British Journal of Clinical Psychology (2000), 39, 35±51 Printed in Great Britain 35

# 2000 The British Psychological Society

Prevalence and predictors of post-traumatic

stress symptoms following childbirth

Jo Czarnocka and Pauline Slade*

Clinical Psychology Unit, Department of Psychology, University of She¬eld, UK

Objectives. To identify the prevalence and potential predictors of post-traumatic

stress type symptoms following labour.

Design. A large sample, within-participants design with initial assessment and

postal follow-up was utilized.

Method. Two hundred and sixty-four women who had `normal’ births were
assessed within 72 hours on potential predictive measures and at 6 weeks post-
partum for levels of symptoms of intrusions, avoidance and hyperarousal on a
questionnaire derived from DSM±IV (American Psychiatric Association, 1994)
criteria. Symptoms of depression and anxiety were also assessed.

Results. Three per cent showed questionnaire responses suggesting clinically

signi®cant levels on all three post-traumatic stress dimensions and a further 24% on
at least one of these dimensions. Forward stepwise regression analysis yielded
models for predicting outcome variables. Perceptions of low levels of support from
partner and staå, patterns of blame and low perceived control in labour were found
to be particularly related to experience of post-traumatic stress symptoms. Personal
vulnerability factors such as previous mental health di¬culties and trait anxiety
were also related to such symptoms as well as being relevant predictors for anxiety
and depression.

Conclusions. A proportion of women reports all three aspects of post-traumatic

stress type symptoms following childbirth with many more reporting some
components. A broader conceptualization of post-partum distress which takes
account of the impact of labour is required. There may be opportunities for
prevention through providing care in labour that enhances perceptions of control
and support.

Post-traumatic stress is characterized by symptoms of re-experiencing of a trauma,

