Research Update April-June 2019

Effect of the Sacred Hour on Postnatal Depression in Traumatic Childbirth: a Randomized Controlled Trial.

Abdollahpour S1Bolbolhaghighi N2Khosravi A3.

J Caring Sci. 2019 Jun 1;8(2):69-74. doi: 10.15171/jcs.2019.010. eCollection 2019 Jun.


 Introduction: the implementation of the baby’s nine instinctive stages as a sacred hour after birth is very effective in starting breastfeeding. About half of newly delivered mothers have reported a traumatic childbirth experience often associated with mental health problems. The present study aimed to examine the effect of the sacred hour on the depression in traumatic childbirths. Methods: In this clinical trial, 84 mothers who had experienced a traumatic childbirth were randomly allocated into the intervention (n = 42) and control (n = 42) groups. The intervention group received sacred hour (baby’s nine instinctive responses), but the control group received only the routine care. Postnatal depression was evaluated as primary outcome at 2 week, 4-6 week and 3 month intervals after the delivery. The data were analyzed using t test, chi-square test and the repeated measures analysis of variance. Results: The results showed that the marginal total mean (SD: standard deviation) scores of depression in the intervention and control groups were 7.5 (2.6) and 9.6 (2.6); therefore, the mean difference (95% CI) between the groups (-2.1, (-3.2,-0.95)) was significant. Conclusion: The implementation of the sacred hour is recommended as a preventive approach to reduce the postnatal depression in women with a traumatic childbirth experience.

KEYWORDS: Breastfeeding; Childbirth; Postnatal depression; The sacred hour; Traumatic


Perinatal Posttraumatic Stress Disorder: A Review of Risk Factors, Diagnosis, and Treatment.

Cirino NH1Knapp JM2.

Obstet Gynecol Surv. 2019 Jun;74(6):369-376. doi: 10.1097/OGX.0000000000000680.


IMPORTANCE: Perinatal posttraumatic stress disorder (P-PTSD) occurs in approximately 3% to 15% of women in the postpartum period. It is often underrecognized, poorly characterized, and undertreated. If untreated, it can lead to maternal and infant morbidity.

OBJECTIVE: The aim of this review article is to discuss P-PTSD as it relates to the obstetrician gynecologist, focusing specifically on identifying perinatal risk factors, P-PTSD diagnostic tools, and treatment options.

EVIDENCE ACQUISITION: PubMed, PsycINFO, Cochrane Library, and Scopus were searched on MeSH terms and free text for terms related specifically to P-PTSD. Because of the lack of data on treatment specifically for the perinatal population, a second search for general PTSD treatment guidelines was conducted and incorporated into this review.

RESULTS: Risk factors have been identified in the literature in 4 major categories: obstetric, psychiatric, social, and subjective distress during delivery. Two diagnostic tests, the general PTSD diagnostic tool, the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, and the specific diagnostic tool, the Perinatal Post-Traumatic Stress Disorder Questionnaire, can both be helpful for the clinician to diagnose patients who may have P-PTSD. Individual trauma-focused psychotherapy is first line for treatment of P-PTSD. Immediate debriefing interventions and non-trauma-focused psychotherapy has not been shown to be helpful. If trauma-focused psychotherapy is not available or not preferred, selective serotonin reuptake inhibitors and non-trauma-focused psychotherapy can be used.

CONCLUSIONS AND RELEVANCE: When designing and carrying out the program, the beginning of the intervention and adherence should be considered. To increase adherence, the program should be attractive and it should meet the participants’ needs.

CONCLUSIONS AND RELEVANCE: Identifying and treating P-PTSD have important implications for maternal and neonatal health. Few treatment studies exist for P-PTSD specifically, so combining P-PTSD research with current guidelines for PTSD is necessary to inform clinical practice.


The moderating effects of traumatic stress on vulnerability to emotional distress during pregnancy.

Tung I1Keenan K2Stepp SD1Hipwell AE1.

