This longitudinal population-based study aimed to investigate the prospective relationship between PTSD symptoms following childbirth and prenatal attachment in the subsequent pregnancy. Data were derived from the Norwegian Akershus Birth Cohort (ABC), a large population-based prospective cohort study. Data from 1473 women who had given birth at least once before and who had completed questionnaires at 17 and 32 weeks of gestation were included. Confirmatory factor analysis of the short version of the Prenatal Attachment Inventory was conducted to validate the scale. Further, structural equation modeling techniques were used to estimate prospective associations of PTSD symptoms following childbirth with prenatal attachment. Finally, to explore potential mechanisms of the association, mediation and moderation analyses were conducted. PTSD symptoms following previous childbirth were found to be prospectively related to higher levels of prenatal attachment in the subsequent pregnancy, while controlling for important confounding factors, such as symptoms of maternal depression and anxiety, previous pregnancy loss, and sociodemographic factors (maternal age, educational level, marital status, and number of children). When fear of childbirth was included as a potential mediating variable, the prospective relationship between PTSD symptoms following childbirth and prenatal attachment in the subsequent pregnancy increased, thereby indicating a suppressor effect. Fear of childbirth did not act as a significant moderator. Our findings suggest that a subsequent pregnancy following a traumatic childbirth may for some women represent an opportunity for a higher level of prenatal attachment, whereas high levels of fear of childbirth may be detrimental for prenatal attachment.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Tax calculation will be finalised during checkout.
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
Tax calculation will be finalised during checkout.
Alhusen JL, Gross D, Hayat MJ, Rose L, Sharps P (2012a) The role of mental health on maternal-fetal attachment in low-income women. J Obstet Gynecol Neonatal Nurs 41:E71–E81. https://doi.org/10.1111/j.1552-6909.2012.01385.x
Alhusen JL, Gross D, Hayat MJ, Woods AB, Sharps PW (2012b) The influence of maternal–fetal attachment and health practices on neonatal outcomes in low-income, urban women. Res Nurs Health 35:112–120. https://doi.org/10.1002/nur.21464
American Psychiatric Association (APA) (2013) Diagnostic and statistical manual of mental disorders: DSM-V. American Psychiatric Association, Washington, DC
Ayers S, Wright DB, Thornton A (2018) Development of a measure of postpartum ptsd: the City Birth Trauma Scale 9 https://doi.org/10.3389/fpsyt.2018.00409
Beck CT, Watson S (2010) Subsequent childbirth after a previous traumatic birth. Nurs Res 59:241–249
Bollen KA (1989) Structural equations with latent variables. Wiley, New York
Bosquet Enlow M, Egeland B, Carlson E, Blood E, Wright RJ (2014) Mother-infant attachment and the intergenerational transmission of posttraumatic stress disorder. Dev Psychopathol 26:41–65. https://doi.org/10.1017/s0954579413000515
Bowlby J (2005) A secure base. Clinical applications of attachment theory, 2nd edn. Routledge Classics, New York
Brandon AR, Pitts S, Denton WH, Stringer CA, Evans HM (2009) A history of the theory of prenatal attachment. Journal of Prenatal & Perinatal Psychology & Health 23:201–222
Brodén M (2007) Graviditetens Muligheter, 2nd edn. Akademisk Forlag, Copenhagen
Cannella BL (2005) Maternal–fetal attachment: an integrative review. J Adv Nurs 50:60–68. https://doi.org/10.1111/j.1365-2648.2004.03349.x
Cook N, Ayers S, Horsch A (2017) Maternal posttraumatic stress disorder during the perinatal period and child outcomes: a systematic review. J Affect Disord 225:18–31. https://doi.org/10.1016/j.jad.2017.07.045
Cox JL, Holden JM, Sagovsky R (1987) Detection of postnatal depression. Development of the 10-item Edinburgh postnatal depression scale. Br J Psychiatry J Ment Sci 150. https://doi.org/10.1192/bjp.150.6.782
Cranley MS (1981) Development of a tool for the measurement of maternal attachment during pregnancy. Nurs Res 30:281–284
Davies J, Slade P, Wright I, Stewart P (2008) Posttraumatic stress symptoms following childbirth and mothers’ perceptions of their infants. Infant Ment. Health J 29:537–554
Eberhard-Gran M, Eskild A, Tambs K, Schei B, Opjordsmoen S (2001) The Edinburgh Postnatal Depression Scale: validation in a Norwegian community sample. Nord J Psychiatry 55:113–117
