Original Research
org
OBSTETRICS
A diagnostic questionnaire for childbirth related
posttraumatic stress disorder: a validation study
Isha Hemant Arora, BTech; Georgia G. Woscoboinik, BS; Salma Mokhtar; Beatrice Quagliarini, MD; Alon Bartal, PhD;
Kathleen M. Jagodnik, PhD; Robert L. Barry, PhD; Andrea G. Edlow, MD, MSc; Scott P. Orr, PhD;
Sharon Dekel, PhD, MS, MPhil
BACKGROUND: Labor and delivery can entail complications and severe
maternal morbidities that threaten a woman’s life or cause her to believe that
her life is in danger. Women with these experiences are at risk for developing
posttraumatic stress disorder. Postpartum posttraumatic stress disorder, or
childbirth-related posttraumatic stress disorder, can become an enduring
and debilitating condition. At present, validated tools for a rapid and efficient
screen for childbirth-related posttraumatic stress disorder are lacking.
OBJECTIVE: We examined the diagnostic validity of the Posttraumatic
Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition, for detecting posttraumatic stress disorder among
women who have had a traumatic childbirth. This Checklist assesses the 20
Diagnostic and Statistical Manual of Mental Disorders, posttraumatic stress
disorder symptoms and is a commonly used patient-administrated screening
instrument. Its diagnostic accuracy for detecting childbirth-related post-
traumatic stress disorder is unknown.
STUDY DESIGN: The sample included 59 patients who reported a
traumatic childbirth experience determined in accordance with the Diag-
nostic and Statistical Manual of Mental Disorders, Fifth Edition, posttraumatic
stress disorder criterion A for exposure involving a threat or potential threat to
the life of the mother or infant, experienced or perceived, or physical injury.
The majority (66%) of the participants were less than 1 year postpartum (for
full sample: median, 4.67 months; mean, 1.5 years) and were recruited via
the Mass General Brigham’s online platform, during the postpartum unit
hospitalization or after discharge. Patients were instructed to complete the
Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual
of Mental Disorders, Fifth Edition, concerning posttraumatic stress disorder
symptoms related to childbirth. Other comorbid conditions (ie, depression
and anxiety) were also assessed. They also underwent a clinician interview
for posttraumatic stress disorder using the gold-standard Clinician-Admin-
istered PTSD Scale for Diagnostic and Statistical Manual of Mental Disorders,
Fifth Edition. A second administration of the Checklist was performed in a
subgroup (n¼43), altogether allowing an assessment of internal consis-
tency, test-retest reliability, and convergent and diagnostic validity of the
Checklist. The diagnostic accuracy of the Posttraumatic Stress Disorder
Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth
Edition, in reference to the Clinician-Administered PTSD Scale for Diagnostic
and Statistical Manual of Mental Disorders, Fifth Edition, was determined
Cite this article as: Arora IH, Wascoboinik GG, Mokhtar S, et al. A diagnostic questionnaire for childbirth related
posttraumatic stress disorder: a validation study. Am J Obstet Gynecol 2024;231:134.e1-13.
0002-9378
ª 2023 The Author(s). Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
https://doi.org/10.1016/j.ajog.2023.11.1229
134.e1 American Journal of Obstetrics & Gynecology JULY 2024
ajog.
using the area under the receiver operating characteristic curve; an optimal
cutoff score was identified using the Youden’s J index.
RESULTS: One-third of the sample (35.59%) met the Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition, criteria for a post-
traumatic stress disorder diagnosis stemming from childbirth. The Post-
traumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of
Mental Disorders, Fifth Edition, symptom severity score was strongly
correlated with the Clinician-Administered PTSD Scale for Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition, total score (r¼0.82;
P<.001). The area under the receiver operating characteristic curve was
0.93 (95% confidence interval, 0.87e0.99), indicating excellent diagnostic
performance of the Posttraumatic Stress Disorder Checklist for Diagnostic
and Statistical Manual of Mental Disorders, Fifth Edition. A cutoff value of 28
optimized the sensitivity (0.81) and specificity (0.90) and correctly diagnosed
86% of women. A higher value (32) identified individuals with more severe
posttraumatic stress disorder symptoms (specificity, 0.95), but with lower
sensitivity (0.62). Checklist scores were also stable over time (intraclass
correlation coefficient, 0.73), indicating good test-retest reliability. Post-
traumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of
Mental Disorders, Fifth Edition, scores were moderately correlated with the
depression and anxiety symptom scores (Edinburgh Postnatal Depression
Scale: r¼0.58; P<.001 and the Brief Symptom Inventory, anxiety subscale:
r¼0.51; P<.001).
CONCLUSION: This study demonstrates the validity of the Post-
traumatic Stress Disorder Checklist for Diagnostic and Statistical Manual
of Mental Disorders, Fifth Edition, as a screening tool for posttraumatic
stress disorder among women who had a traumatic childbirth experience.
The instrument may facilitate screening for childbirth-related post-
traumatic stress disorder on a large scale and help identify women who
might benefit from further diagnostics and services. Replication of the
findings in larger, postpartum samples is needed.
Key words: CAPS-5, CB-PTSD, childbirth, childbirth-related PTSD,
Clinician-Administered PTSD Scale for the DSM-5, deliveries, diagnosis,
maternal mental health, maternal morbidity, obstetrical, PCL-5, post-
partum, postpartum depression, postpartum psychopathology,
postpartum PTSD, postpartum screening, posttraumatic stress disorder,
PTSD, PTSD Checklist for DSM-5, validation
Introduction
Childbirth is a physically and psycho-
logically intense event. Of the pregnant
women in the United States, 46% will
have at least 1 unexpected
complication.1e3 About one-third of
women report a highly stressful, poten-
tially traumatic birth experience, often
ajog.org OBSTETRICS Original Research

