Prevalence of Postpartum Post-Traumatic Stress Disorder Following Postpartum Haemorrhage: A Systematic Review and Meta-Analysis

Prevalence of Postpartum Post-Traumatic Stress Disorder Following Postpartum Haemorrhage: A Systematic Review and Meta-Analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Prevalence of Postpartum Post-Traumatic Stress Disorder Following Postpartum Haemorrhage: A Systematic Review and Meta-Analysis Ziwei Du, Rongfeng Qi, Ruijing Xin, Mingjian Zheng, Bing Zhang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5982274/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Postpartum haemorrhage (PPH) is not only an important cause of maternal death during the perinatal period but also an important cause of postpartum mental-related diseases. The overall prevalence of Postpartum Post-Traumatic Stress Disorder (PP-PTSD) in the community sample was 4% (95%CI: 2.77–5.71), but the incidence of PP-PTSD caused by PPH has not been reported by meta-analysis and systematic review. Methods: Eleven network databases were systematically searched, including 4 Chinese databases and 7 international databases. The Medical Subject Headings (MeSH) thesaurus combined with Boolean operator, studies were searched from the inception of each database to December 1, 2024. All the retrieved articles were screened according to the inclusion and exclusion criteria, and finally, the studies included in this study. A random effects model was used to pool weighted estimates of PP-PTSD prevalence. Subgroup analysis and meta-regression were used to find possible sources of heterogeneity. In addition, sensitivity analysis and publication bias were used to evaluate the stability and bias of the included studies. Statistical analysis was performed by R software. Results: A total of 15 studies were included in this systematic review and meta-analysis, with a total of 1530 postpartum women who experienced PPH, of whom 265 were diagnosed with PP-PTSD. The pooled prevalence estimate of PP-PTSD after PPH was found to be 19% (95% CI 11–28). The results of the subgroup analysis showed significant differences in the prevalence of screening PP-PTSD tools (P < 0.05). The meta-regression results showed that screening PP-PTSD tools and the definition of PPH may be the source of heterogeneity in this meta-analysis. Sensitivity analysis showed that the pooled estimated prevalence of PP-PTSD was stable, and there was no clear publication bias in the included studies. Discussions: The pooled prevalence of PP-PTSD in postpartum women experiencing PPH was about 19%, which was significantly higher than that in the general postpartum women. However, only 15 studies were included in our meta-analysis, and even fewer could be included in subgroup analyses, which may have limited the pool of the estimated prevalence. But this finding also suggests that attention should be paid not only to maternal PPH treatment during the perinatal period but also to the high risk of PPH leading to PP-PTSD after delivery. Other: The study protocol was also registered with PROSPERO (the International Prospective Register of Systematic Reviews) under the registration ID CRD42024618460. And no funding of any kind was received for this meta-analysis. Postpartum Post-Traumatic Stress Disorder Postpartum Haemorrhage Meta-Analysis Prevalence Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 1. Introduction Post-Traumatic Stress Disorder (PTSD) is a long-term persistent or delayed mental disorder that occurs after individuals have personally experienced or witnessed sudden, catastrophic, or threatening traumatic events [ 1 ]. The types of traumatic events include stress traumatic events closely related to medicine, such as delivery, induced abortion, premature delivery, and major neonatal diseases [ 2 ]. Postpartum Post-Traumatic Stress Disorder (PP-PTSD) was first proposed by Bydlowski and Raoul-Duval as a delayed mental stress disorder that occurs after maternal birth trauma [ 3 ]. According to the Diagnostic and Statistical Manual of Mental Disorders- Fifth Edition (DSM-V), the main clinical manifestations of PP-PTSD are: (1) experiencing the negative feelings of childbirth again; (2) avoiding everything related to childbirth to childbirth; (3) increased alertness in a state of excessive stress. The above symptoms usually last longer than 1 month [ 4 ]. The prevalence of PP-PTSD has been reported to vary widely, ranging from 5%-8% among women within 1–3 months postpartum in community samples, however, the estimated prevalence of PP-PTSD among women with significant clinical symptoms of childbirth trauma ranges from 9.6–27.3% [ 5 ]. PP-PTSD caused by childbirth trauma affects not only the health of the mother but also the mother-infant relationship and partnership, which is a major public health problem [ 6 – 8 ]. Postpartum Haemorrhage (PPH) is considered to be a serious complication of labor and one of the important causes of maternal death [ 9 ], which is defined as blood loss exceeding 500ml during vaginal delivery and 1000ml during cesarean section within 24 hours after fetal delivery [ 10 ]. At present, more attention has been paid to the treatment of PPH, which mainly includes the application of oxytocin, tranexamic acid, uterine gauzing packing, uterine compression suture (B-Lynch), and second-line hemostasis methods such as uterine artery embolization (UAE) and emergency postpartum hysterectomy (EPH) [ 11 ]. However, there are few studies on the psychological trauma caused by PPH. Some studies have reported that postpartum trauma including PPH is one of the important reasons for the increased incidence of PP-PTSD [ 12 , 13 ]. Previous systematic reviews and meta-analyses have reported the prevalence of PP-PTSD after delivery [ 5 ], but none of these reviews reported the prevalence of PP-PTSD due to PPH separately. To the best of our knowledge, there is no systematic review and meta-analysis on the pooled prevalence of PPH leading to PP-PTSD. Therefore, this systematic review and meta-analysis will use qualitative and quantitative methods to systematically analyze the studies on the prevalence of PP-PTSD caused by PPH, and provide reliable information for the prevention of PP-PTSD. 2. Methods The systematic review and meta-analysis of this study were performed according to the new PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines [ 14 ]. This meta-analysis was secondary literature review, no ethical review was required. The study protocol was also registered with PROSPERO (the International Prospective Register of Systematic Reviews) under the registration ID CRD42024618460. 2.1 Search Strategy The main search network databases in this study were international databases and Chinese databases, among which the international databases including MEDLINE(PubMed), Web of Science (SCI), PsycINFO, CINAHL, Scopus, ClinicalTrials.gov, Cochrane Library and the Chinese database included China National Knowledge Infrastructure (CNKI), Chinese Sci-Tech Journal Database (VIP), Chinese BioMedical Literature Service System (SinoMed), and Wanfang database. The publication time of the included literature was limited from the inception of each database through to December 1, 2024, and the languages of articles were limited to English and Chinese. The search strategy of this study defined three key terms as ‘Postpartum Hemorrhage’, ‘Postpartum Period’, ‘Post-Traumatic Stress Disorder’, and listed all synonyms of the three key terms through specific MeSH terms. The synonyms of each key term were connected and searched for literature by Boolean operands ‘OR’, and finally the three key terms and all their synonyms were connected and searched for literature by Boolean operands ‘AND’. To ensure the inclusion of all eligible papers, reference lists of papers included in the full-text review and relevant reviews were also retrieved. 2.2 Inclusion and exclusion criteria Studies that met the following inclusion criteria were included in this systematic review: (1) Subject: aged ≥ 18 years; Published before December 1, 2024; (2) The main contents of the original study were: the prevalence of PP-PTSD in pregnant population; (3) Cross-sectional studies or cross-sectional case-control studies or cohort studies; (4) The diagnostic criteria of PP-PTSD and PPH were clearly reported; (5) the number of PPH patients identified in the literature, or who received second-line treatment for PPH such as UAE or hysterectomy, and the number of PP-PTSD patients. (6) PP-PTSD persisted for at least 1 month after delivery; (7) The numbers of PP-PTSD in different periods were reported in the literature, and only the most recent follow-up time data were extracted. Exclusion criteria: (1) The language of the literature was not Chinese or English, and the literature types were reviews, case reports, comments, letters, and editorials; (2) no standardized screening tools were used to estimate prevalence; (3) unable to obtain original data/duplicate literature; (4) The quality of literature was poor. 2.3 Selection process and data extraction All the retrieved articles were screened by two authors (Z.W-D and R.J-X) independently according to the title and abstract of the article, and then the full text of the article was read and the data were extracted according to the inclusion and exclusion criteria. If there was any disagreement, the third author (R.F-Q) would review and discuss the decision. A self-designed standardized data extraction form was used by two authors (Z.W-D and R.J-X) to extract the following data: last name of the first author, year of publication, country of study, study design, study setting, age of the study subjects, number of PPH patients, number of PP-PTSD patients, PP-PTSD assessment tool, definition of PPH, and interval between postpartum and PP-PTSD questionnaire. All the studies in this meta-analysis included only self-report questionnaires scales to evaluate PP-PTSD patients, and the scales included Impact of Event Scale-Revised (IES-R); Impact of Event Scales (IES); Post-traumatic Stress Checklist-Civilian version (PCL-C); Post-traumatic Stress Checklist (PCL), Perinatal Post Traumatic Stress Disorder Questionnaire (PPQ), PTSD Symptom Scale-Self Report (PSS-SR), PTSD Symptom Scale (PSS). 2.4 Quality assessment The risk of bias and study quality of cross-sectional studies were evaluated using the Joanna Briggs Institute (JBI) criteria, which includes 8 evaluation items. The scores of “YES”, “NO”, “Unclear”, and “Not applicable” were 8 points in total, and the higher the score, the higher the quality of the literature [ 15 ]. Cohort studies were evaluated using the Newcastle-Ottawa scale (NOS). The scale included 3 aspects of research subject selection, comparability, and outcome measurement, and 8 items. Except for comparability, the remaining items could be scored up to 1 point, and the full score was 9 points [ 16 ]. In this study, the literature with ≥ 6 points was included. 