Discussion
MAIN FINDINGS
Although the studies identified by the quantitative search provided
varied results, eight out of the 12 studies found mode of birth to be
significantly associated with maternal development of symptoms of PTSD
postnatally. Meta-analysis showed that PTSD symptoms were worse in women
who had CS compared to those who had VD (p=0.005). Symptoms were also
worse in women who had EmCS than in those who had either SVD
(p<0.001) or ElCS (p<0.001). The significant
difference between EmCS and ElCS may have confounded the first analysis
which pooled these two CS groups. Evidence showed that women who had CS
births worried more about the safety of their baby and felt less
satisfied overall with their birthing experience , a finding which
reflects the literature indicating that women may perceive CS as more
traumatic than VD .
All of the midwives interviewed by Nyberg et al. reported being
asked by women with postnatal PTSD for an ElCS in a subsequent
pregnancy, but did not believe that this was the optimum mode of birth
for this group of women. The other included qualitative study compared
the experiences of women who did and did not develop symptoms of PTSD
after an EmCS . Women who did not develop PTSD felt more supported by
staff and more involved with the decision to proceed to a caesarean.
This study suggests that although EmCS may be associated with an
increased likelihood of postnatal PTSD, compassionate care and ensuring
that women are involved in decision-making can mediate against this
effect.
The importance of the impact of inadequate support from staff during
labour and birth on women with PTSD supported findings from Nyberget al. This study reported that many women with postnatal PTSD
later told specialist midwives that they felt a lack of support and
control during the birth resulting in their PTSD . These findings
provide some insight into how a perceived lack of support from labour
ward staff could have a considerable detrimental effect on maternal
mental health outcomes. NICE guidelines recommend that women are offered
the opportunity to talk about their birth experiences at every postnatal
contact, which may mitigate against this. No studies were found which
evaluated the role of support from partners, families and peers as a
potential mitigating factor against PTSD. This is an important avenue
for future research.
STRENGTHS AND LIMITATIONS
This is the first systematic review and meta-analysis to combine
information from small and medium sized studies, and present synthesised
findings about the association of birth mode and maternal postnatal
PTSD, reducing the uncertainty that is associated with each single
study. However, there are several limitations. There was an issue with
the inclusion criterion of “live, term, singleton births”. Six of the
included studies did not specify this within their paper, and although
efforts were made to contact authors to verify this, only three replied
to confirm their paper met this criterion. This left three studies
included on a benefit of the doubt basis .
The meta-analysis compiled the most relevant clinical information,
utilising robust statistical methods to synthesise the evidence on
birthing methods and PTSD symptoms. A statistician (DG) performed both
MA and NMA to utilise all direct and indirect information. A potential
limitation with this was the assumption of equivalence in the measures
used in the difference studies and the follow-up points. If these
assumptions fail to hold then they may have introduced heterogeneity
into the studies. A meta-analysis of SMDs assumes the populations of
each study contain equivalent variation.
CONCLUSION
Although there was some variation in the studies, an overall conclusion
can be made that mode of birth has an impact on PTSD in the postnatal
period. Women who have emergency CS and instrumental VD might be at an
increased risk, although it is important to note that women with all
types of birth experience go on to develop PTSD, and the disorder is not
limited to those who had a birth that would be deemed traumatic from a
clinical perspective. Qualitative data indicated that although elective
CS may not be associated with postnatal PTSD, they might have a negative
impact on women with pre-existing postnatal PTSD. Support and
involvement in decision-making from staff during labour may have a
protective effect against women who experience emergency obstetric
intervention, but more work must be done to confirm the above findings.