May Research Update

Predicting Posttraumatic Stress Disorder after Childbirth

O’Donovan, A.; Alcorn, K.L.; Patrick, J.C.; Creedy, D.K.; Dawe, S. & Devilly, G.J. (2014).

http://www.sciencedirect.com/science/article/pii/S0266613814000916 on 22 Apr 2014.

A prospective longitudinal study of which factors predict PTSD after childbirth in a sample of 933 women. Fourteen predictors distinguished women who reported childbirth related PTSD from those who did not. Of these, 11 were pre-birth factors and 3 were birth-related. Pre-birth factors predominantly consisted of previous traumatic events, with personal characteristics and psychological history. Birth-related predictors were feelings, pain and poor perceived control/dissociation during labour.

 

Partner experiences of ‘near-miss’ events in pregnancy and childbirth in the UK: A qualitative study.

Hinton, L., Locock, L.,  Knight, M. (2014 )

http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0091735#pone-0091735-t002

Qualitative study of 35 women who experienced a life-threatening obstetric emergency during the birth of their child and 11 of their partners. Partners reported the emergency during birth as shocking and distressing and they felt powerless and excluded.  Support and good communication from staff were very important. Some reported severe long-term emotional effects, including depression, flashbacks and PTSD. Partners felt there was little support or acknowledgement of these experiences.

 

Transition to parenthood and mental health in first-time parents.

Parfitt, Y., & Ayers, S. (2014)

http://onlinelibrary.wiley.com/doi/10.1002/imhj.21443/full

A study of 40 couples having their first baby using semi-structured clinical interviews five months after birth. One in four men and women reported anxiety in pregnancy, reducing to 21% of women and 8% of men after birth. Postpartum PTSD was experienced by 5% of parents. Postpartum mental health problems were significantly associated with postpartum sleep deprivation, complications in labour, lack of support, feeling unworthy as a parent, and anger toward the infant. Few gender differences were found.

 

Factors associated with posttraumatic stress disorder and its coping styles in parents of preterm and full-term infants.

Ghorbani, M., Dolatian, M., Shams, J., Alavi-Majd, H., Tavakolian, S.

http://www.ncbi.nlm.nih.gov/pubmed/24762347

This study of 82 couples compared psychological distress and trauma in parents of pre-term infants compared to full-term infants.  Mothers of pre-term babies were significantly more likely to experience post-traumatic stress disorder than mothers of full-term infants, but this was not found amongst fathers in the two groups.  Furthermore, differences in coping were identified between mothers in the two groups and between fathers in the two groups.  The authors recommend that education strategies should consider means of facilitating adaptive coping styles in parents of pre-term infants.

Iranian mothers’ perceptions of the impact of the environment on psychological birth trauma: A qualitative study.

Taghizadeh Z1Arbabi MKazemnejad AIrajpour ALopez V.

http://www.ncbi.nlm.nih.gov/pubmed/24758150

The authors conducted interviews with 23 women in Iran in order to ascertain environmental effects upon their childbirth experience.  Content analysis identified two main themes: human and non-human environment.  Within these, a number of categories emerged: communication with the mother, awareness of mother’s needs, support for mother, medical clinical competence, professional responsibility, hospital’s physical structure, hospital’s equipment, routine care in hospital and rules governing the hospital environment.  The authors discuss the need for interventions to improve human and non-human environment in pursuit of reduced childbirth related trauma.

 

A Quasi-experimental Outcomes Analysis of a Psychoeducation Intervention for Pregnant Women with Abuse-related Posttraumatic Stress.

Rowe HSperlich MCameron HSeng J.

http://www.ncbi.nlm.nih.gov/pubmed/24754455

This study, part of a larger trial, aimed to test the effectiveness of a psycho-educational intervention in women exposed to childhood mistreatment.  Women were recruited in pregnancy.  They either participated as part of a pre-test post-test intervention study (N = 17) or as part of a matched prospective observational study during which women received treatment as usual (N = 43).  Women in the intervention group had better mean scores on measures of post-traumatic stress, depression, mother-infant bonding, perceptions of care, dissociation of labour and experience of labour, but only dissociation in labour and perceptions of care were statistically significant.  The authors conclude that the intervention appears to improve the labour experience of women exposed to prior trauma.

Childbirth related fears and psychological birth trauma in younger and older age adolescents.

Anderson CA1Gill M2.

http://www.ncbi.nlm.nih.gov/pubmed/24726421

This study explored adolescents’ fears about traumatic birth.  A convenience sample of 201 adolescents completed measures of childbirth fear and childbirth related trauma.  The majority of the sample reported fear.  There were some differences between ages, with younger participants more likely to report higher overall fear ratings and less likely to report fear of loss of control and fear of dying.  Just over 29% of adolescents reported subclinical traumatic stress scores, 32% scored mild to moderate on traumatic stress and 6.7% scored in the severe range.  There were no significant differences across ages.

