Assessment of perinatal anxiety: diagnostic accuracy of five measures.

BACKGROUND: Anxiety in pregnancy and after giving birth (the perinatal period) is highly prevalent but under-recognised. Robust methods of assessing perinatal anxiety are essential for services to identify and treat women appropriately. AIMS: To determine which assessment measures are most psychometrically robust and effective at identifying women with perinatal anxiety (primary objective) and depression (secondary objective). METHOD: We conducted a prospective longitudinal cohort study of 2243 women who completed five measures of anxiety and depression (Generalized Anxiety Disorder scale (GAD) two- and seven-item versions; Whooley questions; Clinical Outcomes in Routine Evaluation (CORE-10); and Stirling Antenatal Anxiety Scale (SAAS)) during pregnancy (15 weeks, 22 weeks and 31 weeks) and after birth (6 weeks). To assess diagnostic accuracy a sample of 403 participants completed modules of the Mini-International Neuropsychiatric Interview (MINI). RESULTS: The best diagnostic accuracy for anxiety was shown by the CORE-10 and SAAS. The best diagnostic accuracy for depression was shown by the CORE-10, SAAS and Whooley questions, although the SAAS had lower specificity. The same cut-off scores for each measure were optimal for identifying anxiety or depression (SAAS ≥9; CORE-10 ≥9; Whooley ≥1). All measures were psychometrically robust, with good internal consistency, convergent validity and unidimensional factor structure. CONCLUSIONS: This study identified robust and effective methods of assessing perinatal anxiety and depression. We recommend using the CORE-10 or SAAS to assess perinatal anxiety and the CORE-10 or Whooley questions to assess depression. The GAD-2 and GAD-7 did not perform as well as other measures and optimal cut-offs were lower than currently recommended.

Single-session visuospatial task procedure to prevent childbirth-related posttraumatic stress disorder: a multicentre double-blind randomised controlled trial.

Preventive evidence-based interventions for childbirth-related posttraumatic stress disorder (CB-PTSD) are lacking. Yet, 18.5% of women develop CB-PTSD symptoms following an unplanned caesarean section (UCS). This two-arm, multicentre, double-blind superiority trial tested the efficacy of an early single-session intervention including a visuospatial task on the prevention of maternal CB-PTSD symptoms. The intervention was delivered by trained maternity clinicians. Shortly after UCS, women were included if they gave birth to a live baby, provided consent, and perceived their childbirth as traumatic. Participants were randomly assigned to the intervention or attention-placebo group (allocation ratio 1:1). Assessments were done at birth, six weeks, and six months postpartum. Group differences in maternal CB-PTSD symptoms at six weeks (primary outcomes) and six months postpartum (secondary outcomes) were assessed with the self-report PTSD Checklist for DSM-5 (PCL-5) and by blinded research assessors with the Clinician-administered PTSD scale for DSM-5 (CAPS-5). Analysis was by intention-to-treat. The trial was prospectively registered (ClinicalTrials.gov, NCT03576586). Of the 2068 women assessed for eligibility, 166 were eligible and 146 were randomly assigned to the intervention (n = 74) or attention-placebo control group (n = 72). For the PCL-5, at six weeks, a marginally significant intervention effect was found on the total PCL-5 PTSD symptom count (ß = -0.43, S.E. = 0.23, z = -1.88, p < 0.06), and on the intrusions (ß = -0.73, S.E. = 0.38, z = -1.94, p < 0.0525) and arousal (ß = -0.55, S.E. = 0.29, z = -1.92, p < 0.0552) clusters. At six months, a significant intervention effect on the total PCL-5 PTSD symptom count (ß = -0.65, S.E. = 0.32, z = -2.04, p = 0.041, 95%CI[-1.27, -0.03]), on alterations in cognition and mood (ß = -0.85, S.E. = 0.27, z = -3.15, p = 0.0016) and arousal (ß = -0.56, S.E. = 0.26, z = -2.19, p < 0.0289, 95%CI[-1.07, -0.06]) clusters appeared. No group differences on the CAPS-5 emerged. Results provide evidence that this brief, single-session intervention carried out by trained clinicians can prevent the development of CB-PTSD symptoms up to six months postpartum.

