A systematic review of the relationship between severe maternal morbidity and post-traumatic stress disorder

Psychological impact of Placenta Accreta Spectrum disorders (PAS) and risk of Post-Traumatic Stress Disorder (PTSD): A cross-sectional study

OBJECTIVE

Placenta Accreta Spectrum disorders (PAS) are a group of obstetric complications with an increasing incidence. The high maternal and neonatal morbidity and mortality associated with PAS leads to concerns about the negative psychological impact, and even the risk of developing Post-Traumatic Stress Disorder (PTSD). The aim of this study was to assess the psychological impact of PAS diagnosis and intervention during pregnancy and postpartum and its potential association with PTSD.

STUDY DESIGN

A cross-sectional study was conducted, including cases of PAS FIGO grade 2 and 3 treated at University Hospital Center São João, between 2010-2023. Only cases with histopathological confirmation after peripartum hysterectomy were included. Data were obtained from electronic medical records (Sclinic® and Obscare®). The impact of Event Scale - Revised (IES-R), a validated questionnaire, was applied, after surgery for PAS, to assess the psychological impact of PAS diagnosis and treatment.

RESULTS

Fourteen cases of PAS were identified. The mean maternal age was 36.8 years. Approximately 86 % of cases had antenatal suspicion. The mean gestational age at delivery was 34 weeks. Of the 14 women, only 11 responded to the request to participate in the study (7 interviewed in person and 4 remotely). Four women had IES-R scores indicative of high risk of PTSD (IES-R>33 points), one had an intermediate risk (IES-R between 24-32 points), and 6 fell into the low-risk category. The mean score was 22.4 points. The analysis of IES-R results by clusters showed higher scores in the intrusion category, which relates to intrusive and unwanted thoughts, images and memories.

CONCLUSION

Given the high morbidity and mortality described in women with PAS, the risk of PTSD should be acknowledged, motivating early intervention to prevent the development of severe and potentially chronic symptoms. Supportive measures and psychiatric and/or psychological follow-up should be promptly implemented, ideally by multidisciplinary teams.

Psychological interventions to pregnancy-related complications in patients with post-traumatic stress disorder: a scoping review

OBJECTIVE

This scoping review sought to investigate the association between pregnancy-related complications and post-traumatic stress disorder (PTSD) among postpartum women, then summarize effective psychological interventions for pregnancy-related PTSD or sub-PTSD.

METHOD

Publications in English and Chinese were searched in PubMed, Embase, Cochrane, ISI Web of Science, China National Knowledge Infrastructure (CNKI), and WanFang databases using the subject headings of "Stress Disorders, Post-Traumatic", "Pregnant Women", and "psychotherapy". To ensure that as many relevant studies are incorporated as possible, free terms such as prenatal, postnatal, perinatal and gestation were also used. Intervention studies and related cases published by July 1st, 2023, were also searched.

RESULTS

Twenty-one articles (including 3,901 mothers) were included in this review. Evidence showed that typical psychological interventions exhibited great effect, and family support programs, peer support, online yoga, and music therapy were also effective in reducing risk and improving the psychological well-being of the studied population.

CONCLUSION

Fetal abnormalities, miscarriage, premature birth, infants with low birth weights, hypertension, pre-eclampsia, HELLP syndrome, and hyperemesis gravidarum are associated with an increased risk of PTSD. Moreover, high-risk pregnant women may benefit from psychological interventions such as cognitive behavioral therapy (CBT). It may also be feasible and well-accepted for music therapy and exposure therapy to lessen the intensity of PTSD in mothers.

Association of Postpartum Mental Illness Diagnoses with Severe Maternal Morbidity

Background: This study aimed to determine whether birthing people who experience severe maternal morbidity (SMM) are more likely to be diagnosed with a postpartum mental illness. Materials and Methods: Using the Massachusetts All Payer Claims Database, this study used modified Poisson regression analysis to assess the association of SMM with mental illness diagnosis during the postpartum year, accounting for prenatal mental illness diagnoses and other patient characteristics. Results: There were 128,161 deliveries identified, with 55.0% covered by Medicaid. Of these, 3.1% experienced SMM during pregnancy and/or delivery hospitalization, and 20.1% had a mental illness diagnosis within 1 year postpartum. In adjusted regression analyses, individuals with SMM had a 10.6% increased risk of having any mental illness diagnosis compared to individuals without SMM, primarily due to an increased risk of a depression or post-traumatic stress disorder diagnosis among people with SMM than those without SMM. Conclusions: Individuals who experienced SMM had a higher risk of a mental illness diagnosis in the postpartum year. Given increases in SMM in the United States in recent decades, policies to mitigate mental health sequelae of SMM are urgently needed.

Postpartum Psychiatric Outcomes following Severe Maternal Morbidity in an Urban Safety-Net Hospital

OBJECTIVE

Severe maternal morbidity (SMM) may be associated with postpartum psychiatric morbidity. However, the direction and strength of this relationship remain unclear. Our goal was to estimate the association between SMM and postpartum inpatient mental health care utilization.

STUDY DESIGN

We examined all liveborn deliveries at a large, safety-net hospital in Atlanta, Georgia, from 2013 to 2021. SMM at or within 42 days of delivery was identified using International Classification of Disease codes. The primary outcome of interest was hospitalization with a psychiatric diagnosis in the year following the delivery. We used inverse probability of treatment weighting based on propensity scores to adjust for demographics, index delivery characteristics, and medical, psychiatric, and obstetric history. We fit log-binomial models with generalized estimating equations to calculate adjusted risk ratios (aRRs) and 95% confidence intervals (CIs).

RESULTS

Among 22,233 deliveries, the rates of SMM and postpartum hospitalization with a psychiatric diagnosis, respectively, were 6.8% (n = 1,149) and 0.8% (n = 169). The most common psychiatric diagnosis was nonpsychotic mood disorders (without SMM 0.4%, n = 79; with SMM 1.7% n = 24). After weighting, 2.2% of deliveries with SMM had a postpartum readmission with a psychiatric diagnosis, compared with 0.7% of deliveries without SMM (aRR: 3.2, 95% CI: [2.0, 5.2]). Associations were stronger among individuals without previous psychiatric hospitalization.

CONCLUSION

Experiencing SMM was associated with an elevated risk of postpartum psychiatric morbidity. These findings support screening and treatment for mild and moderate postpartum psychiatric disorders in the antenatal period.

KEY POINTS

· Experiencing SMM was associated with three-fold excess risk of postpartum psychiatric admission.. · Experiencing SMM was not associated with an elevated risk of outpatient psychiatric care use.. · Experience SMM was not associated with outpatient psychiatric morbidity diagnoses..

Association of severe postpartum hemorrhage and development of psychological disorders: Results from the prospective and multicentre HELP MOM study

OBJECTIVE

Post-partum hemorrhage (PPH) is the leading preventable cause of worldwide maternal morbidity and mortality. Risk factors for psychological disorders following PPH are currently unknown. HELP-MOM study aimed to determine the incidence and identify risk factors for psychological disorders following PPH.

METHODS

HELP-MOM study was a prospective, observational, national, and multicentre study including patients who experienced severe PPH requiring sulprostone. The primary endpoint was the occurrence of psychological disorders (anxiety and/or post-traumatic disorder and/or depression) following PPH, assessed at 1, 3, and 6 months after delivery using HADS, IES-R, and EPDS scales.

RESULTS

Between November 2014 and November 2016, 332 patients experienced a severe PPH and 236 (72%) answered self-questionnaires at 1, 3, and 6 months. A total of 161 (68%) patients declared a psychological disorder following severe PPH (146 (90.1%) were screened positive for anxiety, 96 (58.9%) were screened positive for post-traumatic stress disorder, and 94 (57.7%) were screened positive for post-partum depression). In multivariable analysis, the use of intra-uterine tamponnement balloon was associated with a lower risk to be screened positive for psychological disorder after severe PPH (OR = 0.33 [IC95% 0.15-0.69], p = 0.004, and after propensity score matching (OR=0.34 [IC95% 0.12-0.94], p = 0.04)). Low hemoglobin values during severe PPH management were associated with a higher risk of being screened positive for psychological disorders. Finally, we did not find differences in desire or pregnancy between patients without or with psychological disorders occurring in the year after severe PPH.

DISCUSSION

Severe PPH was associated with significant psychosocial morbidity including anxiety, post-traumatic disorder, and depression. This should engage a psychological follow-up. Large cohorts are urgently needed to confirm our results.

REGISTRATION

ClinicalTrials.gov under number NCT02118038.

Association of severe maternal morbidity with bonding impairment and self-harm ideation: A multicenter prospective cohort study

BACKGROUND

Evidence on the association between severe maternal morbidity (SMM) and mother-infant bonding and self-harm ideation is limited. We aimed to examine these associations and the mediating effect of Neonatal Intensive Care Unit (NICU) admission at one-month postpartum.

