The Policy Center for Maternal Mental Health was honored to host our recent webinar Birth Trauma: Understanding Its Origins and The Urgent Need To Do More on December 11, 2024. The Policy Center was joined by Caroline Fisher O’Neill from Otsuka and Dr. Sharon Dekel of Harvard, and a mother who shared her story. The webinar brought together the complex relationship between birth trauma and post-traumatic stress disorder (PTSD). 

Opening Remarks
  • Joy Burkhard, Executive Director of the Policy Center for Maternal Mental Health, emphasized the critical need to address birth trauma and PTSD due to the maternal mortality and morbidity crisis in the U.S.
  • The webinar was sponsored by Otsuka, a company focused on mental health innovation, represented by Caroline Fisher O’Neill, who highlighted the challenges in diagnosing and treating PTSD, particularly in maternal contexts.
Personal Testimony
  • A mother, Allison Parent, shared her personal experience of birth trauma during an emergency C-section in 2023. She recounted feelings of imminent death, dissociation, and subsequent PTSD symptoms, including physical triggers and flashbacks. You can watch Allison’s story here.
Keynote Presentation: Dr. Sharon Dekel
  • Dr. Dekel, Harvard psychologist and PTSD researcher, presented on childbirth-related PTSD (CB-PTSD), highlighting:
    • Prevalence: 5-20% of women may develop CB-PTSD, with higher rates in medically complicated births (e.g., emergency cesareans).
    • Psychological Impact: Trauma is perceived subjectively, even in objectively similar childbirth scenarios. Women with prior trauma or mental health conditions are at greater risk.
    • Physiological Insights: CB-PTSD is associated with heightened physiological stress responses and distinct brain activity patterns, notably in the insula (fear network).
    • Parenting Impact: Symptoms can impair mother-infant bonding, with the infant potentially becoming a trauma trigger.
Research Findings
  • Risk Factors: Pre-existing mental health conditions, traumatic birth experiences, and subjective perceptions of the event.
  • Communities of Color: CB-PTSD disproportionately affects Black and Latina women, likely due to systemic inequities and heightened stress responses.
  • Screening and Treatment Gaps:
    • Screening for maternal mental health disorders is critical given mental health conditions are a risk factor. 
    • The U.S. has not yet prioritized screening for CB-PTSD. 
    • Existing tools like the Edinburgh Postnatal Depression Scale focus on depression rather than trauma-specific symptoms.
    • CB-PTSD screening tools exist and are available on the Policy Center’s website. However, these tools are not designed for the immediate postpartum period. 
    • Initial conversations with women who had medically complex labor and deliveries are necessary in the immediate postpartum period. 
    • Full assessment, diagnosis, and corresponding exposure therapy can be provided by psychologists trained in PTSD and exposure therapy and trauma. 
    • There are shortages of CB-PTSD treatment programs. 
    • Promising research involves using AI models to analyze birth narratives for predicting CB-PTSD.
    • New drug treatments are being studied. 
Clinical Practice Recommendations 
  • Screening and treatment of maternal mental health disorders, including anxiety and depression, in routine prenatal care is critical to mitigating the risk for CB-PTSD
  • Early screening/identification and intervention for birth trauma is crucial, especially in the immediate postpartum period (1-5 days). 
  • Routine postpartum care should integrate psychological screening alongside physical screening, including screening for birth trauma and PTSD 
  • It is essential for those who disclose symptoms of PTSD to be referred to providers or treatment programs developed by master’s-level or higher mental health providers, such as psychologists who specialize in CB-PTSD. 
Additional Questions and Answers

Due to very high levels of engagement and the numerous questions received during the webinar, the following questions which were not addressed live, were answered after the event by Dr. Dekel:

Q: Do you all have empirical literature to support maternal mental health? If so, where can it be found for those researching this topic?

A: You can find references about maternal mental health generally here: https://policycentermmh.org/maternal-mental-health-fact-sheet/

Q: Is there a write-up of Dr Dekel’s research?

Here are a few of the many scientific papers Dr. Dekel has published.  Please see the Dekel Lab Website where you can find links to much more information and studies.

Q: Is this being taught in medical schools?

A: I wish! In general, there is limited emphasis on perinatal psychiatry. 

Q: Can a master’s-level clinician complete these assessments?

A: If you are talking about the CAP-5, the gold standard clinician structured interview to confirm PTSD diagnosis, then yes, I believe that with sufficient training, master-level clinicians could perform the assessment. 

