https://orcid.org/0000-0001-7458-7500
Figures
Abstract
The aim of this study was to examine psychometric properties of the revised Posttraumatic Stress Checklist (PCL-5) for Diagnostic and Statistical Manual– 5th Edition (DSM-5) in Greek postpartum women after Cesarean Section(CS) (emergency-elective).So far, there was no study in Greece assessing psychometric properties of the PCL-5 in women after CS. The participating women (N = 469), who gave birth with emergency and elective CS at the Greek University Hospital of Larisa, have consented to participate in two phases of the survey and completed self-report questionnaires, the 2nd day after CS and at the 6th week after CS. Measures used in this study were the PCL-5 for DSM-5, the Life Events Checklist (LEC-5), Criteria B, C, D, E, and Criterion A, specifically designed for detection of posttraumatic stress disorder (PTSD) symptoms in postpartum period. To evaluate the internal reliability of the PCL-5 two different indices of internal consistency were calculated, i.e., Cronbach’s alpha (.97) and Guttman’ssplit-half (.95), demonstrating high reliability level. The data were positively skewed, suggesting that the reported levels of PTSD among our participants were low. Factor analyses demonstrated acceptable construct validity; a comparison of thePCL-5 with the other measures of the same concept showed a good convergent validity of the scale. Overall, all the results suggest that the four-factor PCL-5 seemed to work adequately for the Greek sample of women after CS.
Citation: Orovou E, Theodoropoulou IM, Antoniou E (2021) Psychometric properties of the Post Traumatic Stress Disorder Checklist for DSM-5 (PCL-5) in Greek women after cesarean section. PLoS ONE 16(8): e0255689. https://doi.org/10.1371/journal.pone.0255689
Editor: Kenta Matsumura, University of Toyama: Toyama Daigaku, JAPAN
Received: February 18, 2021; Accepted: July 21, 2021; Published: August 13, 2021
Copyright: © 2021 Orovou et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data is included within the manuscript and Supporting Information files.
Funding: We have no funders.
Competing interests: The authors have declared that no competing interests exist.
Introduction
The Posttraumatic Stress Disorder (PTSD) is a mental health problem that some people develop after experiencing or witnessing a life-threatening event like combat, disaster, assault or sexual violence (Criterion A) [1]. The most common PTSD symptoms are clustered into a four-dimensional structure: Intrusion/re-experiencing (Criterion B), avoidance (Criterion C), negative alterations in cognition and mood (Criterion D) and alteration in arousal and reactivity (Criterion E) [2–4].
One of the most frequently used PTSD measure is the Posttraumatic Stress Disorder Checklist (PCL) which has recently undergone substantial revision in the 5th Edition of Diagnostic and Statistical Manual (DSM-5), developed by Weathers et al, 2013 [5]. The PTSD was formally recognized in the Diagnostic and Statistical Manual 3rd version (DSM-III) in 1980 [6], but its diagnostic criteria have been repeatedly revised in the editions of the DSM. Several important revisions were made to the PCL in updating it for the DSM-5.Thus, according to the DSM-5 [2], PTSD has been moved out of the anxiety disorders section and moved to a new category identified as “trauma and stressor-related disorders” [7].The continuing evolution of the field of symptomatology highlights that PTSD remains a complex disorder making accurate measurement of symptoms even more important [8]. Furthermore, a new dissociative subtype of PTSD was created. This subtype, in addition to meeting full PTSD criteria, captures persons who meet dissociative symptoms (depersonalization or derealization) and emotional detachment [9].
The prevalence of PTSD is two times greater in women than in men; it is influenced by hormonal disorders, stressful life events, such as sexual abuse [10,11] and childbirth experiences [12]. For several years a childbirth experience was viewed by scientists as a positive experience for women. Nevertheless, in recent year several studies have shown that childbirth can become a traumatic event; about 1.5%-6% of mothers may develop Postpartum PTSD (P-PTSD) [13,14]. Many researchers also have identified the kind of delivery, and in particular cesarean delivery, as a major risk factor for the development of P-PTSD [15–17], with a great correlation of PTSD to emergency cesarean section (EMCS) and elective cesarean section (ELCS) [18,19]. Other main risk factors for P-PTSD area history of previous mental disorder [19,20], preterm labor [19–22], inclusion of neonate in neonatal intensive care unit [23,24], lack of breastfeeding [19,25,26] and a lack of support from spouse during the perinatal period [14,19,23].The factors that can lead to P-PTSD are common in postpartum women of all countries. Given that CS is associated with P-PTSD [27–29], in Greek mothers the problem is greater due to the high prevalence of CS. Actually, every year in Greece, more than half of deliveries are cesarean deliveries [30] deteriorating the problem.
Furthermore, women who undergo CS are more likely to develop postpartum mental disorders [31,32] and especially P-PTSD compared to women who undergo vaginal birth [16,33] and, therefore, deserve a closer follow-up during the postpartum period [34,35].This great difference between vaginal delivery and CS, given the increasing rate of CS in Greece and worldwide, created a need for a validated measure of P-PTSD after CS. Nowadays, there is a lack of valid scale that measures P-PTSD after CS. Previously, research about P-PTSD has typically adapted questionnaires for use in groups such as militaries and veterans, which may not be applicable to postpartum women after CS. Research in the postpartum period, comparing general PTSD measures with specific postpartum PTSD measures, shows that an agreement between these measures on the identification of diagnostic cases of P-PTSD is low [36]. Considering the increasing rate of postpartum women after a cesarean delivery, a properly adjusted questionnaire is necessary to investigate this special population.