METHODS

This multicenter, prospective cohort study was conducted in Japan (n = 5398). SMM included preeclampsia, eclampsia, severe postpartum hemorrhage, placental abruption, and a ruptured uterus. Lack of affection (LA) and Anger and Rejection (AR) were assessed using the Mother-Infant Bonding Scale (MIBS), and self-harm ideation was assessed using the 10th item of the Edinburgh Postnatal Depression Scale (EPDS). Linear and logistic regression models were used to examine the association between SMM and MIBS score and self-harm ideation. A structural equation model (SEM) was employed to examine the mediating effect of NICU admission on the association between SMM and mother-infant bonding and postpartum depressive symptoms.

RESULTS

Women with SMM had a 0.21 (95 % confidence interval [CI]: 0.03-0.40) point higher MIBS score and a decreasing trend in the risk of self-harm ideation (odds ratio 0.28, 95 % CI: 0.07-1.14) compared to those without SMM. SEM analysis revealed that SMM was associated with MIBS partially through NICU admission.

LIMITATIONS

EPDS scores during pregnancy could be an unmeasured confounder.

CONCLUSIONS

Women with SMM had higher MIBS scores, particularly on the LA subscale, which was partially mediated by NICU admission. Psychotherapy to support parent-infant relationships is necessary for women with SMM.

Effectiveness of Psychological Interventions to Improve the Mental Well-Being of Parents Who Have Experienced Traumatic Childbirth: A Systematic Review and Meta-Analysis

Considering the adverse impact that traumatic childbirth experiences can have on parental mental well-being, studies that have investigated the potential of providing postnatal psychological support for this group of parents require evaluation. This systematic review aimed to examine the effectiveness of psychological interventions at improving the mental well-being of parents who have experienced traumatic childbirth in terms of anxiety, depression, fear of childbirth, and post-traumatic stress disorder (PTSD) symptoms. Seven electronic databases were searched from their respective inception dates up to January 2021. Only quantitative studies that reported the effects of psychological interventions on anxiety, depression, fear of childbirth, and/or PTSD symptoms in selective (at risk of traumatic childbirth experience) or indicated (self-defined childbirth experience as traumatic for any reason) populations of parents (mothers and/or fathers) were included. Eight studies were included and meta-analyses were conducted using a random-effect model. All studies were conducted on mothers only, and one study had minimal father involvement. Results showed that psychological interventions were more effective in reducing fear of childbirth and improving PTSD symptoms compared to anxiety and depression. Greater improvement in depression was reported at 3-8 weeks' follow-up than at immediate post-intervention. Subgroup analyses showed that technology-based interventions were feasible, and indicated interventions were more effective than selective interventions. Conducting future interventions in more geographical regions, engaging and including fathers more actively, incorporating both personalized professional therapy and informal peer support, striving for flexibility and convenience, as well as addressing topics on self-doubt and coping skills can improve current interventions.

The Involvement of Neonatal Intensive Care Unit and Other Perinatal Factors in Postpartum PTSD After Cesarean Section

BACKGROUND

The experience of a neonate hospitalised in the Neonatal Intensive Care Unit (NICU) is an understandably traumatic experience for the parents, especially, for the mothers of neonates. This mental distress resulting from preterm birth and/or NICU hospitalisation can be understood as post-traumatic symptomatology, according to the Diagnostic and Statistical Manual-5 version. The aim of this study is to investigate the impact of the admission of a neonate to the NICU (from any reason) on the development of postpartum post-traumatic stress disorder (PTSD) in a sample of women after cesarean sections.

MATERIAL AND METHODS

A total of 469 women who gave birth with cesarean section from July 2019 to June 2020 participated in this study, from the original sample of 490 women who consented to participate. Data were obtained from the researcher's socio-demographic questionnaire, the past traumatic Life Events Checklist, the perinatal stressor Criterion A, and the Post-Traumatic Stress Checklist from the Diagnostic and Statistical Manual-5 version.

RESULTS

A percentage of 46.64% of sample experienced postpartum PTSD. Factors associated with PTSD were placenta previa type4, abruption, bleeding (β = .07, p = .049), premature contractions (β = .08, p = .039), heavy medical history or previous gynecological history and preeclampsia (β = .08, p = .034), abnormal heart rate, premature rupture of membrane, premature contractions, infections (β = .14, p = .004), life of child in danger (β = .12, p = .025), complications involving child (β = .15, p = .002), complications involving both (child and mother) (β = .12, p = .011), traumatic cesarean section (β = .041, p < .001) and prematurity (β = .12, p = .022).

CONCLUSIONS

Additional measures must be taken for mothers of children who have been admitted to the NICU with psychological support interventions and reassessment of their mental state.

Reproductive health after thoracic transplantation: An ISHLT expert consensus statement

Pregnancy after thoracic organ transplantation is feasible for select individuals but requires multidisciplinary subspecialty care. Key components for a successful pregnancy after lung or heart transplantation include preconception and contraceptive planning, thorough risk stratification, optimization of maternal comorbidities and fetal health through careful monitoring, and open communication with shared decision-making. The goal of this consensus statement is to summarize the current evidence and provide guidance surrounding preconception counseling, patient risk assessment, medical management, maternal and fetal outcomes, obstetric management, and pharmacologic considerations.

Longitudinal patterns of the relation between anxiety, depression and posttraumatic stress disorder among postpartum women with and without maternal morbidities in Northwest Ethiopia: a cross-lagged autoregressive structural equation modelling

BACKGROUND

The postpartum period is a time where mothers can undergo significant changes that increase vulnerability for depression, anxiety and posttraumatic stress disorder symptoms. However, the direct and indirect factors of depression, anxiety and posttraumatic stress disorder symptoms and their direction of relationships following childbirth is not well investigated in Ethiopia. The aim of this study was to determine the direct and indirect factors of depression, anxiety and posttraumatic stress disorder symptoms and their direction of relationships following childbirth.

METHODS

A total of 775 women consented to participate at the first, second and third follow-up of the study (6th, 12th and 18th week of postpartum period) during October, 2020 - March, 2021. Women were recruited after childbirth and before discharge using the World Health Organization maternal morbidity working group criteria to identify exposed and non-exposed groups. A cross-lagged autoregressive path analysis and linear structural equation modelling were carried out using Stata version 16 software.

RESULTS

Prevalence rates of anxiety were 18.5%, 15.5% and 8.5% at the 6th, 12th and 18th week of postpartum respectively. The prevalence rates for depression were also found to be 15.5%, 12.9% and 8.6% respectively during the same follow up period and for posttraumatic stress disorder it was found to be 9.7%, 6.8% and 3.5% at the 6th, 12th and 18th week of postpartum respectively. Moreover, anxiety and depression were found to be a causal risk factors for posttraumatic stress disorder in the postpartum period. Direct maternal morbidity, fear of childbirth, higher gravidity, perceived traumatic childbirth and indirect maternal morbidity were found to have a direct and indirect positive association with depression, anxiety and posttraumatic stress disorder. In contrast, higher parity, higher family size and higher social support have a direct and indirect negative association.

CONCLUSION

Postnatal mental health screening, early diagnosis and treatment of maternal morbidities, developing encouraging strategies for social support and providing adequate information about birth procedures and response to mothers' needs during childbirth are essential to improve maternal mental health in the postpartum period.

Longitudinal path analysis for the directional association of depression, anxiety and posttraumatic stress disorder with their comorbidities and associated factors among postpartum women in Northwest Ethiopia: A cross-lagged autoregressive modelling study

INTRODUCTION

Vulnerability for depression, anxiety and posttraumatic stress disorder symptoms due to perceived traumatic birth increase during the postpartum period. Traumatic birth has been defined as an event occurring during labour and birth that may be a serious threat to the life and safety of the mother and/or child. However, the comorbidity and multimorbidity of depression, anxiety and PTSD with their direct and indirect predictors is not well investigated in the postpartum period. In addition, the longitudinal directional association of depression, anxiety and PTSD with their comorbidities is not studied in Ethiopia.

OBJECTIVE

The aim of this study was to assess prevalence of postnatal comorbid and multimorbid anxiety, depression and PTSD. It also aimed to determine the directional association of postnatal anxiety, depression and PTSD with the comorbidity and multimorbidity of these mental health problems over time and to explore the factors that are directly or indirectly associated with comorbidity and multimorbidity of anxiety, depression and PTSD.

METHODS

A total of 775 women were included at the first, second and third follow-up of the study (6th, 12th and 18th week of postpartum period) during October, 2020 -March, 2021. A cross-lagged autoregressive path analysis was carried out using Stata 16.0 software in order to determine the autoregressive and cross-lagged effects of depression, anxiety and PTSD with their comorbidities. In addition, a linear structural equation modelling was also carried out to determine the direct and indirect effects of independent variables on the comorbidities of depression, anxiety and PTSD.

