Assessment and screening tools for childbirth-related psychological trauma in nursing practice – A systematic review

While more than 4 children are born every second in the world (140 million per year), almost a third of these childbirths are described as traumatic experiences by mothers [1]. Every year, 3.1–6.3% of mothers are affected by post-partum post-traumatic stress disorder [2‐4]. This rate can rise 15.7–18.9% in women with high-risk factors [2‐4]. A better screening and management of this disorder are therefore major public health issues on an international level. Childbirth-related post-traumatic stress disorder (PTSD) is manifested by recurrent memories of the traumatic event, avoidance of related stimuli and high levels of stress, and can often be accompanied by depression and anxiety. This disorder has repercussions on interpersonal relationships, on the father’s experience, on the reception of the newborn and then on the mother-child bond, and creates apprehension about future pregnancies [5]. Despite its prevalence and significant impact, childbirth-related PTSD is frequently under-diagnosed in maternity wards. Psychological suffering related to childbirth, unlike physical suffering, remains under-recognized, underscoring the need for a better detection and management [6].

These figures are part of a context marked by significant concerns within the international community, as evidenced by the World Health Organization recommendations from 2018 on intrapartum care for a positive childbirth experience, as well as various UN resolutions on maternal health and preventable maternal mortality and morbidity [7, 8]. This reflects a collective awareness of the importance of women’s health in the perinatal period. The intensified screening and management of a mental health disorder with such a high prevalence during the perinatal period inevitably require substantial human and material resources, which are not always available. However, many healthcare systems face high hospital pressure everywhere in the world [9, 10]. As an example, the OECD countries report an average of 3.6 medical doctors per 1,000 inhabitants and nearly 9 nurses per 1,000 inhabitants, underscoring the importance of prioritizing paramedical staff in addressing healthcare gaps, particularly in screening, prevention, and patient referral efforts [9‐11]. This reality underscores the practical challenges that healthcare professionals encounter in the effective implementation of screening and intervention strategies with these types of tools. This highlights the urgent need to adapt health policies to fully harness the potential of paramedical professionals in adressing unmet healthcare needs. Nurses and advanced practice nurses (APNs), with their accessibility and close proximity to patients, represent a significant resource for tacking mental health challenges during the perinatal period. Expanded nursing skills in assessment, screening, prevention, and research provide an additional opportunity to identify and support mental health disorders related to the perinatal period.

In this context characterized by a high prevalence of these disorders and a high attention to the quality of obstetrical care, nurses and APNs, whose practice is evidence-based, will be responsible for screening these disorders using reliable and validated assessment tools. Additionally, they are going to have a key role in promoting research on this subject.

Thus, this systematic review aims to assess and compare the psychometric properties of screening and assessment tools for birth-related psychotrauma. Its goal is to offer validated solutions intended for use in both clinical practice and research by perinatal child psychiatric nurses and APNs.

This work was exclusively conducted via the PubMed database. Five additional databases were queried (PubMed, Scopus, CINAHL, MEDLINE, HAL, Web of Science), but did not yield additional content. A PRISMA methodology for systematic literature review (Page et al., 2021) was employed in this work. Database searches were conducted between April 2023 and July 2023.The literature review was conducted with the aim of addressing the following research question: “Which assessment and screening tools for birth-related psychological traumas offer perspectives for clinical practice and research in perinatal mental health?“.

Our results revealed high internal reliability for all assessment tools examined in this review depending on the studies and instruments (Cronbach’s alpha coefficients ranging between 0.84 and 0.93). These results are very encouraging when compared to those of other well-known scales such as the HAD scale (Cronbach 0.83) [20, 21].

The employed methodology was consistent, facilitating a comparison among these three tools. It is noteworthy that the sample sizes for the studies involving these three instruments are relatively substantial, ranging from N = 142 to N = 705.

Interestingly, the mode of data collection, whether online or in-person, did not impact the Cronbach’s alpha results. This gives these tools great potential for daily clinical use, especially considering the increasing use of smartphone apps in various health fields, such as suicide risk prevention [22].

However, among these scales, the TES stands out as it has only been the subject of one study aimed at validation. Furthermore, this study is limited in its alignment with another measure of psychotrauma, thereby constraining its robustness. On the other hand, both the PPQ and the City BiTS demonstrated good convergent validity with other psychotrauma measurement tools.

This review highlighted the significance of specific screening tools for postpartum PTSD, a critical yet often overlooked area in perinatal mental healthcare. Advanced practice nurses, responsible for conducting psychiatric assessments and guiding patient care, are ideally positioned to integrate these tools into their practice and raise awareness among nursing teams involved in supporting families during the postpartum period.

According to the latest research findings, the City BiTS emerges as the tool with the most comprehensive validation, with the PPQ and the TES following closely behind. This pattern instills confidence in the efficacy of City BiTS for various applications.

Furthermore, the Cith BiTS is built upon DSM-5 criteria, making it the most appropriate for both research and clinical practice, in alignment with current diagnostic standards. It additionally provides the capability to distinguish between general symptoms and those specifically associated with childbirth, utilizing its two subscales. This feature proves particularly valuable for conducting differential diagnoses [23]. Furthermore, the City BiTS is presently undergoing translation or testing in 14 different languages, with a dedicated version designed for partners of mothers, thereby significantly expanding its reach and applicability [24]. This multilingual translation facilitates standardized assessments in countries experiencing high rates of migration [25]. Refugee women are recognized as being at higher risk for various obstetric complications, thereby increasing the likelihood of birth-related psychological trauma [26]. Moreover, the City BiTS is a free tool, available in open access on the City University’s website [23] (Fig. 2).

