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One in Three Suffers Posttraumatic Stress Disorder: A Look Behind the Headlines

by David White, MD CCFP, Associate Professor, Dept of Family & Community Medicine, University of Toronto

Dr. David White reviews the study “Postpartum Post-Traumatic Stress Disorder Symptoms: The Uninvited Birth Companion“ that made news headlines earlier this month.  This post,  is part two of a two part series. (Read part one here, where Penny Simkin discussed how the media created sensationalistic headlines from the study.) Dr. White demonstrates how important it is to go to the source,  and evaluate the study design for oneself.  I appreciate Dr. White sharing his  summary and review of the research behind the study. – SM

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Creative Commons Image by Horia Varlan

The dramatic headline caught my eye: “One in Three Post-Partum Women Suffers PTSD Symptoms After Giving Birth: Natural Births a Major Cause of Post-Traumatic Stress, Study Suggests.”[i] As a family doctor who provides maternity care, I was both puzzled and alarmed. Where were all these women? Each year, I care for about 50 women through pregnancy, birth and post-partum. Am I failing to recognize the 16 or 17 who develop PTSD? Are they suffering without proper care?

The article claimed “Of the women who experienced partial or full post-trauma symptoms, 80 percent had gone through a natural childbirth, without any form of pain relief.”

On reflection, I became skeptical. So I read the original research paper.[ii] To their credit, the authors acknowledge, “Controversy remains whether childbirth should be included under the definition of a traumatic event that meets the criteria for post-traumatic stress disorder.” Unfortunately, their own study is so riddled with problems that it can only add confusion.

First, there is the matter of selection: 102 women agreed to participate, 89 completed the two assessments. There is no mention of how many women were approached, or how many women had births at the hospital during the study period. So there is no way to assess possible selection bias. Suspicion is warranted when a crucial methodological detail is omitted.

Then there is the issue of diagnostic criteria. The diagnosis of PTSD requires that the symptoms last more than one month and cause significant impairment in social, occupational, or other important areas of functioning (both DSM-IV-TR and ICD-10). The researchers administered their survey instrument within a few days of birth and again at one month post-partum. The latter just barely meets the criterion for duration. And could there be a cuing effect from administering an initial questionnaire within a few days of birth?

The findings report “full PTSD”, “partial PTSD” and “PTSD symptomatology”. However the tool used by the researchers, a self-administered questionnaire called Posttraumatic Stress Diagnostic Scale (PDS®), indicates only whether someone meets the DSM diagnostic criteria or not.[iii]

Now to the analysis, which piles questionable analysis onto this shaky diagnostic platform.  ”For processing the data we needed to select a group large enough to be statistically significant but homogenous enough to offer meaningful results.” So they lump together those missing one or two symptoms with those who actually have PTSD. The justification for this methodological legerdemain is that others have done it. They reference a study by Stein, Walker et al[iv] that is considerably more careful. It differs substantially in that it used telephone interviews, a different assessment tool and analyzed full and partial PTSD separately.

The results are reported in a way that even makes it difficult to determine what group they are analyzing. Is it the “full PTSD” (3) + “Partial PTSD” (7) = 10? No, it is 3 (“full) + 4 (“missing 1 or 2 symptoms”) =7. But look at Table 2, showing 5 in the row labeled “PTSD”. Table 3 has it back up to 7.

Table source: http://www.ima.org.il/imaj/ar12jun-02.pdf

The terminology for the groups seems variable. At times it is “PTSD group”, at others it is “women with PTSD symptoms” and the Tables simply apply the label “PTSD.”

Terminology problems continue: “control group” is used regularly to denote those who did not manifest PTSD symptoms, an odd usage for a study in which there is no intervention or randomization.

While studying Table 2, check out the mode of delivery: Natural 45, Cesarean 42 (20 elective), Instrumental 2. That indicates a Cesarean section rate of 47%. Could this be a biased sample?