RESULTS

Comorbidity of anxiety with depression was the most common (14.5%, 12.1% and 8.1%) at the 6th, 12th and 18th week of postnatal period respectively. With regard to the direction of association, comorbidity of PTSD (due to perceived traumatic birth) with depression, PTSD with anxiety, depression with anxiety and triple comorbidity predicted depression and anxiety in subsequent waves of measurement. Direct and indirect maternal morbidity, fear of childbirth and perceived traumatic childbirth were found to have a direct and indirect positive association with comorbidities of depression, anxiety and PTSD. In contrast, higher parity, higher family size and higher social support had a direct and indirect negative association with these mental health disorders.

CONCLUSION

Postnatal mental health screening, early diagnosis and treatment of maternal morbidities, developing encouraging strategies for social support and providing adequate information about birth procedures and response to mothers' needs during childbirth are essential to avert comorbidity of anxiety, depression and PTSD in the postpartum period.

Traumatic Childbirth Experiences of New Parents: A Meta-Synthesis

Childbirth is usually a joyous occasion. However, a significant proportion of parents experienced traumatic childbirths and suffered post-traumatic consequences, which needs urgent attention. Therefore, this review aimed to explore and understand the traumatic childbirth experiences of parents. A systematic review of qualitative studies was done. The consolidated evidence was meta-summarized and meta-synthesized based on Sandelowski and Barroso's approach for synthesizing qualitative research. Seven electronic databases, including PubMed, CINAHL, Embase, PsycINFO, Cochrane, Scopus, and Web of Science, were searched from each database's inception to April 2020. Retrieved studies were screened using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and 19 studies were included in this review. All included studies were meta-summarized and meta-synthesized. An overarching theme, "traumatic birth: an evolving voyage," with three main themes, (1) "proceedings to traumatic birth," (2) "internal and external battles," and (3) "muddling through to beating the odds," and 10 subthemes were identified. Overall, parents felt fluctuations of emotions that seemed to be never-ending journeys. They expressed that various factors led to their traumatic birth experiences, especially health care providers' dismissive attitudes. Parents commonly reported feelings of powerlessness and fear for the safety of mothers and infants. Their constant battles to overcome traumatic experiences affected some of their relationships. To deal with the trauma, some mothers displayed avoidance behaviors while others relied on social support. As health care providers play important roles in influencing outcomes of childbirth, they should be mindful of the care provided during labors and childbirths.

Women´s experiences of preeclampsia as a condition of uncertainty: a qualitative study

Background

Preeclampsia is a severe condition that annually affects about 3–8% of pregnancies worldwide. Preeclampsia is thereby one of the most common pregnancy complications for both mother and child. Despite that, there is limited research exploring the women´s perspective of experiencing preeclampsia.

Aim

The aim of this study was to describe women´s experiences of preeclampsia to improve the support and care given during and after pregnancy.

Methods

A qualitative descriptive interview study was undertaken. Nine women, diagnosed with preeclampsia, were recruited from a maternity unit in southern Sweden. The descriptive phenomenological method according to Amadeo Giorgi was used to analyse the data.

Results

The women´s experiences of PE were expressed as A condition of uncertainty, meaning that it was an unexpected and unknown situation. This main result consisted of 1) incomprehensible diagnosis message, 2) ambivalent feeling when the unexpected happens, 3) confusing contradictory messages, 4) appreciated support from the midwife, 5) need for continuous information. The nature of preeclampsia can sometimes deteriorate rapidly both for the mother and/or the child, often resulting in conversion from a planned vaginal spontaneous delivery to an emergency Caesarean section. The women narrated diffuse symptoms, and they experienced that they got contradictory information from different health care professionals regarding the severity of their disease. Detailed and continuous information is requested throughout the course of the disease, and the postpartum period.

Conclusion

This qualitative study reveal a need for improved clinical management. Health care professionals must be aware that women and their partners need detailed, consistent and repeated information about severity and prognosis to diminish the condition of uncertainty, confusion and fearful experience. The clinical implication would be a standardized preeclampsia education for pregnant women early on in the pregnancy, to raise awareness of preeclamptic symptoms. Furthermore, there is a need for harmonized guidelines and individualized support to the woman and her partner both at the antenatal care and the maternity ward and inpatient care at the hospital.

Depression, anxiety and posttraumatic stress disorder six months following preeclampsia and normotensive pregnancy: a P4 study

Background

Mental health is an integral part of overall health. Mental health disorders following childbirth are common and poor maternal mental health has consequences for both the mother and her infant. Preeclampsia is also relatively common in pregnancy but there is little known about the intersection between these two important conditions. Gaining a better understanding of the psychological consequences following preeclampsia is important, especially the link with depression, anxiety and posttraumatic stress disorder. If women who experience preeclampsia are recognised as being at increased risk of poor mental health, targeted screening in the postpartum period should be implemented.

Aims

To describe the prevalence and symptom severity of depression, anxiety and posttraumatic stress disorder at six months postpartum in women, who had a diagnosis of preeclampsia, compared to those who had normal blood pressure in pregnancy.

Methods

The mental health component of the prospective cohort study, the Postpartum, Physiology, Psychology and Paediatric follow-up study (P4 Study) was used. Women diagnosed with preeclampsia (n = 90) and those who were normotensive during pregnancy (n = 302) completed the Edinburgh Postnatal Depression Scale, General Anxiety Disorder Scale, and the Posttraumatic Stress Diagnostic Scale or Posttraumatic Stress Diagnostic Sclae-5 at six months postpartum.

Results

At six months postpartum, depressive scores were similar in both groups but a higher proportion of women from the preeclampsia group scored above the threshold for depression (2% v 7% p = 0.04). There were no differences between the groups in the prevalence or severity of anxiety or PTSD. However, more women in the preeclampsia group reported their birth experience as a traumatic event (1% vs 7%, p = 0.01). On correlation testing and modelling, booking Edinburgh Postnatal Depression Scale score, any mental health history, experiencing birth as traumatic and the General Anxiety Disorder Scale score were independent predictors of postpartum Edinburgh Postnatal Depression Scale scores.

Conclusion

The postpartum clinical care of women with preeclampsia often focusses on the immediate physical health issues, but these women may also benefit from mental health screening. Targeted screening of preeclamptic women in the postpartum period may lead to more timely referral and initiation of treatment.

Trial registration

Retrospectively registered on 18/11/2013 with the Australian and New Zealand Clinical Trials Registry. Registration Number: ACTRN12613001260718.

Posttraumatic Stress Disorder Symptoms 2 Months After Vaginal Delivery

OBJECTIVE

To assess the prevalence of posttraumatic stress disorder (PTSD) symptoms and identify characteristics associated with it 2 months after singleton vaginal delivery at or near term.

METHODS

We conducted an ancillary cohort study of the TRAAP (TRAnexamic Acid for Preventing postpartum hemorrhage after vaginal delivery) randomized controlled trial in 15 French hospitals in 2015-2016. Women who had singleton vaginal delivery after 35 weeks of gestation were enrolled. After randomization, characteristics of labor and delivery were prospectively collected and paid special attention to postpartum blood loss. Posttraumatic stress disorder profile and provisional diagnosis were assessed 2 months after childbirth by two self-administered questionnaires: the IES-R (Impact of Event Scale-Revised) and the TES (Traumatic Event Scale). Associations between potential risk factors and PTSD symptoms were analyzed by multivariable logistic or linear regression modeling, depending on the type of dependent variable.

RESULTS

Questionnaires were returned by 2,740 of 3,891 women for the IES-R and 2,785 of 3,891 women for the TES (70.4% and 71.6% response rate). The prevalence of PTSD symptoms was 4.9% (95% CI 4.1-5.8%; 137/2,785) with the TES, and the prevalence of PTSD provisional diagnosis was 1.6% (95% CI 1.2-2.1%; 44/2,740), with the IES-R and 0.4% (95% CI 0.2-0.8%; 9/2,080) with the TES. Characteristics associated with a higher risk of PTSD in multivariable analysis were vulnerability factors - notably migrant status and history of psychiatric disorder (adjusted odds ratio [aOR] 2.7 95% CI 1.4-5.2) - and obstetric factors - notably induced labor (aOR 1.5 95% CI 1.0-2.2), being labor longer than 6 hours (aOR 1.7 95% CI 1.1-2.5), postpartum hemorrhage of 1,000 mL or more (aOR 2.0 95% CI 1.0-4.2), and bad memories of delivery at day 2 postpartum (aOR 4.5 95% CI 2.4-8.3) as assessed with the IES-R. Results were similar with the TES.

