You are on page 1of 8


Posttraumatic Stress Disorder in Pregnancy:
Prevalence, Risk Factors, and Treatment
Cynthia A. Loveland Cook, PhD, Louise H. Flick, DrPH, Sharon M. Homan, PhD,
Claudia Campbell, PhD, Maryellen McSweeney, PhD, and Mary Elizabeth Gallagher, PhD
OBJECTIVE: To estimate the prevalence of posttraumatic
stress disorder and its treatment in economically disadvantaged pregnant women.
METHODS: The sample included 744 pregnant Medicaideligible women from Women, Infants and Children Supplemental Nutrition Program sites in 5 counties in rural
Missouri and the city of St. Louis. Race (black and white)
was proportional to clients seen at each site. Women were
assessed by using standardized measures of posttraumatic
stress disorder, 18 other psychiatric disorders, environmental stressors, and pregnancy characteristics. Logistic regression identified risk factors associated with posttraumatic
stress disorder.
RESULTS: Posttraumatic stress disorder prevalence was
7.7% (n ⴝ 57/744). Comorbid disorders were common.
Women with posttraumatic stress disorder were 5 times
more likely to have a major depressive episode (odds ratio
5.17; 95% confidence interval 2.61, 10.26) and more than 3
times as likely to have generalized anxiety disorder (odds
ratio 3.25; 95% confidence interval 1.22, 8.62). Besides these
comorbid disorders, risk factors for posttraumatic stress
disorder included a history of maternal separation for 6
months and multiple traumatic events. Although most
women with posttraumatic stress disorder reported moderate impairment in their daily lives, only 7 of the 57
women with this disorder reported speaking with any
health professional about it in the last 12 months.
CONCLUSIONS: The prevalence of posttraumatic stress disorder in pregnancy and low treatment rates suggest that screening for this disorder should be considered in clinical practice.
(Obstet Gynecol 2004;103:710 –7. © 2004 by The American
College of Obstetricians and Gynecologists.)

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.


VOL. 103, NO. 4, APRIL 2004
© 2004 by The American College of Obstetricians and Gynecologists.
Published by Lippincott Williams & Wilkins.

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.1–3
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.
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


Only 160 (21. * General Equivalency Diploma is coded as high school graduate.0 Values are n (%) unless otherwise specified. had experienced at least one previous live birth.8%) were in their second trimester.0%) refused to participate. and 18 other common psychiatric disorders were Cook et al Posttraumatic Stress Disorder in Pregnancy 711 .locations. Louis and 1 rural site refused or were unable to participate in the study. 2 sites in the city of St. NO.0) 305 (41. The Diagnostic Interview Schedule. assesses the presence of current and lifetime psychiatric diagnoses based on symptom.8) 356 (47.5%) were black. and 316 (42. Posttraumatic stress disorder. Despite their relatively young age.8) 59 (7. Eligible women were enrolled at each site until their numbers were proportional by race for women seen at the respective site.3 ⫾ 5.9) 8 (1. 428 (57. 4.0 4. in addition to race.5%) first receiving care in their second trimester. This was determined by having 12 or more errors on the dementia section of the Diagnostic Interview Schedule. severity. Two of 5 mothers (41.5) 311 (41.7%) women received prenatal care for the first time during their last trimester.8%) or 311 partic- VOL.5 ⫾ 4. Mothers as young as 13 years old were included. and duration criteria in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders-IV. Maternal age ranged from 13 to 43 years. 59. having (or being eligible for) Medicaid coverage of health services. 41. ipants had not finished high school.5) 21 (2. geographic location. research assistants obtained informed consent from eligible pregnant women who sought services at their local Women. However. Louis (305 of 744. and 11 (1. Nine of 10 women (672 of 744) had their initial prenatal care visit in their first trimester. Of the total 878 women approached.6%) were unavailable for scheduled interviews. Past interpretations of Missouri statutes allow pregnant minors to consent to medical care and participate in research without parental consent.5%) were white (Table 1). 