Pathways to Birth Trauma: Prenatal PTSD as a Mediator Between Adverse Childhood Experiences and Childbirth-Related PTSD Symptoms

Abstract

Background:

Extensive research highlights the risk of PTSD following traumatic childbirth. However, PTSD during pregnancy—whether preexisting or emerging prenatally—receives far less attention despite its associated harmful effects on maternal and infant well-being. To fill this gap, the current study examines predictors of childbirth-related PTSD symptoms, including maternal ACEs and prenatal PTSD symptoms in 91 mothers from a diverse community sample (47% particpants of c) within the United States.

Methods:

Participants completed questionnaires on ACEs and PTSD symptoms during their third trimester of pregnancy and childbirth-related PTSD symptoms at 6-weeks postpartum. The current study used a path analysis model to examine the mediating effects of prenatal PTSD on the relationship between ACEs and childbirth-related PTSD symptoms at 6-weeks postpartum.

Results:

Findings indicated that ACEs have implications for childbirth-related PTSD symptoms at 6-weeks postpartum with a significant indirect effect through prenatal PTSD, standardized indirect effect = 0.20, 95% CI = [0.02, 0.36], p = 0.03.

Conclusion:

Screening for childhood adversity during pregnancy may have dual benefits for prenatal and postpartum health, such that screening can help identify women at risk for prenatal PTSD as well as those at risk for later childbirth-related trauma symptoms who may benefit from trauma-informed targeted prevention and intervention efforts.

1 |. Introduction

Negative or traumatic birth experiences are defined as objective or subjective instances of physical trauma related to pregnancy and childbirth, including perineal tears, pelvic organ prolapse, and stillbirth, and/or psychological trauma, consisting of intense fear, horror, or helplessness [1, 2]. Notably, negative childbirth experiences are associated with the development of childbirth-related postpartum posttraumatic stress disorder (PTSD) [3–5]. Approximately 12% of people who have given birth report childbirth-related postpartum PTSD symptoms, with nearly 5% meeting clinical criteria for postpartum PTSD following a traumatic birth experience [6]. Various factors increase susceptibility to PTSD following childbirth, including preexisting psychiatric disorders, complications during pregnancy and labor, fear of childbirth, perception of inadequate support, and feelings of loss of control [5–9]. While extensive research highlights the risk of PTSD following traumatic childbirth, PTSD symptoms during pregnancy, whether preexisting or emerging prenatally, receive far less attention despite its associated harmful effects on maternal and infant well-being.

Across all pregnant and postpartum people, approximately 3%–4% have a diagnosis of PTSD, with rates rising to nearly 20% among high-risk populations [10, 11]. However, these rates are likely underestimated, given prenatal PTSD typically goes unassessed and untreated [12, 13]. This is particularly troubling as PTSD is associated with increased risk of maternal morbidity as well as adverse birth outcomes like preterm birth and low birth weight, especially among birthing persons of color [10, 11, 14]. Furthermore, the pregnancy itself may mirror experiences associated with past traumatic events. For example, common prenatal care experiences such as frequent or invasive medical appointments, unwanted or unexpected physical touch from others, loss of bodily autonomy, reminders of one’s own previous traumatic birth experience, hearing about others’ traumatic birth experiences, reminders of past reproductive trauma, or physical discomfort or pain may make the prenatal period particularly susceptible to the emergence or exacerbation of trauma symptoms [15–17].

Another salient risk factor for PTSD during pregnancy includes early exposure to chronic and recurrent stressors, such as adverse childhood experiences (ACEs; [4, 18]). Specifically, early experiences of adversity can increase the risk for mental health complications during pregnancy, including PTSD, which in turn may compromise maternal and child health [18–20]. Several studies have reported on the cumulative impact of ACEs during the perinatal period, such as increased risk for maternal mental health problems, health risk behaviors during pregnancy and postpartum, negative birth outcomes, and infant ACEs [18, 21–26]. However, much of the perinatal PTSD literature is informed by postpartum experiences of PTSD following traumatic childbirth, leaving much to be known about the experience of prenatal PTSD.

Thus, the current study aims to fill this gap and uses a path analysis to examine prenatal PTSD symptoms as a mediator of the relationship between maternal ACEs and childbirth-related PTSD symptoms at 6-weeks postpartum. It is hypothesized that higher ACEs scores will be associated with greater prenatal PTSD symptoms, and in turn, predict greater childbirth-related postpartum PTSD symptoms. Additionally, it is hypothesized that prenatal PTSD symptoms will mediate the relationship between maternal ACEs and childbirth-related PTSD symptoms at 6 weeks postpartum.

