Assessment of childbirth-related PTSD: Psychometric properties of the Ukrainian version of City Birth Trauma Scale

Assessment of childbirth-related PTSD: Psychometric properties of the Ukrainian version of City Birth Trauma Scale | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Assessment of childbirth-related PTSD: Psychometric properties of the Ukrainian version of City Birth Trauma Scale Magdalena Chrzan-Dętkoś, Natalia Murawska, Liudmyla Krupelnytska, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4929867/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background There is no validated Ukrainian instrument for assessing childbirth-related Post-Traumatic Stress Disorder (CB-PTSD) according to DSM-5 criteria. Objectives Evaluate the psychometric properties of the Ukrainian version of the City Birth Trauma Scale (City BiTS) and examine its factor structure. Method In a cross-sectional study, 320 women completed online questionnaires, including the City BiTS, Edinburgh Postnatal Depression Scale (EPDS), Generalized Anxiety Disorder (GAD-7) questionnaire, and a sociodemographic questionnaire. Results The prevalence of CB-PTSD in Ukraine was 6.2%. Confirmatory analyses were conducted to assess the fit of two-factor and four-factor models, as well as a bifactor model. The bifactor model was found to be the best-fitting model. The examination of the bifactor indices supported the computation of a total PTSD score as well as the use of the General Symptoms subscale, which emerged as distinct and well-defined factors. Both subscales (Birth-Related Symptoms subscale and General Symptoms subscale) and the total scale demonstrated high internal consistency (Cronbach's α = .92). Convergent and divergent validity testing indicated robust validity, particularly for General symptoms score. Conclusions The City BiTS emerged as a reliable and valid measure, recommended for use among Ukrainian women in the postpartum period as a screening method. Trial registration. Clinical trial registration was completed at ClinicalTrials.gov under identifier NCT05654987 (Date: December 16, 2022).. birth trauma PTSD war Ukraine postpartum women validation EPDS GAD-7 City BiTS Introduction Childbirth elicits a complex array of emotions, including stress, pain, excitement, and joy in varying proportions [ 1 ]. Yet, for some women, it manifests as an overwhelmingly negative experience, provoking distressing emotions and reactions with lasting adverse effects on their lives [ 2 ]. While accidents, wars, and natural disasters are recognized traumatic stressors, research and clinical practice suggest that traumatic childbirth can also be recognized as a sudden and catastrophic event. It can induce a profound sense of loss of body integrity and pose risks to the lives of both mother and baby. Reviews and meta-analyses indicate that childbirth-related posttraumatic stress disorder (CB-PTSD) affects 4–6% of postpartum women in community samples after birth and up to 16,8% of postpartum women experiences clinically significant CB-PTSD symptoms [3; 4]. The prevalence of CB-PTSD is notably higher in high-risk samples ranging from 15 to 18% among women with a history of sexual abuse, emergency caesarean section, preterm delivery, or severe pregnancy complications [5; 6]. PTSD is defined as a condition that develops after exposure to an event in which there is a real or perceived threat of death or physical harm to oneself or others, as outlined in DSM-5-TR’s [ 7 ] and ICD 11’s [ 8 ] A criterion. The other symptoms, as outlined by DSM-5-TR [ 7 ], are organized into four clusters, including B - intrusion or re-experiencing the traumatic event; C - avoidance of anything related to the traumatic event; D - negative alterations in cognitions and mood; and E - arousal and reactivity. According to DSM-5-TR criteria and empirical studies, PTSD symptoms typically manifest within six months of a stressful event or the cessation of its impact [ 9 ]. However, delayed expression is common, with symptoms appearing after six months post-trauma [ 7 ]. The previuos exposure to traumatic experiences constitutes a greater risk of PTSD [ 10 ]. We assume that, as with the Ukrainian-Russian war, which began in 2014, with a full-scale invasion in 2022, the proportion of women with CB-PTSD may be higher than in non-war-affected countries. More than a third of internally displaced pregnant women who lived in the war zone in eastern Ukraine after 2014, were diagnosed with PTSD [ 11 ]. Exposure to armed conflict, changes in everyday life, previous traumatic experiences and lack of support associated with war constitute risk factors for CB-PTSD [5; 12]. Although Kurapov et al. [ 13 ] study showed that the level of PTSD and complex PTSD (CPTSD) is relatively low in the Ukrainian general population, the number of postpartum mothers who experienced war-related traumatic events with active PTSD during pregnancy can be significant and can predispose them to CB-PTSD - however we do not know the prevalence of CB-PTSD and needs of war-affected mothers in this region. Although a routine inquiry about birth trauma by healthcare providers is essential for all postnatal women, this is particularly important for those who have been affected by very stressful events. Screening tools, such as “The City Birth Trauma Scale”, offer a contemporary method for assessing birth trauma based on DSM-5 criteria for clinical and as well as for research purposes [ 14 ]. The City Birth Trauma Scale (City BiTS) is the only measure of CB-PTSD that follows DSM-5 criteria. Beyond the original English validation, the City Birth Trauma Scale (City BiTS) has undergone validation and translation into Lithuanian [ 15 ], Australian [ 16 ], Swedish [ 17 ], Brazilian [ 18 ], German [ 19 ], French [ 20 ], Spanish [ 21 ], Croatian [ 9 ], Turkish [ 22 ], Chinese [ 23 ] and Hebrew [ 24 ] language. Depending on the language version, the questionnaire has been found to have 2 factors: Birth-related Symptoms (BRS) and General Symptoms (GS) (English, Brazilian, Spanish, Swedish, German, Hebrew, Chinese validations), 4 factors: Re-experiencing symptoms, Avoidance symptoms, Negative cognitions and mood, Hyperarousal (Turkish version) and bi-factor model with a global CB-PTSD factor and two specific factors of Birth-related Symptoms (BRS) and General Symptoms (GS) (Australian, Croatian, French and Lithuanian validation). However, as far as we know, there is currently no research conducted on the psychometric properties of this instrument among Ukrainian women, which may result in undiagnosed cases. The primary objective of this study was to analyze the psychometric properties of the Ukrainian version of the City BiTS and elucidate the latent factor structure of CB-PTSD. Specifically, we aimed to: Examine the factor structure of Ukrainian version of City BiTS. Therefore, three models were tested: a four-factor model based on DSM – 5 PTSD symptoms: Intrusion, Avoidance, Negative Cognitions and Mood, and Hyperarousal), a two-factor model ( Avoidance and Intrusion as one factor and Cognition and Hyperarousal as another) and a bifactor model (incorporating a general factor and two specific factors). Analyze the reliability of the City BiTS in the Ukrainian sample. Establish convergent validity of the City BiTS via correlations with the Impact of Event Scale Revised (IES-R) and divergent validity via correlations with the Edinburgh Postnatal Depression Scale (EPDS) and the General Anxiety Disorder (GAD-7). Methods Design Data comes from an observational cohort study (“Perinatal mental health for refugee women (PMH-RW) study”; Clinical Trial registration NCT04595123). This project aimed to assess the impact of the war on the mental health of pregnant and postpartum women by studying potential risk and protective factors. Participants Inclusion criteria for participation was: being a (i) biological mother of an infant up to 12 months of age; (ii) 18 years or older; (iii)war refugee from Ukraine (entrance to EU countries from 24 February 2022) or staying in Ukraine after/during the war. 371 women access the questionnaire, and 51 were excluded due to missing information in the City BiTS, therefore we included in the analysis 320 women. About two thirds (71.%; n = 226) of the women were living in Ukraine at the same place as before the war, 10.1% ( n = 32) were internally displaced (different place within Ukranian region), 18.9% ( n = 60t) moved to other/host countries. Data on region was missing for 2 participants. Participants in the sample were mostly highly educated, partnered or married, from the large cities, with good enough financial situation before the war which got worse since the beginning of the war (Table 1 ). Concerning obstetric factors, most women were primiparous (60.1%) with a singleton pregnancy (98.4%), but none had medical complications. Table 1 Characteristics of the participants Sociodemographic N % Educational level Incomplete secondary education 4 1.2 Full secondary education (High School) 46 14.4 University degree 270 84.4 Marital status Single 6 1.9 Partnered/Married 279 87.2 Divorced/Separated 30 9.4 Widowed 4 1.2 Other 1 0.3 Place of residence Large city 224 70.2 Small town 64 20.1 Rural area 31 9.7 Missing 1 0.3 Financial situation before war Very good 54 16.9 Good enough 242 75.9 Not very good 18 5.6 Very bad 5 1.6 Financial situation since the beginning of the war Much better 5 1.6 Improved 14 4.3 Unchanged 112 35.0 Somewhat worsen 135 42.2 Much worsen 54 16.9 Birth-related variables Parity Multiparus 127 39.9 Primiparous 191 60.1 Medical complications during pregnancy No complications 320 100 Type of pregnancy Singleton 314 98.4 Twin 5 1.6 Perinatal mental health M SD EPDS 11.19 6.24 IES – R 22.58 16.57 GAD – 7 6.55 4.32 Instruments Sociodemographic and Obstetric Data Sociodemographic data were collected using the Assessment, Care, and Trust - Pregnant and New Mothers (ACT - PNM) questionnaire created for this study. The ACT - PNM includes questions about educational level, naritial status, place of residence, financial situation before the war and since the beginning of the war, medical complication during pregnancy andtype of pregnancy, Birth-Related Posttraumatic Symptoms The City Birth Trauma Scale (City BiTS; Ayers, 2018 14 ) comprises 29 items, with 20 items dedicated to measuring the four clusters of symptoms following the DSM-5 criteria: Re-experiencing (5 items), Avoidance (2 items), Negative Cognitions and Mood (7 items), and Hyperarousals (6 items) during the preceding week. Additional nine items evaluate various aspects such as stressor criteria (2 items - criterion A), symptom duration (1 item - criterion F), symptom onset (1 item) distress levels and disability (2 items - criterion G), dissociative symptoms (2 items), and alternative explanations (1 item - criterion H). Response options are binary (yes/no) or four-point Likert scale ranging from 0 ( not at all ) to 3 ( five or more times ). The total score ranges from 0 to 60 points, with a higher score indicative of greater symptom severity. The scale contains two binary questions (yes/no) focusing on the stressor criteria (criterion A), specifically regarding the risk of death or serious injury to either the mother or the baby during labor, delivery, or immediately after. One anwser YES to these question is required for the diagnosis of PTSD The frequency of intrusive thoughts (criterion B), avoidance behaviors (criterion C), negative thoughts/mood (criterion D), and hyperarousal symptoms (criterion E) in the week prior to the evaluation are assessed through the remaining 20 items. CB-PTSD is considered if one symptom from B and C criterion is present and two from D and E. The original version of the City BiTS showed excellent reliability with Cronbach's Alpha = 0.92 for the total scale [ 14 ], with exploratory factor analysis revealing two factors accounting for 56% of the variance: (i) Birth-related symptoms (predominantly consisting of items which measure intrusion, avoidance, and negative cognitions/mood related to birth; 40.8%) and (ii) General symptoms (mainly consisting of items assessing negative cognitions/mood and hyperarousal; 15.5%). The City BiTS was translated into Ukrainian using the back-translation method [ 25 ]. Two expert translators translated the scale into Ukrainian; another translator and linguist back-translated it into English. The original and back-translated English versions exhibited concordance. A pilot sample of 3 participants assessed the comprehensibility of the Ukrainian version, resulting in no modifications to the questionnaire. Symptoms of Post-Traumatic Stress Disorder The Impact of Event Scale-Revised [ 26 ] is a tool used to evaluate self-reported symptoms of post-traumatic stress disorder (PTSD) experienced within the last 7 days, especially in the response sets of intrusion, avoidance, and hyperarousal, as well as total subjective stress. It comprises 22 items rated on a five-point Likert scale ranging from 0 to 4, with descriptors ranging from 'Not at all' to 'Extremely'. The total score ranges from 0 to 88, where a higher score indicates greater symptom severity. Internal consistency was high (Cronbach's α = .95). The internal consistency calculated for our sample was identical. Symptoms of Postpartum Depression The Edinburgh Postnatal Depression Scale (EPDS) [ 27 ] is a widely used self-assessment tool designed to measure depression in postpartum women. It consists of 10 items rated on a four-point scale from 0 to 3, with possible scores from 0 to 30 where a higher score indicates greater symptom severity. Cronbach ɑ was .87 in the original study [ 27 ]. In the current study, the Cronbach ɑ was also .87. Symptoms of Anxiety The General Anxiety Disorder (GAD-7) [ 28 ] is a 7-item instrument that assesses symptoms of general anxiety disorder. It screens for anxiety symptoms in the general population and according to the criteria established by the DSM-IV [ 29 ] and DSM-IV-TR [ 30 ]. Response options include four-point Likert scale that ranges from 0 to 3. The total score on the GAD-7 ranges