Abstract
This chapter provides an overview of trauma, stress, and post-traumatic stress symptoms during pregnancy and postpartum. Trauma-informed perinatal mental health care must consider the multifaceted strengths and vulnerabilities of each birthing person and seek to understand how what happened to an individual before, during, and after birth may impact her own health and the well-being of her family. In addition to a summary of the literature on perinatal PTSD, this chapter focuses on birth trauma, childhood maltreatment, and the COVID-19 pandemic as three critical traumatic stressors that may confer risk. Effects of these traumatic stressors on pregnancy and birth outcomes, perinatal mental health, and parenting outcomes are discussed. Given the potential intergenerational impact of untreated and unresolved trauma, this chapter ends with assessment and treatment recommendations for perinatal women and mothers of young children exposed to trauma or significant adversity, with an emphasis on the ways in which evidence-based dyadic interventions may help mitigate the intergenerational transmission of trauma and toxic stress.
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Stress is a universal experience and an adaptive reaction to stressors (i.e., the causes or sources of stress), wherein the environmental, physical, or emotional demands exceed an individual’s resources, yielding a reactive and involuntary cascade of physiological and bodily responses. Although the term “stress” encompasses a range of positive and negative experiences, an individual’s acute stress response (e.g., secretion of adrenal hormones, increased heart rate and respiration) is typically transient, and the body returns to baseline homeostasis after a stressor is removed. Nevertheless, certain stressors may disrupt or recalibrate the body’s stress response, resulting in persistent or maladaptive stress reactivity that continues even after the original threat is no longer present. Such dysregulation of the body’s stress response is likely to occur when stressors are prolonged and uncontrollable in nature, commonly referred to as chronic stress [1] or toxic stress [2]. As a related construct, trauma is a specific and extreme stressor, defined as disturbing events or experiences involving actual or perceived threat of death, injury, or bodily harm [3, 4]. Traumatic stress inherently overwhelms an individual’s coping mechanisms [5] and may yield lasting effects on psychological, relational, and physical health. When the traumatic experiences are interpersonal in nature (e.g., inflicted by a caregiver or romantic partner) and occur early in development (i.e., during the first decade of life; [6]), trauma can have especially deleterious consequences.
In the context of current or lifetime trauma, the perinatal period may be a time of increased risk for the initial onset, recurrence, and exacerbation of post-traumatic stress symptoms and other psychopathology [7,8,9]. For example, risks for perinatal mental health concerns are particularly high for women with a history of reproductive trauma and childhood sexual abuse, given the psychosexual changes associated with pregnancy and prenatal care procedures that may be perceived as invasive and triggering [10,11,12]. Furthermore, although childbirth in and of itself is not traumatic, birth trauma and childbirth-related post-traumatic stress disorder can occur following subjective appraisals of actual or threatened death, injury, or bodily harm to the mother or child [13,14,15]. Overall, the physical and psychological effects of trauma may detrimentally impact a birthing person’s health and behavior during pregnancy; delivery and birth outcomes; postpartum mental health and maternal functioning; and the developing parent-child relationship.
Identifying risks for perinatal traumatic stress and minimizing its detrimental effects is especially important, given that pregnancy and postpartum inherently overlap with sensitive periods of child brain development. The intergenerational transmission of trauma and stress can occur through unique and combined genetic, epigenetic, parenting, and environmental mechanisms, which can translate into neuroendocrine and neuroanatomical changes in offspring, thereby altering behavior and development across the life span [1, 16, 17]. As such, a mother’s well-being during the perinatal period has significant implications for her own physical and mental health as well as the health and well-being of her offspring.
In the current chapter, we focus on trauma, stress, and post-traumatic stress symptoms during pregnancy and postpartum. We begin the chapter with a general overview of trauma effects on the individual, briefly highlighting common physiological and psychological outcomes. Next, we provide an overview of three specific types of traumatic stress and their effects on pregnant and postpartum women: birth trauma, childhood maltreatment, and the COVID-19 pandemic. Finally, we end with a discussion of assessment and treatment options for birthing people with a history of trauma and stress, focusing on the importance of timely screening and effective treatments for both individuals and caregiver-infant dyads, which may help mitigate the intergenerational transmission of trauma and toxic stress.
