The Role Of Attachment In The Development Of Post-Traumatic Stress Disorder (PTSD) After Childbirth: A Comparison Of Women

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The Role Of Attachment In The Development Of Post-Traumatic Stress Disorder (PTSD) After Childbirth: A Comparison Of Women In Saudi And The UK


This paper presents a proposal for a study on the role of attachment in the development of PTSD after childbirth. The research will be conducted on Saudi and UK women during the first two weeks of postnatal period. The paper will explore the impact of six main attachment sub-factors, namely, attachment style, religiosity, culture, support, shuttered assumptions and parent-infant bonding. As it will be noted, significant research has been conducted on the role of attachment in the development of PTSD after childbirth in the UK. However, no prior studies have been conducted on the issue in the context of Saudi Arabia. This research aims to bridge that gap and will utilize quantitative data that will be collected using questionnaire. Data collected will be analyzed using descriptive statistics (means, variances, and correlations). A work plan for the research project is also presented in the paper.




1.1 Purpose of the Study. 3

1.2 Importance of the Study. 4


2.1 Attachment style. 5

2.2 Effect of Parent-Baby Bonding. 6

2.3 Shutter assumptions. 7

2.4 Religion. 8

2.5 Support 9

2.6 Culture. 11


3.1 Study Design. 13

3.2 Sample. 13

3.3 Research Procedure. 14

3.3.1 Data Collection. 14

3.3.2 Validity of Data collection Instruments. 14

3.3.3 Reliability of Data collection Instruments. 15

3.4 Measures. 15

3.4.1 Attachment style. 15

3.4.2 Support 16

3.4.3 Parent-infant relationship. 16

3.4.4 Shuttered Assumptions. 16

3.4.5 Religiosity. 17

3.4.5 Culture. 17

3.4.6 Attachment 17

3.5 Data Analysis. 18

4.0 WORK PLAN.. 18



Table 2: Work Plan. 20


The birth of a child is understood as a normative event in the society. However, giving birth is a time that involves substantial psychological and neural-hormonal changes which may present numerous challenges to a woman’s life. As Ayers & Ford (2009) explains, the birth of baby involves unique psychological and physiological demands and requires substantial adjustment. Majority of women have positive experiences after giving birth. However, a proportion of women encounter difficulties or even traumatic experiences after giving birth. In most cases, parents who are unable to effectively adjust to traumatic experiences develop PTSD. Unlike many other life experiences, giving birth is particularly important since it has wide-ranging impact on a woman’s emotions. Depression in women after giving birth has also been associated with poor cognitive development in children and depression in their partners (Ayers & Ford, 2009).

Attachment has been shown to influence the ability for people to cope with and manage stress and to retain psychological resilience after child birth (Gormley & McNiel, 2010). Attachment theory founded by John Bowlby might provide a theoretical explanation for the issue. Bowlby (1969/1982, 1973) conceptualized attachment as the innate motivation that drives an infant to seek proximity to the mother during stressful periods (Mikulincer et al, 2006). Bowlby further suggested that when a child contently interacts with a sensitive and supportive caregiver, he or she develops a cognitive schema of general support availability for minimizing or coping with stress during potentially threatening situations. In other words, humans are born with a unique psychological system that motivates them to seek proximity and support from attachment figures or significant others in times of need.

According to Bowlby, the relationships with significant others are presented in the mind in terms of stable working models (Gormley & McNiel, 2010). People form expectations in their minds that the attachment figures or significant others are going to provide support in times of need. When the attachment figures are unsupportive or unavailable, felt security is undermined and the individual may develop stress, emotional problems and health problems. On the other hand, an individual may follow insecure attachment, which can be conceptualized in terms of two major dimensions; anxiety and avoidance. Attachment-related anxiety refers to an individual’s degree of worries that attachment figures will not be available or will not be supportive in times of need. Avoidance is the extent to which an individual may distrust partner’s goodwill for support and subsequent withdrawal and maintenance of emotional distance and behavioral independence (Gormley & McNiel, 2010).