192 of 744 (25. Another 303 (40. or 161 of the 744 subjects.0%).8 Following approval of the study protocol by the Institutional Review Board.5%) of the 744 women were married.8%) delivered a previous pregnancy more than 3 weeks early. Only 5 of 744 (0. and the remaining 279 (37.8) 39 (5.1) 10 (1.9) 22.3) 523 (70. Infants and Children Supplemental Nutrition Program enrollment at any point in their pregnancy. Only one subject was ineligible because of cognitive impairment. State-level data on the number of pregnant women seen at the identified sites in the previous year overestimated eligible subjects for the study period.8%) reported having had at least one serious medical problem in their lifetime. with a mean of 22.5%) were in their last trimester. APRIL 2004 Table 1. Replacement sites in the same geographical areas were selected based on their willingness to participate. Eighty-four (18. Our original plan was to sample participants from all the rural sites and representative urban sites. thereby precluding the random sampling of black and white subjects at each site. Inclusion criteria for subjects.5 3.0%) initially refused to enroll. One of 5.0%) than in the city of St.8) 43 (5.1) 439 (59.8%) did not appear for their interviews. and Women. Infants and Children Supplemental Nutrition Program sites between February 2000 and August 2001.0) 508 (68. 132 (15. Exclusion criteria included cognitive impairment that interfered with understanding of the interview questions. Nearly 60%. More women resided in the rural Missouri (439 of 744. with another 56 (7. and 171 of 744 (23. † Full-time work is 35 hours or more per week.3) 160 (21. Sociodemographic Characteristics of Sample (n ⫽ 744) Characteristic Race Black White Education* ⬍ High school High school graduate Vocational or some college Bachelor’s degree Graduate degree Marital status Never married Married Separated Divorced Widowed Residence Rural Urban History of serious illness None One Two Age (y) Mean ⫾ standard deviation Median Full-time work in last year (mo)† Mean ⫾ standard deviation Median n (%) 428 (57.0%) enrollees were under 19 years of age. 14 (1. a well known standardized diagnostic interview. included being pregnant. 103.5) 316 (42.3) 1 (0. and 25 (2. Ninety-three (11. Of the 744 women who did participate in the study.3 ⫾ 5.2 (standard deviation [SD]) years. and being able to speak English. were interviewed during their first trimester of pregnancy.5%) received no prenatal care at all.2 21. All eligible women were then enrolled at each site in the order in which they were identified. Trained research assistants administered a 2-hour in-person interview using the Diagnostic Interview Schedule9 and other study instruments.3) 192 (25. treatment for the disorder. or 428 of 744 of the women.

1%) reported difficulties with family. 89. Cary. Fourth.2%). They were somewhat less likely to report a sense of having a foreshortened future (31 of 57.9%) reported 1 or more comorbid psychiatric disorders. 61. environmental. 91. Second. onset of symptoms. 35. we calculated the prevalence of current posttraumatic stress disorder and assessed treatment for this disorder. and being in a serious accident (18 of 57. age of exposure. Forty-one women (71. friends. we calculated adjusted odds ratios (ORs) with 95% confidence intervals (CIs) to identify those risk factors that could be used as screening criteria to identify pregnant women with posttraumatic stress disorder in clinical practice. 12.6%). irritability or outbursts of anger (51 of 57. attitude about pregnancy.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. 96. 7. and pregnancy-related factors and posttraumatic stress disorder.1%) had 2.3 ⫾ 0. being mugged or robbed (26 of 57.4 (SD) traumatic events over their lifetime. First.8 [SD]). we fitted logistic regression models to the data to determine the association between medical. experiencing a natural disaster (22 of 57. The posttraumatic stress disorder module of the Diagnostic Interview Schedule begins with a list of 17 traumatic events. 