The association of delivering during a war with the risk for postpartum depression, anxiety and impaired maternal-infant bonding

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Methods : A prospective cohort study was performed in women who gave birth in a tertiary medical center, during (October-November 2023) and before (March-May 2020) the Israel-Hamas War. All participants completed validated self-reported questionnaires: The Edinburgh Postnatal Depression Scale (EPDS>=10), State-Trait Anxiety Inventory (STAI>39) and the Postpartum Bonding Questionnaire (PBQ>=26). Results : A total of 502 women were included, 230 delivered during the War and 272 delivered before. Rates of symptoms of postpartum depression (PPD) were higher in women delivering during the war (26.6% vs. 12.4%, p <0.001), while multivariable regression revealed two times higher risk (adjusted OR 2.35, 95% CI 1.16-4.74, p =0.017). Rate of postpartum anxiety risk was also higher (34.3% vs 17.0%, p <0.001), and reached a trend towards significance accounting for other risk factors (adjusted OR 2.06, 95% CI 0.97-4.36, p =0.058). Finally, delivery during the war was related to specific factors of impaired MIB. However, did not increase the overall impaired score (PBQ>=26) (10.2 ± 14.1 vs 8.3 ± 6.9, p=0.075). Conclusion : The study revealed increased risk of PPD, marginal significance risk for PPA and some aspects of impairments in MIB among women delivering during the war. Maternal mental illness in the postpartum period has negative impact on the whole family. Therefore, comprehensive screening and adequate resources should be placed in women delivering in war-conflict zones. War Terror Stress Postpartum Depression Anxiety Maternal-Infant Bonding 1. Introduction The Israel-Hamas war, struck on October 7th, 2023, with terrorists of the Hamas organization from Gaza Strip surprisingly infiltrating to southern Israel by land, sea and air at several locations and advancing towards Israeli towns and communities near the border. In conjunction, heavy rockets fire was targeted at towns and cities in the south and other regions in Israel. This event represents the largest terrorism attack in the history of Israel; it entailed actions regarded as crimes of war as has been identified by the UN Human Rights Council . Approximately 1,200 citizens and soldiers were murdered, and 253 individuals were taken hostage including children, women, and elderly, and people of foreign nationality. In response, Israel declared war and the Israeli Defense Forces (IDF) invaded Gaza striking numerous targets within the Strip. In the writing of this manuscript the war continues. The aftermath of the Hamas attack and the war have surged fear, anxiety, and traumatic stress among the general population of Israel . This accords with a large body of studies on the substantial impact of war and terrorism on the long-term psychological health not only of high-exposed individuals but also of the general population . Among the Israeli population were women giving birth and entering the postpartum period in the wake of these events. They were exposed to collective trauma during a time in which risk for psychological disturbance and psychiatric disorders are known to ensue in a significant portion of women during non-war conditions , and around the optimal time for the formation of MIB which is instrumental for child development . Although exposure to war has been associated with adverse pregnancy outcomes, such as preterm deliveries and low birth weight , knowledge on the impact of war trauma on postpartum mental health and maternal-infant bonging (MIB) is scares. Psychopathology processes induced by major stressors have been shown to have a salient role in interfering with postpartum coping . A body of studies show that various physiological and psychosocial-related stressors occurring during pregnancy and delivery contribute to the development of postpartum depression (PPD) . PPD can emerge within the first weeks after delivery and may remain enduring beyond the first postpartum year . According to the World Health Organization, more than 10% of postpartum women experience PPD . PPD impairs maternal quality of life and social functioning and increases risk for co-morbid psychiatric conditions (e.g., substance use) and physical illness (e.g., obesity) . It’s adversity on the developing child has been well-documented as well as its contributing role as a causal factor of maternal death . Stress conditions during pregnancy and labor have been relate to psychopathology processes and may serve a critical role in development of PPD . Although PPD is the most common complications of childbirth, clinical levels of postpartum anxiety (PPA) are also manifested by a large portion of women in the postpartum period . PPA occurs along with PPD but also as a separate entity and impairs daily functioning and overall well-being . Women with significant life stressors are vulnerable to develop PPA . Several maternal complications have been related to PPA, such as reduced breastfeeding, lack of maternal emotional and behavioral sensitivity to the infant, and poor bonding . The postpartum period and particularly the first postpartum days are considered an optimal opportunity for the formation of MIB. MIB is defined as the maternal affection towards the infant that influences the emotional bond that the mother develops with her infant and the ensuing of appropriate maternal behavior . MIB mediates child development and exerts positive effects on the well-being of the adult offspring. Impaired bonding associates with lack of maternal affectional involvement, increased irritability, aggressive impulses, and outright rejection of the infant . These behaviors may progress to avoidance, neglect and even child abuse . Disturbance in the wellbeing of the mother after delivery can interfere with the formation of maternal bonding and impaired bonding has been documented as mediating the adverse effect of postpartum psychopathology on child development. While PPD and PPA may be relate to development of inadequate MIB, an impaired bonding may result in a mental illness . Trauma exposure has been further shown to adversely impact MIB . however limited knowledge exists regarding the tool of exposure to war conditions. To this end, we studied a high-exposure sample of early postpartum women who gave birth in the first two months of the Hamas-Israel war. Participants resided in the south region of Israel, i.e., had direct exposure to Hamas terrorist attacks and/or air strikes. They delivered in the Soroka University Medical Center (SUMC), the main provider of the tertiary hospital care services for the Negev population exposed to the military attacks, between October and November 2023. We set to examine the immediate consequences of the Israel-Hamas war on postpartum women’s (1) mental health pertaining to symptoms of depression and anxiety and (2) bonding with their infant. 2. Material and Methods 2.1 Population and settings The study sample entailed women who delivered a singleton live-born infant at the Soroka University Medical Center (SUMC) and were 1–3 days postpartum. The study group included women who delivered between October 17 and November 24, 2023, i.e., during the first weeks of the Israel-Hamas War. Control group included women who delivered at the SUMC between January 4, 2020 and September 4, 2020, i.e., before the War era. SUMC is located in the center of the Negev region. It is the largest birth center in Israel with more than 17,000 births a year. It serves as a referral center for all patients from the Negev region. Exclusion criteria were past or present psychosis, suicidal ideation, substance abuse, medical complications in infant health (i.e., newborns with congenital anomalies or chromosomal abnormalities or requirement for intensive care unit (ICU) hospitalization) and multiple birth. The study was approved by the local Institutional Review Board (IRB- 0208-22-SOR) and written consent was obtained from all participants. 2.2 Study measures Postpartum depression symptoms were assessed using the Edinburgh Postnatal Depression Scale (EPDS). This is a 10-item well-validated questionnaire which is widely used in routine perinatal care to screen for maternal PPD in accordance with the American College of Obstetricians and Gynecologists (ACOG) recommendations (Committee Opinion No 2018) . Scores range from 0–30, with higher scores representing higher symptom severity. A cutoff score of 10 is recommended for determining clinically significant symptoms of depression and risk for postpartum depression . Postpartum anxiety symptoms were measured using the 20-item State scale which is part of the widely used State-Trait Anxiety Inventory (STAI) . The State scale assess the presence and severity of symptoms of anxiety in the past two weeks on a 4-point scale. Scores range from 20–80 with higher scores indicating greater anxiety level . A cutoff score of 39–40 is recommended to detect clinically significant symptoms of anxiety and risk for PPA . Mother-infant bonding impairment was assessed using the Postpartum Bonding Questionnaire (PBQ), a reliable and validated screening tool for assessing disorders of the mother–infant relationship . The measure consists of 25 statements assessing the attitudes of mothers towards their infants in which agreement with is statement is rated on Likert scale ranging from 0 (always) to 5 (never). Total scores range between 0–125, with higher scores indicative of more impairment . The PBQ is comprised of four factors: (I) impaired Bonding (12 items), (II) Rejection and Anger (7 items), (III) Anxiety about Care (4 items), and (IV) Risk of Abuse (2 items). In accordance with previous studies , cutoff scores of 12, 17, 10, and 3, are suggested for bonding impairment for each factor respectively and total score of 26 showed high specificity (85–100%) in detecting MIB impairments . Sociodemographic and obstetrical-related information Sociodemographic variables including maternal age, ethnicity, marital status, education was obtained through a self-report questionnaire. Additional information was drawn from participants electronic medical records (EMRs) and included history of chronic or psychiatric illness, gravidity, parity, previous Cesarean section or perinatal mortality, fertility treatment, mode of delivery and pregnancy complications (e.g., pregnancy- related hypertensive disorders, gestational diabetes and postpartum hemorrhage), gestational age at birth, birth weights and Apgar at birth. 2.3 Statistical analysis Sample size was determined to achieve power of 80% for bilateral hypothesis with statistical significance set at 95% (α error of 5%). A sample of 214 women was calculated to be sufficient to detect a difference of 3 in mean total bonding score between the groups and SD of 7.6 . Comparison of Impaired Bonding sub-scale (a score of more than 12) between the two groups, was based on the 10% expected rate of impaired bonding in total population . A sample of 188 women was calculated to be sufficient to detect a difference of 7% in the rate of impaired bonding between the groups. Missing data were missing at random and were handled by exclusion of participants with missing information in the study measure from the specific analysis. Statistical analysis was performed using SPSS version 29.0. Study groups (delivery of a live- born infant during the war era or before) comparison on continuous variables was performed using independent T-tests and group differences in the distribution of categorical variables with Chi-square tests. Multiple logistic regression models were constructed to examine the relationship between war-exposure and mental health outcomes, while adjusting for confounding variables. The strategy for model building was as follows: Background characteristics were compared between the study groups. Variables indicative of study group differences that were significantly associated with the outcome variable (p = < 0.1) were treated as confounding variables; they were tested in the multivariable models, to determine the association between war-exposure and mental health/bonding outcomes not accounted by other factors. 