Synthesis of Mixed Research on Posttraumatic Stress Related to Traumatic Birth

Published:April 05, 2019DOI:



      To synthesize mixed-research results (quantitative and qualitative) on posttraumatic stress in women who experienced traumatic births.

      Data Sources

      PubMed, Scopus, and PsycINFO databases.

      Study Selection

      Quantitative and qualitative studies were included if they were published in English from January 1, 2009, through December 31, 2018, and focused on posttraumatic stress in the postpartum period related to traumatic childbirth.

      Data Extraction

      The final sample consisted of 59 studies: 4 qualitative and 55 quantitative. Both authors independently appraised each study using the Critical Appraisal Skills Programme. Quantitative studies were synthesized by narrative synthesis and vote counting, and qualitative studies were synthesized by content analysis.

      Data Synthesis

      In the included studies, prevalence rates of elevated posttraumatic stress ranged from 0.8% to 26%. Significant predictors of posttraumatic stress that occurred before childbirth and those that were birth related were identified. Reports of six intervention studies to decrease posttraumatic stress symptoms after traumatic births were included. These interventions focused on postnatal debriefing, expressive writing, online cognitive behavioral therapy, a brief cognitive intervention, and the implementation of the nine instinctive stages of the infant during the first hour after birth. We created four themes from the findings of the qualitative studies: Distressing Symptoms, Detrimental Effect of Posttraumatic Stress on Women’s Relationships With Their Infants and Partners, Critical Influence of Support, and Debriefing.


      When a woman experiences posttraumatic stress related to a traumatic birth, the entire family unit is vulnerable. Findings from quantitative predictor studies can be used to develop an instrument to screen women for risk factors for posttraumatic stress related to birth trauma. Primary interventions are needed to prevent women from experiencing traumatic births.


      To read this article in full you will need to make a payment
      AWHONN Member Login
      AWHONN Members, full access to the journal is a member benefit. Use your society credentials to access all journal content and features

      Purchase one-time access:

      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Abdollahpour S.
        • Khosravi A.
        • Bolbolhaghighi N.
        The effect of the Magical Hour on post-traumatic stress disorder (PTSD) in traumatic childbirth: A clinical trial.
        Journal of Reproductive and Infant Psychology. 2016; 34: 403-412
        • ∗Alcorn K.L.
        • O’Donovan A.
        • Patrick J.C.
        • Devilly G.J.
        A prospective longitudinal study of the prevalence of post-traumatic stress disorder resulting from childbirth events.
        Psychological Medicine. 2010; 40: 1849-1859
        • American Psychiatric Association
        Diagnostic and statistical manual of mental disorders.
        5th ed. Author, Washington, DC2013
        • Anderson C.
        • McCarley M.
        Psychological birth trauma in adolescents experiencing an early birth.
        MCN: American Journal of Maternal/Child Nursing. 2013; 38: 170-176
        • Ayers S.
        • Bond R.
        • Bertullies S.
        • Wijma K.
        The aetiology of post-traumatic stress following childbirth: A meta-analysis and theoretical framework.
        Psychological Medicine. 2016; 46: 1121-1134
        • Ayers S.
        • Harris R.
        • Sawyer A.
        • Parfitt Y.
        • Ford E.
        Posttraumatic stress disorder after childbirth: Analysis of symptom presentation and sampling.
        Journal of Affective Disorders. 2009; 119: 200-204
        • Ayers S.
        • Jessop D.
        • Pike A.
        • Parfitt Y.
        • Ford E.
        The role of adult attachment style, birth intervention and support in posttraumatic stress after childbirth: A prospective study.
        Journal of Affective Disorders. 2014; 155: 295-298
        • Ayers S.
        • Wright D.M.
        • Thornton A.
        Development of a measure of postpartum PTSD: The City Birth Trauma Scale.
        Frontiers in Psychiatry. 2018; 9: 409
        • Beck A.T.
        • Steer R.A.
        • Brown G.K.
        Manual for the Beck Depression Inventory-II.
        Psychological Corporation, San Antonio, TX1996
        • Beck C.T.
        Posttraumatic stress disorder after birth: A metaphor analysis.
        MCN: American Journal of Maternal/Child Nursing. 2016; 41: 76-83
        • Beck C.T.
        • Gable R.K.
        • Sakala C.
        • Declercq E.
        Posttraumatic stress disorder in new mothers: Results from a two-stage U.S. National Survey.
        Birth. 2011; 38: 216-227
        • Beck C.T.
        • Harrison L.
        Posttraumatic stress in mothers related to giving birth prematurely: A mixed research synthesis.
        Journal of the American Psychiatric Nurses Association. 2017; 23: 241-257
        • Brandão T.
        • Brites R.
        • Nunes O.
        • Piers M.
        • Hipólito J.
        Anxiety and depressive symptoms during pregnancy, perceived control and posttraumatic stress symptoms after childbirth: A longitudinal mediation analysis.
        Journal of Health Psychology. 2018; (Advance online publication.)
        • Callahan J.L.
        • Borja S.E.
        • Hynan M.Y.
        Modification of the Perinatal PTSD Questionnaire to enhance clinical utility.
        Journal of Perinatology. 2006; 26: 533-539
        • Çapik A.
        • Durmaz H.
        Fear of childbirth, postpartum depression, and birth-related variables as predictors of posttraumatic stress disorder after childbirth.
        Worldviews on Evidence-Based Nursing. 2018; 15: 455-463
        • Cook N.
        • Ayers S.
        • Horsch A.
        Maternal posttraumatic stress disorder during the perinatal period and child outcomes: A systematic review.
        Journal of Affective Disorders. 2018; 225: 18-31
        • Critical Appraisal Skills Programme
        CASP checklists.
        Author, Oxford, UK2018 (Retrieved from)
        • ∗de la Cruz C.
        • Coulter M.
        • O’Rourke K.
        • Mbah A.K.
        • Salihu H.M.
        Post-traumatic stress disorder following emergency peripartum hysterectomy.
        Archives of Gynecology and Obstetrics. 2016; 294: 681-688
        • de Oliveira A.G.
        • Reichenheim M.E.
        • Moraes C.L.
        • Howard L.M.
        • Lobato G.
        Childhood sexual abuse, intimate partner violence during pregnancy, and posttraumatic stress symptoms following childbirth: A path analysis.