Dev Psychopathol. 2019 Jun 17:1-14. doi: 10.1017/S0954579419000531. [Epub ahead of print]


Emotional distress during pregnancy is likely influenced by both maternal history of adversity and concurrent prenatal stressors, but prospective longitudinal studies are lacking. Guided by a life span model of pregnancy health and stress sensitization theories, this study investigated the influence of intimate partner violence (IPV) during pregnancy on the association between childhood adversity and prenatal emotional distress. Participants included an urban, community-based sample of 200 pregnant women (aged 18-24) assessed annually from ages 8 to 17 for a range of adversity domains, including traumatic violence, harsh parenting, caregiver loss, and compromised parenting. Models tested both linear and nonlinear effects of adversity as well as their interactions with IPV on prenatal anxiety and depression symptoms, controlling for potential confounds such as poverty and childhood anxiety and depression. Results showed that the associations between childhood adversity and pregnancy emotional distress were moderated by prenatal IPV, supporting a life span conceptualization of pregnancy health. Patterns of interactions were nonlinear, consistent with theories conceptualizing stress sensitization through an “adaptive calibration” lens. Furthermore, results diverged based on adversity subdomain and type of prenatal IPV (physical vs. emotional abuse). Findings are discussed in the context of existing stress sensitization theories and highlight important avenues for future research and practice.

KEYWORDS: adverse childhood experiences; early adversity; intimate partner violence; pregnancy stress; stress sensitization


Effect of Brief Cognitive Behavioral Counseling and Debriefing on the Prevention of Post-traumatic Stress Disorder in Traumatic Birth: A Randomized Clinical Trial.

Abdollahpour S1Khosravi A2Motaghi Z3Keramat A2Mousavi SA4.

Community Ment Health J. 2019 Jun 8. doi: 10.1007/s10597-019-00424-6. [Epub ahead of print]


OBJECTIVE: Planning to promote the health of mothers in postpartum is important in all countries. This study aimed to determine the effectiveness of two counseling method on prevention of post-traumatic stress after childbirth.

METHODS: In this clinical trial, 193 of mothers who had experienced a traumatic birth were randomly assigned to three groups. Participants were assessed using IES_R questionnaire at 4-6 weeks and 3 months after delivery.

RESULTS: Debriefing and brief cognitive behavioral counseling (CBC) significantly improved the symptoms of postpartum traumatic stress disorder. After 3 months, CBC had a significant effect on the symptoms.

CONCLUSION: Screening of traumatic childbirth, implementation of supportive care, and early counseling prior to the initiation of post-traumatic stress are recommended.


KEYWORDS: Brief cognitive behavioral counseling; Debriefing; PTSD; Traumatic birth


Post traumatic stress disorder (PTSD): The psychological sequelae of abnormally invasive placenta (AIP).

Tol ID1Yousif M2Collins SL3.

Placenta. 2019 Jun;81:42-45. doi: 10.1016/j.placenta.2019.04.004. Epub 2019 Apr 16.


INTRODUCTION: Abnormally invasive placenta (AIP) is a rare pregnancy complication often resulting in postpartum haemorrhage (PPH) and emergency peripartum hysterectomy (EPH). The risk of developing post traumatic stress disorder (PTSD) following unexpectedly traumatic childbirth is known however there is no evidence regarding PTSD in AIP. This pilot study assesses the risk of PTSD for women with AIP compared to women having an uncomplicated caesarean delivery (CD) or unexpected PPH or EPH.

METHODS: Retrospective case-controlled questionnaire study in a UK Tertiary obstetric unit. Women with AIP (Group-1) were matched by delivery date to control groups: Group-2, women with an uncomplicated CD; Group-3 women referred to a specialist clinic for suspected AIP, but had a normal placenta and uncomplicated CD; Group-4, women who had an unexpected EPH and/or severe (>3000 mls) PPH. 218 women were sent a validated PTSD screening questionnaire (Impacts of Events Scale-Revised [IES-R]).

RESULTS: Likelihood of PTSD was recorded for 69 women who responded, revealing significantly higher PTSD scores for women with AIP compared to uncomplicated CD (P = 0.001). No significant difference was seen between AIP and EPH/PPH (P = 0.89). The number of women with scores high enough to indicate probable PTSD was significantly greater with AIP than uncomplicated CD group (P = 0.045).

DISCUSSION: This study demonstrates that women antenatally diagnosed with AIP and anticipating a potentially traumatic delivery, are at significantly increased risk of developing PTSD. Improved awareness of the negative psychological impact of AIP may increase the number of women being identified and treated, thereby improving their quality of life.

Copyright © 2019. Published by Elsevier Ltd.

