Understanding Relationships Between Birth Trauma, Helplessness, and Perinatal Mental Health Disorders

Understanding Relationships Between Birth Trauma, Helplessness, and Perinatal Mental Health Disorders | 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 Understanding Relationships Between Birth Trauma, Helplessness, and Perinatal Mental Health Disorders Stephanie Hanson This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8156257/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: Birth trauma and perinatal mental health disorders (PMHDs) are significant public health concerns, yet their interrelationships and underlying psychosocial mechanisms remain underexplored. This study examined associations between birth trauma, feelings of helplessness, and PMHDs among postpartum women. Methods: A cross-sectional survey was administered to U.S. women 4–7 months postpartum via Amazon Mechanical Turk. Eligible participants (N = 249) completed validated measures assessing birth trauma, helplessness, and PMHDs, including depression, anxiety, obsessive-compulsive disorder (OCD), bipolar disorder, and psychosis. Modified Poisson and linear regression models evaluated associations, adjusting for sociodemographic and obstetric factors. Results Birth trauma was reported by 21.3% of participants, and 21.7% reported feelings of helplessness. PMHD prevalence was high: OCD (93.6%), depression (84.7%), anxiety (81.9%), bipolar disorder (10%), and psychosis (3.2%). All participants reporting birth trauma screened positive for at least one PMHD. Birth trauma was positively associated with helplessness (adjusted RR = 1.40; 95% CI: 1.18–1.66). Higher helplessness scores predicted increased risk and symptom severity for depression (RR = 1.10), anxiety (RR = 1.13), and OCD (RR = 1.05), with linear models confirming associations across all PMHDs. Associations with bipolar disorder and psychosis were weaker and inconsistent across models. Conclusions Findings highlight helplessness as a potential psychological mechanism linking birth trauma to diverse PMHDs. Integrating trauma-informed, empowerment-oriented care into perinatal practice and routine screening for birth trauma and helplessness may mitigate postpartum psychopathology. Future research should employ longitudinal designs to clarify causal pathways and inform targeted interventions. Psychology perinatal mental health birth trauma birth women's health Background For many women, childbirth can be a traumatic experience; and approximately 45% of women who give birth experience birth trauma (Alcorn et al., 2010 ). Nearly 20% of women also report perinatal mental health disorders (Womersley & Alderson, 2024 ). Perinatal mental health disorders (PMHDs) include six disorders that occur during the traditionally defined perinatal period (i.e., conception through one year postpartum): perinatal depression, perinatal anxiety, perinatal post-traumatic stress disorder, perinatal obsessive-compulsive disorder, perinatal bipolar disorder, and postpartum psychosis (Howard et al., 2020 ). Some scholars have separately linked birth trauma and perinatal depression to long-term physical and mental health consequences for both the mother and the infant (Meltzer-Brody & Stuebe, 2014 ), including cardiometabolic disease (Schwartz et al., 2009), reduced lactation initiation and duration (Dennis & McQueen, 2009 ; Grigoriadis et al, 2013) and delayed infant development (Meltzer-Brody & Stuebe, 2014 ). Some scholars have also linked birth trauma to perinatal post-traumatic stress disorder and perinatal depression (Molloy et al., 2021 ; Priddis et al., 2018 ; Sun et al. 2023 ). However, there has been limited exploration of psychosocial factors that may influence the relationship between birth trauma and all PMHD health outcomes. Although the literature on birth trauma and PMHDs has expanded in recent decades, empirical inquiry has disproportionately concentrated on birth trauma’s association with perinatal depression and perinatal post-traumatic stress disorder (PTSD). Numerous quantitative and qualitative studies have documented that women who appraise their childbirth as traumatic are at significantly higher risk of developing perinatal depression (Ayers et al., 2016 ; Bell & Anderson, 2016; Molloy et al. 2021 ) and perinatal PTSD (Ayers et al., 2016 ; Dekel et al., 2017 ; Grekin & O’Hara, 2014 ; Simpson & Catling, 2016 ), with robust evidence linking trauma-related intrusions, hyperarousal, and negative mood to persistent postpartum functional impairment. In contrast, far fewer investigations have examined how birth trauma may contribute to the onset or exacerbation of other PMHDs—such as perinatal anxiety, perinatal obsessive-compulsive disorder, perinatal bipolar disorder, or postpartum psychosis—despite their documented prevalence and potential for severe maternal and infant morbidity (Howard et al., 2020 ; Womersley & Alderson, 2024 ). This imbalance in the literature limits the comprehensiveness of the collective understanding of the broader psychiatric sequelae of birth trauma and constrains the development of tailored preventive and therapeutic interventions beyond those targeting depressive and PTSD symptomatology. Conceptually, birth trauma and PMHDs may be linked through empowerment theory. Empowerment theory includes four concepts that are positively associated with intrapersonal empowerment (CPAE; self-efficacy, perceived competence, motivation to control, and perceived control) and four concepts that are negatively associated with intrapersonal empowerment (CNAE; helplessness, powerlessness, loss of sense of control, and social isolation) (Zimmerman, 1995 ). Women in non-perinatal populations with mental health disorders, including depression and anxiety, often report feelings of helplessness (Abdoli et al., 2022), powerlessness (Gunasiri et al., 2022 ), and loss of sense of control (Capaldi et al., 2025 ), which individuals report as being negative contributors to their PMHD symptoms; however, these concepts have only loosely been linked to the perinatal population in extant literature. The aim of this study was to examine two research questions: (1) What are the relationships between birth trauma and helplessness? and (2) What are the relationships between helplessness and PMHDs? Helplessness was randomly chosen as the first concept to examine as a potential factor in these relationships. Understanding these relationships would provide opportunities for the development and implementation of interventions designed to mitigate the negative PMHD outcomes associated with birth trauma. Methods Data Source and Data Collection Participants were recruited for this cross-sectional study via Amazon’s Mechanical Turk (MTurk) crowdsourcing platform. Inclusion criteria required participants to: (a) be at least 18 years old, (b) residing in the United States, (c) be fluent in written and spoken English, (d) be between four and seven months postpartum, (e) not be enrolled in inpatient mental health or substance use treatment, and (f) not be experiencing an active mental health crisis or emergency. Eligibility was assessed using a self-report screening survey. Individuals meeting these criteria proceeded to an electronic consent (eConsent) process in which they reviewed the informed consent document and indicated agreement to participate. Following consent, participants completed a 167-item online questionnaire assessing demographic variables and mental health outcomes. All procedures, including screening, consent, and survey completion, were administered via REDCap, a HIPAA-compliant data collection platform developed by Vanderbilt University (Patridge & Bardyn, 2018). Participants received $ 20 for completing the survey, which was conducted in December 2024. Data quality was ensured through multiple safeguards. Captcha verification confirmed human participation. Several items were repeated in varied formats or across different survey sections to evaluate internal consistency; cases with inconsistent responses were excluded. For duplicate submissions, only the first complete entry was retained. A priori power analysis indicated a minimum of 166 participants was required to detect statistically significant differences at 80% power with α = .05, assuming postpartum mental health disorder (PMHD) prevalence rates of 40% among those with birth trauma and 20% among those without (Isobel et al., 2024). Of 300 survey completions, 7 duplicates, 35 low-quality or inconsistent responses, and 9 cases reporting PMHD symptom onset prior to childbirth were excluded, yielding a final analytic sample of 249 participants. Sample The final sample (N = 249) represented 35 U.S. states. Participants’ ages ranged from 22 to 55 years (M = 29.75, SD = 4.30). Most identified as White (97.6%, n = 243) and non-Hispanic/Latino (95.2%, n = 237). Household income distribution was as follows: $ 25,000– $ 34,999 (19.3%, n = 48), $ 35,000– $ 49,999 (10.0%, n = 25), $ 50,000– $ 74,999 (22.1%, n = 55), $ 75,000– $ 99,999 (15.3%, n = 38), and $ 100,000– $ 149,999 (15.3%, n = 38). Most held a Bachelor’s (66.7%, n = 166) or Master’s degree (30.9%, n = 77). Insurance coverage included Medicaid (70.2%, n = 181) and private insurance (22.9%, n = 57). Most births occurred in hospital settings (73.4%, n = 183), and just over half were vaginal deliveries (52.6%, n = 131). Measures Birth Trauma and Post-Traumatic Stress Disorder Birth trauma was measured using the 29-item City Birth Trauma Scale (CBTS; Ayers et al., 2018 ). The first two items assessed Criterion A for trauma—actual or perceived threat of death or serious injury to the mother or infant during labor, birth, or immediately afterward. Endorsing either item constituted birth trauma. Although the CBTS includes items assessing PTSD symptoms, these were not analyzed because postpartum PTSD was excluded from this study. Postpartum Depression Depression symptoms were assessed using the Edinburgh Postnatal DepressionScale (EPDS; Cox et al., 1987 ). This 10-item self-report scale measures depressive symptoms over the past 7 days, rated from 0 to 3, with six items reverse-scored. Total scores range from 0 to 30, categorized as minimal (0–6), mild (7–13), moderate (14–19), and severe (20–30). A cutoff of ≥ 13 indicated probable postpartum depression (Levis et al., 2020). Reliability for the EPDS has been reported as α = 0.83 for a one-factor model (Moyer et al., 2024 ); in this sample, α = 0.79. Postpartum Anxiety Anxiety symptoms were measured with the Perinatal Anxiety Screening Scale (PASS; Somerville et al., 2014), a 31-item scale assessing symptom frequency over the past month on a 0 (“not at all”) to 3 (“almost always”) scale. Total scores (0–93) are categorized as minimal (0–20), moderate (21–41), or severe (42–93). A cutoff score of ≥ 21 indicated clinically significant anxiety. Previous research in U.S. samples reported α = 0.96 (Koukopoulos et al., 2021); in this study, α = 0.96. Postpartum Obsessive-Compulsive Disorder Obsessive-compulsive symptoms were measured using the Dimensional Obsessive-CompulsiveScale (DOCS; Abramowitz, 2010). This 20-item measure assesses four domains: germs/contamination, responsibility for harm or bad luck, unacceptable thoughts, and symmetry/completeness. Items are scored from 0 (“none at all”) to 4 (“8 + hours/day” or “complete disruption”), yielding total scores from 0 to 80. A score ≥ 21 indicated probable OCD. In this sample, α = 0.93. Postpartum Bipolar Disorder Bipolar symptoms were assessed using the Mood Disorder Questionnaire (MDQ; Hirschfield et al., 2000). Participants responded “yes” or “no” to 13 items, then indicated whether symptoms occurred simultaneously and the degree of functional impairment. A positive screen required ≥ 7 endorsed symptoms, concurrent occurrence, and at least moderate impairment. The MDQ has been validated for perinatal populations (American College of Obstetrics and Gynecology, 2024 ). In this sample, α = 0.80. Postpartum Psychosis Psychosis symptoms were assessed using the Psychosis Symptom Checklist (PSC; Policy Center for Maternal Mental Health, 2022 ), which measures the presence of 16 symptoms (e.g., delusions, hallucinations, paranoia, catatonia). The total score reflects the number of symptoms endorsed; a cutoff score ≥ 6 was applied, representing two standard deviations above the sample mean. In this sample, α = 0.35. Helplessness Helplessness was measured using one prompt that was specific to each woman’s most recent birth. The prompt was, “How often did you feel helpless during birth?” Participants could respond by selecting 0 = “I never felt helpless during birth,” 1 = “I rarely felt helpless during birth,” 2 = “I sometimes felt helpless during birth,” 3 = “I often felt helpless during birth”, or 4 = “I felt helpless most of the time during birth.” Sociodemographic and Birth-related Variables The survey included both sociodemographic and birth-related items, all of which were self-reported. Age, race, ethnicity, and number of previous births were collected via open-text responses. Participants selected responses from predefined options for state of residence, total household income, birth modality, and delivery type. Household income was reported using standardized ranges from the United States Census Bureau (United States Census Bureau, 2024 ). Race, ethnicity, and state of residence were excluded from analysis due to insufficient cell sizes. Insurance type, education level, and birth location were coded as categorical variables. Birth modality was coded as a binary variable, and delivery type was coded as a categorical variable. Data Analysis Data analysis was completed using SPSS Version 29.0.2.0 (IBM Corporation, 2023). Graphical exploration of the relationships confirmed linear associations between exposures and outcomes to ensure helplessness could be input into models as a continuous predictor. Modified Poisson regression with a log link and robust standard errors and linear regression analyses were performed to answer the study research questions. Modified Poisson regression results for the relationship between birth trauma and helplessness are presented in Table 3. Crude and adjusted linear regression results for the relationship between birth trauma and helplessness are presented in Table 4. Modified Poisson regression analyses were run to examine the relationship between helplessness and the presence or absence of a positive screening result for all included PMHDs. Linear regression analyses were run to examine the relationship between helplessness and total symptoms for each PMHD. For the covariance matrix in the modified Poisson regression, the robust estimator was selected. When the modified Poisson regressions were run, helplessness was put in as a continuous predictor, and binary outcomes were put into the models for the included PMHDs. For linear regression analyses, helplessness was included in all models as a continuous variable. For all included PMHDs, total scores on each of the screening scales was the dependent variable, with higher scores representing increased presentation of symptoms. All modified Poisson regression analyses and linear regression analyses were adjusted for age, income, insurance, birth