Pregnancy and PTSD

By Alexa Kightlinger

Experiencing trauma is a relatively common human experience. In fact, a WHO World Mental Health Survey examined responses from 68,894 individuals across 24 countries. From there, it was calculated that 70.4% of respondents had experienced some sort of lifetime trauma (Kessler et al., 2017), though I would argue this number may be even higher. When thinking about the different kinds of trauma people go through, what kind of events come to mind? For most, sexual assault, rape, and the unexpected death of a loved one spring to mind. Death has seemingly become synonymous with trauma. Birth, on the other hand, could never be a negative experience. Right? Sure, the nine months of carrying to term and laborious hours in the delivery room often are expected to be outweighed by the love a mother feels when she holds her child for the first time, but what about the aftereffects? The postpartum depression, heavy bleeding, and retained placenta are some common experiences that many women suffer from that are not talked about.  As with most things associated with pregnancy, the negatives are frequently and conveniently left out of the birth journey narrative. By leaving this information out, we tend to isolate women who experience these symptoms, making them unlikely to seek out the help they need in fear of judgment from others.

As a quick reminder, post-traumatic stress disorder (PTSD) is a psychiatric disorder resulting from the stress of witnessing or experiencing a traumatic event (Iribarren et al., 2005). Luckily, despite the large percentage of individuals who at some point in their lives go through a traumatic event, only a small number will develop PTSD (Atwoli et al., 2015). Similar trends are seen within the pregnant population. Though 10-20% of women report birth as a traumatic event (Haagen et al., 2015), 3% of those women go on to develop PTSD (Yildiz et al., 2016). This percentage may be higher in high-risk populations, ranging from 20% to 24% (Yildiz et al., 2016; Muzik et al., 2017), depending on the research you reference.

Symptoms

Another difficult factor in diagnosing PTSD due to pregnancy is that many symptoms mirror those of postpartum depression. Both include negative mood and cognition, making it hard to differentiate between the two. Not only does misdiagnosis not allow mothers to get the needed treatment, but PTSD can continually worsen if not diagnosed and treated after delivery occurs (Khoramroudi, 2018). Additionally, these symptoms can be exacerbated if women have had prior reproductive trauma or a traumatic childhood (Musik et al., 2017). 

Risks of maternal PTSD can be grouped into different factors: antenatal, perinatal, and postpartum. Research conducted in 2024 by Horsch and others attempted to categorize the symptoms among the predetermined groupings. Antenatal factors are considered depression in pregnancy, fear of childbirth, a history of sexual abuse, mental health problems, or complications during pregnancy, while perinatal factors are described as negative birth experiences (this is subjective), operative birth, lack of support, maternal morbidity, or dissociation. Meanwhile, postpartum factor examples can be depression, postpartum physical complications, and poor coping/stress. 

The resulting children are also affected. A systematic literature review explored associations with material PTSD that were linked with low birth weight, low breastfeeding rates, issues with mother-infant bonding, and eating/sleeping difficulties in children (Cook et al., 2018). Self-reports on child development were also said to be negatively impacted, though research acknowledges the mother’s depressive symptoms may bias this data (Suarez & Yakupova, 2024). To remedy this, they suggest adding reports from the father and other caregivers, which may increase both reliability and accuracy of the mother's initial report. 

Diagnostic Difficulties

PTSD and pregnancy are a difficult combination to mix as human research is limited within this field. Maternal PTSD may increase poor pregnancy and birthing outcomes: ectopic pregnancy, miscarriages, early births, and low birth weight (Musik et al., 2017). The likelihood of mothers developing PTSD increases if there were complications during the pregnancy or childbirth process. However, there is a chance that PTSD may occur because of noncomplicated pregnancies. 

Due to the gaps in the literature on childbirth-related PTSD and traumatic birthing experience, maternity services after childbirth are not able to offer the services needed to treat maternal PTSD. To further complicate matters, gaps in the literature make it hard to identify proper screening techniques, timings of when to screen, and who to screen. The lack of resources impacts the entire family and each interpersonal relationship within the family unit (eg, the couple dyad and both parent-infant dyads). Sexual dysfunction and blame for negative birth events occur between mother and partner, and it is often common for new mothers to report feelings of rejection towards the baby (Ayers et al., 2006). Additionally, 1% of birth partners are at risk of developing PTSD (Birth Trauma Association).  Insufficient treatment causes lasting effects on these relationships, leaving no room for healing or improvement.