2.5 Statistical analysis All statistical analyses were conducted using the “irr”, “meta” and “metafor” packages in R software, version 4.4.1 (R Foundation). The random effects meta-analysis model was used to estimate the prevalence of PP-PTSD by combining the individual studies due to the substantial heterogeneity among studies [ 17 ]. In order to achieve the closest method to the normal distribution of raw rates for each study, all raw incidence rates were transformed using the Freeman–Tukey Double arcsine method [ 18 ]. Total effect estimates and 95% confidence intervals (CI) of results were represented as forest plots. The index of heterogeneity squared (I 2 ) statistics corresponding to 95% confidence intervals (CI) was used to assess the heterogeneity among studies, with I 2 values below 25%, between 25% and 75%, and > 75% considered low, moderate, and high levels of heterogeneity, respectively. PP-PTSD assessment scale (IES-R VS. Non-IES-R), country (developed country VS. developing country), definition of PPH (> 1000ml VS. EPH/UAE), study setting (Multi-centre VS. Single-centre) and study design (Cohort study VS. Cross-sectional) were used to evaluate the possible source of heterogeneity across the studies. At the same time, the chi-square test was used to compare the significance of the difference between the various subgroups. Therefore, we performed subgroup analyses and mixed-model meta-regression analyses of the above factors to explore the potential impact on the observed heterogeneity. Sensitivity analyses were performed by sequentially excluding each study to determine the effect of each study on the overall prevalence estimates [ 19 ]. Funnel plots and Egger’s regression test were used to assess publication bias [ 20 , 21 ]. P-value < 0.05 was considered statistically significant for all analyses. 3. Results 3.1 Search results According to the above search formula, a total of 990 studies were selected, of which 772 studies and 218 studies were found in the international database and the Chinese database, respectively. We excluded 155 and 63 duplicate studies from the international and Chinese databases, respectively, and excluded 544 and 141 studies that did not meet the requirements by reading the title and abstract. A total of 77 English studies and 14 Chinese studies were full-text reviewed, 11 and 3 review articles, 36 and 5 articles with no clear number of PP-PTSD patients, 13 and 4 articles without a clear definition of PPH or a specific number of PPH patients were excluded, respective. A total of 15 studies were included in the final analysis, including 13 English studies and 2 Chinese studies [12,13], [22-34]. Figure.1 3.2 Characteristics of Selected Studies All included studies were published between 2011 and 2024, including 3 cross-sectional studies and 12 cohort studies. Among the countries where research was carried out, France had a total of 6 studies, followed by China and the United States, which each accounted for 2 studies, and the rest of the United Kingdom, Sri Lanka, Australia, Switzerland, and the Netherlands each accounted for 1 study. There were 7 multi-center studies and 8 single-center studies. The number of people diagnosed with PPH in these 15 studies ranged from 8 to 385, for a total of 1530 individuals, of whom 265 were diagnosed with PP-PTSD. All studies used fully self-reported scales to identify PP-PTSD (five studies used IES-R, three used PCL-C, two used IES, two used PSS, and the remaining three studies used TSQ, PPQ, and PCL-5 respectively). Seven studies defined PPH as > 1000ml, 2 studies defined PPH according to ICD-10, and 3 studies defined PPH as > 1500ml, 2000ml, and 3000ml, respectively. In addition, one case of UAE and two cases of EPH were included in this study, which were clearly defined as second-line treatment for PPH. Finally, the time span of the questionnaire survey was wide, from 1 month to 8 years, but 11 studies were completed within 2 months of delivery. (Table. 1) Table 1 Characteristics of fifteen included studies. Study(year) Study design Country Study setting Age Mean (SD) PPH cases PP-PTSD cases Screening PP-PTSD tools Definition of PPH Time of measurement Froeliger,2024[12] Prospective Cohort Study France Multi-centre (N=27) N/A 385 31 IES-R≥33 ICD-10 2mo Deniau, 2024[13] Prospective Cross-sectional France Multi-centre (N=10) 34 236 96 IES>30 >1000ml 1mo Wang,2024[22] Prospective Cohort Study China Single centre 30.37(3.05) 118 20 PCL-C≥38 >1000ml 42d Wei,2022[23] Prospective Cohort Study China Single centre 31.26(3.05) 82 15 PCL-C≥38 >1000ml 45d Froeliger, 2022[24] Prospective Cohort Study France Multi-centre (N=15) N/A 83 9 IES-R>33 >1000ml 2mo Bernasconi2021[25] Retrospective Cohort Study Switzerland Single centre 33 38 8 TSQ UAE 8ye Gankanda, 2021[26] Prospective Cross-sectional Sri Lanka Multi-centre (N=4) 28.38(5.5) 8 0 PSS-SR>13 >1000ml 2mo Kountanis, 2020[27] Prospective Cross-sectional USA Single centre N/A 57 6 PPQ≥19 ICD-10 42d Van Steijn, 2020[28] Prospective Cohort Study Netherlands Multi-centre (N=8) N/A 187 13 PCL-5≥32 ≥2000ml 42d Tol, 2019[29] Retrospective Cohort Study United Kingdom Single centre N/A 22 7 IES-R>32 >3000ml 1-18mo Sentilhes, 2017[30] Prospective Cohort Study France Single centre N/A 14 2 IES≥26 >1000ml 12mo de la Cruz 2016[31] Retrospective Cohort Study USA Multi-centre (N=8) N/A 74 18 PSS≥15 EPH 1mo Michelet, D,2015[32] Retrospective Cohort Study France Single centre N/A 35 22 IES-R>30 EPH 26.5mo Ricbourg, 2015[33] Prospective Cohort Study France Single centre N/A 20 9 IESR≥30 >1000ml 1mo Thompson ,2011[34] Prospective Cohort Study Australian Multi-centre (N=17) N/A 171 9 PCL>44 >1500ml 2mo Abbreviations: N/A, not available; IES-R, Impact of Event Scale - Revised; IES, Impact of Event Scales; PCL-C, Post-traumatic Stress Checklist-Civilian version; PPQ, Perinatal Post Traumatic Stress Disorder; PSS-SR, PTSD Symptom Scale-Self Report; PCL, PTSD Checklist; PSS, PTSD Symptom Scale; EPH, Emergency Peripartum Hysterectomy Table 2 and Table 3 show the quality evaluation results of cross-sectional studies evaluated by JBI and cohort studies evaluated by NOS, respectively. The total scores of all studies were ≥6, the quality scores ranged from six to eight. Table 2 A quality assessment of included three Cross-sectional studies by JBI tools Study 1. Were the criteria for inclusion in the sample clearly defined? 2. Were the study subjects and the setting described in detail? 3. Was the exposure measured in a valid and reliable way? 4. Were objective, standard criteria used for measurement of the condition? 5. Were confounding factors identified? 6. Were strategies to deal with confounding factors stated? 7. Were the outcomes measured in a valid and reliable way? 8. Was appropriate statistical analysis used? Total score Deniau, 2024[13] 1 1 1 1 0 0 1 1 6 Gankanda, 2021[26] 1 1 1 1 0 0 1 1 6 Kountanis, 2020[27] 1 1 1 1 1 1 1 1 8 Table 3 A quality assessment of included twelve Cohort studies by NOS tools Study 1.Representativeness of the exposed cohort 2. Selection of the non-exposed cohort 3. Ascertainment of exposure 4.Demonstration that outcome of interest was not present at start of the study 5. Comparability of cohorts on the basis of the design or analysis controlled for confounders 6. Assessment of outcome 7. Was follow-up long enough for outcomes to occur 8. Adequacy of follow-up of cohorts Total score Froeliger,2024[12] 1 1 1 1 1 1 1 0 7 Wang,2024[22] 1 1 1 1 1 1 0 1 7 Wei,2022[23] 1 1 1 1 1 1 0 1 7 Froeliger, 2022[24] 1 1 1 1 1 1 1 0 7 Bernasconi,2021[25] 1 1 1 0 1 1 0 1 6 Van Steijn, 2020[28] 1 1 1 1 1 1 1 0 7 Tol, 2019[29] 1 1 1 1 1 1 1 0 7 Sentilhes, 2017[30] 1 1 1 0 1 1 1 0 6 de la Cruz2016[31] 1 1 1 1 0 1 1 0 6 Michelet, D,2015[32] 1 1 1 0 0 1 1 1 6 Ricbourg, 2015[33] 1 1 1 1 1 1 1 1 8 Thompso n,2011[34] 1 1 1 1 1 1 1 1 8 3.3 The pooled prevalence of PP-PTSD after PPH (meta-analysis) As shown in the forest plot in Figure 2, the pooled prevalence estimate of PP-PTSD after PPH was found to be 19% (95% CI: 11-28). There was significant heterogeneity across the studies used for this analysis ( I 2 = 92.6%; P<0.0001). 3.4 Subgroup analysis Subgroup analyses were performed to identify possible sources of the apparent heterogeneity observed. As shown in Table 4, the prevalence of PP-PTSD was 15% (95%CI: 0.09;0.23, I 2 =92.5%, P 1000ml and it was 35% (95%CI: 0.12;0.62, I 2 =88.7%, P =0.0001) for EPH/UAE. The prevalence of PP-PTSD in developed countries was 21% (95%CI: 0.11;0.31, I 2 =94.1%, P <0.0001) and it was 15% (95%CI: 0.10;0.21, I 2 =15.7%, P =0.31) for developing country. The prevalence of PP-PTSD in cohort study was 19% (95%CI: 0.11;0.29, I 2 =88.9%, P <0.001), cross-sectional studies was 16% (95%CI: 0.0;0.44, I 2 =93.2%, P <0.001). The prevalence of PP-PTSD was 12% (95%CI 0.05;0.23, I 2 =95.6%, P <0.001) for Multi-centre studies and it was 26% (95%CI: 0.15;0.39, I 2 =82.2%, P <0.001) for Single-centre studies. However, there was no significant difference in the prevalence of the above subgroup analysis. Conversely, the prevalence of PP-PTSD in the IES-R screening tools studies was 28% (95%CI: 0.14;0.46, I 2 =95.6%, P <0.0001) and it was 12% (95%CI: 0.07;0.18, I 2 =78%, P <0.0001) for non-IES-R studies, the observed difference was statistically significant ( χ2= 3.89, P =0.04). Table 4 Subgroup analysis of the pooled prevalence of PP-PTSD after PPH Subgroup analysis Number of studies Incidence of PP-PTSD Number of PPH Pooled prevalence (95%CI) Heterogeneity I 2 , p χ2 p Definition of PPH 2.38 0.123 >1000ml 12 217 1383 15% (0.09;0.23) 92.5%(p<0.0001) EPH 3 48 147 35% (0.12;0.62) 88.7%(p=0.0001) Country 0.59 0.44 Developed country 12 197 1322 21% (0.11;0.31) 95%(p<0.0001) Developing country 3 35 208 15% (0.10;0.21) 15.7%(p=0.31) Study design 0.04 0.85 Cohort study 12 163 1229 19% (0.11;0.29) 88.9%(p<0.001) Cross-sectional 3 102 301 16% (0.0-0.44) 93.2%(p<0.001) Study setting 2.95 0.08 Multi-centre 7 176 1144 12% (0.05;0.23) 95.6%(p<0.001) Single-centre 8 89 386 26% (0.15;0.39) 82.2%(p<0.001) Screening PP-PTSD tools 3.89 0.04 IES-R 7 176 795 28% (0.14;0.46) 95.6%(p<0.0001) No-IES-R 8 89 735 12% (0.07;0.18) 78%(p<0.0001) 3.5 Meta-regression analysis As shown in Table 5, Meta-regression analysis showed that variables of definition of PPH, and Screening PP-PTSD tools as significant moderators for heterogeneity ( P <0.05). Table 5 Meta-regression analysis of the potential moderators Number of studies Estimate Standard error Z P Country 15 0.074 0.116 0.645 0.51 Definition of PPH 15 0.279 0.103 2.78 0.005 Screening PP-PTSD tools 15 -0.244 0.081 -3.01 0.002 Study design 15 0.11 0.093 1.18 0.23 Study setting 15 0.131 0.077 1.69 0.089 3.6 Sensitivity analysis and publication bias Sensitivity analysis showed that after leave-one removal of the 15 eligible studies, the pooled prevalence of PP-PTSD after PPH varied from 16% (95% CI: 0.1;0.23) to 20% (95%CI: 0.12;0.29), with the corresponding I 2 statistic varying from 91.5% to 93.1%. These results suggested that they did not identify any single study as disproportionately influencing the overall estimate of the incidence of PP-PTSD after PPH. (Figure 3) In the current systematic review and meta-analysis, we found no evidence of potential publication bias for the prevalence of PP-PTSD after PPH as evidenced by inspection of the funnel plot (symmetric) and results of regression tests associated with the funnel plot (Egger’s test) (B=2.26, SE=2.08, P =0.29). (Figure.4,5) 4. Discussion 4.1 Main findings of the study A total of 15 studies were included in this systematic review and meta-analysis, in which 265 out of 1530 PPH-exposed maternal women reported PP-PTSD, and pooled prevalence of PP-PTSD was 19% (95%CI: 11%-28%), which was significantly higher than a systematic review reported by Yildiz et al.