location, birth modality, delivery type, and number of previous live births. In Table 5, modified Poisson regression results are presented for the relationship between helplessness and PMHDs. Crude and adjusted linear regression results for the relationship between helplessness and PMHDs are presented in Table 6. Results Women’s Reports of Birth Trauma, Helplessness, and PMHDs Birth experience and mental health data is presented in Table 2. Slightly more than one-fifth of respondents reported experiencing birth trauma ( n = 53, 21.3%). Nearly the same number of respondents (21.7%, n = 54) reported feelings of helplessness. Within the sample, the prevalence for each PMHD was: depression ( n = 211, 84.7%), anxiety ( n = 204, 81.9%), OCD ( n = 223, 93.6%), bipolar disorder ( n = 25, 10%), and psychosis ( n = 8, 3.2%). Each of the 53 respondents who reported birth trauma screened positive for at least one PMHD. Within the entire sample, 1.6% of participants ( n = 4) screened positive for no PMHDs, 10.4% ( n = 26) screened positive for one PMHD, 12.0% ( n = 30) screened positive for two PMHDs, 63.9% ( n = 159) screened positive for three PMHDs, 9.6% ( n = 24) screened positive for four PMHDs, 2.4% screened positive for five PMHDs. Of the 53 participants who self-reported experiencing birth trauma, 49 (92.5%) screened positive for depression, 53 (100%) screened positive for anxiety, 51 (96.2%) screened positive for OCD, 17 (32.1%) screened positive for bipolar disorder, and eight (15.1%) screened positive for psychosis. For the 196 participants who did not self-report experiencing birth trauma, 82.7% ( n = 162) screened positive for depression, 77.0% ( n = 151) screened positive for anxiety, 0% ( n = 0) screened positive for PTSD, 92.9% ( n = 182) screened positive for OCD, 4.1% screened positive for bipolar disorder, and 0% ( n = 0) screened positive for psychosis. Birth Trauma and Helplessness In the adjusted modified Poisson regression model (Table 3), there was a positive association between birth trauma and feelings of helplessness (RR: 1.40; 95% CI: 1.18–1.66). In the linear regression model, there was a positive relationship between birth trauma and helplessness (β = 0.47; 95% CI: 0.18–0.76). A positive association between birth trauma and helplessness was also present in the linear regression model after adjusting for age, income, insurance type, education level, birth location, birth modality, delivery type, and number of previous live births (β = 0.57; 95% CI: 0.27–0.86). Helplessness and PMHDs Depression The modified Poisson regression analysis revealed an increased risk for developing depression when postpartum depression is a binary outcome (RR: 1.10; 95% CI: 1.03–1.18), after adjusting for age, income, insurance, degree, birth location, birth modality, delivery type, and number of previous live births when comparing individuals with higher total helplessness scores to individuals with lower total helplessness scores. When the total score on the EPDS was used as a continuous outcome variable in the adjusted linear regression analysis there was a positive relationship between helplessness and postpartum depression (β: 1.37; 95% CI: 0.75–1.99). Anxiety The modified Poisson regression analysis for anxiety (Table 5) indicated that individuals with increased helplessness scores have an increased relative risk for screening positive for postpartum anxiety when compared with individuals with lower helplessness scores (RR: 1.13; 95% CI: 1.06–1.19), after adjusting for age, income, insurance, degree, birth location, birth modality, delivery type, and number of previous births. When the total score on the PASS was the continuous outcome variable (Table 6), adjusted linear regression analysis also showed a positive correlation between higher total helplessness scores and higher scores on the PASS (β: 6.89; 95% CI: 4.74–9.04). Obsessive-Compulsive Disorder Individuals who had higher total helplessness scores were at a slightly increased risk for screening positive for obsessive-compulsive disorder, when compared with individuals who did not have a high total helplessness score in the adjusted, modified Poisson regression model (Table 5) (RR: 1.05; 95% CI: 1.01–1.10). When the total score on the DOCS was used as a continuous outcome variable, there was a positive association between feelings of helplessness and screening positive for OCD (β: 5.54; 95% CI: 4.25–6.84) in the adjusted linear regression model (Table 6). Bipolar Disorder The modified Poisson regression analysis found that after being adjusted for age, income, insurance, degree, birth location, birth modality, delivery type, and number of previous live births (Table 5), there was an increased risk for screening positive for postpartum bipolar disorder for individuals who had higher total helplessness scores than for individuals who had lower total helplessness scores (RR: 1.07; 95% CI: 0.69–1.65). When total score on the MDQ was utilized as the outcome variable in the adjusted linear regression model (Table 6), there was a positive association between total helplessness score and a higher score on the MDQ (β: 0.18; 95% CI: 0.08–0.28). Postpartum Psychosis The modified Poisson regression analysis (Table 5) showed that individuals were at an increased risk for screening positive for postpartum psychosis when total helplessness score was increased compared with screening positive for postpartum psychosis when total helplessness score was lower (RR: 0.81; 95% CI: 0.45–1.46). When the total score on the PSC was a continuous variable in the linear regression model (Table 6), there was a positive association between helplessness and higher scores on the PSC (β: 0.32; 95% CI: 0.15–0.49). Discussion This study examined the prevalence of birth trauma, feelings of helplessness, and postpartum mental health disorders (PMHDs) among women, as well as the associations between these variables. The findings underscore the significant psychological burden experienced by postpartum individuals and highlight the complex interplay between birth experiences and mental health outcomes. Prevalence of Birth Trauma and PMHDs Approximately one-fifth of respondents reported experiencing birth trauma (21.3%), a figure consistent with prior research estimating birth trauma prevalence between 18% and 34% (Ayers et al., 2016 ; Dekel et al. 2017 ). Similarly, feelings of helplessness were reported by 21.7% of participants, suggesting that perceived lack of control during childbirth remains a salient contributor to negative birth experiences. Notably, the prevalence of PMHDs in this sample was strikingly high, with obsessive-compulsive disorder (OCD) reported by 93.6% of participants, followed by depression (84.7%) and anxiety (81.9%). These rates exceed those typically documented in population-based studies, where postpartum depression and anxiety are estimated at 10–20% (Gavin et al., 2005; Dennis et al., 2017). The elevated prevalence may reflect sample characteristics such as recruitment from high-risk populations or reliance on self-report screening tools, which tend to yield higher estimates. Birth Trauma and Mental Health All participants who reported birth trauma screened positive for at least one PMHD, reinforcing the strong association between traumatic birth and adverse psychological outcomes. Compared to those without birth trauma, individuals with trauma exhibited higher rates of bipolar disorder (32.1% vs 4.1%) and psychosis (15.1% vs 0%), suggesting that birth trauma may exacerbate vulnerability to severe psychiatric conditions. These findings align with prior evidence linking traumatic childbirth to increased risk of postpartum PTSD, depression, and anxiety (Grekin & O’Hara, 2014 ), and extend the literature by highlighting associations with bipolar disorder and psychosis—areas that remain unexplored. Helplessness as a Predictor of PMHDs Feelings of helplessness emerged as a significant predictor of multiple PMHDs. Higher helplessness scores were associated with increased risk for depression (RR = 1.10), anxiety (RR = 1.13), and OCD (RR = 1.05), even after adjusting for sociodemographic and obstetric factors. Linear regression analyses further demonstrated positive correlations between helplessness symptom severity across all measured disorders. These findings underscore the role of perceived control and agency during childbirth in shaping postpartum mental health trajectories. The association between helplessness and bipolar disorder, while positive, did not reach statistical significance in the Poisson model, suggesting that additional factors may mediate this relationship. Interestingly, helplessness was not associated with increased risk of psychosis in the Poisson model (RR = 0.81), though continuous analyses in the linear regression model indicated a positive correlation with psychosis symptom scores. This discrepancy may reflect limitations in statistical power given the low prevalence of psychosis in the sample. Limitations and Future Directions Several limitations should be acknowledged. First, the prevalence rates for PMHDs observed in this study were substantially higher than those reported in population-based research. This discrepancy likely reflects the use of self-report tools and recruitment via Amazon Mechanical Turk, which may attract individuals with elevated mental health concerns. Consequently, findings should be interpreted with caution and not generalized to the broader postpartum population. Second, the measure of helplessness consisted of one single item, limiting construct validity and the ability to capture the multidimensional nature of this concept. Future research should employ validated multi-item scales to strengthen measurement reliability. Third, the sample lacked diversity, with participants predominantly identifying as White and highly educated. This homogeneity constrains the generalizability of results and underscores the need for studies involving more racially, ethnically, and socioeconomically diverse populations. Fourth, internal consistency for the psychosis measure was low (α = 0.35), reducing confidence in findings related to psychosis. Future studies should consider alternative instruments with stronger psychometric properties. Additionally, prior mental health history and social support were not assessed, which may have introduced unmeasured confounding. The cross-sectional design further limits causal inference; longitudinal studies are needed to clarify temporal relationships among birth trauma, helplessness, and PMHDs. Finally, helplessness was assessed only in the context of childbirth and not during pregnancy or postpartum, which may overlook important variations in perceived control across the perinatal period. Implications The findings of this study underscore important considerations for clinical practice and public health strategies aimed at improving maternal mental health outcomes. Despite limitations related to sample representativeness and measurement, the observed associations between birth trauma, helplessness, and PMHDs highlight the need for trauma-informed and empowerment-oriented approaches in perinatal care. From a clinical perspective, integrating routine screening for birth trauma and perceived helplessness into postpartum care protocols could facilitate identification of individuals at elevated risk for mental health difficulties. However, given the high prevalence rates observed in this study—likely influenced by sampling and self-report measures—screening tools should be applied judiciously and interpreted in conjunction with clinical assessment. Interventions that enhance maternal agency and perceived control during childbirth, such as shared decision-making and respectful communication, may help mitigate feelings of helplessness and reduce downstream psychological distress. Public health initiatives should prioritize equitable access to culturally sensitive perinatal mental health services, particularly for populations underrepresented in this study. Expanding provider training in trauma-informed care and empowerment strategies can foster supportive birth environments that reduce vulnerability to PMHDs. Policy efforts to address structural barriers—such as insurance coverage and availability of specialized mental health resources—remain critical for improving outcomes. Finally, future research should employ longitudinal designs and more diverse samples to clarify causal pathways and strengthen generalizability. Using validated multi-item measures of helplessness and psychometrically robust instruments for all PMHDs will enhance reliability. Addressing these gaps will allow for the development of targeted interventions that effectively reduce the burden of postpartum mental illness and promote maternal well-being. Conclusion This study illuminated the profound impact of birth trauma and associated feelings of helplessness on the development and severity of PMHDs. The pervasive presence of multiple PMHDs among women reporting birth trauma underscores the urgency of recognizing traumatic childbirth as a critical public health issue. Helplessness emerged as a potentially pivotal psychological mechanism that may drive the onset and exacerbation of diverse postpartum psychopathologies, offering a valuable target for intervention. These findings call for a shift in perinatal care toward trauma-informed, empowerment-centered practices that promote maternal agency and psychological safety. Future research employing longitudinal designs and qualitative methodologies are needed to further elucidate the causal pathways and develop tailored interventions. Ultimately, integrating trauma awareness and empowerment strategies within clinical and public health frameworks holds promise for significantly improving maternal mental health outcomes and fostering healthier family systems. Declarations This study was approved for human subjects research by the IRB at South Dakota State University (IRB-2402020-EXP). All study participants completed an informed consent process before completing the study survey. References Abdoli, N., Salari, N., Darvishi, N., Jafarpour, S., Solaymani, M., Mohammadi, M., & Shohaimi, S. (2022). The global prevalence of major depressive disorder (MDD) among the elderly: A systematic review and meta-analysis. Neuroscience and biobehavioral reviews , 132 , 1067–1073. https://doi.org/10.1016/j.neubiorev.2021.10.041 Abramowitz, J. S., Deacon, B. J., Olatunji, B. O., Wheaton, M. G., Berman, N. C., Losardo, D., Timpano, K. R., McGrath, P. B., Riemann, B. C., Adams, T., Björgvinsson, T., Storch, E. A., & Hale, L. R. (2010). Assessment of obsessive-compulsive symptom dimensions: development and evaluation of the Dimensional Obsessive-Compulsive Scale. Psychological assessment , 22 (1), 180–198. https://doi.org/10.1037/a0018260 American College of Obstetrics and Gynecology. (2024). Perinatal mental health toolkit . Retrieved December 12 from https://www.acog.org/programs/perinatal-mental-health Alcorn, K. L., O'Donovan, A., Patrick, J. C., Creedy, D., & Devilly, G. J. (2010). A prospective longitudinal study of the prevalence of post-traumatic stress disorder resulting from childbirth events. Psychological medicine , 40 (11), 1849–1859. https://doi.org/10.1017/S0033291709992224 Avci, N., & Kaydirak, M. M. (2023). A qualitative study of women's experiences with obstetric violence during childbirth in Turkey. Midwifery , 121 (July). https://doi.org/10.1016/j.midw.2023.103658 Ayers, S., Bond, R., Bertullies, S., & Wijma, K. (2016). The aetiology of post‐traumatic stress following childbirth: A meta‐analysis and theoretical framework. Psychological Medicine , 46(6), 1121–1134. https://doi.org/10.1017/S0033291715002706 Ayers, S., Wright, D. B., & Thornton, A. (2018). Development of a Measure of Postpartum PTSD: The City Birth Trauma Scale. Front Psychiatry , 9 , 409. https://doi.org/10.3389/fpsyt.2018.00409 Beck, C. T. (2004). Birth trauma: In the eye of the beholder. Nursing Research, 53 (1), 28–35. https://doi.org/10.1097/00006199-200401000-00005 Bell, A. F., & Andersson, E. (2016). The birth experience and women's postnatal depression: A systematic review. Midwifery , 39, 112–123. https://doi.org/10.1016/j.midw.2016.04.014 Capaldi, C. A., Wassef, K., Varin, M., Vallières, E., & Roberts, K. C. (2025). Sense of control and positive mental health outcomes among adults in Canada during the COVID-19 pandemic. Health reports , 36 (4), 14–26. https://doi.org/10.25318/82-003-x202500400002-eng Cox, J. L., Holden, J. M., & Sagovsky, R. (1987). Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. The British journal of psychiatry: the journal of mental science , 150 , 782–786. https://doi.org/10.1192/bjp.150.6.782 Curtis, R. C. (2017). Self-Defeating Behaviors. In Reference Module in Neuroscience and Biobehavioral Psychology. Elsevier. https://doi.org/https://doi.org/10.1016/B978-0-12-809324-5.06551-2 Dekel, S., Stuebe, C., & Dishy, G. (2017). Childbirth induced posttraumatic stress syndrome: A systematic review of prevalence and risk factors. Frontiers in Psychology, 8, 560. https://doi.org/10.3389/fpsyg.2017.00560 Dennis, C. L., & McQueen, K. (2009). The relationship between infant-feeding outcomes and postpartum depression: a qualitative systematic review. Pediatrics , 123 (4), e736–e751. https://doi.org/10.1542/peds.2008-1629 Fairbrother, N., Albert, A., Keeney, C., Tchir, D., & Cameron, R. B. (2023). Screening for Perinatal OCD: A Comparison of the DOCS and the EPDS. Assessment, 30(4), 1028- 1039. https://doi.org/10.1177/10731911211063223 Grekin, R., & O’Hara, M. W. (2014). Prevalence and risk factors of postpartum posttraumatic stress disorder: A meta-analysis. Clinical Psychology Review, 34(5), 389–401. https://doi.org/10.1016/j.cpr.2014.05.003 Grigoriadis, S., VonderPorten, E. H., Mamisashvili, L., Tomlinson, G., Dennis, C. L., Koren, G., Steiner, M., Mousmanis, P., Cheung, A., Radford, K., Martinovic, J., & Ross, L. E. (2013). The impact of maternal depression during pregnancy on perinatal outcomes: a systematic review and meta-analysis. The Journal of clinical psychiatry , 74 (4), e321– e341. https://doi.org/10.4088/JCP.12r07968 Gunasiri, H., Wang, Y., Watkins, E. M., Capetola, T., Henderson-Wilson, C., & Patrick, R. (2022). Hope, Coping and Eco-Anxiety: Young People's Mental Health in a Climate- Impacted Australia. International journal of environmental research and public health , 19 (9), 5528. https://doi.org/10.3390/ijerph19095528 Hirschfeld RMA, Williams JBW, Spitzer RL, et al. Development and validation of a screening instrument for bipolar spectrum disorder: the Mood Disorder Questionnaire. Am J Psychiatry. 2000;157:1873–1875. https://doi:10.1176/appi.ajp.157.11.1873 Howard, L. M., Goss, C., Leese, M., Appleby, L., & Thornicroft, G. (2004). The psychosocial outcome of pregnancy in women with psychotic disorders. Schizophrenia research , 71 (1), 49–60. https://doi.org/10.1016/j.schres.2004.01.003 Howard, L. M., Khalifeh, H., & Molyneaux, E. (2020). Perinatal mental health: A guide to the Edinburgh Postnatal Depression Scale (EPDS). BMJ , 371, m3794. https://doi.org/10.1136/bmj.m3794 Howard, L. M., & Khalifeh, H. (2020). Perinatal mental health: a review of progress and challenges. World psychiatry: official journal of the World Psychiatric Association (WPA) , 19 (3), 313–327. https://doi.org/10.1002/wps.20769 IBM Corporation. Released 2023. IBM SPSS Statistics for Windows, Version 29.0.2.0 Armonk, NY: IBM Corp. Jeste, D.V., Smith, J., Lewis-Fernández, R. et al. Addressing social determinants of health in individuals with mental disorders in clinical practice: review and recommendations. Transl Psychiatry 15 , 120 (2025). https://doi.org/10.1038/s41398-025-03332-4 Jones, I., Chandra, P. S., Dazzan, P., & Howard, L. M. (2014). Bipolar disorder, affective psychosis, and schizophrenia in pregnancy and the post-partum period. Lancet (London, England) , 384 (9956), 1789–1799. https://doi.org/10.1016/S0140-6736(14)61278-2 Koukopoulos, A., Mazza, C., De Chiara, L., Sani, G., Simonetti, A., Kotzalidis, G. D., Armani, G., Callovini, G., Bonito, M., Parmigiani, G., Ferracuti, S., Somerville, S., Roma, P., & Angeletti, G. (2021). Psychometric Properties of the Perinatal Anxiety Screening Scale Administered to Italian Women in the Perinatal Period. Front Psychiatry , 12 , 684579. https://doi.org/10.3389/fpsyt.2021.684579 Marcin, J. P., Schembri, M. S., He, J., & Romano, P. S. (2003). A population-based analysis of socioeconomic status and insurance status and their relationship with pediatric trauma hospitalization and mortality rates. American journal of public health , 93 (3), 461–466. https://doi.org/10.2105/ajph.93.3.461 McMaughan, D. J., Oloruntoba, O., & Smith, M. L. (2020). Socioeconomic Status and Access to Healthcare: Interrelated Drivers for Healthy Aging. Frontiers in public health , 8 , 231. https://doi.org/10.3389/fpubh.2020.00231 Meltzer-Brody, S., & Stuebe, A. (2014). The long-term psychiatric and medical prognosis of perinatal mental illness. Best practice & research. Clinical obstetrics & gynaecology , 28 (1), 49–60. https://doi.org/10.1016/j.bpobgyn.2013.08.009 Molloy, E., Biggerstaff, D. L., & Sidebotham, P. (2021). A phenomenological exploration of parenting after birth trauma: Mothers perceptions of the first year. Women and birth : journal of the Australian College of Midwives , 34 (3), 278-287.https://doi.org/10.1016/j.wombi.2020.03.004 Moyer, S. W., Ameringer, S., Elswick, R. K., Nunziato, J. D., & Kinser, P. A. (2024). Exploration of the psychometric properties of the EPDS-US, a validation study. Journal of Affective Disorders, 352, 193-198. https://doi.org/https://doi.org/10.1016/j.jad.2024.02.025 Overmier, J. B. (2002). On learned helplessness. Integrative Physiological & Behavioral Science , 37 , 4-8. Policy Center for Maternal Mental Health. (2022). Psychosis Symptom Checklist and Overview . Retrieved August 12 from https://policycentermmh.org/app/uploads/2024/04/PolicyCenterforMaternalMentalHealthsPsychosisSymptomChecklistPSC2.28.2022.pdf Priddis, H. S., Keedle, H., & Dahlen, H. (2018). The Perfect Storm of Trauma: The experiences of women who have experienced birth trauma and subsequently accessed residential parenting services in Australia. Women and Birth, 31(1), 17-24. https://doi.org/10.1016/j.wombi.2017.06.007 Saini G, Seema S, Jaitley R. Understanding Postpartum Depression through Learned Helplessness Theory. Open Psychol J, 2024; 17: e18743501307219. http://dx.doi.org/10.2174/0118743501307219240910064849 Schwarz, E. B., Ray, R. M., Stuebe, A. M., Allison, M. A., Ness, R. B., Freiberg, M. S., & Cauley, J. A. (2009). Duration of lactation and risk factors for maternal cardiovascular disease. Obstetrics and gynecology , 113 (5), 974–982. https://doi.org/10.1097/01.AOG.0000346884.67796.ca Seligman, M. E. (1972). Learned helplessness. Annual review of medicine , 23 (1), 407-412. Simpson, M., & Catling, C. (2016). Understanding psychological trauma and posttraumatic stress disorder in the perinatal period. Women and Birth , 29(3), 203–207. https://doi.org/10.1016/j.wombi.2015.10.009 Somerville, S., Dedman, K., Hagan, R., Oxnam, E., Wettinger, M., Byrne, S., Coo, S., Doherty, D., & Page, A. C. (2014). The Perinatal Anxiety Screening Scale: development and preliminary validation. Archives of women's mental health , 17 (5), 443–454. https://doi.org/10.1007/s00737-014-0425-8 Sun, X., Fan, X., Cong, S., Wang, R., Sha, L., Xie, H., Han, J., Zhu, Z., & Zhang, A. (2023). Psychological birth trauma: A concept analysis. Frontiers in psychology , 13 , 1065612. https://doi.org/10.3389/fpsyg.2022.1065612 United States Census Bureau. (2024). Data . Retrieved August 12 from https://www.census.gov/data.html Womersley, K., & Alderson, H. (2024). Perinatal mental health. Medicine, 52(10), 632-636. https://doi.org/https://doi.org/10.1016/j.mpmed.2024.07.009 Zimmerman, M. A. (1995). Psychological empowerment: issues and illustrations. Am J Community Psychol, 23(5), 581-599. https://doi.org/10.1007/BF02506983 Tables Table 3.1. Participant Demographics (N=249) n % Age 22-24 25-29 30-34 35-55 20 141 77 11 8.0 56.6 31.0 4.4 Race White Native American Alaska Native Middle Eastern 243 4 1 1 97.6 1.6 0.4 0.4 Ethnicity Hispanic/Latino Non-Hispanic/Latino 12 237 4.8 95.2 Income $0-14,999 $15,000-24,999 $25,000-34,999 $35,000-49,999 $50,000-74,999 $75,000-99,999 $100,000-149,999 $150,000-199,999 $200,000 or more 1 35 48 25 55 38 38 8 1 0.4 14.1 19.3 10.0 22.1 15.3 15.3 3.2 0.4 Insurance Medicaid IHS Private Obamacare Other 181 4 57 3 4 72.7 1.6 22.9 1.2 1.6 Education Associate Bachelor Master Doctoral/Professional 3 166 77 3 1.2 66.7 30.9 1.2 Table 3.2. Birthing Experience and Mental Health (N=249) n % Birth Location Hospital Birthing Center Home 183 10 56 73.5 4.0 22.5 Birth Modality Vaginal Cesarean Section (C-Section) 131 118 52.6 47.4 Number of Previous Live Births 0 1 2 3 4 5 43 153 48 3 1 1 17.3 61.4 19.3 1.2 0.4 0.4 Self-Reported Experiencing Birth Trauma 53 21.3 Experienced Birth Trauma and Screened Positive for at Least One PMHD 53 21.3 Prevalence of PMHDs Depression Anxiety OCD Bipolar Disorder Psychosis 211 204 223 25 8 84.7 81.9 93.6 10.0 3.2 Table 3.3. Modified Poisson Regression Results with Birth Trauma as the Predictor and Helplessness as the Outcome Variable Unadjusted Adjusted* Helplessness Helplessness B SE p Exp(B) 95% CI B SE p Exp(B) 95% CI Birth trauma 0.27 0.08 <0.001 1.31 1.12-1.54 0.34 0.09 <0.001 1.40 1.18-1.66 *Adjusted for age, income, insurance, education, birth location, birth modality, delivery type, and previous number of live births Table 3.4. Linear Regression Results with Birth Trauma as the Predictor and Helplessness as the Outcome Variable Unadjusted Adjusted* Helplessness Helplessness SE t F p B 95% CI SE t F p B 95% CI Birth trauma 0.15 3.18 10.11 0.002 0.47 0.18-0.76 0.15 3.77 4.84 <0.001 0.57 0.27-0.86 *Adjusted for age, income, insurance, education, birth location, birth modality, delivery type, and previous number of live births Table 3.5. Modified Poisson Regression Results with Helplessness as the Predictor and PMHDs as the Outcome Variable Unadjusted Adjusted* Helplessness Depression Depression B SE p Exp(B) 95% CI B SE p Exp(B) 95% CI 0.09 0.03 0.004 1.10 1.03-1.17 0.10 0.03 0.006 1.10 1.03-1.18 Helplessness Anxiety Anxiety B SE p Exp(B) 95% CI B SE p Exp(B) 95% CI 0.15 0.03 <0.001 1.16 1.09-1.23 0.12 0.03 <0.001 1.13 1.06-1.19 Helplessness OCD OCD B SE p Exp(B) 95% CI B SE p Exp(B) 95% CI 0.06 0.02 0.002 1.07 1.02-1.11 0.05 0.02 0.01 1.05 1.01-1.10 Helplessness Bipolar Bipolar B SE p Exp(B) 95% CI B SE p Exp(B) 95% CI 0.27 0.23 0.21 1.33 0.85-2.08 0.65 0.21 0.22 1.07 0.69-1.65 Helplessness Psychosis Psychosis B SE p Exp(B) 95% CI B SE p Exp(B) 95% CI 0.15 0.31 0.63 1.16 0.64-2.12 -0.22 0.30 0.47 0.81 0.45-1.46 *Adjusted for age, income, insurance, education, birth location, birth modality, delivery type, and previous number of live births Table 3.6. Linear Regression Results with Helplessness as the Predictor and PMHDs as the Outcome Variable Unadjusted Adjusted* Helplessness Depression Depression SE t F p B 95% CI SE t F p B 95% CI 0.31 4.35 18.95 <0.001 1.34 0.73-1.94 0.32 4.34 4.65 0.001 1.37 0.75-1.99 Helplessness Anxiety Anxiety SE t F p B 95% CI SE t F p B 95% CI 1.22 7.31 53.41 <0.001 8.88 6.49-11.27 1.09 6.31 19.63 <0.001 6.89 4.74-9.04 Helplessness OCD OCD SE t F p B 95% CI SE t F p B 95% CI 0.66 10.02 100.43 <0.001 6.56 5.27-7.85 0.66 8.46 16.48 <0.001 5.54 4.25-6.84 Helplessness Bipolar Bipolar SE t F p B 95% CI SE t F p B 95% CI 0.06 2.56 6.54 0.01 0.143 0.03-0.25 0.05 3.64 11.81 <0.001 0.18 0.08-0.28 Helplessness Psychosis Psychosis SE t F p B 95% CI SE t F p B 95% CI 0.10 4.85 23.52 <0.001 0.51 0.30-0.71 0.09 3.65 21.08 <0.001 0.32 0.15-0.49 *Adjusted for age, income, insurance, education, birth location, birth modality, delivery type, and previous number of live births Additional Declarations The authors declare no competing interests. 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-8156257","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":547591537,"identity":"85cd72c0-f8f1-456f-8197-98c13ee8d15e","order_by":0,"name":"Stephanie Hanson","email":"data:image/png;base64,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","orcid":"https://orcid.org/0000-0003-2452-1540","institution":"South Dakota State University","correspondingAuthor":true,"prefix":"","firstName":"Stephanie","middleName":"","lastName":"Hanson","suffix":""}],"badges":[],"createdAt":"2025-11-19 14:15:17","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-8156257/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8156257/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":96605190,"identity":"c32ca2d2-94d8-4d91-b364-4111712c72fe","added_by":"auto","created_at":"2025-11-24 09:21:02","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":57626,"visible":true,"origin":"","legend":"","description":"","filename":"Manuscript2Final.docx","url":"https://assets-eu.researchsquare.com/files/rs-8156257/v1/5331899265c5c1d3c560d7a5.docx"},{"id":96587210,"identity":"ee9282db-2904-4b38-becd-c956f4695b63","added_by":"auto","created_at":"2025-11-24 05:11:35","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":342,"visible":true,"origin":"","legend":"","description":"","filename":"rs8156257.json","url":"https://assets-eu.researchsquare.com/files/rs-8156257/v1/b7aa1f3e922b806d53512252.json"},{"id":96587212,"identity":"db422ae1-eba8-414a-83ce-c647402039d0","added_by":"auto","created_at":"2025-11-24 05:11:35","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":162070,"visible":true,"origin":"","legend":"","description":"","filename":"rs81562570enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-8156257/v1/52f9184d889e5f2ea9e19867.xml"},{"id":96605662,"identity":"6d4e5f3e-76b2-405f-bae5-172d35d260a9","added_by":"auto","created_at":"2025-11-24 09:23:47","extension":"xml","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":151527,"visible":true,"origin":"","legend":"","description":"","filename":"rs81562570structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8156257/v1/c35e9e0ffd98b95e5c1ffb78.xml"},{"id":96605840,"identity":"b66555fc-b4e9-4c4b-aed1-0606a0970deb","added_by":"auto","created_at":"2025-11-24 09:24:11","extension":"html","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":178828,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8156257/v1/1800bc02a958989ccdb39b2b.html"},{"id":96608456,"identity":"b7b55cfd-48c3-4fa2-8fb7-bd3b089f6f0f","added_by":"auto","created_at":"2025-11-24 09:28:33","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1317388,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8156257/v1/f8ee10f3-d83e-425f-b6f3-8f60e2089ba9.