The experience of post-traumatic stress disorder following childbirth

› SPECIALIST Practice

The experience of post-traumatic stress disorder following childbirth Post-traumatic stress disorder (PTSD) is a significant mental health problem, which women can develop following childbirth. Partners and staff are also at risk and a larger group of women develop sub-clinical trauma symptoms. PTSD can have an impact on future childbearing, the wider family, intimate sexual relationships and bonding. The relationship between mothers and maternity staff is crucial. Health visitors can help by: supporting realistic expectations of delivery antenatally; early identification of high-risk mothers via rigorous histories; facilitating communication and the father’s role in the birth; early identification, screening and referral to specialist perinatal mental health professionals; supporting care pathways; supporting the parent–infant relationship; and facilitating access to social support.

Key words

› Stress disorders, Post-traumatic › Postnatal care › Childbirth › Psychology › Mental health

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ost-traumatic stress disorder (PTSD) is a debilitating mental health problem, which can be diagnosed antenatally and/or postnatally, and which can have significant negative effects for the new mother, her baby and wider family. It is defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM–5) as a trauma- and stressor-related disorder following direct or indirect exposure to, or witnessing of, actual or threatened death, serious injury or sexual violence (American Psychiatric Association, 2013). This description means that childbirth can fulfil the criteria necessary to be given a diagnosis of PTSD, which has been the case since DSM–IV was released in 1994 (Bailham and Joseph, 2003). PTSD is characterised by the following

Aimee Poote, clinical psychologist; and Kirstie McKenzie-McHarg, consultant clinical psychologist, Department of Clinical Health Psychology, Warwick Hospital [email protected]

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Intrusion symptoms such as: recurrent, involuntary, intrusive memories; traumatic nightmares; dissociation and flashbacks; intense or prolonged distress following exposure to triggers; physiological reactivity post-triggers Consistent avoidance of thoughts, feelings or triggers related to the trauma. This can include avoidance of people, places, conversations, activities, objects or situations Alterations in cognitions and mood including: loss of trauma-related memories; negative beliefs and expectations about the world and oneself; excessive self-blame; negative trauma-related emotions such as fear, horror, anger, guilt or shame; loss of interest in previously pleasurable activities; feelings of alienation from others; an inability to experience positive emotions Alterations in arousal and reactivity including: irritability or aggressive behaviour; self-destructive or reckless behaviour; hypervigilance; exaggerated startle response; difficulties with concentration; sleep disturbance.

PTSD following childbirth PTSD following childbirth (PTSD FC) is qualitatively different from PTSD after other traumas. Ayers et al (2008) discussed some of the ways in which PTSD FC differs from PTSD following other traumas; these include the fact that birth is a predictable event, typically undertaken voluntarily and generally seen, on a cultural level, as a positive event. This differs from other stressors that can lead to PTSD such as sexual assault, road traffic accident, or exposure to conflict. PTSD FC may result from an objectively traumatic delivery event, such as a postpartum haemorrhage in which the woman believes she will die, or a sudden drop in the baby’s heart rate in which she fears her baby will die. It can also result from a more subjectively traumatic experience, for example when women feel abandoned or unheard in labour (Elmir et al, 2010). Because criteria for diagnosis include the witnessing of such events, partners are also at risk of PTSD, and this has been reported in

Journal of Health Visiting › February 2015 › Volume 3 Issue 2

© 2015 MA Healthcare Ltd

› Abstract

indications, over a period of at least 1 month, resulting in significant functional impairment:



these groups (Stramrood et al, 2013), although the prevalence is unclear (Bradley et al, 2008). Partner studies in Norway (Ayers et al, 2007) and the UK (Bradley et al, 2006) estimate the prevalence at 0–5%. In addition, staff have been identified as being vulnerable to developing secondary traumatic stress, having established an empathic relationship and bearing witness for women who experience traumatic birth events (Baird and Kracen, 2006). Empathic relationships between women and professionals can lead to similar distress being experienced by the professional (Goldblatt, 2009) and increased empathy has itself been identified as a factor that increases the risk of staff developing PTSD symptoms after witnessing traumatic births (Sheen et al, 2014). Distancing strategies, such as a focus on technical aspects of care, have been reported by professionals as a means of reducing empathic engagement and protecting oneself from distress (Austin et al, 2009). Given the importance of the relationship between women and health professionals during the perinatal period, access to good psychological supervision is crucial to ensure the health of all professionals establishing and maintaining such empathic relationships. Philipp and Carr (2001) describe the psychological stages of a normal pregnancy commencing with the stage pre-conception and before a woman realises she is pregnant. If a pregnancy is planned, it is during this time that women begin to visualise themselves as mothers in addition to being partners, daughters or friends. In a normal, wanted pregnancy, the woman then moves consecutively through stages of ambivalence, peace and anxiety. Women have expectations developed over a period of years about motherhood, pregnancy and childbirth. A traumatic labour may shatter the mother’s expectations of birth as a positive event (Ayers et al, 2008), regardless of the severity or nature of the trauma. Following childbirth, women are expected to have near-constant contact with the baby and form a strong bond. This may exacerbate symptoms of PTSD if the baby acts as a reminder or trigger for trauma symptoms (Ayers et al, 2008). Conversely, such exposure can help to reduce avoidance, thus reducing trauma symptoms (Ayers et al, 2008). Diagnosis can be complicated as a result of the nature of life with a newborn. For example, sleep disturbance, difficulties with concentration and hypervigilance to threat are all symptoms of PTSD, but are also normal ways of presenting for new mothers (McKenzie-McHarg et


al, 2015), and may also be symptoms of postnatal depression or anxiety disorders.

How common is PTSD following childbirth? A recent meta-analysis estimates the prevalence of PTSD FC at 3.1% for the general postnatal female population and 15.7% in high-risk groups (Grekin and O’Hara, 2014). One prospective study found that after excluding mothers who entered pregnancy already experiencing PTSD, 1–3% developed PTSD as a direct response to birth (Ayers and Pickering, 2001). This equates to approximately 7000–21 000 women meeting diagnostic criteria for PTSD in the UK each year as a direct consequence of their childbirth experience. There is also evidence of many more women presenting with sub-clinical trauma symptoms (Czarnocka and Slade, 2000). Ayers et al (2008) highlight the importance of trauma-related distress, and not relying on diagnostic criteria. Trauma responses may most helpfully be conceptualised as a continuum, and sub-clinical trauma responses treated accordingly (Ayers et al, 2008).

Specific causes and risk factors of PTSD following childbirth Less than 1% of births in the UK result in infant death or ‘life-threatening “near miss” episodes’, while many more women report trauma symptoms (Ayers et al, 2008: 15). A subjectively traumatic delivery may be interpreted as routine by health professionals (Lapp et al, 2010). In addition, those who experience objectively traumatic deliveries do not necessarily go on to develop PTSD FC (Ayers et al, 2008). It can be concluded that subjective understanding of the events is crucial (Lapp et al, 2010), as highlighted by the inclusion of threatened death, serious injury or sexual violence in the DSM–5 diagnostic criteria (American Psychiatric Association, 2013). Olde et al’s (2006) review of the literature highlighted risk factors for the development of PTSD FC, including a history of psychological problems, trait anxiety, obstetric intervention, negative staff–woman contact, loss of control over the birth situation, and poor partner support. Risk factors can be divided into predisposing factors that make a woman vulnerable to developing PTSD FC, and precipitating factors which trigger PTSD FC. Lapp et al (2010) reviewed the literature and found an inconsistent evidence-base, as described below. The review described the following predisposing factors: psychiatric history (Soderquist et al, 2009); previous counselling, depression, anxiety or

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Perceived lack of care Poor communication from medical staff Perception of unsafe care Feeling as if medical staff are exclusively focused on the outcome (clinically efficient and successful), no matter the cost to the mother herself. There is a high comorbidity with depression, with rates estimated from 20–75% (White et al, 2006; Stramrood et al, 2011).