[35], including 59 studies from 23 countries, with a total sample size of 24267 women, and a pooled prevalence of PP-PTSD of 4% (95%CI: 2.77%-5.71%) in the general maternal population in the community sample. 4.2 Interpretation Uterine atony, pernicious placenta previa, severe soft birth canal laceration, or coagulopathy are the common causes of postpartum hemorrhage [36,37]. These birth traumas may not only increase the risk of childbirth but also increase the risk of PP-PTSD due to more adverse and unpleasant birth experiences. Our study also confirmed the higher prevalence of PP-PTSD caused by PPH compared with PP-PTSD in the community sample. Although the sources of possible heterogeneity were identified through subgroup analysis and meta-regression, the pooled estimates of PP-PTSD incidence in our meta-analysis should be interpreted with more caution because of the significant heterogeneity. 4.2.1 Study design, Country, and Study setting In the subgroup analysis, there were no significant differences in the prevalence of pooled PP-PTSD among study design, country, and study setting, and no heterogeneity was found in the meta-regression. The prevalence of PP-PTSD in the cohort study 19% (95%CI: 0.11;0.29) was generally similar to that in the cross-sectional study 16% (95%CI: 0.0;0.44), indicating that the study design of the included studies was as objective as possible and less selective bias, as confirmed by our sensitivity analysis [38,39]. However, in terms of countries, our study included more developed countries (12 cases) and developing countries (3 cases). The prevalence of PP-PTSD in the developed countries was 21% (95%CI: 0.11;0.31), which appeared to be higher than in developing countries 15% (95%CI: 0.10;0.21), which seems to be quite different from the pooled prevalence of postpartum mental disorders of 31% (95%CI 23%-40) in low-income women in the study by Fellmeth et al, [40]. It may be due to the relatively complete social security and more attention to maternal mental health problems in developed countries, while there seems to be insufficient attention to PP-PTSD caused by PPH in developing countries, resulting in relatively few studies. Therefore, follow-up studies need to include more relevant studies in developing countries. In terms of study design, a total of 7 cases were included in the single-center study and 8 cases were included in the multi-center study. Subgroup analysis showed that the incidence of PP-PTSD in the single-center study was 26% (95%CI: 0.15; 0.39) appeared to be higher than in the multi-center study 12% (95%CI 0.05; 0.23). Although multi-center studies seem likely to include a larger sample, the results are often compromised by more confounding factors that need to be controlled. Auer et al [41]. Also supported the inclusion of a single center sample for pooling of prevalence. However, the number of PPH in our study was small, which could easily affect the outcome of the pooled prevalence. 4.2.2 Screening PP-PTSD tools The most important screening tool for PP-PTSD was the self-report questionnaire, and the IES-R questionnaire was the most widely used questionnaire in the 7 studies included in this meta-analysis. Subgroup analysis showed that the PP-PTSD screening tool IES-R had a significantly higher positive rate than the no-IES-R, and the difference between the two groups was statistically significant, and meta-regression analysis also showed that it may be the source of study heterogeneity. Although self-report questionnaires have high specificity and sensitivity compared to structured clinical interviews [42,43]. However, the structured interview is still considered the gold standard for the diagnosis of PP-PTSD [44]. However, in clinical practice, due to postpartum women's lack of knowledge about PP-PTSD and difficulties in cooperation, most studies have prioritized the use of more convenient and acceptable questionnaires. Due to the variety of PP-PTSD screening questionnaires in this study, a more detailed subgroup analysis cannot be carried out. Subsequent clinical studies can further analyze the reliability and validity of different evaluation scales for PP-PTSD diagnosis. 4.2.4 Definition of PPH Due to the various definitions of PPH in the studies included in our meta-analysis, in order to ensure the number of subgroup analysis studies, PPH was divided into >1000ml and PPH resulted in EPH and UAE. Subgroup analysis showed that the prevalence of PP-PTSD was higher in the EPH/UAE group 35% (95%CI: 0.12;0.62) than in the >1000ml group 15% (95%CI: 0.09;0.23), although the difference was not statistically significant. However, many studies have shown that the treatment of EPH and UAE caused by PPH tends to experience more disturbing feelings and longer-lasting mental trauma [45,46]. One EPH case and one UAE case were followed up for a long time (26.5 mo-8years), and the questionnaire survey may have a certain recall bias, but it was still proved from the side that the duration of PP-PTSD is longer. In addition, meta-regression results suggested that the definition of PPH might be a source of heterogeneity. Therefore, subsequent studies may need to analyze the prevalence of PP-PTSD in patients with simple PPH and those who need EPH or UAE due to PPH separately, and further cohort studies with large samples are needed if necessary. 4.3 Strengths and Limitations To the best of our knowledge, this meta-analysis is the first time focusing on the prevalence of PP-PTSD exposed to PPH. The results of our study's sensitivity analysis and publication bias demonstrate the robustness of the estimated prevalence of PP-PTSD. However, some limitations of the study should be acknowledged. First, only 15 studies were included in our meta-analysis, and even fewer could be included in subgroup analyses, which may have limited the pool of the estimated prevalence. Second, our meta-analysis showed a high degree of heterogeneity, which may be due to the inherent nature of the data from the included studies, although we used subgroup analyses and meta-regression to find sources of heterogeneity, which makes it difficult for clinicians to match exactly with their clinical situations. Finally, most of the studies included in our meta-analysis focused on developed countries, which may limit the generalizability of PP-PTSD prevalence in developing countries. 4.4 Conclusion Our systematic review and meta-analysis revealed that about 19% of women exposed to PPH developed PP-PTSD, a prevalence higher than that observed in the general obstetric population. The increased prevalence of PP-PTSD indicates that PPH has a significant impact on maternal mental health, suggesting that women experiencing PPH need more comprehensive postpartum care including mental illness. Declarations Ethics approval and consent to participate This meta-analysis was secondary literature review, no ethical review was required. Consent for publication All authors read and approved the final version manuscript for publication. Acknowledgments We are delighted to acknowledge all the authors from the included studies. Authors’ contributions ZiWei Du conceptualized the study, performed the search conducted analyses, and conducted the quality assessment, write-up, and approval of the final manuscript. Rongfeng Qi and Ruijing Xin were involved in data extraction, and read and approved the final manuscript. Mingjian Zheng and Bing Zhang participated in the discussion and consensus and revised and approved the final manuscript. Competing interests The authors declare no competing interests. Availability of data and material All data generated or analyzed during this study are included in this article. Funding The authors declare that there is no funding. 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Am J Obstet Gynecol, 231(5), e5431–54336. https://doi.org/10.1016/j.ajog.2024.03.011 Deniau B, Ricbourg A, Weiss E, Paugam-Burtz C, Bonnet MP, Goffinet F, Mignon A, Morel O, Le Guen M, Binczak M, Carbonnel M, Michelet D, Dahmani S, Pili-Floury S, Bouthors D, Mebazaa AS, A., Gayat E. Association of severe postpartum hemorrhage and development of psychological disorders: Results from the prospective and multicentre HELP MOM study. Anaesth Crit care pain Med. 2024;43(2):101340. https://doi.org/10.1016/j.accpm.2023.101340 . Page, M. J., McKenzie, J. E., Bossuyt, P. M., Boutron, I., Hoffmann, T. C., Mulrow,C. D., Shamseer, L., Tetzlaff, J. M., Akl, E. A., Brennan, S. E., Chou, R., Glanville,J., Grimshaw, J. M., Hróbjartsson, A., Lalu, M. M., Li, T., Loder, E. W., Mayo-Wilson,E., McDonald, S., McGuinness, L. A., … Moher, D. (2021). The PRISMA 2020 statement:an updated guideline for reporting systematic reviews. BMJ (Clinical research ed.),372, n71. https://doi.org/10.1136/bmj.n71. Munn Z, Stone, Jennifer C1;, Aromataris E1;, Klugar. Miloslav2; Sears, Kim3; Leonardi-Bee, Jo4; Barker, Timothy Hugh1. Assessing the risk of bias of quantitative analytical studies: introducing the vision for critical appraisal within JBI systematic reviews. JBI Evidence Synthesis 21(3):p 467–471, March 2023. 10.11124/JBIES-22-00224 Lo CK, Mertz D, Loeb M. Newcastle-Ottawa Scale: comparing reviewers' to authors' assessments. BMC Med Res Methodol. 2014;14:45. https://doi.org/10.1186/1471-2288-14-45 . Riley RD, Higgins JP, Deeks JJ. Interpretation of random effects meta-analyses. BMJ. 2011;342:d549. https://doi.org/10.1136/bmj.d549 . Miller JJ. The Inverse of the Freeman – Tukey Double Arcsine Transformation. Am Stat. 1978;32(4):138. https://doi.org/10.1080/00031305.1978.10479283 . Leeflang MM, Rutjes AW, Reitsma JB, Hooft L, Bossuyt PM. Variation of a test's sensitivity and specificity with disease prevalence. CMAJ: Can Med Association J = J de l'Association medicale canadienne. 2013;185(11):E537–44. https://doi.org/10.1503/cmaj.121286 . Furuya-Kanamori L, Barendregt JJ, Doi SAR. A new improved graphical and quantitative method for detecting bias in meta-analysis. Int J Evid Based Healthc. 2018;16(4):195–203. https://doi.org/10.1097/XEB.0000000000000141 . Vittinghoff E, McCulloch CE. Relaxing the rule of ten events per variable in logistic and Cox regression. Am J Epidemiol. 2007;165(6):710–8. https://doi.org/10.1093/aje/kwk052 . Wang Y, Chang X, Li L. (2024). To analyze the current status and influencing factors of post-traumatic stress disorder in patients with massive hemorrhage after cesarean section. J Inner Mongolia Medical Journal, 2024,56(2):234–236. 10.16096/J.cnki.nmgyxzz. 56.02.02 . Wei Wenjing Z, Deng P, Huang. Analysis of the occurrence status and influencing factors of PTSD in primiparas with massive hemorrhage after cesarean section. J Mol Diagnosis Therapy. 2022;14(12):2207–10. 10.3969/j.issn.1674-6929.2022.12.044 . Froeliger A, Deneux-Tharaux C, Seco A, Sentilhes L. & TRAnexamic Acid for Preventing postpartum hemorrhage after vaginal delivery (TRAAP) Study Group* (2022). Posttraumatic Stress Disorder Symptoms 2 Months After Vaginal Delivery. Obstet Gynecol, 139(1), 63–72. https://doi.org/10.1097/AOG.0000000000004611 Bernasconi M, Eggel-Hort B, Horsch A, Vial Y, Denys A, Quibel T, Baud D. Paternal and maternal long-term psychological outcomes after uterine artery embolization for severe post-partum hemorrhage. Sci Rep. 2021;11(1):13990. https://doi.org/10.1038/s41598-021-92847-z . Gankanda WI, Gunathilake IAGMP, Kahawala NL, Ranaweera AKP. Prevalence and associated factors of post-traumatic stress disorder (PTSD) among a cohort of Srilankan post-partum mothers: a cross-sectional study. BMC Pregnancy Childbirth. 