Many women experience traumatic events already prior to or during pregnancy, and delivery of a child may also be perceived as a traumatic event, especially in women with prior post-traumatic stress disorder (PTSD). PTSD is one of the most debilitating mental disorders and the 12-month prevalence in the German general population is 2.3% (95%CI: 1.8–2.9) (1). Women are more often affected by PTSD than men (12 month-rate in women and men: 3.6%; 95%CI: 2.8–4.7; and 0.9%, 95%CI: 0.6–1.5) and most of them experience traumatic events already prior to pregnancy (1). Still, the peripartum period is considered to be a vulnerable time frame for the onset, recurrence, and exacerbation of PTSD symptoms and other mental disorders in women (e.g., peripartum anxiety and depressive disorders) (2). Due to traumatic experiences prior to or during pregnancy about 3.3% of pregnant women suffer from PTSD and prevalence rates in risk populations (e.g., history of intimate partner violence) are even higher (about 18%) (3). In addition, up to one-third of women who have recently given birth describe their birth experience as traumatic (4), up to 10% suffer from clinically relevant posttraumatic stress symptoms during the first weeks thereafter (5–8), and up to 4% develop the full clinical picture of PTSD (3, 7, 9, 10). The prevalence of postpartum PTSD is even higher in at-risk populations (e.g., up to 19% after preterm delivery, emergency cesarean section, or still birth) (3, 7, 9, 10).

Birth-related PTSD might be unique in several ways, and it seems important to distinguish between lifetime PTSD and birth-related traumatization. Birth experience may become traumatic if the birth involves actual or threatened death or an injury for a woman or for the infant (2, 11, 12). Birth-related traumatization affects the mother-child-dyad and childcare of the baby might trigger maternal traumatic memories of birth. Given that childcare is usually associated with an increased vigilance, the hyperarousal criteria should be considered with caution. Risk factors of birth-related traumatization are a history of sexual trauma and intimate partner violence, depression or anxiety in pregnancy, fear of childbirth, complications during pregnancy, obstetric interventions/ operative delivery, peripartum infant complications, a subjective negative birth experience, and perception of inadequate intrapartum care or lack of social support (5, 11–14).

Both, lifetime PTSD and birth-related traumatization may be associated with postpartum depressive and anxiety disorders, whereas the relation to pregnancy- and child-related fears is less studied (5, 15–17). Moreover, PTSD in the context of pregnancy and childbirth might affect the partnership (e.g., sexual problems) and the mother-child-dyad (e.g., bonding) (16, 18, 19). For instance, traumatic memories or re-experiencing of the childbirth might reduce emotional availability of the mother to the infant, especially if the infant serves as a trigger of the event. This, in turn, could be crucial for the type of attachment the infant develops to the mother. Mother-child dyads may be further fragiled by the numbness affected women are likely to perceive (20). Some studies showed that birth-related PTSD symptoms are associated with bonding and breastfeeding difficulties that may have long-term health implications for infants (21, 22). In addition, symptoms of hyperarousal and intrusion might lead to impaired childcare and interaction with the child (e.g., angry or intrusive interaction) (19, 23, 24) and comorbid maternal depression might contribute additionally to parenting impairment (25, 26). A review by Christie et al. (27) found that parental PTSD was associated with impaired functioning across various parenting domains and less optimal parent-child relationships (27). The Perinatal Interactional Model of Intergenerational transmission of traumatization proposes that maternal PTSD leads to suboptimal caregiving behavior and parent-child interactions, which undermine child regulatory capacity and increase distress leading to poorer social-emotional outcomes for offspring of parents with PTSD (28). Moreover, Pat-Horenczyk et al. (29) suggested the idea of relational emotional regulation in which difficulties with emotion regulation pass from mother faced with trauma to the child (29). In line with this, Davies and colleagues showed that women with postpartum PTSD symptoms following childbirth and postpartum depression perceive their attachment relationships to be less optimal and rated their infants as being temperamentally more difficult and less easy to soothe as compared to non-symptomatic women (9). Moreover, some prospective studies found maternal postpartum PTSD to be associated with difficult temperament and/ or poorer cognitive and social-emotional development in infants up to 2 years (19, 30). Especially interpersonal trauma might be crucial for the relation between mother and child and for early child development (e.g., neuropsychological development) (2, 31, 32).