50.4%) or an inability to recall important aspects of the trauma (7 of 57.8%) of the 57 women experienced the traumatic event that precipitated posttraumatic stress disorder before they were 15 years old. 712 Cook et al Posttraumatic Stress Disorder in Pregnancy RESULTS Of the 744 women in this study. 8.9%). 38. Fourteen (24.6%) had 1 comorbid psychiatric diagnosis. 31. OBSTETRICS & GYNECOLOGY . psychological distress when exposed to cues resembling the trauma (55 of 57.6%). and another 16 (26. We used a 5-step analytic strategy. 101 (13. seeing someone being seriously injured or killed. 12 (21. We tested our model for goodness of fit using the Hosmer and Lemeshow statistic. NC). The most commonly reported symptoms of posttraumatic stress disorder were intrusive distressing recollections of the trauma (57 of 57. we created descriptive statistics and summary profiles.5%). 100. pregnancy-related morbidity. In this study. places. In comparison with other current psychiatric disorders examined. difficulty concentrating (52 of 57. Another 0.8%) and nicotine dependence (63 of 744. following major depressive episode (80 of 744. as well as symptom counts.3%). living conditions. and stressors. based on a scale ranging from 0 (none) to 4 (severe). One in 13 women (57 of 744. Data entry with verification and statistical analyses were conducted using SAS-PC 8 (SAS Institute.9 This lay-administered standardized interview assesses diagnostic criteria in Diagnostic and Statistical Manual of Mental Disorders-IV. or people associated with the trauma (51 of 57. being sexually assaulted by a nonrelative (29 of 57. and treatment. Posttraumatic stress disorder is precipitated by exposure to one or more traumatic events. Twenty-one (36. Items adapted from the Pregnancy Risk Assessment Monitoring System10 provided information on pregnancy history and environmental stressors.6%). or being in a natural disaster. On average. 89. Developed by the Centers for Disease Control. degree of disruption in work or social relationships. Twenty-eight of the 57 women with current posttraumatic stress disorder (49. posttraumatic stress disorder during pregnancy was based on symptoms occurring in the 12 months before and including the pregnancy interview. Third.5%).5%). Measurement of sociodemographic characteristics was based on items in the Diagnostic Interview Schedule.1%). and avoidance of activities. 84. seeing someone killed or seriously injured (22 of 57.6%). The most common events included the unexpected death of a close friend or relative (48 of 57. being sexually assaulted by a relative (20 of 57. pregnancy. 10. Finally. Treatment for posttraumatic stress disorder focused on whether or not subjects talked to a physician or other health professional about posttraumatic stress disorder–related behaviors or feelings in the past year. and environmental characteristics between women with and those without posttraumatic stress disorder.2%) had 3 or more. we evaluated risk factors for posttraumatic stress disorder using ␹2 tests and Student t tests to identify any significant differences in sociodemographic. experiencing combat conditions.6%). the 57 women with current posttraumatic stress disorder had a mean of 4. onset and recency of symptoms. having something terrible happen to a close friend or relative (35 of 57.measured by using the fourth version of the Diagnostic Interview Schedule.6%) had a diagnosis of posttraumatic stress disorder at some point in their lives. 54. 38.4%).7%) had a current diagnosis of posttraumatic stress disorder.2%).9 ⫾ 2. and treatment in the previous 12 months. Pregnant women with posttraumatic stress disorder reported moderate impairment in their daily functioning (mean 2. including being attacked or raped. this instrument assesses maternal health indicators related to prenatal care. posttraumatic stress disorder was the third most common.0%). Subjects identify the worst event that ever happened to them and then respond to questions about posttraumatic stress disorder symptoms. remission. and/or work during the same time period. 45. being threatened with a weapon.

