Photograph courtesy of Alexa Miller Gallo & Natasha Wheat
What Is Postpartum PTSD?
The experience of childbirth is one of the most profound moments of becoming a mother, but researchers have found that for some women, it can trigger a form of PTSD similar to that of war veterans—a condition that is marked by flashbacks, nightmares, obsessive thoughts, and emotional distress. “Childbirth is clearly not war,” says researcher and psychologist Sharon Dekel. “But the common notion is that it should be a very happy event, so it’s hard to think about childbirth as also a very stressful experience that is capable of evoking PTSD in some women.”
Dekel, an assistant professor of psychology at Harvard Medical School and a principal investigator at Massachusetts General Hospital in the Department of Psychiatry, studies the mental health of women in the course of the perinatal period, focusing on mothers who had a stressful or traumatic childbirth experience. Her lab’s focus is on understanding the psychological and biological implications for the mother and, potentially, for the child. Her lab has found that mothers who have PTSD experience less maternal bonding with their baby, which prompts what Dekel calls a “vicious feedback loop.” In some cases of postpartum PTSD, the baby is a constant reminder or emotional trigger of the traumatic event.
A traumatic birth experience can be defined in many ways. For some, it could be pregnancy loss, but for others, it could be when a birth doesn’t go according to whatever the plan may have been. A stressful pregnancy or delivery doesn’t always lead to PTSD, explains Dekel. But when it does, it differs from postpartum depression in both symptoms and treatment. There isn’t enough research yet to fully understand why or how this condition develops, but part of the work being done at Dekel’s lab uses brain imaging to identify the factors that lead to postpartum PTSD .
While research is gaining momentum, the wider message, says Dekel, is more profound: “We need to make women feel more comfortable. Mothers need to know it’s okay to ask for help. If we can do these things, we can improve ourselves as a society.”
A Q&A with Sharon Dekel, PhD
PTSD is a stress-related disorder that is evoked when there are traumatic reminders of the event. When we speak about postpartum psychological distress or postpartum mental illness, the common knowledge is that, unfortunately, a significant number of women experience postpartum blues, and the focus has been on postpartum depression. What we know today is actually above and beyond postpartum depression. There are other mental illnesses or psychological burdens that a woman could face in the postpartum period, and one of these burdens could be developing post-traumatic stress disorder, which is evoked by a stressful childbirth experience.
Our data suggests that being a first-time mother increases your chances of having a traumatic delivery, but it doesn’t necessarily mean you’re going to have PTSD. We also see that women who had an unscheduled Cesarean—which we know objectively is likely to be more stressful for the majority of women—are among those who would be most at risk. In our recent study published in the Archives of Women’s Mental Health, we found that mothers who had an unscheduled Cesarean were at least three times more likely to develop PTSD.
There might be preexisting factors that would make the mother at risk for developing postpartum PTSD. And the more the exposure is objectively traumatic, the more you’re likely, given your prior vulnerability, to develop a mental illness. Those vulnerability factors are a combination of prior factors—which would be the mental health history of the mother, prior trauma exposure, and a history of negative life events—and environmental factors, like income and age, such as those who are younger and those who are first-time moms. Then it’s the magnitude of the stressor and the traumatic exposure itself, such as the mode of delivery and any medical complications in the birth. Was it vaginal? Was it unscheduled? Was it vaginal-assisted? In our lab, we see that the woman’s emotional response to the birth is an important factor.
On average, roughly 6 percent of mothers would have clinical postpartum PTSD, but different studies might report different prevalence rates. And this is having really severe symptoms that causes so much distress it impairs functioning. If we have 4 million mothers who gave birth in the state, roughly 240,000 women would have postpartum PTSD. If we just looked into women at risk, which will be mothers who have a premature delivery, unscheduled Cesarean, or emergency Cesarean, then the rates are much higher. Some studies report that up to 19 percent of women would have postpartum PTSD symptoms.
