ORIGINAL RESEARCH

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 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.)
LEVEL OF EVIDENCE: II-2

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.

710

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.13
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.
MATERIALS AND METHODS
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

0029-7844/04/$30.00
doi:10.1097/01.AOG.0000119222.40241.fb

locations. Trained research assistants administered a

2-hour in-person interview using the Diagnostic Interview
Schedule9 and other study instruments. The Diagnostic
Interview Schedule, a well known standardized diagnostic
interview, assesses the presence of current and lifetime
psychiatric diagnoses based on symptom, severity, and
duration criteria in the American Psychiatric Associations
Diagnostic and Statistical Manual of Mental Disorders-IV.8
Following approval of the study protocol by the Institutional Review Board, research assistants obtained informed consent from eligible pregnant women who
sought services at their local Women, Infants and Children Supplemental Nutrition Program sites between
February 2000 and August 2001. Our original plan was
to sample participants from all the rural sites and representative urban sites. However, 2 sites in the city of St.
Louis and 1 rural site refused or were unable to participate in the study. Replacement sites in the same geographical areas were selected based on their willingness
to participate. All eligible women were then enrolled at
each site in the order in which they were identified.
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, thereby precluding
the random sampling of black and white subjects at each
site. Eligible women were enrolled at each site until their
numbers were proportional by race for women seen at
the respective site.
Inclusion criteria for subjects, in addition to race,
geographic location, and Women, Infants and Children
Supplemental Nutrition Program enrollment at any
point in their pregnancy, included being pregnant, having (or being eligible for) Medicaid coverage of health
services, and being able to speak English. Mothers as
young as 13 years old were included. Past interpretations
of Missouri statutes allow pregnant minors to consent to
medical care and participate in research without parental
consent. Exclusion criteria included cognitive impairment that interfered with understanding of the interview
questions. This was determined by having 12 or more
errors on the dementia section of the Diagnostic Interview Schedule. Only one subject was ineligible because
of cognitive impairment.
Of the total 878 women approached, 132 (15.0%)
refused to participate. Ninety-three (11.0%) initially refused to enroll, 14 (1.6%) were unavailable for scheduled
interviews, and 25 (2.8%) did not appear for their interviews. Of the 744 women who did participate in the
study, 428 (57.5%) were black, and 316 (42.5%) were
white (Table 1). Only 160 (21.5%) of the 744 women
were married. More women resided in the rural Missouri (439 of 744, 59.0%) than in the city of St. Louis (305
of 744, 41.0%). Two of 5 mothers (41.8%) or 311 partic-

VOL. 103, NO. 4, APRIL 2004

Table 1. Sociodemographic Characteristics of Sample (n

744)
Characteristic
Race
Black
White
Education*
High school
High school graduate
Vocational or some college
Bachelors 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 (57.5)
316 (42.5)
311 (41.8)
356 (47.8)
59 (7.9)
8 (1.1)
10 (1.3)
523 (70.3)
160 (21.5)
21 (2.8)
39 (5.3)
1 (0.1)
439 (59.0)
305 (41.0)
508 (68.3)
192 (25.8)
43 (5.9)
22.3 5.2
21.0
4.5 4.5
3.0

Values are n (%) unless otherwise specified.

* General Equivalency Diploma is coded as high school graduate.

Full-time work is 35 hours or more per week.

ipants had not finished high school. Maternal age ranged

from 13 to 43 years, with a mean of 22.3 5.2 (standard
deviation [SD]) years, and 171 of 744 (23.0%) enrollees
were under 19 years of age. Despite their relatively
young age, 192 of 744 (25.8%) reported having had at
least one serious medical problem in their lifetime.
One of 5, or 161 of the 744 subjects, were interviewed
during their first trimester of pregnancy. Another 303
(40.8%) were in their second trimester, and the remaining 279 (37.5%) were in their last trimester. Nine of 10
women (672 of 744) had their initial prenatal care visit in
their first trimester, with another 56 (7.5%) first receiving
care in their second trimester. Only 5 of 744 (0.7%)
women received prenatal care for the first time during
their last trimester, and 11 (1.5%) received no prenatal
care at all. Nearly 60%, or 428 of 744 of the women, had
experienced at least one previous live birth. Eighty-four
(18.8%) delivered a previous pregnancy more than 3
weeks early.
Posttraumatic stress disorder, treatment for the disorder, and 18 other common psychiatric disorders were

