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. Author manuscript; available in PMC: 2021 Aug 1.
Published in final edited form as: Arch Womens Ment Health. 2019 Oct 25;23(4):557–564. doi: 10.1007/s00737-019-01006-x

Beyond Postpartum Depression: Posttraumatic Stress-Depressive Response Following Childbirth

Sharon Dekel a,b,*, Tsachi Ein-Dor c, Gabriella Dishy a, Philip Mayopoulos a
PMCID: PMC7182486  NIHMSID: NIHMS1541525  PMID: 31650283

Abstract

Objective

Although depression following childbirth is well recognized, much less is known about comorbid postpartum psychiatric conditions. Some women can endorse posttraumatic stress related to the childbirth experience accompanied by symptoms of depression. The objective of our study was to examine the nature of the comorbidity of symptoms of childbirth-related posttraumatic stress disorder (PTSD) and postpartum depression.

Method

We studied a sample of 685 women who were on average three months following childbirth and collected data about their mental health pertaining to PTSD, depression, general distress, and childbirth experience.

Results

The vast majority of women with elevated childbirth-related PTSD symptoms also endorsed elevated postpartum depression symptoms. Factor analysis revealed that symptoms of childbirth-related PTSD and postpartum depression loaded onto one single factor rather than two factors. Stepwise multi-nominal regression analysis revealed that childbirth stressors, including obstetric complications and peritraumatic distress in birth, predicted the likelihood of developing comorbid childbirth-related PTSD and postpartum depression, but not depression alone.

Conclusion

The findings suggest that beyond postpartum depression, postpartum women suffer from a posttraumatic stress-depressive response in the wake of a traumatic childbirth experience. Increasing awareness in routine postpartum care about traumatic childbirth and its associated emotional sequela is warranted.

Introduction

Approximately 138 million women give birth every year (Organization 2015). For some women, the postpartum period is a time of psychological vulnerability. Although postpartum depression is the most documented complication of birth (Dekel et al. 2019b; Werner et al., 2015; Yim et al., 2015), accumulating studies indicate that women can also suffer from postpartum childbirth-related PTSD (CB-PTSD) precipitated by a highly stressful childbirth experience (Ayers et al. 2016; Dekel et al. 2019a; Dekel et al. 2017b; Yildiz et al. 2017). CB-PTSD is not limited to stillbirth and pre-term deliveries with infant medical complications (Andersen et al. 2012; Olde et al. 2006). As much as 25% of women are expected to experience CB-PTSD symptoms at a clinical level after giving birth to a healthy baby at-term (Dekel et al. 2017b), which may interfere with maternal bonding (Davies et al. 2008; Dekel et al. 2019c) to the detriment of the child. Obstetric complications as well as a woman’s negative emotional response to childbirth and other premorbid and possibly biological factors may increase CB-PTSD risk (Andersen et al. 2012; Ayers et al. 2016).

Not surprisingly, existing studies indicate that women experiencing CB-PTSD often report symptoms of depression, with comorbid rates for the most part in the moderate to high range (Soderquist et al. 2009; Wenzel et al. 2005; White et al. 2006). This may suggest postpartum depressive reactions can be implicated in trauma exposure. High co-morbid rates of PTSD and depression in non-postpartum samples has been repeatedly documented (Dekel et al. 2014; Rytwinski et al. 2013), and have been associated with elevated symptom burden, functional impairment, and increased costs (Sher 2005). Along this line, comorbid CB-PTSD and depression may pose a significant threat to the mother’s overall wellbeing and her child’s health and thus requires scientific attention. To our knowledge, research on the nature of co-occurrence of postpartum CB-PTSD and depression is lacking and no study examined the interrelationships among their constructs.

At least two theories could be proposed for the co-occurrence of CB-PTSD and depression following birth, according with explanations for comorbidity in non-postpartum individuals (Flory and Yehuda 2015). Postpartum CB-PTSD and depression may be deemed independent childbirth outcomes. Some biological studies of non-postpartum samples document opposing dysregulations in the body’s stress response in PTSD and depression (Oquendo et al. 2003; Yehuda 2002). Comorbidity may therefore represent merely overlapping symptoms of the two conditions. It is also possible that a third factor or a group of factors may increase the vulnerability for endorsing both.