More fun with numbers: the text reports that 80% of women with PTSD symptoms reported feeling very uncomfortable in the undressed state: Table 3 shows 3 out of 7 reporting this.

Table source: http://www.ima.org.il/imaj/ar12jun-02.pdf

And the figure that 80% of those with PTSD had gone through natural labour? It appears to come from Table 2, showing that 4 out of 5 women in the “PTSD” group had “Natural” childbirth. I scoured the tables and text in vain to find why the PTSD group is 5 in Table 2 and 7 in Table 3.

The definitions of mode of delivery should be more precise. The authors describe natural births as “non-interventional” but we really don’t know about analgesia use in this group. This matters, because they found “A significantly smaller number of women who developed PTSD symptoms received analgesia during delivery compared to the control group.” For this to make sense, it is essential distinguish vaginal births with and without effective pain relief.

This definitional and analytic fog leads to the conclusion that a lot of women have PTSD symptoms following birth. The authors don’t trouble themselves to explain why their numbers don’t square with the excellent community-prevalence study in the references, in which “The estimated prevalence of full PTSD was 2.7% for women and 1.2% for men. The prevalence of partial PTSD was 3.4% for women and 0.3% for men.”4

This study brings discredit to an admittedly difficult field, one in which researchers must address the criticism of medicalizing normal life experiences.

I’m a GP, not an expert in PTSD. But I think I can recognize “significant impairment in social, occupational, or other important areas of functioning.” The important issue for practitioners is whether we identify and help those at risk and who need assistance. Screening for post-partum depression is important. Adding a simple open-ended question such as “tell me about your birth” is likely to yield much more benefit in practice than this study.

I appreciate Dr. White’s analysis and wonder how many other professionals bothered to examine the research behind the headlines, in order to come to their own conclusions about the study design, assumptions and findings.  What do you think of this research?  Did you understand the terms being used or how the results were determined?  Do you think any journalists who wrote the sensational headlines took the time to look at the study themselves?  It is always important to be a critical thinker for yourself, examine the information and ask questions.  Sometimes, the research does not match up with the front page news, or the study may not have been well-designed.  Please share your thoughts, questions and comments here, with Dr. White, Penny Simkin, myself and Science & Sensibility readers. – SM

References

[i] American Friends of Tel Aviv University (2012, August 8). One in three post-partum women suffers PTSD symptoms after giving birth: Natural births a major cause of post-traumatic stress, study suggests. ScienceDaily. Retrieved August 14, 2012, from http://www.sciencedaily.com­ /releases/2012/08/120808121949.htm

[ii] Postpartum Post-Traumatic Stress Disorder symptoms: The Uninvited Birth Companion, Inbal Shlomi Polachek, Liat Huller Harari, Micha Baum, Rael D. Strous: IMAJ 2012; 14: 347–353, accessed at http://www.ima.org.il/imaj/ar12jun-02.pdf

[iii] The actual PDS® tool can be downloaded at (for a price): http://psychcorp.pearsonassessments.com/HAIWEB/Cultures/en-us/Productdetail.htm?Pid=PAg510&Mode=summary

A useful review of the PDS® is at: http://occmed.oxfordjournals.org/content/58/5/379.full.pdf+html

[iv] Stein, M. B., Walker, J. R., Hazen, A. L., & Forde, D. R. (1997). Full and partial posttraumatic stress disorder: Findings from a community survey. The American Journal of Psychiatry, 154(8), 1114-9. Retrieved from http://search.proquest.com/docview/220491145?accountid=14771

A useful overview of PTSD at

http://www.ptsd.va.gov/professional/pages/ptsd-overview.asp

A review of research issues in PTSD following childbirth:

Pauline Slade: Towards a conceptual framework for understanding post-traumatic stress symptoms following childbirth and implications for further research. Journal of Psychosomatic Obstetrics & Gynecology (January 2006), 27 (2), pg. 99-105, accessed at http://resolver.scholarsportal.info.myaccess.library.utoronto.ca/resolve/0167482x/v27i0002/99_tacffucaiffr

About David White

David White is a community-based family doctor in Toronto and Associate Professor of Family & Community Medicine at the University of Toronto. (DFCM, U of T). He currently serves as the Interim Director of UTOPIAN, the practice-based research network comprising all teaching sites affiliated with the Department of Family & Community Medicine at the University of Toronto.