3. Results A total of 502 women were included in the final analysis. Among them 230 delivered during the War (exposure group) and 272 delivered and studied before the War (non-exposure group). The exposure group represents 62% of women admitted to the SUMC’s maternity wards during this time period accounting for excluded cases out of 68% of women who agreed to participate. Maternal demographic and obstetric features of women who delivered before and during the Israel-Hamas war are summarized in Table A. Mean maternal age was 29 in both groups (29.3 ± 5.9 vs 29.2 ± 5.4, p = 0.888) and in both groups the majority of women were married (92.5% vs 94.5%, p = 0.557). No significant differences were found in history of chronic and psychiatric illness. The rate of Bedouin women compared to Jewish women was higher among women delivering during the war. Educational level was also different between both groups. In regard to obstetrical history, rates of prior Cesarean delivery (20.5% vs 16.6%, p = 0.002) and previous perinatal mortality, defined as previous pregnancy complicated with intra-uterine fetal death, intra-partum death or post-partum death, was more common among women delivering during the war compared to controls (4.8% vs 0%, p < 0.001). Likewise, in regard to recent childbirth, rates of Cesarean delivery were higher among the war-exposed group (32.6% vs 14.7%, p < 0.001), although no significant differences were noted in pregnancy course, i.e., use of fertility treatments and complications, i.e., gestational diabetes, pregnancy- related hypertensive disorders and postpartum hemorrhage. History of psychiatric illness, preterm birth and low newborn weight showed marginal significance to women delivering during the war. Finally, neonatal characteristics were comparable between groups, including gestational age at birth (38.8 ± 1.6 vs 38.9 ± 1.6, p = 0.500), newborn weight (3190.3 ± 522.2 vs 3203.9 ± 460.3, p = 0.757), and Apgar scores ( = 10). As presented in Table B, rates of PPD symptoms were higher in the war-exposed group in comparison with controls (26.6% vs. 12.4%, p < 0.001). Multivariable logistic regression model controlling for the contribution of ethnicity, education, Cesarean delivery, and prior perinatal mortality revealed an independent association between exposure to war and risk for PPD (Table C). Adjusted risk for PPD in women delivering during the war was more than two times higher compared to women who delivered before the war era (adjusted odds Ratio, OR- 2.35, 95% CI 1.16–4.74, p = 0.017). Women delivering during the war era were also more likely to endorse clinically significant symptoms of PPA suggesting high risk for PPA (STAI > 39, 34.3% vs 17.0%, respectively, p < 0.001). When accounting for the same contributing factors (ethnicity, education, Cesarean delivery, and prior perinatal mortality) the multivariable regression revealed only a marginally significant independent association between delivery during the war and risk for PPA (Adjusted OR 2.06, 95% CI 0.97–4.36, p = 0.058), as presented in Table D. Chi-square analysis revealed no significant differences between study groups in risk for overall maternal-infant bonding impairment (10.2 ± 14.1 vs 8.3 ± 6.9, p = 0.075), as presented in Table E. BPQ scores on the Rejection and Anger factor (2.2% vs 0%, p = 0.0.27) and the Risk of abuse (4.8% vs 0.4%, p = 0.003) factors were significantly higher in women delivering during the war than those delivering before the war, suggesting risk for severe problems in mother-infant relationships. The groups did not differ on other bonding factors, i.e., General impaired bonding (7.8% vs 5.5% p = 0.363) and Anxiety about care (1.0% vs 0%, p = 0.119) (Table C). Likewise, multivariable regression model controlling for the contributing factors (ethnicity, Cesarean delivery, previous perinatal mortality, and PPD symptoms), revealed no independent significant association between delivering during the war ear and bonding impairment (Adjusted OR 1.81, 95% CI- 0.51–6.39, p = 0.351), as presented in Table F. 4. Discussion 4.1 Principal Findings The main finding of the study was the independent association between women who delivered during the Hamas-Israel war and increased risk of PPD as evident in the first postpartum days. Likewise, rates of clinical symptoms of PPA were higher in women delivering during the war although the differences were with marginal significance accounting for risk factors. Additionally, delivery during the war was related to higher scores of some factors of impaired MIB. 4.2 Results in the Context of What is known Several studies have evaluated the influence of war trauma and military violence on the perinatal and delivery outcomes. However, to the best of our knowledge, little is known regarding the impact of war trauma on the mother during the important postpartum period, and how exposure to stress-related war trauma may have an adverse effect on maternal mental health and MIB. Existing literature has extensively demonstrated the negative and long-term consequences of exposure to natural disasters, such as hurricanes, floods and earthquakes, and war and terrorism-related trauma on the mental health of the general population. Trauma exposed individuals present a high vulnerability group at great risk for a range of mental disorders 50 . The mental health sequalae of women deriving during exposure to terrorism attacks and war has received little empirical scrutiny. However, studies have been conducted about the effect of trauma in the context of natural disasters. Substantial PPD was reported in women exposed to the 2005 Katarina Hurricane, especially among high-exposure individuals, however the overall rates of PPD were not higher than the general population 51 . PPD was found associated with nontangible (psychosocial) loss of resources 52 . A qualitative study suggests significance effect on the women’s own life and direct impact on her functioning as a mother 53 . Several factors may explain the increased mental health adversity among postpartum women. First, lack of social support. Second, partner deployment and lack of support person in delivery, and in the transition to motherhood, and third, endorsement of posttraumatic stress that increases vulnerability for PPD. Lack of social support is a known major risk factor for PPD. In a meta-analyses and systematic reviews of risk factors for PPD, lack of social support was concluded as a salient risk factor of PPD 54 . A comparison of recent newcomers to Canada, included refugee, asylum seeker and immigrant, groups characterized by impaired social support, showed a significant increase in PPD compared to Canadian-born group 55 . Higher incidence has been demonstrated in occupied territories which also suffer from decrease in social support 56 . Our study was conducted in the first weeks of the war, which were characterized by lack of preparedness of psychosocial support to the population which may explain our findings. Additional two studies who conducted after the Katerina Hurricane and related prenatal consequences, used the Revised prenatal distress questionnaire (NuPDQ) and demonstrated higher rates of anxiety 57 58 . Both studies included women who did not have experience the hurricane and one of them also took place 5-7 years after the disaster. Therefore, concluded that indirect disaster exposure may also affected by traumatic events. Additionally, both studies related the social support as a key role of the development of health problem risk. Our study did not reveal a significant increased anxiety risk among women delivering during the war using the STAI questionnaire, although a trend for endorsing higher rates of PPA symptoms was documented. Less than a handful of studies exist on the effect of war and terrorism on maternal-infant attachment. In two studies, of Palestinian women who delivered during the 2014 war on Gaza, severe exposure to war trauma was not associated with MIB at delivery, and 4 and 6 months postpartum 59 60 . These findings largely accord with our results.It has been further shown that the source and function of social support mediates unimpaired or impaired bonding 61 . Severe war trauma was associated with poor social support which in turn associated with more MIB problems. 4.3 Clinical Implications War trauma and military conflicts force populations to face losses and destruction and live with feelings of fear, insecurity, and despair 62 63 . The literature depicts a significance mental health cost of these conflicts 64 65 . The number of people worldwide live and suffer from military conflicts continue to increase 66 . Pregnant women and mothers are particularly vulnerable in conditions of war 67 . Our study revealed increased risk of PPD in women who deliver during conditions of war. PPD has significance consequences and costs 68 69 . Women with PPD are likely to experience future episodes of depression and co-morbid mental illnesses 70 . Depressed women may also suffer from providing appropriate maternal care and their infants are at risk for developmental problem 71 72 . Developing a tailored screening system to early on identify women at risk of developing PPD during times of war is necessary, as well as providing the required support to dealing with the illness and decrease the consequential damage. Screening for symptoms of PPA may be also considered given the high co-occurrence of both conditions. Our findings provide some evidence suggesting that conditions of war may increase more severe forms of bonding impairment in a minority woman. Understanding the important of the mother-infant unit and the relevance of supporting this unit at times of elevated stress is warranted. 4.4 Research Implications The present study was conducted immediately after the outbreak of the Israel-Hamas war and assessed high exposure mothers in the very first days after delivering in a large hospital that served as the main hospital in this war. Hence, we evaluated mothers at critical time point for the development of mental health problems and MIB impairment. The duration of exposure may play a major role in the impact of war trauma on postpartum mental health and maternal psychiatric symptoms may surface in the first weeks and months postpartum. Future studies may examine the effect of the duration of war trauma on postpartum mental health outcomes and measure long-term potential effects. Repeated time point assessment may add important information. Furthermore, although the SUMC serves as a main hospital in the Israel-Hamas War, additional studies may compare the results in other Israeli hospitals which gave care to affected women during the war. 4.5 Strengths and Limitations This study fills in a critical gap in knowledge on the mental health consequences of giving birth during times of war and in the aftermath of a unpresidential terrorist attack by studying women who gave birth in the first weeks and days since the Hamas-Israel war and revealing mental health status during the very immediate postpartum. The strengths of our study also include the relatively large cohort of women including women who gave birth before the war. Due to the Israeli law which ensures all women, the samples of women in this hospital are representative, relatively heterogenous and includes both Jewish and Bedouin populations. This study controlled for potential confounding factors while comparing two very similar groups of postpartum women who delivered at the SUMC, with common demographic and obstetrical characteristics. Furthermore, we utilized reliable and well-validated tools for the assessment of the risk of PPD as well as PPA, and MIB. There are also several limitations worth noting. First, being a cross-sectional study, the results can establish associations but not causality. Second, assessing the mothers immediately after birth at a single time point, without a follow-up examination, cannot identify a longitudinal pattern and influence and may be subject to overlooking increased impairments and symptoms that may develop outside the immediate postpartum. Third, all measures are mothers' reports. Although we used validated questionnaires, incorporating additional assessments, such as diagnostic interviews and observational methods, could further validated the findings. Conclusions Our study assessed the immediate postpartum mental health implications of the Israel-Hamas war, which struck on October 7th, 2023. The study revealed increased risk of PPD and tendency, however not significant, in increased risk for PPA among women who deliver during the war. The study also revealed higher scores of some factors of impaired MIB. As these states effect the mother, her infant and other family members, implementation of appropriate supporting resources and serves are needed in countries who face military conflict or war state. Screening for depression and anxiety in postpartum units followed by early assessment by professionals of those found at risk should be considered first steps to prevent chronic mental health complications. In addition, adopting a multidisciplinary approach that integrates medical, psychological and social interventions with awareness to the optional postpartum consequences is likely to endure preparation during unpresidential times. Declarations Author Contributions Statement : All authors contributed to the study conception and design. Material preparation, data collection, analysis and first draft of the manuscript were written and performed by Hadar Klapper Goldstein. All authors commented on previous versions of the manuscript and also read and approved the final manuscript. Funding Statement: The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Competing Interests Statement: The authors have no relevant financial or non-financial interests to disclose. Author Contributions Statement: All authors contributed to the study conception and design. Material preparation, data collection, analysis and first draft of the manuscript were written and performed by Hadar Klapper Goldstein. All authors commented on previous versions of the manuscript and also read and approved the final manuscript. Ethics approval and Consent to participate Statements: The study was approved by the local Institutional Review Board (IRB- 0208-22-SOR) and written consent was obtained from all participants. Consent to publish Statement: The authors affirm that human research participants provided informed consent for publication. Presentation: The abstract would be presented at the 2024 SMFM Global Congress on the 27 of September 2024 (Session Title: Oral Concurrent Session 6 - Stillbirth and Maternal Mental Health Presentation ID #: 30query upon request). References "Israel/Palestine: Devastating Civilian Toll as Parties Flout Legal Obligations". Human Rights Watch. 9 October 2023. Archived from the original on 9 October 2023. Retrieved 9 October 2023. Levi-Belz Y, Groweiss Y, Blank C, Neria Y. PTSD, depression, and anxiety after the October 7, 2023 attack in Israel: a nationwide prospective study. eClinicalMedicine. 2024. https://doi.org/10.1016/j.eclinm.2023.102418. Carpiniello B. 