How do different childbirth experience scales predict childbirth-related posttraumatic stress symptoms and disorder?

Figures & data

Table 1. Background characteristics of the study population.

Background characteristics
Age, years, mean ± standard deviation (range), N	31.3 ± 4.5 (18–48), 1511
Cohabiting, n (%)	1470 (96.3)
Academic degree education, n (%)	598 (39.3)
Full-time job, n (%)	1221 (80.7)
Smoking during pregnancy, n (%)	156 (10.4)
Body mass index before pregnancy, mean ± standard deviation (range), N	24.1 ± 4.6 (15.8–55.5), 1461
Obstetric history
Nulliparous, n (%)	899 (58.9)
Earlier miscarriages, n (%)	321 (21.0)
Earlier terminations of pregnancies, n (%)	147 (9.6)
Earlier stillbirths, n (%)	10 (0.7)
Earlier vacuum extractions, n (%)	102 (10.7)
Earlier cesarean sections, n (%)	115 (12.2)
Current pregnancy
Infertility treatment^a, n (%)	112 (7.6)
Hospital care during pregnancy, n (%)	69 (4.7)
Gestational diabetes, n (%)	257 (17.4)
Current childbirth
Gestational age at the time of labor, mean ± standard deviation (range), N	39.6 ± 1.5 (26–42), 1479
Gestational age less than 37 weeks at the time of labor, n (%)	41 (2.8)
Spontaneous vaginal birth, n (% of all births)	1061 (71.7)
Vacuum extraction, n (% of all births)	165 (11.2)
Elective cesarean section, n (% of all births)	67 (4.5)
Emergency cesarean section, n (% of all births)	172 (11.6)
Epidural or spinal or their combination analgesia, n (% of vaginal deliveries)	919 (74.1)
Induction of labor, n (%)	329 (22.2)
Use of oxytocin, n (%)	960 (64.9)
Episiotomy, n (%)	350 (23.7)
Postpartum interventions
Blood loss over 1000 ml, n (%)	167 (11.3)
Intervention in the third stage of labor^b, n (%)	72 (4.9)
Newborn
Birthweight (g), mean ± standard deviation (range), N	3519.6 ± 491.5 (570.0–5120.0), 1478
Apgar (1 min) <7, n (%)	86 (5.8)
Treatment in neonatal intensive care unit within seven days after birth, n (%)	113 (7.6)

^a Including IVF, ICSI, FET, insemination, and ovulation induction.

^b Including surgical evacuation of placenta, curettage, and obstetric anal sphincter injury repairment.

Table 2. Childbirth experience in different trauma subgroups based on Traumatic Event Scale (TES) [6].

Factor	Mean ± standard deviation
	All	Primiparous	Multiparous
All
VAS1	80.5 ± 16.3	77.8 ± 17.3	84.3 ± 13.9^b
VAS2	78.4 ± 22.7	76.0 ± 23.7	81.8 ± 20.9^b
W-DEQ-B	46.7 ± 25.3	48.9 ± 25.1	43.7 ± 25.3^b
DSS	32.0 ± 4.8	31.8 ± 4.7	32.3 ± 4.9^c
No traumatic experience
VAS1	82.6 ± 13.8	80.1 ± 14.8	86.1 ± 11.5^b
VAS2	82.4 ± 18.2	80.5 ± 14.8	85.1 ± 16.4^b
W-DEQ-B	42.0 ± 20.6	44.2 ± 21.1	38.7 ± 19.4^b
DSS	32.7 ± 4.1	32.6 ± 4.2	33.0 ± 4.1
Traumatic experience
VAS1	62.0 ± 23.1^a	57.9 ± 23.8	68.7 ± 20.1^c
VAS2	42.4 ± 27.8^a	39.5 ± 26.8	47.5 ± 29.0
W-DEQ-B	90.7 ± 22.9^a	89.2 ± 21.5	93.1 ± 24.9
DSS	25.1 ± 5.1^a	25.0 ± 4.5	25.3 ± 6.0
Partial PTSD
VAS1	59.5 ± 22.5^a	57.1 ± 24.0	64.0 ± 19.2
VAS2	35.0 ± 23.7^a	33.4 ± 22.9	38.1 ± 25.3
W-DEQ-B	97.2 ± 21.0^a	95.5 ± 18.5	100.5 ± 25.1
DSS	24.1 ± 4.7^a	24.2 ± 3.9	23.9 ± 6.1
Full PTSD
VAS1	55.6 ± 24.3^a	63.0 ± 25.5	46.0 ± 20.7
VAS2	36.3 ± 20.2^a	39.2 ± 23.1	32.5 ± 16.6
W-DEQ-B	101.1 ± 20.3^a	95.1 ± 19.8	110.0 ± 19.0
DSS	21.9 ± 3.8^a	23.7 ± 2.6	19.7 ± 4.1

VAS1: Visual Analogue Scale measured within a week after childbirth; VAS2: Visual Analogue Scale measured a few months after childbirth; W-DEQ-B: Wijma Delivery Experience Questionnaire; DSS: Delivery Satisfaction Scale.

