Adolescent Psychological Birth Trauma Following Cesarean Birth. Cheryl Anderson RN, PhD, CNS and Christina Perez RN, BSN

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1 1 Birth trauma among adolescents Adolescent Psychological Birth Trauma Following Cesarean Birth 6 Cheryl Anderson RN, PhD, CNS and Christina Perez RN, BSN 7 University of Texas at Arlington, College of Nursing 8 PO Box 19407, Arlington, Texas (817) / Fax-(817) Author Note This research was supported in part by grants from Sigma Theta Tau International (STTI), Small Grants Awards; Delta Theta Chapter, STTI, the University of Texas at Arlington; the Sharon Davies Memorial Awards, Freedom from Fear; and the Hispanic Center in Nursing and Health, College of Nursing, University of Texas at Arlington 18 Keywords: childbirth stress, adolescents, depressive symptoms, cesarean birth, violence 1

2 2 Birth trauma among adolescents 19 Abstract This study explored associations between depressive symptoms, violence exposure, and psychological birth trauma (PBT) among 44 adolescents experiencing cesarean births. Within 72 hours postpartum, symptoms of PBT were measured via a subjective rating of the birth experience and the Impact of Event Scale (IES). The Edinburgh Postnatal Depression Scale measured depressive symptoms. Single questions assessed violence exposure including child abuse, partner violence, and traumatic life experiences as attribute variables. Adolescents were typically single with an unplanned, first pregnancy. A similar number of adolescents reported a negative or positive birth experience. Correlations between IES scores, parity, depressive symptoms, partner violence, gestational age, and a negative birth appraisal suggested interconnected prenatal vulnerabilities for birth trauma and adverse infant outcomes. Partner violence and depressive symptoms need continuous assessment throughout pregnancy. The potential for continued symptoms and presence of violence beyond discharge requires follow-up and education in pediatric settings at well-baby and routine visits

3 3 Birth trauma among adolescents Adolescent Psychological Birth Trauma Following Cesarean Birth Adolescent childbearing in the United States (US) continues to be recognized as a significant public health concern with consequential emotional, financial, and social issues (Mollborn & Morningstar, 2009). Childbearing adolescents are at high risk for depression, violence, and pregnancy complications (Barnet, Liu, & DeVoe, 2008; Rosen, Seng, Tolman, & Mallinger, 2007). Both psychological, such as depressed mood, and physiological maternal and infant complications can influence the need for a cesarean birth (Barber, et al., 2011; Salazar-Pousada, Arroyo, Hildalgo, Perez-Lopez, & Chedraui, 2010). Cesarean birth has been found to associate with both a negative birth appraisal and symptoms indicative of traumatic stress (Beck, 2004a; Gamble & Creedy, 2005). A past history of violence also has been linked with birth trauma (Ayers, 2004). The childbirth experience has been increasingly recognized as a potentially traumatic event (Ayers, 2004; Beck, 2004a; Zaers, Waschke, & Ehlert, 2008). Birth trauma is an event occurring during the labor and delivery process that involves actual or threatened serious injury or death to mother or infant (Beck, 2004b, p.53) and may interfere with a woman s normal stress response and coping ability (Gamble & Creedy, 2005). A birth experience can be wonderful or horrifying but a woman who feels traumatized by the childbirth experience can express feelings of terror and vulnerability (Zaers, Waschke, & Ehlert, 2008). Available literature reveals no consistent definition of traumatic birth or systematic way to assess birth trauma (Elmir, Schmied, Wilkes & Jackson, 2010). The determination of birth trauma resides in the eyes of the beholder (Beck, 2004a). Assessment is achieved through diagnostics or a screen of symptoms using a variety of measurement tools. Symptoms of acute severity can be time-limiting and fade within one month or suggest more psychological distress 3

