Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

Childbirth Induced Posttraumatic Stress Syndrome: A Systematic Review of Prevalence and Risk Factors

Childbirth Induced Posttraumatic Stress Syndrome: A Systematic Review of Prevalence and Risk Factors REVIEW published: 11 April 2017 doi: 10.3389/fpsyg.2017.00560 Childbirth Induced Posttraumatic Stress Syndrome: A Systematic Review of Prevalence and Risk Factors 1, 2 2 2 Sharon Dekel *, Caren Stuebe and Gabriella Dishy 1 2 Department of Psychiatry, Harvard Medical School, Boston, MA, USA, Department of Psychiatry, Massachusetts General Hospital, Charlestown, MA, USA Background: Posttraumatic stress related with the childbirth experience of full-term delivery with health outcomes has been recently documented in a growing body of studies. The magnitude of this condition and the factors that might put a woman at risk for developing childbirth-related postpartum posttraumatic stress disorder (PP-PTSD) symptoms are not fully understood. Methods: In this systematic review of 36 articles representing quantitative studies of primarily community samples, we set to examine PP-PTSD prevalence rates and associated predictors with a focus on the role of prior PTSD and time since childbirth. Results: A significant minority of women endorsed PP-PTSD following successful birth. Acute PP-PTSD rates were between 4.6 and 6.3%, and endorsement of clinically Edited by: Alessandra Simonelli, significant PP-PTSD symptoms was identified in up to 16.8% of women in community University of Padua, Italy samples of high quality studies. Negative subjective experience of childbirth emerged as Reviewed by: the most important predictor. Endorsement of PTSD before childbirth contributed to PP- Ana Lúcia R. Moreira, Centro Hospitalar do Oeste, Portugal PTSD; nevertheless, women without PTSD also exhibited PP-PTSD, with acute rates at Serge Brand, 4.6%, signifying a new PTSD onset in the postpartum period. University of Basel, Switzerland Conclusion: Although the majority of women cope well, childbirth for some can be *Correspondence: Sharon Dekel perceived as a highly stressful experience and even result in the development of PP- sdekel@mgh.harvard.edu PTSD symptoms. More research is needed to understand postpartum adaption and childbirth-related posttraumatic stress outcomes. Specialty section: This article was submitted to Keywords: postpartum PTSD, childbirth, systematic review, posttraumatic stress, delivery, obstetrics, Psychopathology, psychopathology, resilience a section of the journal Frontiers in Psychology Received: 23 November 2016 INTRODUCTION Accepted: 27 March 2017 Published: 11 April 2017 Many people think of childbirth as a uniformly happy event. This belief may be responsible for the Citation: paucity of research into its possible deleterious outcomes. As unpleasant as it may be to face this, Dekel S, Stuebe C and Dishy G (2017) such research as exists indicates that childbirth may have negative (as well as positive) psychological Childbirth Induced Posttraumatic effects. Postpartum women may experience psychological distress, and some may even develop Stress Syndrome: A Systematic mental disorders. Although postpartum depression has been extensively described (O’Hara and Review of Prevalence and Risk McCabe, 2013), accumulating data suggests that new mothers may also exhibit a posttraumatic Factors. Front. Psychol. 8:560. doi: 10.3389/fpsyg.2017.00560 stress response induced by the childbirth experience and may even suffer from childbirth-related Frontiers in Psychology | www.frontiersin.org 1 April 2017 | Volume 8 | Article 560 Dekel et al. PTSD and Childbirth postpartum traumatic stress disorder (PP-PTSD) following childbirth. An estimated lifetime prevalence of PTSD in women successful birth (Olde et al., 2006; Grekin and O’Hara, 2014). is 10.4% and those who develop symptoms are highly susceptible As many as a third of women rate their delivery as to PTSD endorsement in relation to subsequent traumatic events psychologically traumatic (Ayers and Pickering, 2001), and as (Kessler et al., 1995). PTSD is associated with a negative appraisal many as one quarter report some component of clinically of subsequent events (Ehlers and Clark, 2000). In accord with significant PP-PTSD symptoms (Czarnocka and Slade, 2000). Ayers (2004) the vulnerability factor of prior PTSD is likely Co-morbidity of PP-PTSD and postpartum depression is high, to interact with birth events to determine appraisal of birth as as evident in up to 72% of cases of women endorsing PP-PTSD traumatic and development of a traumatic stress responses. Thus, (Yildiz et al., 2017), and some may also endorse suicide ideation, prepartum PTSD symptoms may continue into the postpartum as evident in 23% of cases (Dekel et al., in preparation). PP-PTSD period and trigger PP-PTSD. In contrast, PP-PTSD may signify may impair maternal bonding and indirectly have adverse affects the occurrence of first-time posttraumatic stress syndrome onset. on infant health (Williams et al., 2016). Hence, PP-PTSD is a Having a difficult childbirth experience (subjective or objective) problem deserving of attention. for some women might be extreme enough to result in PP-PTSD A stress-diathesis model has been proposed to understand without having prior PTSD symptoms. The childbirth event the factors giving rising to PP-PTSD (Ayers, 2004). Accordingly, would then be regarded as the index event of traumatic exposure, PP-PTSD is the outcome of the interplay between pre-birth although other vulnerability factors are possible. Women with a vulnerability factors, risk factors in birth, and factors after history of trauma exposure, who do not exhibit prepartum PTSD, birth (Ayers et al., 2016). Factors such as pre-existing maternal may be a special case. Trauma history may reduce the ability to psychiatric problems, a negative birth experience, and lack of cope with subsequent stressful events (Dekel et al., 2013a), as social support, have been consistently reported as commonly noted in a sensitization effect (Breslau et al., 1999; Dekel et al., endorsed risk factors (e.g., Andersen et al., 2012). These risks are 2013b). Thus, women with trauma history may exhibit a delayed broadly comparable with factors associated with PTSD in relation PTSD response induced by childbirth. to other stressors (Ozer et al., 2003). Another factor to consider in understanding incidences of Much less agreement concerns the estimates of the incidence PP-PTSD is the passage of time since childbirth. Although the of PP-PTSD. PP-PTSD rates are between 1 and 30%, too wide majority of individuals endorse posttraumatic stress symptoms a range to be very useful (Andersen et al., 2012; Grekin and (i.e., PTS) in the immediate aftermath of trauma, symptoms O’Hara, 2014). Partial PP-PTSD, i.e., PTSD symptoms occurring subside for most survivors and a significant minority fails to at a clinically significant level, has also been noted, but again with recover (Bonanno et al., 2005; Shalev, 2009). Previous studies a similar pattern of widely estimated rates (Czarnocka and Slade, assessed rates of PP-PTSD at different time points ranging from 2000; Soet et al., 2003; Polachek et al., 2012). the first days following childbirth to several months, which may Several review studies have been conducted on the topic. Olde account for the wide prevalence rates among the studies. et al. (2006) groundbreaking qualitative review of 19 studies Thus, in the following systematic review, we examined the published between 1997 and 2003 identified PP-PTSD following prevalence rates of PP-PTSD with a focus on the time period of successful birth in up to 5.6% of women at 6 weeks postpartum. A symptoms endorsement following childbirth. We set to examine subsequent review by Andersen et al. (2012) of 31 studies between PP-PTSD in relation to the endorsement of new posttraumatic 2003 and 2010 utilized a study quality ranking. They noted PP- stress syndrome as well as in relation to prior PTSD. We also PTSD rates in high quality studies were up to 4.6% between set to examine the risk factors involved in the development of three and 12 months postpartum. Recent reviews importantly PP-PTSD. targeted community in comparison to at-risks samples (Grekin and O’Hara, 2014). As might be expected, PP-PTSD rates were METHODS approximately fivefold higher (15.7%) in at-risk groups than in the community (3.1%). Yildiz et al. (2017) report similar results Study Criteria Selection from reviewing 28 studies using a diagnostic measure of PTSD, The search of literature targeted a wide range of studies, documenting once again a wide PP-PTSD rate variability among published from January 1980 until 1 August 2016. A search the studies. of PubMed and PsychInfo databases was performed using any These reviews support the existence of PTSD following combination of keywords: posttraumatic stress, posttraumatic childbirth; however, some clarification remains. While earlier stress disorder, traumatic stress with childbirth, PTSD, reviews reported on the prevalence of PTSD during the postpartum, or postnatal. Studies were also found through postpartum period, it is not clear whether the studies were the “Related Citations” function on PubMed and through the limited to those reporting on PTSD induced by childbirth. To reference lists of previously identified studies. Previous reviews our knowledge, a review comparing PP-PTSD prevalence in the on PTSD following childbirth were another basis to identify context of prior PTSD versus a first time onset in the postpartum studies. period was not conducted to-date. Such analysis is important to Studies included in our review were quantitative studies, fully grasp the magnitude of the childbirth stressor. published in English, and met the following criteria: (a) full-term PP-PTSD can be conceptualized in at least two ways. PTSD successful births; (b) indication of prevalence of PP-PTSD, at a related to the childbirth event may develop in the context of maximum initial assessment of 6 months postpartum; and (c) endorsement of existing posttraumatic stress syndrome before PP-PTSD stressor specified in relation to childbirth. Frontiers in Psychology | www.frontiersin.org 2 April 2017 | Volume 8 | Article 560 Dekel et al. PTSD and Childbirth TABLE 1 | Quality Coding System Criteria. A total of 93 articles were identified via the search criteria. Of this total, 57 articles were removed either for failure to meet I. DATA COLLECTION criteria or to avoid duplicate samples. The final review included Single item measures 0 36 articles, with 32 representing community samples and four Study-specific measures 1 representing at-risk groups. Self-report questionnaire 2 Clinical interview 3 Study Rating System II. SAMPLE SIZE A quality rating system modeled off Andersen et al. (2012) ≤29 0 was utilized to assess identified studies. This system is based 30–99 1 in part upon the Meta-analysis of Observational Studies in 100–199 2 Epidemiology (MOOSE) technique (Stroup et al., 2000). It is 200–399 3 designed to assess study quality by accounting for methodological ≥400 4 differences among the studies. In this review, several factors III. NATURE OF SAMPLE were assessed to determine study quality such as sample size, Self-selective 0 method of data collection, measurement used, etc. Table 1 Target/risk group 2 indicates the full list of factors, their corresponding items, Representative 4 and the point value assigned to each item. For example, the IV. INITIAL RESPONSE RATE factor Data Collection included four items: single-item measures, Cross-sectional only 0 study-specific measures, self-report questionnaire, and clinical interview. Single-item measures were assigned a point value of < 50% 1 50-75% 2 one, leading up to clinical interview, which was assigned a point value of four. Thus, a study would be given a score ranging > 75% 3 from one to four for data collection. The sum of each factor V. PRESENCE OF PRE-PARTUM MEASUREMENTS resulted in an overall study quality score, ranging from 2 to 27 No 0 points. Yes 1 According to their study quality score, each study was ranked VI. HISTORY OF TRAUMA as either A or B. The A category included studies with the No 0 highest methodological ranking, and, for the relevance of this Yes 1 review, those that controlled for PTSD symptom endorsement VI. HISTORY OF PTSD before childbirth (“controlled studies”). The B category included No 0 studies that may have received a lower quality score due to Yes 1 smaller sample size, fewer postpartum time assessments, lack VII. POST-PARTUM COLLECTION POINTS of perinatal assessments, etc., or due to less relevance to this One Time 1 review. All studies in B did not control for PTSD before childbirth Two Times 2 (“uncontrolled studies”). Three+ Times 3 Two research assistants analyzed and rated the 36 identified VIII. PTSD ASSESSMENT