Lisa Kane Low

Prevalence, Trauma History, and Risk for Posttraumatic Stress Disorder Among Nulliparous Women in Maternity Care

OBJECTIVE: To estimate prevalence and assess the association of types of trauma with posttraumatic stress disorder (PTSD) in a sociodemographically and racially mixed sample of women from both predominantly Medicaid and privately insured settings who are expecting their first infant. METHODS: Structured telephone diagnostic interview data were analyzed for prevalence of trauma exposure, PTSD, comorbidity, risk behaviors, and treatment-seeking among 1,581 diverse English-speaking nulliparous women. RESULTS: The overall rate of lifetime PTSD was 20.2%, 17% in the predominantly private-payer settings, and 24% in the predominantly public-payer settings. The overall rate of current PTSD was 7.9%, 2.7% in the predominantly private-payer settings and 13.9% in the predominantly public-payer settings. Those with current PTSD were more likely to be African American, pregnant as a teen, living in poverty, with high school education or less, and living in higher-crime areas. Adjusted odds of having current PTSD were highest among those whose worst trauma exposure was abuse (odds ratio 11.9, 95% confidence interval 3.6–39.9), followed by reproductive trauma (odds ratio 6.1, 95% confidence interval 1.5–24.4). Health risk behaviors and exposures were concentrated among those with PTSD. CONCLUSION: These findings affirm that PTSD affects pregnant women. Women with PTSD in pregnancy were more likely to have had exposures to childhood abuse and prior traumatic reproductive event, to have cumulative sociodemographic risk factors, comorbid depression and anxiety, and to have sought mental health treatment in the past. Obstetric risk behaviors occur more in women with PTSD. LEVEL OF EVIDENCE: II

Post-traumatic stress disorder, child abuse history, birthweight and gestational age: a prospective cohort study

Please cite this paper as: Seng J, Low L, Sperlich M, Ronis D, Liberzon I. Post‐traumatic stress disorder, child abuse history, birthweight and gestational age: a prospective cohort study. BJOG 2011;118:1329–1339.

Graphic integration of causal factors of pelvic floor disorders : an integrated life span model

There is growing interest in causal factors for pelvic floor disorders. These conditions include pelvic organ prolapse and urinary and fecal incontinence and are affected by a myriad of factors that increase occurrence of symptomatic disease. Unraveling the complex causal network of genetic factors, birth-induced injury, connective tissue aging, lifestyle and comorbid factors is challenging. We describe a graphical tool to integrate the factors affecting pelvic floor disorders. It plots pelvic floor function in 3 major life phases: (1) development of functional reserve during an individuals growth, (2) variations in the amount of injury and potential recovery that occur during and after vaginal birth, and (3) deterioration that occurs with advancing age. This graphical tool accounts for changes in different phases to be integrated to form a disease model to help assess the overlap of different causal factors.

Childhood Abuse History, Posttraumatic Stress Disorder, Postpartum Mental Health, and Bonding: A Prospective Cohort Study

INTRODUCTION Research is needed that prospectively characterizes the intergenerational pattern of effects of childhood maltreatment and lifetime posttraumatic stress disorder (PTSD) on womens mental health in pregnancy and on postpartum mental health and bonding outcomes. This prospective study included 566 nulliparous women in 3 cohorts: PTSD-positive, trauma-exposed resilient, and not exposed to trauma. METHODS Trauma history, PTSD diagnosis, and depression diagnosis were ascertained using standardized telephone interviews with women who were pregnant at less than 28 gestational weeks. A 6-week-postpartum interview reassessed interim trauma, labor experience, PTSD, depression, and bonding outcomes. RESULTS Regression modeling indicates that posttraumatic stress in pregnancy, alone, or comorbid with depression is associated with postpartum depression (R(2) = .204; P < .001). Postpartum depression alone or comorbid with posttraumatic stress was associated with impaired bonding (R(2) = .195; P < .001). In both models, higher quality of life ratings in pregnancy were associated with better outcomes, while reported dissociation in labor was a risk for worse outcomes. The effect of a history of childhood maltreatment on both postpartum mental health and bonding outcomes was mediated by preexisting mental health status. DISCUSSION Pregnancy represents an opportune time to interrupt the pattern of intergenerational transmission of abuse and psychiatric vulnerability. Further dyadic research is warranted beyond 6 weeks postpartum. Trauma-informed interventions for women who enter care with abuse-related PTSD or depression should be developed and tested.