from 0 to 21. The internal consistency of the original version of the GAD-7 was excellent (Cronbach α = .92) [ 28 ]. In the current study, the Cronbach ɑ was .87. Procedure The data collection method is described in detail elsewhere (omitted for blind revision). Data was collected through an online questionnaire using the Qualtrics® XM survey platform from 01 December 2022 to 1 October 2023. Invitations for participation were disseminated through various platforms, including Facebook groups, Instagram, personal contacts, and Ukrainian support centers in European countries. Participation was anonymous, and participants were required to read the informed consent before completing the questionnaires. The study information detailed the voluntary nature of participation and the possibility of leaving the study at any time. The study received ethical approval from institutions (blinded for the peer review process) . Statistical analysis The sample size was calculated as 5 to 10 participants per item [ 31 ] suggesting that having at least 200 participants would be sufficient to conduct factor analysis, which was substantially exceeded. To calculatestatistical analyses, we used SPSS Version 29.0. We employed descriptive statistics and frequency anayses to explore the prevalence of CB-PTSD and the criteria for PTSD. Descriptive statistics were also used to analyze individual items and subscales. The factor structure of the City BiTS was assessed using confirmatory factor analyses (CFA) with maximum likelihood estimation in AMOS© 26. Three models were examined: 1) a four-factor model comprising four correlated factors (Intrusions, Avoidance, Negative Cognitions and Mood, and Hyperarousal; 2) a two-factor model comprising two correlated factors (Birth-Related PTSD Symptoms and General PTSD Symptoms); and 3) a bifactor model comprising two uncorrelated factors (Birth-Related PTSD Symptoms and General PTSD Symptoms) and a general factor of PTSD. In the bifactor model, all items loaded on the general factor, had nonzero loadings on the domain-specific factor that they were designed to measure and zero loadings on the other factors. In all three models, modification indices were reviewed to enhance model fit. Whenever pairs of items were part of the same subscale, their measurement errors were allowed to correlate [ 32 ]. The fit of the models was assessed through the comparative fit index (CFI), the Tucker-Lewis Index (TLI), the root-mean-square error of approximation (RMSEA), and the standardized root-mean-square residual (SRMR). The cut-offs for adequate and good model fit were CFI and TLI values ≥ .90 and ≥ .95, RMSEA values ≤ .08 and ≤ .06, and SRMR values ≤ .10 and ≤ .08, respectively [33; 34]. The Akaike Information Criterion (AIC) [ 35 ] was used to compare the models. The model with the smallest AIC values was considered the best-fitting model. Factor loadings of .32 or above were considered meaningful [ 36 ]. Several bifactor model-based psychometric indexes were computed. Higher values of the explained common variance (ECV) indicate a strong general factor and suggest unidimensionality [37; 38]. The ECV for specific factors is only relative to items loading on that factor. The percentage of uncontaminated correlations (PUC) [39; 40] is another strength index. Higher values of PUC suggest that the parameter estimates in a unidimensional model are less likely to be biased. According to Rodriguez et al. [ 41 ], "when ECV is > .70 and PUC > .70 relative bias will be slight, and the common variance can be regarded as essentially unidimensional" (p. 232). The omega reliability coefficients and the relative omega were also computed. For the general factor, the relative omega represents the percentage of the reliable variance in the multidimensional composite due to the general factor. For specific factors, this index represents the proportion of reliable variance in the subscale composite that is independent of the general factor. The H index, a measure for evaluating how well a factor is captured by a group of items [ 42 ] was also calculated. High values (> .80) indicate a well-defined variable [ 41 ]. Additionally, the factor determinacy index was calculated, with values exceeding .90 necessary for individual assessment purposes [ 43 ]. Internal consistency was evaluated through item-total correlation, inter-subscale correlation, average inter-item correlation, McDonald's omega, and Cronbach's alpha coefficients. Good internal consistency was considered when Cronbach's alpha exceeds .70 and mean inter-item correlations are above .15 [ 44 ], with item-total correlations surpassing .30 [ 45 ]. External validation was conducted through Pearson correlations between the City BiTS and the Impact of Event Scale-Revised (IES-R), Edinburgh Postnatal Depression Scale (EPDS) and General Anxiety Disorder (GAD-7). Results Descriptive statistics Table 2 depicts the mean, standard deviation, range, skewness, and kurtosis for the 22 City BiTS items (items for criteria B-E and two questions about dissociative symptoms). The results indicated that all items demonstrated a complete range of values from 0 to 3. Three of the items exceeded the proposed cut-off of 3 for skewness (2, 7, 8) and three items exceeded the proposed cut-off of 10 for kurtosis (2, 7, 8) [ 46 ]. The item-total correlation of the items in the 'Re-experiencing' subscale ranged from r = 0.362 to 0.617, in the 'Avoidance' subscale, ranged from r = 0.429 to 0.557, in the 'Negative Cognition and Mood' subscale, from r = 0.269 and 0.756, in the 'Hyperarousal' subscale from r = 0.603 to 0.745, and in the 'Dissociative' subscale from r = 0.492 to 0.631. All item-total correlations are positive and statistically significant (p < .01; see Table 2 ). Only for item 8 the correlation coefficient is lower than .30. Table 2 Descriptive statistics of the City BiTS items and correlations with total score Range Mean SD Skewness Kurtosis % of responses with a score of 0 % of responses with a score of 3 Item-Total Score Correlation Coefficients r-Pearson 1. Recurrent unwanted memories of the birth 0–3 0.58 .92 1.42 0.84 65.3 6.6 .60 ** 2. Bad dreams or nightmares about the birth 0–3 0.18 .51 3.22 11.06 86.6 0.9 .36 ** 3. Flashbacks to the birth and/or reliving the experience 0–3 0.47 .82 1.64 1.62 70.6 3.4 .62 ** 4. Getting upset when reminded of the birth 0–3 0.44 .83 1.82 2.26 73.4 4.4 .60 ** 5. Feeling tense or anxious when reminded of the birth 0–3 0.47 .81 1.63 1.64 70.0 3.4 .62 ** 6. Trying to avoid thinking about the birth 0–3 0.34 .77 2.34 4.53 80.0 4.44 .56 ** 7. Trying to avoid things that remind me of the birth 0–3 0.18 .54 3.41 11.78 88.4 1.3 .44 ** 8. Not able to remember details of the birth 0–3 0.19 .53 3.26 11.21 86.6 1.3 .27 ** 9. Blaming myself or others for what happened during the birth 0–3 0.38 .80 2.06 3.13 78.1 4.1 .55 ** 10. Feeling strong negative emotions about the birth 0–3 0.47 .85 1.76 2.02 71.6 5.0 .58 ** 11. Feeling negative about myself or thinking something awful will happen 0–3 0.61 .94 1.35 0.57 65.0 6.9 .67 ** 12. Lost interest in activities that were important to me 0–3 0.61 .98 1.43 0.69 66.3 9.1 .58 ** 13. Feeling detached from other people 0–3 1.05 1.18 0.57 -1.26 48.8 17.8 .76 ** 14. Not able to feel positive emotions 0–3 0.64 1.01 1.33 0.35 65.9 9.4 .75 ** 15. Feeling irritable or aggressive 0–3 1.23 1.15 0.33 -1.35 37.5 19.4 .72 ** 16. Feeling self-destructive or acting recklessly 0–3 0.48 .90 1.80 1.98 73.8 6.9 .64 ** 17 Feeling tense and on edge 0–3 1.11 1.12 0.48 -1.20 41.3 16.3 .75 ** 18. Feeling jumpy or easily startled 0–3 0.86 1.04 0.84 -0.64 51.2 10.3 .68 ** 19. Problems concentrating 0–3 0.95 1.05 0.72 -0.79 45.9 11.6 .65 ** 20 Not sleeping well because of things that are not due to the baby’s sleep pattern 0–3 0.87 1.09 0.83 -0.79 55 12.2 .60 ** 21 Feeling detached or as if you are in a dream 0–3 0.64 .99 1.31 0.35 64.8 8.8 .63 ** 22 Feeling things are distorted or not real 0–3 0.31 .71 2.35 4.75 80.8 2.5 .49 ** Note: ** p < .01 Table 3 depicts descriptive analysis for the City BiTS total scale and subscales, including range, mean, standard deviation, skewness, and kurtosis. None of them exceeded the cut-off of 3 for skewness and 10 for kurtosis [ 46 ]. Table 3 Descriptive statistics of the City BiTS Range Mean SD Skewness Kurtosis Total scale 0–52 12.09 11.11 1.12 0.99 4 factor solution Reexperiencing 0–15 2.15 3.08 1.73 2.54 Avoidance 0–6 0.52 1.18 2.66 7.11 Negative cognitions and mood 0–18 3.94 4.28 1.06 0.40 Hyperarousal 0–18 5.49 5.03 0.77 -0.38 2 factor solution Birth-related Symptoms 0–27 3.70 5.22 1.93 3.72 General Symptoms 0–30 8.39 7.89 0.83 -0.29 Confirmatory Factor Analyses The results of confirmatory factor analysis of Four Factor Correlated Model, Two Factor Correlated Model and Bifactor Model are presented in Table 4 . The bifactor model was significantly better than the two-factor model, Δχ 2 (19) = 64.84, p < .001, as well as the four-factor model, Δχ 2 (16) = 181.39, p < .001. As presented in Table 5 , in the bifactor model, all items loaded significantly on the PTSD general factor, with nearly all items showing factor loadings surpassing .32. However, items 10, 14, 17, 18, 20, 21, and 22, although significant, had factor loadings below .32. As presented in Table 5 , items belonging to the Birth-Related Symptoms factor did not load significantly on its specific factor, whereas items belonging to the General Symptoms factor loaded significantly both on the general and the specific factor. Items from the General Symptoms factor presented weaker factor loadings on the general factor (from .21 to .45) and stronger factor loadings on the specific factor (.43 to .72). Table 4 Confirmatory Factor Analysis of the City BiTS Model χ 2 df RMSEA CFI TLI AIC 1. Correlated four-factor model 689.17 164 .100 .845 .821 781.17 2. Correlated four-factor model (with correlated residuals) 495.68 158 .082 .901 .880 599.68 3. Correlated two-factor model 599.59 169 .089 .873 .857 681.59 4. Correlated two-factor model (with correlated residuals) 379.13 161 .065 .936 .924 477.13 5. Bifactor model 491.15 150 .084 .900 .873 611.15 6. Bifactor model (with correlated residuals) 314.29 142 .062 .949 .932 450.29 Notes: χ² test; df = degrees of freedom; CFI = Comparative Fit Index; RMSEA = Root Mean Square Error of Approximation; TLI = Tucker-Lewis Index; AIC = Akaike Information Criterion Table 5 Standardized Factor Loadings for the Bifactor Model of the City BiTS (n = 320) Items General Factor BRS GS Intrusions 3. Recurrent unwanted memories of the birth .69 .02 4. Bad dreams or nightmares about the birth .42 .33 5. Flashbacks to the birth and/or reliving the experience .72 − .08 6. Getting upset when reminded of the birth .80 − .21 7. Feeling tense or anxious when reminded of the birth .84 − .19 Avoidance 8. Trying to avoid thinking about the birth .74 − .25 9. Trying to avoid things that remind me of the birth .64 .20 Negative moods and cognitions 10. Not able to remember details of the birth .23 − .07 11. Blaming myself or others for what happened during the birth .53 .08 12. Feeling strong negative emotions about the birth .73 .05 13. Feeling negative about myself or thinking something awful will happen .45 .43 14. Lost interest in activities that were important to me .21 .61 15. Feeling detached from other people .38 .72 16. Not able to feel positive emotions .40 .71 Hyperarousal 17. Feeling irritable or aggressive .31 .71 18. Feeling self-destructive or acting recklessly .28 .62 19. Feeling tense and on edge .33 .71 20. Feeling jumpy or easily startled .25 .66 21. Problems concentrating .22 .54 22. Not sleeping well not due to the baby’s sleep pattern .27 .68 Note: BRS = Birth Related Symptoms; GS = General Symptoms Bifactor Indices for the Bifactor Model The ECV of the general factor was .544, which indicates that the general factor only explains 54.4% of the common variance extracted, supporting the non-unidimensionality of the scale. The OmegaH for the total score was .635 and the relative omega was .685, which indicates that 68.5% of the reliable variance in the total score can be accounted for by the general factor. The PUC was .526. With regards to the subscales, the OmegaH index and the relative omega of the Birth-Related Symptoms subscale was zero, which indicates that none of the reliable variance in this subscale is independent of the general factor. In contrast, the General Symptoms subscale presented an OmegaH index of .739 and a relative omega of .883, which indicates that 81% of the reliable variance can be attributable to this subscale and is independent of the general factor. The H index was .916 for the total score and .883 for the General Symptoms subscale, indicating that these factors are well-defined factors. In contrast, the H index of the Birth-Related Symptoms subscale was only .252, suggesting a weakly defined latent factor (see Table 6 ). Table 6 Bifactor Indices for the Bifactor Model Bifactor model ECV Omega/ OmegaS OmegaH/ OmegaHS Relative omega Factor determinacy H index General Factor .544 .927 .635 .685 .954 .916 Birth Related Symptoms .068 .882 .000 .000 .608 .252 General Symptoms .804 .912 .739 .810 .942 .883 Note: ECV = explained common variance; OmegaS and OmegaHS are omega indices for the subscales. Reliability As presented in Table 7 , the Cronbach’s alpha and McDonald's Omega coefficients demonstrated exelant reliability. Table 7 Internal consistency of the City BiTS scale and subscales Cronbach´s alpha McDonald´s omega Mean inter-item correlation Total scale .92 .92 .31 Subscale 4 factor solution Reexperiencing .84 .86 .49 Avoidance .73 - .61 Negative cognitions and mood .79 .80 .33 Hyperarousal .88 .88 .55 2 factor solution Birth-related Symptoms .88 .89 .41 General Symptoms .91 .92 .52 Convergent and Divergent Validity The convergent validity of the City BiTS was tested via correlations with the IES-R. The City BiTS total scale and subscales correlated significantly with the IES-R total score (total score: r = .53; p < .001; Birth-related Symptoms score: r = .36; p < .001; General Symptoms score: r = .50; p < .001) Divergent validity of the City BiTS we tested via correlations with depression symptoms (EPDS) and anxiety symptoms (EPDS-3A, GAD-7). The City BiTS total score correlated significantly, with a moderate effect size, with the EDPS ( r = .60; p < .001) total score andGAD-7 ( r = .58; p < .001). The Birth-related Symptoms score correlated significantly, with a moderate effect size, with the EDPS ( r = .37; p < .001), GAD-7 ( r = .31; p < .001),. The General Symptoms score correlated significantly, with a moderate effect size, with the EDPS ( r = .61; p < .001) total score, GAD-7 ( r = .61; p < .001) PTSD Criteria Responses to the City BiTS following DSM-5 criteria for PTSD are shown in Table 8 . About 37% of women fulfilled criterion A of DSM-5 by indicating that they believed they or their baby would be seriously injured or even die during childbirth (or immediately afterwards). More than half of them re-experienced the birth and reported negative cognition and mood. More than 70% experienced hyperarousal and one-fifth of them reported avoidance symptoms. 