“I wasn’t meant to give birth that early”: Posttraumatic stress and preterm birth

By Dr Alexandra Sawyer, University of Sussex

The preterm birth rate for live births ranges from about 5% to 10% in Europe (Euro-Peristat Project, 2013). Preterm birth is the most important determinant of adverse outcome in terms of survival, quality of life, psychosocial and emotional impact on the family and costs for health services.

Most studies looking at psychological outcomes following preterm birth have focused on depression and anxiety. However, only recently has the birth of a preterm baby been explored as a traumatic experience. The birth of a preterm baby can occur suddenly and the parents are often not prepared physically or emotionally (Lindberg & Ohrling, 2008). Parents can be overwhelmed with the concern of whether or not their child will survive and of future health problems (Lohr, Von Gontard, & Roth, 2000). Preterm babies are often taken away from their mother immediately so they can be stabilised and transferred to the neonatal unit. It is not surprising therefore that the emotional distress of the birth combined with early separation from the baby may contribute to a posttraumatic stress response.  Below are two quotes from women we have interviewed about their experiences of giving birth to a very preterm baby (Sawyer, Rabe, Abbott, Gyte, Duley, & Ayers, 2013):

“It’s daunting going in a room when you’ve never been in.  All your bits are going to be on show.  And you’re worried about your children.  Are they gonna survive?  Are they gonna be born stillborn?” (Twins born at 30 weeks gestation)

“… I hadn’t seen anything of him, and I just saw this like incubator whisked off and off he went.  So none of this bonding ‘you’ve got a baby boy, here he is’ or ‘have a look at him’.  Didn’t give me that opportunity.  Nothing.  I hadn’t seen him from coming out to after I’d recovered in recovery.  I hadn’t.. I didn’t see any of that.  He was gone.  It was like ‘have I had baby?’ ” (Baby born at 27 weeks gestation)

 

Studies report high prevalence rates of posttraumatic stress disorder (PTSD) following preterm birth: 7% (Kersting et al., 2009), 17% (Stramrood et al., 2011), 23% (Misund, Nerdrum, Braten, Pripp, & Diseth, 2013), and 41% (Pierrehumbert, Nicole, Muller-Nix, Forcada-Guex, & Ansermet, 2003). The research also suggests that posttraumatic stress symptoms persist beyond one year after birth. For example, Ahlund, Clarke, Hill, & Thalange (2009) found that 2-3 years after preterm birth mothers still reported relatively high symptoms of posttraumatic stress compared to mothers of healthy term babies. Several review papers have also identified preterm birth as a strong predictor of the development of PTSD following childbirth (e.g. Anderson, Melvaer, Videbech, Lamont, & Joergensen, 2012; Olde, van der Hart, Leber, & van Son, 2006). Therefore, early indications are that women who give birth to a preterm baby report more posttraumatic stress symptoms which last for a considerably longer time, compared to women who give birth to a term baby.

A number of studies have reported that PTSD following childbirth can negatively impact parent-infant relationships (Nicholls & Ayers, 2007). For example, Feeley et al. (2011) found that mothers of preterm babies who displayed high levels of posttraumatic symptoms were less sensitive and less effective at structuring the interaction when playing with their baby. Another study found that mothers of preterm babies who had high levels of posttraumatic stress symptoms were more likely to display a controlling type of interaction with their baby, which was characterised by hostility (Forcada-Guex, Borghini, Pierrehumbert, Ansermet, & Muller-Nix, 2011). This type of attachment dyad has been associated with eating problems, hearing and speech difficulties and poorer social/personal development in the infant (Shaw et al., 2013).

Of course not all parents who give birth to a preterm baby will display posttraumatic stress symptoms, and many parents adjust well. However, these early research studies suggest that we do need to identify women at risk of developing posttraumatic stress symptoms in order to optimise the health of mothers and their babies. Routine screening for perinatal PTSD in mothers who have given birth to a preterm infant is recommended (Feeley et al., 2011). This would help plan supportive interventions in the neonatal period, particularly for those most at risk. However, as with the general perinatal PTSD research, two key questions need to be considered first: 1) What is the best way to screen for perinatal PTSD, and 2) How do we treat vulnerable women once identified?  But, what is most critical is that healthcare professionals are aware that the birth of a preterm baby and subsequent hospitalisation may lead to a posttraumatic stress response in some parents.

Bliss is an excellent charity which provides care and support for premature and sick babies and their families. They offer a free help and advice line: 0500 618140 (or email:   hello@Bliss.org.uk).