Potential consequences of PTSD following childbirth Women with PTSD FC may delay or avoid future pregnancies or request elective caesarean section as a means of avoiding vaginal delivery (Creedy et al, 2000). Recent meta-syntheses describe feelings of anger, self-blame, suicidal ideation, loss of positive affect, isolation and dissociation (Fenech and Thomson, 2014). PTSD FC can have consequences for the whole family system (Fenech and Thomson, 2014). There is evidence of avoidance of sex (Nicholls and Ayers, 2007) in order to avoid conception and triggering PTSD symptoms (Fenech and Thomson, 2014). There is also evidence of comorbidity within couples, with the male partner’s symptoms having an impact on the woman’s own PTSD (Iles et al, 2011).

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There is some evidence that maternal PTSD can be associated with bonding difficulties between mother and baby, with qualitative research suggesting that women may struggle to form a positive mother–baby bond (Davies et al, 2008). Any conclusions drawn regarding the impact of PTSD FC—particularly in the longer term—on family relationships and child development should be tentative, given the lack of evidence (McKenzieMcHarg et al, 2015). The comorbidity of depression with PTSD FC is important. There is already a significant evidence-base detailing the impact of postnatal depression (PND) on the infant, and a number of studies have looked at depressed women both with and without PTSD (National Childbirth Trust, 2011). Depressed women with PTSD were more likely to have experienced childhood sexual abuse, have greater severity of depressive symptoms, increased social isolation, and lower overall functioning than their counterparts without PTSD. More severe PTSD, particularly avoidance and emotional numbness, was associated with worse maternal psychopathology and parenting skills, after controlling for severity of depression (Ammerman et al, 2012). This implies that PTSD has an additional impact on the mother’s ability to parent, over and above the impact of any depression. Schechter et al (2005) report that women with PTSD struggle to develop an integrated, balanced image of their child, while Davies et al (2008) state that those women with PTSD FC (including where only partial criteria are met) describe their infants as more difficult, less easy to soothe and prone to higher rates of distress, which negatively affects the relationship. Women in special circumstances such as those with premature babies have also been studied, and there is evidence that these children are seen as vulnerable, leading to significantly higher likelihood of overly intrusive parenting styles (Shaw et al, 2013).

How health visitors can help to prevent PTSD following childbirth Prevention of perinatal PTSD is problematic and there are limited evidence-based interventions currently available. A recent review concluded that the evidence for counselling and/or debriefing immediately following trauma with the aim of preventing the onset of trauma symptoms is inconsistent (Lapp et al, 2010), and the National Institute for Health and Care Excellence (NICE, 2014) antenatal and postnatal mental health guidelines suggest that formal critical incident debriefing is unhelpful and not recommended.



PTSD; socio-demographic factors (Czarnocka and Slade, 2000); primiparity; socioeconomic group; personality (Soet et al, 2003); trait anxiety; anxiety sensitivity; neuroticism, trauma (Lev-Wiesel et al, 2009); previous childbirth-related trauma; sexual abuse (Hauer et al, 2009); pre-existing maladaptive schemas; negative cognitive appraisal of past childbirth; autobiographical memory specificity; and fear of upcoming childbirth (Soderquist et al, 2009). Precipitating factors were: nature of delivery (Alcorn et al, 2010); type and number of interventions; duration; fear of harm to self or baby (Leeds and Hargreaves, 2008); perception of poor care (Cigoli et al, 2006); negative perception of interactions; loss of control (Leeds and Hargreaves, 2008); feeling powerless; high levels of pain or inadequate pain relief (Soet et al, 2003); peritraumatic dissociation (Stadlmayr et al, 2007); feeling of unreality; negative appraisal of birth experience (Edworthy et al, 2008); negative emotional reactions; and perceived low levels of social support (Lemola et al, 2007). The four primary themes that were identified in the review were:



