The development of a comprehensive understanding of the effect of childbearing on women has been an incredibly gradual process. The evolution of humanity generated curiosity, which leads to an enhanced understanding of the biological processes that occur during childbirth. Various medical professionals are proficient in understanding the intricacies of the physical components associated with childbirth. However, humanity seems to be grossly behind on the complexities and consequences that childbirth can have on a mother’s mind. Stigma, societal expectations, and gender inequity are just a few of the significant barriers that many women face when dealing with mental distress post-delivery. This literature review was written to explore one facet of maternal mental health distress. Specifically, I explore postpartum posttraumatic stress disorder (P-PTSD) and the consequences of birth trauma on women, their children, and social circles.
Childbirth is usually considered to be a meaningful and ultimately positive event for a woman and her family (De Graaff, Honig, Van Panpus, & Stramrood, 2017; Santoro, Stagni-Brenca, Olivari, Confalonieri, & Di Blasio, 2018). However, the literature approximates up to 44% of women experience traumatic childbirth with up to 15% developing a P-PTSD diagnosis in high-risk populations (De Graff et al., 2017; Grekin & O’Hara, 2014). This is an incredibly high proportion of women who deem their birthing experience to be adversely affected by trauma. Postpartum posttraumatic stress disorder is a perinatal mood and anxiety disorder (PMAD) that results from a perceived traumatic childbirth experience from the birthing mother. Postpartum posttraumatic stress disorder symptomology includes persistent recurring intrusive memories of the traumatic birth experience, dissociation, nightmares, feelings of shame or guilt, helplessness, and depressive behaviors (Beck, 2004b; Grekin & O’Hara, 2014). Fortunately, over recent decades researchers have acknowledged the significance of P-PTSD, and the literature has been evolving to explore P-PTSD more rigorously (McKenzie-McHarg et al., 2015).
Postpartum posttraumatic stress disorder can be incredibly difficult for healthcare professionals and mental health practitioners to effectively comprehend (Beck, 2004a). There are characteristics of P-PTSD that are unique from other PMADs (Beck, 2004a; Ayers, Wright, & Thornton, 2018). Women suffering from P-PTSD are involuntarily exposed to the source of their trauma in almost every aspect of their daily lives, which can have profound consequences on many of their familial relationships (Beck, 2004b; Fenech & Thomson, 2014). As such, it is important to understand the possible triggers most commonly associated with P-PTSD symptoms along with creating detection and prevention strategies to aid mothers suffering from P-PTSD (Dikmen-Yildiz, Ayers, & Phillips, 2017; Iles & Pote, 2015).
The literature indicated the emergence of a screening tool for P-PTSD (Ayers et al., 2018). The City Birth Trauma Scale was developed in order to screen for women who might be experiencing P-PTSD symptoms (Ayers et al., 2018). Whilst there is demonstrated reliability and validity, further research needs to be conducted to determine the effectiveness of a true postpartum population (Ayers et al., 2018). This literature review is designed to thoroughly explore the recent P-PTSD research and to discern the unique characteristics of P-PTSD in order to gain a more comprehensive understanding of what P-PTSD entails. Discerning the unique characteristics of P-PTSD will ultimately enable researchers to continue developing effective screening tools so that appropriate treatment strategies can be employed specifically for P-PTSD.
Exploring the Subjectivity of Trauma in Childbirth
A traumatic childbirth is a subjective experience unique to each mother (Beck, 2004a). This subjectivity makes diagnosing P-PTSD difficult as it may not fulfill the specified diagnostic criteria in the Diagnostic and Statistical Manual of Mental Health Disorders 5th Edition (DSM-5) for posttraumatic stress disorder (PTSD) trauma (American Psychiatric Association, 2013; Grekin & O’Hara, 2014). Several themes emerged in the literature regarding what constitutes a traumatic birth experience for mothers such as an emergency cesarean section or infant distress, insufficient medical care, prolonged agonizing labor, and a humiliating or degrading experience for the mother (Beck, 2004a). Many aspects of the list of traumatic birth experiences would arguably meet the criteria for trauma in the DSM-5 such as emergency cesarean section or infant distress (American Psychiatric Association, 2013). However, there are also experiences that rely on the perception of the mother – such as a humiliating experience – which may not fulfill the DSM-5 criteria for PTSD trauma, yet the mothers are exhibiting varying degrees of P-PTSD symptoms (American Psychiatric Association, 2013; Beck, 2004a). Criterion A of the DSM-5 suggests that individuals need to experience or witness a threat of death, serious injury-causing harm, or the threat of physical integrity yourself or others in order to meet part of the diagnostic criteria for PTSD (American Psychiatric Association, 2013). The event of a childbirth might not meet criterion A according to the medical professionals, however, some women might perceive their childbirth event as a near death experience or analogous to rape (Beck, 2004a). This might create subjectivity surrounding the diagnosis of P-PTSD symptoms. Some of the other subjective characteristics of P-PTSD women might display are feeling degraded or violated, enduring long painful labors without adequate pain management, and experiencing helplessness as the women perceive their concerns as not being heard by their medical team (Beck, 2004b).
