Establishing Postpartum PTSD After Traumatic Childbirth

A Massachusetts General Hospital psychiatrist is working to establish formal recognition of childbirth-related posttraumatic stress disorder (CB-PTSD). Her work aims to inform healthcare providers that postpartum PTSD differs from postpartum depression and that it can affect not only a mother's mental health but also her ability to care for her child.

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"When we think about childbirth, we think about people having a positive event. And even if the event is not positive, if the baby is healthy, then the birth is considered a success. But the emotional toll of a traumatic delivery is not something we speak much about," says Sharon Dekel, PhD, MPhil, MS, principal investigator of the Dekel Laboratory, and founding director of the Postpartum Traumatic Stress Disorders Research Program in the Department of Psychiatry.

Incidence of Traumatic Childbirth

Dr. Dekel's Postpartum Traumatic Stress Disorders Research Program is working to establish a formal label for CB-PTSD in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Defining it can facilitate screening and interventions to better identify and treat women who suffer from CB-PTSD during a critical period for maternal health and child development. She recently issued "A Call for a Formal Diagnosis for Childbirth-Related PTSD" in Nature Mental Health.

"I began my career, like most PTSD researchers, focusing on war veterans and individuals who are exposed to extreme forms of trauma, such as captivity and terrorism. As I became a mother, I began studying women's mental health. The more I read about the birth experience, the more I began considering the childbirth event as a potential trauma for some people," Dr. Dekel says. "This work is important because trauma survivors are often silent, especially when the traumatic event somehow contradicts societal norms."

Worldwide, more than 140 million women give birth each year. About 20% experience complications, leading to more stressful labor and delivery. And a small percentage experience life-threatening complications, such as severe maternal morbidity (2.45%) and maternal near-miss (1.68%).

Experiencing an event that threatens one's life can lead to PTSD, a psychiatric disorder that can occur after a terrifying event. PTSD is more often associated with people who have survived the war, a natural disaster, a serious accident, or a life-threatening disease. However, Dr. Dekel says increasing evidence shows that a traumatic birth can lead to postpartum PTSD, with findings published in the American Journal of Obstetrics and Gynecology.

According to her research, an estimated 4.6% to 6.3% of women develop symptoms of childbirth-related (CB-PTSD), including:

• Attempts to avoid the trauma or reminders of the trauma
• Intrusive thoughts, memories, or nightmares that make the mother feel like she is re-experiencing the trauma
• Trouble taking care of the infant or impairment in maternal-infant bonding

Postpartum PTSD Versus Postpartum Depression

Many women with CB-PTSD are diagnosed with postpartum depression. Dr. Dekel notes that both conditions can coexist, but distinguishing between them is important because their etiologies, symptoms, and treatments differ. Postpartum depression is categorized as a depressive disorder, whereas CB-PTSD is more in the anxiety and stress domain.

"The main difference is that PTSD is a condition triggered by exposure to an external event and reminders of that event," she explains. "PTSD symptoms can be evoked and maintained by reminders of the trauma. As a result, the infant may become an unfortunate constant reminder of the birth trauma and trigger distress in the mother. Therefore, maternal PTSD is strongly tied to having a difficult time taking care of the baby."

Dr. Dekel's current research aims to elucidate how much the infant induces neural reactivities in areas of the brain that relate to fear processing. Her team has recently completed the first neuroimaging study of women who had traumatic childbirth experiences under NIH funding.

"There are concrete alterations that happen both on the physiological level and on the neural level in the brain that show us that people are seriously struggling," she says.

Screening for PTSD After Childbirth

Dr. Dekel's team is developing screening methodologies to identify mothers at risk for CB-PTSD. In a recent paper published in the American Journal of Obstetrics and Gynecology, she and colleagues demonstrated the validity of the Posttraumatic Stress Disorder Checklist to help identify women who might benefit from services to diagnose and treat CB-PTSD.

In another paper published in Nature Portfolio, Dr. Dekel and colleagues assessed whether tools such as ChatGPT and OpenAI's ADA model (text-embedding-ada-002) can accurately assess maternal childbirth narratives to help clinicians diagnose CB-PTSD.

They have found that risk factors for CB-PTSD may include:

• History of other trauma, including traumatic childbirth
• Less support from loved ones or the healthcare team
• Low income
• Minority status
• Obstetrical complications and unscheduled interventions such as cesarean delivery or the need for the neonatal intensive care unit
• The tendency toward low levels of resilience or high levels of negative appraisal

Helping Women Who Experience Traumatic Childbirth

"There is a lot we can do to optimize the health of these mothers who have complicated deliveries—and their infants. In the hospital, we have real-time access to them as the trauma unfolds," Dr. Dekel says.

Healthcare professionals can help by giving women a sense of agency or control as they give birth as much as possible.

"We definitely see that more support might be a protective factor that you would be less likely to develop PTSD," Dr. Dekel says.

Examples include simply asking mothers about their goals and preferences, paying attention to their basic needs, and offering support.

Treatment for women who are diagnosed with CB-PTSD includes revisiting the birth story through structured writing, which is what the Dekel team is currently investigating under NIH funding as a potential preventive approach, participating in cognitive behavioral therapy, and other forms of trauma exposure. Intervening in the days and hours after having a complicated delivery may reduce the odds of developing CB-PTSD, Dr. Dekel says.

Mass General's Commitment to Optimizing Maternal Health and Reducing Health Disparities

This line of research is possible because of Mass General's focus on collaboration between disciplines, Dr. Dekel says. Her psychiatry team works closely with the Mass General Obstetrics team to develop new protocols and novel interventions for treating mothers who have traumatic deliveries.

"At Mass General, we talk a lot about reducing disparities in mental health outcomes and access to care. And I definitely see our work as one of the initiatives to eliminate some disparities that we, unfortunately, know do exist when it comes to postpartum mental health. The goal is that all infants, regardless of the race or ethnicity of their mother, have the same chances of success and well-being as they become adults," Dr. Dekel says.

Learn more about the Post-traumatic Stress Disorder Research Laboratory

Learn more about the Department of Psychiatry