avoidance of reminders and hyperarousal. Early diagnostic criteria speci®ed that the
traumatic event should be `an event that would evoke symptoms of distress in most
people and is outside the range of usual human experience ’ (DSM±III±R ; American
Psychiatric Association, 1987). The possibility of responding in this way to more
normative experiences has only recently begun to be appreciated. In DSM±IV
(American Psychiatric Association, 1994), the victim’s appraisal of the traumatic
event is now more prominent and included in the criterion set, as a response of
* Requests for reprints should be addressed to Dr Pauline Slade, Clinical Psychology Unit, Department of
Psychology, University of She¬eld, Psychology Building, Western Bank, She¬eld S10 2TP, UK.
36 Jo Czarnocka and Pauline Slade
`intense fear, helplessness or horror’ to an `extreme traumatic stressor involving
direct personal experience of a event that involves actual or threatened death or
serious injury, or other threat to one’s integrity; or witnessing a event that involves
death, injury or threat to the physical integrity of another person; or learning about
unexpected or violent death, serious harm, or threat of death or injury experienced
by family member or other close associate ’. Childbirth experiences may well include
some of the speci®ed features. High levels of fear are well documented and the
process of giving birth even today is a time of increased risk of injury and} or
mortality (Grimes, 1994). Nevertheless it is important to emphasize that for many
women labour and delivery may encompass none of these features.
Evidence that the experience of labour continues to impact after the birth is
reported by Arizmendi and Aåonso (1987) who studied groups of women in the ®rst
and third trimester of pregnancy and the post-partum. The most intense concerns for
all three groups focused upon the baby’s welfare, labour and delivery, and issues
regarding the partner. However, unpleasant thoughts of labour and delivery peaked
in the post-partum group, often taking the form of memories of a di¬cult labour,
upset about the professional care received, and ruminations over unexpected
procedures and the possible eåects of these on the mother and baby.
Evidence that the experience of intense pain itself can act as a traumatic event is
provided by Schreiber and Galai-Gat (1993) who examined a man who had sustained
an injury under traumatic conditions, but for whom the pain was the traumatic event
as measured by the content of his intrusions, nightmares and ¯ashbacks. Melzack,
Taenzer, Feldman, and Kinch (1981) found that the pain typically reported in
childbirth is rated as extremely intense. It is also recognized that there is a high
reliability for labour pain assessments made in labour, at 24 and 48 hours post-partum
and indeed at 3 years following the birth (Niven, 1988 ; Niven & Gijsbers, 1984),
indicating a reasonable degree of accuracy in memory for the pain of labour.
More recently, some group and single case studies have begun to identify women
who appear to be experiencing post-traumatic stress symptoms following labour
and childbirth (Ballard, Stanley, & Brockington, 1995 ; Fones, 1996 ; Ichida, 1996 ;
Moleman, Van der Hart, & Van der Kolk 1992). Ballard et al. (1995) describe four
case studies where, following childbirth, post-traumatic stress-like symptoms
emerged with varying severity and presentation. Each delivery was perceived to be
`traumatic emotionally ’, all four patients were depressed and three of the four
`felt the need to avoid contact with their infants’. The authors highlight a
long} complicated labour together with feelings of lack of control over the situation
as potentially important aetiological factors.
There are few studies involving larger samples. Niven (1988) found that in a group
of 33 women, ®ve had marked post-traumatic stress type symptoms, including
intrusive thoughts, nightmares and `daymares ’. Menage (1993) studied a small self-
selected group of volunteers regarding their past experiences of obstetric and
gynaecological procedures. Women who reported a traumatic experience exhibited
symptoms of post-traumatic stress disorder (PTSD) assessed using the PTSD±I
questionnaire (Watson, Juba, Manifold, Kucala, & Anderson, 1991). Their scores
indicated a level of trauma similar to a group that had experienced combat trauma.
Important factors identi®ed by the study included levels of control, attitude of the
 Post-traumatic stress symptoms following childbirth 37
doctor, degree to which patients’ views were listened to, the level of information-
giving during the actual procedure and if consent was perceived to have been given.
Also of relevance was the fact that 30 % of this sample reported a history of sexual
abuse.
It would appear that childbirth may act as a signi®cant stressor and trigger for
post-traumatic stress symptoms in some women. While this possibility is recognized
in a recent clinical text (Riley, 1995), there are no systematic studies of large
unselected samples and no information is available about prevalence or predictors of
such symptoms in this context. The aim of the present study was to assess the
prevalence of the post-traumatic stress symptoms of intrusions, avoidance and
hyperarousal and to explore the relevance of potential predictors.
Aspects of labour and delivery, women’s personal perception of the experience and
personal history, which might be expected to be associated with such symptoms on
the basis of the literature, were examined. In particular, factors relating to labour
such as its overall personal impact, unexpectedness and duration (Barton, 1969 ;
Berren, Beigel, & Ghertner, 1980 ; Sowder, 1985), the perceived threat to life (Foa
& Rothbaum, 1989), levels of pain, support and types of intervention experienced
(Blanchard et al., 1995 ; Murray & Cartwright, 1993 ; Niven, 1985), and feelings of
being well informed and listened to by staå (Menage, 1993) were of potential
relevance. In addition, perceived control (Arntz & Schmidt, 1989 ; Kushner, Riggs,
Foa, & Miller, 1992 ; Menage, 1993), appraisal of performance regarding coping,
and whether women blamed themselves or others for any di¬culties they experienced
(Joseph, Brewin, Yule, & Williams, 1991, 1993 ; Joseph, Williams, & Yule, 1995)
were considered. Personal vulnerability stress factors in terms of prior mental health
problems and trait and current levels of anxiety (Helzer, 1981 ; McFarlane, 1989 ;
Resnick, Kilpatrick, Best, & Kramer, 1992) were also included. Although relevant,
no attempt was made to assess history of sexual abuse because of the method of data
collection.
Method
Participants
The sample was drawn from a population of newly delivered women in-patients within two hospitals
in She¬eld. For inclusion, participants were required to be aged over 18 years, to have delivered a
healthy baby, to have a good command of English and to have no plans to move out of the area in the
near future. Of 400 women initially approached by the researcher on the postnatal wards, 298 completed
the ®rst questionnaire pack, indicating a response rate of 74.5 %. Ten women declined to participate in
the study and a further 92 did not return the forms.

Procedure
All newly delivered women meeting the inclusion criteria were asked to participate in a study looking
at women’s experiences of childbirth. It was explained that participation was voluntary and that refusal
to participate would not aåect future care. Those who agreed to participate were given an information
sheet, a consent form to sign and return and a questionnaire booklet to complete. Once completed, the
documents were sealed in an envelope and handed in to staå for safe-keeping. Con®dentiality was
assured and staå did not open the envelopes. Code numbers were used for identi®cation purposes. Data
were collected by the researcher on at least 4 days out of 7 per week for a period of 12 weeks, with women
being recruited within 72 hours of giving birth. At 6 weeks post-partum the participants received a
postal follow-up questionnaire booklet. This time point was chosen in order to avoid interpretation by
38 Jo Czarnocka and Pauline Slade

Table 1. A brief description of the participants’ characteristics frequencies are shown with
percentages in brackets unless otherwise speci®ed

Age range 18±41 years M 5 28.94

(in years) SD 5 5.19
Planned pregnancy 183 (69.3)
Marital status Married Cohabiting Single Other
172 (65.4) 70 (26.6) 16 (6.1) 5 (1.9)
Parental status Primiparas Multiparas
170 (64.6) 93 (35.4)
Baby’s sex Boy Girl Twins
135 (51) 124 (47) 5 (2)
A past mental None Yes
health problema 224 (84.8) 40 (15.2)
Type of problem Depression Anxiety Stress Other
(Yes 5 15.2) 21 (8) 6 (2.3) 4 (1.5) 8 (3.1)
a Includes GP treatment for past psychiatric} psychological problems.

ensuring a criterion of symptom experience which exceeded the 4-week duration necessary for the post-
traumatic stress disorder (PTSD) diagnostic criteria. In addition, this is often perceived as the point of
return to normal life, when the medical `all-clear ’ is given and routine screening takes place.