The role of labor pain and overall birth experience in the development of posttraumatic stress symptoms: a longitudinal cohort study.

Garthus-Niegel S1Knoph Cvon Soest TNielsen CSEberhard-Gran M.

http://www.ncbi.nlm.nih.gov/pubmed/24654643

A prospective longitudinal study of 1893 women who delivered their babies by SVD.  Data was collected during pregnancy, whilst on the maternity ward and eight weeks post-partum.  Labour pain and birth experience both significantly contributed to post-traumatic stress symptoms, with overall birth experience mediating the relationship between labour pain and post-traumatic stress.  The authors recommend further work to identify childbirth factors that may protect women from negative experience with the aim of improving clinical care.

 

Exploring the process of writing about and sharing traumatic birth experiences online.

Blainey SH1Slade P.

http://www.ncbi.nlm.nih.gov/pubmed/24620933

A qualitative study concerned with the acceptability and usefulness of writing about traumatic birth experience.  Twelve women who had written stories about their traumatic experience for posting on-line were interviewed just after writing their story and again one month after the story was posted on-line.  Overall, women evaluated the intervention positively, particularly being able to organise their experience and to distance themselves from it.  The authors suggest that the intervention is worthy of systematic evaluation.

Screening for symptoms of postpartum traumatic stress in a sample of mothers with preterm infants.

Shaw RJ1Lilo EAStorfer-Isser ABall MBProud MSVierhaus NSHuntsberry AMitchell KAdams MMHorwitz SM.

http://www.ncbi.nlm.nih.gov/pubmed/24597585

This study aimed to identify risk factors for anxiety, depression and traumatic stress in mothers of premature babies.  Mothers of babies born at 26 – 34 weeks gestation (N = 135) completed measures of socio-demographic status and of psychological distress.  It was not possible to distinguish mothers who scored within ranges indicative of psychological distress from those who did not on the basis of either maternal socio-demographic status or severity of the infant’s medical condition.  It is advocated that universal screening should be conducted for symptoms of psychological distress.

 

Modification and preliminary use of the five-minute speech sample in the postpartum: associations with postnatal depression and posttraumatic stress.

Iles J1Spiby HSlade P.

http://www.ncbi.nlm.nih.gov/pubmed/24477915

This study considered partner support during birth and its role in birth-related traumatic stress.  Speech samples from 372 couples were coded for couple support.  Measures of postnatal depression and traumatic stress were completed at six and thirteen weeks’ post-partum.  Maternal traumatic stress was associated with criticisms of the partner during childbirth, general relationship criticisms and men’s perception of helplessness.  Absence of partner empathy and any positive comments regarding the partner’s support during childbirth were associated with postnatal depression.

“She was perfect, a beautiful baby girl… only sleeping”: Stillbirth and PTSD in the era of DSM-5

by Elizabeth Ford, Research Fellow, Brighton & Sussex Medical School. http://www.bsms.ac.uk/research/our-researchers/elizabeth-ford/

Parents anticipate the arrival of their baby for months, often talking to and interacting with him or her in the womb. The death of a baby during pregnancy, or at birth, is usually very unexpected and is a major bereavement for the whole family. Stillbirth, defined as the loss of a baby after 24 weeks gestation, is unfortunately a common event in the UK, with 11 stillbirths occurring every day. Stillbirth has profound mental health consequences for those affected and is thought to be a trigger for post-traumatic stress disorder (PTSD). One study found current and lifetime diagnosis rates of PTSD in mothers following stillbirth in the UK to be 20% and 29% respectively (Turton et al, 2001), and there is a high risk of women who have PTSD also experiencing anxiety and depression.

The way women are treated by both professionals and family and friends following a stillbirth can have a considerable impact on their psychological adjustment. Following a stillbirth, it is still the practice in many parts of the world for the baby’s body to be disposed of with no proper funeral, for the mother to be told she “can always have another baby” and for the baby’s importance to be diminished by others (Froen et al., 2011). All of these factors can contribute to a mother’s sense of isolation and lack of support, compounding her grief.

Factors which associate maternal mental health status and stillbirth have been studied and include the time since the baby died, the gestational age of the baby, professional and social support, and subsequent pregnancy (Crawley et al., 2013). There is a mixed picture of the value of the practice of encouraging parents to view and hold their stillborn infant. Some studies have found it worsens psychological outcomes (Hughes et al, 2002), some that it improves them (Radestad et al., 1996), and others that it makes no difference. Parents report appreciating and valuing the experience of holding their baby and making mementos such as photographs, footprints or keeping a lock of hair (Crawley et al., 2013).