16 women (6.2%) fulfilled all criteria for CB-PTSD. Table 8 PTSD and PTSD criteria prevalence (N = 320). Frequency Percent PTSD Yes 16 6.2 Criterion A Stressor Criterion Fulfilled 118 36.9 Criterion B Re-experiencing symptoms Fulfilled 168 52.5 Criterion C Avoidance symptoms Fulfilled 70 21.9 Criterion D Negative cognitions and mood Fulfilled 183 57.2 Criterion E Hyperarousal Fulfilled 230 71.9 Criterion F Duration Fulfilled 135 42.2 Criterion G Distress and impairment Fulfilled 136 42.5 Criterion H Exclusion criteria Fulfilled 12 3.8 Discussion The current study details the Ukrainian validation of the City BiTS, a measure specifically designed to assess CB-PTSD, aligning with DSM-5 criteria. Consistent with other language versions, the Ukrainian City BiTS was found to be a reliable and valid instrument. In line with the Croatian [ 9 ], French [ 20 ], and Australian [ 16 ] adaptations of the City BiTS, the bifactor model, comprising a general factor along with two specific factors related to childbirth-related symptoms and general symptoms, demonstrated the best fit to the data . The correlations between City BiTS and IES-R are lower than in other studies [9; 19]. The association of depression and anxiety scores with the Birth-related Symptoms subscale was lower compared to the General Symptoms subscale and the overall scale of the City BiTS, indicating divergent validity. These results are in line with other studies [24; 9; 19] and demonstrate good construct validity of the Ukranian CITY BiTS. In our sample, 6.2% of women fulfilled DSM-5 diagnostic criteria for CB-PTSD. The CB-PTSD symptoms among Ukrainian postpartum mothers, although measured during war conditions, does not differ significantly compared to results obtained in postpartum mothers in other countries or even had lower birth PTSD prevalence. For the comparison, we have chosen the online suerveys as the anonymity offered by the online environment may increase participants’ willingness to disclose sensitive or perceived as shameful information [ 47 ]. The incidence rate in Ukrainian population is 2.5 – almost 3 times higher than in in Germany − 2.6% [ 19 ], Israel − 2.4% [ 24 ] but lower than in the UK − 7.1% [ 14 ], 11.8% [ 9 ] (online survey) and Lithuania − 8% [ 15 ]. About 37% of our respondents met criterion A by indicating that they believed they or their baby would be seriously injured or even die during childbirth (or immediately afterwards), which is however much higher than in other European countries. For example in Croatia 31.18% of online assessed mothers fulfilled Criterion A [ 9 ], in Germany (also online assessment) − 22% ;[ 19 ], in England − 20.3% [ 14 ]; Ayers et alonline survey), in Lithuania (also online assessment) − 28.6% [ 15 ]. More than half of our participants re-experienced the birth and reported negative cognition and mood. More than 70% experienced hyperarousal and one-fifth of them reported avoidance symptoms. Strengths and Limitations This study has several strengths. The study procedure was directed following the Standards for Educational and Psychological Testing [ 48 ]. It includes a large sample of postpartum Ukrainian women. Regardless of these strengths, this study has some limitations. First, the data were collected during Ukrainian-Russian war, which could influence the generalizability of the results. The participants were gathered online, which limits inclusion to individuals who engage with technology and social platforms where the study was promoted. The majority of the respondents were women with higher education and a good financial situation, which may not reflect the results obtained by other social groups. Due to the technical problem, responses to items referring to participants' age were not recorded.Another limitation of our study is that we do not have data about PTSD symptoms prior to childbirth. Conclusion and Implications for Practice The Ukranian validation of the The City Birth Trauma Scale is valid and reliable method to measure birth-related PTSD in research and clinical work. The CB-PTSD incidence rate is 6.2% and is similar to other countries, 37% of the participants fulfill the criterion A of DSM-5, indicating that they believed they or their baby would be seriously injured or even die, what is one of the highest number in Europe. We encourage midwives and health care professionals to be aware of any related needs that may arise from the elvated CB-PTSD symptoms, such as the necessity for discussing this experience or increased anxiety related to subsequent deliveries. Declarations Ethics approval and consent to participate: The research was condacted in accordance with the Declaration of Helsinki The studies involving human participants were reviewed and approved by Comité de Ética de la Investigación, UNED (Madrid), the Research Ethics Committee of the Faculty of Psychology of Taras Shevchenko National University of Kyiv. The patients/participants provided their written informed consent to participate in this study. Consent for publication Not applicable Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests Funding This paper is based upon work from the COST Action Riseup-PPD CA 18138 and was supported by COST under COST Action Riseup-PPD CA18138 www.cost.eu. However, sponsor did not have any involvement in the study design, collection, analysis and interpretation of data, writing of the report nor the decision to submit the article for publication. Authors' contributions Mch-D contributed to conception and design of the study, wrote and edited the first draft of the manuscript. AU contributed to conception and design of the study. HG-L organized the database. NM contribute dto the design of the study writing the draft and edited version and descriptive statistics part. LK and OM-L and AV contributed to conception and design of the study and provided the translation of the method as well to the data collection process. SNR and HM and RC contributed to the methodology and data analysis. SNR and RC and MR-M reviewed and edited the final version. All authors contributed to the article and approved the submitted version. Acknowledgments We would like to thank to all Ukrainian women who have participated in the study and were eager to share their experience in this extremely difficult war situation which affected their lives and their country. References Raphael-Leff J. Healthy Maternal Ambivalence. Stud Maternal. 2010;2(1):1-15. doi: 10.16995/sim.97. Netsi E, Pearson RM, Murray L, Cooper P, Craske MG, Stein A. Association of Persistent and Severe Postnatal Depression With Child Outcomes. JAMA Psychiatry. 2018;75(3):247-53. doi: 10.1001/jamapsychiatry.2017.4363. Dekel S, Stuebe C, Dishy G. Childbirth induced posttraumatic stress syndrome: a systematic review of prevalence and risk factors. Front Psychol. 2017;8:560. doi: 10.3389/fpsyg.2017.00560. Heyne CS, Kazmierczak M, Souday R, Horesh D, Lambregtse-van den Berg M, Weigl T, et al. Prevalence and risk factors of birth-related posttraumatic stress among parents: A comparative systematic review and meta-analysis. 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Structural equation modeling with AMOS: Basic concepts, applications, and programming. 2nd ed. New York: Taylor & Francis; 2010. Browne MW, Cudeck R. Alternative ways of assessing model fit. In: Bollen KA, Long JS, editors. Testing structural equation models. Newbury Park, CA: Sage; 1993. p. 136-62. Hu L, Bentler PM. Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. Struct Equ Modeling. 1999;6(1):1-55. doi: 10.1080/10705519909540118. Akaike H. Factor analysis and AIC. Psychometrika. 1987;52(3):317-32. doi: 10.1007/BF02294359. Tabachnick BG, Fidell LS. Using multivariate statistics. 5th ed. Boston: Pearson; 2007. Sijtsma K. On the use, the misuse, and the very limited usefulness of Cronbach's alpha. Psychometrika. 2009;74(1):107-20. doi: 10.1007/s11336-008-9101-0. Ten Berge JMF, Sočan G. The greatest lower bound to the reliability of a test and the hypothesis of unidimensionality. Psychometrika. 2004;69(4):613-25. doi: 10.1007/bf02289858. Bonifay WE, Reise SP, Scheines R, Meijer RR. When are multidimensional data unidimensional enough for structural equation modeling? An evaluation of the DETECT multidimensionality index. Struct Equ Modeling. 2015;22(4):504-16. doi: 10.1080/10705511.2014.938596. Reise, S. P., Scheines, R., Widaman, K. F., & Haviland, M. G. (2013). Multidimensionality and structural coefficient bias in structural equation modeling: A bifactor perspective. Educational and Psychological Measurement, 73(1), 5-26. https://doi.org/10.1177/0013164412449831 Rodriguez, A., Reise, S. P., & Haviland, M. G. (2016). Applying bifactor statistical indices in the evaluation of psychological measures. Journal of Personality Assessment, 98(3), 223-237. https://doi.org/10.1080/00223891.2015.1089249 Hancock, G. R., & Mueller, R. O. (2001). Rethinking Construct Reliability within Latent Variable Systems. In R. Cudeck, S. du Toit, & D. S?rbom (Eds.), Structural Equation Modeling: Present und Future—A Festschrift in Honor of Karl Joreskog (pp. 195-216). Lincolnwood, IL: Scientific Software International. Ferrando, P., & Lorenzo-Seva, U. (2017). Assessing the Quality and Appropriateness of Factor Solutions and Factor Score Estimates in Exploratory Item Factor Analysis. Educational and Psychological Measurement, 78. https://doi.org/10.1177/0013164417719308 Nunnally, J.C. and Bernstein, I.H. (1994) The Assessment of Reliability. Psychometric Theory, 3, 248-292. Field, A. (2005) Reliability analysis. In: Field, A., Ed., Discovering Statistics Using spss. 2nd Edition, Sage, London Kline, R.B. (2011) Principles and Practice of Structural Equation Modeling. Guilford Press, New York. Chrzan-Dętkoś, M.; Murawska, N.; Walczak-Kozłowska, T.(2022). ‘Next Stop: Mum’: Evaluation of a Postpartum Depression Prevention Strategy in Poland. International . J. Environ. Res. Public Health; 19, 11731. https://doi.org/10.3390/ijerph191811731 American Educational Research Association et al. (2014,editors). The Standards for Educational and Psychological Testing. American Educational Research Association. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4929867","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":354614099,"identity":"7ee28247-f002-410c-b8f0-d4728c8ae4e2","order_by":0,"name":"Magdalena Chrzan-Dętkoś","email":"","orcid":"","institution":"University of Gdańsk","correspondingAuthor":false,"prefix":"","firstName":"Magdalena","middleName":"","lastName":"Chrzan-Dętkoś","suffix":""},{"id":354614100,"identity":"aabfa70e-bbda-4eeb-ab4e-a135401a1a42","order_by":1,"name":"Natalia Murawska","email":"","orcid":"","institution":"University of Gdańsk","correspondingAuthor":false,"prefix":"","firstName":"Natalia","middleName":"","lastName":"Murawska","suffix":""},{"id":354614101,"identity":"08b53a07-7fc3-490d-818f-ce56c98314a5","order_by":2,"name":"Liudmyla Krupelnytska","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3UlEQVRIiWNgGAWjYBACCTBZAMQHGBgPMFQkEKvFAKwFiM6QrIWxjQgtkrPPmD1gMDic2HftjMGBn/PS8gwO8Bh+wKdFmi/H3ACkZebtHIODvdtyioFajCXwaZHj4TGTAGnZANRygHdbReKGAzwGxGs5+HcOWIvxD7wOQ9ZymLchB6TFDK8tkj1s5UC/pBvPvJ1WcFjmWFrizMNsZRb4tEicYd72gKHCWrbvdvLGh29qkhP7jjdvvoFPCxCwMf9haAbSHAYQPjMB9SAtQFwHxOwPCKsdBaNgFIyCEQkAhsBOxm6vq4cAAAAASUVORK5CYII=","orcid":"","institution":"Taras Shevchenko National University of Kyiv","correspondingAuthor":true,"prefix":"","firstName":"Liudmyla","middleName":"","lastName":"Krupelnytska","suffix":""},{"id":354614102,"identity":"468233b1-774b-4a41-85b6-5c8bf97f9f7c","order_by":3,"name":"Helena Moreira","email":"","orcid":"","institution":"University of Coimbra","correspondingAuthor":false,"prefix":"","firstName":"Helena","middleName":"","lastName":"Moreira","suffix":""},{"id":354614103,"identity":"86cdfc6a-fab4-42fc-bb49-2490e70ec9eb","order_by":4,"name":"Maria F. 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Yet, for some women, it manifests as an overwhelmingly negative experience, provoking distressing emotions and reactions with lasting adverse effects on their lives [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. While accidents, wars, and natural disasters are recognized traumatic stressors, research and clinical practice suggest that traumatic childbirth can also be recognized as a sudden and catastrophic event. It can induce a profound sense of loss of body integrity and pose risks to the lives of both mother and baby. Reviews and meta-analyses indicate that childbirth-related posttraumatic stress disorder (CB-PTSD) affects 4\u0026ndash;6% of postpartum women in community samples after birth and up to 16,8% of postpartum women experiences clinically significant CB-PTSD symptoms [3; 4]. The prevalence of CB-PTSD is notably higher in high-risk samples ranging from 15 to 18% among women with a history of sexual abuse, emergency caesarean section, preterm delivery, or severe pregnancy complications [5; 6].