KEYWORDS: Abnormally invasive placenta; Placenta accreta; Post traumatic stress disorder; Postnatal mental health


Predictors of traumatic birth experience among a group of Iranian primipara women: a cross sectional study.

Ghanbari-Homayi S1Fardiazar Z2Meedya S3Mohammad-Alizadeh-Charandabi S4Asghari-Jafarabadi M5Mohammadi E6Mirghafourvand M7.

BMC Pregnancy Childbirth. 2019 May 22;19(1):182. doi: 10.1186/s12884-019-2333-4.


BACKGROUND: Traumatic birth experience has undesirable effects on the life of the mother, child, family, and society. The identification of predictive factors can be useful in improving birth experiences among women. This study aimed to assess the prevalence of a traumatic birth experience and identify its predictors among a group primiparous women.

METHODS: A cross-sectional study was conducted among 64 health centres in Tabriz, the second largest city in Iran. Cluster sampling was used to recruit 800 eligible women at one to 4 months postpartum. The Persian version of the Childbirth Experience Questionnaire was used to measure the womens’ birth experiences. Data were collected through face to face interviews and analysed mainly by multivariable logistic regression.

RESULTS: The prevalence of traumatic birth experience was 37% in the study group. The independent predictors of the traumatic birth experience were related to antenatal and intrapartum factors. The antenatal predictor was the lack of exercise during pregnancy (OR = 2.81, CI 1.40-5.63, P = .003) and the intrapartum predictors were the absence of pain relief during labour and birth (OR = 4.24, CI 2.12-8.50, P < .001), and the fear of childbirth (OR = 3.47, CI 1.68-7.19, P < .001).

CONCLUSIONS: The findings revealed the high rate of traumatic birth experience among the primimarous women and identified the importance of a woman-centered care where a woman can actively make decision about the care she receives receive during labour and birth.

KEYWORDS: Cross-sectional study; Prevalence; Risk factors; Traumatic birth; Traumatic birth experience


Peritraumatic dissociation in childbirth-evoked posttraumatic stress and postpartum mental health.

Thiel F1,2Dekel S3,4.

Arch Womens Ment Health. 2019 May 21. doi: 10.1007/s00737-019-00978-0. [Epub ahead of print]


A significant minority of women can suffer from postpartum posttraumatic stress disorder (PP-PTSD) following childbirth, in particular if involving obstetrical complications. While peritraumatic dissociation has been repeatedly shown to play a significant role in coping in the aftermath of trauma, little is known about peritraumatic dissociation in relation to positive adaptation following childbirth or failure thereof. We studied a large sample of 846 women who were on average 3 months postpartum. Participants completed an anonymous survey with psychometric measures pertaining to peritraumatic dissociation, PP-PTSD, postpartum depression, and other psychiatric symptoms. Women who had assisted vaginal deliveries or unscheduled Cesareans reported higher peritraumatic dissociation levels than those who had regular vaginal deliveries or scheduled Cesareans. Peritraumatic dissociation predicted PP-PTSD above and beyond premorbid and other childbirth-related factors. In contrast, we found that when controlling for PP-PTSD symptoms, higher levels of peritraumatic dissociation were associated with lower depression and other psychiatric symptom severity. Childbirth can evoke a dissociative response for some women. Rather than the mere focus on the mode of delivery and premorbid health, our findings highlight the role of the women’s immediate emotional response in PP-PTSD. Screening women for dissociative responses immediately following childbirth may offer a tool for identifying women at risk for PP-PTSD. The multifaceted role of peritraumatic dissociation in psychological adaptation as potentially adaptive on the one hand, and maladaptive on the other, warrants future scientific attention.

KEYWORDS: Childbirth; Peritraumatic dissociation; Postpartum posttraumatic stress


Women’s Perceptions of Living a Traumatic Childbirth Experience and Factors Related to a Birth Experience.

Rodríguez-Almagro J1Hernández-Martínez A2,3Rodríguez-Almagro D4Quirós-García JM5Martínez-Galiano JM6,7Gómez-Salgado J8,9.

Int J Environ Res Public Health. 2019 May 13;16(9). pii: E1654. doi: 10.3390/ijerph16091654.