1 Physical and Psychological Trauma Effects
Individual reactions to traumatic events fall on a continuum, from resilient and adaptive responses to significant psychiatric distress and poor functioning. Although the vast majority of people who experience trauma do not develop significant or ongoing psychological sequelae, trauma can detrimentally alter an individual’s beliefs, functioning, and interpersonal behavior [1, 18, 19]. Even when individuals do not experience trauma-related mental health symptoms or consciously recall what happened to them, trauma may leave a physiological imprint on the brain and the body. For example, childhood abuse and maltreatment can alter brain pathways involved in stress regulation (e.g., the hypothalamic pituitary adrenal axis), as well as connectivity between regions crucial to emotional health (e.g., the limbic system and medial prefrontal cortex; for review, see [20]). Furthermore, cumulative adverse childhood experiences or “ACEs” substantially increase risk for adult-onset disease, including cancer, cardiovascular, metabolic, gastrointestinal, and other inflammatory diseases [21,22,23,24]. This link between traumatic stress and health outcomes is critically important in the perinatal period, as both proximal and distal stressors can impact pregnancy and birth outcomes, including hypertension, impaired uterine blood flow, preterm birth, and low birth weight [25,26,27,28,29,30,31,32].
Based on a combination of retrospective and prospective research, trauma exposure is consistently associated with increased risk for negative mental health outcomes, including post-traumatic stress disorder (PTSD), depression, anxiety disorders, substance use disorders, and more generalized emotion dysregulation. And yet, many of the symptoms associated with such psychological “dysfunction” may have been protective in the context of ongoing trauma, wherein the individual developed responses or behaviors to actively cope with the stress or prevent further harm [19]. From a strengths-based and trauma-informed perspective, we therefore acknowledge that current diagnostic systems may pathologize behavior and functioning that once served an adaptive role in the face of trauma [33, 34].
Despite the variety of psychological responses that may emerge secondary to traumatic stress, in this chapter we primarily highlight and focus on perinatal PTSD. In order to meet criteria for PTSD, individuals must identify a criterion traumatic event and endorse a combination of symptoms that include re-experiencing (e.g., flashbacks or intrusive memories), avoidance of trauma reminders, negative changes in mood/cognition, and increased arousal or activation in response to trauma-related stimuli [35]. In the perinatal period, estimated prevalence rates for PTSD vary widely depending on the period of assessment, measurement methods, and sample type. Within an urban and racially diverse pregnant sample, Seng et al. [11] found the risk of developing PTSD during pregnancy was six times higher among individuals with demographic risk factors (e.g., younger age, poverty, less than high school education) and those with a history of prior miscarriage or terminated pregnancy. Consistent with the broader obstetric literature on racial differences in perinatal outcomes (see, e.g., American College of Obstetricians and Gynecologists [36] and Hardeman et al. [37]), one study among pregnant women in the United States found Black women were slightly more likely to have higher rates of lifetime PTSD, but had four times the rate of concurrent PTSD during pregnancy [38, 39]. Unfortunately, other studies have reported perinatal women with combined demographic risk and PTSD symptoms are also more likely to have comorbid psychopathology, including a fivefold increase in risk for major depressive disorder and threefold risk for generalized anxiety disorder [40].
In two separate meta-analytic investigations, substantial differences in PTSD prevalence emerged when comparing high-risk perinatal women to community samples [41, 42]. Of note, high-risk groups in both studies included individuals with psychological risk factors (e.g., history of sexual violence, childhood abuse, high fear of giving birth, prior birth trauma), as well as individuals with notable medical risks for the mother or fetus (e.g., preeclampsia, prior preterm birth or emergency caesarean, identified fetal anomalies). Grekin and O’Hara [41] found a PTSD prevalence of 3.1% in community samples but 15.7% in high-risk samples. More recently, Yildiz et al. [42] showed a similar postpartum PTSD prevalence of 4.0% in community samples but 18.5% in high-risk samples. One novel aspect of Yildiz et al.’s [42] meta-analysis was the focus on PTSD prevalence during pregnancy and postpartum. Once again, a stark differential risk pattern emerged in pregnancy: the prevalence of prenatal PTSD was 3.3% in community samples and 18.95% in high-risk samples. Across both pregnancy and postpartum, Yildiz et al. [42] found the course of perinatal PTSD was generally characterized by increases in PTSD prevalence during the first 6 months after birth. Although prospective longitudinal studies of perinatal PTSD are somewhat limited (see, e.g., [43]), it is possible that the higher point prevalence in the immediate postpartum period may relate to acute birth trauma or childbirth experiences that are re-traumatizing for women with prior trauma or a history of PTSD [42].
Looking more closely at risk for postpartum PTSD, symptoms typically occur via two etiological patterns: (1) a continuation, exacerbation, or recurrence of PTSD symptoms in the context of more general trauma history and (2) new-onset PTSD symptoms triggered specifically by childbirth experiences [41, 43,44,46]. In the former group, postpartum PTSD symptoms emerge or re-emerge secondary to lifetime events that occurred prior to birth, pregnancy, or even conception, including criterion stressors such as childhood sexual abuse, rape, or intimate partner violence [41, 45]. Within the latter group, wherein childbirth itself is the traumatic event, PTSD symptoms emerge secondary to distressing labor and delivery experiences [41, 42, 44, 45,46,48]. In the next sections, we further elaborate on birth trauma and two other types of traumatic stress (i.e., childhood maltreatment and the COVID-19 pandemic), exploring ways in which these traumatic and stressful experiences may detrimentally impact perinatal women’s mental and physical health, birth outcomes, and the developing parent-child relationship.