\u003c/p\u003e \u003cp\u003ePTSD is defined as a condition that develops after exposure to an event in which there is a real or perceived threat of death or physical harm to oneself or others, as outlined in DSM-5-TR\u0026rsquo;s [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] and ICD 11\u0026rsquo;s [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] A criterion. The other symptoms, as outlined by DSM-5-TR [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], are organized into four clusters, including B - intrusion or re-experiencing the traumatic event; C - avoidance of anything related to the traumatic event; D - negative alterations in cognitions and mood; and E - arousal and reactivity. According to DSM-5-TR criteria and empirical studies, PTSD symptoms typically manifest within six months of a stressful event or the cessation of its impact [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. However, delayed expression is common, with symptoms appearing after six months post-trauma [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe previuos exposure to traumatic experiences constitutes a greater risk of PTSD [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. We assume that, as with the Ukrainian-Russian war, which began in 2014, with a full-scale invasion in 2022, the proportion of women with CB-PTSD may be higher than in non-war-affected countries. More than a third of internally displaced pregnant women who lived in the war zone in eastern Ukraine after 2014, were diagnosed with PTSD [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Exposure to armed conflict, changes in everyday life, previous traumatic experiences and lack of support associated with war constitute risk factors for CB-PTSD [5; 12]. Although Kurapov et al. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] study showed that the level of PTSD and complex PTSD (CPTSD) is relatively low in the Ukrainian general population, the number of postpartum mothers who experienced war-related traumatic events with active PTSD during pregnancy can be significant and can predispose them to CB-PTSD - however we do not know the prevalence of CB-PTSD and needs of war-affected mothers in this region.\u003c/p\u003e \u003cp\u003eAlthough a routine inquiry about birth trauma by healthcare providers is essential for all postnatal women, this is particularly important for those who have been affected by very stressful events. Screening tools, such as \u0026ldquo;The City Birth Trauma Scale\u0026rdquo;, offer a contemporary method for assessing birth trauma based on DSM-5 criteria for clinical and as well as for research purposes [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The City Birth Trauma Scale (City BiTS) is the only measure of CB-PTSD that follows DSM-5 criteria. Beyond the original English validation, the City Birth Trauma Scale (City BiTS) has undergone validation and translation into Lithuanian [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], Australian [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], Swedish [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], Brazilian [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], German [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], French [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], Spanish [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], Croatian [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], Turkish [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], Chinese [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] and Hebrew [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] language. Depending on the language version, the questionnaire has been found to have 2 factors: Birth-related Symptoms (BRS) and General Symptoms (GS) (English, Brazilian, Spanish, Swedish, German, Hebrew, Chinese validations), 4 factors: Re-experiencing symptoms, Avoidance symptoms, Negative cognitions and mood, Hyperarousal (Turkish version) and bi-factor model with a global CB-PTSD factor and two specific factors of Birth-related Symptoms (BRS) and General Symptoms (GS) (Australian, Croatian, French and Lithuanian validation).\u003c/p\u003e \u003cp\u003eHowever, as far as we know, there is currently no research conducted on the psychometric properties of this instrument among Ukrainian women, which may result in undiagnosed cases. The primary objective of this study was to analyze the psychometric properties of the Ukrainian version of the City BiTS and elucidate the latent factor structure of CB-PTSD.\u003c/p\u003e \u003cp\u003eSpecifically, we aimed to:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eExamine the factor structure of Ukrainian version of City BiTS. Therefore, three models were tested: a four-factor model based on DSM \u0026ndash; 5 PTSD symptoms: Intrusion, Avoidance, Negative Cognitions and Mood, and Hyperarousal), a two-factor model ( Avoidance and Intrusion as one factor and Cognition and Hyperarousal as another) and a bifactor model (incorporating a general factor and two specific factors).\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eAnalyze the reliability of the City BiTS in the Ukrainian sample.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eEstablish convergent validity of the City BiTS via correlations with the Impact of Event Scale Revised (IES-R) and divergent validity via correlations with the Edinburgh Postnatal Depression Scale (EPDS) and the General Anxiety Disorder (GAD-7).\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eDesign\u003c/h2\u003e \u003cp\u003eData comes from an observational cohort study (\u0026ldquo;Perinatal mental health for refugee women (PMH-RW) study\u0026rdquo;; Clinical Trial registration NCT04595123). This project aimed to assess the impact of the war on the mental health of pregnant and postpartum women by studying potential risk and protective factors.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eInclusion criteria for participation was: being a (i) biological mother of an infant up to 12 months of age; (ii) 18 years or older; (iii)war refugee from Ukraine (entrance to EU countries from 24 February 2022) or staying in Ukraine after/during the war.\u003c/p\u003e \u003cp\u003e371 women access the questionnaire, and 51 were excluded due to missing information in the City BiTS, therefore we included in the analysis 320 women. About two thirds (71.%; \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;226) of the women were living in Ukraine at the same place as before the war, 10.1% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;32) were internally displaced (different place within Ukranian region), 18.9% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;60t) moved to other/host countries. Data on region was missing for 2 participants. Participants in the sample were mostly highly educated, partnered or married, from the large cities, with good enough financial situation before the war which got worse since the beginning of the war (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Concerning obstetric factors, most women were primiparous (60.1%) with a singleton pregnancy (98.4%), but none had medical complications.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of the participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSociodemographic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eN\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducational level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncomplete secondary education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFull secondary education\u003c/p\u003e \u003cp\u003e(High School)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUniversity degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e270\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e84.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarital status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePartnered/Married\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e279\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e87.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDivorced/Separated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWidowed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlace of residence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLarge city\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e224\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmall town\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRural area\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMissing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFinancial situation before war\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVery good\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGood enough\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e242\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot very good\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVery bad\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFinancial situation since the beginning of the war\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMuch better\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImproved\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnchanged\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e112\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSomewhat worsen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e135\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMuch worsen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBirth-related variables\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMultiparus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e127\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimiparous\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e191\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedical complications during pregnancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo complications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e320\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of pregnancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingleton\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e314\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e98.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTwin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePerinatal mental health\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eM\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eSD\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEPDS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIES \u0026ndash; R\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.57\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGAD \u0026ndash; 7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eInstruments\u003c/h2\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003eSociodemographic and Obstetric Data\u003c/h2\u003e \u003cp\u003eSociodemographic data were collected using the Assessment, Care, and Trust - Pregnant and New Mothers (ACT - PNM) questionnaire created for this study. The ACT - PNM includes questions about educational level, naritial status, place of residence, financial situation before the war and since the beginning of the war, medical complication during pregnancy andtype of pregnancy,\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003eBirth-Related Posttraumatic Symptoms\u003c/h2\u003e \u003cp\u003eThe City Birth Trauma Scale (City BiTS; Ayers, 2018 14 ) comprises 29 items, with 20 items dedicated to measuring the four clusters of symptoms following the DSM-5 criteria: Re-experiencing (5 items), Avoidance (2 items), Negative Cognitions and Mood (7 items), and Hyperarousals (6 items) during the preceding week. Additional nine items evaluate various aspects such as stressor criteria (2 items - criterion A), symptom duration (1 item - criterion F), symptom onset (1 item) distress levels and disability (2 items - criterion G), dissociative symptoms (2 items), and alternative explanations (1 item - criterion H).\u003c/p\u003e \u003cp\u003eResponse options are binary (yes/no) or four-point Likert scale ranging from 0 (\u003cem\u003enot at all\u003c/em\u003e) to 3 (\u003cem\u003efive or more times\u003c/em\u003e). The total score ranges from 0 to 60 points, with a higher score indicative of greater symptom severity. The scale contains two binary questions (yes/no) focusing on the stressor criteria (criterion A), specifically regarding the risk of death or serious injury to either the mother or the baby during labor, delivery, or immediately after. One anwser YES to these question is required for the diagnosis of PTSD The frequency of intrusive thoughts (criterion B), avoidance behaviors (criterion C), negative thoughts/mood (criterion D), and hyperarousal symptoms (criterion E) in the week prior to the evaluation are assessed through the remaining 20 items. CB-PTSD is considered if one symptom from B and C criterion is present and two from D and E.\u003c/p\u003e \u003cp\u003eThe original version of the City BiTS showed excellent reliability with Cronbach's Alpha\u0026thinsp;=\u0026thinsp;0.92 for the total scale [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], with exploratory factor analysis revealing two factors accounting for 56% of the variance: (i) Birth-related symptoms (predominantly consisting of items which measure intrusion, avoidance, and negative cognitions/mood related to birth; 40.8%) and (ii) General symptoms (mainly consisting of items assessing negative cognitions/mood and hyperarousal; 15.5%).\u003c/p\u003e \u003cp\u003eThe City BiTS was translated into Ukrainian using the back-translation method [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Two expert translators translated the scale into Ukrainian; another translator and linguist back-translated it into English. The original and back-translated English versions exhibited concordance. A pilot sample of 3 participants assessed the comprehensibility of the Ukrainian version, resulting in no modifications to the questionnaire.