2021;21(1):626. https://doi.org/10.1186/s12884-021-04058-z . Kountanis JA, Muzik M, Chang T, Langen E, Cassidy R, Mashour GA, Bauer ME. Relationship between postpartum mood disorder and birth experience: a prospective observational study. Int J Obstet Anesth. 2020;44:90–9. https://doi.org/10.1016/j.ijoa.2020.07.008 . van Steijn ME, Scheepstra KWF, Zaat TR, van Rooijen DE, Stramrood CAI, Dijksman LM, Valkenburg-van den Berg AW, Wiltenburg W, van der Post JAM, Olff M, van Pampus MG. Severe postpartum hemorrhage increases risk of posttraumatic stress disorder: a prospective cohort study. J Psychosom Obstet Gynaecol. 2021;42(4):335–45. https://doi.org/10.1080/0167482X.2020.1735343 . Tol ID, Yousif M, Collins SL. Post traumatic stress disorder (PTSD): The psychological sequelae of abnormally invasive placenta (AIP). Placenta. 2019;81:42–5. https://doi.org/10.1016/j.placenta.2019.04.004 . Sentilhes L, Maillard F, Brun S, Madar H, Merlot B, Goffinet F, Deneux-Tharaux C. Risk factors for chronic post-traumatic stress disorder development one year after vaginal delivery: a prospective, observational study. Sci Rep. 2017;7(1):8724. https://doi.org/10.1038/s41598-017-09314-x . de la Cruz CZ, Coulter M, O'Rourke K, Mbah AK, Salihu HM. Post-traumatic stress disorder following emergency peripartum hysterectomy. Arch Gynecol Obstet. 2016;294(4):681–8. https://doi.org/10.1007/s00404-016-4008-y . Michelet D, Ricbourg A, Gosme C, Rossignol M, Schurando P, Barranger E, Mebazaa A, Gayat E. Emergency hysterectomy for life-threatening postpartum haemorrhage: Risk factors and psychological impact. Gynecologie obstetrique Fertil. 2015;43(12):773–9. https://doi.org/10.1016/j.gyobfe.2015.10.010 . Ricbourg A, Gosme C, Gayat E, Ventre C, Barranger E, Mebazaa A. Emotional impact of severe post-partum haemorrhage on women and their partners: an observational, case-matched, prospective, single-centre pilot study. Eur J Obstet Gynecol Reprod Biol. 2015;193:140–3. https://doi.org/10.1016/j.ejogrb.2015.07.020 . Thompson JF, Roberts CL, Ellwood DA. Emotional and physical health outcomes after significant primary post-partum haemorrhage (PPH): a multicentre cohort study. Aust N Z J Obstet Gynaecol. 2011;51(4):365–71. https://doi.org/10.1111/j.1479-828X.2011.01317.x . Yildiz PD, Ayers S, Phillips L. The prevalence of posttraumatic stress disorder in pregnancy and after birth: A systematic review and meta-analysis. J Affect Disord. 2017;208:634–45. https://doi.org/10.1016/j.jad.2016.10.009 . Bienstock JL, Eke AC, Hueppchen NA. Postpartum Hemorrhage. N Engl J Med. 2021;384(17):1635–45. https://doi.org/10.1056/NEJMra1513247 . Patek K, Friedman P. Postpartum Hemorrhage-Epidemiology, Risk Factors, and Causes. Clin Obstet Gynecol. 2023;66(2):344–56. https://doi.org/10.1097/GRF.0000000000000782 . Belbasis L, Bellou V, Clifton NJ.), 1793, 1–6. https://doi.org/10.1007/978-1-4939-7868-7_1 Grimes DA, Schulz KF. Cohort studies: marching towards outcomes. Lancet (London England). 2002;359(9303):341–5. https://doi.org/10.1016/S0140-6736(02)07500-1 . Fellmeth G, Fazel M, Plugge E. Migration and perinatal mental health in women from low- and middle-income countries: a systematic review and meta-analysis. BJOG: Int J Obstet Gynecol. 2017;124(5):742–52. https://doi.org/10.1111/1471-0528.14184 . Auer A, Barabas M, Coode-Bate J, Cetti R, Walmsley B, Keoghane S. Single-centre versus multi-centre pooled morbidity data in PCNL and the implications for informed consent. Scandinavian J Urol. 2020;54(2):171–4. https://doi.org/10.1080/21681805.2020.1740780 . Christianson S, Marren J. The Impact of Event Scale - Revised (IES-R). Medsurg nursing: official J Acad Medical-Surgical Nurses. 2012;21(5):321–2. Sveen J, Low A, Dyster-Aas J, Ekselius L, Willebrand M, Gerdin B. Validation of a Swedish version of the Impact of Event Scale-Revised (IES-R) in patients with burns. J Anxiety Disord. 2010;24(6):618–22. https://doi.org/10.1016/j.janxdis.2010.03.021 . Mylle J, Maes M. Partial posttraumatic stress disorder revisited. J Affect Disord. 2004;78(1):37–48. https://doi.org/10.1016/s0165-0327(02)00218-5 . Eggel B, Bernasconi M, Quibel T, Horsch A, Vial Y, Denys A, Baud D. Gynecological, reproductive and sexual outcomes after uterine artery embolization for post-partum haemorrage. Sci Rep. 2021;11(1):833. https://doi.org/10.1038/s41598-020-80821-0 . Sentilhes L, Gromez A, Clavier E, Resch B, Descamps P, Marpeau L. Long-term psychological impact of severe postpartum hemorrhage. Acta Obstet Gynecol Scand. 2011;90(6):615–20. https://doi.org/10.1111/j.1600-0412.2011.01119.x . Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5982274","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":436404030,"identity":"b5e98b20-a27e-4f72-82d9-751002d4833a","order_by":0,"name":"Ziwei 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PRISMA\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5982274/v1/cf74d35021482073a5e362b6.png"},{"id":81177892,"identity":"1c82ae87-ec7a-4bc3-9be4-3340c7806c43","added_by":"auto","created_at":"2025-04-23 06:47:00","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":202724,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eForest plot showing the prevalence of PP-PTSD among women suffering PPH in the fifth included studies.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5982274/v1/fac85be99a740444ac9a393f.png"},{"id":81177612,"identity":"143a51fb-a655-47a7-b8c1-a384900f518c","added_by":"auto","created_at":"2025-04-23 06:39:00","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":138629,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSensitivity analysis of the eligible studies\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-5982274/v1/cce1c054ac2127ec6093e879.png"},{"id":81177598,"identity":"db1e640c-57d1-4705-b4f4-30b0672a7bf9","added_by":"auto","created_at":"2025-04-23 06:39:00","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":46897,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFunnel plot of the risk of publication bias for the eligible studies\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-5982274/v1/4bc7327c427ac3114d0c7aa4.png"},{"id":81177894,"identity":"776a7ba1-2b43-4fb0-b6b3-cb2c2c50ed09","added_by":"auto","created_at":"2025-04-23 06:47:01","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":36242,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eEgger’s funnel plot of the eligible studies\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-5982274/v1/ca36e3ea1d7971b8b3ae6ba7.png"},{"id":81412288,"identity":"e9176ae1-b46c-43f1-b237-831f20feb502","added_by":"auto","created_at":"2025-04-25 21:19:34","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2484816,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5982274/v1/d63bebf1-77c4-4fb2-9d92-a4b7b05a933b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Prevalence of Postpartum Post-Traumatic Stress Disorder Following Postpartum Haemorrhage: A Systematic Review and Meta-Analysis","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003ePost-Traumatic Stress Disorder (PTSD) is a long-term persistent or delayed mental disorder that occurs after individuals have personally experienced or witnessed sudden, catastrophic, or threatening traumatic events [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The types of traumatic events include stress traumatic events closely related to medicine, such as delivery, induced abortion, premature delivery, and major neonatal diseases [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Postpartum Post-Traumatic Stress Disorder (PP-PTSD) was first proposed by Bydlowski and Raoul-Duval as a delayed mental stress disorder that occurs after maternal birth trauma [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. According to the Diagnostic and Statistical Manual of Mental Disorders- Fifth Edition (DSM-V), the main clinical manifestations of PP-PTSD are: (1) experiencing the negative feelings of childbirth again; (2) avoiding everything related to childbirth to childbirth; (3) increased alertness in a state of excessive stress. The above symptoms usually last longer than 1 month [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The prevalence of PP-PTSD has been reported to vary widely, ranging from 5%-8% among women within 1\u0026ndash;3 months postpartum in community samples, however, the estimated prevalence of PP-PTSD among women with significant clinical symptoms of childbirth trauma ranges from 9.6\u0026ndash;27.3% [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. PP-PTSD caused by childbirth trauma affects not only the health of the mother but also the mother-infant relationship and partnership, which is a major public health problem [\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePostpartum Haemorrhage (PPH) is considered to be a serious complication of labor and one of the important causes of maternal death [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], which is defined as blood loss exceeding 500ml during vaginal delivery and 1000ml during cesarean section within 24 hours after fetal delivery [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. At present, more attention has been paid to the treatment of PPH, which mainly includes the application of oxytocin, tranexamic acid, uterine gauzing packing, uterine compression suture (B-Lynch), and second-line hemostasis methods such as uterine artery embolization (UAE) and emergency postpartum hysterectomy (EPH) [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. However, there are few studies on the psychological trauma caused by PPH. Some studies have reported that postpartum trauma including PPH is one of the important reasons for the increased incidence of PP-PTSD [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Previous systematic reviews and meta-analyses have reported the prevalence of PP-PTSD after delivery [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], but none of these reviews reported the prevalence of PP-PTSD due to PPH separately.\u003c/p\u003e \u003cp\u003eTo the best of our knowledge, there is no systematic review and meta-analysis on the pooled prevalence of PPH leading to PP-PTSD. Therefore, this systematic review and meta-analysis will use qualitative and quantitative methods to systematically analyze the studies on the prevalence of PP-PTSD caused by PPH, and provide reliable information for the prevention of PP-PTSD.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003eThe systematic review and meta-analysis of this study were performed according to the new PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. This meta-analysis was secondary literature review, no ethical review was required. The study protocol was also registered with PROSPERO (the International Prospective Register of Systematic Reviews) under the registration ID CRD42024618460.