Although identified by the World Health Organization (WHO) as a global health priority, maternal mental health does not receive much attention even in the health systems of developed countries. With pregnancy monitoring protocols placing priority on the physical health of the mother, there is a paucity of literature documenting the traumatising effects of the birth process. To address this knowledge gap, this qualitative descriptive study aimed to investigate women perceptions of living a traumatic childbirth experience and the factors related to it. Qualitative data, collected via semi-structured interviews with 32 participants recruited from parent support groups and social media in Spain, were analyzed through a six-phase inductive thematic analysis. Data analysis revealed five major themes-“Birth Plan Compliance”, “Obstetric Problems”, “Mother-Infant Bond”, “Emotional Wounds” and “Perinatal Experiences”-and 13 subthemes. The majority of responses mentioned feelings of being un/misinformed by healthcare personnel, being disrespected and objectified, lack of support, and various problems during childbirth and postpartum. Fear, loneliness, traumatic stress, and depression were recurrent themes in participants’ responses. As the actions of healthcare personnel can substantially impact a birth experience, the study findings strongly suggest the need for proper policies, procedures, training, and support to minimise negative consequences of childbirth.

KEYWORDS: childbirth; maternal mental health; patient safety; postpartum; pregnancy; quality improvement; traumatic childbirth; women’s perception of birth experience


Trajectories of stress biomarkers and anxious-depressive symptoms from pregnancy to postpartum period in women with a trauma history.

Ghosn F1Almansa B1Moreno-Giménez A1Sahuquillo-Leal R1Serrano-Lozano E1Hervás D2Diago V3Cháfer-Pericás C4Vento M4García Blanco A1,4.

Eur J Psychotraumatol. 2019 Apr 29;10(1):1601990. doi: 10.1080/20008198.2019.1601990. eCollection 2019.


Background: Cross-sectional studies have found that a trauma history can be associated with anxious-depressive symptomatology and physiological stress dysregulation in pregnant women. Methods: This prospective study examines the trajectories of both anxiety and depressive symptoms and salivary cortisol and α-amylase biomarkers from women with (n = 42) and without (n = 59) a trauma history at (i) 38th week of gestation (T1), (ii) 48 hours after birth (T2), and (iii) three months after birth (T3). Results: The quantile regression model showed that trauma history was associated with higher cortisol levels at T1 and this difference was sustained along T2 and T3. Conversely, there were no significant differences in α-amylase levels between groups across the three time points and both groups showed an increase in α-amylase levels from T2 to T3. The ordinal mixed model showed that trauma history was associated with higher anxiety symptoms at T1 and this remained constant from T1 to T2 but was reversed from T2 to T3. In contrast, both groups showed similar depressive symptoms across the three time points. Conclusions: Whereas physiological stress dysregulation (in terms of higher cortisol levels) was maintained from pregnancy to postpartum period, pregnancy and childbirth were the most vulnerable stages for developing anxious symptoms in mothers with trauma history.

KEYWORDS: Trauma; anxiety; depression; postpartum; pregnancy; stress biomarkers


Perceived Psychological Traumatic Childbirth in Iranian Mothers: Diagnostic Value of Coping Strategies.

Abdollahpour S1Mousavi SA2Esmaily H3Khosrav A4.

Osong Public Health Res Perspect. 2019 Apr;10(2):72-77. doi: 10.24171/j.phrp.2019.10.2.05.


OBJECTIVES: The aim of this study was to investigate the diagnostic value of a stress coping scale for predicting perceived psychological traumatic childbirth in mothers.

METHODS: This cross-sectional study was performed on 400 new mothers (within 48 hours of childbirth). Psychological traumatic childbirth was evaluated using the 4 diagnostic criteria of Diagnostic and Statistical Manual of Mental Disorders. Coping was measured using Moss and Billings’ Stress Coping Strategies Scale.

RESULTS: The overall mean score of stress coping was 29 ± 14.2. There were 193 (43.8%) mothers that had experienced a psychological traumatic childbirth. A stress coping score ≤ 30, with a sensitivity of 90.16 (95% CI = 85.1-94.0), and a specificity of 87.44 (95% CI = 82.1-91.6), was determined as a predictor of psychological traumatic childbirth. So that among mothers with stress coping scores ≤ 30, 87% had experienced a psychological traumatic childbirth.

