Highlight
- Approximately 17% of women experience posttraumatic stress symptoms (PSS) related to vaginal delivery within two months postpartum.
- Distinct PSS trajectories were observed: asymptomatic, recovered, emerging, and persistent symptoms.
- Persistent PSS trajectory is associated with younger age, non-European origin, prior psychiatric history, adverse delivery memories, and postpartum anemia.
- Emerging PSS symptoms are linked to obstetric factors such as prior abortions, hospitalization during pregnancy, labor induction, and fatigue, with epidural analgesia showing a protective effect.
Study Background
Childbirth, while typically a joyous occasion, can be perceived as traumatic by a subset of women, leading to the development of posttraumatic stress symptoms (PSS) and potentially childbirth-related posttraumatic stress disorder (PTSD). The incidence of such psychological distress postpartum has clinical consequences for maternal mental health and infant care but remains under-recognized and insufficiently characterized. Particularly, the temporal evolution or trajectories of PSS following vaginal delivery and their antecedent risk factors are poorly documented, limiting targeted interventions and screening strategies. This study addresses this gap by prospectively delineating symptom trajectories and identifying modifiable and non-modifiable risk factors in a large multicenter cohort.
Study Design
This investigation was an ancillary cohort study embedded within the TRAAP trial—which primarily assessed tranexamic acid for preventing postpartum hemorrhage—conducted across 15 French university hospitals from 2015 to 2016. The study population included women delivering vaginally at or beyond 35 weeks’ gestation. Comprehensive labor and delivery characteristics were systematically collected. The Impact of Event Scale-Revised (IES-R), a validated self-administered instrument measuring distress related to traumatic events, was employed to evaluate PSS at two postpartum time points: day 2 and at 2 months. An IES-R score threshold of 22 was used to identify significant symptomatology. Four symptom trajectories were classified: asymptomatic (IES-R <22 at both time points), recovered (score ≥22 at day 2 but <22 at 2 months), emerging (score <22 at day 2 but ≥22 at 2 months), and persistent (score ≥22 at both points). To account for attrition bias, prevalences were weighted through inverse probability weighting. Risk factors for trajectory classifications were examined using multivariable logistic regression adjusting for potential confounders.
Key Findings
Of the 3891 eligible women, 2344 (60.2%) completed IES-R assessments at both time points. After correction for nonresponse, the distribution of PSS trajectories was as follows: 83.4% (95% CI, 81.8-85.0) asymptomatic, 11.0% (9.7-12.4) recovered, 2.1% (1.6-2.8) emerging, and 3.5% (2.7-4.4) persistent.
Among women exhibiting early symptoms (IES-R ≥22 at day 2), those with persistent symptoms (vs. recovery) were characterized by:
– Younger maternal age (adjusted odds ratio [aOR] 0.8 per increasing age category; 95% CI, 0.6-0.9)
– Non-European origin (aOR 1.8; 95% CI, 1.2-2.6)
– History of psychiatric disorders (aOR 1.9; 95% CI, 1.2-2.4)
– Negative subjective memories of delivery (aOR 2.4; 95% CI, 1.3-4.6)
– Postpartum anemia with hemoglobin <9 g/dL at day 2 (aOR 1.8; 95% CI, 1.1-2.7)
In women without early PSS (IES-R <22 at day 2), emergence of symptoms by 2 months (relative to sustained asymptomatic status) was associated with:
– Previous abortion (aOR 2.6; 95% CI, 1.6-3.9)
– Hospitalization during pregnancy (aOR 2.8; 95% CI, 1.4-4.7)
– Labor induction (aOR 1.7; 95% CI, 1.1-2.8)
– Negative memories of delivery (aOR 3.7; 95% CI, 1.4-5.6)
– Fatigue on day 2 postpartum (aOR 2.2; 95% CI, 1.4-3.5)
Epidural analgesia demonstrated a protective effect against emerging symptoms (aOR 0.2; 95% CI, 0.1-0.7).
These findings underscore that approximately 1 in 20 women experience ongoing or emerging PSS within two months after uncomplicated term vaginal delivery.
Expert Commentary
This study provides valuable prospective evidence on the nuanced trajectories of childbirth-related PSS, beyond the simplistic dichotomous presence or absence of symptoms. The identification of differential risk profiles for persistent versus emerging symptoms is particularly insightful, highlighting the role of both preexisting psychosocial vulnerabilities and obstetric factors.
The association between postpartum anemia and persistent PSS is a novel finding that warrants further exploration, possibly reflecting the physiological burden contributing to psychological distress. Likewise, the protective correlation of epidural analgesia with emerging symptoms strengthens the argument for effective pain management as a potential modifier of postpartum psychological outcomes.
However, some limitations should be noted. The reliance on self-reported PSS using IES-R, while validated, does not equate to formal PTSD diagnosis. The 60.2% follow-up completeness raises the possibility of selection bias despite statistical corrections. The study population being limited to French university hospital settings may affect external generalizability, particularly in diverse healthcare systems.
Nevertheless, this work aligns with current perspectives emphasizing early identification and tailored support for women at risk of postpartum PTSD. Incorporating psychological screening alongside obstetric reviews in the postpartum period is pragmatic and could mitigate chronic mental health sequelae.
Conclusion
Childbirth-related posttraumatic stress symptoms manifest in heterogeneous trajectories, with a noteworthy proportion of women experiencing persistent or emerging symptoms within two months postpartum after vaginal delivery. Distinct risk factors differentiate these trajectories, encompassing sociodemographic vulnerabilities, obstetric events, subjective delivery experience, and physiological status such as anemia.
These data should inform clinician awareness, guide screening protocols, and drive prevention strategies targeting women at elevated risk of prolonged psychological distress after childbirth. Future research should validate these findings across broader populations, explore mechanistic pathways, and evaluate interventions to ameliorate childbirth-related trauma sequelae.
Funding and Trial Registration
This ancillary study derived from the TRAAP trial, registered as NCT02482410, was funded by the French Ministry of Health.
References
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