Ehlers A, Clark DM, Hackmann A, McManus F, Fennell M (2005) Cognitive therapy for post-traumatic stress disorder: development and evaluation. Behav Res Ther 43:413–431
Favrod C, Holmes EA, Vial Y, Morisod Harari M, Horsch A (2018) Spontaneous childbirth-related mental images among pregnant women: a mixed-method study. J Reprod Infant Psychol 36:393–405. https://doi.org/10.1080/02646838.2018.1472749
Figueiredo B, Costa R, Pacheco A, Pais ÁJM, Journal CH (2009) Mother-to-infant emotional involvement at birth. 13:539–549. https://doi.org/10.1007/s10995-008-0312-x
Garthus-Niegel S, Størksen HT, Torgersen L, Von Soest T, Eberhard-Gran M (2011) The Wijma Delivery Expectancy/Experience Questionnaire – a factor analytic study. J Psychosom Obstet Gynecol 32:160–163. https://doi.org/10.3109/0167482X.2011.573110
Garthus-Niegel S, von Soest T, Vollrath M, Eberhard-Gran M (2013) The impact of subjective birth experiences on post-traumatic stress symptoms: a longitudinal study Archives of Women’s Mental Health:1–10
Garthus-Niegel S, Knoph C, von Soest T, Nielsen CS, Eberhard-Gran M (2014a) The role of labor pain and overall birth experience in the development of posttraumatic stress symptoms: a longitudinal cohort study. Birth 41:108–115. https://doi.org/10.1111/birt.12093
Garthus-Niegel S, von Soest T, Knoph C, Simonsen TB, Torgersen L, Eberhard-Gran M (2014b) The influence of women’s preferences and actual mode of delivery on post-traumatic stress symptoms following childbirth: a population-based, longitudinal study. BMC Pregnancy Childbirth 14:191. https://doi.org/10.1186/1471-2393-14-191
Garthus-Niegel S, Ayers S, von Soest T, Torgersen L, Eberhard-Gran M (2015) Maintaining factors of posttraumatic stress symptoms following childbirth: a population-based, two-year follow-up study. J Affect Disord 172:146–152. https://doi.org/10.1016/j.jad.2014.10.003
Garthus-Niegel S, Ayers S, Martini J, von Soest T, Eberhard-Gran M (2017) The impact of postpartum post-traumatic stress disorder symptoms on child development: a population-based, 2-year follow-up study. Psychol Med 47:161–170. https://doi.org/10.1017/s003329171600235x
Garthus-Niegel S, Horsch A, Ayers S, Junge-Hoffmeister J, Weidner K, Eberhard-Gran M (2018a) The influence of postpartum PTSD on breastfeeding: a longitudinal population-based study. Birth 45:193–201. https://doi.org/10.1111/birt.12328
Garthus-Niegel S, Horsch A, Bickle Graz M, Martini J, von Soest T, Weidner K, Eberhard-Gran M (2018b) The prospective relationship between postpartum PTSD and child sleep: a 2-year follow-up study. J Affect Disord 241:71–79. https://doi.org/10.1016/j.jad.2018.07.067
Garthus-Niegel S, Horsch A, Handtke E, von Soest T, Ayers S, Weidner K, Eberhard-Gran M (2018c) The impact of postpartum posttraumatic stress and depression symptoms on couples’ relationship satisfaction: a population-based prospective study 9 https://doi.org/10.3389/fpsyg.2018.01728
Gottvall K, Waldenstrom U (2002) Does a traumatic birth experience have an impact on future reproduction? BJOG Int J Obstet Gynaecol 109:254–260
Grekin R, O'Hara MW (2014) Prevalence and risk factors of postpartum posttraumatic stress disorder: a meta-analysis. Clin Psychol Rev 34:389–401. https://doi.org/10.1016/j.cpr.2014.05.003
Hart R, McMahon CA (2006) Mood state and psychological adjustment to pregnancy. Arch Womens Ment Health 9:329–337. https://doi.org/10.1007/s00737-006-0141-0
Hjelmstedt A, Widström A-M, Collins A (2006) Psychological correlates of prenatal attachment in women who conceived after in vitro fertilization and women who conceived naturally birth 33:303–310 https://doi.org/10.1111/j.1523-536X.2006.00123.x
Horowitz MJ, Wilner NN, Alvarez WW (1979) Impact of events scale: a measure of subjective stress. Psychosom Med:41. https://doi.org/10.1097/00006842-197905000-00004
Horsch A, Ayers S (2016) Chapter 39 - childbirth and stress A2 - fink, George. In: Stress: concepts, cognition, emotion, and behavior. Academic Press, San Diego, pp 325–330. https://doi.org/10.1016/B978-0-12-800951-2.00040-6
MacKinnon DP, Krull JL, Lockwood CMJPS (2000) Equivalence of the mediation. Prev Sci 1:173–181. https://doi.org/10.1023/a:1026595011371
McArdle JJ (1994) Structural factor analysis experiments with incomplete data multivariate behavioral research 29:409-454 https://doi.org/10.1207/s15327906mbr2904_5
Muller ME (1993) Development of the Prenatal Attachment Inventory. West J Nurs Res 15:199–211; discussion 211-195. https://doi.org/10.1177/019394599301500205
Muller ME, Mercer RT (1993) Development of the prenatal attachment inventory. West J Nurs Res 15:199–215