The purpose of this study was to examine the psychometric properties of the PCL-5 in postpartum women after CS in Greece. Specifically, the aim was to assess the consistency and reliability of the PCL-5, the construct validity trough factor analyses, and convergent validity using correlations between the PCL-5 and other measures of PTSD, in a sample of women after CS. For several reasons, this task was far more challenging than the translation of a psychometric instrument for different populations, because the established standards for such procedures cannot be transferred to this population. So far there are no studies assessing the psychometric properties of the PCL-5, in its Greek translation, applied on a special group of postpartum women. However, we expect a good match of the four-factor PCL-5, being applied to the current study sample.
Material and methods
Participants
Participants were all postpartum women who underwent a CS (N = 469), with a mean age 32.58 ± 6.15(SD) years. A proportion of them with an ELCS was 61.4% (N = 288), while 38.6% (N = 181) had an EMCS. The majority of them were married (88.5%, N = 415), while 10.0% (N = 47) were engaged or in relationship, and 1.5% (N = 7) were single or divorced. Overall, 43.4% (N = 204) of the sample completed undergraduate or/and postgraduate studies, with similar number of them who finished a high school (N = 196, 41.8%); 10.7% (N = 69) participants finished primary school or junior high. Most of them were from an urban area (79.5%, N = 373) and Greeks (90.2%, N = 423). The financial status for more than half of the participants was middle (68.2%, N = 320), low for 29.0% (N = 136) of them and high for 2.8% (N = 13) of the sample. All postpartum mothers gave their written consent for their participation in the survey and had medical charts from which the past and current medical data were obtained. Excluded from the survey were underage mothers, women who had difficulties in understanding the Greek language or other difficulties at a cognitive level which could create a problem in understanding the psychometric tools. Additionally, women who used psychotropic substances or drugs were excluded from the study to meet the PTSD Criterion E, according to the DSM-5 rules.
Procedure
The data was collected in two stages, the 2nd day after CS and at the 6th week after CS. During the first stage, after informing the women about the purpose of the study and the importance of their participation, socio-demographic and medical data were collected, along with possible past-traumatic life events and birthtrauma. All women were informed on how to complete the questionnaires, and afterwards they completed them without the presence of others in their room. During the second stage, which was arranged for the end of the postpartum period, the PCL-5 was administrated via a telephone interview, again, without the presence of other people.
Ethics
The study was approved by the University Hospital of Larisa Ethics Commission. Approval: 18838/08-05-2019.
Measures
All measures were translated into the Greek version by two Greek-English bilingual researchers, reviewed by an accredited translator, and back translated by an English-Greek bilingual researcher, all without prior knowledge of the research project. Therefore, it involved 2-part translation process—an initial translation by two bilingual researchers, followed by a full review of that translation by a translator, in order to confirm completeness, pick up typos or inadvertent translator error, check the accuracy of the translation and review quality of expression. Afterward, it was back translated to English by another bilingual researcher, to confirm that is accurate.
Socio-demographic questionnaire.
The research-made screening form includes items on social, demographic, obstetric, neonatal, mental characteristics and previous medical history of the participants. It also included information about the experience of a traumatic CS.
Life Events Checklist-5 (LEC-5) of DSM-5 [37].
The Life Events Checklist (LEC-5) is a self-report measure designed to screen past traumatic life events in a person’s life. The LEC-5 is the most widely used self-report measure for adults, composed of 17 items; each item represents traumas, such as natural disasters, accidents, assaults, sexual violence or other stressful life events. It is the only screening tool that responders can determine different levels of exposure to a traumatic event using five nominal levels of answers:"happened to me", "witnessed it", "learned about it", "part of my job", "not sure" and "does not apply" [37–40].
Criterion A of DSM-5 [3].
Criterion A, the first of the 8 previously mentioned criteria (A, B, C, D, E, F, G& H) that must be met for the PTSD diagnosis, is met when a person was exposed to death, threatened death, serious injury or sexual abuse in one the following ways: (a) direct exposure, (b) witness to the event, (c) information of the event, and (d) exposure in the working area [1,41]. However, for the purpose of this research, criterion A has been adapted with appropriate questions that determine the exposure of the mother or infant to death, threatened death, or serious health complications of both, according to the requirements of the DSM-5.
Post-traumatic stress checklist (PCL-5) of DSM-5 [7].
The PCL-5 is a20-item self-report psychometric tool, which was developed to measure and evaluate PTSD symptoms. The scale includes 20 items, rated on a 5-point Likert type scale. The responses are categorized as1 (not at all), 2 (a little bit), 3 (moderately), 4 (quite a bit) and 5(extremely), with regards to traumatic life experiences [7,18]. The scale is composed out of four factors: intrusion/re-experiencing, avoidance, negative alterations in cognition and mood, and arousal and reactivity. A provisional PTSD diagnosis can be made if a score of each item is 2 or above (range 0 to 4), when there is a score of one or more in the categories of criteria B and C and two or more in categories D and E, and by summing the score (range 0–80) for each of the 20 items [7,9,18]. Cronbach’s alpha for the PCL-5 in other studies ranged from .76 to .97 [42–45]; alpha coefficient reached an index of .97 in the present study.
Data analyses
The 20-item PCL-5 version was first psychometrically examined for possible extreme skewness, multicollinearity, large measurement errors and poor reliability potential. All analyses were conducted using the statistical data processing packages SPSS 22.0 and AMOS 22.0. There were no missing data. Following that, the reliability indices were measured, and after wards the construct validity trough factor analyses, and divergent validity, by calculating the correlations between the PCL-5 total and factor scores, and scores from the other measures used in the current study. Exploratory factor analyses (EFA) were conducted to examine the factors’ loadings, while a series of confirmatory factor analyses (CFA) models were conducted in order to determine the latent structure that best fit PTSD symptoms as measured by the PCL-5.