        Archives of Women’s Mental Health. 2017; 20: 297-309
        • de Schepper S.
        • Vercauteren T.
        • Tersago J.
        • Jacquemyn Y.
        • Raes F.
        • Franck E.
        Posttraumatic stress disorder after birth and the influence of maternity team care during labour and birth: A cohort study.
        Midwifery. 2016; 32: 87-92
        • Delicate A.
        • Ayers S.
        • Easter A.
        • McMullen S.
        The impact of childbirth-related post traumatic stress on a couple’s relationship: A systematic review and meta-synthesis.
        Journal of Reproductive and Infant Psychology. 2018; 36: 102-115
        • DeMier R.L.
        • Hynan M.T.
        • Harris H.B.
        • Manniello R.L.
        Perinatal stressors as predictors of symptoms of posttraumatic stress in mothers of infants at high risk.
        Journal of Perinatology. 1996; 16: 276-280
        • DiBlasio P.
        • Camisasca E.
        • Caravita S.C.S.
        • Ionio C.
        • Milani L.
        • Valtolina G.G.
        The effects of expressive writing on postpartum depression and posttraumatic stress symptoms.
        Psychological Reports. 2015; 117: 856-882
        • DiBlasio P.
        • Miragoli S.
        • Camisasca E.
        • DiVita A.M.
        • Pizzo R.
        • Pipitone L.
        Emotional distress following childbirth: An intervention to buffer depressive and PTSD symptoms.
        Europe’s Journal of Psychology. 2015; 11: 214-232
        • Dikmen-Yildiz P.
        • Ayers S.
        • Phillips L.
        Factors associated with post-traumatic stress symptoms (PTSS) 4-6 weeks and 6 months after birth: A longitudinal population-based study.
        Journal of Affective Disorders. 2017; 221: 238-245
        • Dikmen-Yildiz P.
        • Ayers S.
        • Phillips L.
        Longitudinal trajectories of post-traumatic stress disorder (PTSD) after birth and associated risk factors.
        Journal of Affective Disorders. 2018; 229: 377-385
        • Foa E.B.
        Manual for the posttraumatic stress diagnostic scale (PDS).
        National Computer Systems, Inc, Minneapolis, MN1995
        • Foa E.B.
        • McLean C.P.
        • Zang Y.
        • Zhong J.
        • Powers M.B.
        • Kauffman B.Y.
        • Knowles K.
        Psychometric properties of the Posttraumatic Diagnostic Scale for DSM-5 (PDS-5).
        Psychological Assessment. 2016; 28: 1166-1171
        • Foa E.B.
        • Riggs D.S.
        • Dancu C.V.
        • Rothbaum B.O.
        Reliability and validity of a brief instrument for assessing posttraumatic stress disorder.
        Journal of Trauma and Stress. 1993; 6: 459-473
        • Ford E.
        • Ayers S.
        Support during birth interacts with prior trauma and birth intervention to predict postnatal post-traumatic stress symptoms.
        Psychology and Health. 2011; 26: 1553-1570
        • Furuta M.
        • Sandall J.
        • Cooper D.
        • Bick D.
        Predictors of birth-related post-traumatic stress symptoms: Secondary analysis of a cohort study.
        Archives of Women’s Mental Health. 2016; 19: 987-999
        • Garthus-Niegel S.
        • Ayers S.
        • von Soest T.
        • Torgersen L.
        • Eberhard-Gran M.
        Maintaining factors of posttraumatic stress symptoms following childbirth: A population-based, two-year follow-up study.
        Journal of Affective Disorders. 2015; 172: 146-152
        • Garthus-Niegel S.
        • Horsch A.
        • Handtke E.
        • von Soest T.
        • Ayers S.
        • Weidner K.
        • Eberhard-Gran M.
        The impact of postpartum posttraumatic stress and depression symptoms in couples’ relationship satisfaction: A population-based prospective study.
        Frontiers in Psychology. 2018; 9: 1728
        • ∗Garthus-Niegel S.
        • Knoph C.
        • von Soest T.
        • Nielsen C.S.
        • Eberhard-Gran M.
        The role of labor pain and overall birth experience in the development of posttraumatic stress symptoms: A longitudinal cohort study.
        Birth. 2014; 41: 108-115
        • Garthus-Niegel S.
        • von Soest T.
        • Knoph C.
        • Simonsen T.B.
        • Torgersen L.
        • Eberhard-Gran M.
        The influence of women’s preferences and actual mode of delivery on post traumatic stress symptoms following childbirth: A population-based, longitudinal study.
