Posttraumatic Stress Disorder after Pregnancy, Labor, and Delivery

Marsha M. Cohen, M.D.; Donna Ansara, M.Sc.; Berit Schei, M.D., Ph.D.; Noreen Stuckless, Ph.D.; Donna E. Stewart, M.D.

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In This Article

Abstract and Introduction

Objectives: Other studies of posttraumatic stress disorder (PTSD) after birth did not include questions about prior traumatic life events. This study sought to determine if a difficult birth was associated with symptoms of PTSD as well as considering sociodemographics, history of violence, depression, social support, and traumatic life events.
Methods: New mothers were recruited on the postpartum ward of six Toronto-area hospitals (n = 253) and were interviewed by telephone 8-10 weeks postpartum (n = 200). We dichotomized the postpartum stress (PTS) into high PTS (answered "yes" to 3 or more items) or low PTS (answered "yes" to 0-2 items). We calculated the odds ratios between difficult birth, other factors, and the binary PTS variable.
Results: Results of multivariable logistic regression revealed that no factor suggestive of a difficult birth was significantly related to high PTS scores, except having two or more maternal complications (odds ratio [OR] = 4.0, 95% confidence interval [CI] = 1.312.8). Other independent predictors of high PTS scores were depression during pregnancy (OR = 18.9, 95% CI = 5.862.4), having two or more traumatic life events (OR = 3.2, 95% CI = 1.28.3), being Canadian born (OR = 3.2, 95% CI = 1.38.1), and having higher household income (lowest income group, OR = 0.1, 95% CI = 0.020.5), intermediate income group OR = 0.4, 95% CI = 0.20.8).
Conclusions: In this study, postpartum stress symptoms appeared to be related more to stressful life events and depression than to pregnancy, labor, and delivery.

The fourth edition of Diagnostic and Statistical Manual of Mental Disorders[1] (DSM-IV) defines posttraumatic stress disorder (PTSD) as a reaction to an event, either personally experienced or witnessed, that involves actual or threatened death or serious injury or a threat to the physical integrity of self or others. As well, the response to the traumatic event must involve intense fear, helplessness, or horror. The three principal symptoms of PTSD are (1) reexperiencing the traumatic event (criterion B, e.g., nightmares, flashbacks, intrusive and recurrent thoughts of the event), (2) persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (criterion C), and (3) increased arousal (criterion D, e.g., difficulty sleeping, irritability, hypervigilance, difficulty concentrating). In contrast to earlier versions of the DSM that require exposure to a traumatic event that is "generally outside the range of usual human experience," the DSM-IV allows a broader range of experiences provided they precipitate acute feelings of fear, helplessness, or horror.

Several authors have proposed that a posttraumatic stress (PTS)-like disorder may occur after a distressing pregnancy, labor, or delivery.[2,3,4,5,6] This hypothesis suggests that a difficult or traumatic birth may act as a significant stressor in a fashion similar to known stressors, such as violence or war, and living through this experience might trigger the symptoms of PTS (i.e., reexperiencing the traumatic event, increased arousal, and avoidance of stimuli associated with the event).

Other study findings have supported this hypothesis. A large Swedish study investigating PTSD after childbirth (between 1 and 13 months) found that 1.7% of 1650 study women met the criteria of a PTSD profile.[6] Similarly, a study from Australia showed that of 499 participants interviewed 4-6 weeks after birth, 5.6% met the DSM-IV criteria for PTSD.[7] A study of 264 women in the U.K. found that 3% of respondents endorsed questionnaire items suggestive of PTSD 6 weeks postpartum,[8] and another study of 289 women from the U.K. found that 2.8% of women fulfilled the criteria for PTSD at 6 weeks postpartum.[9] Finally, a prospective study of 103 U.S. women reported that 1.9% met the DSM-IV criteria for PTSD 4 weeks after childbirth.[10] These studies suggest that about 2%-6% of women will experience a PTSD reaction at some point in the early period after childbirth.

Previous studies have examined potential factors that may explain or be associated with PTSD after childbirth. These include sociodemographic factors[4,6,8] (e.g., age, education), pregnancy, labor and delivery-related factors,[4,9,10] obstetrical interventions,[7] coping or expectations of labor and birth,[4,8,10] and prior psychiatric history[6,8,9] (e.g., depression during pregnancy). One study[10] found that antecedent factors, including a history of sexual assault and social support, were predictive of PTSD. A recent review of PTSD found that prior trauma was a significant factor in predicting PTSD.[11] To our knowledge, however, none of the previous studies of PTSD after childbirth have examined such issues as traumatic life events and interpersonal violence. To shed more light on whether a difficult birth is associated with symptoms of PTSD, we conducted a study to determine the proportion of women who exhibited the symptoms of PTS 2 months after birth and the factors associated with elevated symptoms of PTSD.

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