Trait anxiety and unplanned delivery mode enhance the risk for childbirth-related post-traumatic stress disorder symptoms in women with and without risk of preterm birth: A multi sample path analysis

Abstract

Childbirth-related post-traumatic stress disorder (CB-PTSD) occurs in 3-7% of all pregnancies and about 35% of women after preterm birth (PTB) meet the criteria for acute stress reaction. Known risk factors are trait anxiety and pain intensity, whereas planned delivery mode, medical support, and positive childbirth experience are protective factors. It has not yet been investigated whether the effects of anxiety and delivery mode are mediated by other factors, and whether a PTB-risk alters these relationships. 284 women were investigated antepartum and six weeks postpartum (risk-group with preterm birth (RG-PB) N = 95, risk-group with term birth (RG-TB) N = 99, and control group (CG) N = 90). CB-PTSD symptoms and anxiety were measured using standardized psychological questionnaires. Pain intensity, medical support, and childbirth experience were assessed by single items. Delivery modes were subdivided into planned vs. unplanned delivery modes. Group differences were examined using MANOVA. To examine direct and indirect effects on CB-PTSD symptoms, a multi-sample path analysis was performed. Rates of PTS were highest in the RG-PB = 11.58% (RG-TB = 7.01%, CG = 1.1%). MANOVA revealed higher values of CB-PTSD symptoms and pain intensity in RG-PB compared to RG-TB and CG. Women with planned delivery mode reported a more positive birth experience. Path modeling revealed a good model fit. Explained variance was highest in RG-PB (R2 = 44.7%). Direct enhancing effects of trait anxiety and indirect reducing effects of planned delivery mode on CB-PTSD symptoms were observed in all groups. In both risk groups, CB-PTSD symptoms were indirectly reduced via support by medical staff and positive childbirth experience, while trait anxiety indirectly enhanced CB-PTSD symptoms via pain intensity in the CG. Especially in the RG-PB, a positive birth experience serves as protective factor against CB-PTSD symptoms. Therefore, our data highlights the importance of involving patients in the decision process even under stressful birth conditions and the need for psychological support antepartum, mainly in patients with PTB-risk and anxious traits. Trial registration number: NCT01974531 (ClinicalTrials.gov identifier).

Fig 1. Flowchart of measurement time points and sample sizes of all subgroups.

Fig 2. Percentage of women with planned vs. unplanned delivery mode per subgroup.

Fig 3. Bar graphs for each of the observed significant mean differences (CB-PTSD symptoms).

(A) CB-PTSD symptoms six weeks postpartum. RG-PB = risk-group with preterm birth; RG-TB = risk-group with term-birth; CG = control-group. Error bars represent 95% confidence intervals.

Fig 4. Bar graphs for each of the observed significant mean differences (pain intensity).

(B) Subjective pain intensity. RG-PB = risk-group with preterm birth; RG-TB = risk-group with term-birth; CG = control-group. Error bars represent 95% confidence intervals.

Fig 5. Bar graphs for each of the observed significant mean differences (subjective birth experience).

(C) Subjective birth experience. RG-PB = risk-group with preterm birth; RG-TB = risk-group with term-birth; CG = control-group. Error bars represent 95% confidence intervals.

Fig 6. Path model for prediction of CB-PTSD symptoms 6 weeks postpartum in the risk group with preterm birth (RG-PB).

Significant paths (p < .01) are represented by solid lines, non-significant paths by dashed lines.

Fig 7. Path model for prediction of CB-PTSD symptoms 6 weeks postpartum in the risk group with term birth (RG-TB).

Significant paths (p < .01) are represented by solid lines, non-significant paths by dashed lines.

Fig 8. Path model for prediction of CB-PTSD symptoms 6 weeks postpartum in the control group (CG).

Significant paths (p < .01) are represented by solid lines, non-significant paths by dashed lines.