The aetiology of post-traumatic stress following childbirth: a meta-analysis and theoretical framework.

There is evidence that 3.17% of women report post-traumatic stress disorder (PTSD) after childbirth. This meta-analysis synthesizes research on vulnerability and risk factors for birth-related PTSD and refines a diathesis-stress model of its aetiology. Systematic searches were carried out on PsycINFO, PubMed, Scopus and Web of Science using PTSD terms crossed with childbirth terms. Studies were included if they reported primary research that examined factors associated with birth-related PTSD measured at least 1 month after birth. In all, 50 studies (n = 21 429) from 15 countries fulfilled inclusion criteria. Pre-birth vulnerability factors most strongly associated with PTSD were depression in pregnancy (r = 0.51), fear of childbirth (r = 0.41), poor health or complications in pregnancy (r = 0.38), and a history of PTSD (r = 0.39) and counselling for pregnancy or birth (r = 0.32). Risk factors in birth most strongly associated with PTSD were negative subjective birth experiences (r = 0.59), having an operative birth (assisted vaginal or caesarean, r = 0.48), lack of support (r = -0.38) and dissociation (r = 0.32). After birth, PTSD was associated with poor coping and stress (r = 0.30), and was highly co-morbid with depression (r = 0.60). Moderator analyses showed that the effect of poor health or complications in pregnancy was more apparent in high-risk samples. The results of this meta-analysis are used to update a diathesis-stress model of the aetiology of postpartum PTSD and can be used to inform screening, prevention and intervention in maternity care.

Nulliparous pregnant women's narratives of imminent childbirth before and after internet-based cognitive behavioural therapy for severe fear of childbirth: a qualitative study.

OBJECTIVE: To describe the expectations concerning imminent childbirth before and after 8 weeks of internet-based cognitive behavioural therapy (ICBT) among nulliparous pregnant women with severe fear of childbirth. DESIGN: Qualitative study of nulliparous pregnant women's narratives before and after CBT. SETTING: The first ICBT programme for treating severe fear of childbirth. SAMPLE: Fifteen nulliparous pregnant Swedish women with severe fear of childbirth participating in an ICBT self-help programme. METHODS: Semi-structured open-ended questions over the internet before and after 8 weeks of ICBT. The data were analysed using thematic analysis. MAIN OUTCOME MEASURES: The participants' narratives pertaining to five different situations during labour and delivery before and after ICBT. RESULTS: After therapy, participants described a more realistic attitude towards imminent childbirth, more self-confidence and more active coping strategies. They perceived their partners and the staff as more supportive. They were more aware of the approaching meeting with their baby when giving birth. CONCLUSIONS: Following the ICBT programme, participants changed their attitude towards imminent childbirth from negative to more positive. This was manifested in positive and more realistic expectations regarding themselves, their partner and the staff that would look after them.

Impact of stress coping capacity on recovery from abdominal hysterectomy in a fast-track programme: a prospective longitudinal study.

OBJECTIVE: To evaluate the effect of stress coping capacity in combination with mode of anaesthesia on postoperative recovery in fast-track abdominal hysterectomy. DESIGN: Prospective longitudinal study. SETTING: Five hospitals in the south-east of Sweden. POPULATION: A cohort of 162 women undergoing fast-track abdominal hysterectomy for benign conditions. METHODS: Self-administered questionnaires, the Stress Coping Inventory (SCI) and the Swedish Postoperative Symptom Questionnaire (SPSQ), and clinical information were collected prospectively. Stress coping capacity was categorised as high or low according to the summed score of the SCI. Comparisons of effect variables were adjusted using a propensity score-matching model. MAIN OUTCOME MEASURES: Associations between stress coping capacity and hospital stay, sick leave, use of analgesic and self-reported postoperative symptoms. RESULTS: Women with high stress coping capacity had a significantly shorter sick leave, experienced postoperative symptoms significantly less often, and with lower intensity, than women with low stress coping capacity. With the exception of symptom intensity, these findings were related to having had the operation under spinal anaesthesia as opposed to general anaesthesia. Hospital stay, use of analgesics and abdominal pain were not related to stress coping capacity. CONCLUSIONS: In patients for whom spinal anaesthesia was applied, high stress coping seems to be a quality that helps patients manage the burden of surgery. It is desirable for the individual, as well as for the healthcare system, to enhance recovery by using intervention programmes designed to improve or manage stress coping, particularly for individuals with low stress coping capacity. This recommendation merits further investigation.