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Posttraumatic Stress Disorder in Pregnancy

711

measured by using the fourth version of the Diagnostic

Interview Schedule.9 This lay-administered standardized interview assesses diagnostic criteria in Diagnostic and
Statistical Manual of Mental Disorders-IV, as well as symptom counts, onset and recency of symptoms, degree of
disruption in work or social relationships, and treatment
in the previous 12 months. The posttraumatic stress
disorder module of the Diagnostic Interview Schedule
begins with a list of 17 traumatic events, including being
attacked or raped, experiencing combat conditions, seeing someone being seriously injured or killed, being
threatened with a weapon, or being in a natural disaster.
Subjects identify the worst event that ever happened to
them and then respond to questions about posttraumatic
stress disorder symptoms, age of exposure, onset of
symptoms, remission, and treatment. In this study, posttraumatic stress disorder during pregnancy was based on
symptoms occurring in the 12 months before and including the pregnancy interview. Treatment for posttraumatic stress disorder focused on whether or not subjects
talked to a physician or other health professional about
posttraumatic stress disorderrelated behaviors or feelings in the past year.
Measurement of sociodemographic characteristics
was based on items in the Diagnostic Interview Schedule.
Items adapted from the Pregnancy Risk Assessment
Monitoring System10 provided information on pregnancy history and environmental stressors. Developed
by the Centers for Disease Control, this instrument
assesses maternal health indicators related to prenatal
care, attitude about pregnancy, pregnancy-related morbidity, living conditions, and stressors.
Data entry with verification and statistical analyses
were conducted using SAS-PC 8 (SAS Institute, Cary,
NC). We used a 5-step analytic strategy. First, we created
descriptive statistics and summary profiles. Second, we
calculated the prevalence of current posttraumatic stress
disorder and assessed treatment for this disorder. Third,
we evaluated risk factors for posttraumatic stress disorder using 2 tests and Student t tests to identify any
significant differences in sociodemographic, pregnancy,
and environmental characteristics between women with
and those without posttraumatic stress disorder. Fourth,
we fitted logistic regression models to the data to determine the association between medical, environmental,
and pregnancy-related factors and posttraumatic stress
disorder. We tested our model for goodness of fit using
the Hosmer and Lemeshow statistic. Finally, 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.

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Posttraumatic Stress Disorder in Pregnancy

RESULTS
Of the 744 women in this study, 101 (13.6%) had a
diagnosis of posttraumatic stress disorder at some point
in their lives. One in 13 women (57 of 744, 7.7%) had a
current diagnosis of posttraumatic stress disorder. Another 0.9% (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. In comparison with other current
psychiatric disorders examined, posttraumatic stress disorder was the third most common, following major
depressive episode (80 of 744, 10.8%) and nicotine dependence (63 of 744, 8.6%).
Posttraumatic stress disorder is precipitated by exposure to one or more traumatic events. On average, the 57
women with current posttraumatic stress disorder had a
mean of 4.9 2.4 (SD) traumatic events over their
lifetime. The most common events included the unexpected death of a close friend or relative (48 of 57,
84.2%), having something terrible happen to a close
friend or relative (35 of 57, 61.4%), being sexually assaulted by a nonrelative (29 of 57, 50.9%), being mugged
or robbed (26 of 57, 45.6%), experiencing a natural
disaster (22 of 57, 38.6%), seeing someone killed or
seriously injured (22 of 57, 38.6%), being sexually assaulted by a relative (20 of 57, 35.1%), and being in a
serious accident (18 of 57, 31.6%). Twenty-one (36.8%)
of the 57 women experienced the traumatic event that
precipitated posttraumatic stress disorder before they
were 15 years old.
The most commonly reported symptoms of posttraumatic stress disorder were intrusive distressing recollections of the trauma (57 of 57, 100.0%), psychological
distress when exposed to cues resembling the trauma (55
of 57, 96.5%), difficulty concentrating (52 of 57, 91.2%),
irritability or outbursts of anger (51 of 57, 89.5%), and
avoidance of activities, places, or people associated with
the trauma (51 of 57, 89.5%). They were somewhat less
likely to report a sense of having a foreshortened future
(31 of 57, 54.4%) or an inability to recall important
aspects of the trauma (7 of 57, 12.3%).
Pregnant women with posttraumatic stress disorder
reported moderate impairment in their daily functioning
(mean 2.3 0.8 [SD]), based on a scale ranging from 0
(none) to 4 (severe). Twenty-eight of the 57 women with
current posttraumatic stress disorder (49.1%) reported
difficulties with family, friends, and/or work during the
same time period. Forty-one women (71.9%) reported 1
or more comorbid psychiatric disorders. Fourteen
(24.6%) had 1 comorbid psychiatric diagnosis, 12
(21.1%) had 2, and another 16 (26.2%) had 3 or more.