Muthén LK, Muthén BO (1998-2017) Mplus User's Guide, 6th edn. Muthén & Muthén, Los Angeles
Neal LA, Busuttil W, Rollins J, Herepath R, Strike P, Turnbull G (1994) Convergent validity of measures of post-traumatic stress disorder in a mixed military and civilian population. J Trauma Stress 7:447–455
Nettelbladt P, Hansson L, Stefansson CG, Borgquist L, Nordstrom G (1993) Test characteristics of the Hopkins Symptom Check List-25 (HSCL-25) in Sweden, using the Present State Examination (PSE-9) as a caseness criterion. Soc Psychiatry Psychiatr Epidemiol 28:130–133
Nilsen RM et al (2009) Self-selection and bias in a large prospective pregnancy cohort in Norway. Paediatr Perinat Epidemiol 23:597–608
Preis H, Benyamini Y, Eberhard-Gran M, Garthus-Niegel S (2018) Childbirth preferences and related fears - comparison between Norway and Israel. BMC Pregnancy Childbirth 18:362–362. https://doi.org/10.1186/s12884-018-1997-5
Redshaw M, Martin C (2013) Babies, ‘bonding’ and ideas about parental ‘attachment’. Journal of Reproductive and Infant Psychology 31:219–221. https://doi.org/10.1080/02646838.2013.830383
Rubertsson C, Pallant JF, Sydsjö G, Haines HM, Hildingsson I (2015) Maternal depressive symptoms have a negative impact on prenatal attachment – findings from a Swedish community sample. J Reprod Infant Psychol 33:153–164. https://doi.org/10.1080/02646838.2014.992009
Rubin R (1984) Maternal identity and the maternal experience. Am J Nurs 84:1480
Ryding EL, Wirfelt E, Wängborg I-B, Sjögren B, Edman G (2007) Personality and fear of childbirth 86:814-820 https://doi.org/10.1080/00016340701415079
Sawyer A, Ayers S (2009) Post-traumatic growth in women after childbirth. Psychol Health 24:457–471. https://doi.org/10.1080/08870440701864520
Sawyer A, Ayers S, Young D, Bradley R, Smith H (2012) Posttraumatic growth after childbirth: a prospective study. Psychol Health 27:362–377. https://doi.org/10.1080/08870446.2011.578745
Sawyer A, Nakić Radoš S, Ayers S, Burn E (2015) Personal growth in UK and Croatian women following childbirth: a preliminary study. J Reprod Infant Psychol 33:294–307. https://doi.org/10.1080/02646838.2014.981801
Schafer JL, Graham JW (2002) Missing data: our view of the state of the art. Psychol Methods 7:147–177. https://doi.org/10.1037/1082-989X.7.2.147
Sjogren B (1997) Reasons for anxiety about childbirth in 100 pregnant women. J Psychosom Obstet Gynaecol 18:266–272
Statistics Norway (2017). http://www.ssb.no/
Storksen HT, Garthus-Niegel S, Vangen S, Eberhard-Gran M (2013) The impact of previous birth experiences on maternal fear of childbirth. Acta Obstet Gynecol Scand 92:318–324. https://doi.org/10.1111/aogs.12072
Tedeschi RG, Park CL, Calhoun LG (1998) Posttraumatic growth: positive transformations in the aftermath of crisis. Lawrence Erlbaum Associates Publishers, Mahwah
Van den Bergh B, Simons A (2009) A review of scales to measure the mother–foetus relationship. J Reprod Infant Psychol 27:114–126. https://doi.org/10.1080/02646830802007480
Walsh J (2010) Definitions matter: if maternal–fetal relationships are not attachment, what are they? Arch Womens Ment Health 13:449–451. https://doi.org/10.1007/s00737-010-0152-8
Wijma K, Wijma B, Zar M (1998) Psychometric aspects of the W-DEQ; a new questionnaire for the measurement of fear of childbirth. J Psychosom Obstet Gynaecol 19. https://doi.org/10.3109/01674829809048501
Yarcheski A, Mahon NE, Yarcheski TJ, Hanks MM, Cannella BL (2009) A meta-analytic study of predictors of maternal-fetal attachment. Int J Nurs Stud 46:708–715
Yildiz PD, Ayers S, Phillips L (2017) The prevalence of posttraumatic stress disorder in pregnancy and after birth: a systematic review and meta-analysis. J Affect Disord 208:634–645. https://doi.org/10.1016/j.jad.2016.10.009
Supported by the Norwegian Research Council (project no. 191098), and a project grant from the Swiss National Science Foundation (grant number 32003B_172982/1 [to AH]).
Conflict of interest
The authors declare that they have no conflict of interest.
Informed consent was obtained from all individual participants included in the study.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Garthus-Niegel, S., Horsch, A., von Soest, T. et al. Posttraumatic stress symptoms following childbirth: associations with prenatal attachment in subsequent pregnancies. Arch Womens Ment Health 23, 547–555 (2020). https://doi.org/10.1007/s00737-019-01011-0
- Posttraumatic stress disorder
- PTSD following childbirth
- Prenatal attachment
- Fear of childbirth
- Akershus Birth Cohort