For those women who do experience PTSD following stillbirth, there is a higher risk of relationship breakdown, and persistent symptoms of PTSD even seven years later (Turton et al., 2009). Relationship breakdown was also associated with holding the baby after the stillbirth, and with low perceived support from the partner. Relationship breakdown and divorce are serious and pervasive consequences of PTSD (Kessler et al 1998), which in turn can cause poverty, low income, poor health and low life satisfaction. These findings underline the importance of offering parents appropriate psychological help in coping with their loss and in supporting each other through its aftermath.

The publication of the new Diagnostic and Statistical Manual for Psychological Disorders (DSM-5) in 2013 is an opportunity to reflect on the experience of stillbirth and how we consider normal grief reactions following a devastating loss. Some argue that “medicalising normal grief stigmatizes and reduces the normalcy and dignity of the pain, short-circuits the expected existential processing of the loss, reduces reliance on the many well-established cultural rituals for consoling grief, and would subject many people to unnecessary and potentially harmful medication treatment” (Frances, 2010). Grief is inescapable following loss of loved ones, and is a long process rather than a short one, it can work itself through in different ways in different people.

However, DSM-5 allows for the diagnosis of a psychiatric disorder following the loss of a loved one. In DSM-5, depressive symptoms which occur following a bereavement are considered to respond to the same psychosocial and medication treatments as non–bereavement-related depression, and it has been found that evidence does not support the separation of loss of a loved one from other stressors in terms of its likelihood of precipitating a major depressive episode or the relative likelihood that the symptoms will remit spontaneously (DSM5.org). DSM-5 criteria for PTSD have changed significantly. The new criteria define a single traumatic event more rigidly, as being exposed to death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, with the following clarifications:

  • A life-threatening illness or debilitating medical condition is not necessarily considered a traumatic event. Medical incidents that qualify as traumatic events involve sudden catastrophic events (e.g. waking during surgery, anaphylactic shock)
  • Witnessed events include … a medical catastrophe in one’s child (e.g. a life threatening haemorrhage)
  • Indirect exposure through learning about an event is limited to experiences affecting close relatives or friends and experiences that are violent or accidental (e.g. death due to natural causes does not qualify)

The sudden and unexpected death of a much-anticipated baby falls within these criteria as both a sudden catastrophic medical event and the witnessing of a catastrophe in one’s child. Therefore post-traumatic stress symptoms following a stillbirth can still lead to diagnosis of PTSD.

DSM-5 also includes the new “Persistent Complex Bereavement Disorder” which is characterised by persistent yearning for and preoccupation with the deceased and the circumstances of their death; intense sorrow and emotional pain; marked difficulty accepting the death; feeling shocked, stunned or emotionally numb; difficulty with positive reminiscing; bitterness or anger following the loss; and maladaptive appraisals; persisting for more than 12 months after the loss. There may also be excessive avoidance of reminders, among other social and identity disturbances (Friedman, 2013). The onus therefore is on clinicians to distinguish between the flashbacks and intrusions of PTSD, and the yearning and preoccupation of complex bereavement, when making a diagnosis of either disorder following the loss of a loved one.

 

This article was primarily written for researchers in the field of perinatal mental health but if you are affected by the issues discussed, you can access support and advice through the Stillbirth & Neonatal Death charity: http://uk-sands.org/

Perinatal mental health in low income countries

Less than 40% of women worldwide receive postnatal care (WHO, 2010), leaving large numbers of women potentially at risk of suffering undiagnosed and untreated postnatal mental health difficulties, including PTSD.  In the millennium year 2000, world leaders signed the United Nations Millennium Declaration and endorsed a framework of development based upon eight Millennium Development Goals (MDGs), including a goal to improve maternal health (WHO | Millennium Development Goals (MDGs)).  In 2007, a United Nations Population Fund (UNFPA)-World Health Organization (WHO) International Meeting demonstrated its commitment to the inclusion of reproductive mental health in strategies arising from the MDGs.  The report of this meeting, commonly referred to as ‘The Hanoi Expert Statement’, can be found here.

