Key factors associated with the development of childbirth-related acute and posttraumatic stress symptoms: a prospective cohort study on the role of pain-related constructs

Background: Overwhelming pain during childbirth can contribute to the development of childbirth-related posttraumatic stress disorder (CB-PTSD). However, no single study investigating the path towards CB-PTSD has included multiple pain-related constructs and considered childbirth-related acute stress disorder (CB-ASD) as an outcome.Objective: This study aimed to evaluate the complex interactions and mediating roles of pain-related factors contributing to the development of CB-ASD and CB-PTSD, including pain experienced prior to and during childbirth, pain catastrophizing and childbirth-related pain expectations, while considering the global childbirth experience, prior trauma, anxiety and depression.Methods: This prospective population-based cohort questionnaire study (N = 172) assessed prenatal measures (pain and its functional impact, pain catastrophizing, past trauma exposure, depression and anxiety symptoms, childbirth pain expectation) and childbirth-related measures (pain intensity and catastrophizing, perceived pain-related support, and global childbirth experience). Outcomes of interest were CB-ASD 1-week and CB-PTSD 1-month post-partum. Several structural equation modelling (SEM) models, grounded in a theoretical framework, were evaluated and compared to identify the combinations of variables that best fit the observed data and understand their mutual influences.Results: In the final model, childbirth-related pain expectations and the functional impact of pain during pregnancy were related to childbirth pain intensity. Prenatal pain catastrophizing was associated with childbirth pain catastrophizing, and childbirth pain expectation was associated with perceived pain-related support during childbirth. Childbirth pain catastrophizing played a mediating role between childbirth pain intensity and global childbirth experience, and a partial mediating role between pain support during childbirth and the global childbirth experience. The global childbirth experience was related to CB-ASD symptoms following childbirth, which in turn were associated with CB-PTSD symptoms.Conclusion: Pain catastrophizing appears as a key factor associated with CB-ASD and CB-PTSD symptoms. Pain management and childbirth outcomes might be optimized through preventive interventions targeting at-risk pregnant women.