Research Update December 2019-August 2020

BMJ Open, 2019 Dec 30;9(12):e032469, doi: 10.1136/bmjopen-2019-032469.

Improving mental health and physiological stress responses in mothers following traumatic childbirth and in their infants: study protocol for the Swiss TrAumatic biRth Trial (START)

Vania Sandoz 1Camille Deforges 1Suzannah Stuijfzand 1Manuella Epiney 2Yvan Vial 3Nicole Sekarski 4Nadine Messerli-Bürgy 5Ulrike Ehlert 6Myriam Bickle-Graz 7Mathilde Morisod Harari 8Kate Porcheret 9Daniel S Schechter 8 10Susan Ayers 11Emily A Holmes 12Antje Horsch 13 7START Research Consortium


Introduction: Emergency caesarean section (ECS) qualifies as a psychological trauma, which may result in postnatal post-traumatic stress disorder (PTSD). Maternal PTSD may not only have a significant negative impact on mother-infant interactions, but also on long-term infant development. The partner’s mental health may also affect infant development. Evidence-based early interventions to prevent the development of postpartum PTSD in mothers are lacking. Immediately after a traumatic event, memory formation is vulnerable to interference. There is accumulating evidence that a brief behavioural intervention including a visuospatial task may result in a reduction in intrusive memories of the trauma.

Methods and analysis: This study protocol describes a double-blind multicentre randomised controlled phase III trial testing an early brief maternal intervention including the computer game ‘Tetris’ on intrusive memories of the ECS trauma (≤1 week) and PTSD symptoms (6 weeks, primary outcome) of 144 women following an ECS. The intervention group will carry out a brief behavioural procedure including playing Tetris. The attention-placebo control group will complete a brief written activity log. Both simple cognitive tasks will be completed within the first 6 hours following traumatic childbirth. The intervention is delivered by midwives/nurses in the maternity unit.The primary outcome will be differences in the presence and severity of maternal PTSD symptoms between the intervention and the attention-placebo control group at 6 weeks post partum. Secondary outcomes will be physiological stress and psychological vulnerability, mother-infant interaction and infant developmental outcomes. Other outcomes will be psychological vulnerability and physiological regulation of the partner and their bonding with the infant, as well as the number of intrusive memories of the event.

Ethics and dissemination: Ethical approval was granted by the Human Research Ethics Committee of the Canton de Vaud (study number 2017-02142). Dissemination of results will occur via national and international conferences, in peer-reviewed journals, public conferences and social media.

Trial registration number: NCT03576586.

Keywords: HRV; PTSD; cortisol; early intervention; infant development; maternal mental health.

Journal of Obstetrics and Gynaecology, 2019 Dec 8;1-5, doi: 10.1080/01443615.2019.1673714. Online ahead of print.

Can gestation be considered as trauma in adolescent girls: post-traumatic stress disorder in teen pregnancy

Aslı Sürer Adanir1Arif Önder1Gül Alkan Bülbül2Aysel Uysal2Esin Özatalay1


Although post-traumatic stress disorder (PTSD) in adolescent pregnancy has been reported at high rates in the limited research in this area, no studies have evaluated gestation as trauma in teens. This study, aimed to evaluate PTSD in this high risk group. All pregnant adolescents who presented to our obstetrics and gynaecology clinics in a one-year period were invited to participate in the study. Adolescents with a history of domestic or dating violence, rape, and sexual abuse were excluded. PTSD was rated using the Child Post-Traumatic Stress Disorder-Reaction Index. When the pregnant adolescents and control group were compared, various severities of PTSD were observed in nearly two-thirds of the study group. Although there was clinically significant PTSD among 23.3% of the controls, PTSD was more frequently seen in adolescents with pregnancy compared with their healthy peers. Educating adolescents about birth control methods and preventing child marriages will be protective in this respect.Impact statement.

What is already known on this subject? Teen pregnancy has significant psychosocial and economic impacts for adolescents, their offspring, and the community in terms of education and employment, increased risk of abuse and neglect, and the physical and emotional well-being of the offspring. Pregnancy and birth-related risks are also higher than in adults. In this context, pregnancy itself may be accepted as trauma for adolescents.

What do the results of this study add? There has been limited research on PTSD in pregnant teens and is mainly associated with traumatic childhood events. This is the first study to examine pregnancy-related PTSD and related conditions in this group.

What are the implications of these findings for clinical practice and/or further research? The prevalence of pregnancy related-PTSD in pregnant teens can be considered high and alarming, considering the fact that most of them had never been treated for it at all. Healthcare providers serving this population need to be trained to recognise the core symptoms of PTSD, and should direct adolescents for professional assistance if needed. Strategies such as higher quality sexual health education and greater access to reproductive health services to reduce adolescent pregnancy and marriage are also imperative.

Keywords: Post-traumatic stress disorder; adolescent girls; teen pregnancy.

Journal of Psychomatics Obstetrics and Gynaecology, 2019 Dec;40(4):304-310. doi: 10.1080/0167482X.2018.1512095. Epub 2018 Sep 11.

