Speaker 1: 0:10

Hi guys, welcome back to Preview Alliance podcast. This is Sarah, and today we have a very, very special guest and exciting topic. I am going to put a trigger warning on this episode, just in case you guys are not in the space or place to talk about traumatic birth experiences Because, as I know, I've experienced it myself and sometimes you're are not in the space or place to talk about traumatic birth experiences Because, as I know, I've experienced you myself and sometimes you're just not in that space. This is a great episode, though, that if that has affected you or someone you love, that you take a time and pause and really listen to it or come back to it if it's not the place, but something that everyone needs to hear. And my special guest today is coming to us from Harvard, dr Sharon Dickel. I am so pumped to have you on and to hear you explain. Something that's so important to me and so many women is your research on the postpartum traumatic stress disorder research program that you started and are doing, so welcome.

Speaker 2: 0:58

Thank you so much, sarah, and thank you so much for you know making sure we have these discussions to promote education for patients and providers. Briefly about myself I'm an associate professor of Harvard Medical School and I am also a clinical psychologist. My lab is based at the Massachusetts General Hospital in which we perform clinical and translational research to better define the kind of biological signature of PTSD-induced biotraumatic delivery and also develop novel screening tools and early-on interventions to hopefully altogether reduce the odds of developing PTSD and comorbid or co-occurring conditions.

Speaker 1: 1:45

I love that. What led you to focus on this? Because of trauma, specifically after childbirth, because I never thought about childbirth and trauma until I experienced it. So what led you to be kind of this groundbreaking frontier land of research?

Speaker 2: 2:02

That's a great question, sarah. I am often asked this question and then I kind of go retrospectively in time. I think I've been doing the research kind of on a more large scale since, I would say, 2017. So you know more than a decade, and I have to say that unfortunately I don't have a moment. But I think what happened is I am a mother of three girls Now. They're more in their teenager years and overall my birth experiences were actually positive.

Speaker 2: 2:34

But as I began to read the literature on maternal mental health, as somebody who my I would say, prior professional identity was studying PTSD in the context of war, captivity and terrorism, so my expertise is really understanding how people adopt and cope maladaptively or adaptively with stressful events that are even perceived as traumatic. And the more I kind of thought about what I know and then reading the literature on childbirth at the time was mostly understood as childbirth as a physiologically intense event and these potential hormonal changes might result for some people in depression. I was thinking more about the childbirth as a stressful event. And then the more I read the literature, the more I saw that there is a huge gap in the research-based knowledge about what are the prevalences of birth trauma? Who are the people at risk for birth trauma? Can we even qualify giving birth as a traumatic event like we think about going to war or know about going to war or captivity in which these stressful traumatic events actually result in a psychopathology in this case, mental disorder, such as PTSD? That is, not only people are feeling upset, but there is actually a biological basis. As we know, there is neural changes in the brain level. So the more I read the literature with my knowledge, I really felt there's so much information that is lacking.

Speaker 2: 4:06

And then in around I think it was like 2017, I collaborated with Postpartum Support At the time. This is a nonprofit organization and their leadership was very interested in really learning more about what it means psychologically to have a stressful traumatic experience, what it means psychologically to have a stressful traumatic experience. And in this study survey, which I think we surveyed around 800 people and we used the same self-report measures that are commonly used in PTC research to examine the morbidity of being exposed to war, terrorism and captivity we saw that many people these are all postpartum people around, I would say maybe three, two months postpartum reported PTC symptoms that they attributed to their birth experience. So that was kind of the first step to really characterize the magnitude of birth trauma by getting information on patient self-reports. And then I would say to me as coming more from a kind of biological-driven approach in this study, led to a subsequent study that we did at Mass General Hospital, in which basically we invited people who believed that they had a traumatic delivery so that was a subjective perception and then not only did we assess them with the same questionnaires but we also added diagnostic assessment, which is, for example, the CAPS, which is a clinician number, one kind of gold standard interview to assess if you have PTSD by DSM. You know, dsm is the Diagnostic Statistical Manual for Mental Health Disorders and, as importantly, we applied a physiological paradigm. It's called a script of an imagery in which people are asked to imagine their trauma and as they're imagining the trauma, we measure heart rates, skin conductors and other physiological markers. And why is that important? Because heightened physiological activity is considered by NIH and, you know, I would say, by PTC researchers and also used in the court to confirm whether a person really is experiencing PTC or not. And this is very important, especially in the postpartum, because we know that mental illness are comorbid, they often co-occur and we do know that, especially in the postpartum, people are experiencing maybe depression, maybe anxiety and maybe PTSD. So an ongoing kind of question that we had was even if people report PTSD, is that really PTSD? Maybe it's general anxiety or maybe it's depression, and I would like to also emphasize that I'm part of the neuroscience division. In my division at the time, many senior male investigators were really wondering whether this is even possible, that people would experience birth trauma. We spoke about the hysterical mother women who might be kind of, you know, overly dramatic and then have depression. But you know, there are these very crazy ladies who, you know it's not really a common response to childbirth.