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eUnderstanding Relationships Between Birth Trauma, Helplessness, and Perinatal Mental Health Disorders\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eFor many women, childbirth can be a traumatic experience; and approximately 45% of women who give birth experience birth trauma (Alcorn et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). Nearly 20% of women also report perinatal mental health disorders (Womersley \u0026amp; Alderson, \u003cspan citationid=\"CR120\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Perinatal mental health disorders (PMHDs) include six disorders that occur during the traditionally defined perinatal period (i.e., conception through one year postpartum): perinatal depression, perinatal anxiety, perinatal post-traumatic stress disorder, perinatal obsessive-compulsive disorder, perinatal bipolar disorder, and postpartum psychosis (Howard et al., \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Some scholars have separately linked birth trauma and perinatal depression to long-term physical and mental health consequences for both the mother and the infant (Meltzer-Brody \u0026amp; Stuebe, \u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e2014\u003c/span\u003e), including cardiometabolic disease (Schwartz et al., 2009), reduced lactation initiation and duration (Dennis \u0026amp; McQueen, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2009\u003c/span\u003e; Grigoriadis et al, 2013) and delayed infant development (Meltzer-Brody \u0026amp; Stuebe, \u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). Some scholars have also linked birth trauma to perinatal post-traumatic stress disorder and perinatal depression (Molloy et al., \u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Priddis et al., \u003cspan citationid=\"CR97\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Sun et al. \u003cspan citationid=\"CR115\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). However, there has been limited exploration of psychosocial factors that may influence the relationship between birth trauma and all PMHD health outcomes.\u003c/p\u003e\u003cp\u003eAlthough the literature on birth trauma and PMHDs has expanded in recent decades, empirical inquiry has disproportionately concentrated on birth trauma\u0026rsquo;s association with perinatal depression and perinatal post-traumatic stress disorder (PTSD). Numerous quantitative and qualitative studies have documented that women who appraise their childbirth as traumatic are at significantly higher risk of developing perinatal depression (Ayers et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Bell \u0026amp; Anderson, 2016; Molloy et al. \u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) and perinatal PTSD (Ayers et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Dekel et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Grekin \u0026amp; O\u0026rsquo;Hara, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Simpson \u0026amp; Catling, \u003cspan citationid=\"CR108\" class=\"CitationRef\"\u003e2016\u003c/span\u003e), with robust evidence linking trauma-related intrusions, hyperarousal, and negative mood to persistent postpartum functional impairment. In contrast, far fewer investigations have examined how birth trauma may contribute to the onset or exacerbation of other PMHDs\u0026mdash;such as perinatal anxiety, perinatal obsessive-compulsive disorder, perinatal bipolar disorder, or postpartum psychosis\u0026mdash;despite their documented prevalence and potential for severe maternal and infant morbidity (Howard et al., \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Womersley \u0026amp; Alderson, \u003cspan citationid=\"CR120\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). This imbalance in the literature limits the comprehensiveness of the collective understanding of the broader psychiatric sequelae of birth trauma and constrains the development of tailored preventive and therapeutic interventions beyond those targeting depressive and PTSD symptomatology.\u003c/p\u003e\u003cp\u003eConceptually, birth trauma and PMHDs may be linked through empowerment theory. Empowerment theory includes four concepts that are positively associated with intrapersonal empowerment (CPAE; self-efficacy, perceived competence, motivation to control, and perceived control) and four concepts that are negatively associated with intrapersonal empowerment (CNAE; helplessness, powerlessness, loss of sense of control, and social isolation) (Zimmerman, \u003cspan citationid=\"CR122\" class=\"CitationRef\"\u003e1995\u003c/span\u003e). Women in non-perinatal populations with mental health disorders, including depression and anxiety, often report feelings of helplessness (Abdoli et al., 2022), powerlessness (Gunasiri et al., \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), and loss of sense of control (Capaldi et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2025\u003c/span\u003e), which individuals report as being negative contributors to their PMHD symptoms; however, these concepts have only loosely been linked to the perinatal population in extant literature.\u003c/p\u003e\u003cp\u003eThe aim of this study was to examine two research questions: (1) What are the relationships between birth trauma and helplessness? and (2) What are the relationships between helplessness and PMHDs? Helplessness was randomly chosen as the first concept to examine as a potential factor in these relationships. Understanding these relationships would provide opportunities for the development and implementation of interventions designed to mitigate the negative PMHD outcomes associated with birth trauma.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eData Source and Data Collection\u003c/h2\u003e\u003cp\u003eParticipants were recruited for this cross-sectional study via Amazon\u0026rsquo;s Mechanical Turk (MTurk) crowdsourcing platform. Inclusion criteria required participants to: (a) be at least 18 years old, (b) residing in the United States, (c) be fluent in written and spoken English, (d) be between four and seven months postpartum, (e) not be enrolled in inpatient mental health or substance use treatment, and (f) not be experiencing an active mental health crisis or emergency. Eligibility was assessed using a self-report screening survey. Individuals meeting these criteria proceeded to an electronic consent (eConsent) process in which they reviewed the informed consent document and indicated agreement to participate.\u003c/p\u003e\u003cp\u003eFollowing consent, participants completed a 167-item online questionnaire assessing demographic variables and mental health outcomes. All procedures, including screening, consent, and survey completion, were administered via REDCap, a HIPAA-compliant data collection platform developed by Vanderbilt University (Patridge \u0026amp; Bardyn, 2018). Participants received \u003cspan\u003e$\u003c/span\u003e20 for completing the survey, which was conducted in December 2024.\u003c/p\u003e\u003cp\u003eData quality was ensured through multiple safeguards. Captcha verification confirmed human participation. Several items were repeated in varied formats or across different survey sections to evaluate internal consistency; cases with inconsistent responses were excluded. For duplicate submissions, only the first complete entry was retained.\u003c/p\u003e\u003cp\u003eA priori power analysis indicated a minimum of 166 participants was required to detect statistically significant differences at 80% power with α\u0026thinsp;=\u0026thinsp;.05, assuming postpartum mental health disorder (PMHD) prevalence rates of 40% among those with birth trauma and 20% among those without (Isobel et al., 2024). Of 300 survey completions, 7 duplicates, 35 low-quality or inconsistent responses, and 9 cases reporting PMHD symptom onset prior to childbirth were excluded, yielding a final analytic sample of 249 participants.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSample\u003c/h3\u003e\n\u003cp\u003eThe final sample (N\u0026thinsp;=\u0026thinsp;249) represented 35 U.S. states. Participants\u0026rsquo; ages ranged from 22 to 55 years (M\u0026thinsp;=\u0026thinsp;29.75, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;4.30). Most identified as White (97.6%, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;243) and non-Hispanic/Latino (95.2%, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;237). Household income distribution was as follows: \u003cspan\u003e$\u003c/span\u003e25,000\u0026ndash;\u003cspan\u003e$\u003c/span\u003e34,999 (19.3%, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;48), \u003cspan\u003e$\u003c/span\u003e35,000\u0026ndash;\u003cspan\u003e$\u003c/span\u003e49,999 (10.0%, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;25), \u003cspan\u003e$\u003c/span\u003e50,000\u0026ndash;\u003cspan\u003e$\u003c/span\u003e74,999 (22.1%, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;55), \u003cspan\u003e$\u003c/span\u003e75,000\u0026ndash;\u003cspan\u003e$\u003c/span\u003e99,999 (15.3%, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;38), and \u003cspan\u003e$\u003c/span\u003e100,000\u0026ndash;\u003cspan\u003e$\u003c/span\u003e149,999 (15.3%, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;38). Most held a Bachelor\u0026rsquo;s (66.7%, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;166) or Master\u0026rsquo;s degree (30.9%, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;77). Insurance coverage included Medicaid (70.2%, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;181) and private insurance (22.9%, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;57). Most births occurred in hospital settings (73.4%, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;183), and just over half were vaginal deliveries (52.6%, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;131).\u003c/p\u003e\n\u003ch3\u003eMeasures\u003c/h3\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eBirth Trauma and Post-Traumatic Stress Disorder\u003c/h2\u003e\u003cp\u003eBirth trauma was measured using the 29-item \u003cem\u003eCity Birth Trauma Scale\u003c/em\u003e (CBTS; Ayers et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). The first two items assessed Criterion A for trauma\u0026mdash;actual or perceived threat of death or serious injury to the mother or infant during labor, birth, or immediately afterward. Endorsing either item constituted birth trauma. Although the CBTS includes items assessing PTSD symptoms, these were not analyzed because postpartum PTSD was excluded from this study.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003ePostpartum Depression\u003c/h3\u003e\n\u003cp\u003eDepression symptoms were assessed using the \u003cem\u003eEdinburgh Postnatal DepressionScale\u003c/em\u003e (EPDS; Cox et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e1987\u003c/span\u003e). This 10-item self-report scale measures depressive symptoms over the past 7 days, rated from 0 to 3, with six items reverse-scored. Total scores range from 0 to 30, categorized as minimal (0\u0026ndash;6), mild (7\u0026ndash;13), moderate (14\u0026ndash;19), and severe (20\u0026ndash;30). A cutoff of \u0026ge;\u0026thinsp;13 indicated probable postpartum depression (Levis et al., 2020). Reliability for the EPDS has been reported as α\u0026thinsp;=\u0026thinsp;0.83 for a one-factor model (Moyer et al., \u003cspan citationid=\"CR89\" class=\"CitationRef\"\u003e2024\u003c/span\u003e); in this sample, α\u0026thinsp;=\u0026thinsp;0.79.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003ePostpartum Anxiety\u003c/h2\u003e\u003cp\u003eAnxiety symptoms were measured with the \u003cem\u003ePerinatal Anxiety Screening Scale\u003c/em\u003e (PASS; Somerville et al., 2014), a 31-item scale assessing symptom frequency over the past month on a 0 (\u0026ldquo;not at all\u0026rdquo;) to 3 (\u0026ldquo;almost always\u0026rdquo;) scale. Total scores (0\u0026ndash;93) are categorized as minimal (0\u0026ndash;20), moderate (21\u0026ndash;41), or severe (42\u0026ndash;93). A cutoff score of \u0026ge;\u0026thinsp;21 indicated clinically significant anxiety. Previous research in U.S. samples reported α\u0026thinsp;=\u0026thinsp;0.96 (Koukopoulos et al., 2021); in this study, α\u0026thinsp;=\u0026thinsp;0.96.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003ePostpartum Obsessive-Compulsive Disorder\u003c/h3\u003e\n\u003cp\u003eObsessive-compulsive symptoms were measured using the \u003cem\u003eDimensional Obsessive-CompulsiveScale\u003c/em\u003e (DOCS; Abramowitz, 2010). This 20-item measure assesses four domains: germs/contamination, responsibility for harm or bad luck, unacceptable thoughts, and symmetry/completeness. Items are scored from 0 (\u0026ldquo;none at all\u0026rdquo;) to 4 (\u0026ldquo;8\u0026thinsp;+\u0026thinsp;hours/day\u0026rdquo; or \u0026ldquo;complete disruption\u0026rdquo;), yielding total scores from 0 to 80. A score\u0026thinsp;\u0026ge;\u0026thinsp;21 indicated probable OCD. In this sample, α\u0026thinsp;=\u0026thinsp;0.93.\u003c/p\u003e\n\u003ch3\u003ePostpartum Bipolar Disorder\u003c/h3\u003e\n\u003cp\u003eBipolar symptoms were assessed using the \u003cem\u003eMood Disorder Questionnaire\u003c/em\u003e (MDQ; Hirschfield et al., 2000). Participants responded \u0026ldquo;yes\u0026rdquo; or \u0026ldquo;no\u0026rdquo; to 13 items, then indicated whether symptoms occurred simultaneously and the degree of functional impairment. A positive screen required\u0026thinsp;\u0026ge;\u0026thinsp;7 endorsed symptoms, concurrent occurrence, and at least moderate impairment. The MDQ has been validated for perinatal populations (American College of Obstetrics and Gynecology, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). In this sample, α\u0026thinsp;=\u0026thinsp;0.80.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003ePostpartum Psychosis\u003c/h2\u003e\u003cp\u003ePsychosis symptoms were assessed using the \u003cem\u003ePsychosis Symptom Checklist\u003c/em\u003e (PSC; Policy Center for Maternal Mental Health, \u003cspan citationid=\"CR94\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), which measures the presence of 16 symptoms (e.g., delusions, hallucinations, paranoia, catatonia). The total score reflects the number of symptoms endorsed; a cutoff score\u0026thinsp;\u0026ge;\u0026thinsp;6 was applied, representing two standard deviations above the sample mean. In this sample, α\u0026thinsp;=\u0026thinsp;0.35.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eHelplessness\u003c/h2\u003e\u003cp\u003eHelplessness was measured using one prompt that was specific to each woman\u0026rsquo;s most recent birth. The prompt was, \u0026ldquo;How often did you feel helpless during birth?\u0026rdquo; Participants could respond by selecting 0 = \u0026ldquo;I never felt helpless during birth,\u0026rdquo; 1 = \u0026ldquo;I rarely felt helpless during birth,\u0026rdquo; 2 = \u0026ldquo;I sometimes felt helpless during birth,\u0026rdquo; 3 = \u0026ldquo;I often felt helpless during birth\u0026rdquo;, or 4 = \u0026ldquo;I felt helpless most of the time during birth.