Postpartum psychological distress after emergency team response during childbirth

R Gina Silverstein 1 2Michael Centore 3Andrea Pollack 3Gabrielle Barrieau 4Priya Gopalan 5Grace Lim 3 6


Purpose: To evaluate the feasibility and acceptability of a protocol determining the relationship between emergency team response (ETR) during childbirth and acute stress disorder (ASD) and post-traumatic stress disorder (PTSD) symptoms.

Methods: In a prospective, observational, cohort design, women experiencing ETR during childbirth were approached and recruited on postpartum day-1 and followed for six weeks. Demographics, obstetric and birth characteristics, ASD scores and PTSD scores (by Impact of Events Scale, IES and PCL-civilian) were recorded. Recruitment and retention rates were recorded, and scores were compared to women who did not experience ETR.

Results: Three hundred sixty-nine were approached and 249 were enrolled (67.5% recruitment rate). One hundred twenty-five completed all procedures (50.2% retention). Twenty experienced ETR (3.5% event rate), 12 enrolled (60.0% recruitment rate) and 8 completed the study (66.7% retention). The ETR group had higher PCL and IES scores (PCL: ETR median 12, non-ETR median 2, p = .08; IES: ETR median 22.5, non-ETR median 20, p = .08). ASD scores were similar between groups.

Conclusions: Methodology investigating the link between ETR and postpartum psychological distress is feasible and acceptable. A relationship between ETR and PTSD symptoms appears to exist, with ETR being associated with higher PTSD scores compared to non-ETR childbirths. Methods that incorporate awareness of the unique concerns of vulnerable populations are needed.

Keywords: ASD; PTSD; Postpartum; morbidity; obstetric; trauma.


Journal of Family Psychology, 2019 Dec;33(8):1000-1006.  doi: 10.1037/fam0000557. Epub 2019 Jul 18.

Prospective, dyadic links between posttraumatic stress disorder symptoms and family violence in the early years of parenthood

Amy D Marshall 1Yunying Le 2Steffany J Fredman 2Mark E Feinberg 3Emily C Taverna 1Damon E Jones 3


Cross-sectional research has suggested that posttraumatic stress disorder (PTSD) symptom severity may be an important predictor of family violence perpetration; however, causal inference is limited by the absence of studies designed to prospectively predict family violence by PTSD symptoms. In the current study, PTSD symptoms were assessed among 250 trauma-exposed heterosexual couples 10 months after having their 1st child. The number of acts of psychological and physical intimate partner aggression (IPA) and parent-to-child aggression (PCA) that occurred during the past year was assessed at 10 and 24 months postpartum to account for stability in family violence perpetration when prospectively predicting perpetration. Longitudinal actor-partner interdependence models revealed that women’s and men’s PTSD symptoms positively predicted increases in the frequency of their own perpetration of psychological and physical IPA as well as psychological PCA. Additionally, partners’ PTSD symptoms prospectively predicted psychological and physical IPA perpetration but not psychological or physical PCA perpetration, suggesting that partners’ PTSD symptoms may directly impact dyadic processes during incidents of IPA but may not generally affect the family environment in a way that potentiates all forms of aggression. No significant gender differences were revealed. Overall, results of the current study largely support existing research and theory while clarifying inconsistencies that have emerged when examining cross-sectional associations. Further, the current results highlight the potential utility of PTSD treatment as an avenue for aggression prevention and intervention efforts during the early parenting years. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Journal of Affective Disorders, 2020 Feb 1;262:310-316. doi: 10.1016/j.jad.2019.11.006. Epub 2019 Nov 4.

Association of antepartum depression, generalized anxiety, and posttraumatic stress disorder with infant birth weight and gestational age at delivery

Bizu Gelaye 1Sixto E Sanchez 2Ana Andrade 3Oswaldo Gómez 3Ann L Coker 4Nancy Dole 5Marta B Rondon 6Michelle A Williams 3


Background: Low- and middle-income countries bear a disproportionate burden of preterm birth (PTB) and low infant birth weight (LBW) complications where affective and anxiety disorders are more common in the antepartum period than in industrialized countries.

Objective: To evaluate the extent to which early pregnancy antepartum depression, generalized anxiety disorder, and posttraumatic stress disorder (PTSD) are associated with infant birth weight and gestational age at delivery among a cohort of pregnant women in Peru.

Methods: Our prospective cohort study consisted of 4408 pregnant women. Antepartum depression, generalized anxiety, and PTSD were assessed in early pregnancy using the Patient Health Questionnaire-9, Generalized Anxiety Disorder Scale-7 and PTSD Checklist – Civilian Version, respectively. Pregnancy outcome data were obtained from medical records. Multivariable linear and logistic regression procedures were used to estimate adjusted measures of association (β coefficients and odds ratios) and 95% confidence intervals (CI).

