Post-traumatic stress disorder (PTSD) is common among women of child-bearing age.  While we are increasingly attentive to screening for depressive symptoms during pregnancy and after delivery, less often do we inquire about PTSD symptoms.  Childbirth-related PTSD (CB-PTSD) may be precipitated by a stressful or traumatic childbirth experience.  Of note, childbirth-related PTSD is not limited to stillbirth or to deliveries associated with infant medical complications; in fact, as many as 25% of women experience CB-PTSD symptoms after giving birth to a healthy full-term baby (Dekel et al, 2017).

Depressive symptoms often co-occur with PTSD, and in non-postpartum samples comorbidity has been associated with greater symptom burden, functional impairment, and worse response to treatment.  To better understand the connection between PTSD and depression during the postpartum period, Sharon Dekel, PhD and colleagues studied a group of 685 postpartum women, including women reporting PTSD and postpartum depressive symptoms. 

In this study, women who had given birth to a live baby in the previous 6 months were recruited through announcements on postpartum websites.  Participants were on average 31 years of age (SD = 4.80).  The majority (93%) were married or lived with a domestic partner (6% single and 1% divorced/separated), had at least a college level education (71%, which among them a third had graduate level education), and were middle class.

At the time of study entry, women were on average 3 months postpartum (between 1 day postpartum and 6 months postpartum, with 12% less than 1 month postpartum).  Most of the participants (n=541, 79%) had a full-term delivery of a healthy baby; 144 (21%) had a preterm delivery, which in most cases (84%) resulted in the newborn being admitted to the neonatal intensive care unit (NICU).

PTSD symptoms related to the childbirth experience were identified using the PTSD checklist for DSM-5 (PCL-5).  General distress following childbirth was measured using the Brief Symptom Inventory (BSI) which assesses 53 psychiatric symptoms (e.g., depression, obsessive compulsive, panic) and offers a global symptom severity index (GSI) score. Peritraumatic (acute) reactions to childbirth were assessed using the Peritraumatic Distress Inventory (PDI) and the Peritraumatic Dissociative Experiences Questionnaire (PDEQ).

Results

In this group of women 18% (n = 122) of the women were identified as having probable CB-PTSD and another 14 women reported acute traumatic stress. Of those with CB-PTSD or acute stress, 19% (26 out of 136) reported PTSD symptoms before childbirth. Elevated depressive symptoms were observed in 57% (n = 391) of the total sample.  Of those with postpartum depression, 33% (130 out of 391) reported depressive symptoms before childbirth.

The prevalence of comorbidity was high; 90% (123 out of 136) of those classified with CB-PTSD also experienced elevated postpartum depressive symptoms, while a third (123 out of 391) of those classified with postpartum depression had also experienced CB-PTSD.  The likelihood for CB-PTSD and depression comorbidity was higher if the mother was younger, had pre-childbirth mental health problems, had experienced a longer duration of childbirth, and had an emergency cesarean section.

The Bottom Line

While this study does not yield information regarding the prevalence of childbirth-related PTSD, previous studies indicate that clinically significant PP-PTSD symptoms have been identified in up to 16.8% of women in community samples. This study contributes to our understanding of childbirth-related PTSD with the following findings:

  • PTSD commonly co-occurs with depressive symptoms, with 90% in this study reporting both.
  • About a third of the women with postpartum depression also had CB-PTSD
  • Risk factors for morbidity included younger maternal age, mental health problems before pregnancy, longer duration of childbirth, and emergency cesarean section

Currently it is recommended that all postpartum women should be screened for postpartum depression.  Given the high degree of comorbidity of PTSD and depression in this setting, it is likely that women with PTSD will be captured using standard depression screening.  However, treatments targeting only depression may not address childbirth-related PTSD symptoms, a factor which may ultimately negatively impact treatment outcomes.  

Ruta Nonacs, MD PhD

Read More:

Dekel S, Ein-Dor T, Dishy GA, Mayopoulos PA.  Beyond postpartum depression: posttraumatic stress-depressive response following childbirth.  Arch Womens Ment Health. 2020 Aug;23(4):557-564.

Dekel S, Stuebe C, Dishy G.  Childbirth Induced Posttraumatic Stress Syndrome: A Systematic Review of Prevalence and Risk Factors. Front Psychol. 2017 Apr 11;8:560.