Childbirth-related posttraumatic stress disorder: definition, risk factors, pathophysiology, diagnosis, prevention, and treatment.

Psychological birth trauma and childbirth-related posttraumatic stress disorder represent a substantial burden of disease with 6.6 million mothers and 1.7 million fathers or co-parents affected by childbirth-related posttraumatic stress disorder worldwide each year. There is mounting evidence to indicate that parents who develop childbirth-related posttraumatic stress disorder do so as a direct consequence of a traumatic childbirth experience. High-risk groups, such as those who experience preterm birth, stillbirth, or preeclampsia, have higher prevalence rates. The main risks include antenatal factors (eg, depression in pregnancy, fear of childbirth, poor health or complications in pregnancy, history of trauma or sexual abuse, or mental health problems), perinatal factors (eg, negative subjective birth experience, operative birth, obstetrical complications, and severe maternal morbidity, as well as maternal near misses, lack of support, dissociation), and postpartum factors (eg, depression, postpartum physical complications, and poor coping and stress). The link between birth events and childbirth-related posttraumatic stress disorder provides a valuable opportunity to prevent traumatic childbirths and childbirth-related posttraumatic stress disorder from occurring in the first place. Childbirth-related posttraumatic stress disorder is an extremely distressing mental disorder and has a substantial negative impact on those who give birth, fathers or co-parents, and, potentially, the whole family. Still, a traumatic childbirth experience and childbirth-related posttraumatic stress disorder remain largely unrecognized in maternity services and are not routinely screened for during pregnancy and the postpartum period. In fact, there are gaps in the evidence on how, when, and who to screen. Similarly, there is a lack of evidence on how best to treat those affected. Primary prevention efforts (eg, screening for antenatal risk factors, use of trauma-informed care) are aimed at preventing a traumatic childbirth experience and childbirth-related posttraumatic stress disorder in the first place by eliminating or reducing risk factors for childbirth-related posttraumatic stress disorder. Secondary prevention approaches (eg, trauma-focused psychological therapies, early psychological interventions) aim to identify those who have had a traumatic childbirth experience and to intervene to prevent the development of childbirth-related posttraumatic stress disorder. Tertiary prevention (eg, trauma-focused cognitive behavioural therapy and eye movement desensitization and reprocessing) seeks to ensure that people with childbirth-related posttraumatic stress disorder are identified and treated to recovery so that childbirth-related posttraumatic stress disorder does not become chronic. Adequate prevention, screening, and intervention could alleviate a considerable amount of suffering in affected families. In light of the available research on the impact of childbirth-related posttraumatic stress disorder on families, it is important to develop and evaluate assessment, prevention, and treatment interventions that target the birthing person, the couple dyad, the parent-infant dyad, and the family as a whole. Further research should focus on the inclusion of couples in different constellations and, more generally, on the inclusion of more diverse populations in diverse settings. The paucity of national and international policy guidance on the prevention, care, and treatment of psychological birth trauma and the lack of formal psychological birth trauma services and training, highlight the need to engage with service managers and policy makers.

Traumatic birth and childbirth-related post-traumatic stress disorder: International expert consensus recommendations for practice, policy, and research.

BACKGROUND: Research suggests 1 in 3 births are experienced as psychologically traumatic and about 4% of women and 1% of their partners develop post-traumatic stress disorder (PTSD) as a result. AIM: To provide expert consensus recommendations for practice, policy, and research and theory. METHOD: Two consultations (n = 65 and n = 43) with an international group of expert researchers and clinicians from 33 countries involved in COST Action CA18211; three meetings with CA18211 group leaders and stakeholders; followed by review and feedback from people with lived experience and CA18211 members (n = 238). FINDINGS: Recommendations for practice include that care for women and birth partners must be given in ways that minimise negative birth experiences. This includes respecting women's rights before, during, and after childbirth; and preventing maltreatment and obstetric violence. Principles of trauma-informed care need to be integrated across maternity settings. Recommendations for policy include that national and international guidelines are needed to increase awareness of perinatal mental health problems, including traumatic birth and childbirth-related PTSD, and outline evidence-based, practical strategies for detection, prevention, and treatment. Recommendations for research and theory include that birth needs to be understood through a neuro-biopsychosocial framework. Longitudinal studies with representative and global samples are warranted; and research on prevention, intervention and cost to society is essential. CONCLUSION: Implementation of these recommendations could potentially reduce traumatic births and childbirth-related PTSD worldwide and improve outcomes for women and families. Recommendations should ideally be incorporated into a comprehensive, holistic approach to mental health support for all involved in the childbirth process.