Respondents versus non-respondents

The response rate of the postal follow-up was exceptionally high at 89% (68 % of the potential initial
sample). Respondents were compared with non-respondents at follow-up using independent t tests in
order to establish if the two groups diåered. Only two signi®cant diåerences were found amongst the
large number of variables considered, equivalent to a rate expected to occur by chance statistically.
Those not completing the follow-up were likely to have more children (t(293) 5 3.14, p ! .01) and to
have attended fewer antenatal classes (t(286) 5 2.78, p ! .01).
Table 1 brie¯y summarizes the sample’s demographic characteristics. Participants were also asked to
indicate which procedures or interventions they had experienced from a given list.

Materials
Time one. The following measures were completed by participants within 72 hours of
delivery :
(i) The trait anxiety section of the State±Trait Anxiety Inventory (Spielberger,
1983). This scale attempts to measure stable individual diåerences in anxiety
`proneness’ which in turn is implicated in the elevation of people’s state
anxiety when they are faced with stressful or threatening situations.
(ii) A 6-item Perceived Control Scale (PCON), which measures perceptions of
control in a health care setting, was administered using a 6-point Likert scale
(Wallston, 1989).
(iii) A set of 24 questions asked participants about their perceptions of their
experience of labour and delivery. Each item was derived from the PTSD
 Post-traumatic stress symptoms following childbirth 39
literature as detailed in the introduction of this paper. Participants were asked
to rate their perceptions on a scale of 1 to 10, regarding items considering
severity of pain, amount of distress associated with the experience, satisfaction
and con®dence with coping, preparedness, fear for self and baby, unexpected-
ness of procedures and outcome, support from partner and staå, perceived
control, feeling informed and listened to by staå, responsibility for di¬culties
experienced, and comparison of personal performance in labour with others.
(iv) Demographic data, information about any previous consultation for mental
health di¬culties and details of recalled procedures during labour and delivery
were also requested.

Time two. The following postal follow-up measures were completed at 6 weeks post-
partum.

(i) The Post-traumatic Stress Disorder Questionnaire measure (PTSD±Q). The

PTSD±I (interview) scale was developed by Watson et al. (1991) to assess post-
traumatic stress symptoms as de®ned by DSM±IV (American Psychiatric
Association, 1994). It includes 17 questions which directly relate to the criteria
of DSM±IV and focuses upon the three aspects of intrusions, avoidance and
hyperarousal and records the frequency of post-traumatic stress symptoms. On
a scale of 1 to 7 rated from not at all to always scores of 4 (commonly) or above
were considered clinically signi®cant. A minimum number of such items (at
least one for intrusions, three for avoidance and two for hyperarousal) is
required per section, in accordance with DSM±IV (American Psychiatric
Association, 1994) criteria. Therefore a woman categorized as ful®lling all
three dimensions would be required to report at least common experience of
one of the following items for the intrusions dimension: involuntary upsetting
memories, nightmares, re-experiencing of the stressor or upsetting reminders.
For avoidance, a minimum of three items from trying to avoid thinking about
the stressor, avoiding activities or situations acting as reminders, inability to
recall important aspects, loss of interest in previously rewarding activity,
feeling cut-oå emotionally from others, being unable to express emotions or
negativity about the future, was necessary. For hyperarousal two items from
reminders leading to physical tension, increased startle response, super-
awareness to menace, di¬culty in concentration, loss of temper or sleeping
problems were required. These items map directly onto the DSM±IV criteria.
Duration of symptoms is also assessed to ful®l the 4-week criteria. Watson et
al. (1991) report that the PTSD±I measure shows a 92 % concurrence with
diagnostic categorization systems based on DSM and present data indicating
the adequacy of its psychometric properties in terms of test±retest reliability
and internal consistency. In this study, the PTSD±I was converted to a self-
report questionnaire (PTSD±Q) and labour and delivery was speci®ed as the
`traumatic event ’. Cronbach’s alpha was calculated to be 0.87.
(ii) The Impact of Events Scale (IES; Horowitz, Wilner, & Alvarez, 1979). This
scale considers symptoms of intrusions and avoidance relating to a speci®ed
40 Jo Czarnocka and Pauline Slade
event. A score of more than 19 on either intrusions or avoidance sub-scales is
regarded as clinically signi®cant.
(iii) The EdinburghPostnatal Depression Scale (EPDS; Cox, Holden, & Sagovsky,
1987). This scale is used to assess depressive symptoms in the post-partum (cut-
oå 12} 13).
(iv) The state anxiety part of the State±Trait Anxiety Inventory(STAI ; Spielberger,
1983).
(v) Finally, participants were asked about the occurrence of any subsequent
stressful events following their discharge from hospital and whether or not
their plans regarding future pregnancies had altered following their recent
experience.
A small pilot study of the measures was completed to check for ease of comprehension
and face validity.
Results
Comparisons of primiparous and multiparous women
Primiparas were compared with multiparas across all measures with the ®nding that
they felt less in control of the situation during labour and delivery (t(290) 5 2.19,
p ! .05), felt less prepared than multiparas (t(292) 5 3.27, p ! .001) and found the
procedures during labour and delivery more unexpected (t(292) 5 4.76, p ! .001).
Primiparas were also signi®cantly more fearful for their baby (t(292) 5 3.41, p !
.001) and perceived their experience as worse than they had expected (t(290) 5 2.17,
p ! .05). No other signi®cant diåerences were found. In particular, parity did not
diåerentiate between distressed or non-distressed groups. However, the fact that a
lower proportion of multiparous women completed follow-up needs to be taken into
account in interpreting ®ndings.