2 |. Methods

2.1 |. Participants and Study Procedures

Participants (n = 91) were recruited from university-affiliated perinatal clinics and community events serving a racially diverse and medically underserved community. Participants were assessed at two time points: third trimester of pregnancy (baseline) and 6-weeks postpartum. Prenatal assessments occurred on average at 33 weeks gestation (range = 28–40 weeks), and postnatal assessments at 6 weeks postpartum (range = 4–11 weeks). The study received approval from the authors’ university Institutional Review Board, and all participants provided informed consent and were compensated $20 for each survey.

Participants, on average, were 28.5 years old (SD = 5.15, range = 19–40) and almost half of the sample reported having a high school education or less (40%). The majority of the sample (55%) reported an annual income less than $40,000. The racial breakdown of the sample included 53% White, 11% Black or African American, 14% Native American or Alaskan Native, 1% Asian, 1% Native Hawaiian or Other Pacific Islander, 14% Biracial or Multiracial, and 6% Other. Complete demographic data are provided in Table 1.

TABLE 1 |.

Sociodemographic variables.

Variables	%	M	SD
Age	—	28.48	5.15
Income
<$5000	12.9%	—	—
$6000–$20,000	14.1%	—	—
$21,000–$40,000	28.2%	—	—
$41,000–$60,000	22.4%	—	—
$61,000–$80,000	7.1%	—	—
$81,000–$100,000	7.1%	—	—
> $101,000	8.3%
Education
Did not complete High School	9.1%	—	—
High school/GED	30.7%	—	—
Some college	34.1%	—	—
College degree	13.6%	—	—
Graduate degree	12.5%	—	—
Race/ethnicity
White	53.4%	—	—
Black or African American	11.4%	—	—
Native American or Alaska Native	13.6%	—	—
Native Hawaiian or other Pacific Islander	1.1%
Asian	1.1%	—	—
Biracial or multiracial	13.6%
Other	5.7%	—	—

2.2 |. Prenatal PTSD Symptom Data Collection

Aligned with the instrument protocol, prenatal PTSD symptom data were only collected from the 49 participants (54%) who had endorsed a history of lifetime trauma exposure at baseline. The remaining 42 participants who indicated no trauma history were assigned missing scores to reflect inapplicability rather than loss to follow-up. Importantly, those not assessed did not differ from the trauma-exposed group on any demographic variables. We also analyzed the mediation model using alternative coding, with nontrauma participants coded as zero symptom scores. However, this yielded a nonsignificant indirect effect, underscoring that this relationship is driven by trauma exposure.

2.3 |. Attrition at 6-Weeks Postpartum

Although 91 women completed baseline surveys, approximately 16% of the total sample (n = 15) was lost to attrition at 6-weeks postpartum (retained at 6-weeks, n = 76). This rate of attrition is relatively low compared with other research studying similar populations of mothers in the early postpartum [27]. Participants missing at 6-weeks postpartum did not differ from retained participants on age or race, but differed on education level, with a higher educational level being associated with a greater likelihood of retention, t(86) = −2.14, p = 0.03.

2.4 |. Measures

2.4.1 |. Demographics

At baseline, participants completed a demographic questionnaire relevant to these analyses, including the following information: age, race, income, and education level.

2.4.2 |. Maternal Adverse Childhood Experiences

During the third trimester of pregnancy, participants completed the Adverse Childhood Experiences questionnaire (ACEs; [28]). This measure retrospectively assesses for traumatic childhood events prior to the age of 18. The scale assesses 10 adverse experiences including emotional, sexual, and physical abuse, neglect, and household dysfunction experienced before 18 years old. Participants provided a yes/no (1 = yes, 0 = no) response to adversity, summed for a total score (possible range 0 to 10), with higher scores indicating greater exposure to adverse childhood events. The 10-item ACEs measure has demonstrated robust psychometric properties in perinatal populations, including high internal consistency and construct validity [29]. Cronbach’s coefficient alpha in this sample was 0.80.

