May Be More Common
Than Previously Believed
August 5, 2008; Page D1
Amid the debate over how to effectively manage maternal mental-health disorders, a new type of postpartum illness is gaining attention: post-traumatic-stress disorder due to childbirth.
PTSD is most commonly associated with combat veterans and victims of violent crime, but medical experts say it also can be brought on by a very painful or complicated labor and delivery in which a woman believes she or her baby might die. Symptoms can include anxiety, flashbacks and a numbness to daily life. Even as medical advances have resulted in many more lives saved during high-risk births, extreme medical interventions can leave a mother severely stressed -- especially if she feels powerless or mistreated by health providers.
PTSD is much less common than postpartum depression, which has become better-understood by the public as celebrities like actress Brooke Shields and former CIA agent Valerie Plame have spoken out about their experiences. The National Institute of Mental Health estimates that postpartum depression affects 15% of mothers.
The incidence of childbirth-related PTSD hasn't been widely studied. But a new survey suggests the disorder could be more widespread than previously believed. Of more than 900 U.S. mothers surveyed, 9% screened positive for meeting all of the formal criteria for PTSD set out in the Diagnostic and Statistical Manual of Mental Disorders, or DSM-IV, a handbook of mental-health conditions. And 18% of respondents had some signs of the disorder. The survey, which included an established PTSD screening tool, was conducted by Harris Interactive for Childbirth Connection, a nonprofit maternity-care organization in New York. Separate earlier studies outside the U.S. had estimated the prevalence of childbirth-related PTSD at between 1.5% and 5.9%.
Shari Lusskin, director of reproductive psychiatry at New York University Medical Center, who wasn't involved in the survey, cautions that many aspects of PTSD still aren't understood, especially as it may apply to childbirth. "We don't want to overmedicalize a normal part of human development," she says. "Just because you had a traumatic birth, doesn't mean you'll get PTSD."
Still, the survey results are likely to add fuel to a debate about how to better identify and treat maternal mood disorders and whether widespread, systematic screening is warranted. New Jersey in 2006 passed a law that requires every new mother be screened for risk of depression prior to discharge from a hospital and again at her first post-birth doctor's visit, although women can decline the screening.
'Drugging of Mothers'
Other states, including Illinois and Texas, have passed laws to promote greater educational efforts about postpartum mental illness. And now the first federal law on postpartum mood disorders, which would fund research, treatment and public awareness, is working its way through Congress. Opponents say the law would lead to more "drugging of mothers."
Gena Zaks, of Baltimore, became suicidal with violent nightmares after the premature, emergency birth of twins in 2004, one of whom faced life-threatening respiratory problems. Ms. Zaks was diagnosed with several postpartum conditions, including PTSD and depression. "I was crying nonstop for six days in the hospital," says the 34-year-old mother. "Nobody said anything to me about depression."
Monica Bristow, a clinical psychologist in Redmond, Wash., who counsels mothers with PTSD, says one key to treatment is sharing the story of the trauma with a professional who can understand and validate the experience. Medication can be used to alleviate symptoms like insomnia and anxiety, she says, but nondrug techniques, like relaxation or gradual re-exposure to the trauma through memory in a constructive setting, can be more long-lasting and effective.
A history of sexual abuse or other trauma can also put women at greater risk for PTSD from childbirth, says counselor and childbirth educator Penny Simkin, of Seattle. She says discussing such information with a health professional before giving birth can help reduce the risk.
Maternity-care providers say the increase in the number of medical obstetric procedures in labor and delivery, like Caesarean sections and premature births, could be contributing to PTSD. These providers also note that childbirth-related PTSD became more of a focus of study only after 1995, when the American Psychiatric Association broadened criteria for the disorder.
PTSD, whether brought on by childbirth, natural disaster or some other trauma, can happen immediately, or months after the event. It may occur when someone has experienced an event that involves actual or threatened death or serious injury, and responds with intense fear, helplessness or horror.
Cheryl Beck, a professor at the University of Connecticut School of Nursing who researches birth trauma and was an adviser on the Childbirth Connection survey, says the mothers who reported signs of PTSD in the survey appeared to have a higher rate of medical interventions and describe feeling powerless in a threatening environment.
The survey also found that African-American women, those without private health insurance and women with unplanned pregnancies were more likely to have PTSD symptoms. The survey, called New Mothers Speak Out, available at childbirthconnection.org, also covered a range of other post-birth issues. Executive Director Maureen Corry noted the majority of mothers with PTSD and depression symptoms didn't seek professional help.
In 2003, Liv Lane spent 29 hours in labor. After a painful, vacuum-assisted delivery, she gave birth to a son whose lung had collapsed and whose heart had moved to the right side of his body, a condition known as pneumothorax. Ms. Lane, 33, of Shorewood, Minn., says the baby was whisked away and she was left alone, scared and unsure if he would survive. She says the hospital staff also ignored her calls that pain medication wasn't working. The baby, Ryder, eventually recovered.
At her eight-week postpartum checkup, Ms. Lane told the nurse practitioner she'd been sobbing every day and "fantasizing about driving off a bridge." She says the nurse suggested reading some parenting magazines. "I felt ashamed that I'd even asked for support," Ms. Lane says.
A therapist later diagnosed Ms. Lane with PTSD. She began a year and a half of treatment that included psychotherapy. Ms. Lane says she then felt ready for a second baby. But when she got pregnant, her flashbacks, anxiety attacks and panic about her son's safety resurfaced.
She took measures to make this birth different. In consultation with her doctors, Ms. Lane switched hospitals and opted for a scheduled C-section, believing that a vaginal birth might re-trigger the trauma. Her doctor prescribed Zoloft at the end of her pregnancy to alleviate anxiety. She also made sure that her husband or another support person would be with her through labor. The experience was "wonderful," she says. Baby Truman is now 3 months old.
Bill in Congress
The proposed federal legislation on postpartum mood disorders, called the Melanie Blocker Stokes Mothers Act, named after a woman who jumped to her death from a Chicago hotel with postpartum psychosis, was approved by the House of Representatives in October. Last week, the proposal got caught up in a package of bills that failed to reach a final vote on the Senate floor. Democratic supporters say the measure, which doesn't include mandatory screening but does authorize a study about its benefits, could be back later this fall.
Amy Philo, of Frisco, Texas, is using her Web site, uniteforlife.org to help galvanize opposition to the measure, which she believes is designed to enrich pharmaceutical companies. "This bill will result in an increased number of women being referred and treated with drugs," Ms. Philo says. Ms. Philo, who calls herself a "Zoloft survivor" because of the adverse reaction she experienced after being prescribed the drug following a postpartum panic attack, believes antidepressants are unsafe and sees mental-health screening as an invasion of privacy.
Susan Stone, a clinical social worker in New Jersey and past president of Postpartum Support International, a nonprofit proponent of the Mothers Act, says the law's intent is to provide effective care, whether it's talk therapy, medications or some combination, to suffering mothers. "Every woman needs to be assessed individually," she says.