Women who have given birth to healthy babies without any overt distress or life-threating event during the delivery can still develop P-PTSD (Haagen, Moerbeek, Olde, van der Hart, & Kleber, 2015). Research suggested that there could be factors prior to the perceived traumatic childbirth, which could influence whether a mother might develop P-PTSD (Grekin & O’Hara, 2014). For example, Grekin and O’Hara (2014) suggested that factors such as anxiety and depression during a woman’s pregnancy were positively correlated with the women exhibiting P-PTSD symptoms post-birth. How the women perceived their medical team, as well as if they had a strong social support system during their labor and delivery process were also found to have a significant impact on the development of P-PTSD (Dikmen-Yildiz et al., 2017).
In addition to the subjectivities in what each unique mother might consider traumatic in their birthing experience, there may also be incongruences between what medical professionals label a traumatic birth, compared to how the women perceive their labor and delivery experiences (Grekin & O’Hara, 2014). Grekin and O’Hara (2014) suggested that mothers might perceive their child birthing experiences as traumatic, whereas the birth may be considered average to the medical staff. Medical professionals are better able to recognize the initial risks for P-PTSD if there is an overt medical trauma such as an emergency cesarean session, aided extraction, or a hemorrhage (McKenzie-McHarg et al., 2015). This leaves a significant proportion of women who felt they had a traumatic childbirth experience without any overt medical distress left unseen (McKenzie-McHarg et al., 2015).
Grekin and O’Hara (2014) suggested that P-PTSD is an inherently complex and difficult disorder to diagnose, and this difficulty is increased due to the inability to effectively recognize PTSD symptoms within the initial postpartum stage. One possible explanation for the difficulty in identifying P-PTSD symptoms is a result of inconsistent definitions of the initial stressors, due to the subjectivity of P-PTSD (Grekin & O’Hara, 2014). Grekin and O’Hara (2014) demonstrated that women could perceive traumatic childbirth from birth itself, as well as from other traumatic occurrences happening in the postpartum period. This result suggested that even the event of childbirth might not be a consistent stressor for all mothers (Grekin & O’Hara, 2014). Verreault et al. (2012) suggested that women who had experienced past sexual assault or PTSD were three times more likely to develop P-PTSD following childbirth. The increased prevalence of P-PTSD could be attributed to the pregnancy, triggers during childbirth, or an unrelated stressor in the perinatal period that serves as a reminder from previous traumatic events (Verreault et al., 2012).
An Analysis of Trauma and its Effects
Despite the many inconsistencies in P-PTSD onset and symptomology, there can also be behavioral characteristics that are similar amongst women suffering from P-PTSD. Fenech and Thomson (2014) were able to decipher common themes found with some women suffering from P-PTSD including living with constant reminders of the trauma they experienced. Some of the women found their babies to be the source of their trauma, while other women would attribute sexual intimacy with their partners as a reminder of their trauma (Fenech & Thomson, 2014). Many aspects of daily life can function as reminders of the trauma endured for women suffering from P-PTSD, which can drastically affect the mother-child and other familial relationships (Beck, 2004b; Fenech & Thomson, 2014).
Impact on Mother-Child Relationship
Beck (2004b) conducted a study in which she examined narratives from women who had suffered from traumatic births. The results demonstrated women who had experienced their births as traumatic would actively avoid their infants, become internally numb when dealing with their infants, or avoid other mothers and children who had not experienced traumatic births (Beck, 2004b). Beck (2004b) suggested that there were a small number of instances in which the numbness mothers felt towards their infants could continue for years. One woman indicated she continued to struggle to form a meaningful connection with her then three-year-old toddler (Beck, 2004b). All the adverse feelings the mothers felt towards their infants had a significant negative impact on the mother-child relationship, as well as on other familial relationships (Fenech & Thomson, 2014). As P-PTSD could impact the mother-child relationship, it is important to explore the current literature to determine if any long-term adverse consequences manifest.