4 4 Birth trauma among adolescents with continued, chronic symptomatology. A review of several studies by Ayers (2004) reflected that one in ten women may experience a traumatic stress response; 9% of women may display severe symptoms of posttraumatic stress disorder (PTSD). Often these women describe the childbirth experience with anger, panic, or feelings of being out of control, overwhelmed, and giving up, or dissociation, and thoughts of death (Beck & Watson, 2008; Simkin, 2011). Although several published studies have addressed birth trauma in adults, minimal research describes the birth trauma of adolescents. The purpose of our study is to explore associations between depressive symptoms, violence exposure, and psychological birth trauma (PBT) among adolescents experiencing a cesarean birth. Violence exposure includes report of child abuse, partner violence, and traumatic life experiences. PBT is operationalized through two measures: the adolescent s appraisal of the birth experience via a one item rating scale and a screen of symptoms for traumatic stress via the Impact of Event Scale (IES). Study Design and Methods Our exploratory, descriptive study used a convenience sample of 44 multi-ethnic adolescents who experienced a cesarean birth from two postpartum units of a large, county hospital serving primarily lower income minorities. The current sample represented all adolescents reporting a cesarean birth from a larger, longitudinal study exploring PBT over nine months postpartum; therefore, no power analysis was performed. Inclusion criteria were adolescents 13 to 19 years of age, English or Spanish speaking, experiencing a cesarean birth, and able to assent/consent or have parental consent as needed. Because of the limited research in this area we used minimal exclusion criteria including language limitations and fetal demise. Instruments 4

5 5 Birth trauma among adolescents We measured PBT via a subjective appraisal of the birth experience and symptoms of traumatic stress following childbirth through the Impact of Event Scale (IES) (Horowitz, Wilner, & Alvarez, 1979). We added a screen of depressive symptoms because of the recognized comorbidity between depression and posttraumatic stress (White, Matthey, Boyd, & Barnett, 2006). All instruments reflected assessment of symptoms for the prior week; therefore, antenatal symptoms are suggested. Spanish and English versions of all measurement tools were available and suitable to ninth grade reading abilities. Survey completion took 45 minutes. We assessed birth appraisal via one specific question which asked adolescents to rate their birth experiences between 1 ( great /non-traumatic) to 10 ( awful /traumatic). Arbitrarily one to three reflected a non-traumatic experience and eight to ten reflected a traumatic experience. For an objective indictor of traumatic stress we used the IES. A moderate correlation between birth appraisal and IES scores (rs =.418, p=.006) established convergent validity of both tools. The IES has adequate reliability of >0.80 reported for both adults and adolescents (Anderson & Logan, 2010; Davies, Slade, Wright, & Stewart, 2008) and 0.89 for the present study. The 15 item IES is scored from 0-5 for a total score; higher scores reflect more stressful impact due to trauma. Scores ranged between 0 and 8 (no symptoms), 9 and 25 (mild symptoms), 26 and 43 (moderate symptoms), and 44 to 75 (severe symptoms) (Horowitz et al., 1979). For depressive symptoms we used the 10 item Edinburgh Postnatal Depression Scale, EPDS (Cox, Holden, & Sagovsky, 1987). Adequate reliabilities among multiethnic adolescent populations have been noted (Anderson (2010; Birkeland, Thompson, & Phares, 2005). Reliability established for the current study was Four possible responses for each question are scored from 0-3, creating a range between 0 and 30. A cut-off score of 13 and above 5

