Establishing the validity of a diagnostic questionnaire for childbirth-related posttraumatic stress disorder

Abstract

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 post-traumatic stress disorder (PTSD). Postpartum PTSD, or childbirth-related PTSD, can become an enduring and debilitating condition. At present, validated tools for a rapid and efficient screen for childbirth-related PTSD are lacking. We examined the diagnostic validity of the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 (PCL-5) for detecting PTSD in women who have had a traumatic childbirth. The PCL-5 assesses the 20 DSM-5 PTSD symptoms and is a commonly used patient-administrated screening instrument. Its diagnostic accuracy in regard to childbirth-related PTSD is unknown. The sample included 59 patients who reported a traumatic childbirth experience. A traumatic childbirth was determined in accordance with the DSM-5 PTSD Criterion A for exposure involving threat or potential threat to the life of the mother or infant, experienced or perceived, or physical injury. The majority (66%) were less than 1 year postpartum (for full sample: median = 4.67 months; mean = 1.5 years) recruited via Mass General Brigham's online platform or during postpartum unit hospitalization/ after discharge. Patients were instructed to complete the PCL-5 concerning PTSD symptoms related to childbirth. Other co-morbid conditions (i.e., depression and anxiety) were also assessed. They also underwent a clinician interview for PTSD using the gold-standard, Clinician-Administered PTSD Scale for DSM-5 (CAPS-5). A second administration of the Checklist was performed in a sub-group (n = 43), altogether allowing for an assessment of internal consistency, test-retest reliability, and convergent and diagnostic validity of the PCL-5. Diagnostic accuracy of the PCL-5 in reference to the CAPS-5 was determined using the Receiver Operating Characteristic (ROC) area under curve (AUC); an optimal cutoff score was identified with Youden's J index. One-third of the sample (35.59%) met DSM-5 criteria for a PTSD diagnosis stemming from childbirth. The PCL-5 symptom severity score was strongly correlated with the CAPS-5 total score (ρ = 0.82, p < 0.001). The AUC was 0.93 (95% CI: 0.87-0.99), indicating excellent diagnostic performance of the PCL-5. A cutoff value of 28 maximized sensitivity (0.81) and specificity (0.90), and correctly diagnosed 86.44% of women. A higher value (32) identified individuals with more severe PTSD symptoms (specificity, 0.95), but with lower sensitivity (0.62). PCL-5 scores were stable over time (intraclass correlation coefficient, ICC = 0.73), indicating good test-retest reliability. PCL-5 scores were moderately correlated with depression and anxiety symptom scores (Edinburgh Postnatal Depression Scale, EPDS, ρ = 0.58, p < 0.001) and Brief Symptom Inventory (BSI, anxiety sub-scale, ρ = 0.51, p < 0.001). This study demonstrates the validity of the PCL-5 as a screen for PTSD among women who had a traumatic childbirth experience. The instrument may facilitate screening for childbirth-related PTSD on a large scale and help to identify women who might benefit from further diagnostics and services. Replication of findings in large postpartum samples is needed.