PTSD, Moral Injury Increase Risk of Pregnancy Complications

April 15, 2020
Samara Rosenfeld

The findings suggest that screening for PTSD and moral injury while women are pregnant is important to identify those who may need treatment for such problems.

Yael Nillni, PhD

Higher levels of posttraumatic stress disorder (PTSD) and moral injury could lead to pregnancy complications, according to recent study findings.

The findings suggested that screening for PTSD and moral injury while women are pregnant could be important to identify those who may need treatment for such problems.

Yael Nillni, PhD, and a team of investigators found that PTSD and moral injury were predictors of adverse pregnancy outcomes, including preterm birth and gestational diabetes. PTSD symptoms predicted postpartum depression, anxiety, and a self-described difficult pregnancy.

Nillni, from the National Center for PTSD at VA Boston Healthcare System, and the team used data from a nationwide prospective cohort study, the Veterans Metrics Initiative (TVMI). A sample of 48,965 US veterans who separated from active-duty service or activated reservist status within the last 90 days were invited to participate in TVMI.

Veterans were invited to participate in an online survey.

More than 44,000 veterans were reachable and invited, and 9566 completed the first survey and 581 submitted partial responses—23% response rate. The response rate was on par with those for other studies done with post-9/11 veterans.

Of the women enrolled in the study (1734), 18% reported having had a pregnancy <3 years of separating from military service.

In the baseline survey, women reported demographic and military characteristics, including age; ethnicity; race; education level; marital status; household socioeconomic status; service branch; paygrade; and military occupation.

The investigators assessed lifetime trauma exposure by asking about exposure during different developmental periods—before 18 years old, after 18 years old but before joining military, during military, and since separating from service.

Two-thirds (66.7%) of the women reported experiencing at some point in their life, 31.1% before 18 years old, 22% during adulthood but before joining the military, 54.4% during the military, and 9.7% within the past 3 months of the survey.

PTSD was measured with the Primary Care PTSD Screen for DSM-5, a self-reported screening measure for PTSD. Participants indicated (yes/no) whether they experienced symptoms of reexperiencing, avoidance, negative alterations in cognitions and mood, and hyperarousal. Higher scores represented more symptoms.

Nearly 30% of the women met criteria for probable PTSD. Internal consistency of reliability was high.

Nillni and the team assessed moral injury during a second timepoint with the Moral Injury Events Scale—a nine-item measure where respondents indicated on a six-point scale the degree they agree with statements that assessed transgressions of deeply held moral beliefs during service. Higher scores represented more severe moral injury.

Internal consistency of reliability was high.

Pregnancy outcomes were measured through 5 more follow-up surveys.

Participants reported if they experienced a pregnancy since separating form the military and if they experienced miscarriage; stillbirth; birth prior to 37 weeks gestational age; ectopic/tubal pregnancy; emergency C-section; high blood pressure’ gestational diabetes; or other medical condition present during pregnancy. The women also indicated whether they experienced postpartum depression and/or anxiety after any of their pregnancies since separation from service.

Overall, 51.3% experience and adverse outcome, most commonly a miscarriage (24.8%), followed by preeclampsia or gestational diabetes (22%), an emergency C-section (8.5%), and preterm birth (5.7%).

Nearly 30% of the participants experienced postpartum depression and/or anxiety.

Women rated their pregnancy as neutral on a scale of “very easy” to “very difficult.”

After adjusting for age, racial/ethnic minority status, and lifetime trauma exposure, PTSD symptoms (aOR, 1.16; 95% CI, 1-1.35) and moral injury (aOR, 1.27; 95% CI, 1.06-1.41) significantly predicted increased risk of an adverse pregnancy outcome.

When controlling for age, minority status, and trauma, only PTSD symptoms significantly predicted increase risk of experiencing postpartum depression and/or anxiety (aOR, 1.43; 95% CI, 1.22-1.68).

The findings emphasized the importance of screening for pregnant women within and outside Veterans Affairs healthcare settings.

The study, “The Impact of PTSD and Moral Injury on Women Veterans’ Perinatal Outcomes Following Separation From Military Service,” was published online in the Journal of Traumatic Stress.


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