“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).

Genetic screening for postnatal depression

Issues for consideration by Rose Coates, PhD student, University of Sussex

I am doing research on conceptualising and screening for postnatal mental health problems and am writing in response to the recent publication of research by Engineer and colleagues identifying possible genetic markers for postnatal depression.  A lot of media reports interpreted this as leading to genetic screening for postnatal depression (e.g. Sky News) and I was contemplating what this means for mothers experiencing any kind of postnatal distress. On the one hand, any research into postnatal depression is welcome and raises awareness of how prevalent and debilitating it is. We also need to understand physiological vulnerability as well as psychological and social vulnerabilities. On the other hand, I have a number of concerns about the focus on genetic screening for postnatal depression.

My first concern is that not all women who screen positive will go on to develop postnatal depression. The potential value of genetic screening therefore needs to be balanced against the potential impact on women of being told they might get postnatal depression. Screening positive could increase stress and anxiety during pregnancy, which studies have shown is associated with preterm labour and poor infant outcomes (e.g. Schuurmans & Karrasch, 2013, Dunkel Schetter & Tanner. 2012). After birth, women might persistently worry about any feelings of distress and quick to pathologise symptoms that may be a normal part of the transition to motherhood.

My second concern is that some women who screen negative will go on to develop postnatal depression. In these circumstances, will women feel that their experience is less valid because the test gave them the all-clear? Will it be clear to women that the test is screening for only one marker of elevated risk for postnatal depression and not the many other forms of distress that women can and do experience e.g. anxiety, PTSD, bonding and adjustment disorders? Given the lack of knowledge and information about other forms of postnatal distress in the public sphere this seems unlikely. Beyond mothers, will midwives and health visitors be given enough training and time to fully understand and communicate these issues of the tests sensitivity and specificity?

My third concern and perhaps the most worrying aspect to me are reports in the media that the screen could be a time- and money-saving method of detecting mothers at risk of depression. The implication is that midwives and health visitors could use this test with new mothers in their care instead of asking about wellbeing and women disclosing feelings of distress. Many studies show that what mothers want, and what helps them through distress, is talking to someone supportive (e.g. Cuijpers et al., 2008). Of course there will always be some mothers who do not want to disclose their feelings but it is not certain that screening for increased genetic risk of depression will lead to improved help and support for this group anyway.

In my view, more research and consideration of the impact of screening on women is needed. As Engineer and colleagues take pains to acknowledge, their results are based on a small convenience sample and they assessed postnatal depression using a score of 10 or more on the Edinburgh Postnatal Depression Scale (EPDS).  Irrespective of the utility of using the EPDS to detect postnatal depression, the usual cut-off score is 13 or more, which likely accounts for their high prevalence of probable depression (24%). The EPDS was also given only once postpartum (4-6 weeks) so it is possible a number of women who screened positive may simply be experiencing transient distress. Matthey (2010) argues that two high scores on the EPDS, separated by two weeks, and combined with a clinical interview provide a more accurate assessment for ongoing depression. It is therefore important that we consider the impact of screening on women and the best way in which to do this.

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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.

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).