Personal Stories

The Birth Trauma Association is a charity in the UK that is dedicated to supporting women and families who have experienced traumatic birth. One of the unique components of the website is a section devoted to stories mothers have been brave enough to share. This allows us a first-hand look at the feelings, fears, and experiences these women have faced, but more importantly, offers a feeling of connection between women who have gone through the same. After reading through several stories, I’ve compiled a short list of quotes below that struck a chord with me.

“The mood in the room lightens now that my baby has been born. The midwife who shouted at me to be quiet apologises and I tell her it’s ok, more to make her feel better; but it’s not ok, it never will be. I’ve never felt so betrayed by a woman who was supposed to be my advocate. But the assault is not over even now.” - Jacqueline

“I may physically be over what happened, but I struggled to have a smear test recently due to the trauma of the failed induction. I dread my next one because of this. I also have not been able to consider having another baby until very recently – though I'm still not sure I feel able to do this.” - Alison

These women are not simply statistics in research. They are sisters, wives, mothers, and friends. Most importantly, though, they are human. We owe it to these individuals to make the birthing process a positive event.

Advocating

As with most things, educating yourself and others is the best way to stop the spread of misinformation, greatly reducing the negative stigma surrounding maternal PTSD. More likely than not, someone you know has gone through a negative birthing event, even if it did not result in PTSD. 

Let's not stop there. Write to your local policymakers to collaborate with organizations advocating to amplify the voices of women with maternal PTSD. Work towards legislation that may encourage training for doctors, nurses, midwives, and OB/GYNs on how to recognize signs and correctly respond to each unique situation. 

I think Olivia, who suffered a rare condition in which the placenta attaches to the womb, puts it best. 

“When people hear the term PTSD, they think they know what it is – a mental health condition that soldiers suffer after witnessing horrors of war. No one really believes that it can happen to a woman following the birth of her baby. No one wants to hear this. Birth is supposed to be a glorious, life-changing event when precious memories are created that will be cherished of the rest of the woman’s life. But that wasn’t the case for me

I have been well for a long time now – but like those soldiers who witness the horrors of war, I can never forget. I can never unsee what I saw and I will never be who I was before that day.”

References

Atwoli, L., Stein, D. J., Koenen, K. C., & McLaughlin, K. A. (2015). Epidemiology of posttraumatic stress disorder: prevalence, correlates, and consequences. Current Opinion in Psychiatry, 28(4): 307-311. https://doi.org/10.1097/YCO.0000000000000167

Ayers, S., Eagle, A., & Waring, H. (2006). The effects of childbirth-related post-traumatic stress disorder on women and their relationships: a qualitative study. Psychology, Health & Medicine, 11(4): 389-398. https://doi.org/10.1080/13548500600708409 

Cook, N., Ayers, S., & Horsch, A. (2018). Maternal posttraumatic stress disorder during the perinatal period and child outcomes: A systematic review. Journal of Affective Disorders, 1(225): 18-31. https://doi.org/10.1016/j.jad.2017.07.045

Horsch, A., Garthus-Niegel, S., Ayers, S., Hartmann, K., Vaisbuch, E., & Lalor, J. (2024). Childbirth-related posttraumatic stress disorder: definition, risk factors, pathophysiology, diagnosis, prevention, and treatment. American Journal of Obstetrics and Gynecology, 230(3), 1116-11276.  https://doi.org//S0002-9378(23)00713-5

Iribarren, J., Prolo, P., Neagos, N., & Chiappelli, F. (2005). Post-Traumatic Stress Disorder: Evidence-Based Research for the Third Millennium. Evidence-Based Complementary and Alternative Medicine, 2(4): 503-512. https://doi.org/10.1093/ecam/neh127 

Khoramroudi, R. (2018). The prevalence of posttraumatic stress disorder during pregnancy and postpartum period. Journal of Family Medicine and Primary Care, 7(1): 220-223. https://doi.org/10.4103/jfmpc.jfmpc_272_17 

Muzik, M., McGinnis, E. W., Bocknek, E., Morelen, D., Rosenblum, K., Liberzon, I., Seng, J., & Abelson, J. L. (2017). Depression and Anxiety, 33(7): 584-591. https://doi.org/10.1002/da.22465 

Suarez, A., & Yakupova, V. (2024). Effects of postpartum PTSD on maternal mental health and child socioemotional development - a two-year follow-up study. BMC Pediatrics, 24(1): 789. https://doi.org/10.1186/s12887-024-05282 

Yildiz, P. D., Ayers, S., & Phillips, L. (2016). The prevalence of posttraumatic stress disorder in pregnancy and after birth: A systematic review and meta-analysis. Journal of Affective Disorders, 208, 634-645. https://doi.org/10.1016/j.jad.2016.10.009