2 Birth Trauma and Childbirth-Related PTSD
Historically, studies of postpartum PTSD have not consistently distinguished childbirth-related PTSD (i.e., CB-PTSD) from more general postpartum PTSD precipitated by lifetime traumatic events; however, the study of birth trauma and risk for CB-PTSD is a growing field [42, 44, 47, 49]. Objectively, labor and delivery involve acute physiological changes, from drastic hormonal shifts to extreme bodily pain, changes in cardiac and respiratory output, and blood loss. Although the majority of birthing people do not develop PTSD following childbirth, given the complexity of labor and delivery, it is perhaps unsurprising that even full-term, healthy births may be experienced as stressful or traumatic [44, 50]. Using established PTSD criteria (APA 2013), childbirth can be characterized as a criterion traumatic event when there is actual or threatened death or bodily harm to the mother or neonate. Based on data from phenomenological interviews among women with a history of birth trauma [51], further expanded this definition of birth trauma to include traumatic experiences in which women feel dehumanized or stripped of their dignity during labor and delivery.
Consistent with PTSD in the general population [52, 53], subjective appraisals of traumatic birth experiences are a strong predictor of CB-PTSD [52,53,56]. Notably, women’s birth appraisals may substantially differ from the perceptions of obstetricians and other clinical staff, who may otherwise deem certain birth-related medical events and procedures as “routine” [49]. The prevalence of CB-PTSD among birthing people who describe their labor and delivery as traumatic varies widely across prior studies, ranging from 9% to 44% [57]. In the United States, Black, Indigenous, People of Color (BIPOC) are more likely to report mistreatment during labor and delivery [58], including behaviors frequently associated with traumatic birth appraisals, such as loss of autonomy and being ignored by providers. As noted, however, only a minority of women who identify their birth experiences as traumatic go on to develop clinically significant CB-PTSD. In a study of CB-PTSD, Alcorn et al. [59] found 43% of the sample subjectively described childbirth as a trauma event; however, only 3.6% developed clinically significant postpartum PTSD. In a prospective, longitudinal, observational study, Kountanis et al. [60] recently reported rates of new-onset CB-PTSD at 6 weeks and 3 months postpartum of 6.2% and 5.1%, respectively. In comparison, when considering subclinical symptoms (e.g., hyperarousal, re-experiencing, avoidance), another study found up to one third of first-time mothers experience some form of post-traumatic stress symptoms secondary to childbirth [61].
When identifying and differentiating individuals who go on to develop CB-PTSD from those who do not experience post-traumatic stress symptoms, attention must be paid to interactive and multifaceted risk factors. The emergence of CB-PTSD is often conceptualized within a diathesis-stress model, wherein a combination of pre-birth vulnerability factors and birth-specific risk factors predicts negative outcomes [44, 62]. In a meta-analysis exploring the etiology of CB-PTSD, Ayers et al. [47] reported the vulnerability factors most strongly associated with CB-PTSD were a prior history of trauma and PTSD; depression during pregnancy; fear of childbirth; and health complications during pregnancy. The birth-related risk factors most strongly associated with CB-PTSD included negative subjective appraisals of birth; dissociation during labor and delivery; having an operative delivery (i.e., assisted vaginal or caesarean); and poor support during birth [47]. Overall, these results are highly consistent with more general (i.e., not childbirth-specific) risks for postpartum PTSD [41]. Qualitative and interview-based data further highlight higher risk for birth trauma associated with perceptions of low control and poor communication during labor and delivery; across multiple studies, traumatic birth experiences are often characterized by limited information from medical staff about what is occurring, lack of consent, and not involving women in medical decision-making [49, 57, 63]. In particular, Beck [64] identified risk for traumatic birth when women have low feelings of self-agency combined with the perception that medical procedures were “acted on” them. Additional experiences common to traumatic birth may include feeling abandoned or alone during labor and delivery; limited or poor-quality birthing support (e.g., from partners, doulas); and discrepancies between birth expectations and reality [49, 57, 63].
