Attentional Biases in Birth-Related PTSD

by Rebecca Webb, Centre for Maternal & Child Health Research, City University London

While birth can be a positive experience for many women, up to one third of women describe their birth as traumatic (Olde et al, 2006). The role of cognitive processes and biases in postpartum PTSD is unclear. Ehlers and Clark (2000) suggest that PTSD develops through an interaction between previous experiences, beliefs and coping strategies and the actual event itself. This interaction influences the ongoing appraisal of the event, which creates and maintains the PTSD symptoms. There is some support for this theory in postpartum PTSD (Ford et al 2010).

One of the cognitive processes thought to influence the development of PTSD is selective attention towards threatening stimuli. This phenomenon can be measured in a number of ways but is commonly assessed using an emotional Stroop task.  In the classic Stroop task, participants name the colour of words presented to them.  Some of the words are consistent with their colour e.g. ‘Blue’, whilst others are not (‘Blue’).  Participants are slower to name the inconsistent words. This paradigm has subsequently been used to compare response times to colour-naming of emotional words compared to neutral words, with emotional words exhibiting slower response times. Cisler et al., (2011) conducted a meta-analysis of the emotional Stroop paradigm undertaken with participants with PTSD. They found that people with PTSD were slower to name the colour of trauma related words, which is thought to represent captured attention, i.e. the trauma related word held the attention of the participant, slowing them down. The results from these studies suggest PTSD is associated with hyper-vigilance towards threat-relevant information. This, however, may lead to the person avoiding threat, which can maintain anxiety as the individual never gains counter information about the threat.

It is not clear whether this attentional bias is the same in birth-related PTSD. Only one study has used an emotional Stroop paradigm to investigate whether women with birth-related PTSD have similar attentional biases to threat related stimuli as those with PTSD arising from non-childbirth-related events. Dale-Hewitt et al, (2012) conducted a labour related emotional Stroop task with women who were either categorised as having PTSD, or having experienced their birth as traumatic on one of three dimensions of PTSD (avoidance, intrusion, hyper-vigilance). Contrary to the evidence from non-birth-related PTSD, women who scored high on avoidance and intrusion, but not hyper-vigilance, were faster at performing the emotional Stroop task. The authors argue that the mechanisms in birth-related PTSD may differ from non-birth-related PTSD because the baby is constantly there in the form of a reminder. Therefore, rather than avoiding the trauma, as in other event related PTSD, labour related words may be continuously activated in memory (Foa et al, 1989), meaning the mothers need less time to identify these words as threatening and can apply ignoring strategies more quickly.

Dale-Hewitt et al’s findings suggest that attentional biases in birth-related PTSD and other event related PTSD may differ in terms of causal and maintaining factors. However, the lack of birth-related PTSD Stroop data makes it hard to draw any conclusions since it is impossible to generalise from a single study.  Furthermore, the use of the Stroop paradigm to measure attentional biases in PTSD has been widely questioned. Kimble et al. (2004) found that only 44% of all studies (including unpublished dissertations) identified a Stroop effect for trauma related words in people with PTSD.

Despite the difficulty in drawing a conclusion from these results, one thing is clear; the cognitive processes behind birth-related PTSD need to be examined further. This may provide key clues to the aetiology and maintaining factors, which could therefore lead to more effective treatments in the future.

2013 research update

By Sue Thompson, Research Fellow, City University London

Research on PTSD in pregnancy and after birth is increasing and new studies are being published all the time.  This year, several new studies focusing on risk factors for PTSD have been published and this blog provides a brief overview of some of these.

Maternal factors feature consistently in the research, and recent publications demonstrate this.  For example, Shaban et al (2013) investigated PTSD in a sample of 600 Iranian women.  Prevalence of PTSD was 17.2% at 6 to 8 weeks postpartum.  Mothers with a history of neuropsychiatric conditions were at increased risk of PTSD, with moderate/severely depressed women around five times more likely to experience PTSD than non-depressed counterparts.  Interestingly, PTSD rates were 2.86 times higher in working women than in home makers.

Perhaps surprisingly, Shaban et al did not find any effects related to birth mode, stillbirth, analgesia, complications of pregnancy or delivery or maternal coping.  This is in contrast to many other studies, including Rowlands & Redshaw (2012) who looked at the role of mode of birth in PTSD-like symptoms in 5,332 women in the UK. They found that, in general, women reported most adverse physical and psychological symptoms at 10 days postpartum, with an improvement in health over the next three months.  However, women who had undergone emergency caesarean section or forceps delivery were more likely to report symptoms of PTSD at one and three months respectively.  Similarly, Boorman et al (2013), studied the effect of a traumatic birthing experience on the emotional well-being of 890 new mothers in Australia and found that mode of birth, particularly emergency caesarean section, increased the risk of perceiving traumatic birth in the early post-partum period.  They also considered the degree to which women reported traumatic birth experiences in the context of DSM-IV criteria for traumatic events.  Women experiencing either one or both DSM-IV criteria were more likely to meet the criteria for depression (measured by the Edinburgh Postnatal Depression Scale and The Depression Anxiety and Stress Scale 21) in the early postpartum period.  Both Boorman et al (2013) and Shaban et al (2013) also found that pre-existing depression was associated with birth-related traumatic event reporting – although this effect was, to some extent, dependent upon the depression measure used.

Inevitably, there are methodological differences across these studies, particularly in relation to the measurement of PTSD, depression and anxiety, making direct comparisons difficult.  Furthermore, there may be cultural differences that render results subject to particular peculiarities of the specific populations to which they refer.  That said, the ability to consider predictors of postpartum PTSD is a useful starting point for the development of diagnostic measures and treatment plans designed to protect the health of new mothers.

We will be writing regular research updates so please let us know when you publish relevant studies

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

The Truth About Traumatic Birth
My Postpartum Voice


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