OBSTETRICS & GYNECOLOGY

Table 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
17.5
5.3
3.5
1.8
35.1

11.1, 31.3
9.8, 29.4
1.8, 14.4
1.0, 11.9
0.3, 9.3
24.0, 48.1

24
13
2
32

42.2
22.8
3.5
56.1

30.2, 55.0
13.8, 35.2
1.0, 11.9
43.3, 68.2

10
6
2
1
1
1
13

17.5
10.5
3.5
1.8
1.8
1.8
22.8

9.8, 29.4
4.9, 21.1
1.0, 11.9
0.0, 9.3
0.0, 9.3
0.0, 9.3
13.8, 35.2

1
41

1.8
71.9

0.0, 9.3
59.2, 81.9

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.

The most prevalent categories of comorbid diagnoses for

women with posttraumatic stress disorder were mood
disorders, followed by anxiety and substance-related
disorders (Table 2). Of individual comorbid diagnoses,
the most prevalent was major depressive episode (24 of
57, 42.2%). Other common diagnoses included manic
episode (13 of 57, 22.8%), generalized anxiety disorder
(11 of 57, 19.3%), nicotine dependence (10 of 57, 17.5%),
and social phobia (10 of 57, 17.5%). Relatively few
women reported alcohol abuse or dependence, despite
its known association with posttraumatic stress disorder.
On average, women with posttraumatic stress disorder
in this study had 1.8 1.7 (SD) comorbid diagnoses.
Only 7 of the 57 women with current posttraumatic
stress disorder (12.3%) received treatment in the previous year for this disorder. One fourth of the women (15
of 57, 26.3%) wanted treatment for posttraumatic stress
disorder but did not receive it. The remaining subjects
(35 of 57, 61.4%) neither wanted nor received treatment
for this disorder. Of the 50 women who did not receive
posttraumatic stress disorder treatment in the previous
year, 8 did receive treatment for another psychiatric
diagnosis. There were no statistically significant differences in sociodemographic characteristics between
women who did and did not receive treatment. However, women who received services had significantly
more comorbid psychiatric disorders than those who did

VOL. 103, NO. 4, APRIL 2004

not receive services (mean 2.6 2.0 [SD] and 1.5 1.5
[SD], respectively; t 2.26, P .05). We found no
significant differences between the 2 groups in level of
impairment in the year before the interview.
The next analyses focused on identifying those characteristics associated with risk for posttraumatic stress
disorder, including sociodemographic, environmental,
and medical risk factors (Table 3). Although sociodemographic characteristics were not significantly different for
women with and those without posttraumatic stress disorder, 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, generalized anxiety disorder,
drug dependence or abuse, and nicotine dependence.
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. 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.
A statistical model was developed to identify risk
factors that would facilitate the clinical identification of
pregnant women with posttraumatic stress disorder. By
using logistic regression, risk factors were identified that
significantly differentiated women with and without the

Cook et al

Posttraumatic Stress Disorder in Pregnancy

713

Table 3. Sociodemographic, Environmental, 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 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)

29
34
30
43
12

50.9
59.7
52.6
75.4
21.1

401
405
281
541
95

58.4
59.0
40.9
78.8
13.8

1.21
0.01
2.98
0.34
2.23

.27
.92
.08
.56
.14

28
17
3
6
7
24
10
7
2
11

49.1
29.8
5.3
10.5
12.3
42.9
17.9
12.5
3.5
19.3

222
175
69
34
102
56
52
19
6
16

32.4
25.6
10.0
5.0
14.9
8.2
7.7
2.8
0.9
2.3

6.62
0.50
1.38
3.22
0.28
64.9
5.87
14.5
3.43
43.4

.01
.48
.24
.07
.58
.001
.01
.001
.06
.001

37
12
54
25

64.9
21.4
94.7
43.9

284
61
444
173

41.5
9.0
64.7
25.2

11.8
8.8
21.5
9.4

.001
.003
.001
.002

LBW low birth weight.