Living with P-PTSD can have exceptionally negative consequences for mothers being able to effectively form attachment bonds with their new infants (Beck, 2004b; Fenech & Thomson, 2014). Some women reported enduring constant painful flashbacks of their traumatic childbirth experiences throughout the day, and as such, they contrived an exterior facade when interacting with their infants but emotionally felt unable to truly connect with them (Beck, 2004b). This was particularly true when the women’s expectations of her childbirth experiences did not correspond with the reality of her labor and delivery (Verreault et al., 2012). Negative thoughts and emotions towards her childbirth experience, hyperarousal related to her childbirth, and symptoms of avoidance can increase two months post-delivery, which can adversely affect the mother’s ability to effectively bond with her child (Ionio & Blasio, 2014).
Postpartum PTSD symptoms can have a negative impact on the mother-child relationship (Fenech & Thomson, 2014; Ionio & Blasio, 2014). Research has demonstrated that the number of P-PTSD symptoms the mother outwardly displays is positively correlated with the infant’s behaviors such as increased crying, along with disorganized and avoidance behaviors (Ionio & Blasio, 2014). Mothers who exhibit a high level of P-PTSD symptoms have infants that show more avoidance behaviors, look away from their mothers more frequently and are less interested in interacting with adults (Ionio & Blasio, 2014). Women who are struggling with P-PTSD display many adverse behaviors, many of which are similar to women suffering from postpartum depression (PPD) (Ionio & Blasio, 2014).
Impact on the Family and Social Support
Some mothers suffering from P-PTSD suggested they viewed the act of sexual intimacy as an ongoing threat, as the sexual activity could lead to pregnancy and childbirth, which is what caused the painful and traumatic symptoms they are experiencing (Iles & Pote, 2015). Many women would actively avoid intimacy with their partners, as the act of penetration could initiate flashbacks of their traumatic birth experiences (Beck, 2004b). For some women, the act of sexual intimacy reintroduced flashbacks or nightmares of prior sexual trauma, however other women projected the trauma of their childbirth experiences onto the act of sexual intimacy with their partners (Beck, 2004a; Beck, 2004b; Fenech & Thompson, 2014).
Roberts, Norman, and Barton (2016) noted one possible projection of pattern behaviors that women suffering from P-PTSD might exhibit. Roberts et al., (2016) indicated that the women would display sudden and unexpected outbursts of anger and hostility towards their partners. Most of those women attributed their anger to the fact that they did not perceive their partners as sufficiently understanding the trauma they endured (Roberts et al., 2016). Women suffering from P-PTSD also found it immensely difficult to effectively communicate what kind of support they needed from their partners (Roberts et al., 2016). One observed pattern was that partners did not understand what kind of support to provide to mothers. As a result, mothers were more likely to feel extensive guilt after their angry outbursts with their partners, and thus experienced greater disconnect and distress (Roberts et al., 2016).
Roberts et al. (2016) suggested women suffering from P-PTSD may inadvertently isolate themselves from their friends and social gatherings, as the women do not believe that their friends can adequately understand what they endured living with P-PTSD. Research has suggested that some women with P-PTSD tend to obsessively communicate their trauma birth experience with members of their social circle (Roberts et al., 2016). Over time the mother’s friends become less sensitive and empathic of her situation, which might lead to them actively avoid her (Roberts et al., 2016). Conversely, some mothers with P-PTSD will avoid their prior social circles in fear that they would not understand the trauma she endured during childbirth (Fenech & Thomson, 2014; Roberts et al., 2016).
Postpartum PTSD can also affect the family unit in unexpected or unplanned ways. Some women unilaterally decide they no longer want to have subsequent children (Beck, 2004b; McKenzie-McHarg et al., 2015). This can cause a disconnect between the mothers suffering from P-PTSD and their partners, particularly if their partner wants more children (Beck, 2004b). Fear of subsequent childbirths is a major symptom of the traumatic birthing experience, and for the majority of women with P-PTSD the fear of childbirth increases after the arrival of their first child (Dikmen-Yildiz et al., 2017). Beck (2004b) suggested that unexpectedly deciding against subsequent children could cause the mothers further distress, as the mother has to additionally grieve the family that would never be.
Understanding the Specific Triggers of P-PTSD
Haagen et al. (2015) conducted a study in order to design a predictive model that health practitioners could use to determine the probability of women developing P-PTSD following childbirth. The researchers found home births (14.4%) and elective cesarean section deliveries (12.5%) had the lowest perceived experiences of trauma; comparatively, emergency cesarean section deliveries (47.1%) had the highest experiences of trauma (Haagen et al., 2015). It is also interesting to note a significant number of women found hospital births (27%) to be more traumatic when compared to women having home births (14.5%) (Haagen et al., 2015). This research highlights the variability of traumatic childbirth instances. Planned homebirths could still yield a traumatic birth experience for the mother (Haagen et al., 2015). Therefore, it might be particularly beneficial that all women are screened for potential P-PTSD symptoms despite the type of delivery or childbirth location.
