Negative experiences following childbirth
Approximately 110,000 women give birth in Sweden annually [
1]. Childbirth can be associated with both positive and negative psychological reactions, and a woman’s negative experience of labour and birth can affect her emotional wellbeing [
2]. Between 9 and 45% of women reported a traumatic childbirth [
3‐
5]. The experience of labour and birth is subjective, multidimensional and complex including physiological and psychological factors. There are several risk factors for negative childbirth-experiences such as unexpected medical problems, lack of social support, emotional state and care given during labour [
2]. Negative and traumatic experiences during childbirth can sometimes lead to the development of posttraumatic stress symptoms and even posttraumatic stress disorder (PTSD).
Posttraumatic stress following childbirth
In a meta-analysis, the prevalence for PTSD following childbirth (PTSD FC) was 3.1% among community samples and 15.7% among high-risk samples (e.g. pregnancy complications, emergency caesarean section, preterm birth) [
6]. In a more recent review [
7], the estimated prevalence was 2.4% among community samples, and 4.9% including both community plus high-risk samples when controlling for previous PTSD. The prevalence for clinically significant post-traumatic stress symptoms ranged between 9.6 and 27.3% [
7]. The variation in prevalence rates may be explained by the timing and method used for assessment of PTSD criteria and symptoms [
6,
7]. Prevalence rates were consistently higher in both studies when assessed close to childbirth. The prevalence rates above are based on the fourth edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-IV-TR) [
8]. There is no sub-clinical or partial PTSD diagnose in DSM-IV, which is reflected in the heterogeneity regarding definition and label of clinically significant post-traumatic stress symptoms.
The definition of stressors for the development of PTSD according to DSM-IV can be applied to posttraumatic stress FC. A diagnosis of PTSD required affirming the following criteria: the stressor criterion (A) included stressful situations in which a person experience, witness, or is confronted with an event that involves actual death or threat of death or serious injury, or a threat to the physical integrity of self or others; the three symptom criteria re-experiencing (B), avoidance (C), and increased arousal (D); the duration criterion (E), and the influence criterion (F). Several risk factors are associated with PTSD FC, such as psychological factors (e.g. fear of childbirth), prepartum and partum factors (e.g. type of delivery) and postpartum factors (e.g. poor coping) [
6,
9]. In a systematic review, five categories of risk factors for PTSD FC are identified: negative perception of childbirth, maternal mental health, history of trauma and PTSD, delivery mode and complications, and low social support [
7].
Beside the symptoms of PTSD FC there is a strong association with postpartum depressive symptoms [
6,
10] and comorbidity rates between 20 and 75% have been reported [
10,
11]. Dysfunctional coping is common [
12] and in terms of quality of life, women with PTSD FC reported negative changes in their mood, psychological well-being and social interaction [
13]. PTSD FC and depression can also seriously affect the mother’s bonding with the baby with initial feelings of rejection towards the baby and in the long term she might develop either an avoidant or anxious attachment with her child [
13]. Several aspects of infant development and behaviour, including patterns of eating, sleeping, and cognition, are mediated by parental posttraumatic reactions and depression [
14]. Breastfeeding can also be negatively affected after a negative childbirth experience [
15]. There is a higher risk of negative impact on the partner-relationship among women with PTSD FC than among women without. Sexual dysfunction and disagreements are common [
13,
16] and those with PTSD FC and depression are more likely to avoid sexual relationships, wait longer before they get pregnant again, and give birth to fewer children [
17,
18]. Few studies have examined the role of the partner and how his/her experience may affect the mother, the child, parenthood and any future plans to have more children [
19]. It is suggested that providing additional support to partners in the early postpartum period may help alleviate any acute distress and reduce the detrimental impact the early postnatal symptoms may have on the partners [
16]. Partner support seems important at all stages: stronger social partner support at mid-pregnancy was associated with lower emotional distress after childbirth [
20] and stronger postnatal emotional partner support was associated with lower levels of symptoms of depression and hyper arousal [
21].
Interventions for women with negative experiences and PTSD FC
There has been relatively little research on psychological treatment for women with negative birth-experiences and PTSD FC [
9]. The focus of this research has mostly been on postpartum counselling and debriefing (psychological interventions intended to reduce the psychological morbidity that arises after exposure to trauma). Results indicate that, in general, debriefing does not prevent psychiatric disorders or mitigate the effects of traumatic stress, even though people generally find debriefing helpful in the process of recovering from traumatic stress [
22]. Gamble and Creedy [
23] concluded that postpartum counselling and debriefing are often only general and nonspecific, and are not described in detail for replication. In addition, these interventions should be given by trained psychotherapists only. A systematic review [
24] showed no preventive effect from a single debriefing session but did show some risk for developing PTSD. Postnatal debriefing should not be offered routinely after a traumatic birth [
25].