that are important for infant social-

AJOG at a Glance emotional and cognitive
Why was this study conducted? development.20e22 Posttraumatic stress
Childbirth can be life-threatening or potentially perceived as a threatening symptoms are evoked and maintained by
experience for some women. An estimated 6% of women develop posttraumatic reminders of the trauma; consequently,
stress disorder (PTSD) stemming from childbirth. Recommended screening to the infant may become a trigger of
identify this group of individuals is lacking. distress for the mother. Repeated daily
exposure to reminders of the childbirth
Key findings trauma may hinder maternal recovery
Assessment of childbirth-related PTSD using the self-report PTSD Checklist for and interfere with successful maternal-
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (PCL-5) infant breastfeeding and bonding.21,22
shows excellent diagnostic accuracy in women who experienced or perceived CB-PTSD can lead to avoidance of
threat to her life or the infant’s life or serious injury related to childbirth. A cutoff physical intimacy and serve as a disin-
score of 28 on the PCL-5 optimizes diagnostic sensitivity and specificity. A cutoff centive to pursue future pregnancy.23,24
of 32 has greater specificity for identifying women with higher PTSD symptom CB-PTSD is commonly co-morbid
levels. with depression,25e27 causing increased
depressive symptom severity, functional
What does this add to what is known? impairment, and suicidal behavior as
The PCL-5 is a simple, patient-administered tool that serves as a valid screening observed in nonpostpartum samples.10
method for PTSD related to a traumatic childbirth experience. It can serve as a Currently, there are no recommended
first, efficient step in the diagnostic process. screening guidelines for CB-PTSD
following traumatic childbirth. The
gold-standard assessment for PTSD is
the Clinician-Administered PTSD Scale
accompanied by complications and un- DSM, Fifth Edition.9 It is conceptualized for DSM-5 (CAPS-5),28e30 a structured
planned obstetrical inteventions.4e6 A by 4 symptom clusters, namely intrusion clinical interview administered by a
small number (1.8%) will experience and avoidance (both are trauma spe- trained clinician. This assessment cannot
severe maternal morbidity (SMM)7 (eg, cific), negative alterations in mood and be rapidly and easily administered to
heart attack, heart failure, eclampsia, cognition, and hyperarousal or hyper(- screen for women who may be suffering
sepsis or blood infection, and hysterec- re)activity with a duration of more from CB-PTSD.
tomy) with serious short- and long-term than 1 month.9 These manifestations are The Posttraumatic Stress Disorder
health impacts.8 linked with substantial daily distress, Checklist (PCL) is the most widely used,
Among the potential sequelae of impaired social and occupational func- self-reported patient screening tool for
complicated deliveries is posttraumatic tioning, and alterations in neural struc- PTSD in healthcare settings.31 The
stress disorder (PTSD), a psychiatric ture and activity.11 Individuals with Department of Veterans Affairs recom-
disorder stemming from direct or indi- PTSD often experience complications mends the PCL as the standard tool to
rect exposure to an event involving that may manifest as affective and anxi- assist with making a provisional diag-
actual or threatened death or serious ety disorders. They are likely to avoid nosis of PTSD and to determine recom-
injury or sexual violence.9 Such exposure seeking treatment, and more than 30% mendations for treatment.32 The PCL-5
may trigger psychological and biological of these individuals never experience assesses the 20 DSM-5 PTSD symptoms
processes including conditioned fear, remission of their symptoms.10 and their severity concerning a specified
sensitization, and negative appraisals Childbirth-related PTSD (CB-PTSD) trauma. The PCL shows excellent psy-
that lead to PTSD10 (Appendix 1 con- refers to the development of PTSD after chometric properties31,33e35 and diag-
tains a glossary of psychiatric terms). giving birth.12,13 CB-PTSD occurs in nostic accuracy when compared with the
PTSD was first introduced into the 4.7% to 6.3% of women overall4,14,15 and CAPS diagnostic interview in trauma-
American nosologic psychiatric classifi- in a range of 18.5% to 41.2% of in- exposed populations, including veter-
cation scheme (ie, the Diagnostic and dividuals following complicated de- ans; survivors of sexual assault, natural
Statistical Manual of Mental Disorders liveries.14,16 This rate resembles PTSD disasters, and automobile accidents; and
[DSM]) in 1980, influenced by the psy- prevalence in survivors of road accidents medical patients.29,36e38
chiatric morbidities of soldiers returning and physical violence.17,18 Black and Previous studies, including those by
from the Vietnam War. Its empirical Latinx women are 3 times more likely to our group, have shown that the PCL-5
basis has been largely derived from experience acute traumatic stress re- has good psychometric properties (ie,
combat veterans and subsequently actions to childbirth than White internal consistency and construct val-
broadened to include civilian trauma.10 women.19 idity) when used to evaluate PTSD
PTSD is classified in the trauma- and Untreated CB-PTSD presents unique related to childbirth.39e41 However, the
stressor-related disorders category in the challenges to mother-infant interactions instrument has not been validated as a