He obtained his medical degree and completed residency in Family Medicine at the University of Toronto. He began clinical practice in 1977 at Sioux Lookout, working at the Zone Hospital and flying into remote First Nations villages in northwestern Ontario. In this setting he began a long-term affiliation with U of T. On returning to Toronto in 1980, he joined the Family Medicine Teaching Unit at Toronto Western Hospital, and later moved to Mount Sinai Hospital. In 1999 he was appointed Chief of Family & Community Medicine at North York General Hospital (NYGH).

His current academic activities include clinical teaching in his community office and in obstetrics, research in health care delivery, and mentoring of junior faculty. Contact Dr. White

Childbirth Education, Depression, Evidence Based Medicine, Guest Posts, Maternal Mental Health, Maternity Care, New Research, Perinatal Mood Disorders, Postpartum Depression, PTSD, Research, Uncategorized , , , , , , , , , , , , , , ,

  1. August 21st, 2012 at 10:53 | #1

    Thank you for this analysis Dr. White.

    Sharon, you question whether the journalists writing these headlines took the time to critically evaluate the article. Valid question!

    We are at a time in society when the amount of information presented to us is overwhelming. Headlines and abstracts whiz by our eyes at breakneck speed. We are faced with a choice: do we perform a brief skim of each title and abstract to find out what is new and noteworthy, or do we select a few pieces and dive in a little more deeply to determine the full story?

    What Penny and David have shown us is that we miss essential information if we only rely on third-party summaries and abstracts. The story is simply not complete without these key pieces of information. I hope this event, certainly not the first or last time it has occurred, can be used as a learning lesson for consumers, healthcare providers, childbirth educators, and journalists alike!

  2. August 21st, 2012 at 13:20 | #2

    @Lisa Baker Lisa, yes, but I wonder how many people in the power positions to influence policy actually read what needs to be read! I know I feel overwhelmed with the volume of information that flashes by. It is almost too much…how do medical professionals and health care providers stay informed?

  3. August 24th, 2012 at 05:55 | #3

    Thank-you Dr. White for pointing out weakness in this study.

    I have worked in a variety of settings and have been mulling over my observations. When a patient comes into the labor/delivery unit of a hospital with a detailed birth plan, the nurses generally say, “She’ll be a c-section.” The conflict between her expectations and the hospital way of doing things sets a tone of conflict.

    When I have assisted at home births there is little conflict. Instead the caregivers work WITH the laboring patient’s instincts and provide emotional support. Sometimes guidance or direction is given but the tone is generally without conflict.

    How do you measure the conflict between a woman’s expectations and hospital procedures?

  4. avatar
    David White
    August 26th, 2012 at 07:20 | #4

    Carol: great observations. Your question about measuring the conflict between a woman’s expectations and hospital procedures is a very important one.

    I did a quick search of the literature and did not find anything that directly addressed your question in those terms. A lot has been written on patient expectations, patient-centredness, patient and provider perspectives and patient satisfaction. Assessments of satisfaction and dissatisfaction are how the concept of possible conflict is normally framed, perhaps because researching “conflict” might imply bias.

    I am not all that familiar with the nursing literature, but an example of this type of work is:
    Patient satisfaction with nursing care in the context of health care: a literature study
    Scandinavian Journal of Caring Sciences (December 2002), 16 (4), pg. 337-344
    Peter Johansson; Magnus Oléni; Bengt Fridlund

    Birth in hospital is different from most hospital care because birth is generally a healthy and normal experience. So expectations are understandably different from someone who goes to hospital for injury or illness.

