Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Email this article to a Colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My Articles & Searches Download to citation manager Citing Articles via Google Scholar Articles by Morland, L. Articles by Friedman, M. Search for Related Content PubMed Citation Articles by Morland, L. Articles by Friedman, M. Posttraumatic Stress Disorder Child Abuse Spouse Abuse

Posttraumatic Stress Disorder and Pregnancy Health: Preliminary Update and Implications

Received March 17, 2006; revised May 25, 2006; accepted June 13, 2006. From the Dept. of Psychiatry, John A. Burns School of Medicine, Univ. of Hawaii; the National Center for PTSD, Pacific Island Division, VA Pacific Island Healthcare System; the Dept. of Obstetrics, Gynecology, and Women’s Health, John A. Burns School of Medicine, Univ. of Hawaii; the Dept. of Pediatrics, John A. Burns School of Medicine, Univ. of Hawaii, and the National Center for PTSD, Executive Division, White River Junction, VT. Send correspondence and reprint requests to Dr. Morland, Dept. of Psychiatry, John A. Burns School of Medicine, Univ. of Hawai’i at Manoa. e-mail: leslie.morland{at}va,gov
©2007 The Academy of Psychosomatic Medicine

ABSTRACT

TOP ABSTRACT INTRODUCTION METHOD RESULTS DISCUSSION REFERENCES

 
Posttraumatic stress disorder (PTSD) is pervasive among women of childbearing age. The cascade of behavioral health and neuroendocrine changes commonly associated with PTSD may adversely affect perinatal health. The authors examined the relationship between PTSD and perinatal health in a sample of 101 women seeking prenatal care on the island of Oahu, Hawaii. Trauma, PTSD, and psychological and behavioral health were assessed during prenatal care. Pregnancy health, labor and delivery information, and birth outcomes were abstracted from medical records post-partum. Findings suggest that women with PTSD entering pregnancy are at increased risk for engaging in high-risk health behaviors, such as smoking, alcohol consumption, substance use, poor prenatal care, and excessive weight gain. Authors discuss clinical and research implications.

INTRODUCTION

TOP ABSTRACT INTRODUCTION METHOD RESULTS DISCUSSION REFERENCES

 
Violence against women is a widespread problem. Large epidemiological studies suggest that 25%–50% of women are exposed to interpersonal trauma over their lifespan, and prevalence rates of posttraumatic stress disorder (PTSD) are reported to be between 10% and 12% in the general population.^1–3 Exposure to trauma peaks between the ages of 16 and 20 years, suggesting that trauma and subsequent PTSD often occur before childbearing.¹ Despite the high rates of PTSD among women, limited research has examined the potential impact of PTSD on perinatal health. Harris-Brit and colleagues⁴ reported that 69% of pregnant women in their convenience sample had experienced a violent traumatic event, the majority involving interpersonal violence that occurred before the pregnancy. Furthermore, 58% of their sample met criteria for clinical PTSD, with many women indicating that their PTSD affected their day-to-day functioning during pregnancy.

The cascade of bio-psycho-behavioral changes commonly associated with PTSD may adversely affect childbearing, with serious consequences for perinatal health and birth outcomes.^5–7 For instance, PTSD has been linked to neuroendocrine alterations (dysregulation of cortisol, vasopressin, oxytocin, etc.) that may directly predispose women to birth complications⁵ and infants to a putative risk for developing a biological vulnerability to PTSD.⁸ PTSD is also associated with high rates of psychiatric comorbidities, such as depression and anxiety disorders.^9,10 Numerous studies have demonstrated that significant stress and/or depression, predicts preterm delivery, low birth weight, or reduced fetal growth.^11–16 In several studies, the effects of maternal stress, after controlling for medical risk, accounted for approximately 10% of the gestational variations and thus produced effects of considerable clinical significance.