Results
Descriptive statistics and reliability indices of the scale are presented in Table 1. To evaluate the internal reliability of the PCL-5, two different indices of internal consistency were calculated (i.e., Cronbach’s alpha &Guttman’s split-half), and the mean inter-item correlations to estimate item-to-scale homogeneity.
A standard of values greater than .70 [46] was set for both forms of internal consistency coefficients. As shown in Table 1, Cronbach’s α coefficients for the total PCL-5, along with four latent factors, were very good (from .79 to .97). Guttman’s split-half coefficients were similar, additionally showing great internal consistency of the scale (from .79 to .95), relating the present sample. Furthermore, inter-item correlations, ranging from .414 to .763, showed very good item-to-scale homogeneity. The correlations between factors were also strong, ranging between .794 and .943. Reported levels of PTSD among participants were low, since the data were positively skewed.
Factors validity
Initially, it was decided to follow a quick-screening of the PCL-5on exploratory factor analysis basis, in order to determine whether the same factors as the theoretically expected ones would be observed. This analysis studied whether all the items are sufficiently reliable, and whether the four factors were observed in this sample, showing good construct validity. Factor loadings are shown in Table 2.
The factors extracted are those that had given values greater than 1, a criterion of primary importance for determining the number of factors (Kaiser-Guttman criterion). The analysis was performed by the method of principal component analysis (PCA), with varimax axis rotation and Kaiser normalization. Commonly used PCA method combines manifest (observed) variables into weighted linear combinations that end up as components, where the component correlations and component scores match exactly. It seeks to create optimized weighted linear combinations of variable. Varimax rotation is most often used method as well, as it maximizes the variance within a factor in a way that greater loadings are increased and smaller are minimized [47]. In order to control the presence of some weak items (with unsatisfactory loadings), an exploratory factor analysis was initially performed with the principal axis factoring method in order to provide starting values. No items were excluded.
According to the Kaiser Meyer Olkin criterion (KMO = .96) for the PCL-5 the sample was suitable for further analysis, as well as the table of interrelationships of the 20 questions, according to the Bartlett criterion (χ2 = 8265.30, df = 190, p < .001). As theoretically expected, four factors emerged to which 74.12% of the variance is attributed. Factor loadings, though, appeared to function somewhat differently than the theoretically expected factor structure. The first factor, intrusion, originally having 5 items, explains 25.63% of the total variance and, relating to this study sample, consists of 9 items (all 5 items of intrusion, 2 items of avoidance, 1 item of negative alterations in cognitions and mood, and 1 item of alterations in arousal and reactivity).The second factor, negative alterations in cognitions and mood I, consists of 4 items (3 items of negative alterations in cognitions and mood factor, and 1 item of alterations in arousal and reactivity), differing from the originally expected7-item loadings, and explains 18.00% of the total variance. The third factor, alterations in arousal and reactivity consist of 4 items, instead of 6 as in prototype scale, explains 17.70% of the total variance, while the fourth factor, negative alterations in cognitions and mood II, explains 12.79% of the total variance of the PCL-5 and consists of 3 items, instead of 7, as previously mentioned. However, it seems that all items load satisfactory, but to some extent were differently recognized from this research sample, with the factor avoidance, consisting of 2 items, not being recognized at all, and the factor negative alterations in cognitions and mood being split in two. In addition, it is observed that item 6 - “Avoiding memories, thoughts, or feelings related to the stressful experience?”, loads in the first three factors with a higher value by .01 and .02 in the first factor. Item 7 - “Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)?”, loads in the first two factors with a higher value by .19 in the first. Next, item 11 –“Having strong negative feelings such as fear, horror, anger, guilt, or shame?”, has a higher value by .04 in the fifth factor, comparing to the first, while item 12 –“Loss of interest in activities that you used to enjoy?”, has a higher value by .20 in the second, comparing to the first factor. Subsequently, item 15 - “Irritable behavior, angry outbursts, or acting aggressively?” has a higher value by .13 in the second, comparing to the first factor. Finally, item 17 “Being "superalert" or watchful or on guard?” loads in the first three factors with a higher value by .10 and .14 in the third, while item 18 “Feeling jumpy or easily startled?” has a higher value by .04 in the first, comparing to the third factor. However, after removing the items that load in two/three factors at the same time, it is observed that the percentage of variance explained does not change significantly (the difference is 2.04%), therefore, the factor’s structure remained as presented.
In the next phase, confirmatory factor analyses were employed for the prototype scale [48], and the following criteria and indices were evaluated: χ2(chi-square), χ2/df (chi-square over degrees of freedom), RMSEA (root mean square error of approximation), RMR (root mean square residual), GFI (goodness of fit index), CFI (comparative fix index), and TLI (Tucker-Lewis index -in comparison with the null model) and AIC (Akaike information criterion -in comparison with the null model) (Table 3). For GFI, CFI, and TLI, typically values over .90 indicate adequate model fit, whereas values over .95 indicate good model fit [49].