articles. Inter-rater agreement between the research assistants Post-Partum only 0 was high and reached 92%. If disagreements in coding arose, the Pre- and Post-Partum 1 disagreement was discussed and resolved to reach a consensus. Post-Partum and IOC 2 In the next step, we calculated PTSD prevalence rates within Pre-, Post-, and IOC 3 studies in Groups A and B by taking into consideration IX. INITIAL POST-PARTUM ASSESSMENT the time of postpartum assessment. In accordance with Years 1 PTSD DSM-4 (American Psychiatric Association, 2000), PP- Months 2 PTSD assessed more than 1 month and up to 3 months Weeks 3 postpartum was labeled “acute PP-PTSD,” and assessment Days 4 more than 3 months and up to 6 months postpartum was SUM OF POINTS 2–27 labeled “chronic PP-PTSD.” In addition, PP-PTSD symptoms measured within 1 month postpartum were labeled postpartum The drop-out rate among studies was evaluated after the initial time point. The prevalence of high drop-out rates in some studies could indicate selection bias. A sum of points posttraumatic stress, i.e., PP-PTS. PTSD rate for each time was calculated based on the coding factors below. The minimum and maximum scores point was created by computing the mean PTSD value. achievable were 2 and 27, respectively. Studies scoring 2–18 points were ranked as B, We also computed the overall PP-PTSD rate assessed by and 19–27 points were ranked as A. IOC, Index of Childbirth. averaging the time categories (PP-PTS + acute PTSD + chronic PTSD). factors had to be of statistical significance. Each identified risk Risk Factor Analysis factor was assigned a point value based on the group rank of Risk factors for PP-PTSD, if presented by the studies, were the study. For example, a risk factor identified from a Group A identified and analyzed. To be included in the analysis, risk study was assigned a point value of two. Risk factors identified Frontiers in Psychology | www.frontiersin.org 3 April 2017 | Volume 8 | Article 560 Dekel et al. PTSD and Childbirth TABLE 2 | Group A Studies. Study Sample size Type of sample Study site Measures of PP-PTSD Measurement times postpartum Abedian et al., 2013 n = 100 Women with preeclampsia Iran PPQ 6 weeks a,b Alcron et al., 2010 n = 866 Community Australia PDS T1: 4-6 weeks T2: 12 weeks T3: 24 weeks Ayers et al., 2009 n = 1423 Community UK PDS 3-12 months Ayers and Pickering, 2001 n = 289 Community UK MMPI-2 PTSD Scale T1: 6 weeks T2: 6 months Boorman et al., 2014 n = 890 Community Australia Criterion A1 and A2 assessment 14 days Cigoli et al., 2006 n = 160 Community Italy PTSD-Q 3–6 months Cohen et al., 2004 n = 200 Community Canada DTS 8–10 weeks Czarnocka and Slade, 2000 n = 264 Community UK PTSD-Q 6 weeks Davies et al., 2008 n = 211 Community UK PTSD-Q 6 weeks Ford et al., 2010 n = 138 Community UK PDS T1: 3 weeks T2: 3 months Garthus-Niegel et al., 2014 n = 1700 Community Norway IES 8 weeks Ionio and Blasio, 2014 n = 19 Community Italy PPQ T1: 2 days T2: 2 months Milosavljevic et al., 2016 n =1 26 community Serbia CAPS T1: 1 month T2: 2 months T3: 3 months Polachek et al., 2012 n = 89 Community Israel PDS 1 month a,b Schwab et al., 2012 n = 56 Community Iran PDS 6 weeks a,b Seng et al., 2013 n = 566 Community USA NWS PTSD module 6 weeks Soderquist et al., 2006 n = 1224 Community Sweden TES T1: 1 month T2: 4 months T3: 7 months T4: 11 months Son et al., 2005 n = 248 Community Netherlands IES T1: 3 months T2: 6 months T3: 12 months Sumner et al., 2012 n = 206 Low-income Latinas South America PCL-C T1: 7 months T2: 13 months Verreault et al., 2012 n = 308 Community Canada SCID-I; MPSS-SR 1 month a,b Vossbeck-Elsebusch et al., 2014 n = 224 Community Germany PDS 1–6 months White et al., 2006 n = 318 Community Australia PSS-SR T1: 6 weeks T2: 6 months T3: 12 months a,b Zambaldi et al., 2011 n = 400 Community Brazil M.I.N.I. 2–26 weeks PP-PTSD endorsement was defined as reaching a score above the cut-off for PTSD symptom severity, or as being in accord with DSM PTSD symptom criteria (DSM-4 or DSM-5). CAPS, Clinician-Administered PTSD Scale; DTS, Davidson Trauma Scale; IES, Impact of Event Scale; M.I.N.I., Mini-International Neuropsychiatric Interview; MMPI-2 PTSD Scale, Minnesota Multiphasic Personality Inventory-2 Posttraumatic Stress Disorder Scale; MPSS-SR, Modified PTSD Symptom Scale Self-Report; NWS PTSD Module, National Women’s Study PTSD Module; PCL-C, PTSD Checklist-Civilian Version; PDS, Posttraumatic Stress Diagnostic Scale – Self-report version; PPQ, Perinatal PTSD Questionnaire; PSS-SR, Posttraumatic Stress Symptom Scale – Self-report version; PTSD-Q, Posttraumatic Stress Disorder Questionnaire; SCID-I, Structured Clinical Interview for DSM-4; TES, Traumatic Event Scale. Studies that did not control for prior PP-PTSD. Studies that controlled for prior PP-PTSD. from Group B were assigned a point value of one. If multiple account for risk factors that did not fall within the five identified studies reported the same risk factor, that risk factor received a categories. summed score. Risk factors of similar nature were then grouped into RESULTS categories. For example, risk factors such as prenatal depression and perinatal anxiety were grouped under the category “Maternal Study Classification Mental Health.” Five categories were created. The category score The identified 36 articles meeting inclusion criteria were was the sum of the individual risk factors, and was above categorized into groups A and B in accordance with the 15 for each category. A miscellaneous category was added to proposed coding system. Group A included 23 studies which Frontiers in Psychology | www.frontiersin.org 4 April 2017 | Volume 8 | Article 560 Dekel et al. PTSD and Childbirth were categorized according to whether they controlled for For “Uncontrolled” studies in Group A, the overall PP-PTSD endorsement of PTSD prior to childbirth (controlled) or not prevalence was 5.5%. Rates of PP-PTS and acute PP-PTSD were (uncontrolled) (See Table 2). Group B included 13 studies (See similar, at 6.7 and 6.3%, respectively. Again, chronic PP-PTSD Table 3). rates were lower at 3.4%. The overall partial PP-PTSD rate, as might be expected, was much higher, at 16.8%; three times higher PP-PTSD Prevalence than the rates for overall PP-PTSD. For example, a uncontrolled All 36 articles included in this review reported the prevalence of study (N = 308 of community sample) reported partial and childbirth-related PP-PTSD, with 18 studies also reporting the full PP-PTSD rates of 7.6 and 16.6%, respectively, at 1 month prevalence of partial PP-PTSD. (Verreault et al., 2012). Table 4 presents PP-PTSD prevalence according to group In Group B, the overall PP-PTSD prevalence including at-risk classification (A and B), time of postpartum assessment, and type samples was 6.2%. The prevalence rates also varied according of sample (community vs. at-risk). As indicated previously: “PP- to time of assessment, with lowest rates found for PP-PTS PTS” noted was for symptoms ≤1 month postpartum; “acute and highest for acute PP-PTSD. PP-PTS prevalence was 1.0%, PP-PTSD” for symptoms >1month postpartum but <3 months whereas acute PP-PTSD was 8.1% in the community sample postpartum; and “chronic PP-PTSD” for symptoms >3 months and 11.1% when including at-risk groups. Chronic PP-PTSD and ≤6 months. Overall, PP-PTSD and partial PTSD referred to prevalence was lower than acute, with rates of 4.6% in community symptoms across time points. samples and 6.7% including at-risk samples. Rates of partial For “Controlled” studies in Group A, the overall PP-PTSD PP-PTSD were highest at 27.3%. prevalence was 4.9%, including at-risk samples. Though PP- PP-PTSD Risk Factors PTS rates were 0.8%, acute PP-PTSD rates were much higher, with 4.6% in community samples and 10.1% including at-risk. Five categories of risk factors were identified: negative perception Chronic PP-PTSD rates were 1.8% in the community sample and of childbirth, maternal mental health, trauma history, and PTSD, 3.9% including at-risk samples, suggesting a decline in PP-PTSD delivery mode and complications, and low social support. Table 5 endorsement. Overall partial PP-PTSD was 9.6%. For example, a presents the categories and their risk factors. controlled community study (N = 211 of primi- and multiparas Factors relating to negative subjective experience of childbirth women who underwent various modes of delivery with healthy received the highest weighted score of 28 points, and were thus outcomes) reported rates of full and partial PP-PTSD at 3.8 and identified as the most potent predictors of PP-PTSD. The most 21.3%, respectively, at 6 weeks postpartum (Davies et al., 2008). significant risk factor, reported by five studies, was negative TABLE 3 | Group B Studies. Study Sample size Type of sample Study site Measures of PTSD Measurement times post-partum Adewuya et al., 2006 n = 876 Community Nigeria M.I.N.I 6 weeks Beck et al., 2011 n = 903 Community USA PSS-SR 6 months Ghorbani et al., 2014 n = 82 Community Iran PSS <2 months Leeds and Hargreaves, n = 102 Community UK PCL; PPQ 6–12 months Modarres et al., 2012 n = 400 Women with traumatic delivery Iran PSS-I 6–8 weeks Olde et al., 2005 n = 140 Community Netherlands PSS-SR T1: 1–7 days T2: 3 months Parfitt and Ayers, 2009 n = 152 Community UK PDS 10 months Ryding et al., 1997 n = 25 Community Sweden CI; FET T1: 1–9 days T2: 1–2 months Sexton et al., 2015 n = 214 Women who had experienced child USA NWS PTSD 4 months abuse and neglect Shaban et al., 2013 n = 600 Community Iran PSDS 6–8 weeks Soet et al., 2003 n = 103 Community USA Telephone interview including TES 1 months Wijma et al., 1997 n = 1640 Community Sweden TES T1: 1–13 months Zaers et al., 2008 n = 60 Community Germany PDS T1: 6 weeks T2: 6 months PP-PTSD endorsement was defined as reaching a score above the cut-off for PTSD symptom severity, or as being in accord with DSM PTSD symptom criteria [DSM-4 (American Psychiatric Association, 2000) and DSM-5 (American Psychiatric Association, 2013)]. CI, Clinical Interview; FET, Fisher’s Exact Test; M.I.N.I., Mini-International Neuropsychiatric Interview; NWS PTSD, National Women’s Study PTSD Module; PCL, Posttraumatic Stress Disorder Checklist; PDS, Posttraumatic Stress Diagnostic Scale; PPQ, Perinatal PTSD Questionnaire; PSDS, Posttraumatic Stress Disorder Symptom Scale; PSS, Posttraumatic Stress Disorder Symptoms Scale; PSS-I, Posttraumatic Symptom Scale-Interview; PSS-SR, Posttraumatic a b c Stress Symptom Scale-Self-report version; TES, Traumatic Event Scale. Sample that completed PTSD assessment. Sample that only includes full-term births. Mean postpartum measurement time. Two-thirds of women in the sample had experienced child abuse and neglect. Frontiers in Psychology | www.frontiersin.org 5 April 2017 | Volume 8 | Article 560 Dekel et al. PTSD and Childbirth TABLE 4 | Prevalence rates for PP-PTSD in relation to PTSD history and time of assessment. A B PP-PTSD Controlled Uncontrolled Uncontrolled PP-PTS 0.80% 6.70% (1.3–14.3) 1.00% (0–1.9) a b a b a b a b Acute PP-PTSD 10.10% ; 4.60% (1.2–37.8) ; (1.2–11.2) 6.30% (0–21.5) 11.10% ; 8.10% (1.2–21.5) ; (1.2–17.2) a b a b a b a b Chronic PP-PTSD 3.90% ; 1.80% (0–9.65) ; (0–3.1) 3.40% (0.9–6) 6.70% ; 4.60% (1.2–19.6) ; (1.2–6.4) a b a b Overall 4.90% ; 2.40% 5.50% 6.20% ; 4.50% Partial PP-PTSD 9.60% (1.3–21.3) 16.80% (6.1–28.8) 27.30% (9.1–19.6) Numbers reflect percentage of women who endorse PP-PTSD symptoms. Numbers in parentheses indicate range of prevalence rates reported. PP-PTSD, Postpartum Posttraumatic Stress Disorder. PP-PTS, PTSD symptoms assessed within one month postpartum. Acute PP-PTSD, PTSD assessed more than one month postpartum but less than three. Chronic PP-PTSD, PTSD assessed from three months postpartum on. Controlled and uncontrolled studies, studies that did and did not control for PTSD prior to childbirth. Population sample including both community and at-risk groups; Community samples. delivery experience (Wijma et al., 1997; Son et al., 2005; Zaers Adewuya et al., 2006; Zambaldi et al., 2011; Modarres et al., et al., 2008; Verreault et al., 2012; Garthus-Niegel et al., 2014). 