What about the Dads………

By Ylva Parfitt, PhD student, University of Sussex

It is now well established that some mothers suffer from posttraumatic stress (PTSD) following childbirth, but what about the dads?  In principle, fathers who witness a difficult or complicated birth may also experience symptoms of PTSD. However, research concerning PTSD in fathers is still scarce.

Qualitative studies (Eriksson, Salander & Hamberg, 2007; White, 2007) and quantitative studies (Johnson, 2002; Skari et al., 2002) suggest that men can experience intense fear and raised stress related to the birth of their baby. For example, Skari et al. (2002) found that 37% of mothers and 13% of fathers reported psychological distress with severe intrusive symptoms in 2% of fathers and 6% of mothers a few days after birth, reducing to 2% six months after birth for both genders. However, it is unclear whether men develop full symptoms of PTSD following childbirth.  Bradley, Slade & Leviston’s (2008) quantitative investigation of PTSD in men six weeks after birth failed to find any cases of fully symptomatic PTSD, although 12% of men had symptoms on at least one dimension (mainly hyperarousal). In this study, PTSD symptoms in fathers were associated with trait anxiety, fewer children, unplanned pregnancy and being at the birth. In their recent review of mental health problems in fathers following childbirth, Bradley and Slade (2011) concluded that fathers attending the birth could experience intrusive thoughts and images, especially those who did not feel that they supported their partners sufficiently during the labour and birth.

If either parent suffers from PTSD this may have implications for their relationship with the baby (Muzik et al, 2013; Parfitt & Ayers, 2009). However, again research is limited and findings are inconclusive. One study of mothers and fathers found that PTSD symptoms were more strongly associated with bonding impairment than symptoms of depression (Parfitt and Ayers 2009), whilst another did not find any links between maternal PTSD symptoms and parenting stress (McDonald, Slade, Spiby & Iles 2011). A recent study using videos to examine interaction between fathers and infants found that symptoms of PTSD and depression were associated with less passive infant behavior and greater infant difficulty (Parfitt, Pike & Ayers, 2013).

There is currently very little research which has looked at the effects of PTSD symptoms in dads on their child’s development and well-being. In a study of PTSD symptoms in parents of preterm babies, Pierrehumbert, Muller-Nix, Forcada-Guex and Ansermet (2003) found that the severity of PTSD symptoms was associated with the child’s sleeping and eating problems at 18 months of age. Interestingly, eating problems were significantly associated with higher levels of PTSD symptoms in fathers, but not in mothers.

The lack of research in this area makes it difficult to draw any firm conclusions at this time but it is clear that dads need to be considered more in research looking at postpartum PTSD and the impact of this on the family.

“I’m much stronger than I thought” – Posttraumatic growth following childbirth

by Alexandra Sawyer, Research Fellow, University of Sussex

There are many examples in religion, philosophy, and literature of individuals who have been transformed positively by their experience and struggle with challenging and traumatic events. However, only in the last few decades have researchers begun to research positive changes that individuals report following challenging life events. Positive changes have been documented in a range of individuals following a variety of stressful events, including sexual assault, heart disease, breast cancer, HIV/AIDS, arthritis, terrorist attacks, bereavement, immigration, infertility and natural disasters (see Linley & Joseph, 2004, for a review).

Many different terms have been used in the literature to describe these positive changes but the most commonly used term is posttraumatic growth (PTG). A simple definition of PTG is “positive psychological change as a result of the struggle with life crises or traumatic life events” (Tedeschi & Calhoun, 1996). However, stressful events, which are not necessarily traumatic, like some illnesses, work-related stress, and immigration have been shown to facilitate PTG. Therefore we prefer to use ‘growth’ to describe the experience of positive change following a challenging event. Three broad areas of growth have been reported in the literature: changes in interpersonal relationships, changes in self-perception, and changes in life-philosophy (Tedeschi, Park, & Calhoun, 1998).