Experience of symptoms
Within the strict guidelines of the PTSD±Q, 3 % of the sample (eight participants)
showed the number, frequency and duration (minimum 4 weeks) of symptoms
indicative of clinically signi®cant levels of intrusions, avoidance and hyperarousal.
This group will be labelled the fully symptomatic post-traumatic stress group (FS).
Others reported clinically signi®cant symptoms for the individual sub-scales in terms
of: 14 % (37) intrusions, 7.2 % (19) avoidance symptoms, and 27.3 % (72) clinically
signi®cant levels of hyperarousal. Given that one of the items within the hyperarousal
section relates to sleep, and it is reasonable to assume that many women with new
babies will experience disrupted sleep because of infant feeding, this item was
removed from the analysis. Consequently, the number of participants experiencing
clinically signi®cant symptoms of hyperarousal fell to 17 % (45). When all three
symptom dimensions are collapsed together, this partially symptomatic group (PS)
represents 24.2 % (64) of the whole sample. Combined with the fully symptomatic
group, 27.2 % (72) of the total sample may be conceptualized as experiencing at least
one element of post-traumatic stress symptoms to a clinically signi®cant degree.
 Post-traumatic stress symptoms following childbirth 41
Mean scores for the three groups on the PTSD±Q were as follows: FS 5 68.00
(SD 5 15.59), PS 5 41.84 (SD 5 8.87) and non-symptomatic (NS) 5 27.88
(SD 5 6.14).
As regards results taken from the other commonly used measure of post-traumatic
stress symptoms, the IES indicated that 9.9 % of the sample reported clinically
signi®cant levels ( " 19) of intrusions or avoidance with 7.6 % reporting intrusions,
4.2 % reporting avoidance and 1.9 % reporting both. Mean scores for intrusions and
avoidance were 4.09 (SD 5 5.99) and 7.65 (SD 5 7.23) respectively.
Mean score for the EPDS was 6.56 (SD 5 4.74). Using the 12} 13 cut-oå on the
EPDS, 10.6 % of the sample was identi®ed as reporting signi®cant levels of
depressive symptoms. Of the eight participants in the FS group based on the
PTSD±Q, only three were above cut-oås on the IES, with six being above the 12} 13
cut-oå on the EPDS.

Comparisons between symptomatic and non-symptomatic groups for demographics and

medical interventions
Three groups were identi®ed for initial analysisÐthe fully symptomatic group (FS,
N 5 8) reporting signi®cant levels in terms of frequency, duration and intensity on
all three dimensions, the partially symptomatic group (PS, N 5 64) reporting
clinically signi®cant symptoms for at least one sub-scale but who did not report
all features of post-traumatic stress symptoms and those with no clinically
signi®cant symptom scales on the PTSD±Q, referred to as the non-symptomatic
group (NS, N 5 192).
One-way ANOVAs were carried out initially to compare group means with regard
to total number of children in the family, mother’s age and duration of labour. No
signi®cant diåerences were found. For categorical data, because of low frequencies,
the two symptomatic groups (FS and PS) were combined for comparison with NS.
Individuals in symptomatic groups were less likely to have a partner present, less
likely to have planned their pregnancy and more likely to have had a past mental
health di¬culty. They were also more likely to have decided not to go ahead with
future planned pregnancies based on their labour and delivery (negative) experience.
The only signi®cant aspect relating to obstetric procedures and interventions" was
that symptomatic groups were signi®cantly more likely to have experienced an
episiotomy during childbirth. No signi®cant results were found for nature of onset
of labour, use of induction, method of monitoring progress, type of pain relief,
breech presentation, type of delivery or vaginal tear.