When the same set of data is used for an exploratory and for a confirmatory factor analysis, a sense of cyclical research practice is created. However, in a confirmatory analysis, correlations (loadings) of items within a factor to which they belong are maximally controlled, while loadings of factors to which items do not belong are considered as zero value and are controlled based on this matter. Also, from a substantive point of view, exploratory and confirmatory factor analysis should lead to the same conclusions when applied to the same data. However, models are different, as in an exploratory factor analysis (or in principal component analysis) non-zero correlations of items with all dimensions that arise in data are allowed. If, therefore, confirmatory factor analysis cannot confirm results of exploratory factor analysis on the same data (which is often the case), one cannot expect confirmatory factor analysis to confirm results of exploratoryfactor analysis in a different sample or population [50]. For these reasons, we present here both the exploratory and the confirmatory analyses results, with special emphasis certainly on the confirmatory approach.
It is observed that the original four-factor structural model, χ2(164) = 1014.64, p < .001, RMSEA = .105 (confidence intervals .099 - .112), RMR = .038, GFI = .82, CFI = .90, TLI = .88, AIC = 8439.92 was not fully confirmed by our data (Table 3).However, after model modification, with 45 error covariance, which differ from zero and strictly withinfactors, and which we identified through the modification indices, the model of the PCL-5 with 20 questions, χ2(126) = 434.79, p < .001, RMSEA = .60 (confidence intervals .058 - .75), RMR = .024, GFI = .92, CFI = .96, TLI = .94, AIC = 602.79, was satisfactory confirmed by our data. For best-fitting model, we decided to allow for those error covariances to differ, as confirmatory factor analysis can include error covariances designating that two measures covary due to other than the shared factor’s influence, such as method effects [51]. As expected, due to the large sample size, chi-square remained statistically significant. Still, RMSEA, RMR, AIC and χ2/df decreased, whereas GFI, TLI and CFI increased. We could have dropped some items to enhance factor consistency and reduce error levels, thus stabilizing the solution, but this would have negative effects on the factors’ theoretically expected validity, leading to a theoretically non-defensible solution. However, the PCL-5 conforms to the original dimensions contained in the scale, as proposed by the creators of the scale (Fig 1). In other words, these results suggest that the four-factor structure of the PCL-5 seems to work adequately for the Greek sample of women after c-section.
Scale validity
Due to the above-mentioned scale skewness, Spearman’s correlations were used to assess convergent scale validity. Namely, to evaluate validity of the PCL-5 in the context of this study, the relationship between known predictor variables of PTSD and the PCL-5 was examined. Moreover, there were significant positive correlations between symptoms of PTSD investigated by the PCL-5 scale, with A, B, C, D, E post-traumatic stress disorders criterions and Life Event Checklist (LEC-5).Concretely, to evaluate the PCL-5 associations with the PTSD criterions, we examined correlations between both total and factor PCL-5 scores, and B, C, D, E criterions and LEC-5, indicating presence of PTSD symptoms and known to be strongly associated with exposure to traumatic events, as well as with criterion A, specifically created for this study. As presented in Table 4, all the correlations were strong, ranging from .443 to .835, showing that diverse types of traumatic events were significantly positively correlated with the PCL-5, and implying very good convergent scale validity, relating the sample of the present research.
Discussion
The aim of this study was to fill an important gap in the literature by evaluating the psychometric properties of the PCL-5 among Greek women after CS. In fact, there is no reliable and valid screening instrument for postpartum PTSD [52,53], therefore this scale was used to determine the presence of a PTSD diagnosis in women after birth via caesarian section. Nevertheless, the PCL-5 is one of the most commonly used self-report measures of PTSD symptoms, but, to our knowledge, this is the first study in Greece using the PCL-5 questionnaire in general as a screening tool for postpartum PTSD.
The Cronbach’s alpha and Guttman’ssplit-half coefficient, as well as factors and item-total correlations were computed to assess the internal consistency and homogeneity of the PCL-5. Some aspects of validity were examined too. Construct validity was examined trough exploratory factor analyses, to see whether the four-factor scale specified by the DSM-5 was observed in this sample. To complement the EFA, confirmatory factor analyses were conducted in order to evaluate the fit of four-factor model, identified in the literature. Furthermore, the convergent validity assessed by Spearman’s correlation coefficient was evaluated by examining correlations between the PCL-5 total and factor scores and specific measures regarding the same concept.
Overall, our results support a very good factor structure of the PCL-5, relating to the sample of the current study. The analyses which were satisfactory, as assessed with both Cronbach’s alpha and Guttman’ssplit-half coefficients and the mean inter-item correlations, indicated that PCL-5 has highly acceptable reliability and homogeneity. Finally, the scale also demonstrated good construct and convergent validity. Concretely, it was reported an excellent Cronbach’s alpha value of .97 for the total score, comparing to the values for the PCL-5 of other studies, ranging from .76 to .97 [42–45]. However, the above studies concerned PTSD in other populations and not specifically in postpartum women; i.e. women after CS. Additionally, the current study provided valuable evidence for the construct validity of the PCL-5 with a four-factor structure, though presenting some differentiation of factor loadings in EFA, in relation to the scale as proposed in the theory. It can be presumably referred to some culture perception differences, or lacking of more focused items targeting this specific moment in life of a woman. Our findings however, are in line with some results from prior studies, reporting moderate factor structure discrepancy, when comparing to the theoretical scale construct [54,55]. Quite many error covariance sin CFA could be explained by this discrepancy, but good four-factor model fit seems to be evident and applicable to the current study population. The results do not refer to any cut-off score, because in practical use, the optimal cut-off score should be considered cautiously; a woman who was screened positive may require further investigation to confirm PTSD diagnosis.