Alternatively, co-existing postpartum CB-PTSD and depression may signify a unified childbirth-related phenotype. Suffering from prior depression is a strong vulnerability factor for developing CB-PTSD, while prior PTSD is found to render the woman vulnerable to postpartum depression (Oh et al. 2016; Soderquist et al. 2009; van Son et al. 2005). Biological studies of non-postpartum samples further show distinctive biomarkers associated with comorbid PTSD and depression in comparison to PTSD or depression alone (Dekel et al. 2017a; Jovanovic et al. 2012; Morris et al. 2012; Zhu et al. 2017), supporting a defined comorbid condition.

To this end, we studied a sample of 685 postpartum women, including women endorsing CB-PTSD and postpartum depression symptoms. We focused our analysis on the questions of whether comorbid symptoms of CB-PTSD and postpartum depression represent a single construct, and whether variables predicting the likelihood to develop the comorbid condition are different from predictors of postpartum depression or CB-PTSD alone.

Methods

Participants

The present study is part of a larger research project on the childbirth experience and psychological sequelae. Data was obtained from women who gave birth to a live baby in the last six months (inclusion criteria). We recruited participants through study announcements on postpartum websites (e.g., Postpartum Progress) who met study inclusion criteria: were 18 years and older, and had given birth to a live baby in the last six months. Participants completed an anonymous online survey in English about their childbirth experience and their mental health between November 2016 and April 2017. There was no monetary incentive. Partners Human Research Committee (PHRC) determined that project meets criteria for exemption.

846 women agreed to participate, and among them, 94% met inclusion criteria (N=795). We excluded a further 110 participants from the data set due to non-response on most measures, leaving a final sample of 685 women. 541 (79%) participants had an at term delivery with healthy baby outcomes while 144 (21%) had a preterm delivery, which in most cases (84% of preterm incidences) resulted in the newborn being admitted to the neonatal intensive care unit (NICU).

Participants were on average 31 years of age (SD=4.80) and middle class (median income = $50,000-$99,000.The majority (93%) were married or lived with a domestic partner (6% single and 1% divorced/separated), had at least a college-level education (71%, which among them a third had graduate level education), and resided in North America (66%). The rest were from Europe (11%), Australia (8%), Asia (4%), Africa (5%), Middle East (3%), Latin America (1%), and 2% did not provide relevant information. The majority of participants delivered vaginally (64%) and were on average three months postpartum (ranging between one day postpartum to six months postpartum, with 12% being less than one month postpartum). Sample characteristics are presented in Table 1.

Table 1.

Sociodemographic and childbirth-related characteristics of the sample

Variable n (%)/ M (SD)
Mean age of mother 31-yr (SD=4.80)
Mean age of child 3-mo (SD=3.00)
Education
Formal college degree or higher 488 (71.2%)
No formal degree 197 (28.8%)
Household income:
< 50K 173 (25.2%)
50K – 100K 247 (36.1%)
>100K 265 (38.7%)
Marital status:
Married or living with partner 637 (93%)
Single 48 (7%)
Primiparity:
Primiparas 384 (56%)
Multiparas 301(44%)
Planned pregnancy 507 (74%)
Fertility treatment 78 (11.4%)
Gestation week:
At-term 541 (90%)
Preterm 144 (10%)
Obstetric complication in birth 324 (47.3%)
Mode delivery:
Vaginal 439 (64%)
Cesarean 246 (36%)
Single birth 594 (86.7%)
Medical complications in newborn 120 (17.0%)
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Note. The final sample size was 685. Age of child = refers to child age during assessment completion. Per-term delivery = before 37 weeks of gestation. Complications in newborn = medical complications resulting in neonatal admission to intensive care unit.

Measures

PTSD symptoms related to the childbirth experience were assessed with the widely used PTSD checklist for DSM-5 (PCL-5) (Weathers et al. 2013). The PCL-5 is a 20-item self-report measure of PTSD symptom frequency in relation to an index event corresponding to DSM-5 symptom criteria (Association 2013). We anchored the index event to “the most recent childbirth”. Participants rated their symptoms over the past month (or since recent childbirth if less than one month postpartum) on a 5-point Likert scale, ranging from 0 (not at all) to 4 (extremely). The PCL-5 has good internal consistency and concurrent validity (Bovin et al. 2016) and has been previously used to assess childbirth-related PTSD (Scheepstra et al. 2017; Stramrood and Slade 2017; Sumner et al. 2012). Reliability value in the present study was high (α = .95). In accord with DSM-5 PTSD symptom classification, we classified individuals with “probable CB-PTSD” symptoms if they endorsed at least one intrusion item, one avoidance, two alterations in cognitions and mood, and two items of reactivity and hyperarousal, with at least moderate severity indicative for symptom endorsement.