Most research looking at psychological adjustment following childbirth has focused on negative psychological outcomes, whilst positive psychological outcomes have been relatively ignored. However, researchers are beginning to recognise the need to explore a range of possible responses (Allan, Carrick-Sen, & Martin, 2013, Ayers, Joseph, McKenzie-McHarg, Slade, & Wijma, 2009). Aldwin and Levenson (2004) were amongst the first researchers to suggest that developmental events have the potential to promote growth, and it is only in the last few years that research has begun to explore childbirth as one of these events. One qualitative study explored women’s accounts of a subsequent childbirth after a previous traumatic birth and found evidence of one of the domains of growth: a sense of personal strength (Beck & Watson, 2010). Women felt that their previous experience of birth had provided them with a sense of strength and empowerment when dealing with the subsequent birth. Only two studies have looked specifically at growth following childbirth in the UK. In a cross-sectional Internet study (Sawyer & Ayers, 2009) 219 women who had given birth within the previous three years completed the Posttraumatic Growth Inventory; a 21-item questionnaire assessing five areas of positive change (PTGI; Tedeschi & Calhoun, 1996). Approximately 50% of women reported at least moderate levels of growth and growth scores were comparable to other samples (e.g. victims of assault, accidents) using the PTGI. This study also explored how coping strategies related to growth. Approach coping strategies (e.g. seeking guidance and support) were significantly associated with higher levels of growth. Another study explored growth in a longitudinal, prospective study of women recruited from hospital clinics (Sawyer, Ayers, Bradley, Young, & Smith, 2012). Posttraumatic stress symptoms during pregnancy and type of delivery (elective or emergency caesarean section) significantly predicted higher levels of growth after childbirth. In both of these studies women reported most growth in the Appreciation of Life domain of the PTGI, and the least amount of growth in the Spiritual Change domain.

In my view, assessment of growth following childbirth is important for a number of reasons. Firstly, as mentioned earlier there is an increasing awareness for a broader focus on psychological adjustment following childbirth. If we examine positive and negative psychological outcomes together, a more comprehensive account of adjustment can be developed. Secondly, longitudinal studies in other populations suggest that growth following a challenging event may be associated with better adjustment in the long term. Findings from such studies suggest that growth may be a useful clinical target in clinical and healthcare settings and there are promising studies that demonstrate that growth may be integrated into clinical interventions (see Antoni et al., 2001, Stanton et al., 2002). Therefore the promotion of growth may be a possible option for therapists working with traumatised women.  However, until the potential effectiveness of interventions aimed at developing growth has been further explored, caution should be taken when using them clinically with postnatal women. Thirdly, there is a lack of longitudinal, prospective studies of growth. From a theoretical viewpoint childbirth is a naturally occurring and predictable event, which allows the role of different variables in the development of growth to be considered prospectively. Childbirth provides a valuable opportunity to explore how pre-event variables (for example mental health, social support, coping) influences experiences of growth, which can in turn inform current theories of growth.

In this short overview I hope I have illustrated why I think it is important and interesting to widen our focus of psychological adjustment following childbirth to include growth. For those who would like to read further about growth, including theories and measurement, I recommend the papers by Joseph & Linley (2006), Tedeschi & Calhoun (2004), and Zoellner & Maercker (2006).

Perinatal PTSD on the internet

By Donna Moore, PhD student, Centre for Maternal and Child Health, City University London

If you enter the search term “PTSD birth” into Google it yields approximately 692,000 results. There is a growing “voice” on the WWW concerning birth trauma. There are professional websites such as the Birth Trauma Association and sites run by survivors. There are pages dedicated to PTSD and childbirth on popular parenting sites such as Netmums. There are perinatal PTSD forums, discussion boards, Twitter feeds, yahoo groups, web logs (blogs), YouTube videos, chat rooms, Google+ and facebook pages. People are hashtagging, tweeting, pinning, liking and sharing…and I’m blogging about it!

In my research I have reviewed websites for postnatal mental illness; postnatal depression, anxiety, PTSD, and psychosis. I reviewed resources on the world wide web (WWW) to identify the top websites for healthcare professionals and women with postnatal illness to use. The WWW provides information on symptoms, risk factors and treatment options and this could have implications for screening and prevention. There are also a range of resources for women including self-help tools (i.e. letters to healthcare professionals, prevention and stories), support (i.e. forums, email and personal messaging) and additional resources (i.e. leaflets, podcasts and audio/visual).

The internet offers continuous access with information just a click away (or a press of the app on a mobile phone). Women can utilise the WWW’s features without worrying about what others may think of them as they can search and participate anonymously. Birth stories feature regularly on perinatal PTSD websites which could also indicate some cathartic effects of sharing ones experience of trauma. There are growing and vibrant virtual communities offering women the space to have an online “voice”. Healthcare professionals could gain valuable insight into women’s experiences of birth trauma and suggest online resources to their clients.

Furthermore, healthcare professionals working in this area can benefit from using the internet in many ways. Academic online networking sites such as LinkedIn and ResearchGate can assist in collaboration with other researchers, exchanging ideas and disseminating research (no need to rely solely on networking at conferences). Indeed, this website is run by a network of researchers and clinicians who are working together to reduce birth trauma and perinatal PTSD across the world. There are many possibilities to expand and promote perinatal PTSD research globally.

Healthcare professionals could suggest quality websites to their clients to provide education and additional support. After all, it is crucial to increase public and professional awareness of perinatal PTSD and continue to help women who suffer and their families. I look forward to hearing this virtual voice get louder and louder.