Using exploratory and confirmatory factor analytic approaches, the multi-dimensionality of the PCL-5was surely confirmed, which is consistent with the majority of studies conducted in primary care settings [54–56], or general population-based research setting [57,58]. The scale also demonstrated convergent validity, with high correlations, ranging from .477 to .812, with A, B, C, D, E post-traumatic stress disorders criterions and the Life Event Checklist.
Generally, reviewing related studies on some other populations, psychometric properties of the PCL-5 appeared also satisfactory, as among female Filipino domestic workers, where high Cronbach’s alpha demonstrated excellent scale reliability, with very good convergent validity and high correlations with depression, generalized anxiety, rumination, and direct trauma exposure [59]. The results of the studies on trauma-exposed college students [60] and US veterans [61] indicated good internal consistency, satisfactory reliability, and significant correlations with measures of other constructs (convergent and discriminant validity). Also, the first validation study of the Malay version of a PCL-5 for Malaysian fire and rescue officers demonstrates a valid and reliable scale for screening probable PTSD diagnosis [62]. However, it seems that the results of the current research follow the related studies on other populations who experienced traumatic events.
Conclusions
This study has several strengths. First it is applied to the population clearly enduring a highly traumatic experience, but lacking a valid screening instrument for measuring PTSD symptoms, especially after an urgent CS. Second, it is a relatively large sample size, and implementation of a demanding analytic plan. Furthermore, the study expands the literature by including assessment of the Greek-language version of the PCL-5 among women in postpartum period, after CS. Such evidence is also important in mental health intervention delivery, particularly in assessing change and intervention effectiveness. The study provides a potential foundation for further investigations into mental health and trauma after CS. Despite these strengths, some limitations must be considered when interpreting the study findings. The most evident limitation is the absence of gold standard measures for validation analyses and to better support the findings of the convergent scale validity. Also, the current study does not provide data for discriminant (divergent) validity of the scale. Additionally, it could be also interesting to add some postpartum trauma related question/s, in order to analyze the original PCL-5 scale, supported by such item/s. Also, there is a lack of evidence for measuring discriminate validity. Nevertheless, despite those yet unanswered question, the results suggest that the Greek language version of the PCL-5 may be used as a screening tool in postpartum period after CS, as it presented very strong reliability and good structural and convergent validity.
As expected, positively skewed data suggested low reported levels of PTSD among participants, that is common finding for this population [18]. The reason of including both emergency and elective CS groups in the study, although it might appear as a study limitation, was dramatically increased reported maternal morbidity with CS compared with vaginal delivery [63]. Of course, it could be beneficial to analyze psychometric properties of the PCL-5 of only those that undergone emergency CS. However, satisfactory results of the current study could suggest that such analyses could demonstrate even more fitting results. Finlay, further studies that evaluate validation, the utility of correct classification, as well as determination of the optimal cut-off score of, would provide more evidence, relevant for measuring PTSD symptoms in postpartum period.
Acknowledgments
The authors would like to thank Mrs. Maroula Paulatou, Dr Dimitrios Xirofotos and Ms. Orestes Papazisis, who helped in the translation of the PCL-5, LEC-5 and Criterion A, and Professor Alexandros Daponte, dean of Medical Faculty of University of Thessaly, for his help to collect the research sample.
References
- 1.
PTSD Basics—PTSD: National Center for PTSD [Internet]. [cited 2020 Dec 29]. Available from: https://www.ptsd.va.gov/understand/what/ptsd_basics.asp.
- 2.
DSM-5 Diagnostic Classification. In: Diagnostic and Statistical Manual of Mental Disorders [Internet]. American Psychiatric Association; 2013 [cited 2020 Nov 17]. (DSM Library). Available from: https://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425596.x00DiagnosticClassification.
- 3.
Treatment (US) C for SA. Exhibit 1.3–4, DSM-5 Diagnostic Criteria for PTSD [Internet]. Substance Abuse and Mental Health Services Administration (US); 2014 [cited 2020 Dec 29]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK207191/.
- 4.
Adult PTSD Self-Report Measures—PTSD: National Center for PTSD [Internet]. [cited 2020 Dec 29]. Available from: https://www.ptsd.va.gov/professional/assessment/adult-sr/index.asp.
- 5. Weathers F, Litz B, Herman D, Huska JA, Keane T. The PTSD Checklist (PCL): Reliability, validity, and diagnostic utility. Pap Present Annu Conv Int Soc Trauma Stress Stud. 1993 Jan 1.
- 6. Pichot P. [DSM-III: the 3d edition of the Diagnostic and Statistical Manual of Mental Disorders from the American Psychiatric Association]. Rev Neurol (Paris). 1986;142(5):489–99. pmid:3787052
- 7.
PTSD Checklist for DSM-5 (PCL-5)—PTSD: National Center for PTSD [Internet]. [cited 2020 Mar 6]. Available from: https://www.ptsd.va.gov/professional/assessment/adult-sr/ptsd-checklist.asp.
- 8. Ashbaugh AR, Houle-Johnson S, Herbert C, El-Hage W, Brunet A. Psychometric Validation of the English and French Versions of the Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5). PLOS ONE [Internet]. 2016 [cited 2021 Feb 4];11(10):e0161645. Available from: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0161645. pmid:27723815
- 9. Schiavone FL, Frewen P, McKinnon M, Lanius RA. The Dissociative Subtype of PTSD: An Update of the Literature. 2018;29(3):13.
- 10.
How Common is PTSD in Women?—PTSD: National Center for PTSD [Internet]. [cited 2020 Dec 29]. Available from: https://www.ptsd.va.gov/understand/common/common_women.asp.