My team has studied over 1,500 women using clinical assessments, questionnaires, and physiological tools. We’ve seen that the stress or the magnitude of the childbirth experience could be as extreme as other, more-known traumatic events, such as PTSD in the context of combat exposure. Based on my work, the childbirth experience for some women could evoke a similar psychological response as that of soldiers who go to war. We use the same self-reporting measures to assess traumatic childbirths that have been used in trauma research on sexual abuse survivors and war veterans. We give the same traumatic exposure questionnaire that has been repeatedly used in other research and use the same tools, and they show us that the responses are similar.
Unfortunately, for some mothers who have postpartum PTSD, the child could be a traumatic reminder for the mother. In my clinical observation of women we studied in our lab, we have mothers who report that they are dreading one-on-one interaction with their baby. When they interact with their baby, they have these flashbacks, and they get a very intense physiological arousal because the baby reminds them of their traumatic childbirth experience. Post-traumatic stress disorder is a mental illness. It’s not just that the woman reports she feels overwhelmed or distressed; it’s biological changes that are happening to this woman. And like any illness, this is a very severe condition that should be treated to prevent any transmission of a condition to the child.
In general, working or treating women in the postpartum period is extremely important because we know that the mental health of the mother is very important to ensure the optimal development of a child. Based on the work here in my lab, with women who developed postpartum PTSD, there is the risk they could struggle connecting with their babies. When the maternal bonding is impaired, that could, again unfortunately, have an adverse effect, delaying the development of the child. Eventually, the impairment of maternal bonding could result in a less than optimal environment for the child, which would increase the risk of mental illness in the child. Ideally, we want to make the mother healthy, to protect her and make her a happy mother, and also to protect the child from risk and really make sure that our society is a healthy one.
The Diagnostic Statistical Manual of Mental Health Disorders includes postpartum depression but not postpartum PTSD. Currently, there is no screening for postpartum PTSD in routine ob-gyn care. There is screening for postpartum depression, but depression and PTSD are different conditions that require different treatments. For a lot of the women we see in our lab, one of the recurring themes is that they said they aren’t really sure what is happening. They don’t have a term for what they are experiencing. They felt guilty for not being able to connect with their baby. Again, with more scientific discoveries to better characterize postpartum PTSD, if a woman comes to her primary-care physician or OB-treating physician and says, “Listen, I think I’m having flashbacks” or “I’m having a hard time sleeping, and every time I think about childbirth, I feel physically and emotionally very upset,” then we would be able to screen her accurately and say that she has postpartum PTSD—and let’s see what services we can offer her either in the hospital or community.
One of the great advances for us as a society is that those mothers who might be at risk for developing postpartum PTSD are those who are then carefully followed by the medical system. At Mass General, a mother who has an unscheduled C-section is likely to be at the hospital for about four days. We could identify her if she had a stressful response to childbirth, and we could treat her or, if not, at a minimum, educate her about whatever she’s feeling and at least normalize her condition. This might be based on the screening that we would give to these women immediately after birth. With additional funding, my lab is in the process of examining the possibility that a blood test could identify the women at risk. I’m hoping that with more research to improve OB care, we will be able to change the status quo in terms of postpartum PTSD.
It is an NIH-funded clinical trial, and we are examining the effects of oxytocin intervention to boost maternal bonding, decrease symptoms of depression, and potentially decrease symptoms of PTSD. This oxytocin intervention is not necessarily targeting women who had a traumatic delivery, but we are assuming that some women in our study might have gone through one. We are interested in learning whether an oxytocin intervention could also be helpful to decrease, if not prevent, a stress response from childbirth. What we’ve seen in our study of 1,500 women is that if the woman’s immediate emotional response to childbirth—what we call a peritraumatic response—is a really negative stress response, it is a very strong indicator that they might eventually develop PTSD in the long term. The PTSD could develop, at a minimum, a month after the trauma exposure.
The idea is that an early internatal intervention, which would be given to mothers in the first days after they give birth, could improve maternal bonding in the optimal time for child development and also potentially decrease any kind of stress response following the childbirth experience. This is the clinical trial we’re currently testing. Specialized interventions for postpartum PTSD that relates to the childbirth experience are almost entirely lacking.