Similar to the broader PTSD literature, there is also a strong association between CB-PTSD and perinatal depression [41, 47], with moderate to high rates of comorbidity [65]. For example, as many as 72% of women with postpartum PTSD may endorse clinically significant depressive symptoms [42]. Given the degree of comorbidity, Dekel et al. [65] recently explored whether CB-PTSD and postpartum depression may actually represent a “single posttraumatic stress-depressive response” (p. 562). Within their sample, the authors found 90% of women classified with CB-PTSD had elevated levels of depression, whereas 31% of those with postpartum depression had comorbid symptoms of CB-PTSD. Factor-analytic results further supported a one-factor model, even after controlling for overlapping symptoms within CB-PTSD and depression diagnostic criteria [65]. Given these results, Dekel et al. [65] concluded that a distinct subset of women may develop a unique depression-stress phenotype secondary to traumatic childbirth, and when this is the case, it is critical for effective treatments to address the depressive symptoms in the context of comorbid post-traumatic stress and the underlying traumatic event.
Birth trauma and CB-PTSD may also pose unique intergenerational challenges to offspring development and the early parent-child relationship. Although up to one quarter of women may develop CB-PTSD in the context of a healthy full-term birth [44], Grekin and O’Hara found a strong relationship between infant complications (e.g., low birth weight, preterm birth, NICU stay) and PTSD among high-risk postpartum samples. Thus, some mothers may be faced with the dual challenges of attending to their child’s medical and developmental complications while also managing their own postpartum PTSD symptoms. Within the growing literature on motherhood and parenting outcomes among women with postpartum PTSD, only a select number of studies have focused on mothers with CB-PTSD. Ostensibly, given that the criterion trauma in CB-PTSD involves the birth of the child, one might expect difficulties with maternal bonding or connecting with the infant. Prior findings indicate that mothers with CB-PTSD describe their 6-week-old newborns as less emotionally warm and more demanding [66]; rate their 18-month-old children higher in internalizing and externalizing disorders [67]; and self-report interactions with their 24-month-old toddlers as difficult [68]. Among a relatively large sample of 685 postpartum women, Dekel et al. [69] compared subgroups of mothers with probable CB-PTSD, those with postpartum PTSD unrelated to birth trauma, and those with no PTSD symptoms. The authors found that the CB-PTSD group had the poorest self-reported ratings of mother-to-infant attachment, even after controlling for other demographic, psychiatric, and childbirth-related confounds (e.g., parity, type of delivery, NICU admission; [69]). In one of the few qualitative studies examining the parenting experiences of women with CB-PTSD, Beck and Watson [70] identified phenomenological parenting themes of numbness/detachment, high reactivity (i.e., anger, crying), distressing cognitive changes (e.g., catastrophic thinking), and limited social interactions outside the home. Overall, these findings underscore the potential intergenerational impact of birth trauma and CB-PTSD, with parent-child interactions representing an important behavioral target for intervention among high-risk dyads. In the next section, we will expand our focus on the risk factors and consequences of perinatal traumatic stress by examining how a mother’s history of maltreatment in her own childhood may impact birth outcomes, perinatal mental health, and parenting practices.
3 Childhood Maltreatment
Although the perinatal period is generally a time of heightened vulnerability for physical and mental health challenges, such risks are significantly heightened for individuals with childhood maltreatment histories [69,70,73]. Childhood maltreatment (CM) is defined as “…all types of physical and/or emotional ill-treatment, sexual abuse, neglect, negligence, and commercial or other exploitation, which results in actual or potential harm to the child’s health, survival, development or dignity in the context of a relationship of responsibility, trust or power” [74]. Though prevalence rates vary by definition and population, 61% of adults report at least one adverse childhood experience prior to the age of 18 (e.g., abuse, neglect, household dysfunction; [75]); and globally, approximately 20% of women report experiences of childhood sexual abuse [76]. Among women in the perinatal period, prevalence rates of CM range from 11% to 35% in community samples [77] and 47% to 80% among higher-risk mothers (e.g., teen mothers, low-income mothers [78, 79]).
It is well established that a history of CM puts women at greater risk for physiological and psychological disruptions during pregnancy [16, 38, 39, 71]. Broadly speaking, women with CM histories have heightened risk for antenatal complications such as premature contractions, cervical insufficiency, gestational diabetes, previa, abruption, preeclampsia, intrauterine growth restriction, being of overweight status, and/or being hospitalized during pregnancy [38, 39, 80, 81]. Some of the physiological disruptions associated with CM histories may help explain the greater risk for health complications during pregnancy. For example, women with CM histories have greater risk for thyroid dysfunction and subclinical hypothyroidism during pregnancy [82], as well as higher levels of placental corticotropin-releasing hormone (pCRH) and a steeper increase in release of pCRH [83]. The association between CM history and mental health symptoms is also well-replicated in the perinatal period. A systemic review that included research with over 26,000 participants found that CM is strongly associated with a greater risk for depression and PTSD during pregnancy and postpartum, even when controlling for history of mental illness, sociodemographic variables, and psychosocial factors [71].