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Original Research OBSTETRICS ajog.org

screening tool to inform the diagnosis of

TABLE 1
CB-PTSD. Thus, validation of the PCL-5
Demographics and childbirth-related information of the study sample.
and development of clinical cutoff values
for determining CB-PTSD are needed. Variable N (%) or M (SD)
Existing checklist cutoffs obtained from Maternal age at delivery (y) 32.23 (4.73)
general,30 trauma-exposed adult pop-
ulations may not be applicable to women Primiparity
exposed to birth trauma because of Primiparas 39 (66.1%)
inherent differences with other forms of Multiparas 20 (33.9%)
traumas.
Obstetrical complications or conditions
This study assessed the diagnostic
benefit of the PCL-5 in a sample of Hemorrhaging or excessive blood loss 18 (30.51%)
women who had experienced a trau- Hysterectomy 4 (6.78%)
matic childbirth. The study compared Preeclampsia or eclampsia 11 (18.64%)
the performance of the PCL-5 with that Blood transfusion or infusion 5 (8.47%)
of the gold-standard clinician assess-
ment (CAPS-5) and considered optimal Gestational diabetes 4 (6.78%)
cutoff scores for making a provisional Infection 1 (1.69%)
CB-PTSD diagnosis. The study also Fetal intolerance 23 (38.98%)
examined the PCL-5 accordance with Failed labor progression 17 (28.81%)
measurements of similar constructs (ie,
depression and anxiety) and the stability Arrest of descent 3 (5.08%)
of the instrument over time. Placenta abruption 2 (3.39%)
Maternal acuity 2 (3.39%)
Materials and Methods Placenta previa or low-lying placenta 4 (6.78%)
Study population Cord prolapse 1 (1.69%)
A total of 59 women who had a traumatic Nuchal cord 3 (5.08%)
childbirth experience were included in
ICU admission, maternal 2 (3.39%)
the study. Of those, 66% (n¼39) were
less than 1 year postpartum (median, Mode of delivery
4.67 months; mean, 1.5 years for the full Vaginal 14 (23.73%)
sample). Table 1 presents the cohort’s Vaginal assisted 8 (13.56%)
demographics. Traumatic exposure was
Scheduled Cesarean delivery 3 (5.08%)
defined in accordance with the quali-
fying exposure to a trauma according to Unscheduled or emergency Cesarean delivery 34 (57.62%)
the DSM-5 criterion A for PTSD, namely Gestation age (wk) 39.18 (1.96)
threat or potential threat to life or Neonatal medical complications 8 (13.56%)
serious injury, experienced or perceived,
to the mother and/or the newborn. Demographic information at psychometric testing
Patients completed the PCL-5 and an Maternal age (y) 33.47 (4.63)
assessment for co-morbid mental health Years after delivery 1.5 (2.1)
symptoms. They also underwent a
Marital status
diagnostic interview using the gold-
standard tool (CAPS-5) to evaluate Married or living with partner 55 (93.22%)
traumatic exposure and PTSD symptom Single 4 (6.78%)
endorsement. A subgroup (n¼43) Education
completed a second round of adminis-
Formal college degree or higher 52 (88.14%)
tration of the PCL-5 approximately 5
weeks after the initial one (mean [M], No formal degree 7 (11.86%)
4.99; standard deviation [SD], 4.86). The Race
sample was derived from 2 studies on the White 43 (72.88%)
mental health sequelae of birth trauma
Asian or Asian-American 7 (11.86%)
that targeted women who had a stressful
childbirth, identified using the Peri- Arora. Screening for childbirth posttraumatic stress disorder using the Posttraumatic Stress Disorder Checklist. Am J
Obstet Gynecol 2024. (continued)
traumatic Distress Inventory (PDI).42,43