Risk factors in pregnancy for post-traumatic stress and depression after childbirth.

OBJECTIVE: The objective of this study was to find risk factors in pregnancy for post-traumatic stress and depression 1 month after childbirth. Furthermore, the relation between post-traumatic stress and depression was explored. DESIGN: A prospective longitudinal study. SETTING: Pregnant women in Linköping and Kalmar, Sweden. POPULATION: A total of 1224 women were assessed in pregnancy, week 12-20 and 32, as well as 1 month postpartum. METHODS: Post-traumatic stress and depression after delivery were assessed 1 month postpartum. Potential risk factors were assessed in early and late pregnancy. Variables measured during pregnancy were trait anxiety, depression, fear of childbirth, childbirth-related traumatic stress, stress coping capacity, social support, parity, educational level, age, gestation week, parity, educational level, civil status, previous psychological/psychiatric counselling, and previous experience of any traumatic events. Delivery mode was assessed from the medical records. MAIN OUTCOME MEASURES: Prevalence of post-traumatic stress (criteria A, B, C, D, E, and F according to DSM-IV) and depression (Beck's depression inventory). RESULTS: One month postpartum, 12 (1.3%) women had post-traumatic stress (met symptom criteria B, C, and D for post-traumatic stress disorder according to Diagnostic and statistical manual of mental disorders, 4th edition [DSM-IV]). The most important risk factors in pregnancy were depression in early pregnancy (OR=16.3), severe fear of childbirth (OR=6.2), and 'pre'-traumatic stress (in view of the forthcoming delivery) in late pregnancy (OR=12.5). The prevalence of depression was 5.6%. Post-traumatic stress and depression were positively related 1 month postpartum and were predicted by mainly the same factors. CONCLUSIONS: Risk factors for post-traumatic stress and depression after childbirth can be assessed in early pregnancy. Post-traumatic stress and depression also seem to share the same underlying vulnerability factors.

The association between ill-health and abuse: a cross-sectional population based study.

The lifetime prevalence of physical, sexual and psychological abuse was studied cross-sectionally in a representative sample of Swedish women. The association between the three kinds of abuse and ill-health, and the relation between magnitude of abuse and various health problems were also investigated. The Abuse Screening Inventory (ASI), measuring experiences of physical, sexual and psychological abuse and including questions on health and social situation, was sent by mail to 6,000 women, randomly selected from the population register. The questionnaire was completed and returned by 4,150 (70%) of 5,896 eligible women. Various kinds of abuse were reported by 1,142 women (27.5%). The prevalence rates were 19.4% for physical abuse, 9.2% for sexual abuse and 18.2% for psychological abuse. Abused women reported more ill-health and a less advantageous social situation than non-abused women. There was an association between magnitude of abuse and health problems. Also a low magnitude of abuse was substantially associated with ill-health.

Psychological wellbeing after laparoscopic and abdominal hysterectomy--a randomised controlled multicentre study.

OBJECTIVE: To compare laparoscopic hysterectomy and abdominal total hysterectomy regarding influence on postoperative psychological wellbeing and surgical measures. DESIGN: A prospective, open, randomised multicentre trial. SETTING: Five hospitals in the South East of Sweden. POPULATION: Hundred and twenty-five women scheduled for hysterectomy for benign conditions were enrolled in the study, and 119 women completed the study. Fifty-six women were randomised to abdominal hysterectomy and 63 to laparoscopic hysterectomy. METHODS: Psychometric tests measuring general wellbeing, depression and anxiety preoperatively and 5 weeks and 6 months postoperatively. MAIN OUTCOME MEASURES: Effects of operating method on the psychological wellbeing postoperatively. Analysis of data regarding operating time, peroperative and postoperative complications, blood loss, hospital stay and recovery time. RESULTS: No significant differences in the scores were observed between the two groups in any of the four psychometric tests. Both the surgical methods were associated with a significantly higher degree of psychological wellbeing 5 weeks postoperatively compared with preoperatively. The operating time was significantly longer for the laparoscopic hysterectomy group, but the duration of the stay in hospital and sick-leave were significantly shorter for laparoscopic hysterectomy group compared with the abdominal hysterectomy group. CONCLUSIONS: General psychological wellbeing is equal after laparoscopic and abdominal hysterectomy within 6 months after the operation. The advantages of the laparoscopic hysterectomy are the shorter stay in hospital and shorter sick-leave, but these issues must be balanced by a longer duration of the operation.

