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A basic premise of obstetric practice is to optimize pregnancy outcomes through preventive and ameliorative
From Saint Louis University, St. Louis, Missouri; and Tulane University, New
Orleans, Louisiana.
This research was funded by the National Institute of Mental Health (R01/
MH57736-03), SLU2000 Research Initiative, and Saint Louis University
Beaumont Award.
710
treatment. One area of clinical practice gaining increasing attention is the mental health of pregnant women and
its effect on birth outcomes. Community prevalence
studies estimate that 20 30% of all women experience at
least one psychiatric disorder in a given year. Women of
childbearing age have even higher reported rates.13
One psychiatric disorder affecting a disproportionate
number of women of childbearing age is posttraumatic
stress disorder, with lifetime rates ranging from 10.4%
to 13.8%.4 7
People diagnosed with posttraumatic stress disorder
usually have experienced or witnessed life-threatening traumatic events that elicit feelings of horror, terror, and fear.8
For women, the precipitating events most often are rape,
childhood physical abuse, physical assault, or being threatened with a weapon.4,5,7 A large proportion of women
experience trauma before the age of 25 years.6 Common
symptoms of posttraumatic stress disorder include intrusive recollections of the traumatic stressor, avoidant/
numbing behaviors, and hyper-arousal symptoms.8
Little research has focused on posttraumatic stress
disorder in pregnancy to estimate either its prevalence or
the likelihood of treatment for the disorder. Consequently, this study aims to estimate the prevalence of
posttraumatic stress disorder in economically disadvantaged pregnant women, describe the proportion of
women receiving treatment, and identify the associated
risk factors that can facilitate screening for the disorder in
clinical practice.
MATERIALS AND METHODS
Using a prospective cohort design, we recruited 744
pregnant Medicaid-eligible women at Women, Infants
and Children Supplemental Nutrition Program sites in
the city of St. Louis and in 5 rural counties in southeastern Missouri. Both areas have high levels of poverty and
rates of infant mortality and low birth weight infants that
exceeded national averages at that time. The sample was
limited to black and white women, because they make up
the vast majority of the population in both geographic
0029-7844/04/$30.00
doi:10.1097/01.AOG.0000119222.40241.fb
n (%)
428 (57.5)
316 (42.5)
311 (41.8)
356 (47.8)
59 (7.9)
8 (1.1)
10 (1.3)
523 (70.3)
160 (21.5)
21 (2.8)
39 (5.3)
1 (0.1)
439 (59.0)
305 (41.0)
508 (68.3)
192 (25.8)
43 (5.9)
22.3 5.2
21.0
4.5 4.5
3.0
Cook et al
711
712
Cook et al
RESULTS
Of the 744 women in this study, 101 (13.6%) had a
diagnosis of posttraumatic stress disorder at some point
in their lives. One in 13 women (57 of 744, 7.7%) had a
current diagnosis of posttraumatic stress disorder. Another 0.9% (7 of 744) reported symptoms of posttraumatic stress disorder but did not meet the criteria of
Diagnostic and Statistical Manual of Mental Disorders-IV for a
current diagnosis. In comparison with other current
psychiatric disorders examined, posttraumatic stress disorder was the third most common, following major
depressive episode (80 of 744, 10.8%) and nicotine dependence (63 of 744, 8.6%).
Posttraumatic stress disorder is precipitated by exposure to one or more traumatic events. On average, the 57
women with current posttraumatic stress disorder had a
mean of 4.9 2.4 (SD) traumatic events over their
lifetime. The most common events included the unexpected death of a close friend or relative (48 of 57,
84.2%), having something terrible happen to a close
friend or relative (35 of 57, 61.4%), being sexually assaulted by a nonrelative (29 of 57, 50.9%), being mugged
or robbed (26 of 57, 45.6%), experiencing a natural
disaster (22 of 57, 38.6%), seeing someone killed or
seriously injured (22 of 57, 38.6%), being sexually assaulted by a relative (20 of 57, 35.1%), and being in a
serious accident (18 of 57, 31.6%). Twenty-one (36.8%)
of the 57 women experienced the traumatic event that
precipitated posttraumatic stress disorder before they
were 15 years old.
The most commonly reported symptoms of posttraumatic stress disorder were intrusive distressing recollections of the trauma (57 of 57, 100.0%), psychological
distress when exposed to cues resembling the trauma (55
of 57, 96.5%), difficulty concentrating (52 of 57, 91.2%),
irritability or outbursts of anger (51 of 57, 89.5%), and
avoidance of activities, places, or people associated with
the trauma (51 of 57, 89.5%). They were somewhat less
likely to report a sense of having a foreshortened future
(31 of 57, 54.4%) or an inability to recall important
aspects of the trauma (7 of 57, 12.3%).
Pregnant women with posttraumatic stress disorder
reported moderate impairment in their daily functioning
(mean 2.3 0.8 [SD]), based on a scale ranging from 0
(none) to 4 (severe). Twenty-eight of the 57 women with
current posttraumatic stress disorder (49.1%) reported
difficulties with family, friends, and/or work during the
same time period. Forty-one women (71.9%) reported 1
or more comorbid psychiatric disorders. Fourteen
(24.6%) had 1 comorbid psychiatric diagnosis, 12
(21.1%) had 2, and another 16 (26.2%) had 3 or more.
