Most people experience a traumatic event at some point in their lives, and many recover over time. But some develop posttraumatic stress disorder, or PTSD, which drastically alters their daily functioning and enjoyment of life.
The National Center for PTSD estimates that five out of every 100 people in the U.S., or 13 million Americans, have PTSD at any given time. Women are more likely than men to suffer PTSD, as are veterans and people from marginalized populations.
PTSD can intensify during the perinatal period, which includes pregnancy, childbirth and the months immediately following. Most at risk are people with a history of childhood sexual abuse or assault and those with a severe fear of childbirth or who develop life-threatening medical complications for either mother or baby, said Michelle L. Miller, PhD, an assistant professor of psychiatry and director of the Traumatic Stress Clinic at the Indiana University School of Medicine.
What does PTSD look like during pregnancy and postpartum?
Miller recently piloted a PTSD therapy intervention for perinatal women. She presented her findings at the HEALeR Collaborative, a research center focused on eliminating health care disparities. While it’s hard to pinpoint numbers, national data shows that between 3-19% of pregnant and postpartum women experience PTSD, depending on risk factors, with the highest rate among Black women — up to 30%.
Symptoms of PTSD may include nightmares, intrusive memories, flashbacks, detachment from others, avoidance of triggering environments or thoughts, difficulty concentrating, irritability and reckless behavior.
“Pregnancy and the postpartum period are full of physical, mental and emotional challenges,” Miller said. “PTSD adds an extra challenge. You might be dealing with having flashbacks and intrusive memories while being up three times in the middle of the night with your baby.”
During pregnancy, PTSD symptoms can lead to severe reactions to physical examinations and avoidance of prenatal care. After childbirth, it can affect bonding and attachment or manifest as inordinate fear for the baby’s safety.
People experiencing PTSD commonly have other conditions including depression, anxiety, substance use and eating disorders, all of which can lead to negative outcomes for mothers and children. As part of its strategic plan, IU School of Medicine is working with IU Health to improve mental health care as well as reduce Indiana’s rate of maternal and infant deaths. The most recent March of Dimes Report Card gave Indiana a “D” for maternal and infant health.
As part of the IU School of Medicine Department of Mental Health Services’ Combating Stigma Video Series, Kyra Reed, MD, an assistant professor who works in pediatric emergency medicine, recently shared her own story of mental distress following a traumatic birth experience and her child’s feeding difficulties.
“I had rarely, if ever, heard anyone in my profession share a story of navigating their own mental health crisis, and I wanted others to not be ashamed or to feel so alone,” Reed said.
Hope for people with PTSD
Miller would like every pregnant woman in the state of Indiana to be screened for PTSD and connected to resources when indicated. IU’s obstetricians are eager to partner in trauma-informed care.
“This research is important because pregnancy is a time of great change and stresses, both positive and negative, for women and families,” said David Haas, MD, MS, the Munsick Professor of Obstetrics and Gynecology and the OB-GYN department’s vice chair of research. “People who enter pregnancy with prior trauma and PTSD may have higher baseline stress and triggers that can lead to adverse mental and pregnancy outcomes.”
For Miller’s study, pregnant women could participate in screening at three hospitals: a high-risk obstetrics center at Eskenazi Health, the Coleman Center at IU Health University Hospital, and Logansport Memorial Hospital, serving a rural population.
High rates of women who were screened reported trauma exposure at some point in their life — up to 50% of participants in one of the samples. Rates of PTSD varied from 8-20% depending on the clinical setting. Women with high-risk pregnancies and those from low-resource areas were most at risk.
Miller’s team piloted a six-session, virtual program using Narrative Exposure Therapy (NET) for those who screened positive for PTSD.
“It’s telling your story in a new way that allows for the memory network to change,” Miller explained. “Participation in NET can take away the fear associated with a traumatic memory, so, while the memory may remain, it no longer causes the same amount of distress or pain.”
Impacting maternal health statewide
The pilot was so effective in reducing participants’ PTSD symptoms that Miller is preparing to launch a statewide perinatal PTSD study this fall. In her initial study, women from marginalized communities had lower participation rates; some started the program but dropped out before completing all therapy sessions.
“We’re going back and talking to everyone — those who completed a screening but didn't engage in the study, those who did participate, and even those who would be eligible but never heard of NET before — to get feedback and see what’s missing from our protocol so we can best engage traumatized perinatal women,” Miller said.
Haas, who is Miller’s research mentor, said accumulating more data on NET’s benefits and the overall prevalence of PTSD among women of reproductive age is needed to advocate for the program’s expansion throughout the state. He would like to see people screened for PTSD even before they become pregnant.
“The work Dr. Miller is doing to address PTSD in the perinatal period has the potential to set these individuals up for better long-term mental health and improved pregnancy outcomes,” he said.