General distress following childbirth (i.e., postpartum distress) was measured by the widely used Brief Symptom Inventory (BSI) which has evidenced adequate reliability along with concurrent and convergent validity (Derogatis 1993), and has been previously used to assess postpartum conditions (Orun et al. 2013; Ross et al. 2003). This self-report measure targets 53 psychiatric symptoms (e.g., depression, obsessive compulsive, panic) and offers a global (symptom) severity index (GSI) score. The frequency of each symptom endorsed over the last seven days is rated on a 5-point Likert scale ranging from 0 to 4 (not at all to extremely). Reliability for the total score was high (α = .98).

Depression symptoms following childbirth (i.e., postpartum depression) were measured via the depression subscale of the Brief Symptom Inventory (BSI), which has been previously used to assess depression in postpartum samples (Horowitz et al. 1996; Ross et al. 2003). In this study, reliability for the 6-item scale was high (α = .92). We used the suggested cutoff score of .73 to identify women with clinically significant depression symptoms (Boulet and Boss 1991). While not customized for diagnostic purposes, sensitivity and specificity of the depression scale is similar to those obtained by diagnostic interviews (Peveler and Fairburn 1990).

Peritraumatic (acute) reactions to childbirth occurring during or immediately after childbirth pertained to distress and dissociation. The reactions were assessed using the well validated Peritraumatic Distress Inventory (PDI) (Brunet et al. 2001) and Peritraumatic Dissociative Experiences Questionnaire (PDEQ) (Marmar et al. 1997), both which were anchored to “the most recent childbirth”. The PDI is a 13-item self-report measure to assess distress surrounding the event on a scale ranging from 0 (not at all) to 4 (extremely true) (e.g., feeling “guilty”, “helpless”) and has been used to assess childbirth-related distress (Boudou et al. 2007). The PDI has been shown to have good psychometrics (Brunet et al. 2001) and reliability in this study was high (α = .89). The PDEQ is a 10-item self-report measure of acute dissociative response to the traumatic event on a scale ranging from 0 (not at all) to 4 (extremely true) (e.g., “I felt as though I was watching what was happening to me”; “What was happening seemed unreal to me”). It has been used to assess childbirth-related dissociation (Boudou et al. 2007; Choi and Seng 2016) and has previously produced high reliability and adequate validity (Birmes et al. 2005; Bui et al. 2011). Reliability value in this study was high (α = .91). We also included two single items to assess overall appraisal of childbirth pertaining to sense of fear and danger (“Did you feel highly distressed or fearful during or immediately after the delivery?” and “Did you feel you were or your baby was in danger during or immediately after the delivery?”) rated on a 0 (not at all) to 4 (extremely) scale.

Trauma exposure history was assessed with the commonly used Life Events Checklist for DSM-5 (LEC-5) (Weathers et al. 2013), a 17-item self-report measure of level of exposure to potentially traumatic events. The measure includes 16 pre-defined categories of events and one item noted as “other event” of various levels of exposure on a 6-point nominal scale. The LEC-5 is considered a valid standalone measure of trauma (Gray et al. 2004). Reliability in the current study was adequate (α = .86).

Childbirth-related and demographic information was assessed via single items designed for the purpose of this study. Items relevant for the current study include age, education level (ordinal scale ranging from elementary to doctoral degree), primiparity, and experiencing obstetric complications during childbirth (i.e., from labor until birth completion) (Yes vs. No). We also asked about previous childbirth-related trauma (i.e. miscarriage, stillbirth, prematurity) rated by the number of events endorsed, and pre-childbirth mental health problems (i.e. endorsement of PTSD and depression before childbirth) based on a binary response (Yes vs. No).

Statistical Analysis

Overall, 8.6% of the data were missing. 99.4% had 1 to 20 items missing (Mdn = 4 items) and 0.6% of the sample had complete data in all variables. Little’s Missing Completely At Random (MCAR) test had indicated that the data were missing completely at random, χ2(2654) = 1642.80, p = 1.00. To handle missing data, we subsequently used Multiple Imputation (Rubin 2009).

To examine rates of CB-PTSD, postpartum depression, and comorbid CB-PTSD and postpartum depression symptoms by the childbirth experience, we compared between at-term deliveries with healthy baby outcomes and complicated deliveries (e.g., pre-term delivery, medical complication in newborn).