Women’s perceptions of their experience as assessed within 72 hours of delivery

One-way ANOVAs were compared to examine the diåerences between the three
groups across a number of psychological factors experienced during labour and
delivery such as perceived control on the PCON (Wallston, 1989), perceptions
of pleasure, pain, distress, elements of personal coping, preparedness, fear for self and
baby, unexpectedness of procedures, perceived support, control, blame, if women
" Details of frequencies of diåerent obstetric interventions are available from the authors.
42 Jo Czarnocka and Pauline Slade

Table 2. Chi-square tests comparing fully and partially symptomatic (FS 1 PS)
groups with the rest of the participants (NS)a

Chi-square
Group Yes (N ) No (N ) test Odds ratio

Partner FS 1 PS 62 10 7.71**b partner absent:

attended birth NS 183 8 partner present
2.7
Planned FS 1 PS 33 38 (1 unsure) 12.85*** unplanned:
pregnancy NS 45 145 (2 unsure) planned
2.8
A past mental FS 1 PS 16 56 3.85* present: absent
health problem NS 24 168 2
Future planned FS 1 PS 18 (6 unsure) 48 16.22*** negatively
pregnancies NS 15 (2 aåected 164 aåected : not
negatively positively) negatively aåected
aåected 4.1
Episiotomy FS 1 PS 25 46 5.64* present: absent
NS 40 151 2.1
* p ! .05 ; ** p ! .01 ; *** p ! .001.
a Comparisons between FS and the rest of the sample using Fisher’s Exact Test were signi®cant for the
®rst three variables.
b Fisher’s Exact Test, two-tail (Siegel, 1956).
Note. Variation in (N ) totals indicates missing data.

felt well informed about their progress and if they felt that they were listened to
regarding their wishes and views. Signi®cant results are reported in Table 3 together
with eåect sizes (d) calculated according to Schwartzer (1988). According to Cohen
(1992) most of these variables demonstrated at least moderate eåects.
Lower perceived control (PCON) and higher trait anxiety are evident in
symptomatic groups together with greater fear for self and baby. Symptomatic
women were more distressed by the pain although there was no diåerence in their
ratings of severity of pain experienced. Similarly groups did not diåer in their ratings
of pleasure.
Symptomatic groups reported the experience as being worse than expected and
had been less con®dent in their ability to cope and showed greater blame to both self
and staå for any di¬culties encountered during labour. They perceived staå and
partner as less supportive in labour and felt less well informed about progress and
less listened to by staå. As this study was essentially exploratory in purpose the
Bonferroni correction to reduce the possibility of type I error was not applied.
However, if this was applied and p ! .001 used, ®ndings on perceived control, self
and staå blame, fearfulness for self and trait anxiety remain. Analyses of covariance
for the variables in Table 3 were conducted using trait anxiety as the covariate. All
remained signi®cant except for distress from the overall labour experience and how
well informed women felt about the progress of labour, both of which now only
reached p ! .06.
 Post-traumatic stress symptoms following childbirth 43

Table 3. Signi®cant comparisons between groups (fully symptomatic (FS), partially

symptomatic (PS) and non-symptomatic (NS)) for time one variables using one-way
ANOVA and Scheåe! test for post hoc comparison

Eåect
size (d) and
Scheåe!
FS PS NS F signi®cance

Control, con®dence, expectation and blame

Perceived control 21.13 (4.12) 22.11 (4.95) 24.11 (3.54) 7.57*** 0.51b
(PCON)
Feeling in control of 2.50 (0.93) 2.88 (1.21) 3.50 (0.98) 10.93*** 1.02a} 0.61b
situation in labour
Getting questions 4.13 (0.98) 4.08 (1.36) 4.42 (0.61) 5.18** 0.40b
answered in labour
Allowed to play active 4.00 (0.76) 3.77 (0.99) 4.14(0.74) 4.86** 0.46b
role in labour
Con®dence in coping 3.00 (2.33) 5.86 (2.33) 5.88 (2.14) 6.69** 1.34a} 1.21c
in labour
Labour experience 6.63 (3.42) 6.11 (3.20) 4.82 (2.91) 5.37** 0.43b
worse than expected
Self responsible for 5.38 (2.26) 4.31 (2.97) 3.05 (2.52) 7.67*** 0.48b
any di¬culties in
labour
Staå responsible for 3.50 (3.25) 2.50 (2.39) 1.74 (1.33) 7.76*** 1.22a} 0.46b
any di¬culties in
labour
Anxiety and distress
Trait anxiety (STAI) 44.75 (6.30) 38.23 (8.37) 34.97 (7.89) 8.90*** 1.24a} 0.41b
Fearfulness for self in 7.63 (2.56) 5.50 (2.68) 4.55 (2.43) 8.42*** 1.26a} 0.38b
labour (on average)
Fearfulness for self in 8.75 (1.75) 6.42 (3.02) 5.61 (2.70) 6.40** 1.17a
labour (at worst)
Fearfulness for baby 8.99 (1.64) 7.03 (2.79) 6.25 (2.97) 4.43** 0.93a
in labour (at worst)
Distress from pain in 7.63 (2.19) 7.59 (2.40) 6.32 (2.66) 6.32** 0.49b
labour
Distress from overall 8.00 (1.93) 6.75 (2.59) 5.79 (2.40) 6.18** 0.39a} 0.92b
labour experience
Support
Supportiveness of staå 8.71 (2.21) 9.11 (1.60) 9.61 (0.81) 6.82** 1.0a
in labour
Supportiveness of 9.00 (1.77) 9.59 (1.03) 9.80 (0.74) 4.26* 1.0a
partner} relative in
labour
How well informed of 7.63 (3.02) 8.05 (2.38) 8.81 (1.54) 5.33** 0.42b
progress of labour
44 Jo Czarnocka and Pauline Slade