    I came across a relevant article, actually a thesis by Deborah Ann McKinley, called “Measurement of obstetrical patient expectations and satisfaction” (University of Guelph (Canada), 1995. MM975150). Key quote: “Aspects of the birth experience found to be most able to predict overall obstetrical patient satisfaction, in descending order of importance, included: information, nursing, baby’s safety, birth type (cesarean sections less satisfied than vaginal births), and choice of rooming in. ”

    So nursing care is obviously critical. And the finding that women who had vaginal births expressed more satisfaction than those with cesarean sections is what one would expect intuitively. Of course it does not fit at all with the suggestion that women with (so-called) “Natural” birth were more likely to experience PTSD symptoms.

    Hope this helps. All the best, — David

  5. avatar
    Disappointed
    August 27th, 2012 at 11:07 | #5

    With all due respect, I don’t understand the reaction to this article. It seems your philosophical beliefs about positive and negative outcomes in birth are keeping you from taking a real look at what it has to say, and I think that’s a shame.

    Your criticisms of this piece could just as easily apply to almost any other article in the subject area. It is simply impossible to create a perfect study, especially when dealing with ethical constraints and the complexities of something like childbirth and mental health. This study has limitations, as all studies do, but that’s no reason to nitpick exclusively at this one, ignore its findings, and then enthusiastically embrace findings from other imperfect (or… cough cough… biased) studies that support your preconceived ideas.

    Why is the idea that unmedicated childbirth could be traumatic so threatening to you? Why do you insist on perpetuating the notion that natural childbirth is superior and ignoring the fact that for many women it is genuinely painful, traumatic, or damaging? If you wonder why women are reluctant to share their feelings with you, consider that they may be ashamed of their own reactions and that part of their reaction may be avoidance of discussing the trauma. Further, they may fear–rightly it appears–that since you do not believe natural childbirth can be traumatic you will also not understand their reactions and they will be judged, ridiculed, or even reported to social services.

    Natural childbirth was traumatic to me. My caregivers probably felt justified in their care and pleased that they had managed to avoid interventions. Unfortunately, their failure to provide real choices in my care (a cesarean would have been a godsend; an epidural would at least have relieved the excruciating pain and the horrifying awareness of what was happening to me) resulted in very significant impairment in my functioning that required years of therapy, both mental and physical, and a repair operation to address. I never spoke to my care providers about it because I was too ashamed and didn’t feel they would have been receptive to it. Instead I quietly found treatment for myself and along the way discovered that there are lots of other women suffering silently too. Dismissing the findings of this article does a real disservice to women like us.

  6. avatar
    Kate
    August 30th, 2012 at 08:38 | #6

    Perhaps I’m not reading something correctly, but where is the “1 in 3″ figure coming from? According to their statistics (Table 2), 5 women in 89 reported symptoms of PTSD. Where are their numbers coming from to claim 1 in 3? And according to their numbers from Table 2, 8.9% of women having “natural” (whatever they meant by that) birth experienced PTSD vs 5% of women with elective c-sections–those aren’t terribly significant differences. Then again, with an 89 person study, can one really expect statistical significance?

  7. March 22nd, 2013 at 14:07 | #7

    I would not be so sure you WOULD definitely pick up on PTSD in your patients, frankly. My care-providers didn’t. (Granted, my OB was the cause of a lot of it, so she’s not the best example, but my internist is wonderful and yet I’m sure has no clue.) I haven’t been formally diagnosed, but feel free to read my blog and see what you think.

    I did not have an unmedicated birth — I loathe the word natural in this context, as it has in my life been used again and again to tell me that my behavior as a woman is inappropriate — but given my experience, I think an unmedicated birth might well have been as much if not more traumatic for me.

    Frankly, it seems to me a real weakness of this site that studies that in any way question LLL orthodoxy are always subject to such withering scrutiny. I agree with the commenter above who asks whether studies that confirm the views of the group are questioned in the same way. If not, the word “science” should not, in my opinion, be part of the blog title.

  1. May 14th, 2013 at 09:48 | #1