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.

The influence of antenatal imaging on prenatal bonding in uncomplicated pregnancies: a mixed methods analysis.

BACKGROUND: Prenatal bonding describes the emotional connection expectant parents form to their unborn child. Research acknowledges the association between antenatal imaging and enhanced bonding, but the influencing factors are not well understood, particularly for fathers or when using advanced techniques like fetal magnetic resonance imaging (MRI). This study aimed to identify variables which may predict increased bonding after imaging. METHODS: First-time expectant parents (mothers = 58, fathers = 18) completed a two-part questionnaire (QualtricsXM™) about their expectations and experiences of ultrasound (n = 64) or fetal MRI (n = 12) scans in uncomplicated pregnancies. A modified version of the Prenatal Attachment Inventory (PAI) was used to measure bonding. Qualitative data were collected through open-ended questions. Multivariate linear regression models were used to identify significant parent and imaging predictors for bonding. Qualitative content analysis of free-text responses was conducted to further understand the predictors' influences. RESULTS: Bonding scores were significantly increased after imaging for mothers and fathers (p < 0.05). MRI-parents reported significantly higher bonding than ultrasound-parents (p = 0.02). In the first regression model of parent factors (adjusted R2 = 0.17, F = 2.88, p < 0.01), employment status (ß = -0.38, p < 0.05) was a significant predictor for bonding post-imaging. The second model of imaging factors (adjusted R2 = 0.19, F = 3.85, p < 0.01) showed imaging modality (ß = -0.53), imaging experience (ß = 0.42) and parental excitement after the scan (ß = 0.29) were significantly (p < 0.05) associated with increased bonding. Seventeen coded themes were generated from the qualitative content analysis, describing how scans offered reassurance about fetal wellbeing and the opportunity to connect with the baby through quality interactions with imaging professionals. A positive scan experience helped parents to feel excited about parenthood. Fetal MRI was considered a superior modality to ultrasound. CONCLUSIONS: Antenatal imaging provides reassurance of fetal development which affirms parents' emotional investment in the pregnancy and supports the growing connection. Imaging professionals are uniquely positioned to provide parent-centred experiences which may enhance parental excitement and facilitate bonding.

Changes to women's childbirth plans during the COVID-19 pandemic and posttraumatic stress symptoms: a cross-national study.

A considerable number of women giving birth during COVID-19 pandemic reported being concerned about changes to their childbirth plans and experiences due to imposed restrictions. Research prior to the pandemic suggests that women may be more at risk of post-traumatic stress symptoms (PTSS) due to unmet expectations of their childbirth plans. Therefore, this study aimed to examine if the mismatch between women's planned birth and actual birth experiences during COVID-19 was associated with women's postpartum PTSS. Women in the postpartum period (up to 6 months after birth) across 11 countries reported on childbirth experiences, mental health, COVID-19-related factors, and PTSS (PTSD checklist DSM-5 version) using self-report questionnaires (ClinicalTrials.gov: NCT04595123). More than half (64%) of the 3532 postpartum women included in the analysis reported changes to their childbirth plans. All changes were significantly associated with PTSS scores. Participants with one and two changes to their childbirth plans had a 12% and 38% increase, respectively, in PTSS scores compared to those with no changes (Exp(ß) = 1.12; 95% CI [1.06-1.19]; p < 0.001 and Exp(ß) = 1.38; 95% CI [1.29-1.48]; p < 0.001). In addition, the effect of having one change in the childbirth plan on PTSS scores was stronger in primigravida than in multigravida (Exp(ß) = 0.86; 95% CI [0.77-0.97]; p = 0.014). Changes to women's childbirth plans during the COVID-19 pandemic were common and associated with women's postpartum PTSS score. Developing health policies that protect women from the negative consequences of unexpected or unintended birth experiences is important for perinatal mental health.

The impact of antenatal imaging on parent experience and prenatal attachment: a systematic review.