Personal influencing factors associated with Pap smear testing and cervical cancer

Pap smear is a screening test that detects abnormal cells before they advance to cancer. Unfortunately, not all women obtain routine screening. The method used was a qualitative study exploring personal influences regarding Pap smears. Face-to-face interviews with 7 low-income African American women who do and do not obtain Pap smears (between 21 and 37 years of age) were conducted at a health department about their social influence, previous health care experience, and cognitive appraisal regarding Pap smears and cervical cancer. Women were found to be socially influenced by their family and their physician. Previous health care experience with the Pap and pelvic was perceived as negative. Cognitively, Pap smears were believed to test for sexually transmitted diseases, including HIV, and the women also felt that if one took good care of oneself it reduced the risk for cervical cancer. It was concluded that exploring beliefs associated with Pap smears and perceptions of vulnerability to cervical cancer and giving correct information and counseling may increase Pap smear screening in women.

Exploring posttraumatic stress disorder symptom profile among pregnant women

Posttraumatic stress disorder (PTSD) is more prevalent in perinatal than general samples of women (6–8% vs. 4–5%). To explore potential causes, we examined the symptom profiles of women belonging to two separate samples: a perinatal clinic sample (n = 1581) and a subsample of women in a similar age range from the U. S. National Womens Study (NWS) (n = 2000). Within the perinatal sample, risk ratios were higher for all 17 PTSD symptoms among women with current PTSD compared with unaffected women, suggesting that higher rates are not likely due to measurement error. The younger age and greater social disadvantage in the perinatal clinic sample contributed only a small proportion of variance in symptom levels compared with extent of trauma exposure and pre-existing PTSD. Compared with the national study samples symptom profile, the perinatal sample had higher rates of occurrence of five symptoms: detachment, loss of interest, anger and irritability, trouble sleeping, and nightmares. This analysis confirms that PTSD rates are higher in perinatal samples, which is likely due to exacerbation of pre-existing PTSD among women of a younger age and greater social disadvantage. Further elucidation is warranted, including identifying triggers and determining if there are needs for pregnancy-specific interventions.

Exploring Women's Postpartum Sexuality: Social, Psychological, Relational, and Birth‐Related Contextual Factors

INTRODUCTION Womens postpartum sexuality can be influenced by factors related to physical, personal, and relationship transitions after the newborn arrives. Despite this, many experiential and social factors remain unexplored. AIMS This study aims to (i) investigate a range of variables thought to influence postpartum sexuality; (ii) expand the focus beyond latency to penis-vagina intercourse; and (iii) assess positive aspects of postpartum sexuality. METHODS Via retrospective reporting on the first 3 months postpartum, 304 women completed an online questionnaire. MAIN OUTCOME MEASURES The main outcome measures were retrospective reports of sexual desire (Sexual Desire Inventory), latency to resumption of sexual activity, and perceptions of partners sexual desire. Other measures were birth experience (Questionnaire Measuring Attitudes About Labor and Delivery), breastfeeding status, perceptions of social support (Multidimensional Scale of Perceived Social Support), stress (Perceived Stress Scale), and body image (Body Image Self-Consciousness Scale). RESULTS Significant differences in time to resumption were found. Women performed oral sex on their partners earlier than engaging in masturbation, which was followed by intercourse and then receiving oral sex. Post hoc analyses identified birth experience, social support, importance of partners sexual fulfillment, and perception of partners desire as contributors to this pattern. Womens postpartum sexual desire was influenced by their perceptions of their partners postpartum sexuality and individuals level of fatigue. Results suggested that postpartum desire was not significantly influenced by breastfeeding status, vaginal issues, or psychosocial variables including stress, body image, or social support. CONCLUSION Results suggest that womens perceptions of their partners sexuality impact postpartum sexuality more than the physical factors most commonly studied (e.g., vaginal trauma and breastfeeding). These results portray postpartum sexuality as a multidimensional phenomenon and highlight the need for further research that addresses its social context.