To examine whether postpartum depression is a cluster of probable CB-PTSD or a distinct condition, we conducted an exploratory factor analysis (with maximum likelihood) in which we explored the factor matrix of the CB-PTSD symptom clusters (in accord with DSM-5 symptom criteria for PTSD) and postpartum depression symptoms. We then conducted another factor analysis excluding for four CB-PTSD symptoms (sleep problems, irritability, concentration difficulty, and anhedonia) to examine the relationship between CB-PTSD and postpartum depression symptoms accounting for possible overlapping symptoms (Elhai et al. 2011).

To examine whether the same or different factors are implicated in the likelihood of developing probable CB-PTSD and comorbid postpartum depression in comparison to only CB-PTSD, only postpartum depression, or no CB-PTSD or postpartum depression, we conducted a backward stepwise multi-nominal regression analysis. The CB-PTSD and depression comorbidity group was the outcome variable. Predictors in the analysis were primiparity, maternal age, level of education, pre-childbirth mental health problems, history of childbirth trauma, history of non-childbirth-related trauma, obstetric complications in childbirth, emergency cesarean (yes, no), peritraumatic dissociation and distress related to childbirth, sense of danger and distress in childbirth, pain in labor and delivery, sleep deprivation prior to delivery, duration of childbirth, newborn health complications (i.e., prematurity resulting with NICU admission), and current general postpartum distress and PTSD not related to childbirth.

Results

Childbirth-related PTSD, postpartum depression, and comorbidity rates

18% (n = 122) of participants were classified as probable CB-PTSD and 14 met CB-PTSD symptoms criteria as early as less than four weeks post-delivery, indicating endorsement of acute traumatic stress. Of those with CB-PTSD/acute stress, 19% (26 out of 136) reported PTSD symptoms before childbirth. 57% (n = 391) of the sample had elevated postpartum depression symptoms. Of those with postpartum depression, 33% (130 out of 391) reported depressive symptoms before childbirth.

Importantly, as much as 90% (123 out of 136) of those classified with CB-PTSD had also experienced elevated postpartum depression symptoms while a third (123 out of 391) of those classified with postpartum depression had also experienced CB-PTSD. There were no differences among study nationality groups in CB-PTSD or comorbidity rates. Group differed however in rates of postpartum depression, χ2(7) = 17.87, p = 0.04, with Middle Eastern and Asian women reporting the highest rates (78% and 85%, respectively). Table 2 further shows differences in rates of CB-PTSD, postpartum depression, and comorbid symptoms between women who delivered at-term healthy babies and those who did not. As can be seen, the likelihood for suffering from comorbid symptoms was higher following preterm delivery.

Table 2.

Childbirth-related PTSD and postpartum depression rates by childbirth experience

Complications Healthy RR (95% CI)
None 29.2% 44.2%
Depression only 41.0% 38.6% 1.47 (1.03 2.11)
CB-PTSD only 3.5% 1.5% 2.57 (1.23 5.40)
CB-PTSD+Depression comorbidity 26.4% 15.7% 2.07 (1.41 3.04)
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Note. Complications = preterm delivery, medical complication in the newborn and/or newborn admission to the intensive neonatal care unit (NICU). Healthy = delivery at term with healthy newborn outcomes. CB-PTSD= childbirth-related posttraumatic stress disorder. Depression = depression following childbirth; RR = relative risk as compared to the none group; 95% CI = 95% confidence interval

Is postpartum depression a cluster of childbirth-related PTSD or a distinct condition?

A factor analysis examining the relationship between CB-PTSD and postpartum depression symptoms revealed one cohesive factor. This factor explained 72.30% of the variance (eigenvalue = 3.62), on which all of the CB-PTSD symptom clusters and postpartum depression symptoms were loaded: depression (.83), re-experiencing (.71), avoidance (.68), negative thoughts and feelings (.97), and hyper-arousal (.82). In fact, the loading of depression was the second highest. A second factor analysis excluding overlapping symptoms (i.e., sleep difficulty, irritability, concentration difficulty, and anhedonia) also revealed one cohesive factor. This factor explained 67.66% of the variance (eigenvalue = 3.38), on which all of the CB-PTSD symptom clusters and postpartum depression symptoms were loaded: depression (.78), re-experiencing (.74), avoidance (.71), negative thoughts and feelings (.96), and hyper-arousal (.65). The loading of depression remained the second highest.