Attachment system functioning has been shown to be quit relevant to an individual’s mental health and adjustment to stressful situations. The sense of being supported and being loved by attachment figures results naturally in a stable sense of self-esteem and positive representation of others, and enhances ability to cope with and manage stress (Mikulincer et al 2006). On the other hand, attachment insecurities are perceived as risk factors that foster affectivity, reduces resilience in times of stress, and contributes to emotional difficulties, maladjustment, and psychopathology. As mentioned earlier, giving birth is a situation that demands unique psychological, physical and emotional needs. Adequate support from partner and other attachment figures has been associated with improved mental health and quick adjustment and recovery among women after childbirth (Gormley & McNiel, 2010). Women with more positive perceptions of the world and self are more likely to seek or to attract support from attachment figures. Attachment to a particular culture and religion may also influence accessibility to physical, psychological and emotional support after childbirth. Studies have also found association between a woman’s attachment to her child and development of stress and depression during postnatal period.

The role of attachment in the development of PTSD after childbirth is particularly relevant in this study given that approximately 0.6 million women give birth in both UK and Saudi Arabia every year, according to Central Intelligence Agency (2013) statistics. At the same time, research evidence shows that between 1% and 9% of women develop PTSD after giving birth, depending on the target population of study (Ayers & Ford, 2009). It is likely that cultural differences between UK and Saudi may lead to differences in PTSD prevalence rates after childbirth in the two countries.

 1.1 Purpose of the Study

The main purpose of this study is to determine the role of attachment in the development of PTSD after childbirth. Studies have shown that attachment factors such as attachment style, religiosity, culture, held world assumptions and social support may influence the development of PTSD after childbirth. However, studies are rare that explore the overall impact of all the aforementioned attachment factors. The purpose of this study is to explore the overall impact of the all the above factors in order to gain a more comprehensive understanding of the role of attachment in the development of PTSD after childbirth. Secondly, numerous studies have been conducted to determine the role of culture in development of PTSD in western and non-western countries. However, no prior studies have paid attention to the role of Islamic culture and religion in the development of PTSD after childbirth in Saudi Arabia. Therefore, this study aims to bridge that gap by comparing the impact of culture and religion in the development of PTSD after childbirth among UK and Saudi women.

1.2 Importance of the Study

The present study will contribute to the society in various ways. To start with, it will provide evidence of existence as well as prevalence rate of PTSD in Saudi Arabia. Clinicians in Saudi Arabia will find the information useful as reference for establishment of better and more effective treatment strategies for PTSD symptoms among women after childbirth. Secondly, the study will provide opportunity for making comparison between the impacts of Saudi’s Islamic culture and UK’s western culture in the development of PTSD after childbirth. This is vital given that the role of Saudi’s Islamic culture in the development of PTSD after childbirth has not been explored before. In addition, the study will provide an opportunity to determine the combined impact of different attachment sub-factors in the development of PTSD after childbirth. Finally, the study will be useful to clinicians, mothers and the society at large since it will provide them with vital knowledge on how attachment can help to mitigate effects of traumatic experiences after childbirth.


Numerous studies, mainly influenced by Bowlby’s attachment theory, have explored the role of attachment in the development of PTSD after childbirth. As mentioned earlier, the main attachment factors that may influence development of PTSD are attachment style, parent-infant bonding, shuttered assumptions model, religiosity, support, and culture. Therefore, a comprehensive understanding of the role of attachment in the development of PTSD after childbirth can be achieved by exploring the role played by each of the aforementioned factors.

2.1 Attachment style

There are just few studies that have paid attention to the relationship between attachment styles and development of PTSD.  O’Connor and Elklit (2008) investigated the impact of attachment styles in development of PTSD among young adults. The study utilized a sample of 328 Danish students with an average age of 29.2 years. The results of this study found that attachment styles have a strong association with PTSD symptoms, emotional coping, social support, negative affectivity and attributions. In addition, the study found the distributions of attachment styles in relation to the symptoms of PTSD to be uni-directional.