\u0026rdquo;\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eSociodemographic and Birth-related Variables\u003c/h2\u003e\u003cp\u003eThe survey included both sociodemographic and birth-related items, all of which were self-reported. Age, race, ethnicity, and number of previous births were collected via open-text responses. Participants selected responses from predefined options for state of residence, total household income, birth modality, and delivery type. Household income was reported using standardized ranges from the United States Census Bureau (United States Census Bureau, \u003cspan citationid=\"CR118\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eRace, ethnicity, and state of residence were excluded from analysis due to insufficient cell sizes. Insurance type, education level, and birth location were coded as categorical variables. Birth modality was coded as a binary variable, and delivery type was coded as a categorical variable.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003eData analysis was completed using SPSS Version 29.0.2.0 (IBM Corporation, 2023). Graphical exploration of the relationships confirmed linear associations between exposures and outcomes to ensure helplessness could be input into models as a continuous predictor. Modified Poisson regression with a log link and robust standard errors and linear regression analyses were performed to answer the study research questions.\u003c/p\u003e\u003cp\u003eModified Poisson regression results for the relationship between birth trauma and helplessness are presented in Table\u0026nbsp;3. Crude and adjusted linear regression results for the relationship between birth trauma and helplessness are presented in Table\u0026nbsp;4.\u003c/p\u003e\u003cp\u003eModified Poisson regression analyses were run to examine the relationship between helplessness and the presence or absence of a positive screening result for all included PMHDs. Linear regression analyses were run to examine the relationship between helplessness and total symptoms for each PMHD. For the covariance matrix in the modified Poisson regression, the robust estimator was selected. When the modified Poisson regressions were run, helplessness was put in as a continuous predictor, and binary outcomes were put into the models for the included PMHDs. For linear regression analyses, helplessness was included in all models as a continuous variable. For all included PMHDs, total scores on each of the screening scales was the dependent variable, with higher scores representing increased presentation of symptoms. All modified Poisson regression analyses and linear regression analyses were adjusted for age, income, insurance, birth location, birth modality, delivery type, and number of previous live births. In Table\u0026nbsp;5, modified Poisson regression results are presented for the relationship between helplessness and PMHDs. Crude and adjusted linear regression results for the relationship between helplessness and PMHDs are presented in Table\u0026nbsp;6.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eWomen\u0026rsquo;s Reports of Birth Trauma, Helplessness, and PMHDs\u003c/h2\u003e\u003cp\u003eBirth experience and mental health data is presented in Table\u0026nbsp;2. Slightly more than one-fifth of respondents reported experiencing birth trauma (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;53, 21.3%). Nearly the same number of respondents (21.7%, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;54) reported feelings of helplessness.\u003c/p\u003e\u003cp\u003eWithin the sample, the prevalence for each PMHD was: depression (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;211, 84.7%), anxiety (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;204, 81.9%), OCD (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;223, 93.6%), bipolar disorder (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;25, 10%), and psychosis (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;8, 3.2%). Each of the 53 respondents who reported birth trauma screened positive for at least one PMHD. Within the entire sample, 1.6% of participants (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;4) screened positive for no PMHDs, 10.4% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;26) screened positive for one PMHD, 12.0% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;30) screened positive for two PMHDs, 63.9% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;159) screened positive for three PMHDs, 9.6% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;24) screened positive for four PMHDs, 2.4% screened positive for five PMHDs.\u003c/p\u003e\u003cp\u003eOf the 53 participants who self-reported experiencing birth trauma, 49 (92.5%) screened positive for depression, 53 (100%) screened positive for anxiety, 51 (96.2%) screened positive for OCD, 17 (32.1%) screened positive for bipolar disorder, and eight (15.1%) screened positive for psychosis. For the 196 participants who did not self-report experiencing birth trauma, 82.7% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;162) screened positive for depression, 77.0% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;151) screened positive for anxiety, 0% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0) screened positive for PTSD, 92.9% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;182) screened positive for OCD, 4.1% screened positive for bipolar disorder, and 0% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0) screened positive for psychosis.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eBirth Trauma and Helplessness\u003c/h2\u003e\u003cp\u003eIn the adjusted modified Poisson regression model (Table\u0026nbsp;3), there was a positive association between birth trauma and feelings of helplessness (RR: 1.40; 95% CI: 1.18\u0026ndash;1.66). In the linear regression model, there was a positive relationship between birth trauma and helplessness (β\u0026thinsp;=\u0026thinsp;0.47; 95% CI: 0.18\u0026ndash;0.76). A positive association between birth trauma and helplessness was also present in the linear regression model after adjusting for age, income, insurance type, education level, birth location, birth modality, delivery type, and number of previous live births (β\u0026thinsp;=\u0026thinsp;0.57; 95% CI: 0.27\u0026ndash;0.86).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eHelplessness and PMHDs\u003c/h2\u003e\u003cdiv id=\"Sec19\" class=\"Section3\"\u003e\u003ch2\u003eDepression\u003c/h2\u003e\u003cp\u003eThe modified Poisson regression analysis revealed an increased risk for developing depression when postpartum depression is a binary outcome (RR: 1.10; 95% CI: 1.03\u0026ndash;1.18), after adjusting for age, income, insurance, degree, birth location, birth modality, delivery type, and number of previous live births when comparing individuals with higher total helplessness scores to individuals with lower total helplessness scores. When the total score on the EPDS was used as a continuous outcome variable in the adjusted linear regression analysis there was a positive relationship between helplessness and postpartum depression (β: 1.37; 95% CI: 0.75\u0026ndash;1.99).\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003eAnxiety\u003c/h2\u003e\u003cp\u003eThe modified Poisson regression analysis for anxiety (Table\u0026nbsp;5) indicated that individuals with increased helplessness scores have an increased relative risk for screening positive for postpartum anxiety when compared with individuals with lower helplessness scores (RR: 1.13; 95% CI: 1.06\u0026ndash;1.19), after adjusting for age, income, insurance, degree, birth location, birth modality, delivery type, and number of previous births. When the total score on the PASS was the continuous outcome variable (Table\u0026nbsp;6), adjusted linear regression analysis also showed a positive correlation between higher total helplessness scores and higher scores on the PASS (β: 6.89; 95% CI: 4.74\u0026ndash;9.04).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003eObsessive-Compulsive Disorder\u003c/h2\u003e\u003cp\u003eIndividuals who had higher total helplessness scores were at a slightly increased risk for screening positive for obsessive-compulsive disorder, when compared with individuals who did not have a high total helplessness score in the adjusted, modified Poisson regression model (Table\u0026nbsp;5) (RR: 1.05; 95% CI: 1.01\u0026ndash;1.10). When the total score on the DOCS was used as a continuous outcome variable, there was a positive association between feelings of helplessness and screening positive for OCD (β: 5.54; 95% CI: 4.25\u0026ndash;6.84) in the adjusted linear regression model (Table\u0026nbsp;6).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003eBipolar Disorder\u003c/h2\u003e\u003cp\u003eThe modified Poisson regression analysis found that after being adjusted for age, income, insurance, degree, birth location, birth modality, delivery type, and number of previous live births (Table\u0026nbsp;5), there was an increased risk for screening positive for postpartum bipolar disorder for individuals who had higher total helplessness scores than for individuals who had lower total helplessness scores (RR: 1.07; 95% CI: 0.69\u0026ndash;1.65). When total score on the MDQ was utilized as the outcome variable in the adjusted linear regression model (Table\u0026nbsp;6), there was a positive association between total helplessness score and a higher score on the MDQ (β: 0.18; 95% CI: 0.08\u0026ndash;0.28).\u003c/p\u003e\u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\u003ch2\u003ePostpartum Psychosis\u003c/h2\u003e\u003cp\u003eThe modified Poisson regression analysis (Table\u0026nbsp;5) showed that individuals were at an increased risk for screening positive for postpartum psychosis when total helplessness score was increased compared with screening positive for postpartum psychosis when total helplessness score was lower (RR: 0.81; 95% CI: 0.45\u0026ndash;1.46). When the total score on the PSC was a continuous variable in the linear regression model (Table\u0026nbsp;6), there was a positive association between helplessness and higher scores on the PSC (β: 0.32; 95% CI: 0.15\u0026ndash;0.49).\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study examined the prevalence of birth trauma, feelings of helplessness, and postpartum mental health disorders (PMHDs) among women, as well as the associations between these variables. The findings underscore the significant psychological burden experienced by postpartum individuals and highlight the complex interplay between birth experiences and mental health outcomes.\u003c/p\u003e\u003cdiv id=\"Sec25\" class=\"Section2\"\u003e\u003ch2\u003ePrevalence of Birth Trauma and PMHDs\u003c/h2\u003e\u003cp\u003eApproximately one-fifth of respondents reported experiencing birth trauma (21.3%), a figure consistent with prior research estimating birth trauma prevalence between 18% and 34% (Ayers et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Dekel et al. \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Similarly, feelings of helplessness were reported by 21.7% of participants, suggesting that perceived lack of control during childbirth remains a salient contributor to negative birth experiences. Notably, the prevalence of PMHDs in this sample was strikingly high, with obsessive-compulsive disorder (OCD) reported by 93.6% of participants, followed by depression (84.7%) and anxiety (81.9%). These rates exceed those typically documented in population-based studies, where postpartum depression and anxiety are estimated at 10\u0026ndash;20% (Gavin et al., 2005; Dennis et al., 2017). The elevated prevalence may reflect sample characteristics such as recruitment from high-risk populations or reliance on self-report screening tools, which tend to yield higher estimates.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec26\" class=\"Section2\"\u003e\u003ch2\u003eBirth Trauma and Mental Health\u003c/h2\u003e\u003cp\u003eAll participants who reported birth trauma screened positive for at least one PMHD, reinforcing the strong association between traumatic birth and adverse psychological outcomes. Compared to those without birth trauma, individuals with trauma exhibited higher rates of bipolar disorder (32.1% vs 4.1%) and psychosis (15.1% vs 0%), suggesting that birth trauma may exacerbate vulnerability to severe psychiatric conditions. These findings align with prior evidence linking traumatic childbirth to increased risk of postpartum PTSD, depression, and anxiety (Grekin \u0026amp; O\u0026rsquo;Hara, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2014\u003c/span\u003e), and extend the literature by highlighting associations with bipolar disorder and psychosis\u0026mdash;areas that remain unexplored.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec27\" class=\"Section2\"\u003e\u003ch2\u003eHelplessness as a Predictor of PMHDs\u003c/h2\u003e\u003cp\u003eFeelings of helplessness emerged as a significant predictor of multiple PMHDs. Higher helplessness scores were associated with increased risk for depression (RR\u0026thinsp;=\u0026thinsp;1.10), anxiety (RR\u0026thinsp;=\u0026thinsp;1.13), and OCD (RR\u0026thinsp;=\u0026thinsp;1.05), even after adjusting for sociodemographic and obstetric factors. Linear regression analyses further demonstrated positive correlations between helplessness symptom severity across all measured disorders. These findings underscore the role of perceived control and agency during childbirth in shaping postpartum mental health trajectories. The association between helplessness and bipolar disorder, while positive, did not reach statistical significance in the Poisson model, suggesting that additional factors may mediate this relationship. Interestingly, helplessness was not associated with increased risk of psychosis in the Poisson model (RR\u0026thinsp;=\u0026thinsp;0.81), though continuous analyses in the linear regression model indicated a positive correlation with psychosis symptom scores. This discrepancy may reflect limitations in statistical power given the low prevalence of psychosis in the sample.