Last week, I shared Part 1 of my interview with Dr. Rebecca Moore, lead psychiatrist for the Tower Hamlets Perinatal Mental Health service based in London, U.K. Her clinical interests include PTSD and birth trauma, premenstrual dysphoric disorder (PMDD), the treatment of anxiety and depression in the perinatal period, and supporting the parent infant bond. Dr. Moore is passionate about improving services for women traumatized by birth and hosts an annual forum on Birth Trauma in London in December each year. Her goal is to form networks with those working with families with Birth Trauma around the world to share knowledge and innovative practices.
I recently spoke with her to understand more about Birth Trauma and PTSD. Here is Part 2 of our interview.
Dr. Jain: It appears to me there are a couple scenarios of how Postpartum PTSD might occur:
A woman already has PTSD (treated or untreated) and the psychological stressors associated with pregnancy/giving birth trigger a relapse of her PTSD symptoms
The actual experience of giving birth is traumatic—either the mother’s life is threatened or she witnesses a threat to the life of her newborn. This trauma then serves as the stressor, which can, in some cases, lead to PTSD.
Can you speak about other scenarios?
Dr. Moore: These are the most common routes to PTSD after birth that we see; the variance is in the individual stories and responses to trauma that we hear.
I think it’s important to flag up here that the woman’s life might not actually be in danger, it is her response to events that she perceives as traumatic, so she might have a non life threatening bleed but find that traumatic or it may be the after care that is traumatic—care on the postnatal ward, for example. What medical professionals might class as “normal” may be far from normal to the mother involved. Women have repeatedly spoken to me of this issue.
It is important to distinguish between women who feel angry about their birth experience and have irritability and intrusive thoughts about their birth, but who lack the other symptoms of PTSD.
Subclinical symptoms are really important in my opinion and incredibly common, and these women may not have diagnosable PTSD but must still be heard and listened to and supported.
Dr. Jain: If one does a Google search for Birth Trauma or Postpartum PTSD, it is impossible to ignore the number of self-help organizations, patient advocacy groups, and online support forums that pop up. Indeed, prevalence statistics for Postpartum PTSD from Western studies are approximately 1 to 3%. From an epidemiological standpoint, this would make it quite common. Yet Postpartum PTSD is something that receives very little attention in medical schools and psychiatry training programs. Is this a case of medical science needing to catch up with what is happening every day on the frontlines?
Dr. Moore: Absolutely!
I think at present this is a really neglected area of teaching and training whilst being something that affects thousands and thousands of women each year here in England.
My sense is that this is changing. Certainly here we are starting to see Birth Trauma being discussed and talked about, and networks of professionals are coming together to push for more training and better awareness.
It’s something that I feel really passionate about, and locally I run a Birth Reflections Clinic to allow women to debrief after a traumatic birth and an Annual Birth Trauma Conference in London (this year December 9th 2016, which all are welcome to attend free of charge). I lecture medical students, psychiatrists, health visitors, and midwives, and I feel this is an area that should be a key part of the undergraduate and postgraduate curriculum.
Here in the UK we are really fortunate to have some amazing web forums, such as MatExp, which allows members to share best practices and knowledge. There are many excellent blogs by women writing about their own Birth Trauma, such as Unfold Your Wings or Ghostwritermummy, which helps raise awareness. There are also some nice sites sharing good birth experiences, which can be empowering for first time mothers to read and prepare for birth, such as tellmeagoodbirthstory.com.
Dr. Jain: Related to this, there appear to be some very real social and systemic phenomenon that may be exacerbating the issue of Postpartum PTSD: Unrealistic images/perceptions of what birth and motherhood should be driven by popular media/culture (similar to the propagation of unrealistic body images for women); the very high tech and invasive medical environment where many women in high income settings give birth; and advances in neonatal care and NICU care that have changed the way we treat and care for premature babies.