Table 3 (continued)

Eåect
size (d) and
Scheåe!
FS PS NS F signi®cance

Degree wishes and 7.37 (3.29) 8.45 (1.93) 8.96 (1.42) 5.36** 1.04a
views listened to by
staå in labour
* p ! .05 ; ** p ! .01 ; *** p ! .001.
a FS signi®cantly diåerent from NS at 0.05 Scheåe! test.
b PS signi®cantly diåerent from NS at 0.05 Scheåe! test.
c FS signi®cantly diåerent from PS at 0.05 Scheåe! test.

Predictive models
A correlation matrix was generated between time one variables and outcome
variables. To maximize predictive power only variables at time one which correlated
signi®cantly at 0.2 ( p ! .05) and above with the outcome variables were entered into
a forward stepwise multiple regression analysis (Tabachnick & Fidell, 1996). This
choice of method was made as there is insu¬cient evidence on which to base forced
entry models and the purpose of this study was essentially exploratory. The results
for total scores (used as a continuous measure) on the PTSD±Q, the intrusions and
avoidance scales on the IES, the EPDS and the STAI are shown in Table 4. Each
table reports the variance accounted for by the predictor variables (R# ), and the
signi®cance level at the ®nal stage of analysis. In addition, the standardized regression
coe¬cient (or beta weight) is shown, which indicates the importance of the
independent contribution of each variable to the prediction of the outcome variable
when all the other variables in the equation are held constant. As this statistic is
standardized, it may be compared across variables in a manner that is not possible
when comparing change in R# or levels of signi®cance. Any variation in (N ) is due
to missing data.
Within the model predicting the PTSD±Q scores, 29 % of the variance is
accounted for by the ®ve variables entered. Only 18 % of the variance was accounted
for in the model predicting intrusions. Ten variables were entered for this equation,
resulting in the model presented. Six variables were entered for the avoidance model,
with four remaining signi®cant for inclusion in the regression analysis (see Table 4).
In order to consider whether responses could be attributed to pre-existing anxiety
further regression analyses were conducted using trait anxiety as a forced ®rst
predictor variable. For both intrusions and avoidance it accounted for only small
proportions of the variance and the subsequent predictors remained virtually
unchanged.
Four predictor variables were entered for analysis with regard to the EPDS
(measure of depressive symptoms). Finally, the highest amount of variance accounted
 Post-traumatic stress symptoms following childbirth 45

Table 4. Forward stepwise multiple regression predicting PTSD±Q scores, IES

intrusions and IES avoidance. EPDS and state anxiety. Stepwise analyses for intrusion
and avoidance are followed by analyses with trait anxiety forced in as the ®rst
predictor.

Cumulative
PTSD±Q (total score) R# Regression weights

Trait anxiety .13 .22***

Blamed staå for di¬culties .19 .24***
Partner (not) attended birth .24 .20***
Fear for self .27 .17**
Past mental health problem .29 2 .17**

Cumulative
Intrusions R# Regression weights

Fear for self .10 .17*

Partner (not) attended birth .14 .18**
Distress re overall experience .17 .15*
Trait anxiety .18 .13*

Intrusions
with trait anxiety forced in as Cumulative
®rst predictor R# Regression weights

Trait anxiety .06 .12*

Partner (not) attended birth .14 .17**
Fear for self .16 .20**
Experience worse than expected .18 .14*

Cumulative
Avoidance R# Regression weights

Partner (not) attended birth .14 .30***

Distress re overall experience .22 .21***
How well informed .25 2 .17**
Unexpectedness of procedures .27 .15*

Avoidance
with trait anxiety forced in as Cumulative
®rst predictor R# Regression weights

Trait anxiety .07 .10

Partner (not) atttended birth .16 .27***
Distress re overall experience .22 .18**
How well informed .24 2 .15**
Unexpectedness of procedures .25 .15*
46 Jo Czarnocka and Pauline Slade

Table 4 (continued)