        BMC Pregnancy & Childbirth. 2014; 14: 191
        • Graffigna G.
        • Barello S.
        • Bonanomi A.
        The role of Patient Health Engagement Model (PHE-model) in affecting patient activation and medication adherence: A structural equation model.
        PLOS ONE. 2017; 12: e0179865
        • Grekin R.
        • O’Hara M.W.
        Prevalence and risk factors of postpartum posttraumatic stress disorder: A meta-analysis.
        Clinical Psychological Review. 2014; 34: 389-401
        • Halperin O.
        • Sarid O.
        • Cwikel J.
        The influence of childbirth experiences on women’s postpartum traumatic stress symptoms: A comparison between Israeli Jewish and Arab women.
        Midwifery. 2015; 31: 625-632
        • Heyvaert M.
        • Hannes K.
        • Onghena P.
        Using mixed methods research synthesis for literature reviews.
        Sage Publications, Los Angeles, CA2017
        • Hoedjes M.
        • Berks D.
        • Vogel I.
        • Franx A.
        • Visser W.
        • Duvekot J.J.
        • Steegers E.A.P.
        Symptoms of post-traumatic stress after preeclampsia.
        Journal of Psychosomatic Obstetrics & Gynecology. 2011; 32: 126-134
        • Hong Q.
        • Pluye P.
        • Bujold M.
        • Wassef M.
        Convergent and sequential synthesis designs: Implications for conducting and reporting systematic reviews of qualitative and quantitative evidence.
        Systematic Reviews. 2017; 6: 61
        • Horsch A.
        • Vial Y.
        • Favrod C.
        • Harrari M.M.
        • Blackwell S.E.
        • Watson P.
        • Holmes E.A.
        Reducing intrusive traumatic memories after emergency caesarean section: A proof-of-principle randomized controlled study.
        Behaviour Research and Therapy. 2017; 94: 36-47
        • Iles J.
        • Pote H.
        Postnatal posttraumatic stress: A grounded theory model of first-time mothers’ experiences.
        Journal of Reproductive and Infant Psychology. 2015; 33: 238-255
        • ∗Isbir G.G.
        • Inci F.
        • Bektas M.
        • Yildiz P.D.
        • Ayers S.
        Risk factors associated with posttraumatic stress symptoms following childbirth in Turkey.
        Midwifery. 2016; 41: 96-103
        • Kendall-Tackett K.
        Childbirth-related posttraumatic stress disorder: Symptoms and impact on breastfeeding.
        Clinical Lactation. 2014; 5: 51-55
        • King L.
        • McKenzie-McHarg K.
        • Horsch A.
        Testing a cognitive model to predict posttraumatic stress disorder following childbirth.
        BMC Pregnancy and Childbirth. 2017; 17: 32
        • King L.A.
        • King D.W.
        • Leskin G.
        • Foy D.W.
        The Los Angeles Symptom Checklist: A self-report measure of posttraumatic stress disorder.
        Assessment. 1995; 2: 1-17
        • König J.
        • Schmid S.
        • Löser E.
        • Neumann O.
        • Buchholz S.
        • Kästner R.
        Interplay of demographic variables, birth experience, and initial reactions in the prediction of symptoms of posttraumatic stress one year after giving birth.
        European Journal of Psychotraumatology. 2016; 7: 32377
        • Krippendorff K.
        Content analysis: An introduction to its methodology.
        Sage Publications, Thousand Oaks, CA2019
        • ∗Latha K.
        Assessment of post-traumatic stress disorder symptoms among postnatal mothers who underwent emergency lower segmental caesarean section, Government Hospital, Tambaram.
        International Journal of Pharmaceutical and Clinical Research. 2016; 83: 172-175
        • Lev-Wiesel R.
        • Daphna-Tekoah S.
        • Hallak M.
        Childhood sexual abuse as a predictor of birth-related posttraumatic stress and postpartum posttraumatic stress.
        Child Abuse & Neglect. 2009; 33: 877-887
        • Lopez U.
        • Meyer M.
        • Loures V.
        • Iselin-Chaves I.
        • Epiney M.
        • Kern C.
        • Haller G.
        Post-traumatic stress disorder in parturients delivering by caesarean section and the implication of anaesthesia: A prospective cohort study.
        Health and Quality of Life Outcomes. 2017; 15: 118
        • Maqbool N.
        • Baqai S.
        • Tariq A.
        • Iram N.
        Post traumatic stress symptoms after child birth: Frequency, risk factor and effect on quality of life.
