Post-traumatic stress disorder following childbirth: prevalence and associated factors-a prospective cohort study

Posttraumatic stress disorder prevalence and childbirth: update meta-analysis after the introduction of the DSM-5 and COVID-19 pandemic

PURPOSE

Meta-analyses were previously performed to estimate PTSD prevalence in the postpartum period. Significant events that could impact this outcome occurred in the last decade, such as the publication of the DSM-5 in 2013 and the COVID-19 pandemic in 2020. This systematic literature review with a meta-analysis addressed studies published after 2014 to estimate PTSD prevalence after childbirth.

METHOD

The methodological guidelines recommended by PRISMA were followed. The meta-analysis estimate was the proportion of PTSD cases. The restricted maximum likelihood (REML) was the method adopted for estimation in addition to multilevel random effect models. Subgroup analyses were performed to assess the impact of interest variables.

RESULTS

The estimated prevalence was 0.10 (95%CI: 0.8-0.13; I2 = 98.5%). No significant differences were found regarding the introduction of the DSM-5 (p = 0.73) or COVID-19 (p = 0.97), but instead, between low- and middle-income countries, e.g., the Middle East presents a higher prevalence (p < 0.01) than European countries.

CONCLUSIONS

There is a potential increase in PTSD prevalence rates after childbirth in the last decade not associated with the pandemic or the current diagnostic classification. Most studies showed a methodological fragility that must be overcome to understand this phenomenon better and support preventive actions and treatment for puerperal women.

The Social Context of Pregnancy, Respectful Maternity Care, Biomarkers of Weathering, and Postpartum Mental Health Inequities: A Scoping Review

Background: Mental health disorders are the number one cause of maternal mortality and a significant maternal morbidity. This scoping review sought to understand the associations between social context and experiences during pregnancy and birth, biological indicators of stress and weathering, and perinatal mood and anxiety disorders (PMADs). Methods: A scoping review was performed using PRISMA-ScR guidance and JBI scoping review methodology. The search was conducted in OVID Medline and Embase. Results: This review identified 74 eligible English-language peer-reviewed original research articles. A majority of studies reported significant associations between social context, negative and stressful experiences in the prenatal period, and a higher incidence of diagnosis and symptoms of PMADs. Included studies reported significant associations between postpartum depression and prenatal stressors (n = 17), socioeconomic disadvantage (n = 14), negative birth experiences (n = 9), obstetric violence (n = 3), and mistreatment by maternity care providers (n = 3). Birth-related post-traumatic stress disorder (PTSD) was positively associated with negative birth experiences (n = 11), obstetric violence (n = 1), mistreatment by the maternity care team (n = 1), socioeconomic disadvantage (n = 2), and prenatal stress (n = 1); and inverse association with supportiveness of the maternity care team (n = 5) and presence of a birth companion or doula (n = 4). Postpartum anxiety was significantly associated with negative birth experiences (n = 2) and prenatal stress (n = 3). Findings related to associations between biomarkers of stress and weathering, perinatal exposures, and PMADs (n = 14) had mixed significance. Conclusions: Postpartum mental health outcomes are linked with the prenatal social context and interactions with the maternity care team during pregnancy and birth. Respectful maternity care has the potential to reduce adverse postpartum mental health outcomes, especially for persons affected by systemic oppression.

Factors Associated with Obstetric Violence Implicated in the Development of Postpartum Depression and Post-Traumatic Stress Disorder: A Systematic Review

Postpartum depression (PPD) and post-traumatic stress disorder (PTSD) continue to be prevalent, and disabling women with mental disorders and obstetric violence (OV) may be a trigger for them, particularly during maternity. We aimed to analyze the association between manifestations of OV with the development of PPD and PTSD during pregnancy, childbirth, and postpartum. This systematic review was based on the PRISMA 2020 statement and explored original articles published between 2012 and 2022. A total of 21 articles were included in the analysis, and bias was assessed by the Effective Public Health Practice Project's Quality Assessment Tool. The highest rate of PPD symptoms appeared in women under 20 years old, multiparous, and with low education levels. The higher PTSD ratio was present in women under 35 years, primiparous, and with secondary studies. The mode of labor (instrumental or C-section) was identified as a major risk factor of PPD, being mediator variables of the informal coercion of health professionals and dissatisfaction with newborn healthcare. Instead, partner support during labor and high satisfaction with healthcare during birth were protective factors. Regarding PTSD, the mode of labor, several perineal tears, and the Kristeller technique were risk factors, and loss of autonomy and coercion modulated PTSD symptomatology. The protective factors for PTSD were respect for the labor plan, adequate communication with health professionals, social support during labor, and the skin-to-skin procedure. This systematic review provides evidence that OV contributes to PPD and PTSD, being important in developing standardized tools to prevent it. This study recommends changes in maternal healthcare policies, such as individualized healthcare assistance, humanized pregnancy protocols, and women's mental health follow-up, and improvements in the methodological quality of future research.