PTSD has also been found to be linked with a variety of behavioral health risk factors, such as smoking, alcohol consumption, and poor health care,¹ and all of these factors have been consistently found to be linked to poor perinatal health and adverse birth outcomes.^17,18 For example, Dobie et al.¹⁹ found that women who screened positive for PTSD had an increase in negative health behaviors; including alcohol consumption, smoking, substance abuse, and contact with multiple sexual partners. Also, with regard to endorsing higher levels of somatic complaints, women with PTSD report symptoms of depression, eating disorders, and panic disorder; they have also reported higher rates of obesity, fibromyalgia, irritable bowel syndrome, emphysema, and sexually transmitted infection.¹⁹ Engaging in high-risk behaviors such as smoking and alcohol consumption during pregnancy have also been linked to a range of early child-development issues, such as neurocognitive problems and behavior difficulties.^20,21

Limited research has investigated the influence of PTSD on perinatal health and birth outcomes. One large retrospective study examining archival data found pregnant women with PTSD to have higher rates of ectopic pregnancy, spontaneous abortion, hyperemesis, preterm contractions, and excessive fetal growth.⁶ PTSD may be an important underlying mechanism for understanding poor perinatal health, birth complications, and adverse birth outcomes, both via associated high-risk behaviors and via neuroendocrine pathways. PTSD can affect perinatal health directly (e.g., via immunologic and endocrine factors) or it can lead to maladaptive responses (e.g., anxiety, depression, somatization), which can contribute to negative health status (e.g., smoking, substance abuse, or overeating to soothe emotional discomfort or reduce unwanted sexual attention, possibly leading to obesity). This can affect a woman’s overall perinatal health.²² Thus, it is important to understand the relationship between PTSD and perinatal health.

To our knowledge, this is the first project to examine sequentially the relationship between PTSD and pregnancy health and birth outcomes. Furthermore, this study examines an ethnically diverse sample of women seeking prenatal care on the Pacific island of Oahu. The main hypothesis of this study is that women entering pregnancy with a history of trauma and current PTSD will affirm more health-risk behaviors during pregnancy and have more adverse birth complications. The central objective of this project is to better characterize the relationship between PTSD and pregnancy health-behaviors and to explore the different pathways through which traumatic stress and PTSD may influence perinatal health. We investigate the clinical benefits, limitations, and implications of examining this population.

METHOD

TOP ABSTRACT INTRODUCTION METHOD RESULTS DISCUSSION REFERENCES

 
A group of 101 women, between ages 18 and 35, seeking prenatal care during their first trimester, were recruited from a hospital-based obstetrics/gynecology clinic and from private physicians’ offices associated with a community medical center for women and children on Oahu, Hawaii. We conducted a 30-minute interview in English in a private area after patients completed the IRB-approved consent process. Demographic information was obtained on age, ethnicity, marital status, education, and income. The Traumatic Life Events Questionnaire (TLEQ) assessed the various types of trauma that women had experienced during their lifetime, including interpersonal violence, such as domestic abuse and sexual assault.²³ The TLEQ also assessed peri-traumatic fear, helplessness, and horror reported in response to the affirmed trauma exposure. Current PTSD symptoms after the identified trauma exposure were measured with the PTSD Checklist–Civilian Version (PCL–C).²⁴

Levels of state-anxiety were measured with the 20-item State–Trait Anxiety Inventory (STAI).²⁵ Depressive symptoms were measured with the Center for Epidemiologic Studies Depression Scale (CES–D).²⁶ Report of alcohol use was obtained with the TWEAK (Tolerance, Worry, Eye-opener, Amnesia, and Cut down drinking).²⁷ Behavioral health information on smoking, drug use, alcohol consumption, nutrition, exercise, and healthcare utilization were assessed through a self-report format in a questionnaire developed for this study. A labor-and-delivery checklist was also used to abstract information from participants’ medical records about obstetric history, medical history, perinatal health, and birth outcomes after delivery. Information included medical history and conditions and pregnancy outcomes, such as spontaneous abortion, ectopic pregnancy, pre-term contractions, preeclampsia, gestational diabetes, birth weight and maternal weight, and gestational age at delivery. Descriptive and bivariate statistical analysis, including chi-square tests, were conducted. Women meeting diagnostic criteria for PTSD, meeting the DSM–IV criteria, those with subclinical PTSD symptoms, and those without PTSD were compared for demographic, trauma exposure, behavioral health, perinatal health, and pregnancy/birth outcomes. Consistent with the literature, PTSD at subclinical level was defined as endorsing at least one traumatic life event that resulted in fear, helplessness, or horror, and at least one symptom from Category B (re-experiencing), three symptoms from Category C (avoidance), and two from Category D (arousal) at a subclinical level of intensity.