1 24 13 2 32 42. generalized anxiety disorder. women who received services had significantly more comorbid psychiatric disorders than those who did VOL.8. 35. 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.3 9.5 3.9 0. The next analyses focused on identifying those characteristics associated with risk for posttraumatic stress disorder. generalized anxiety disorder (11 of 57. women with posttraumatic stress disorder in this study had 1.05). P ⬍ .2%). Current Comorbid Psychiatric Disorders in Pregnant Women With Posttraumatic Stress Disorder (n ⫽ 57) Prevalence Comorbid psychiatric disorder Number* % 95% Confidence limit 11 10 3 2 1 20 19.3 59.8%). APRIL 2004 not receive services (mean 2.9.0 13.26.8 1. The remaining subjects (35 of 57. 9. 35. A statistical model was developed to identify risk factors that would facilitate the clinical identification of pregnant women with posttraumatic stress disorder.2 10 6 2 1 1 1 13 17.8. 8 did receive treatment for another psychiatric diagnosis.1 11. 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.3%).5 10. 61. and nicotine dependence. 9. Of individual comorbid diagnoses.8 71.5 ⫾ 1. followed by anxiety and substance-related disorders (Table 2). 17. despite its known association with posttraumatic stress disorder.5 56.1. respectively. 11. 26.0 [SD] and 1.7 (SD) comorbid diagnoses. Only 7 of the 57 women with current posttraumatic stress disorder (12.8. There were no statistically significant differences in sociodemographic characteristics between women who did and did not receive treatment.0. environmental.8 1.1 30.0. 11.6 ⫾ 2.8 3.3%) received treatment in the previous year for this disorder.5%). 31. However.5 [SD]. 9. 29.2. 48. and medical risk factors (Table 3). 55.0. 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.8.1 1.3 0.8 35.5 1. t ⫽ 2.0. On average.3 3. 42. Relatively few women reported alcohol abuse or dependence.3 17.9 43. 9.5 1. risk factors were identified that significantly differentiated women with and without the Cook et al Posttraumatic Stress Disorder in Pregnancy 713 . 68.3.4%) neither wanted nor received treatment for this disorder.4 1.9 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.5%). 4. Other common diagnoses included manic episode (13 of 57.2 1.2 1 41 1.3 13.0. The most prevalent categories of comorbid diagnoses for women with posttraumatic stress disorder were mood disorders.3%) wanted treatment for posttraumatic stress disorder but did not receive it.2. One fourth of the women (15 of 57. 17. 21.3 24. 103.8 ⫾ 1. the most prevalent was major depressive episode (24 of 57. 14.0.8 9.0. including sociodemographic.5 5.4 1. drug dependence or abuse.0. 19.3 0. Although sociodemographic characteristics were not significantly different for women with and those without posttraumatic stress disorder. NO. 29. nicotine dependence (10 of 57. and social phobia (10 of 57. Of the 50 women who did not receive posttraumatic stress disorder treatment in the previous year.4 4.2 22. 81.3.9 0.Table 2. 22. By using logistic regression. We found no significant differences between the 2 groups in level of impairment in the year before the interview. 11.9 0.8.8 22. 9.

49 1. 3.2 7.9 8. 3. † Physical abuse could be perpetrated by anyone. acquaintance or stranger.23 .62 0.003 ⬍ .39 6. 95% CI 1. Table 4.87 0.92 . all are in the last 12 months unless otherwise specified.9 21.5 3.07 .5 19.89 0. † Derived from multiple logistic regression. 2.14 28 17 3 6 7 24 10 7 2 11 49.4 59. 10. disorder.8 0. 8.54 .3 42. 3.Table 3.9 12.34 2.4 25. 22. Because the statistic of 1.2 11. 22. 5.45 .61. Sociodemographic.8 5. As shown in Table 4.21 0.8 21.001 .54 ⬍ .62 0.001 .0 14. pregnant women with posttraumatic stress disorder had 5 times the adjusted odds of having a major depressive episode (OR 5.25 10. 8.9 17.3 10.38 3.002 ␹2 P LBW ⫽ low birth weight.1 29.26 0.4 . 2. Subjects with posttraumatic stress disorder were nearly 2 times as likely to have been separated from their mothers for at least 6 months during their childhood (OR 1.21 1.99. * High environmental stress was defined as experiencing 5 or more stressful life experiences in the last 12 months. Risk Factors Associated With Posttraumatic Stress Disorder in Pregnant Women (n ⫽ 744) Risk factor* Adjusted odds ratio† 95% Confidence interval P ⱖ 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 1.27 2.001 .1 401 405 281 541 95 58.22 1.9 2.65.5 9.26) and more than 3 times the adjusted odds of generalized anxiety disorder (OR 3.001 .54).01.02 .7 43.48 .43. 714 Cook et al Posttraumatic Stress Disorder in Pregnancy OBSTETRICS & GYNECOLOGY . The Hosmer and Lemeshow goodness-of-fit test statistic was 1.01 ⬍ .06 exceeds .4 ⬍ . Environmental.64.9 284 61 444 173 41.97.49 3.22.28 64.001 37 12 54 25 64.4 94. ‡ Multiple trauma was defined as having experienced 2 or more traumas.08 .41 .3 6.31 0.6 75.05.9 59.002 .05 * Coding categories of risk factors were as follows: 1 ⫽ present and 0 ⫽ not present.01 .60.53 .25.01 2. we rejected the null hypotheses and concluded that the data fit the specified model.56 .61 1. 3.3 222 175 69 34 102 56 52 19 6 16 32.7 2.62).001 . friend.27 .58 ⬍ .5 12. family member.50 1.8 13.25 1.17. 95% CI 1. the adjusted odds ratios reflect the odds of posttraumatic stress disorder adjusted for the other risk factors in the model.22 5.22. 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 ⱖ 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) n % n % 29 34 30 43 12 50. Women with the disorder were more than 6 times as likely to have experienced 2 or more traumatic events in their lives (OR 6.22). 95% CI 2.8 8.9 5. 95% CI 1.9 3. The cutoff score represents the midpoint in which one half of the sample had fewer than 5 stressors and the remainder had 5 or more.22 0.24 .98 0.0 5.4 21.06 with 7 degrees of freedom and a P value of .08 1.43 43.7 52.0 40.56 .01.7 25. 10.0 64.8 1. including the subject’s partner.5 9.06 ⬍ .17 1.61.87 14.