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Search Strategy\u003c/h2\u003e \u003cp\u003eThe main search network databases in this study were international databases and Chinese databases, among which the international databases including MEDLINE(PubMed), Web of Science (SCI), PsycINFO, CINAHL, Scopus, ClinicalTrials.gov, Cochrane Library and the Chinese database included China National Knowledge Infrastructure (CNKI), Chinese Sci-Tech Journal Database (VIP), Chinese BioMedical Literature Service System (SinoMed), and Wanfang database. The publication time of the included literature was limited from the inception of each database through to December 1, 2024, and the languages of articles were limited to English and Chinese.\u003c/p\u003e \u003cp\u003eThe search strategy of this study defined three key terms as \u0026lsquo;Postpartum Hemorrhage\u0026rsquo;, \u0026lsquo;Postpartum Period\u0026rsquo;, \u0026lsquo;Post-Traumatic Stress Disorder\u0026rsquo;, and listed all synonyms of the three key terms through specific MeSH terms. The synonyms of each key term were connected and searched for literature by Boolean operands \u0026lsquo;OR\u0026rsquo;, and finally the three key terms and all their synonyms were connected and searched for literature by Boolean operands \u0026lsquo;AND\u0026rsquo;. To ensure the inclusion of all eligible papers, reference lists of papers included in the full-text review and relevant reviews were also retrieved.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Inclusion and exclusion criteria\u003c/h2\u003e \u003cp\u003eStudies that met the following inclusion criteria were included in this systematic review: (1) Subject: aged\u0026thinsp;\u0026ge;\u0026thinsp;18 years; Published before December 1, 2024; (2) The main contents of the original study were: the prevalence of PP-PTSD in pregnant population; (3) Cross-sectional studies or cross-sectional case-control studies or cohort studies; (4) The diagnostic criteria of PP-PTSD and PPH were clearly reported; (5) the number of PPH patients identified in the literature, or who received second-line treatment for PPH such as UAE or hysterectomy, and the number of PP-PTSD patients. (6) PP-PTSD persisted for at least 1 month after delivery; (7) The numbers of PP-PTSD in different periods were reported in the literature, and only the most recent follow-up time data were extracted. Exclusion criteria: (1) The language of the literature was not Chinese or English, and the literature types were reviews, case reports, comments, letters, and editorials; (2) no standardized screening tools were used to estimate prevalence; (3) unable to obtain original data/duplicate literature; (4) The quality of literature was poor.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Selection process and data extraction\u003c/h2\u003e \u003cp\u003eAll the retrieved articles were screened by two authors (Z.W-D and R.J-X) independently according to the title and abstract of the article, and then the full text of the article was read and the data were extracted according to the inclusion and exclusion criteria. If there was any disagreement, the third author (R.F-Q) would review and discuss the decision. A self-designed standardized data extraction form was used by two authors (Z.W-D and R.J-X) to extract the following data: last name of the first author, year of publication, country of study, study design, study setting, age of the study subjects, number of PPH patients, number of PP-PTSD patients, PP-PTSD assessment tool, definition of PPH, and interval between postpartum and PP-PTSD questionnaire. All the studies in this meta-analysis included only self-report questionnaires scales to evaluate PP-PTSD patients, and the scales included Impact of Event Scale-Revised (IES-R); Impact of Event Scales (IES); Post-traumatic Stress Checklist-Civilian version (PCL-C); Post-traumatic Stress Checklist (PCL), Perinatal Post Traumatic Stress Disorder Questionnaire (PPQ), PTSD Symptom Scale-Self Report (PSS-SR), PTSD Symptom Scale (PSS).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Quality assessment\u003c/h2\u003e \u003cp\u003eThe risk of bias and study quality of cross-sectional studies were evaluated using the Joanna Briggs Institute (JBI) criteria, which includes 8 evaluation items. The scores of \u0026ldquo;YES\u0026rdquo;, \u0026ldquo;NO\u0026rdquo;, \u0026ldquo;Unclear\u0026rdquo;, and \u0026ldquo;Not applicable\u0026rdquo; were 8 points in total, and the higher the score, the higher the quality of the literature [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Cohort studies were evaluated using the Newcastle-Ottawa scale (NOS). The scale included 3 aspects of research subject selection, comparability, and outcome measurement, and 8 items. Except for comparability, the remaining items could be scored up to 1 point, and the full score was 9 points [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In this study, the literature with \u0026ge;\u0026thinsp;6 points was included.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Statistical analysis\u003c/h2\u003e \u003cp\u003eAll statistical analyses were conducted using the \u0026ldquo;irr\u0026rdquo;, \u0026ldquo;meta\u0026rdquo; and \u0026ldquo;metafor\u0026rdquo; packages in R software, version 4.4.1 (R Foundation). The random effects meta-analysis model was used to estimate the prevalence of PP-PTSD by combining the individual studies due to the substantial heterogeneity among studies [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In order to achieve the closest method to the normal distribution of raw rates for each study, all raw incidence rates were transformed using the Freeman\u0026ndash;Tukey Double arcsine method [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Total effect estimates and 95% confidence intervals (CI) of results were represented as forest plots. The index of heterogeneity squared (I\u003csup\u003e2\u003c/sup\u003e) statistics corresponding to 95% confidence intervals (CI) was used to assess the heterogeneity among studies, with I\u003csup\u003e2\u003c/sup\u003e values below 25%, between 25% and 75%, and \u0026gt;\u0026thinsp;75% considered low, moderate, and high levels of heterogeneity, respectively.\u003c/p\u003e \u003cp\u003ePP-PTSD assessment scale (IES-R VS. Non-IES-R), country (developed country VS. developing country), definition of PPH (\u0026gt;\u0026thinsp;1000ml VS. EPH/UAE), study setting (Multi-centre VS. Single-centre) and study design (Cohort study VS. Cross-sectional) were used to evaluate the possible source of heterogeneity across the studies. At the same time, the chi-square test was used to compare the significance of the difference between the various subgroups. Therefore, we performed subgroup analyses and mixed-model meta-regression analyses of the above factors to explore the potential impact on the observed heterogeneity.\u003c/p\u003e \u003cp\u003eSensitivity analyses were performed by sequentially excluding each study to determine the effect of each study on the overall prevalence estimates [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Funnel plots and Egger\u0026rsquo;s regression test were used to assess publication bias [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. P-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant for all analyses.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003e\u003cstrong\u003e3.1 Search results\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAccording to the above search formula, a total of 990 studies were selected, of which 772 studies and 218 studies were found in the international database and the Chinese database, respectively. We excluded 155 and 63 duplicate studies from the international and Chinese databases, respectively, and excluded 544 and 141 studies that did not meet the requirements by reading the title and abstract. A total of 77 English studies and 14 Chinese studies were full-text reviewed, 11 and 3 review articles, 36 and 5 articles with no clear number of PP-PTSD patients, 13 and 4 articles without a clear definition of PPH or a specific number of PPH patients were excluded, respective. A total of 15 studies were included in the final analysis, including 13 English studies and 2 Chinese studies [12,13], [22-34]. Figure.1\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2 Characteristics of Selected Studies\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll included studies were published between 2011 and 2024, including 3 cross-sectional studies and 12 cohort studies. Among the countries where research was carried out, France had a total of 6 studies, followed by China and the United States, which each accounted for 2 studies, and the rest of the United Kingdom, Sri Lanka, Australia, Switzerland, and the Netherlands each accounted for 1 study. There were 7 multi-center studies and 8 single-center studies. The number of people diagnosed with PPH in these 15 studies ranged from 8 to 385, for a total of 1530 individuals, of whom 265 were diagnosed with PP-PTSD. All studies used fully self-reported scales to identify PP-PTSD (five studies used IES-R, three used PCL-C, two used IES, two used PSS, and the remaining three studies used TSQ, PPQ, and PCL-5 respectively). Seven studies defined PPH as \u0026gt; 1000ml, 2 studies defined PPH according to ICD-10, and 3 studies defined PPH as \u0026gt; 1500ml, 2000ml, and 3000ml, respectively. In addition, one case of UAE and two cases of EPH were included in this study, which were clearly defined as second-line treatment for PPH. Finally, the time span of the questionnaire survey was wide, from 1 month to 8 years, but 11 studies were completed within 2 months of delivery. (Table. 1)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1 Characteristics of fifteen included studies.\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"769\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy(year)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy design\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCountry\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy setting\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMean\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePPH cases\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePP-PTSD cases\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eScreening PP-PTSD tools\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDefinition of PPH\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime of measurement\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFroeliger,2024[12]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003eProspective Cohort Study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003eFrance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003eMulti-centre\u003c/p\u003e\n \u003cp\u003e(N=27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e385\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003eIES-R\u0026ge;33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003eICD-10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e2mo\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDeniau, 2024[13]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003eProspective Cross-sectional\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003eFrance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003eMulti-centre\u003c/p\u003e\n \u003cp\u003e(N=10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e236\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003eIES\u0026gt;30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026gt;1000ml\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e1mo\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWang,2024[22]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003eProspective Cohort Study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003eChina\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003eSingle centre\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e30.37(3.