* High environmental stress was defined as experiencing 5 or more stressful life experiences in the last 12 months. 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.

Physical abuse could be perpetrated by anyone, including the subjects partner, family member, friend, acquaintance or stranger.

Multiple trauma was defined as having experienced 2 or more traumas.

disorder. As shown in Table 4, pregnant women with

posttraumatic stress disorder had 5 times the adjusted
odds of having a major depressive episode (OR 5.17;
95% CI 2.61, 10.26) and more than 3 times the adjusted
odds of generalized anxiety disorder (OR 3.25; 95% CI
1.22, 8.62). Women with the disorder were more than 6
times as likely to have experienced 2 or more traumatic
events in their lives (OR 6.61; 95% CI 1.97, 22.22).

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 1.89;
95% CI 1.01, 3.54). The Hosmer and Lemeshow goodness-of-fit test statistic was 1.06 with 7 degrees of freedom
and a P value of .99. Because the statistic of 1.06 exceeds
.05, we rejected the null hypotheses and concluded that
the data fit the specified model.

Table 4. Risk Factors Associated With Posttraumatic Stress Disorder in Pregnant Women (n 744)
Risk factor*

Adjusted odds ratio

95% Confidence interval

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

1.22
5.17
1.49
1.49
3.25
1.21
1.39
6.61
1.89

0.65, 2.27
2.61, 10.26
0.57, 3.87
0.43, 5.08
1.22, 8.62
0.64, 2.31
0.60, 3.25
1.97, 22.22
1.01, 3.54

.54
.001
.41
.53
.02
.56
.45
.002
.05

* Coding categories of risk factors were as follows: 1 present and 0 not present; all are in the last 12 months unless otherwise specified.

Derived from multiple logistic regression, the adjusted odds ratios reflect the odds of posttraumatic stress disorder adjusted for the other risk
factors in the model.

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OBSTETRICS & GYNECOLOGY

DISCUSSION
In this study of economically disadvantaged pregnant
women, posttraumatic stress disorder was the third most
common psychiatric disorder, with a prevalence of 7.7%,
closely paralleling the 8.1% reported earlier by Ayers et
al.11 The lifetime prevalence of posttraumatic stress disorder (13.6%) also corresponds to that found in the
general population of pregnant and nonpregnant women.4 7 Despite comparable rates in other studies, our
findings may not be generalizable to pregnant women
from higher socioeconomic levels or to women who are
not black or white. Some research reports higher rates of
posttraumatic stress disorder in low-income populations.12 Another factor that could influence generalizability is sampling from only urban and rural sites in a single
state. Despite these limitations, posttraumatic stress disorder is common enough to be a clinical concern, particularly because the biological and psychological symptoms of this disorder may directly or indirectly affect
birth outcomes. Breslau et al6 found that posttraumatic
stress disorder significantly increased the probability of
alcohol abuse and dependence. Although the use of
alcohol may temporarily alleviate anxiety, promote
sleep, and erase memories of trauma, its negative effect
on fetal health is well documented.13 Neuroendocrine
changes associated with chronic stress influence maternalfetal health, including maternal vulnerability to hypertension and increased susceptibility to infection.14,15
Posttraumatic stress disorder may exert similar effects,
although no known research has documented this relationship in pregnant women. However, research links
high-risk behaviors to persons with posttraumatic stress
disorder. Many of these behaviors, such as smoking,
poor nutrition, and interpersonal violence, have known
negative consequences for both pregnant women and
their newborns.9,16 In a recent study, women with posttraumatic stress disorder had more complications of
pregnancy, including more ectopic pregnancies, miscarriages, hyperemesis, and preterm contractions than their
counterparts without posttraumatic stress disorder.17
The underlying mechanisms of how this disorder affects
these outcomes are unknown.
Only 12.3% (7 of 57) of the women with posttraumatic
stress disorder received treatment for this disorder. 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. Among
women who have been sexually abused, avoidance of
reminders of the trauma may hinder their seeking
needed health care services, including intrusive medical
procedures in prenatal care. Yet it is the prenatal care