Table 2. Current Comorbid Psychiatric Disorders in Pregnant Women With Posttraumatic Stress Disorder (n 57)
Prevalence
Comorbid psychiatric disorder
Number*
11
10
3
2
1
20
19.3
17.5
5.3
3.5
1.8
35.1
11.1, 31.3
9.8, 29.4
1.8, 14.4
1.0, 11.9
0.3, 9.3
24.0, 48.1
24
13
2
32
42.2
22.8
3.5
56.1
30.2, 55.0
13.8, 35.2
1.0, 11.9
43.3, 68.2
10
6
2
1
1
1
13
17.5
10.5
3.5
1.8
1.8
1.8
22.8
9.8, 29.4
4.9, 21.1
1.0, 11.9
0.0, 9.3
0.0, 9.3
0.0, 9.3
13.8, 35.2
1
41
1.8
71.9
0.0, 9.3
59.2, 81.9
Anxiety disorder
Generalized anxiety disorder
Social phobia
Obsessive-compulsive disorder
Specific phobia
Panic disorder
Any anxiety disorder
Mood disorder
Major depressive episode
Manic episode
Hypomanic episode
Any mood disorder
Substance-related disorder
Nicotine dependence
Marijuana abuse and/or dependence
Alcohol abuse and/or dependence
Amphetamine abuse and/or dependence
Tranquilizer abuse and/or dependence
Hallucinogen abuse and/or dependence
Any substance-related disorder
Psychotic disorder
Schizophrenia
Any comorbid psychiatric disorder
* Numbers do not total 57 and percentages do not total 100% because subjects can have more than one comorbid diagnosis.
not receive services (mean 2.6 2.0 [SD] and 1.5 1.5
[SD], respectively; t 2.26, P .05). We found no
significant differences between the 2 groups in level of
impairment in the year before the interview.
The next analyses focused on identifying those characteristics associated with risk for posttraumatic stress
disorder, including sociodemographic, environmental,
and medical risk factors (Table 3). Although sociodemographic characteristics were not significantly different for
women with and those without posttraumatic stress disorder, women with the disorder were significantly more
likely to have had one or more serious medical illnesses
in their lifetime and to have met the diagnostic criteria for
major depressive episode, generalized anxiety disorder,
drug dependence or abuse, and nicotine dependence.
Pregnant women with posttraumatic stress disorder experienced significantly higher levels of life event stress
and physical abuse in the previous 12 to 15 months than
women without posttraumatic stress disorder. They also
were significantly more likely to report separation from
their mother as a child for more than 6 months and to
have experienced multiple traumas in their lives.
A statistical model was developed to identify risk
factors that would facilitate the clinical identification of
pregnant women with posttraumatic stress disorder. By
using logistic regression, risk factors were identified that
significantly differentiated women with and without the
Cook et al
713
Table 3. Sociodemographic, Environmental, and Medical Characteristics of Medicaid-Eligible Women With and Without
Posttraumatic Stress Disorder
Characteristic
Sociodemographic characteristic
Black
Rural residence
High school education
Single
Aged 18 years
Pregnancy/medical characteristic
History of 1 illnesses
Unwanted pregnancy
Late entry into prenatal care
Father of baby carried weapon
Previous LBW infant or premature delivery
Major depressive disorder
Nicotine dependence
Drug abuse and/or dependence
Alcohol abuse and/or dependence
Generalized anxiety disorder
Environmental
High environmental stress*
Physical abuse in last 15 months
Multiple trauma
Prolonged separation from mother in childhood
Posttraumatic
stress disorder
(n 57)
No
posttraumatic
stress disorder
(n 687)
29
34
30
43
12
50.9
59.7
52.6
75.4
21.1
401
405
281
541
95
58.4
59.0
40.9
78.8
13.8
1.21
0.01
2.98
0.34
2.23
.27
.92
.08
.56
.14
28
17
3
6
7
24
10
7
2
11
49.1
29.8
5.3
10.5
12.3
42.9
17.9
12.5
3.5
19.3
222
175
69
34
102
56
52
19
6
16
32.4
25.6
10.0
5.0
14.9
8.2
7.7
2.8
0.9
2.3
6.62
0.50
1.38
3.22
0.28
64.9
5.87
14.5
3.43
43.4
.01
.48
.24
.07
.58
.001
.01
.001
.06
.001
37
12
54
25
64.9
21.4
94.7
43.9
284
61
444
173
41.5
9.0
64.7
25.2
11.8
8.8
21.5
9.4
.001
.003
.001
.002
Physical abuse could be perpetrated by anyone, including the subjects partner, family member, friend, acquaintance or stranger.