This means that formal, structured debriefing services should not be offered to women by health visitors, midwives or other professionals. However, women value the space to discuss their experiences (Bailey and Price, 2008). Therefore, services which allow women to talk at their own instigation within a birth listening or similar service may be of benefit, if a formal approach is avoided. There is evidence that a significant cause of a woman perceiving her birth experience as traumatic is the actions of maternity staff, which can result in care being experienced as dehumanising, disrespectful or uncaring (Elmir et al, 2010). Professionals’ manner and communication can significantly affect a woman’s feelings of control during labour (Salter, 2009) and her ability to make informed decisions (Eliasson et al, 2008). While health visitors do not generally attend births, their earlier involvement in the antenatal period offers an opportunity to discuss the planned birth and ensure that the woman has a realistic appraisal of the potential experience of labour and birth, particularly in the case of a first baby, or where there has been a previous traumatic experience. Health visitors, alongside midwives, play an important role in providing information and early referral (if necessary) for those women with high anxiety, previous trauma or unrealistic beliefs about birth. For women who have had a previous traumatic delivery, early identification of tokophobia (fear of childbirth) is crucial so that they can be referred for appropriate support and information during the antenatal period. It is known that choice, information and involvement in decisions are potentially protective against a traumatic birth experience (Goodall et al, 2009). Health visitors are in a position to facilitate communication and enhance the father’s role prior to the delivery experience. As there is evidence that previous trauma is predictive of vulnerability to recurrent trauma (Czarnocka and Slade, 2000), health visitors are well placed to identify women who have previously experienced trauma, either in the perinatal period or more generally, and ensure that these women are identified early as being potentially more vulnerable. In practice, rigorous history-taking, specifically paying attention to past traumatic experiences, psychiatric history, and expectations about the current pregnancy and upcoming birth, may be beneficial (Alcorn et al, 2010). Thorough communication between health professionals and women during and after childbirth should be encouraged (Paul, 2008).


» Health visitors are well placed to identify women who have previously experienced trauma, either in the perinatal period or more generally, and ensure that these women are identified early as being potentially more vulnerable. « How health visitors can support women who are experiencing PTSD following childbirth The Birth Trauma Association (2011) asserts that health visitors play a vital role in identifying the impact of PTSD FC and delineating between PTSD FC and PND. There is considerable overlap in symptoms between PTSD FC and PND, particularly since the publication of DSM–5, which added a fourth cluster of symptoms: negative alterations in cognitions and mood (American Psychiatric Association, 2013). This cluster includes symptoms such as persistent and exaggerated negative beliefs, self-blame, persistent negative emotional state, markedly diminished interest or participation in significant activities, and persistent inability to experience positive emotions—all of which would be recognised as potential symptoms of PND. However, there are unique symptoms of PTSD FC, particularly in the ‘intrusions’ cluster. This details symptoms such as recurrent involuntary and intrusive distressing memories or dreams related to the trauma. Women experiencing PTSD FC would be expected to demonstrate intrusive thoughts or memories of this type, and this may take the form of flashbacks, nightmares or thoughts that the woman feels unable to control. Women are usually discharged from hospital within hours or days of giving birth, but the clinical diagnosis of PTSD requires that women are still experiencing symptoms at least 1 month post-trauma; women may therefore be identified from 1 month onwards (Lapp et al, 2010), and health visitors play a vital role here. This is supported by Ammerman et al (2009), who assert that home visiting provides a unique portal through which mothers can be identified and treated. In the UK context, this identification and treatment may be within the scope of the Healthy Child Programme (Department of Health, 2009), given the possible links to difficulties in the parent–child relationship and the explicit aims of the programme to focus on parent–child attachment and identification of difficulties that

