Trauma

A Resilient Pregnancy

Even if pregnancy is stress or traumatic, there are ways to improve coping

Posted Mar 17, 2018

At a symposium on new moms and stress at Bar Ilan University in Israel this week, I met a fascinating researcher, Dr. Susan Ayers from the Open University in London, UK. Pregnancy, she says, has been described as a perfect storm of stress, with a cascade of physical health problems, economic strain, and even an increased risk of intimate partner violence. Add to this nagging in-laws and the growing cost of food when eating for two, and it’s little wonder that women are at risk of post-traumatic stress disorder (PTSD) from the experience. According to a growing body of international research, women who are poor or racially and socially marginalized are at even greater risk for the disorder.

Ayers and her colleagues around the world estimate that 3-4% of women experience trauma during their pregnancies. That number rises dramatically to 39% for women who are living with a violent spouse. That’s bad news for the foetus as stress on mothers programs the child while in the womb to adapt its genetic expression to cope with what it expects will be a dangerous environment after birth. That means hypervigilance (anxiety) or hypovigilance (avoidant behaviors) become far more common among babies born after a mother’s stressful pregnancy.

This connection between stress on moms and child behavior was best shown in a study of women who were pregnant during a major ice storm in Montreal, Canada, in 1998. The ice storm caused huge and prolonged power outages, with plenty of reasons for mothers to feel anxious and worried. Cold, having to leave home to live in shelters, family separation, and shortages of everything required to keep physically healthy and psychologically safe prevented mothers from experiencing the factors we know buffer them from the heightened stress of pregnancy and birth. The take away lesson is clear: how moms appraised the impact of the ice storm on their lives (Was it a nuisance or an extremely difficult problem?) changed their children’s epigenetic methylation in hundreds of separate sites of the child’s genome. That meant some genes were turned off or remained on when they shouldn’t have been which could result in potentially lifelong changes to how children respond to stress.

Even if a woman gets through her pregnancy relatively unstressed, as many as 20% of women will experience a traumatic birth (defined as atypical complications or pain). One in five of these women, or an additional 4% of all women, can expect to experience PTSD as a consequence of these traumatic deliveries. That means that post-natal, one in twelve women will be experiencing the after-effects of trauma in their lives, placing limits on their ability to parent and do self-care. Irritability, anxiety, relationship strain and avoiding thinking about the birth are just some of the simpler symptoms. But problems can also grow into reluctance to bond with the child (the child is perceived to have caused the mother’s experience of trauma), sexual dysfunction (why would a new mom ever risk pregnancy again?), hesitation to seek health care (hospitals become associated with the trauma), and a vow to never have more children (a condition called Tokophobia). Ayers tells the story of one mother who described her experience of the birth of her child like a car crash, and the thought of another pregnancy as being akin to getting into the same car again, driving the same route, and knowing a crash is coming.

Unfortunately, we have largely overlooked women’s experiences of trauma during pregnancy, which is a shame as treatment is relatively simple, especially when problems are treated early. This wilful oversight is even worse when we compare it to the attention that veterans receive for their PTSD. In the UK, Ayers estimates that there are twice as many women experiencing PTSD related to pregnancy and childbirth as there are soldiers who have been psychologically wounded by war. Neither crisis should be ignored, but the statistic helps to put into perspective the size of the problem and the need for action.

A Resilient Pregnancy

Much of this trauma can be avoided if we change pre-natal and post-natal care in our hospitals and clinics, and give women the information they need to anticipate the stress they could experience. Resilience is both the capacity of women to prepare themselves for the experience of a traumatic birth and the redesign of our medical systems to minimize the chances that stress occurs in the first place.

First, though, let’s be clear: many women do not show signs of PTSD despite a traumatic birth. In one Turkish study, almost two-thirds of women who had traumatic births avoided negative outcomes. Even better, a study of UK women showed that a traumatic birth actually produced an overall experience of positive growth (called post-traumatic growth) after a difficult birthing experience. That growth may not occur immediately, but when a woman draws meaning from her experience and is valued for the efforts she made during the delivery, there is a good chance that she will reflect on the experience as having been worthwhile. Of course, none of this excuses the need to minimize potentially traumatizing events in the first place.