To investigate research question 1, analyses were based on the following three diagnostic groups:

Women with PTSD prior to or during pregnancy were characterized by a lower educational level (education: ≤ 10 years: reference: 25.0%, PTSD prior to or during pregnancy: 52.0%; Chi²=6.891, p = 0.009) compared to women with neither anxiety nor depressive disorder until delivery (Table 1). Moreover, women with PTSD prior to or during pregnancy reported more often nicotine consumption during pregnancy (16.0% vs. 3.0%; Chi²=6.394, p = 0.001) and lower social support during pregnancy (F-Sozu: M=4.1, SD=0.7 vs. M=4.5, SD=0.4; t = 3.122, p > 0.001) as compared to the reference group. There were no significant differences between the groups with regard to age, marital status, and monthly household income (Table 1).

Table 2 shows maternal and infant outcomes in women with PTSD prior to or during pregnancy compared with or without interpersonal trauma (N = 25) to women with neither anxiety nor depressive disorder until T3 (N = 100). Women with history of PTSD reported more fear of childbirth and fear of epidural anesthesia and perceived delivery more often as traumatic (including re-experiencing delivery later on). Moreover, infants of women with PTSD prior to delivery and interpersonal trauma (N = 17) were at higher risk for feeding problems.

To investigate research question 2, analyses were based on the following three diagnostic groups:

Table 3 shows maternal and infant outcomes in women with birth-related traumatization compared to women with neither anxiety nor depressive disorder until T3 and no birth-related traumatization. A higher risk for child-related fears, postpartum anxiety disorders, and sexual problems was reported by women with birth-related traumatization. Moreover, infants of mothers with birth-related traumatization and postpartum depression were at higher risk for feeding and sleeping problems.

This prospective longitudinal study demonstrated that (1) women with PTSD prior to or during pregnancy presented with a disadvantageous psycho-social situation, reported more pronounced fear of childbirth, and indicated more often a traumatic birth experience compared to women without anxiety and depressive disorder prior to delivery. Moreover, infants of women with PTSD and interpersonal trauma, had a higher risk for feeding problems. (2) Women with birth-related traumatization indicated numerous adverse outcomes (e.g., postpartum anxiety and depression, child-related fears, sexual problems), and in case of additional postpartum depression, the infants were more often affected by feeding and sleeping problems.

The first research question examined the associations of PTSD prior to or during pregnancy with specific maternal and infant outcomes. As expected and in line with previous research, women with PTSD prior to or during pregnancy reported more often pregnancy- and child-related fears and they were further at higher risk for a traumatic birth experience compared to women without anxiety and depressive disorder prior to delivery (12). Moreover, those women presented with a disadvantageous psycho-social situation (lower educational level, less social support) and indicated more often nicotine consumption during pregnancy (66, 67). These factors can be associated with a cascade of behavioral health and neuroendocrine changes that may not only have negative consequences for the affected women, but also for the infants (68, 69). Regarding the current discussion on intergenerational transmission of trauma effects it is particularly interesting that women with lifetime PTSD reported more pronounced pregnancy-related fears (70). Yehuda and Lehrner recently highlighted that preconception trauma in parents might be associated with epigenetic changes and developmentally programmed effects that can result from offspring's early environmental in utero and postnatal exposures leading to an increased susceptibility of the infant to later environmental distress (70, 71). We found a higher risk for infant regulatory disorders (feeding problems) in mothers with PTSD prior to or during pregnancy and interpersonal traumata (2, 28, 29, 31, 32). However, no significant associations were seen for e.g., temperament, neuropsychological development, or bonding. One explanation could be that lifetime PTSD was not present anymore during the perinatal period in some of the women due to recovery or successful therapy. However, it still seems to be relevant for the development of infant feeding problems in case of interpersonal trauma. Another explanation might be the limited statistical power to detect differences between the respective groups (see limitations section).

The second research question pertains to birth-related traumatization. As expected, women with birth-related traumatization reported more often sexual problems as compared to the reference group (12). Given that sexual problems impede the partnership or interfere with further family planning, affected women might profit from targeted early interventions supporting them and their partners to successfully cope with sexual dysfunctions and associated problems (18, 72). In line with previous evidence, women with birth-related traumatization reported more often postpartum anxiety and depressive disorders as compared to the reference group (12). This is important to note, since traumatic birth experience might change the way affected mothers interact with their infants, especially if postpartum depression is also present (e.g., avoiding contact with or being emotionally unavailable for the infant) (73, 74). Moreover, we saw a higher risk for infant regulatory disorders (sleeping and feeding problems) in mothers with birth-related traumatization and postpartum depression. This was in line with the results by Garthus-Niegel and colleagues who reported an association of PTSD and impaired child sleep (75). However, no significant associations were seen for e.g., temperament, neuropsychological development, or bonding. This was surprising since other prospective studies found maternal postpartum PTSD to be associated with poorer cognitive and social-emotional development in infants up to 2 years (19, 30). However, Garthus-Niegel et al. (19) did not find significant associations with other domains of child development (fine/gross motor or communication development) which was also not seen in our sample (19).