        Pakistan Journal of Medical and Health Sciences. 2017; 11: 1267-1270
        • Meades R.
        • Pond C.
        • Ayers S.
        • Warren F.
        Postnatal debriefing: Have we thrown the baby out with the bath water?.
        Behaviour Research and Therapy. 2011; 49: 367-372
        • Michelet D.
        • Ricbourg A.
        • Gosme C.
        • Rossignol M.
        • Schurando P.
        • Barranger E.
        • Gayat E.
        Emergency hysterectomy for life-threatening postpartum haemorrhage: Risk factors and psychological impact.
        Gynecologie, Obstetrique & Fertilite. 2015; 43: 773-779
        • Milosavljevic M.
        • Tosevski D.L.
        • Soldatovic I.
        • Vukovic O.
        • Miljevic C.
        • Peljto A.
        • Olff M.
        Posttraumatic stress disorder after vaginal delivery at primiparous women.
        Scientific Reports. 2016; 6: 27554
        • Modarres M.
        • Afrasiabi S.
        • Rahnama P.
        • Montazeri A.
        Prevalence and risk factors of childbirth-related post-traumatic stress symptoms.
        BMC Pregnancy and Childbirth. 2012; 12: 88
        • Nicholls K.
        • Ayers S.
        Childbirth-related post-traumatic stress disorder in couples: A qualitative study.
        British Journal of Health Psychology. 2007; 12: 491-509
        • Nieminen K.
        • Berg I.
        • Frankenstein K.
        • Viita L.
        • Larsson K.
        • Persson U.
        • Wijma K.
        Internet-provided cognitive behavior therapy of posttraumatic stress symptoms following childbirth—A randomized controlled trial.
        Cognitive Behaviour Therapy. 2016; 45: 287-306
        • ∗O’Donovan A.
        • Alcorn K.L.
        • Patrick J.C.
        • Creedy D.K.
        • Dawe S.
        • Devilly G.J.
        Predicting posttraumatic stress disorder after childbirth.
        Midwifery. 2014; 30: 935-941
        • Onoye J.M.
        • Goebert D.
        • Morland L.
        • Matsu C.
        • Wright T.
        PTSD and postpartum mental health in a sample of Caucasian, Asian, and Pacific Islander women.
        Archives of Women’s Mental Health. 2009; 12: 393-400
        • Patton M.Q.
        Qualitative evaluation and research methods.
        Sagem Publications, Newbury Park, CA1990
        • Peeler S.
        • Stedmon J.
        • Chung M.C.
        • Skirton H.
        Women’s experiences of living with postnatal PTSD.
        Midwifery. 2018; 56: 70-78
        • ∗Polachek I.S.
        • Harari L.H.
        • Baum M.
        • Strous R.D.
        Postpartum anxiety in a cohort of women from the general population: Risk factors and association with depression during last week of pregnancy, postpartum depression and postpartum PTSD.
        Israeli Journal of Psychiatry and Related Sciences. 2014; 51: 128-134
        • Popay J.
        • Roberts H.
        • Sowden A.
        • Petticrew M.
        • Arai L.
        • Rodgers M.
        • Duffy S.
        Guidance on the conduct of narrative synthesis in systematic reviews: A product from the ESRC methods programme.
        2006 (Retrieved from)
        • Porcel J.
        • Feigal C.
        • Poye L.
        • Postma I.R.
        • Zeeman G.G.
        • Olowoyeye A.
        • Wilson M.
        Hypertensive disorders of pregnancy and risk of screening positive for Posttraumatic Stress Disorder: A cross-sectional study.
        Pregnancy Hypertension. 2013; 3: 254-260
        • Sandelowski M.
        • Voils C.
        • Barroso J.
        Defining and designing mixed research synthesis studies.
        Research in the Schools. 2006; 13: 29
        • Schwab W.
        • Marth C.
        • Bergant A.M.
        Post-traumatic stress disorder postpartum: The impact of birth on the prevalence of post-traumatic stress disorder (PTSD) in multiparous women.
        Geburtshilfe und Frauenheilkunde. 2012; 72: 56-63
        • ∗Sentilhes L.
        • Maillard F.
        • Brun S.
        • Madar H.
        • Merlot B.
        • Goffinet F.
        • Deneux-Tharaux C.
        Risk factors for chronic post-traumatic stress disorder development one year after vaginal delivery: A prospective, observational study.
        Scientific Reports. 2017; 7: 8724
        • Shoban Z.
        • Dolatian M.
        • Shams J.
        • Alavi-Majd H.
        • Mahmo-di Z.
        • Sajjadi H.