^a p < .001 in comparison to women without traumatic childbirth experience.

^b p < .001 in comparison to primiparous.

^c p < .05 in comparison to primiparous.

Table 3. Answers to simple questions in different trauma subgroups based on Traumatic Event Scale (TES) [6].

	Answer negative, % (N)	Answer positive, % (N)	Comparison to women without traumatic childbirth experience, p- value (Chi square (exact) test)
“Did the childbirth experience differ from your expectations?”
No traumatic experience (reference group)	20.4 (266)	79.6 (1040)
Traumatic experience	70.2 (99)	29.8 (42)	<.001
Partial PTSD	77.8 (70)	22.2 (20)	<.001
Full PTSD	93.8 15	6.3 (1)	<.001
“Has the thought of having more children appealed to you?”
No traumatic experience (reference group)	36.0 (469)	64.0 (834)
Traumatic experience	56.0 (79)	44.0 (62)	<.001
Partial PTSD	63.3 (57)	36.7 (33)	<.001
Full PTSD	75.0 (12)	25.0 (4)	.002
“Did you get efficient pain relief during labor?”
No traumatic experience	17.9 (230)	82.1 (1053)
Traumatic experience	53.2 (75)	46.8 (66)	<.001
Partial PTSD	53.3 (48)	46.7 (42)	<.001
Full PTSD	50.0 (8)	50.0 (8)	.004

Figure 1. Receiver operating characteristic (ROC) curve for identifying partial PTSD in Traumatic Event Scale (TES) [6]. VAS1: Visual Analogue Scale measured within a week after childbirth; VAS2: Visual Analogue Scale measured a few months after childbirth; W-DEQ-B: Wijma Delivery Experience Questionnaire; DSS: Delivery Satisfaction Scale; AUC: area under ROC curve; J: Youden Index.

To identify partial PTSD, the area under receiver operating characteristic (ROC) curve (AUC) was highest in W-DEQ-B; second, in VAS2; third, in DSS; and lowest in VAS1. Partial PTSD possessed Youden indexes for VAS1 with a cutoff value of 72.2, VAS2 with a cutoff value of 69.8, W-DEQ-B with a cutoff value of 68.5, and for DSS with a cutoff value of 29.5.

Table 4. Discriminative and predictive potential for partial post-traumatic stress disorder (PTSD) according to Traumatic Event Scale (TES) [6] with the suggested cutoff values for Visual Analogue Scale (VAS), Wijma Delivery Experience Questionnaire (W-DEQ-B) [13], and Delivery Satisfaction Scale (DSS) [14].

Cutoff value	Negative childbirth experience, number (% of all)	Sensitivity, %	Specificity, %	Positive predictive value, %	Negative predictive value, %	Positive likelihood ratio	Negative likelihood ratio	Overall diagnostic accuracy, %
VAS1
40	32 (2.3)	17.3	98.6	43.8	95.0	12.4	0.8	93.8
50	78 (5.7)	30.9	95.9	32.1	95.7	7.5	0.7	92.1
60	129 (9.4)	44.4	92.8	27.9	96.4	6.2	0.6	89.9
70	281 (20.5)	65.4	82.3	18.9	97.4	3.7	0.4	81.3
VAS2
40	109 (7.6)	63.6	93.9	40.3	97.5	10.4	0.4	92.0
50	210 (14.6)	79.6	89.7	33.3	98.5	7.7	0.2	89.0
60	254 (17.6)	85.2	86.8	29.5	98.9	6.5	0.2	86.7
70	341 (23.6)	92.0	80.8	23.8	99.4	4.8	0.1	81.5
W-DEQ-B
65	301 (22.3)	96.3	82.5	26.3	99.7	5.5	0.04	83.3
75	183 (13.6)	84.1	91.0	37.7	98.9	9.3	0.2	90.6
80	151 (11.2)	80.5	93.3	43.7	98.7	12.0	0.2	92.5
85	120 (8.9)	72.0	95.2)	49.2	98.1	14.9	0.3	93.8
DSS
20	29 (2.1)	23.0	99.3	69.0	95.1	33.5	0.8	94.6
25	155 (11.1)	59.8	92.1	33.6	97.2	7.6	0.4	90.1
30	449 (32.1)	93.1	71.9	18.0	99.4	3.3	0.1	73.2

VAS1 was measured within a week after childbirth and VAS2 and the others a few months after childbirth. Bolded cutoff values represent this study’s recommendations.

Figure 2. Childbirth experience screening protocol with Visual Analogue Scale (VAS) to identify women at risk for post-traumatic stress disorder (PTSD) based on Traumatic Event Scale (TES) [6].

Flowchart of childbirth experience screening protocol. If VAS ≤50 within a week after childbirth, a brief and early counseling intervention should be offered. Despite early VAS grading, VAS screening should be repeated a few months after childbirth. If VAS is then ≤50, a more thorough evaluation with TES should be done, and those with partial or full PTSD should be referred to a perinatal psychologist.

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Data availability statement

The datasets generated and/or analyzed during the current study are not publicly available due to limitations of ethical approval involving the patient data and anonymity but are available from the corresponding author on reasonable request.