4.1 Principal Findings
The main finding of the study was the independent association between women who delivered during the Hamas-Israel war and increased risk of PPD as evident in the first postpartum days. Likewise, rates of clinical symptoms of PPA were higher in women delivering during the war although the differences were with marginal significance accounting for risk factors. Additionally, delivery during the war was related to higher scores of some factors of impaired MIB.
4.2 Results in the Context of What is known
Several studies have evaluated the influence of war trauma and military violence on the perinatal and delivery outcomes. However, to the best of our knowledge, little is known regarding the impact of war trauma on the mother during the important postpartum period, and how exposure to stress-related war trauma may have an adverse effect on maternal mental health and MIB.
Existing literature has extensively demonstrated the negative and long-term consequences of exposure to natural disasters, such as hurricanes, floods and earthquakes, and war and terrorism-related trauma on the mental health of the general population. Trauma exposed individuals present a high vulnerability group at great risk for a range of mental disorders50. The mental health sequalae of women deriving during exposure to terrorism attacks and war has received little empirical scrutiny. However, studies have been conducted about the effect of trauma in the context of natural disasters. Substantial PPD was reported in women exposed to the 2005 Katarina Hurricane, especially among high-exposure individuals, however the overall rates of PPD were not higher than the general population51. PPD was found associated with nontangible (psychosocial) loss of resources52. A qualitative study suggests significance effect on the women’s own life and direct impact on her functioning as a mother53.
Several factors may explain the increased mental health adversity among postpartum women. First, lack of social support. Second, partner deployment and lack of support person in delivery, and in the transition to motherhood, and third, endorsement of posttraumatic stress that increases vulnerability for PPD. Lack of social support is a known major risk factor for PPD. In a meta-analyses and systematic reviews of risk factors for PPD, lack of social support was concluded as a salient risk factor of PPD54. A comparison of recent newcomers to Canada, included refugee, asylum seeker and immigrant, groups characterized by impaired social support, showed a significant increase in PPD compared to Canadian-born group55. Higher incidence has been demonstrated in occupied territories which also suffer from decrease in social support56. Our study was conducted in the first weeks of the war, which were characterized by lack of preparedness of psychosocial support to the population which may explain our findings.
Additional two studies who conducted after the Katerina Hurricane and related prenatal consequences, used the Revised prenatal distress questionnaire (NuPDQ) and demonstrated higher rates of anxiety57 58. Both studies included women who did not have experience the hurricane and one of them also took place 5-7 years after the disaster. Therefore, concluded that indirect disaster exposure may also affected by traumatic events. Additionally, both studies related the social support as a key role of the development of health problem risk. Our study did not reveal a significant increased anxiety risk among women delivering during the war using the STAI questionnaire, although a trend for endorsing higher rates of PPA symptoms was documented.
Less than a handful of studies exist on the effect of war and terrorism on maternal-infant attachment. In two studies, of Palestinian women who delivered during the 2014 war on Gaza, severe exposure to war trauma was not associated with MIB at delivery, and 4 and 6 months postpartum59 60. These findings largely accord with our results.It has been further shown that the source and function of social support mediates unimpaired or impaired bonding 61. Severe war trauma was associated with poor social support which in turn associated with more MIB problems.
4.3 Clinical Implications
War trauma and military conflicts force populations to face losses and destruction and live with feelings of fear, insecurity, and despair62 63. The literature depicts a significance mental health cost of these conflicts64 65. The number of people worldwide live and suffer from military conflicts continue to increase66. Pregnant women and mothers are particularly vulnerable in conditions of war67. Our study revealed increased risk of PPD in women who deliver during conditions of war. PPD has significance consequences and costs68 69. Women with PPD are likely to experience future episodes of depression and co-morbid mental illnesses70. Depressed women may also suffer from providing appropriate maternal care and their infants are at risk for developmental problem71 72. Developing a tailored screening system to early on identify women at risk of developing PPD during times of war is necessary, as well as providing the required support to dealing with the illness and decrease the consequential damage. Screening for symptoms of PPA may be also considered given the high co-occurrence of both conditions. Our findings provide some evidence suggesting that conditions of war may increase more severe forms of bonding impairment in a minority woman. Understanding the important of the mother-infant unit and the relevance of supporting this unit at times of elevated stress is warranted.
4.4 Research Implications
The present study was conducted immediately after the outbreak of the Israel-Hamas war and assessed high exposure mothers in the very first days after delivering in a large hospital that served as the main hospital in this war. Hence, we evaluated mothers at critical time point for the development of mental health problems and MIB impairment. The duration of exposure may play a major role in the impact of war trauma on postpartum mental health and maternal psychiatric symptoms may surface in the first weeks and months postpartum. Future studies may examine the effect of the duration of war trauma on postpartum mental health outcomes and measure long-term potential effects. Repeated time point assessment may add important information. Furthermore, although the SUMC serves as a main hospital in the Israel-Hamas War, additional studies may compare the results in other Israeli hospitals which gave care to affected women during the war.
4.5 Strengths and Limitations
This study fills in a critical gap in knowledge on the mental health consequences of giving birth during times of war and in the aftermath of a unpresidential terrorist attack by studying women who gave birth in the first weeks and days since the Hamas-Israel war and revealing mental health status during the very immediate postpartum. The strengths of our study also include the relatively large cohort of women including women who gave birth before the war. Due to the Israeli law which ensures all women, the samples of women in this hospital are representative, relatively heterogenous and includes both Jewish and Bedouin populations. This study controlled for potential confounding factors while comparing two very similar groups of postpartum women who delivered at the SUMC, with common demographic and obstetrical characteristics. Furthermore, we utilized reliable and well-validated tools for the assessment of the risk of PPD as well as PPA, and MIB.
There are also several limitations worth noting. First, being a cross-sectional study, the results can establish associations but not causality. Second, assessing the mothers immediately after birth at a single time point, without a follow-up examination, cannot identify a longitudinal pattern and influence and may be subject to overlooking increased impairments and symptoms that may develop outside the immediate postpartum. Third, all measures are mothers' reports. Although we used validated questionnaires, incorporating additional assessments, such as diagnostic interviews and observational methods, could further validated the findings.