The combination of CM history and perinatal psychopathology may be particularly detrimental to birth outcomes and child development. For example, in the context of CM and maternal PTSD symptoms, risks for low birth weight and shorter gestation are heightened [38, 39], as are risks for breastfeeding challenges and bonding impairment [8, 9]. Consistent with the idea of intergenerational transmission of risk, offspring of women with CM histories may be at greater risk for subsequent mental and physical health challenges [16, 43, 83]. More specifically, endocrine and immune processes play an essential role in fetal development, and disruptions to these neurobiological processes may partially explain the transmission of risk from maternal CM history to negative neurodevelopmental outcomes among children [16, 80,81,82,85]. For example, Moog et al. [85] found newborns of mothers with CM histories had smaller brain size and gray matter volume at birth compared to newborns of mothers who did not have a history of CM. Further, research suggests there is a dose-dependent effect of CM, such that worse severity (i.e., frequency/intensity) is associated with worse offspring outcomes [16]. In sum, CM has the potential to impact maternal physical and psychological well-being during the perinatal period, and in turn, these maternal changes can influence intrauterine development in profound ways.
Nevertheless, the impact of CM on perinatal risk is probabilistic rather than deterministic, and processes of risk and resilience are complex and multifaceted. Although it is well known that postpartum depression increases risk for parenting difficulties—and subsequent child biopsychosocial outcomes [84,85,86,89]—research on the unique impact of CM and/or postpartum PTSD symptoms on parenting outcomes has a less consistent and clear picture [90, 91]. For example, although mothers with CM histories may perceive themselves as being less confident or competent in parenting, these perceptions are not always associated with observed challenges in parenting behaviors [92]. Further, prior observational research documented that CM history in the absence of psychopathology did not confer risk for negative parenting behaviors [91], nor was CM history associated with maternal parenting behaviors or reflective functioning [93]. In another study, mothers with CM histories reported higher bonding impairment with their infants than mothers without CM histories, but the persistence of bonding problems across the postpartum period was predicted by psychological symptoms rather than CM status [72].
One way to help make sense of the contradictory results around CM and parenting is to think about the numerous risk and protective factors across the mother’s own developmental trajectory [71], as well as the complexity of the post-traumatic changes that may emerge as a mother transitions into parenthood [94]. In a study of CM survivors during the postpartum period, Fava et al. [94] found higher CM severity combined with higher demographic risk was associated with greater positive post-traumatic change (e.g., being intentional about protecting their child from abuse and staying calm in the face of challenging child behaviors because they want to give their child a better childhood than they experienced [94]). Thus, although CM history may increase risk for perinatal mental health difficulties, and these symptoms can in turn increase risk for parenting challenges, the pathway from CM to parenting is one marked by both risk and resilience. Ultimately, it is important to recognize that women with CM histories are very much capable of nurturing, safe, and effective parenting, despite what happened to them.
In the subsequent section, we will end our review of specific traumatic stressors and their effects on perinatal mental health by highlighting a far-reaching, once-in-a-century stressor that has detrimentally affected individuals and communities across the globe: the COVID-19 pandemic. We will specifically highlight unique challenges facing perinatal women and explore the impact of the pandemic on increased risk for perinatal mental health concerns, including high levels of stress, depression, anxiety, and perinatal PTSD.
4 COVID-19 Pandemic
In 2020, the global coronavirus pandemic brought an accumulation of physical, psychological, and social stressors for much of the world population. Given the widespread and multifaceted consequences—including the threat of severe illness, death, or loss of a loved one—attention to the mental health impact of COVID-19 (i.e., the disease caused by SARS-CoV-2) among perinatal women is warranted. At the time of this chapter’s publication, rapidly emerging data on pregnancy and birth outcomes associated with COVID-19 created a moving target of literature to review. Understanding the risks and consequences associated with prenatal COVID-19 infection was further complicated by difficulties separating the direct effects of the disease from indirect changes to maternity care and other social determinants of health [95], as well as challenges in identifying infected individuals given limited universal testing and indications that up to 90% of pregnant women infected with SARS-CoV-2 are asymptomatic [95, 96]. Nevertheless, several recent systematic reviews and meta-analyses indicate that prenatal COVID-19 infection is associated with heightened risk for preterm birth prior to 37 weeks [95, 97, 98], caesarean delivery [95, 98], and maternal intensive care unit admission [97]. These risks are particularly high for infected women of increased maternal age and those with pre-existing medical comorbidities [95, 97]. Thus far, risk of vertical transmission to the neonate appears rare [95, 98], although one review found higher risk of NICU admission among babies born to mothers with COVID-19 [97]. Taken together, the emerging data on COVID-19 appear somewhat contradictory insofar as positive pregnant women may present as asymptomatic or severely ill (e.g., requiring admission to intensive care unit), which ultimately heightens confusion among this population and adds to the rising mental health toll in perinatal women.
