Construct Validity and Psychometric Properties of the Hebrew Version of the City Birth Trauma Scale

Abstract

As many as third of the women perceive their childbirth as traumatic and although prevalence rates vary between studies, around 2–5% of women in community samples may develop childbirth-related postpartum post-traumatic stress disorder (PPTSD). The City Birth Trauma Scale (BiTS) was developed to address the need for a DSM-5-based instrument that assesses PPTSD. The BiTS is a self-report questionnaire, which covers all DSM-5 PTSD criteria, including the four symptom clusters – re-experiencing, avoidance, negative mood and cognitions and hyperarousal symptoms. The present study aimed to describe the psychometric properties and validate the Hebrew version of the BiTS. Five hundred and four mothers of 0- to 12-month-old infants were sampled using social media and the snowball method. Respondents completed an online survey consisting of a demographic questionnaire and the Hebrew versions of the BiTS, the impact of event scale-revised (IES-R), the Edinburgh postpartum depression scale (EPDS), and the Pittsburgh Sleep Quality Index (PSQI). The Hebrew BiTS demonstrated high internal consistency for the total scale (Cronbach α = 0.90) and good internal consistency (Cronbach’s α = 0.75–0.85) for the subscales. An exploratory factor (EFA) analysis yielded a two-factors solution, accounting for 45% of variance, with general symptoms loaded on Factor 1, and childbirth-related symptoms loaded on Factor 2, with both factors demonstrating high internal consistency (Cronbach’s α = 0.90, 0.85, respectively). High convergent validity for the symptom cluster subscales was demonstrated with the parallel IES-R subscales, EPDS and PSQI. A two-step cluster analysis indicated that dysphoric and hyperarousal symptoms best differentiated the severity of symptoms of respondents across measures. In sum, the Hebrew BiTS was psychometrically sound, indicating its utility for clinical and non-clinical research. The EFA and cluster analyses support the differentiation between symptoms of dysphoria and hyperarousal from trauma (i.e., childbirth) specific symptoms, suggesting that symptoms relating to specific aspects of the trauma differ qualitatively from general symptom in the phenomenology of PPTSD. Further research using clinical samples and comparing the BiTS to DSM-5 diagnosis using clinical interview is needed.

Measuring and conceptualizing PTSD following childbirth: Validation of the City Birth Trauma Scale.

“…Three items from the Negative cognitions and mood cluster loaded on the factor of Birthrelated symptoms, and the rest of the items loaded on the General symptoms factor. This is similar to previous validation studies Handelzalts et al, 2018).…”

“…More specifically, women who had birth by instrumental vaginal delivery and emergency section had significantly higher levels of Birth-related symptoms. This is consistent with the validation of the Hebrew version of the City BiTS in postpartum women in Israel (Handelzalts et al, 2018), with the exception that in the latter study only women who underwent the emergency section reported higher levels of symptoms.…”

“…Intrusions and Avoidance symptoms loaded on the first factor as Birth-related symptoms, while Negative cognitions and mood and Hyperarousal symptoms loaded on the second factor as General symptoms . Validation of a Hebrew version of the City Birth Trauma Scale also found the same two-factor structure (Handelzalts, Hairston, & Matatyahu, 2018). This two-factor structure is also consistent with previous studies of postpartum PTSD using other measures of PTSD VALIDATION OF THE CITY BITS 5 (Ayers, Harris, Sawyer, Parfitt, & Ford, 2009;Reichenheim et al, 2018;Stramrood et al, 2010).…”

“…(1) test the four-factor model with four correlated clusters of PTSD symptoms: Intrusion, Avoidance, Negative cognitions and mood, and Hyperarousal; the two-factor model with two correlated dimensions of postpartum PTSD: birth-related symptoms and general symptoms Handelzalts et al, 2018); and a bifactor model;…”

Cross-cultural adaptation of the City Birth Trauma Scale for the Brazilian context

“…The original psychometric study, conducted with 950 postpartum women, showed bifactorial structure (birth-related/general symptoms), excellent reliability (α = 0.92) and a high association with distress, unpaired functioning, and desire for treatment (r = 0.50-0.61) 10 . Other than that, it had already been translated and validated into Hebrew 11 and Croatian 10 , in which their psychometric qualities were also replicated.…”