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003eSymptoms of Post-Traumatic Stress Disorder\u003c/h2\u003e \u003cp\u003eThe Impact of Event Scale-Revised [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] is a tool used to evaluate self-reported symptoms of post-traumatic stress disorder (PTSD) experienced within the last 7 days, especially in the response sets of intrusion, avoidance, and hyperarousal, as well as total subjective stress. It comprises 22 items rated on a five-point Likert scale ranging from 0 to 4, with descriptors ranging from 'Not at all' to 'Extremely'. The total score ranges from 0 to 88, where a higher score indicates greater symptom severity. Internal consistency was high (Cronbach's α\u0026thinsp;=\u0026thinsp;.95). The internal consistency calculated for our sample was identical.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003eSymptoms of Postpartum Depression\u003c/h2\u003e \u003cp\u003eThe Edinburgh Postnatal Depression Scale (EPDS) [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] is a widely used self-assessment tool designed to measure depression in postpartum women. It consists of 10 items rated on a four-point scale from 0 to 3, with possible scores from 0 to 30 where a higher score indicates greater symptom severity. Cronbach ɑ was .87 in the original study [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. In the current study, the Cronbach ɑ was also .87.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003eSymptoms of Anxiety\u003c/h2\u003e \u003cp\u003eThe General Anxiety Disorder (GAD-7) [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] is a 7-item instrument that assesses symptoms of general anxiety disorder. It screens for anxiety symptoms in the general population and according to the criteria established by the DSM-IV [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] and DSM-IV-TR [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Response options include four-point Likert scale that ranges from 0 to 3. The total score on the GAD-7 ranges from 0 to 21. The internal consistency of the original version of the GAD-7 was excellent (Cronbach α\u0026thinsp;=\u0026thinsp;.92) [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. In the current study, the Cronbach ɑ was .87.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eProcedure\u003c/h2\u003e \u003cp\u003eThe data collection method is described in detail elsewhere (omitted for blind revision). Data was collected through an online questionnaire using the Qualtrics\u0026reg; XM survey platform from 01 December 2022 to 1 October 2023. Invitations for participation were disseminated through various platforms, including Facebook groups, Instagram, personal contacts, and Ukrainian support centers in European countries. Participation was anonymous, and participants were required to read the informed consent before completing the questionnaires. The study information detailed the voluntary nature of participation and the possibility of leaving the study at any time. The study received ethical approval from institutions \u003cem\u003e(blinded for the peer review process)\u003c/em\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eThe sample size was calculated as 5 to 10 participants per item [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] suggesting that having at least 200 participants would be sufficient to conduct factor analysis, which was substantially exceeded.\u003c/p\u003e \u003cp\u003eTo calculatestatistical analyses, we used SPSS Version 29.0. We employed descriptive statistics and frequency anayses to explore the prevalence of CB-PTSD and the criteria for PTSD. Descriptive statistics were also used to analyze individual items and subscales. The factor structure of the City BiTS was assessed using confirmatory factor analyses (CFA) with maximum likelihood estimation in AMOS\u0026copy; 26. Three models were examined: 1) a four-factor model comprising four correlated factors (Intrusions, Avoidance, Negative Cognitions and Mood, and Hyperarousal; 2) a two-factor model comprising two correlated factors (Birth-Related PTSD Symptoms and General PTSD Symptoms); and 3) a bifactor model comprising two uncorrelated factors (Birth-Related PTSD Symptoms and General PTSD Symptoms) and a general factor of PTSD. In the bifactor model, all items loaded on the general factor, had nonzero loadings on the domain-specific factor that they were designed to measure and zero loadings on the other factors. In all three models, modification indices were reviewed to enhance model fit. Whenever pairs of items were part of the same subscale, their measurement errors were allowed to correlate [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe fit of the models was assessed through the comparative fit index (CFI), the Tucker-Lewis Index (TLI), the root-mean-square error of approximation (RMSEA), and the standardized root-mean-square residual (SRMR). The cut-offs for adequate and good model fit were CFI and TLI values\u0026thinsp;\u0026ge;\u0026thinsp;.90 and \u0026ge;\u0026thinsp;.95, RMSEA values\u0026thinsp;\u0026le;\u0026thinsp;.08 and \u0026le;\u0026thinsp;.06, and SRMR values\u0026thinsp;\u0026le;\u0026thinsp;.10 and \u0026le;\u0026thinsp;.08, respectively [33; 34]. The Akaike Information Criterion (AIC) [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] was used to compare the models. The model with the smallest AIC values was considered the best-fitting model. Factor loadings of .32 or above were considered meaningful [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSeveral bifactor model-based psychometric indexes were computed. Higher values of the explained common variance (ECV) indicate a strong general factor and suggest unidimensionality [37; 38]. The ECV for specific factors is only relative to items loading on that factor. The percentage of uncontaminated correlations (PUC) [39; 40] is another strength index. Higher values of PUC suggest that the parameter estimates in a unidimensional model are less likely to be biased. According to Rodriguez et al. [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e], \"when ECV is \u0026gt;\u0026thinsp;.70 and PUC\u0026thinsp;\u0026gt;\u0026thinsp;.70 relative bias will be slight, and the common variance can be regarded as essentially unidimensional\" (p. 232).\u003c/p\u003e \u003cp\u003eThe omega reliability coefficients and the relative omega were also computed. For the general factor, the relative omega represents the percentage of the reliable variance in the multidimensional composite due to the general factor. For specific factors, this index represents the proportion of reliable variance in the subscale composite that is independent of the general factor.\u003c/p\u003e \u003cp\u003eThe H index, a measure for evaluating how well a factor is captured by a group of items [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e] was also calculated. High values (\u0026gt;\u0026thinsp;.80) indicate a well-defined variable [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Additionally, the factor determinacy index was calculated, with values exceeding .90 necessary for individual assessment purposes [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eInternal consistency was evaluated through item-total correlation, inter-subscale correlation, average inter-item correlation, McDonald's omega, and Cronbach's alpha coefficients. Good internal consistency was considered when Cronbach's alpha exceeds .70 and mean inter-item correlations are above .15 [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e], with item-total correlations surpassing .30 [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eExternal validation was conducted through Pearson correlations between the City BiTS and the Impact of Event Scale-Revised (IES-R), Edinburgh Postnatal Depression Scale (EPDS) and General Anxiety Disorder (GAD-7).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eDescriptive statistics\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e depicts the mean, standard deviation, range, skewness, and kurtosis for the 22 City BiTS items (items for criteria B-E and two questions about dissociative symptoms). The results indicated that all items demonstrated a complete range of values from 0 to 3. Three of the items exceeded the proposed cut-off of 3 for skewness (2, 7, 8) and three items exceeded the proposed cut-off of 10 for kurtosis (2, 7, 8) [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe item-total correlation of the items in the 'Re-experiencing' subscale ranged from \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.362 to 0.617, in the 'Avoidance' subscale, ranged from \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.429 to 0.557, in the 'Negative Cognition and Mood' subscale, from \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.269 and 0.756, in the 'Hyperarousal' subscale from \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.603 to 0.745, and in the 'Dissociative' subscale from \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.492 to 0.631. All item-total correlations are positive and statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;.01; see Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Only for item 8 the correlation coefficient is lower than .30.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eDescriptive statistics of the City BiTS items and correlations with total score\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRange\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eMean\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eSD\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eSkewness\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eKurtosis\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e% of responses with a score of 0\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e% of responses with a score of 3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eItem-Total Score Correlation Coefficients\u003c/p\u003e \u003cp\u003e\u003cem\u003er-Pearson\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1. Recurrent unwanted memories of the birth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e65.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e6.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.60\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2. Bad dreams or nightmares about the birth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e11.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e86.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.36\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3. Flashbacks to the birth and/or reliving the experience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e70.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e3.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.62\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4. Getting upset when reminded of the birth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e73.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e4.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.60\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5. Feeling tense or anxious when reminded of the birth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e70.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e3.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.62\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6. Trying to avoid thinking about the birth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e4.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e80.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e4.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.56\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7. Trying to avoid things that remind me of the birth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e11.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e88.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.44\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8. Not able to remember details of the birth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e11.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e86.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.27\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9. Blaming myself or others for what happened during the birth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e78.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e4.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.55\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10. Feeling strong negative emotions about the birth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e71.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e5.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.58\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11. Feeling negative about myself or thinking something awful will happen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e65.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e6.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.67\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12. Lost interest in activities that were important to me\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e66.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e9.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.58\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13. Feeling detached from other people\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-1.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e48.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e17.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.76\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14. Not able to feel positive emotions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e65.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e9.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.75\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15. Feeling irritable or aggressive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-1.