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e118\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003ePCL-C\u0026ge;38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026gt;1000ml\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e42d\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWei,2022[23]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003eProspective Cohort Study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003eChina\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003eSingle centre\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e31.26(3.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003ePCL-C\u0026ge;38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026gt;1000ml\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e45d\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFroeliger, 2022[24]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003eProspective Cohort Study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003eFrance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003eMulti-centre\u003c/p\u003e\n \u003cp\u003e(N=15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003eIES-R\u0026gt;33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026gt;1000ml\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e2mo\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBernasconi2021[25]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003eRetrospective Cohort Study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003eSwitzerland\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003eSingle centre\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003eTSQ\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003eUAE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e8ye\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGankanda, 2021[26]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003eProspective Cross-sectional\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003eSri Lanka\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003eMulti-centre\u003c/p\u003e\n \u003cp\u003e(N=4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e28.38(5.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003ePSS-SR\u0026gt;13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026gt;1000ml\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e2mo\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eKountanis, 2020[27]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003eProspective Cross-sectional\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003eUSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003eSingle centre\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003ePPQ\u0026ge;19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003eICD-10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e42d\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVan Steijn, 2020[28]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003eProspective Cohort Study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003eNetherlands\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003eMulti-centre\u003c/p\u003e\n \u003cp\u003e(N=8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e187\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003ePCL-5\u0026ge;32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026ge;2000ml\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e42d\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTol, 2019[29]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003eRetrospective Cohort Study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003eUnited Kingdom\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003eSingle centre\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003eIES-R\u0026gt;32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026gt;3000ml\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e1-18mo\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSentilhes, 2017[30]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003eProspective Cohort Study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003eFrance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003eSingle centre\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003eIES\u0026ge;26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026gt;1000ml\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e12mo\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ede la Cruz 2016[31]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003eRetrospective Cohort Study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003eUSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003eMulti-centre\u003c/p\u003e\n \u003cp\u003e(N=8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003ePSS\u0026ge;15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003eEPH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e1mo\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMichelet, D,2015[32]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003eRetrospective Cohort Study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003eFrance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003eSingle centre\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003eIES-R\u0026gt;30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003eEPH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e26.5mo\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRicbourg, 2015[33]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003eProspective Cohort Study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003eFrance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003eSingle centre\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003eIESR\u0026ge;30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026gt;1000ml\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e1mo\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eThompson\u003c/strong\u003e\u003cstrong\u003e,2011[34]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003eProspective Cohort Study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003eAustralian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003eMulti-centre\u003c/p\u003e\n \u003cp\u003e(N=17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e171\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003ePCL\u0026gt;44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026gt;1500ml\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e2mo\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eAbbreviations:\u003c/strong\u003e N/A, not available; IES-R, Impact of Event Scale - Revised; IES, Impact of Event Scales; PCL-C, Post-traumatic Stress Checklist-Civilian version; PPQ, Perinatal Post Traumatic Stress Disorder; PSS-SR, PTSD Symptom Scale-Self Report; PCL, PTSD Checklist; PSS, PTSD Symptom Scale; EPH, Emergency Peripartum Hysterectomy\u003c/p\u003e\n\u003cp\u003eTable 2 and Table 3\u0026nbsp;show the quality evaluation results of cross-sectional studies evaluated by JBI and cohort studies evaluated by NOS, respectively. The total scores of all studies were \u0026ge;6, the quality scores ranged from six to eight.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2 A quality assessment of included three Cross-sectional studies by JBI tools\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"662\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1. Were the criteria for inclusion in the sample clearly defined?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2. Were the study subjects and the setting described in detail?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3. Was the exposure measured in a valid and reliable way?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4. Were objective, standard criteria used for measurement of the condition?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e5. Were confounding factors identified?\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e6. Were strategies to deal with confounding factors stated?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e7. Were the outcomes measured in a valid and reliable way?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e8. Was appropriate statistical analysis used?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDeniau, 2024[13]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGankanda, 2021[26]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eKountanis, 2020[27]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3 A quality assessment of included twelve Cohort studies by NOS tools\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"119%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.Representativeness of the exposed cohort\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2. Selection of the non-exposed cohort\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3.\u0026nbsp;Ascertainment of exposure\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4.Demonstration that outcome of interest was not present at start of the study\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e5. Comparability of cohorts on the basis of the design or analysis controlled for confounders\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e6. Assessment of outcome\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e7. Was follow-up long enough for outcomes to occur\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e8. Adequacy of follow-up of cohorts\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFroeliger,2024[12]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWang,2024[22]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWei,2022[23]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFroeliger, 2022[24]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBernasconi,2021[25]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVan Steijn, 2020[28]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTol, 2019[29]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSentilhes, 2017[30]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ede la Cruz2016[31]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMichelet, D,2015[32]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRicbourg, 2015[33]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eThompso n,2011[34]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.3 The pooled prevalence of PP-PTSD after PPH (meta-analysis)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs shown in the forest plot in Figure 2, the pooled prevalence estimate of PP-PTSD after PPH was found to be 19% (95% CI: 11-28). There was significant heterogeneity across the studies used for this analysis (\u003cem\u003eI\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e = 