Cumulative
EPDS R# Regression weights

Trait anxiety .17 .30***

Past mental health problem .23 2 .28***
Could get questions answered .28 2 .23***
Blamed self for di¬culties .31 .16**

Cumulative Regression
State anxiety R# weights

Trait anxiety .29 .48***

Past mental health problem .33 2 .24***
Allowed active roleÐhealth care .36 2 .15**
* 5 ! .05 ; ** 5 ! .01 ; *** 5 ! .001.
Note. Total number of variables entered in ®nal equation: PTSD±Q 5 5, Intrusions 5 10, Avoidance
5 6, EPDS 5 4, State anxiety 5 7.

for within the study was for state anxiety. Seven variables were initially entered into
the equation, with three emerging as signi®cant for the ®nal analysis, accounting for
36 % of the variance.
Discussion
In this exploratory study, 3 % of the sample (eight participants) showed signi®cant
levels of all three dimensions of post-traumatic stress symptoms as measured by the
PTSD±Q. A further quarter of the sample showed signi®cant symptoms on at least
one dimension. While the questionnaire measure does not provide diagnosis, it is
speci®cally derived from the clinical interview questions and format utilized by
Watson et al. (1991) to provide diagnostic categorization according to DSM±IV and
the results are likely to show some predictive capacity. It must be noted that although
good internal reliability was evident the validity of the questionnaire format has not
been formally established.
Three per cent may be considered as a small ®gure in terms of prevalence.
However, there are approximately 700 000 births annually in England and Wales
(Slade, 1996), thus the projected number of women with signi®cant post-traumatic
stress symptoms at 6 weeks post-partum may be around 21 000 a year. The current
emphasis in postnatal care is focused upon depressive symptoms. It is now
widespread practice for health visitors to use the EPDS as a screening instrument for
depressive symptoms at 6 weeks post-partum. While six of the eight (75 %)
individuals identi®ed as fully symptomatic in this study showed concurrent depressive
symptoms, as indicated by the cut-oå on the EPDS, the remainder (25 %) did not
and would not be detected by this screening measure. Even if there were systematic
national implementation using EPDS screening, up to 5250 women, who according
to the PTSD±Q measure were fully symptomatic in terms of post-traumatic stress
 Post-traumatic stress symptoms following childbirth 47
symptoms, may remain undetected each year. It seems likely that a broader
conceptualization of the term of postnatal distress may be warranted in order to take
more speci®c account of the role of the labour experience and the nature of
presenting di¬culties. However, before any screening for post-traumatic stress
symptoms would be appropriate, a much greater knowledge of the pattern of
experiences is required in terms of their typical duration and spontaneous recovery
rates together with evidence of e¬cacy of interventions.
It must be noted that the PTSD±Q provided higher estimates of both intrusions
and avoidance than the IES. In addition, the total PTSD±Q encompasses scores for
hyperarousal which may obviously be considered an expression of general anxiety.
Trait anxiety strongly diåerentiated between the three groups and also acted as the
primary predictor for total PTSD±Q scores. One question is whether reports merely
re¯ect the high levels of anxiety symptoms reported in community samples of women
(Melzer, Gill, Petticrew, & Hinds, 1995). It could be argued that general measures
of anxiety symptoms do not encompass aspects relating to a speci®c event such as
those coded on the intrusions and avoidance scales. Indeed, when trait anxiety was
forced into their respective regression analyses it accounted for low levels of
variation. As an event is required and it is di¬cult to specify an equivalent event to
labour and birth it was not possible to estimate distress in a control group.
Nevertheless it seems likely that trait anxiety may act as a vulnerability factor for
subsequent post-traumatic stress symptoms following labour as has also been
suggested in other contexts (Joseph et al., 1995). The following discussion considers
the variables that acted as signi®cant predictors after eåects of trait anxiety had been
taken into account.
The partner not attending the birth was associated with post-traumatic stress type
symptoms. A variety of reasons can be postulated for this ®nding. Partners have been
shown to be of bene®t in facilitating women to use coping strategies (Copstick,
Taylor, Hayes, & Morris, 1986 ; Klaus, Kennel, Robertson, & Sosa, 1986 ; Slade,
Escott, Spiby, & Henderson, 1995) and their absence may adversely aåect coping in
labour. This is supported by the fact that the fully symptomatic group diåered
signi®cantly from the other two groups in that they felt less con®dent about being
able to cope during labour and delivery.
Alternatively, the partner’s absence from the labour may have an eåect as a result
of women having no opportunity to discuss the experience and possibly reframe
di¬cult aspects of the labour experience with someone who is aware of the detail of
the process. Partner absence may therefore aåect the existence or quality of any
informal debrie®ng or support provided immediately after the birth. Possible reasons
for partner absence may be a source of distress in themselves in that this may act as
an indicator of pre-existing di¬culties in the relationship. Another diåerence
between the groups was the frequency of the pregnancy being unplanned and this
may have in¯uenced the partner’s attitude to the pregnancy, labour and birth.
The participants in the fully symptomatic post-traumatic stress group also
perceived their attending partner} relative and staå as less supportive during labour
