Post-traumatic stress disorder (PTSD) is common among women of child-bearing age. While we are increasingly attentive to screening for depressive symptoms during pregnancy and after delivery, less often do we inquire about PTSD symptoms. Postpartum or childbirth-related PTSD (CB-PTSD) is not uncommon and may be precipitated by a stressful or traumatic childbirth experience. Sharon Dekel, PhD, Director of the Postpartum Traumatic Stress Laboratory at Mass General, and her team have found that while childbirth-related PTSD may emerge after deliveries associated with more severe medical complications or death of the infant (stillbirth); PTSD may also occur after what many would consider an uncomplicated delivery. In fact, as many as 17% of women in community samples experience CB-PTSD symptoms, even after giving birth to a healthy full-term baby (Dekel et al, 2017).
Childbirth-related PTSD can become an enduring and debilitating condition, yet we do not routinely screen for this condition. At present, validated tools for rapid and efficient screening for childbirth-related PTSD are not available. In a recent study, Dekel’s team examined the diagnostic validity of the PTSD Checklist (PCL-5) for the identification of PTSD in a group of women who had recently experienced a traumatic childbirth. The PCL-5 is a patient-administrated 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 childbirth experience. In accordance with the definition of PTSD in the DSM-5, a traumatic childbirth experience was defined as an exposure involving threat or potential threat to the life of the mother or her infant or physical injury.
Participants completed the PCL-5, focusing specifically on PTSD symptoms related to childbirth. Co-morbid conditions, including depression and anxiety, were assessed using the Edinburgh Postnatal Depression Scale (EPDS) and the Brief Symptom Inventory (BSI). The diagnosis of PTSD was confirmed with a clinician interview using the gold-standard, Clinician-Administered PTSD Scale for DSM-5 (CAPS-5).
PCL-5 Scores in Postpartum Women Reporting a Traumatic Birth Experience
The majority of the participants (66%) were interviewed within the first postpartum year (median = 4.67 months; mean = 1.5 years). Approximately one-third of the sample (35.59%) met DSM-5 criteria for childbirth-associated PTSD. The PCL-5 symptom severity score was strongly correlated with the CAPS-5 total score (ρ = 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 cutoff value of 28 maximized the sensitivity (0.81) and specificity (0.90) of the screening tool and allowed for the correct diagnosis of PTSD in 86.4% of the women. When a higher cutoff score (32) was used, the PCL-5 identified individuals with more severe PTSD symptoms (specificity, 0.95), but with lower sensitivity (0.62). PCL-5 scores were stable over time.
The PCL-5 scores were moderately correlated with depression and anxiety symptom scores (EPDS, ρ = 0.58, p < 0.001) and BSI, anxiety subscale (ρ = 0.51, p < 0.001).
Using 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-associated 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 should be screened for postpartum depression and depression. Given the high comorbidity of PTSD with depression and anxiety in this population, screening tools measuring depression and anxiety, for example the EPDS and the GAD-7, may also flag women with childbirth-related PTSD. However, these screening tools may miss other women with CB-PTSD without comorbid depression or anxiety. Furthermore, targeting only postpartum depression and anxiety may not address the symptoms of childbirth-related PTSD, 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 to identify women who might benefit from PTSD-specific interventions.
Researchers involved in this study included Isha Hemant Arora, Georgia Woscoboinik, Salma Mokhtar, Beatrice Quagliarini, Alon Bartal, Kathleen Jagodnik, Robert L Barry, Andrea Edlow, Scott P Orr, and Sharon Dekel.
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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.