Some useful websites
The Birth Trauma Association
PaTTCh – Prevention and Treatment of Traumatic Childbirth

Trauma After Birth (TABS)
Birth Trauma Association Canada   
 

Online support groups
Babycentre traumatic birth support group
PNI.ORG – active and supportive forum for all postnatal mental illnesses
SANDS – forum for stillbirth and neonatal death
Solace for Mothers – support for women who had a traumatic birth

Facebook groups
Birth Talk
Birth Trauma Association

Blogs
The Truth About Traumatic Birth
My Postpartum Voice

Twitter
@birthPTSD

Treatment of PTSD following childbirth: the importance of context

By Kirstie McKenzie-McHarg, Clinical Psychologist and founding member

I work as a clinical psychologist and manage a perinatal psychology service in the UK. A basic dilemma that exists when treating PTSD following childbirth (PTSD FC) is that of whether the presentation of PTSD in the perinatal population the same as, or different from, PTSD caused by other events?  If the presentation is the same, we can utilise existing approved treatments.  If it is different, we may need to adapt our approaches to allow for these differences.  Trauma-focused cognitive behaviour therapy (CBT) is a PTSD treatment recommended by NICE guidelines. A paper by Ayers, McKenzie-McHarg & Eagle (2007) presents case studies which suggest that standard CBT approaches to women experiencing PTSD FC are effective and appropriate to use with this population.

However, the context of PTSD FC differs from that of PTSD following other events.  In PTSD FC, women are expected to take home a dependent newborn and to care for the baby.  For some women, the baby is a lasting reminder of their traumatic birth experience, and bonding and attachment may be affected.  There are significant postnatal hormonal changes for women.  Childbirth itself is considered by society to be a positive event, unlike any other stressor leading to PTSD such as war, assault or traffic accident. Therefore women may experience others as lacking in understanding, making comments such as ‘aren’t you lucky, you have a beautiful baby’.  There are very often sexual problems for women experiencing PTSD FC.  All of these specific difficulties are in addition to the normal postnatal background of extreme fatigue, increased social isolation, decreased independence and increased responsibility.  As such, it is important that the postnatal context of women with PTSD FC is taken into account when intervention is planned.

Clinicians working with PTSD in the perinatal context therefore need to consider how to work effectively when the mother may need to bring the baby to every session; for example, if the mother is highly anxious and therefore cannot leave her baby, or if she is breastfeeding.  There is also a need to recognise that some women will experience a tension between significant anger and resentment at the changes in her status and health, and simultaneously experiencing an overwhelming and confusing protective instinct for an infant she may resent.

The clinical space therefore must provide a safe and containing environment in which new mothers can express their conflicting emotions, and admit to potentially shaming or even dangerous thoughts about themselves and their baby.  While the creation of this safe space presents a challenge when working clinically with any individual with PTSD (due to their avoidance of discussing the trauma) it is additionally difficult in a postnatal population.  This is because many women fear that admitting negative emotions towards their baby may result in a referral to social services and the subsequent loss of their baby.  In summary, while the broad therapeutic approach we use for intervention for PTSD may remain the same, consideration of the perinatal context is critical.

Conferences and perinatal PTSD research

The recent ISPOG conference had a lot of research on perinatal PTSD, anxiety, and fear of childbirth, which made it a really stimulating conference for those of us working in this area. Every year it is difficult to decide which conferences to go to in order to find out more about perinatal PTSD and present our research. It was one of the reasons we set up the research network in 2005 – to facilitate discussion and exchange of ideas between researchers in this area. Similarly, coordinating efforts to attend the same conferences provides great opportunities to hear about each other’s research and discuss collaborations – as the ISPOG conference recently demonstrated.

 We have done some digging to see if we can help and have come up with a list conferences that are relevant to perinatal PTSD, or where we know people in the network are attending. This year, the Perinatal Mental Health conference in November looks particularly interesting, although the deadline for submissions has already passed. If you want to present your work to an international audience, the International Marce Society conference in 2014 is on Change in perinatal mental health so promises to be a good forum for our work.  If you know of other good conferences – especially if you are presenting perinatal PTSD research – please add them by clicking on the speech bubble.