Results: After adjusting for confounders, women with antepartum generalized anxiety (32.6% prevalence) had higher odds of LBW (adjusted odds ratio (OR)=1.47; 95%CI: 1.10-1.95) and were more likely to deliver small for gestational age (OR = 1.39; 95%CI: 1.01-1.92) infants compared to those without anxiety. Compared to those without PTSD, women with PTSD (34.5%) had higher odds of delivering preterm (OR = 1.28; 95%CI: 1.00-1.65) yet PTSD was not associated with LBW nor gestational age at delivery. Women with antepartum depression (26.2%) were at no increased risk of delivering a preterm, low-birth-weight or small-for-gestational-age infant.

Limitations: Our ability to make casual inferences from this observational study is limited; however, these findings are consistent with prior studies.

Conclusion: Generalized anxiety disorder during pregnancy appeared to increase odds of delivering a low-birth-weight or small-for-gestational-age infant, while PTSD was associated with increased odds of delivering preterm. Our findings, and those of others, suggest antenatal care should be tailored to screen for and provide additional mental health services to patients.

Keywords: Anxiety; Birth weight; Depression; Posttraumatic stress disorder; Pregnancy; Preterm delivery.

Journal of Women’s Health,  2020 Feb;29(2):200-209.

Prevalence of Post-Traumatic Stress Disorder Following Caesarean Section: A Systematic Review and Meta-Analysis

Yanfang Chen 1Xiaoxian Yang 2Chentao Guo 3Yan Liao 4Lixing Guo 1Wenjun Chen 5Innie Chen 4 6Daniel Krewski 7 8Shi Wu Wen 4 6 8Ri-Hua Xie 1


Background: While caesarean section (CS) can be a lifesaving intervention when performed in a timely manner to overcome dystocia or other complications, it is a traumatic event and may increase the risk of post-traumatic stress disorder (PTSD). No attempt has been made to assess prevalence of PTSD after CS specifically. This study aimed to quantify pooled prevalence of PTSD after CS through a systematic review and meta-analysis.

Methods: MEDLINE, PsycINFO, EMBASE, and CINAHL were searched using PTSD terms crossed with CS terms. Studies were included if they reported the prevalence of PTSD after CS using an instrument based on Diagnostic and Statistical Manual of Mental Disorders-criteria to identify PTSD. The pooled prevalence was then estimated by meta-analysis in overall eligible studies and in subgroups.

Results: Nine studies were included with a total of 1,134 postpartum women, of which 136 were identified as having PTSD. Pooled prevalence of PTSD after CS was 10.7% (95% confidence interval [CI]: 4.0-20.2). Pooled prevalence of PTSD after emergency CS (10.3% [95% CI: 1.7-24.9]) was higher than that after elective CS (7.1% [95% CI: 0.7-19.4]), but the difference was not statistically significant. Subgroup analysis showed that pooled prevalence of PTSD after CS differed according to study setting, time interval of PTSD assessment, and type of participants. Meta-regression analysis showed that study setting and type of study participants were significant sources of heterogeneity.

Conclusions: Women with CS apparently have higher rates of PTSD as compared with women without CS. However, the susceptibility to PTSD appears to vary based on emergency/elective CS, study methodology, self-perceived traumatic birth, and country of study. Further targeted research is needed to elucidate the role of these factors in relationship between CS and PTSD.

Keywords: caesarean section; meta-analysis; post-traumatic stress disorder; prevalence.

Women and Birth, 2020 Feb;33(1):e95-e104. doi: 10.1016/j.wombi.2018.11.014. Epub 2018 Dec 19.

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

Nadine E de Vries 1Claire A I Stramrood 2Lynn M Sligter 3Anne-Marie Sluijs 4Maria G van Pampus 4


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.

Keywords: Fear of childbirth; Midwives; Postpartum; Posttraumatic stress disorder; Pregnancy.


Objective: Mounting evidence indicates the detrimental impact of posttraumatic stress following childbirth (PTS-FC). Nevertheless, research on preventive strategies is scarce. We recently reported that ultrasound visual biofeedback during second stage of labor was associated with immediate beneficial medical outcomes (increased pushing efficacy, decreased perineal tearing), as well as greater feelings of maternal connectedness toward her newborn immediately postlabor. The current study assessed the potential longer-term psychological benefits of these outcomes in buffering risk for PTS-FC. The study follows up the previously reported sample to examine the longitudinal clinical effect of the visual biofeedback intervention on symptoms of acute stress at 2 days postpartum and subsequent symptoms of PTS-FC at 1 month postpartum.

Method: A sample of 26 nulliparous women received visual biofeedback and was compared to a group of women receiving standard obstetrical coaching. Maternal feelings of connectedness and acute stress symptoms were assessed 2 days postpartum and PTS-FC was assessed 1 month postpartum.

Results: Double-mediation analyses revealed a significant indirect relation between visual biofeedback and decreased PTS-FC symptoms 1 month postpartum. The relation was significantly mediated by increased feelings of maternal connectedness immediately postpartum, which in turn was associated with decreased symptoms of acute stress 2 days postpartum.

Conclusions: These results suggest that the visual biofeedback intervention during childbirth may decrease risk for PTS-FC. Importantly, findings suggest the preventive potential of fostering feelings of maternal connectedness toward her newborn to reduce symptoms of PTS-FC. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

BMC Pregnancy Childbirth,2020 Mar 6;20(1):142. doi: 10.1186/s12884-020-2826-1.