Speaker 2: 7:15

When we posted the opportunity to take part in our study and that was again at Mass General back, I think, in 2017 or so then usually, you know, the joke in Boston is there's too many researchers and it's very difficult to have access to people who want to participate in research because everybody does research. Yeah, this study, we put the posting online and again online through MGA, so it was public, but I don't think it actually reached, you know, millions of women in the US. Not at all. And also, the study required an in-person assessment, so only people who really resided close to the hospital could participate. And within three days we had hundreds of people who responded. And then I was wondering who are these people? Am I myself? Is this really more the hysterical mother myself? This is really more the hysterical mother.

Speaker 2: 8:04

And then you know, we, with our team myself leading the team we did these initial screening over the phone and it was very obvious to us that rarely was anybody here malingering. The people really experienced traumatic, very stressful birth events. And what was as shocking to us was I expected that most people who would reach us would be people who are in the early postpartum or let's say, within the first year's postpartum, and we had enough people who actually were a decade after giving birth Initially by IRB. I think the study was defined to people who are one year postpartum. I didn't even think other people would be preoccupied with the childbirth experience, that they would like to volunteer in a study, because even if they had PTSD, I assumed this would be already part of the past. But as we know, when people actually have a mental illness or when things are really unresolved, it's very difficult to just let it go. So we had people and we had to kind of modify our eligibility to study also people who gave birth a decade ago.

Speaker 2: 9:08

And then what we found, using these kind of you know, physiological what I would call a state-of-the-art assessment, we found, although the sample was not as big as we hoped, but we did find the physiological activity of these mothers when they recalled the childbirth experience, which happened, I think, on average three years postpartum. So again, they were not so much in the early postpartum period at all. Then the same activity that we know is a signature of PTSD was actually found in this cohort of postpartum women in regard to the childbirth. And, as importantly, you know, in research we try to have a good control group. So we found that when you ask these same people to imagine another stressful event in their life, they were not reactive, meaning that their activity was specific to childbirth. So the PTC symptoms that are reported are not because maybe they have a history of sexual assault and when they reviewed the questionnaire they maybe got confused between what event are we actually assessing their PTSD symptoms In regard to? Based on our assessment, I think we can say with confidence that this kind of biological, physiological alteration, which again means that you are highly to be in this kind of hyper arousal, kind of heightened stressful mode, when you are thinking about your childbirth and, as we know, about PTSD, ptsd is a condition in which and this is, I think, what makes it so morbid many cues that are associated with the trauma, as we call it, directly or indirectly could also provoke the same stress response. So, again, our data shows that these people are experiencing the same stress response.

Speaker 2: 10:49

In comparison to studies, that the majority of participants were people who were exposed to different levels of war exposure. Most studies included, I think, soldiers. So really, we're talking about what we call the most common types of trauma and showing that the childbirth experience for some people could really be registered as stressful as going to war. And to me that was like okay, I was like confident that something needs to be done and we, you know, in small steps. We want to remain honest. We are, you know, doing different studies.

Speaker 2: 11:26

We recently completed a neuroimaging study to better understand what happens to the maternal brain and how the maternal brain is impacted by exposure to traumatic childbirth.

Speaker 2: 11:38

Understanding how can we better screen for maternal knowledge, what we call childbirth CB, ptsd. There is so much more that can be done and I also feel very confident to say that and I see that repeatedly in our studies that we're doing more recently and studies that we compensate quite generously for coming to our study visits in person Studies, by the way, supported by the NIH very grateful for the NIH support that is likely that those who are really, really struggling do not participate in research because it's just very painful for them to even consider recalling the birth trauma or being assessed for PTC symptoms. As we know, avoidance is one of the core symptoms of PTC. So, as much as we can, we are trying to capture the pathology, to understand people at risk, to develop good, effective interventions. But it's likely that many people were unlikely, unfortunately, to reach because they're not doing so well and they just don't want to leave their houses or they don't want to participate in this kind of research because it's too provoking.

