Fear of childbirth, postnatal post-traumatic stress disorder and midwifery care.

The impact of maternal mental health disorders on women and their children is significant. Stress and psychological problems during pregnancy are associated with preterm labour, poor infant outcomes and greater cognitive, behavioural and interpersonal problems in young children (Glasheen et al., 2010). Similarly, postnatal psychological problems have an adverse impact on the woman, child, and relationships. The World Health Organisation lists psychological illness as a significant indirect cause of maternal death in the first year after birth (WHO, 2008). This has led to an international call for the integration of maternal mental health into maternal and child health care programmes (Rahman et al., 2013). In the UK, the importance of women's mental health during pregnancy and after birth has been the focus of a number of recent reports from organisations such as the NSPCC (Hogg, 2013), Royal College of Midwives, Institute of Health Visitors and charities (Boots Family Trust, 2013), and a cross-party parliamentary manifesto (Leadsom et al., 2013). In November 2013 the Maternal Mental Health Alliance published a report on the importance and role of specialist mental health midwives (MMHA, 2013) and the UK Government announced specialist perinatal mental health staff would be trained for all birthing units by 2017 (Department of Health, 2013). In this context, recognition of the range of mental health problems that women can suffer from becomes even more important. Historically, research has focused on the most common or severe psychological disorders that occur, namely postnatal depression and puerperal psychosis, which has raised public awareness of these disorders. However, evidence is clear that women can suffer from a range of disorders at this time including anxiety disorders such as panic, generalised anxiety, phobias and adjustment or stress-related disorders, such as post-traumatic stress disorder (PTSD). Collectively, anxiety disorders appear to be as common as depression. For example, a meta-analysis of postnatal depression suggests it affects up to 19% of women (Gavin et al., 2005). Similarly, a Canadian study found 16% of women had postnatal anxiety disorders (Wenzel et al., 2005). Two, less recognised disorders are particularly relevant to midwifery care because they directly affect women's perinatal experiences or arise as a result of birth experience. These are fear of childbirth (tokophobia) in pregnancy and PTSD in response to difficult or traumatic births. These disorders can have an impact on women throughout pregnancy and after birth. They can also negatively affect women's relationships with their partner and infant (Nicholls and Ayers, 2007; Parfitt et al., 2013). These disorders can be inter-related in that fear of childbirth can arise as a result of a previous traumatic birth experience. The important point for midwifery is that both disorders are potentially preventable or reducible through appropriate midwifery and perinatal mental health care. This special issue of Midwifery focusses on fear of childbirth and postnatal PTSD in order to inform our understanding and hence prevention and treatment. As a relatively new area of research there are still many gaps in our knowledge. However, research is rapidly increasing and this journal includes papers on key issues as well as reviews synthesising the evidence. The first section focusses on fear of childbirth and includes papers on the aetiology of fear of childbirth, women's perceptions of morbidity, and midwives views on antenatal management. The second section focusses on postnatal PTSD and includes papers examining diagnostic criteria, the role of support, the impact on women, and treatment. Consideration of fear of childbirth, PTSD, and how papers in this issue contribute to our knowledge is provided below.