INTRODUCTION: Medical imaging in pregnancy (antenatal imaging) is routine. However, the effect of seeing fetal images on the parent-fetal relationship is not well understood, particularly for fathers or partners, or when using advanced imaging technologies. This review aimed to explore how parent experience and prenatal attachment is impacted by antenatal imaging. METHOD: Database searches were performed between September 2020 and April 2021 Inclusion criteria were English language primary research studies published since 2000, describing or reporting measures of attachment after antenatal imaging in expectant parents. The Pillar Integration Process was used for integrative synthesis. FINDINGS: Twenty-three studies were included. Six pillar themes were developed: 1) the scan experience begins before the scan appointment; 2) the scan as a pregnancy ritual; 3) feeling actively involved in the scan; 4) parents' priorities for knowledge and understanding of the scan change during pregnancy; 5) the importance of the parent-sonographer partnership during scanning; and 6) scans help to create a social identity for the unborn baby. CONCLUSION: Antenatal imaging can enhance prenatal attachment. Parents value working collaboratively with sonographers to be actively involved in the experience. Sonographers can help facilitate attachment by delivering parent-centred care tailored to parents' emotional and knowledge needs.

Community-based perinatal mental health peer support: a realist review.

BACKGROUND: Peer support has been suggested as an alternative or complement to professional support for mothers with perinatal mental health difficulties. The aim of this realist review was to synthesise the evidence on perinatal mental health peer support programmes outside mental health services, to understand what is it about community-based perinatal mental health peer support that works, for whom, in what circumstances, in what respects, and why. METHODS: Applying realist methodology, an initial theoretical model was tested against evidence from empirical studies. 29 empirical studies were included, covering 22 antenatal and postnatal mental health interventions that offered one-to-one or group peer support, in person or by telephone. Data extraction identified the configurations of contexts (C), mechanisms (M) and outcomes (O) relevant to mothers' use of peer support and to the positive and negative effects of using peer support. RESULTS: 13 C-M-O configurations explained take-up of peer support. These were based on mothers' perceptions that peer support would offer empathetic understanding and non-judgemental acceptance outside their social circle; their relationships with primary health professionals; their cultural background and perspectives on mental health; their desire for professional support; overcoming practical barriers; the format of the support; and the use of volunteers. A further 13 C-M-O configurations explained positive impact on mothers. These were based on receiving empathetic listening, acceptance, affirmation and normalisation; peers sharing ideas about self-care, coping, and services; peers using therapeutic techniques; the opportunity to give support to others; meaningful social relationships with volunteers and other mothers; and other benefits of attending a group. There were 8 C-M-O configurations explaining negative impact. These were based on lack of validation; self-criticism from downward and upward social comparison; a culture of negativity; peers being judgemental or directive; not feeling heard; peer support as a stressful social relationship; and distress at endings. CONCLUSIONS: Peer support works in complex ways that are affected by personal and social contexts. Providers, commissioners and evaluators can use this review to understand and maximise the valuable benefits of peer support, to minimise potential risks, and to devise ways of reaching mothers who do not currently engage with it.

The acceptability and feasibility of a randomised trial exploring approaches to managing impacted fetal head during emergency caesarean section: a qualitative study.

BACKGROUND: Caesarean sections (CS) account for 26% of all births in the UK, of which at least 5% are done at full dilatation, in the second stage of labour. Second stage CS may be complicated by the fetal head being deeply impacted in the maternal pelvis, requiring specialist skills to achieve a safe birth. Numerous techniques are used to manage impacted fetal head, however, there are no national clinical guidelines in the UK. AIM: To explore health professionals' and women's views on the acceptability and feasibility of a randomised controlled trial (RCT) designed to explore approaches to managing an impacted fetal head during emergency CS. METHODS: Semi-structured interviews with 10 obstetricians and 16 women (6 pregnant and 10 who experienced an emergency second stage CS). Interviews were transcribed and analysed using systematic thematic analysis. RESULTS: The findings considered the time at which you obtain consent, how and when information about the RCT is presented, and barriers and facilitators to recruiting health professionals and women into the RCT. Obstetricians emphasised the importance of training in the techniques, as well as the potential conflict between the RCT protocol and current site or individual practices. Women said they would trust health professionals' to use the most appropriate technique and abandon the RCT protocol if necessary. Similarly, obstetricians raised the tension between the RCT protocol versus safety in reverting to what they knew under emergency situations. Both groups reflected on how this might affect the authenticity of the results. A range of important maternal, infant and clinical outcomes were raised by women and obstetricians. However, there were varying views on which of the two RCT designs presented to participants would be preferred. Most participants thought the RCT would be feasible and acceptable. CONCLUSIONS: This study suggests an RCT designed to evaluate different techniques for managing an impacted fetal head would be feasible and acceptable. However, it also identified a number of challenges that need to be considered when designing such an RCT. Results can be used to inform the design of RCTs in this area.