RESULTS

TOP ABSTRACT INTRODUCTION METHOD RESULTS DISCUSSION REFERENCES

 
Our sample of 101 pregnant women comprised Asian (40%), Caucasian (20%), Native Hawaiian/Pacific Islander (39%), and other (1%) patients; the mean age was 27 years. Sixteen percent of the sample met DSM–IV diagnostic criteria for PTSD on the basis of their TLEQ and PCL–C scores, with approximately 23% showing "subclinical" levels of PTSD. A trend was found for PTSD by ethnicity, with the largest percentage of the PTSD group being women of Pacific Islander descent (²[6]=10.79; p=0.095). This was likely due to the higher rates of childhood sexual and physical abuse reported in the Native Hawaiian/Pacific Islander women in this study. Prevalence rates on baseline data (first assessment) from our study revealed that the highest rates for current PTSD during the first trimester were among Native Hawaiian/Pacific Islander women, as compared with Asian and Caucasian women (24% versus 19% and 7%, respectively). Although only 66 women provided income information, significant differences were found for PTSD by income category, with a majority of PTSD women having a household annual income of $40,000 or less (²[4]=9.72; p <0.05). There were no significant differences found in connection with PTSD and marital status or education level.

Although natural disasters were the most common trauma experienced before pregnancy, PTSD among pregnant women occurred nearly exclusively as a result of interpersonal violence experienced before the pregnancy (child abuse, sexual assault, and domestic violence; see Table 1).

View this table: [in this window] [in a new window]

TABLE 1. PTSD by Type of Trauma

There were also behavioral-health patterns correlated with PTSD; these included increased alcohol use, smoking, substance use, abnormal maternal weight gain, and poor prenatal care. All such factors have been shown elsewhere to be linked with adverse birth outcomes (see Table 2). Other risk factors, such as depression and anxiety, were also significantly elevated in the PTSD group. PTSD was not, however, significantly associated with birth outcomes in this study (i.e., labor and delivery complications, congenital anomalies, low birth weight, mode of delivery, etc.), but this was likely because of the small sample size and low base rates for birth complications in general.

View this table: [in this window] [in a new window]

TABLE 2. Behavioral Health and Pregnancy Outcomes by PTSD Category

DISCUSSION

TOP ABSTRACT INTRODUCTION METHOD RESULTS DISCUSSION REFERENCES

 
To our knowledge, this is one of the first studies to examine the relationship between current PTSD and perinatal health. Among the sample of women seeking prenatal care and entering our study, the prevalence of an abuse history was over 60%, and the prevalence of PTSD at study intake was 16%; an additional 23% had subclinical PTSD, suggesting that trauma exposure and PTSD are pervasive problems in this population. PTSD has serious consequences for general health at any stage of development, but when a woman enters pregnancy with a diagnosis of PTSD, the bio-psycho-behavioral alterations associated with it may have serious implications, both directly and indirectly, for perinatal health. The results from this study clearly indicate that women entering pregnancy with a diagnosis of PTSD are at an increased risk for engaging in high-risk health behaviors during pregnancy. This includes behaviors that are well known to adversely affect perinatal health and fetal development, such as smoking, alcohol use, poor prenatal care, and excessive maternal weight gain.

To date, most studies that have examined the influence of stress on pregnancy outcomes have measured stress without the profound consequence of PTSD. This project expands on such research with general stress and includes a focus on the impact of PTSD associated with traumatic stress. Interestingly, our research supports PTSD as an indirect pathway to an increased risk for adverse pregnancy health.

The preliminary data from this study has several important implications. Given the association between PTSD and increased behavioral health risk during pregnancy, screening for a history of trauma exposure and a diagnosis of PTSD early in prenatal care is indicated. Screening populations at particular risk for PTSD, such as populations with high rates of domestic violence or community violence, is critical. Women who are entering pregnancy after a return from deployment to a combat zone as part of an Operation Iraqi Freedom/Operation Enduring Freedom mission may also be at particular risk for PTSD. Going forward, it seems important to do more than merely screen women who come in for prenatal care. It is also important to educate women’s healthcare providers about the role PTSD has in women’s reproductive health. It is critical that we help pregnant women and their providers understand how their PTSD may affect their day-to-day functioning during pregnancy. Identification and early intervention with high-risk populations may improve perinatal health and possibly reduce adverse birth outcomes. Mental health intervention early in prenatal care can address the self-medicating role of many of these high-risk behaviors (alcohol, smoking, overeating) and should focus on teaching women with PTSD more beneficial coping behaviors.