2012; Boorman et al., 2014; Vossbeck-Elsebusch et al., 2014; Fear of childbirth for the self and/or baby and low internal locus Milosavljevic et al., 2016). Two studies also noted instrumental of control during childbirth were also significant factors noted deliveries as a significant risk factor (Adewuya et al., 2006; in this category, and were reported by several studies (Czarnocka Milosavljevic et al., 2016). and Slade, 2000; Soet et al., 2003; Adewuya et al., 2006; Soderquist The final category pertained to low levels of social support, et al., 2006; Leeds and Hargreaves, 2008; Garthus-Niegel et al., and received a weighted score of 17 points. Three studies referred 2014). to low levels of social support in general as a risk factor (Soet The next most significant group of risk factors included those et al., 2003; Ford et al., 2010; Sumner et al., 2012). The remaining pertaining to maternal mental health. This group received a studies were more specific in regards to the support group, weighted score of 25 points. The presence of prenatal depression with one study reporting low family support, three studies was the most commonly noted factor within this group, as reporting low staff support, and three studies reporting low documented in five studies (Cohen et al., 2004; Soderquist partner support (Czarnocka and Slade, 2000; Cigoli et al., 2006; et al., 2006; Leeds and Hargreaves, 2008; Sumner et al., 2012; Parfitt and Ayers, 2009; Beck et al., 2011; Ford and Ayers, 2011). Shaban et al., 2013). Having a history of psychological problems Previous counseling related to childbirth or pregnancy was also a prior to pregnancy was found to significantly contribute to the contributing factor (Soderquist et al., 2006). endorsement of PP-PTSD as well (Soderquist et al., 2006; Leeds Finally, we identified common risk factors that did not fit into and Hargreaves, 2008; Zaers et al., 2008; Zambaldi et al., 2011; the noted risk factors categories. These factors largely pertain to Boorman et al., 2014). Perinatal somatoform and anxiety were demographics and included the risk factors such as young age, also significant factors cited by six studies (Soet et al., 2003; Olde low income, primiparity, and multiparity (Zambaldi et al., 2011; et al., 2005; Zaers et al., 2008; Zambaldi et al., 2011; Verreault Abedian et al., 2013; Boorman et al., 2014; Vossbeck-Elsebusch et al., 2012; Shaban et al., 2013). Finally, acute postpartum et al., 2014). depression symptoms were found to predict later PP-PTSD (Beck et al., 2011). DISCUSSION Factors falling within the trauma history and PTSD category comprised the third highest weighted score of 24 points. A history Posttraumatic stress syndrome related with the childbirth of trauma exposure of any type was the most commonly reported experience has been largely overlooked. That a mostly voluntary risk factor as noted in three studies (White et al., 2006; Zaers event implicated in reproduction can trigger PP-PTSD does not et al., 2008; Ayers et al., 2009). Childhood sexual trauma in reconcile with the positive notion of childbirth. Yet, childbirth particular was found to be a highly cited factor, as well as pre- involves drastic physiological changes of hormonal imbalance, traumatic stress in pregnancy (Soderquist et al., 2006; Lev-Wiesel blood and body weight loss, increased cardiac output, and is and Daphna-Tekoah, 2010; Verreault et al., 2012; Sexton et al., often accompanied by acute bodily pain and sleep deprivation. 2015). As might be expected, the endorsement of PTSD during Not surprisingly, a full-term delivery with healthy outcomes may pregnancy was a strong predictor of PP-PTSD (Seng et al., 2013). nonetheless be associated with threat on bodily integrity and a Trauma related to interpersonal violence and having a previous sense of fear and loss of control. traumatic birth experience were other frequently reported factors There are two competing theories on childbirth-related PTSD. (Polachek et al., 2012; Sumner et al., 2012). First, PP-PTSD signifies amplification of pre-existing traumatic Risk factors related to delivery mode and complications stress symptoms. Second, PP-PTSD indicates a new PTSD onset constituted the fourth highest weighted category of 22 points. induced by the childbirth experience rather than continuation of Emergency cesarean section and complications with the perinatal PTSD. We explored predictions from these theories by pregnancy and/or baby were the most cited risk factors in this analyzing 36 articles reporting the rates of PP-PTSD symptoms category, reported by seven studies total (Cohen et al., 2004; associated with the experience of healthy, full-term birth. Frontiers in Psychology | www.frontiersin.org 6 April 2017 | Volume 8 | Article 560 Dekel et al. PTSD and Childbirth Overall, the prevalence rates of PP-PTSD, in its acute form (between 1 and 3 months postpartum) were 5–8% in community samples. The prevalence of clinically significant symptoms of PP-PTSD, was higher, and ranged between 9.6 and 27.3%. It is estimated that four million babies are born in the States each year. While our results suggest that at a minimum only 5 out of 100 women will experience a sort of PP-PTSD, when translated to the larger sample of four million, this is roughly two hundred thousand mothers at-risk. New PTSD onset following childbirth was noted in the studies reviewed here, suggesting that for some women childbirth can be perceived as a highly stressful experience capable of triggering PTSD without having prior PTSD. In fact, rates of new PTSD onset evident in samples of women without PTSD before childbirth were slightly lower than in samples including women with or without PTSD history, 4.6 vs. 6.3% for acute PP-PTSD in studies of high quality. Although these findings may be attributed to differences in the nature of the samples, we applied a quality approach to compare between the studies. Alternatively, the findings may suggest that for a significant sub-group of women, PTSD symptoms do not carry on from pregnancy to childbirth but rather develop for the first time in the immediate postpartum period. Although several reviews have been conducted on PTSD in relation to childbirth, this is the first attempt to distinguish between syndromes of new and prior PTSD endorsement. Various risk factors were also reviewed and identified as potentially predictive of the development of PP-PTSD, mainly pre-trauma related factors and peritraumatic aspects related to the childbirth. Although predisposing mental health conditions and prior trauma were associated with subsequent PP-PTSD, peritraumatic factors and early emotional symptoms emerged as the strongest predictor. Obstetrical factors and related complications, which may entail threat to life of mother and/or baby, were ranked as less important. These findings accord with the previous reviews (Andersen et al., 2012) and are also in line with the literature of PTSD in relation to other stressors (Ozer et al., 2003). It has been documented that the subjective experience of the traumatic event is a more important factor in predicting PTSD than its objective stressor severity (Bowman, 1999; Dekel et al., 2016a). Subjective negative childbirth experience, as our data reveals, pertains to having a negative appraisal of the event (primary appraisal) and of one’s ability to cope with the stressor (secondary appraisal) (Lazarus, 1981). These kinds of negative appraisals have been linked with the development and endurance of PTSD following traumatic experiences (Dunmore et al., 2001). Several limitations in this review should be noted. Although identified studies used well-validated measures of PP-PTSD symptoms, whether participants had clinically diagnosed PP- PTSD was assessed by some studies but not in all. While we identified common risk factors for PP-PTSD, the interplay between the factors was not assessed, and there might be other unknown factors that have not been studied yet. Analysis of quantitative studies allowed for study comparison; however, qualitative studies may have offered important information as well. We applied a quality rating to compare and integrate studies, but might have overlooked factors that may bias the Frontiers in Psychology | www.frontiersin.org 7 April 2017 | Volume 8 | Article 560 TABLE 5 | Risk factors associated with PP-PTSD. Subjective experience of childbirth 28 Maternal mental health 25 Trauma history and PTSD 24 Delivery mode and complications 22 Low social support 17 Negative delivery experience 8 Prenatal depression 8 Previous traumatic events 9 Emergency caesarean section 7 Staff 6 Fear of childbirth for self and/or baby 6 History of psychological problems 7 Childhood sexual trauma 5 Complications with pregnancy and/or baby 5 Overall 5 Low internal locus of control during childbirth 5 Perinatal anxiety 5 Prenatal PTSD 2 Instrumental delivery 4 Partner 4 Post-traumatic cognitions 4 Perinatal somatoform 3 Previous traumatic birth experience 2 Planned caesarean birth 2 Family 2 Pain in labor 3 Postpartum depression 1 Pre-traumatic stress in pregnancy 2 Long labor duration 1 Low coping ability 1 Manual removal of placenta 1 Perinatal dissociation 1 Preterm birth 1 Unexpectedness of procedures 1 Pressure to have an induction and epidural analgesia 1 PP-PTSD, Postpartum Posttraumatic Stress Disorder. Dekel et al. PTSD and Childbirth results. Although we mainly reviewed community samples, to identify at-risk women in the immediate peripartum period important confounding factors such as age, medical issues and to intervene accordingly. At a broader level, our findings during birth, mode of delivery, and peripartum anxiety, were suggest that by nature women are resilient and cope well with not taken into account when reporting PP-PTSD rates. We the childbirth experience. Childbirth is not inevitably appraised included samples derived from different world regions, which as traumatic. Examining biological factors underlining positive offers a broad perspective on PP-PTSD but might create wide adaptation and posttraumatic stress reactions is likely to provide variations in prevalence rates. Ideally, we would have targeted insight into this under-researched scientific territory. large, prospective, longitudinal studies to clarify childbirth- related PTSD with/without PTSD or trauma history and the AUTHOR CONTRIBUTIONS moderating factor of culture (Dekel et al., 2016b). Future studies are warranted to examine the various pathways for the SD supervised coding of articles and data analysis and headed development of PP-PTSD and its symptom trajectory. manuscript writing. CS identified and coded articles, completed Within the context of these limitations, the current review data analysis, and contributed to manuscript writing. GD provides important evidence for the endorsement of PTSD identified and coded articles. related with childbirth. Although there has been controversy regarding whether PTSD could be induced by childbirth, our FUNDING findings indicate that a significant sub-group of women with and without prior PTSD may develop PP-PTSD of an enduring This work was supported by MGH ECOR Claflin Distinguished nature. The development of PTSD in relation to a relatively Scholar Award and the Brain and Behavior Research Foundation predicted event (i.e., birth) during routine clinical care offers (NARSAD) Grant awarded to SD. the opportunity to potentially identify women at high risk for PP-PTSD and provide specific preventive interventions, both ACKNOWLEDGMENTS of which are currently lacking. As this study demonstrates, having a negative childbirth experience is an important factor We thank Ms. Olivia Lanman for assisting with the coding of the reviewed studies. implicated in PP-PTSD. Childbirth accounts may be a useful tool REFERENCES Beck, C. T., Gable, R. K., Sakala, C., and Declercq, E. R. (2011). Posttraumatic stress disorder in new mothers: results from a two-stage Abedian, Z., Narges, S., Mokhber, N., and Esmaily, H. (2013). Comparing U.S. national survey. Birth 38, 216–227. doi: 10.1111/j.1523-536X.2011. post-traumatic stress disorder in primiparous and multiparous 00475.x women with preeclampsia. J. Midwifery Reprod. Health 1, 13–18. Bonanno, G. A., Rennicke, C., and Dekel, S. (2005). Self-enhancement doi: 10.22038/jmrh.2013.755 among high-exposure survivors of the September 11th terrorist attack: Adewuya, A. O., Ologun, Y. A., and Ibigbami, O. S. (2006). Post- resilience or social maladjustment? J. Pers. Soc. Psychol. 88, 984–998. traumatic stress disorder after childbirth in Nigerian women: prevalence doi: 10.1037/0022-3514.88.6.984 and risk factors. BJOG 113, 284–288. doi: 10.1111/j.1471-0528.2006. Boorman, R. J., Devilly, G. J., Gamble, J., Creedy, D. K., and Fenwick, J. 00861.x (2014). Childbirth and criteria for traumatic events. Midwifery 30, 255–261. Alcron, K. L., O’Donovan, A., Patrick, J. C., Creedy, D., and Devilly, G. J. doi: 10.1016/j.midw.2013.03.001 (2010). A prospective longitudinal study of the prevalence of post-traumatic Bowman, M. L. (1999). Individual differences in posttraumatic distress: stress disorder resulting from childbirth events. Psychol. Med. 40, 1849–1859. problems with the DSM-IV model. Can. J. Psychiatry 44, 21–33. doi: 10.1017/S0033291709992224 doi: 10.1177/070674379904400103 American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Breslau, N., Chilcoat, H. D., Kessler, R. C., and Davis, G. C. (1999). Previous Mental Disorders, 4th Edn. Washington, DC: Author. exposure to trauma and PTSD effects of subsequent trauma: results American Psychiatric Association. (2013). Diagnostic and Statistical Manual of from the detroit area survey of trauma. Am. J. Psychiatry 156, 902–907. Mental Disorders, 5th Edn. Arlington, VA: Author. doi: 10.1176/ajp.156.6.902 Andersen, L. B., Melvaer, L. B., Videbech, P., Lamont, R. F., and Joergensen, J. Cigoli, V., Gilli, G., and Saita, E. (2006). Relational factors in psychopathological S. (2012). Risk factors for developing post-traumatic stress disorder following responses to childbirth. J. Psychosom. Obstet. Gynaecol. 