PTSD–induced pregnancy was mentioned for the first time in 1990 (1). In PTSD cases, after trauma some symptoms are manifested in which individual is very high risk for severe injury, death or physical injury (2-4). In these conditions, some reactions such as severe fear, helplessness, fatigue and weakness, numbness, apathy, irritability, sleep and concentration disorders would appear. Individuals imagine events in their minds and would like to prevent to remind it (3). It is known as PTSD if it lasts for more than four weeks (1). The main symptoms are re-experiencing of stressful conditions (e.g. previous stressors, returning to past and nightmares, preventing thoughts and situations which are reminder for him and irritable symptoms like sleep problems and difficulty with concentration) (1,4).
PTSD could related to a history of mental health, unwanted pregnancy, nulliparity, history of hospitalization due to pregnancy complications, hyperemesis gravidarum early contractions, history of abortion, type of delivery, neonatal disorders, history of hospitalization for neonate in NICU, neonatal care stress, dissatisfaction of neonates' sex in some cultures (3) history of traumatic pregnancy (3,5) high level of anxiety, feeling of lack of control (2,4) emotional distress (2) complicated pregnancy like complications and medical problems of pregnancy (3). Preeclampsia is one of the medical problems which are complex and pregnancy specific syndrome with prevalence of 6%-8% (4). Some studies have reported prevalence of 28% for PTSD following pregnancy (6).
Mothers with PTSD experience nightmare, furiosity and anxiety. They could not also cope with new motherhood role (2). On the other hand, stress and fear of delivery may predict PTSD (7). The score of fear of delivery in primiparous women is significantly higher than multiparious (8).
As the stress of the first child-bearing is categorized in severe stresses, it is expected that primiparous women experience more problems. It is due to facing new responsibilities like caring and breast feeding the neonate having no previous experience. The first birth, of course, is being paid more attention by the relatives because it is the first life events; consequently mother and neonate are supported well. Multiparous women receive less support due to general myth that they are experienced and have enough knowledge of parenting (9). Soderquist reported a higher incidence of PTSD among multiparous women (7). As pregnancy and postpartum period are critically time periods for mental health disorders and also worsening of mental problems (3) and because to our knowledge there is no study in this relation in Iran, we conducted this study to compare PTSD in primiparous and multiparous mothers with preeclampsia.
Materials and Methods
This descriptive study was conducted on 100 pregnant women with preeclampsia who were diagnosed and hospitalized in governmental maternity departments for termination of their pregnancy within the week before starting the study. They were selected by convenience sampling. Sample size was calculated 80 using formula of comparing means (40 participants for each group). In present study, 60 primiparous and 50 mulitparous women were introduced to study (n=110).
Due to attrition, data of 56 primiparous and 44 multiparous (n=100) were analyzed. Inclusion criteria were term pregnancy; age higher than 18 years old and singleton pregnancy. Exclusion criteria were prenatal death, NICU hospitalization more than 24 hours, experiencing stressful events during study, unhealthy child birth, major depression and high level of anxiety. At first, demographic data questionnaire, Beck Depression Inventory II (BDI-II) and Spielberger State-Trait Anxiety Inventory (STAI) questionnaire were completed.
Participants were screened using Trauma History Screen questionnaire. They were excluded if they answered "Yes" to each question. In muliparous women, Prenatal Post traumatic stress Questionnaire (PPQ) was also completed for PTSD due to prenatal events in previous deliveries. Women with a score of more than 6 were excluded. In the first 24 hour after delivery, maternal- neonatal data were collected. In the 2nd postpartum week, maternal-neonatal data and social support questionnaire, Beck II depression questionnaire and Spielberger State-Trait Anxiety Inventory (STAI) and PTSD questionnaire were completed.
Trauma History Screen questionnaire included 14 Yes-No questions about different events. Social support was measured using modified Hopkins questionnaire. It was a questionnaire including 20 questions with Likert Scale from zero to four (never=0), (rarely=1), (usually=2), (often=3), (always=4). PPQ had 14 YES-NO questions.Participants whose score was higher than 6 were considered as PTSD. Demographic data questionnaire, delivery data and maternal-neonatal data questionnaire had questions for type of delivery, fetal presentation, labor duration, pain and fatigue score, blood pressure, preeclampsia tests, weight and Apgar at birth and transferring to NICU. Maternal-neonatal data questionnaire in 2nd postpartum week included questions for neonatal feeding and mother's satisfaction of the sex of neonate. Content validity was used for confirming validity of questionnaires. Reliability of modified Hopkins and PTSD questionnaires were confirmed by Cronbach's alpha and internal consistency (α=90%). Reliability of self-structured questionnaire were confirmed by test-retest (α=95%). Beck II depression questionnaire and Spielberger State- Trait Anxiety Inventory (STAI) were valid and reliable. Data were analyzed using descriptive and analytical statistics. Chi-Square, independent
t-test, Mann-Whitney U test and Kruskal-Wallis were used for comparing two groups of PTSD and non PTSD to obtain correlation Spearman coefficient was used. Data analyzed by SPSS version 16.