Q: Have you seen or studied women’s experiences when their infant is admitted to the NICU, and has an extended NICU stay?

A: NICU admission versus no NICU admission increases the risk for CB-PTSD in part because infant medical complications add to the morbid experience of childbirth. An extended stay in the NICU is likely to interfere with developing maternal-infant bonding. This is another added stressor often in the context of birth trauma.

Q: How many weeks postpartum would you recommend screening for CB-PTSD?

A: By DSM-5, PTSD symptoms assessment would ideally be given within 1 month postpartum. You need to have symptoms for at least 1 month to receive a PTSD diagnosis. However, a PTSD symptom questionnaire could be given earlier (e.g., 2 weeks postpartum), as early detection is key to effective treatment. Then you could detect people with elevated symptoms. 

Because we think about PTSD as a failure to recover, it means that the normal response is having some degree of PTSD symptoms following trauma exposure but for many people, the symptoms resolve naturally. If you screen early, you might be detecting people who appear at high risk (endorse symptoms) but will not develop PTSD. So sensitivity of your assessment would be high but not specificity. 

Q: How do assessments pick up on possible delayed emotional awareness of the severity of a traumatic birth in a mother?

A: That’s a great question. This is the problem with self-report questionnaires. People may not only under-report but possibly minimize their distress or not even realize that they are experiencing a traumatic response. Training clinicians however are likely to identify traumatic reactions and the more perinatal providers will be educated about birth trauma and PTSD the more there will be an opportunity to detect people at risk via one-on-one conversation about the recent birth experience. Based on our research, we see that most people want to talk about their recent trauma. Repeated follow-up on people who had complicated deliveries may give opportunities for people to open up.  

Q: Have you looked at PTSD/mental health concerns in relation to provider type? There is some research that midwifery care leads to lower anxiety/depression and of course, there is a lot of research that midwifery care results in lower rates of preterm birth, cesarean section etc., events that may be experienced as more traumatic.

A: Midwifery is strongly associated with positive birth outcomes. The more people feel they can trust the team, the better the outcomes. In our ongoing NIH-funded study, we also see the pattern of midwifery and better outcomes. Often people who choose to be followed during pregnancy by a midwife rather than an obstetrician have a healthy pregnancy to begin with, so we do not have clear cut data of a casual relationship. But an important direction for future research!

Q: This [Dr. Beck trauma is in the] “eye of the beholder” framing is a bit troubling, because yes, it is an extremely subjective experience, but it is usually the result of concrete external things going really wrong–especially not being listened to. 

A: Childbirth has a subjective element to it, like any event we experience. Usually when there are objective stressors (e.g., complications, unscheduled interventions) then people perceive the event as traumatic. Indeed, concrete things went wrong. People will perceive childbirth as an even more distressing event when there is a lack of or limited staff support. 

Q: How do feelings of being “in-control” — trust, communication, etc – affect whether a person’s experience triggers CB-PTSD.

A: Feeling helpless and lacking control during and immediately following childbirth increase the risk for CB-PTSD. We have some preliminary data that good communication with staff associates positively with a higher degree of control and this sense of agency is likely to be critical especially when childbirth is medically complicated. 

 Q: Do we know if there is any effect of pregnancy being unplanned (a result of sexual assault or teen pregnancy for example) resulting in a higher likelihood of CB-PSTD, regardless of medical interventions during childbirth? Essentially, can the birth experience in itself be a trauma for those patients?

A: People with a history of sexual assault (SA) are at heightened risk for CB-PTSD. Unplanned pregnancy is also associated with CB-PTSD. Unfortunately, we find that SA increases the risk for a medically complicated delivery and in turn CB-PTSD. However, if childbirth is perceived in a way that resembles the trauma of the sexual assault that also results in pregnancy, it is possible that the person could have a trauma response to childbirth even when there are no complications. 

Q: Would a policy that “flags” people who had objectively traumatizing birth experiences to connect them IN THE HOSPITAL with services be useful and should we be pushing for this from a policy perspective?

A: There is a window of opportunity for effective treatment in the very early postpartum to “flag” people in the hospital [who have experienced traumatic birth and are at risk for PTSD]. This could be the first step towards prevention. Importantly, not everyone with objective traumatic birth will experience birth trauma or will [go on to] have CB-PTSD. Therefore, screening among this high-risk [population] to identify those who would require treatment is essential.

Q: Do these statistics include fetal demise?

A: Very important point! Thank you. Our prevalence of CB-PTSD is derived from cohorts of women who gave birth to a live baby. Stillbirth is a robust risk factor for PTSD and we are in the process of studying CB-PTSD induced by stillbirth.