The perceived impact of birth trauma witnessed by maternity health professionals: A systematic review.

OBJECTIVES: Maternity health professionals (MHPs) caring for women may witness or be involved in traumatic births. This can be associated with MHPs experiencing secondary traumatic stress (STS) or probable post-traumatic stress disorder (PTSD), which may impact MHPs emotionally and physically. The aims of this review were therefore to determine: (i) the prevalence of STS and PTSD in maternity health professionals; and (ii) the impact of witnessing birth trauma on maternity health professionals. METHODS: A mixed-methods systematic review was carried out by conducting literature searches on CINAHL, MEDLINE, PsychARTICLES, PsychINFO and PsychTESTS databases. Searches were conducted from the inception of databases up to February 2022 using search terms on MHPs and birth trauma combined. Methodological quality and bias were assessed. Data were synthesised using thematic synthesis. RESULTS: A total of 18 studies were included in the review. Sample size ranged from 9 to 2,165 (total N = 8,630). Participants included midwives, nurses and obstetricians aged 18-77 years. Many MHPs had witnessed a traumatic birth event (45% - 96.9%) with the prevalence of STS ranging from 12.6%-38.7% and the proportion of participants meeting diagnostic criteria for PTSD ranging from 3.1%-46%. MHPs reported positive and negative effects associated with witnessing traumatic birth events. Synthesis of quantitative and qualitative papers identified five themes: Negative emotions and symptoms; Responsibility and regret; Impact on practice and care; Challenging professional identity; and Team support being essential. DISCUSSION: Witnessing traumatic birth events is associated with profound emotional and physical impacts on MHPs, signifying the importance of acknowledging and addressing this in the maternity workforce. It is important to raise awareness of the impact of birth trauma on MHPs. Effective education and training guidelines, a supervisory network, ways to change practice and policy, and support and treatment should be provided to assist and improve the outcomes and work-life of MHPs' who witness traumatic births.

Postpartum Depressive Symptoms and Experiences During COVID-19.

PURPOSE: To identify postpartum depression risk and describe experiences of women in the first 6 weeks after giving birth during the COVID-19 pandemic. STUDY DESIGN AND METHODS: Using a convergent mixed-methods approach, we recruited a convenience sample of women living in the United States who gave birth March 1, 2020 or later from social media Web sites. Participants completed the Postpartum Depression Screening Scale-Short Form and provided written answers to open-ended questions regarding their experiences at home with their new infant. RESULTS: Our 262 participants were on average 32.6 years of age, the majority were White (82%), married or partnered (91.9%), and college educated (87.4%). Mean postpartum depression score was 17.7 (SD = 5.9) with 75% scoring ≥14, indicating significant postpartum depressive symptoms. Qualitative content analysis revealed five themes: Isolation and seclusion continue; Fear, anxiety, and stress filled the days; Grieving the loss of normal: It's just so sad; Complicated by postpartum depression: A dark time; and There is a silver lining. Quantitative and qualitative findings provided a holistic view of women's depressive symptoms and experiences at home with their infants during the COVID-19 pandemic. CLINICAL IMPLICATIONS: Although policies that reduce risk of COVID-19 exposure and infection for patients and the health care team must continue to be implemented, the adverse effects of depressive symptoms on maternal-infant wellbeing within the context of increased isolation due to the pandemic need to be kept at the forefront. Nurses need to be aware of the consequences of women sheltering in place and social distancing on maternal-infant outcomes, particularly on depression and likelihood of breastfeeding.

"Nobody Listened". Mothers' Experiences and Needs Regarding Professional Support Prior to Their Admission to an Infant Mental Health Day Clinic.

Challenges during the perinatal period can lead to maternal distress, negatively affecting mother-infant interaction. This study aims to retrospectively explore the experiences and needs regarding professional support of mothers with difficulties in mother-infant interaction prior to their admission to an infant mental health day clinic. In-depth semi-structured interviews were conducted with 13 mothers who had accessed an infant mental health day clinic because of persistent severe infant regulatory problems impairing the wellbeing of the infant and the family. Data were transcribed and analyzed using the Qualitative Analysis Guide of Leuven (QUAGOL). Three themes were identified: 'experience of pregnancy, birth, and parenthood'; 'difficult care paths'; and 'needs and their fulfillment'. The first theme consisted of three subthemes: (1) 'reality does not meet expectations', (2) 'resilience under pressure', and (3) 'despair'. Mothers experienced negative feelings that were in contradiction to the expected positive emotions associated with childbirth and motherhood. Resilience-related problems affected the mother-child relationship, and infants' regulatory capacities. Determined to find solutions, different healthcare providers were consulted. Mothers' search for help was complex and communication between healthcare providers was limited because of a fragmented care provision. This hindered the continuity of care and appropriate referrals. Another pitfall was the lack of a broader approach, with the emphasis on the medical aspects without attention to the mother-child dyad. An integrated care pathway focusing on the early detection of resilience-related problems and sufficient social support can be crucial in the prevention and early detection of perinatal and infant mental health problems.