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e37.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e19.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.72\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16. Feeling self-destructive or acting recklessly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e73.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e6.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.64\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e17 Feeling tense and on edge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-1.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e41.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e16.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.75\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18. Feeling jumpy or easily startled\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-0.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e51.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e10.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.68\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e19. Problems concentrating\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-0.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e45.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e11.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.65\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20 Not sleeping well because of things that are not due to the baby\u0026rsquo;s sleep pattern\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-0.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e12.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.60\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e21 Feeling detached or as if you are in a dream\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e64.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e8.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.63\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e22 Feeling things are distorted or not real\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e4.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e80.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.49\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003eNote: ** p\u0026thinsp;\u0026lt;\u0026thinsp;.01\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e depicts descriptive analysis for the City BiTS total scale and subscales, including range, mean, standard deviation, skewness, and kurtosis. None of them exceeded the cut-off of 3 for skewness and 10 for kurtosis [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eDescriptive statistics of the City BiTS\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRange\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSkewness\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eKurtosis\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal scale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u0026ndash;52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e11.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.99\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e4 factor solution\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReexperiencing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u0026ndash;15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e2.54\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAvoidance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u0026ndash;6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e7.11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNegative cognitions and mood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u0026ndash;18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.40\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHyperarousal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u0026ndash;18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e-0.38\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e2 factor solution\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBirth-related Symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u0026ndash;27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e3.72\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGeneral Symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u0026ndash;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e7.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e-0.29\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eConfirmatory Factor Analyses\u003c/h2\u003e \u003cp\u003eThe results of confirmatory factor analysis of Four Factor Correlated Model, Two Factor Correlated Model and Bifactor Model are presented in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. The bifactor model was significantly better than the two-factor model, Δχ\u003csup\u003e2\u003c/sup\u003e(19)\u0026thinsp;=\u0026thinsp;64.84, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001, as well as the four-factor model, Δχ\u003csup\u003e2\u003c/sup\u003e(16)\u0026thinsp;=\u0026thinsp;181.39, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001.\u003c/p\u003e \u003cp\u003eAs presented in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e, in the bifactor model, all items loaded significantly on the PTSD general factor, with nearly all items showing factor loadings surpassing .32. However, items 10, 14, 17, 18, 20, 21, and 22, although significant, had factor loadings below .32. As presented in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e, items belonging to the Birth-Related Symptoms factor did not load significantly on its specific factor, whereas items belonging to the General Symptoms factor loaded significantly both on the general and the specific factor. Items from the General Symptoms factor presented weaker factor loadings on the general factor (from .21 to .45) and stronger factor loadings on the specific factor (.43 to .72).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eConfirmatory Factor Analysis of the City BiTS\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModel\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eχ\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003edf\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRMSEA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCFI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTLI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAIC\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1. Correlated four-factor model\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e689.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e164\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.845\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.821\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e781.17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2. Correlated four-factor model (with correlated residuals)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e495.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e158\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.082\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.901\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.880\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e599.68\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3. Correlated two-factor model\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e599.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e169\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.089\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.873\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.857\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e681.59\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4. Correlated two-factor model (with correlated residuals)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e379.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e161\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.065\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.936\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.924\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e477.13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5. Bifactor model\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e491.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e150\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.084\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.900\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.873\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e611.15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6. Bifactor model (with correlated residuals)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e314.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e142\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.062\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.949\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.932\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e450.29\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eNotes: χ\u0026sup2; test; df\u0026thinsp;=\u0026thinsp;degrees of freedom; CFI\u0026thinsp;=\u0026thinsp;Comparative Fit Index; RMSEA\u0026thinsp;=\u0026thinsp;Root Mean Square Error of Approximation; TLI\u0026thinsp;=\u0026thinsp;Tucker-Lewis Index; AIC\u0026thinsp;=\u0026thinsp;Akaike Information Criterion\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eStandardized Factor Loadings for the Bifactor Model of the City BiTS (n\u0026thinsp;=\u0026thinsp;320)\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItems\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGeneral Factor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBRS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGS\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eIntrusions\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3. Recurrent unwanted memories of the birth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4. Bad dreams or nightmares about the birth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5. Flashbacks to the birth and/or reliving the experience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6. Getting upset when reminded of the birth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7. Feeling tense or anxious when reminded of the birth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eAvoidance\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8. Trying to avoid thinking about the birth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9. Trying to avoid things that remind me of the birth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNegative moods and cognitions\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10. Not able to remember details of the birth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11. Blaming myself or others for what happened during the birth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12. Feeling strong negative emotions about the birth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13. Feeling negative about myself or thinking something awful will happen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.43\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14. Lost interest in activities that were important to me\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.61\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15. Feeling detached from other people\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.72\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16. Not able to feel positive emotions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.71\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eHyperarousal\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e17. Feeling irritable or aggressive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.71\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18. Feeling self-destructive or acting recklessly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.62\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e19. Feeling tense and on edge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.71\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20. Feeling jumpy or easily startled\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.66\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e21. Problems concentrating\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.54\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e22. Not sleeping well not due to the baby\u0026rsquo;s sleep pattern\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.68\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eNote: BRS\u0026thinsp;=\u0026thinsp;Birth Related Symptoms; GS\u0026thinsp;=\u0026thinsp;General Symptoms\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eBifactor Indices for the Bifactor Model\u003c/h2\u003e \u003cp\u003eThe ECV of the general factor was .544, which indicates that the general factor only explains 54.4% of the common variance extracted, supporting the non-unidimensionality of the scale. The OmegaH for the total score was .635 and the relative omega was .685, which indicates that 68.5% of the reliable variance in the total score can be accounted for by the general factor. The PUC was .526.\u003c/p\u003e \u003cp\u003eWith regards to the subscales, the OmegaH index and the relative omega of the Birth-Related Symptoms subscale was zero, which indicates that none of the reliable variance in this subscale is independent of the general factor. In contrast, the General Symptoms subscale presented an OmegaH index of .739 and a relative omega of .883, which indicates that 81% of the reliable variance can be attributable to this subscale and is independent of the general factor.