Melbourne School of Population and Global Health - Theses
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ItemThe impact of traumatic life events on perinatal mental health: a longitudinal Australian cohort study( 2015)Background: Traumatic life events are those that involve threatened or actual harm to an individual or close other, and to which they respond with intense feelings of helplessness or terror. Traumatic experiences pose risks to mental health, with exposure to maltreatment in childhood strongly associated with poorer adult psychological wellbeing. Sexual abuse in childhood appears to be a risk for mental health problems among women who are pregnant or have recently given birth. However methodological shortcomings characterise this research, and the impact of other forms of abuse and neglect in childhood, or other traumatic exposures on perinatal mental health, has been under-examined. Traumatic exposure can lead to increased risk of symptom development following the experience of a later traumatic event, in the absence of pre-existing Posttraumatic Stress Disorder (PTSD). Emerging research has investigated whether PTSD can occur as a result of a difficult childbirth experience. However the possible contribution of prior lifetime exposure to trauma to the development of postnatal trauma symptoms has not been investigated. The relationship between traumatic exposure and symptom development is moderated by individual factors including personality and social factors. Style of relationship functioning, or attachment is likely to be particularly relevant. A secure, or healthy, attachment style may moderate the adverse effects of trauma in the perinatal period. Method: A prospective longitudinal study was conducted in a cohort of women recruited in late pregnancy from large public and private maternity hospitals in Melbourne, Australia. Nulliparous, pregnant women over the age of 18, with sufficient English fluency and ability to provide consent, were invited to participate consecutively. Data was collected by structured telephone interviews in the third trimester of pregnancy, and at 6 weeks postpartum. Standardized self-report questionnaires were administered to assess history of childhood maltreatment and lifetime trauma exposure, as well as known risk factors for poorer perinatal mental health including history of mental health problems, quality of intimate partner relationship, and availability of social support. Postnatal interviews assessed symptoms of depression and PTSD, as well as obstetric outcomes and subjective appraisal of the birth. Results: Of the 368 women who were eligible and invited, 213 (58%) undertook the first interview. Of these, 208 (98%) provided complete data. The study sample was representative of all women who gave birth in Victoria at the time, in terms of marital status, ethnicity and health insurance status but were older, more highly educated and more were in professional occupations. In univariate analyses, experiences of childhood emotional and physical abuse and neglect were significantly associated with more severe antenatal symptoms of depression and anxiety (p < 0.001 to 0.04). Neglect was associated with postnatal symptoms of depression (p = 0.033 and 0.003). No forms of childhood maltreatment were associated with childbirth related PTSD (p = 0.440 to 0.921). Childhood sexual abuse was not associated with any perinatal mental health outcome (p = 0.12 to 0.86). Compared to other forms of trauma exposure, childhood maltreatment was associated with worse depression (p < 0.0001) and anxiety (p < 0.0001) in pregnancy and depression postnatally (p = 0.040). Trauma that did not involve interpersonal violence was associated with better mental health, when compared to all other forms of exposure and with no trauma exposure. Multivariate analyses revealed that childhood maltreatment made a significant independent contribution to higher anxiety symptoms in pregnancy (β = 0.18, p < 0.05). A more secure adult attachment style was protective against depression (β = 0.39, p < 0.001), anxiety (β = 0.35, p < 0.001) and fear of childbirth (β = 0.35, p < 0.001). However, developing symptoms of postnatal PTSD was associated with variables that were proximal to the birth, such as greater fear during birth (OR 1.15, p < 0.0001) perception of poor staff support (OR 0.932, p < 0.03) and birthing in a public hospital setting (OR 4.10, p < 0.04) and not with any antenatal variables except older age (OR 1.13, p < 0.02). Prior lifetime trauma exposure was not independently associated with PTSD resulting from childbirth. Conclusions: Childhood maltreatment, which includes several forms of abuse and neglect, is a risk factor for antenatal anxiety, and is associated with depressive symptoms during both pregnancy and the postpartum. A more secure attachment style is protective against these difficulties. Identification of these attributes could help to predict which women are at increased risk of perinatal psychological distress, in order to target interventions accordingly. Adjustments to hospital practices pertaining to the management of childbirth could reduce the risk of developing PTSD as a result of childbirth.