Effectiveness of midwife-led brief counseling intervention on post-traumatic stress disorder, depression, and anxiety symptoms of women experiencing a traumatic childbirth: a randomized controlled trial

Leila Asadzadeh 1Elham Jafari 2Roghieh Kharaghani 1Farhad Taremian 3


Background: This study investigated the effectiveness of brief midwife-led counseling based on Gamble and colleagues’ approach in decreasing post-traumatic stress disorder, depression, and anxiety symptoms among a group of women who had experienced a traumatic childbirth.

Methods: From among 270 pregnant women screened to participate in the study, 90 women experienced a traumatic childbirth. They were randomly assigned into two groups: intervention (n = 45) and control group (n = 45). We did a face-to-face counseling session within 72 h after giving birth and a telephone counseling session four to 6 weeks after giving birth for the intervention group. The control group only received the postnatal routine care. The outcome measures were post-traumatic stress disorder, depression, and anxiety symptoms.

Results: At the three-month follow-up, the intervention group showed significantly higher improvement on post-traumatic stress disorder, depression, and anxiety symptoms compared to the control group.

Conclusions: Gamble and colleagues’ midwife-led brief counseling could be an effective approach to reduce psychological distress of women who have experienced a traumatic childbirth.

Trial registration number: IRCT201608285417N2, Date of Registration: 2/21/2017.

Keywords: Anxiety; Depression; Iran; Midwife-led brief counseling; Post-traumatic stress disorder; Traumatic childbirth.

Perspectives in Psychiatric Care, 2020 Mar 16. doi: 10.1111/ppc.12501. Online ahead of print.

The risk factors for postpartum posttraumatic stress disorder and depression

Fadime Bayri Bingol 1Meltem Demirgoz Bal 1


Purpose: In this study, we examined the association between specific birth-related variables and postpartum posttraumatic stress disorder (PTSD) and depressive symptoms.

Design and methods: In this descriptive study, data were collected using a personal information form, the City Birth Trauma Scale, and the Edinburgh Postpartum Depression Scale.

Findings: The findings revealed that 8.5% of participants met all the diagnostic criteria for PTSD. The risk of developing depression was 9.7 times higher among women who met all the criteria for PTSD than among those who did not meet all the criteria.

Practice implications: During the postpartum period, at-risk mothers should be followed and screened for PTSD and depressive symptoms.

Keywords: childbirth; postpartum; postpartum depression; postpartum posttraumatic stress disorder


Women and birth,2020 Mar;33(2):e129-e135. doi: 10.1016/j.wombi.2019.03.008. Epub 2019 Apr 4.

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

Antonio Hernández-Martínez 1Julian Rodríguez-Almagro 2Milagros Molina-Alarcón 3Nuria Infante-Torres 4Ana Rubio-Álvarez 5Juan Miguel Martínez-Galiano 6


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.

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

American Journal of Obstetrics and Gynaecology, 2020 Apr;222(4):367.e1-367.e22.

Posttraumatic stress, anxiety and depression following miscarriage and ectopic pregnancy: a multicenter, prospective, cohort study

Jessica Farren 1Maria Jalmbrant 2Nora Falconieri 3Nicola Mitchell-Jones 4Shabnam Bobdiwala 2Maya Al-Memar 2Sophie Tapp 2Ben Van Calster 5Laure Wynants 6Dirk Timmerman 7Tom Bourne 8


Background: Early pregnancy losses are common, but their psychologic sequelae are often overlooked. Previous studies have established links between miscarriage and early symptoms of anxiety and depression. However, the incidence of posttraumatic stress symptoms and the psychologic response specifically to ectopic pregnancies have not been investigated.

Objective: The purpose of this study was to investigate levels of posttraumatic stress, depression, and anxiety in women in the 9 months after early pregnancy loss, with a focus on miscarriage and ectopic pregnancy. Morbidity at 1 month was compared with a control group in healthy pregnancy.

Study design: This was a prospective cohort study. Consecutive women were recruited from the early pregnancy and antenatal clinics at 3 London hospitals and received emailed surveys that contained standardized psychologic assessments that included the Hospital Anxiety and Depression Scale and Posttraumatic stress Diagnostic Scale, at 1, 3, and 9 months after loss. Control subjects were assessed after a dating scan. We assessed the proportion of participants who met the screening criteria for posttraumatic stress and moderate/severe anxiety or depression. We used logistic regression to calculate adjusted odds ratios.