Women's knowledge of and attitudes towards group B streptococcus (GBS) testing in pregnancy: a qualitative study.

BACKGROUND: 20-25% pregnant women in the UK carry group B streptococcus (GBS) which, if left undetected, is transmitted from pregnant mothers to their babies during birth in 36% of cases. This transmission leads to early onset GBS infection (EOGBS) in 1% of babies which is a significant cause of mortality and morbidity in newborns. The literature available suggests women's knowledge of GBS is low, with many women unaware of the GBS bacterium. In addition, attitudes towards GBS testing have not been widely examined, with research mostly focusing on attitudes towards potential GBS vaccination. AIM: To examine women's knowledge of GBS in pregnancy and their attitudes towards GBS testing. METHODS: Semi-structured interviews with 19 women (5 pregnant and 14 postpartum). Interviews were transcribed and analysed using systematic thematic analysis. RESULTS: Four main theme categories were identified. Participants had varying levels of awareness of GBS, with the information provided by health professionals not being clearly explained or the importance of GBS being downplayed. Participants wanted more information and to feel informed. Overall, the majority had positive attitudes towards being offered and taking up GBS testing, and this study identified some of the key factors influencing their decision. These included: seeing GBS testing as just another routine procedure during pregnancy; that it would lower the risk of their baby becoming unwell; provide reassurance; and allow them to prepare; and provide informed choices. Participants also expressed a few common concerns about GBS testing: questioning the invasiveness of the procedure; risks to themselves and the baby; and the risk of receiving antibiotics. CONCLUSIONS: Women need clear, detailed information about GBS and GBS testing, and women's concerns are important to address if routine GBS testing is implemented. The efficacy of implementing routine universal testing in the UK is currently being investigated in a large multi-centre clinical trial; the GBS3trial, further qualitative research is needed to look at the acceptability of different methods of GBS testing, as well as the acceptability of GBS testing to women in specific groups, such as those planning a home birth or those from different ethnic backgrounds.

Exploring interprofessional collaboration during the implementation of a parent-infant mental health service: A qualitative study.

We examined interprofessional working in a newly implemented parent-infant mental health service team supporting families experiencing bonding and attachment difficulties. The aim was to identify forms of interprofessional work undertaken, barriers and facilitators of this work, and families' and healthcare professionals' perceptions of it. Semi-structured interviews were carried out with 21 stakeholders (5 parents, 4 team clinicians, 9 service referrers, 3 service commissioners) and were analyzed thematically. Interprofessional activities identified included building the service team's cohesion and shared practice, building partner networks, interagency communication, coordination of roles, and raising awareness of infant mental health and parent-infant relationship needs. Enablers and barriers to interprofessional working were broadly consistent with findings from previous studies of related services, but with additional emphasis on consultative work as an enabler. Healthcare professionals reported benefiting from the case consultations and training on infant mental health provided by the service team. Parents reported that good interprofessional working enhanced satisfaction and engagement with the service. Findings indicate the centrality of interprofessional working for parent-infant mental health teams, with implications for future service implementation, service development, and understanding of mechanisms by which such services may influence family outcomes.

Two are better than one? The impact of lay birth companions on childbirth experiences and PTSD.