27, 91–97. childbirth: a systematic review. Acta Obstet. Gynecol. Scand. 91, 1261–1272. doi: 10.1080/01674820600714566 doi: 10.1111/j.1600-0412.2012.01476.x Cohen, M. M., Ansara, D., Schei, B., Stuckless, N., and Stewart, D. E. Ayers, S. (2004). Delivery as a traumatic event: prevalence, risk factors, and (2004). Posttraumatic stress disorder after pregnancy, labor, and delivery. treatment for postnatal posttraumatic stress disorder. Clin. Obstet. Gynecol. 47, J. Womens Health (Larchmt). 13, 315–324. doi: 10.1089/1540999043230 552–567. doi: 10.1097/01.grf.0000129919.00756.9c 16473 Ayers, S., Bond, R., Bertullies, S., and Wijma, K. (2016). The aetiology of Czarnocka, J., and Slade, P. (2000). Prevalence and predictors of post-traumatic post-traumatic stress following childbirth: a meta-analysis and theoretical stress symptoms following childbirth. Br. J. Clin. Psychol. 39(Pt 1), 35–51. framework. Psychol. Med. 46, 1121–1134. doi: 10.1017/S00332917150 doi: 10.1348/014466500163095 02706 Davies, J., Slade, P., Wright, I., and Stewart, P. (2008). Posttraumatic stress Ayers, S., Harris, R., Sawyer, A., Parfitt, Y., and Ford, E. (2009). Posttraumatic stress symptoms following childbirth and mothers’ perceptions of their infants. Infant disorder after childbirth: analysis of symptom presentation and sampling. J. Ment. Health J. 29, 537–554. doi: 10.1002/imhj.20197 Affect. Disord. 119, 200–204. doi: 10.1016/j.jad.2009.02.029 Dekel, S., Mandl, C., and Solomon, Z. (2013b). Is the Holocaust implicated Ayers, S., and Pickering, A. D. (2001). Do women get posttraumatic stress disorder in posttraumatic growth in second-generation Holocaust survivors? as a result of childbirth? A prospective study of incidence. Birth 28, 111–118. A prospective study. J. Trauma. Stress 26, 530–533. doi: 10.1002/jts. doi: 10.1046/j.1523-536X.2001.00111.x 21836 Frontiers in Psychology | www.frontiersin.org 8 April 2017 | Volume 8 | Article 560 Dekel et al. PTSD and Childbirth Dekel, S., Solomon, Z., and Ein-Dor, T. (2016a). PTSD symptoms lead to Ozer, E. J., Best, S. R., Lipsey, T. L., and Weiss, D. S. (2003). Predictors of modification in the memory of the trauma: a prospective study of former posttraumatic stress disorder and symptoms in adults: a meta-analysis. Psychol. prisoners of war. J. Clin. Psychiatry 77, e290–e296. doi: 10.4088/JCP. Bull. 129, 52–73. doi: 10.1037/0033-2909.129.1.52 14m09114 Parfitt, Y., and Ayers, S. (2009). The effect of post-natal symptoms of post- Dekel, S., Solomon, Z., and Rozenstreich, E. (2013a). Secondary salutogenic effects traumatic stress and depression on the couple’s relationship and parent- in veterans whose parents were Holocaust survivors? J. Psychiatr. Res. 47, baby bond. J. Reprod. Infant Psychol. 27, 127–142. doi: 10.1080/026468308023 266–271. doi: 10.1016/j.jpsychires.2012.10.013 50831 Dekel, S., Stanger, V., Georgakopoulos, E. R., Stuebe, C. M., and Dishy, G. A. Polachek, I. S., Harari, L. H., Baum, M., and Strous, R. D. (2012). Postpartum post- (2016b). Peripartum depression, traditional culture, and Israeli society. J. Clin. traumatic stress disorder symptoms: the uninvited birth companion. Isr. Med. Psychol. 72, 784–794. doi: 10.1002/jclp.22360 Assoc. J. 14, 347–353. Dunmore, E., Clark, D. M., and Ehlers, A. (2001). A prospective investigation Ryding, E. L., Wijma, B., and Wijma, K. (1997). Posttraumatic stress reactions after of the role of cognitive factors in persistent posttraumatic stress disorder emergency cesarean section. Acta Obstet. Gynecol. Scand. 76, 856–861. (PTSD) after physical or sexual assault. Behav. Res. Ther. 39, 1063–1084. Schwab, W., Marth, C., and Bergant, A. M. (2012). Post-traumatic stress disorder doi: 10.1016/S0005-7967(00)00088-7 post partum: the impact of birth on the prevalence of post-traumatic stress Ehlers, A., and Clark, D. M. (2000). A cognitive model of posttraumatic stress disorder (PTSD) in multiparous women. Geburtshilfe Frauenheilkd. 72, 56–63. disorder. Behav. Res. Ther. 38, 319–345. doi: 10.1016/S0005-7967(99)00123-0 doi: 10.1055/s-0031-1280408 Ford, E., and Ayers, S. (2011). Support during birth interacts with prior trauma and Seng, J. S., Sperlich, M., Low, L. K., Ronis, D. L., Muzik, M., and Liberzon, I. (2013). birth intervention to predict postnatal post-traumatic stress symptoms. Psychol. Childhood abuse history, posttraumatic stress disorder, postpartum mental Health 26, 1553–1570. doi: 10.1080/08870446.2010.533770 health, and bonding: a prospective cohort study. J. Midwifery Womens Health Ford, E., Ayers, S., and Bradley, R. (2010). Exploration of a cognitive model to 58, 57–68. doi: 10.1111/j.1542-2011.2012.00237.x predict post-traumatic stress symptoms following childbirth. J. Anxiety Disord. Sexton, M. B., Hamilton, L., McGinnis, E. W., Rosenblum, K. L., and Muzik, 24, 353–359. doi: 10.1016/j.janxdis.2010.01.008 M. (2015). The roles of resilience and childhood trauma history: main and Garthus-Niegel, S., von Soest, T., Knoph, C., Simonsen, T. B., Torgersen, L., and moderating effects on postpartum maternal mental health and functioning. J. Eberhard-Gran, M. (2014). The influence of women’s preferences and actual Affect. Disord. 174, 562–568. doi: 10.1016/j.jad.2014.12.036 mode of delivery on post-traumatic stress symptoms following childbirth: Shaban, Z., Dolatian, M., Shams, J., Alavi-Majd, H., Mahmoodi, Z., and a population-based, longitudinal study. BMC Pregnancy Childbirth 14:191. Sajjadi, H. (2013). Post-traumatic stress disorder (PTSD) following childbirth: doi: 10.1186/1471-2393-14-191 prevalence and contributing factors. Iran. Red Crescent Med. J. 15, 177–182. Ghorbani, M., Dolatian, M., Shams, J., and Alavi-Majd, H. (2014). Anxiety, doi: 10.5812/ircmj.2312 post-traumatic stress disorder and social supports among parents of Shalev, A. (2009). Posttraumatic stress disorder and stress-related disorders. premature and full-term infants. Iran. Red Cresecent Med. J. 16:e13461. Psychiatr. Clin. North Am. 32, 687–704. doi: 10.1016/j.psc.2009. doi: 10.5812/ircmj.13461 06.001 Grekin, R., and O’Hara, M. W. (2014). Prevalence and risk factors of postpartum Soderquist, J., Wijma, B., and Wijma, K. (2006). The longitudinal course of post- posttraumatic stress disorder: a meta-analysis. Clin. Psychol. Rev. 34, 389–401. traumatic stress after childbirth. J. Psychosom. Obstet. Gynaecol. 27, 113–119. doi: 10.1016/j.cpr.2014.05.003 doi: 10.1080/01674820600712172 Ionio, C., and Blasio, P. D. (2014). Post-traumatic stress symptoms after childbirth Soet, J. E., Brack, G. A., and DiIorio, C. (2003). Prevalence and predictors of and early mother—child interactions: an exploratory study. J. Reprod. Infant women’s experience of psychological trauma during childbirth. Birth 30, 36–46. Psychol. 32, 163–181. doi: 10.1080/02646838.2013.841880 doi: 10.1046/j.1523-536X.2003.00215.x Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., and Nelson, C. B. Son, M. V., Verkerk, G., Hart, O. V. D., Komproe, I., and Pop, V. (2005). (1995). Posttraumatic stress disorder in the National Comorbidity Survey. Prenatal depression, mode of delivery and perinatal dissociation as predictors of Arch. Gen. Psychiatry 52, 1048–1060. doi: 10.1001/archpsyc.1995.039502400 postpartum posttraumatic sress: an empirical study. Clin. Psychol. Psychother. 66012 12, 297–312. doi: 10.1002/cpp.446 Lazarus, R. S. (1981). “The stress and coping paradigm,” in Models for Clinical Stroup, D. F., Berlin, J. A., Morton, S. C., Olkin, I., Williamson, G. D., Rennie, Psychopathology, eds C. C. D. Eisdorfer, A. Kleinman, and P. Maxim (New York, D., et al. (2000). Meta-analysis of observational studies in epidemiology: NY: Spectrum), 177–214. a proposal for reporting. Meta-analysis Of Observational Studies in Leeds, L., and Hargreaves, I. (2008). The psychological consequences of Epidemiology (MOOSE) group. JAMA 283, 2008–2012. doi: 10.1001/jama.283. childbirth. J. Reprod. Infant Psychol. 26, 108–122. doi: 10.1080/026468307016 15.2008 88299 Sumner, L. A., Wong, L., Schetter, C. D., Myers, H. F., and Rodriguez, M. Lev-Wiesel, R., and Daphna-Tekoah, S. (2010). The role of peripartum (2012). Predictors of posttraumatic stress disorder symptoms among low- dissociation as a predictor of posttraumatic stress symptoms following income latinas during pregnancy and postpartum. Psychol. Trauma 4, 196–203. childbirth in Israeli Jewish women. J. Trauma Dissociation 11, 266–283. doi: 10.1037/a0023538 doi: 10.1080/15299731003780887 Verreault, N., Da Costa, D., Marchand, A., Ireland, K., Banack, H., Dritsa, M., Milosavljevic, M., Lecic Tosevski, D., Soldatovic, I., Vukovic, O., Miljevic, et al. (2012). PTSD following childbirth: a prospective study of incidence C., Peljto, A., et al. (2016). Posttraumatic stress disorder after vaginal and risk factors in Canadian women. J. Psychosom. Res. 73, 257–263. delivery at primiparous women. Sci. Rep. 6:27554. doi: 10.1038/srep doi: 10.1016/j.jpsychores.2012.07.010 27554 Vossbeck-Elsebusch, A. N., Freisfeld, C., and Ehring, T. (2014). Predictors of Modarres, M. A., Afrasiabi, S., Rahnama, P., and Montazeri, A. (2012). Prevalence posttraumatic stress symptoms following childbirth. BMC Psychiatry 14:200. and risk factors of childbirth-related post-traumatic stress symptoms. BMC doi: 10.1186/1471-244X-14-200 Pregnancy Childbirth 12:88. doi: 10.1186/1471-2393-12-88 White, T., Matthey, S., Boyd, K., and Barnett, B. (2006). Postnatal depression O’Hara, M. W., and McCabe, J. E. (2013). Postpartum depression: current and post-traumatic stress after childbirth: prevalence, course and co- status and future directions. Annu. Rev. Clin. Psychol. 9, 379–407. occurrence. J. Reprod. Infant Psychol. 24, 107–120. doi: 10.1080/02646830600 doi: 10.1146/annurev-clinpsy-050212-185612 643874 Olde, E., van der Hart, O., Kleber, R. J., van Son, M. J., Wijnen, H. A., and Wijma, K., Soderquist, J., and Wijma, B. (1997). Posttraumatic stress disorder Pop, V. J. (2005). Peritraumatic dissociation and emotions as predictors of after childbirth: a cross sectional study. J. Anxiety Disord. 11, 587–597. PTSD symptoms following childbirth. J. Trauma Dissociation 6, 125–142. doi: 10.1016/S0887-6185(97)00041-8 doi: 10.1300/J229v06n03_06 Williams, C., Patricia Taylor, E., and Schwannauer, M. (2016). A web-based Olde, E., van der Hart, O., Kleber, R., and van Son, M. (2006). Posttraumatic survey of mother-infant bond, attachment experiences, and metacognition in stress following childbirth: a review. Clin. Psychol. Rev. 26, 1–16. posttraumatic stress following childbirth. Infant Ment. Health J. 37, 259–273. doi: 10.1016/j.cpr.2005.07.002 doi: 10.1002/imhj.21564 Frontiers in Psychology | www.frontiersin.org 9 April 2017 | Volume 8 | Article 560 Dekel et al. PTSD and Childbirth Yildiz, P. D., Ayers, S., and Phillips, L. (2017). The prevalence of posttraumatic Conflict of Interest Statement: The authors declare that the research was stress disorder in pregnancy and after birth: a systematic review and meta- conducted in the absence of any commercial or financial relationships that could analysis. J. Affect. Disord. 208, 634–645. doi: 10.1016/j.jad.2016.10.009 be construed as a potential conflict of interest. Zaers, S., Waschke, M., and Ehlert, U. (2008). Depressive symptoms and symptoms of post-traumatic stress disorder in women after childbirth. J. Psychosom. Copyright © 2017 Dekel, Stuebe and Dishy. This is an open-access article distributed Obstet. Gynaecol. 29, 61–71. doi: 10.1080/01674820701804324 under the terms of the Creative Commons Attribution License (CC BY). The use, Zambaldi, C. F., Cantilino, A., and Sougey, E. B. (2011). Bio-socio-demographic distribution or reproduction in other forums is permitted, provided the original factors associated with post-traumatic stress disorder in a sample of author(s) or licensor are credited and that the original publication in this journal postpartum Brazilian women. Arch. Womens Ment. Health 14, 435–439. is cited, in accordance with accepted academic practice. No use, distribution or doi: 10.1007/s00737-011-0224-4 reproduction is permitted which does not comply with these terms. Frontiers in Psychology | www.frontiersin.org 10 April 2017 | Volume 8 | Article 560 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Frontiers in Psychology Pubmed Central

Childbirth Induced Posttraumatic Stress Syndrome: A Systematic Review of Prevalence and Risk Factors

Frontiers in Psychology , Volume 8 – Apr 11, 2017

Loading next page...
