“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).

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

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).