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» PTSD is not well-recognised as a direct consequence of the birth experience, and women with PTSD FC may be incorrectly diagnosed with PND. However, it is equally important not to pathologise or over-medicalise the woman’s experience. « may affect the health and wellbeing of families. Early identification of women experiencing PTSD is critical, but the lack of available tools can make this challenging for health professionals. PTSD is not well-recognised as a direct consequence of the birth experience, and women with PTSD FC may be incorrectly diagnosed with PND. However, it is equally important not to pathologise or over-medicalise the woman’s experience. For instance, Ayers et al (2008) observe that it is normal to experience feelings of hyperarousal after giving birth. Screening for PTSD FC is not common, and the disorder remains largely unrecognised outside specialist perinatal and/or maternity services. The process of screening can raise anxiety and thus it is important to administer screening in an appropriate manner, and ensure that referral routes exist (McKenzie-McHarg et al, 2015). Appropriate measures for PTSD FC which have been validated in the perinatal population are required (Alderdice et al, 2013). However, where these are available they are often not consistently used or applied (Rowan et al, 2010). Screening and detection before and after delivery could be developed to identify women presenting with PTSD symptoms after childbirth (Ayers et al, 2008; Beck and Watson, 2008). Women with PND, and those who show attachment difficulties with their infant, should be followed-up for possible PTSD (Davies et al, 2008). It is also critical to recognise the impact of women experiencing a range of PTSD FC symptoms—even if they do not have a sufficient number or type of symptoms to allow a formal diagnosis to be made by an appropriate health professional—particularly when considering the full range of distress. Many women may not meet full caseness for a diagnosis of PTSD, but clinically their experience may still have a negative impact on their functioning. Given the potential impact of PTSD on women and their families, intervention remains important if there is an impact on distress or functioning (McKenzie-McHarg et al, 2015). In order to facilitate early identification,

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clinical pathways for care referring to PTSD FC must fit within the maternity context to ensure practitioners are informed about PTSD FC and clear about referral and management options. Lack of training in mental health has been identified as a core barrier to addressing issues of perinatal mental illness (Byatt et al, 2012), and training should be available to and accessed by health visitors. Available and accessible care pathways and onward referral are important for confident practitioner identification and assessment. Evidence highlights that midwives, health visitors and obstetricians are reluctant to ask women about psychological issues when pathways are not evident (Jomeen et al, 2009; 2013; Leddy et al, 2011; McKenzie-McHarg et al, 2015). In terms of specific interventions, treatment for PTSD FC requires onward referral to a mental health professional with specific expertise in treating the disorder. For many areas of the country this may mean local mental health services. Wherever possible, treatment should be provided within a perinatal context, by a practitioner with access to the place of birth. This will assist in providing intervention that relies on exposure to the place in which the traumatic event occurred. A critical role for health visitors is in supporting a secure attachment relationship between mothers with PTSD FC and their babies. Although most women with PTSD FC have normal relationships with their babies, the clinical experience of these authors suggests that a small percentage is at risk of becoming either disengaged from their babies or overly intrusive. These women may benefit from referral to an appropriate parent–infant or perinatal attachment services. The Creating Opportunities for Parent Empowerment (COPE) programme aims to educate parents about the possibility of vulnerable child syndrome, with the goal of limiting the development of an overprotective parenting style (Melnyk et al, 2001). Health visitors are also well placed to consider important aspects of safeguarding when mothers with mental health issues are caring for their babies. Cognitive behavioural therapy and eye movement desensitisation and reprocessing (EMDR) are helpful in PTSD following other traumas, and are promising areas requiring more research for PTSD FC (Stramrood et al, 2012). It has also been reported that in terms of adaptation, variables such as social support and coping are likely to be important (Sawyer and Ayers, 2009). Health visitors are well placed to support partners as well as mothers, provide





intervention to support the mother–partner relationship, and identify mothers who are without appropriate personal support.

Conclusion PTSD FC is a significant mental health problem which may be caused by the childbirth experience. It can have detrimental effects on the mother, baby and wider family. Health visitors can play an important role in prevention, identification, support and onward referral of women experiencing PTSD FC. For health visitors to be able to support postnatal women fully following a traumatic birth experience, additional training in postnatal mental health issues—in particular, incorporating information and skillsbased learning on managing and supporting PTSD FC—would be necessary and helpful. There may also be a role for health visitors in supporting pregnant women who have already experienced a traumatic previous birth and ensuring that they have access to appropriate psychological interventions where necessary. Finally, health visitors have a good knowledge of the importance of the parent–infant attachment relationship and have the skills to recognise difficulties where they arise. Health visitors may be able to provide supportive interventions for mothers in this situation, and/or to refer to JHV specialist services as appropriate.