        Post Traumatic Stress Disorder (PTSD) following childbirth: Prevalence and contributing factors.
        Iranian Red Crescent Medical Journal. 2013; 15: 177-182
        • ∗Shahar G.
        • Herishanu-Gilutz S.
        • Holcberg G.
        • Kofman O.
        In first-time mothers, post-partum depressive symptom prospectively predict symptoms of post-traumatic stress.
        Journal of Affective Disorders. 2015; 186: 168-170
        • Skinner E.M.
        • Barnett B.
        • Dietz H.P.
        Psychological consequences of pelvic floor trauma following vaginal birth: A qualitative study from two Australian tertiary maternity units.
        Archives of Women’s Mental Health. 2018; 21: 341-351
        • Soltani N.
        • Abedian Z.
        • Mokhber N.
        • Esmaily H.
        The association of family support after childbirth with posttraumatic stress disorder in women with preeclampsia.
        Iranian Red Crescent Medical Journal. 2015; 17: e17865
        • ∗Sorenson D.S.
        • Tschetter L.
        Prevalence of negative birth perception, disaffirmation, perinatal trauma symptoms, and depression among postpartum women.
        Perspectives in Psychiatric Care. 2009; 46: 14-25
        • Stramrood C.A.I.
        • Paarlberg K.M.
        • Huis in ’T Veld E.M.J.
        • Berger L.W.A.R.
        • Vingerhoets A.J.J.M.
        • Wijmar Schultz W.C.M.
        • van Pampus M.G.
        Posttraumatic stress following childbirth in homelike- and hospital settings.
        Journal of Psychosomatic Obstetrics & Gynecology. 2011; 32: 88-97
        • Takegata M.
        • Haruna M.
        • Matsuzaki M.
        • Shiraishi M.
        • Okano T.
        • Severinsson E.
        Aetiological relationships between factors associated with postnatal traumatic symptoms among Japanese primiparas and multiparas: A longitudinal study.
        Midwifery. 2017; 44: 14-23
        • ∗Thiel F.
        • Ein-Dor T.
        • Dishy G.
        • King A.
        • Dekel S.
        Examining symptom clusters of childbirth-related posttraumatic stress disorder.
        Primary Care Companion for CNS Disorders. 2018; 20: 18m02322
        • ∗Tomsis Y.
        • Gelkopf M.
        • Yerushalmi H.
        • Zipori Y.
        Different coping strategies influence the development of PTSD among first-time mothers.
        Journal of Maternal-Fetal & Neonatal Medicine. 2018; 31: 1304-1310
        • van Heumen M.A.
        • Hollander M.H.
        • van Pampus M.G.
        • van Dillen J.
        • Stramrood C.A.I.
        Psychosocial predictors of postpartum posttraumatic stress disorder in women with a traumatic childbirth experience.
        Frontiers in Psychiatry. 2018; 9: 348
        • Verreault N.
        • Da Costa D.
        • Marchand A.
        • Ireland K.
        • Banack H.
        • Dritsa M.
        • Khalife S.
        PTSD following childbirth: A prospective study of incidence and risk factors in Canadian women.
        Journal of Psychosomatic Research. 2012; 73: 257-263
        • Vossbeck-Elsebusch A.
        • Freisfeld C.
        • Ehring T.
        Predictors of posttraumatic stress symptoms following birth.
        BMC Psychiatry. 2014; 14: 200
        • Weiss D.S.
        • Marmar C.R.
        The impact of event scale—Revised.
        in: Wilson J.P. Keane T.M. Assessing psychological trauma and PTSD: A handbook for practitioners. Guilford Press, New York, NY1997: 399-411
        • Wijma K.
        • Söderquist J.
        • Wijma B.
        Posttraumatic stress disorder after childbirth: A cross sectional study.
        Journal of Anxiety Disorders. 1997; 11: 587-597
        • Yildiz P.D.
        • Ayers S.
        • Phillips L.
        The prevalence of posttraumatic stress disorder in pregnancy and after birth: A systematic review and meta-analysis.
        Journal of Affective Disorders. 2017; 208: 634-645
        • Zambaldi C.F.
        • Cantilino A.
        • Sougey E.B.
        Bio-socio-demographic factors associated with post-traumatic stress disorder in a sample of postpartum Brazilian women.
        Archives of Women’s Mental Health. 2011; 14: 435-439


      Cheryl Tatano Beck, DNSc, CNM, FAAN, is a distinguished professor in the School of Nursing, University of Connecticut, Storrs, CT.


      Sharon Casavant, MS, RN, is a research assistant in the School of Nursing, University of Connecticut, Storrs, CT.