So how can we improve women’s chances of not experiencing PTSD before and after the birth of their children? Here are a few suggestions I heard at the symposium.

Minimize exposure to violence. A woman in an emotionally or physically abusive relationship is at much greater risk for psychological problems after her child’s birth. If she is experiencing violence (and intimate partner violence, when it does occur, usually increases during pregnancy), then she needs to speak with her health care provider. Indeed, she needs the professional and legal help required to stop the violence.

Build a network of social supports. Just as women think about their child’s bedroom (if the baby will have its own room), it is just as important that women build a set of relationships that will be there for them if/when the pregnancy and birth become complicated. Women tend to report very specific “hotspots” when it comes to trauma causing experiences. One third of these can be attributed to their experience of health care and health care providers, another third to their child’s challenges (especially if the child is born premature), and another third to problems with the mother’s interpersonal relationships. This third set of problems can be addressed before problems occur. Mothers who set clear expectations of others and ask for help when it’s needed seem to cope better with a traumatic birth. Younger women tend to prefer support from their partners. Older mom’s are happy with support from anyone, even their own mothers who they report can sometimes be annoying if they downplay the seriousness of the traumatic events.

Improve health care. Ayers likes to show two photographs. One of a neonatal unit for premature babies in a typical hospital with plenty of intimidating whirring machines and smocked nurses walking efficiently between neonates sleeping in their plastic bubbles. The experience on those units, according to interviews with mothers, is stressful. It also turns out to be stressful for the babies and inhibits their neurological development if they aren’t picked up enough. Ayers’ second picture is of a redesigned unit, with each child in a quiet room, the incubator placed next to a window and a comfortable rocking chair where parents can provide their premature baby skin-to-skin contact in a soothing environment. The long-term payoff for such a redesign is likely years of less tertiary health care and social services to fix damaged brains and over-stimulated nervous systems of children born too early or already at risk.

Prevent problems before they occur. Much of trauma can be avoided if health professionals assessed women for vulnerability (and strengths). In partnership with institutional change, knowing if women are at risk for anxiety, depression or relationship violence can lead to early interventions that are known to be effective. Postnatal, too, women need their healthcare professionals to screen for PTSD and if it does appear, to provide access to psychological counselling as quickly as possible. These interventions will not only decrease symptoms, they can also help women draw meaning from the experience and improve their resistance to future stress.

If there ever was an argument for the cost-effectiveness of early intervention and the promotion of resilience, it is the expeditious treatment of trauma among new mothers.

All of this echoes what I’ve written previously about resilience. It is far more than individual strengths or our ability to pick ourselves up after a bad experience. Our individual resilience depends on the quality of the systems that surround us and how well they give us what we need. Whether that’s a supportive spouse, economic support, quality food, or great health care, the result for pregnant women is the same. A resilient pregnancy, birth, and post-natal environment that ensures mom and child (and dad’s too) have the resources they need to survive the stress of this monumental life transition.

References

Ayers, S. & Pickering, A. D. (2001). Do women get posttraumatic stress disorder as a result of childbirth? A prospective study of incidence. Birth, 28(2), 111-118.

Dikmen-Yildiz, P., Ayers, S., & Phillips, L. (2017). Longitudinal trajectories of post-traumatic stress disorder (PTSD) after birth and associated risk factors. Journal of Affective Disorders, 229, Pages 377–385

Lee, S., Ayers, S., & Holden, D. (2016). Risk perception and choice of polace of birth in women with high risk pregnancies: A qualitative study. Midwifery, 38, 49-54.

Sawyer, A., Ayers, S., Young, D., Bradley, R., & Smith, H. (2012). Posttraumatic growth after childbirth: A prospective study. Psychology and Health, 27(3), 362-377.

King, S., Dancause, K., Turcotte‐Tremblay, A., Veru, F., & Laplante, D. P. (2012). Using natural disasters to study the effects of prenatal maternal stress on child health and development. Birth Defects Research (Part C), 96, 273–288.