2.4.3 |. Prenatal PTSD

During participants’ third trimester, the Posttraumatic Diagnostic Scale (PDS-5; [30]) was also completed. The first two questions of the measure screen for trauma history and identify an index trauma. Participants discontinued the survey if there was no trauma history indicated. If a history of trauma was reported, participants completed an additional 20 items that measured PTSD symptom severity according to DSM-5 criteria. The final four items assessed distress, functional impact, symptom onset, and duration of symptoms. Each symptom is rated on a 5-point scale of frequency and severity ranging from 0 (Not at all) to 4 (6 or more times a week/severe). A total PTSD symptom severity score was calculated by summing the 20 items related to symptoms (range 0–80) with higher scores indicating greater severity, and scores ≥ 31 reaching the clinical cut-off for PTSD. Cronbach’s coefficient alpha was 0.97.

2.4.4 |. Childbirth-Related PTSD

At 6-weeks postpartum, childbirth-related trauma symptoms were assessed using the City Birth Trauma Scale (CBTS; [3]). The questionnaire includes 29 items that measure symptoms of trauma, specific to the birthing experience, according to DSM-5 criteria. Symptom frequency is measured over the last week on a 4-point scale ranging from 0 (Not at all) to 3 (5 or more times). Total childbirth-related PTSD symptoms are calculated by summing the four symptom subscales (items 3–22), where scores range from 0 to 60 and higher scores indicate greater trauma symptoms related to the birth experience. Cronbach’s coefficient alpha was 0.91.

2.5 |. Data Analytic Plan

Descriptive statistics and bivariate associations were calculated for all variables. A path model in Mplus 8.0 [31] was used to examine the hypothesized model. Missing data were handled using Full Information Maximum Likelihood (FIML) estimation with bootstrapping procedures to correct for standard error bias associated with missing data and to derive confidence intervals for the mediating effect [32, 33]. Although the number of observations varied across measures and time points (see Table 2), ML estimation in MPlus enabled the use of any available data from all 91 participants to estimate the model. This full use of our data brings our sample size closer to those reported in recent studies on perinatal populations as well as research on sample size requirements for common types of SEM, including path analysis [34]. In analyzing the indirect effect, bootstrapping with 5000 repetitions was used to derive confidence intervals as recommended in the literature [33, 35]. Finally, due to previous findings showing socioeconomic status (SES) and other demographic information may be related to health outcomes (e.g., [36]), we examined household income, maternal age, and maternal education as potential covariates. However, only maternal education showed significant correlations with ACEs. Given this finding in our sample and that maternal education attainment has been shown to serve as a reliable indicator for long-term SES, with significant implications for infant well-being [23, 37, 38], the model only included maternal level of education as a covariate. Maternal education was specified to predict childbirth-related PTSD at 6 weeks and was correlated with the predictor ACEs.

TABLE 2 |.

Descriptives and correlations of key study variables.

Variable	n	M	SD	1.	2.
1. ACEs total score	90	3.18	2.68	—
2. Prenatal PTSD	49	14.57	16.91	0.40**	—
3. Childbirth-related PTSD	76	7.75	9.58	0.22	0.48**

^**p < 0.01.

3 |. Results

3.1 |. Descriptive Statistics and Correlations

Descriptive statistics on all study variables are presented in Table 1. Nearly 50% of the sample reported experiencing at least one ACE, with nearly one-fourth of the sample indicating 6+ ACEs. On average, participants reported experiencing 3 ACEs (M = 3.18, SD = 2.68) prior to adulthood, and total scores ranged from 0 to 9.

Table 2 presents descriptive statistics for and correlations among key study variables. Of the 49 participants who were exposed to at least one traumatic event during their lifetime, interpersonal violence (i.e., sexual abuse, physical assault) was most frequently identified as the most bothersome experience. With regard to PTSD symptoms, approximately 12% reported symptom scores at or above the clinically significant cut-off (scores ≥ 31), while the majority of participants reported symptoms below the clinical cut-off for PTSD (M = 14.75, SD = 16.91).

On average, participants reported experiencing subclinical levels of childbirth-related PTSD symptoms (M = 7.75, SD = 9.58), and total scores ranged from 0 to 40. Notably, 12% of participants reported that they believed that they or their baby would be seriously injured, and 12% indicated that they believed their baby would die during birth. Additionally, simple bivariate correlations were conducted. Maternal ACEs were negatively and significantly correlated with maternal education (r = −0.22, p = 0.01) and positively and significantly correlated with prenatal PTSD symptoms (r = 0.40, p = 0.005). Prenatal PTSD was positively and significantly correlated with childbirth-related PTSD (r = 0.48, p = 0.001).