6 6 Birth trauma among adolescents indicates symptoms of depression (Cox et al., 1987). Additional discussion of the IES and EPDS among adolescents is published in Anderson (2010) and Anderson & Logan (2010). We used single yes/no questions to assess traumatic life experiences and violence exposure (child abuse and partner violence). The item traumatic life experiences was operationalized as any non-childbearing traumatic event (excluding child abuse and partner violence) and asked on the survey as any past life experiences that were very traumatic to you? Data Collection and Analysis Our study was approved by the Institutional Review Board (IRB) of both the academic and hospital settings. Charge nurses provided room numbers for potential subjects by age. Within 72 hours, either the primary investigator (PI) or a trained graduate research assistant (GRA) initiated contact, distributed the surveys, and remained in the room until survey completion. Assent and consent as necessary was obtained from the adolescent and/or parent/guardian by the PI or GRA. Data were entered into SPSS version 19 and analyzed using frequencies, percentages, means, and standard deviations. We used Pearson s Product-Moment Correlation Coefficient to determine associations. ANOVA was used to determine significant differences among groups for symptoms of depression, PBT, or violence by sample characteristics. Significance level was set at.05. Results Caucasian, Hispanic, African American, and other adolescents ranged in age between15 and 19 (M= 18.11, SD=1.18). Adolescents were primarily African American or Latina, first time single mothers, representing the ninth grade and above. Approximately 18% were married; however, over half (53.5%) of the adolescents reported an unplanned pregnancy. Thirty-five (79.5%) infants were born at 38 weeks or greater gestational age. A small number of adolescents disclosed traumatic life experiences (11.6%), child abuse (7%), or partner violence (2.3%). 6

7 7 Birth trauma among adolescents Nearly half (47.7%) of adolescents appraised their childbirth experiences as great /nontraumatic. However, over one in five (22.7%) appraised the experience as awful /traumatic. IES scores, ranged between 0 and 52 with 33.3% of the adolescents scoring below 9 indicating subclinical symptoms of traumatic stress. One half of the adolescents scored between 26 and 52 indicating moderate to severe symptoms of acute traumatic stress. Depressive symptoms characterized 16.7% of the adolescents (Table 1). A significant difference in IES scores was found for adolescents who reported depressive symptoms, F=9.19(21), p=.001 with mean IES scores for symptomatic adolescents of versus 20.1 for adolescents without depressive symptoms. Adolescents reporting symptoms of depression also more likely reported past traumatic life experiences, F=4.14(1), p=.04. Mean depression scores also varied by IES scores with a mean EPDS score of for adolescents scoring greater than 25 on the IES versus a mean EPDS score of 4.06 for adolescents scoring less than 26 on the IES. Report of birth appraisal was found to differ by age, F=4.06(4), p=.01; marital status, F= 5.95(1), p=.020; gestational age, F=3.69 (3), p=.02; and report of partner violence, F=5.12 (1), p=.02. Because of small sample size, post hoc analyses for age, marital status, or gestational age could not be done. A comparison of means is not displayed because a single adolescent represented some categories; however, younger, single adolescents reporting partner violence, and birth prior to 38 weeks gestation might be suggested as most likely to report a negative birth appraisal. Significant correlations were noted between gestational age, IES scores, and birth appraisal. Age and parity also associated with gestational age; however, parity alone associated with IES scores (Table 2). Discussion 7

8 8 Birth trauma among adolescents Both birth appraisal and IES scores signaled signs of acute traumatic stress among numerous adolescents shortly after birth. Existing studies among primarily adult women have revealed that approximately one-third of women appraise their childbirth as traumatic, with about 10% having a severe traumatic stress response in the weeks that follow birth (Ayers, 2004). In a review of several studies Simkin (2011) noted the prevalence for traumatic births to be between19% and 33% of women. Very few studies, however, have defined the time of measurement as within 72 hours of birth. Skari et al. (2002) administered several instruments at three data points including initially a zero to four days contact. Using the General Health Questionanire-28 at this early time period, 37% of mothers (N=127) between the ages of 18 and 39 reported clinically important psychological distress and 6% of mothers reported depression. Timing, type of measurement, and various conceptual definitions or outcome variables for PBT, such as PTSD, posttraumatic stress, acute stress reaction, or traumatic stress response, make comparisons across studies difficult. Furthermore, risk factors, signs of PBT, or consequences of PBT for the adolescent versus the adult childbearing woman are not well researched. It was shown, however, with the current study that not all childbearing adolescents experience PBT. Other studies show that not all women experiencing a traumatic birth will develop the full syndrome of PTSD (Ayers, 2004). While much continued research in needed, many adolescents will be traumatized with potentially the younger, single adolescent reporting partner violence, past traumatic experiences, depressive symptoms, and birth prior to 38 weeks gestation suggested to be at highest risk for PBT. Parity also correlated with higher IES scores among this study s adolescents and has been examined in previous studies; however, with inconsistent findings (Ayers, 2004). 8

