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SHORT COMMUNICATION
Health services utilization of women following a traumatic birth
E. Turkstra &D. K. Creedy &J. Fenwick &A. Buist &
P. A. Scuffham &J. Gamble
Received: 29 September 2014 /Accepted: 24 December 2014
#Springer-Verlag Wien 2015
Abstract This cohort study compared 262 women with high
childbirth distress to 138 non-distressed women. At
12 months, high distress women had lower health-related
quality of life compared to non-distressed women (EuroQol
five-dimensional (EQ-5D) scale 0.90 vs. 0.93, p=0.008),
more visits to general practitioners (3.5 vs. 2.6, p=0.002)
and utilized more additional services (e.g. maternal health
clinics), with no differences for infants. Childbirth distress
has lasting adverse health effects for mothers and increases
health-care utilization.
Keywords Health-related quality of life .Health-care
utilization .Childbirth trauma .Mental health .Distress
Introduction
During the perinatal period, some women may be vulnerable
to mental health distress and other health issues. Perinatal
mental health difficulties are more common than often
thought, are likely to recur in other pregnancies or later in life,
can become chronic and have long-term consequences for
mothers, infants and partner relationships. Most perinatal
studies relating to anxiety examine post-traumatic stress
symptoms triggered by adverse childbirth events. While the
majority of childbirths are not traumatic, studies indicate that
2–6 % of women meet the diagnostic criteria for post-
traumatic stress disorder following childbirth (Creedy et al.
2000;Maggionietal.2006; Soderquist et al. 2006). Problems
persist over time and spontaneous recovery have not been
consistently observed (Maggioni et al. 2006; Soderquist
et al. 2006). Some studies indicate that women with postnatal
distress have higher health service utilization in the first few
months postpartum (Dennis 2004; Bennett et al. 2014).
A randomized controlled trial compared a midwife-led
counselling intervention (Promoting Resilience in Mothers’
Emotions (PRIME)), with parenting support provided to
women reporting high distress symptoms after birth (Fenwick
et al. 2013; Turkstra et al. 2013). A matched cohort of women
with no childbirth distress was also included. In this paper, we
discuss the impact of high versus no childbirth distress on
health-related quality of life (HRQoL) and health-care re-
source utilization.
Methods
Wome n (n= 890) were recruited in the third trimester of preg-
nancy and screened within 24–72 h of birth and asked if dur-
ing labour or birth, they had been fearful for their life or their
baby’s life, or feared serious injury or permanent damage (as
E. Turkstra (*):P. A. Scuffham
Centre for Applied Health Economics, School of Medicine, Griffith
University, Queensland, Australia
e-mail: e.turkstra@griffith.edu.au
P. A. Scuffham
e-mail: p.scuffham@griffith.edu.au
E. Turkstra :D. K. Creedy :P. A. Scuffham :J. Gamble
Griffith Health Institute, Griffith University, Queensland, Australia
D. K. Creedy
e-mail: d.creedy@griffith.edu.au
J. Gamble
e-mail: j.gamble@griffith.edu.au
J. Fenwick
Griffith Health Institute, Griffith University and Gold Coast Hospital,
Queensland, Australia
e-mail: j.fenwick@griffith.edu.au
A. Buist
University of Melbourne, Melbourne, Australia
e-mail: a.buist@unimelb.edu.au
Arch Womens Ment Health
DOI 10.1007/s00737-014-0495-7
per criterion A of the DSM IV-TR for post-traumatic stress
disorder (American Psychiatric Association 2000)). Mothers
screening positive were randomly allocated to receive the
counselling intervention(PRIME) or parenting support (active
control), as there were no differences between the two arms in
health-related quality of life (Turkstra et al. 2013). For the
purpose of this post-hoc analysis, all randomised women were
combined and allocated to the high distress group (n=262). A
cohort of women without childbirth trauma was matched (age,
marital status, education and parity) and allocated to the no
distress group (n=138). Women reporting traumatic stress re-
ceived contact from the research midwives on two occasions
to deliver the allocated intervention. All women completed
outcome measures by phone with a researcher blind to group
allocation.
Ethical considerations
Approval was obtained from the human research ethics com-
mittees of all participating university and hospital sites. Wom-
en gave written informed consent. All women were monitored
for psychological safety by research staff. A risk protocol with
referral pathways was followed.
Data analyses
Participant characteristics were self-reported during the third
trimester of pregnancy, and birth events were reported 24–
72 h after birth for both cohorts. HRQoL and health service
utilization data were collected by telephone at 6 weeks and 6
and 12 months following birth.
HRQoL data were calculated using the generic preference-
based instrument EuroQol five-dimensional (EQ-5D-3L)
scale on mobility, self-care, usual activities, pain/discomfort
and anxiety/depression, with three levels per dimension (no
problems, some problems and severe problems). Australian
weights were used to generate utility values (Viney et al.
2011). The resource utilization was based on self-reporting
(GP visits, GP home visits, emergency department visits, re-
ferral to psychological treatment, additional services and
hospitalization).
To assess differences in baseline characteristics between
the high distress and non-distress groups Pearson chi-
squared tests were used for categorical data. For the EQ-5D
and health services utilization, data were analysed using gen-
eral linear model repeated measures. Multiple imputation
techniques were applied to adjust for missing data. At
12 months, 76 % of the high distress group and 73 % of the
non-distress group provided data, with no differences in base-
line characteristics between those with or without missing
data. For all analyses, the antenatal question “have you ever
sought help for a mental health condition”(Yes/No) and
“State”(Queensland/Western Australia) were used as
predictors. All statistical analyses were performed using SPSS
(version 22.0).