Q: Is anyone working on a peer-based model to help address this? Like they do in other behavioral health settings?

A: This is a great idea. I am not aware of this approach being implemented formally in perinatal care. It could be important to learn from others about their experiences but it is also important not to become too concerned about having a complicated childbirth. So we need to find a good balance between learning from other experiences and listening to your own journey…

Policy Center:  We have developed peer support add-on training specific for maternal mental health. Peers with CB-PTSD could absolutely use their lived experience to support those with a traumatic birth.  This type of treatment is ripe for a specialized behavioral health tech program to fill this void.   Importantly, Postpartum Support International also offers a birth trauma support group (it’s important to note this group doesn’t necessarily address PTSD). https://www.postpartum.net/group/birth-trauma-support/

Q: What are the protective factors or protective interventions that birthing people could employ when preparing for birth?

A: This is a great question. Generally speaking, preparation would entail having good social support in place, considering a birth plan as well as remaining open to the idea that this plan might eventually change. Often working with a midwife and doula during pregnancy is helpful. For people with underlying mental health problems or a history of birth trauma, it is important to receive appropriate services during pregnancy. You want to reduce levels of anxiety about forthcoming delivery through various forms of talk therapy or other alternative approaches (e.g., physical exercise, and mindfulness).   

Q: What about the lack of postpartum depression, anxiety, etc DSM diagnosis? Any thoughts on whether this will change?

A: With more research, we will be able to clarify the uniqueness of perinatal mental disorders versus other conditions outside of the peripartum postpartum period. A classification of perinatal conditions is critical to increase awareness and detection. I do believe we are likely to see some modifications in future DSM editions.  At present, many people remain under-diagnosed and under-treated, and having a formal recognition of perinatal mental disorders is likely to have a direct impact on improving birth outcomes and maternal and infant health.  

Webinar Closing 
  • Dr. Dekel emphasized evidence-based interventions such as trauma exposure therapy and mother-infant bonding strategies.
  • A significant challenge remains in overcoming stigma and encouraging open discussions about trauma during postpartum care.

Resources: 

  • You can find birth trauma and CB-PTSD screening tools on the Policy Center’s website here: https://policycentermmh.org/mmh-screening-tools/  
  • Here is a resource on general PTSD from Otsuka here. Further, the PTSD campaign called “Tethered to PTSD” acknowledges PTSD starts with trauma and 4 symptom clusters. The website has information on general PTSD symptoms and diagnosis, as well as the current treatment landscape: https://tetheredtoptsd.com/.
Recommendations for Hospitals and Policy Makers

The Policy Center for Maternal Mental Health outlined these preliminary recommendations for systemic and practice changes, including:

Reduce Traumatic Birth 

  • Traumatic birth can arise from high levels of medical intervention, long and/or extremely painful labor, or perceived lack of support. Hospitals can:
    • Reduce Medical Interventions, including C-sections
    • Offer adequate pain management support
    • Adopt policies, and training/accountability measures that support the role of labor and delivery doulas and emphasize actively listening to and respectfully responding to mothers and their birth partners 
  • Examine Your Protocol for Medical Intervention and monitor Quality Improvement, Refer to New CMS Guidelines (Nov 2024) 
  • Provide patients/partners with a real-time ombudsman and retrospective grievance process.
  • Review grievance and quality indicators like HCAHPS maternity care patient-reported experience data and develop quality improvement programs to improve birth outcomes and reduce incidence of traumatic birth/CB-PTSD

Integrate MH screening/tx into routine prenatal & postpartum care State Medicaid and Commercial Insurers should Implement HRSA & ACOG Guidelines: 

  • Incentivize and Monitor Delivery of Maternal Mental Health (MMH) screening/care and postpartum care through 12 mos
    • Consider fee-for-Service (FFS) payment with pay-for-performance (P4P) Incentives
    • Track MMH Screening (HEDIS)
    • Provide the 30-Day follow-up Outreach (HEDIS)
  • Implement Quality Improvement Interventions, to incentivize change 

Build up Mental Health Workforce, including CB-PTSD Providers

  • Congress, State Legislatures and HRSA
    • Provide grants/scholarships to train additional master’s-level mental health providers and psychologists to support MMH including assessment and tx of CB-PTSD

In closing, this webinar and related resources underscore the urgency of addressing CB-PTSD as a critical aspect of maternal mental health, with a focus on research, policy, and clinical care innovations.