9 9 Birth trauma among adolescents Unresolved physical, sexual, and/or emotional trauma from early life has been shown to be a major risk factor for developing birth related PTSD (Simkin, 2011). Because of developmental immaturity, limited resources, or lack of skills to resolve conflicts, adolescents experience high rates of trauma and other serious life stressors including partner violence and unwanted pregnancies (Ickovics et al., 2006). In the current study higher IES and depressive scores and reported past traumas were found to co-occur. Adolescents who experience trauma have been found to be at heightened risk for emotional distress and likelihood of PTSD and depression over young and middle-age adults (Ickovics et al., 2006). Rather depression is a sequel to PTSD or an exemplar of shared symptomatology, almost 17% of this study s adolescents reported depressive symptoms. Similar to other s previous research findings Young, Miller and Khan (2010) noted that depressive episodes may affect up to 15% of non-childbearing adolescents, particularly if there is a concurrent interpersonal conflict or stressful life event. Depressive symptoms have been found to characterize 25% to as high as 40% of inner city pregnant and parenting adolescents (Hodgkinson, Colantuoni, Roberts, Berg-Cross, & Belcher, 2009; Shanok & Miller, 2007). A prevalence rate of 68% was noted for childbearing adolescents attending an alternative school for pregnant and parenting teens (Logsdon, Cross, Williams, & Simpson, 2004). Associations have been found between depression, increased stress, a negative birth experience, a traumatic stress response, and preterm birth (Ayers, 2004; Bryanton, Gagnon, Johnson, & Hatem, 2008). Adolescents in the current study who gave birth prior to 38 weeks often appraised their birth experience as awful/traumatic. Additionally, age and parity were noted to be associated with gestational age. Connections between age, parity, and early gestational age births are described in a separate study (Anderson, in press). 9

10 10 Birth trauma among adolescents Adolescents under 20 years of age have been shown to be at risk for adverse infant outcomes such as the birth of a preterm infant (Khashan, Baker, & Kenny, 2010). Khashan, Baker, and Kenny also discussed a link between subsequent births (parity) and preterm birth. Adolescents in the current study experienced the additional stress of a cesarean birth which has been considered to influence appraisal of the birth experience for both adults and adolescents (Bryanton et al., 2008). Both planned and emergency cesarean births have been shown to associate with birth perception (Bryanton et al., 2008; Waldenstrom, Hidingsson, Rubertsson, & Radestad, 2004). For these young, single woman an emergency cesarean is assumed; however, the reason for the cesarean birth is unknown. Of interest, cesarean births have been linked with depression (Salazar-Pousada et al., 2010). Only recently has there been recognition of the consequences of birth trauma among adult women. Both the consequence of poor maternal-infant attachment and difficulties initiating breast feeding can be important to adolescents who may be already at a developmental or educational disadvantage (Beck, 2004b; Beck & Watson, 2010). Beck and Watson (2010) noted that a traumatic childbirth experience may weaken mother-infant bonds, affect relationships with children, and impair relationships with partners. Not surprisingly women reporting symptoms of postpartum depression also may show weak mother-infant bonds, early cessation of breastfeeding, and negative family dynamics (Beck, 2008). Findings presented from this study are based on a small sample of adolescents and suggest the importance of additional research. Yet, numerous studies repeatedly reveal the interrelationships between depressive symptoms, violence, symptoms of PTSD, and adverse infant outcomes for all childbearing aged women (D Andrea, Sharma, Zelechoski, & Spinazzola, 2011; Rosen, Seng, Tolman, & Mallinger, 2010). Traumatic stress, while potentially associated 10

