In this study, the prevalence of PTSD at one, two and six months postpartum, was 2.7% (n = 6), 0.9% (n = 2) and 0.5% (n = 1), respectively and the overall prevalence was 3.6%. These are comparable to the prevalence rates of most of the studies done in other countries. Several cross-sectional studies, including those conducted in Iran and Nigeria, have found that the prevalence of postpartum PTSD after one month of delivery was in the range of 1.2–9.4% (4). A meta-analysis including 50 studies (N = 21, 429) from 15 countries studying PTSD symptoms in postpartum mothers showed a global prevalence of 3.17% at one month postpartum, which is compatible with the findings of this study (6).
A Serbian study which was conducted using a scale which is different to the tool used in this study, the Clinician-Administered PTSD Scale (CAPS), also supports similar rates of postpartum PTSD at the first month which was 2.4% (10). However, the same study found that 9.5% of the mothers had a clinically significant level of disabling PTSD symptoms (partial PTSD), which was not amounting to the full disorder. Moreover, at the second and the third months postpartum, the prevalence of partial PTSD 5.9% and 1.3%, respectively, while none of the participants had full PTSD (10). Symptoms of partial PTSD were not analyzed in our study, as the validated tool used did not categorize them specifically. However, the pattern found in the Serbian study is similar to our study, as rates of full PTSD was seen to follow a declining trend with time (at two and six months, prevalence of PTSD being 0.9% and 0.5%, respectively) suggesting a probable self-limiting natural course of the condition over time.
Various studies have found different prevalence rates. A two staged study conducted in the USA, using the same tool used in this study, the PTSD Symptom Scale-Self Report (PSS-SR), found a higher prevalence of postpartum PTSD of 9% after 1 month, while 18% experienced high levels of post-traumatic symptoms (partial postpartum PTSD) (9). Another cross sectional study done in a fetal high-risk maternity hospital in the city of Rio de Janeiro, Brazil, using a different tool, the “Stress Disorder Checklist; PCL-C”, found a higher prevalence (9.4%) of post-partum PTSD (10). Socio-cultural differences between the two countries may have played a role in these observed differences of prevalence. The study done in Brazil included a selected high-risk population for postpartum PTSD (mothers with pregnancy complications and high fetal risk).
Some studies demonstrate a lower prevalence compared to this study. A Dutch study (11) involving 428 women shows a prevalence of 1.2%. A Swedish study of 1640 postpartum mothers, that used the Traumatic Event Scale (TES), shows a prevalence of PTSD of 1.7%. (12). Socio-cultural factors, levels of obstetric care and the usage of different scales may play a role in these observed differences.
In our study, only two significant associations with postpartum PTSD were demonstrate; Verbal abuse during labour (p = 0.04) and presence of Postpartum Depression (PPD) (P = < 0.001). There are several studies and a meta-analysis in favor of the presence of PPD being a well-documented risk factor for postpartum PTSD (5–7, 12). In contrast, very few studies had specifically looked into the effect of verbal abuse during labour on the development of PTSD (4).
According to studies worldwide, several factors associated with the development of PTSD following childbirth have been identified. Among the known pre-pregnancy associated factors, low educational level (14), unplanned pregnancy (9),fear of child birth (6), family history of mental disease (6), nulliparity (12) or three or more previous births (10) were not found to be significantly associated with postpartum PTSD in our study.
Intra-pregnancy factors associated with postpartum PTSD include gestational age at delivery (14), number of antenatal care visits (14), poor health or complications in pregnancy (6), hospital admission due to pregnancy complications [OR 11.86 (95% CI: 6.36–22.10)] (15), increased fear of childbirth (10), higher expected intensity of pain (10) and intimate partner violence (10). However, none of these factors showed a significant association with postpartum PTSD in our study.
Documented intra-partum factors associated with postpartum PTSD are, duration of labour (14), mode of delivery (14), negative subjective birth experiences (6), having an operative birth (operative vaginal or caesarean section) (6, 15), lack of support (6) and poor maternal experience of control during childbirth [OR 5.05(95% CI: 2.69–9.48)] (15). However, none of these factors were significantly associated with PTSD in our study.
Among documented postpartum factors found to be associated with postpartum PTSD are poor neonatal outcome (10), low neonatal APGAR Score at delivery (7), neonatal and maternal intensive care (5), birth defects (4), lack of support from family and partner (6, 9), postpartum physical problems (9), lack of exclusive breast feeding at one month (9) and not having an opportunity to discuss concerns with health care staff about mental wellbeing (9). In our study, none of these associations reached the level of significance. Possible reasons for the lack of association may be the total sample size and number of mothers with postpartum PTSD being lesser than expected.
Being a small sample size, there is a limitation in generalizing these results to the entire population of the country where social and economic backgrounds might differ. Since this is a cross sectional study, it is difficult to establish the exact temporal relationships between the associated factors (e.g. when PPD and PTSD both present at the time of data collection, it is uncertain which developed earlier). Partial PTSD patients were not analyzed since the validated study instrument used did not specifically categorize them.