Ethical issues were considered under supervision of Ethics committee of Mashhad University of Medical Sciences.
No significant difference was used between two groups in terms of sex, weight, feeding method, the duration of being in NICU ward and the satisfaction of neonate sex. They also showed also no significant difference for state and trait anxiety and depression score at admission and at 6 weeks after delivery. Most primiparous women had high school diploma and multiparous had junior high school level which was statistically significant (p≤0.001). Most of them were housewife (P≤0.003). 43.1% of primiparous had unwanted pregnancy in comparison with 5.4% in primiparous women (P≤0.001). Mean age of multiparous was higher than primiparous mothers (Table 1).
Most of primiparous referred to both health care centers and physicians for prenatal care. Multiparous women monthly referred to health care centers. 56% of subjects were primiparous and 44% were multiparous. The prevalence of PTSD in two groups was not significantly different. The mean score of PTSD in muliparous women was higher which was not significantly different with primiparous women (Table 2 and 3). Mean of postpartum social support in week 6 in primiparous women was significantly higher than multiparous women (P≤0.001) (Figure 1).
A significant relationship was found between postpartum social support in week 2 and week 6 and mean score of PTSD. However, a significant difference was found in terms of social support at week 2 and 6 postpartum between two groups of subjects with and without PTSD. (Table 4 and 5). Based on Kruskal-Wallis test no significant difference was found between educational level, maternal job and desire to pregnancy with PTSD mean score.
Similarly, Chi-square test revealed no significant relationship between educational level, maternal job and desire to pregnancy with prevalence of PTSD.
The present study showed no significant relationship between mothers' age and PTSD like what Modares found (3). No significant relationship also was found between age and PTSD mean score. In two other studies there was likewise no relationship between age and PTSD (5, 7). But Ford et al. (2010) reported significant relationship between age and PTSD (10). Iles et al. (2011) showed negative relationship between age and stress signs (11). In present study mean age was 27.19 years, but in the previous studies it was 31.7 and 32.12 years respectively. It seems that the cause of significant relationship could be related to wider distribution of age in these studies compared to the present study.
Modares et al. (2010) showed significant difference between educational level and PTSD, while it was not significant in this study (3).
Adewaya et al. (2005) and Modares et al. (2010) reported significant relationship between desire to pregnancy and PTSD, however it was not significant in this study, although PTSD mean score in unwanted pregnancies was higher (3,5).
We found significant relationship between postpartum social support in week 2 and week 6 with PTSD which was found in other studies as well, however some studies reported relationship between postpartum social support at 2nd and 6th week with PTSD mean score (3,5). There was significant difference in primiparous and multiparous women between postpartum social support in 2nd and 6th week. In Nazari's et al. (2012) study, primiparous women in the first and second month postpartum got higher score of social support which was similar to this study (9). Cheng (2009) in a study on Chinese mothers in the USA showed that higher parity is associated with less social support (12).
The rate of PTSD was 21.4% in primiparous and 31.8% in multiparous women. However, it was not significantly different (P=0.240). Mean score of PTSD in multiparous was higher than primiparous women which was not also different (P=0.053). It was similar to the study of Soderquist (59% for multiparous vs. 41% for primiparous) (7).
According to the findings, postpartum social support in multiparous was less than primiparous women. On the other hand unwanted pregnancy was higher among multiparous women. Both of them could be possible causes for PTSD in multiparous in comparison with primiparous women. Traditionally, family members support mother from the beginning of delivery and help her in neonatal care. This support good is in the first weeks. It decreases gradually by time and mother and neonate enter their new world with each other. Primiparous mothers, of course, receive more support than multiparous mothers, because they are at the central point of attention in family while multiparous women due to having previous childbirth is deemed more experienced.
Adopting prospective design for the study and control of confounding factors such as postpartum social support in confounding week 2 and week 6, depression and State - Trait anxiety at admission and week 6 are of the strengths of this study. The strict inclusion and exclusion criteria could be considered of limitation which causes less generalization.
As multiparous mothers receive less attention in comparison with primiparous women, it is suggested that staff reminds this point to the families. They may deprive from social support due to having previous experience.
This paper is driven from a Master thesis in Midwifery approved by Vice-Chancellor for Research, Mashhad University of Medical Sciences, Mashhad, Iran (Code: 900955). Their financial support is highly appreciated. We also thank women who cordially took part in this study.
Conflict of Interest
No conflict of interest exists.