\u003c/p\u003e \u003cp\u003eThe H index was .916 for the total score and .883 for the General Symptoms subscale, indicating that these factors are well-defined factors. In contrast, the H index of the Birth-Related Symptoms subscale was only .252, suggesting a weakly defined latent factor (see Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eBifactor Indices for the Bifactor Model\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBifactor model\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eECV\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOmega/ OmegaS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOmegaH/ OmegaHS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRelative omega\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFactor determinacy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eH index\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeneral Factor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.544\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.927\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.635\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.685\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.954\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.916\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBirth Related Symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.068\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.882\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.608\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.252\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeneral Symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.804\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.912\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.739\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.810\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.942\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.883\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eNote: ECV\u0026thinsp;=\u0026thinsp;explained common variance; OmegaS and OmegaHS are omega indices for the subscales.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eReliability\u003c/h2\u003e \u003cp\u003eAs presented in Table\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e, the Cronbach\u0026rsquo;s alpha and McDonald's Omega coefficients demonstrated exelant reliability.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eInternal consistency of the City BiTS scale and subscales\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eCronbach\u0026acute;s alpha\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eMcDonald\u0026acute;s omega\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMean inter-item correlation\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal scale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.31\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eSubscale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4 factor solution\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReexperiencing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.49\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAvoidance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.61\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNegative cognitions and mood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.33\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHyperarousal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.55\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2 factor solution\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBirth-related Symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.41\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGeneral Symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.52\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eConvergent and Divergent Validity\u003c/h2\u003e \u003cp\u003eThe convergent validity of the City BiTS was tested via correlations with the IES-R. The City BiTS total scale and subscales correlated significantly with the IES-R total score (total score: \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.53; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001; Birth-related Symptoms score: \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.36; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001; General Symptoms score: \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.50; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001)\u003c/p\u003e \u003cp\u003eDivergent validity of the City BiTS we tested via correlations with depression symptoms (EPDS) and anxiety symptoms (EPDS-3A, GAD-7). The City BiTS total score correlated significantly, with a moderate effect size, with the EDPS (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.60; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001) total score andGAD-7 (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.58; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001). The Birth-related Symptoms score correlated significantly, with a moderate effect size, with the EDPS (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.37; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001), GAD-7 (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.31; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001),. The General Symptoms score correlated significantly, with a moderate effect size, with the EDPS (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.61; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001) total score, GAD-7 (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.61; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003ePTSD Criteria\u003c/h2\u003e \u003cp\u003eResponses to the City BiTS following DSM-5 criteria for PTSD are shown in Table\u0026nbsp;\u003cspan refid=\"Tab8\" class=\"InternalRef\"\u003e8\u003c/span\u003e. About 37% of women fulfilled criterion A of DSM-5 by indicating that they believed they or their baby would be seriously injured or even die during childbirth (or immediately afterwards). More than half of them re-experienced the birth and reported negative cognition and mood. More than 70% experienced hyperarousal and one-fifth of them reported avoidance symptoms. 16 women (6.2%) fulfilled all criteria for CB-PTSD.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab8\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 8\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003ePTSD and PTSD criteria prevalence (N\u0026thinsp;=\u0026thinsp;320).\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercent\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePTSD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCriterion A Stressor Criterion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFulfilled\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e118\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e36.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCriterion B Re-experiencing symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFulfilled\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e168\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e52.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCriterion C Avoidance symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFulfilled\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e21.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCriterion D Negative cognitions and mood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFulfilled\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e183\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e57.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCriterion E Hyperarousal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFulfilled\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e230\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e71.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCriterion F Duration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFulfilled\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e135\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e42.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCriterion G Distress and impairment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFulfilled\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e136\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e42.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCriterion H Exclusion criteria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFulfilled\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe current study details the Ukrainian validation of the City BiTS, a measure specifically designed to assess CB-PTSD, aligning with DSM-5 criteria. Consistent with other language versions, the Ukrainian City BiTS was found to be a reliable and valid instrument.\u003c/p\u003e \u003cp\u003eIn line with the Croatian [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], French [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], and Australian [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] adaptations of the City BiTS, the bifactor model, comprising a general factor along with two specific factors related to childbirth-related symptoms and general symptoms, demonstrated the best fit to the data .\u003c/p\u003e \u003cp\u003eThe correlations between City BiTS and IES-R are lower than in other studies [9; 19]. The association of depression and anxiety scores with the Birth-related Symptoms subscale was lower compared to the General Symptoms subscale and the overall scale of the City BiTS, indicating divergent validity. These results are in line with other studies [24; 9; 19] and demonstrate good construct validity of the Ukranian CITY BiTS.\u003c/p\u003e \u003cp\u003eIn our sample, 6.2% of women fulfilled DSM-5 diagnostic criteria for CB-PTSD. The CB-PTSD symptoms among Ukrainian postpartum mothers, although measured during war conditions, does not differ significantly compared to results obtained in postpartum mothers in other countries or even had lower birth PTSD prevalence. For the comparison, we have chosen the online suerveys as the anonymity offered by the online environment may increase participants’ willingness to disclose sensitive or perceived as shameful information [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. The incidence rate in Ukrainian population is 2.5 – almost 3 times higher than in in Germany − 2.6% [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], Israel − 2.4% [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] but lower than in the UK − 7.1% [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], 11.8% [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] (online survey) and Lithuania − 8% [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAbout 37% of our respondents met criterion A by indicating that they believed they or their baby would be seriously injured or even die during childbirth (or immediately afterwards), which is however much higher than in other European countries. For example in Croatia 31.18% of online assessed mothers fulfilled Criterion A [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], in Germany (also online assessment) − 22% ;[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], in England − 20.3% [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]; Ayers et alonline survey), in Lithuania (also online assessment) − 28.6% [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. More than half of our participants re-experienced the birth and reported negative cognition and mood. More than 70% experienced hyperarousal and one-fifth of them reported avoidance symptoms.\u003c/p\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and Limitations\u003c/h2\u003e \u003cp\u003eThis study has several strengths. The study procedure was directed following the Standards for Educational and Psychological Testing [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. It includes a large sample of postpartum Ukrainian women.\u003c/p\u003e \u003cp\u003eRegardless of these strengths, this study has some limitations. First, the data were collected during Ukrainian-Russian war, which could influence the generalizability of the results. The participants were gathered online, which limits inclusion to individuals who engage with technology and social platforms where the study was promoted. The majority of the respondents were women with higher education and a good financial situation, which may not reflect the results obtained by other social groups. Due to the technical problem, responses to items referring to participants' age were not recorded.Another limitation of our study is that we do not have data about PTSD symptoms prior to childbirth.\u003c/p\u003e \u003c/div\u003e "},{"header":"Conclusion and Implications for Practice","content":"\u003cp\u003eThe Ukranian validation of the The City Birth Trauma Scale is valid and reliable method to measure birth-related PTSD in research and clinical work.\u003c/p\u003e\u003cp\u003eThe CB-PTSD incidence rate is 6.2% and is similar to other countries, 37% of the participants fulfill the criterion A of DSM-5, indicating that they believed they or their baby would be seriously injured or even die, what is one of the highest number in Europe.\u003c/p\u003e\u003cp\u003eWe encourage midwives and health care professionals to be aware of any related needs that may arise from the elvated CB-PTSD symptoms, such as the necessity for discussing this experience or increased anxiety related to subsequent deliveries.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe research was condacted in accordance with the Declaration of Helsinki The studies involving human participants were reviewed and approved by Comit\u0026eacute; de \u0026Eacute;tica de la Investigaci\u0026oacute;n, UNED (Madrid), the Research Ethics Committee of the Faculty of Psychology of Taras Shevchenko National University of Kyiv. The patients/participants provided their written informed consent to participate in this study.\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThis paper is based upon work from the COST Action Riseup-PPD CA 18138 and was supported by COST under COST Action Riseup-PPD CA18138 www.cost.eu. However, sponsor did not have any involvement in the study design, collection, analysis and interpretation of data, writing of the report nor the decision to submit the article for publication.