11 11 Birth trauma among adolescents with all these health problems, does not typically develop into PTSD (Ayers, 2004). For many adolescents in this study as well, symptoms of depression or PBT may indicate only transient symptoms or a reaction to an overwhelming situation rather than the emergence of something more devastating. Of importance is the finding that nearly one-half of this study s adolescents reported a positive birth experience attesting to the resiliency of many of these young women. Application All maternal child health nurses are in a position where they may encounter the traumatized adolescent post birth, if not at the bedside postpartum, in the pediatric setting for well-baby, routine, or emergency visits. Recognition that an adolescent mother may be a victim of abuse or symptomatic of PBT and/or postpartum depression is an important part of a comprehensive assessment that extends past the hospital stay as symptoms can be delayed. Awareness that symptoms of depression may overlap with symptoms of PBT encourages the nurse to look beyond signs commonly characteristic of depression. After birth, symptoms such as dazed, agitated, withdrawn, disoriented, or depressed may alert the nurse to an acute traumatic stress following childbirth (Church & Scalan, 2002). A verbal statement of trauma or nightmares, flashbacks, fears of recurrence, amnesia, panic attacks, or emotional distress may also be seen (Simkin, 2011) before or after hospital discharge. Reexperiencing and/or avoidance symptoms, particularly in the first six weeks following birth can suggest a traumatic stress reaction. Symptoms evident for at least one month with significant impairment to one s life may suggest actual PTSD (Ayers, 2004). While one in ten women may display signs of a traumatic stress disorder following birth, it continues to go unrecognized and perhaps unexpected to most healthcare providers. The more prevalent and treatable mental health problem of depression has garnered much attention among 11

12 12 Birth trauma among adolescents healthcare providers; however, it often goes unrecognized as well. Being the mother of young children places a woman at risk for depression and depressive symptoms; in fact, pediatric settings show rates of depressive symptoms among mothers to range between 12% and 47% (Olsen & DiBrigida, 1994). Adolescent mothers particularly report high rates of depression/depressive symptoms the first postpartum year (Schmidt, Wiemann, Rickert, & Obrien-Smith, 2006) signaling their increased need for assessment beyond discharge. An infant s first health care visit following birth designates a great opportunity for both a well- baby check and a mental health assessment of mother. Because of the prevalence of depression pediatric providers have been urged for over two decades to screen for maternal mental health and family stresses (Orr, James, burns, & Thompson, 1989). Heneghan, Silver, Bauman, and Stein (2000) summarized the importance of making assessments in the pediatric primary care setting: 1) pediatric primary care visits may be one of the only health care systems in which mothers are consistently involved, 2) mothers interact on a regular basis with the health care provider (pediatrician or pediatric nurse practitioner (PNP), 3) pediatric providers may be motivated to identify the depressed mother because of the known consequences of depression on the well-being of the infant or child, and 4) mothers may be more comfortable discussing personal issues with the pediatric provider they may already know. Yet, despite encouragement to assess depression in this setting, pediatric providers have been found not to recognize mothers even with high levels of self-reported depressive symptoms (Heneghan et al., 2000). Heneghan et al. revealed that pediatricians recognized depression more often than PNPs; however, the difference was not significant. Additionally the longer the mother-baby/child sought health care from a particular pediatric provider the better the likelihood that depression/depressive symptoms would be recognized (Heneghan et al., 2000). 12