Pregnancy related risk perception in pregnant women, midwives & doctors: a cross-sectional survey.

BACKGROUND: Risk perception in relation to pregnancy and birth is a complex process influenced by multiple personal, psychological and societal factors. Traditionally, the risk perception of healthcare professionals has been presented as more objective and authoritative than that of pregnant women. Doctors have been presented as more concerned with biomedical risk than midwives. Such dichotomies oversimplify and obscure the complexity of the process. This study examines pregnancy-related risk perception in women and healthcare professionals, and what women and professionals believe about each other's risk perception. METHODS: A cross sectional survey of set in UK maternity services. Participants were doctors working in obstetrics (N = 53), midwives (N = 59), pregnant women (N = 68). Participants were recruited in person from two hospitals. Doctors were also recruited online. Participants completed a questionnaire measuring the degree of perceived risk in various childbirth-related scenarios; and the extent to which they believed others agreed with them about the degree of risk generally involved in childbirth. Main outcome measures were the degree of risk perceived to the mother in baby in pregnancy scenarios, and beliefs about own perception of risk in comparison to their own group and other groups. RESULTS: There were significant differences in total risk scores between pregnant women, doctors and midwives in perception of risk to the mother in 68/80 scenarios. Doctors most frequently rated risks lowest. Total scores for perceived risk to the baby were not significantly different. There was substantial variation within each group. There was more agreement on the ranking of scenarios according to risk. Each group believed doctors perceived most risk whereas actually doctors most frequently rated risks lowest. Each group incorrectly believed their peers rated risk similarly to themselves. CONCLUSIONS: Individuals cannot assume others share their perception of risk or that they make correct assessments regarding others' risk perception. Further research should consider what factors are taken into account when making risk assessments.

A postgraduate Optimum Birth module to increase midwives' readiness to work in midwifery-led settings: A mixed-methods evaluation.

BACKGROUND: Midwifery-led birth settings have been recommended as the most cost-effective birthplaces for healthy women experiencing uncomplicated pregnancies. However, midwives complete most of their training in obstetric units where birth interventions are common. To prepare for working in a midwifery-led setting training is a key priority. This study evaluated a postgraduate-level midwifery module on Optimum Birth (defined as birth which supports physiology and empowerment, avoiding unnecessary intervention) designed to prepare midwives for supporting women in midwifery-led settings. METHODS: A mixed-methods design was employed. Pre-module and post-module questionnaires measured attitudes, knowledge, confidence, and learning outcomes. Qualitative data collection included a final-day focus group and 8- to 10-week follow-up interviews. The target for recruitment was 15 postgraduate midwives. Fifteen midwives practicing in three London boroughs enrolled of whom 14 completed the module. Pre-total and post-total scores were analyzed with paired-sample t tests. Qualitative data were analyzed using thematic analysis. RESULTS: Quantitative and qualitative data indicated that the module increased participants' self-reported skills, knowledge, and confidence in practicing Optimum Birth. Qualitative data indicated ways in which midwives were implementing changes to promote Optimum Birth in their place of work. Attitudes were highly positive pre-module and post-module. CONCLUSIONS: The Optimum Birth module provided appropriate training for preparing midwives for the shift toward working in midwifery-led settings. Midwifery leaders and managers should implement strategies to develop midwives' philosophy, knowledge, and skills to increase their readiness to work in midwifery-led birth settings.

Feasibility and Acceptability of a Web-Based Treatment with Telephone Support for Postpartum Women With Anxiety: Randomized Controlled Trial.

