Susan Ayers

The effects of childbirth-related post-traumatic stress disorder on women and their relationships: A qualitative study

Abstract There is converging evidence that 1% – 2% of women develop post-traumatic stress disorder (PTSD) as a result of childbirth. The current study aimed to explore the long-term effects of childbirth-related PTSD on women, their relationship with their partner and their relationship with their child. Semi-structured interviews were carried out with six women who reported clinically significant PTSD after birth, ranging from 7 months to 18 years beforehand. Interviews were transcribed and analysed using thematic analysis. Childbirth-related PTSD was found to have wide-ranging effects on women and their relationships. Women reported changes in physical well-being, mood and behaviour, social interaction, and fear of childbirth. Women reported negative effects on their relationship with their partner, including sexual dysfunction, disagreements and blame for events of birth. The mother – baby bond was also seriously affected. Nearly all women reported initial feelings of rejection towards the baby but this changed over time. Long-term, women seemed to have either avoidant or anxious attachments with their child. It is concluded that childbirth-related PTSD can have severe and lasting effects on women and their relationships with their partner and children. Further research is needed to compare this to normal difficulties experienced by women after having children.

Anxiety measures validated in perinatal populations: A systematic review

BACKGROUND Research and screening of anxiety in the perinatal period is hampered by a lack of psychometric data on self-report anxiety measures used in perinatal populations. This paper aimed to review self-report measures that have been validated with perinatal women. METHODS A systematic search was carried out of four electronic databases. Additional papers were obtained through searching identified articles. Thirty studies were identified that reported validation of an anxiety measure with perinatal women. RESULTS Most commonly validated self-report measures were the General Health Questionnaire (GHQ), State-Trait Anxiety Inventory (STAI), and Hospital Anxiety and Depression Scales (HADS). Of the 30 studies included, 11 used a clinical interview to provide criterion validity. Remaining studies reported one or more other forms of validity (factorial, discriminant, concurrent and predictive) or reliability. The STAI shows criterion, discriminant and predictive validity and may be most useful for research purposes as a specific measure of anxiety. The Kessler 10 (K-10) may be the best short screening measure due to its ability to differentiate anxiety disorders. The Depression Anxiety Stress Scales 21 (DASS-21) measures multiple types of distress, shows appropriate content, and remains to be validated against clinical interview in perinatal populations. LIMITATIONS Nineteen studies did not report sensitivity or specificity data. The early stages of research into perinatal anxiety, the multitude of measures in use, and methodological differences restrict comparison of measures across studies. CONCLUSION There is a need for further validation of self-report measures of anxiety in the perinatal period to enable accurate screening and detection of anxiety symptoms and disorders.

Pre- and postnatal psychological wellbeing in Africa: A systematic review

BACKGROUND Perinatal mental health disorders are recognised as an important public health issue in low-income countries as well as in developed countries. This paper reviews evidence on the prevalence and risk factors of maternal mental health disorders in African women living in Africa. METHODS A systematic review of the literature was conducted. Studies were mainly located through computerised databases, and additionally through hand searching references of identified articles and reviews. Thirty-five studies, with a total of 10,880 participants, were identified that reported prevalence rates of maternal psychological health in eight African countries. RESULTS Depression was the most commonly assessed disorder with a weighted mean prevalence of 11.3% (95% CI 9.5%-13.1%) during pregnancy and 18.3% (95% CI 17.6%-19.1%) after birth. Only a small number of studies assessed other psychological disorders. Prevalence rates of pre- and postnatal anxiety were 14.8% (95% CI 12.3%-17.4%) and 14.0% (95% CI 12.9%-15.2%), respectively; and one study reported the prevalence of PTSD as 5.9% (95% CI 4.4%-7.4%) following childbirth. Lack of support and marital/family conflict were associated with poorer mental health. Evidence relating sociodemographic and obstetric variables to mental health was inconclusive. LIMITATIONS Most studies included in this review were cross-sectional and measures of mental health varied considerably. CONCLUSIONS This paper demonstrates that maternal mental health disorders are prevalent in African women, and highlights the importance of maternal mental health care being integrated into future maternal and infant health policies in African countries.

Delivery as a traumatic event: prevalence, risk factors, and treatment for postnatal posttraumatic stress disorder

This review looks at the evidence for posttraumatic stress disorder (PTSD) after birth. Postnatal traumatic stress responses are divided into appraisal of birth as traumatic, traumatic stress responses (severe symptoms of intrusions and avoidance that do not fulfill all the criteria for PTSD), and PTSD. Evidence is examined for the prevalence of these types of responses after birth and for prenatal, perinatal, and postnatal vulnerability and risk factors. Screening tools that could be used are outlined and possible intervention and treatment approaches considered. Various conceptual and methodological issues are also raised. It is concluded that up to 10% of women have severe traumatic stress responses to birth, although only 1% to 2% of women actually develop chronic postnatal PTSD. The limited research available suggests that a history of psychiatric problems, mode of delivery, and low support during labor put women at increased risk of postnatal PTSD, although there is unlikely to be a simple relationship between mode of delivery and traumatic stress responses. A model of the possible pathways between vulnerability/risk factors and postnatal PTSD is proCorrespondence: Susan Ayers, PhD, C.Psychol., Psychology Department, University of Sussex, Brighton, BN1 9QH, UK. E-mail: S.Ayers@sussex.ac.uk CLINICAL OBSTETRICS AND GYNECOLOGY Volume 47, Number 3, 552–567

Post-traumatic stress disorder following childbirth: current issues and recommendations for future research

Background. An increasing body of research shows that a proportion of women experience significant symptoms of Post-Traumatic Stress Disorder (PTSD) following childbirth. Aims and method. An international group of researchers, clinicians, and user-group representatives met in 2006 to discuss the research to date into PTSD following childbirth, issues and debates within the field, and recommendations for future research. This paper reports the content of four discussions on (1) prevalence and comorbidity, (2) screening and treatment, (3) diagnostic and conceptual issues, and (4) theoretical issues. Conclusions. Current knowledge from the perspectives of the researchers is summarized, dilemmas are articulated and recommendations for future research into PTSD following childbirth are made. In addition, methodological and conceptual issues are considered.