CONCLUSION

Approximately 1 of 20 women with vaginal delivery have PTSD symptoms at 2 months postpartum. History of psychiatric disorder, postpartum hemorrhage, and bad memories of deliveries at day 2 were the main factors associated with a PTSD profile.

Unmet Birth Expectations and Birth Trauma among Adolescents

PURPOSE

To assess and compare birth expectations of younger and older age adolescents and explore if unmet expectations predict psychological birth trauma (PBT).

STUDY DESIGN AND METHODS

This secondary analysis expands findings of a previous study (N = 303) which classified adolescents' perceptions of birth into four main themes. The previous study used a mixed-methods approach providing data related to birth expectations. For the current study, expectations were determined by themes as met or unmet by three reviewers. Of 116 useable written narrations, responses of younger (ages 13-17) versus older (ages 18-19) adolescents were compared and explored for impact on PBT.

RESULTS

Birth expectations for both age groups were more often unmet than met. Despite a smaller cohort, younger adolescents provided more remarks than older adolescents. There were no differences between groups on unmet birth expectations (p = .16). Unmet expectations most often related to pain with older adolescents more inclined to state poor pain management. Younger adolescents more often feared dying. Unmet expectations did not predict PBT.

CLINICAL IMPLICATIONS

Comprehensive prenatal care can allow for early, open conversations to assess labor knowledge and misconceptions, fear of birth, existing supports, and overall birth expectations, with a premier focus on expected labor pain and pain management. Multiparous adolescents should receive prenatal assessments of posttraumatic stress (PTS) symptoms (a recognized predictor of posttraumatic stress syndrome) potentially originating from a previous traumatic birth. Following birth, symptoms of acute stress and PTS should be assessed of all adolescents, especially if experienced numerous unmet labor expectations.

A way forward in the maternal mortality crisis: addressing maternal health disparities and mental health

Our objective was to review the role of maternal health disparities and mental health in the maternal mortality crisis in the USA, and discuss how perinatal care quality improvement in these areas is a critical lever for reducing maternal death. This paper summarizes content from a plenary talk delivered at the 2020 Biennial Meeting of the International Marcé Society for Perinatal Mental Health, in commemoration of the Society's 40th anniversary. The talk synthesized literature on two characteristics of the maternal mortality crisis in the US: (1) wide racial and ethnic disparities in maternal mortality and severe morbidity and (2) the impact of mental health and substance use disorders on maternal death, and introduced a framework for how health care quality gaps contribute to both of these issues. The US remains an outlier among similar nations in its alarmingly high rates of maternal mortality. Achieving significant progress on this measure will require confronting longstanding racial and ethnic disparities that exist throughout the pregnancy-postpartum continuum, as well as addressing the under-reported issue of maternal self-harm. Suicide and overdose are leading but under-recognized causes of death among pregnant and postpartum women in some states. Health care delivery failures, including inadequate risk assessment, care coordination, and communication, are identified in the literature on drivers of maternal health disparities and self-harm. Many of the same steps to improve quality of perinatal care can help to reduce health disparities and address the essential role of mental health in maternal well-being.

COVID-19 in Pregnancy and Early Childhood (COPE): study protocol for a prospective, multicentre biobank, survey and database cohort study

INTRODUCTION

There is limited knowledge on how the SARS-CoV-2 affects pregnancy outcomes. Studies investigating the impact of COVID-19 in early pregnancy are scarce and information on long-term follow-up is lacking.The purpose of this project is to study the impact of COVID-19 on pregnancy outcomes and long-term maternal and child health by: (1) establishing a database and biobank from pregnant women with COVID-19 and presumably non-infected women and their infants and (2) examining how women and their partners experience pregnancy, childbirth and early parenthood in the COVID-19 pandemic.

METHODS AND ANALYSIS

This is a national, multicentre, prospective cohort study involving 27 Swedish maternity units accounting for over 86 000 deliveries/year. Pregnant women are included when they: (1) test positive for SARS-CoV-2 (COVID-19 group) or (2) are non-infected and seek healthcare at one of their routine antenatal visits (screening group). Blood, as well as other biological samples, are collected at different time points during and after pregnancy. Child health up to 4 years of age and parent experience of pregnancy, delivery, early parenthood, healthcare and society in general will be examined using web-based questionnaires based on validated instruments. Short- and long-term health outcomes will be collected from Swedish health registers and the parents' experiences will be studied by performing qualitative interviews.

ETHICS AND DISSEMINATION

Confidentiality aspects such as data encryption and storage comply with the General Data Protection Regulation and with ethical committee requirements. This study has been granted national ethical approval by the Swedish Ethical Review Authority (dnr 2020-02189 and amendments 2020-02848, 2020-05016, 2020-06696 and 2021-00870) and national biobank approval by the Biobank Väst (dnr B2000526:970). Results from the project will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04433364.

Paternal and maternal long-term psychological outcomes after uterine artery embolization for severe post-partum hemorrhage

This study intend to compare the long-term psychological impact (depression, post-traumatic stress disorder) on both partners between patients that underwent uterine artery embolization (UAE) for post-partum hemorrhage (PPH) and uneventful deliveries. Women who experienced severe PPH treated by UAE in our institution between 2003 and 2013 were identified in our obstetrical database. These cases were matched to controls with uneventful deliveries. Matching criteria were maternal age, parity, ethnicity, year of delivery, birthweight, gestational age and mode of delivery. Patients and their partners completed validated questionnaires measuring post-traumatic stress (TSQ), as well as depression symptoms (MINI). A total of 63 cases of PPH and 189 matched controls (1:3) participated in a study exploring gynecological and obstetrical outcomes. With a mean of 8 years post-index delivery, patients after PPH showed increased risk of depression (p = 0.015) and post-traumatic stress disorder (22.2% versus 4.8%, p < 0.005) compared to controls. PPH remains strongly associated with post-traumatic stress disorder, even after adjustment for depression (adjusted odds ratio 5.1; 95% confidence intervals 1.5–17.5). Similarly, partners of patients with PPH showed a propensity to depression (p = 0.029) and post-traumatic stress disorder (11.5% versus 1.5%, p = 0.019). In conclusion, both women and their partners are at increased risk of long-term psychological adverse outcomes after PPH. Couples may benefit from psychological support.

Interventions to treat fear of childbirth in pregnancy: a systematic review and meta-analysis

Background

Between 5% and 14% of women suffer from fear of childbirth (FOC) which is associated with difficulties during birth and in postnatal psychological adjustment. Therefore, effective interventions are needed to improve outcomes for women. A systematic review and meta-analysis was used to identify effective interventions for treating women with FOC.

Methods

Literature searches were undertaken on online databases. Hand searches of reference lists were also carried out. Studies were included in the review if they recruited women with FOC and aimed to reduce FOC and/or improve birth outcomes. Data were synthesised qualitatively and quantitatively using meta-analysis. The literature searches provided a total of 4474 citations.

Results

After removing duplicates and screening through abstracts, titles and full texts, 66 papers from 48 studies were identified for inclusion in the review. Methodological quality was mixed with 30 out of 48 studies having a medium risk of bias. Interventions were categorised into six broad groups: cognitive behavioural therapy, other talking therapies, antenatal education, enhanced midwifery care, alternative interventions and interventions during labour. Results from the meta-analysis showed that most interventions reduced FOC, regardless of the approach (mean effect size = −1.27; z = −4.53, p < 0.0001) and that other talking therapies may reduce caesarean section rates (OR 0.48, 95% CI 0.48–0.90).

Conclusions

Poor methodological quality of studies limits conclusions that can be drawn; however, evidence suggests that most interventions investigated reduce FOC. Future high-quality randomised controlled trials are needed so that clear conclusions can be made.

Barriers and facilitators to implementing perinatal mental health care in health and social care settings: a systematic review

The improvement of perinatal mental health formed part of WHO's Millennium Development Goals. Research suggests that the implementation of perinatal mental health care is variable. To ensure successful implementation, barriers and facilitators to implementing perinatal mental health services need to be identified. Therefore, we aimed to identify the barriers and facilitators to implementing assessment, care, referral, and treatment for perinatal mental health into health and social care services. In this systematic review, we searched CINAHL, Embase, MEDLINE, and PsycINFO with no language restrictions for primary research articles published between database inception and Dec 11, 2019. Forward and backward searches of included studies were completed by March 31, 2020. Studies were eligible if they made statements about factors that either facilitated or impeded the implementation of perinatal mental health assessment, care, referral, or treatment. Partial (10%) dual screening was done. Data were extracted with EPPI-Reviewer 4 and analysed by use of a thematic synthesis. The protocol is registered on PROSPERO, CRD42019142854. Database searching identified 21 535 citations, of which 46 studies were included. Implementation occurred in a wide range of settings and was affected by individual (eg, an inability to attend treatment), health-care professional (eg, training), interpersonal (eg, trusting relationships), organisational (eg, clear referral pathways), political (eg, funding), and societal factors (eg, stigma and culture). A complex range of barriers and facilitators affect the implementation of perinatal mental health policy and practice. Perinatal mental health services should be flexible and women-centred, and delivered by well trained health-care professionals working within a structure that facilitates continuity of carer. Strategies that can be used to improve implementation include, but are not limited to, co-production of services, implementation team meetings, funding, and coalition building. Future research should focus on implementation barriers and facilitators dependent on illness severity, the health-care setting, and inpatient care.