CONCLUSION: Investigating the degree of coping with stress can be used as an accurate diagnostic tool for psychological traumatic childbirth. It is recommended that during pregnancy, problem-solving and stress management training programs be used as psychological interventions for mothers with low levels of stress control. This will ensure that they can better cope with traumatic childbirth and post-traumatic stress in the postpartum stage.

KEYWORDS: childbirth; post-traumatic stress disorder; pregnancy


Posttraumatic stress and affecting factors in couples after perinatal loss: A Turkish sample.

Baransel ES1Uçar T1.

Perspect Psychiatr Care. 2019 Apr 24. doi: 10.1111/ppc.12390. [Epub ahead of print]


PURPOSE: We aimed to determine the posttraumatic stress levels and the factors affecting them in couples (154 women and 154 men) after a perinatal loss in Turkey.

CONCLUSIONS: In women, an ending of the pregnancy between gestational weeks 30 and 37 and being employed reduced the posttraumatic stress level. In men, seeing the baby after birth, having no alcohol, and having high education and income levels decreased the posttraumatic stress level.

PRACTICE IMPLICATIONS: Knowledge of the factors affecting posttraumatic stress may help identify those couples in whom the probability of this disorder occurring is increased.

© 2019 Wiley Periodicals, Inc.

KEYWORDS: midwifery; nursing; perinatal loss; posttraumatic stress disorder


Post-traumatic stress disorder and hypertensive disorders of pregnancy among military women.

Nash MC1Kip KE1Wang W1Custer M1O’Rourke K1.

Paediatr Perinat Epidemiol. 2019 May;33(3):238-247. doi: 10.1111/ppe.12546. Epub 2019 Apr 21.


BACKGROUND: Women are more likely to develop post-traumatic stress disorder (PTSD) than men. Limited research exists evaluating the risk of hypertensive disorders of pregnancy (HDP) among military women with PTSD.

METHODS: We conducted a retrospective cohort study using US Department of Defense (DoD) data comprised of all active-duty women giving birth to their first, liveborn singleton infant using DoD-sponsored health insurance from 1 January 2004 to 31 December 2008 (n = 34 176). Birth hospitalisation records, maternal mental health visits, and Post-Deployment Health Assessment (PDHA) and Reassessment (PDHRA) screenings were included. The HDP outcome (yes vs no) was defined using ICD-9-CM codes in the maternal birth hospitalisation record. Women fit into one of four PTSD exposure categories (confirmed, probable, possible, none). Confirmed cases had a PTSD ICD-9-CM diagnosis code. Probable/possible cases were classified using PDHA screening items. We used multiple log-linear regression to assess PTSD (confirmed, any vs none) and the risk of HDP overall, and then explored effect modification by military service and demographic variables. We assessed the risk of HDP among deployed mothers with PTSD (confirmed, probable/possible vs none) who completed a PDHA, and explored effect modification by race/ethnicity. We also assessed risk of HDP with differing PTSD lead times.

RESULTS: Overall, PTSD was not associated with HDP except among mothers whose PTSD was diagnosed ≥1 year prior to conception (RR 1.42, 95% CI 1.06, 1.90).

CONCLUSIONS: Post-traumatic stress disorder preceding conception by at least a year appeared to confer an increased risk of HDP, but further research is needed using more thorough PTSD assessment.

KEYWORDS: deployment; hypertensive disorders of pregnancy; military; post-traumatic stress disorder


Validation of the Hebrew Birth Satisfaction Scale – Revised (BSS-R) and its relationship to perceived traumatic labour.

Skvirsky V1Taubman-Ben-Ari O1Hollins Martin CJ2Martin CR3.

J Reprod Infant Psychol. 2019 Apr 13:1-7. doi: 10.1080/02646838.2019.1600666. [Epub ahead of print]


OBJECTIVE AND BACKGROUND: The Birth Satisfaction Scale-Revised (BSS-R) is a multi-dimensional measure which is recommended by international clinical guidelines for global use as the birth satisfaction outcome measure of choice. The current investigation sought to develop a Hebrew version of the BSS-R for use in the Jewish-Israeli context and examine the relationship between BSS-R domains and the perception of the experience of labour as traumatic.

METHODS: Following review, translation, and back-translation for linguistic equivalence, a Hebrew version of the BSS-R (H-BSS-R) was prepared and psychometrically evaluated using key indices of validity and reliability. Complete multivariate normal data from 288 first-time Jewish Israeli mothers within two years after childbirth was entered into the analysis.