92.6%; P\u0026lt;0.0001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.4 Subgroup analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSubgroup analyses were performed to identify possible sources of the apparent heterogeneity observed. As shown in Table 4, the prevalence of PP-PTSD was 15% (95%CI: 0.09;0.23, \u003cem\u003eI\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e=92.5%, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.0001) for the definition of PPH \u0026gt;1000ml and it was\u0026nbsp;35% (95%CI: 0.12;0.62, \u003cem\u003eI\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e =88.7%, \u003cem\u003eP\u003c/em\u003e=0.0001)\u0026nbsp;for EPH/UAE. The prevalence of PP-PTSD in developed countries was 21% (95%CI: 0.11;0.31, \u003cem\u003eI\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e=94.1%, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.0001) and it was 15% (95%CI: 0.10;0.21, \u003cem\u003eI\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e=15.7%, \u003cem\u003eP\u003c/em\u003e=0.31) for developing country. The prevalence of PP-PTSD in cohort study was 19% (95%CI: 0.11;0.29, \u003cem\u003eI\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e=88.9%, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.001), cross-sectional studies was\u0026nbsp;16% (95%CI: 0.0;0.44, \u003cem\u003eI\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e=93.2%, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.001). The prevalence of PP-PTSD was 12% (95%CI 0.05;0.23, \u003cem\u003eI\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e=95.6%, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.001) for Multi-centre studies and it was\u0026nbsp;26% (95%CI: 0.15;0.39, \u003cem\u003eI\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e=82.2%, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.001)\u0026nbsp;for Single-centre studies. However, there was no significant difference in the prevalence of the above subgroup analysis. Conversely, the prevalence of PP-PTSD in the IES-R screening tools studies was 28% (95%CI: 0.14;0.46, \u003cem\u003eI\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e=95.6%, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.0001) and it was 12% (95%CI: 0.07;0.18, \u003cem\u003eI\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e=78%, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.0001) for non-IES-R studies, the observed difference was statistically significant (\u003cstrong\u003e\u0026chi;2=\u003c/strong\u003e3.89, \u003cem\u003eP\u003c/em\u003e=0.04).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4 Subgroup analysis of the pooled prevalence of PP-PTSD after PPH\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"620\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSubgroup analysis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of studies\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eIncidence of PP-PTSD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of PPH\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePooled prevalence\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(95%CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHeterogeneity\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eI\u003csup\u003e2\u003c/sup\u003e, \u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026chi;2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDefinition of PPH\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.123\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026gt;1000ml\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e217\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1383\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15% (0.09;0.23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e92.5%(p\u0026lt;0.0001)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; EPH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e147\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e35% (0.12;0.62)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e88.7%(p=0.0001)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCountry\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.44\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Developed country\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e197\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1322\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e21% (0.11;0.31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e95%(p\u0026lt;0.0001)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Developing country\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e208\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15% (0.10;0.21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15.7%(p=0.31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy design\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; Cohort study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e163\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1229\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e19% (0.11;0.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e88.9%(p\u0026lt;0.001)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; Cross-sectional\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e102\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e301\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e16% (0.0-0.44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e93.2%(p\u0026lt;0.001)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy setting\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; Multi-centre\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e176\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1144\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12% (0.05;0.23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e95.6%(p\u0026lt;0.001)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; Single-centre\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e386\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e26% (0.15;0.39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e82.2%(p\u0026lt;0.001)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eScreening PP-PTSD tools\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; IES-R\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e176\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e795\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e28% (0.14;0.46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e95.6%(p\u0026lt;0.0001)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; No-IES-R\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e735\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12% (0.07;0.18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e78%(p\u0026lt;0.0001)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.5 Meta-regression analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs shown in Table 5, Meta-regression analysis showed that variables of definition of PPH, and Screening PP-PTSD tools as significant moderators for heterogeneity (\u003cem\u003eP\u003c/em\u003e\u0026lt;0.05).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5 Meta-regression analysis of the potential moderators\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of studies\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEstimate\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStandard error\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eZ\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCountry\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e0.074\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e0.116\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e0.645\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.51\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDefinition of PPH\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e0.279\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e0.103\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e2.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.005\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eScreening PP-PTSD tools\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-0.244\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e0.081\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-3.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy design\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e0.093\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e1.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.23\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy setting\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e0.131\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e0.077\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e1.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.089\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e3.6 Sensitivity analysis and publication bias\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSensitivity analysis showed that after leave-one removal of the 15 eligible studies, the pooled prevalence of PP-PTSD after PPH varied from 16% (95% CI: 0.1;0.23) to 20% (95%CI: 0.12;0.29), with the corresponding I\u003csup\u003e2\u003c/sup\u003e statistic varying from 91.5% to 93.1%. These results suggested that they did not identify any single study as disproportionately influencing the overall estimate of the incidence of PP-PTSD after PPH. (Figure 3)\u003c/p\u003e\n\u003cp\u003eIn the current systematic review and meta-analysis, we found no evidence of potential publication bias for the prevalence of PP-PTSD after PPH as evidenced by inspection of the funnel plot (symmetric) and results of regression tests associated with the funnel plot (Egger\u0026rsquo;s test) (B=2.26, SE=2.08, \u003cem\u003eP\u003c/em\u003e=0.29). (Figure.4,5)\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003e\u003cstrong\u003e4.1 Main findings of the study\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 15 studies were included in this systematic review and meta-analysis, in which 265 out of 1530 PPH-exposed maternal women reported PP-PTSD, and pooled prevalence of PP-PTSD was 19%\u0026nbsp;(95%CI: 11%-28%), which was significantly higher than a systematic review reported by Yildiz et al.[35], including 59 studies from 23 countries, with a total sample size of 24267 women, and a pooled prevalence of PP-PTSD of 4% (95%CI: 2.77%-5.71%) in the general maternal population in the community sample.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.2 Interpretation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUterine atony, pernicious placenta previa, severe soft birth canal laceration, or coagulopathy are the common causes of postpartum hemorrhage [36,37]. These birth traumas may not only increase the risk of childbirth but also increase the risk of PP-PTSD due to more adverse and unpleasant birth experiences.