Trajectories of childbirth-related posttraumatic stress symptoms after a vaginal delivery: a multicenter prospective study.

Abstract

Childbirth can be experienced as traumatic and lead to posttraumatic stress symptoms. The evolution of childbirth-related posttraumatic stress symptoms remains poorly documented. We aimed to characterize posttraumatic stress symptom trajectories after vaginal delivery and identify associated risk factors. Ancillary cohort of the TRanexamic Acid for Preventing postpartum hemorrhage after vaginal delivery trial in 15 French university hospitals (2015-2016) including women delivering vaginally after 35 weeks' gestation. After randomization, characteristics of the labor and delivery were prospectively collected. Posttraumatic stress symptoms were assessed at day 2 and 2 months postpartum using the self-administered Impact of Event Scale-Revised questionnaire. Four trajectories were defined: asymptomatic (Impact of Event Scale-Revised <22 at both time points), recovered (≥22 at day 2; <22 at 2 months), emerging (<22 at day 2; ≥22 at 2 months), and persistent (≥22 at both). Prevalences were corrected for nonresponse using inverse probability weighting. Risk factors were assessed using multivariable logistic regression. Among 3891 women, 2344 (60.2%) completed the Impact of Event Scale-Revised at both assessments. Corrected prevalences were 83.4% (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 with posttraumatic stress symptoms at day 2, persistent symptoms compared with recovery were associated with younger age (adjusted odds ratio, 0.8; 95% confidence interval, 0.6-0.9), non-European origin (adjusted odds ratio, 1.8; 95% confidence interval, 1.2-2.6), psychiatric history (adjusted odds ratio, 1.9; 95% confidence interval, 1.2-2.4), bad memories of delivery (adjusted odds ratio, 2.4; 95% confidence interval, 1.3-4.6), and hemoglobin <9 g/dL at day 2 (adjusted odds ratio, 1.8; 95% confidence interval, 1.1-2.7). Among women without posttraumatic stress symptoms at day 2, emerging symptoms compared with asymptomatic trajectories were associated with previous abortion (adjusted odds ratio, 2.6; 95% confidence interval, 1.6-3.9), hospitalization during pregnancy (adjusted odds ratio, 2.8; 95% confidence interval, 1.4-4.7), labor induction (adjusted odds ratio, 1.7; 95% confidence interval, 1.1-2.8), bad memories of delivery (adjusted odds ratio, 3.7; 95% confidence interval, 1.4-5.6), and fatigue at day 2 (adjusted odds ratio, 2.2; 95% confidence interval, 1.4-3.5), while epidural analgesia reduced the risk (adjusted odds ratio, 0.2; 95% confidence interval, 0.1-0.7). About 1 in 20 women present an unfavorable posttraumatic stress symptom trajectory up to 2 months after a term vaginal delivery. The risk factors for a persistent trajectory were notably preexisting vulnerabilities, bad memories of delivery, and postpartum anemia at day 2 postpartum, whereas emerging trajectories were more closely associated with obstetric risk factors. These findings may help inform potential postpartum posttraumatic stress disorder screening strategies and highlight targets for preventive efforts.