Elsevier

Midwifery

Volume 30, Issue 2, February 2014, Pages 255-261
Midwifery

Childbirth and criteria for traumatic events

https://doi.org/10.1016/j.midw.2013.03.001Get rights and content

Abstract

Objective

for some women childbirth is physically and psychologically traumatic and meets Criterion A1 (threat) and A2 (intense emotional response) for Posttraumatic Stress Disorder of the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV).This study differentiates Criterion A1 and A2 to explore their individual relationship to prevalence rates for posttraumatic stress, each other, and associated factors for childbirth trauma.

Design and setting

women were recruited at three hospitals from October 2008 to October 2009. Questionnaires were completed at recruitment and at 14 days post partum.

Participants

women in the third trimester of pregnancy (n=890) were recruited by a research midwife while waiting for their antenatal clinic appointment. Participants were over 17 years of age, expected to give birth to a live infant, not undergoing psychological treatment, and able to complete questionnaires in English.

Findings

this study found 14.3% of women met criteria for a traumatic childbirth. When the condition of A2 was removed, the prevalence rate doubled to 29.4%. Approximately half the women who perceived threat in childbirth did not have an intense negative emotional response. Predictors of finding childbirth traumatic were pre-existing psychiatric morbidity, being a first time mother and experiencing an emergency caesarean section.

Key conclusions

the fear response is an important diagnostic criterion for assessing psychologically traumatic childbirth. The identification of risk factors may inform maternity service delivery to prevent traumatic birth and postpartum approaches to care to address long-term negative consequences.

Implications for practice

prevention and treatment of traumatic childbirth are improved through knowledge of potential risk factors and understanding the woman's subjective experience.

Introduction

Recent research in Australia found that 45.5% of women giving birth are likely to report childbearing as traumatic (Alcorn et al., 2010), leading to a projected 135,000 Australian women each year self-rating childbirth as traumatic. Experiencing a traumatic birth can negatively impact on a woman's emotional well-being, her relationship with her new baby and her spouse (Beck, 2004a, Ayers et al., 2006, Parfitt and Ayers, 2009), extinguish her desire for more children (Allen, 1998), and increase her likelihood of requesting a surgical delivery for future births (McCourt et al., 2007). Traumatic birth may lead to the development of Posttraumatic Stress Disorder (PTSD), with estimated prevalence rates ranging from 1% to 6% at four to six weeks post partum (Creedy et al., 2000, Soet et al., 2003, Adewuya et al., 2006, Soderquist et al., 2006, Edworthy et al., 2008, Alcorn et al., 2010).

The Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV: American Psychiatric Association, 1994) defines a traumatic event as ‘where the person experienced, witnessed, or was confronted with event or events that involved actual or threatened death or serious injury, or a threat to physical integrity of self or others’ (Criterion A1) and where the same person experienced an intense emotional response of fear, horror, or helplessness (Criterion A2). Both criteria must be endorsed to meet the guidelines for a traumatic event (as opposed to self-describing an event as ‘traumatic’). In the development of the fifth edition of the diagnostic manual, it is proposed that Criterion A2, the emotional response, be removed (American Psychiatric Association, 2010).

A recent study of women's experience of childbirth found that almost half (45.8%) of women who met Criteria A1 of threat did not report fear, horror or helplessness (Alcorn et al., 2010). A better understanding of how Criteria A1 and A2 relate to emotional pathology, and each other, would inform the design of successful resilience interventions for women most at risk of developing PTSD following a traumatic childbirth. This study examines the prevalence and associated factors of a traumatic birthing experience, and its immediate effect on emotional well-being of new mothers. First we gauged the prevalence and tested the relationship between Criteria A1, A2 and overall experiencing of a traumatic birth (A1 and A2 together). We then tested if each criterion was related to adverse emotional reactions in women. As interventions to prevent such reactions are desirable, we then tested which pre-existing characteristics of the mother and her birth predict traumatic childbirth.

Section snippets

Method

The present study was part of a larger randomised control trial evaluating the efficacy of a counselling intervention on mental health outcomes of emotionally distressed postpartum women (Fenwick et al., 2011). Measures used in this study were collected prior to intervention.

Findings

PASW Statistics (IBM SPSS Inc., 2010) and ClinTools Software (Devilly, 2005) were used for analysis. Hypothesis testing was non-directional (i.e. two-tailed testing), and alpha was set at .05.

Prevalence of the traumatic event

At 14.3%, this study found a lower prevalence rate of Criterion A traumatic births than comparative childbirth studies. The difference may be related to measurement variation. Alcorn et al. (2010) and Soet et al. (2003) reported rates of 45.5% and 34% respectively and used adapted Criterion A wording to include elements reflective of childbirth. Alcorn et al. did, however, use the Posttraumatic Diagnostic Scale. This study's finding is closer to the 19.7% prevalence rate reported by Ayers et

Conflict of interest

The authors declare that there are no conflicts of interest.

Author contribution

All authors meet the criteria for authorship, have approved the final article and all entitled to authorship are listed as authors.

Acknowledgements

This research was supported by a National Health & Medical Research Project Grant (ID: 481900).

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