Although continuous support during childbirth is recommended by the World Health Organization (WHO) and has well-established benefits, the practice is still not routinely implemented in all maternity settings. We studied the possible effect of an additional lay companion (other than the partner) on childbirth experience and postpartum post-traumatic stress disorder (PTSD). Two hundred and forty-six women, who gave birth in maternity wards of a large tertiary health center in Israel, responded to questionnaires in person at 1-4 days (Demographic questions and the childbirth experience questionnaire) and on-line at 8-10 weeks postpartum (City Birth Trauma Scale). Obstetric data were taken from the medical files. Women who were accompanied by their partners and an additional companion were lower in birth-related PTSD symptoms (M = 1.17, SD = 2.61) than women accompanied by only their partner (M = 1.53, SD = 2.79) (F(2, 240) = 4.0, p < 0.05). Women who had a single companion (M = 1.44, SD = 2.61) showed more birth-related PTSD symptoms than women who had two or more companions (M = 1.17, SD = 2.52) (F(1, 241) = 6.4, p < 0.05). In addition, women who had a single companion were higher in general PTSD symptoms (M = 3.91, SD = 4.73) than women who had two or more companions (M = 2.31, SD = 4.29) (F(1, 241) = 4.2, p < 0.05). No differences were found in childbirth experiences of women with single or multiple companions. Allowing more than one lay companion (other than the partner) may be a simple cost-effective way of providing beneficial support in all birth settings, promoting respectful maternity care and reducing childbirth-related PTSD levels and by that future psychopathology sequela.

Health-care practitioners' assessment and observations of birth trauma in mothers and partners.

BACKGROUND: Evidence shows that traumatic childbirth can cause ongoing distress, often referred to as birth trauma. This can have an impact on parents and the couple relationship, and consequently identifying and supporting parents with birth trauma is important to practice. AIM: To investigate the experiences of health-care practitioners from the United Kingdom (UK) in assessment for birth trauma, perceived occurrence of birth trauma and observed impact on parents and the couple relationship. METHODS: An online survey of UK health-care practitioners working with parents in the first postnatal year. RESULTS: A sample of 202 practitioners reported identifying birth trauma in 34.4% of mothers and 25.0% of partners. Assessment for birth trauma was only conducted for 50.3% of mothers and 25.9% of partners. The most observed symptoms were re-experiencing among mothers (87.1%) and avoidance among partners (50.9%). Birth trauma was perceived as impacting on the couple relationship for 29.8% of mothers and 26.9% of partners. Written responses provided more detailed observations of the impact of birth trauma. CONCLUSION: Understanding how birth trauma may present differently in mothers and partners could support effective assessment. Once birth trauma is identified, parents require personalised support to help them cope with the impact.

The acceptability to women of techniques for managing an impacted fetal head at caesarean section and of randomised trials evaluating those techniques: a qualitative study.

BACKGROUND: This study aimed to explore women's views on the acceptability of different techniques for managing an impacted fetal head at caesarean; and the feasibility and acceptability of conducting a trial in this area. METHODS: Qualitative semi-structured interviews with a systematic sample of women who experienced second stage emergency caesarean section at a tertiary National Health Service (NHS) hospital in England, UK. Thematic analysis was used to extract women's views. RESULTS: Women varied in their perceptions of the acceptability of different techniques for managing impacted fetal head. Trust in medical expertise and prioritising the safety of the baby were important contextual factors. Greater consensus was found around informed choice in trials where subthemes considered the timing of invitation, reduced capacity to give consent in emergency situations, and the importance of birth outcomes and having good rapport with healthcare professionals who invite women into trials. Finally, women reflected on the importance of supportive antenatal and postpartum education for impacted fetal head. CONCLUSIONS: This research provides information on the acceptability of techniques and any trial to evaluate these techniques. Findings illustrate the importance of context and quality of care to both acceptability and approaching women to take part in a future trial.

When birth is not as expected: a systematic review of the impact of a mismatch between expectations and experiences.