Is the likelihood of childbirth-related PTSD and postpartum depression comorbidity predicted by different or same factors as childbirth-related PTSD or postpartum depression alone?

The multi-nominal regression analysis revealed several predictors for the likelihood of developing CB-PTSD and depression comorbidity as compared with only CB-PTSD, only postpartum depression, or no disorder (i.e., no CB-PTSD or depression). Results of the reduced model are presented in Table 3.

Table 3.

Multi-nominal regression coefficients for predicting the likelihood for postpartum PTSD and postpartum depression comorbidity

Comorbidity vs. None Comorbidity vs. PP-depression Comorbidity vs. PP-PTSD
b OR b OR b OR
Newborn complications −0.78 0.46 0.42 1.52 0.23 1.26
Primiparity 0.13 1.14 −0.92**b 2.51 1.06 2.89
Age of mother −0.13**a 1.14 0.02 1.02 0.15 1.16
Level of education −0.42 0.66 −0.04 0.97 0.18 1.20
Pre-childbirth mental health problems −1.35** 0.26 −0 82* 0.44 −0.08 0.92
History of childbirth trauma 0.35 1.42 0.29 1.34 −1.57* 0.21
History of non-childbirth trauma 0.01 1.01 −0.03 0.98 0.09 1.09
Obstetric complications in childbirth −0.19 0.83 −0.72* 0.49 0.04 1.04
Duration of childbirth −0.02** 0.98 −0.03*** 0.97 −0.01 0.99
Emergency cesarean −1.24* 0.29 −0.86* 0.42 −0.31 0.73
Peritraumatic distress −0.46* 0.63 −0.68*** 0.51 −0.23 0.80
Postpartum general distress −7 54*** 0.01 −1.31*** 0.27 −4 27*** 0.01
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Note. Complication group = childbirth-related infant health complications resulting in NICU admission. PP = postpartum. OR = odd ratios. Comorbidity PTSD + depression served as the reference group (coded 0) and thus negative coefficients relate to higher likelihood for comorbidity.

a

= refers to younger age and higher likelihood for comorbidity

b

= refers to not being primiparous and higher likelihood for comorbidity.

***

p < .001

The analysis indicated that compared to no disorder, the likelihood for CB-PTSD and depression comorbidity is increased if a mother is younger, has pre-childbirth mental health problems, has withstood longer duration of childbirth, has an emergency cesarean, higher peritraumatic distress, and higher postpartum general distress. The likelihood for comorbidity is increased in comparison to only postpartum depression if the mother is not primiparous, has pre-childbirth mental health problems, obstetric complications in childbirth, has withstood longer duration of childbirth, has an emergency cesarean, higher peritraumatic distress, and has higher postpartum general distress. Finally, the likelihood for comorbidity is increased in comparison to only CB-PTSD if a mother has a history of childbirth trauma and higher postpartum general distress.

Discussion

Two opposing views can explain the endorsement of PTSD along with depression symptoms following childbirth. Comorbidity may reflect overlapping symptoms due to symptom classification. If this is the case, then effective treatment for one condition should also help in reducing the other condition (Flory and Yehuda 2015). An alternative view is that comorbidity signifies a distinct phenotype and reflects a fundamental dimension of psychopathology (Flory and Yehuda 2015), possibly separated from postpartum depression. If this is the case, women receiving treatment targeting depression may not fully benefit when the presentation includes PTSD symptomatology. Our study is the first to examine the nature of the comorbid childbirth-related PTSD and postpartum depression condition in a large postpartum sample in the first months following childbirth.

The main findings reveal a one factor model of CB-PTSD and postpartum depression symptoms, even after removing overlapping symptoms. Our findings demonstrate that in cases where CB-PTSD and postpartum depression co-occur in the early postpartum period, these conditions appear indistinguishable. A single factor presentation accords with previous work in non-postpartum samples (Dekel et al. 2014; Elhai et al. 2011; O’Donnell et al. 2004).

The co-occurrence of CB-PTSD and depression in the postpartum period is not an exception, but rather common. In the present study, although a significant number of mothers had elevated depression, the vast majority of women classified with CB-PTSD also experienced postpartum depression symptoms regardless of the child stressor (with or without medical complications in the child). The risk for suffering from co-morbid symptoms following pre-term delivers increased by twofold, suggesting that a posttraumatic stress-depressive response is associated with the magnitude of the childbirth stressors.