- 11. Olff M. Sex and gender differences in post-traumatic stress disorder: an update. Eur J Psychotraumatology [Internet]. 2017 Sep 29 [cited 2020 Dec 26];8(sup4). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5632782/.
- 12. Rodríguez-Almagro J, Hernández-Martínez A, Rodríguez-Almagro D, Quirós-García JM, Martínez-Galiano JM, Gómez-Salgado J. Women’s Perceptions of Living a Traumatic Childbirth Experience and Factors Related to a Birth Experience. Int J Environ Res Public Health [Internet]. 2019 May [cited 2020 Dec 29];16(9). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6539242/. pmid:31085980
- 13. Garthus-Niegel S, von Soest T, Vollrath ME, Eberhard-Gran M. The impact of subjective birth experiences on post-traumatic stress symptoms: a longitudinal study. Arch Womens Ment Health [Internet]. 2013 Feb 1 [cited 2020 Dec 30];16(1):1–10. Available from: pmid:22940723
- 14. Mahmoodi Z, Dolatian M, Shaban Z, Shams J, Alavi-Majd H, Mirabzadeh A. Correlation between Kind of Delivery and Posttraumatic Stress Disorder. Ann Med Health Sci Res. 2016 Dec;6(6):356–61. pmid:28540103
- 15. Shaban Z, Dolatian M, Shams J, Alavi-Majd H, Mahmoodi Z, Sajjadi H. Post-Traumatic Stress Disorder (PTSD) Following Childbirth: Prevalence and Contributing Factors. Iran Red Crescent Med J [Internet]. 2013 Mar [cited 2020 Dec 30];15(3):177–82. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3745743/. pmid:23983994
- 16. Andersen LB, Melvaer LB, Videbech P, Lamont RF, Joergensen JS. Risk factors for developing post-traumatic stress disorder following childbirth: a systematic review. Acta Obstet Gynecol Scand [Internet]. 2012 [cited 2020 Dec 30];91(11):1261–72. Available from: https://obgyn.onlinelibrary.wiley.com/doi/abs/10.1111/j.1600-0412.2012.01476.x. pmid:22670573
- 17. Ayers S, Bond R, Bertullies S, Wijma K. The aetiology of post-traumatic stress following childbirth: a meta-analysis and theoretical framework. Psychol Med [Internet]. 2016 Apr [cited 2020 Dec 30];46(6):1121–34. Available from: https://www.cambridge.org/core/journals/psychological-medicine/article/aetiology-of-posttraumatic-stress-following-childbirth-a-metaanalysis-and-theoretical-framework/10D8B61EB50E47820CEF4053800D0BE3. pmid:26878223
- 18. Lopez U, Meyer M, Loures V, Iselin-Chaves I, Epiney M, Kern C, et al. Post-traumatic stress disorder in parturients delivering by caesarean section and the implication of anaesthesia: a prospective cohort study. Health Qual Life Outcomes [Internet]. 2017 Jun 2 [cited 2020 Dec 30];15. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5457569/. pmid:28577570
- 19. Orovou E, Dagla M, Iatrakis G, Lykeridou A, Tzavara C, Antoniou E. Correlation between Kind of Cesarean Section and Posttraumatic Stress Disorder in Greek Women. Int J Environ Res Public Health [Internet]. 2020 Jan [cited 2020 Mar 6];17(5):1592. Available from: https://www.mdpi.com/1660-4601/17/5/1592. pmid:32121561
- 20. Seng JS, Low LMK, Sperlich M, Ronis DL, Liberzon I. Prevalence, trauma history, and risk for posttraumatic stress disorder among nulliparous women in maternity care. Obstet Gynecol [Internet]. 2009 Oct [cited 2021 Feb 4];114(4):839–47. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3124073/. pmid:19888043
- 21. Holditch‐Davis D, Bartlett TR, Blickman AL, Miles MS. Posttraumatic Stress Symptoms in Mothers of Premature Infants. J Obstet Gynecol Neonatal Nurs [Internet]. 2003 [cited 2021 Jan 19];32(2):161–71. Available from: https://onlinelibrary.wiley.com/doi/abs/10.1177/0884217503252035. pmid:12685667
- 22. Shaw RJ, Brecht CJ, St. John N, Lilo E, Corcoran J, Jo B, et al. PREVENTION OF POSTPARTUM TRAUMATIC STRESS IN MOTHERS WITH PRETERM INFANTS: MANUAL DEVELOPMENT AND EVALUATION. Issues Ment Health Nurs [Internet]. 2013 Aug [cited 2021 Jan 19];34(8):578–86. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3904539/. pmid:23909669
- 23. Staver MA, Moore TA, Hanna KM, Harris-Haman PA, Zukowsky K. Maternal Distress in the Neonatal Intensive Care Unit: A Concept Analysis. Adv Neonatal Care [Internet]. 2019 Oct 1 [cited 2021 Jan 19];19(5):394–401. Available from: https://researchexperts.utmb.edu/en/publications/maternal-distress-in-the-neonatal-intensive-care-unit-a-concept-a. pmid:31306234
- 24. Bonacquisti A, Geller PA, Patterson CA. Maternal depression, anxiety, stress, and maternal-infant attachment in the neonatal intensive care unit. J Reprod Infant Psychol. 2020 Jul;38(3):297–310. pmid:31795733
- 25. Klein M, Vanderbilt D, Kendall-Tackett K. PTSD and Breastfeeding: Let It Flow. ICAN Infant Child Adolesc Nutr [Internet]. 2014 Aug 1 [cited 2021 Jan 19];6(4):211–5. Available from: https://doi.org/10.1177/1941406414541665.