Mikulincer and Shaver (2007) reviewed cross-sectional, prospective and longitudinal studies that included clinical samples and found that attachment insecurity was prevalent among individuals with variety of PTSD. Similar results have been reported in other studies. For instance, attachment insecurities has been found to be associated with depression (Catanzaro & Wei, 2010), PTSD (Ein-Dor et al, 2010), and suicidal tendencies (Gormley & McNiel, 2010). Meyer and Pilkonis (2005) found that the association between attachment insecurity and PTSD is dependent on prior experience of psychological, sexual or physical abuse. Studies involving large community samples usually give contradicting results. For instance, Mikulincer and Shaver (2007) found that studies involving large community samples showed no association between attachment style and PTSD symptoms. The present study will augment existing literature and will provide additional knowledge on the impact of attachment styles in the development of PTSD symptoms.

2.2 Effect of Parent-Baby Bonding

There are numerous studies that have focused on the association between parent-baby bonding and PTSD symptoms. However, majority of the prior studies have focused on the impact of PTSD symptoms on parent-baby bond rather than the effect of parent-infant bond in the development of PTSD symptoms. Despite that, the studies express the significance of parent-baby bond in the development of PTSD symptoms after child birth. Parfitt and Ayers (2009) sought to examine the effects of PTSD symptoms on the relationship between couples as well as on parent-baby bond. The study utilized information gathered using internet-based questionnaires from 150 parents (26 men and 126 women) on PTSAD symptoms, quality of couple’s relationship, depression and parent baby bond.  The results of this study showed a strong correlation between parent-baby bond and symptoms of PTSD and depression. Forcada-Guex et al (2011) administered Perinatal Posttraumatic Stress Disorder Questionnaire on 47 mothers of pre-term infants and 25 mothers of full-term infants. The study found that mothers of full-term infants had relatively less PTSD symptoms, showed stronger parent-infant bond, demonstrated balanced representations of the infants and were likely to follow “cooperative dyadic pattern of interaction with the infant (Forcada-Guex et al, 2011). On the other hand, pre-term mothers portrayed more PTSD symptoms, had more distorted representations of their infants and were more likely to follow a controlling dyadic pattern of interaction (Forcada-Guex et al (2011). Generally, the findings of the study indicated a strong correlation between the parent-infant relationship and PTSD symptoms.

However, Ayers, Wright and Wells (2007) found little association between parent-baby bond and PTSD symptoms. The authors collected information from 64 couples about symptoms of PTSD, birth, parent-baby bond and the couple’s relationships. The study found 5 percent of the respondents to have severe symptoms of PTSD after birth. Further, women portrayed stronger parent-child bond compared to men. However, no significant difference was found between the magnitude of PTSD symptoms portrayed by men and women. In other words, the study did not find strong association between parent-baby bond and PTSD symptoms. Lack of strong association may be attributed to methodology that was used in conducting the research. Although the current study will focus on women, it will provide a more clear understanding of the effect of parent-infant bond in the development of PTSD after childbirth.

2.3 Shutter assumptions

The theory of shattered assumptions developed by Ronnie Janoff-Bulman (1983;1992) (as cited in Lilly, Valdez & Graham-Bermann, 2011) can also be used to explain the role of attachment in the development of PTSD. The theory contends that people carry with them three key assumptions: the world is meaningful, the world is benevolent and the self is worthy. According to Janoff-Bulman the three assumptions enable human beings to make sense of the world and the events happening around them. They are integrated in the belief system of a human being and they assist people in overcoming unsafe and chaotic aspects of the world. However, the theory of shattered assumptions contends that the basic assumptions can be shattered by trauma, disintegrating a person’s belief system. When this happens, an individual may suffer from distress until the basic assumptions are restored (Lilly et al, 2011).

When testing theory among young adults, Lilly et al (2011) hypothesized that the basic assumptions aid in the creation, restoration and maintenance of sense of attachment security within an individual. Positive assumptions lead to an increase in meaningful interactions which impart a sense of safety, provide psychological resources for dealing with adversities and problems, and triggers positive emotions (such as love, gratitude, satisfaction and relief). In a study that recruited women who have survived from intimate partner violence, Lilly et al (2011) concluded that persons who hold onto the basic assumptions are less perturbed and recover quickly from associated distress. On the other hand, Lilly et al (2011) found that shattered assumptions lead individuals to feel insecure and to make less meaningful interactions. Janoff-Bulman’s argument has also been supported by other studies that have linked more negative world assumptions to more symptoms of PTSD (Nygaard & Heir, 2012; Zukerman & Korn, 2013). This study will augment prior research by focusing on the role of world assumptions in the development of PTSD.

