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Health Series: Research Spotlight

How do we best measure the effect of PTSD on women following traumatic childbirth?

Study first to show the full benefits of the City Birth Trauma Scale designed specifically to diagnose post-traumatic stress disorder (PTSD) in women after childbirth, and developed by Susan Ayers, Professor of Child and Maternal Health at City.

by Shamim Quadir

A recent study has evaluated and recommended the recently developed City Birth Trauma Scale, the only questionnaire developed specifically to diagnose PTSD in women after childbirth.

The Scale was developed by academics at City, University of London, and is based on the current criteria for PTSD outlined by the latest Diagnostic and Statistical Manual of Mental Disorders (DSM-5); a globally used standard for psychiatric diagnoses.

It’s thought that up to one-third of women report childbirth as a traumatic experience, and recent research by City academics has shown that post-traumatic stress disorder (PTSD) following childbirth occurs in 3-4% of women. This increases to 15-18% of women in high-risk groups, such as those who have a history of sexual abuse, had an emergency caesarean section, premature birth or severe pregnancy complications.

Conducted by academics from the Catholic University of Croatia and City, University of London, the study surveyed 603 first-time mothers in Croatia who had given birth within the previous 12 months with the City Birth Trauma scale.

Questions included ‘yes’ or ‘no’ answer questions such as ‘Did you believe you or your baby would be seriously injured?’ and questions with a choice of answers (‘0’ - not at all, ‘1’ - once, ‘2’ – two to four times, and ‘3’ - five or more times), relating to the frequency of a symptoms over the previous week such as ‘Getting upset when reminded of the birth’ and ‘Trying to avoid things that remind me of the birth’.

To validate the Scale the mothers were also surveyed with widely used and validated questionnaires relating to the processing of traumatic events (IES-R Scale), depression (EPD Scale) and anxiety (subscale from the DASS-21 Scale).

The study confirmed that grouping of measures on the Scale into those related to birth-related symptoms (e.g. from questions related to distressing memories and avoiding thinking about the birth) and general symptoms of PTSD (e.g. negative mood, irritability, and tension) could be used independently or together to accurately explain the responses of the new mothers who participated in the study.

This grouping of measures was used to show that the high-risk groups including first-time mothers, and those who had an instrumental vaginal delivery or emergency caesarean section (C-section) reported more PTSD symptoms than those who had not.

The Scale was found to be a reliable and valid measure for the diagnosis of postpartum PTSD and therefore highly recommended for use in the postpartum population.

Prior to the study, most measures of PTSD used with women after childbirth had been developed from research into PTSD in other groups of people such as military veterans.  Those few that had been developed specifically for women after childbirth were based on the out-dated criteria for PTSD set out in the fourth edition of the (DSM-4), which was superseded in 2013 by DSM-5 with updated criteria for the diagnosis of PTSD.

Susan Ayers, Professor of Child and Maternal Health at City, University of London, principle investigator of the study, and who also developed the City Birth Trauma Scale, said:


Since we published the City Birth Trauma Scale in 2018, I’ve been struck by how many people have contacted us and asked to use the scale, which shows just how needed it was. The scale has already been translated into 10 languages and research studies in the UK, Israel, and now Croatia, found the scale has similar properties in different populations so is a reliable measure of PTSD after birth.

The study was published in the journal, Psychological Trauma: Theory, Research, Practice, and Policy.

Watch Professor Ayers talk about post-traumatic stress in pregnancy and childbirth:

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