- 26. Groër MW. Differences between exclusive breastfeeders, formula-feeders, and controls: a study of stress, mood, and endocrine variables. Biol Res Nurs. 2005 Oct;7(2):106–17. pmid:16267372
- 27. Cohen MM, Ansara D, Schei B, Stuckless N, Stewart DE. Posttraumatic Stress Disorder after Pregnancy, Labor, and Delivery. J Womens Health [Internet]. 2004 Apr 1 [cited 2021 Jan 2];13(3):315–24. Available from: https://www.liebertpub.com/doi/10.1089/154099904323016473.
- 28. Sorenson DS, Tschetter L. Prevalence of negative birth perception, disaffirmation, perinatal trauma symptoms, and depression among postpartum women. Perspect Psychiatr Care. 2010 Jan;46(1):14–25. pmid:20051075
- 29. Ford E, Ayers S, Bradley R. Exploration of a cognitive model to predict post-traumatic stress symptoms following childbirth. J Anxiety Disord. 2010;24(3):353–9. pmid:20176458
- 30. Antoniou E, Orovou E, Iliadou M, Sarella A, Palaska E, Sarantaki A, et al. Factors Associated with the Type of Cesarean Section in Greece and Their Correlation with International Guidelines. Acta Inform Medica [Internet]. 2021 Mar [cited 2021 May 29];29(1):38–44. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8116101/.
- 31. Sadat Z, Taebi M, Saberi F, Kalarhoudi MA. The relationship between mode of delivery and postpartum physical and mental health related quality of life. Iran J Nurs Midwifery Res [Internet]. 2013 [cited 2021 Feb 4];18(6):499–504. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3917135/. pmid:24554950
- 32. Möller L, Josefsson A, Bladh M, Lilliecreutz C, Andolf E, Sydsjö G. Mental health after first childbirth in women requesting a caesarean section; a retrospective register-based study. BMC Pregnancy Childbirth [Internet]. 2017 Sep 29 [cited 2021 Feb 4];17(1):326. Available from: pmid:28969603
- 33. Modarres M, Afrasiabi S, Rahnama P, Montazeri A. Prevalence and risk factors of childbirth-related post-traumatic stress symptoms. BMC Pregnancy Childbirth [Internet]. 2012 Sep 3 [cited 2021 Jan 18];12(1):88. Available from: pmid:22938705
- 34. Kealy MA, Small RE, Liamputtong P. Recovery after caesarean birth: a qualitative study of women’s accounts in Victoria, Australia. BMC Pregnancy Childbirth [Internet]. 2010 Aug 18 [cited 2021 Feb 4];10(1):47. Available from: pmid:20718966
- 35. Benton M, Salter A, Tape N, Wilkinson C, Turnbull D. Women’s psychosocial outcomes following an emergency caesarean section: A systematic literature review. BMC Pregnancy Childbirth [Internet]. 2019 Dec 30 [cited 2021 Jan 18];19(1):535. Available from: pmid:31888530
- 36. Stramrood CAI, Veld EMJH in ‘T, Pampus MGV, Berger LWAR, Vingerhoets AJJM, Schultz WCMW, et al. Measuring posttraumatic stress following childbirth: a critical evaluation of instruments. J Psychosom Obstet Gynecol [Internet]. 2010 Mar 1 [cited 2021 Feb 4];31(1):40–9. Available from: pmid:20146642
- 37.
Life Events Checklist for DSM-5 (LEC-5)—PTSD: National Center for PTSD [Internet]. [cited 2020 Mar 6]. Available from: https://www.ptsd.va.gov/professional/assessment/te-measures/life_events_checklist.asp.
- 38. Goodman LA, Corcoran C, Turner K, Yuan N, Green BL. Assessing traumatic event exposure: general issues and preliminary findings for the Stressful Life Events Screening Questionnaire. J Trauma Stress. 1998 Jul;11(3):521–42. pmid:9690191
- 39. Kubany ES, Haynes SN, Leisen MB, Owens JA, Kaplan AS, Watson SB, et al. Development and preliminary validation of a brief broad-spectrum measure of trauma exposure: the Traumatic Life Events Questionnaire. Psychol Assess. 2000 Jun;12(2):210–24. pmid:10887767
- 40. Gray MJ, Litz BT, Hsu JL, Lombardo TW. Psychometric properties of the life events checklist. Assessment. 2004 Dec;11(4):330–41. pmid:15486169
- 41. McFarlane AC. PTSD and DSM-5: unintended consequences of change. Lancet Psychiatry [Internet]. 2014 Sep 1 [cited 2021 Jan 24];1(4):246–7. Available from: https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(14)70321-9/abstract. pmid:26360842
- 42. Armour C, Tsai J, Durham TA, Charak R, Biehn TL, Elhai JD, et al. Dimensional structure of DSM-5 posttraumatic stress symptoms: support for a hybrid Anhedonia and Externalizing Behaviors model. J Psychiatr Res. 2015 Feb;61:106–13. pmid:25479765
- 43. Frewen PA, Brown MFD, Steuwe C, Lanius RA. Latent profile analysis and principal axis factoring of the DSM-5 dissociative subtype. Eur J Psychotraumatology [Internet]. 2015 Apr 1 [cited 2021 Feb 7];6. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4390557/. pmid:25854673
- 44. Hoge CW, Riviere LA, Wilk JE, Herrell RK, Weathers FW. The prevalence of post-traumatic stress disorder (PTSD) in US combat soldiers: a head-to-head comparison of DSM-5 versus DSM-IV-TR symptom criteria with the PTSD checklist. Lancet Psychiatry. 2014 Sep;1(4):269–77. pmid:26360860
- 45. Keane TM, Rubin A, Lachowicz M, Brief D, Enggasser JL, Roy M, et al. Temporal stability of DSM–5 posttraumatic stress disorder criteria in a problem-drinking sample. Psychol Assess. 2014;26(4):1138–45. pmid:24932642
- 46.