RESULTS: The H-BSS-R was found to have a good fit to the BSS-R tridimensional measurement model, excellent internal consistency, divergent and known-group discriminant validity. Moreover, women who experienced their labour as traumatic had significantly lower H-BSS-R subscale scores than women who reported that their birth experience was non-traumatic.

CONCLUSION: The H-BSS-R is a robust and valid measure suitable for use with Jewish-Israeli women, as well as for investigating the relationship between traumatic labour and birth satisfaction.

KEYWORDS: Birth Satisfaction Scale – Revised (BSS-R); Hebrew; Israel; birth trauma; validation


Synthesis of Mixed Research on Posttraumatic Stress Related to Traumatic Birth.

Beck CTCasavant S.

J Obstet Gynecol Neonatal Nurs. 2019 Apr 5. pii: S0884-2175(19)30031-0. doi: 10.1016/j.jogn.2019.02.004. [Epub ahead of print]


OBJECTIVE: To synthesize mixed-research results (quantitative and qualitative) on posttraumatic stress in women who experienced traumatic births.

DATA SOURCES:PubMed, Scopus, and PsycINFO databases.

STUDY SELECTION: Quantitative and qualitative studies were included if they were published in English from January 1, 2009, through December 31, 2018, and focused on posttraumatic stress in the postpartum period related to traumatic childbirth.

DATA EXTRACTION: The final sample consisted of 59 studies: 4 qualitative and 55 quantitative. Both authors independently appraised each study using the Critical Appraisal Skills Programme. Quantitative studies were synthesized by narrative synthesis and vote counting, and qualitative studies were synthesized by content analysis.

DATA SYNTHESIS: In the included studies, prevalence rates of elevated posttraumatic stress ranged from 0.8% to 26%. Significant predictors of posttraumatic stress that occurred before childbirth and those that were birth related were identified. Reports of six intervention studies to decrease posttraumatic stress symptoms after traumatic births were included. These interventions focused on postnatal debriefing, expressive writing, online cognitive behavioral therapy, a brief cognitive intervention, and the implementation of the nine instinctive stages of the infant during the first hour after birth. We created four themes from the findings of the qualitative studies: Distressing Symptoms, Detrimental Effect of Posttraumatic Stress on Women’s Relationships With Their Infants and Partners, Critical Influence ofSupport, and Debriefing.

CONCLUSION: When a woman experiences posttraumatic stress related to a traumatic birth, the entire family unit is vulnerable. Findings from quantitative predictor studies can be used to develop an instrument to screen women for risk factors for posttraumatic stress related to birth trauma. Primary interventions are needed to prevent women from experiencing traumatic births.

KEYWORDS: PTSD; mixed research synthesis; posttraumatic; stress disorder; traumatic birth


Perinatal factors related to post-traumatic stress disorder symptoms 1-5 years following birth.

Hernández-Martínez A1Rodríguez-Almagro J2Molina-Alarcón M3Infante-Torres N4Rubio-Álvarez A5Martínez-Galiano JM6.

Women Birth. 2019 Apr 3. pii: S1871-5192(18)31633-0. doi: 10.1016/j.wombi.2019.03.008. [Epub ahead of print]


BACKGROUND: The relationship between perinatal variables and post-traumatic stress disorder (PTSD) symptoms was studied. However, the role of some variables in PTSD symptoms is unclear.

AIM: Determine the prevalence of PTSD symptoms after 1 year postpartum and their relationship with perinatal variables.

METHODS: A cross-sectional study with 1531 puerperal women in Spain. Data were collected on socio-demographic variables, perinatal variables (maternal characteristics, procedures during labour and birth, birth outcomes and time since birth) and the newborn. An online questionnaire was used, which included the Perinatal Post-traumatic Stress Questionnaire (PPQ). Crude and adjusted odds ratios (OR) were calculated using binary logistic regression.