13 13 Birth trauma among adolescents Direct questioning related to maternal functioning or use of an appropriate screening tool is encouraged. Available short screens can help nurses quickly identify depressive or PBT symptoms and make recommendations for immediate and long term interventions and resources. Use of the EPDS is a short, easily administered tool to screen for depressive symptoms. Copies are available on the web in English and Spanish and can be distributed across hospital units and community clinics. The use of the IES to screen for birth trauma needs additional exploration before use in clinical practice; however, clinical screens as appropriate or modified for the specific population/setting are available at With the often concurrent presence of violence in adolescents displaying symptoms of depression and PBT, an assessment of mental health and family stressors should include violence exposure. Assessing violence exposure among adolescents can be difficult but high denial rates can be reduced with the use of direct questions of assessment and routine provision of straightforward information and community resources. An assessment of partner violence can be made via administration of the short Abuse Assessment Screen, also available on the web. Interventions aimed at reducing PBT and useful at immediate and extended postpartum can include: 1) praise and complement a job well done (in labor or as a parent); 2) accept perception of birth as traumatic and acknowledge birth trauma if present with anticipation that the new mother may show symptoms later; 3) share resources; and 4) allow communication- on her time (Simkin, 2011). Education related to symptoms and consequences of depression and PBT and presence of violence can be provided in the hospital at discharge and the pediatric setting. Consequences of maternal depression, violence, and/or PTSD can be noted in either the hospital or pediatric setting of mother, infant, and older children. Near toddler age children of depressed mothers may be hard to manage, or show temper tantrums, inability to get along with 13

14 14 Birth trauma among adolescents other children, or signs of unhappiness or excessive fears (Civic & Holt, 2000). Assessments initiated at first prenatal contact and continued throughout pregnancy and postpartum via observations made in both the hospital and pediatric setting direct effective interventions for best maternal and infant outcomes. Pregnancy and motherhood can be perceived as traumatic to the adolescent but although traumatic events can be distressing or resulting in adverse outcomes, positive sequelae are possible (Ickovics et al., 2006). Findings of our study revealed that almost 50% of adolescents reported a positive birth experience. Why the adolescent s birth experience was positive for some and not for others is still unclear but perhaps resiliency can be considered. Salazar-Pousada et al. (2010) described the importance of resilience on adolescent personality maturation and suggested that future research focus on increasing adolescent resiliency. We would offer, that given these suggestions, clinical implications could include: 1) assessing resiliency and coping behaviors as relates to adaptation to pregnancy and parenting and in general to determine potentially vulnerable adolescents who would be in need of extra attention, information, and support, including adolescents with other children, 2) providing additional support throughout pregnancy, labor, and the extended postpartum to aid in increasing resiliency, and 3) helping adolescents to manage negative feelings and communicate needs. Interventions focused on adolescent resiliency might be helpful in decreasing both the adolescent childbirth rate as well as potential consequences of depression, violence, and PBT. Limitations of study Studies on adolescent birth trauma and resiliency during pregnancy and postpartum are lacking. This study has provided new insights; however, limitations of the study exist. We acknowledge that failing to support previously found associations such as between depressive 14

15 15 Birth trauma among adolescents symptoms and violence exposure may have been due to sample size, sample bias, or selection of measurement tools. A one item rating of the birth experience with arbitrarily set anchors may not accurately describe the birth experience despite a significant association with IES scores. The reason for the cesarean birth was unknown and may also have influenced the associations revealed. Disclosure of violence exposure was less than indicated in the literature for an adolescent population and can only be assumed to be true. Undisclosed violence exposure may have existed and influenced the depression and PBT found among the adolescents. Recommendations for further research include a larger, more diverse population and additional assessment of the adolescent support network. 323 References Anderson, C & McCarly, M. (in press). Psychological birth trauma in adolescents experiencing an early birth. MCN The American Journal of Maternal Child. Anderson, C. (2010). Using the Edinburgh Postnatal Depression Scale to screen for symptoms of depression among Latina, African American, and Caucasian adolescents. Southern Online Journal of Nursing Research, 10, NP. Anderson, C. & Logan, D. (2010). Impact of traumatic birth on Latina adolescent mothers. Issues in Mental Health Nursing, 31, doi: / _ Ayers, S. (2004). Delivery as a traumatic event: Prevalence, risk factors and treatment for postnatal posttraumatic stress disorder. Clinical Obstetrics and Gynecology, 47, Barnet, B., Liu, J., & DeVoe, M. (2008). Double jeopardy: Depressive symptoms and rapid subsequent pregnancy in adolescent mothers. Archives Pediatric Adolescent Medicine, 162, Beck, C.T. (2004a). Birth trauma: in the eye of the beholder. Nursing Research, 53,