Results: Seven hundred thirty-seven of 1098 women (67%) with early pregnancy loss (including 537 miscarriages and 116 ectopic pregnancies) and 171 of 187 control subjects (91%) agreed to participate. Four hundred ninety-two of the women with losses (67%) completed the Hospital Anxiety and Depression Scale after 1 month; 426 women (58%) completed it after 3 months, and 338 women (46%) completed it after 9 months. Eighty-seven control subjects (51%) participated. Criteria for posttraumatic stress were met in 29% of women with early pregnancy loss after 1 month and in 18% after 9 months (odds ratio per month, 0.80; 95% confidence interval, 0.72-0.89). Moderate/severe anxiety was reported in 24% after 1 month and in 17% after 9 months (odds ratio per month, 0.69; 95% confidence interval, 0.50-0.94). Moderate/severe depression was reported in 11% of the women after 1 month and 6% of the women after 9 months (odds ratio per month, 0.87; 95% confidence interval, 0.53-1.44). After miscarriage, proportions after 9 months were 16% for posttraumatic stress, 17% for anxiety, and 5% for depression. Corresponding figures after ectopic pregnancy were 21%, 23%, and 11%, respectively. In contrast, among control women with viable pregnancies, 13% reported moderate-to-severe anxiety (odds ratio loss at 1 month vs controls: 2.14; 95% confidence interval, 1.14-4.36), and 2% reported moderate-to-severe depression (odds ratio loss at 1 month vs control subjects: 3.88; 95% confidence interval, 1.27-19.2).

Conclusion: Women experience high levels of posttraumatic stress, anxiety, and depression after early pregnancy loss. Distress declines over time but remains at clinically important levels at 9 months.

Keywords: Hospital Anxiety and Depression Scale; pregnancy; psychology.


Psychoneuroendocrinology, 2020 Apr;114:104604. doi: 10.1016/j.psyneuen.2020.104604. Epub 2020 Feb 7.

Adverse childhood experiences, posttraumatic stress, and FKBP5 methylation patterns in postpartum women and their newborn infants

Damion J Grasso 1Stacy Drury 2Margaret Briggs-Gowan 3Amy Johnson 4Julian Ford 3Garry Lapidus 5Victoria Scranton 3Christine Abreu 6Jonathan Covault 3


Background: Genetic variation and epigenetic mechanisms involving the stress-related gene FKBP5 have been implicated in the intergenerational transmission of trauma-related effects in adult offspring of trauma-exposed caregivers, but these processes have not been fully explored in postpartum women and their newborn infants.

Methods: Women recruited from a prenatal care clinic during their third trimester of pregnancy (N = 114) completed a battery of instruments assessing adverse childhood experiences (ACEs), adversity in adulthood, posttraumatic stress disorder (PTSD) symptoms, negative emotional state, and emotion dysregulation. FKBP5 rs1360780 genotype and intron 7 methylation were derived from saliva collected from postpartum mothers and their newborn infants within 24 h of delivery.

Results: Allele-specific associations of methylation with maternal ACEs and prenatal trauma-related symptoms were evident; however, relations differed between mothers and newborns. In mothers carrying the stress sensitive T-allele (CT and TT genotypes), maternal FKBP5 methylation negatively correlated with threat-based ACEs and maternal PTSD symptoms during pregnancy, but not deprivation-based ACEs. In infants homozygous for the C allele (CC genotype), infant FKBP5 methylation positively correlated with maternal threat-based ACEs and prenatal PTSD symptom severity, but not deprivation-based ACEs or adversity in adulthood.

Conclusions: Our results provide evidence that links maternal threat-based ACEs and trauma-related symptoms during pregnancy with allele-specific epigenetic patterns in postpartum women and their newborn infants. These findings provide mechanistic insight into the potential intergenerational impact of ACEs and the effect of maternal PTSD symptoms during pregnancy.

Keywords: Adversity; Epigenetics; Maternal factors; Post-traumatic stress disorder; Prenatal.

Journal of Reproductive and Infant Psychology, 2020 Apr 22;1-15. doi: 10.1080/02646838.2020.1754371. Online ahead of print.

Maternal prenatal depression, PTSD, and problematic parenting: the mediating role of maternal perceptions of infant emotion

Gloria Romero 1Alissa Huth-Bocks 2Erin Puro-Gallagher 3Jessica Riggs 4


Background: Perinatal illness is alarmingly common and has negative effects on maternal and infant well-being. Depression and posttraumatic stress disorder (PTSD), specifically, are characterised by negative views of the self and others, which may impact a mother’s perceptions of herself and her child.

Objective: This study examined the relationship between depression and PTSD symptoms, maternal perceptions of infant emotions, and parenting behaviours.

Methods: 120 pregnant, mostly low-income women and their infants (after birth) participated in a longitudinal study. Maternal depression and PTSD symptoms were assessed during pregnancy and 1 year postpartum; maternal perceptions of infant emotions and parenting quality were assessed at 1 year.

Results: Correlation analyses revealed significant, negative associations between prenatal (but not postnatal) psychiatric symptoms and positive perceptions of infant emotions, as well as between positive perceptions of infant emotions and negative parenting. Results also revealed significant indirect effects of prenatal depressive and PTSD symptoms on negative parenting via perceptions of infant emotion (95% CIs:.0013 -.0200 and.0008 -.0083, respectively).

Conclusion: Findings highlight that mothers should be routinely screened for psychiatric symptoms during the perinatal period, and perceptions of infant emotions may be an important target for parent-infant mental health interventions.

Keywords: Maternal depression; infant emotion; maternal PTSD; parenting.