Speaker 1: 12:38

I appreciate that so much and you know, I think a good. Next question is you're hearing these stories and you've probably heard several. Is there a few that maybe has just really resonated with you, that's helped shape you? Or you know that maybe some of those male investigators heard or you shared with them, or that you know birth trauma people just don't generally connect it, and so give us some of those experiences that your patients have shared with you. So cause I think people are going did I experience a birth trauma? I think I did. Maybe they've been told no, that's you know. It just happened. You and baby are safe. There's a lot of gaslighting, there's a lot of denial. Just share with us some of these, what you've witnessed and heard.

Speaker 2: 13:22

Sure, I think you know. Again, I like to always compare the childbirth trauma and the childbirth PTSD in kind of this kind of larger perspective of trauma in general, and one of the almost impossible missions that we have is, early on, offering screening for survivors and identifying people at risk. So, for example, I'm thinking about my PhD was a 9-11. On 9-11, you know, unpredictable events, which is really the core definition often of trauma. How can we get access to survivors and screen them on time? And going back to your question, what I found very unfortunate and this is also, I think, a strong force that leads me to continue and do this research, research is that I hear from patients that, as they are in the postpartum unit, so after they gave birth, and often in the context of complicated deliveries so that would be unscaled cesarean vaginal delivery, vaginal delivery, sorry in the context of obstetrical complications, it would require staying in the hospital for a few days, severe ones, life-threatening, but also maybe even major ones which are not life-threatening but require monitoring. People, as they're in the postpartum unit, are experiencing PTC symptoms. So they would be experiencing this heightened arousal. They would be experiencing even nightmares and they would be experiencing this overall sense of helplessness, nightmares when it comes to PTSD is a very strong predictor of having a negative outcome, meaning very strong predictor of high likelihood of developing PTSD. So it just strikes me so unfortunate how is it possible that in our era, with all the support and all the knowledge that we have that today maternal mental health disorders are the number one complications of childbirth and, overall, the number one at least identified reason that people end their life. So when we talk about maternal death, nevertheless we are not really screening for kind of more comprehensive screening, which would also include screening for these early on signs of PTSD. So in other types of traumas you might not even know who is at risk because you won't really know, like you know, what is the degree of exposure the person had in 9-11 or how can I know the people went home. Like here we have people who are staying in the hospital, not for a couple of hours, usually for a couple of days because, as our data shows, the vast majority of people who would have what I would say childbirth trauma, which I usually define as a real threat to your life or the life of your baby, or potential threats. So you didn't really think fully you're going to die, but the thought was maybe there or thinking about if things would not become better, there might be a risk in the future. So usually that is in the context of obstetrical complication and for these people we know they stay in the hospital for several days. So how can we make sure that there is some degree of in screening in the hospital or at least initial conversations with people to support them, not to think that they're actually going crazy, because they're okay?

Speaker 2: 16:33

Why am I having nightmares? This is, you know, having nightmares of a traumatic event. In general is so scary. Having a nightmare after you potentially gave birth for maybe more than 24 hours and experienced a lot of pain and are sleep deprived and you have your newborn as part of the you know, the policy of rooming in next to you. I can't even imagine how terrifying this scenario could be for someone who's just, you know, kind of psychologically recovering.

Speaker 2: 17:02

And as one of our participants in our study who developed PTSD and we assessed her recurrently, she said you know, it's amazing that there is so much attention to the baby and making sure I know how to change their diaper, I know how to breastfeed my baby, or at least giving me some guidance, but nobody basically asked me how I'm doing and if they did, if the question was imposed, it was more kind of hoping that I would just say I'm fine. So there's no really real conversations. And you know, in general we talk about prevention of conditions and when it comes to childbirth, ptsd. I think, because we have this kind of unique opportunity to have these discussions, of course, you know, coming from kind of more empirical-based approaches, we understand exactly how should we screen, what questions should we ask to engage in these early conversations to support mothers. Then there is so much more that we could be doing and we're not doing it yet.