In 2011, Fisher et al reviewed, for the WHO, the prevalence and risk factors for perinatal mental health conditions in women from low and lower-middle income countries.  Prevalence rates were available from only 8% of these countries in relation to antenatal care and 15% of these countries for postnatal care.  Whilst studies were of reasonable quality, there were difficulties with samples as women from more advantaged backgrounds were often over-represented.  Furthermore, particularly for postnatal studies, there was a degree of exclusion of women on the basis of, for example, illiteracy or history of psychiatric problems, meaning that prevalence may have been underestimated.  Despite this, both antenatal and postnatal prevalence rates were higher than in high-income countries.  Most of the studies identified by Fisher et al reported risk factors for perinatal mental health conditions.  These factors were, to a large degree, reflective of the risk factors found in high-income countries.  They ranged from socioeconomic factors such as relative disadvantage, younger age and being unmarried.  Family and social relationships, such as the relationship with the baby’s father and in-laws, and social support were also associated with risk – as were general health of the mother, past mental health conditions and infant characteristics, such as child gender.  In some cases, there were interactions between factors, for example, child gender and relationship with the father (particularly violence), and a possible association with increased risk to the woman.

Unfortunately, as Fisher et al note, the studies relating to mental health in relation to low and lower-economic countries are concerned almost entirely with depression and fail to consider other disorders.  There was no focus upon PTSD within these data, a situation that is consistent with our own reviews of the literature on PTSD in low and lower-middle income countries.  However, we have identified articles reporting results that could potentially be related to PTSD.  For example: (a) Sawyer et al (2011) interviewed Gambian women and identified lack of support from men and recognition of the danger associated with childbirth as topics of concern to women; (b) Kempe et al (2013) considered Yemeni women’s perceptions of their own authority during childbirth, reporting that some women considered a loss of their own authority when attended by trained medical/nursing staff – particularly when women gave birth in institutions such as hospitals, where they felt particularly restricted – and a sense of estrangement and hopelessness.  The fact that it is not possible to substantiate such speculation, or to make cross-cultural comparisons, or to even identify prevalence rates identifies a need for further investigation in this area.

The MDGs were agreed in the year 2000 and have a target date for 2015.  We are nearing the end of 2013 and it is disappointing to note the current apparent lack of focus upon maternal mental health, and the absence of any recognition of the existence of PTSD in low and lower-middle income countries.  Of concern is the apparent failure to address the need for adequate postnatal care, including monitoring of mental health conditions, in such a large proportion of the world’s childbearing women.  There is clearly a need for greater emphasis upon research in these areas.

The first few months

Welcome to our latest blog.  It is five months since the International Network for Perinatal PTSD published its first blog.  At that time, the Network comprised a small group of interested parties and a web-site.  Today, we have 76 subscribers, a twitter feed and have published a number of communications.  This week, we thought that we would take stock of how we are doing, what you can get from the network and how you can get involved.

How are we doing?
Our subscribers and members are located across the globe, from America, Australia, Japan and a number of European countries, as well as the United Kingdom.  The members all have a special interest in perinatal PTSD, and come from backgrounds in academia, clinical psychology and the charity sector.

The aim of the network is to disseminate research about perinatal PTSD – and to stimulate discussion both about research that has been completed and research that needs to be done.  To that end, we have published a number of blogs, including consideration of the impact of DSM-V on perinatal PTSD, predicting and measuring perinatal PTSD, treating perinatal PTSD and the impact of childbirth upon fathers.  Further blogs are planned for the very near future.

What can you get from the network?
You can access information about research into perinatal PTSD, including our pre-set search on PubMed here. As the network grows, there will be greater opportunities for information sharing and collaboration with others.  Also, since the network is still at a relatively young stage, there is scope for us all to shape its direction in a way that satisfies the needs of our members, subscribers and visitors – one reason for you to get involved…

How can you get involved?
Our members and subscribers have a great deal of knowledge and experience in this area so please contribute to the network through commenting on blogs, sending us your own blog articles, and letting us know of any relevant talks, events or conferences so we can publicise these and let other members know about them.

We would like the blog to be representative of the Network’s focus on sharing knowledge.   Comments relating to the blogs are encouraged – we are always interested to hear your views – and there have been a wide range of replies and comments to the blogs posted to date.  In addition, we are trying to increase awareness of PTSD and encourage network membership through social media:  our twitter feed already has 37 followers!

So, the message this week is that we are attracting steadily increasing numbers of subscribers and members from all over the globe.  We are working hard to raise the profile of perinatal PTSD through a variety of mechanisms – and we want all of our members and subscribers to be able to join in offering their expertise and experience, whether that be writing a blog, giving us ideas for developing the Network, identifying topics that should be covered in the blogs, raising the profile of the Network, re-tweeting us or just carrying on reading our pages.  Working together to raise the profile of perinatal PTSD, to learn more about it and to find the best way to treat it – or even to protect against it.

Twitter:  @birthPTSD

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.

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

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.

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).