Sexual and Reproductive Health, 2020 Apr 27;25:100516. doi: 10.1016/j.srhc.2020.100516. Online ahead of print

Potentially traumatic events, fear of childbirth and posttraumatic stress disorder during pregnancy in Stockholm, Sweden: A cross-sectional study

Anna Persson 1Sofia Lindmark 2Kerstin Petersson 3Erin Gabriel 4Malin Thorsell 5Karolina Lindström 6Mona Göransson 7Gunilla Cardell 8Åsa Magnusson 9


Objectives: To estimate the prevalence of potentially traumatic events (PTEs), fear of childbirth (FOC), and support for it as well as posttraumatic stress disorder (PTSD) among pregnant women attending maternal care in Stockholm, Sweden.

Methods: A cross-sectional study was conducted. Pregnant women attending lectures in preparation for childbirth at the major hospitals in Stockholm were asked to complete questionnaires anonymously. Main outcome measures were the prevalence of PTEs, FOC, support for FOC and PTSD.

Results: One thousand one hundred fifty-seven women in late pregnancy attending lectures in preparation for childbirth at hospitals in Stockholm, Sweden, were asked to participate, 945 chose to participate, resulting in a response rate of 81.7 percent. Most pregnant women, 78.5 percent (95% confidence interval (CI) 75.6-81.3), reported having experienced at least one PTE. The prevalence of having experienced different types of violence is presented. FOC was found among 28.8 percent (95% CI 25.7-32.0) of pregnant women, while only 10.9 percent (95% CI 10.5-11.2) received support for FOC. The prevalence of current PTSD was 4.1 percent (95% CI 2.8-5.8).

Conclusions: The majority of pregnant women had experienced PTEs, and experiences of violence were common, as was FOC. Approximately one in 25 women attending general maternal care in Stockholm, Sweden, was estimated to have current PTSD. This highlights the need to prevent violence, find pregnant women suffering from FOC or PTSD, to develop an evidence-based treatment for FOC and to provide such treatment for PTSD.

Keywords: Mental Health; Parturition; Pregnant Women; Stress Disorders, Post-Traumatic.


Journal of Affective Disorders, 2020 May 1;268:134-140. doi: 10.1016/j.jad.2020.03.006. Epub 2020 Mar 3.

The role of posttraumatic stress and depression symptoms in mother-infant bonding

Sandra Nakić Radoš 1Marijana Matijaš 2Maja Anđelinović 2Anto Čartolovni 3Susan Ayers 4


Background: There is some evidence posttraumatic stress disorder (PTSD) following childbirth may impact on the mother-infant bond. However, the evidence is inconsistent over whether PTSD or co-morbid depressive symptoms are primarily related to impaired bonding. This study therefore aimed to examine the relationship between PTSD symptoms, depressive symptoms and mother-infant bonding.

Methods: A cross-sectional online study included 603 mothers of infants aged 1-12 months. Measures were taken of PTSD (City Birth Trauma Scale, Ayers et al., 2018) which has two subscales of birth-related PTSD symptoms and general PTSD symptoms; depression (Edinburgh Postnatal Depression Scale, Cox et al., 1987) and mother-infant bonding (Postpartum Bonding Questionnaire, Brockington et al., 2001).

Results: Impaired bonding was related to both dimensions of PTSD symptoms and depressive symptoms in bivariate analysis. Path analysis testing the model of whether depressive symptoms mediated the effect of PTSD symptoms on mother-infant bonding found a differential role of birth-related and general PTSD symptoms. Birth-related PTSD symptoms did not have any effect on bonding or depressive symptoms. In contrast, general PTSD symptoms had a direct effect on bonding and an indirect effect on bonding via depressive symptoms.

Limitations: Self-report measures of PTSD and depression symptoms were used.

Conclusions: Further research regarding different aspects of postpartum PTSD, depression and other disorders in the context of mother-infant bonding are needed. Future preventive programs should focus on diminishing symptoms of postpartum PTSD and depression so that the mother-infant bonding remains optimal.

Keywords: Bonding; Childbirth; Infant; Postnatal depression; Posttraumatic stress disorder.

Psychiatry Research, 2020 May 22;290:113090. doi: 10.1016/j.psychres.2020.113090. Online ahead of print.

Risk factors for developing posttraumatic stress disorder following childbirth


Women can develop childbirth-related posttraumatic stress disorder (CB-PTSD) in at-term delivery with healthy baby outcome as well as following pre-term delivery and neonatal complications, a potential added stressor. No study compares risk factors of CB-PTSD associated with different infant outcomes. We investigated CB-PTSD risk factors by comparing women with or without neonatal complications. Analysis reveals the importance of antepartum and birth-related risk factors in CB-PTSD above and beyond child outcomes, suggesting childbirth is an independent stressor capable of evoking CB-PTSD.

Keywords: Traumatic childbirth; maternal mental health; posttraumatic stress disorder.

BJOG, 2020 Jun;127(7):886-896.doi: 10.1111/1471-0528.16163. Epub 2020 Feb 27.

