Symptom presentation of childbirth-related post-traumatic stress in 31 countries: the INTERSECT study

Georgina Constantinou; Susan Ayers; Rebecca Webb; Jonathan E Handelzalts; D B Wright; Christopher Grollman; Grace Lucas; N Awad-Sirhan; Kathleen Baird; Ramish Batool; See article text for complete listing of authors.; Elaine Jefford; INTERSECT Consortium

doi:10.1016/j.jad.2026.122092

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Symptom presentation of childbirth-related post-traumatic stress in 31 countries: the INTERSECT study

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Symptom presentation of childbirth-related post-traumatic stress in 31 countries: the INTERSECT study

Georgina Constantinou, Susan Ayers, Rebecca Webb, Jonathan E Handelzalts, D B Wright, Christopher Grollman, Grace Lucas, N Awad-Sirhan, Kathleen Baird, Ramish Batool, …

Journal of Affective Disorders, Vol.Advanced access, 122092

07-Jun-2026

DOI: https://doi.org/10.1016/j.jad.2026.122092

PMID: 42259491

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Abstract

PTSD

postpartum

pregnancy

symptom presentation

screening

Background Childbirth-related post-traumatic stress disorder (CB-PTSD) is an important international health concern. Despite increasing recognition of the public health burden of CB-PTSD, little is known about how CB-PTSD symptoms present across different countries. Aims This study examined cross-national differences in CB-PTSD symptom severity and presentation to inform culturally sensitive screening and intervention strategies. Method Data were drawn from the International Survey of Childbirth-Related Trauma (INTERSECT) cross-sectional survey of 11,302 women 6–12 weeks postpartum in 31 countries using a standard protocol. CB-PTSD symptoms were assessed using the City Birth Trauma Scale, measuring DSM-5 symptom components (re-experiencing, avoidance, negative cognitions and mood, hyperarousal). Results Participants were mostly married, aged 30–34 years, with average household income, and higher education. CB-PTSD symptom severity varied substantially across countries, with the highest mean scores in Pakistan (M = 23.49, SD = 13.23) and lowest in Nigeria (M = 1.89, SD = 3.66). Despite these differences, symptom patterns were largely consistent across countries, with avoidance symptoms lowest and hyperarousal symptoms highest. Exceptions were observed in countries with particularly high symptom levels. Decision tree analysis identified avoidance symptoms (>3.1) as the strongest discriminator of CB-PTSD cases vs non-cases (F(1,11,204) = 4820.54, p = .000), followed by negative cognitions and mood (>10; F(1,716) = 143.69, p = .000). Conclusions While CB-PTSD severity varies internationally, symptom presentation is largely consistent, supporting its relevance as an international construct. Avoidance symptoms were the least commonly endorsed yet the most discriminative for identifying CB-PTSD in decision tree analyses, suggesting they may serve as a useful clinical flag for women who warrant more detailed assessment. Variations in symptom expression in countries with high levels of symptoms highlight the importance of culturally sensitive approaches to screening and assessment.

Details

Title: Symptom presentation of childbirth-related post-traumatic stress in 31 countries: the INTERSECT study
Authors: Georgina Constantinou (Corresponding Author) - St George's, University of London
Susan Ayers - St George's, University of London
Rebecca Webb - St George's, University of London
Jonathan E Handelzalts - Tel Hai Academic College
D B Wright - University of Nevada, Las Vegas
Christopher Grollman - St George's, University of London
Grace Lucas - St George's, University of London
N Awad-Sirhan - Universidad del Desarrollo
Kathleen Baird - University of Technology Sydney
Ramish Batool - Beaconhouse National University
See article text for complete listing of authors. (Author)
Elaine Jefford - University of the Sunshine Coast
INTERSECT Consortium (Research Group)
Publication details: Journal of Affective Disorders, Vol.Advanced access, 122092
Publisher: Elsevier BV
DOI: 10.1016/j.jad.2026.122092
ISSN: 1573-2517
PMID: 42259491
Data Availability: Data and supporting documentation for the INTERSECT study (2024) are available through the UK Data Service: SN: 9295, Doi:https://doi.org/10.5255/UKDA-SN-9295-1, URL: https://beta.ukdataservice.ac.uk/datacatalogue/studies/study?id=9295.
Grant note: The International Survey of Childbirth-Related Trauma (INTERSECT, www.intersectstudy.org) was conducted by the INTERSECT Consortium, funded by the Miriam de Senarclens Fondation and City St. George's, University of London. Study in Croatia was funded and supported by an approved research project of the Catholic University of Croatia: “Determinants, outcomes, and interrelation of mental and physical health during pregnancy and postpartum (MumHealth)”. Funding in Chile was provided by ANID under the project “Fondecyt de Iniciación 11170338” and by research funding from the Psychology Department at Universidad del Desarrollo. Funding in Germany was provided by the Deutsche Forschungsgemeinschaft (DFG, German Research Foundation; GA 2287/7-1 and SCHE 1986/6-1). HEI-Lab are funded by FCT - Fundação para a Ciência e Tecnologia, I.P. through the project with the reference UIDB/05380/2020 and DOI identifier doi:10.54499/UIDB/05380/2020. Raquel Costa is funded by the European Social Fund and FCT – Fundação para a Ciência e a Tecnologia, I.P. (Individual CEEC 2023.06934.CEECIND; doi:10.54499/2023.06934.CEECIND/CP2877/CT0001). The study in Iceland was funded and supported by University of Iceland Research Fund. The Swedish study was supported by Fredrik och Ingrid Thurings Stiftelse, award number 2020-0056.
Organisation Unit: School of Health - Midwifery
Language: English
Record Identifier: 991235801102621
Output Type: Journal article

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