 
/lp/pubmed-central/childbirth-induced-posttraumatic-stress-syndrome-a-systematic-review-vI00oWftCW

References (75)

Publisher
Pubmed Central
Copyright
Copyright © 2017 Dekel, Stuebe and Dishy.
ISSN
1664-1078
eISSN
1664-1078
DOI
10.3389/fpsyg.2017.00560
Publisher site
See Article on Publisher Site

Abstract

REVIEW published: 11 April 2017 doi: 10.3389/fpsyg.2017.00560 Childbirth Induced Posttraumatic Stress Syndrome: A Systematic Review of Prevalence and Risk Factors 1, 2 2 2 Sharon Dekel *, Caren Stuebe and Gabriella Dishy 1 2 Department of Psychiatry, Harvard Medical School, Boston, MA, USA, Department of Psychiatry, Massachusetts General Hospital, Charlestown, MA, USA Background: Posttraumatic stress related with the childbirth experience of full-term delivery with health outcomes has been recently documented in a growing body of studies. The magnitude of this condition and the factors that might put a woman at risk for developing childbirth-related postpartum posttraumatic stress disorder (PP-PTSD) symptoms are not fully understood. Methods: In this systematic review of 36 articles representing quantitative studies of primarily community samples, we set to examine PP-PTSD prevalence rates and associated predictors with a focus on the role of prior PTSD and time since childbirth. Results: A significant minority of women endorsed PP-PTSD following successful birth. Acute PP-PTSD rates were between 4.6 and 6.3%, and endorsement of clinically Edited by: Alessandra Simonelli, significant PP-PTSD symptoms was identified in up to 16.8% of women in community University of Padua, Italy samples of high quality studies. Negative subjective experience of childbirth emerged as Reviewed by: the most important predictor. Endorsement of PTSD before childbirth contributed to PP- Ana Lúcia R. Moreira, Centro Hospitalar do Oeste, Portugal PTSD; nevertheless, women without PTSD also exhibited PP-PTSD, with acute rates at Serge Brand, 4.6%, signifying a new PTSD onset in the postpartum period. University of Basel, Switzerland Conclusion: Although the majority of women cope well, childbirth for some can be *Correspondence: Sharon Dekel perceived as a highly stressful experience and even result in the development of PP- sdekel@mgh.harvard.edu PTSD symptoms. More research is needed to understand postpartum adaption and childbirth-related posttraumatic stress outcomes. Specialty section: This article was submitted to Keywords: postpartum PTSD, childbirth, systematic review, posttraumatic stress, delivery, obstetrics, Psychopathology, psychopathology, resilience a section of the journal Frontiers in Psychology Received: 23 November 2016 INTRODUCTION Accepted: 27 March 2017 Published: 11 April 2017 Many people think of childbirth as a uniformly happy event. This belief may be responsible for the Citation: paucity of research into its possible deleterious outcomes. As unpleasant as it may be to face this, Dekel S, Stuebe C and Dishy G (2017) such research as exists indicates that childbirth may have negative (as well as positive) psychological Childbirth Induced Posttraumatic effects. Postpartum women may experience psychological distress, and some may even develop Stress Syndrome: A Systematic mental disorders. Although postpartum depression has been extensively described (O’Hara and Review of Prevalence and Risk McCabe, 2013), accumulating data suggests that new mothers may also exhibit a posttraumatic Factors. Front. Psychol. 8:560. doi: 10.3389/fpsyg.2017.00560 stress response induced by the childbirth experience and may even suffer from childbirth-related Frontiers in Psychology | www.frontiersin.org 1 April 2017 | Volume 8 | Article 560 Dekel et al. PTSD and Childbirth postpartum traumatic stress disorder (PP-PTSD) following childbirth. An estimated lifetime prevalence of PTSD in women successful birth (Olde et al., 2006; Grekin and O’Hara, 2014). is 10.4% and those who develop symptoms are highly susceptible As many as a third of women rate their delivery as to PTSD endorsement in relation to subsequent traumatic events psychologically traumatic (Ayers and Pickering, 2001), and as (Kessler et al., 1995). PTSD is associated with a negative appraisal many as one quarter report some component of clinically of subsequent events (Ehlers and Clark, 2000). In accord with significant PP-PTSD symptoms (Czarnocka and Slade, 2000). Ayers (2004) the vulnerability factor of prior PTSD is likely Co-morbidity of PP-PTSD and postpartum depression is high, to interact with birth events to determine appraisal of birth as as evident in up to 72% of cases of women endorsing PP-PTSD traumatic and development of a traumatic stress responses. Thus, (Yildiz et al., 2017), and some may also endorse suicide ideation, prepartum PTSD symptoms may continue into the postpartum as evident in 23% of cases (Dekel et al., in preparation). PP-PTSD period and trigger PP-PTSD. In contrast, PP-PTSD may signify may impair maternal bonding and indirectly have adverse affects the occurrence of first-time posttraumatic stress syndrome onset. on infant health (Williams et al., 2016). Hence, PP-PTSD is a Having a difficult childbirth experience (subjective or objective) problem deserving of attention. for some women might be extreme enough to result in PP-PTSD A stress-diathesis model has been proposed to understand without having prior PTSD symptoms. The childbirth event the factors giving rising to PP-PTSD (Ayers, 2004). Accordingly, would then be regarded as the index event of traumatic exposure, PP-PTSD is the outcome of the interplay between pre-birth although other vulnerability factors are possible. Women with a vulnerability factors, risk factors in birth, and factors after history of trauma exposure, who do not exhibit prepartum PTSD, birth (Ayers et al., 2016). Factors such as pre-existing maternal may be a special case. Trauma history may reduce the ability to psychiatric problems, a negative birth experience, and lack of cope with subsequent stressful events (Dekel et al., 2013a), as social support, have been consistently reported as commonly noted in a sensitization effect (Breslau et al., 1999; Dekel et al., endorsed risk factors (e.g., Andersen et al., 2012). These risks are 2013b). Thus, women with trauma history may exhibit a delayed broadly comparable with factors associated with PTSD in relation PTSD response induced by childbirth. to other stressors (Ozer et al., 2003). Another factor to consider in understanding incidences of Much less agreement concerns the estimates of the incidence PP-PTSD is the passage of time since childbirth. Although the of PP-PTSD. PP-PTSD rates are between 1 and 30%, too wide majority of individuals endorse posttraumatic stress symptoms a range to be very useful (Andersen et al., 2012; Grekin and (i.e., PTS) in the immediate aftermath of trauma, symptoms O’Hara, 2014). Partial PP-PTSD, i.e., PTSD symptoms occurring subside for most survivors and a significant minority fails to at a clinically significant level, has also been noted, but again with recover (Bonanno et al., 2005; Shalev, 2009). Previous studies a similar pattern of widely estimated rates (Czarnocka and Slade, assessed rates of PP-PTSD at different time points ranging from 2000; Soet et al., 2003; Polachek et al., 2012). the first days following childbirth to several months, which may Several review studies have been conducted on the topic. Olde account for the wide prevalence rates among the studies. et al. (2006) groundbreaking qualitative review of 19 studies Thus, in the following systematic review, we examined the published between 1997 and 2003 identified PP-PTSD following prevalence rates of PP-PTSD with a focus on the time period of successful birth in up to 5.6% of women at 6 weeks postpartum. A symptoms endorsement following childbirth. We set to examine subsequent review by Andersen et al. (2012) of 31 studies between PP-PTSD in relation to the endorsement of new posttraumatic 2003 and 2010 utilized a study quality ranking. They noted PP- stress syndrome as well as in relation to prior PTSD. We also PTSD rates in high quality studies were up to 4.6% between set to examine the risk factors involved in the development of three and 12 months postpartum. Recent reviews importantly PP-PTSD. targeted community in comparison to at-risks samples (Grekin and O’Hara, 2014). As might be expected, PP-PTSD rates were METHODS approximately fivefold higher (15.7%) in at-risk groups than in the community (3.1%). Yildiz et al. (2017) report similar results Study Criteria Selection from reviewing 28 studies using a diagnostic measure of PTSD, The search of literature targeted a wide range of studies, documenting once again a wide PP-PTSD rate variability among published from January 1980 until 1 August 2016. A search the studies. of PubMed and PsychInfo databases was performed using any These reviews support the existence of PTSD following combination of keywords: posttraumatic stress, posttraumatic childbirth; however, some clarification remains. While earlier stress disorder, traumatic stress with childbirth, PTSD, reviews reported on the prevalence of PTSD during the postpartum, or postnatal. Studies were also found through postpartum period, it is not clear whether the studies were the “Related Citations” function on PubMed and through the limited to those reporting on PTSD induced by childbirth. To reference lists of previously identified studies. Previous reviews our knowledge, a review comparing PP-PTSD prevalence in the on PTSD following childbirth were another basis to identify context of prior PTSD versus a first time onset in the postpartum studies. period was not conducted to-date. Such analysis is important to Studies included in our review were quantitative studies, fully grasp the magnitude of the childbirth stressor. published in English, and met the following criteria: (a) full-term PP-PTSD can be conceptualized in at least two ways. PTSD successful births; (b) indication of prevalence of PP-PTSD, at a related to the childbirth event may develop in the context of maximum initial assessment of 6 months postpartum; and (c) endorsement of existing posttraumatic stress syndrome before PP-PTSD stressor specified in relation to childbirth. Frontiers in Psychology | www.frontiersin.org 2 April 2017 | Volume 8 | Article 560 Dekel et al. PTSD and Childbirth TABLE 1 | Quality Coding System Criteria. A total of 93 articles were identified via the search criteria. Of this total, 57 articles were removed either for failure to meet I. DATA COLLECTION criteria or to avoid duplicate samples. The final review included Single item measures 0 36 articles, with 32 representing community samples and four Study-specific measures 1 representing at-risk groups. Self-report questionnaire 2 Clinical interview 3 Study Rating System II. SAMPLE SIZE A quality rating system modeled off Andersen et al. (2012) ≤29 0 was utilized to assess identified studies. This system is based 30–99 1 in part upon the Meta-analysis of Observational Studies in 100–199 2 Epidemiology (MOOSE) technique (Stroup et al., 2000). It is 200–399 3 designed to assess study quality by accounting for methodological ≥400 4 differences among the studies. In this review, several factors III. NATURE OF SAMPLE were assessed to determine study quality such as sample size, Self-selective 0 method of data collection, measurement used, etc. Table 1 Target/risk group 2 indicates the full list of factors, their corresponding items, Representative 4 and the point value assigned to each item. For example, the IV. INITIAL RESPONSE RATE factor Data Collection included four items: single-item measures, Cross-sectional only 0 study-specific measures, self-report questionnaire, and clinical interview. Single-item measures were assigned a point value of < 50% 1 50-75% 2 one, leading up to clinical interview, which was assigned a point value of four. Thus, a study would be given a score ranging > 75% 3 from one to four for data collection. The sum of each factor V. PRESENCE OF PRE-PARTUM MEASUREMENTS resulted in an overall study quality score, ranging from 2 to 27 No 0 points. Yes 1 According to their study quality score, each study was ranked VI. HISTORY OF TRAUMA as either A or B. The A category included studies with the No 0 highest methodological ranking, and, for the relevance of this Yes 1 review, those that controlled for PTSD symptom endorsement VI. HISTORY OF PTSD before childbirth (“controlled studies”). The B category included No 0 studies that may have received a lower quality score due to Yes 1 smaller sample size, fewer postpartum time assessments, lack VII. POST-PARTUM COLLECTION POINTS of perinatal assessments, etc., or due to less relevance to this One Time 1 review. All studies in B did not control for PTSD before childbirth Two Times 2 (“uncontrolled studies”). Three+ Times 3 Two