The finding that 75% of the women with PTSD reported a history of witnessing family violence as a child, and 68.8% of women with PTSD reported a history of physical abuse by a partner suggests a pervasive intergeneration cycle of domestic violence in this population. It is imperative that women who screen positive for domestic violence during pregnancy are empowered to leave the abusive relationships for their own safety and the sake of future generations.

There are a number of limitations to our study. First, our sample size is not large enough to rule out a Type 2 error or disclose an effect of PTSD on birth outcome. The base rates of birth complications, used as outcome variables in our study, are low in the general population, ranging from 1%–12%, with premature birth being the most frequent birth complication, occurring in 1 in 8 births in the United States.²⁸ Other complications (i.e., ectopic pregnancy, birth defects, preeclampsia, hyperemesis, and gestational diabetes) occur less than 5% of the time.²⁸ With our current sample size (16 in the PTSD-positive group), our power is only about 42% with three groups and moderate effect size. With a power of 0.8 and a 0.05 significance level, we would need 39 participants per group to detect a significant effect. Given our small sample size, our ability to detect associations between a diagnosis of PTSD and adverse birth outcomes was limited. However, our preliminary data clearly suggest that PTSD may be a mechanism for poor perinatal health via associated high-risk behaviors. Finally, our participants were not given a rigorous diagnostic evaluation. However, the self-report TLEQ and the PCL–C scales used in this study to determine presence of PTSD, has been found to be highly correlated with well-known PTSD interviews such as the Clinician-Administered PTSD Scale (CAPS),²⁹ and both have been validated with the population of Asian/Pacific Island women.²³

Future investigations, using larger sample sizes, will allow for greater sensitivity to detect the direct and indirect pathways through which PTSD may influence perinatal health and birth outcomes. Future multisite collaborative studies could help extract meaningful data by having higher numbers to add to statistical power. Also, future prospective research examining underlying biological mechanisms, such as immunologic and endocrine factors, may contribute to a better understanding of the interactions between trauma exposure, PTSD, and perinatal health.

REFERENCES

TOP ABSTRACT INTRODUCTION METHOD RESULTS DISCUSSION REFERENCES

 