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TABLE 1
Demographics and childbirth-related information of the study sample.
(continued)
Variable
Black or African-American
Other
Ethnicity
Hispanic or Latinx
Not Hispanic or Latinx
Medical information was derived from electronic medical records and/or patient self-reporting; demographic information
pertains to patient’s status at study assessment. Neonatal complications were defined as medical complications requiring
neonatal intensive care unit admission. Two patients had missing data for maternal age at delivery and study assessment, and
percentages were calculated based on valid values (n¼59).
ICU, intensive care unit; M, mean; SD, standard deviation.
Arora. Screening for childbirth posttraumatic stress disorder using the Posttraumatic Stress Disorder Checklist. Am J
Obstet Gynecol 2024.
Patients were recruited between October
2018 and March 2020 primarily from the
general public via study advertisement
on the Mass General Brigham (MGB)
online platform and between February
2021 and March 2023 from Mass Gen-
eral’s postpartum unit or remotely using
information from obstetrical medical
records indicative of obstetrical compli-
cations or conditions and unplanned
interventions. Both studies were
approved by the MGB Human Research
Committee. Patients provided written
informed consent after a full explanation
of the study procedures. Eligible women
who underwent an assessment during
which the diagnostic (CAPS-5) inter-
view was conducted were included in
this study (n¼30 and n¼29 from the
respective studies; study 1: 197/258
positive screen [PDI >21]; 43/51 con-
sented and were eligible; 13 did not un-
dergo interviews; study 2: performed
during COVID-19; 74/148 positive
screen [PDI >13]; 40/43 consented and
were eligible; 11 lost to follow-up).
Measures
PTSD symptoms were assessed using the
PCL-5,31 a 20-item, self-administered
questionnaire designed to determine
the presence and severity of the DSM-5
PTSD symptoms related to a specified
event; the Checklist (Appendix 2) can be
completed in w5 to 10 minutes.32 Pa-
tients rated the extent to which they have
been bothered by each PTSD symptom
OBSTETRICS
N (%) or M (SD)
1 (1.7%)
8 (13.56%)
7 (11.86%)
52 (88.14%)
during the past month on 5-point scales
(0: “Not at all;” 1: “A little bit;” 2:
“Moderately;” 3: “Quite a bit;” 4:
“Extremely”). Total scores ranged be-
tween 0 and 80; higher scores indicate
higher symptom severity. For this study,
patients rated PTSD symptoms related
to their childbirth experience. The PCL-
5 has excellent reliability and validity in
trauma-exposed samples.44e47
The PTSD diagnostic status was
assessed using the CAPS-5,28 a 30-item,
structured clinical interview that cor-
responds with the DSM-5 PTSD criteria
and takes 45 to 60 minutes to admin-
ister. A trained clinician determined the
presence of a traumatic event according
to DSM-5 criterion A (exposure to
actual or threatened death or serious
injury by experiencing it or witnessing
it) and then assessed the severity of each
of the 20 DSM-5 PTSD symptoms on a
5-point scale (0: “Absent;” 1: “Mild;” 2:
“Moderate;” 3: “Severe;” 4: “Extreme”).
Total symptom severity was obtained by
summing the scores (0e80). Symptom
duration and onset, subjective distress,
and impairment in functioning were
also examined. A diagnosis of PTSD
was established by following the DSM-5
criteria, that is, the presence of a trau-
matic event (criterion A), presence of
symptoms (score 2) in accord with
DSM-5 clusters (at least 1 symptom
each in the category of intrusion and
avoidance and 2 symptoms each in the
hyperarousal and negative alterations in
JULY 2024 American Journal of Obstetrics & Gynecology
Original Research
cognitions and mood categories) that
have persisted for more than 1 month
(criterion F). Symptoms must cause
either clinically significant distress or
functional impairment (criterion G).
Subsyndromal PTSD was defined by
meeting criteria for 3 symptom clus-
ters.48 The CAPS-5 is a psychometri-
cally strong measure of DSM-5
PTSD.28,49
Comorbid symptoms of depression
and anxiety were assessed using the
Edinburgh Postnatal Depression Scale
(EPDS) and Brief Symptom Inventory
(BSI),50 respectively. The EPDS is the
recommended screening tool for peri-
partum depression in medical set-
tings.51,52 The BSI measures symptom
severity during the past week on 5-point
(0e4) scales; it has adequate psycho-
metric properties.16,53 We administered
the 6-item BSI anxiety subscale (note: 1
item for 2 patients was missing; total
score sums all validated items).
Analysis
Descriptive statistics were computed
using proportions for categorical vari-
ables and M and SD for continuous
variables (Appendix 1 contains a glos-
sary of statistical terms).
We measured internal consistency and
stability of the PCL-5 using Cronbach’s
alpha and intraclass correlation coeffi-
cient (ICC)54 (Appendix 3 contains a list
of acronyms and abbreviations used in
this paper). We determined the PCL-5’s
convergent validity using Spearman’s
rho correlations between the PCL-5 and
the diagnostic interview (CAPS-5),
depression (EPDS), and anxiety (BSI)
total symptom scores.
To determine the diagnostic accuracy
of the PCL-5, we analyzed the area under
the receiver operating characteristic
(ROC) curve (AUC), which served as a
measure of model performance.55 AUC
values of 0.8 indicate good discrimi-
native power.56 We identified optimal
cutoff scores for the PCL-5 via Youden’s J
index57 generated using the ROC curve
analysis. We calculated a range of
Checklist sensitivity (probability of pa-
tient with a CAPS-5 PTSD diagnosis
having a positive PCL-5 screen) and
specificity (probability of patient
134.e4
Original Research OBSTETRICS ajog.org

without a CAPS-5 PTSD diagnosis hav-

FIGURE 1
ing a negative PCL-5 screen) values,
Association of PCL-5 PTSD symptom severity scores with CAPS-5 diagnostic
positive predictive value (PPV) (proba-
scores
bility of patient with positive PCL-5
screen receiving a CAPS-5 diagnosis),
negative predictive value (NPV) (prob-
ability of patient with negative PCL-5
screen not receiving a CAPS-5 diag-
nosis), and overall diagnostic efficiency
(ODE) (proportion of patients correctly
diagnosed) using the CAPS-5 diagnosis
as the external criterion. Statistical ana-
lyses were completed using R (version
4.3.0; R Core Team, Vienna, Austria)58
and related packages.59e63

Results
In total, 35.59% (n¼21) of the sample
met the DSM-5 criteria for PTSD stem-
ming from a traumatic childbirth with
an average diagnostic CAPS-5 PTSD
severity score of 28.43 (SD, 6.84); 20.3%
(n¼12) met the criteria for sub-
syndromal PTSD.