Despite Medicaid coverage. Strong deterrents to mental health service use include hearing bad things about the care provided at a facility and fearing the stigma associated with mental health treatment. miscarriages. difficulty with reduction of tobacco or other substance use. Only 12. housing problems involving relocation.15 Posttraumatic stress disorder may exert similar effects.14.9. posttraumatic stress disorder may not be identified in prenatal care settings. hyperemesis. Although the use of alcohol may temporarily alleviate anxiety.7%. its negative effect on fetal health is well documented.16 In a recent study. and interpersonal violence. some women with posttraumatic stress disorder received treatment. although no known research has documented this relationship in pregnant women. with a prevalence of 7. and erase memories of trauma. Women with posttraumatic stress disorder also may have limited understanding of the value of mental health treatment.12 Another factor that could influence generalizability is sampling from only urban and rural sites in a single state. Greater awareness of symptoms related to this disorder. Breslau et al6 found that posttraumatic stress disorder significantly increased the probability of alcohol abuse and dependence.4 –7 Despite comparable rates in other studies. and long waiting times for appointments. women with posttraumatic stress disorder had more complications of pregnancy. Optimal outcomes for women with Cook et al Posttraumatic Stress Disorder in Pregnancy 715 . Some research reports higher rates of posttraumatic stress disorder in low-income populations. health providers in both prenatal and primary care settings may miss the diagnosis of the disorder.1% reported earlier by Ayers et al.DISCUSSION In this study of economically disadvantaged pregnant women. An informed approach to helping women with these problems is likely to increase compliance with prenatal care visit schedules and health-promoting behavior. have known negative consequences for both pregnant women and their newborns.11 The lifetime prevalence of posttraumatic stress disorder (13. avoidance of reminders of the trauma may hinder their seeking needed health care services. barriers to their access may be prohibitive. including maternal vulnerability to hypertension and increased susceptibility to infection. such as fear of pelvic exams. however. 4. Among women who have been sexually abused.19 More likely. mental health services are often limited in rural and inner city areas in this country. particularly because the biological and psychological symptoms of this disorder may directly or indirectly affect birth outcomes. Yehuda17 posits that traumatized persons with posttraumatic stress disorder are more likely to visit their primary care physicians than mental health professionals for treatment of symptoms. including intrusive medical procedures in prenatal care. poor nutrition. Prenatal assessments should detect those who need more extensive evaluation of posttraumatic stress disorder and provide treatment for the disorder. In this study. When services do exist. promote sleep.6%) also corresponds to that found in the general population of pregnant and nonpregnant women. and preterm contractions than their counterparts without posttraumatic stress disorder. Despite these limitations. our findings may not be generalizable to pregnant women from higher socioeconomic levels or to women who are not black or white. will enhance more effective responses by health professionals.18 Another consideration is the often painful re-experiencing of trauma that can be inherent in the treatment of this disorder. Many of these behaviors. 103. a disincentive cited by the New Freedom Commission on Mental Health. Several factors are involved in the low treatment rates among pregnant women with posttraumatic stress disorder.13 Neuroendocrine changes associated with chronic stress influence maternal–fetal health. APRIL 2004 setting itself that offers an ideal opportunity to identify pregnant women with posttraumatic stress disorder and make referrals for mental health treatment. Yet it is the prenatal care VOL. a large proportion of women reported they did not want treatment. posttraumatic stress disorder was the third most common psychiatric disorder. and thus treatment referrals are not even made. such as lack of transportation. In this study. 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. inadequate child care.3% (7 of 57) of the women with posttraumatic stress disorder received treatment for this disorder. including more ectopic pregnancies. posttraumatic stress disorder is common enough to be a clinical concern. With the substantial overlap between symptoms of posttraumatic stress disorder and those of depression and anxiety disorders. closely paralleling the 8. However. and anxiety that seems disproportionate to presenting circumstances. Another factor may involve women’s perceptions of their need for services.17 The underlying mechanisms of how this disorder affects these outcomes are unknown. NO. research links high-risk behaviors to persons with posttraumatic stress disorder. The importance of adequate screening and treatment of posttraumatic stress disorder during pregnancy is strongly supported in the literature. but it was for another psychiatric disorder. such as smoking.

