant cause of postpartum posttraumatic stress disorder (PTSD) in women.

AIMS: The objective of this study is to examine the effect of fear of childbirth, postpartum depression, and certain birth-related variables on postpartum PTSD.

METHODS: This study is a cross-sectional study. The study was carried out in a maternity hospital nonstress unit between December 1, 2015, and February 29, 2016. Three hundred and one pregnant women who met the criteria for inclusion in the study made up the research sample.

RESULTS: Fear of childbirth and postpartum depression significantly and positively predicted the level of posttraumatic stress after childbirth (β = 0.17, p < .01; β = 0.68, p < .001). Fear of childbirth explains 3% of the total variance in posttraumatic stress (R2  = .03, adjusted R2  = .02, F = 7.141, p < .01), while postpartum depression explains 47% of it (R2  = .47, adjusted R2  = .46, F = 196.35, p < .001). Satisfaction with the attitudes of the medical staff during childbirth, defining the childbirth experience, and the state of experiencing postpartum problems by the mother are significant predictors of postpartum posttraumatic stress (β = -0.21, p < .01; β = -0.14, p < .05; β = 0.17, p < .01). When these three variables are addressed together, they explain 14% of the total variance (R2  = .14, adjusted R2 = .13, F = 9.33, p < .001).

LINKING EVIDENCE TO ACTION: Postpartum PTSD is a situation that must be carefully emphasized in terms of maternal, baby, and family health. For this reason, it is necessary to evaluate postpartum PTSD more quickly and objectively, and healthcare providers have major duties in this respect.

Treatment of depression, anxiety, and trauma-related disorders during the perinatal period: A systematic review.

Clin Psychol Rev. 2018 Dec;66:136-148. doi: 10.1016/j.cpr.2018.06.004. Epub 2018 Jun 9.

Nillni YI1Mehralizade A2Mayer L3Milanovic S3.


Women with psychiatric disorders during pregnancy and the postpartum period (i.e., perinatal period) are at increased risk for adverse maternal and child outcomes. Effective treatment of psychiatric disorders during the perinatal period is imperative. This review summarizes the outcomes of 78 studies focused on the treatment of depression, anxiety, and trauma-related disorders during the perinatal period. The majority of studies focused on perinatal depression (n = 73). Of the five studies focused on anxiety or trauma-related disorders, only one was a randomized controlled trial (RCT). The most studied treatment was cognitive behavioral therapy (CBT; n = 22), followed by interpersonal psychotherapy (IPT; n = 13). Other interventions reviewed include other talk therapies (n = 5), collaborative care models (n = 2), complementary and alternative medicine approaches (n = 18), light therapy (n = 3), brain stimulation (n = 2), and psychopharmacological interventions (n = 13). Eleven studies focused specifically on treatment for low-income and/or minority women. Both CBT and IPT demonstrated a significant benefit over control conditions. However, findings were mixed when these interventions were examined in low-income and/or minority samples. There is some support for complementary and alternative medicine approaches (e.g., exercise). Although scarce, SSRIs demonstrated good efficacy when compared to a placebo. However, SSRIs did not outperform another active treatment condition (e.g., CBT). There is a tremendous need for more studies focused on treatment of perinatal anxiety and trauma-related disorders, as well as psychopharmacological effectiveness studies. Limitations and future directions of perinatal treatment research, particularly among low-income and/or minority populations, are discussed.


The prospective relationship between postpartum PTSD and child sleep: A 2-year follow-up study.

J Affect Disord. 2018 Dec 1;241:71-79. doi: 10.1016/j.jad.2018.07.067. Epub 2018 Jul 24.

Garthus-Niegel S1Horsch A2Bickle Graz M3Martini J4von Soest T5Weidner K6Eberhard-Gran M7.


BACKGROUND: The main aim of this study was to examine the prospective impact of maternal postpartum PTSD on several standardized child sleep variables two years postpartum in a large, population-based cohort of mothers. Moreover, we investigated the influence of numerous potential confounding maternal and child factors. Finally, we tested potential reverse temporal associations between child sleep eight weeks postpartum and maternal PTSD symptoms two years postpartum.

METHODS: This study is part of the population-based Akershus Birth Cohort, a prospective cohort study at Akershus University Hospital, Norway. Data from the hospital’s birth record, from questionnaires at 17 weeks gestation, eight weeks and two years postpartum were used. At two years postpartum, 39% of the original participants could be retained, resulting in a study population of n = 1480. All child sleep variables significantly correlated with postpartum PTSD symptoms were entered into multiple linear regression analyses, adjusting for confounding factors.

RESULTS: Postpartum PTSD symptoms were related to all child sleep variables, except daytime sleep duration. When all significant confounding factors were included into multivariate regression analyses, postpartum PTSD symptoms remained a significant predictor for number and duration of night wakings (β = 0.10 and β = 0.08, respectively), duration of settling time (β = 0.10), and maternal rating of their child’s sleep problems (β = 0.12, all p<.01. Child sleep at eight weeks postpartum was not significantly related to maternal sleep two years postpartum when controlling for postpartum PTSD at eight weeks.

LIMITATIONS: Child outcomes were based on maternal reporting and might be influenced by maternal mental health.

CONCLUSIONS: Our results showed for the first time that maternal postpartum PTSD symptoms were prospectively associated with less favorable child sleep, thus increasing the risk of developmental or behavioral problems through an indirect, but treatable pathway. Early detection and treatment of maternal postpartum PTSD may prevent or improve sleep problems and long-term child development.

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