Emerging research indicates that perinatal women may be particularly vulnerable to intense worries or distress about the novel coronavirus [99, 100], including concerns about the health and safety of themselves, their unborn child, and other family members [101, 102]. Among pregnant women in the United States, Preis and colleagues identified two categories of pandemic-related stress: (1) feeling unprepared for birth due to the pandemic (i.e., “preparedness stress”) and (2) fear of perinatal COVID-19 infection [103], with 30% of 4451 pregnant women reporting high levels of stress in each of these domains. In a similarly large sample pregnant women in the United States, fear of infection was endorsed by 93% of participants [104]. Liu et al. [105] also assessed levels of COVID-19-specific health worries and grief and loss associated with the pandemic (e.g., feelings of sadness related to not being able to celebrate the birth of one’s child with loved ones; bitterness at changes in daily routine or limited social support); within this perinatal sample, 18% reported high levels of COVID-19 health worries, and 9% reported high levels of grief [105].
Beyond the direct distress associated with fear of contracting COVID-19, indirect pandemic-related stressors may particularly affect perinatal women, resulting in chronic stress and high cumulative stress load. Notably, COVID-19 abruptly and dramatically changed the face of prenatal care, birth experiences, parenting support, and other psychosocial resources. In order to minimize COVID-19 disease risks for the mother and fetus, health systems and providers understandably adopted new approaches to perinatal care, including remote or telehealth consultations with providers, fewer consultation and postpartum services, or limiting the presence of partners or labor support staff during birth [106, 107]. Given the important and protective role a supportive partner, family member, or doula may have on labor and birth experiences—especially for women with prior trauma histories and BIPOC women—it is reasonable to expect associated increases in traumatic birth experiences [106]. Moyer et al. [104] reported that 25.8% of pregnant women stopped prenatal care during the COVID-19 pandemic, whereas 15.2% used video visits, and 31.8% used phone visits for prenatal care; in turn, these reductions in prenatal care and use of phone-based visits were associated with increases in pregnancy-related anxiety [104].
Other psychosocial stressors exacerbated by COVID-19 include financial stress, unemployment, eviction, and food insecurity [100, 107, 108]. Within their sample of 2740 pregnant women in the United States, Moyer et al. [104] found high levels of stress related to concerns about food availability (59%), loss of work or household income (63.7%), loss of childcare (56.3%), and conflict between household members (37.5%). As families spend more time together at home under these stressful circumstances, pandemic-related increases in domestic and intimate partner violence also pose significant safety risks for perinatal women and their children [100, 107, 108]. Finally, broader public health initiatives and social distancing guidelines (e.g., limiting contact with others outside one’s immediate household) inherently reduce or eliminate access to social connections and concrete parenting support for postpartum women [100, 106, 108]. For multiparous women, the negative psychosocial impact of social distancing may include simultaneous demands of childcare, homeschooling, and remote work [108, 109]. The necessary and lifesaving importance of COVID-19 social distancing practices notwithstanding, such measures conflict with the instinctive human drive for social connection [100] and may limit empirically supported intervention approaches that aim to increase positive social support or feelings of belonging, known to reduce stress and promote resilience among perinatal women.
Relying on outcomes from prior epidemics and public health emergencies (e.g., severe acute respiratory syndrome [SARS], Middle East respiratory syndrome coronavirus [MERS-CoV] [110, 111]), stress induced by such extreme events can increase risks for negative perinatal outcomes, including perinatal mental health disorders [107]. For pregnant and postpartum women already at elevated risk for perinatal mood and anxiety disorders, the mental health implications of COVID-19 may therefore be profound [106], especially among women from marginalized populations or otherwise under-resourced communities [108]. Based on preliminary cross-cultural findings, prevalence rates of perinatal depression and anxiety increased during the COVID-19 pandemic. Across pregnancy and postpartum, rates of clinically significant perinatal mental health concerns have ranged from 23.6% to 37% among five studies assessing depression [105, 108,109,114]; 13.6% to 57% among six studies assessing general anxiety [102, 105, 108,109,110,115]; and 10.2% to 10.3% among two studies assessing PTSD [102, 105]. Two studies also looked at rates of pregnancy-specific anxiety (i.e., worries about the pregnancy and birth itself) in the context of COVID-19, with one reporting pregnancy-specific anxiety scores almost three times higher than similar samples assessed prior to the pandemic [115] and the other study identifying within-individual increases in pregnancy-specific anxiety from pre- to post-pandemic onset [104].
