Improving maternal postpartum mental health screening guidelines requires assessment of post-traumatic stress disorder

Abstract

Post-traumatic stress disorder (PTSD) has a prevalence of 4–17% in the postpartum period and, like better known postpartum depression (PPD), is linked to reduced quality maternal-child interactions, decreased maternal sense of life satisfaction and functioning, and negative impacts on child development. Currently, provincial and public health organizations throughout Canada screen new mothers for PPD with the Edinburgh Postpartum Depression Scale, which while laudable does not capture PTSD. PTSD is highly associated with PPD, 65% of women with PTSD also present with PPD, presenting a significant gap in postpartum maternal mental health screening. Numerous self-report PTSD screening questionnaires are available that could be incorporated into routine maternal postpartum mental health care. Furthermore, across Canada, regional differences in availability of maternal mental health screening, services, and programs suggest a gap in one of the tenets of Canadian health care—lack of universality. Not only does Canada require national maternal mental health screening, service and program guidelines, but PTSD screening must be incorporated, in order to identify and treat new mothers experiencing mental health problems.

Postpartum depression (PPD), characterized by feelings of sadness, worry, and fatigue, affects 18% of Canadian mothers (Statistics Canada 2019), putting their children at risk for cognitive and socio-emotional development problems (Kingston et al. 2012). Likewise, post-traumatic stress disorder (PTSD) has an incidence of 4–17% among postpartum mothers (Verreault et al. 2012) and places children at risk for altered mother-child bonding attachment and poor social-emotional development (Garthus-Niegel et al. 2017). PTSD is a stress-related disorder triggered by exposure to actual or threatened death or serious injury, characterized by symptoms of re-experiencing the traumatic event, avoidance, negative cognitions and mood, hyper-vigilance, and aggressive, reckless, or self-destructive behaviours (American Psychiatric Association 2013). Unlike PPD, for which screening is recommended and implemented in a patchwork of regions across Canada, PTSD has been largely ignored.

Post-traumatic stress disorder

According to Statistics Canada, in 2016, as many as 99,000 women experience PTSD symptoms in the postpartum period, with over 21,000 meeting the criteria for PTSD diagnosis. Traumatic life experiences, such as childhood sexual abuse and prenatal intimate partner violence, fears and expectations about childbirth, and negative cognitive appraisal and subjective perception of childbirth and post-childbirth experiences, predict the development of postpartum PTSD (Oliveira et al. 2017; Verreault et al. 2012). Subjective childbirth experience has been identified as the most important predictor of postpartum PTSD, likely influenced by interpersonal difficulties, obstetric complications, provider care factors (e.g., control and communication), and lack of social support during childbirth (Patterson et al. 2019). However, PTSD related to birth experiences may result in resilience (61.9%), recovery (18.5%), chronic PTSD (13.7%), or delayed PTSD (5.8%) (Dikmen-Yildiz et al. 2018). Identified as a protective factor against PTSD (Verreault et al. 2012), social support contributes to resilience (Dikmen-Yildiz et al. 2018), and women with PTSD perceive less social support as well as decreased support over time (Soderquist et al. 2006). Low satisfaction with social support provided by health professionals predicts chronic and delayed PTSD (Dikmen-Yildiz et al. 2018). Maternity care providers’ adherence to trauma-informed principles of social support, safety, trustworthiness, collaboration, and empowerment may be critical to promote PTSD recovery and resilience (Sperlich et al. 2017).

PTSD is highly associated with PPD. Among women with PTSD, 65% also present with PPD, and 22% of women with PPD also present with PTSD (Soderquist et al. 2006). Preliminary research shows that PTSD is an important moderating factor in the association between birth experience of emergency versus planned cesarean section and PPD (Grisbrook et al., unpublished). The association between PTSD and PPD demonstrates that maternal mental health presents a significant concern for new mothers and their families and that screening for PPD will fail to identify most mothers with PTSD.

Feelings of rejection and avoidance toward the infant frequently occur among women experiencing PTSD (Ayers et al. 2006). Mothers with PTSD also tend to be hypervigilant, anxious, and overprotective toward the infant (Ayers et al. 2006), resulting in disordered maternal-child relationships and in-secure maternal-infant attachment (Parfitt and Ayers 2009) and placing children at risk for behavioural and developmental problems (Stein et al. 2014). PTSD also affects mothers’ sense of life satisfaction and functioning as well as the relationship with her partner (Parfitt and Ayers 2009). The significant influence of PTSD on parenting behaviours, family relationships, altered maternal-child attachment, and the development of PPD demonstrate the importance of screening for this condition in the postpartum period.

Improving maternal mental health assessment

Internationally, Australia’s Centre of Perinatal Excellence, the UK National Institute for Health and Care Excellence, the US Preventive Services Task Force, and the World Health Organization recommend universal postpartum mental health screening and follow-up. However, in Canada, maternal mental health screening is not universal, with only five Canadian provinces on board including the BC Reproductive Mental Health Program, Alberta Health Services Healthy Children and Families Program, New Brunswick Perinatal Mental Health Program, Reproductive Care Program of Nova Scotia, and Saskatchewan Prevention Institute. Screening is limited to PPD assessment with the Edinburgh Postnatal Depression Scale (EPDS (Cox et al. 1987)). The EPDS takes 5 min to administer, has a sensitivity of 86% and is valid for use with mothers, partners, and adoptive parents (Cox et al. 1987). However, the EPDS does not evaluate PTSD symptoms. With a 65% co-occurrence of PPD and PTSD in the postpartum period, consideration should be given to the interplay of these factors in maternal mental health. Furthermore, while some provinces and regional organizations such as the MotherFirst Working Group, the Registered Nurses’ Association of Ontario, and the Winnipeg Regional Health Authority recommend postpartum mental health screening, Health Canada has yet to provide leadership. In short, Canada requires national guidelines for maternal mental health screening that should recommend screening for PPD as well as PTSD and provision of follow-up services and supports as part of routine maternal postpartum care.