Speaker 2: 17:59

I do remain optimistic because I believe that gradually I know in my hospital we're gradually developing a protocol in which a screener for PTC will be given to high risk patients. So there's much more awareness and I'm so grateful for that. But there's still so much that could be done and I think because of this void, currently I would say the responsibility goes on the patients, to make sure that they are not blaming yourself or feeling guilty, because that is a common response that I hear from people in our studies and they said my body failed me, I failed my baby because I had an unplanned cesarean. Now I can't even breastfeed. I feel guilty that my experience of childbirth was so negative because other people maybe you know it's kind of, maybe it's my doing. I feel guilty that my experience of childbirth was so negative because other people maybe you know it's kind of, maybe it's my doing, I you know. I even have a participant who told me she thinks she didn't really eat enough tomatoes and therefore this is the reason why she is not healthy and therefore she maybe had an unscheduled cesarean and therefore now she can't really function and she's at risk for having PTSD. So it's so not okay that we let people feel guilty and shamed because the birth was a trauma and now they're having a difficult time taking care of themselves, taking care of their child.

Speaker 2: 19:13

And I think again, because there's so much still lack of good screening, lack of good treatment that is implemented in routine maternal care, meaning in the first postpartum days. Potentially people do can get good treatment in the community, but that would be a little bit later on. Then I think it falls on the responsibility of, ideally, the treating team to identify people who might need resources and help. But unfortunately I think we need to make sure that you know, as we're talking about our audience, that women advocate and say you know, I'm not feeling well, something doesn't seem to me like it makes sense. And I, who can I speak with? What are the? You know any kind of educational material? What are the resources that your hospital has to support me? Because I know the more they receive treatment, even light therapy, early on as we're now testing under NIH, a psychological brief intervention the better, most likely their outcome will be. So you just want you know, even, as we know, even self-disclosure about traumatic experience without getting really full-blown treatment supposed to be very, very helpful if it's done with somebody that you feel like you can trust and it's done really in the early time period after trauma exposure.

Speaker 2: 20:27

Because I know you mentioned the audience is also pregnant people. I think, for pregnant people, we do see that in our study that there's a significant group of people have, at different levels, fear about the forthcoming delivery. So I think you know, again, as we want to take more on a more trauma-informed care approach and maybe this is not necessarily implemented in our hospitals yet in the US and, of course, globally then I would really encourage patients who are feeling anxious about their forthcoming delivery, to talk with their provider, with their PCP, with their obstetrician, to ask to see maybe a social worker or any other more mental health member that is available during pregnancy to really express these concerns and to find ways to maybe reduce level of anxiety overall. We know the physical exercise is very helpful. Mindfulness approaches again, social support there's a lot of ways, but it would be very unhelpful to come to the delivery when you're already very, very anxious. That is not ideal.

Speaker 2: 21:31

So you want to really make sure that you're taking care of yourself already as much as possible during pregnancy. And, of course, for people as we see, unfortunately the data shows that people who had a birth trauma and develop PTSD in general, if you are exposed to a traumatic event and you develop PTSD, your chances of developing PTSD in a subsequent trauma, regardless of childbirth trauma or not, are increasing versus somebody who has no history for trauma or no history for PTSD. So I really encourage people who are hearing our podcast. If you know that your prior pregnancy you think it was quite traumatic and or you also think you develop PTSD symptoms, ideally you want to make sure you are treating yourself kindly by getting the treatment you need already when you are pregnant, with your subsequent pregnancy, because this is really the time that so many things could be modified.

Speaker 2: 22:25

And you know we talk about this concept of a psychological growth, that our team has shown that actually you can develop psychological growth, which is basically this idea that you feel stronger, you have better appreciation of your life, you have better connections with others. So it's ideal you really grow psychologically more than you were before trauma exposure and we see in our data that we publish work people who are experiencing distress in regard to the trauma are those who are lucky to grow. So that would mean that mothers who are having birth trauma or PTSD of childbirth, then not only by trying to get the right treatment, not only I would predict that their symptoms would go down, but also there could be a sense of what we talk about experiencing psychological growth and a sense of maternal resilience, which I think is critical, especially for people who are about to become pregnant again. We see in our study that one of the most frequent complications of childbirth PTSD or even what I would call subclinical PTSD so you don't really endorse a DSM full criteria, but you do have some levels of PTSD symptoms is people tell us I would never give birth again Because, as I mentioned, avoidance is a core factor of PTSD and I always try to explore with people, you know, how much these plans are a factor of the childbirth event.