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec28\" class=\"Section2\"\u003e\u003ch2\u003eLimitations and Future Directions\u003c/h2\u003e\u003cp\u003eSeveral limitations should be acknowledged. First, the prevalence rates for PMHDs observed in this study were substantially higher than those reported in population-based research. This discrepancy likely reflects the use of self-report tools and recruitment via Amazon Mechanical Turk, which may attract individuals with elevated mental health concerns. Consequently, findings should be interpreted with caution and not generalized to the broader postpartum population. Second, the measure of helplessness consisted of one single item, limiting construct validity and the ability to capture the multidimensional nature of this concept. Future research should employ validated multi-item scales to strengthen measurement reliability. Third, the sample lacked diversity, with participants predominantly identifying as White and highly educated. This homogeneity constrains the generalizability of results and underscores the need for studies involving more racially, ethnically, and socioeconomically diverse populations. Fourth, internal consistency for the psychosis measure was low (α\u0026thinsp;=\u0026thinsp;0.35), reducing confidence in findings related to psychosis. Future studies should consider alternative instruments with stronger psychometric properties. Additionally, prior mental health history and social support were not assessed, which may have introduced unmeasured confounding. The cross-sectional design further limits causal inference; longitudinal studies are needed to clarify temporal relationships among birth trauma, helplessness, and PMHDs. Finally, helplessness was assessed only in the context of childbirth and not during pregnancy or postpartum, which may overlook important variations in perceived control across the perinatal period.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec29\" class=\"Section2\"\u003e\u003ch2\u003eImplications\u003c/h2\u003e\u003cp\u003eThe findings of this study underscore important considerations for clinical practice and public health strategies aimed at improving maternal mental health outcomes. Despite limitations related to sample representativeness and measurement, the observed associations between birth trauma, helplessness, and PMHDs highlight the need for trauma-informed and empowerment-oriented approaches in perinatal care.\u003c/p\u003e\u003cp\u003eFrom a clinical perspective, integrating routine screening for birth trauma and perceived helplessness into postpartum care protocols could facilitate identification of individuals at elevated risk for mental health difficulties. However, given the high prevalence rates observed in this study\u0026mdash;likely influenced by sampling and self-report measures\u0026mdash;screening tools should be applied judiciously and interpreted in conjunction with clinical assessment. Interventions that enhance maternal agency and perceived control during childbirth, such as shared decision-making and respectful communication, may help mitigate feelings of helplessness and reduce downstream psychological distress.\u003c/p\u003e\u003cp\u003ePublic health initiatives should prioritize equitable access to culturally sensitive perinatal mental health services, particularly for populations underrepresented in this study. Expanding provider training in trauma-informed care and empowerment strategies can foster supportive birth environments that reduce vulnerability to PMHDs. Policy efforts to address structural barriers\u0026mdash;such as insurance coverage and availability of specialized mental health resources\u0026mdash;remain critical for improving outcomes.\u003c/p\u003e\u003cp\u003eFinally, future research should employ longitudinal designs and more diverse samples to clarify causal pathways and strengthen generalizability. Using validated multi-item measures of helplessness and psychometrically robust instruments for all PMHDs will enhance reliability. Addressing these gaps will allow for the development of targeted interventions that effectively reduce the burden of postpartum mental illness and promote maternal well-being.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study illuminated the profound impact of birth trauma and associated feelings of helplessness on the development and severity of PMHDs. The pervasive presence of multiple PMHDs among women reporting birth trauma underscores the urgency of recognizing traumatic childbirth as a critical public health issue. Helplessness emerged as a potentially pivotal psychological mechanism that may drive the onset and exacerbation of diverse postpartum psychopathologies, offering a valuable target for intervention. These findings call for a shift in perinatal care toward trauma-informed, empowerment-centered practices that promote maternal agency and psychological safety. Future research employing longitudinal designs and qualitative methodologies are needed to further elucidate the causal pathways and develop tailored interventions. Ultimately, integrating trauma awareness and empowerment strategies within clinical and public health frameworks holds promise for significantly improving maternal mental health outcomes and fostering healthier family systems.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eThis study was approved for human subjects research by the IRB at South Dakota State University (IRB-2402020-EXP). All study participants completed an informed consent process before completing the study survey. \u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAbdoli, N., Salari, N., Darvishi, N., Jafarpour, S., Solaymani, M., Mohammadi, M., \u0026amp; Shohaimi, S. (2022). The global prevalence of major depressive disorder (MDD) among the elderly: A systematic review and meta-analysis. \u003cem\u003eNeuroscience and biobehavioral reviews\u003c/em\u003e, \u003cem\u003e132\u003c/em\u003e, 1067\u0026ndash;1073. https://doi.org/10.1016/j.neubiorev.2021.10.041 \u003c/li\u003e\n\u003cli\u003eAbramowitz, J. S., Deacon, B. J., Olatunji, B. O., Wheaton, M. G., Berman, N. C., Losardo, D., Timpano, K. R., McGrath, P. B., Riemann, B. C., Adams, T., Bj\u0026ouml;rgvinsson, T., Storch, E. A., \u0026amp; Hale, L. R. (2010). Assessment of obsessive-compulsive symptom dimensions: development and evaluation of the Dimensional Obsessive-Compulsive Scale. \u003cem\u003ePsychological assessment\u003c/em\u003e, \u003cem\u003e22\u003c/em\u003e(1), 180\u0026ndash;198. https://doi.org/10.1037/a0018260 \u003c/li\u003e\n\u003cli\u003eAmerican College of Obstetrics and Gynecology. (2024). \u003cem\u003ePerinatal mental health toolkit\u003c/em\u003e. Retrieved December 12 from https://www.acog.org/programs/perinatal-mental-health \u003c/li\u003e\n\u003cli\u003eAlcorn, K. L., O\u0026apos;Donovan, A., Patrick, J. C., Creedy, D., \u0026amp; Devilly, G. J. (2010). A prospective longitudinal study of the prevalence of post-traumatic stress disorder resulting from childbirth events. \u003cem\u003ePsychological medicine\u003c/em\u003e, \u003cem\u003e40\u003c/em\u003e(11), 1849\u0026ndash;1859. https://doi.org/10.1017/S0033291709992224 \u003c/li\u003e\n\u003cli\u003eAvci, N., \u0026amp; Kaydirak, M. M. (2023). A qualitative study of women\u0026apos;s experiences with obstetric violence during childbirth in Turkey. \u003cem\u003eMidwifery\u003c/em\u003e,\u003cem\u003e 121\u003c/em\u003e(July). https://doi.org/10.1016/j.midw.2023.103658 \u003c/li\u003e\n\u003cli\u003eAyers, S., Bond, R., Bertullies, S., \u0026amp; Wijma, K. (2016). The aetiology of post‐traumatic stress following childbirth: A meta‐analysis and theoretical framework. \u003cem\u003ePsychological Medicine\u003c/em\u003e, 46(6), 1121\u0026ndash;1134. https://doi.org/10.1017/S0033291715002706 \u003c/li\u003e\n\u003cli\u003eAyers, S., Wright, D. B., \u0026amp; Thornton, A. (2018). Development of a Measure of Postpartum PTSD: The City Birth Trauma Scale. \u003cem\u003eFront Psychiatry\u003c/em\u003e,\u003cem\u003e 9\u003c/em\u003e, 409. https://doi.org/10.3389/fpsyt.2018.00409 \u003c/li\u003e\n\u003cli\u003eBeck, C. T. (2004). Birth trauma: In the eye of the beholder. \u003cem\u003eNursing Research, 53\u003c/em\u003e(1), 28\u0026ndash;35. https://doi.org/10.1097/00006199-200401000-00005 \u003c/li\u003e\n\u003cli\u003eBell, A. F., \u0026amp; Andersson, E. (2016). The birth experience and women\u0026apos;s postnatal depression: A systematic review. \u003cem\u003eMidwifery\u003c/em\u003e, 39, 112\u0026ndash;123. https://doi.org/10.1016/j.midw.2016.04.014 \u003c/li\u003e\n\u003cli\u003eCapaldi, C. A., Wassef, K., Varin, M., Valli\u0026egrave;res, E., \u0026amp; Roberts, K. C. (2025). Sense of control and positive mental health outcomes among adults in Canada during the COVID-19 pandemic. \u003cem\u003eHealth reports\u003c/em\u003e, \u003cem\u003e36\u003c/em\u003e(4), 14\u0026ndash;26. https://doi.org/10.25318/82-003-x202500400002-eng \u003c/li\u003e\n\u003cli\u003eCox, J. L., Holden, J. M., \u0026amp; Sagovsky, R. (1987). Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. \u003cem\u003eThe British journal \u003c/em\u003e \u003cem\u003eof psychiatry: the journal of mental science\u003c/em\u003e, \u003cem\u003e150\u003c/em\u003e, 782\u0026ndash;786. https://doi.org/10.1192/bjp.150.6.782 \u003c/li\u003e\n\u003cli\u003eCurtis, R. C. (2017). Self-Defeating Behaviors. In Reference Module in Neuroscience and Biobehavioral Psychology. Elsevier. https://doi.org/https://doi.org/10.1016/B978-0-12-809324-5.06551-2 \u003c/li\u003e\n\u003cli\u003eDekel, S., Stuebe, C., \u0026amp; Dishy, G. (2017). Childbirth induced posttraumatic stress syndrome: A systematic review of prevalence and risk factors. \u003cem\u003eFrontiers in Psychology, 8,\u003c/em\u003e 560. https://doi.org/10.3389/fpsyg.2017.00560 \u003c/li\u003e\n\u003cli\u003eDennis, C. L., \u0026amp; McQueen, K. (2009). The relationship between infant-feeding outcomes and postpartum depression: a qualitative systematic review. \u003cem\u003ePediatrics\u003c/em\u003e, \u003cem\u003e123\u003c/em\u003e(4), e736\u0026ndash;e751. https://doi.org/10.1542/peds.2008-1629 \u003c/li\u003e\n\u003cli\u003eFairbrother, N., Albert, A., Keeney, C., Tchir, D., \u0026amp; Cameron, R. B. (2023). Screening for Perinatal OCD:\u003cem\u003e A Comparison of the DOCS and the EPDS. Assessment, \u003c/em\u003e30(4), 1028- 1039. https://doi.org/10.1177/10731911211063223\u003c/li\u003e\n\u003cli\u003eGrekin, R., \u0026amp; O\u0026rsquo;Hara, M. W. (2014). Prevalence and risk factors of postpartum posttraumatic stress disorder: A meta-analysis.\u003cem\u003e Clinical Psychology Review, 34(5),\u003c/em\u003e 389\u0026ndash;401. https://doi.org/10.1016/j.cpr.2014.05.003 \u003c/li\u003e\n\u003cli\u003eGrigoriadis, S., VonderPorten, E. H., Mamisashvili, L., Tomlinson, G., Dennis, C. L., Koren, G., Steiner, M., Mousmanis, P., Cheung, A., Radford, K., Martinovic, J., \u0026amp; Ross, L. E. (2013). The impact of maternal depression during pregnancy on perinatal outcomes: a systematic review and meta-analysis. \u003cem\u003eThe Journal of clinical psychiatry\u003c/em\u003e, \u003cem\u003e74\u003c/em\u003e(4), e321\u0026ndash; e341. https://doi.org/10.4088/JCP.12r07968 \u003c/li\u003e\n\u003cli\u003eGunasiri, H., Wang, Y., Watkins, E. M., Capetola, T., Henderson-Wilson, C., \u0026amp; Patrick, R. (2022). Hope, Coping and Eco-Anxiety: Young People\u0026apos;s Mental Health in a Climate- Impacted Australia. \u003cem\u003eInternational journal of environmental research and public health\u003c/em\u003e, \u003cem\u003e19\u003c/em\u003e(9), 5528. https://doi.org/10.3390/ijerph19095528 \u003c/li\u003e\n\u003cli\u003eHirschfeld RMA, Williams JBW, Spitzer RL, et al. Development and validation of a screening instrument for bipolar spectrum disorder: the Mood Disorder Questionnaire. Am J Psychiatry. 2000;157:1873\u0026ndash;1875. https://doi:10.1176/appi.ajp.157.11.1873 \u003c/li\u003e\n\u003cli\u003eHoward, L. M., Goss, C., Leese, M., Appleby, L., \u0026amp; Thornicroft, G. (2004). The psychosocial outcome of pregnancy in women with psychotic disorders. \u003cem\u003eSchizophrenia \u003c/em\u003e \u003cem\u003eresearch\u003c/em\u003e, \u003cem\u003e71\u003c/em\u003e(1), 49\u0026ndash;60. https://doi.org/10.1016/j.schres.2004.01.003 \u003c/li\u003e\n\u003cli\u003eHoward, L. M., Khalifeh, H., \u0026amp; Molyneaux, E. (2020). Perinatal mental health: A guide to the Edinburgh Postnatal Depression Scale (EPDS). \u003cem\u003eBMJ\u003c/em\u003e, 371, m3794. https://doi.org/10.1136/bmj.m3794 \u003c/li\u003e\n\u003cli\u003eHoward, L. M., \u0026amp; Khalifeh, H. (2020). Perinatal mental health: a review of progress and challenges. \u003cem\u003eWorld psychiatry: official journal of the World Psychiatric Association (WPA)\u003c/em\u003e, \u003cem\u003e19\u003c/em\u003e(3), 313\u0026ndash;327. https://doi.org/10.1002/wps.20769 \u003c/li\u003e\n\u003cli\u003eIBM Corporation. Released 2023. IBM SPSS Statistics for Windows, Version 29.0.2.0 Armonk, NY: IBM Corp. \u003c/li\u003e\n\u003cli\u003eJeste, D.V., Smith, J., Lewis-Fern\u0026aacute;ndez, R. \u003cem\u003eet al.\u003c/em\u003e Addressing social determinants of health in individuals with mental disorders in clinical practice: review and recommendations. \u003cem\u003eTransl Psychiatry\u003c/em\u003e \u003cstrong\u003e15\u003c/strong\u003e, 120 (2025). https://doi.org/10.1038/s41398-025-03332-4 \u003c/li\u003e\n\u003cli\u003eJones, I., Chandra, P. S., Dazzan, P., \u0026amp; Howard, L. M. (2014). Bipolar disorder, affective psychosis, and schizophrenia in pregnancy and the post-partum period. \u003cem\u003eLancet (London, \u003c/em\u003e \u003cem\u003eEngland)\u003c/em\u003e, \u003cem\u003e384\u003c/em\u003e(9956), 1789\u0026ndash;1799. https://doi.org/10.1016/S0140-6736(14)61278-2 \u003c/li\u003e\n\u003cli\u003eKoukopoulos, A., Mazza, C., De Chiara, L., Sani, G., Simonetti, A., Kotzalidis, G. D., Armani, G., Callovini, G., Bonito, M., Parmigiani, G., Ferracuti, S., Somerville, S., Roma, P., \u0026amp; Angeletti, G. (2021). Psychometric Properties of the Perinatal Anxiety Screening Scale Administered to Italian Women in the Perinatal Period. \u003cem\u003eFront Psychiatry\u003c/em\u003e,\u003cem\u003e 12\u003c/em\u003e, 684579. https://doi.org/10.3389/fpsyt.2021.684579 \u003c/li\u003e\n\u003cli\u003eMarcin, J. P., Schembri, M. S., He, J., \u0026amp; Romano, P. S. (2003). A population-based analysis of socioeconomic status and insurance status and their relationship with pediatric trauma hospitalization and mortality rates. \u003cem\u003eAmerican journal of public health\u003c/em\u003e, \u003cem\u003e93\u003c/em\u003e(3), 461\u0026ndash;466. https://doi.org/10.2105/ajph.93.3.461 \u003c/li\u003e\n\u003cli\u003eMcMaughan, D. J., Oloruntoba, O., \u0026amp; Smith, M. L. (2020). Socioeconomic Status and Access to Healthcare: Interrelated Drivers for Healthy Aging. \u003cem\u003eFrontiers in public health\u003c/em\u003e, \u003cem\u003e8\u003c/em\u003e, 231. https://doi.org/10.3389/fpubh.2020.00231 \u003c/li\u003e\n\u003cli\u003eMeltzer-Brody, S., \u0026amp; Stuebe, A. (2014). The long-term psychiatric and medical prognosis of perinatal mental illness. \u003cem\u003eBest practice \u0026amp; research. Clinical obstetrics \u0026amp; gynaecology\u003c/em\u003e, \u003cem\u003e28\u003c/em\u003e(1), 49\u0026ndash;60. https://doi.org/10.1016/j.bpobgyn.2013.08.009 \u003c/li\u003e\n\u003cli\u003eMolloy, E., Biggerstaff, D. L., \u0026amp; Sidebotham, P. (2021). A phenomenological exploration of parenting after birth trauma: Mothers perceptions of the first year. \u003cem\u003eWomen and birth : \u003c/em\u003e \u003cem\u003ejournal of the Australian College of Midwives\u003c/em\u003e, \u003cem\u003e34\u003c/em\u003e(3), 278-287.https://doi.org/10.1016/j.wombi.2020.03.004 \u003c/li\u003e\n\u003cli\u003eMoyer, S. W., Ameringer, S., Elswick, R. K., Nunziato, J. D., \u0026amp; Kinser, P. A. (2024). Exploration of the psychometric properties of the EPDS-US, a validation study. Journal of Affective Disorders, 352, 193-198. https://doi.org/https://doi.org/10.1016/j.jad.2024.02.025 \u003c/li\u003e\n\u003cli\u003eOvermier, J. B. (2002). On learned helplessness. \u003cem\u003eIntegrative Physiological \u0026amp; Behavioral \u003c/em\u003e \u003cem\u003eScience\u003c/em\u003e, \u003cem\u003e37\u003c/em\u003e, 4-8.