2.4 Religion

Numerous studies have shown religiosity to have a moderating effect on the negative effects of posttraumatic stress. However, studies focusing on association between religiosity and PTSD after child birth are rare. A recent study by Zukerman and Korn (2013) 777 Israeli undergraduate students found a significant relationship between religious coping and world assumptions held by the respondents. Respondents who coped well with religion had more positive world assumptions while individuals who portrayed negative religious coping had more negative world assumptions. In addition, negative world assumptions were associated with more symptoms of attachment insecurity and PTSD. Zukerman and Korn (2013) concluded that religiosity affects world assumptions directly by shielding negative effects of negative experiences.

Another study carried out among veterans by Rosmarin et al (2009) showed that Jews with weak religious faith were relatively more hopeless and stressed. Gerber, Boals and Schuettler (2011) found similar results in a study that utilized a sample of 1,016 participants. The study found strong association between positive religious coping and post-traumatic growth and a strong association between negative religious coping and development of PTSD symptoms. On the other hand, research among veterans carried out by Resick, Monson and Chard (2008) found no significant association between religiosity coping and PTSD. However, Resick et al (2008) used the rate at which respondents sought counseling services as a proxy for measuring PTSD rather than focusing on the symptoms of PTSD. Although relevant, the results derived from the study are not convincing enough to overturn the findings of the other studies. The present study will explore the role of religiosity in order to gain better understand its impact on development of PTSD.

2.5 Support

Earlier studies have found support to be strongly associated with the development of PTSD after childbirth. One of the most relevant studies was conducted by Iles et al (2011) on a sample of 372 couples who were on their first seven days of postpartum. The study sought to determine the role of partner attachment and perception of partner support on the development of PTSD symptoms after childbirth. The study found significant association between symptoms of PTSD within couples. Men’s acute trauma symptoms predicted the presence PTSD symptoms among their partners. Essentially, the findings showed that PTSD symptoms were more prevalent among women who were less satisfied with partner support (Iles et al, 2011). The study carried out by Iles et al (2011) confirmed the findings of an earlier research by Moller, Hwang and Wickberg (2006) which found partner attachment and support to be essential during marriage transition to adulthood as well as during early postpartum. Moller et al (2006) also found that individuals following secure attachment style were more inclined to seek support from their partners while insecure attachment may lead an individual to withdraw, reducing access to support. Generally Moller et al (2006) showed that attachment and support available to a woman from her partner may affect her psychological adjustment after childbirth. Despite, Iles et al (2011) suggested that attachment may have a direct association with PTSD irrespective of perceptions of support. For instance, an insecure attachment base may lead to an increase in PTSD symptoms directly without operating via social support (Iles et al, 2011).

According to Iles et al (2011), it is not yet clear whether a partner’s avoidance character has an impact on the other partner’s psychological adjustment or in suppressing depression and post-traumatic stress after childbirth. It is possible that a man who has insecure attachment to her partner may not provide the necessary support during times of difficulty, impacting on the psychological wellbeing of the partner. Ditzen et al (2008) also found insecure attachment and dissatisfaction with partner support to have significant association with higher PTSD symptoms. Tsai et al (2012) found PTSD symptoms to be more prevalent among individuals with less social support, less cohesion in their families, greater difficulties in their relationships with partners, and lower life satisfaction. Lemola, Stadlmayr, and Grob (2007) found that women who were more satisfied with partner support were less likely to develop PTSD symptoms. The authors found that women who perceived their partners as providing adequate emotional support discussed with them their concerns and worries without fear of criticism. Various studies have also shown the significance of social support from fiends and relatives (Mikulincer et al, 2006), and wider community (Mikulincer & Shaver, 2007) in the development of PTSD symptoms.

However, some studies have derived contradicting results. Stapleton et al (2012) and Elsenbruch et al (2006) found that lower perceptions of support among women during pregnancy were associated with more PTSD symptoms after child birth. However, Elsenbruch et al (2006) did not assess the relationship within .............

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