\u0026nbsp;Our study also confirmed the higher prevalence of PP-PTSD caused by PPH compared with PP-PTSD in the community sample. Although the sources of possible heterogeneity were identified through subgroup analysis and meta-regression, the pooled estimates of PP-PTSD incidence in our meta-analysis should be interpreted with more caution because of the significant heterogeneity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.2.1 Study design, Country, and Study setting \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the subgroup analysis, there were no significant differences in the prevalence of pooled PP-PTSD among study design, country, and study setting, and no heterogeneity was found in the meta-regression. The prevalence of PP-PTSD in the cohort study 19% (95%CI: 0.11;0.29) was generally similar to that in the cross-sectional study\u0026nbsp;16% (95%CI: 0.0;0.44), indicating that the study design of the included studies was as objective as possible and less selective bias, as confirmed by our sensitivity analysis [38,39].\u003c/p\u003e\n\u003cp\u003eHowever, in terms of countries, our study included more developed countries (12 cases) and developing countries (3 cases). The prevalence of PP-PTSD in the developed countries was 21% (95%CI: 0.11;0.31), which appeared to be higher than in developing countries 15% (95%CI: 0.10;0.21), which seems to be quite different from the pooled prevalence of postpartum mental disorders of 31% (95%CI 23%-40) in low-income women in the study by Fellmeth et al, [40]. It may be due to the relatively complete social security and more attention to maternal mental health problems in developed countries, while there seems to be insufficient attention to PP-PTSD caused by PPH in developing countries, resulting in relatively few studies. Therefore, follow-up studies need to include more relevant studies in developing countries.\u003c/p\u003e\n\u003cp\u003eIn terms of study design, a total of 7 cases were included in the single-center study and 8 cases were included in the multi-center study. Subgroup analysis showed that the incidence of PP-PTSD in the single-center study was 26% (95%CI: 0.15; 0.39) appeared to be higher than in the multi-center study 12% (95%CI 0.05; 0.23). Although multi-center studies seem likely to include a larger sample, the results are often compromised by more confounding factors that need to be controlled. Auer et al [41]. Also supported the inclusion of a single center sample for pooling of prevalence. However, the number of PPH in our study was small, which could easily affect the outcome of the pooled prevalence.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.2.2 Screening PP-PTSD tools\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe most important screening tool for PP-PTSD was the self-report questionnaire, and the IES-R questionnaire was the most widely used questionnaire in the 7 studies included in this meta-analysis. Subgroup analysis showed that the PP-PTSD screening tool IES-R had a significantly higher positive rate than the no-IES-R, and the difference between the two groups was statistically significant, and meta-regression analysis also showed that it may be the source of study heterogeneity. Although self-report questionnaires have high specificity and sensitivity compared to structured clinical interviews [42,43]. However, the structured interview is still considered the gold standard for the diagnosis of PP-PTSD [44]. However, in clinical practice, due to postpartum women\u0026apos;s lack of knowledge about PP-PTSD and difficulties in cooperation, most studies have prioritized the use of more convenient and acceptable questionnaires. Due to the variety of PP-PTSD screening questionnaires in this study, a more detailed subgroup analysis cannot be carried out. Subsequent clinical studies can further analyze the reliability and validity of different evaluation scales for PP-PTSD diagnosis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.2.4 Definition of PPH\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDue to the various definitions of PPH in the studies included in our meta-analysis, in order to ensure the number of subgroup analysis studies, PPH was divided into \u0026gt;1000ml and PPH resulted in EPH and UAE. Subgroup analysis showed that the prevalence of PP-PTSD was higher in the EPH/UAE group\u0026nbsp;35% (95%CI: 0.12;0.62)\u0026nbsp;than in the \u0026gt;1000ml group 15% (95%CI: 0.09;0.23), although the difference was not statistically significant. However, many studies have shown that the treatment of EPH and UAE caused by PPH tends to experience more disturbing feelings and longer-lasting mental trauma [45,46]. One EPH case and one UAE case were followed up for a long time (26.5 mo-8years), and the questionnaire survey may have a certain recall bias, but it was still proved from the side that the duration of PP-PTSD is longer. In addition, meta-regression results suggested that the definition of PPH might be a source of heterogeneity. Therefore, subsequent studies may need to analyze the prevalence of PP-PTSD in patients with simple PPH and those who need EPH or UAE due to PPH separately, and further cohort studies with large samples are needed if necessary.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.3 Strengths and Limitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo the best of our knowledge, this meta-analysis is the first time focusing on the prevalence of PP-PTSD exposed to PPH. The results of our study\u0026apos;s sensitivity analysis and publication bias demonstrate the robustness of the estimated prevalence of PP-PTSD. However, some limitations of the study should be acknowledged. First, only 15 studies were included in our meta-analysis, and even fewer could be included in subgroup analyses, which may have limited the pool of the estimated prevalence. Second, our meta-analysis showed a high degree of heterogeneity, which may be due to the inherent nature of the data from the included studies, although we used subgroup analyses and meta-regression to find sources of heterogeneity, which makes it difficult for clinicians to match exactly with their clinical situations. Finally, most of the studies included in our meta-analysis focused on developed countries, which may limit the generalizability of PP-PTSD prevalence in developing countries.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.4 Conclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur systematic review and meta-analysis revealed that about 19% of women exposed to PPH developed PP-PTSD, a prevalence higher than that observed in the general obstetric population. The increased prevalence of PP-PTSD indicates that PPH has a significant impact on maternal mental health, suggesting that women experiencing PPH need more comprehensive postpartum care including mental illness.\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis meta-analysis was secondary literature review, no ethical review was required.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final version manuscript for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe are delighted to acknowledge all the authors from the included studies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eZiWei Du conceptualized the study, performed the search conducted analyses, and conducted the quality assessment, write-up, and approval of the final manuscript. Rongfeng Qi and Ruijing Xin were involved in data extraction, and read and approved the final manuscript.\u0026nbsp;Mingjian Zheng and Bing Zhang participated in the discussion and consensus and revised and approved the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analyzed during this study are included in this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that there is no funding.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eShalev A, Liberzon I, Marmar C. Post-Traumatic Stress Disorder. 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Sci Rep. 2021;11(1):833. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1038/s41598-020-80821-0\u003c/span\u003e\u003cspan address=\"10.1038/s41598-020-80821-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSentilhes L, Gromez A, Clavier E, Resch B, Descamps P, Marpeau L. Long-term psychological impact of severe postpartum hemorrhage. Acta Obstet Gynecol Scand. 2011;90(6):615\u0026ndash;20. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/j.1600-0412.2011.01119.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1600-0412.2011.01119.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Postpartum, Post-Traumatic Stress Disorder, Postpartum Haemorrhage, Meta-Analysis, Prevalence","lastPublishedDoi":"10.21203/rs.3.rs-5982274/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5982274/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003ePostpartum haemorrhage (PPH) is not only an important cause of maternal death during the perinatal period but also an important cause of postpartum mental-related diseases. The overall prevalence of Postpartum Post-Traumatic Stress Disorder (PP-PTSD) in the community sample was 4% (95%CI: 2.77\u0026ndash;5.71), but the incidence of PP-PTSD caused by PPH has not been reported by meta-analysis and systematic review.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eEleven network databases were systematically searched, including 4 Chinese databases and 7 international databases. The Medical Subject Headings (MeSH) thesaurus combined with Boolean operator, studies were searched from the inception of each database to December 1, 2024. All the retrieved articles were screened according to the inclusion and exclusion criteria, and finally, the studies included in this study. A random effects model was used to pool weighted estimates of PP-PTSD prevalence. Subgroup analysis and meta-regression were used to find possible sources of heterogeneity. In addition, sensitivity analysis and publication bias were used to evaluate the stability and bias of the included studies. Statistical analysis was performed by R software.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eA total of 15 studies were included in this systematic review and meta-analysis, with a total of 1530 postpartum women who experienced PPH, of whom 265 were diagnosed with PP-PTSD. The pooled prevalence estimate of PP-PTSD after PPH was found to be 19% (95% CI 11\u0026ndash;28). The results of the subgroup analysis showed significant differences in the prevalence of screening PP-PTSD tools (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The meta-regression results showed that screening PP-PTSD tools and the definition of PPH may be the source of heterogeneity in this meta-analysis. Sensitivity analysis showed that the pooled estimated prevalence of PP-PTSD was stable, and there was no clear publication bias in the included studies.\u003c/p\u003e\u003ch2\u003eDiscussions:\u003c/h2\u003e \u003cp\u003eThe pooled prevalence of PP-PTSD in postpartum women experiencing PPH was about 19%, which was significantly higher than that in the general postpartum women. However, only 15 studies were included in our meta-analysis, and even fewer could be included in subgroup analyses, which may have limited the pool of the estimated prevalence. But this finding also suggests that attention should be paid not only to maternal PPH treatment during the perinatal period but also to the high risk of PPH leading to PP-PTSD after delivery.\u003c/p\u003e\u003ch2\u003eOther:\u003c/h2\u003e \u003cp\u003eThe study protocol was also registered with PROSPERO (the International Prospective Register of Systematic Reviews) under the registration ID CRD42024618460. 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