Mental Health, Demographic, and Risk Behavior Profiles of Pregnant Survivors of Childhood and Adult Abuse

Our objective was to address the gap in knowledge about the extent to which perinatal mental health and risk behaviors are associated with childhood and adult experiences of abuse that arises because of barriers to screening and disclosure about past and current abuse. Survey data from an ongoing study of the effects of posttraumatic stress on childbearing were used to describe four groups of nulliparous women: those with no abuse history, adult abuse only, childhood abuse only, and abuse that occurred during both periods. The rates of abuse history disclosure were higher in the research context than in the clinical settings. Mental health morbidity and risk behaviors occurred in a dose-response pattern with cumulative abuse exposure. Rates of current posttraumatic stress disorder ranged from 4.1% among those never abused to 11.4% (adult only), 16.0% (childhood only), and 39.2% (both periods). Women abused during both periods also were more likely to be using tobacco (21.5%) and drugs (16.5%) during pregnancy. We conclude that mental health and behavioral risk sequelae affect a significant portion of both childhood and adult abuse survivors in prenatal care. The integration into the maternity setting of existing evidence-based interventions for the mental health and behavioral sequelae of abuse is needed.

MRI Findings in Patients Considered High Risk for Pelvic Floor Injury Studied Serially After Vaginal Childbirth

OBJECTIVE The purpose of this article is to characterize pelvic floor injury after vaginal childbirth with serial MRI. SUBJECTS AND METHODS MR images (3-T) were obtained early (1 month) and late (7 months) after first childbirth in 19 women with risk factors for pelvic floor injury. All women underwent multiplanar intermediate-weighted sequences, and 11 women underwent fluid-sensitive sequences. MR images were evaluated for levator edema and tears and for pubic abnormalities. RESULTS Three women had unilateral high-grade tears, three had unilateral low-grade tears, and one had bilateral high- and low-grade tears of the levator ani muscles. All tears were focal at the pubis. Levator edema was present in all women on initial imaging and was resolved at follow-up. Six women had bone marrow edema, five with fracture line. None showed a pattern indicating nerve damage separate from muscle tears. CONCLUSION MRI showed focal levator ani muscle tears at the pubis with bone marrow edema and fracture in patients at risk for pelvic floor injury.

Moving toward patient-centered care: Women's decisions, perceptions, and experiences of the induction of labor process

BACKGROUND Patient preferences and clinician practices are possible causative factors to explain the increase in induction of labor, but scientific studies that demonstrate this link are limited. The purpose of this study is to identify factors that influence inductions from the perspective of women. METHODS A qualitative investigation using grounded theory methodology was conducted. Women were interviewed preinduction and postinduction. Analysis of the interviews was conducted using constant comparison to identify codes, categories, and themes. Through this process the complex intersection between women, their clinician, and the application of evidence-based care in clinical practice was explored. RESULTS Five major themes from the preinduction interview were identified; safety of baby, womens trust in their clinician, relief of discomfort and/or anxiety, diminish potential or actual risk, and lack of informed decision making. Five major themes were identified from the postinduction interview; lack of informed decision making, induction as part of a checklist, womens trust in their clinician, happy with induction, and opportunities to improve the experience. CONCLUSIONS Lack of informed decision making was cited as a barrier to optimal care. This study has important implications for patient-centered research and clinical care, requiring the inclusion of women and the salient concepts of care that they identify.