Thorndike RM. Book Review : Psychometric Theory (3rd ed.) by Jum Nunnally and Ira Bernstein New York: McGraw-Hill, 1994, xxiv + 752 pp. Appl Psychol Meas [Internet]. 1995 Sep 1 [cited 2021 Feb 13];19(3):303–5. Available from: https://doi.org/10.1177/014662169501900308.
- 47.
Osborne JW. Best practices in exloratory factor analysis. Louisville, Ky.: CreateSpace Independent Publishing Platform; 2014.
- 48.
Jöreskog KG. Factor analysis by least squares and maximum likelihood methods. In Wiley, New York; 1977 [cited 2021 Feb 7]. Available from: http://urn.kb.se/resolve?urn=urn:nbn:se:uu:diva-22118.
- 49. Hu L, Bentler PM. Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. Struct Equ Model Multidiscip J [Internet]. 1999 Jan 1 [cited 2021 Feb 7];6(1):1–55. Available from: https://doi.org/10.1080/10705519909540118.
- 50. van Prooijen J-W, van der Kloot WA. Confirmatory Analysis of Exploratively Obtained Factor Structures. Educ Psychol Meas [Internet]. 2001 Oct 1 [cited 2021 Feb 7];61(5):777–92. Available from: https://doi.org/10.1177/00131640121971518.
- 51. Galanaki EP, Mylonas K, Vogiatzoglou PS. Evaluating voluntary aloneness in childhood: Initial validation of the Children’s Solitude Scale. Eur J Dev Psychol [Internet]. 2015 Nov 2 [cited 2021 Feb 7];12(6):688–700. Available from: https://doi.org/10.1080/17405629.2015.1071253.
- 52. Ayers S, Wright DB, Thornton A. Development of a Measure of Postpartum PTSD: The City Birth Trauma Scale. Front Psychiatry [Internet]. 2018 Sep 18 [cited 2021 Jan 5];9. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6153962/. pmid:30279664
- 53. Gelaye B, Zheng Y, Medina-Mora ME, Rondon MB, Sánchez SE, Williams MA. Validity of the posttraumatic stress disorders (PTSD) checklist in pregnant women. BMC Psychiatry [Internet]. 2017 May 12 [cited 2021 Jan 5];17(1):179. Available from: pmid:28494804
- 54. Cook JM, Elhai JD, Areán PA. Psychometric properties of the PTSD Checklist with older primary care patients. J Trauma Stress. 2005 Aug;18(4):371–6. pmid:16281234
- 55. Cuevas C, Bollinger A, Vielhauer M, Morgan E, Sohler N, Brief D, et al. HIV/AIDS Cost Study: Construct Validity and Factor Structure of the PTSD Checklist in Dually Diagnosed HIV-Seropositive Adults. J Psychol Trauma. 2006 Jan 1;5:29–51.
- 56. DuHamel KN, Ostrof J, Ashman T, Winkel G, Mundy EA, Keane TM, et al. Construct Validity of the Posttraumatic Stress Disorder Checklist in Cancer Survivors: Analyses Based on Two Samples. Psychol Assess. 2004;16(3):255–66. pmid:15456381
- 57. Schinka JA, Brown LM, Borenstein AR, Mortimer JA. Confirmatory factor analysis of the PTSD checklist in the elderly. J Trauma Stress. 2007;20(3):281–9. pmid:17597125
- 58. Vera-Villarroel P, Celis-Atenas K, Córdova-Rubio N, Zych I, Buela-Casal G. Chilean Validation of the Posttraumatic Stress Disorder Checklist–Civilian Version (PCL–C) after the Earthquake on February 27, 2010. Psychol Rep [Internet]. 2011 Aug 1 [cited 2021 Feb 7];109(1):47–58. Available from: pmid:22049647
- 59. Hall BJ, Yip PSY, Garabiles MR, Lao CK, Chan EWW, Marx BP. Psychometric validation of the PTSD Checklist-5 among female Filipino migrant workers. Eur J Psychotraumatology [Internet]. [cited 2021 May 29];10(1). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6366408/. pmid:30774783
- 60. Blevins CA, Weathers FW, Davis MT, Witte TK, Domino JL. The Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5): Development and Initial Psychometric Evaluation. J Trauma Stress. 2015 Dec;28(6):489–98. pmid:26606250
- 61. Bovin MJ, Marx BP, Weathers FW, Gallagher MW, Rodriguez P, Schnurr PP, et al. Psychometric properties of the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (PCL-5) in veterans. Psychol Assess. 2016 Nov;28(11):1379–91. pmid:26653052
- 62. Mat Salleh MN, Ismail H, Mohd Yusoff H. Reliability and validity of a post-traumatic checklist-5 (PCL-5) among fire and rescue officers in Selangor, Malaysia. J Health Res [Internet]. 2020 Jan 1 [cited 2021 May 29];ahead-of-print(ahead-of-print). Available from: pmid:34296069
- 63. Burrows LJ, Meyn LA, Weber AM. Maternal morbidity associated with vaginal versus cesarean delivery. Obstet Gynecol. 2004 May;103(5 Pt 1):907–12. pmid:15121564