Development of a Measure of Postpartum PTSD: The City Birth Trauma Scale

Abstract

Post-traumatic stress disorder (PTSD) affects 4% of women after birth yet there are very few questionnaire measures of postpartum PTSD that have been validated in this population. In addition, none of the available questionnaires assess postpartum PTSD in accordance with criteria specified in the latest edition of the Diagnostic and Statistical Manual [DSM-5, (1)]. The City Birth Trauma Scale is a 29-item questionnaire developed to measure birth-related PTSD according to DSM-5 criteria of: stressor criteria (A), symptoms of re-experiencing (B), avoidance (C), negative cognitions and mood (D), and hyperarousal (E), as well as duration of symptoms (F), significant distress or impairment (E), and exclusion criteria or other causes (H). Two additional items from DSM-IV were also included on the basis of evidence suggesting they might be important in this population. The first was criterion A2 that women responded to events during birth with intense fear, helplessness or horror. The second was symptoms of emotional numbing. Items were first reviewed by researchers (n = 9) and postpartum women (n = 8) and revised accordingly. The questionnaire was then completed by 950 women recruited online. Results showed the City Birth Trauma Scale had excellent reliability (Cronbach's α = 0.92) and is easy to understand (Flesch reading score 64.17). Exploratory factor analysis found two factors which together accounted for 56% of the variance: (i) Birth-related symptoms (40.8% variance) and (ii) General symptoms (15.5% variance). PTSD symptoms were highly associated with distress, impaired functioning, and women reporting they wanted treatment (r = 0.50–0.61). Removing DSM-IV A2 criteria only increased births classified as traumatic by 2%. Adding the item on emotional numbing did not change the psychometric properties of the scale. These items were therefore removed. The City Birth Trauma Scale has good psychometric properties and the two symptom clusters identified are consistent with previous research on symptoms of postpartum PTSD. This scale therefore provides a promising measure of PTSD following childbirth that can be used in research and clinical practice. Future research should examine the scale's predictive validity using clinical interviews.

The risk factors for postpartum posttraumatic stress disorder and depression

“…These figures are similar that have been reported by the developers of the CityBiTS (mean = 11.7 ± 11.0, % = 7.1). 11 Other studies that have assessed PP-PTSD symptoms have reported figures that range from 3% to 39%. 7,13,14 These rates may have varied widely because the studies used different samples and examined different phases of the postpartum period.…”

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

“…City Birth Trauma Scale (City BiTS; Ayers et al, 2018) consists of 29 items measuring birth-related PTSD according to DSM-5 criteria. City BiTS includes criterion A for the traumatic event (2 items; 0no, 1-yes), frequency of symptoms from B-E criteria over the previous week (20 items; 0 -not at all, 1 -once, 2 -2-4 times, and 3 -5 or more times), , criterion F for the duration of symptoms (1 item; 0less than 1 month, 1 -1-3 months, and 2 -3 months or more), criterion G for distress and impairment (2 items; 0no, 1sometimes, 2yes), and exclusion criteria H (1 item; 0 -no, 1maybe, 2yes).…”

“…Also, criterion A was changed so that it is no longer necessary for people to both experience the traumatic event (Criterion A1) and intense negative emotions, such as fear, helplessness, or horror (Criterion A2). The removal of the Criterion A2 in relation to postpartum PTSD resulted in somewhat mixed findings: some studies found more postpartum women fulfilled stressor criteria when A2 was removed (Boorman et al, 2013;Devilly, Gullo, Alcorn, & O'Donovan, 2014) whereas other studies did not find a large difference when A2 was VALIDATION OF THE CITY BITS 4 removed (Ayers, Wright, & Thornton, 2018). Another difference in DSM-5 was the removal of emotional numbing symptoms and the addition of the symptoms of Negative alterations in cognitions and mood (Criterion D).…”

Posttraumatic stress symptoms following childbirth: associations with prenatal attachment in subsequent pregnancies

“…Therefore, it would be important to test that the positive association between PTSD and prenatal attachment still holds when controlling for treatment status. Nevertheless, the likelihood of study participants having received treatment for PTSD following childbirth is rather small, given the short interval between the two assessment points and the fact that birth trauma is usually undetected and women do not receive timely and adequate treatment (Ayers et al 2018).…”