research assistants analyzed and rated the 36 identified VIII. PTSD ASSESSMENT articles. Inter-rater agreement between the research assistants Post-Partum only 0 was high and reached 92%. If disagreements in coding arose, the Pre- and Post-Partum 1 disagreement was discussed and resolved to reach a consensus. Post-Partum and IOC 2 In the next step, we calculated PTSD prevalence rates within Pre-, Post-, and IOC 3 studies in Groups A and B by taking into consideration IX. INITIAL POST-PARTUM ASSESSMENT the time of postpartum assessment. In accordance with Years 1 PTSD DSM-4 (American Psychiatric Association, 2000), PP- Months 2 PTSD assessed more than 1 month and up to 3 months Weeks 3 postpartum was labeled “acute PP-PTSD,” and assessment Days 4 more than 3 months and up to 6 months postpartum was SUM OF POINTS 2–27 labeled “chronic PP-PTSD.” In addition, PP-PTSD symptoms measured within 1 month postpartum were labeled postpartum The drop-out rate among studies was evaluated after the initial time point. The prevalence of high drop-out rates in some studies could indicate selection bias. A sum of points posttraumatic stress, i.e., PP-PTS. PTSD rate for each time was calculated based on the coding factors below. The minimum and maximum scores point was created by computing the mean PTSD value. achievable were 2 and 27, respectively. Studies scoring 2–18 points were ranked as B, We also computed the overall PP-PTSD rate assessed by and 19–27 points were ranked as A. IOC, Index of Childbirth. averaging the time categories (PP-PTS + acute PTSD + chronic PTSD). factors had to be of statistical significance. Each identified risk Risk Factor Analysis factor was assigned a point value based on the group rank of Risk factors for PP-PTSD, if presented by the studies, were the study. For example, a risk factor identified from a Group A identified and analyzed. To be included in the analysis, risk study was assigned a point value of two. Risk factors identified Frontiers in Psychology | www.frontiersin.org 3 April 2017 | Volume 8 | Article 560 Dekel et al. PTSD and Childbirth TABLE 2 | Group A Studies. Study Sample size Type of sample Study site Measures of PP-PTSD Measurement times postpartum Abedian et al., 2013 n = 100 Women with preeclampsia Iran PPQ 6 weeks a,b Alcron et al., 2010 n = 866 Community Australia PDS T1: 4-6 weeks T2: 12 weeks T3: 24 weeks Ayers et al., 2009 n = 1423 Community UK PDS 3-12 months Ayers and Pickering, 2001 n = 289 Community UK MMPI-2 PTSD Scale T1: 6 weeks T2: 6 months Boorman et al., 2014 n = 890 Community Australia Criterion A1 and A2 assessment 14 days Cigoli et al., 2006 n = 160 Community Italy PTSD-Q 3–6 months Cohen et al., 2004 n = 200 Community Canada DTS 8–10 weeks Czarnocka and Slade, 2000 n = 264 Community UK PTSD-Q 6 weeks Davies et al., 2008 n = 211 Community UK PTSD-Q 6 weeks Ford et al., 2010 n = 138 Community UK PDS T1: 3 weeks T2: 3 months Garthus-Niegel et al., 2014 n = 1700 Community Norway IES 8 weeks Ionio and Blasio, 2014 n = 19 Community Italy PPQ T1: 2 days T2: 2 months Milosavljevic et al., 2016 n =1 26 community Serbia CAPS T1: 1 month T2: 2 months T3: 3 months Polachek et al., 2012 n = 89 Community Israel PDS 1 month a,b Schwab et al., 2012 n = 56 Community Iran PDS 6 weeks a,b Seng et al., 2013 n = 566 Community USA NWS PTSD module 6 weeks Soderquist et al., 2006 n = 1224 Community Sweden TES T1: 1 month T2: 4 months T3: 7 months T4: 11 months Son et al., 2005 n = 248 Community Netherlands IES T1: 3 months T2: 6 months T3: 12 months Sumner et al., 2012 n = 206 Low-income Latinas South America PCL-C T1: 7 months T2: 13 months Verreault et al., 2012 n = 308 Community Canada SCID-I; MPSS-SR 1 month a,b Vossbeck-Elsebusch et al., 2014 n = 224 Community Germany PDS 1–6 months White et al., 2006 n = 318 Community Australia PSS-SR T1: 6 weeks T2: 6 months T3: 12 months a,b Zambaldi et al., 2011 n = 400 Community Brazil M.I.N.I. 2–26 weeks PP-PTSD endorsement was defined as reaching a score above the cut-off for PTSD symptom severity, or as being in accord with DSM PTSD symptom criteria (DSM-4 or DSM-5). CAPS, Clinician-Administered PTSD Scale; DTS, Davidson Trauma Scale; IES, Impact of Event Scale; M.I.N.I., Mini-International Neuropsychiatric Interview; MMPI-2 PTSD Scale, Minnesota Multiphasic Personality Inventory-2 Posttraumatic Stress Disorder Scale; MPSS-SR, Modified PTSD Symptom Scale Self-Report; NWS PTSD Module, National Women’s Study PTSD Module; PCL-C, PTSD Checklist-Civilian Version; PDS, Posttraumatic Stress Diagnostic Scale – Self-report version; PPQ, Perinatal PTSD Questionnaire; PSS-SR, Posttraumatic Stress Symptom Scale – Self-report version; PTSD-Q, Posttraumatic Stress Disorder Questionnaire; SCID-I, Structured Clinical Interview for DSM-4; TES, Traumatic Event Scale. Studies that did not control for prior PP-PTSD. Studies that controlled for prior PP-PTSD. from Group B were assigned a point value of one. If multiple account for risk factors that did not fall within the five identified studies reported the same risk factor, that risk factor received a categories. summed score. Risk factors of similar nature were then grouped into RESULTS categories. For example, risk factors such as prenatal depression and perinatal anxiety were grouped under the category “Maternal Study Classification Mental Health.” Five categories were created. The category score The identified 36 articles meeting inclusion criteria were was the sum of the individual risk factors, and was above categorized into groups A and B in accordance with the 15 for each category. A miscellaneous category was added to proposed coding system. Group A included 23 studies which Frontiers in Psychology | www.frontiersin.org 4 April 2017 | Volume 8 | Article 560 Dekel et al. PTSD and Childbirth were categorized according to whether they controlled for For “Uncontrolled” studies in Group A, the overall PP-PTSD endorsement of PTSD prior to childbirth (controlled) or not prevalence was 5.5%. Rates of PP-PTS and acute PP-PTSD were (uncontrolled) (See Table 2). Group B included 13 studies (See similar, at 6.7 and 6.3%, respectively. Again, chronic PP-PTSD Table 3). rates were lower at 3.4%. The overall partial PP-PTSD rate, as might be expected, was much higher, at 16.8%; three times higher PP-PTSD Prevalence than the rates for overall PP-PTSD. For example, a uncontrolled All 36 articles included in this review reported the prevalence of study (N = 308 of community sample) reported partial and childbirth-related PP-PTSD, with 18 studies also reporting the full PP-PTSD rates of 7.6 and 16.6%, respectively, at 1 month prevalence of partial PP-PTSD. (Verreault et al., 2012). Table 4 presents PP-PTSD prevalence according to group In Group B, the overall PP-PTSD prevalence including at-risk classification (A and B), time of postpartum assessment, and type samples was 6.2%. The prevalence rates also varied according of sample (community vs. at-risk). As indicated previously: “PP- to time of assessment, with lowest rates found for PP-PTS PTS” noted was for symptoms ≤1 month postpartum; “acute and highest for acute PP-PTSD. PP-PTS prevalence was 1.0%, PP-PTSD” for symptoms >1month postpartum but <3 months whereas acute PP-PTSD was 8.1% in the community sample postpartum; and “chronic PP-PTSD” for symptoms >3 months and 11.1% when including at-risk groups. Chronic PP-PTSD and ≤6 months. Overall, PP-PTSD and partial PTSD referred to prevalence was lower than acute, with rates of 4.6% in community symptoms across time points. samples and 6.7% including at-risk samples. Rates of partial For “Controlled” studies in Group A, the overall PP-PTSD PP-PTSD were highest at 27.3%. prevalence was 4.9%, including at-risk samples. Though PP- PP-PTSD Risk Factors PTS rates were 0.8%, acute PP-PTSD rates were much higher, with 4.6% in community samples and 10.1% including at-risk. Five categories of risk factors were identified: negative perception Chronic PP-PTSD rates were 1.8% in the community sample and of childbirth, maternal mental health, trauma history, and PTSD, 3.9% including at-risk samples, suggesting a decline in PP-PTSD delivery mode and complications, and low social support. Table 5 endorsement. Overall partial PP-PTSD was 9.6%. For example, a presents the categories and their risk factors. controlled community study (N = 211 of primi- and multiparas Factors relating to negative subjective experience of childbirth women who underwent various modes of delivery with healthy received the highest weighted score of 28 points, and were thus outcomes) reported rates of full and partial PP-PTSD at 3.8 and identified as the most potent predictors of PP-PTSD. The most 21.3%, respectively, at 6 weeks postpartum (Davies et al., 2008). significant risk factor, reported by five studies, was negative TABLE 3 | Group B Studies. Study Sample size Type of sample Study site Measures of PTSD Measurement times post-partum Adewuya et al., 2006 n = 876 Community Nigeria M.I.N.I 6 weeks Beck et al., 2011 n = 903 Community USA PSS-SR 6 months Ghorbani et al., 2014 n = 82 Community Iran PSS <2 months Leeds and Hargreaves, n = 102 Community UK PCL; PPQ 6–12 months Modarres et al., 2012 n = 400 Women with traumatic delivery Iran PSS-I 6–8 weeks Olde et al., 2005 n = 140 Community Netherlands PSS-SR T1: 1–7 days T2: 3 months Parfitt and Ayers, 2009 n = 152 Community UK PDS 10 months Ryding et al., 1997 n = 25 Community Sweden CI; FET T1: 1–9 days T2: 1–2 months Sexton et al., 2015 n = 214 Women who had experienced child USA NWS PTSD 4 months abuse and neglect Shaban et al., 2013 n = 600 Community Iran PSDS 6–8 weeks Soet et al., 2003 n = 103 Community USA Telephone interview including TES 1 months Wijma et al., 1997 n = 1640 Community Sweden TES T1: 1–13 months Zaers et al., 2008 n = 60 Community Germany PDS T1: 6 weeks T2: 6 months PP-PTSD endorsement was defined as reaching a score above the cut-off for PTSD symptom severity, or as being in accord with DSM PTSD symptom criteria [DSM-4 (American Psychiatric Association, 2000) and DSM-5 (American Psychiatric Association, 2013)]. CI, Clinical Interview; FET, Fisher’s Exact Test; M.I.N.I., Mini-International Neuropsychiatric Interview; NWS PTSD, National Women’s Study PTSD Module; PCL, Posttraumatic Stress Disorder Checklist; PDS, Posttraumatic Stress Diagnostic Scale; PPQ, Perinatal PTSD Questionnaire; PSDS, Posttraumatic Stress Disorder Symptom Scale; PSS, Posttraumatic Stress Disorder Symptoms Scale; PSS-I, Posttraumatic Symptom Scale-Interview; PSS-SR, Posttraumatic a b c Stress Symptom Scale-Self-report version; TES, Traumatic Event Scale. Sample that completed PTSD assessment. Sample that only includes full-term births. Mean postpartum measurement time. Two-thirds of women in the sample had experienced child abuse and neglect. Frontiers in Psychology | www.frontiersin.org 5 April 2017 | Volume 8 | Article 560 Dekel et al. PTSD and Childbirth TABLE 4 | Prevalence rates for PP-PTSD in relation to PTSD history and time of assessment. A B PP-PTSD Controlled Uncontrolled Uncontrolled PP-PTS 0.80% 6.70% (1.3–14.3) 1.00% (0–1.9) a b a b a b a b Acute PP-PTSD 10.10% ; 4.60% (1.2–37.8) ; (1.2–11.2) 6.30% (0–21.5) 11.10% ; 8.10% (1.2–21.5) ; (1.2–17.2) a b a b a b a b Chronic PP-PTSD 3.90% ; 1.80% (0–9.65) ; (0–3.1) 3.40% (0.9–6) 6.70% ; 4.60% (1.2–19.6) ; (1.2–6.4) a b a b Overall 4.90% ; 2.40% 5.50% 6.20% ; 4.50% Partial PP-PTSD 9.60% (1.3–21.3) 16.80% (6.1–28.8) 27.30% (9.1–19.6) Numbers reflect percentage of women who endorse PP-PTSD symptoms. Numbers in parentheses indicate range of prevalence rates reported. PP-PTSD, Postpartum Posttraumatic Stress Disorder. PP-PTS, PTSD symptoms assessed within one month postpartum. Acute PP-PTSD, PTSD assessed more than one month postpartum but less than three. Chronic PP-PTSD, PTSD assessed from three months postpartum on. Controlled and uncontrolled studies, studies that did and did not control for PTSD prior to childbirth. Population sample including both community and at-risk groups; Community samples. delivery experience (Wijma et al., 1997; Son et al., 2005; Zaers Adewuya et al., 2006; Zambaldi et al., 2011; Modarres et al., et al., 2008; Verreault et al., 2012; Garthus-Niegel et al., 2014). 