16 16 Birth trauma among adolescents Bry Beck, C.T. (2004b). Post-traumatic stress disorder due to childbirth: The aftermath. Nursing Research, 53, Beck, C.T. (2008). State of science on postpartum depression. MCN The American Journal of Maternal Child, 33, Beck, C.T., & Watson, S. (2008). Impact of birth trauma on breast feeding: A tale of two pathways. Nursing Research, 57, doi: /01.NMC cf Birkeland, R., Thompson, J.K., & Phares, V. (2005). Adolescent motherhood and postpartum depression. Journal of Clinical Child and Adolescent Psychology, 34, Bryanton, J., Gagnon, A.J., Johnson, C., & Hatem, M. (2008). Predictors of women s perceptions of the childbirth experience. Journal of Obstetric, Gynecologic and Neonatal Nursing, 37, Church, S., & Scanlan, M. (2002). Post-traumatic stress disorder after childbirth. The Practising Midwife, 5(6), Civic, D & Holt, V. (2000). Maternal depressive symptoms and child behavior problems in nationally representative normal birth weight sample, Maternal Child Health J. 4, Cox, J. L., Holden, J. M. and Sagovsky, R. (1987). Detection of postnatal depression: Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry, 150, D Andrea, W.D., Sharma, R. Zelechoski, A.D., Spinazzola, J. (2011). Physical health problems after single trauma exposure: When stress takes root in the body. Journal of the American Psychiatric Nurses Association, 17, Davies, J., Slade, P., Wright, I., & Stewart, P. (2008). Posttraumatic stress symptoms following childbirth and mothers perceptions of their infants. Infant Mental Health Journal, 29,

17 17 Birth trauma among adolescents Elmir, R., Schmied, V., Wilkes, L., Jackson, D. (2010). Women s perceptions and experiences of a traumatic birth. Journal of Advanced Nursing, 66, doi: /j x Gamble, J., & Creedy, D. (2005). Psychological trauma symptoms of operative birth. British Journal of Midwifery, 13, Heneghan, A.M., Silver, E.J., Bauman, L.J., & Stein, E.K. (2000). Do pediatricians recognize mothers with depressive symptoms? Pediatrics,106, Hodgkinson, S.C., Colantuoni, E., Roberts, D., Berg-Cross, L., & Belcher, H.M. (2009). Depressive symptoms and birth outcomes among pregnant teenagers. Journal of Pediatric Adolescent Gyncology,18, Horowitz, M.,Wilner, N. & Alvarez,W. (1979). Impact of Event Scale: A measure of subjective stress. Psychosomatic Medicine, 41, I Ickovics, J.R., Meade, C.S., Kershaw, T.S., Milan, S., Lewis, J.B., Ethier, K.A. (2006). Urban teens: Trauma, Posttraumatic growth and emotional distress among female adolescents. Journal of Counseling and Clinical Psychology, 74, doi: / x Khashan, A.S., Baker, P.N., & Kenny, L.C. (2010). Preterm birth and reduced birthweight in first and second teenage pregnancies: A register-based cohort study. BMC Pregnancy and Childbirth, 10, Logsdon, M.C., Cross, R., Williams, B., Simpson, T. (2004). Prediction of postpartum social support and symptoms of depression in pregnant adolescents: A pilot study. The Journal of School Nursing, 20,