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Spielberger, Charles & Gorsuch, Richard & Lushene, Robert & Vagg, PR & Jacobs, Gerard. (1983). Manual for the State-Trait Anxiety Inventory (Form Y1 – Y2). Barnes, L.L., Harp, D., & Jung, W.S. (2002). Reliability Generalization of Scores on the Spielberger State-Trait Anxiety Inventory. Educational and Psychological Measurement, 62, 603 - 618. Julian LJ. Measures of anxiety: State-Trait Anxiety Inventory (STAI), Beck Anxiety Inventory (BAI), and Hospital Anxiety and Depression Scale-Anxiety (HADS-A). Arthritis Care Res (Hoboken). 2011 Nov;63 Suppl 11(0 11):S467-72. doi: 10.1002/acr.20561. PMID: 22588767; PMCID: PMC3879951. Kvaal K, Ulstein I, Nordhus IH, Engedal K. The Spielberger State-Trait Anxiety Inventory (STAI): the state scale in detecting mental disorders in geriatric patients. Int J Geriatr Psychiatry 2005;20:629–34. Prokopowicz A, Stanczykiewicz B, Uchmanowicz I. Validation of the Numerical Anxiety Rating Scale in postpartum females: a prospective observational study. 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The association between epidural analgesia during labor and mother-infant bonding. J Clin Anesth. 2022 Sep;80:110795. doi: 10.1016/j.jclinane.2022.110795. Epub 2022 Apr 27. PMID: 35489303. Lehnig F, Nagl M, Stepan H, Wagner B, Kersting A. Associations of postpartum mother-infant bonding with maternal childhood maltreatment and postpartum mental health: a cross-sectional study. BMC Pregnancy Childbirth. 2019 Aug 5;19(1):278. doi: 10.1186/s12884-019-2426-0. PMID: 31382903; PMCID: PMC6683437 Fergusson DM, Horwood LJ, Boden JM, Mulder RT. Impact of a major disaster on the mental health of a well-studied cohort. JAMA Psychiatry. 2014 Sep;71(9):1025-31. doi: 10.1001/jamapsychiatry.2014.652. PMID: 25028897. Harville EW, Xiong X, Pridjian G, Elkind-Hirsch K, Buekens P. Postpartum mental health after Hurricane Katrina: a cohort study. BMC Pregnancy Childbirth. 2009 Jun 8;9:21. doi: 10.1186/1471-2393-9-21. PMID: 19505322; PMCID: PMC2702337. Ehrlich M, Harville E, Xiong X, Buekens P, Pridjian G, Elkind-Hirsch K. Loss of resources and hurricane experience as predictors of postpartum depression among women in southern Louisiana. J Womens Health (Larchmt). 2010 May;19(5):877-84. doi: 10.1089/jwh.2009.1693. PMID: 20438305; PMCID: PMC2875990. Levy, Mindy. “Maternity in the Wake of Terrorism: Rebirth or Retraumatization?” Journal of Prenatal and Perinatal Psychology and Health 20 (2006): 221. Zhao XH, Zhang ZH. Risk factors for postpartum depression: An evidence-based systematic review of systematic reviews and meta-analyses. Asian J Psychiatr. 2020 Oct;53:102353. doi: 10.1016/j.ajp.2020.102353. Epub 2020 Aug 30. PMID: 32927309. Stewart DE, Gagnon A, Saucier JF, Wahoush O, Dougherty G. Postpartum depression symptoms in newcomers. Can J Psychiatry. 2008 Feb;53(2):121-4. doi: 10.1177/070674370805300208. PMID: 18357931. Qandil S, Jabr S, Wagler S, Collin SM. Postpartum depression in the Occupied Palestinian Territory: a longitudinal study in Bethlehem. BMC Pregnancy Childbirth. 2016 Nov 25;16(1):375. doi: 10.1186/s12884-016-1155-x. PMID: 27887649; PMCID: PMC5124263. Giarratano GP, Barcelona V, Savage J, Harville E. Mental health and worries of pregnant women living through disaster recovery. Health Care Women Int. 2019 Mar;40(3):259-277. doi: 10.1080/07399332.2018.1535600. Epub 2019 Apr 26. PMID: 31026188; PMCID: PMC7098448. Barcelona de Mendoza V, Harville E, Savage J, Giarratano G. Association of Complementary and Alternative Therapies With Mental Health Outcomes in Pregnant Women Living in a Postdisaster Recovery Environment. J Holist Nurs. 2016 Sep;34(3):259-70. doi: 10.1177/0898010115609250. Epub 2015 Oct 26. PMID: 26503992; PMCID: PMC4846591. Punamäki RL, Isosävi S, Qouta SR, Kuittinen S, Diab SY. War trauma and maternal-fetal attachment predicting maternal mental health, infant development, and dyadic interaction in Palestinian families. Attach Hum Dev. 2017 Oct;19(5):463-486. doi: 10.1080/14616734.2017.1330833. Epub 2017 May 30. PMID: 28556692. Qouta SR, Vänskä M, Diab SY, Punamäki RL. War trauma and infant motor, cognitive, and socioemotional development: Maternal mental health and dyadic interaction as explanatory processes. Infant Behav Dev. 2021 May;63:101532. doi: 10.1016/j.infbeh.2021.101532. Epub 2021 Feb 13. PMID: 33588286. Punamäki RL, Isosävi S, Qouta SR, Kuittinen S, Diab SY. War trauma and maternal-fetal attachment predicting maternal mental health, infant development, and dyadic interaction in Palestinian families. Attach Hum Dev. 2017 Oct;19(5):463-486. doi: 10.1080/14616734.2017.1330833. Epub 2017 May 30. PMID: 28556692. Levy, Mindy. “Maternity in the Wake of Terrorism: Rebirth or Retraumatization?” Journal of Prenatal and Perinatal Psychology and Health 20 (2006): 221. Carpiniello B. The Mental Health Costs of Armed Conflicts-A Review of Systematic Reviews Conducted on Refugees, Asylum-Seekers and People Living in War Zones. Int J Environ Res Public Health. 2023 Feb 6;20(4):2840. doi: 10.3390/ijerph20042840. PMID: 36833537; PMCID: PMC9957523. Carpiniello B. The Mental Health Costs of Armed Conflicts-A Review of Systematic Reviews Conducted on Refugees, Asylum-Seekers and People Living in War Zones. Int J Environ Res Public Health. 2023 Feb 6;20(4):2840. doi: 10.3390/ijerph20042840. PMID: 36833537; PMCID: PMC9957523. Garry S, Checchi F. Armed conflict and public health: into the 21st century. J Public Health (Oxf). 2020 Aug 18;42(3):e287-e298. doi: 10.1093/pubmed/fdz095. Erratum in: J Public Health (Oxf). 2021 Apr 12;43(1):e110. PMID: 31822891. Carpiniello B. The Mental Health Costs of Armed Conflicts-A Review of Systematic Reviews Conducted on Refugees, Asylum-Seekers and People Living in War Zones. Int J Environ Res Public Health. 2023 Feb 6;20(4):2840. doi: 10.3390/ijerph20042840. PMID: 36833537; PMCID: PMC9957523. Punamäki RL, Qouta SR, Diab SY. The role of maternal attachment in mental health and dyadic relationships in war trauma. Heliyon. 2019 Dec 12;5(12):e02867. doi: 10.1016/j.heliyon.2019.e02867. PMID: 31890934; PMCID: PMC6926227. Gurung B, Jackson LJ, Monahan M, Butterworth R, Roberts TE. Identifying and assessing the benefits of interventions for postnatal depression: a systematic review of economic evaluations. BMC Pregnancy Childbirth. 2018 May 21;18(1):179. doi: 10.1186/s12884-018-1738-9. PMID: 29783936; PMCID: PMC5963067. Glavin K, Leahy-Warren P. Postnatal depression is a public health nursing issue: perspectives from norway and ireland. Nurs Res Pract. 2013;2013:813409. doi: 10.1155/2013/813409. Epub 2013 Sep 5. PMID: 24089636; PMCID: PMC3780656. Glavin K, Leahy-Warren P. Postnatal depression is a public health nursing issue: perspectives from norway and ireland. Nurs Res Pract. 2013;2013:813409. doi: 10.1155/2013/813409. Epub 2013 Sep 5. PMID: 24089636; PMCID: PMC3780656. Glavin K, Leahy-Warren P. Postnatal depression is a public health nursing issue: perspectives from norway and ireland. Nurs Res Pract. 2013;2013:813409. doi: 10.1155/2013/813409. Epub 2013 Sep 5. PMID: 24089636; PMCID: PMC3780656. Gurung B, Jackson LJ, Monahan M, Butterworth R, Roberts TE. Identifying and assessing the benefits of interventions for postnatal depression: a systematic review of economic evaluations. BMC Pregnancy Childbirth. 2018 May 21;18(1):179. doi: 10.1186/s12884-018-1738-9. PMID: 29783936; PMCID: PMC5963067 Tables Table A – Maternal Sociodemographic, clinical, pregnancy and delivery data Characteristics Mothers in the war period ( n = 230) n (%) Mothers before the war period ( n = 272) n (%) p value Maternal age, years (mean ± SD) 29.3 ± 5.9 29.2 ± 5. 4 0.888 Ethnicity Bedouin 1 41 (61. 3 ) 122 (45.0) <0.001 Jewish 89 (38. 7 ) 149 (55.0) Marital status Married 49 (92.5) 242 (94.5) 0.557 Other 4 (7.5) 14 (5.5) Educational status Elementary school 1 (2.0) 0 (0) <0.001 High school 3 (5.9) 10 (3.9) University- bachelor degree 31 (60.8) 242 (94.5) University- graduate school 4 (7.8) 4 (1.6) History of chronic illness 24 (10.4) 34 (12.5) 0.462 History of psychiatric illness 5 (2.2) 1 (0.4) 0.064 Gravidity 1 40 (17.4) 48 (17.6) 0.314 2-4 119 (51.7) 152 (55.9) > 5 71 (30.9) 72 (26.5) Parity 1 52 (22.6) 67 (24.6) 0.497 2-4 92 (40.0) 117 (43.0) > 5 86 (37.4) 88 (32.4) Previous Cesarean section 0 182 (79.5) 227 (83.5) 0.002 1 27 (11.8) 40 (14.7) 2 20 (8.7) 4 (1.5) > 3 0 (0) 1 (0.4) Previous perinatal mortality 11 (4.8) 0 (0.0) <0.001 Fertility treatments None 221 (96.5) 255 (93.8) 0.158 Treatment 8 (3.5) 17 (6.3) Pregnancy- related hypertensive disorders 10 (4.3) 8 (2.9) 0.398 Maternal diabetes mellitus 16 (7.0) 13 (4.8) 0.298 Gestational age at birth, weeks (mean ± SD) 38. 8 ± 1.6 38.9 ± 1.6 0.500 Preterm delivery 24 (10.5) 17 (6.3) 0.088 Cesarean section 75 (32.6) 40 (14.7) <0.001 Birth weight, gr (mean ± SD) 3190.3 ± 522.2 3203.9 ± 460.3 0.757 Low birth weight (birth weight < 2500 g) 22 (9.6) 15 (5.5) 0.084 Apgar 1st min < 7 14 (6.1) 11 (4.1) 0.288 Apgar 5st min < 7 1 (0.4) 1 (0.4) 0.902 Postpartum Hemorrhage 2 (0.9) 3 (1.1) 0.790 * Pregnancy- related hypertensive disorders include preeclampsia, gestational hypertension and chronic hypertension Table B- Impaired postpartum Bonding Questionnaire (PBQ), risk for postpartum depression (EPDS) and anxiety (STAI) among women before and during the war Characteristics Mothers in the war period n (%) Mothers before the war period n (%) p value Total EPDS score ≥ 10 51 (26.6) 32 (12.4) <0.001 Total STAI score ≥ 39 61 (34.3) 26 (17.0) <0.001 Impaired bonding subscale ( 12 items) 13 ( 7.8 ) 11 ( 5.5 ) 0 . 363 Rejection and anger subscale ( 7 items ) 4 ( 2 .2) 0 (0) 0.0 27 Anxiety about care subscale ( 4 items ) 2 ( 1.0 ) 0 (0) 0. 119 Risk of abuse subscale ( 2 items ) 1 0 ( 4.8 ) 1 (0.4) 0.003 Table C – Multivariable logistic regression model for the association between war trauma and risk for postpartum depression Exp (Beta) 95% CI p value Delivery during the war (versus delivery before the war) 2.35 1.16-4.74 0.017 Ethnicity 0.87 0.53-1.42 0.584 Previous perinatal mortality 0.89 0.17-4.58 0.890 Cesarean section 0.75 0.41-1.36 0.351 Table D– Multivariable logistic regression model for the association between war trauma and maternal anxiety Exp (Beta) 95% CI p value Delivery during the war (versus delivery before the war) 2.06 0.97- 4.36 0.058 Ethnicity 0.79 0.47-1.32 0.374 Previous perinatal mortality 1.25 0.33- 4.65 0.732 Cesarean section 0.78 0.43-1.39 0.402 Table E – Postpartum Bonding Questionnaire (PBQ) results among women before and during the war (mean scores ± SD). Characteristics Mothers in the war period (n = 230) (Mean scores ± SD) Mothers before the war period ( n = 272) (Mean scores ± SD) p value Total PBQ score 10.2 ( 14.1 ) 8 .3 ( 6.9 ) 0.0 75 Table F – Multivariable linear regression model (gamma) for the association between war trauma and mother-infant bonding total score Exp (Beta) 95% CI p value Delivery during the war (versus delivery before the war) 1.81 0.51-6.39 0.351 Ethnicity 1.64 0.65 - 4.08 0.288 Previous perinatal mortality 3.36- 0.31-35.47 0.313 Cesarean section 1.10 0.37 - 3.27 0.860 EDPS >10 3.55 1.33-9.43 0.011 Cite Share Download PDF Status: Published Journal Publication published 05 Oct, 2024 Read the published version in Archives of Gynecology and Obstetrics → Version 1 posted Editorial decision: Major Revision 05 Aug, 2024 Reviewers agreed at journal 30 Jul, 2024 Reviewers invited by journal 01 Jul, 2024 Editor assigned by journal 28 Jun, 2024 First submitted to journal 26 Jun, 2024 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. 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Introduction","content":"\u003cp\u003eThe Israel-Hamas war, struck on October 7th, 2023, with terrorists of the Hamas organization from Gaza Strip surprisingly infiltrating to southern Israel by land, sea and air at several locations and advancing towards Israeli towns and communities near the border. In conjunction, heavy rockets fire was targeted at towns and cities in the south and other regions in Israel.\u003c/p\u003e \u003cp\u003eThis event represents the largest terrorism attack in the history of Israel; it entailed actions regarded as crimes of war as has been identified by the UN Human Rights Council\u003ca class=\"FNLink\" href=\"#Fn1\" id=\"#FNLinkFn1\"\u003e\u003c/a\u003e. Approximately 1,200 citizens and soldiers were murdered, and 253 individuals were taken hostage including children, women, and elderly, and people of foreign nationality. In response, Israel declared war and the Israeli Defense Forces (IDF) invaded Gaza striking numerous targets within the Strip. In the writing of this manuscript the war continues. The aftermath of the Hamas attack and the war have surged fear, anxiety, and traumatic stress among the general population of Israel\u003ca class=\"FNLink\" href=\"#Fn2\" id=\"#FNLinkFn2\"\u003e\u003c/a\u003e. This accords with a large body of studies on the substantial impact of war and terrorism on the long-term psychological health not only of high-exposed individuals but also of the general population\u003ca class=\"FNLink\" href=\"#Fn3\" id=\"#FNLinkFn3\"\u003e\u003c/a\u003e \u003ca class=\"FNLink\" href=\"#Fn4\" id=\"#FNLinkFn4\"\u003e\u003c/a\u003e \u003ca class=\"FNLink\" href=\"#Fn5\" id=\"#FNLinkFn5\"\u003e\u003c/a\u003e \u003ca class=\"FNLink\" href=\"#Fn6\" id=\"#FNLinkFn6\"\u003e\u003c/a\u003e.\u003c/p\u003e \u003cp\u003eAmong the Israeli population were women giving birth and entering the postpartum period in the wake of these events. They were exposed to collective trauma during a time in which risk for psychological disturbance and psychiatric disorders are known to ensue in a significant portion of women during non-war conditions\u003ca class=\"FNLink\" href=\"#Fn7\" id=\"#FNLinkFn7\"\u003e\u003c/a\u003e, and around the optimal time for the formation of MIB which is instrumental for child development\u003ca class=\"FNLink\" href=\"#Fn8\" id=\"#FNLinkFn8\"\u003e\u003c/a\u003e. Although exposure to war has been associated with adverse pregnancy outcomes, such as preterm deliveries and low birth weight \u003ca class=\"FNLink\" href=\"#Fn9\" id=\"#FNLinkFn9\"\u003e\u003c/a\u003e \u003ca class=\"FNLink\" href=\"#Fn10\" id=\"#FNLinkFn10\"\u003e\u003c/a\u003e \u003ca class=\"FNLink\" href=\"#Fn11\" id=\"#FNLinkFn11\"\u003e\u003c/a\u003e, knowledge on the impact of war trauma on postpartum mental health and maternal-infant bonging (MIB) is scares.