\u003c/li\u003e\n\u003cli\u003ePolicy Center for Maternal Mental Health. (2022). \u003cem\u003ePsychosis Symptom Checklist and Overview\u003c/em\u003e. Retrieved August 12 from https://policycentermmh.org/app/uploads/2024/04/PolicyCenterforMaternalMentalHealthsPsychosisSymptomChecklistPSC2.28.2022.pdf \u003c/li\u003e\n\u003cli\u003ePriddis, H. S., Keedle, H., \u0026amp; Dahlen, H. (2018). The Perfect Storm of Trauma: The experiences of women who have experienced birth trauma and subsequently accessed residential parenting services in Australia. Women and Birth, 31(1), 17-24. https://doi.org/10.1016/j.wombi.2017.06.007 \u003c/li\u003e\n\u003cli\u003eSaini G, Seema S, Jaitley R. Understanding Postpartum Depression through Learned Helplessness Theory. Open Psychol J, 2024; 17: e18743501307219. http://dx.doi.org/10.2174/0118743501307219240910064849 \u003c/li\u003e\n\u003cli\u003eSchwarz, E. B., Ray, R. M., Stuebe, A. M., Allison, M. A., Ness, R. B., Freiberg, M. S., \u0026amp; Cauley, J. A. (2009). Duration of lactation and risk factors for maternal cardiovascular disease. \u003cem\u003eObstetrics and gynecology\u003c/em\u003e, \u003cem\u003e113\u003c/em\u003e(5), 974\u0026ndash;982. https://doi.org/10.1097/01.AOG.0000346884.67796.ca \u003c/li\u003e\n\u003cli\u003eSeligman, M. E. (1972). Learned helplessness. \u003cem\u003eAnnual review of medicine\u003c/em\u003e, \u003cem\u003e23\u003c/em\u003e(1), 407-412.\u003c/li\u003e\n\u003cli\u003eSimpson, M., \u0026amp; Catling, C. (2016). Understanding psychological trauma and posttraumatic stress disorder in the perinatal period. \u003cem\u003eWomen and Birth\u003c/em\u003e, 29(3), 203\u0026ndash;207. https://doi.org/10.1016/j.wombi.2015.10.009 \u003c/li\u003e\n\u003cli\u003eSomerville, S., Dedman, K., Hagan, R., Oxnam, E., Wettinger, M., Byrne, S., Coo, S., Doherty, D., \u0026amp; Page, A. C. (2014). The Perinatal Anxiety Screening Scale: development and preliminary validation. \u003cem\u003eArchives of women\u0026apos;s mental health\u003c/em\u003e, \u003cem\u003e17\u003c/em\u003e(5), 443\u0026ndash;454. https://doi.org/10.1007/s00737-014-0425-8 \u003c/li\u003e\n\u003cli\u003eSun, X., Fan, X., Cong, S., Wang, R., Sha, L., Xie, H., Han, J., Zhu, Z., \u0026amp; Zhang, A. (2023). Psychological birth trauma: A concept analysis. \u003cem\u003eFrontiers in psychology\u003c/em\u003e, \u003cem\u003e13\u003c/em\u003e, 1065612. https://doi.org/10.3389/fpsyg.2022.1065612 \u003c/li\u003e\n\u003cli\u003eUnited States Census Bureau. (2024). \u003cem\u003eData\u003c/em\u003e. Retrieved August 12 from https://www.census.gov/data.html \u003c/li\u003e\n\u003cli\u003eWomersley, K., \u0026amp; Alderson, H. (2024). Perinatal mental health. Medicine, 52(10), 632-636. https://doi.org/https://doi.org/10.1016/j.mpmed.2024.07.009 \u003c/li\u003e\n\u003cli\u003eZimmerman, M. A. (1995). Psychological empowerment: issues and illustrations. Am J Community Psychol, 23(5), 581-599. https://doi.org/10.1007/BF02506983 \u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 3.1.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eParticipant Demographics (N=249)\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"432\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 62.2685%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.287%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003en\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.4444%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 62.2685%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 22-24\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 25-29\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 30-34\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 35-55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.287%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003cp\u003e141\u003c/p\u003e\n \u003cp\u003e77\u003c/p\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.4444%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e8.0\u003c/p\u003e\n \u003cp\u003e56.6\u003c/p\u003e\n \u003cp\u003e31.0\u003c/p\u003e\n \u003cp\u003e4.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 62.2685%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRace\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eWhite\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Native American\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Alaska Native\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Middle Eastern\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.287%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e243\u003c/p\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.4444%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e97.6\u003c/p\u003e\n \u003cp\u003e1.6\u003c/p\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 62.2685%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEthnicity\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eHispanic/Latino\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Non-Hispanic/Latino\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.287%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003cp\u003e237\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.4444%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e4.8\u003c/p\u003e\n \u003cp\u003e95.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 62.2685%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIncome\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;$0-14,999\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;$15,000-24,999\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;$25,000-34,999\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;$35,000-49,999\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;$50,000-74,999\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;$75,000-99,999\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;$100,000-149,999\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;$150,000-199,999\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;$200,000 or more\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.287%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.4444%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003cp\u003e14.1\u003c/p\u003e\n \u003cp\u003e19.3\u003c/p\u003e\n \u003cp\u003e10.0\u003c/p\u003e\n \u003cp\u003e22.1\u003c/p\u003e\n \u003cp\u003e15.3\u003c/p\u003e\n \u003cp\u003e15.3\u003c/p\u003e\n \u003cp\u003e3.2\u003c/p\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 62.2685%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInsurance\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Medicaid\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;IHS\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Private\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Obamacare\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Other\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.287%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e181\u003c/p\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003cp\u003e57\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.4444%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e72.7\u003c/p\u003e\n \u003cp\u003e1.6\u003c/p\u003e\n \u003cp\u003e22.9\u003c/p\u003e\n \u003cp\u003e1.2\u003c/p\u003e\n \u003cp\u003e1.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 62.2685%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducation\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Associate\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Bachelor\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Master\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Doctoral/Professional\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.287%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003cp\u003e166\u003c/p\u003e\n \u003cp\u003e77\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.4444%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e1.2\u003c/p\u003e\n \u003cp\u003e66.7\u003c/p\u003e\n \u003cp\u003e30.9\u003c/p\u003e\n \u003cp\u003e1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3.2.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eBirthing Experience and Mental Health (N=249)\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"432\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 62.2685%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.287%;\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.4444%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 62.2685%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBirth Location\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Hospital\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Birthing Center\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Home\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.287%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e183\u003c/p\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003cp\u003e56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.4444%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e73.5\u003c/p\u003e\n \u003cp\u003e4.0\u003c/p\u003e\n \u003cp\u003e22.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 62.2685%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBirth Modality\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eVaginal\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Cesarean Section (C-Section)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.287%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e131\u003c/p\u003e\n \u003cp\u003e118\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.4444%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e52.6\u003c/p\u003e\n \u003cp\u003e47.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 62.2685%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of Previous Live Births\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e0\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 1\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 2\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 3\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 4\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.287%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003cp\u003e153\u003c/p\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.4444%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e17.3\u003c/p\u003e\n \u003cp\u003e61.4\u003c/p\u003e\n \u003cp\u003e19.3\u003c/p\u003e\n \u003cp\u003e1.2\u003c/p\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 62.2685%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSelf-Reported Experiencing Birth Trauma\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.287%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.4444%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e21.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 62.2685%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExperienced Birth Trauma and Screened Positive for at Least One PMHD\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.287%;\"\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.4444%;\"\u003e\n \u003cp\u003e21.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 62.2685%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrevalence of PMHDs\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Depression\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Anxiety\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; OCD\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Bipolar Disorder\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Psychosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.287%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e211\u003c/p\u003e\n \u003cp\u003e204\u003c/p\u003e\n \u003cp\u003e223\u003c/p\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.4444%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e84.7\u003c/p\u003e\n \u003cp\u003e81.9\u003c/p\u003e\n \u003cp\u003e93.6\u003c/p\u003e\n \u003cp\u003e10.0\u003c/p\u003e\n \u003cp\u003e3.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3.3.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eModified Poisson Regression Results with Birth Trauma as the Predictor and Helplessness as the Outcome\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"798\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 366px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnadjusted\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 342px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdjusted*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 366px;\"\u003e\n \u003cp\u003eHelplessness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 342px;\"\u003e\n \u003cp\u003eHelplessness\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExp(B)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExp(B)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eBirth trauma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e1.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e1.12-1.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e0.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e1.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e1.18-1.66\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*Adjusted for age, income, insurance, education, birth location, birth modality, delivery type, and previous number of live births\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3.4.\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eLinear Regression Results with Birth Trauma as the Predictor and Helplessness as the Outcome\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"863\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"6\" valign=\"top\" style=\"width: 399px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnadjusted\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"6\" valign=\"top\" style=\"width: 382px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdjusted*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" valign=\"top\" style=\"width: 399px;\"\u003e\n \u003cp\u003eHelplessness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"6\" valign=\"top\" style=\"width: 382px;\"\u003e\n \u003cp\u003eHelplessness\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e\u003cstrong\u003et\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eF\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u003cstrong\u003et\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eF\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003eBirth trauma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e3.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e10.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e0.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.18-0.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e3.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e4.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e0.