Speaker 2: 23:46

Or maybe you know there's also other reasons why people, people's values and almost always it's related to the birth being a trauma and this trauma made them change their plan. And again, I think that's such a unfortunate outcome of having a birth trauma that this is what I would say influencing your reproductive trajectory. That is very, very unfortunate. So we really want to, kind of you know, we want to early on, untangle this very vicious cycle.

Speaker 1: 24:18

Yeah, I resonate with so much and the nightmares I remember with my first, my oldest. The nightmare started for me early and I remember you saying you know how scary that was. I was thinking about he was in the NICU, so we're in the hospital longer and having those nightmares and I did question if we were ever going to have another child. We went on to, we did, did in the blaming and I shared with you earlier before we started recording birthdays. The memory of the birthday is very difficult for me, even almost seven and four years later. What else? If someone's listening, because they're hearing it, I think they're resonating. What else is common, kind of what they say or what you see, so we can help people again, kind of sort out and put a name to some symptoms they're experiencing.

Speaker 2: 25:03

So you know, in general we think about PTSD as a condition that has like four clusters of we can call it, you know, four characteristics.

Speaker 2: 25:14

There is more of these re-experiencing symptoms, or what we'd call about intrusiveness, that is, trauma specific. So you know, and I think it's important to remember, trauma specific because people could have a lot of intrusive thoughts about how many times did I breastfeed my baby? Is my baby breathing well enough? There's a lot of what we call and that might even be normal as part of postpartum adjustment, but the intrusiveness for PTC would be specific to the childbirth event, especially to the traumatic elements of the childbirth. So the intrusiveness could be in the form of nightmares about the childbirth or any reminders, could be in the form of intrusive thoughts. And intrusive thoughts again, it's not that you would be saying, okay, let me just think about my childbirth experience would be more in the form that you, without necessarily wanting to think about it, it has more of an intrusive quality and it could be whether it's a reminder or not, no reminder, and it could be even to the more be called extreme level, that not only you have the thought but you have a flashback, and a flashback would be basically that you are kind of going back in time and you are potentially and the more I would say extreme level would be that you can really vividly see yourself back there. So it's not just a thought. A thought would be more of a memory. This would be really a visual image of how you were feeling, or really seeing yourself, let's say, in the OR, or it could be like a sensation. So, you know, we have people who tell me and this is really unfortunate I look at my baby, the baby reminds me of the childbirth, and then I kind of really go back in time and I can see myself bleeding and they kind of have the entire scenario of the OR and what happened and all the obstetrical morbidity. Or people could talk, for example, about I'm breastfeeding my baby.

Speaker 2: 26:57

The breastfeeding creates, I feel like you know these contraction pain and the contraction pain again is another trigger to the labor and delivery experience. Or people who have cesarean deliveries tell me, you know, I look at the scar and the scar kind of reminds me of what happened. And again, for the PTSD, it's about the intrusive quality coming from the cue of the trauma and the difficulty to say okay, I see the scar, for example, but I don't want to think about it. Somebody who maybe is not having PTSD. There could be an initial trigger, but then they can just go about their day and not necessarily get overwhelmed. But people in our study who do have PTSD, often in response to the trigger be it the baby, the scar, the pain from the related breast milk contraction they would need to stop the activity, distance themselves. And some people tell me they just go to sleep because it's kind of too much and they tell their partner or whoever is around to take care of the child because they really cannot cope, it's so overwhelming and kind of destroys their day. So the PTC is about this kind of you know, again, this would be the intrusiveness that also impairs the functioning. So this is the first cluster, the intrusiveness.

Speaker 2: 28:04

Then we have the avoidance, which would be people who, as I mentioned, you know they cannot think about the possibility of giving birth again. And, more concretely, if they're in their early postpartum, they will tell me I cannot come and see my obstetrician and I cannot come to the postpartum follow-up visit. I really can't. Or they will tell you I'm coming but I feel so hyper aroused, or I find myself parking outside the hospital because I can't park in the same garage that I parked when I came to labor and delivery. So a lot of avoidance behavior, even though they're forcing themselves to come to the hospital. So that's kind of the second cluster, the avoidance.

Speaker 2: 28:39

And then the third cluster will be what we call negative alterations in mood. So this is often related to also depression. So it's difficult to kind of distinguish Are people maybe also experiencing depression? But when it comes for PTSD it's mostly people would say I blame myself for the birth experience. Because of me I had a pan-cesarean in this case and because of me the baby went to the NICU. So a lot of self-blame or blaming the team in a way that maybe is kind of too much what we call out of proportion, very low self-esteem, feeling like there is overall not a lot of pleasure and activities that you usually enjoy.