Vasomotor symptoms decrease in women with breast cancer randomized to treatment with applied relaxation or electro-acupuncture: a preliminary study.

OBJECTIVE: To evaluate the effect of applied relaxation and electro-acupuncture on vasomotor symptoms in women treated for breast cancer. METHODS: Thirty-eight postmenopausal women with breast cancer and vasomotor symptoms were randomized to treatment with electro-acupuncture (n = 19) or applied relaxation (n = 19) during 12 weeks. The number of hot flushes was registered daily in a logbook before and during treatment and after 3 and 6 months of follow-up. RESULTS: Thirty-one women completed 12 weeks of treatment and 6 months of follow-up. After 12 weeks of applied relaxation, the number of flushes/24 h had decreased from 9.2 (95% confidence interval (CI) 6.6-11.9) at baseline to 4.5 (95% CI 3.2-5.8) and to 3.9 (95% CI 1.8-6.0) at 6 months follow-up (n = 14). The flushes/24 h were reduced from 8.4 (95% CI 6.6-10.2) to 4.1 (95% CI 3.0-5.2) after 12 weeks of treatment with electro-acupuncture and to 3.5 (95% CI 1.7-5.3) after 6 months follow-up (n = 17). In both groups, the mean Kupperman Index score was significantly reduced after treatment and remained unchanged 6 months after end of treatment. CONCLUSION: We suggest that applied relaxation and electro-acupuncture should be further evaluated as possible treatments for vasomotor symptoms in postmenopausal women with breast cancer.

A comparison of acupuncture and oral estradiol treatment of vasomotor symptoms in postmenopausal women.

OBJECTIVE: To compare the effects of electro-acupuncture with oral estradiol and superficial needle insertion on hot flushes in postmenopausal women. MATERIAL AND METHODS: Forty-five postmenopausal women with vasomotor symptoms were randomized to electro-acupuncture, superficial needle insertion or oral estradiol treatment during 12 weeks, with 6 months' follow-up. The number and severity of flushes were registered daily and the Kupperman index and a general estimate of climacteric symptoms were completed before, during and after therapy. RESULTS: In the electro-acupuncture group, the mean number of flushes/24 h decreased from 7.3 to 3.5 (ANOVA, p < 0.001). Eleven of the 15 women had at least a 50% decrease in number of flushes (with a mean decrease of 82%). Superficial needle insertion decreased the number of flushes/24 h from 8.1 to 3.8 (p < 0.001). In seven out of 13 women, the number of flushes decreased by at least 50% (mean decrease 83%). In the estrogen group, the number of flushes decreased from 8.4 to 0.8 (p < 0.001). The decrease in number of flushes persisted during the 24-week follow-up period in all treatment groups. The Kupperman index and the general climacteric symptom score decreased, and remained unchanged 24 weeks after treatment in all groups (p < 0.001). Electro-acupuncture decreased the number of flushes/24 h significantly over time, but not to the same extent as the estrogen treatment. No significant difference in effect was found between electro-acupuncture and the superficial needle insertion. CONCLUSION: We suggest that acupuncture is a viable alternative treatment of vasomotor symptoms in postmenopausal women and cannot recommend superficial needle insertion as an inactive control treatment.

Development of the Delivery Fear Scale.

This article reviews the development of the Delivery Fear Scale (DFS) to measure fear during labor and delivery. In an initial study, 92 women in labor answered a list of 60 items, expressing fear-related appraisals and their contrasts that were characteristic of women in labor. The items were then selected by means of an item-total analysis. In a second study, the final list of ten items was tested psychometrically, and a semi-structured interview was performed on 45 women in labor, to explore the women's descriptions of the content of each of the ten items. According to the content analysis of the interviews, the dominating connotation of the ten items is fear based on the appraisal of being captured. The studies show that the DFS is a questionnaire that almost effortlessly can be completed within 60-90 seconds during any moment of labor and delivery. The scale has a good reliability: Cronbach's alpha was 0.88 in both studies.

Traumatic stress after childbirth: the role of obstetric variables.

