Postpartum posttraumatic and acute stress in mothers and fathers of infants with very low birth weight: Cross-sectional results from a controlled multicenter cohort study

Highlights

• Posttraumatic stress and disorders in parents after preterm and birth at term were examined.

• Postpartum posttraumatic stress (PTSS) was higher in parents of preterm infants.

• This risk for acute stress disorders was increased in mothers with preterm infants.

• The risk for postpartum stress disorders was not elevated in parents with preterm infants.

• Important risk factors for PTSS were stress during birth, social support and preterm birth.

Abstract

Background

The birth of a preterm infant can be stressful and traumatic for parents and may cause posttraumatic stress symptoms and disorders. There is a dearth of data from controlled studies regarding level, prevalence, risk, and predictors of these symptoms in parents after preterm birth.

Methods

As part of the longitudinal HaFEn-study, data from parents of infants with very low birth weight (VLBW), and term infants were cross-sectionally analyzed. We recruited parents at the three largest perinatal care centers in Hamburg, Germany. Posttraumatic stress symptoms were assessed with a standardized questionnaire, and acute and posttraumatic stress disorders with a clinical interview one month postpartum. Stress during birth, lifetime psychiatric diagnoses, social support, pregnancy risks, and mode of delivery were also evaluated. To examine predictors of posttraumatic stress symptoms in both parents simultaneously, we constructed multiple random coefficient models.

Results

230 mothers and 173 fathers were included. The risk for acute stress disorder was increased in mothers with VLBW infants but not in fathers. While the risk for posttraumatic stress disorder was not elevated, the level of posttraumatic stress symptoms was higher in both parents with VLBW infants. Predictors for posttraumatic stress symptoms were stress during birth, low social support, psychiatric lifetime diagnoses, the birth of a VLBW infant, and female parent sex.

Limitations

Results reported here are cross-sectional. Thus, no temporal relationships can be established.

Conclusions

Although posttraumatic stress disorders were rare, our results suggest that posttraumatic stress symptoms and acute stress disorders are common in parents of VLBW infants.

Introduction

The birth of a child can be a stressful and traumatic experience for parents and cause clinical levels of posttraumatic stress symptoms (PTSS), acute stress disorder (ASD), or even posttraumatic stress disorder (PTSD) (Andersen et al., 2012, Grekin and O'Hara, 2014, Olde et al., 2006b, Yildiz et al., 2017). This may be even more true after preterm birth (Hynan et al., 2013, Karatzias et al., 2007), especially with an infant of very low gestational age or very low birth weight (very preterm 28 to <32 weeks, VPT, Very Low Birth Weight < 1500 g, VLBW). The delivery of an infant with VLBW or VPT is an event often associated with immediate life-threatening conditions for the child and sometimes even for the mother. Immediately after birth, VLBW or VPT infants need neonatal intensive care and the further course remains uncertain. Frequently, parents are ill prepared for premature delivery as it often occurs suddenly, and they feel helpless. Thus, the birth of an infant with VLBW or VPT can be experienced as traumatic event.

According to DSM-5 (American Psychiatric Association, 2013), ASD and PTSD are classified in the Trauma- and Stressor-Related Disorders. For the diagnosis of both disorders, individuals must have been exposed to a traumatic event. The diagnosis of PTSD comprises symptoms from each of four different symptom clusters: intrusion symptoms, avoidance, negative alterations in cognitions and mood, and alterations in arousal and reactivity; symptoms must persist for at least one month. For the diagnosis of ASD, nine symptoms from any of the five categories of intrusion, negative mood, dissociation, avoidance, and arousal must be present at least three days up to one month.

Regarding the etiology of birth-related PTSD, recently Ayers et al. (2016) updated their diatheses-stress model that include vulnerability factors, risk factors in birth and postnatal factors. Vulnerability factors for postpartum PTSD include depression in pregnancy, fear of childbirth, complications in pregnancy, and history of PTSD or psychological problems. Birth experience, operative birth, lack of support and dissociation were identified as risk factors in birth. Postnatal factors associated with postpartum PTSD were depression and other comorbid symptoms, and stress and poor coping. Given the specific situation of parents with VLBW or VPT infants it can be assumed that all three factors (vulnerability, birth and postnatal) are more prevalent than in parents with term infants. In their meta-analysis of postpartum PTSD due to childbirth and other events, Grekin and O'Hara (2014) separately identified risk factors in community samples and high-risk samples (e.g., after preterm birth, severe pregnancy complications). Current depression, labor experiences, and a history of psychopathology were found as important risk factors for PTSD and PTSS in community samples, and current depression and infant complications in at-risk samples.

Recent meta-analyses reported similar mean prevalences of postpartum PTSD: 3.1% and 4.0% in women in community samples, and 15.7% and 18.5% in women in high-risk groups (Grekin and O'Hara, 2014, Yildiz et al., 2017). Data on paternal postpartum PTSD are limited. Bradley et al. (2008) reported no significant symptoms across all three dimensions of PTSD (avoidance, hyperarousal, and intrusions), whereas Ayers et al. (2007) described severe PTSD symptoms in 5% of men, assessing two dimensions of PTSD.

The current state of research in postpartum PTSS, ASD and PTSD in parents with preterm infants indicates higher symptom levels and prevalences: Compared with parents of term infants, parents of preterm infants showed higher levels of postpartum PTSS (e.g., Kersting et al., 2004, Mehler et al., 2014, Pierrehumbert et al., 2003). 15% of mothers and 8% of fathers of infants in the Neonatal Intensive Care Unit (NICU) (Lefkowitz et al., 2010) and 12% of parents with VLBW and extremely low birth weight (ELBW) infants (Elklit et al., 2007) met diagnostic criteria for PTSD. ASD, which is a potential precursor of PTSD, was found in 18% of mothers with premature infants (<33 gestational weeks) at one month after birth (Jubinville et al., 2012). 44% of mothers and no father of infants in the NICU met symptom criteria for ASD two to four weeks after hospitalization (Shaw et al., 2006). The few studies assessing postpartum PTSS in both parents of preterm infants report higher levels in mothers than in fathers (Elklit et al., 2007, Ionio et al., 2016).

In summary, the majority of studies on postpartum PTSS, ASD and PTSD in parents with preterm infants include small samples; mainly mothers were assessed, and data are based on self-reports. To the best of our knowledge, there are no controlled studies measuring PTSS levels and symptom predictors (self-report) as well as PTSD and ASD risk and prevalence estimates (diagnostic interviews) after the birth of a VLBW infant in both parents. For this reason, this study aimed at a) investigating the level of postpartum PTSS, b) estimating the prevalence of and risk for postpartum PTSD and ASD in both parents with a preterm VLBW infant compared to parents with term infants and c) identifying predictors for postpartum PTSS.

We tested four distinct hypotheses:

• The level of postpartum PTSS is significantly higher in parents after the birth of a VLBW infant,

• the prevalence of and risk for postpartum ASD is significantly higher in parents after the birth of a VLBW infant,

• the prevalence of and risk for postpartum PTSD is significantly higher in parents after the birth of a VLBW infant, and

• birth status (VLBW/term), stress during birth, lifetime psychiatric diagnoses, social support, risks during pregnancy, mode of delivery (caesarean section vs. vaginal delivery) and female parent sex are risk factors for postpartum PTSS (see 2.3.2 Predictors).