\u003c/p\u003e \u003cp\u003ePsychopathology processes induced by major stressors have been shown to have a salient role in interfering with postpartum coping\u003ca class=\"FNLink\" href=\"#Fn12\" id=\"#FNLinkFn12\"\u003e\u003c/a\u003e. A body of studies show that various physiological and psychosocial-related stressors occurring during pregnancy and delivery contribute to the development of postpartum depression (PPD)\u003ca class=\"FNLink\" href=\"#Fn13\" id=\"#FNLinkFn13\"\u003e\u003c/a\u003e. PPD can emerge within the first weeks after delivery and may remain enduring beyond the first postpartum year\u003ca class=\"FNLink\" href=\"#Fn14\" id=\"#FNLinkFn14\"\u003e\u003c/a\u003e \u003ca class=\"FNLink\" href=\"#Fn15\" id=\"#FNLinkFn15\"\u003e\u003c/a\u003e. According to the World Health Organization, more than 10% of postpartum women experience PPD\u003ca class=\"FNLink\" href=\"#Fn16\" id=\"#FNLinkFn16\"\u003e\u003c/a\u003e. PPD impairs maternal quality of life and social functioning and increases risk for co-morbid psychiatric conditions (e.g., substance use) and physical illness (e.g., obesity)\u003ca class=\"FNLink\" href=\"#Fn17\" id=\"#FNLinkFn17\"\u003e\u003c/a\u003e. It\u0026rsquo;s adversity on the developing child has been well-documented as well as its contributing role as a causal factor of maternal death\u003ca class=\"FNLink\" href=\"#Fn18\" id=\"#FNLinkFn18\"\u003e\u003c/a\u003e. Stress conditions during pregnancy and labor have been relate to psychopathology processes and may serve a critical role in development of PPD\u003ca class=\"FNLink\" href=\"#Fn19\" id=\"#FNLinkFn19\"\u003e\u003c/a\u003e.\u003c/p\u003e \u003cp\u003eAlthough PPD is the most common complications of childbirth, clinical levels of postpartum anxiety (PPA) are also manifested by a large portion of women in the postpartum period \u003ca class=\"FNLink\" href=\"#Fn20\" id=\"#FNLinkFn20\"\u003e\u003c/a\u003e. PPA occurs along with PPD but also as a separate entity and impairs daily functioning and overall well-being\u003ca class=\"FNLink\" href=\"#Fn21\" id=\"#FNLinkFn21\"\u003e\u003c/a\u003e. Women with significant life stressors are vulnerable to develop PPA\u003ca class=\"FNLink\" href=\"#Fn22\" id=\"#FNLinkFn22\"\u003e\u003c/a\u003e. Several maternal complications have been related to PPA, such as reduced breastfeeding, lack of maternal emotional and behavioral sensitivity to the infant, and poor bonding \u003ca class=\"FNLink\" href=\"#Fn23\" id=\"#FNLinkFn23\"\u003e\u003c/a\u003e \u003ca class=\"FNLink\" href=\"#Fn24\" id=\"#FNLinkFn24\"\u003e\u003c/a\u003e \u003ca class=\"FNLink\" href=\"#Fn25\" id=\"#FNLinkFn25\"\u003e\u003c/a\u003e \u003ca class=\"FNLink\" href=\"#Fn26\" id=\"#FNLinkFn26\"\u003e\u003c/a\u003e.\u003c/p\u003e \u003cp\u003eThe postpartum period and particularly the first postpartum days are considered an optimal opportunity for the formation of MIB. MIB is defined as the maternal affection towards the infant that influences the emotional bond that the mother develops with her infant and the ensuing of appropriate maternal behavior\u003ca class=\"FNLink\" href=\"#Fn27\" id=\"#FNLinkFn27\"\u003e\u003c/a\u003e. MIB mediates child development and exerts positive effects on the well-being of the adult offspring. Impaired bonding associates with lack of maternal affectional involvement, increased irritability, aggressive impulses, and outright rejection of the infant \u003ca class=\"FNLink\" href=\"#Fn28\" id=\"#FNLinkFn28\"\u003e\u003c/a\u003e. These behaviors may progress to avoidance, neglect and even child abuse\u003ca class=\"FNLink\" href=\"#Fn29\" id=\"#FNLinkFn29\"\u003e\u003c/a\u003e. Disturbance in the wellbeing of the mother after delivery can interfere with the formation of maternal bonding\u003ca class=\"FNLink\" href=\"#Fn30\" id=\"#FNLinkFn30\"\u003e\u003c/a\u003e and impaired bonding has been documented as mediating the adverse effect of postpartum psychopathology on child development. While PPD and PPA may be relate to development of inadequate MIB, an impaired bonding may result in a mental illness\u003ca class=\"FNLink\" href=\"#Fn31\" id=\"#FNLinkFn31\"\u003e\u003c/a\u003e\u003ca class=\"FNLink\" href=\"#Fn32\" id=\"#FNLinkFn32\"\u003e\u003c/a\u003e. Trauma exposure has been further shown to adversely impact MIB \u003ca class=\"FNLink\" href=\"#Fn33\" id=\"#FNLinkFn33\"\u003e\u003c/a\u003e. however limited knowledge exists regarding the tool of exposure to war conditions.\u003c/p\u003e \u003cp\u003eTo this end, we studied a high-exposure sample of early postpartum women who gave birth in the first two months of the Hamas-Israel war. Participants resided in the south region of Israel, i.e., had direct exposure to Hamas terrorist attacks and/or air strikes. They delivered in the Soroka University Medical Center (SUMC), the main provider of the tertiary hospital care services for the Negev population exposed to the military attacks, between October and November 2023. We set to examine the immediate consequences of the Israel-Hamas war on postpartum women\u0026rsquo;s (1) mental health pertaining to symptoms of depression and anxiety and (2) bonding with their infant.\u003c/p\u003e"},{"header":"2. Material and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Population and settings\u003c/h2\u003e \u003cp\u003eThe study sample entailed women who delivered a singleton live-born infant at the Soroka University Medical Center (SUMC) and were 1\u0026ndash;3 days postpartum. The study group included women who delivered between October 17 and November 24, 2023, i.e., during the first weeks of the Israel-Hamas War. Control group included women who delivered at the SUMC between January 4, 2020 and September 4, 2020, i.e., before the War era.\u003c/p\u003e \u003cp\u003eSUMC is located in the center of the Negev region. It is the largest birth center in Israel with more than 17,000 births a year. It serves as a referral center for all patients from the Negev region. Exclusion criteria were past or present psychosis, suicidal ideation, substance abuse, medical complications in infant health (i.e., newborns with congenital anomalies or chromosomal abnormalities or requirement for intensive care unit (ICU) hospitalization) and multiple birth. The study was approved by the local Institutional Review Board (IRB- 0208-22-SOR) and written consent was obtained from all participants.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Study measures\u003c/h2\u003e \u003cp\u003e\u003cem\u003ePostpartum depression symptoms\u003c/em\u003e were assessed using the Edinburgh Postnatal Depression Scale (EPDS). This is a 10-item well-validated questionnaire\u003ca class=\"FNLink\" href=\"#Fn34\" id=\"#FNLinkFn34\"\u003e\u003c/a\u003e which is widely used in routine perinatal care to screen for maternal PPD in accordance with the American College of Obstetricians and Gynecologists (ACOG) recommendations (Committee Opinion No 2018)\u003ca class=\"FNLink\" href=\"#Fn35\" id=\"#FNLinkFn35\"\u003e\u003c/a\u003e. Scores range from 0\u0026ndash;30, with higher scores representing higher symptom severity. A cutoff score of 10 is recommended for determining clinically significant symptoms of depression and risk for postpartum depression\u003ca class=\"FNLink\" href=\"#Fn36\" id=\"#FNLinkFn36\"\u003e\u003c/a\u003e\u003ca class=\"FNLink\" href=\"#Fn37\" id=\"#FNLinkFn37\"\u003e\u003c/a\u003e.\u003c/p\u003e \u003cp\u003e\u003cem\u003ePostpartum anxiety symptoms\u003c/em\u003e were measured using the 20-item State scale which is part of the widely used State-Trait Anxiety Inventory (STAI)\u003ca class=\"FNLink\" href=\"#Fn38\" id=\"#FNLinkFn38\"\u003e\u003c/a\u003e\u003ca class=\"FNLink\" href=\"#Fn39\" id=\"#FNLinkFn39\"\u003e\u003c/a\u003e. The State scale assess the presence and severity of symptoms of anxiety in the past two weeks on a 4-point scale. Scores range from 20\u0026ndash;80 with higher scores indicating greater anxiety level\u003ca class=\"FNLink\" href=\"#Fn40\" id=\"#FNLinkFn40\"\u003e\u003c/a\u003e. A cutoff score of 39\u0026ndash;40 is recommended to detect clinically significant symptoms of anxiety\u003ca class=\"FNLink\" href=\"#Fn41\" id=\"#FNLinkFn41\"\u003e\u003c/a\u003e and risk for PPA\u003ca class=\"FNLink\" href=\"#Fn42\" id=\"#FNLinkFn42\"\u003e\u003c/a\u003e.\u003c/p\u003e \u003cp\u003e \u003cem\u003eMother-infant bonding impairment\u003c/em\u003e was assessed using the Postpartum Bonding Questionnaire (PBQ), a reliable and validated screening tool for assessing disorders of the mother\u0026ndash;infant relationship\u003ca class=\"FNLink\" href=\"#Fn43\" id=\"#FNLinkFn43\"\u003e\u003c/a\u003e. The measure consists of 25 statements assessing the attitudes of mothers towards their infants in which agreement with is statement is rated on Likert scale ranging from 0 (always) to 5 (never). Total scores range between 0\u0026ndash;125, with higher scores indicative of more impairment\u003ca class=\"FNLink\" href=\"#Fn44\" id=\"#FNLinkFn44\"\u003e\u003c/a\u003e. The PBQ is comprised of four factors: (I) impaired Bonding (12 items), (II) Rejection and Anger (7 items), (III) Anxiety about Care (4 items), and (IV) Risk of Abuse (2 items). In accordance with previous studies\u003ca class=\"FNLink\" href=\"#Fn45\" id=\"#FNLinkFn45\"\u003e\u003c/a\u003e, cutoff scores of 12, 17, 10, and 3, are suggested for bonding impairment for each factor respectively and total score of 26 showed high specificity (85\u0026ndash;100%) in detecting MIB impairments\u003ca class=\"FNLink\" href=\"#Fn46\" id=\"#FNLinkFn46\"\u003e\u003c/a\u003e.\u003c/p\u003e \u003cp\u003e \u003cem\u003eSociodemographic and obstetrical-related information\u003c/em\u003e Sociodemographic variables including maternal age, ethnicity, marital status, education was obtained through a self-report questionnaire. Additional information was drawn from participants electronic medical records (EMRs) and included history of chronic or psychiatric illness, gravidity, parity, previous Cesarean section or perinatal mortality, fertility treatment, mode of delivery and pregnancy complications (e.g., pregnancy- related hypertensive disorders, gestational diabetes and postpartum hemorrhage), gestational age at birth, birth weights and Apgar at birth.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Statistical analysis\u003c/h2\u003e \u003cp\u003eSample size was determined to achieve power of 80% for bilateral hypothesis with statistical significance set at 95% (α error of 5%). A sample of 214 women was calculated to be sufficient to detect a difference of 3 in mean total bonding score between the groups and SD of 7.6\u003ca class=\"FNLink\" href=\"#Fn47\" id=\"#FNLinkFn47\"\u003e\u003c/a\u003e.\u003c/p\u003e \u003cp\u003eComparison of Impaired Bonding sub-scale (a score of more than 12) between the two groups, was based on the 10% expected rate of impaired bonding in total population\u003ca class=\"FNLink\" href=\"#Fn48\" id=\"#FNLinkFn48\"\u003e\u003c/a\u003e. A sample of 188 women was calculated to be sufficient to detect a difference of 7% in the rate of impaired bonding between the groups.\u003c/p\u003e \u003cp\u003eMissing data were missing at random and were handled by exclusion of participants with missing information in the study measure from the specific analysis. Statistical analysis was performed using SPSS version 29.0. Study groups (delivery of a live- born infant during the war era or before) comparison on continuous variables was performed using independent T-tests and group differences in the distribution of categorical variables with Chi-square tests. Multiple logistic regression models were constructed to examine the relationship between war-exposure and mental health outcomes, while adjusting for confounding variables. The strategy for model building was as follows: Background characteristics were compared between the study groups. Variables indicative of study group differences that were significantly associated with the outcome variable (p\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.1) were treated as confounding variables; they were tested in the multivariable models, to determine the association between war-exposure and mental health/bonding outcomes not accounted by other factors.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eA total of 502 women were included in the final analysis. Among them 230 delivered during the War (exposure group) and 272 delivered and studied before the War (non-exposure group). The exposure group represents 62% of women admitted to the SUMC\u0026rsquo;s maternity wards during this time period accounting for excluded cases out of 68% of women who agreed to participate.\u003c/p\u003e \u003cp\u003eMaternal demographic and obstetric features of women who delivered before and during the Israel-Hamas war are summarized in Table A. Mean maternal age was 29 in both groups (29.3\u0026thinsp;\u0026plusmn;\u0026thinsp;5.9 vs 29.2\u0026thinsp;\u0026plusmn;\u0026thinsp;5.4, p\u0026thinsp;=\u0026thinsp;0.888) and in both groups the majority of women were married (92.5% vs 94.5%, p\u0026thinsp;=\u0026thinsp;0.557). No significant differences were found in history of chronic and psychiatric illness. The rate of Bedouin women compared to Jewish women was higher among women delivering during the war. Educational level was also different between both groups.