In a sample of 1550 recently delivered women, traumatic stress after childbirth was studied in relation to obstetric variables. A post-traumatic stress disorder (PTSD) symptom profile and traumatic stress symptoms were assessed by means of the Traumatic Event Scale (TES). Obstetric data comprised delivery mode, duration of the second stage of labor (the time from cervical dilation of 10 cm to partus) and the use of analgesia/anesthesia. Traumatic stress symptoms and having a PTSD symptom profile were both significantly related to the experience of an emergency cesarean section or an instrumental vaginal delivery. It is of clinical importance, however, that most women with a PTSD symptom profile were found in the normal vaginal delivery group (NVD). This implies that a normal vaginal delivery can be experienced as traumatic, just as an emergency cesarian section is not necessarily traumatic. Traumatic stress symptoms were neither substantially correlated to the duration of the second stage of labor, nor to the use of analgesia/anesthesia.

Effects of electro-acupuncture on psychological distress in postmenopausal women.

OBJECTIVES: To evaluate effects of electro-acupuncture (EA) on general psychological distress and relate to experience of climacteric symptoms in 30 postmenopausal women. DESIGN: A randomised single-blind controlled design was used to evaluate effects of EA and extremely superficial needle insertion, with the latter serving as a near-placebo control. SETTINGS: The Linköping University Hospital in Sweden. INTERVENTIONS: Fourteen treatments during 12 weeks with follow-ups at 3 and 6 months. OUTCOME MEASURES: General psychological well-being, mood and experience of climacteric symptoms. RESULTS: Mood Scale improved only in EA group and not until 12 weeks compared to baseline, from 110 to 129 (P = 0.01), and to 120 at 3-month follow-up (P = 0.04). Mood was significantly better than control at 8 (P = 0.05) and 12 weeks (P = 0.01). Visual analogue scale estimation of climacteric symptoms was decreased at 4 weeks in both groups, and lasted throughout the study period, in EA group from 5 to 2 (P = 0.04) and in control group from 5 to 3 (P = 0.02) at 6-month follow-up. Well-being was ameliorated from 4 weeks in EA and from 8 weeks in control group until end of study (P = 0.01, P = 0.03). No significant differences on climacteric symptoms or well-being existed between the groups. CONCLUSIONS: This study does not show that EA is better than superficial needle insertion for the amelioration of general psychological distress and experience of climacteric symptoms in women with vasomotor symptoms after menopause. However, the more pronounced effect on mood suggests that EA might have additional effects compared with superficial needle insertion.

Fear during labor.

BACKGROUND: The aims of the present study were to compare primiparous and multiparous women's experiences of fear of delivery during an early stage of active labor (cervix dilatation 3-5 centimeters) and to study whether fear of delivery, measured during the early stage of active labor, was a predictor of the amount of pain relief received during the remaining part of labor (cervix dilatation 5 cm - partus), of the duration of the remaining part of labor, and of the occurrence of instrumental vaginal delivery and emergency cesarean section. METHOD: Thirty-five primiparous and 39 multiparous women answered the Delivery Fear Scale (DFS) once during the early stage of labor and before they had received any pain relief. RESULTS: Primiparous women reported higher levels of fear than multiparous women did. Fear during the first phase of labor predicted only the total amount of pain relief received during labor. CONCLUSION: The clinical implications of the study are that the delivery staff should consider women's fear during labor and pay attention especially to primiparous women's increased risk of higher levels of fear during an early stage of active labor, as compared with multiparous women's. The challenge for staff of a delivery ward is to support the woman in labor in a way that decreases fear, which in turn might reduce the woman's need of pain relief.

Vulvar vestibulitis syndrome and vaginismus. A case report.

BACKGROUND: Recent reports have argued for a revision of the criteria used for the establishment of a diagnosis of vulvar vestibulitis syndrome (VVS). On theoretical grounds it might be hypothesized that women with VVS also suffer from vaginismus. CASE: A young woman presented with a history, symptoms and objective findings typical of vaginismus, yet she suffered from continuous, burning pain and itching in the vestibule. Earlier in the course of the problem she had received a diagnosis VVS. The patient was treated with behavioral therapy developed for vaginismus. Notations made during the course of therapy supported the assumption that the pain and itching were conditioned responses to penetration in the same way that a vaginal muscular reflex is. CONCLUSION: Differential diagnostic difficulties exist in the field of VVS and vaginismus. Psychophysiologic theories are needed as the basis for research to clarify the connections between different diagnostic entities associated with coital burning pain and itching in the vestibule.

Can women's cognitive appraisals be registered throughout childbirth?

The aims of the present study were: (a) to examine whether it was possible to measure women's cognitive appraisals hourly during the whole process of labor and delivery, and (b) to explore how the appraisals varied during labor. Measurements from 12 nulliparous women are presented. The findings indicate that it is possible to study psychological appraisals directly, in detail and continuously during the process of labor and delivery. The women's cognitive appraisals varied throughout labor both per individual woman and between the participating women.