Speaker 2: 29:12

But again, that could also be signs of depression. Then we have the cluster number four, which would be the heightened arousal and hyperactivity, which would be people who feel like, you know, you always feel like aroused, you kind of, versus feeling like more calm, and sometimes everything feels like it's a big task because you are feeling like even, let's say you go out, you find yourself like scanning for your environment, you become very hypervigilant, you have this strong stutter reaction. These are all symptoms of hyperarousal, including, I would say, a strong marker would be problems falling or staying asleep, although again, for mothers who are postpartum that could be a sign also of depression. That could also be a sign of the baby not sleeping well or issues that relate to breastfeeding. So sometimes it's difficult to distinguish what is PTSD or not.

Speaker 2: 30:00

But but I think if you have these signs you definitely want to think about you know how can I take care of myself and therefore seek the necessary treatment, because there are experts out there and there is good educational material these days and a lot of ways people could help themselves. And I think again take home message that we know that many maternal mental health conditions, including p PTSD, could be preventable. You know there are conditions for, let's say, you know talk about Alzheimer's conditions. You know some forms of cancer that we cannot prevent. But here it's very optimistic. There's a lot of possibilities for prevention if we receive the effective treatment in the right time.

Speaker 1: 30:39

No, that is. You know, I didn't go to my six weeks follow-up appointments and now I'm going. I probably didn't go because I didn't want to go back to this. You know, I called it the scene of the crime and 60% of women do not attend their six weeks follow-up appointment.

Speaker 1: 30:52

That we have studied, and to me that's resonating that there could be external factors. I mean, I remember my mother-in-law was in rehab across from the hospital I delivered and I felt like I was almost having a panic attack staring at the labor and delivery entrance, and that was three plus years out of a delivery. So I think it's important too, as you said, it's not just that immediate time. I mean, I'm working through things. That's almost seven years, so that's one thing too, too. I wanted to touch on is I think people like to lump the trauma in with postpartum depression or postpartum anxiety. How can someone self-advocate for themselves and say, no, I am having this as a result of my trauma. This is not to be lumped in with depression, because I think everybody kind of knows postpartum depression and it's easy way for people just to put you in that category.

Speaker 2: 31:44

That's such an important question, it is difficult. I think it's difficult especially because often there's a pushback from what we know, what we hear from our participants. Often people do say you know I'm not doing well and you know providers would say this is just part of postpartum. You're not sleeping well because you know you're sleep deprived, so this is just part of postpartum. You're not sleeping well because you're sleep deprived, so it's just going to become better. Or people are told you have postpartum depression. Your EPDS, you know the Edinburgh Postnatal Depression Scale shows that your score is high and it could be high for people who have PTSD, because PTSD is often comorbid with depression and depression is often an outcome of unresolved PTSD. So it would not be surprising. We have the data to show that in our published work. So it is very tricky. It would be very, very tricky. I would say that again, if people are experiencing nightmares, intrusive thoughts that related to the childbirth experience, flashbacks, the sense of hypervigilance, it seems much more likely to be PTSD than depression. And, of course, if the birth was complicated in a way that there's obstetrical complications, I think it is more likely that they have PTC or PTC with some elements for depression and they should do everything they can to advocate for themselves. I hope that over time in the US, a questionnaire such as a PCL, which is the PTC checklist for DSM-5, which we have shown in our published work in AJOG, we show that this questionnaire is strongly correlated with the diagnostic assessment. So the PCL, along with the PCL-5, along with the EPDS, could be given to people that we think might be at high risk for developing PTC, fall and Chabar. So instead of the patient advocating for themselves, that would be a screener and that would be a better way to identify who has PTC. We have published work hopefully that will be eventually implemented in routine care of how can we screen people for the risk of having PTC in the immediate postpartum, before the PTC symptoms actually develop, because by the DSM to have PTC you have to be one month after trauma. So people can't really have full-blown PTC. Usually you don't experience all these symptoms in a way that we can actually determine PTC in the first days. So therefore the question such as PCL might not do such a good service would be more for the postpartum care.