those with both posttraumatic stress disorder and depression may require additional mental health services. 7. Arch Gen Psychiatry 1994. Leech SL. Although women diagnosed with depression may also benefit from these treatment approaches. 10.48: 216 –22. Birth 2001. initiating support groups. Bassuk EL. Psychiatric disorders in America: the epidemiologic catchment area study. 2003. Rourke KM.20 For example. and more than 6 times more likely to have a history of multiple traumatic events. however. Schultz L. Zhao S. Revised prevalence estimates of mental disorders in the United States: using a clinical significance criterion to reconcile 2 surveys’ estimates. 3. 3 times more likely to have generalized anxiety disorder. 4th ed. Fischer LA. Nelson C. Regier DA. overlapping treatment for both posttraumatic stress disorder and the most common co-occurring diagnosis. Pickering AD.26:1584 –91. Cornelius MD.28:111– 8. Peterson EL.22 Comprising 7 questions on symptoms. commonly used brief assessments for depression. Larkby C. Research demonstrates that many obstetrician– gynecologists already conduct varying degrees of screening for depression in their practice. scheduling more frequent visits. Dansky BS. Rauh V. Alcohol Clin Exp Res 2002. supporting continuity of care with the same provider. depression. Culhane JF. Posttraumatic stress disorder in the national comorbidity survey. Shulman HB. spousal abuse.3:199 –209. 8. Resnick HS. 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. Hogan VK. Cottler LB. Psychiatric sequelae of posttraumatic stress disorder in women.52:1048 – 60. Approaches to helping women with posttraumatic stress disorder include offering supportive counseling. and domestic violence could be used to prescreen for the disorder. DC: American Psychiatric Association. Robins DIS/dishisto. Diagnostic interview schedule for the DSM-IV (DIS-IV). Narrow WE.wustl. Regier DA. Arch Gen Psychiatry 2002. Kessler RC. Arch Gen Psychiatry 1997. lack of knowledge about available treatment. may also include eye movement desensitization and reprocessing and exposure therapy. The high prevalence of posttraumatic stress disorder and low rates of treatment. teaching stress reduction techniques. supports the provision of comprehensive treatment in prenatal care settings. Gilbert BC. Agnew K. Davis GC. Ayers S. However. Am J Psychiatry 1998. Breslau N. Rauh V. Bromet E. rather than one after the other. Andreski P. 5. Best CL. Nelson CB. The Pregnancy Risk Assessment Monitoring System (PRAMS): methods and 1996 response rates from 11 states. Robles N. Day N. Retrieved August 26. 12. 1991. Matern Child Health J 2001. Perloff JN. Arch Gen Psychiatry 1991.54:81–7. Compton WM. 1994. Davis GC. Richardson GA. Washington. 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. can include cognitive-behavioral therapy and antidepressant medications.51:8 –19. 2. Arch Gen Psychiatry 1995. Eshleman. Buckner JC. McCollum KF. Bucholz KK. Sonnega A.61:984 –91. Do women get posttraumatic stress disorder as a result of childbirth? A prospective study of incidence. or inaccessible mental health services. 15. 14. Ultimately. Rogers MM. Prenatal alcohol exposure predicts continued deficits in offspring size at 14 years of age. Robins LN. North CS. Breslau N.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. 13.htm. McGonagle K. New York (NY): The Free Press. Matern Child Health J 1999. Barve SS. Hughes M. Kessler RC. Saunders BE. 9. Diagnostic and statistical manual of mental disorders.59:115–23. OBSTETRICS & GYNECOLOGY . Peterson E. 