BACKGROUND: Pregnancy and childbirth are significant events in women's lives and most women have expectations or plans for how they hope their labour and birth will go. It is possible that strong expectations about labour and birth lead to dissatisfaction or other negative outcomes if these expectations are not met, but it is not clear if this is the case. The aim was therefore to synthesise prospective studies in order to understand whether unmet birth expectations are associated with adverse outcomes for women, their partners and their infants. METHOD: Searches were carried out in Academic Search Complete; CINAHL; Medline; PsycINFO, PsychArticles, PubMed, SCOPUS and Web of Science. Forward and backward searches were also completed. Studies were included if they reported prospective empirical research that examined the association between a mismatch in birth expectations/experience and postnatal outcomes in women, their children and/or their partners. Data were synthesised qualitatively using a narrative approach where study characteristics, context and methodological quality were extracted and summarised and then the differences and similarities among studies were used to draw conclusions. RESULTS: Eleven quantitative studies were identified for inclusion from nine countries. A mismatch between birth expectations and experiences was associated with reduced birth satisfaction. Three studies found a link between a mismatch and the development of postnatal post-traumatic stress disorder (PTSD). The evidence was inconsistent for postnatal depression, and fear of childbirth. Only one study looked at physical outcomes in the form of health-related quality of life. CONCLUSIONS: A mismatch between birth expectations and experiences is associated with birth satisfaction and it may increase the risk of developing postnatal PTSD. However, it is not clear whether a mismatch is associated with other postnatal mental health conditions. Further prospective research is needed to examine gaps in knowledge and provide standardised methods of measuring childbirth expectations-experiences mismatch. To ensure women's expectations are met, and therefore experience a satisfying birth experience, maternity providers should provide sensitive care, which acknowledges women's needs and preferences, is based on open and clear communication, is delivered as early in pregnancy as possible, and enables women to make their own decisions about care. TRIAL REGISTRATION: Protocol registration: PROSPERO CRD42020191081 .

Posttraumatic stress symptoms following childbirth: associations with prenatal attachment in subsequent pregnancies.

This longitudinal population-based study aimed to investigate the prospective relationship between PTSD symptoms following childbirth and prenatal attachment in the subsequent pregnancy. Data were derived from the Norwegian Akershus Birth Cohort (ABC), a large population-based prospective cohort study. Data from 1473 women who had given birth at least once before and who had completed questionnaires at 17 and 32 weeks of gestation were included. Confirmatory factor analysis of the short version of the Prenatal Attachment Inventory was conducted to validate the scale. Further, structural equation modeling techniques were used to estimate prospective associations of PTSD symptoms following childbirth with prenatal attachment. Finally, to explore potential mechanisms of the association, mediation and moderation analyses were conducted. PTSD symptoms following previous childbirth were found to be prospectively related to higher levels of prenatal attachment in the subsequent pregnancy, while controlling for important confounding factors, such as symptoms of maternal depression and anxiety, previous pregnancy loss, and sociodemographic factors (maternal age, educational level, marital status, and number of children). When fear of childbirth was included as a potential mediating variable, the prospective relationship between PTSD symptoms following childbirth and prenatal attachment in the subsequent pregnancy increased, thereby indicating a suppressor effect. Fear of childbirth did not act as a significant moderator. Our findings suggest that a subsequent pregnancy following a traumatic childbirth may for some women represent an opportunity for a higher level of prenatal attachment, whereas high levels of fear of childbirth may be detrimental for prenatal attachment.

Evaluation of the CORE-10 to assess psychological distress in pregnancy.

BACKGROUND: Women experience diverse symptoms of mental ill-health in pregnancy, yet measures usually only assess depression or anxiety. Measures may, therefore, miss out on identifying women experiencing distress. OBJECTIVE: We aimed to examine the validity and reliability of the CORE-10: a short measure with broad coverage of symptoms of distress and associated functioning, in pregnant women. METHODS: 366 women 26-38 weeks pregnant completed online measures of distress (CORE-10), depression (Whooley questions), anxiety (Generalised Anxiety Disorder-2), and a single item measuring worry about psychological health. We examined convergent and factorial validity and concordance rates of the measures. RESULTS: Levels of distress were high, with anxiety the most reported symptom. The CORE-10 showed good convergent validity. A two-factor structure representing 'symptoms' and 'ways of coping' best fit this sample. Internal reliability of the symptoms' factor was good. DISCUSSION: The self-selected online sample may not be representative of pregnant women in the third trimester and a diagnostic interview was not used. Based on this validation study, the CORE-10 potentially offers an assessment of a broad range of symptoms of postnatal distress within the confines of a measure brief enough to be usable in clinical settings. Further validation is needed.