Table 4. Risk Factors Associated With Posttraumatic Stress Disorder in Pregnant Women (n 744)
Risk factor*
1 Illnesses in lifetime
Major depressive episode
Nicotine dependence
Drug abuse and/or dependence
Generalized anxiety disorder
High life events stress
Physical abuse
Multiple lifetime traumas
Prolonged separation from mother in childhood
1.22
5.17
1.49
1.49
3.25
1.21
1.39
6.61
1.89
0.65, 2.27
2.61, 10.26
0.57, 3.87
0.43, 5.08
1.22, 8.62
0.64, 2.31
0.60, 3.25
1.97, 22.22
1.01, 3.54
.54
.001
.41
.53
.02
.56
.45
.002
.05
* Coding categories of risk factors were as follows: 1 present and 0 not present; all are in the last 12 months unless otherwise specified.
Derived from multiple logistic regression, the adjusted odds ratios reflect the odds of posttraumatic stress disorder adjusted for the other risk
factors in the model.
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Cook et al
DISCUSSION
In this study of economically disadvantaged pregnant
women, posttraumatic stress disorder was the third most
common psychiatric disorder, with a prevalence of 7.7%,
closely paralleling the 8.1% reported earlier by Ayers et
al.11 The lifetime prevalence of posttraumatic stress disorder (13.6%) also corresponds to that found in the
general population of pregnant and nonpregnant women.4 7 Despite comparable rates in other studies, our
findings may not be generalizable to pregnant women
from higher socioeconomic levels or to women who are
not black or white. Some research reports higher rates of
posttraumatic stress disorder in low-income populations.12 Another factor that could influence generalizability is sampling from only urban and rural sites in a single
state. Despite these limitations, posttraumatic stress disorder is common enough to be a clinical concern, particularly because the biological and psychological symptoms of this disorder may directly or indirectly affect
birth outcomes. Breslau et al6 found that posttraumatic
stress disorder significantly increased the probability of
alcohol abuse and dependence. Although the use of
alcohol may temporarily alleviate anxiety, promote
sleep, and erase memories of trauma, its negative effect
on fetal health is well documented.13 Neuroendocrine
changes associated with chronic stress influence maternalfetal health, including maternal vulnerability to hypertension and increased susceptibility to infection.14,15
Posttraumatic stress disorder may exert similar effects,
although no known research has documented this relationship in pregnant women. However, research links
high-risk behaviors to persons with posttraumatic stress
disorder. Many of these behaviors, such as smoking,
poor nutrition, and interpersonal violence, have known
negative consequences for both pregnant women and
their newborns.9,16 In a recent study, women with posttraumatic stress disorder had more complications of
pregnancy, including more ectopic pregnancies, miscarriages, hyperemesis, and preterm contractions than their
counterparts without posttraumatic stress disorder.17
The underlying mechanisms of how this disorder affects
these outcomes are unknown.
Only 12.3% (7 of 57) of the women with posttraumatic
stress disorder received treatment for this disorder. Seng
et al16 suggest that women with abuse-related posttraumatic stress disorder may not seek mental health treatment but might be open to other forms of help. Among
women who have been sexually abused, avoidance of
reminders of the trauma may hinder their seeking
needed health care services, including intrusive medical
procedures in prenatal care. Yet it is the prenatal care
Cook et al
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posttraumatic stress disorder and co-occurring psychiatric diagnoses is associated with treating them simultaneously, rather than one after the other.20 For example,
overlapping treatment for both posttraumatic stress disorder and the most common co-occurring diagnosis,
depression, can include cognitive-behavioral therapy
and antidepressant medications. Unique approaches to
treatment for posttraumatic stress disorder, however,
may also include eye movement desensitization and
reprocessing and exposure therapy.
Identification of risk factors in this study demonstrated that women with posttraumatic stress disorder
were 5 times more likely to have a major depressive
episode, 3 times more likely to have generalized anxiety
disorder, and more than 6 times more likely to have a
history of multiple traumatic events. Screening for posttraumatic stress disorder based on multiple traumatic
events is likely to contribute to the unnecessary reliving
of these experiences. However, commonly used brief
assessments for depression, spousal abuse, and domestic
violence could be used to prescreen for the disorder.
Research demonstrates that many obstetrician gynecologists already conduct varying degrees of screening
for depression in their practice.21 Women who are diagnosed with depression could then be evaluated for the
presence or absence of posttraumatic stress disorder by
using the screening tool developed and tested by Breslau
et al.22 Comprising 7 questions on symptoms, the instrument identifies posttraumatic stress disorder with a sensitivity of 80% and specificity of 97% when using 4 or
more symptoms as the cutoff score.
The high prevalence of posttraumatic stress disorder
and low rates of treatment, whether from inadequate
identification of the disorder in clinical practice, lack of
knowledge about available treatment, or inaccessible
mental health services, supports the provision of comprehensive treatment in prenatal care settings. Approaches to helping women with posttraumatic stress
disorder include offering supportive counseling, teaching stress reduction techniques, initiating support
groups, supporting continuity of care with the same
provider, scheduling more frequent visits, and initiating
nurse telephone calls between visits. Although women
diagnosed with depression may also benefit from these
treatment approaches, those with both posttraumatic
stress disorder and depression may require additional
mental health services. Ultimately, the benefit of detecting and treating posttraumatic stress disorder early in
pregnancy is prevent or diminish its untoward physiological and psychological effects on mothers and their
newborns.
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Cook et al
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