\u003c/p\u003e \u003cp\u003eIn regard to obstetrical history, rates of prior Cesarean delivery (20.5% vs 16.6%, p\u0026thinsp;=\u0026thinsp;0.002) and previous perinatal mortality, defined as previous pregnancy complicated with intra-uterine fetal death, intra-partum death or post-partum death, was more common among women delivering during the war compared to controls (4.8% vs 0%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Likewise, in regard to recent childbirth, rates of Cesarean delivery were higher among the war-exposed group (32.6% vs 14.7%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), although no significant differences were noted in pregnancy course, i.e., use of fertility treatments and complications, i.e., gestational diabetes, pregnancy- related hypertensive disorders and postpartum hemorrhage. History of psychiatric illness, preterm birth and low newborn weight showed marginal significance to women delivering during the war. Finally, neonatal characteristics were comparable between groups, including gestational age at birth (38.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6 vs 38.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6, p\u0026thinsp;=\u0026thinsp;0.500), newborn weight (3190.3\u0026thinsp;\u0026plusmn;\u0026thinsp;522.2 vs 3203.9\u0026thinsp;\u0026plusmn;\u0026thinsp;460.3, p\u0026thinsp;=\u0026thinsp;0.757), and Apgar scores (\u0026lt;\u0026thinsp;7).\u003c/p\u003e \u003cp\u003eChi-square analysis revealed significant differences among women delivering during and before the war in endorsement of clinically significant symptoms of PPD (EPDS\u0026thinsp;\u0026gt;\u0026thinsp;=\u0026thinsp;10). As presented in Table B, rates of PPD symptoms were higher in the war-exposed group in comparison with controls (26.6% vs. 12.4%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Multivariable logistic regression model controlling for the contribution of ethnicity, education, Cesarean delivery, and prior perinatal mortality revealed an independent association between exposure to war and risk for PPD (Table C). Adjusted risk for PPD in women delivering during the war was more than two times higher compared to women who delivered before the war era (adjusted odds Ratio, OR- 2.35, 95% CI 1.16\u0026ndash;4.74, p\u0026thinsp;=\u0026thinsp;0.017). Women delivering during the war era were also more likely to endorse clinically significant symptoms of PPA suggesting high risk for PPA (STAI\u0026thinsp;\u0026gt;\u0026thinsp;39, 34.3% vs 17.0%, respectively, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). When accounting for the same contributing factors (ethnicity, education, Cesarean delivery, and prior perinatal mortality) the multivariable regression revealed only a marginally significant independent association between delivery during the war and risk for PPA (Adjusted OR 2.06, 95% CI 0.97\u0026ndash;4.36, p\u0026thinsp;=\u0026thinsp;0.058), as presented in Table D.\u003c/p\u003e \u003cp\u003eChi-square analysis revealed no significant differences between study groups in risk for overall maternal-infant bonding impairment (10.2\u0026thinsp;\u0026plusmn;\u0026thinsp;14.1 vs 8.3\u0026thinsp;\u0026plusmn;\u0026thinsp;6.9, p\u0026thinsp;=\u0026thinsp;0.075), as presented in Table E. BPQ scores on the Rejection and Anger factor (2.2% vs 0%, p\u0026thinsp;=\u0026thinsp;0.0.27) and the Risk of abuse (4.8% vs 0.4%, p\u0026thinsp;=\u0026thinsp;0.003) factors were significantly higher in women delivering during the war than those delivering before the war, suggesting risk for severe problems in mother-infant relationships. The groups did not differ on other bonding factors, i.e., General impaired bonding (7.8% vs 5.5% p\u0026thinsp;=\u0026thinsp;0.363) and Anxiety about care (1.0% vs 0%, p\u0026thinsp;=\u0026thinsp;0.119) (Table C). Likewise, multivariable regression model controlling for the contributing factors (ethnicity, Cesarean delivery, previous perinatal mortality, and PPD symptoms), revealed no independent significant association between delivering during the war ear and bonding impairment (Adjusted OR 1.81, 95% CI- 0.51\u0026ndash;6.39, p\u0026thinsp;=\u0026thinsp;0.351), as presented in Table F.\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003e\u003cem\u003e4.1 Principal Findings\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe main finding of the study was the independent association between women who delivered during the Hamas-Israel war and increased risk of PPD as evident in the first postpartum days.\u0026nbsp;Likewise, rates of clinical symptoms of PPA\u0026nbsp;were higher in women delivering during the war although the differences were with marginal significance\u0026nbsp;accounting for risk factors. Additionally, delivery during the war was related to higher scores of some factors of impaired MIB.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e4.2 Results in the Context of What is known\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSeveral studies have evaluated the influence of war trauma and military violence on the perinatal and delivery outcomes. However, to the best of our knowledge, little is known regarding the impact of war trauma on the mother during the important postpartum period, and how exposure to stress-related war trauma may have an adverse effect on maternal mental health and MIB. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eExisting literature has extensively demonstrated the negative and long-term consequences of exposure to natural disasters, such as hurricanes, floods and earthquakes, and war and terrorism-related trauma on the mental health of the general population. Trauma exposed individuals present a high vulnerability group at great risk for a range of mental disorders\u003csup\u003e50\u003c/sup\u003e. The mental health sequalae of women deriving during exposure to terrorism attacks and war has received little empirical scrutiny. However, studies have been conducted about the effect of trauma in the context of natural disasters. Substantial PPD was reported in women exposed to the 2005 Katarina Hurricane, especially among high-exposure individuals, however the overall rates of PPD were not higher than the general population\u003csup\u003e51\u003c/sup\u003e. PPD was found associated with nontangible (psychosocial) loss of resources\u003csup\u003e52\u003c/sup\u003e. A qualitative study suggests significance effect on the women’s own life and direct impact on her functioning as a mother\u003csup\u003e53\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eSeveral factors may explain the increased mental health adversity among postpartum women. First, lack of social support. Second, partner deployment and lack of support person in delivery, and in the transition to motherhood, and third, endorsement of posttraumatic stress that increases vulnerability for PPD. Lack of social support is a known major risk factor for PPD. In a meta-analyses and systematic reviews of risk factors for PPD, lack of social support was concluded as a salient risk factor of PPD\u003csup\u003e54\u003c/sup\u003e. A comparison of recent newcomers to Canada, included refugee, asylum seeker and immigrant, groups characterized by impaired social support, showed a significant increase in PPD compared to Canadian-born group\u003csup\u003e55\u003c/sup\u003e. Higher incidence has been demonstrated in occupied territories which also suffer from decrease in social support\u003csup\u003e56\u003c/sup\u003e. \u0026nbsp;Our study was conducted in the first weeks of the war, which were characterized by\u0026nbsp;lack of preparedness of psychosocial support to the population which may explain our findings.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Additional two studies who conducted after the Katerina Hurricane and related prenatal consequences, used the Revised prenatal distress questionnaire (NuPDQ) and demonstrated higher rates of anxiety\u003csup\u003e57\u003c/sup\u003e \u003csup\u003e58\u003c/sup\u003e. Both studies included women who did not have experience the hurricane and one of them also took place 5-7 years after the disaster. Therefore, concluded that indirect disaster exposure may also affected by traumatic events. Additionally, both studies related the social support as a key role of the development of health problem risk. Our study did not reveal a significant increased anxiety risk among women delivering during the war using the STAI questionnaire, although a trend for endorsing higher rates of PPA symptoms was documented. \u0026nbsp; \u003c/p\u003e\n\u003cp\u003eLess than a handful of studies exist on the effect of war and terrorism on maternal-infant attachment. In two studies, of Palestinian women who delivered during the 2014 war on Gaza, severe exposure to war trauma was not associated with MIB at delivery, and 4 and 6 months postpartum\u003csup\u003e59 60\u003c/sup\u003e. These findings largely accord with our results.It has been further shown that the source and function of social support mediates unimpaired or impaired bonding\u0026nbsp;\u003csup\u003e61\u003c/sup\u003e. Severe war trauma was associated with poor social support which in turn associated with more MIB problems.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e4.3 Clinical Implications\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWar trauma and military conflicts force populations to face losses and destruction and live with feelings of fear, insecurity, and despair\u003csup\u003e62 63\u003c/sup\u003e. The literature depicts a significance mental health cost of these conflicts\u003csup\u003e64 65\u003c/sup\u003e. The number of people worldwide live and suffer from military conflicts continue to increase\u003csup\u003e66\u003c/sup\u003e. Pregnant women and mothers are particularly vulnerable in conditions of war\u003csup\u003e67\u003c/sup\u003e. Our study revealed increased risk of PPD in women who deliver during conditions of war. PPD has significance consequences and costs\u003csup\u003e68\u003c/sup\u003e \u003csup\u003e69\u003c/sup\u003e.\u0026nbsp;Women with PPD are likely to experience future episodes of depression and co-morbid mental illnesses\u003csup\u003e70\u003c/sup\u003e. Depressed women may also suffer from providing appropriate maternal care and their infants are at risk for developmental problem\u003csup\u003e71\u003c/sup\u003e \u003csup\u003e72\u003c/sup\u003e. Developing a tailored screening system to early on identify women at risk of developing PPD during times of war is necessary, as well as providing the required support to dealing with the illness and decrease the consequential damage. Screening for symptoms of PPA may be also considered given the high co-occurrence of both conditions. Our findings provide some evidence suggesting that conditions of war may increase more severe forms of bonding impairment in a minority woman. Understanding the important of the mother-infant unit and the relevance of supporting this unit at times of elevated stress is warranted. \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e4.4 Research Implications\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe present study was conducted immediately after the outbreak of the Israel-Hamas war\u0026nbsp;and assessed high exposure mothers in the very first days after delivering in a large hospital that served as the main hospital in this war. Hence, we evaluated mothers at critical time point for the development of mental health problems and MIB impairment. The duration of exposure may play a major role in the impact of war trauma on postpartum mental health and maternal psychiatric symptoms may surface in the first weeks and months postpartum. \u0026nbsp;Future studies may examine the effect of the duration of war trauma on postpartum mental health outcomes and measure long-term potential effects. Repeated time point assessment may add important information. Furthermore, although the SUMC serves as a main hospital in the Israel-Hamas War, additional studies may compare the results in other Israeli hospitals which gave care to affected women during the war.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e4.5 Strengths and Limitations\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis study fills in a critical gap in knowledge on the mental health consequences of giving birth during times of war and in the aftermath of a unpresidential terrorist attack by studying women who gave birth in the first weeks and days since the Hamas-Israel war and revealing mental health status during the very immediate postpartum. The strengths of our study also include the relatively large cohort of women including women who gave birth before the war. Due to the Israeli law which ensures all women, the samples of women in this hospital are representative, relatively heterogenous and includes both Jewish and Bedouin populations. This study controlled for potential confounding factors while comparing two very similar groups of postpartum women who delivered at the SUMC, with common demographic and obstetrical characteristics. Furthermore, we utilized reliable and well-validated tools for the assessment of the risk of PPD as well as PPA, and MIB.