Intertwined disparities: Applying the maternal-infant dyad lens to advance perinatal health equity

Differences in the quality of delivery hospital care contribute to persistent, intertwined racial and ethnic disparities in both maternal and infant health. Despite the shared causal pathways and overlapping burden of maternal and infant health disparities, little research on perinatal quality of care has addressed obstetric and neonatal care jointly to improve outcomes and reduce health inequities for the maternal-infant dyad. In this paper, we review the role of hospital quality in shaping perinatal health outcomes, and investigate how a framework that considers the mother-infant dyad can enhance our understanding of the full burden of obstetric and neonatal disparities on health and society. We conclude with a discussion of how integrating a maternal-infant dyad lens into research and clinical intervention to improve quality of care can move the needle on disparity reduction for both women and infants around the time of birth and throughout the life course.

[Questionnaires for the Assessment of Birth Expectancy and Birth Experience (Part 2 of a series on psychological assessment during the peripartum period)]

Giving birth is an intense experience and typically accompanied by severe pain. In addition to medical complications, subjective factors are likely to affect the birth experience. These include previous experiences with pregnancy and birth, previous traumatic experiences as well as birth expectations. Various questionnaires allow a standardized assessment of birth expectations and the birth experience. However, to date there is no questionnaire available in the German language that is based on diagnostic symptoms of birth-related posttraumatic stress disorder. Furthermore, current screening-tools were developed for women while men's perspectives have been neglected in research on the parental birth experience. Nonetheless, questionnaires seem to be well suited for the assessment of the birth experience of both mothers and fathers. In this way, support services could be expanded, since parents sometimes report a negative birth experience even in medically uncomplicated births. Along with the goal of enabling parents to have a positive birth experience, the prevention of the development of subclinical or even full-blown posttraumatic stress disorder after birth also plays an important role.

A prospective cohort study of post-traumatic stress disorder and maternal-infant bonding after first childbirth

OBJECTIVE

To investigate risk factors for childbirth-related post-traumatic stress disorder (CR-PTSD) measured 1-month after first childbirth, and the association between CR-PTSD and maternal-infant bonding.

METHODS

In this prospective cohort study 3006 nulliparous women living in Pennsylvania, USA, were asked about CR-PTSD at 1-month postpartum, and maternal-infant bonding at 1, 6 and 12-months postpartum. Multivariable logistic regression models identified risk factors for CR-PTSD and associations between CR-PTSD and maternal-infant bonding at 1, 6 and 12-months postpartum, controlling for confounding variables - including postpartum depression, stress and social support.

RESULTS

Nearly half (47.5%) of the women reported that during labor and delivery they were afraid that they or their baby might be hurt or die, and 225 women (7.5%) reported experiencing one or more CR-PTSD symptoms at 1-month postpartum. Depression, stress and low social support during pregnancy were associated with CR-PTSD, as well as labor induction, delivery complications, poor pain control, and unplanned cesarean delivery. Women with CR-PTSD reported a less positive childbirth experience, less shared decision-making, and were more likely to score in the bottom third on maternal-infant bonding at 1-month postpartum (adjusted odds ratio [aOR] 2.5, 95% CI 1.8-3.3, p < 0.001); at 6-months postpartum (aOR 2.1, 95% CI 1.5-2.8, p < 0.001); and at 12-months postpartum (aOR 2.2, 95% CI 1.6-3.0, p < 0.001).

CONCLUSION

In this large-scale prospective cohort study we found that CR-PTSD was consistently associated with lower levels of maternal-infant bonding over the course of the first year after first childbirth.

Quality of life after maternal near miss: A systematic review

INTRODUCTION

Maternal near miss is a major global health issue; approximately 7 million women worldwide experience it each year. Maternal near miss can have several different health consequences and can affect the women's quality of life, yet little is known about the size and magnitude of this association. The aim of this study was to assess the evidence of the association between women who have experienced maternal near miss and quality of life and women who had an uncomplicated pregnancy and delivery.

MATERIAL AND METHODS

Cochrane library, Embase, CINAHL, Web of Science, MEDLINE, Scopus and PubMed were searched for published studies. Studies were selected according to the PECO model (population, exposure, control and outcome) and were included if they investigated quality of life as an outcome after maternal near miss among women of all ages with no limitation on country or time (up to June 2020). Maternal near miss was defined as a life-threatening condition arising from complications related to pregnancy and/or childbirth. The quality of the studies was assessed according to the Newcastle-Ottawa scale and a Forest plot was constructed based on quality of life outcomes and study quality. PROSPERO registration number: CRD42020169232.

RESULTS

Fifteen studies were included in the review with a total of 31 558 women. Quality of life was reported in various ways, and 25 different confounders were controlled for. Compared with women who did not experience maternal near miss, women exposed to maternal near miss had an overall lower quality of life (n = 2/2), had poorer mental (n = 6/10) and social health (n = 2/3), and maternal near miss had negative economic consequences (n = 4/4). Maternal near miss was not associated with sexual dysfunction (n = 1/5). Ten of 15 studies were assessed as being of poor quality.

CONCLUSIONS

Evidence shows that maternal near miss is negatively associated with various aspects of quality of life. This highlights the importance of addressing the adverse effects associated with maternal near miss and follow up maternal near miss after discharge. Quality of life is a multidimensional concept that is assessed in various ways, and the literature on the field is heterogeneous. More high-quality studies are needed.

Perinatal Loss: The Impact on Maternal Mental Health

Importance

Psychological reactions to perinatal loss, although often self-limited, may lead to significant psychological morbidities. Obstetrician-gynecologists and other maternal health providers play a key role in recognizing the range of psychological responses to perinatal loss and providing education, support, and treatment options to their patients.

Objective

This review aims to define psychological reactions associated with perinatal loss, examine psychotherapy and psychopharmacologic treatments for psychiatric morbidities, discuss interpregnancy interval following perinatal loss, and highlight brief, psychological interventions that can be implemented by maternal health providers.

Evidence Acquisition

Search terms "perinatal loss psychology," "reproductive loss grief," "perinatal psychopharmacology," "psychopharmacology grief," and "interpregnancy interval" were utilized to search PubMed, Google Scholar, and PsycINFO.

Results

Grief is an expected, normal response to perinatal loss. Psychological morbidities, including major depressive disorder, generalized anxiety disorder, and posttraumatic stress disorder, are also associated with perinatal loss. Risk factors for these conditions include history of a psychiatric illness, childlessness, unknown cause of perinatal loss, limited social support, and marital/relationship discord. Careful interviewing and brief screening measures can help identify patients who may suffer from depressive or anxiety disorders following reproductive loss. Patients with perinatal loss can benefit from psychological and possibly pharmacologic treatments. Recommended interpregnancy interval after perinatal loss should be customized by gestational age and cause of loss.

Conclusions and Relevance

Patients with perinatal loss emotionally benefit from their reproductive health care providers acknowledging the psychological aspects of reproductive loss, inquiring about their emotional needs, and providing information regarding grief and mental health referrals.

Cardiovascular Health After Preeclampsia: Patient and Provider Perspective

Background: Preeclampsia predicts future cardiovascular disease (CVD) yet few programs exist for post-preeclampsia care. Methods: The Health after Preeclampsia Patient and Provider Engagement Network workshop was convened at the Radcliffe Institute for Advanced Study in June 2018. The workshop sought to identify: 1) patient perspectives on barriers and facilitators to CVD risk reduction; 2) clinical programs specialized in post-preeclampsia care; 3) recommendations by national organizations for risk reduction; and 4) next steps. Stakeholders included the Preeclampsia Foundation, patients, clinicians who had initiated CVD risk reduction programs for women with prior preeclampsia, researchers, and national task force members. Results: Participants agreed there is insufficient awareness and action to prevent CVD after preeclampsia. Patients suggested a clinician checklist to ensure communication of CVD risks, enhanced training for clinicians on the link between preeclampsia and CVD, and a post-delivery appointment with a clinician knowledgeable about this link. Clinical programs primarily served patients in the first postpartum year, bridging obstetrical and primary care. They recommended CVD risk modification with periodic blood pressure, weight, lipid and diabetes screening. Barriers included the paucity of programs designed for this population and gaps in insurance coverage after delivery. The American Heart Association, the American College of Obstetricians and Gynecologists, and the Preeclampsia Foundation have developed guidelines and materials for patients and providers to guide management of women with prior preeclampsia. Conclusions: Integrated efforts of patients, caregivers, researchers, and national organizations are needed to improve CVD prevention after preeclampsia. This meeting's recommendations can serve as a resource and catalyst for this effort.