These screening tools are very useful in identifying women who could benefit from early interventions to prevent the escalation of postpartum PTSD symptoms and their impact on their infants. They respond to a significant health issue, given the notable prevalence of postpartum PTSD. Research by Handelzalts and Hairston et al. has demonstrated the negative impact of postpartum PTSD on the quality of the mother-baby relationship [27, 28]. The interactive involvement in a child’s development, as evidenced by neuroscience, necessitates maternal availability to avoid neurodevelopmental disorders, which is hindered by maternal distress [29]. Therefore, an early screening initiative for postpartum PTSD among mothers by an advanced practice nurse using one of these tools, is an effective primary preventive strategy against potential child developmental disorders. These measurement instruments perfectly integrate into the clinical practice of nursing in maternity and perinatal cares, particularly through the early detection of traumatic symptoms. Such screenings are essential for timely referrals to perinatal psychiatry services, facilitating early interventions that support both mother and newborn. These tools could be applied during routine postnatal visits, a critical window for detecting psychological trauma and providing adapted care. They facilitate the precise identification and assessment of the traumatic impact of childbirth on parents, with a high acceptability rate [18]. Serving as excellent secondary prevention tools for mothers postpartum, and primary prevention tools for newborns, they could effectively mitigate the impact of parental mental health issues on early development by using efficient early interventions [30‐34].

In the research field, they are recognized to be effective measurement tools providing precise and objective data, particularly for working on research projects aiming to identify risk factors, assess the effectiveness of care modalities, or evaluate the consequences of traumatic childbirth on the mental well-being of parents, and the impact of parental relational withdrawal secondary to psychological trauma on the neurodevelopment of the newborn. All this data could contribute to improving the psychological support for women and their babies during the perinatal period by creating innovative and effective care modalities.

There already are several studies in the scientific literature offering interesting perspectives about the evolution of perinatal care practices by identifying risk factors or consequences of birth-related PTSD or by assessing some care interventions [30‐34]. For example, some risk factors for postpartum PTSD were identified using the three assessment tools observed in this review [35‐43]. The City BiTS data shows that 18% of women consider their childbirth as traumatic [35]. However, there seems to be a decline in this figure’s occurrence between 1 week and 6 weeks postpartum [40]. Conducting research to pinpoint the level of spontaneous resolution or stabilization of the disorder over a more extended period would offer insights into the optimal timing or frequency for screening and monitoring these symptoms in clinical practice. Additionally, City BiTS has identified a significant comorbidity between “general symptoms” and “birth-related symptoms” of postpartum PTSD as well as depression symptoms [36]. These scales, valuable in comprehending, detecting, and addressing birth-related psychological trauma, identify several risk factors associated with postpartum PTSD, such as obstetric complications like emergency cesarean sections, hemorrhages, and various other complications. They also demonstrate a significant correlation among themselves, identifying both risk and protective factors [17, 35‐42] (Supplementary Table 1). It has shed light on the relative impact of epidural anesthesia on postpartum PTSD, as no association was found between epidural analgesia and postpartum PTSD [37]. In addition to conduct screening actions, these tools could enhance best practice recommendations, thereby empowering clinicians in their therapeutic decisions [7]. So far, these tools have shown the effectiveness of some interventions for birth-related psychological trauma. For instance, interventions aimed at improving perceptions of control, expressive writing intervention, the “Promoting Mothers’ Ability to Communicate” program, the use of EMDR, or even guided online CBT could be beneficial in preventing and/or minimizing birth-related PTSD [30‐34]. Some of these studies offer promising perspectives in managing and supporting individuals with this type of disorder (Supplementary material Table 2).

Finally, the City BiTS and PPQ have helped identify the consequences of birth-related psychological trauma on mothers and their children (Supplementary material Table 3). General symptoms of postpartum PTSD and depression are determining factors influencing the impact of adult attachment styles on the mother-child relationship [27]. Indeed, there’s an alteration in the mother-child bond with feelings of rejection and/or anger directed towards the infant among mothers displaying an avoidant attachment style, intensified by postpartum PTSD [28]. Additionally, there are negative emotions and perceptions related to childbirth, and less active participation during childbirth among women with a high PPQ score [43]. This underscores the significance of employing these tools in preventing neurodevelopmental disorders in newborns linked to maternal psychological unavailability stemming from maternal distress [29]. However, the symptoms specific to birth-related trauma from the City BiTS subscale do not seem to affect the mother-child relationship, unlike the mother’s adult attachment style, which has a significant impact on it [27].

Screening tools for birth-related psychological trauma offer numerous perspectives for investigation in both research and clinical practice. They improve nurses’ practices by supplying validated and pertinent screening tools for identifying and preventing postpartum PTSD. This review emphasizes the significant importance of this screening in supporting parents and their babies during the postpartum period. These tools offer promising avenues for research and screening in this field.