Post-traumatic stress disorder (PTSD) is common among women of childbearing age. While we are increasingly careful to screen for symptoms of depression during pregnancy and postpartum, we less often ask about symptoms of PTSD. After giving birth or PTSD related to childbirth (CB-PTSD) is not uncommon and can be precipitated by a stressful or traumatic birth experience. Sharon Dekel, PhD, Director of Postpartum Traumatic Stress Workshop at Mass General, and her team have found that while cChildbirth-related PTSD can occur after births associated with more serious medical complications or the death of the infant (stillbirth). PTSD can also occur after what many would consider a simple childbirth.
In fact, up to 17% of women in community samples experience symptoms of CB-PTSD, even after giving birth to a healthy full-term baby (Dekel et al, 2017).
Childbirth-related PTSD can become an ongoing and debilitating condition, yet we don’t routinely screen for this condition. Currently, no validated tools are available for rapid and effective screening for PTSD related to childbirth. In a recent study, Dekel’s group examined the diagnostic validity of the PTSD Checklist (PCL-5) for identifying PTSD in a group of women who had recently experienced a traumatic birth. The PCL-5 is a patient-administered screening instrument that assesses 20 PTSD symptoms according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). While this tool is commonly used to screen for PTSD in the general population, its diagnostic accuracy in screening for childbirth-related PTSD has not been examined.
In this study, the sample included 59 patients who reported having a traumatic birth experience. According to the definition of PTSD in the DSM-5, a traumatic birth experience was defined as an exposure that poses a threat or potential threat to the life of the mother or her infant or physical injury.
Participants completed the PCL-5, specifically focusing on childbirth-related PTSD symptoms. Comorbidities, including depression and anxiety, were assessed using the Edinburgh Postnatal Depression Scale (EPDS) and the Brief Symptom Inventory (BSI). PTSD diagnosis was confirmed by a clinician interview using the gold scale, Clinician Administered PTSD Scale for DSM-5 (CAPS-5).
PCL-5 scores in postpartum women
The majority of participants (66%) were interviewed in the first year postpartum (mean = 4.67 months, median = 1.5 years). Approximately one-third of the sample (35.59%) met DSM-5 criteria for PTSD related to childbirth. PCL-5 symptom severity score was strongly correlated with CAPS-5 total score (? = 0.82, p < 0.001).
The area under the curve (AUC) was 0.93 (95% CI: 0.87–0.99), indicating excellent diagnostic performance of the PCL-5 in this setting. Using a cut-off value of 28 maximized the sensitivity (0.81) and specificity (0.90) of the screening tool and allowed a correct diagnosis of PTSD in 86.4% of women. When a higher cutoff score (32) was used, the PCL-5 identified individuals with more severe PTSD symptoms (specificity, .95), but with lower sensitivity (.62). PCL-5 scores were stable over time.
PCL-5 scores were moderately correlated with depression and anxiety symptom scores (EPDS, α = 0.58, p <0.001) and BSI, anxiety subscale (? = 0.51, p <0.001).
Use of the PCL-5 as a screening tool for childbirth-related PTSD
This study demonstrates the validity of the PCL-5 as a screening tool for childbirth-related PTSD among women who had experienced a traumatic childbirth experience. The PCL-5 appeared to have excellent diagnostic performance, with high sensitivity (0.81) and specificity (0.90).
Currently, it is recommended that all postpartum women be screened for postpartum depression and depression. Given the high comorbidity of PTSD with depression and anxiety in this population, screening tools that measure depression and anxiety, for example the EPDS and GAD-7, may also flag women with PTSD associated with childbirth. However, these screening tools may miss other women with CB-PTSD without comorbid depression or anxiety. Additionally, targeting postpartum depression and anxiety alone may not address PTSD symptoms associated with childbirth, a factor that may ultimately negatively impact treatment outcomes. In postpartum women, use of the PCL-5 may facilitate screening for childbirth-related PTSD on a large scale and would help identify women who may benefit from PTSD-specific interventions.
The researchers involved in this study were Isha Hemant Arora, Georgia Woscoboinik, Salma Mokhtar, Beatrice Quagliarini, Alon Bartal, Kathleen Jagodnik, Robert L Barry, Andrea Edlow, Scott P Orr and Sharon Dekel.
Ruta Nonacs, MD PhD
bibliographical references
Arora IH, Woscoboinik GG, Mokhtar S, Quagliarini B, Bartal A, Jagodnik KM, Barry RL, Edlow AG, Orr SP, Dekel S. Establishing the validity of a diagnostic questionnaire for childbirth-related posttraumatic stress disorder. Am J Obstet Gynecol. 2023 Nov 21: S0002-9378(23)02031-8.