STRAWB2 (Stress and Wellbeing After Childbirth): a randomised controlled trial of targeted self-help materials to prevent post-traumatic stress disorder following childbirth

P Slade 1H West 1G Thomson 2S Lane 3H Spiby 4R T Edwards 5J M Charles 5C Garrett 6B Flanagan 6M Treadwell 7E Hayden 8A Weeks 9 10


Objectives: To test whether providing psychological self-help materials would significantly lower the incidence of post-traumatic stress disorder (PTSD) at 6-12 weeks postnatally.

Design: Open-label randomised controlled trial, with blinded outcome assessment.

Setting: Community midwifery services in two National Health Service (NHS) trusts in the North West.

Sample: A cohort of 2419 women receiving normal NHS postnatal care.

Methods: Midwives screened women for traumatic birth experience; 678 women who screened positively (28.1%) were randomly allocated to self-help with usual care (n = 336) or to usual care alone (n = 342). The self-help materials were a leaflet and online film designed to prevent the development of PTSD after trauma exposure through explaining how to manage early psychological responses.

Main outcome measure: The primary outcome was a composite of diagnostic and subdiagnostic PTSD at 6-12 weeks postnatally using the gold-standard Clinician-Administered PTSD Scale (CAPS-5) interview.

Results: Of the 678 women correctly randomised plus the nine women randomised in error, 478 (70.5%) were followed up. Diagnostic or subdiagnostic PTSD rates at follow-up did not differ between groups who received self-help (26.7%, 65/243) or usual care alone (26.2%, 64/244) (intention-to-treat analysis: RR 1.02, 95% CI 0.68-1.53). Findings remained consistent in the per-protocol analysis (RR 1.04, 95% CI 0.85-1.27). Women viewed the materials very positively. There were no adverse effects. Health economic micro-costing indicated implementation would be very low cost.

Conclusions: Many women experience a traumatic birth and risk developing PTSD, but self-help strategies without professional support are insufficient and should not be routinely introduced.

Tweetable abstract: Self-help information alone does not reduce the number of women developing PTSD after a traumatic childbirth.

Keywords: Childbirth; Post-traumatic stress disorder; postnatal; prevention; randomised controlled trial.


Psychiatry Research, 2020 Jun;288:112933. doi: 10.1016/j.psychres.2020.112933. Epub 2020 Apr 14.

Effects of expressive writing intervention for women’s PTSD, depression, anxiety and stress related to pregnancy: A meta-analysis of randomized controlled trials

Jialu Qian 1Xiaoli Zhou 2Xueshan Sun 3Mengwei Wu 4Shiwen Sun 5Xiaoyan Yu 6


Expressive writing (EW) is a common psychological intervention that aims to improve the mental health of traumatized individuals. Pregnancy is considered an anxious or traumatic experience for some women, and any crisis in relation to pregnancy is closely associated with their psychological well-being. Post-traumatic stress disorder (PTSD), depression, anxiety and stress are the most prominent emotional and psychological responses that may occur during the process. However, the effects of EW in mediating women’s PTSD, depression, anxiety and stress related to pregnancy remain uncertain, and no qualified meta-analysis has assessed such effects. The aim of this study was to assess the effectiveness of EW as a psychological intervention for women. Five databases, including PubMed, EMBASE, Cochrane, Web of Science and PsycINFO, were searched from inception to September 2019 for eligible studies. Finally, a total of 929 participants from 8 randomized controlled trial (RCT) studies were included. A pooled analysis demonstrated that EW was an efficient therapy for decreasing PTSD. However, the results showed that the EW intervention was not associated with the expected effects on anxiety and stress symptoms. The efficacy of EW for depression was inconclusive. More RCTs are necessary to verify the effectiveness of EW for depression. Studies concentrating on EW’s effects on physical symptoms are necessary, and researchers should create an EW intervention group, neutral writing group and no writing group to examine the true effects of EW. Future research should examine whether longer, more frequent, and more targeted writing interventions would result in different conclusions.

Keywords: Expressive writing; Mental health; Meta-analysis; Pennebaker; Pregnancy; Psychotherapy.

Archives of Women’s Mental Health, 2020 Aug;23(4):557-564. doi: 10.1007/s00737-019-01006-x. Epub 2019 Oct 25.

Beyond postpartum depression: posttraumatic stress-depressive response following childbirth

Sharon Dekel 1 2Tsachi Ein-Dor 3Gabriella A Dishy 4Philip A Mayopoulos 4


Although depression following childbirth is well recognized, much less is known about comorbid postpartum psychiatric conditions. Some women can endorse posttraumatic stress related to the childbirth experience accompanied by symptoms of depression. The objective of our study was to examine the nature of the comorbidity of symptoms of childbirth-related posttraumatic stress disorder (PTSD) and postpartum depression. We studied a sample of 685 women who were on average 3 months following childbirth and collected data about their mental health pertaining to PTSD, depression, general distress, and childbirth experience. The vast majority of women with elevated childbirth-related PTSD symptoms also endorsed elevated postpartum depression symptoms. Factor analysis revealed that symptoms of childbirth-related PTSD and postpartum depression loaded onto one single factor rather than two factors. Stepwise multi-nominal regression analysis revealed that childbirth stressors, including obstetric complications and peritraumatic distress in birth, predicted the likelihood of developing comorbid childbirth-related PTSD and postpartum depression, but not depression alone. The findings suggest that beyond postpartum depression, postpartum women suffer from a posttraumatic stress-depressive response in the wake of a traumatic childbirth experience. Increasing awareness in routine postpartum care about traumatic childbirth and its associated emotional sequela is warranted.