3.2 |. ANOVA

ANOVA analyses revealed that mothers with a history of abuse-type ACEs reported significantly higher prenatal PTSD symptoms compared to those without a childhood abuse history, F(1, 47) = 4.19, p = 0.046. Similarly, mothers with a history of neglect-type ACEs were more likely to report prenatal PTSD symptoms than those without a history of childhood neglect, F(1, 47) = 5.44, p ≤ 0.024. Additionally, mothers with higher ACE scores reported significantly greater prenatal PTSD symptoms, F(2, 46) = 6.59, p = 0.003, with post hoc analyses suggesting the 6+ ACE group differed significantly from both the 0–2 ACE group and the 3–5 ACE group.

3.3 |. Path Analysis

Path analysis was used to examine the mediating role of prenatal PTSD in the relationship between maternal ACEs and childbirth-related PTSD symptoms at 6-weeks postpartum (Figure 1). Maternal education was included as a covariate and correlated with ACEs in the model to improve overall fit (Table 3).

FIGURE 1 |.

Path analysis was used to examine the mediating role of prenatal PTSD on the relationship between maternal ACEs and childbirth-related PTSD symptoms at 6-weeks postpartum. Simple mediation diagram; a, b, c are path coefficients representing standardized regression weights. The c path coefficient represents the direct effect of ACEs on childbirth-related PTSD symptoms. Analyses controlled for maternal level of education. Statistically significant standardized path coefficients are reported. *p < 0.05; **p < 0.01.

TABLE 3 |.

Model coefficients for path analysis.

	β	b (SE)	95% CI
Direct paths
ACEs ➔ Prenatal PTSD	0.40**	2.47 (0.81)	[0.94, 3.82]
ACEs ➔ Childbirth-related PTSD	0.06	0.23 (0.54)	[−0.48, 1.08]
Prenatal PTSD ➔ Childbirth-related PTSD	0.50*	0.30 (2.11)	[0.03, 0.61]
Covariates
Maternal education ➔ Childbirth-related PTSD	0.08	−0.65 (0.80)	[−1.08, 2.10]
Correlations
ACEs with maternal education	−0.22*	−0.67 (0.29)	[−1.25, −0.11]
Indirect Effect
Mediated Path
ACEs ➔ Prenatal PTSD ➔ Childbirth-related PTSD	0.20*	0.73 (0.39)	[0.07, 1.57]

Note: The 95% CI for the indirect effect was bootstrapped with 5000 repetitions ([33]; [39]).

Abbreviations: ACEs, Adverse Childhood Experiences total score; PTSD, posttraumatic stress disorder symptoms.

^*p < 0.05

^**p < 0.01.

Overall, the fit indices for the final model indicated acceptable fit, χ² = 1.29 (1), p = 0.26; RMSEA = 0.06 (90% CI [0.00, 0.29]); CFI = 0.98; TLI = 0.92; and SRMR = 0.04; [40, 41]. According to the R² statistic, the model predicted 16% of the variance in prenatal PTSD symptoms and 28% of the variance in childbirth-related PTSD symptoms at 6-weeks postpartum. For a detailed overview of the model results, including parameter estimates and their corresponding confidence intervals, see Table 3.

The direct effect of ACEs on prenatal PTSD (path a) showed a significant positive association, unstandardized effect = 2.47, 95% CI = [0.94, 3.82], indicating higher ACEs exposure was linked to greater PTSD symptoms during pregnancy. Similarly, prenatal PTSD significantly predicted childbirth-related PTSD (path b), unstandardized effect = 0.30, 95% CI = [0.03, 0.61]. The direct effect from maternal ACEs to childbirth-related trauma symptoms (path c) was not statistically significant, unstandardized effect = 0.23, 95% CI = [−0.48, 1.08]. However, prenatal PTSD symptoms significantly mediated the association between maternal ACEs and childbirth-related PTSD symptoms, unstandardized indirect effect = 0.73, 95% CI = [0.07, 1.57] (see Figure 1 for standardized effects).

4 |. Discussion

Findings from the current study suggest that prenatal PTSD symptoms during the third trimester significantly mediate the relationship between maternal adverse childhood experiences and childbirth-related PTSD symptoms at 6-weeks postpartum. That is, mothers with a history of ACEs are more likely to experience prenatal PTSD symptoms and, in turn, are at greater risk of experiencing childbirth-related PTSD symptoms. These findings provide evidence for ACEs as a salient indicator of prenatal PTSD and also highlight prenatal PTSD as a significant risk factor for the emergence of childbirth-related postpartum PTSD symptoms. Further, findings add to the traumatic birth literature by highlighting the contributing role of childhood adversity in the emergence and/or exacerbation of prenatal PTSD symptoms, which increase the risk for PTSD symptoms following childbirth.