VOL. 103, NO. 4, APRIL 2004

setting itself that offers an ideal opportunity to identify

pregnant women with posttraumatic stress disorder and
make referrals for mental health treatment. 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.
Several factors are involved in the low treatment rates
among pregnant women with posttraumatic stress disorder. Despite Medicaid coverage, mental health services
are often limited in rural and inner city areas in this
country. When services do exist, barriers to their access
may be prohibitive, such as lack of transportation, inadequate child care, housing problems involving relocation, and long waiting times for appointments. Another
factor may involve womens perceptions of their need
for services. In this study, a large proportion of women
reported they did not want treatment. 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.18 Another consideration is the often painful re-experiencing
of trauma that can be inherent in the treatment of this
disorder. Women with posttraumatic stress disorder also
may have limited understanding of the value of mental
health treatment, a disincentive cited by the New Freedom Commission on Mental Health.19 More likely,
however, posttraumatic stress disorder may not be identified in prenatal care settings, and thus treatment referrals are not even made.
The importance of adequate screening and treatment
of posttraumatic stress disorder during pregnancy is
strongly supported in the literature. Prenatal assessments should detect those who need more extensive
evaluation of posttraumatic stress disorder and provide
treatment for the disorder. Greater awareness of symptoms related to this disorder, such as fear of pelvic
exams, difficulty with reduction of tobacco or other
substance use, and anxiety that seems disproportionate
to presenting circumstances, will enhance more effective
responses by health professionals. An informed approach to helping women with these problems is likely to
increase compliance with prenatal care visit schedules
and health-promoting behavior.
With the substantial overlap between symptoms of
posttraumatic stress disorder and those of depression
and anxiety disorders, health providers in both prenatal
and primary care settings may miss the diagnosis of the
disorder. In this study, some women with posttraumatic
stress disorder received treatment, but it was for another
psychiatric disorder. Optimal outcomes for women with

Cook et al

Posttraumatic Stress Disorder in Pregnancy

715

posttraumatic stress disorder and co-occurring psychiatric diagnoses is associated with treating them simultaneously, rather than one after the other.20 For example,
overlapping treatment for both posttraumatic stress disorder and the most common co-occurring diagnosis,
depression, can include cognitive-behavioral therapy
and antidepressant medications. Unique approaches to
treatment for posttraumatic stress disorder, however,
may also include eye movement desensitization and
reprocessing and exposure therapy.
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, 3 times more likely to have generalized anxiety
disorder, and more than 6 times more likely to have a
history of multiple traumatic events. Screening for posttraumatic stress disorder based on multiple traumatic
events is likely to contribute to the unnecessary reliving
of these experiences. However, commonly used brief
assessments for depression, spousal abuse, and domestic
violence could be used to prescreen for the disorder.
Research demonstrates that many obstetrician gynecologists already conduct varying degrees of screening
for depression in their practice.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.22 Comprising 7 questions on symptoms, 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.
The high prevalence of posttraumatic stress disorder
and low rates of treatment, whether from inadequate
identification of the disorder in clinical practice, lack of
knowledge about available treatment, or inaccessible
mental health services, supports the provision of comprehensive treatment in prenatal care settings. Approaches to helping women with posttraumatic stress
disorder include offering supportive counseling, teaching stress reduction techniques, initiating support
groups, supporting continuity of care with the same
provider, scheduling more frequent visits, and initiating
nurse telephone calls between visits. Although women
diagnosed with depression may also benefit from these
treatment approaches, those with both posttraumatic
stress disorder and depression may require additional
mental health services. Ultimately, 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.

716

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Posttraumatic Stress Disorder in Pregnancy

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Address reprint requests to: Dr. Cynthia A. Loveland Cook,
Saint Louis University, School of Social Service, 3550 Lindell
Boulevard, St. Louis, MO 63103; e-mail: cookca@slu.edu.
Received September 10, 2003. Received in revised form January 12,
2004. Accepted January 15, 2004.

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