Posttraumatic Stress Disorder

Checklist for Diagnostic and
Statistical Manual of Mental
Disorders, Fifth Edition, reliability
The total PCL-5 scores exhibited strong
internal consistency (Cronbach’s alpha
[a], 0.93). There was good internal
consistency across the DSM-5 symptom
cluster scores (cluster B: a¼0.84; cluster
C: a¼0.86; cluster D: a¼0.82; and cluster
E: a¼0.82). The PCL-5 demonstrated
satisfactory stability over the 2 adminis-
tration time points (ICC, 0.73; n¼43;
missing data for 7 individuals because
the second administration was added
after the study commenced; 9 lost to
follow-up or incomplete assessment).
Posttraumatic Stress Disorder
Checklist for Diagnostic and
Statistical Manual of Mental
Disorders, Fifth Edition, convergent
validity
The total PCL-5 scores showed strong
positive correlation with the CAPS-5
total severity scores (r¼0.82; P<.001)
(Figure 1). Correlations between the
PCL-5 and symptoms of depression
(EPDS) and anxiety (BSI) were moder-
ately strong (n¼57; EPDS: r¼0.58,
P<.001; BSI: r¼0.51, P<.001).
The figure represents a scatter plot of the PTSD childbirth-related symptom severity scores obtained
on the PCL-5 and CAPS-5. PTSD diagnosis, endorsement (red) or not (blue) per clinician (CAPS-5)
evaluation. Missing data for the PCL-5 (less than 0.35% of all data points, 1 item for 2 patients) were
handled using the most conservative estimate, that is, computing a sum score of all validated items.64
PTSD, posttraumatic stress disorder; CB-PTSD, childbirth-related PTSD; DSM-5, Diagnostic and Statistical Manual of Mental Disorders,
Fifth Edition; CAPS-5, Clinician-Administered PTSD Scale for DSM-5; PCL-5, PTSD Checklist for DSM-5.
Arora. Screening for childbirth posttraumatic stress disorder using the Posttraumatic Stress Disorder Checklist. Am J Obstet
Gynecol 2024.
Posttraumatic Stress Disorder and cases correctly identified (ODE,
Checklist for Diagnostic and 86%). A cutoff score of 32 yielded higher
Statistical Manual of Mental specificity (95%) but lower sensitivity
Disorders, Fifth Edition, diagnostic (62%) with an ODE of 83%. Table 2
accuracy presents PCL-5 cutoff values by diag-
ROC curve analysis for the PCL-5 diag- nostic performance. Analysis of 39 pa-
nosis in relation to the CB-PTSD (CAPS- tients who were <1 year postpartum also
5) diagnosis is presented in Figure 2. The revealed 28 as the optimal cutoff value
AUC, representing the prediction accu- (AUC, 0.94; 95% CI, 0.87e1; sensitivity,
racy of the diagnosis, was 0.93 (95% 80%; specificity, 93%).
confidence interval [CI], 0.87e0.99). The diagnostic accuracy for the PCL-5
This demonstrates excellent diagnostic based on the number of PTSD symp-
performance of the PCL-5. A PCL-5 toms endorsed using the CAPS-5 inter-
cutoff value of 28 produced the optimal view when compared with the CAPS-5
balance between sensitivity and speci- total symptom severity score was lower
ficity (sensitivity, 81%; specificity, 90%) (for the optimal cutoff value: sensitivity,

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FIGURE 2
ROC curve for the PCL-5 compared with the PTSD CAPS-5 diagnosis
The straight diagonal line represents the line of no information, whereas the curved line depicts the
strength of the PCL-5 performance in accurately identifying women with CB-PTSD determined by the
clinician (CAPS-5) diagnostic evaluation.
PTSD, posttraumatic stress disorder; CB-PTSD, childbirth-related PTSD; DSM-5, Diagnostic and Statistical Manual of Mental Disorders,
Fifth Edition; PCL-5, PTSD Checklist for DSM-5; CAPS-5, Clinician-Administered PTSD Scale for DSM-5; ROC, receiver operating
characteristic.
Arora. Screening for childbirth posttraumatic stress disorder using the Posttraumatic Stress Disorder Checklist. Am J Obstet
Gynecol 2024.
66.7%; specificity, 82.4%; PPV, 70%;
NPV, 82.1%).
Comment
Principal findings
We examined the PCL-5 as a diagnostic
screening tool for women who had
experienced a traumatic childbirth. The
PCL-5 is a simple, self-administered
patient measure of the 20 PTSD symp-
toms listed in the DSM. It takes only 5 to
10 minutes to complete. The PCL-5 can
accurately detect the endorsement or
absence of PTSD caused by a traumatic
childbirth when compared with the
gold-standard CAPS-5 clinician diag-
nostic assessment and is stable over time.
There is strong agreement between the
OBSTETRICS
total symptom severity scores obtained
with the 2 measures. Our findings sup-
port the potential usefulness of the PCL-
5 as a brief screening tool to identify
women who may be at risk for PTSD
stemming from a traumatic childbirth
experience.
Results in the context of what is
known
A cutoff score of 28 on the PCL-5 opti-
mizes test sensitivity and specificity such
that the vast majority of women with a
traumatic childbirth experience will be
correctly diagnosed. In total, 81% of the
individuals with CB-PTSD symptom-
atology and 90% of those who do not
have CB-PTSD symptomatology will be
JULY 2024 American Journal of Obstetrics & Gynecology
Original Research
correctly identified. These results are in
accordance with the recommended
sensitivity level of 80% for PTSD
screening instruments65 and high
demonstrated specificity for CB-PTSD.
This study evaluated the diagnostic
use of the PCL-5 checklist for CB-PTSD
and determined an optimal cutoff score.
A study of the ability of PCL-5 to detect
PTSD caused by any traumatic event in a
sample of pregnant women suggested a
cutoff of 26, but this cutoff had low
sensitivity (63%).66 Validation studies of
the PCL-5 in various trauma-exposed
populations suggested cutoffs ranging
from 25 to 45,44e47,67 underscoring the
importance of establishing cutoff scores
for specific trauma-exposed pop-
ulations. A cutoff score of 33 is a
reasonable value to use for provisional
PTSD diagnosis in the military.34
Accordingly, we found that a score of
32 or higher, although less sensitive
(62%), is more specific (95%). Such
identification can enhance the allocation
of services to women who may experi-
ence more functional impairment. A
lower cutoff score of 28 could be used if
the purpose of screening is to identify
cases of probable CB-PTSD.
Clinical implications
At present, although a portion of United
States women may experience life-
threatening events during labor and de-
livery that trigger CB-PTSD, there is
currently no screening guidance for this
condition. The recommended screening
tool for maternal mental health is the
EPDS, which identifies individuals with
peripartum depression but not CB-
PTSD. The high prevalence of comor-
bidity between CB-PTSD and depression
raises concern of misdiagnosing a trau-
matic stress condition that would require
different treatment.
In this study, we provide evidence that
supports the use of the PCL-5 as a valid
screening tool for maternal CB-PTSD.
Using this tool among patients deemed
by their providers to have experienced a
traumatic childbirth, often associated
with obstetrical complications, would
offer a rapid, low-cost, and efficient
method for identifying patients who
could be assessed more extensively (eg,
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Original Research OBSTETRICS ajog.org