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.

Cord pilot trial, comparing alternative policies for timing of cord clamping before 32 weeks gestation: follow-up for women up to one year.

BACKGROUND: The Cord Pilot Trial compared two alternative policies for cord clamping at very preterm birth at eight UK maternity units: clamping after at least 2 min and immediate neonatal care (if needed) with cord intact, or clamping within 20 s and neonatal care after clamping. This paper reports follow-up of the women by two self-completed questionnaires up to one year after the birth. METHODS: Women were given or posted the first questionnaire between four and eight weeks after birth, usually before their baby was discharged, and were posted a second similar questionnaire at one year. The questionnaire included the Hospital Anxiety and Depression Scale; the Preterm Birth Experience and Satisfaction Scale (P-BESS) and questions about their baby's feeding. RESULTS: Of 261 women randomised (132 clamping ≥2 min, 129 clamping ≤20 s), six were excluded as birth was after 35+ 6 weeks (2, 4 in each group respectively). Six were not sent either questionnaire. The first questionnaire was given/sent to 244 and returned by 186 (76%) (79, 74%). The second, at one year, was sent to 242 and returned by 133 (55%) (66, 43%). On the first questionnaire, 89 (49%) had a score suggestive of an anxiety disorder, and 55 (30%) had a score suggestive of depression. Satisfaction with care at birth was high: median total P-BESS score 77 [interquartile range 68 to 84] (scale 17 to 85). There was no clear difference in anxiety, depression, or satisfaction with care between the two allocated groups. The median number of weeks after birth women breastfed/expressed was 16 (95% confidence interval (CI) 13 to 20, n = 119) for those allocated clamping ≥2 min and 12 (95% CI 11 to 16, n = 103) for those allocated clamping ≤20 s. CONCLUSIONS: The response rate was higher for the earlier questionnaire than at one year. A high proportion of women reported symptoms of anxiety or depression, however there were no clear differences between the allocated groups. Most women reported that they had breastfed or expressed milk and those allocated deferred cord clamping reported continuing this for slightly longer. TRIAL REGISTRATION: ISRCTN 21456601, registered 28th February 2013, http://www.isrctn.com/ISRCTN21456601.

No straight lines - young women's perceptions of their mental health and wellbeing during and after pregnancy: a systematic review and meta-ethnography.

BACKGROUND: Young mothers face mental health challenges during and after pregnancy including increased rates of depression compared to older mothers. While the prevention of teenage pregnancy in countries such as the United States and the United Kingdom has been a focus for policy and research in recent decades, the need to understand young women's own experiences has been highlighted. The aim of this meta-ethnography was to examine young women's perceptions of their mental health and wellbeing during and after pregnancy to provide new understandings of those experiences. METHODS: A systematic review and meta-ethnographic synthesis of qualitative research was conducted. Seven databases were systematically searched and forward and backward searching conducted. Papers were included if they were from Organisation for Economic Co-operation and Development countries and explored mental health and wellbeing experiences of young mothers (age under 20 in pregnancy; under 25 at time of research) as a primary research question - or where evidence about mental health and wellbeing from participants was foregrounded. Nineteen papers were identified and the Critical Appraisal Skills Programme checklist for qualitative research used to appraise the evidence. Following the seven-step process of meta-ethnography, key constructs were examined within each study and then translated into one another. RESULTS: Seven translated themes were identified forming a new line of argument wherein mental health and wellbeing was analysed as relating to individual bodily experiences; tied into past and present relationships; underpinned by economic insecurity and entangled with feelings of societal surveillance. There were 'no straight lines' in young women's experiences, which were more complex than dominant narratives around overcoming adversity suggest. CONCLUSIONS: The synthesis concludes that health and social care professionals need to reflect on the operation of power and stigma in young women's lives and its impact on wellbeing. It adds to understanding of young women's mental health and wellbeing during and after pregnancy as located in physical and structural factors rather than individual capacities alone.

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.