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThere are also several limitations worth noting. First, being a cross-sectional study, the results can establish associations but not causality. Second, assessing the mothers immediately after birth at a single time point, without a follow-up examination, cannot identify a longitudinal pattern and influence and may be subject to overlooking increased impairments and symptoms that may develop outside the immediate postpartum. Third, all measures are mothers' reports. Although we used validated questionnaires, incorporating additional assessments, such as diagnostic interviews and observational methods, could further validated the findings. \u0026nbsp;\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eOur study assessed the immediate postpartum mental health implications of the Israel-Hamas war, which struck on October 7th, 2023. The study revealed increased risk of PPD and tendency, however not significant, in increased risk for PPA among women who deliver during the war. The study also revealed higher scores of some factors of impaired MIB. As these states effect the mother, her infant and other family members, implementation of appropriate supporting resources and serves are needed in countries who face military conflict or war state. Screening for depression and anxiety in postpartum units followed by early assessment by professionals of those found at risk should be considered first steps to prevent chronic mental health complications. In addition, adopting a multidisciplinary approach that integrates medical, psychological and social interventions with awareness to the optional postpartum consequences is likely to endure preparation during unpresidential times.\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contributions\u003c/h2\u003e \u003cp\u003e \u003cb\u003eStatement\u003c/b\u003e: All authors contributed to the study conception and design. Material preparation, data collection, analysis and first draft of the manuscript were written and performed by Hadar Klapper Goldstein. All authors commented on previous versions of the manuscript and also read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eFunding Statement: The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003eCompeting Interests Statement: The authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003eAuthor Contributions Statement: All authors contributed to the study conception and design. Material preparation, data collection, analysis and first draft of the manuscript were written and performed by Hadar Klapper Goldstein. All authors commented on previous versions of the manuscript and also read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eEthics approval and Consent to participate Statements: The study was approved by the local Institutional Review Board (IRB- 0208-22-SOR) and written consent was obtained from all participants.\u003c/p\u003e\n\u003cp\u003eConsent to publish Statement: The authors affirm that human research participants provided informed consent for publication.\u003c/p\u003e\n\u003cp\u003ePresentation: The abstract would be presented at the 2024 SMFM Global Congress on the 27 of September 2024 (Session Title: Oral Concurrent Session 6 - Stillbirth and Maternal Mental Health\u003c/p\u003e\n\u003cp\u003ePresentation ID #: 30query upon request).\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003e\u0026quot;Israel/Palestine: Devastating Civilian Toll as Parties Flout Legal Obligations\u0026quot;. Human Rights Watch. 9 October 2023. 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Heliyon. 2019 Dec 12;5(12):e02867. doi: 10.1016/j.heliyon.2019.e02867. PMID: 31890934; PMCID: PMC6926227.\u003c/li\u003e\n \u003cli\u003eGurung B, Jackson LJ, Monahan M, Butterworth R, Roberts TE. Identifying and assessing the benefits of interventions for postnatal depression: a systematic review of economic evaluations. BMC Pregnancy Childbirth. 2018 May 21;18(1):179. doi: 10.1186/s12884-018-1738-9. PMID: 29783936; PMCID: PMC5963067.\u003c/li\u003e\n \u003cli\u003eGlavin K, Leahy-Warren P. Postnatal depression is a public health nursing issue: perspectives from norway and ireland. Nurs Res Pract. 2013;2013:813409. doi: 10.1155/2013/813409. Epub 2013 Sep 5. PMID: 24089636; PMCID: PMC3780656.\u003c/li\u003e\n \u003cli\u003eGlavin K, Leahy-Warren P. Postnatal depression is a public health nursing issue: perspectives from norway and ireland. Nurs Res Pract. 2013;2013:813409. doi: 10.1155/2013/813409. Epub 2013 Sep 5. PMID: 24089636; PMCID: PMC3780656.\u003c/li\u003e\n \u003cli\u003eGlavin K, Leahy-Warren P. Postnatal depression is a public health nursing issue: perspectives from norway and ireland. Nurs Res Pract. 2013;2013:813409. doi: 10.1155/2013/813409. Epub 2013 Sep 5. PMID: 24089636; PMCID: PMC3780656.\u003c/li\u003e\n \u003cli\u003eGurung B, Jackson LJ, Monahan M, Butterworth R, Roberts TE. Identifying and assessing the benefits of interventions for postnatal depression: a systematic review of economic evaluations. BMC Pregnancy Childbirth. 2018 May 21;18(1):179. doi: 10.1186/s12884-018-1738-9. PMID: 29783936; PMCID: PMC5963067\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable A \u0026ndash; Maternal\u0026nbsp;Sociodemographic, clinical, pregnancy and delivery data\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"677\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.88330871491876%\" valign=\"top\"\u003e\n \u003cp\u003eCharacteristics\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.451994091580502%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.986706056129986%\" valign=\"top\"\u003e\n \u003cp\u003eMothers in the war period\u003c/p\u003e\n \u003cp\u003e(\u003cem\u003en\u0026nbsp;\u003c/em\u003e= 230)\u003c/p\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.838995568685377%\" valign=\"top\"\u003e\n \u003cp\u003eMothers before the war period\u003c/p\u003e\n \u003cp\u003e(\u003cem\u003en\u0026nbsp;\u003c/em\u003e= 272)\u003c/p\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.838995568685377%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ep\u0026nbsp;\u003c/em\u003evalue\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.88330871491876%\" valign=\"top\"\u003e\n \u003cp\u003eMaternal age, years (mean\u0026nbsp;\u0026plusmn;\u0026nbsp;SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.451994091580502%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.986706056129986%\" valign=\"top\"\u003e\n \u003cp\u003e29.3\u0026nbsp;\u0026plusmn; 5.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.838995568685377%\" valign=\"top\"\u003e\n \u003cp\u003e29.2\u0026nbsp;\u0026plusmn; 5.\u003cspan dir=\"RTL\"\u003e4\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.838995568685377%\" valign=\"top\"\u003e\n \u003cp\u003e0.888\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.88330871491876%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eEthnicity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.451994091580502%\" valign=\"top\"\u003e\n \u003cp\u003eBedouin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.986706056129986%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003cspan dir=\"RTL\"\u003e41\u003c/span\u003e (61.\u003cspan dir=\"RTL\"\u003e3\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.838995568685377%\" valign=\"top\"\u003e\n \u003cp\u003e122 (45.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.838995568685377%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.89501312335958%\" valign=\"top\"\u003e\n \u003cp\u003eJewish\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.183727034120736%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cspan dir=\"RTL\"\u003e89\u003c/span\u003e (38.\u003cspan dir=\"RTL\"\u003e7\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.921259842519685%\" valign=\"top\"\u003e\n \u003cp\u003e149 (55.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.88330871491876%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eMarital status \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.451994091580502%\" valign=\"top\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.986706056129986%\" valign=\"top\"\u003e\n \u003cp\u003e49 (92.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.838995568685377%\" valign=\"top\"\u003e\n \u003cp\u003e242 (94.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.838995568685377%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.557\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.89501312335958%\" valign=\"top\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.183727034120736%\" valign=\"top\"\u003e\n \u003cp\u003e4 (7.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.921259842519685%\" valign=\"top\"\u003e\n \u003cp\u003e14 (5.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.88330871491876%\" rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eEducational status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.451994091580502%\" valign=\"top\"\u003e\n \u003cp\u003eElementary school\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.986706056129986%\" valign=\"top\"\u003e\n \u003cp\u003e1 (2.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.838995568685377%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.838995568685377%\" rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.89501312335958%\" valign=\"top\"\u003e\n \u003cp\u003eHigh school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.183727034120736%\" valign=\"top\"\u003e\n \u003cp\u003e3 (5.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.921259842519685%\" valign=\"top\"\u003e\n \u003cp\u003e10 (3.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.89501312335958%\" valign=\"top\"\u003e\n \u003cp\u003eUniversity-\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ebachelor degree\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.183727034120736%\" valign=\"top\"\u003e\n \u003cp\u003e31 (60.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.921259842519685%\" valign=\"top\"\u003e\n \u003cp\u003e242 (94.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.89501312335958%\" valign=\"top\"\u003e\n \u003cp\u003eUniversity-\u0026nbsp;\u003c/p\u003e\n \u003cp\u003egraduate school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.183727034120736%\" valign=\"top\"\u003e\n \u003cp\u003e4 (7.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.921259842519685%\" valign=\"top\"\u003e\n \u003cp\u003e4 (1.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.88330871491876%\" valign=\"top\"\u003e\n \u003cp\u003eHistory of\u0026nbsp;\u003c/p\u003e\n \u003cp\u003echronic illness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.451994091580502%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.986706056129986%\" valign=\"top\"\u003e\n \u003cp\u003e24 (10.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.838995568685377%\" valign=\"top\"\u003e\n \u003cp\u003e34 (12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.838995568685377%\" valign=\"top\"\u003e\n \u003cp\u003e0.462\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.88330871491876%\" valign=\"top\"\u003e\n \u003cp\u003eHistory of psychiatric illness\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.451994091580502%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.986706056129986%\" valign=\"top\"\u003e\n \u003cp\u003e5 (2.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.838995568685377%\" valign=\"top\"\u003e\n \u003cp\u003e1 (0.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.838995568685377%\" valign=\"top\"\u003e\n \u003cp\u003e0.064\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.88330871491876%\" rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eGravidity \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.451994091580502%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.986706056129986%\" valign=\"top\"\u003e\n \u003cp\u003e40 (17.4)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.838995568685377%\" valign=\"top\"\u003e\n \u003cp\u003e48 (17.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.838995568685377%\" rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e0.314\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.89501312335958%\" valign=\"top\"\u003e\n \u003cp\u003e2-4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.183727034120736%\" valign=\"top\"\u003e\n \u003cp\u003e119 (51.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.921259842519685%\" valign=\"top\"\u003e\n \u003cp\u003e152 (55.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.89501312335958%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cu\u003e\u0026gt;\u003c/u\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.183727034120736%\" valign=\"top\"\u003e\n \u003cp\u003e71 (30.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.921259842519685%\" valign=\"top\"\u003e\n \u003cp\u003e72 (26.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.88330871491876%\" rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eParity \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.451994091580502%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.986706056129986%\" valign=\"top\"\u003e\n \u003cp\u003e52 (22.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.838995568685377%\" valign=\"top\"\u003e\n \u003cp\u003e67 (24.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.838995568685377%\" rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.497\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.89501312335958%\" valign=\"top\"\u003e\n \u003cp\u003e2-4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.183727034120736%\" valign=\"top\"\u003e\n \u003cp\u003e92 (40.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.921259842519685%\" valign=\"top\"\u003e\n \u003cp\u003e117 (43.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.89501312335958%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cu\u003e\u0026gt;\u003c/u\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.183727034120736%\" valign=\"top\"\u003e\n \u003cp\u003e86 (37.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.921259842519685%\" valign=\"top\"\u003e\n \u003cp\u003e88 (32.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.88330871491876%\" rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003ePrevious Cesarean section\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.451994091580502%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.986706056129986%\" valign=\"top\"\u003e\n \u003cp\u003e182 (79.