Speaker 2: 34:03

We have been using narrative accounts of the childbirth experience. We ask people to provide short accounts of their birth event, focusing on the most distressing elements, and then we apply AI-based models. Events and the language in these stories could potentially offer some degree of predictability of who is likely to develop a PTC or not. So hopefully more research to come and kind of trying to identify novel ways to early on assess for PTC, above and beyond the questionnaires, because we know the questionnaires. I'm sure you know that On the one hand then we use that validate the Christian years in research and also in perinatal care, but because there is a lot of concern and a lot of stigma and a lot of guilt and a lot of concern that the baby might be taken from the patient.

Speaker 2: 34:54

Then we see the people. They tell me because I often ask them why aren't you sharing it with anybody? And I know where people are giving birth and I know there are good providers that would be able to have this conversation with these people. There in my study are participants. They would say I am scared that if I will tell them how bad I'm feeling and share my nightmares, they'll tell me to either stay in the hospital for a couple of days I do not want to stay in the hospital or they'll just take my baby away because they'll think I'm not well enough to take care of the child. So a questionnaire might not be as sensitive as a more what we call a less direct way to assess the subjective experience of childbirth.

Speaker 1: 35:32

Yeah, no, and I resonate with all that and I think that's why I stayed silent for and suffered and I hear it from women but just the point that we're talking about this, I think, is such a huge step. My hope and prayer is that this reaches someone's ear and that they go. This is what I'm experiencing. We say name it to tame it a lot, because it's really scary if we don't know what you're experiencing. Let's speak a little positivity of what have you seen when moms have got treatment, Say they've started therapy, they've worked through the trauma. How is that progression? You know that they do become more resilient, that they're not having the nightmares every night again, they're feeling more equipped.

Speaker 2: 36:11

So I'd like to talk more for a kind of empirical-based perspective, and currently under NIH we have a study that examined a brief psychological intervention and whether this intervention given to people really within the first month postpartum could reduce symptoms of PTSD using expressive writing. We don't have the data analyzed yet but the study is still open to recruitment for people most likely residing in the area of Boston. So to your question, we did publish a meta-analysis study in which we looked at all the published work in English in which they examined different treatment approaches to prevent or reduce symptoms of PTSD, and overall not a lot of published work exists. The I would say, kind of optimistic take-home message it's overall it seems that early interventions that are trauma-focused, ranging from what I would call like more psychological counseling but trauma-focused, to more trauma-focused, empirical-based interventions that we know are commonly used for PTC survivors, such as CBT, emdr, as well as narrative therapy. These interventions look promising. Very much so, but again, I would not feel confident not to say these are the recommended ones, because the research is really almost non-existing.

Speaker 2: 37:35

Very, very, very few studies examined these interventions. I can tell you that for my clinical practice, which I see participants, this is not based on data. It's my observational work. I often see mothers in my prior practice that have PTSD and I work through like a more narrative approach or kind of the trauma exposure narrative therapy and I see that this is helping people and not only reducing their symptoms and making them connect better with their babies, but they're making them have an altered perception of themselves.

Speaker 2: 38:06

So, versus coming from this perception of you know, something is wrong with me. How come this happened to me? Blaming people, but mostly blaming themselves, and feeling very, very guilty and kind of feeling very inadequate. When you, during a time that you have to have so much energy to take care of your newborn, that people, their perception changes. They say, wow, you know, this was actually so traumatic objectively that would have been traumatic to everybody, to any person, because there's so much objectively unfortunate obstetrical morbidity or complications, but I was able to cope. You know, I coped, I took care of my baby, I survived and from this kind of very I would say resilience perspective, that's, I think, is likely to help people to have a positive self-esteem for themselves, regardless if they decide to give birth again or not, just kind of you know a more generous way of how they are perceiving themselves, which we know is good for everybody.

Speaker 1: 39:02

No, and I can speak personally it does get better and it does. I think the hardest step is saying I'm not okay, and that, to me, was very difficult, and it still is to say something that is usually, especially in the South, correlated so strongly. You know, it's supposed to be joyous and you're blessed and you're a happy mom right, and it's. It is such an important conversation. I'm just so incredibly grateful that you have took on the charge. As we said, there's not a lot of research out there. Right, you're making the research, but before you leave, I want to ask you a question. We ask all our guests and this can be a personal response, it doesn't have to be anything based about what all your research is is what is something that now you, you know? You said your girls are in teenage years what do you wish you would have known about motherhood that you've learned now that through you know trials and tribulations. When you first got pregnant, like, what words of advice would you give yourself?