2012; Boorman et al., 2014; Vossbeck-Elsebusch et al., 2014; Fear of childbirth for the self and/or baby and low internal locus Milosavljevic et al., 2016). Two studies also noted instrumental of control during childbirth were also significant factors noted deliveries as a significant risk factor (Adewuya et al., 2006; in this category, and were reported by several studies (Czarnocka Milosavljevic et al., 2016). and Slade, 2000; Soet et al., 2003; Adewuya et al., 2006; Soderquist The final category pertained to low levels of social support, et al., 2006; Leeds and Hargreaves, 2008; Garthus-Niegel et al., and received a weighted score of 17 points. Three studies referred 2014). to low levels of social support in general as a risk factor (Soet The next most significant group of risk factors included those et al., 2003; Ford et al., 2010; Sumner et al., 2012). The remaining pertaining to maternal mental health. This group received a studies were more specific in regards to the support group, weighted score of 25 points. The presence of prenatal depression with one study reporting low family support, three studies was the most commonly noted factor within this group, as reporting low staff support, and three studies reporting low documented in five studies (Cohen et al., 2004; Soderquist partner support (Czarnocka and Slade, 2000; Cigoli et al., 2006; et al., 2006; Leeds and Hargreaves, 2008; Sumner et al., 2012; Parfitt and Ayers, 2009; Beck et al., 2011; Ford and Ayers, 2011). Shaban et al., 2013). Having a history of psychological problems Previous counseling related to childbirth or pregnancy was also a prior to pregnancy was found to significantly contribute to the contributing factor (Soderquist et al., 2006). endorsement of PP-PTSD as well (Soderquist et al., 2006; Leeds Finally, we identified common risk factors that did not fit into and Hargreaves, 2008; Zaers et al., 2008; Zambaldi et al., 2011; the noted risk factors categories. These factors largely pertain to Boorman et al., 2014). Perinatal somatoform and anxiety were demographics and included the risk factors such as young age, also significant factors cited by six studies (Soet et al., 2003; Olde low income, primiparity, and multiparity (Zambaldi et al., 2011; et al., 2005; Zaers et al., 2008; Zambaldi et al., 2011; Verreault Abedian et al., 2013; Boorman et al., 2014; Vossbeck-Elsebusch et al., 2012; Shaban et al., 2013). Finally, acute postpartum et al., 2014). depression symptoms were found to predict later PP-PTSD (Beck et al., 2011). DISCUSSION Factors falling within the trauma history and PTSD category comprised the third highest weighted score of 24 points. A history Posttraumatic stress syndrome related with the childbirth of trauma exposure of any type was the most commonly reported experience has been largely overlooked. That a mostly voluntary risk factor as noted in three studies (White et al., 2006; Zaers event implicated in reproduction can trigger PP-PTSD does not et al., 2008; Ayers et al., 2009). Childhood sexual trauma in reconcile with the positive notion of childbirth. Yet, childbirth particular was found to be a highly cited factor, as well as pre- involves drastic physiological changes of hormonal imbalance, traumatic stress in pregnancy (Soderquist et al., 2006; Lev-Wiesel blood and body weight loss, increased cardiac output, and is and Daphna-Tekoah, 2010; Verreault et al., 2012; Sexton et al., often accompanied by acute bodily pain and sleep deprivation. 2015). As might be expected, the endorsement of PTSD during Not surprisingly, a full-term delivery with healthy outcomes may pregnancy was a strong predictor of PP-PTSD (Seng et al., 2013). nonetheless be associated with threat on bodily integrity and a Trauma related to interpersonal violence and having a previous sense of fear and loss of control. traumatic birth experience were other frequently reported factors There are two competing theories on childbirth-related PTSD. (Polachek et al., 2012; Sumner et al., 2012). First, PP-PTSD signifies amplification of pre-existing traumatic Risk factors related to delivery mode and complications stress symptoms. Second, PP-PTSD indicates a new PTSD onset constituted the fourth highest weighted category of 22 points. induced by the childbirth experience rather than continuation of Emergency cesarean section and complications with the perinatal PTSD. We explored predictions from these theories by pregnancy and/or baby were the most cited risk factors in this analyzing 36 articles reporting the rates of PP-PTSD symptoms category, reported by seven studies total (Cohen et al., 2004; associated with the experience of healthy, full-term birth. Frontiers in Psychology | www.frontiersin.org 6 April 2017 | Volume 8 | Article 560 Dekel et al. PTSD and Childbirth Overall, the prevalence rates of PP-PTSD, in its acute form (between 1 and 3 months postpartum) were 5–8% in community samples. The prevalence of clinically significant symptoms of PP-PTSD, was higher, and ranged between 9.6 and 27.3%. It is estimated that four million babies are born in the States each year. While our results suggest that at a minimum only 5 out of 100 women will experience a sort of PP-PTSD, when translated to the larger sample of four million, this is roughly two hundred thousand mothers at-risk. New PTSD onset following childbirth was noted in the studies reviewed here, suggesting that for some women childbirth can be perceived as a highly stressful experience capable of triggering PTSD without having prior PTSD. In fact, rates of new PTSD onset evident in samples of women without PTSD before childbirth were slightly lower than in samples including women with or without PTSD history, 4.6 vs. 6.3% for acute PP-PTSD in studies of high quality. Although these findings may be attributed to differences in the nature of the samples, we applied a quality approach to compare between the studies. Alternatively, the findings may suggest that for a significant sub-group of women, PTSD symptoms do not carry on from pregnancy to childbirth but rather develop for the first time in the immediate postpartum period. Although several reviews have been conducted on PTSD in relation to childbirth, this is the first attempt to distinguish between syndromes of new and prior PTSD endorsement. Various risk factors were also reviewed and identified as potentially predictive of the development of PP-PTSD, mainly pre-trauma related factors and peritraumatic aspects related to the childbirth. Although predisposing mental health conditions and prior trauma were associated with subsequent PP-PTSD, peritraumatic factors and early emotional symptoms emerged as the strongest predictor. Obstetrical factors and related complications, which may entail threat to life of mother and/or baby, were ranked as less important. These findings accord with the previous reviews (Andersen et al., 2012) and are also in line with the literature of PTSD in relation to other stressors (Ozer et al., 2003). It has been documented that the subjective experience of the traumatic event is a more important factor in predicting PTSD than its objective stressor severity (Bowman, 1999; Dekel et al., 2016a). Subjective negative childbirth experience, as our data reveals, pertains to having a negative appraisal of the event (primary appraisal) and of one’s ability to cope with the stressor (secondary appraisal) (Lazarus, 1981). These kinds of negative appraisals have been linked with the development and endurance of PTSD following traumatic experiences (Dunmore et al., 2001). Several limitations in this review should be noted. Although identified studies used well-validated measures of PP-PTSD symptoms, whether participants had clinically diagnosed PP- PTSD was assessed by some studies but not in all. While we identified common risk factors for PP-PTSD, the interplay between the factors was not assessed, and there might be other unknown factors that have not been studied yet. Analysis of quantitative studies allowed for study comparison; however, qualitative studies may have offered important information as well. We applied a quality rating to compare and integrate studies, but might have overlooked factors that may bias the Frontiers in Psychology | www.frontiersin.org 7 April 2017 | Volume 8 | Article 560 TABLE 5 | Risk factors associated with PP-PTSD. Subjective experience of childbirth 28 Maternal mental health 25 Trauma history and PTSD 24 Delivery mode and complications 22 Low social support 17 Negative delivery experience 8 Prenatal depression 8 Previous traumatic events 9 Emergency caesarean section 7 Staff 6 Fear of childbirth for self and/or baby 6 History of psychological problems 7 Childhood sexual trauma 5 Complications with pregnancy and/or baby 5 Overall 5 Low internal locus of control during childbirth 5 Perinatal anxiety 5 Prenatal PTSD 2 Instrumental delivery 4 Partner 4 Post-traumatic cognitions 4 Perinatal somatoform 3 Previous traumatic birth experience 2 Planned caesarean birth 2 Family 2 Pain in labor 3 Postpartum depression 1 Pre-traumatic stress in pregnancy 2 Long labor duration 1 Low coping ability 1 Manual removal of placenta 1 Perinatal dissociation 1 Preterm birth 1 Unexpectedness of procedures 1 Pressure to have an induction and epidural analgesia 1 PP-PTSD, Postpartum Posttraumatic Stress Disorder. Dekel et al. PTSD and Childbirth results. Although we mainly reviewed community samples, to identify at-risk women in the immediate peripartum period important confounding factors such as age, medical issues and to intervene accordingly. At a broader level, our findings during birth, mode of delivery, and peripartum anxiety, were suggest that by nature women are resilient and cope well with not taken into account when reporting PP-PTSD rates. We the childbirth experience. Childbirth is not inevitably appraised included samples derived from different world regions, which as traumatic. Examining biological factors underlining positive offers a broad perspective on PP-PTSD but might create wide adaptation and posttraumatic stress reactions is likely to provide variations in prevalence rates. Ideally, we would have targeted insight into this under-researched scientific territory. large, prospective, longitudinal studies to clarify childbirth- related PTSD with/without PTSD or trauma history and the AUTHOR CONTRIBUTIONS moderating factor of culture (Dekel et al., 2016b). Future studies are warranted to examine the various pathways for the SD supervised coding of articles and data analysis and headed development of PP-PTSD and its symptom trajectory. manuscript writing. CS identified and coded articles, completed Within the context of these limitations, the current review data analysis, and contributed to manuscript writing. GD provides important evidence for the endorsement of PTSD identified and coded articles. related with childbirth. Although there has been controversy regarding whether PTSD could be induced by childbirth, our FUNDING findings indicate that a significant sub-group of women with and without prior PTSD may develop PP-PTSD of an enduring This work was supported by MGH ECOR Claflin Distinguished nature. The development of PTSD in relation to a relatively Scholar Award and the Brain and Behavior Research Foundation predicted event (i.e., birth) during routine clinical care offers (NARSAD) Grant awarded to SD. the opportunity to potentially identify women at high risk for PP-PTSD and provide specific preventive interventions, both ACKNOWLEDGMENTS of which are currently lacking. As this study demonstrates, having a negative childbirth experience is an important factor We thank Ms. Olivia Lanman for assisting with the coding of the reviewed studies. implicated in PP-PTSD. Childbirth accounts may be a useful tool REFERENCES Beck, C. T., Gable, R. K., Sakala, C., and Declercq, E. R. (2011). Posttraumatic stress disorder in new mothers: results from a two-stage Abedian, Z., Narges, S., Mokhber, N., and Esmaily, H. (2013). Comparing U.S. national survey. Birth 38, 216–227. doi: 10.1111/j.1523-536X.2011. post-traumatic stress disorder in primiparous and multiparous 00475.x women with preeclampsia. J. Midwifery Reprod. Health 1, 13–18. Bonanno, G. A., Rennicke, C., and Dekel, S. (2005). Self-enhancement doi: 10.22038/jmrh.2013.755 among high-exposure survivors of the September 11th terrorist attack: Adewuya, A. O., Ologun, Y. A., and Ibigbami, O. S. (2006). Post- resilience or social maladjustment? J. Pers. Soc. Psychol. 88, 984–998. traumatic stress disorder after childbirth in Nigerian women: prevalence doi: 10.1037/0022-3514.88.6.984 and risk factors. BJOG 113, 284–288. doi: 10.1111/j.1471-0528.2006. Boorman, R. J., Devilly, G. J., Gamble, J., Creedy, D. K., and Fenwick, J. 00861.x (2014). Childbirth and criteria for traumatic events. Midwifery 30, 255–261. Alcron, K. L., O’Donovan, A., Patrick, J. C., Creedy, D., and Devilly, G. J. doi: 10.1016/j.midw.2013.03.001 (2010). A prospective longitudinal study of the prevalence of post-traumatic Bowman, M. L. (1999). Individual differences in posttraumatic distress: stress disorder resulting from childbirth events. Psychol. Med. 40, 1849–1859. problems with the DSM-IV model. Can. J. Psychiatry 44, 21–33. doi: 10.1017/S0033291709992224 doi: 10.1177/070674379904400103 American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Breslau, N., Chilcoat, H. D., Kessler, R. C., and Davis, G. C. (1999). Previous Mental Disorders, 4th Edn. Washington, DC: Author. exposure to trauma and PTSD effects of subsequent trauma: results American Psychiatric Association. (2013). Diagnostic and Statistical Manual of from the detroit area survey of trauma. Am. J. Psychiatry 156, 902–907. Mental Disorders, 5th Edn. Arlington, VA: Author. doi: 10.1176/ajp.156.6.902 Andersen, L. B., Melvaer, L. B., Videbech, P., Lamont, R. F., and Joergensen, J. Cigoli, V., Gilli, G., and Saita, E. (2006). Relational factors in psychopathological S. (2012). Risk factors for developing post-traumatic stress disorder following responses to childbirth. J. Psychosom. Obstet. Gynaecol. 