Distinguished risk factors suggest that two conditions are distinct. Accordingly, our findings further suggest that CB-PTSD and postpartum depression co-occurrence reflect a postpartum condition that is distinguished from postpartum depression alone not only in terms of symptom severity. We found that the comorbid condition is associated with a different combination of risk variables than depression alone. Unlike depression alone, stressors concerning the childbirth event were predictive of the comorbid expression, This in turn would suggest that when postpartum depression is accompanied with CB-PTSD, the depressive symptoms are evoked by a traumatic childbirth experience.

Traumatic childbirth correlates of comorbid CB-PTSD and depression in this sample include objective and subjective stressors not only such as obstetrics complications in labor and delivery and emergency cesarean, but also the woman’s negative appraisal of the birth. Not surprisingly, it has been documented that subjective trauma exposure is a strong factor in predicting posttraumatic stress above and beyond the objective magnitude of the stressor (Dekel and Bonanno 2013; Ozer et al. 2003).

We found less differentiation between the factors implicated in CB-PTSD and postpartum depression comorbidity in comparison to CB-PTSD alone. Distinct conditions may share identical risk factors. Thus, our findings, which appear to suggest similar factors predicting the two conditions, do not justify concluding that the conditions are the same. Evidence in non-postpartum samples shows distinct biological hypothalamic-pituitary adrenocortical axis (HPA) and amygdala activity profile in individuals endorsing PTSD and depression in comparison to those with only PTSD (Dekel et al. 2017a; Kemp et al. 2007). This in turn may suggest that the two conditions are different and do not merely differ in severity, warranting future research on the physiological correlates of comorbid CB-PTSD and postpartum depression to establish whether the conditions are in fact different.

Several limitations in this study should be noted. The cross-sectional nature of the study does not allow clear-cut cause and effect conclusions. We obtained a single assessment with no follow-ups, hence, we cannot make conclusions about the long-term manifestation of symptoms CB-PTSD and depression. We measured CB-PTSD and depression symptoms with well-validated self-report measures but did not include a clinical assessment for these conditions. Obstetric-related information was also obtained by self-reporting, which may be affected by maternal mental state. Measures such as duration of childbirth may reflect perception of the birth experience. Ideally, assessment would integrate subjective and more objective measures of the childbirth experience and information concerning the various stressors of birth, including the influence of the obstetrics team on women’s birth experience. Whilst cross-sectional studies are useful for research at its early stage, longitudinal studies are needed to establish the temporal course of the various postpartum conditions and include baseline assessments of women’s mental health prior to childbirth. Our sample, though large in size, was based on a self-selected Internet sample. Incidences of postpartum psychiatric symptoms are likely to be higher than in community samples, and the final sample may differ from the sample of women approached. The international nature of the study-which involves an unbalanced representation of women from various nationalities-may limit generalization of the findings. A future study should involve a more balanced representation of women from different nationalities.

In summary, this study demonstrates that comorbid PTSD and depression following childbirth may best be conceptualized as a single posttraumatic stress-depressive response. As childbirth-related PTSD symptoms are largely neglected in routine screening for postpartum depression, future efforts should address the recognition and treatment of posttraumatic symptoms in postpartum women reporting depression. This opens avenues for developing specified preventive treatments for the indication of PTSD accompanied with depression following childbirth as well as PTSD alone. A broader screening of psychiatric symptoms may help remedy missed diagnosis of maternal CB-PTSD. Our findings underscore the complexity of postpartum mental health disorders classification and clearly warrant more research to disentangle the various postpartum psychopathologies beyond postpartum depression.

Acknowledgments

The authors would like to thank Ms. Shannon Hennig for her generous support in initiating this research project. We also would like to thank Sabrina Chan for assisting with manuscript editing.

Informed consent: This study entailed an anonymous online survey and no personal identifiable information was collected. Participants were informed that by agreeing to complete the study survey, they are implying their consent to participate in the study.

Footnotes

Conflict of Interest: Sharon Dekel, Tsachi Ein-Dor, Gabriella Dishy and Philip Mayopoulos declare that they have no conflict of interest.

Compliance with Ethical Standards

Ethical approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Partners (Massachusetts General Hospital) Human Research Committee granted this study exemption.

Publisher's Disclaimer: This Author Accepted Manuscript is a PDF file of a an unedited peer-reviewed manuscript that has been accepted for publication but has not been copyedited or corrected. The official version of record that is published in the journal is kept up to date and so may therefore differ from this version.

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