Speaker 2: 40:00

Wow that's. This is a hard question. It's very hard because I think it's important to have and this might contradict what I said, but it's important to have some kind of a balance between being naive and being a self-enhancer and thinking, okay, I'm going to have the best delivery ever, but also being aware of complications. But some kind of a good balance, because we do know that some degree of arrogance and just feeling things will be fine is also helpful. You don't want to be too kind of obsessed about how and this is especially talking for people who are pregnant how childbirth is going to be a scary event, because for most people it's not scary and most people do not develop PTSD or postpartum depression, although a significant portion do. So I think that's important to think about things in perspective. I would say social support I think maybe I was thinking more. You know kind of I can do it, everything will be fine. I think this idea of having a good social support, that you know people you can rely on, which could be you know different people, for different patients, for different mothers, but I think the social support is crucial and the idea of knowing that postpartum is a life-transforming experience that never ends but could be extremely overwhelming. Extremely overwhelming especially, I think, because we do not live in a tribe of, you know, 30 mothers around us. Most people are actually quite isolated in their small nuclear families in the western culture. So I think it's important to prepare postpartum us most people are actually quite isolated in their small nuclear families in the Western culture. So I think it's important to prepare postpartum, regardless of PTC or birth trauma, to have good resources available, which would be the social support, a group of other mothers and having. You know I think I often see for the postpartum PTC.

Speaker 2: 41:45

Going back to my research, not to my personal experience, necessarily A huge stressor is breastfeeding and again, I think any preparation that relates to breastfeeding for people who have the resources, of course, already talking with a breastfeeding consultant and having all these people assist you is something, but again, I think that's quite difficult for people who don't have the same access as some other people might have. So I think it's, I would say, the end of the day it's important to think about. This is going to be the best experience of my life and I still think it's a peak of the person's transformation giving birth and taking care of your newborn. But it's a lot of work. So how can we make sure that people have all the support they deserve not that they need because they are weak, but they deserve to make sure they are thriving not only just coping, but thriving. You know, based on our studies, again, we see many people who are really, really really struggling. Even if they don't have symptoms, they're very isolated and this is post-pandemic. They're very isolated and this is post-pandemic. They're very isolated and it's actually not a fun time for them.

Speaker 2: 42:50

How can we support mothers? I think you know, for anybody who is hearing us and is interested in you know, I'm always in the vision of developing a center for birth trauma and a center that we would be able to offer treatment, because now we can offer a lot of treatments remotely, so not only treatment to people who reside in Boston, but treatment that we could offer remotely for people who reside in different regions in the US and ideally, with more support, treatment that could be even offered for free, regardless of your insurance plan. I think it's something that actually we have the expertise and the knowledge to do. We just need more support and anybody who is interested in learning more about our mission is definitely very expertise and the knowledge to do. We just need more support, and anybody who is interested in learning more about our mission is definitely very welcome to reach out to me.

Speaker 1: 43:34

Tell us, tell listeners who want to read the research. There's several clinicians that will be listening to this as well. Where can they learn more about your lab and read your studies and follow along?

Speaker 2: 43:46

I think the easiest would be to go on the website at the DecaLab or we call it I think these days it's called the Postpartum Traumatic Stress Research Program at Mass General and there will be linked information about current studies, past studies and also information about published work. And then anybody's always welcome to you know, have patients or providers, any questions? I'm always free to be available one-on-one to correspond via email. So it's sdeckle at mghharvardedu.

Speaker 1: 44:15

I am so grateful for this conversation and we are cheering you on. We welcome you back anytime as the research and the data gets published out for us to talk and share the advancements, because I think we always need to be highlighting the work that's being done in the new approaches that are showing that women, as you said, deserve and can be supported and easy to do in this virtual world we live in. So I appreciate you so much and cheering you on always. Thank you so much, Sarah, for inviting me. Okay, listeners, thank you so much. I'll link everything in the show notes and I will see you guys next week.

Speaker 3: 45:06

Maternal mental health is as important as physical health. The preview alliance podcast was created for and by moms dealing with postpartum depression and all its variables, like anxiety, anger and even apathy. Hosted by ceo founder sarah parkers and licensed clinical social worker whitney gay, each episode focus on specific issues relevant to pregnancy and postpartum. Join us and hear how other moms have overcome mental health challenges, as well as access tips and suggestions on dealing with your own challenges as moms. You can also browse our podcast library and listen to previous episodes at any time. Please know you're not alone on this journey. We're here to help.