National Partnership for Maternal Safety: Consensus Bundle on Support After a Severe Maternal Event

Supporting women, families, and clinicians with information, emotional support, and health care resources should be part of an institutional response after a severe maternal event. A multidisciplinary approach is needed for an effective response during and after the event. As a member of the maternity care team, the nurse's role includes coordination, documentation, and ensuring patient safety in emergency situations. The National Partnership for Maternal Safety, under the guidance of the Council on Patient Safety in Women's Health Care, has developed interprofessional work groups to develop safety bundles on diverse topics. This article provides the rationale and supporting evidence for the support after a severe maternal event bundle, which includes structure- and evidence-based resources for women, families, and maternity care providers. The bundle is organized into four domains: Readiness, Recognition, Response, and Reporting and Systems Learning, and it may be adapted by nurses and multidisciplinary leaders in birthing facilities for implementation as a standardized approach to providing support for everyone involved in a severe maternal event.

Postpartum depression and its risk factors in women with a potentially life-threatening complication

OBJECTIVE

To assess the incidence of postpartum depression (PPD) and its risk factors in women with potentially life-threatening complications.

METHODS

Eight hundred and ninety women admitted to a tertiary center in South India with potentially life-threatening complications were recruited for the study. Within seven days of delivery, women underwent mental health assessments using the EPDS and PHQ-9 scale. Counseling was provided and follow-up assessment carried out at 3 months postpartum. Bivariate and multivariate analysis was done to assess the association of risk factors to depression.

RESULTS

PPD was observed in 21% of the study cohort. Women with no formal education (OR -2.66, 95% CI: 1.10- 6.40) and those who had a stillbirth (OR 2.48, 95%CI: 1.57-3.93) were found to be associated with PPD after adjusting for other factors. Occurrence of an obstetric near-miss event did not increase the risk of depression. Most women recovered with postnatal counseling, with only three requiring medication at the end of 3 months.

CONCLUSION

One in five women who develop potentially life-threatening complications developed PPD. A strategy of screening focused on this high-risk group, especially in low resource settings, can lead to early recognition and treatment. This in turn can lead to a reduction in the long-term morbidity associated with PPD.

Relationship between postpartum mood disorder and birth experience: a prospective observational study

BACKGROUND

This study aims to investigate the relationship between the birth experience and the risk of developing postpartum depression or post-traumatic stress disorder.

METHODS

In this prospective, longitudinal, observational study, women were assessed at different time points for depression and post-traumatic stress disorder. The risk of depression or post-traumatic stress disorder based on patient characteristics and specific birth events was assessed within three months postpartum.

RESULTS

We enrolled 600 women; 426 were eligible for postpartum assessment. At six weeks and three months postpartum, 15.9% and 12.7% screened positive for depression respectively. Positive post-traumatic stress disorder screenings at six weeks and three months postpartum were 6.2% and 5.1% respectively. Twenty-seven women (8.3%) with a negative screening at six weeks converted to a positive depression or post-traumatic stress disorder screening at three months. A pre-existing history of anxiety or depression was associated with an increased risk of developing depression (aOR 2.12, 95% CI 1.30 to 3.47) and post-traumatic stress (aOR 3.15, 95% CI 1.42 to 7.02) within three months postpartum. The risk of developing post-traumatic stress disorder within three months postpartum was also increased among patients experiencing their first delivery (aOR 2.55, 95% CI 1.10 to 5.88) or operative management of postpartum hemorrhage (aOR 4.44, 95% CI 1.16 to 17.02).

CONCLUSION

Depression and post-traumatic stress symptoms either persisted or had new onset at three months postpartum. Mental health screening and postpartum follow-up after six weeks should be considered in high-risk patients who have a history of psychopathology, nulliparity, or undergo operative management of postpartum hemorrhage.

Post-Traumatic Stress Disorder and Severe Maternal Morbidity

Post-traumatic stress disorder (PTSD) accompanies miscarriage, intrauterine fetal demise, and preterm birth. Levels of PTSD may be higher for women who experience acute, life-threatening events during labor and delivery. Severe maternal morbidities or near misses for maternal death disproportionately impact African American, Hispanic, American Indian, and women in rural communities. Expanding research demonstrates association between severe maternal morbidity or near-miss events and PTSD. Multiple preceding conditions and intrapartum and postpartum events place women at higher risk for PTSD. Postpartum evaluation provides an opportunity for PTSD screening. Untreated perinatal PTSD impacts long-term maternal and child health and contributes to health disparities.

Postpartum lifestyle interventions among women with pre-eclampsia: a scoping review protocol

INTRODUCTION

Compared to women with normotensive pregnancies, women with a history of pre-eclampsia have a roughly fourfold increased risk of developing chronic arterial hypertension and a twofold increased risk of developing cardiovascular disease (CVD). Lifestyle changes, such as increased physical activity, weight loss, smoking cessation and healthy diet, are effective for CVD prevention in the general population. However, no scoping review or systematic review of postpartum lifestyle interventions among women with pre-eclampsia have, to our best knowledge, been performed. The objective of this scoping review is to provide an overview of the available research literature on postpartum lifestyle interventions to reduce the risk of CVD among women with pre-eclampsia.

METHODS AND ANALYSIS

The protocol is based on the framework outlined by Arksey and O'Malley. Databases to be searched include: PubMed, Embase CINAHL and the JBI Database of Systematic Reviews and Implementation Reports. The search will be performed after the publication of this protocol (estimated to be 1 June 2020) and will be repeated 1 month prior to the submission for publication of the final review (estimated to be 1 January 2021). The review will consider studies that include women in the postpartum period (in particular, but not restricted to, the first 12 months after delivery), with a history of pre-eclampsia. Data will be extracted by two independent reviewers using a data extraction tool including specific details about the population, concept, context, study methods and key findings relevant to the review objective. Any disagreements between the reviewers will be resolved through discussion, or with a third reviewer. The extracted data will be presented in diagrammatic or tabular form that align with the objective of this scoping review. A narrative summary will accompany the tabulated and/or charted results and will describe how the results relate to the reviews objective and questions.

ETHICS AND DISSEMINATION

Since all data will be obtained from publicly available materials, the proposed scoping review does not require ethical approval. The results will be submitted for publication in an open-access peer-reviewed journal and presented at relevant conferences.

Treatment of posttraumatic stress disorder following childbirth

Aim: The aim of this systematic review is to give an overview of the literature on treatment options for posttraumatic stress disorder (PTSD) following childbirth and to assess their efficacy.Method: PubMed, Embase, Web of Science, Cochrane and PsycINFO were searched using "PTSD", "childbirth" and "therapy" as terms for studies in English language published between 2000 and 2017. Additional studies were identified by checking reference lists. Studies were included when presence of PTSD was confirmed prior to treatment and childbirth was the traumatic event focused on. All studies were reviewed on sample size, study design, used instruments, sample characteristics, type of treatment and the result of treatment regarding PTSD (symptoms).Results: Six studies met the inclusion criteria. One study on debriefing, three studies on cognitive behavioral therapy (CBT) and two studies on eye movement desensitization and reprocessing (EMDR) were identified. Both EMDR and CBT appear to be promising therapies for PTSD following childbirth. Debriefing seems to be beneficial when women request it themselves.Conclusions: EMDR and CBT seem to be effective as therapy for PTSD following childbirth. However, evidence is still limited and more controlled trials are needed to draw conclusive results.

Postpartum psychological distress after emergency team response during childbirth

Purpose: To evaluate the feasibility and acceptability of a protocol determining the relationship between emergency team response (ETR) during childbirth and acute stress disorder (ASD) and post-traumatic stress disorder (PTSD) symptoms. Methods: In a prospective, observational, cohort design, women experiencing ETR during childbirth were approached and recruited on postpartum day-1 and followed for six weeks. Demographics, obstetric and birth characteristics, ASD scores and PTSD scores (by Impact of Events Scale, IES and PCL-civilian) were recorded. Recruitment and retention rates were recorded, and scores were compared to women who did not experience ETR. Results: Three hundred sixty-nine were approached and 249 were enrolled (67.5% recruitment rate). One hundred twenty-five completed all procedures (50.2% retention). Twenty experienced ETR (3.5% event rate), 12 enrolled (60.0% recruitment rate) and 8 completed the study (66.7% retention). The ETR group had higher PCL and IES scores (PCL: ETR median 12, non-ETR median 2, p = .08; IES: ETR median 22.5, non-ETR median 20, p = .08). ASD scores were similar between groups. Conclusions: Methodology investigating the link between ETR and postpartum psychological distress is feasible and acceptable. A relationship between ETR and PTSD symptoms appears to exist, with ETR being associated with higher PTSD scores compared to non-ETR childbirths. Methods that incorporate awareness of the unique concerns of vulnerable populations are needed.