Discerning the particular triggers associated with P-PTSD will allow a greater understanding to develop a specific and effective screening tool and treatment strategy for P-PTSD (King et al., 2017; McKenzie-McHarg et al., 2015). Women who have experienced traumatic events in the past have an increased risk of developing P-PTSD after childbirth (Grekin & O’Hara, 2014). Several themes emerged from the literature as to what triggers P-PTSD in women, particularly in births that do not have overt traumatic medical interventions (Roberts et al., 2016). These themes included: a lack of social support, a decrease of control, dissolution of the women’s integrity, and inaccurate or partial memory impairments (Beck 2004a; Roberts et al., 2016). Roberts et al. (2016) suggested that the interruption or discontinuity of the mothers’ memories were very distressing to them as they wanted to fully comprehend and understand what happened to them, but were unable to do so. Many women wish to forget the trauma that elicited their P-PTSD symptoms, but the incongruence of their memories encouraged ruminating over what they could not remember as opposed to forgetting unwanted memories (Roberts et al., 2016). Whilst the memories of the whole birthing experience might be disorganized and incongruent, the specific memories of the particular aspects that triggered P-PTSD during the labor and delivery process tend to be recollected with great acuity (Iles & Pote, 2015).
Cultural Influences on P-PTSD
There are also cultural aspects associated with P-PTSD (Iles & Pote, 2015). Examining narratives from women who were diagnosed with P-PTSD, Iles and Pote (2015) noted the significance that culture and cultural expectations have on the development of P-PTSD. The researchers affirmed that the mothers’ aspirations of the birthing experience typically reflect the cultural expectations of what childbirth entails (Iles & Pote, 2015). The mother’s expectations of what her pregnancy, labor, and delivery should resemble would also have an impact on P-PTSD development (Verreault et al., 2012). If a woman does not feel as though her delivery met the societal expectations for childbirth, the disconnect between her expectations and reality can increase P-PTSD likelihood (Iles & Pote, 2015; Verreault et al., 2012). Furthermore, any disconnection between expectations and reality can lead to feelings of shame and disappointment, which can induce social withdrawal and isolation (Iles & Pote, 2015).
Cultural and personal expectations of the women may also influence a shift in familial relationships following a traumatic childbirth (Grekin & O’Hara, 2014; Verreault et al., 2012). How the mothers’ culture views women in the postpartum period, the stigma of mental health, and if the mother has a strong social support system in place drastically influences the effects of P-PTSD symptoms (Grekin & O’Hara, 2014). Societal expectations of mothers may also have an impact on how women view their childbirth experiences (Grekin & O’Hara, 2014). Different cultures and societal norms may influence what a mother deems traumatic or not, as well as to what degree the event in childbirth is seen as traumatic (Grekin & O’Hara, 2014). As there are a multitude of different triggers that have been associated with P-PTSD, it is important that some aspect of screening for potential P-PTSD risks is done for all women having just given birth (Roberts et al., 2016).
Mediating Factors of P-PTSD
Having strong social supports during pregnancy, labor, and delivery is an immensely important deterrent for P-PTSD (Iles & Pote, 2015). Strong social support allows the mother to voice her concerns and opinions without fear of retribution or judgment, which ultimately helps the women cope with perceived traumatic childbirth and may mediate the development of P-PTSD symptoms (Iles & Pote, 2015). How the women perceived her medical team throughout the labor and delivery process also has a significant impact on P-PTSD (Iles & Pote, 2015). If a woman identifies her medical team as being dismissive or inattentive, there is an increased likelihood that she will develop P-PTSD post-delivery (Iles & Pote, 2015). Even if the women just perceived her medical team to be insufficient in her perinatal care, could increase the probability of P-PTSD, a fact of which health practitioners should be cognizant (Iles & Pote, 2015).
The care received and relationships formed with the medical staff have a significant impact on influencing if a woman will perceive her childbirth experience as traumatic or not (Fenech & Thomson, 2014; McKenzie-McHarg et al., 2015). The quality of the relationships between the mother and the medical staff is strongly associated with P-PTSD, where a higher quality relationship has been shown to lower P-PTSD symptoms (Gerkin & O’Hara, 2014). When a birthing woman felt as though her medical team respected her opinions, acknowledged her requests, and properly informed her of her care, she was more likely to be protected from perceiving her birthing experience as traumatic (Beck, 2004a)
Screening Tools for P-PTSD
There is no universal screening tool utilized for women who might be suffering from P-PTSD (McKenzie-McHarg et al., 2015; Peeler, Chung, Stedmon, & Skirton, 2012). Screening for P-PTSD is not one of the routine screening tools utilized in the postpartum period (McKenzie-McHarg, 2015). This is unlike postpartum depression (PPD) in which screening is done regularly on the majority of postpartum women (Peeler et al., 2012). Presently there is very limited screening or investigation done to determine if a woman is experiencing P-PTSD symptoms at any point after childbirth (Peeler et al., 2012).