and delivery than the other two groups. It is interesting that the partially
symptomatic group felt less well informed about the progress of their labour and
delivery, and that the fully symptomatic group felt that their wishes and views were
48 Jo Czarnocka and Pauline Slade
listened to less by staå than the other groups. It must be noted that no objective
measure of support from either relatives or staå was incorporated in this study. It is
therefore unclear whether they received less objective support or had greater need
than the other groups and therefore perceived themselves as inadequately supported.
This is important as satisfaction with social support has been shown to be as much
a function of the individual as an actual environmental resource (Hill, 1987).
Compared to the non-symptomatic group, the partially symptomatic group tended
to attach more blame to both themselves and staå for di¬culties they experienced
during labour and delivery. The fully symptomatic group showed only elevated
blame to staå. Joseph et al. (1995) highlight the importance of an individual’s causal
attributions regarding the event itself and their appraisal of their own reactions and
emotions at the time of the trauma. Although self-blame has been found to be
associated with negative outcome for victims of trauma, the authors cite evidence
that identi®es that blaming others may actually lead to poorer prognosis. Whilst
blaming self for di¬culties was included in the model for depressive symptoms
blaming staå was a predictor for the PTSD±Q score which, if related to Joseph et al.’s
(1995) work may have implications for long-term outcome. Blaming staå may also
lead to alienation from a potential source of support at the time of labour and
delivery.
Fear for self was also a predictor for the PTSD±Q scores and amount of distress
about the overall experience was included in both intrusion and avoidance models.
Feeling less well informed and that procedures were more unexpected were also
included in the avoidance analysis. These constructs of fear, distress and
unexpectedness all link with the literature on PTSD and individual diåerences
regarding the appraisal of the situation (Foa & Rothbaum, 1989 ; Joseph et al., 1995 ;
Scott & Stradling, 1992).
While groups in this study did not diåer in their ratings of severity of pain levels,
they did diåer signi®cantly in how distressing they found the pain that they
experienced. It would appear that both the symptomatic groups exhibited a lower
tolerance for distress associated with pain. The presence of the partner during birth
has also been associated with levels of pain experienced (Niven, 1992), and absence
of partner may have in¯uenced the women’s perceptions of distress regarding pain
in this study. The three groups also diåered in their perceptions of control. Feeling
more in control may diminish fears of threat to self and baby and improve tolerance
for pain. It is possible that maximizing women’s perceptions of control in labour may
be helpful in preventing post-traumatic stress type symptoms.
A past mental health problem distinguished between groups and was also a
predictor for the PTSD±Q and for anxiety and depressive symptoms, but not for
either intrusions or avoidance. Within this study, a past mental health problem was
utilized as this is more relevant than a past psychiatric history as only a small
proportion of people with mental health problems are referred to specialist services,
with most adult mental health care being provided in general practice settings
(Surtees, 1990). The ®ndings indicate that this may be a particular pre-existing
vulnerability factor which should be considered.
In summary, in terms of their association with post-traumatic stress type
symptoms speci®c aspects of labour and childbirth such as duration, the nature of
 Post-traumatic stress symptoms following childbirth 49
interventions or type of delivery appear unimportant. However, perceptions of
support from partner and staå, perceptions of control and patterns of blaming,
together with factors such as trait anxiety and past mental health problems do appear
to act as predictors. The last two factors also relate to levels of anxiety and depression
at 6 weeks post-partum. More research is necessary to develop further our
understanding of the personal characteristics and provision of care that may interact
with the experience of labour and delivery that leads to distress for some, but not all
individuals. How far perceptions of support and information giving re¯ect an
objective assessment of actual provisions and to what degree they re¯ect enduring
characteristics of the individual or an interaction between the two remains to be
disentangled. There is a need for studies to include objective measures of care
provided in order to identify which individuals may need diåerent levels of support
or care from staå to aid prevention of the symptoms identi®ed in this study.
Meanwhile, the fact that a proportion of women are likely to experience post-
traumatic stress type symptoms following labour should be taken account in the
provision of postnatal services.

Acknowledgements
This work was conducted in the Department of Psychology, University of She¬eld in liaison with the
Northern General Hospital and the Jessop Hospital for Women, She¬eld.
Gratitude is extended to all patients and staå who participated in and contributed to this study.
Particular thanks to Helen Spiby, Midwifery Research Sister, Northern General Hospital and Ms J.
Finch, Clinical Midwife Manager, Jessop Hospital for Women. We would also like to acknowledge
statistical input from Dr P. Jackson.

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Received 30 January 1998; revised version received 24 June 1999