2013 Conferences
Society for Reproductive and Infant Psychology, 17-18 September, UK
Australasian Marcé Conference, 11-12 October, Australia
Perinatal Mental Health Conference, 6-8 November, USA
International Society for Traumatic Stress Studies, 7-9 November, USA

2014 Conferences
North American Society for Psychosocial Obstetrics and Gynecology, 6-9 April 2014, USA
International Confederation of Midwives triennial conference, 2014, Prague
14th World Association for Infant Mental Health World Congress, July 2014, UK
International Marcé Society Biennial Scientific Meeting, 10-13 September 2014, UK
European Health Psychology Society conference, 2014, Austria

2015 Conferences to watch out for
6th World Congress on Women’s Mental Health, details to be announced
International Society for Psychosomatic Obstetrics and Gynaecology, Spain, details to be announced

All change… what does DSM-5 mean for perinatal PTSD?

By Susan Ayers, Centre for Maternal and Child Health, City University London

In May this year the American Psychiatric Association released version 5 of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) to some controversy and criticism, including from Allen Frances, the chair of the previous DSM task force (Psychology Today, 2012). The British Psychological Society also expressed concerns about aspects of DSM-5, and the Division of Clinical Psychology published a detailed statement in response to DSM-5. So what are the implications of DSM-5 for perinatal PTSD?

Key changes in DSM-5 criteria for PTSD are outlined in an APA factsheet. Frustratingly, getting access to the complete diagnostic criteria seems to be difficult unless you purchase the manual. Nonetheless, the key changes outlined by the APA factsheet and gleaned from a few other sources are as follows:

  • PTSD is now classified as a ‘trauma and stressor-related disorder’ rather than an anxiety disorder.
  • Event criteria have changed so the person has to directly experience or witness “actual or threatened death, serious injury or sexual violation”. Previous criterion A2 about individuals responding to this event with intense fear, helplessness or horror has been removed. In addition, certain events are excluded from qualifying as a traumatic event, including the unexpected death of a family member by natural causes. 
  • There are now four symptom clusters of PTSD instead of three: (1) intrusions, (2) avoidance, (3) arousal and (4) negative cognitions and mood. The new category of ‘negative cognitions and mood’ includes some symptoms of numbing that were previously included with avoidance symptoms, in addition to new symptoms such as persistent blame of self or others.
  • Arousal symptoms now include more aggressive or self-destructive behaviours.
  • Two subtypes have been added of PTSD in children and PTSD with dissociative symptoms.

For perinatal PTSD the changes to event criteria are critical. Traumatic births still fit criteria because women can directly experience the threat of death or injury. Similarly, fathers and birth partners may fit criteria by witnessing such events. However, the exclusion of death of a family member by natural causes could (arguably) exclude death of the infant before, during or after birth, depending on how ‘natural causes’ is defined. This raises the question of whether psychological problems arising from perinatal infant death are more appropriately conceptualised as PTSD or complicated grief.

This tightening of event criteria to potentially exclude infant deaths, coupled with the necessity for parents to have four types of symptoms rather than three, means prevalence rates of postpartum PTSD could reduce. On the other hand, the removal of criterion A2 where the person has to respond to the event with intense fear, helplessness or horror could increase prevalence rates of postpartum PTSD. The rationale behind this change is that people respond to traumatic events in different ways (e.g. anger, shame, guilt) and that inclusion of A2 “proved to have no utility in predicting the onset of PTSD” (see APA factsheet).

Postpartum PTSD research certainly supports the notion that women respond to traumatic birth with a wide range of negative emotions (e.g. Ayers, 2007).  However two large studies carried out in the UK and Australia suggest the removal of A2 is likely to inflate prevalence rates of postpartum PTSD because many women perceive a threat of injury or death during birth. In the UK, Ayers et al (2009) looked at prevalence of postpartum PTSD in 502 women in community studies and found 35% of women reported perceived threat of injury or death. Similarly, 35% of women reported feeling intense fear or horror at some point during birth. However, only 19.7% of women reported both perceived threat of death or injury and feeling intense fear, helplessness or horror. This was also the case in an Australian study where Boorman et al (2013) looked at criteria for a traumatic birth in 890 women and found that prevalence of traumatic birth doubled from 14.3% to 29.4% when women’s emotional responses (criterion A2) were removed.

It is therefore not clear whether changes to PTSD diagnostic criteria in DSM-5 will reduce or increase prevalence rates of postpartum PTSD. In other populations the indications are that DSM-5 criteria result in lower prevalence rates (Miller et al, 2012). Research is needed to examine whether this is also the case in perinatal samples. However, before we do this we need to consider how best to measure perinatal PTSD, given the changes introduced by DSM-5. Finally, these diagnostic changes also have implications for screening and access to treatment that we haven’t considered here.

If you have any comments on this article or related issues, such as the measurement of perinatal PTSD, please let us know or leave a reply below. We are keen to publish blog posts or articles from any of our members – just get in touch with Ellinor (ellinor.olander@city.ac.uk) or Susan (susan.ayers.1@city.ac.uk).