Taken together, our findings highlight the importance of early targeted prevention and intervention for affected women (20) and the peripartum period represents an opportunity to interrupt the pattern of intergenerational transmission of trauma. Knowledge of PTSD prior to or during pregnancy that is also associated with a higher risk of traumatic birth experience (e.g., experience of fear, helplessness or horror, or re-experiencing delivery) is crucial for health-care providers to be alert of when they treat these high-risk women (20, 76). Moreover, trauma-informed interventions should be developed and tested especially for women with PTSD and a history of interpersonal trauma or comorbid depression (74, 77). Targets that should be addressed are prevention of re-traumatization during delivery, improvement of maternal partnership problems and social support, and sensitivity training to encourage mother-child-interaction and bonding/ attachment (78–80). First evidence shows that cognitive behavioral therapy (81) and Eye Movement Desensitization and Reprocessing approaches (82–84) may improve PTSD status but require investigation in randomized controlled trials (85). Debriefing may only be successful if women are requesting it themselves (86). Since PTSD can also affect the developing relationship with the child, mother-infant bonding problems should also be addressed (20, 23). For some mothers, their infants are a reminder of their traumatic birth and may therefore trigger avoidance behaviors (i.e., non-initiation of breastfeeding) (21). Here, Mother Baby Connections, a program involving interaction therapy, has brought first promising results (87).

The study shows that PTSD is a highly debilitating disorder and affected (expectant) mothers might profit from early interventions already during pregnancy and the initial postpartum period (89). Our results highlight the crucial role of early identification and treatment of affected women. Women's health care providers should screen for PTSD and subsyndromal posttraumatic stress symptoms in routine assessments during and after pregnancy, especially in women with a reported history of trauma. Such screening will allow women to receive needed treatment and referrals and mitigate the potentially negative sequelae of PTSD (14). However, screening without sufficient services is not helpful and could be triggering for both professionals and families. Thus, a fully trauma informed perinatal system and effective trauma specific interventions during pregnancy and immediately after traumatic births is warranted to ensure that the families receive help for parenting and early bonding (77).

Finally, this post-hoc analysis was conducted with the aim of generating hypotheses for future research. Larger prospective studies are warranted to examine why interpersonal trauma is especially harmful for perinatal outcomes, and to disentangle whether this is driven by the interpersonal trauma in general, or trauma related to mothers' own childhood attachment relationships. It will be important to examine the role of hormonal alterations and other biological or psychosocial factors in the context of perinatal PTSD and to include a comprehensive assessment on psychotherapeutic and pharmacological treatments. Finally, it is important to note, that paternal PTSD after childbirth is a highly understudied and unrecognized problem that should receive more attention.

The datasets presented in this article are not readily available because after consulting the Ethics Committee and due to the sensitive nature of the questions asked in this study, participants were assured that all raw data would remain confidential and would not be shared. Therefore, no openly assessable data files are attached. Further information on the data can be obtained from the corresponding author (JM, email: julia.martini@tu-dresden.de), the Ethics Committee of the Medical Faculty of the Technische Universität Dresden (email: ethikkommission@mailbox.tu-dresden.de), and the Institute of Clinical Psychology and Psychotherapy of the Technische Universität Dresden.

The studies involving human participants were reviewed and approved by Ethics Committee of the Technische Universität Dresden (No: EK 94042007). Written informed consent to participate in this study was provided by the participants' legal guardian.

JM conceptualized and designed the study, designed the data collection instruments, collected data for the study, carried out the statistical analyses and the interpretation of the data, drafted the initial manuscript, and approved the final manuscript as submitted. EA, SK, KW, JR, and SG-N critically reviewed the manuscript and approved the final manuscript as submitted. All authors contributed to the article and approved the submitted version.

The MARI study was funded by the Institute of Clinical Psychology and Psychotherapy, Technische Universität Dresden, Germany and supported in part by the Lundbeck Institute Skodsborg, Denmark. Parts of the field work were additionally supported by the Friends and Sponsors (Gesellschaft der Freunde und Förderer) of the Technische Universität Dresden, Germany.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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