27, 91–97. childbirth: a systematic review. Acta Obstet. Gynecol. Scand. 91, 1261–1272. doi: 10.1080/01674820600714566 doi: 10.1111/j.1600-0412.2012.01476.x Cohen, M. M., Ansara, D., Schei, B., Stuckless, N., and Stewart, D. E. Ayers, S. (2004). Delivery as a traumatic event: prevalence, risk factors, and (2004). Posttraumatic stress disorder after pregnancy, labor, and delivery. treatment for postnatal posttraumatic stress disorder. Clin. Obstet. Gynecol. 47, J. Womens Health (Larchmt). 13, 315–324. doi: 10.1089/1540999043230 552–567. doi: 10.1097/01.grf.0000129919.00756.9c 16473 Ayers, S., Bond, R., Bertullies, S., and Wijma, K. (2016). The aetiology of Czarnocka, J., and Slade, P. (2000). Prevalence and predictors of post-traumatic post-traumatic stress following childbirth: a meta-analysis and theoretical stress symptoms following childbirth. Br. J. Clin. Psychol. 39(Pt 1), 35–51. framework. Psychol. Med. 46, 1121–1134. doi: 10.1017/S00332917150 doi: 10.1348/014466500163095 02706 Davies, J., Slade, P., Wright, I., and Stewart, P. (2008). Posttraumatic stress Ayers, S., Harris, R., Sawyer, A., Parfitt, Y., and Ford, E. (2009). Posttraumatic stress symptoms following childbirth and mothers’ perceptions of their infants. Infant disorder after childbirth: analysis of symptom presentation and sampling. J. Ment. Health J. 29, 537–554. doi: 10.1002/imhj.20197 Affect. Disord. 119, 200–204. doi: 10.1016/j.jad.2009.02.029 Dekel, S., Mandl, C., and Solomon, Z. (2013b). Is the Holocaust implicated Ayers, S., and Pickering, A. D. (2001). Do women get posttraumatic stress disorder in posttraumatic growth in second-generation Holocaust survivors? as a result of childbirth? A prospective study of incidence. Birth 28, 111–118. A prospective study. J. Trauma. Stress 26, 530–533. doi: 10.1002/jts. doi: 10.1046/j.1523-536X.2001.00111.x 21836 Frontiers in Psychology | www.frontiersin.org 8 April 2017 | Volume 8 | Article 560 Dekel et al. PTSD and Childbirth Dekel, S., Solomon, Z., and Ein-Dor, T. (2016a). PTSD symptoms lead to Ozer, E. J., Best, S. R., Lipsey, T. L., and Weiss, D. S. (2003). Predictors of modification in the memory of the trauma: a prospective study of former posttraumatic stress disorder and symptoms in adults: a meta-analysis. Psychol. prisoners of war. J. Clin. Psychiatry 77, e290–e296. doi: 10.4088/JCP. Bull. 129, 52–73. doi: 10.1037/0033-2909.129.1.52 14m09114 Parfitt, Y., and Ayers, S. (2009). The effect of post-natal symptoms of post- Dekel, S., Solomon, Z., and Rozenstreich, E. (2013a). Secondary salutogenic effects traumatic stress and depression on the couple’s relationship and parent- in veterans whose parents were Holocaust survivors? J. Psychiatr. Res. 47, baby bond. J. Reprod. Infant Psychol. 27, 127–142. doi: 10.1080/026468308023 266–271. doi: 10.1016/j.jpsychires.2012.10.013 50831 Dekel, S., Stanger, V., Georgakopoulos, E. R., Stuebe, C. M., and Dishy, G. A. Polachek, I. S., Harari, L. H., Baum, M., and Strous, R. D. (2012). Postpartum post- (2016b). Peripartum depression, traditional culture, and Israeli society. J. Clin. traumatic stress disorder symptoms: the uninvited birth companion. Isr. Med. Psychol. 72, 784–794. doi: 10.1002/jclp.22360 Assoc. J. 14, 347–353. Dunmore, E., Clark, D. M., and Ehlers, A. (2001). A prospective investigation Ryding, E. L., Wijma, B., and Wijma, K. (1997). Posttraumatic stress reactions after of the role of cognitive factors in persistent posttraumatic stress disorder emergency cesarean section. Acta Obstet. Gynecol. Scand. 76, 856–861. (PTSD) after physical or sexual assault. Behav. Res. Ther. 39, 1063–1084. Schwab, W., Marth, C., and Bergant, A. M. (2012). Post-traumatic stress disorder doi: 10.1016/S0005-7967(00)00088-7 post partum: the impact of birth on the prevalence of post-traumatic stress Ehlers, A., and Clark, D. M. (2000). A cognitive model of posttraumatic stress disorder (PTSD) in multiparous women. Geburtshilfe Frauenheilkd. 72, 56–63. disorder. Behav. Res. Ther. 38, 319–345. doi: 10.1016/S0005-7967(99)00123-0 doi: 10.1055/s-0031-1280408 Ford, E., and Ayers, S. (2011). Support during birth interacts with prior trauma and Seng, J. S., Sperlich, M., Low, L. K., Ronis, D. L., Muzik, M., and Liberzon, I. (2013). birth intervention to predict postnatal post-traumatic stress symptoms. Psychol. Childhood abuse history, posttraumatic stress disorder, postpartum mental Health 26, 1553–1570. doi: 10.1080/08870446.2010.533770 health, and bonding: a prospective cohort study. J. Midwifery Womens Health Ford, E., Ayers, S., and Bradley, R. (2010). Exploration of a cognitive model to 58, 57–68. doi: 10.1111/j.1542-2011.2012.00237.x predict post-traumatic stress symptoms following childbirth. J. Anxiety Disord. Sexton, M. B., Hamilton, L., McGinnis, E. W., Rosenblum, K. L., and Muzik, 24, 353–359. doi: 10.1016/j.janxdis.2010.01.008 M. (2015). The roles of resilience and childhood trauma history: main and Garthus-Niegel, S., von Soest, T., Knoph, C., Simonsen, T. B., Torgersen, L., and moderating effects on postpartum maternal mental health and functioning. J. Eberhard-Gran, M. (2014). The influence of women’s preferences and actual Affect. Disord. 174, 562–568. doi: 10.1016/j.jad.2014.12.036 mode of delivery on post-traumatic stress symptoms following childbirth: Shaban, Z., Dolatian, M., Shams, J., Alavi-Majd, H., Mahmoodi, Z., and a population-based, longitudinal study. BMC Pregnancy Childbirth 14:191. Sajjadi, H. (2013). Post-traumatic stress disorder (PTSD) following childbirth: doi: 10.1186/1471-2393-14-191 prevalence and contributing factors. Iran. Red Crescent Med. J. 15, 177–182. Ghorbani, M., Dolatian, M., Shams, J., and Alavi-Majd, H. (2014). Anxiety, doi: 10.5812/ircmj.2312 post-traumatic stress disorder and social supports among parents of Shalev, A. (2009). Posttraumatic stress disorder and stress-related disorders. premature and full-term infants. Iran. Red Cresecent Med. J. 16:e13461. Psychiatr. Clin. North Am. 32, 687–704. doi: 10.1016/j.psc.2009. doi: 10.5812/ircmj.13461 06.001 Grekin, R., and O’Hara, M. W. (2014). Prevalence and risk factors of postpartum Soderquist, J., Wijma, B., and Wijma, K. (2006). The longitudinal course of post- posttraumatic stress disorder: a meta-analysis. Clin. Psychol. Rev. 34, 389–401. traumatic stress after childbirth. J. Psychosom. Obstet. Gynaecol. 27, 113–119. doi: 10.1016/j.cpr.2014.05.003 doi: 10.1080/01674820600712172 Ionio, C., and Blasio, P. D. (2014). Post-traumatic stress symptoms after childbirth Soet, J. E., Brack, G. A., and DiIorio, C. (2003). Prevalence and predictors of and early mother—child interactions: an exploratory study. J. Reprod. Infant women’s experience of psychological trauma during childbirth. Birth 30, 36–46. Psychol. 32, 163–181. doi: 10.1080/02646838.2013.841880 doi: 10.1046/j.1523-536X.2003.00215.x Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., and Nelson, C. B. Son, M. V., Verkerk, G., Hart, O. V. D., Komproe, I., and Pop, V. (2005). (1995). Posttraumatic stress disorder in the National Comorbidity Survey. Prenatal depression, mode of delivery and perinatal dissociation as predictors of Arch. Gen. Psychiatry 52, 1048–1060. doi: 10.1001/archpsyc.1995.039502400 postpartum posttraumatic sress: an empirical study. Clin. Psychol. Psychother. 66012 12, 297–312. doi: 10.1002/cpp.446 Lazarus, R. S. (1981). “The stress and coping paradigm,” in Models for Clinical Stroup, D. F., Berlin, J. A., Morton, S. C., Olkin, I., Williamson, G. D., Rennie, Psychopathology, eds C. C. D. Eisdorfer, A. Kleinman, and P. Maxim (New York, D., et al. (2000). Meta-analysis of observational studies in epidemiology: NY: Spectrum), 177–214. a proposal for reporting. Meta-analysis Of Observational Studies in Leeds, L., and Hargreaves, I. (2008). The psychological consequences of Epidemiology (MOOSE) group. JAMA 283, 2008–2012. doi: 10.1001/jama.283. childbirth. J. Reprod. Infant Psychol. 26, 108–122. doi: 10.1080/026468307016 15.2008 88299 Sumner, L. A., Wong, L., Schetter, C. D., Myers, H. F., and Rodriguez, M. Lev-Wiesel, R., and Daphna-Tekoah, S. (2010). The role of peripartum (2012). Predictors of posttraumatic stress disorder symptoms among low- dissociation as a predictor of posttraumatic stress symptoms following income latinas during pregnancy and postpartum. Psychol. Trauma 4, 196–203. childbirth in Israeli Jewish women. J. Trauma Dissociation 11, 266–283. doi: 10.1037/a0023538 doi: 10.1080/15299731003780887 Verreault, N., Da Costa, D., Marchand, A., Ireland, K., Banack, H., Dritsa, M., Milosavljevic, M., Lecic Tosevski, D., Soldatovic, I., Vukovic, O., Miljevic, et al. (2012). PTSD following childbirth: a prospective study of incidence C., Peljto, A., et al. (2016). Posttraumatic stress disorder after vaginal and risk factors in Canadian women. J. Psychosom. Res. 73, 257–263. delivery at primiparous women. Sci. Rep. 6:27554. doi: 10.1038/srep doi: 10.1016/j.jpsychores.2012.07.010 27554 Vossbeck-Elsebusch, A. N., Freisfeld, C., and Ehring, T. (2014). Predictors of Modarres, M. A., Afrasiabi, S., Rahnama, P., and Montazeri, A. (2012). Prevalence posttraumatic stress symptoms following childbirth. BMC Psychiatry 14:200. and risk factors of childbirth-related post-traumatic stress symptoms. BMC doi: 10.1186/1471-244X-14-200 Pregnancy Childbirth 12:88. doi: 10.1186/1471-2393-12-88 White, T., Matthey, S., Boyd, K., and Barnett, B. (2006). Postnatal depression O’Hara, M. W., and McCabe, J. E. (2013). Postpartum depression: current and post-traumatic stress after childbirth: prevalence, course and co- status and future directions. Annu. Rev. Clin. Psychol. 9, 379–407. occurrence. J. Reprod. Infant Psychol. 24, 107–120. doi: 10.1080/02646830600 doi: 10.1146/annurev-clinpsy-050212-185612 643874 Olde, E., van der Hart, O., Kleber, R. J., van Son, M. J., Wijnen, H. A., and Wijma, K., Soderquist, J., and Wijma, B. (1997). Posttraumatic stress disorder Pop, V. J. (2005). Peritraumatic dissociation and emotions as predictors of after childbirth: a cross sectional study. J. Anxiety Disord. 11, 587–597. PTSD symptoms following childbirth. J. Trauma Dissociation 6, 125–142. doi: 10.1016/S0887-6185(97)00041-8 doi: 10.1300/J229v06n03_06 Williams, C., Patricia Taylor, E., and Schwannauer, M. (2016). A web-based Olde, E., van der Hart, O., Kleber, R., and van Son, M. (2006). Posttraumatic survey of mother-infant bond, attachment experiences, and metacognition in stress following childbirth: a review. Clin. Psychol. Rev. 26, 1–16. posttraumatic stress following childbirth. Infant Ment. Health J. 37, 259–273. doi: 10.1016/j.cpr.2005.07.002 doi: 10.1002/imhj.21564 Frontiers in Psychology | www.frontiersin.org 9 April 2017 | Volume 8 | Article 560 Dekel et al. PTSD and Childbirth Yildiz, P. D., Ayers, S., and Phillips, L. (2017). The prevalence of posttraumatic Conflict of Interest Statement: The authors declare that the research was stress disorder in pregnancy and after birth: a systematic review and meta- conducted in the absence of any commercial or financial relationships that could analysis. J. Affect. Disord. 208, 634–645. doi: 10.1016/j.jad.2016.10.009 be construed as a potential conflict of interest. Zaers, S., Waschke, M., and Ehlert, U. (2008). Depressive symptoms and symptoms of post-traumatic stress disorder in women after childbirth. J. Psychosom. Copyright © 2017 Dekel, Stuebe and Dishy. This is an open-access article distributed Obstet. Gynaecol. 29, 61–71. doi: 10.1080/01674820701804324 under the terms of the Creative Commons Attribution License (CC BY). The use, Zambaldi, C. F., Cantilino, A., and Sougey, E. B. (2011). Bio-socio-demographic distribution or reproduction in other forums is permitted, provided the original factors associated with post-traumatic stress disorder in a sample of author(s) or licensor are credited and that the original publication in this journal postpartum Brazilian women. Arch. Womens Ment. Health 14, 435–439. is cited, in accordance with accepted academic practice. No use, distribution or doi: 10.1007/s00737-011-0224-4 reproduction is permitted which does not comply with these terms. Frontiers in Psychology | www.frontiersin.org 10 April 2017 | Volume 8 | Article 560

Journal

Frontiers in PsychologyPubmed Central

Published: Apr 11, 2017

There are no references for this article.