["Helplessness, Giving up of Any Self-Responsibility and Self-Determination" - a Qualitative Evaluation of Traumatizing Birth Experiences in Relation to Birth Mode]

Background Childbirth is combined with emotional challenges and individual anxiety. Unexpected birth experiences can trigger stress reactions and even post-traumatic stress disorders. Aim of the study The aim of the study was the qualitative evaluation of stressful perceived birth experiences and desired interventions.Methods A content-analytic evaluation of 117 free-text answers was conducted regarding stressful birth experiences and desired interventions using categories and frequencies in relation to birth mode.Findings Five themes emerged from the structured free text analysis: 1) Stressful experiences describing fear concerning the child and separation from the child after an emergency caesarean section; 2) Inadequate communication after an operative vaginal birth and unplanned caesarean section; 3) Feelings of failure and guilt after unplanned birth modes; 4) Helplessness with loss of personal control and the feeling of being at the mercy after an emergency caesarean section; 5) Inadequate support due to the absence of empathy or insufficient care. Expected interventions include immediate debriefing and professional psychological support.Conclusion Women-centered communication during childbirth and debriefing of stressful birth experiences are significant interventions for strengthening maternal well-being and mental health. They can have a positive impact on the development of a healthy mother-child relationship.

Effect of the maternal childbirth experience on a subsequent birth: a retrospective 7-year cohort study of primiparas in Finland

OBJECTIVE

To study the effect of the childbirth experience on the likelihood and interval to a subsequent live birth.

DESIGN

Retrospective analysis of a 7-year cohort.

SETTING

Childbirths in Helsinki University Hospital delivery units.

PARTICIPANTS

All parturients giving birth to a term and living baby from a single pregnancy in Helsinki University Hospital delivery units from January 2012 to December 2018 (n=120 437). Parturients delivering their first child (n=45 947) were followed until the birth of a subsequent child or the end of 2018.

MAIN OUTCOME MEASURE

The interval to a subsequent childbirth connected to the experience of the first childbirth was the primary outcome of the study.

RESULTS

A negative first childbirth experience decreases the likelihood of delivering a subsequent child during the follow-up (adjusted HR=0.81, 95% CI 0.76 to 0.86) compared with those experiencing the first childbirth as positive. For parturients with a positive childbirth experience, the median interval to a subsequent delivery was 3.90 years (3.84-3.97) compared with 5.29 years (4.86-5.97) after a negative childbirth experience.

CONCLUSION

The negative childbirth experience influences reproductive decisions. Consequently, more focus should be placed on understanding and managing the antecedents of positive/negative childbirth experiences.

The global burden of perinatal common mental health disorders and substance use among migrant women: a systematic review and meta-analysis

BACKGROUND

There are one billion migrants globally, of whom 82 million are forced migrants. Pregnant migrants face pre-migration stressors such as conflict, transit stressors including poverty, and post-migration stressors including navigating the immigration system; these stressors can make them vulnerable to mental illness. We aimed to assess the global prevalence of and risk factors for perinatal mental health disorders or substance use among women who are migrants.

METHODS

In this systematic review and meta-analysis, we searched OVID MEDLINE, Embase, PsycINFO, CENTRAL, Global Health, Scopus, and Web of Science for studies published from database inception until July 8, 2022. Cohort, cross-sectional, and interventional studies with prevalence data for any mental illness in pregnancy or the postnatal period (ie, up to a year after delivery) or substance use in pregnancy were included. The primary outcome was the prevalence of perinatal common mental health disorders among women who are migrants, globally. Data for study quality and risk factors were also extracted. A random-effects meta-analysis was used to calculate pooled prevalence estimates, when appropriate. Sensitivity analyses were conducted according to study quality, sample representativeness, and method of outcome assessment. Risk factor data were synthesised narratively. This study is registered with PROSPERO, CRD42021226291.

FINDINGS

18 650 studies were retrieved, of which 135 studies comprising data from 621 995 participants met the inclusion criteria. 123 (91%) of 135 studies were conducted in high-income host countries. Five (4%) of 135 studies were interventional, 40 (30%) were cohort, and 90 (66%) were cross-sectional. The most common regions of origin of participants were South America, the Middle East, and north Africa. Only 26 studies presented disaggregated data for forced migrants or economic migrants. The pooled prevalence of perinatal depressive disorders was 24·2% (range 0·5-95·5%; I² 98·8%; τ² 0·01) among all women who are migrants, 32·5% (1·5-81·6; 98·7%; 0·01) among forced migrants, and 13·7% (4·7-35·1; 91·5%; 0·01) among economic migrants (p<0·001). The pooled prevalence of perinatal anxiety disorders was 19·6% (range 1·2-53·1; I² 96·8%; τ² 0·01) among all migrants. The pooled prevalence of perinatal post-traumatic stress disorder (PTSD) among all migrant women was 8·9% (range 3·2-33·3; I² 97·4%; τ² 0·18). The pooled prevalence of perinatal PTSD among forced migrants was 17·1% (range 6·5-44·3; I² 96·6%; τ² 0·32). Key risk factors for perinatal depression were being a recently arrived immigrant (ie, approximately within the past year), having poor social support, and having a poor relationship with one's partner.

INTERPRETATION

One in four women who are migrants and who are pregnant or post partum experience perinatal depression, one in five perinatal anxiety, and one in 11 perinatal PTSD. The burden of perinatal mental illness appears higher among women who are forced migrants compared with women who are economic migrants. To our knowledge, we have provided the first pooled estimate of perinatal depression and PTSD among women who are forced migrants. Interpreting the prevalence estimate should be observed with caution due to the very wide range found within the included studies. Additionally, 66% of studies were cross-sectional representing low quality evidence. These findings highlight the need for community-based routine perinatal mental health screening for migrant communities, and access to interventions that are culturally sensitive, particularly for forced migrants who might experience a higher burden of disease than economic migrants.

FUNDING

UK National Institute for Health Research (NIHR); March of Dimes European Preterm Birth Research Centre, Imperial College; Imperial College NIHR Biomedical Research Centre; and Nuffield Department of Population Health, University of Oxford.