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.27-0.86\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*Adjusted for age, income, insurance, education, birth location, birth modality, delivery type, and previous number of live births\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3.5.\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eModified Poisson Regression Results with Helplessness as the Predictor and PMHDs as the Outcome\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"809\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"9\" valign=\"top\" style=\"width: 365px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnadjusted\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"9\" valign=\"top\" style=\"width: 342px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdjusted*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eHelplessness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"9\" valign=\"top\" style=\"width: 365px;\"\u003e\n \u003cp\u003eDepression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"9\" valign=\"top\" style=\"width: 342px;\"\u003e\n \u003cp\u003eDepression\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExp(B)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExp(B)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e1.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1.03-1.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e0.006\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e1.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e1.03-1.18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"19\" valign=\"top\" style=\"width: 809px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eHelplessness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"9\" valign=\"top\" style=\"width: 365px;\"\u003e\n \u003cp\u003eAnxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"9\" valign=\"top\" style=\"width: 342px;\"\u003e\n \u003cp\u003eAnxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExp(B)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExp(B)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e1.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1.09-1.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e1.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e1.06-1.19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"19\" valign=\"top\" style=\"width: 809px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eHelplessness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"10\" valign=\"top\" style=\"width: 366px;\"\u003e\n \u003cp\u003eOCD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"8\" valign=\"top\" style=\"width: 342px;\"\u003e\n \u003cp\u003eOCD\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExp(B)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExp(B)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e1.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e1.02-1.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e1.01-1.10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"19\" valign=\"top\" style=\"width: 809px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eHelplessness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"10\" valign=\"top\" style=\"width: 366px;\"\u003e\n \u003cp\u003eBipolar\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"8\" valign=\"top\" style=\"width: 342px;\"\u003e\n \u003cp\u003eBipolar\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExp(B)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExp(B)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e1.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e0.85-2.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e0.69-1.65\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"19\" valign=\"top\" style=\"width: 809px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eHelplessness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"10\" valign=\"top\" style=\"width: 366px;\"\u003e\n \u003cp\u003ePsychosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"8\" valign=\"top\" style=\"width: 342px;\"\u003e\n \u003cp\u003ePsychosis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExp(B)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExp(B)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e1.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e0.64-2.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e-0.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e0.45-1.46\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 102px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 1px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 1px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 1px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 1px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 0px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 2px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 63px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 3px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 4px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*Adjusted for age, income, insurance, education, birth location, birth modality, delivery type, and previous number of live births\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3.6.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eLinear Regression Results with Helplessness as the Predictor and PMHDs as the Outcome\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"914\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"10\" valign=\"top\" style=\"width: 410px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnadjusted\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"11\" valign=\"top\" style=\"width: 402px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdjusted*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eHelplessness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"10\" valign=\"top\" style=\"width: 410px;\"\u003e\n \u003cp\u003eDepression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"11\" valign=\"top\" style=\"width: 402px;\"\u003e\n \u003cp\u003eDepression\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e\u003cstrong\u003et\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eF\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003et\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eF\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e0.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e4.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e18.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e1.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e0.73-1.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e4.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e4.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e1.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e0.75-1.99\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"22\" valign=\"top\" style=\"width: 914px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eHelplessness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"10\" valign=\"top\" style=\"width: 410px;\"\u003e\n \u003cp\u003eAnxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"11\" valign=\"top\" style=\"width: 402px;\"\u003e\n \u003cp\u003eAnxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003et\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eF\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003et\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eF\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e1.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e7.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e53.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e8.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e6.49-11.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e1.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e6.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e19.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e6.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e4.74-9.04\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"22\" valign=\"top\" style=\"width: 914px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eHelplessness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"11\" valign=\"top\" style=\"width: 417px;\"\u003e\n \u003cp\u003eOCD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"10\" valign=\"top\" style=\"width: 395px;\"\u003e\n \u003cp\u003eOCD\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u003cstrong\u003et\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eF\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e\u003cstrong\u003et\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eF\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e10.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e100.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e6.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e5.27-7.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e0.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e8.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e16.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e5.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.25-6.84\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"22\" valign=\"top\" style=\"width: 914px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eHelplessness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"11\" valign=\"top\" style=\"width: 417px;\"\u003e\n \u003cp\u003eBipolar\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"10\" valign=\"top\" style=\"width: 395px;\"\u003e\n \u003cp\u003eBipolar\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u003cstrong\u003et\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eF\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e\u003cstrong\u003et\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eF\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e2.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e6.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e0.143\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e0.03-0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e3.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e11.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.08-0.28\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"22\" valign=\"top\" style=\"width: 914px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eHelplessness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"11\" valign=\"top\" style=\"width: 417px;\"\u003e\n \u003cp\u003ePsychosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"10\" valign=\"top\" style=\"width: 395px;\"\u003e\n \u003cp\u003ePsychosis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u003cstrong\u003et\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eF\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e\u003cstrong\u003et\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eF\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e4.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e23.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e0.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e0.30-0.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e3.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e21.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.15-0.49\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 102px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 58px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 58px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*Adjusted for age, income, insurance, education, birth location, birth modality, delivery type, and previous number of live births\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[{"identity":"23e0dcd6-d6bc-44aa-88c1-08788823aa15","identifier":"10.13039/100000102","name":"Health Resources and Services Administration","awardNumber":"A30MC50003","order_by":0}],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"South Dakota State University","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"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":"perinatal mental health, birth trauma, birth, women's health","lastPublishedDoi":"10.21203/rs.3.rs-8156257/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8156257/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e\u003cp\u003eBirth trauma and perinatal mental health disorders (PMHDs) are significant public health concerns, yet their interrelationships and underlying psychosocial mechanisms remain underexplored. This study examined associations between birth trauma, feelings of helplessness, and PMHDs among postpartum women.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e\u003cp\u003eA cross-sectional survey was administered to U.S. women 4\u0026ndash;7 months postpartum via Amazon Mechanical Turk. Eligible participants (N\u0026thinsp;=\u0026thinsp;249) completed validated measures assessing birth trauma, helplessness, and PMHDs, including depression, anxiety, obsessive-compulsive disorder (OCD), bipolar disorder, and psychosis. Modified Poisson and linear regression models evaluated associations, adjusting for sociodemographic and obstetric factors.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eBirth trauma was reported by 21.3% of participants, and 21.7% reported feelings of helplessness. PMHD prevalence was high: OCD (93.6%), depression (84.7%), anxiety (81.9%), bipolar disorder (10%), and psychosis (3.2%). All participants reporting birth trauma screened positive for at least one PMHD. Birth trauma was positively associated with helplessness (adjusted RR\u0026thinsp;=\u0026thinsp;1.40; 95% CI: 1.18\u0026ndash;1.66). Higher helplessness scores predicted increased risk and symptom severity for depression (RR\u0026thinsp;=\u0026thinsp;1.10), anxiety (RR\u0026thinsp;=\u0026thinsp;1.13), and OCD (RR\u0026thinsp;=\u0026thinsp;1.05), with linear models confirming associations across all PMHDs. Associations with bipolar disorder and psychosis were weaker and inconsistent across models.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eFindings highlight helplessness as a potential psychological mechanism linking birth trauma to diverse PMHDs. Integrating trauma-informed, empowerment-oriented care into perinatal practice and routine screening for birth trauma and helplessness may mitigate postpartum psychopathology. Future research should employ longitudinal designs to clarify causal pathways and inform targeted interventions.\u003c/p\u003e","manuscriptTitle":"Understanding Relationships Between Birth Trauma, Helplessness, and Perinatal Mental Health Disorders","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-24 05:11:30","doi":"10.21203/rs.3.rs-8156257/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":"3c64637b-2a58-4561-ae03-3e9f7b940a8e","owner":[],"postedDate":"November 24th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":58259663,"name":"Psychology"}],"tags":[],"updatedAt":"2026-01-02T11:54:06+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-24 05:11:30","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8156257","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8156257","identity":"rs-8156257","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}