Psychological impact of emergency cesarean section in comparison with elective cesarean section, instrumental and normal vaginal delivery.

The purpose of the study was to compare the psychological reactions of women after emergency Cesarean section (EmCS), elective Cesarean section (ElCS), instrumental vaginal delivery (IVD) and normal vaginal delivery (NVD). The participants (EmCS, n = 71, ElCS, n = 70, IVD, n = 89, and NVD, n = 96) answered questionnaires a few days postpartum and 1 month postpartum. The EmCS group reported the most negative delivery experience at both times, followed by the IVD group. At a few days postpartum the EmCS group experienced more general mental distress than the NVD group, but not when compared with the ElCS or the IVD groups. At 1 month postpartum the EmCS group showed more symptoms of post-traumatic stress than the ElCS and NVD groups, but not when compared to the IVD group. An unplanned instrumental delivery (EmCS or IVD) should be regarded as a pointer with respect to possible post-traumatic stress.

Fear of childbirth during pregnancy may increase the risk of emergency cesarean section.

BACKGROUND: The purpose of our study was to elucidate the association between fear of childbirth, general anxiety, and stress coping during the third trimester of pregnancy, and a subsequent delivery by emergency cesarean section. METHODS: In a case-control study, 1,981 Swedish-speaking women completed three self-assessment questionnaires at 32 weeks' gestation. Ninety-seven of these women were delivered by emergency cesarean section. Fear of childbirth, general anxiety and the stress coping ability of these 97 cases were compared with the same features in 194 controls, matched for age and parity. RESULTS: Women, subsequently delivered by emergency cesarean section, reported a greater anxiety and a poorer stress coping ability, and, most obviously, a greater fear of childbirth at 32 weeks' gestation. After elimination of possible confounders, the odds ratio for emergency cesarean section was examined for women whose scores were above various cut-off points according to the fear of childbirth measuring instrument. For women with a serious fear of childbirth the odds ratio was 3.0 (95% confidence interval 1.4 to 6.6), and the population attributable risk 0.167. CONCLUSION: Fear of childbirth during the third trimester of pregnancy may increase the risk of subsequent emergency cesarean section.

Psychometric aspects of the W-DEQ; a new questionnaire for the measurement of fear of childbirth.

Up to now it has been difficult to study fear of childbirth because of a shortage of adequate psychological measurements. Therefore the Wijma Delivery Expectancy/ Experience Questionnaire (W-DEQ) was developed. This paper presents the theoretical background of the W-DEQ together with a documentation of the first psychometric studies. Examination of construct validity indicates that it seems to be possible to penetrate a psychological construct related to fear of childbirth by means of the W-DEQ, both before and after delivery, in nulliparous as well as in parous women. The questionnaire measures the construct more clearly in parous than in nulliparous women. Internal consistency reliability and split-half reliability of the W-DEQ of > or = 0.87 are good for a new research instrument. More research is on its way to make the W-DEQ suitable even for measurements in applied settings.

Experiences of emergency cesarean section: A phenomenological study of 53 women.

BACKGROUND: Childbirth by emergency cesarean section can be a traumatic experience, but since the result is often a healthy mother and baby, its seriousness is open to doubt. METHOD: Fifty-three women were interviewed approximately two days after emergency cesarean section to ascertain whether or not the trauma met the stressor criterion of posttraumatic stress disorder. A time-spatial model from disaster psychiatry was used to chart the women's thoughts and feelings during consecutive phases of the delivery process. The women's causal attributions of the event were also assessed. RESULTS: Generally speaking, the feeling of the women after they had arrived at the delivery ward changed from one of confidence and safety to one of fear. The decision to undertake a cesarean section brought a feeling of relief, but this was again replaced by fear as the operation approached. The women's thoughts centered around the impending delivery and operation until after the event, when the newborn baby occupied their attention and happiness predominated. In retrospect, 55 percent of the women experienced intense fear for their own life or that of their baby. Eight percent felt very badly treated by the delivery staff and were angry. Almost all the women had adequate knowledge of the reasons for the emergency cesarean section. One in four blamed themselves to some extent for the event. CONCLUSIONS: The stressor criterion of DSM IV is applicable to the trauma of emergency cesarean section. Even if and when a new mother is happy to meet her baby, negative feelings, such as fear, guilt, or anger, may dominate her memories of the birth.