Title: Preventing Post Traumatic Stress Disorder : the Stress and Wellbeing after Childbirth Study (STRAWB)
Funder: Department of Health and Social Care

Abstract: Background Post traumatic stress disorder (PTSD) after childbirth is major cause of psychological distress postnatally, with 3% of women suffering at full diagnostic levels and 5-9% when sub-diagnostic levels (partial PTSD) are included. It adversely affects women s functioning at a critical time for family relationship development. Women with PTSD experience intrusions, repeatedly reliving the traumatic event with images, thoughts and feelings as if back in the original situation. They try to avoid situations or people that may trigger intrusions thereby restricting their life. Relationships, such as with the partner, are adversely affected as the woman feels irritable and constantly under threat. The developing mother-infant relationship can be compromised with negative effects on the infant s emotional and cognitive development. Experiencing an event as traumatic does not inevitably lead to PTSD. Intrusive experiences can be normal early responses to traumatic events. Where women view these intrusive responses as signs of illness or failure to cope and they attempt to avoid these responses this contributes to traumatic memories not being processed in a normal way. It is the unprocessed memories that lead to the flashbacks and nightmares that are characteristic of PTSD. There is therefore potential to prevent the development of PTSD. We have developed and feasibility tested the following through a one year funded study(RCF 2012-13 07): 1) A simple screening tool for use by community midwives to identify women who have experienced birth as traumatic. 2) Self help material derived from the theoretical mechanisms about how PTSD develops. 3) A brief training programme to enable midwives to implement both screening and provision of self help material. The self help material incorporates: 1) Simple explanations as to why women may experience early distressing responses to normalize these responses and reduce their negative evaluation. 2) Explanation why it is important not to block unpleasant images and thoughts and just allow them to be there without either distracting or dwelling on them with simple guided exercises to achieve this. 3) Explanation of how discussion in a supported context helps memory processing and provides an exercise to identify a suitable person, time and place with whom to do this. 4) An exercise using implementation intentions (evidence-based ways of translating plans into actions). This aims to help women translate their new understandings into actions. Aim To assess whether the introduction of a routine programme of identification of women who have experienced their childbirth as traumatic, and the provision of self help material to prevent PTSD improves outcomes when compared to usual care. If this is confirmed what is the cost per case prevented? Research Plan 2640 women will be screened early postnatally (between 7 and 28 days) by community midwives to assess whether they experienced their birth as traumatic. Data from our external pilot work suggests 25% will screen positive. These women will be randomised, 330 per arm, to receive the self help material or usual care. Women will be followed up with the gold standard assessment for PTSD which will be completed by phone at 6-8 weeks postnatally. Data will be analysed using standard summary statistics and hypothesis tests. A cost per PTSD case prevented analysis will be completed. Benefits to Patients and NHS This project has the potential to provide a simple system to reduce the incidence of full and partial PTSD after childbirth that can be readily incorporated into the current care pathway. This will benefit the mental health of women and the quality of relationships with partner and infant. PTSD once established is chronic and treatment is expensive. The current work if successful can substantially reduce NHS care costs.

Lay abstract: Aim(s) To prevent post traumatic stress after childbirth by midwives providing psychological self help material to women whose childbirth has been traumatic. Background Experiencing an event where a person feels their life or another s life has been threatened can lead to post traumatic stress symptoms. These involve reliving the event, having nightmares and intrusive thoughts and images. It leads to a person avoiding activities that can trigger reminders and feeling on edge and irritable. Feeling like this early postnatally at a time when a woman is forming a relationship with her new baby is particularly harmful. Not everyone who has a traumatic event develops post traumatic stress symptoms. These come about because the person has been so distressed by their early responses to the traumatic event they have avoided thinking and talking about them so the brain has been unable to process the unpleasant memories. Understanding what can be distressing but normal responses and reacting to them in a way that can help the brain to make sense of these can help prevent post traumatic stress developing. Design and methods Midwives will identify women who were highly fearful for themselves or their baby in childbirth. Half these women will be given the self help material which includes mental exercises to manage any responses and half will have usual care. We will contact women a month later to assess how many in each group have developed post traumatic stress symptoms. We will also gain their views whether they have needed and used the information. Patient and public involvement The study has been designed with detailed input from the Birth Trauma Association(BTA) and a local expert by experience. Dissemination. Information about effectiveness will be publicised by the BTA, fedback to midwives, and staff responsible for perinatal mental health pathways across the country.

Research activity codes: 7.1 INDIVIDUAL CARE NEEDS
Health categories: MENTAL HEALTH;REPRODUCTIVE HEALTH AND CHILDBIRTH