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. immune/inflammatory. editors. 11. whether from inadequate identification of the disorder in clinical practice. and initiating nurse telephone calls between visits. Prevalence of mental health and substance use disorders among homeless and low-income housed mothers. Traumatic events and posttraumatic stress disorder in an urban population of young adults.posttraumatic stress disorder and co-occurring psychiatric diagnoses is associated with treating them simultaneously. Culhane JE.5:127–34. Stress and preterm birth: neuroendocrine. Robins LN. Rae DS. 6. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Prevalence of civilian trauma and posttraumatic stress disorder in a representative national sample of women. Available at: http://epi. Unique approaches to treatment for posttraumatic stress disorder. Screening for posttraumatic stress disorder based on multiple traumatic events is likely to contribute to the unnecessary reliving of these experiences. Wadhwa PD. Maternal stress is associated with bacterial vaginosis in human pregnancy. J Consult Clin Psychol 1993. et al.155:1561– 4. 4. 716 Cook et al Posttraumatic Stress Disorder in Pregnancy REFERENCES 1. Wadhwa PD. Kilpatrick DG. Bassuk SS. American Psychiatric Association.

and childbearing. MO 63103. Loveland Cook.html. Received September 10. and vascular mechanisms. et al. Treatment of PTSD. School of Social Service. Accepted January 15. Bell M. National Center for PTSD. Pignone MP. 103. Prevention Services Task Force.S. e-mail: cookca@slu. 2003. SMA-03-3832. Am J Psychiatry 1999. NO. Katon W. 20. Yehuda R. Current concepts: post-traumatic stress disorder. 3550 Lindell 22. produce better papers. 2003. posttraumatic stress. Retrieved December 15. Address reprint requests to: Dr. Kessler RC. Rushton JL.136: 765–76. THIRD EDITION OF WRITING GUIDE AVAILABLE A Guide to Writing for Obstetrics & Gynecology was developed to help prospective authors. Friedman M. Depression screening attitudes and practices among obstetrician-gynecologists. Louis. 2003. free of charge. N Engl J Med 2002.101:892– 8. Orleans CT. abbreviations. 2004. Burchell CM. New Freedom Commission on Mental Health.16. Seng JS. St. Peterson EL. Received in revised form January 12.156:908 –11. jargon and acronyms.5: 119 –25. Schultz LR. Breslau N. 4. Obstet Gynecol 2003.346:108 –14. Short screening scale for DSM-IV posttraumatic stress disorder. Rockville (MD): Department of Health and Human Services. from the Editorial Office. Matern Child Health J 2001. Mulrow CD. Topics covered include: • Planning and structuring a manuscript • Writing tips. APRIL 2004 Cook et al Posttraumatic Stress Disorder in Pregnancy 717 . No. Gaynes BN. redundant publication and conflict of interest) • An overview of the peer-review process Copies of the third edition of this booklet are available. J Midwifery Womens Health 2002. especially those who are beginning in medical journal writing. Saint Louis University. Melville Achieving the promise: Transforming mental health care in America. 17. 19. Requests may be submitted by FAX (202-479-0830) or e-mail (obgyn@greenjournal. A conceptual framework for research on lifetime violence. Final Report. LaRocco-Cockburn A. DHHS Pub. 2004. 21. Cynthia A. Ann Intern Med fs_treatment. grammar. and troublesome terms • Common pitfalls of authorship (eg. OBSTETRICS& GYNECOLOGY VOL. Screening for depression in adults: a summary of the evidence for the U.47:337– 46. 18. including an overview of syntax. Available at: http://www.