FINDINGS: 7.2% (110) of the women were identified as being at risk for probable PTSD symptoms. Protective factors were having a birth plan respected (aOR 0.44; 95%CI 0.19-0.99), use of epidural analgesia (aOR 0.44; 95%CI 0.24-0.80) and experiencing skin-to-skin contact (aOR 0.33; 95%CI 0.20-0.55). Risk factors were instrumental birth (aOR 3.32; 95%CI1.73-3.39), caesarean section (aOR 4.80; 95%CI 2.51-9.15), receiving fundal pressure (aOR 1.72; 95%CI 1.08-2.74) and suffering a third/fourth degree perineal tear (aOR 2.73; 95%CI 1.27-5.86). The area under the model’s ROC curve was 0.82 (95%CI 0.79-0.83).

CONCLUSIONS: Women who experience a normal birth, are psychologically prepared for birth (for example, through use of a birth plan), experience skin-to-skin contact with their newborn, and had a sense of physical control through the use of epidural analgesia, are less likely to experience childbirth as traumatic.

Copyright © 2019 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.

KEYWORDS: Mode of birth; Perinatal; Postpartum; Skin-to-Skin contact; Traumatic stress symptoms


The role of trauma and partner support in perinatal depression and parenting stress: An Australian pregnancy cohort study.

Galbally M1,2,3Watson SJ1,2Boyce P4Lewis AJ1.

Int J Soc Psychiatry. 2019 May;65(3):225-234. doi: 10.1177/0020764019838307. Epub 2019 Mar 27.


BACKGROUND: Improving our understanding of the relationship between maternal depression and parenting stress is likely to lie in the range of additional factors that are associated with vulnerability to depression and also to parenting stress.

OBJECTIVES: To examine the role of trauma and partner support, in understanding the relationship between perinatal depression and parenting stress.

METHODS: This study utilises data from 246 women in a pregnancy cohort study that followed women from early pregnancy until their infant was 12 months. Included were both women with a diagnosis of depression and those without depression. The measures included Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Edinburgh Postnatal Depression Scale, Childhood Trauma Questionnaire, Social Support Effectiveness Questionnaire and the Parenting Stress Index.

RESULTS: We found women with depression were more likely to report a history of childhood trauma. Depressive symptoms were positively associated with parenting stress while partner support was negatively associated with parenting stress. The protective role of partner support for parenting distress was observed in those with no history of childhood abuse and low depressive symptoms, but not in those with a trauma history and high depressive symptoms.

CONCLUSIONS: These findings highlight the importance of early trauma in understanding the protective role of support on the relationship between parenting and depression. These findings can inform future studies and the refinement of future interventions aimed at both perinatal depression and parenting.

KEYWORDS: Depression; childhood trauma; parenting; partner support


Postpartum post-traumatic stress disorder: Associated perinatal factors and quality of life.

Hernández-Martínez A1Rodríguez-Almagro J2Molina-Alarcón M3Infante-Torres N4Donate Manzanares M5Martínez-Galiano JM6.

J Affect Disord. 2019 Apr 15;249:143-150. doi: 10.1016/j.jad.2019.01.042. Epub 2019 Feb 10.


BACKGROUND: The relationship between obstetric variables and postpartum post-traumatic stress disorder (PTSD), and its influence on quality of life (QoL), have scarcely been studied.

OBJECTIVE: Determine the prevalence of PTSD at postpartum weeks 4 and 6, and its relation with perinatal variables and quality of life METHOD: A cross-sectional study with 2990 Spanish puerperal women in Spain. Data were collected on socio-demographic and obstetric variables, and on newborns. An online ad hoc questionnaire was used, including the Perinatal Post-traumatic Stress Disorder Questionnaire (PPQ) and SF-36. The crude and adjusted odds ratios were estimated by binary logistic regression.

RESULTS: 10.6% (318) of the women appeared at risk for PTSD symptoms. Factors like having a respected birth plan (aOR: 0.52; 95%CI: 0.34, 0.80), using epidural analgesia (aOR: 0.64; 95%CI: 0.44, 0.92) and performing skin-to-skin contact (aOR: 0.37; 95%CI: 0.28, 0.50) were protective factors against PTSD, among others. Instrumental birth (aOR: 2.50; 95%CI: 1.70, 3.69) and caesarean section (aOR: 3.79; 95%CI: 2.43, 5.92) were found to be risk factors, among others. The area under the ROC curve in this model was 0.79 (95%CI: 0.76, 0.81). The women with PTSD presented a mean difference for QoL of -13.37 points less than those without PTSD (95%CI: -11.08, -15.65).