via a CAPS-5 interview) for CB-PTSD. A

TABLE 2
variety of psychological interventions
Diagnostic use of the PTSD Checklist for DSM-5 by cutoff value scores
are potentially available.68 Decisions
regarding cutoff scores to be used with Cutoff Sensitivity Specificity PPV NPV ODE J-statistic
the PCL-5 may require prioritizing the 18 0.95 0.66 0.61 0.96 0.76 0.61
importance of identifying those women
who are likely to meet the criteria for a 19 0.95 0.66 0.61 0.96 0.76 0.61
CB-PTSD diagnosis over identifying 20 0.95 0.68 0.63 0.96 0.78 0.64
only those with high CB-PTSD symp- 21 0.91 0.74 0.66 0.93 0.80 0.64
toms to facilitate appropriate treatment.
22 0.91 0.74 0.66 0.93 0.80 0.64

Research implications 23 0.86 0.76 0.67 0.91 0.80 0.62

Although screening measures are more 24 0.86 0.79 0.69 0.91 0.81 0.65
effective when used to distinguish in- 25 0.86 0.79 0.69 0.91 0.81 0.65
dividuals who have a disorder from
26 0.81 0.84 0.74 0.89 0.83 0.65
healthy controls,30 women may experi-
ence psychological problems without 27 0.81 0.84 0.74 0.89 0.83 0.65
meeting the diagnostic criteria for CB- 28a 0.81 0.90 0.81 0.90 0.86 0.71
PTSD.4 A subset of our sample exposed 29 0.71 0.92 0.83 0.85 0.85 0.64
to a traumatic childbirth displayed sub-
syndromal CB-PTSD.4,69 For a substan- 30 0.67 0.92 0.82 0.83 0.83 0.59
tial portion of women, symptoms of 31 0.62 0.92 0.81 0.81 0.81 0.54
depression and anxiety persist beyond 32 a
0.62 0.95 0.87 0.82 0.83 0.57
the first postpartum year.70e72 Hence,
33 0.62 0.95 0.87 0.82 0.83 0.57
the observed diagnostic efficacy of the
PCL-5 in this study underscores that this 34 0.62 0.97 0.93 0.82 0.85 0.59
checklist can offer a robust screening 35 0.62 0.97 0.93 0.82 0.85 0.59
method for CB-PTSD. Future, larger- 36 0.62 0.97 0.93 0.82 0.85 0.59
scale studies of postpartum women are
37 0.62 0.97 0.93 0.82 0.85 0.59
needed to replicate our findings and to
determine their generalizability before 38 0.52 0.97 0.92 0.79 0.81 0.50
more widespread deployment. 39 0.47 0.97 0.91 0.77 0.80 0.45
Cuttoff refers to PCL-5 (PTSD in regard to childbirth) total symptom severity score. Cutoffs between 0 and 17 have a sensitivity of
Strengths and limitations 1 and NPV value of 1, whereas cutoffs of 40 and higher have a specificity of 1 and a PPV value of 1.
We examined the validity of one of the PTSD, posttraumatic stress disorder; DSM-5, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition; PCL-5, PTSD
Checklist for DSM-5; PPV, positive predictive value; NPV, negative predictive value; ODE, overall diagnostic efficiency.
most widely used, self-report measures a
PCL-5 score of 28 achieves optimal balances between sensitivity and specificity. A score of 32 results in high specificity.
for PTSD screening and its use in making Arora. Screening for childbirth posttraumatic stress disorder using the Posttraumatic Stress Disorder Checklist. Am J
a provisional PTSD diagnosis in response Obstet Gynecol 2024.
to traumatic childbirth. The diagnostic
accuracy of the PCL-5 was demonstrated
by testing it against the gold-standard
clinician diagnostic assessment for those who gave birth more recently was Conclusion
PTSD (CAPS-5). Optimal clinical cutoff high. The administration of the PCL-5 Obstetrical complications during labor
scores were also suggested that could aid and CAPS-5 was not counterbalanced; and delivery can pose life-threatening or
in the initial diagnostic process. The the PCL-5 was usually completed first. potentially threatening experiences, and
Checklist was evaluated in relation to a We note that studies suggest limited maternal morbidity remains high in
measure of depression symptoms (the order effects.37 Cultural and educational the United States, thereby increasing
EPDS), which is important for under- background may influence symptoms; women’s risk for suffering psychiatric
standing the benefits of a screening tool consequently, our findings may not morbidity in the form of PTSD.73 Well-
specific for traumatic stress. translate to other culturally disparate being screening that addresses potential
Several limitations should be noted. societies. We used the diagnostic mental health needs would be beneficial.
The sample size was small, and more than (CAPS-5) interview as the criterion We provide empirical evidence that
1 year had passed after childbirth for against which to validate the PCL-5. As supports the use of the brief and simple
some patients; however, the proportion of the biological basis of psychiatric con- PTSD self-report scale (PCL-5) as a
women with a formal diagnosis of CB- ditions becomes clearer, biological vali- clinical screening tool for PTSD among
PTSD (or subsyndromal PTSD) and dation should be explored. women who experienced a traumatic