Results
Baseline characteristics
Women with no distress were well matched compared
to women with high distress, with regards to most
baseline characteristics. On average, women were ap-
proximately 30 years of age, approximately 50 %
were nulliparous and the majority were in a relation-
ship (∼90 %) and had a planned pregnancy (∼60 %).
More women in the high distressed group were re-
cruited in Western Australia (40 vs. 30 %; p=0.034;
high distress vs. no distress, respectively) and report-
ed that they received prior mental health help (35 vs.
20 %, p=0.002). High distressed women were less
likely to have had a vaginal birth (42 vs. 56 %) and
more likely to have had an emergency caesarean (30
vs. 18 %).
Health-related quality of life
High distressed women had a lower HRQoL using the
EQ-5D scale at each follow-up compared to no distress
women (p=0.001, Fig. 1). The difference was not statis-
tically significant for women who reported previous men-
tal health problems, while this was statistically significant
for women who did not have previous mental health prob-
lems. Women with no previous health problems, but a
highly distressed birth, reported a lower HRQoL even
12 months later (0.94 vs. 0.92).
Health-care utilization
Health-care utilization was higher during childbirth for
women with a traumatic childbirth, with longer postpar-
tum hospital stay (3.2 vs. 2.6 days, p<0.001), and con-
tinued to be higher 1 year after childbirth (Table 1). The
main differences 1 year after birth were higher number
of GP visits for the mother (3.5 vs. 2.6 visits, p=0.002)
and the likelihood of receiving additional medical ser-
vices (52 vs. 23 %, p=0.015). These additional services
included increased referrals and attendance to psycho-
logical treatment, attendance at child health clinics, lac-
tation support and home visits by midwives. No differ-
ences were observed for the number of emergency de-
partment visits or the likelihood of hospitalization after
birth. There were no differences observed in health-care
utilization for infants.
E. Turkstra et al.
Discussion
Womenwithhighdistressweremorelikelytohavelong-
term lower HRQoL and were more likely to have higher
health-care utilization compared to women with no child-
birth distress. This effect was still significant 1 year after
childbirth. While the mothers had higher health-care utili-
zation, the babies did not see their health-care provider
more often.
Our results confirm previous work that women with birth
trauma have long-lasting effects on their mental wellbeing
(Beck 2006;Becketal.2011). To our knowledge, our study
is the first study to report general HRQoL between women
with no and high distress childbirth up to 1 year after birth,
with lower values for women who were highly distressed.
The results of our study are consistent with other studies
which demonstrated that women experiencing complex preg-
nancies and depressive disorders following birth had higher
health service utilization up to 12 months postpartum (Dennis
2004; Bennett et al. 2014). While increased health-care utili-
zation for the mothers was observed in our study, no differ-
ence in health-care utilization was observed for the babies.
There is limited information available on the health-care
utilization of the infants after high distress birth. Some studies
have investigated postnatal depression or anxiety and health-
care utilization in infants, with no difference in health-care
utilization within the first 14 days post-birth (Paul et al.
2013), and in preventative health-care services up to 1 year
(Farr et al. 2013). However, infants of mothers with depres-
sion or anxiety diagnosed during the postpartum period had
more emergency visits than infants of mothers with no depres-
sion or anxiety (Farr et al. 2013). Due to the smaller sample
size, we may have been unable to detect differences in health-
care utilization in infants.
There are some other limitations with our study. There were
some differences in baseline characteristics and birth interven-
tions between the two cohorts. The health-care utilization data
were all self-reported; for additional services, no information
was available with regards to the frequency of these services,
and for hospitalization, the duration of stay was unknown.
Further, as we did not request a full medical history of the
women in both cohorts, underlying medical conditions may
impact on HRQoL and health-care utilization. We did not
have complete follow-up for all women included in the study,
Tabl e 1 Health-care utilization 12 months after childbirth
High distress mean (SD) N=262 No distress mean (SD) N=138 pvalue
a
Mother (visits per mother)
GP 3.5 (2.3) 2.6 (1.7) 0.002
GP home visit 0.2 (0.5) 0.0 (0.4) 0.984
ED visits 0.4 (0.7) 0.3 (0.6) 0.268
Hospitalization, number of mothers (%) 28 (11 %) 11 (8 %) 0.469
Additional services, number of mothers (%) 135 (52 %) 60 (23 %) 0.015
Baby (visits per baby)
GP 5.1 (2.3) 4.7 (2.2) 0.221
GP home visit 0.6 (1.1) 0.5 (0.8) 0.152
ED visits 0.8 (1.1) 0.8 (1.0) 0.951
Hospitalization, number of babies (%) 38 (15 %) 25 (18 %) 0.276
a
General linear model over 12-month time period, multiple imputations
Fig. 1 Health-related quality of
life, using EQ-5D. General linear
model, multiple imputation
technique; mean (upper 95 %
confidence interval). White bars
are for the no distress group, black
bars are depicting the high
distress group
Health service use after traumatic birth
with a lower follow-up for those women with previous mental
health problems. Advanced statistical methods were used
(multiple imputation) to accommodate for this difference.
In conclusion, women who had a highly distressed child-
birth have lower HRQoL after 12 months of follow-up. Addi-
tionally, these women had more general practitioner visits in
their first year and were more likely to receive additional ser-
vices, such as referral for psychological treatment, attendance
at child health clinics, lactation support and home visits by
midwives. However, there was no difference in the health-
care utilization of infants.
Acknowledgments The study was funded by the Australian National
Health and Medical Research Council (Grant ID 481900).
Conflict of interest The authors do not have a conflict of interest.
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