Childbirth-related post-traumatic stress disorder in couples: A qualitative study

OBJECTIVES Previous research has established that women can develop childbirth-related post-traumatic stress disorder (PTSD), but the effect of this on a couples relationship has not been examined. This study aimed to look at the experience and impact of childbirth-related PTSD in women and their partners. DESIGN This was a qualitative interview study of six couples, where at least one partner had clinically significant symptoms of childbirth-related PTSD. METHODS Semi-structured interviews were conducted separately with each partner and interview transcripts subjected to thematic analysis. RESULTS Analysis identified four themes with 18 subthemes as follows: (1) birth factors (pain, negative emotions in labour, perceived lack of control, lack of choice or lack of involvement in decision-making, restricted movement or physical restraint, and expectations not being met); (2) quality of care (information provision, staff factors, continuity of care and environment); (3) effects on relationship with partner (impact on physical relationship, communication within the relationship, negative emotions within the relationship, receiving or giving support from partner, coping together as a couple and overall effect on the relationship); and (4) effects on relationship with child (perceptions of the child and parent-baby bond). CONCLUSIONS This study suggests that PTSD may have a negative impact on the couples relationship and the parent-baby bond.

Posttraumatic growth and adjustment among individuals with cancer or HIV/AIDS: A meta-analysis

Abstract There is increasing research on posttraumatic growth after life-threatening illnesses such as cancer and HIV/AIDS, although it is unclear whether growth confers any psychological or physical benefits in such samples. Consequently, this meta-analysis explored the relationship between posttraumatic growth and psychological and physical wellbeing in adults diagnosed with cancer or HIV/AIDS and examined potential moderators of these relationships. Analysis of 38 studies (N =7927) of posttraumatic growth after cancer or HIV/AIDS revealed that growth was related to increased positive mental health, reduced negative mental health and better subjective physical health. Moderators of these relationships included time since the event, age, ethnicity, and type of negative mental health outcome. It is hoped that this synthesis will encourage further examination of the potentially complex relationship between posttraumatic growth and adjustment in individuals living with life-threatening medical conditions.

Does Anxiety Sensitivity Predict Post-Traumatic Stress Symptoms Following Childbirth? A Preliminary Report

The aim of the current study was to investigate whether prenatal levels of anxiety sensitivity would predict post-traumatic stress disorder symptoms following childbirth. A total of 40 women completed a series of self-report measures, including the Anxiety Sensitivity Index and the General Health Questionnaire at 36 weeks gestation. The women were followed-up 2 weeks postpartum with self-report measures of post-traumatic stress disorder, mood and birth experiences. Correlational analysis revealed that a combination of pre- and postnatal psychological factors as well as obstetric events was related to post-traumatic stress disorder symptoms. Regression analysis revealed that prenatal anxiety sensitivity predicted post-traumatic stress disorder symptoms, suggesting that anxiety sensitivity may act as an important vulnerability factor in psychopathological responses to childbirth. Further investigation into this construct seems warranted.

Measures of satisfaction with care during labour and birth: a comparative review

BackgroundSatisfaction is the one of the most frequently reported outcome measures for quality of care. Assessment of satisfaction with maternity services is crucial, and psychometrically sound measures are needed if this is to inform health practices. This paper comparatively reviews current measures of satisfaction with care during labour and birth.MethodsA review of the literature was conducted. Studies were located through computerised databases and hand searching references of identified articles and reviews. Inclusion criteria were that the questionnaire was a multi-item scale of satisfaction with care during labour and birth, and some form of psychometric information (either information about questionnaire construction, or reliability, or validity) had to be reported.ResultsNine questionnaires of satisfaction with care during labour and birth were identified. Instruments varied in psychometric properties and dimensions. Most described questionnaire construction and tested some form of reliability and validity. Measures were generally not based on the main theoretical models of satisfaction and varied in scope and application to different types of samples (e.g. satisfaction following caesarean section). For an in-depth measure of satisfaction with intrapartum care, the Intrapartal-Specific Quality from the Patient’s Perspective questionnaire (QPP-I) is recommended. Brief measures with good reliability and validity are provided by the Six Simple Questions (SSQ) or Perceptions of Care Adjective Checklist (PCACL-R).ConclusionsDespite the interest in measures of satisfaction there are only a small number of validated measures of satisfaction with care during labour and birth. It is important that brief, reliable and valid measures are available for use in general and specific populations in order to assist research and inform practice.

Hysterectomy improves quality of life and decreases psychiatric symptoms: a prospective and randomised comparison of total versus subtotal hysterectomy

Objective  To conduct a prospective and concurrent evaluation of changes in health status and quality of life and psychological outcome measures over one year in women randomised to total or subtotal abdominal hysterectomy. The concurrent evaluation was the impact of total versus subtotal hysterectomy on bladder, bowel and sexual function.