134.e7 American Journal of Obstetrics & Gynecology JULY 2024

ajog.org
childbirth. When conducting a com-
prehensive assessment during the tradi-
tional postpartum (4e6 week) visit and
pending more research among post-
partum women, there could be an op-
portunity to use the PCL-5. n ysis. Clin Psychol Rev 2022;94:102157.
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Author and article information
From the Postpartum Traumatic Stress (Dekel) Labora-
tory, Division of Neuroscience, Department of Psychiatry,
Massachusetts General Hospital, Boston, MA (Mses
Arora, Woscoboinik, and Mokhtar and Drs Quagliarini,
Jagodnik, and Dekel); The School of Business Adminis-
tration, Bar-Ilan University, Ramat Gan, Israel (Dr Bartal);
Department of Psychiatry, Harvard Medical School,
Boston, MA (Drs Jagodnik, Orr, and Dekel); Athinoula A.
Martinos Center for Biomedical Imaging, Department of
Radiology, Massachusetts General Hospital, Charles-
town, MA (Dr Barry); Harvard Medical School, Boston, MA
(Dr Barry); Harvard-Massachusetts Institute of Technol-
ogy Health Sciences & Technology, Cambridge, MA (Dr
Barry); Division of Maternal-Fetal Medicine, Department
of Obstetrics and Gynecology, Massachusetts General
Hospital and Harvard Medical School, Boston MA (Dr
Edlow); Vincent Center for Reproductive Biology, Mas-
sachusetts General Hospital, Boston MA (Dr Edlow); and
Division of Neuroscience, Department of Psychiatry,
Massachusetts General Hospital, Boston, MA (Dr Orr).
Received Aug. 8, 2023; revised Nov. 7, 2023;
accepted Nov. 9, 2023.
A.G.E. reports receiving consulting fees from Mirvie,
Ind. and research funding from Merck Pharmaceuticals to
study vaccines in pregnancy, both unrelated to this work.
All other authors report no conflict of interest.
S.D. was supported by grants from the Eunice Ken-
nedy Shriver National Institute of Child Health and Human
Development under grant numbers R01HD108619,
R21HD100817, and R21HD109546. The sponsor was
not involved in study design; in the collection, analysis, or
interpretation of data; in the writing of the report; or in the
decision to submit this article for publication.
Corresponding author: Sharon Dekel, PhD, MS, MPhil.
sdekel@mgh.harvard.edu
ajog.org OBSTETRICS Original Research

Appendix 1

SUPPLEMENTAL TABLE 1
Glossary of psychiatric and statistical terms used in this paper
Term Definition
Psychiatric
Affective disorders A cluster of mental disorders known as mood
disorders in which the underlying feature is
disturbance in the person’s mood
Anxiety disorders A cluster of mental disorders in which the main
feature is extreme and uncontrollable anxiety
Avoidance Avoidance of internal and external reminders of the
traumatic event; DSM-5 PTSD criterion C
Fear conditioning Fear experienced at the time of the trauma resulting
in strong associative learning between the fear
response and cues presented at the time of the
trauma
Fear sensitization Less intense stressors are perceived as stronger
than they are, via increased reactivity of the arousal
system due to traumatization
Functional impairment Used as a criterion that must be met to render a
mental disorder diagnosis; primarily pertains to
impairment in social and occupational functioning
Hyperarousal or hyper(-re)activity Heightened arousal and reactivity manifested in
hypervigilance, strong startle reaction, irritability,
and sleep and concentration problems; DSM-5
PTSD criterion E
Intrusion Reliving the traumatic event through repeated
intrusive memories, flashbacks, nightmares, and
physical reactions to traumatic reminders; DSM-5
PTSD criterion B
Maternal-infant bonding A maternal-driven process that begins after
childbirth and develops throughout the postpartum
year representing maternal feelings and emotions
involving the infant
Negative alterations in mood and Negative thoughts and assumptions about oneself
cognition (self-blame) and the world, and dysphoric mood;
DSM-5 PTSD criterion D
Negative appraisals Dysfunctional cognitive appraisal of the trauma and
its sequelae including both appraisal about the self
and other people/world
Trauma- and stressor-related disorders A category of mental disorders in which the
emotional, behavioral, and biological disturbance
relates to exposure to a stressful, traumatic
experience
Statistical
Area under curve (AUC) The area between a curve and an axis, used as
measure of the effectiveness of diagnostic markers
Confidence interval (CI) The range including a value plus and minus the
variation (margin of error) in that value
Arora. Screening for childbirth posttraumatic stress disorder using the Posttraumatic Stress Disorder Checklist. Am J
Obstet Gynecol 2024. (continued)