Dr. Moore: A question that is often asked is whether women have too high expectations of achieving a natural or drug-free birth, contributing to them being traumatized when birth does not go as expected. The answer to this is complex, but research studies point towards it not being the case. Firstly, women’s expectations are found, on average, to be similar to their experiences. That is, if a woman has broadly positive expectations, she is more likely to have a positive experience. Secondly, if unrealistic expectations were linked to PTSD, we might expect to find more trauma responses in first time mothers. This has been found, but subsequent analysis suggests it is due to the higher rate of intervention in these women. Finally, one study looked at this question directly and found that a difference between expectations and experience in the level of pain, length of labor, medical interventions, and level of control was not associated with PTSD symptoms. However, a difference between expected support from healthcare professionals and the level of care experienced was predictive of PTSD symptoms. Women don’t seem necessarily to be traumatized by the events of birth not happening as they expected, but are more affected when they do not receive the care they expect.
For many women I meet there is a real lack of honest conversations about the process of birth, and my sense is many women enter their labor emotionally unprepared for what might happen and have high expectations of what they want to happen, which may or may not be realistic.
I think there is a much greater need for midwives and obstetricians to have repeated conversations with women about birth and listen to women’s fears, hopes, and preferred choices.
The issue that comes up time and time again here is a lack of continuity of care and that women often see a different midwife at each visit, which means that these discussions don’t happen.
I personally encourage women to think in depth about their birth and the choices they may or may not like, whilst grounding any discussion in the reality of what might happen.
I personally think if women can afford it and would like it, that using an independent midwife or doula can be really beneficial and help provide a constant support and advocate throughout pregnancy and birth.
There is also no doubt that medical interventions and having a baby in the NICU play a role in trauma. There is a wealth of literature showing that these mothers and fathers are at increased risk of developing PTSD.
In 2013, Youngblut et al looked at parent health and functioning 13 months after infant or child NICU/PICU death. Parents (176 mothers, 73 fathers) of 188 deceased infants/children were recruited from 4 NICUs, 4 PICUs, and state death certificates 2 to 3 weeks after death. Data on parent physical health (hospitalizations, chronic illness), mental health (depression, PTSD, alcohol use), and functioning (partner status, employment) were collected in the home at 1, 3, 6, and 13 months after death. Thirteen months after infant/child death, 72% of parents remained partnered, 2 mothers had newly diagnosed cancer, alcohol consumption was below problem drinking levels, parents had 98 hospitalizations (29% stress related) and 132 newly diagnosed chronic health conditions, 35% of mothers and 24% of fathers had clinical depression, and 35% of mothers and 30% of fathers had clinical PTSD. More Hispanic and black mothers than white mothers had moderate/severe depression at 6 months after infant/child death and PTSD at every time point.
Lefkowitz et al looked at the prevalence of PTSD and depression in parents of infants in the NICU, identifying 86 mothers and 41 fathers who completed measures of acute stress disorder (ASD) and of parent perception of infant medical severity 3-5 days after the infant's NICU admission (T1), and measures of PTSD and Postpartum Depression (PPD) 30 days later (T2).
35% of mothers and 24% of fathers met ASD diagnostic criteria at T1, and 15% of mothers and 8% of fathers met PTSD diagnostic criteria at T2. PTSD symptom severity was correlated with concurrent stressors and family history of anxiety and depression. Rates of ASD/PTSD in parents of hospitalized infants are consistent with rates in other acute illness and injury populations, suggesting the relevance of traumatic stress in characterizing parent experience during and after the NICU.
There is a wealth of excellent resources online for parents with babies in the NICU/Special Care Baby Unit (SCBU), such as Bliss, Headspace Perspective, and Tommy’s. These all offer a wealth of practical advice, including telephone support and local groups or buddy schemes.
In my next blog post, I'll share part 3 of my interview with Dr. Moore.
Copyright: Shaili Jain, MD. For more information, please see PLOS Blogs.