Findings also show that mothers who reported 6 or more ACEs endorsed the highest levels of prenatal PTSD symptoms. These findings extend the literature underscoring the importance of early childhood experiences for mental health during pregnancy. Further, these findings are supported by previous research that links ACEs to dysregulated neurophysiological and behavioral states [42] that contribute to increased risk for PTSD [43]. Given that pregnancy is associated with considerable alterations in mood, hormones, motivation, social cognition, sleep, and concentration, the exacerbating impact of ACEs during this period may be particularly salient and warrants further investigation [16, 44, 45].

This result of complete, or total mediation (i.e., the direct association between maternal ACEs and childbirth-related PTSD symptoms was not significant) suggests that the influence of ACEs on childbirth-related PTSD symptoms in postpartum is driven by the increased risk of prenatal PTSD symptoms associated with ACEs. Previous research suggests perinatal care and/or experiences, such as pain, loss of control, excessive uncertainty, and vulnerability related to one’s body may trigger past trauma memories or contribute to the emergence of new trauma-related symptoms [16, 17]. As such, ACEs increase the risk for subsequent trauma and prenatal PTSD symptoms, which in turn increase the risk of experiencing childbirth-related PTSD symptoms. Together, this pathway underscores the importance of screening for both early life adversity and current trauma symptoms before labor and delivery.

Prenatal PTSD and childbirth-related trauma symptoms are also salient risk factors to consider given their associations with negative maternal and infant health outcomes (see [46] for review). Previous research suggests that mothers experiencing PTSD symptoms may also be less sensitive and more controlling during interactions with their infant, contributing to ongoing relational challenges [47]. Although this area of research is underexplored, Pinto et al. [46] hypothesize that PTSD symptoms may increase dysregulation during mother-infant interactions and subsequently contribute to disrupted synchrony, ultimately impairing mother-infant bonding. As such, prenatal PTSD may have intergenerational consequences for maternal and infant health and continues to warrant empirical and clinical attention.

4.1 |. Strengths, Limitations, and Future Directions

The current study has several strengths related to the study population and methods. Specifically, strengths include being one of the first empirical studies to examine ACEs, PTSD symptoms, and birth experiences; recruitment of a sample of racially diverse and economically disadvantaged mothers; and data collection at two timepoints extending from pregnancy into the early postpartum period. Still, this study is not without limitations. Although the hypothesized model was based on empirically supported associations among the variables of interest and all data were collected using validated scales, the small sample size contributed to low power in detecting effects. Thus, caution should be used when interpreting or generalizing the results. Notably, our sample was characterized as relatively low risk (with low average ACE scores and subclinical prenatal PTSD and childbirth-related postpartum trauma symptoms), which highlights the need for future research to examine this question using larger sample sizes with greater variability in adversity and clinical severity. Although we measured PTSD during pregnancy and postpartum, future studies would benefit from the incorporation of objectively substantiated history of child maltreatment (e.g., child welfare records), longitudinal prospective data that includes the preconception period, and repeated measures data collection across the perinatal period to confirm causal effects. Additionally, data were self-reported, and all self-reported data have the possibility of being confounded by mood, recall bias, or social desirability, which is especially salient during the perinatal period. Further, self-report data are also susceptible to being influenced by a lack of comfort in reporting on past experiences, especially related to trauma [48]. Therefore, future work should consider using other methods of data collection that extend beyond dichotomous responses (e.g., clinical interview, qualitative study).

4.2 |. Implications

Our findings have important implications for healthcare providers and professionals working with perinatal and infant populations. First, our data highlight the importance of using trauma-informed care approaches when working with perinatal populations. Specifically, it is important to screen for childhood adversity during pregnancy as it may help to identify women at risk for prenatal PTSD and childbirth-related PTSD symptoms who may benefit from targeted prevention and intervention efforts. Second, these findings suggest that prenatal PTSD symptoms increase the likelihood of childbirth-related PTSD symptoms, such that targeting prenatal PTSD symptoms could potentially mitigate risk for postpartum PTSD and related maternal and infant health complications. Additionally, pregnancy may be a unique and highly impactful period for intervention given expectant mothers are highly motivated to improve long-term health outcomes not only for their own benefit, but also the well-being of their infant [49]. In sum, these findings are especially relevant for perinatal mental health providers, infant mental health professionals, and paraprofessionals who work with women, birthing persons, and families during the perinatal period, especially those with a history of early life adversity.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.