Keywords: Factor analysis; PTSD; Postpartum depression; Posttraumatic stress; Traumatic childbirth.

Archives of Women’s Mental Health, 2020 Aug;23(4):547-555. doi: 10.1007/s00737-019-01011-0. Epub 2019 Nov 27.

Posttraumatic stress symptoms following childbirth: associations with prenatal attachment in subsequent pregnancies

Susan Garthus-Niegel 1 2Antje Horsch 3 4Tilmann von Soest 5Silje Marie Haga 6Filip Drozd 6Susan Ayers 7Malin Eberhard-Gran 6 8 9


This longitudinal population-based study aimed to investigate the prospective relationship between PTSD symptoms following childbirth and prenatal attachment in the subsequent pregnancy. Data were derived from the Norwegian Akershus Birth Cohort (ABC), a large population-based prospective cohort study. Data from 1473 women who had given birth at least once before and who had completed questionnaires at 17 and 32 weeks of gestation were included. Confirmatory factor analysis of the short version of the Prenatal Attachment Inventory was conducted to validate the scale. Further, structural equation modeling techniques were used to estimate prospective associations of PTSD symptoms following childbirth with prenatal attachment. Finally, to explore potential mechanisms of the association, mediation and moderation analyses were conducted. PTSD symptoms following previous childbirth were found to be prospectively related to higher levels of prenatal attachment in the subsequent pregnancy, while controlling for important confounding factors, such as symptoms of maternal depression and anxiety, previous pregnancy loss, and sociodemographic factors (maternal age, educational level, marital status, and number of children). When fear of childbirth was included as a potential mediating variable, the prospective relationship between PTSD symptoms following childbirth and prenatal attachment in the subsequent pregnancy increased, thereby indicating a suppressor effect. Fear of childbirth did not act as a significant moderator. Our findings suggest that a subsequent pregnancy following a traumatic childbirth may for some women represent an opportunity for a higher level of prenatal attachment, whereas high levels of fear of childbirth may be detrimental for prenatal attachment.

Keywords: Akershus Birth Cohort; Fear of childbirth; PTSD following childbirth; Posttraumatic stress disorder; Prenatal attachment.

International Journal of Obstetric Anesthesia, 2020 Aug;43:18-24. doi: 10.1016/j.ijoa.2020.04.009. Epub 2020 May 11.

Post-traumatic stress disorder and postpartum depression and their reported association with recent labor and delivery: a questionnaire survey cohort

S A Freedman 1S Reshef 1C F Weiniger 2


Background: We aimed to investigate the index traumatic event associated with post-traumatic stress disorder (PTSD) and evaluate the timing of the onset of symptoms in relation to the recent delivery.

Methods: Questionnaire study regarding prior exposure to traumatic events, PTSD, postpartum depression (PPD) and fear of childbirth among women two to 12 months postpartum, recruited via targeted internet sites.

Results: Questionnaires were completed by 143 women, with PPD reported by 22 (15.4%), probable PTSD by 11 (7.7%), and fear of childbirth by 14 (9.8%). Overall, 97 (67.8%) women reported a prior traumatic event: 16 (16.5%) reported the recent delivery to be the worst traumatic event and that symptoms began subsequent to this delivery; 17 (17.5%) reported the worst traumatic event was not the recent delivery but symptoms had started postpartum. Significantly higher symptom levels suggestive of PTSD and PPD were found in women whose trauma event was not delivery, yet symptoms started postpartum. Women whose traumatic event pre-dated the delivery also showed significantly higher symptom levels of PTSD. More than half of those describing PTSD related to the recent delivery presented with clinically relevant levels of fear of childbirth, compared with less than a third of women whose PTSD was related to a different event.

Conclusion: PTSD identified postpartum may not be linked to the recent delivery and often pre-dates it. Future studies should identify the trigger traumatic event responsible for PTSD symptoms, to enable a more accurate picture of the reasons for PTSD and fear of childbirth.

Keywords: Fear of childbirth; Index traumatic event; Post-traumatic stress disorder; Postpartum depression; Prior trauma.

One Response

  1. Maureen Treadwell at |

    This is such an interesting study but I would like to add a word of caution. I am the research officer for the Birth Trauma Association and have just got off the phone from a woman who is significantly distressed because she could not get her ‘counsellor’ to listen – just as midwives and doctors had not listened during the birth. The counsellor was focussed on past the events in her life and ‘hidden trauma’. In fact, the woman’s PTSD was related to a quite horrific birth experience where she ended up with shoulder dystocia and refused pain relief. She didn’t have any notable earlier trauma. May be we could do some follow up work. Yes, PTSD following childbirth may not always be a result of the birth – but it very often is and great care needs to be taken to ensure that the HCP has really listened to the narrative.


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