Ayers et al., (2018) developed The City Birth Trauma Scale as a screening tool designed to capture P-PTSD symptoms in postpartum women. Ayers et al., (2018) developed their screening tool to specifically address the DSM-5 criteria for PTSD. Their sample consisted of approximately 950 women in the postpartum period. The women ranged from zero to twelve months postpartum. The City Birth Trauma Scale was able to successfully identify P-PTSD symptoms in some of the postpartum women with good reliability. Reliability and validity measurements were conducted and demonstrated its efficacy. However, the participants in the sample were self-identified, and therefore might not accurately represent all women within the postpartum period (Ayers et al., 2018). Further research would need to be conducted to explore the efficacy specifically with women within P-PTSD populations, as well as differing cultural variations. Further research would also be needed to conduct test-retest reliability and external validity, as there are no other comparable screening tools (Ayers et al., 2018). The City Birth Trauma Scale developed by Ayers et al. (2018) is a relatively new development, that is auspicious and will conceivably influence further screening tool development.
There is a high comorbidity rate between P-PTSD and PPD, as such, it is increasingly important a specific and effective screening tool be developed and utilized for women who are at risk of suffering from P-PTSD (McKenzie-McHarg et al., 2015). Postpartum depression symptoms demonstrated one of the largest affinities with P-PTSD, which emphasized the importance of a specific screening tool for P-PTSD (Grekin & O’Hara, 2014). A major challenge associated with discerning P-PTSD and PPD in an effective screening tool is the way in which traumatic events are classified (Verreault et al., 2012). Inconsistencies in which the medical or mental health professionals classified women’s experiences post-delivery may not have accounted for the specificities of P-PTSD symptoms. The medical or mental health professionals might incorrectly classify women with P-PTSD as having generic childbirth distress (Verreault et al., 2012). An effective screening tool for P-PTSD will ensure that women will receive the correct treatment for their symptoms (McKenzie-McHarg et al., 2015).
Due to the subjectivity of traumatic birth experiences, it is entirely possible that women suffering from P-PTSD are left untreated, as medical professionals did not see an immediate need to screen for P-PTSD (Beck 2004a; McKenzie-McHarg et al., 2015). McKenzie-McHarg et al., (2015) suggested that one of the most widely researched methods for prevention of P-PTSD is debriefing, but there is inconsistent literature validating its efficacy for the deterrence of P-PTSD. One study indicated that debriefing could actually increase P-PTSD symptoms, particularly if the debriefing occurred within hours of the perceived traumatic childbirth (Peeler et al., 2012). One of the most effective predictors of P-PTSD is previous sexual abuse trauma (Verreault et al., 2012). Other effective predictors of potential P-PTSD development for mothers are a lack of positive social interaction, heightened anxiety during pregnancy, the safety of the mother and infant during labor and delivery, as well as use of instruments in a vaginal delivery (King et al., 2017; Verreault et al., 2012). It is important that the health practitioners are aware of these predictors prior to labor and delivery so that they can ensure the women are properly screened for P-PTSD after childbirth (Iles & Pote, 2015; King et al., 2017; Verreault et al., 2012).
Conclusion
With such a high proportion of women potentially experiencing traumatic childbirth, research is needed to explore the nuances of P-PTSD and how it could affect birthing women and their families. Health practitioners have a pivotal role in preventing, screening and identifying, P-PTSD symptoms (Beck, 2004a; McKenzie-McHarg et al., 2015). It is critical to understand the subjectivity of childbirth, and how it could lead to P-PTSD symptoms (Beck, 2004a). Understanding that P-PTSD not only affects the woman, but also her partner and the infant are significant contributors to the overall mental health of the family (Fenech & Thomson, 2014). As such, discerning the unique characteristics of P-PTSD will ensure that researchers can create an effective screening tool and treatment strategy for all women suffering with P-PTSD. Having explored the nuances of P-PTSD, researchers can now place emphasis on the development of a universal and applicable screening tool for P-PTSD, which can then be utilized to innovate a unique treatment strategy for P-PTSD (King et al., 2017; McKenzie-McHarg et al., 2015; Verreault et al., 2012).
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