With more research we need to better understand to what extent these conditions are different. One of the most prominent complications of postpartum PTSD is the bonding impairments. The ideal treatment for postpartum PTSD would not only target the PTSD symptoms but would also focus on promoting attachment and minimizing negative bonding between the mother and the child.
In that sense, postpartum PTSD gets an added layer to the condition versus PTSD because it’s a mother-baby unit that we need to fix, and that requires different treatment than a single individual. First, we want to make sure that any intervention would be safe. We also want to promote breastfeeding, so we need to come up with very safe treatments if we’re speaking about psychopharmacological interventions. Any medication that could be safe for an adult who is not breastfeeding needs to have an even higher level of safety because we know that some drugs can be transmitted to breast milk.
I’ve interviewed so many mothers, and many women who came to our studies were those who clearly had the resources to seek treatment. We studied women up to even ten years following their childbirth experience, and the majority told us that they never actually spoke with anybody about their trauma. These are usually educated women who have the resources to either find somebody within their network or specialized services, and they haven’t done it. So clearly, what we know about postpartum mental illness in general is that there is a big stigma about reporting symptoms, and there’s a lot of shame involved. For many women, the illness remains undiagnosed and untreated. I even had women who are mental health providers who are in treatment themselves, but in the course of their treatment, they never spoke about their traumatic childbirth. They spoke about their baby, about the fact that they might be having a difficult time bonding with their baby, but they never made the connection between the events and their struggle and their stressful childbirth. Ultimately, it’s really about the event, not about the person.
The more women speak about their experience and share the fact that birth was a struggle, the more it will become accepted on a societal level that childbirth is very challenging and that you should ask for help if you might need it. I spoke with a woman recently who is highly educated and has the means to seek therapy, and she said she never discussed her childbirth experience in a thorough, meaningful way with anybody, including her partner. I asked her why, and one of the reasons she gave was that when she speaks with her girlfriends, everybody says, “This was the best time of my life.” So she said she felt embarrassed to share her experience and preferred not to say anything about it.
A recurring theme that we observe with many women when they report their symptoms is that they blame themselves for their traumatic childbirth, for example, if they wanted to have a vaginal delivery but had an unscheduled Cesarean. They felt that they lost control, they felt guilty that they didn’t want to bond with the baby, and they felt it was their fault. If you feel guilty, you don’t feel comfortable asking for help.
We recently launched our brain-imaging study of women who had traumatic deliveries. Some of them had PTSD following childbirth, and some of them did not. We are interested in learning whether there are maternal alterations in the brain that might relate to postpartum PTSD, and we’re especially interested in looking at areas in the brain that we know are involved in maternal care. If we are able to better map these different neural areas or neural activation, then we will be able to develop psychopharmacological interventions that target that specific area in the brain to boost maternal bonding for some women who are really struggling.
We have a collaboration with Mass General’s obstetrics program. We have been studying a large sample of women from the third trimester through the early postpartum period to understand the trajectory of their mental health and see what was happening before they gave birth, their immediate reaction to childbirth, and then what happened to them sometime later in terms of their psychological well-being. With that study, we will eventually be able to identify the most important predictors from what’s happening to the woman immediately after giving birth. Let’s say we have two women who gave birth at Mass General: Both of them had a stressful childbirth experience, but a month and a half later, one of them doesn’t have PTSD and the other does. By getting a lot of detailed information about what was going on with these women immediately after giving birth and their biological information, we might be able to make very strong predictions about what promotes resiliency and recovery and even psychological growth following traumatic childbirth and what are the factors that would make a woman eventually have a difficult time facing the traumatic childbirth exposure.
Sharon Dekel, PhD, is an assistant professor of psychology at Harvard Medical School and the principal investigator at the Dekel Laboratory in the Massachusetts General Hospital Department of Psychiatry. She earned a PhD in clinical psychology from Columbia University and completed her clinical internship training at Columbia Medical Center, followed by a postdoctoral research fellowship in a leading international trauma lab. Dekel is also a licensed clinical psychologist.
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