While universal screening in Canada may be hampered by lack of consistency, insufficient capacity to offer screening programs and analyze cost-effectiveness, under-screening in underserved populations, and limited treatment options (Health Council of Canada 2013), evidence shows screening alone results in clinical benefits and that early detection leads to favourable outcomes (American College of Obstetricians and Gynecologists 2018). Identified as barriers to receiving treatment (Ko et al. 2012), both stigma and perceived threat associated with discussion of mental health concerns are reduced by universal screening (BC Reproductive Mental Health Program 2014). Universal screening addresses the recommendation of the American College of Obstetricians and Gynecologists (2018) to assess maternal mood during newborn care appointments. However, like screening for PPD, a PTSD screening program should be evaluated to examine its safety, effectiveness, quality, equity, accessibility, and accountability to ensure integration in public health, health promotion, and multi-disciplinary care (Health Council of Canada 2013).

The Public Health Agency of Canada acknowledges the (1) perinatal period as a time of change that increases the risk for poor maternal mental health, (2) importance of assessing women’s mental health, and (3) impact of maternal mental health problems and depression on the emotional health of infants and mothers. Yet, to date, they have not proposed mental health screening or follow-up recommendations for the postpartum period. The Canadian Task Force on Preventive Health Care does not currently have a recommendation for routine mental health screening in perinatal and postnatal women. The incidence of PTSD following childbirth and its impact on the health of mothers and children justifies screening of this condition in the postpartum period; however, PTSD remains largely unrecognized in maternity care services. Given the high prevalence rate of PTSD symptoms among new mothers and the high comorbidity between PTSD and PPD, screening for PTSD should be carried out as part of a postpartum mental health assessment.

Universal screening with reliable and valid tools is essential to ensure appropriate treatment and follow-up and decrease stigma. Primary care providers frequently fail to recognize high levels of self-reported depressive symptoms among their patients (Ko et al. 2012); thus, postpartum clinical appointments are insufficient to identify altered maternal mental health. Screening requires consideration of organizational factors that affect implementation in addition to availability of valid measurement tools to accurately identify disorder. While PPD is well assessed with the EPDS, valid measurement of PTSD is also needed. One possibility is the Psychiatric Diagnostic Screening Questionnaire (PDSQ), a brief, psychometrically robust self-report scale with a 15-item subscale for PTSD. It has a Cronbach alpha of 0.94, 92% sensitivity, and a cutoff score of five represents the presence of PTSD symptoms (Zimmerman and Mattia 2001). It has been used in prenatal screening (Leung et al. 2017) and can be rapidly hand-scored, making it feasible for routine clinical practice (Zimmerman and Mattia 2001), but nonetheless requires further evaluation in clinical settings. Another possibility is the City Birth Trauma Scale, a 29-item questionnaire designed to specifically measure postpartum birth-related PTSD according to the DSM-5 criteria (Ayers et al. 2018). The scale has excellent internal consistency, with a Cronbach alpha of 0.92, and is easy to understand with a Flesch reading score of 64.17 (Ayers et al. 2018). Further evaluation requires examination of the concurrent validity with physician or nurse practitioner diagnosis (Ayers et al. 2018) and perhaps shortening with factor analytic techniques to increase feasibility of use. The PTSD Symptom Scale-Self-Report (PSS-SR), a 17-item questionnaire, has been adapted for use after childbirth and has a Cronbach alpha of 0.91 for the childbirth-specific version (Beck et al. 2011).

Selection of a PTSD tool must consider ease of completion and time required to complete and score the scale, as time constraints are barriers to screening in many care settings. Shorter instruments that require further evaluation for childbirth-specific trauma are the Primary Care PTSD (PC-PTSD) Screen (Prins et al. 2002), the Short PTSD Rating Interview (SPRINT) (Connor and Davidson 2001), and the Trauma Screening Questionnaire (TSQ) (Brewin et al. 2002). The PC-PTSD Screen includes five items designed for use in primary care settings, with a sensitivity of 0.95 with a cutoff of three (Prins et al. 2016). The original PC-PTSD has a sensitivity of only 0.70 among women (Prins et al. 2002). The SPRINT consists of eight items requiring only 5–10 min to administer, has an internal consistency of 0.77 at baseline, and is validated for the general population (Connor and Davidson 2001). The 10-item TSQ is validated among crime and disaster victims, was designed for general trauma victims, and has a sensitivity of 0.86 given a cutoff of six (Brewin et al. 2002). The PC-PTSD, SPRINT, and TSQ demonstrate promise regarding ease of administration in primary care settings but require validation with the maternal population.

Conclusion

Postpartum mental health conditions have serious health implications for both mothers and newborns and should be addressed by national guidelines and universally implemented. Failure to incorporate recommendations for PTSD screening in existing guidelines may be due to a lack of recognition of the prevalence and impacts of PTSD on maternal quality of life and family functioning, as well as the need for further validation of existing PTSD screening tools. The overlap between PPD, assessed widely, and PTSD supports the need for PTSD screening in the assessment and provision of maternal mental health care. Given current mental health screening practices in Canada, the processes for decision-making, clinical pathways, and follow-up care required for the implementation of PTSD would be similar to those employed for PPD screening. With so many Canadian women experiencing PTSD, it is imperative that universal maternal mental health screening incorporates measures to evaluate and care for new mothers with PTSD, as well as PPD.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.