Data on risks for perinatal mental health concerns in the context of the COVID-19 pandemic are somewhat comparable to the general literature on high-risk perinatal groups, wherein depression and anxiety is higher among individuals with greater sociodemographic risk (e.g., low education, income, financial strain, food insecurity, being a woman of color [103, 104, 112]; comorbid medical complexity (e.g., pre-existing condition, high-risk pregnancy [103]); current relationship strain or tension in the home [104, 112, 115]; social isolation [112, 115]; or a history of abuse [103]. Unique to the pandemic, fear of infection, health concerns, COVID-19-related grief, and altered prenatal care were also predictive of higher depression, anxiety, and pregnancy-specific anxiety [104, 105, 115]. In particular, women with prior histories of anxiety and depression appear more likely to report increased levels of mental health concerns during the pandemic [104, 105, 112]. Although only two studies have examined perinatal PTSD in the context of COVID-19, perinatal women with a prior diagnosis of PTSD were 3.73 times more likely to develop perinatal PTSD during the pandemic [105]. Furthermore, among a sample of pregnant women in Italy recruited during a period of lockdown in March 2020, those with a history of depression or anxiety had 2.3 times the risk of developing PTSD, and this risk increased to a magnitude of 5.66 for those with a history of comorbid depression and anxiety [102].
Ultimately, conclusions across studies are limited by different measurement tools, reproductive timing, and variable community-level risks for COVID-19; however, the reviewed findings underscore the far-reaching impact and critical importance of attending to perinatal mental health concerns in the ongoing wake of the coronavirus pandemic, especially among certain high-risk groups. Such results contribute to the broader literature on the acute and long-term effects of disasters and traumatic life stress on perinatal mental health [8, 9, 112,113,114,119]. In time, a more thorough and nuanced understanding of long-term implications and potential cohort effects among offspring will emerge with ongoing longitudinal follow-up. Nevertheless, given the importance of mitigating risks for mothers, children, and families, targeted interventions may be paramount to preventing greater downstream effects. We will therefore end our chapter with a brief overview of assessment and treatment options that may help minimize the effects of trauma and stress on perinatal women and their young children, including recommendations for minimizing risks associated with current COVID-19 stressors.
5 Assessment and Treatment
Although an extensive review of assessment and treatment recommendations specific to perinatal stress, trauma, and PTSD is beyond the scope of this chapter, we want to highlight several clinical recommendations that may be beneficial for individual maternal mental health and well-being, as well as evidence-based treatments that can help mitigate the transmission of intergenerational risks for trauma and toxic stress. First and foremost, preventative interventions in the context of obstetric care may help minimize stress and trauma for high-risk perinatal women. Maternity care providers, such as obstetricians, midwives, and nurses, may help reduce risks for re-traumatization or new-onset birth trauma through the promotion of effective communication, informed consent for medical procedures, and respect for birthing people’s agency in making healthcare decisions [63]. The presence of a supportive person (e.g., partner, doula) during birth has also emerged as one of the most important protective factors that can mediate the relationship between prior trauma history and postpartum PTSD, as well as birth trauma and new-onset CB-PTSD [47]. As mentioned, however, many hospitals and medical systems limited the number of supportive people who can be present with a birthing person in the wake of the COVID-19 pandemic. Given these necessary limitations, other trauma-informed approaches to perinatal care may be especially crucial. In this regard, Choi et al. [108] highlighted numerous ways in which medical staff may continue to promote women’s voice and choice during pregnancy, birth, and early postpartum—despite workplace restrictions related to COVID-19. Specific trauma-informed strategies medical systems may consider implementing include naming and acknowledging COVID-19 effects on birth and parenting experiences; implementing telehealth check-ins to ensure connection with hospital specialists (e.g., social workers, lactation consultants); introducing consultation-liaison services to help meet the increased mental health needs of birthing patients; and connecting medical staff with additional coping, stress relief, and psychological support as they continue to care for pregnant and postpartum patients [102,103,108].