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.838995568685377%\" valign=\"top\"\u003e\n \u003cp\u003e227 (83.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.838995568685377%\" rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.89501312335958%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.183727034120736%\" valign=\"top\"\u003e\n \u003cp\u003e27 (11.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.921259842519685%\" valign=\"top\"\u003e\n \u003cp\u003e40 (14.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.89501312335958%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.183727034120736%\" valign=\"top\"\u003e\n \u003cp\u003e20 (8.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.921259842519685%\" valign=\"top\"\u003e\n \u003cp\u003e4 (1.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.89501312335958%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cu\u003e\u0026gt;\u003c/u\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.183727034120736%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.921259842519685%\" valign=\"top\"\u003e\n \u003cp\u003e1 (0.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.88330871491876%\" valign=\"top\"\u003e\n \u003cp\u003ePrevious perinatal mortality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.451994091580502%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.986706056129986%\" valign=\"top\"\u003e\n \u003cp\u003e11 (4.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.838995568685377%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.838995568685377%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.88330871491876%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eFertility treatments\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.451994091580502%\" valign=\"top\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.986706056129986%\" valign=\"top\"\u003e\n \u003cp\u003e221 (96.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.838995568685377%\" valign=\"top\"\u003e\n \u003cp\u003e255 (93.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.838995568685377%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.158\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.89501312335958%\" valign=\"top\"\u003e\n \u003cp\u003eTreatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.183727034120736%\" valign=\"top\"\u003e\n \u003cp\u003e8 (3.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.921259842519685%\" valign=\"top\"\u003e\n \u003cp\u003e17 (6.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.88330871491876%\" valign=\"top\"\u003e\n \u003cp\u003ePregnancy- related hypertensive disorders\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.451994091580502%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.986706056129986%\" valign=\"top\"\u003e\n \u003cp\u003e10 (4.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.838995568685377%\" valign=\"top\"\u003e\n \u003cp\u003e8 (2.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.838995568685377%\" valign=\"top\"\u003e\n \u003cp\u003e0.398\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.88330871491876%\" valign=\"top\"\u003e\n \u003cp\u003eMaternal diabetes mellitus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.451994091580502%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.986706056129986%\" valign=\"top\"\u003e\n \u003cp\u003e16 (7.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.838995568685377%\" valign=\"top\"\u003e\n \u003cp\u003e13 (4.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.838995568685377%\" valign=\"top\"\u003e\n \u003cp\u003e0.298\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.88330871491876%\" valign=\"top\"\u003e\n \u003cp\u003eGestational age\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eat birth, weeks\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(mean\u0026nbsp;\u0026plusmn;\u0026nbsp;SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.451994091580502%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.986706056129986%\" valign=\"top\"\u003e\n \u003cp\u003e38.\u003cspan dir=\"RTL\"\u003e8\u003c/span\u003e \u0026plusmn; 1.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.838995568685377%\" valign=\"top\"\u003e\n \u003cp\u003e38.9\u0026nbsp;\u0026plusmn; 1.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.838995568685377%\" valign=\"top\"\u003e\n \u003cp\u003e0.500\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.88330871491876%\" valign=\"top\"\u003e\n \u003cp\u003ePreterm delivery\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.451994091580502%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.986706056129986%\" valign=\"top\"\u003e\n \u003cp\u003e24 (10.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.838995568685377%\" valign=\"top\"\u003e\n \u003cp\u003e17 (6.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.838995568685377%\" valign=\"top\"\u003e\n \u003cp\u003e0.088\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.88330871491876%\" valign=\"top\"\u003e\n \u003cp\u003eCesarean section\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.451994091580502%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.986706056129986%\" valign=\"top\"\u003e\n \u003cp\u003e75 (32.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.838995568685377%\" valign=\"top\"\u003e\n \u003cp\u003e40 (14.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.838995568685377%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.88330871491876%\" valign=\"top\"\u003e\n \u003cp\u003eBirth weight, gr\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(mean\u0026nbsp;\u0026plusmn;\u0026nbsp;SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.451994091580502%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.986706056129986%\" valign=\"top\"\u003e\n \u003cp\u003e3190.3\u0026nbsp;\u0026plusmn; 522.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.838995568685377%\" valign=\"top\"\u003e\n \u003cp\u003e3203.9\u0026nbsp;\u0026plusmn;\u0026nbsp;460.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.838995568685377%\" valign=\"top\"\u003e\n \u003cp\u003e0.757\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.88330871491876%\" valign=\"top\"\u003e\n \u003cp\u003eLow birth weight (birth weight \u0026lt; 2500 g)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.451994091580502%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.986706056129986%\" valign=\"top\"\u003e\n \u003cp\u003e22 (9.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.838995568685377%\" valign=\"top\"\u003e\n \u003cp\u003e15 (5.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.838995568685377%\" valign=\"top\"\u003e\n \u003cp\u003e0.084\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.88330871491876%\" valign=\"top\"\u003e\n \u003cp\u003eApgar 1st min \u0026lt; 7\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.451994091580502%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.986706056129986%\" valign=\"top\"\u003e\n \u003cp\u003e14 (6.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.838995568685377%\" valign=\"top\"\u003e\n \u003cp\u003e11 (4.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.838995568685377%\" valign=\"top\"\u003e\n \u003cp\u003e0.288\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.88330871491876%\" valign=\"top\"\u003e\n \u003cp\u003eApgar 5st min \u0026lt; 7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.451994091580502%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.986706056129986%\" valign=\"top\"\u003e\n \u003cp\u003e1 (0.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.838995568685377%\" valign=\"top\"\u003e\n \u003cp\u003e1 (0.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.838995568685377%\" valign=\"top\"\u003e\n \u003cp\u003e0.902\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.88330871491876%\" valign=\"top\"\u003e\n \u003cp\u003ePostpartum Hemorrhage\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.451994091580502%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.986706056129986%\" valign=\"top\"\u003e\n \u003cp\u003e2 (0.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.838995568685377%\" valign=\"top\"\u003e\n \u003cp\u003e3 (1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.838995568685377%\" valign=\"top\"\u003e\n \u003cp\u003e0.790\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*\u0026nbsp;Pregnancy- related hypertensive disorders include preeclampsia, gestational hypertension and chronic hypertension\u003c/p\u003e\n\u003cp\u003eTable B- Impaired postpartum Bonding Questionnaire (PBQ), risk for postpartum depression (EPDS) and anxiety (STAI) among women before and during the war\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"94%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.8659793814433%\" valign=\"top\"\u003e\n \u003cp\u003eCharacteristics\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.711340206185568%\" valign=\"top\"\u003e\n \u003cp\u003eMothers in the war period\u0026nbsp;\u003c/p\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.711340206185568%\" valign=\"top\"\u003e\n \u003cp\u003eMothers before the war period\u003c/p\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.711340206185568%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ep\u0026nbsp;\u003c/em\u003evalue\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.8659793814433%\" valign=\"top\"\u003e\n \u003cp\u003eTotal EPDS score \u0026ge; 10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.711340206185568%\" valign=\"top\"\u003e\n \u003cp\u003e51 (26.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.711340206185568%\" valign=\"top\"\u003e\n \u003cp\u003e32 (12.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.711340206185568%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.8659793814433%\" valign=\"top\"\u003e\n \u003cp\u003eTotal STAI score \u0026ge; \u003cspan dir=\"RTL\"\u003e39\u003c/span\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.711340206185568%\" valign=\"top\"\u003e\n \u003cp\u003e61 (34.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.711340206185568%\" valign=\"top\"\u003e\n \u003cp\u003e26 (17.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.711340206185568%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.8659793814433%\" valign=\"top\"\u003e\n \u003cp\u003eImpaired bonding\u0026nbsp;\u003c/p\u003e\n \u003cp\u003esubscale\u003c/p\u003e\n \u003cp\u003e(\u003cspan dir=\"RTL\"\u003e12\u003c/span\u003e items) \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.711340206185568%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cspan dir=\"RTL\"\u003e13\u003c/span\u003e (\u003cspan dir=\"RTL\"\u003e7.8\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.711340206185568%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cspan dir=\"RTL\"\u003e11\u003c/span\u003e (\u003cspan dir=\"RTL\"\u003e5.5\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.711340206185568%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cspan dir=\"RTL\"\u003e0\u003c/span\u003e.\u003cspan dir=\"RTL\"\u003e363\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.8659793814433%\" valign=\"top\"\u003e\n \u003cp\u003eRejection and anger subscale\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(\u003cem\u003e7 items\u003c/em\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.711340206185568%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cspan dir=\"RTL\"\u003e4\u003c/span\u003e (\u003cspan dir=\"RTL\"\u003e2\u003c/span\u003e.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.711340206185568%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.711340206185568%\" valign=\"top\"\u003e\n \u003cp\u003e0.0\u003cspan dir=\"RTL\"\u003e27\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.8659793814433%\" valign=\"top\"\u003e\n \u003cp\u003eAnxiety about care subscale\u003c/p\u003e\n \u003cp\u003e(\u003cem\u003e4 items\u003c/em\u003e)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.711340206185568%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cspan dir=\"RTL\"\u003e2\u003c/span\u003e (\u003cspan dir=\"RTL\"\u003e1.0\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.711340206185568%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.711340206185568%\" valign=\"top\"\u003e\n \u003cp\u003e0.\u003cspan dir=\"RTL\"\u003e119\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.8659793814433%\" valign=\"top\"\u003e\n \u003cp\u003eRisk of abuse\u0026nbsp;\u003c/p\u003e\n \u003cp\u003esubscale\u003c/p\u003e\n \u003cp\u003e(\u003cem\u003e2 items\u003c/em\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.711340206185568%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003cspan dir=\"RTL\"\u003e0\u003c/span\u003e (\u003cspan dir=\"RTL\"\u003e4.8\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.711340206185568%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cspan dir=\"RTL\"\u003e1\u003c/span\u003e (0.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.711340206185568%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cspan dir=\"RTL\"\u003e0.003\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable C \u0026ndash; Multivariable logistic regression model for the association between war trauma and risk for postpartum depression\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"650\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.923076923076923%\" valign=\"top\"\u003e\n \u003cp\u003eExp (Beta)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.923076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.923076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ep\u0026nbsp;\u003c/em\u003evalue\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003eDelivery during the war\u003c/p\u003e\n \u003cp\u003e(versus delivery before the war)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.923076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e2.