Interpretation
The incidence of PTSD following traumatic childbirth varied in different
countries. Two studies[31,32] reported that in the
resource-poor countries, women of reproductive age typically have
socioeconomic and health challenges that interplay in mutually
reinforcing ways, and indeed the incidence of common perinatal mental
disorders in low-income and lower-middle-income countries were higher
than in high-income countries[33]. According to
this systematic review, a subgroup analysis for different countries, the
incidence of PTSD following traumatic childbirth in Asia was highest,
including in Turkey[22]and in
Iran[25]; meta-regression analysis also indicated
that Asia was different from other countries such as
Europe[23,24,26],
Oceania[27,30], and North
America[28,29] in the incidence of PTSD following
traumatic childbirth. One study[34] has found that
a PTSD development was associated with childbirth in a non-western
culture, which may be related to the economic development, cultural
background, and medical level of different countries in the treatment of
postpartum women.
Currently, there are no specific assessment tools for screening for
traumatic birth. A review [35]reported that most
studies were based on the DSM-A criterion, while a few were based on
self-report from postpartum women. Therefore, this study conducted a
subgroup analysis to determine the impact of the two different types of
assessment tools on the incidence of PTSD in postpartum women after a
traumatic birth. The result found that the incidence of screening using
the DSM-A was higher than self-report. An RCT has shown that the
assessment scale based on DSM-A criterion was validated by psychiatrists
for effectiveness in screening for traumatic birth and compatibility
with the definition of traumatic birth[36].
Moghadam et al [37] also confirmed the rationality
and validity of this scale. However, compared with the self-report,
participants were only asked whether they would describe their birth as
traumatic (yes/no) [25,27,30], lacking reliability
and effectiveness. Therefore, it is considered that based on DSM-A
assessment scale is more stringent for screening traumatic childbirth,
and the included participants are more likely to develop postpartum
PTSD.
Two types of PTSD assessment scales, including structured interview
diagnostic scales and self-assessment scales are widely used in the
world and have good reliability and validity. In this systematic review
of subgroup analysis, we found that different assessment tools for
postpartum PTSD women after traumatic childbirth could develop different
incidences. However, meta-regression analysis did not show that the
difference in assessment tools for postpartum PTSD were the source of
heterogeneity. A previous systematic review[18]has shown that the impact of measurement type on postnatal PTSD rate
estimates was not detectable, and Grekin et al[38]have indicated that differences in incidence were not found between
studies that used self-report and clinical assessment measures to
diagnose PTSD. These results should be treated with a degree of caution.
This may be since above half of included studies used self-assessment
scales[22-24,27-30] to assess PTSD symptoms, so
making it difficult to reveal differences between the two methods, which
is an limitation of the current research. Therefore, further research
should target the evaluation effects of different assessment scales on
postpartum PTSD.
Although lacking reliable evidence of significant changes between the
incidence of postpartum PTSD after traumatic birth and assessment tools,
the incidence at different time points might provide some insights into
the course of postpartum PTSD.
In this study, we also found that the PTSD rate was highest in
postpartum 1-4months and the incidence declined gradually over time,
which coincided with a systematic review by
Dikmen-Yildiz[18]. While, Andersen et
al[39] has reported that the incidence of PTSD was
1.3% - 2.4% at 1-2 months postpartum and 0.9% - 4.6% at 3 - 12
months postpartum, suggesting that the rate of PTSD increase gradually
over time. Thus, it can be considered that there are certain differences
in the results of measuring the incidence of postpartum PTSD at
different time points. However, the results on the relationship between
several key time points and PTSD incidence are different. This might be
related to differences in participants and study sites, or during
postpartum PTSD, part of women might develop acute PTSD symptoms (3
months postpartum), delayed PTSD symptoms (6 months postpartum), or
self-healing.
From this systematic review, due to the limited number of studies
included in the measurement of PTSD at 1-4 and 1-12 months postpartum,
we were short of sufficient evidence to support its relationship with
the rate of postpartum PTSD. Hence, this result should be critically
treated. Meanwhile, the relationship between the rate of postpartum PTSD
and the evaluation time points should be further researched to provide a
basis for the subsequent measurement of postpartum PTSD. In addition,
the evaluation time of traumatic birth was the same as PTSD, and it was
not analyzed in this systematic review. However, previous
studies[40,41] also have shown that the evaluation
time of traumatic birth should be measured within 48h or 72h after birth
to avoid retrospective bias that results from a too long time.
This systematic review demonstrated that postpartum women whose babies
were hospitalized in NICU (neonatal intensive care unit) had the highest
incidence of PTSD. However, the evidence recommendation grade of this
result was not sufficient to support those postpartum women whose babies
were hospitalized in NICU had the greatest influence on the rate of PTSD
because only one study[29] was included in the
subgroup analysis, although Grekin et al[38]indicated that infant complications, including NICU hospitalization, had
a large association with postpartum PTSD symptoms. Therefore, a series
of related studies can be performed to explore the impact of neonatal
complications, a moderating variable, on the incidence of postpartum
PTSD after traumatic birth, and provide ideas for reducing the rate of
postpartum PTSD.