JULY 2024 American Journal of Obstetrics & Gynecology 134.e10

Original Research OBSTETRICS ajog.org

SUPPLEMENTAL TABLE 1
Glossary of psychiatric and statistical terms used in this paper (continued)
Term Definition
Cronbach’s alpha Assessment of reliability via comparison of shared
variance, or covariance, among the items
composing an instrument, to the amount of overall
variance
Intraclass correlation coefficient (ICC) Measure of the relatedness of clustered data; used
to measure internal consistency and stability for
test-retest reliability
Negative predictive value (NPV) Measure of accuracy of a negative test result in a
diagnostic test; the number of true negatives divided
by the sum of true negatives and false negatives
Overall diagnostic efficiency (ODE) Percentage of cases accurately identified by a
screening instrument
Positive predictive value (PPV) Measure of accuracy of a positive test result in a
diagnostic test; the number of true positives divided
by the sum of true positives and false positives
Receiver operating characteristic (ROC) Plot of the performance of a classification model at
all classification thresholds; used to evaluate the
accuracy of model predictions
Sensitivity Measure of a model’s ability to detect true positive
instances
Spearman correlation Statistical measure of the strength of a monotonic
relationship between paired data
Specificity Measure of a model’s ability to predict true negative
instances
Youden’s index (J-statistic) Summary measure of the receiver operating
characteristic (ROC) curve; it measures the
effectiveness of a diagnostic marker and facilitates
the selection of an optimal threshold value or cutoff
point for the marker
DSM-5, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition; PTSD, posttraumatic stress disorder.
Arora. Screening for childbirth posttraumatic stress disorder using the Posttraumatic Stress Disorder Checklist. Am J
Obstet Gynecol 2024.

134.e11 American Journal of Obstetrics & Gynecology JULY 2024

ajog.org OBSTETRICS Original Research

Appendix 2

SUPPLEMENTAL TABLE 2
The PTSD Checklist for DSM-5 (PCL-5)
In the past month, how much were you bothered by: Not at all A little bit Moderately Quite a bit Extremely
1. Repeated, disturbing, and unwanted memories of 0 1 2 3 4
your childbirth experience?
2. Repeated, disturbing dreams of your childbirth 0 1 2 3 4
experience?
3. Suddenly feeling or acting as if your childbirth 0 1 2 3 4
experience were actually happening again (as if
you were actually back there reliving it)?
4. Feeling very upset when something reminded you 0 1 2 3 4
of your childbirth experience?
5. Having strong physical reactions when something 0 1 2 3 4
reminded you of your childbirth experience (for
example, heart pounding, trouble breathing,
sweating)?
6. Avoiding memories, thoughts, or feelings related to 0 1 2 3 4
your childbirth experience?
7. Avoiding external reminders of your childbirth 0 1 2 3 4
experience (for example, people, places, conver-
sations, activities, objects, or situations)?
8. Trouble remembering important parts of your 0 1 2 3 4
childbirth experience?
9. Having strong negative beliefs about yourself, other 0 1 2 3 4
people, or the world (for example, having thoughts
such as: I am bad, there is something seriously
wrong with me, no one can be trusted, the world is
completely dangerous)?
10. Blaming yourself or someone else for your 0 1 2 3 4
childbirth experience or what happened after it?
11. Having strong negative feelings such as fear, 0 1 2 3 4
horror, anger, guilt, or shame?
12. Loss of interest in activities that you used to 0 1 2 3 4
enjoy?
13. Feeling distant or cut off from other people? 0 1 2 3 4
14. Trouble experiencing positive feelings (for 0 1 2 3 4
example, being unable to feel happiness or have
loving feelings for people close to you)?
15. Irritable behavior, angry outbursts, or acting 0 1 2 3 4
aggressively?
16. Taking too many risks or doing things that could 0 1 2 3 4
cause you harm?
17. Being “superalert” or watchful or on guard? 0 1 2 3 4
18. Feeling jumpy or easily startled? 0 1 2 3 4
19. Having difficulty concentrating? 0 1 2 3 4
20. Trouble falling or staying asleep? 0 1 2 3 4
The PCL-5 was specified for the childbirth experience. Instructions: Below is a list of problems that people sometimes have in response to a very stressful experience. Please think of your childbirth
experience and read each problem carefully. Then circle one of the numbers to the right to indicate how much you have been bothered by that problem in the past month.
Arora. Screening for childbirth posttraumatic stress disorder using the Posttraumatic Stress Disorder Checklist. Am J Obstet Gynecol 2024.

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Original Research OBSTETRICS ajog.org

Appendix 3

SUPPLEMENTAL TABLE 3
List of abbreviations and acronyms used in this paper
Acronym or abbreviation Full phrase
AUC Area under curve
BSI Brief Symptom Inventory
CAPS-5 Clinician-Administered PTSD Scale for DSM-5
CB-PTSD Childbirth-related posttraumatic stress disorder
CI Confidence interval
DSM Diagnostic and Statistical Manual of Mental Disorders
EPDS Edinburgh Postnatal Depression Scale
ICC Intraclass correlation coefficient
NPV Negative predictive value
ODE Overall diagnostic efficiency
PCL-5 PTSD Checklist for DSM-5
PDI Peritraumatic Distress Inventory
PPV Positive predictive value
PTSD Posttraumatic stress disorder
ROC Receiver operating characteristic
Arora. Screening for childbirth posttraumatic stress disorder using the Posttraumatic Stress Disorder Checklist. Am J
Obstet Gynecol 2024.

134.e13 American Journal of Obstetrics & Gynecology JULY 2024