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.923076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e1.16-4.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.923076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e0.017\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003eEthnicity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.923076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e0.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.923076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e0.53-1.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.923076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e0.584\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003ePrevious perinatal mortality\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.923076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e0.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.923076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e0.17-4.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.923076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e0.890\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003eCesarean section\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.923076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e0.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.923076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e0.41-1.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.923076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e0.351\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable D\u0026ndash; Multivariable logistic regression model for the association between war trauma and maternal anxiety\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"652\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.31797235023041%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.89400921658986%\" valign=\"top\"\u003e\n \u003cp\u003eExp (Beta)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.89400921658986%\" valign=\"top\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.89400921658986%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ep\u0026nbsp;\u003c/em\u003evalue\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.31797235023041%\" valign=\"top\"\u003e\n \u003cp\u003eDelivery during the war\u003c/p\u003e\n \u003cp\u003e(versus delivery before the war)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.89400921658986%\" valign=\"top\"\u003e\n \u003cp\u003e2.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.89400921658986%\" valign=\"top\"\u003e\n \u003cp\u003e0.97- 4.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.89400921658986%\" valign=\"top\"\u003e\n \u003cp\u003e0.058\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.31797235023041%\" valign=\"top\"\u003e\n \u003cp\u003eEthnicity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.89400921658986%\" valign=\"top\"\u003e\n \u003cp\u003e0.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.89400921658986%\" valign=\"top\"\u003e\n \u003cp\u003e0.47-1.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.89400921658986%\" valign=\"top\"\u003e\n \u003cp\u003e0.374\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.31797235023041%\" valign=\"top\"\u003e\n \u003cp\u003ePrevious perinatal mortality\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.89400921658986%\" valign=\"top\"\u003e\n \u003cp\u003e1.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.89400921658986%\" valign=\"top\"\u003e\n \u003cp\u003e0.33- 4.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.89400921658986%\" valign=\"top\"\u003e\n \u003cp\u003e0.732\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.31797235023041%\" valign=\"top\"\u003e\n \u003cp\u003eCesarean section\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.89400921658986%\" valign=\"top\"\u003e\n \u003cp\u003e0.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.89400921658986%\" valign=\"top\"\u003e\n \u003cp\u003e0.43-1.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.89400921658986%\" valign=\"top\"\u003e\n \u003cp\u003e0.402\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;Table E \u0026ndash; Postpartum Bonding Questionnaire (PBQ) results among women before and during the war (mean scores \u0026plusmn; SD).\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"94%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.282828282828284%\" valign=\"top\"\u003e\n \u003cp\u003eCharacteristics\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.252525252525253%\" valign=\"top\"\u003e\n \u003cp\u003eMothers in the war period (n = 230)\u003c/p\u003e\n \u003cp\u003e(Mean scores \u0026plusmn; SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.262626262626263%\" valign=\"top\"\u003e\n \u003cp\u003eMothers before the war period (\u003cem\u003en\u0026nbsp;\u003c/em\u003e= 272)\u003c/p\u003e\n \u003cp\u003e(Mean scores \u0026plusmn; SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.2020202020202%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ep\u0026nbsp;\u003c/em\u003evalue\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.282828282828284%\" valign=\"top\"\u003e\n \u003cp\u003eTotal PBQ score\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.252525252525253%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cspan dir=\"RTL\"\u003e10.2\u003c/span\u003e (\u003cspan dir=\"RTL\"\u003e14.1\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.262626262626263%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cspan dir=\"RTL\"\u003e8\u003c/span\u003e.3 (\u003cspan dir=\"RTL\"\u003e6.9\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.2020202020202%\" valign=\"top\"\u003e\n \u003cp\u003e0.0\u003cspan dir=\"RTL\"\u003e75\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable F \u0026ndash; Multivariable linear regression model (gamma) for the association between war trauma and mother-infant bonding total score\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.53846153846154%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.076923076923077%\" valign=\"top\"\u003e\n \u003cp\u003eExp (Beta)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.923076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.923076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ep\u0026nbsp;\u003c/em\u003evalue\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.53846153846154%\" valign=\"top\"\u003e\n \u003cp\u003eDelivery during the war\u003c/p\u003e\n \u003cp\u003e(versus delivery before the war)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.076923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e1.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.923076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e0.51-6.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.923076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e0.351\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.53846153846154%\" valign=\"top\"\u003e\n \u003cp\u003eEthnicity\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.076923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e1.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.923076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e0.65\u003cspan dir=\"RTL\"\u003e-\u003c/span\u003e4.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.923076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e0.288\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.53846153846154%\" valign=\"top\"\u003e\n \u003cp\u003ePrevious perinatal mortality\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.076923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e3.36-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.923076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e0.31-35.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.923076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e0.313\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.53846153846154%\" valign=\"top\"\u003e\n \u003cp\u003eCesarean section\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.076923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e1.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.923076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e0.37\u003cspan dir=\"RTL\"\u003e-\u003c/span\u003e3.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.923076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e0.860\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.53846153846154%\" valign=\"top\"\u003e\n \u003cp\u003eEDPS \u0026gt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.076923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e3.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.923076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e1.33-9.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.923076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e0.011\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"archives-of-gynecology-and-obstetrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"arch","sideBox":"Learn more about [Archives of Gynecology and Obstetrics](https://www.springer.com/journal/404)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/arch/default.aspx","title":"Archives of Gynecology and Obstetrics","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"War, Terror, Stress, Postpartum, Depression, Anxiety, Maternal-Infant Bonding","lastPublishedDoi":"10.21203/rs.3.rs-4645981/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4645981/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cu\u003ePurpose\u003c/u\u003e: Examine the impact of war conditions on maternal mental health postpartum outcomes pertaining to depression and anxiety, as well as on maternal-infant bonding (MIB).\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eMethods\u003c/u\u003e: A prospective cohort study was performed in women who gave birth in a tertiary medical center, during (October-November 2023) and before (March-May 2020) the Israel-Hamas War. All participants completed validated self-reported questionnaires: The Edinburgh Postnatal Depression Scale (EPDS\u0026gt;=10), State-Trait Anxiety Inventory (STAI\u0026gt;39) and the Postpartum Bonding Questionnaire (PBQ\u0026gt;=26).\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eResults\u003c/u\u003e: A total of 502 women were included, 230 delivered during the War and 272 delivered before. Rates of symptoms of postpartum depression (PPD) were higher in women delivering during the war (26.6% vs. 12.4%, \u003cem\u003ep\u003c/em\u003e\u0026lt;0.001), while multivariable regression revealed two times higher risk (adjusted OR 2.35, 95% CI 1.16-4.74, \u003cem\u003ep\u003c/em\u003e=0.017). Rate of postpartum anxiety risk was also higher (34.3% vs 17.0%, \u003cem\u003ep\u003c/em\u003e\u0026lt;0.001), and reached a trend towards significance accounting for other risk factors (adjusted OR 2.06, 95% CI 0.97-4.36, \u003cem\u003ep\u003c/em\u003e=0.058). Finally, delivery during the war was related to specific factors of impaired MIB. However, did not increase the overall impaired score (PBQ\u0026gt;=26) (10.2 ± 14.1 vs 8.3 ± 6.9, p=0.075).\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eConclusion\u003c/u\u003e: The study revealed increased risk of PPD, marginal significance risk for PPA and some aspects of impairments in MIB among women delivering during the war. Maternal mental illness in the postpartum period has negative impact on the whole family. Therefore, comprehensive screening and adequate resources should be placed in women delivering in war-conflict zones.\u003c/p\u003e","manuscriptTitle":"The association of delivering during a war with the risk for postpartum depression, anxiety and impaired maternal-infant bonding","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-24 06:50:41","doi":"10.21203/rs.3.rs-4645981/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major Revision","date":"2024-08-05T05:46:43+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2024-07-30T19:33:03+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-07-01T20:44:50+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-28T09:20:59+00:00","index":"","fulltext":""},{"type":"submitted","content":"Archives of Gynecology and Obstetrics","date":"2024-06-27T00:46:13+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"archives-of-gynecology-and-obstetrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"arch","sideBox":"Learn more about [Archives of Gynecology and Obstetrics](https://www.springer.com/journal/404)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/arch/default.aspx","title":"Archives of Gynecology and Obstetrics","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"a7b674ef-1c94-4604-9394-85f4044ffac6","owner":[],"postedDate":"July 24th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-10-07T16:06:51+00:00","versionOfRecord":{"articleIdentity":"rs-4645981","link":"https://doi.org/10.1007/s00404-024-07715-8","journal":{"identity":"archives-of-gynecology-and-obstetrics","isVorOnly":false,"title":"Archives of Gynecology and Obstetrics"},"publishedOn":"2024-10-05 15:57:22","publishedOnDateReadable":"October 5th, 2024"},"versionCreatedAt":"2024-07-24 06:50:41","video":"","vorDoi":"10.1007/s00404-024-07715-8","vorDoiUrl":"https://doi.org/10.1007/s00404-024-07715-8","workflowStages":[]},"version":"v1","identity":"rs-4645981","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4645981","identity":"rs-4645981","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}