The Daily Mail tells us one in three mothers has post-traumatic stress disorder after having a baby, and says "having a baby's like being in a terror attack".

The unnecessarily alarmist headlines follow a study of just 89 women in Israel who completed a survey in the month after giving birth. In fact, only three women (3.4%) reported full-blown post-traumatic stress disorder (PTSD) at one month after birth.

Around one in four women (25.9%) had some symptoms but were not considered to have PTSD.

These symptomatic women were more likely to report having had a previous 'traumatic' birth, and to have had pregnancy problems or fears about birth.

The researchers did find that having a Caesarean section or assisted delivery (for example using forceps) was not associated with symptoms of PTSD.

Overall, little can be concluded from this very small survey of women from Israel, a country that may have different maternity care compared with the UK.

A much larger study of women from the UK is needed to assess how common PTSD following birth is in this country, and to see what factors may be associated with it. This will help to ensure that all women who experience emotional or psychological distress during pregnancy or following birth receive the full care and support that they need.

Where did the story come from?

The study was carried out by researchers from Beer Yaakov Mental Health Center, and other medical centres in Israel. No sources of funding are reported.

The study was published in the Israel Medical Association Journal (IMAJ).

News reporting of this study is alarmist, unhelpful and unnecessary, considering its extremely small sample size and uncertain relevance to UK obstetric care and outcomes. There is certainly no firm evidence to equate 'having a baby' with experiencing a 'terror attack'.

What kind of research was this?

This was a survey of 89 women in Israel who were given a questionnaire to complete immediately after birth, and one month after. The questionnaire included the Post-traumatic Stress Diagnostic Scale (PDS), which the authors say is a self-administered questionnaire designed to aid in the diagnosis of PTSD according to diagnostic criteria. However, even if this is a valid measure, a sample of only 89 women is too small on which to base any firm conclusions. A sample of a different 90-100 women could have given completely different results.

Studies assessing the prevalence of a condition among a certain population should ideally assess large numbers of people who are representative of the whole population from which the sample came. Given that pregnancy and birth are extremely common events in society, it would not be difficult to assess a much larger sample than 89 women.

Since the UK may have different antenatal, maternity and postnatal care from Israel, this survey has uncertain relevance to our society. Also, some of the mothers with PTSD symptoms reported feeling very uncomfortable being in a state of undress, and this contributed towards feelings of trauma. As Israel tends to have a more socially conservative culture than the UK, the same factors may not be as significant for UK women.

What did the research involve?

The researchers invited 102 women to their study who were staying in a hospital maternity ward after giving birth. All women were said to be eligible and there had been no restrictions to inclusion, though the study does not say how many women were originally considered for inclusion. A third of the sample were having their first baby, their average age was 32 and 85% were married.

These 102 women were given a questionnaire that was said to include psychosocial and demographic variables, a relationship questionnaire and the International Personality Disorder Examination personality questionnaire. One month later women were asked to complete another questionnaire that was said to have included an inventory exploring mental state after delivery as well as the Post-traumatic Stress Diagnostic Scale. Only 89 of the original 102 sample completed the one-month survey assessing PTSD.

The researchers assessed prevalence of:

PTSD (full diagnostic criteria met)

partial PTSD (one or two symptoms lacking)

PTSD symptoms that did not meet diagnostic criteria.

They also looked at any factors that were associated with these conditions.

What were the basic results?

Three women (3.4%) met full diagnostic criteria for PTSD.

A further 23 women (25.9%) had symptoms of PTSD but did not meet diagnostic criteria. Among these were:

seven women who had partial PTSD and only lacked one or two symptoms

seven women who had partial PTSD and some functional impairment

seven women who met symptomatic criteria but did not have functional impairment

two women who met criteria for PTSD but their symptoms did not last for one month

A significant flaw with the reporting of these results is that the researchers did not provide more information about exactly how they define terms such as functional impairment.

No relationship was found between the development of PTSD symptoms and demographic data (including level of education), or with assisted or Caesarean delivery.

Women who had PTSD symptoms were more likely to report a previous traumatic birth (including subsequent depression and anxiety), medical or psychological problems during pregnancy, or fears about birth. PTSD symptoms were also associated with experiencing more discomfort at being undressed, stronger feelings of danger and not wanting to have additional children.

How did the researchers interpret the results?

The authors conclude that there is a 3.4% prevalence of PTSD following birth among women in Israel. They say that the results “indicate the importance of inquiring about previous pregnancy and birthing experiences and the need to identify at-risk populations... addressing anticipatory concerns of pain prior to delivery as well as respecting dignity and minimizing the undressed state during childbirth”.

Conclusion

The results of this study are primarily of relevance to Israel and suggest that 3.4% of women experience PTSD after birth. However, the reliability of this estimate is limited by the extremely small sample size. Though 102 women originally agreed to participate, it is uncertain how many women were originally asked, and it could be that those women who agreed to participate did so because they were experiencing more emotional problems associated with birth. A sample of a different 90-100 women could have given completely different results. Studies assessing the prevalence of a condition among a certain population should ideally assess large numbers to get a better idea of what the true prevalence is. Given that pregnancy and birth are extremely common events in society, it should not be difficult to assess thousands of women, rather than a small sample of 89. A much larger study would have given a more reliable estimate of prevalence.

Furthermore, prevalence studies are only relevant to the population that they are representative of. Given that the UK may have different antenatal, maternity and postnatal care from Israel, this study has uncertain relevance to our country. Also, culture and society may be quite different in Israel. In this study PTSD symptoms were associated with factors such as distress at being undressed, or not wanting to have any more children. Sources of distress for women in Western society may not be identical to those in these women.

Overall, little can be concluded from this survey of an extremely small sample of women from Israel, a country that may have quite different obstetric care compared with the UK. A large study of women from the UK with clinically confirmed diagnosis of PTSD would be needed to assess how prevalent the condition is following birth in this country. Such a study may be able to show what factors are associated with the illness. This could help to ensure that women who experience significant emotional or psychological distress during pregnancy or following birth receive effective care and support for this serious condition.

Analysis by Bazian

Edited by NHS Website