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Key points Post-traumatic stress disorder following childbirth (PTSD FC) is estimated to affect 3–15% of mothers, with more than 7000–21 000 women per year developing PTSD as a direct result of childbirth, and more experiencing symptoms of trauma PTSD FC can cause significant distress to women and can have an impact on future obstetric decisions, the family system, sexual relationships and parent–infant bonding There is limited evidence supporting interventions for preventing PTSD FC; however, the relationship between women and maternity staff is crucial Health visitors could support realistic expectations of childbirth, provide early identification of high-risk mothers with referral to specialist perinatal mental health professionals, develop care pathways, support the parent–infant relationship and support access to social support relationship and parent–baby bond. J Reprod Infant Psychol 25(1): 40–50. doi: 10.1080/02646830601117175 Bailey M, Price S (2008) Exploring women’s experience of a birth afterthoughts service. Evidence Based Midwifery 6(2): 52–8 Bailham D, Joseph S (2003) Post-traumatic stress following childbirth: A review of the emerging literature and directions for research and practice. Psychol Health Med 8(2):159–68. doi: 10.1080/1354850031000087537 Baird K, Kracen A (2006) Vicarious traumatization and secondary traumatic stress: A research synthesis. Couns Psychol Q 19(2): 181–8. doi: 10.1080/09515070600811899 Beck CT, Watson S (2008) Impact of birth trauma on breast-feeding: a tale of two pathways. Nurs Res 57(4): 228–36. doi: 10.1097/01. NNR.0000313494.87282.90 Birth Trauma Association (2011) Post Natal Post Traumatic Stress Disorder. www.birthtraumaassociation.org.uk/publications/post_natal_ptsd.pdf (accessed 23 January 2015) Bradley R, Slade P, Leviston A (2006) Symptoms of post-traumatic stress in men who have attended their partner’s labour and delivery. Presented at Postnatal PTSD Research Seminar. Brighton, UK Bradley R, Slade P, Leviston (2008) Low rates of PTSD in men attending childbirth: a preliminary study. Br J Clin Psychol 47(3): 295–302. doi: 1348/014466508X279495 Byatt N, Biebel K, Lundquist R, Moore Simas TA, Debordes-Jackson G, Allison J, Ziedonis D (2012) Patient, provider, and system-level barriers and facilitators to addressing perinatal depression. J Reprod Infant Psychol 30(5): 436–49. doi: 10.1080/02646838.2012.74300 Cigoli V, Gilli G, Saita E (2006) Relational factors in psychopathological responses to childbirth. J Psychosom Obstet Gynecol 27(2): 91–7. doi: 10.1080/01674820600714566 Creedy DK, Shochet IM, Horsfall J (2000) Childbirth and the development of acute trauma symptoms: incidence and contributing factors. Birth 27(2): 104–11. doi: 10.1046/j.1523-536x.2000.00104.x Czarnocka J, Slade P (2000) Prevalence and predictors of post-traumatic stress symptoms following childbirth. Br J Clin Psychol 39(Pt 1): 35–51. doi: 10.1348/014466500163095 Davies J, Slade P, Wright I, Stewart P (2008) Posttraumatic stress symptoms following childbirth and mothers’ perceptions of their infants. Infant Ment Health J 29(6): 537–54. doi: 10.1002/imhj.20197 Department of Health (2009) Healthy Child Programme: Pregnancy and the first five years of life. Department of Health, London Edworthy Z, Chasey R, Williams H (2008) The role of schema and appraisals in the development of post‐traumatic stress symptoms following birth. J Reprod Infant Psychol 26(2): 123–38. doi: 10.1080/02646830801918422 Eliasson M, Kainz G, von Post I (2008) Uncaring midwives. Nurs Ethics 15(4): 501–11. doi: 10.1177/0969733008090521 Elmir R, Schmied V, Wilkes L, Jackson D (2010) Women’s perceptions and experiences of a traumatic birth: a meta-ethnography. J Adv Nurs 66(10): 2142–53. doi: 10.1111/j.1365-2648.2010.05391.x Fenech G, Thomson G (2014) Tormented by ghosts from their past’: a meta-synthesis to explore the psychosocial implications of a traumatic birth on maternal well-being. Midwifery 30(2): 185–93. doi: 10/1016/j. midw.2013.12.004

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