\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eMch-D contributed to conception and design of the study, wrote and edited the first draft of the manuscript. AU contributed to conception and design of the study. HG-L organized the database. NM contribute dto the design of the study writing the draft and edited version and descriptive statistics part. LK and OM-L and AV contributed to conception and design of the study and provided the translation of the method as well to the data collection process. SNR and HM and RC contributed to the methodology and data analysis. SNR and RC and MR-M reviewed and edited the final version. All authors contributed to the article and approved the submitted version.\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eAcknowledgments\u0026nbsp;\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eWe would like to thank to all Ukrainian women who have participated in the study and were eager to share their experience in this extremely difficult war situation which affected their lives and their country.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eRaphael-Leff J. Healthy Maternal Ambivalence. Stud Maternal. 2010;2(1):1-15. doi: 10.16995/sim.97.\u003c/li\u003e\n\u003cli\u003eNetsi E, Pearson RM, Murray L, Cooper P, Craske MG, Stein A. Association of Persistent and Severe Postnatal Depression With Child Outcomes. 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Prevalence and risk factors of postpartum posttraumatic stress disorder: a meta-analysis. Clin Psychol Rev. 2014;34(5):389-401. doi: 10.1016/j.cpr.2014.05.003.\u003c/li\u003e\n\u003cli\u003eAmerican Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed., text rev. Washington, DC: American Psychiatric Association; 2022. doi: 10.1176/appi.books.9780890425787.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. ICD-10: international statistical classification of diseases and related health problems. 10th rev., 2nd ed. Geneva: World Health Organization; 2004. Available from: https://iris.who.int/handle/10665/42980\u003c/li\u003e\n\u003cli\u003eNakić Rado\u0026scaron; S, Matija\u0026scaron; M, Kuhar L, Anđelinović M, Ayers S. Measuring and conceptualizing PTSD following childbirth: Validation of the City Birth Trauma Scale. Psychol Trauma. 2020;12(2):147-55. doi: 10.1037/tra0000501.\u003c/li\u003e\n\u003cli\u003eBreslau N, Chilcoat HD, Kessler RC, Davis GC. Previous exposure to trauma and PTSD effects of subsequent trauma: results from the Detroit Area Survey of Trauma. Am J Psychiatry. 1999;156(6):902-7. doi: 10.1176/ajp.156.6.902.\u003c/li\u003e\n\u003cli\u003eAncheva I, Morozova K. Post-traumatic Stress Disorder amongst Internally Displaced Pregnant Females. 2016. doi: 10.9734/JALSI/2016/28130.\u003c/li\u003e\n\u003cli\u003eChan SJ, Ein-Dor T, Mayopoulos PA, Mesa MM, Sunda RM, McCarthy BF, et al. Risk factors for developing posttraumatic stress disorder following childbirth. Psychiatry Res. 2020;290:113090. doi: 10.1016/j.psychres.2020.113090.\u003c/li\u003e\n\u003cli\u003eKurapov A, Kalaitzaki A, Keller V, Danyliuk I, Kowatsch T. The mental health impact of the ongoing Russian-Ukrainian war 6 months after the Russian invasion of Ukraine. Front Psychiatry. 2023;14:1134780. doi: 10.3389/fpsyt.2023.1134780.\u003c/li\u003e\n\u003cli\u003eAyers S, Wright DB, Thornton A. Development of a measure of postpartum PTSD: the City Birth Trauma Scale. Front Psychiatry. 2018;9:409. doi: 10.3389/fpsyt.2018.00409.\u003c/li\u003e\n\u003cli\u003eRiklikienė O, Jara\u0026scaron;iūnaitė-Fedosejeva G, Sakalauskienė E, Luneckaitė Ž, Ayers S. Translation and Validation of the City Birth Trauma Scale With Lithuanian Postpartum Women: Findings and Initial Results. Eval Health Prof. 2024;0(0). doi: 10.1177/01632787241239339.\u003c/li\u003e\n\u003cli\u003eFameli AL, Costa DSJ, Coddington R, Hawes DJ. Assessment of childbirth-related post traumatic stress disorder in Australian mothers: Psychometric properties of the City Birth Trauma Scale. J Affect Disord. 2023;324:559-65. doi: 10.1016/j.jad.2022.12.123.\u003c/li\u003e\n\u003cli\u003eSt\u0026eacute;n G, Ayers S, Malmquist A, Nieminen K, Grundstr\u0026ouml;m H. Assessment of maternal posttraumatic stress disorder following childbirth: Psychometric properties of the Swedish version of City Birth Trauma Scale. Psychol Trauma. 2023;15(7):1153-63. doi: 10.1037/tra0001465.\u003c/li\u003e\n\u003cli\u003eOs\u0026oacute;rio FL, Rossini Darwin AC, Bombonetti EA, Ayers S. Posttraumatic stress following childbirth: psychometric properties of the Brazilian version of the City Birth Trauma Scale. J Psychosom Obstet Gynaecol. 2022;43(3):374-83. doi: 10.1080/0167482X.2021.1977278.\u003c/li\u003e\n\u003cli\u003eWeigl T, Beck-Hiestermann FML, Stenzel NM, Benson S, Schedlowski M, Garthus-Niegel S. Assessment of childbirth-related PTSD: psychometric properties of the German Version of the City Birth Trauma Scale. Front Psychiatry. 2021;12:731537. doi: 10.3389/fpsyt.2021.731537.\u003c/li\u003e\n\u003cli\u003eSandoz V, Hingray C, Stuijfzand S, Lacroix A, El Hage W, Horsch A. Measurement and conceptualization of maternal PTSD following childbirth: Psychometric properties of the City Birth Trauma Scale\u0026mdash;French Version (City BiTS-F). Psychol Trauma. 2022;14(4):696. doi: 10.1037/tra0001068.\u003c/li\u003e\n\u003cli\u003eCaparros-Gonzalez RA, Romero-Gonzalez B, Peralta-Ramirez MI, Ayers S, Gal\u0026aacute;n-Paredes A, Caracuel-Romero A. Assessment of posttraumatic stress disorder among women after childbirth using the City Birth Trauma Scale in Spain. Psychol Trauma. 2021;13(5):545. doi: 10.1037/tra0001007.\u003c/li\u003e\n\u003cli\u003eBayrı Bing\u0026ouml;l F, Bal MD, Dişsiz M, Sormage\u0026ccedil; MT, Yildiz PD. Validity and reliability of the Turkish version of the City Birth Trauma Scale (CityBiTS). J Obstet Gynaecol. 2021;41(7):1023-31. doi: 10.1080/01443615.2020.1821354.\u003c/li\u003e\n\u003cli\u003eShen Z, Zhou Y, Zhu D, Zhu J, Wei J, Cao W. Translation of the Chinese version of the City Birth Trauma Scale and the test of its reliability and validity. Chin J Nurs. 2020;55(11):1757-61. doi: 10.3761/j.issn.0254-1769.2020.11.028.\u003c/li\u003e\n\u003cli\u003eHandelzalts JE, Hairston IS, Matatyahu A. Construct validity and psychometric properties of the Hebrew version of the City Birth Trauma Scale. Front Psychol. 2018;9:1726. doi: 10.3389/fpsyg.2018.01726.\u003c/li\u003e\n\u003cli\u003eBrislin RW. Back-translation for cross-cultural research. J Cross Cult Psychol. 1970;1(3):185-216. doi: 10.1177/135910457000100301.\u003c/li\u003e\n\u003cli\u003eWeiss DS, Marmar CR. The Impact of Event Scale-Revised. In: Wilson JP, Keane TM, editors. Assessing Psychological Trauma and PTSD: A Practitioner\u0026rsquo;s Handbook. New York: Guilford Press; 1997. p. 399-411.\u003c/li\u003e\n\u003cli\u003eCox L, Holden JM, Sagovsky R. Detection of postnatal depression: development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry. 1987;150(6):782-6.\u003c/li\u003e\n\u003cli\u003eSpitzer RL, Kroenke K, Williams JB, L\u0026ouml;we B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166(10):1092-7. doi: 10.1001/archinte.166.10.1092.\u003c/li\u003e\n\u003cli\u003eAmerican Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, DC: American Psychiatric Publishing; 1994.\u003c/li\u003e\n\u003cli\u003eAmerican Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed., text rev. Washington, DC: American Psychiatric Publishing; 2000.\u003c/li\u003e\n\u003cli\u003eBentler PM, Chou CP. Practical issues in structural modeling. Sociol Methods Res. 1987;16:78-117. doi: 10.1177/0049124187016001004.\u003c/li\u003e\n\u003cli\u003eByrne B. Structural equation modeling with AMOS: Basic concepts, applications, and programming. 2nd ed. New York: Taylor \u0026amp; Francis; 2010.\u003c/li\u003e\n\u003cli\u003eBrowne MW, Cudeck R. Alternative ways of assessing model fit. In: Bollen KA, Long JS, editors. Testing structural equation models. Newbury Park, CA: Sage; 1993. p. 136-62.\u003c/li\u003e\n\u003cli\u003eHu L, Bentler PM. Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. Struct Equ Modeling. 1999;6(1):1-55. doi: 10.1080/10705519909540118.\u003c/li\u003e\n\u003cli\u003eAkaike H. Factor analysis and AIC. Psychometrika. 1987;52(3):317-32. doi: 10.1007/BF02294359.\u003c/li\u003e\n\u003cli\u003eTabachnick BG, Fidell LS. Using multivariate statistics. 5th ed. Boston: Pearson; 2007.\u003c/li\u003e\n\u003cli\u003eSijtsma K. On the use, the misuse, and the very limited usefulness of Cronbach\u0026apos;s alpha. Psychometrika. 2009;74(1):107-20. doi: 10.1007/s11336-008-9101-0.\u003c/li\u003e\n\u003cli\u003eTen Berge JMF, Sočan G. The greatest lower bound to the reliability of a test and the hypothesis of unidimensionality. Psychometrika. 2004;69(4):613-25. doi: 10.1007/bf02289858.\u003c/li\u003e\n\u003cli\u003eBonifay WE, Reise SP, Scheines R, Meijer RR. When are multidimensional data unidimensional enough for structural equation modeling? An evaluation of the DETECT multidimensionality index. Struct Equ Modeling. 2015;22(4):504-16. doi: 10.1080/10705511.2014.938596.\u003c/li\u003e\n\u003cli\u003eReise, S. P., Scheines, R., Widaman, K. F., \u0026amp; Haviland, M. G. (2013). Multidimensionality and structural coefficient bias in structural equation modeling: A bifactor perspective. Educational and Psychological Measurement, 73(1), 5-26. https://doi.org/10.1177/0013164412449831\u003c/li\u003e\n\u003cli\u003eRodriguez, A., Reise, S. P., \u0026amp; Haviland, M. G. (2016). Applying bifactor statistical indices in the evaluation of psychological measures. Journal of Personality Assessment, 98(3), 223-237. https://doi.org/10.1080/00223891.2015.1089249 \u003c/li\u003e\n\u003cli\u003eHancock, G. R., \u0026amp; Mueller, R. O. (2001). Rethinking Construct Reliability within Latent Variable Systems. In R. Cudeck, S. du Toit, \u0026amp; D. S?rbom (Eds.), Structural Equation Modeling: Present und Future\u0026mdash;A Festschrift in Honor of Karl Joreskog (pp. 195-216). Lincolnwood, IL: Scientific Software International.\u003c/li\u003e\n\u003cli\u003eFerrando, P., \u0026amp; Lorenzo-Seva, U. (2017). Assessing the Quality and Appropriateness of Factor Solutions and Factor Score Estimates in Exploratory Item Factor Analysis. Educational and Psychological Measurement, 78. https://doi.org/10.1177/0013164417719308 \u003c/li\u003e\n\u003cli\u003eNunnally, J.C. and Bernstein, I.H. (1994) The Assessment of Reliability. Psychometric Theory, 3, 248-292.\u003c/li\u003e\n\u003cli\u003eField, A. (2005) Reliability analysis. In: Field, A., Ed., Discovering Statistics Using spss. 2nd Edition, Sage, London\u003c/li\u003e\n\u003cli\u003eKline, R.B. (2011) Principles and Practice of Structural Equation Modeling. Guilford Press, New York.\u003c/li\u003e\n\u003cli\u003eChrzan-Dętkoś, M.; Murawska, N.; Walczak-Kozłowska, T.(2022). \u0026lsquo;Next Stop: Mum\u0026rsquo;: Evaluation of a Postpartum Depression Prevention Strategy in Poland. International . J. Environ. Res. Public Health; 19, 11731. https://doi.org/10.3390/ijerph191811731\u003c/li\u003e\n\u003cli\u003eAmerican Educational Research Association et al. (2014,editors). The Standards for Educational and Psychological Testing. American Educational Research Association.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"birth trauma, PTSD, war, Ukraine, postpartum, women, validation, EPDS, GAD-7, City BiTS","lastPublishedDoi":"10.21203/rs.3.rs-4929867/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4929867/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere is no validated Ukrainian instrument for assessing childbirth-related Post-Traumatic Stress Disorder (CB-PTSD) according to DSM-5 criteria.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjectives\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEvaluate the psychometric properties of the Ukrainian version of the City Birth Trauma Scale (City BiTS) and examine its factor structure.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn a cross-sectional study, 320 women completed online questionnaires, including the City BiTS, Edinburgh Postnatal Depression Scale (EPDS), Generalized Anxiety Disorder (GAD-7) questionnaire, and a sociodemographic questionnaire.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe prevalence of CB-PTSD in Ukraine was 6.2%. Confirmatory analyses were conducted to assess the fit of two-factor and four-factor models, as well as a bifactor model. The bifactor model was found to be the best-fitting model. The examination of the bifactor indices supported the computation of a total PTSD score as well as the use of the General Symptoms subscale, which emerged as distinct and well-defined factors. Both subscales (Birth-Related Symptoms subscale and General Symptoms subscale) and the total scale demonstrated high internal consistency (Cronbach's α = .92). Convergent and divergent validity testing indicated robust validity, particularly for General symptoms score.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe City BiTS emerged as a reliable and valid measure, recommended for use among Ukrainian women in the postpartum period as a screening method.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration. \u003c/strong\u003eClinical trial registration was completed at ClinicalTrials.gov under identifier NCT05654987 (Date: December 16, 2022)..\u003c/p\u003e","manuscriptTitle":"Assessment of childbirth-related PTSD: Psychometric properties of the Ukrainian version of City Birth Trauma Scale","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-09-17 12:37:57","doi":"10.21203/rs.3.rs-4929867/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9297c38b-7919-4987-bb8a-00a1862d2007","owner":[],"postedDate":"September 17th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-11-26T05:53:14+00:00","versionOfRecord":[],"versionCreatedAt":"2024-09-17 12:37:57","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4929867","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4929867","identity":"rs-4929867","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}