The Impact of Severe Maternal Morbidity on Very Preterm Infant Outcomes

OBJECTIVE

To estimate the prevalence of severe maternal morbidity among very preterm births and determine its association with very preterm infant mortality and morbidity.

STUDY DESIGN

This study used New York City Vital Statistics birth and death records linked with maternal and newborn discharge abstract data for live births between 2010 and 2014. We included 6901 infants without congenital anomalies born between 24^0/7 and 32^6/7 weeks of gestation. Severe maternal morbidity was identified as life-threatening conditions or life-saving procedures. Outcomes were first-year infant mortality, severe neonatal morbidity (bronchopulmonary dysplasia, severe necrotizing enterocolitis, stage 3-5 retinopathy of prematurity, and intraventricular hemorrhage grades 3-4), and a combined outcome of death or morbidity.

RESULTS

Twelve percent of very preterm live-born infants had a mother with severe maternal morbidity. Maternal and pregnancy characteristics associated with occurrence of severe maternal morbidity were multiparity, being non-Hispanic black, and preexisting health conditions, but gestational age and the percentage small for gestational age did not differ. Infants whose mothers experienced severe maternal morbidity had higher first-year mortality, 11.2% vs 7.7% without severe maternal morbidity, yielding a relative risk of 1.39 (95% CI: 1.14-1.70) after adjustment for maternal characteristics, preexisting comorbidities, pregnancy complications, and hospital factors. Severe neonatal morbidity was not associated with severe maternal morbidity.

CONCLUSIONS

Severe maternal morbidity is an independent risk factor for mortality in the first year of life among very preterm infants after consideration of other maternal and pregnancy risk factors.

Depression, Anxiety, and Post-traumatic Stress Disorder Following a Hypertensive Disorder of Pregnancy: A Narrative Literature Review

Introduction: Pregnancy and childbirth can be a source of anxiety and worry for women. This is probably more so for women with a complicated pregnancy. Anxiety and worry may contribute to, or exacerbate, mental health disorders including depression and post-traumatic stress disorder (PTSD). Mental health is an integral part of health and well-being and poor mental health can be detrimental to the woman's welfare and her infant's behavior and cognitive development. It may be undetected, potentially leading to a burden on the woman, her family, the health system, and society. Women with complicated pregnancies, such as those with hypertensive disorders of pregnancy (HDP), may be at greater risk of poor mental health. The aim of this review was to examine whether there is an association between depression, anxiety, and PTSD in postpartum women with a history of HDP.

Methods: A narrative literature review was undertaken. Using the key search terms: preeclampsia, gestational hypertension, hypertensive disorders, pregnancy complications, depression, anxiety, and post-traumatic stress disorder; electronic databases were searched to determine what is known about depression, anxiety, and PTSD after HDP.

Results: In total, 17 publications were included. The relationship between HDP and depression, anxiety, and PTSD was variable between studies and inconsistent. Although some studies reported no significant association, there is a trend for increased prevalence and symptom severity of depression, anxiety, and PTSD following HDP. This trend was particularly evident following the more severe presentations of HDP. It was uncertain whether this association was due to the hypertensive disorder itself, the sequelae of the HDP, such as giving birth to a preterm baby, or it predated the pregnancy.

Conclusions: Women who experience HDP may be at increased risk of developing postpartum depression, anxiety, and PTSD. Awareness of, and screening for, these mental health disorders in the postpartum period will alert clinicians to the need for additional follow-up and referral for women following HDP. More research on the benefits and risks of such an approach is needed.

Association Between Severe Maternal Morbidity and Psychiatric Illness Within 1 Year of Hospital Discharge After Delivery

OBJECTIVE

To estimate whether severe maternal morbidity is associated with increased risk of psychiatric illness in the year after delivery hospital discharge.

METHODS

This retrospective cohort study used International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes within Florida's Healthcare Cost and Utilization Project's databases. The first liveborn singleton delivery from 2005 to 2015 was included; women with ICD-9-CM codes for psychiatric illness or substance use disorder during pregnancy were excluded. The exposure was ICD-9-CM codes during delivery hospitalization of severe maternal morbidity, as per the Centers for Disease Control and Prevention. The primary outcome was ICD-9-CM codes in emergency department encounter or inpatient admission within 1 year of hospital discharge of composite psychiatric morbidity (suicide attempt, depression, anxiety, posttraumatic stress disorder, psychosis, acute stress reaction, or adjustment disorder). The secondary outcome was a composite of ICD-9-CM codes for substance use disorder. We compared women with severe maternal morbidity with those without severe maternal morbidity using multivariable logistic regression adjusting for sociodemographic factors and medical comorbidities. Cox proportional hazard models identified the highest risk period after hospital discharge for the primary outcome.

RESULTS

A total of 15,510 women with severe maternal morbidity and 1,178,458 without severe maternal morbidity were included. Within 1 year of hospital discharge, 2.9% (n=452) of women with severe maternal morbidity had the primary outcome compared with 1.6% (n=19,279) of women without severe maternal morbidity, resulting in an adjusted odds ratio (aOR) 1.74 (95% CI 1.58-1.91). The highest risk interval was within 4 months of discharge (adjusted hazard ratio [adjusted HR] 2.53 [95% CI 2.05-3.12]). Most severe maternal morbidity conditions were associated with higher risk of postpartum psychiatric illness. Women with severe maternal morbidity had nearly twofold higher risk of postpartum substance use disorder (170 [1.1%] vs 6,861 [0.6%]; aOR 1.91 [95% CI 1.64-2.23]).

CONCLUSION

Though absolute numbers were modest, severe maternal morbidity was associated with increased risk of severe postpartum psychiatric morbidity and substance use disorder. The highest period of risk extended to 4 months after hospital discharge.

Prevalence of maternal psychological disorders after immediate postpartum haemorrhage: a repeated cross-sectional study - the PSYCHE* study protoco

INTRODUCTION

The main objective of this study is to assess the prevalence of depression at 2, 6 and 12 months postpartum in women who have had an immediate postpartum haemorrhage (PPH) (blood loss ≥500 mL within 24 hours of delivery). The secondary objectives are to assess the prevalence of anxiety and post-traumatic stress disorder among these women and to evaluate the prevalence of psychological disorders according to the severity of the PPH.

METHODS AND ANALYSIS

This repeated, cross-sectional, single-centre study will take place at the Clermont-Ferrand University Hospital (France). The population will comprise a cohort of women giving birth at a term ≥22 weeks of gestation.For each woman with a PPH (exposed), two women without PPH (unexposed) will be included: the women who give birth immediately before and immediately after her. The PPH will be managed according to French guidelines. The principal endpoint is the prevalence of depression, measured by the Edinburgh Postnatal Depression Scale (EPDS). The intervention will consist of four surveys including various self-completed questionnaires: the first during the immediate postpartum (Post-Delivery Perceived Stress Inventory (PDPSI), Spielberger'sState-Trait Anxiety Inventory (STAI)-Y-A and Y-B and Mini-International Neuropsychiatric Interview (M.I.N.I.) 5.0.0), then at 2 months (EPDS, STAI-Y-A, Generalised Anxiety Disorder (GAD-7) and Revised Impact of Event Scale (IES-R)), and finally at 6 months and 1 year postpartum (EPDS, STAI-Y-A, GAD-7, M.I.N.I. 5.0.0 and IES-R). The study will include 1542 women - 514 with PPH.

ETHICS AND DISSEMINATION

The institutional review board (IRB) approved the study on 14 February 2017 (IRB Sud Est VI: N°AU1243).Results will be reported in peer-reviewed journals and at scientific meetings. Findings from the study will be useful for individualising medical follow-up after childbirth, especially for woman who experienced a PPH, but also more generally in increasing birth professionals' awareness of effects of trauma. The evidence obtained might also lead to modifying practices and including this recommendation in French guidelines on PPH.

TRIAL REGISTRATION NUMBER

NCT03120208.

Structural Racism and Severe Maternal Morbidity in New York State

Objective:

We examined the association between county-level structural racism indicators and the odds of severe maternal morbidity (SMM) in New York State.

Design:

We merged individual-level hospitalization data from the New York State Department of Health Statewide Planning and Research Cooperative System (SPARCS) with county-level data from the American Community Survey and the Vera Institute of Justice from 2011 to 2013 (n = 244 854). Structural racism in each county included in our sample was constructed as the racial inequity (ratio of black to white population) in female educational attainment, female employment, and incarceration.