The effects of structured writing assignments for psychological health have been investigated in many experiments [
26] often using the intervention expressive writing developed by Pennebaker [
27]. Structured writing about emotions associated with traumatic events have a positive effect on psychological wellbeing [
28]. Expressive writing for new mothers reduced their symptoms of depression and posttraumatic stress [
29]. Pre-term birth mothers were randomized to expressive writing or TAU and the intervention was acceptable and reduced post-traumatic stress, depression and improved mental health [
30]. A pilot randomized controlled trial (RCT) investigated the effect of a visuo-spatial task (playing tetris) within 6 hours after emergency caesarean section compared with TAU [
31]. The study showed significantly fewer intrusive memories in the intervention group compared with the control group 1 week after the intervention. This intervention was acceptable among a majority of participants and is interesting due to its simplicity and to the fact that it is easily administered.
The recommended treatment for PTSD is trauma-focused cognitive behaviour therapy (TFCBT) or eye movement desensitisation reprocessing (EMDR) [
32]. TFCBT is the treatment that currently has the strongest research support for PTSD [
33]. The theoretical framework for TFCBT involves confronting trauma related emotional distress via exposure that aim at disconfirming the beliefs that underlie and maintain the PTSD symptoms [
34]. In particular, in vivo and imaginal exposure aim at disconfirming beliefs and perceptions related to traumatic stimuli (both external and internal). In vivo exposure enables new learning by activating distress and subsequent the experience of being capable of coping with the symptoms. Revisiting and recounting the trauma memory via imaginal exposure reorganizes the memory and generate habituation so that the trauma memory can be revisited without harm. It is suggested that the effect of TFCBT for those with PTSD FC is equivalent to those with PTSD due to other events [
35]. There is no specific treatment recommendation for PTSD FC in Sweden but in the United Kingdom and some other western countries the treatment recommendations are based on existing knowledge about treatment of PTSD in general [
36,
37].
To the best of our knowledge, no RCT with face to face CBT for women with PTSD FC has been published. A few case studies have investigated the effects of psychological interventions (CBT, EMDR and expressive writing), with positive results, for women with PTSD FC [
15,
38‐
41]. However, one Swedish RCT investigated internet-delivered CBT (iCBT) vs waitlist for women with PTSD FC with recruitment taking place by using a nationwide invitation [
42]. The iCBT (trauma focused) consisted of 8 weeks with support, which included feedback on homework assignments. The results (pre-post) showed a large between-group effect size at post (ES,
d = 1.25) on the PTSD measure and a small but significant ES on depressive symptoms in favour of the iCBT group. The study was underpowered, but the authors conclude that iCBT can be used to help women with childbirth-related PTSD symptoms [
42]. Depressive symptoms are common among mothers with or without PTSD or negative experiences. A recent trial investigated the effect of a brief online self-help (cognitive skills for negative beliefs) compared to an active comparison group (time management skills) [
43]. There was a significant improvement in mood for the cognitive skills group compared to the control group. The authors conclude that online interventions for negative mood is acceptable and helpful for those without a clinical depression.
In a meta-analysis on iCBT for PTSD due to other events than negative effects of childbirth, medium to large effect sizes were found (0.66 <
g < 0.83) in favour of iCBT vs passive controls [
44]. The authors conclude that iCBT for PTSD is promising and a viable approach for treatment of PTSD. However, more studies with follow-up are needed [
44], and the efficacy of iCBT for those with a negative experience needs to be evaluated [
9]. Finally, we found no CBT or EMDR study that involved the partners of women with negative experiences or PTSD FC. There is also a need for health economic evaluations when investigating treatment interventions; none of the above-mentioned treatment studies presented this.
The current study addresses gaps concerning treatment for this population. First, the intervention consists of two steps, where step-1 is offered to all women with negative birth experiences, regardless of whether they have a PTSD diagnose or not. Those who fulfil the criteria for PTSD FC after step-1 are offered step-2. Second, the partners are invited to join the treatment in step-1. We also include long-term follow ups. The study involves the partner by facilitating a shared treatment experience with the mother, giving information on how to support her emotionally, and providing practical support that may help her to get the greatest benefit from the treatment program. Finally, we will present a health economic evaluation.