18 18 Birth trauma among adolescents Mollborn, S., & Morningstar, E. (2009). Investigating the relationship between teenage childbearing and psychological distress using longitudinal evidence. Journal of Health and Social Behavior, 50, doi: / Olsen, A.L. & DiBrigida, L.A. (1994). Depressive symptoms and work role satisfaction in mothers of toddlers. Pediatrics, 94, Orr, S.T., James, S.A., Burns, B.J. & Thompson, B. (1989). Chronic stressors and maternal depression: Implications for prevention. American Journal of Public Health, 79, Rosen, D., Seng, J.S., Tolman, R.M., Mallinger, G. (2007). Intimate partner violence, depression, and posttraumatic stress disorder as additional predictors of low birth weight infants among low-income mothers. Journal of Interpersonal Violence, 22, doi: / Salazar-Pousada, D., Arroyo, D., Hildalgo, L., Perez-Lopez, F.R., & Chedraui, P. (2010). Depressive symptoms and resilience among pregnant adolescents: A case control study. Obstetrics and Gynecology International, 2010, NP. doi: /2010/ Schmidt, R.M., Wiemann, C.M., Rickert, V.I., & O Brien-Smith, E. (2006). Journal of Adolescent Health, 38, doi: /j.jadohealth Shanok, A.F. & Miller, L. (2007). Depression and treatment with inner city pregnant and parenting teens. Archive Women s Mental Health, 10, Simkin, P. (2011). Pain, suffering, and trauma in labor and prevention of subsequent posttraumatic stress disorder. Science & Sensibility, 20, doi: / Skari, H., Skreden, M., Malt, U.F., Dalholt, M., Ostensen, A.B., Egeland, T., Emblem, R. (2002). Comparative levels of psychological distress, stress symptoms, depression and anxiety after childbirth- a prospective population based study of mothers and fathers. British Journal of Obstetrics & Gynecology, 109,

19 19 Birth trauma among adolescents Waldenstrom, U., Hidingsson, I., Rubertsson, C., & Radestad, I. (2004). A negative birth experience: Prevalence and risk factors in a national sample, Birth,31, White T., Matthey, S., Boyd, K., & Barnett, B. (2006). Postnatal depression and posttraumatic stress after childbirth: prevalence, course and co- occurrence. Journal of Reproductive and Infant Psychology, 24, Young, J.E., Miller, M.R., & Khan, N. (2010). Screening and managing depression in adolescents. Adolescent Health, Medicine and Therapeutics, 1, Zaers, S., Waschke, M., & Ehlert, U. (2008). Depressive symptoms and symptoms of posttraumatic stress disorder in women after childbirth. Journal of Psychosomatic Obstetrics & Gynecology, 29(1),

20 20 Birth trauma among adolescents Table 1. Sample Characteristics of Adolescent Population Characteristic n Percentage Race (N=42) Caucasian Hispanic African American Other Age Parity Grade (N=43) High school graduate Marital Status Single Married Gestational Age week weeks weeks weeks Planning of Pregnancy (N=40) Yes No

21 21 Birth trauma among adolescents Characteristic n Percentage Violence exposure/traumas Child Abuse Partner Violence Traumatic Life Experiences Depressive symptoms EPDS (>12) PBT by IES Scores and Birth Appraisal IES (N=42) Subclinical (score less than 9) Mild Symptoms (9-25) Moderate Symptoms (26-43) Severe Symptoms (44+) Birth Appraisal Rating 1 to 3 ( great /non-traumatic) to to 10 ( awful /traumatic)

22 Table 2. Associations between IES and EPDS scores, birth appraisal, age, parity, and gestational age Variable Age Parity Depressive symptoms: EPDS scores Birth appraisal IES scores.17.36*.72**.40** Gestational age.43**.27**.15.30**.36** 499 *p<.05 **p<