BACKGROUND: Postpartum anxiety can have adverse effects on the mother and child if left untreated. Time constraints and stigma are common barriers to postpartum treatment. Web-based treatments offer potential flexibility and anonymity. What Am I Worried About (WaWa) is a self-guided treatment based on cognitive-behavioral and mindfulness principles for women experiencing postpartum anxiety. WaWa was developed in Australia and consists of 9 modules with optional weekly telephone support. WaWa was adapted to a Web-based version for use in England (Internet-based What Am I Worried About, iWaWa). OBJECTIVE: This study aimed to investigate the feasibility (engagement and usability) and acceptability (usefulness, satisfaction, and helpfulness) of iWaWa among English postpartum women with anxiety. METHODS: Postpartum (<12 months) women with mild-to-severe anxiety were recruited anonymously via social media during an 8-week period. Participants were randomized to the iWaWa treatment (8 weeks) or wait-list control group. Treatment and study feasibility and acceptability were assessed after the treatment, and anxiety symptoms were assessed at baseline, 8 weeks postrandomization, and 12 weeks postrandomization (treatment group only) using Web-based questionnaires. Semistructured telephone interviews were carried out after the treatment period for a more in-depth exploration of treatment acceptability and feasibility. RESULTS: A total of 89 eligible women were recruited through social media and randomized into the treatment (n=46) or wait-list control group (n=43). Women were predominantly Caucasian, well-educated, married, on maternity leave, first-time mothers and reported moderate levels of anxiety. Dropout rates were high, especially in the treatment group (treatment: 82%, 38/46; wait-list control: 51%, 22/43). A total of 26 women started iWaWa with only 2 women completing all 9 modules. Quantitative and qualitative data suggest iWaWa was experienced as generally useful and helpful. Participants enjoyed iWaWa's accessibility, anonymity, and weekly reminders, as well as the introduction to the principles of cognitive-behavioral therapy (CBT) and mindfulness. However, iWaWa was also experienced as not user-friendly enough, too long, and not smartphone-friendly. Parts of the content were experienced as not always relevant and appropriate. Participants felt that iWaWa could be improved by having it in a smartphone app format and by making the content more concise and inclusive of different parenting styles. CONCLUSIONS: Despite interest in iWaWa, the results suggest that both the study and iWaWa were not feasible in the current format. However, this first trial provides useful evidence about treatment format and content preferences that can inform iWaWa's future development, as well as research and development of Web-based postpartum anxiety treatments, in general, to optimize adherence. TRIAL REGISTRATION: ClinicalTrials.gov NCT02434406; https://clinicaltrials.gov/ct2/show/NCT02434406 (Archived by WebCite at http://www.webcitation.org/6xTq7Bwmd).

How women with high risk pregnancies perceive interactions with healthcare professionals when discussing place of birth: A qualitative study.

OBJECTIVES: to investigate women's perceptions of interactions with obstetricians and midwives during high risk pregnancies. The intention was to examine differences and similarities between women planning to give birth at home or in hospital. DESIGN: qualitative study using semi-structured interviews. Setting Maternity department in a hospital in South East England. PARTICIPANTS: twenty-six women with high risk pregnancies, at least 32 weeks pregnant. Half were planning hospital births and half homebirths. MEASUREMENTS AND FINDINGS: semi-structured interviews to investigate women's perception of communication. Results were analysed using thematic analysis. Four themes emerged: women's experiences of communication about risks in pregnancy; women's perceptions of professionals' beliefs about birth; women's trust in professionals; and women's attitude to professionals' advice. Women spoke more positively about communication with midwives than with obstetricians. Women planning hospital births expressed trust in obstetricians. Women planning homebirths expressed more trust in midwives. Women planning hospital births were less likely to question advice from professionals. Women planning homebirths were more inclined to trust their own instincts when these contradicted professional advice. KEY CONCLUSIONS: women prefer to communicate with professionals who are respectful of their thoughts and feelings. They may not follow all professional advice. IMPLICATIONS FOR PRACTICE: professionals working with women with high risk pregnancies should acknowledge women's concerns and deliver impartial, evidence-based advice.

Cognitive behaviour therapy for postnatal post-traumatic stress disorder: case studies.

Background. Approximately 1-2% of women suffer from postnatal post-traumatic stress disorder (PTSD) with wide ranging consequences for these women and their families 1. Appropriate treatment of women who have difficult or traumatic births is not yet established. Evidence in other populations shows that cognitive behavior therapy (CBT) is effective for PTSD and it is therefore the recommended treatment 2. However, a recent review of treatments for postnatal distress concluded that descriptions of postnatal counseling are largely generalized and non-specific, which makes them difficult to assess or replicate 3. Aims and method. The current paper therefore aims to describe the use of CBT interventions to treat postnatal distress, and to illustrate common themes or issues that occur in postnatal PTSD. This paper reports two case studies of women with postnatal PTSD and their treatment using CBT. Conclusions. In these cases, CBT was an effective treatment for postnatal PTSD. A number of implications are explored for the management of pregnancy and labor.