CONCLUSIONS: The women with PTSD symptoms had a worse quality of life at postpartum weeks 4-6. Birth type, analgesia methods and humanising practices, like skin-to-skin contact and using respected birth plans, were related with presence of the postpartum PTSD risk.

Copyright © 2019. Published by Elsevier B.V.

KEYWORDS: Associated factors; Perinatal variables; Post-traumatic stress disorder (PTSD); Postpartum; Quality of life


The forgotten mothers of extremely preterm babies: A qualitative study.

Fowler C1Green J1Elliott D1Petty J2Whiting L2.

J Clin Nurs. 2019 Jun;28(11-12):2124-2134. doi: 10.1111/jocn.14820. Epub 2019 Mar 8.


AIMS AND OBJECTIVES: To explore the experiences of mothers of extremely premature babies during their Neonatal Intensive Care Unit stay and transition home.

BACKGROUND: Mothers of extremely preterm infants (28 weeks’ gestation or less) experience a continuum of regular and repeated stressful and traumatic events, during the perinatal period, during the Neonatal Intensive Care Unit stay, and during transition home.

METHOD: An interpretive description method guided this study. Ten mothers of extremely premature infants who had been at home for less than six months were recruited via a Facebook invitation to participate in semi-structured telephone interviews exploring their experiences in the Neonatal Intensive Care Unit and the transition home. The data were examined using a six-phase thematic analysis approach. The COREQ checklist has been used.

RESULTS: Two main themes emerged: (a) things got a bit dire; and (b) feeling a failure as a mother. Participants had a heightened risk of developing a mental disorder from exposure to multiple risk factors prior to and during birth, as well as during the postnatal period in the Neonatal Intensive Care Unit and their infant’s transition to home. Mothers highlighted the minimal support for their mental health from healthcare professionals, despite their regular and repeated experience of traumatic events.

CONCLUSION: The mothers were at high risk of developing post-traumatic stress symptoms and/or other mental health issues. Of note, study participants relived the trauma of witnessing their infant in the Neonatal Intensive Care Unit, demonstrated hypervigilance behaviour and identified lack of relevant support needed when their infant was at home.

RELEVANCE TO CLINICAL PRACTICE: This study highlights the need for nurses to include a focus on the mothers’ psychosocial needs. Supporting maternal mental health both improves maternal well-being and enables mothers to be emotionally available and responsive to their extremely preterm infant.

KEYWORDS: Neonatal care; mental health; preterm; psychosocial adjustment; qualitative study; women’s health


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

Thomson G1Garrett C2.

Midwifery. 2019 Apr;71:63-70. doi: 10.1016/j.midw.2019.01.004. Epub 2019 Jan 15.


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.

KEYWORDS: Afterbirth support; Birth trauma; Debriefing; Maternity; Survey


“The loss was traumatic… some healthcare providers added to that”: Women’s experiences of miscarriage.

Bellhouse C1Temple-Smith M2Watson S1Bilardi J3.

Women Birth. 2019 Apr;32(2):137-146. doi: 10.1016/j.wombi.2018.06.006. Epub 2018 Aug 25.


BACKGROUND: Miscarriage is a common event in Australia and is estimated to occur in up to one in four confirmed pregnancies. Prior research has demonstrated that miscarriage is associated with significant distress, grief and loss, and in some cases clinically significant levels of depression, anxiety, and Post Traumatic Stress Disorder. Despite these consequences for women’s emotional and mental health, studies have commonly found that women feel that healthcare providers often lack empathy, support, and acknowledgement of their loss.

AIM: The aim of this study is to explore the psychological distress experienced by women as a result of miscarriage, as well as the perceived support provided by healthcare professionals.

METHODS: Fifteen women were recruited in Australia and participated in semi-structured interviews either in person or over the telephone.

FINDINGS: It was found that for most women, the levels of distress, grief, and loss associated with their miscarriages were significant. While women experienced both positive and negative interactions with healthcare providers throughout their miscarriage journeys, all women interviewed expressed their increased distress following negative experiences.

CONCLUSION: A number of recommendations have been provided by women to improve the service of healthcare providers in the event of a miscarriage, including referral to a psychologist, and ongoing follow-up after their miscarriage, which women felt would assist them with managing their distress.

KEYWORDS: Miscarriage; distress; healthcare; recommendations; support



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