Results:

Multilevel logistic regression analysis estimated the association between each of these structural racism indicators and SMM, accounting for individual- and hospital-level characteristics and clustering in facilities. In the models adjusted for individual- and hospital-level factors, county-level racial inequity in female educational attainment was associated with small but statistically significant higher odds of SMM (odds ratio [OR] = 1.17, 95% confidence interval [CI] = 1.47, 1.85). County-level structural racism indicators of female employment inequity and incarceration inequity were not statistically significant. Interaction terms examining potential effect measure modification by race with each structural racism indicator also indicated no statistical difference.

Conclusions:

Studies of maternal disparities should consider multiple dimensions of structural racism as a contributing cause to SMM and as an additional area for potential intervention.

Homicides and socio-environmental determinants of health in Brazil: a systematic literature review

Brazil currently has the highest absolute number of homicides in the world, which results from a complex range of factors. This study aimed at understanding the associations between socio-environmental determinants of health (SDH) and homicides in Brazil through a systematic literature review. The review followed PRISMA guidelines, selecting quantitative and qualitative studies published in Portuguese, English, and Spanish carried out between 2002 and 2017, available in the PubMed, MEDLINE, LILACS, SciELO and BVS-BIREME databases. Two trilingual reviewers tracked studies independently by basing on the eligibility criteria. We critically assessed the selected studies with the Critical Appraisal Skills Programme (CASP) or the Checklist for Analytical Cross-Sectional Studies, depending on the study design. We considered 60 studies and grouped their SDH into categories to develop a narrative synthesis about each SDH. These categories were: territory; race/ethnicity; gender; age; social inequalities and economic factors; development; education; work and employment; drugs and trafficking; other SDH. We found some SDH were more associated with homicides, such as being young, black, male, of low education level, and also people who lived in places of high social inequality, such as urban suburbs and agricultural frontiers. Unemployment and drug trafficking, as well as intersections between various SDH were also prominent. Education seems to be a protective factor for homicide. Despite the limited capacity of interpretation due to the high range of methodological approaches, this review shows the importance of considering SDH and their intersections when developing homicide prevention policies.

Quality of Life after an Episode of Severe Maternal Morbidity: Evidence from a Cohort Study in Brazil

OBJECTIVE

To assess quality of life (QOL) in women who experienced a severe maternal morbidity (SMM) event and associated factors, in comparison to those who did not.

STUDY DESIGN

Retrospective cohort study performed at the maternity of the University of Campinas in Brazil, including 801 women with or without SMM, within 6 months to 5 years after delivery. Women were interviewed by phone and data were electronically stored, using the Brazilian version of the SF36 to assess women's self-perception of quality of life. To analyze a possible relationship between SMM and perceived impairment in quality of life, χ2 and Fisher's Exact tests were used. Multiple analysis using Generalized Linear Models was applied to identify factors independently associated with the general health score. The main outcome measures were general and domain-specific SF36 scores on quality of life.

RESULTS

Maternal morbidity conditions were associated with lower scores of patient perceptions of quality of life in the following domains: physical functioning, role-limiting physical, pain, and general health status. A lower level of school education, not having a partner, caesarean section, and history of previous clinical conditions were associated with a worse perception of general health and quality of life.

CONCLUSION

Health professionals should know the association between life conditions, previous chronic health conditions, and SMM for women during prenatal care to beyond 42 weeks postpartum. Longitudinal and interdisciplinary actions should be put into practice to provide healthcare for these women, with special emphasis on the effective reduction in health inequities.

Severe Maternal Morbidity: post-traumatic suffering and social support

ABSTRACT Objective: To assess the relationship of post-traumatic stress symptoms and the perception of social support in women submitted to Severe Maternal Morbidity (SMM). Method: A prospective cohort study, with 549 women from public hospitals. The Impact of Events and Social Support scales were used. Results: Women with SMM were from the State countryside (p=0.046), with low schooling (p=0.039) and did not work (p<0.001). They presented higher consumption of alcoholic beverages (p<0.001), did not perform prenatal (p<0.001), and were older (28.15 ± 28 years). Women with SMM had higher mean values of avoidance behavior (24.32, SD: 4.16), intrusive thinking (18.28, SD: 3.80), lower social support (0.11, SD: 0.001) with large effect size and lower social support satisfaction (0.69; SD: 0.19), with small effect size. Conclusion: SMM is a differential and negative factor for women’s mental health, and social support can favor their coping.

Post-Traumatic Stress Disorder and severe maternal morbidity: is there an association?

OBJECTIVE

To evaluate the occurrence of Post-Traumatic Stress Disorder among women experiencing a severe maternal morbidity event and associated factors in comparison with those without maternal morbidity.

METHODS

In a retrospective cohort study, 803 women with or without severe maternal morbidity were evaluated at 6 months to 5 years postpartum for the presence of Post-Traumatic Stress Disorder. Interviews were conducted by telephone and electronic data was stored. Data analysis was carried out by using χ2, Fisher's Exact test, and logistic regression analysis.

RESULTS

There was no significant change in the prevalence of Post-Traumatic Stress Disorder related to a previous severe maternal morbidity experience. There were also no differences in diagnostic criteria for severe maternal morbidity (hypertensive syndromes, hemorrhage, surgical intervention or intensive care unit admission required, among other management criteria). Low parity (2.5-fold risk) and increasing age were factors associated with Post-Traumatic Stress Disorder.

CONCLUSIONS

A severe maternal morbidity episode is not associated with Post-Traumatic Stress Disorder symptoms within five years of the severe maternal morbidity event and birth. However, a more advanced maternal age and primiparity increased the risk of Post-Traumatic Stress Disorder. This does not imply that women who had experienced a severe maternal morbidity event did not suffer or need differentiated care.

Post-traumatic stress disorder in the perinatal period: A concept analysis

AIMS AND OBJECTIVES

To report an analysis of the concept of perinatal post-traumatic stress disorder.

BACKGROUND

Prevalence of perinatal post-traumatic stress disorder is rising in the USA, with 9% of the U.S. perinatal population diagnosed with the disorder and an additional 18% being at risk for the condition. Left untreated, adverse maternal-child outcomes result in increased morbidity, mortality and healthcare costs.

DESIGN

Concept analysis via Walker and Avant's approach.

METHODS

The databases Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline, Academic Search Premier and PsychINFO were searched for articles, written in English, published between 2006-2015, containing the terms perinatal and post-traumatic stress disorder.

RESULTS

Perinatal post-traumatic stress disorder owns unique attributes, antecedents and outcomes when compared to post-traumatic stress disorder in other contexts, and may be defined as a disorder arising after a traumatic experience, diagnosed any time from conception to 6 months postpartum, lasting longer than 1 month, leading to specific negative maternal symptoms and poor maternal-infant outcomes. Attributes include a diagnostic time frame (conception to 6 months postpartum), harmful prior or current trauma and specific diagnostic symptomatology defined in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition. Antecedents were identified as trauma (perinatal complications and abuse), postpartum depression and previous psychiatric history. Consequences comprised adverse maternal-infant outcomes.

CONCLUSIONS

Further research on perinatal post-traumatic stress disorder antecedents, attributes and outcomes in ethnically diverse populations may provide clinicians a more comprehensive framework for identifying and treating perinatal post-traumatic stress disorder.

RELEVANCE TO CLINICAL PRACTICE

Nurses are encouraged to increase their awareness of perinatal post-traumatic stress disorder for early assessment and intervention, and prevention of adverse maternal-infant outcomes.

Risk factors for chronic post-traumatic stress disorder development one year after vaginal delivery: a prospective, observational study

Our study aimed to assess the prevalence of post-traumatic stress disorder (PTSD) after childbirth one year after vaginal delivery and to identify characteristics of women and deliveries associated with it. Questionnaires were mailed a year after delivery to 1103 women with prospectively collected delivery and postpartum data, including a question on day 2 assessing their experience of childbirth. PTSD was assessed a year later by the Impact of Event and Traumatic Event Scales; 22 women (4.2%, 95%CI 2.7-6.3%) met the PTSD diagnostic criteria and 30 (5.7%; 95%CI 3.9-8.0%) PTSD profile criteria. Factors associated with higher risk of PTSD profile were previous abortion (aOR 3.6, 95%CI 1.4-9.3), previous postpartum hemorrhage (Aor 5.3, 95%CI 1.3-21.4), and postpartum hemoglobin <9 g/dl (aOR 2.7, 95%CI 1.0-7.5). Among 56 women (10.3%) reporting bad childbirth memories at day 2 postpartum, 11 (21.1%) met PTSD diagnosis and 11 (21.1%) PTSD profile criteria a year later, compared with 11 (2.4%) (P < 0.001) and 18 (3.8%) (P < 0.001), respectively, of the 489 (87.7%) women with good memories. PTSD is not rare at one year after vaginal delivery in a low-risk population. A simple question at day 2 post partum may identify women most at risk of PTSD and help determine if early intervention is needed.