In addition to sensitive and trauma-informed medical practices, adequate and systematic assessment for perinatal PTSD is an essential step toward identifying women and dyads at highest risk for negative trauma and stress-induced outcomes. Given the high psychiatric comorbidity of perinatal PTSD and depression [41, 47, 65], we join others in recommending that women with elevated depression symptoms be screened for PTSD. Furthermore, the development of postpartum PTSD may be partially mitigated by identifying women who describe their experiences during childbirth as traumatic. Once again, it is important to note that subjective childbirth experiences are a critical risk factor; thus, even women with uncomplicated, full-term births should be asked about their thoughts concerning labor and delivery [57]. Perinatal women with significant trauma histories and PTSD—regardless of the criterion event—may benefit from a number of individual psychotherapies. Although there is very limited clinical literature on the efficacy and effectiveness of trauma-focused interventions among pregnant and postpartum women, combining current knowledge of perinatal PTSD with the broader PTSD treatment literature (e.g., “gold standard” exposure-based treatment [120]) is current best practice [121]. Unfortunately, however, the highest-risk mothers with significant trauma histories are often the least likely to have access to therapeutic care. As a result, assessment and treatment referrals are not sufficient, and additional emphasis must be placed on increasing access to and engagement with high-quality, trauma-focused interventions in integrated settings (e.g., integrating mental health into OB-GYN practices). Time-limited, soft-safe entry programs for high-risk mothers of young children, such as Mom Power [122], can also help perinatal women with a history of trauma and PTSD connect to additional therapeutic resources and treatment options.
Given the intergenerational impact of trauma, stress, and perinatal PTSD, mothers and their young children may particularly benefit from dyadic or two-generation treatments. The early parent-child relationship plays a critical role in the intergenerational transmission of risks or resilience. If a young child experiences traumatic stress, his caregiver can help him build resiliency by soothing him and helping him regulate his distress; however, when a mother herself is overwhelmed by her own trauma symptoms, she may be less able to attend to her child’s needs. Specifically, children who experience prolonged and intense physiological stress, without a sensitive and responsive caregiver, are at greater risk for maladaptive physiological stress responses and later problems with behavioral and emotional development [123]. Dyadic approaches to mental health care thereby view the parent-child relationship as the vehicle for positive, intergenerational, healing change; and a mother’s mental well-being, parenting behaviors, representations of her child, and reflective capacity are targets for intervention. A number of evidenced-based interventions were developed for high-risk parent-child dyads, including perinatal women and infants exposed to toxic stress and trauma (for reviews, see [7, 124, 125]). A summary of several dyadic treatments previously published by the authors [7] is provided in Table 10.1. The interventions in Table 10.1 share a common foundation in attachment theory but vary in their specific modality, length, and treatment components. Notably, several of interventions, such as Child-Parent Psychotherapy (CPP; [142, 160]) and Attachment and Biobehavioral Catch-up (ABC; [127]), were designed for young children and their parents exposed to early adversity or trauma. Among the clinical targets, these programs help young children develop a play-based narrative of traumatic experiences (CPP) or help mothers support their child’s emerging regulatory skills in the face of ongoing stressors (ABC). As an illustrative example, CPP places explicit emphasis on the caregiver’s own trauma history and how this may affect her thoughts about and behaviors toward her child [142, 160]. As we understand more about the intergenerational importance of intervening as early as possible, an extension of CPP was recently created for the period of pregnancy through the first 6 months postpartum [161]. Ultimately, the Perinatal Child-Parent Psychotherapy (P-CPP) approach supports birthing people and their partners as they make sense of how their adverse and traumatic life experiences have affected them; how these experiences may be evoked within the parent-child relationship; and how they can create a loving, caring, and safe environment for themselves and their babies, despite what happened.
6 Conclusion
A trauma-informed approach to supporting women and families in the perinatal period must recognize the proximal and distal risk factors that may put perinatal women at risk for developing PTSD. In the current chapter, we summarized the literature on perinatal PTSD, focusing on birth trauma, childhood maltreatment, and the COVID-19 pandemic as three critical traumatic stressors that may confer risk. Trauma-informed perinatal mental health care must consider the multifaceted strengths and vulnerabilities of each birthing person and create space to consider how what happened to an individual before, during, and after birth may impact her own mental health and the well-being of her family. Given the potential intergenerational impact of untreated and unresolved trauma, we briefly identified assessment and treatment options for perinatal women and mothers of young children exposed to trauma or significant adversity, and we highlighted several evidence-based dyadic interventions. Our hope is that the field of perinatal mental health can continue to integrate, acknowledge, and attend to the role of traumatic stress using a multigenerational lens that considers a mother’s own childhood experiences (e.g., childhood maltreatment), her subjective appraisals of labor and delivery, and other contextual stressors and risk factors that may contribute to the development or exacerbation of PTSD. Ultimately, such an approach to perinatal mental health has the potential to build resiliency and effect change across generations.
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Erickson, N.L., Morelen, D., Muzik, M. (2022). Trauma, Stress, and Post-Traumatic Stress Disorder (PTSD) in Perinatal Period. In: Percudani, M., Bramante, A., Brenna, V., Pariante, C. (eds) Key Topics in Perinatal Mental Health. Springer, Cham. https://doi.org/10.1007/978-3-030-91832-3_10
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