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Post-Traumatic Stress Disorder

When the Birth Process Is Traumatic

Research identifies who is at risk for PTSD after delivery.

While childbirth is generally joyful, popularly branded as a positive experience, such is not always the case. Stigma makes it hard for those suffering to get help, especially when everyone expects parents to be bathed in an idyllic glow. In addition to the trials and tribulations surrounding conception, not to mention the challenges of parenting, there is a growing awareness that the birthing process may be traumatic.

Cross-sectional studies (e.g. those that are but a snapshot in time) suggest that factors including emergency childbirth, prior trauma, and adversity during childbirth increase the risk of maternal PTSD and may interfere with the mother-infant bond (Ertan et al., 2021). Research has estimated the risk of PTSD following childbirth from 0 to 21 percent for usual-risk pregnancies, and up to 43 percent in high-risk pregnancies (Khoramroudi, 2018). Fathers also may experience postpartum problems, and over 7 percent report PTSD symptoms after birth (Shobinger et al., 2018). They, too, may suffer depression and anxiety, which interfere with bonding and childcare.

The Stress of Giving Birth

Prospective studies, those that track participants starting before an event occurs or a problem develops and follows them over time, furnish us with more powerful data on causal factors, versus looking for patterns in retrospect. A recent study of PTSD and childbirth, reported in the Archives of Gynecology and Obstetrics, followed nearly 600 women (there were a total of 2,000 asked to participate in a community delivery setting) who agreed to participate in the study.

Participants completed a PTSD scale (the Impact of Events Scale) within a few days of giving birth and again six months later. PTSD symptoms (e.g. avoidance, intrusions, hyperarousal/agitation) were tracked in relation to factors including maternal age, number of prior children, migration status, pregnancy-related illness, support available to mothers during labor, duration of labor, injuries and complications during birthing (e.g. episiotomy), delivery method (vaginal approaches, Caesarian), and weight and head size of the baby.

Statistical analysis found that, overall, 2.9 percent of mothers met PTSD criteria. There were no differences in symptom scores right after birth and six months later, though only half of participants completed the second-time checklist. Older mothers and those who had assistance during labor were less likely to develop PTSD. For every year of higher maternal age, there was a 10 percent reduction in PTSD risk. Having a companion during labor reduced PTSD risk by over 84 percent.

PTSD risk was elevated among migrants and first-time mothers. Pregnancy-related illness such as diabetes and high blood pressure did not impact PTSD scores. While duration of labor and infant characteristics did not influence PTSD rates, mothers with birth injuries and those who required a switch to Caesarian delivery had a greater risk of PTSD. Spontaneous delivery had the lowest PTSD risk.

Reconceptualizing the Impact of Childbirth

Nearly 3 percent of women in this community-based convenience survey reported symptoms consistent with PTSD. The incidence was higher among those with identified risk factors and lower when protective factors were present. While the risk of PTSD in this sample may seem disarmingly low, it is nevertheless significant, and especially so for those at risk. While postpartum screening for depression and anxiety is fairly routine, screening for PTSD is limited (Wenz-Gross et al., 2016).

Given the potential for PTSD and the impact on parents and children, it is important to be aware of the potential for PTSD, especially when there are difficulties during childbirth, for younger parents, and when support is lacking. Some risk factors can be readily modified, such as providing companionship during labor. Those with higher risk identified in advance can be monitored carefully to see whether help is needed. Screening for postpartum problems needs to be expanded to routinely include PTSD.

Future research is required to refine the understanding of risk factors, to work out interventions that protect at-risk mothers, and to identify whether treatment for postpartum psychiatric problems is required. More research is also needed to understand how fathers are affected around pregnancy, childbirth and in the postpartum period.

References

Ertan, D., Hingray, C., Burlacu, E. et al. Post-traumatic stress disorder following childbirth. BMC Psychiatry 21, 155 (2021). https://doi.org/10.1186/s12888-021-03158-6

Khoramroudi R. The prevalence of posttraumatic stress disorder during pregnancy and postpartum period. J Family Med Prim Care. 2018;7(1):220-223. doi:10.4103/jfmpc.jfmpc_272_1

Schobinger Elisabeth, Stuijfzand Suzannah, Horsch Antje, Acute and Post-traumatic Stress Disorder Symptoms in Mothers and Fathers Following Childbirth: A Prospective Cohort Study. Frontiers in Psychiatry, Vol. 11, 2020, https://www.frontiersin.org/article/10.3389/fpsyt.2020.562054

Wenz-Gross, M., Weinreb, L. & Upshur, C. Screening for Post-traumatic Stress Disorder in Prenatal Care: Prevalence and Characteristics in a Low-Income Population. Matern Child Health J 20, 1995–2002 (2016). https://doi.org/10.1007/s10995-016-2073-2

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