1. Breslau N, Davis GC, Andreski P, et al: Traumatic events and posttraumatic stress disorder in an urban population of young adults. Arch Gen Psychiatry 1991; 43:216–222
2. Kessler RC, Sonnega A, Bromet E, et al: Posttraumatic stress disorder in the National Comorbidity Study. Arch Gen Psychiatry 1995; 52:1048–1060[Abstract/Free Full Text]
3. Resnick HS, Kilpatrick DG, Dansky BS, et al: Prevalence of civilian trauma and posttraumatic stress disorder in a representative national sample of women. J Consult Clin Psychology 1993; 61:984–991[CrossRef][Medline]
4. Harris-Britt A, Martin S, Li Y, et al: Posttraumatic stress disorder and associated functional impairments during pregnancy: some consequences of violence against women. Journal of Clinical Psychology in Medical Settings 2004; 11:253–264[CrossRef]
5. Friedman MJ, McEwen BS: PTSD, allostatic load, and medical illness, in Trauma and Health: Physical Health Consequences of Exposure to Extreme Stress. Washington, DC, American Psychological Association, 2003
6. Seng J, Oakley DJ, Samselle CM, et al: Posttraumatic stress disorder and pregnancy complications. Obstet Gynecol 2001; 97:17–22[CrossRef][Medline]
7. Morland L, Leskin G, Block R, et al: Intimate partner violence and miscarriage: an examination of the role of physical abuse, psychological abuse, and PTSD. Presented for the 112^th Annual Convention for The American Psychological Association, Honolulu, HI, 2004
8. Yehuda R, Engel S, Brand SR, et al: Transgenerational effects of posttraumatic stress disorder in babies of mothers exposed to the World Trade Center attacks during pregnancy. J Clin Endocrinol Metab 2005; 90:4115–4118[Abstract/Free Full Text]
9. Keane TM, Kaloupek DG: Comorbid psychiatric disorders in PTSD: implications for research. Ann N Y Acad Sci 1997; 821:24–34[Medline]
10. Keane TM, Wolfe J: Comorbidity in posttraumatic stress disorder: an analysis of community and clinical studies. J Appl Soc Psychol 1990; 20:1776–1788[CrossRef]
11. Pierce GR, Sarason BR, Sarason IG: Social support and pregnancy: a comprehensive review focusing on ethnicity and culture, in The Handbook of Social Support and the Family. Edited by Pierce GR, Sarason BR, Sarason IG. New York, Plenum, 1996, pp 375-412
12. Rini CK, Dunkel-Schetter C, Wadhwa PD, et al: Psychological adaptation and birth outcomes: the role of personal resources, stress, and sociocultural context in pregnancy. Health Psychol 1999; 18:333–345[CrossRef][Medline]
13. Sandman CA, Wadhwa PD, Glynn L, et al: Corticotrophin-releasing hormone and fetal responses in human pregnancy. Ann N Y Acad Sci 1999; 897:66–75[CrossRef][Medline]
14. Sandman CA, Wadhwa PD, Chicz-DeMet A, et al: Maternal corticotropin-releasing hormone and habituation in the human fetus. Dev Psychobiol 1999; 34:163–173[CrossRef][Medline]
15. Wadhwa P, Sandman C, Porto M, et al: The association between prenatal stress and infant birth weight and gestational age at birth: a prospective investigation. Am J Obstet Gynecol 1993; 69:858–865
16. Wadhwa P, Porto M, Garite TJ, et al: Maternal corticotropin-releasing hormone levels in early third trimester predict length of gestation in human pregnancy. Am J Obstet Gynecol 1998; 179:1079–1085[CrossRef][Medline]
17. Randall CL: Alcohol and pregnancy: highlights from three decades of research. J Stud Alcohol 2001; 62:554–561[Medline]
18. Howell EM: The impact of the Medicaid expansions for pregnant women: a synthesis of the evidence. Med Care Res Rev 2001; 58:3–30[Abstract/Free Full Text]
19. Dobie DJ, Kivlahan DR, Maynard C, et al: Posttraumatic stress disorder in female veterans: association with self-reported health problems and functional impairment. Arch Intern Med 2004; 164:394–400[Abstract/Free Full Text]
20. Markussen KL, Dalsgaard S, Obel C, et al: Maternal lifestyle factors in pregnancy: risk of attention-deficit hyperactivity disorder and associated behaviors: review of the current evidence. Am J Psychiatry 2003; 160:1028–1040[Abstract/Free Full Text]
21. Mick E, Biederman J, Faraone S, et al: Case-control study of attention-deficit hyperactivity disorder and maternal smoking, alcohol use, and drug use during pregnancy. J Am Acad Child Adolesc Psychiatry 2002; 41:378–385[CrossRef][Medline]
22. Seng J: Acknowledging posttraumatic stress effects on health: a nursing intervention model. Clin Nurse Spec 2003; 17:34–42[CrossRef][Medline]
23. Kubany ES, Leisen MB, Kaplan AS, et al: Developing and preliminary validation of a brief broad-spectrum measure of trauma exposure: the Traumatic Life Events Questionnaire. Psychol Assess 2000; 12:210–211[CrossRef][Medline]
24. Weathers FW, Litz B: Psychometric properties of the Clinician-Administered PTSD Scale, CAPS-1. PTSD Research Quarterly 1994; 5:2–6
25. Spielberger CD, Gorsuch RL, Lushene R, et al: Manual for the State-Trait Anxiety Inventory (Form Y). Palo Alto, CA, Consult Psychol 1983
26. Radloff LS: The CES-D Scale: a self-report depression scale for research in the general population. Appl Psychol Meas 1977; 1:385–401[CrossRef]
27. Russell M, Bigler L: Screening for alcohol-related problems in an outpatient obstetric-gynecologic clinic. Am J Obstet Gynecol 1979; 134:4–12[Medline]
28. National Center for Health Statistics: Final Natality Data: 2001, prepared by the March of Dimes Perinatal Data Center
29. Blake DD, Weathers FW, Nagy LN: A clinician rating scale for assessing current and lifetime PTSD: The CAPS-1. Behav Ther 1990; 18:187–188

Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Email this article to a Colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My Articles & Searches Download to citation manager Citing Articles via Google Scholar Articles by Morland, L. Articles by Friedman, M. Search for Related Content PubMed Citation Articles by Morland, L. Articles by Friedman, M. Posttraumatic Stress Disorder Child Abuse Spouse Abuse

Get information about faster international access.

Privacy Policy

Copyright © 2007 Academy of Psychosomatic Medicine. All rights reserved.

Home | Search | Current Issue | Past Issues | Subscribe | All APPI Journals | Help | Contact Us