The Relationship Between Birth Trauma and Perinatal Mental Health Disorders: A Cross-Sectional Study

The Relationship Between Birth Trauma and Perinatal Mental Health Disorders: A Cross-Sectional Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Relationship Between Birth Trauma and Perinatal Mental Health Disorders: A Cross-Sectional Study Stephanie Hanson¹ This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8107423/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract Background Globally, 130 million live births occur annually, including 3.6 million in the U.S. in 2023. While many women anticipate a positive birth experience, approximately 45% report birth trauma—a subjective experience that can occur regardless of medical complications. Birth trauma may increase risk for perinatal mental health disorders (PMHDs) such as depression, anxiety, obsessive-compulsive disorder (OCD), bipolar disorder, and psychosis. Existing research primarily focuses on birth trauma and perinatal PTSD, with limited exploration of its relationship to other PMHDs. This study examined associations between birth trauma and five PMHDs. Methods A cross-sectional survey was conducted in December 2024 using Amazon Mechanical Turk and REDCap. Participants (N = 249) were U.S.-based women, 4 weeks–7 months postpartum. Birth trauma was assessed using the City Birth Trauma Scale; PMHDs were measured with validated tools including EPDS, PASS, DOCS, and MDQ. Modified Poisson and linear regressions, adjusted for demographic and birth variables, examined associations. Results Birth trauma was reported by 21.3% of respondents. PMHD prevalence was high: depression (84.7%), anxiety (81.9%), OCD (93.6%), bipolar disorder (10%), and psychosis (3.2%). Birth trauma was significantly associated with increased risk for depression (RR = 1.15), anxiety (RR = 1.34), bipolar disorder (RR = 9.59), and psychosis; OCD risk increase was non-significant. Symptom severity scores were higher across all PMHDs among women reporting birth trauma. Conclusion Birth trauma is positively associated with elevated risk and symptom severity of multiple PMHDs beyond PTSD. Findings highlight the need for integrated postpartum screening and trauma-informed interventions to improve maternal mental health outcomes. Statement of Significance Problem: Birth trauma affects up to 45% of women and is linked to adverse mental health outcomes, yet its relationship with perinatal mental health disorders (PMHDs) beyond PTSD remains underexplored. What is Known: Existing research primarily examines birth trauma in relation to perinatal PTSD, with limited evidence on other PMHDs such as depression, anxiety, OCD, bipolar disorder, and psychosis. What this Paper Adds: This study demonstrates significant associations between birth trauma and increased risk and symptom severity for multiple PMHDs, highlighting the need for integrated, trauma-informed postpartum screening and care. Background Globally, there are approximately 130 million live births each year (World Health Organization, 2024). In the United States, there were approximately 3.6 million live births in 2023 (Martin et al., 2024 ). For most women, an ideal birthing experience includes giving birth naturally, satisfaction with the birth experience, and easy adaptation to the post-birth period (Fahy & Parratt, 2006 ). For many women, the reality of their birthing experience can be traumatic. Trauma is “intense physical and psychological stress reactions that result from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or threatening and that has lasting adverse effects on the individual’s functioning and physical, social, emotional, or spiritual well-being” (Substance Abuse and Mental Health Services Administration, 2012). Birth trauma is a form of psychological trauma that may result from traumatic experiences that occur during the delivery of a fetus or child (Horsch et al., 2024 ). Birth trauma is a subjective experience: a ‘medically textbook’ birth may be traumatic for some women, and a birth that is filled with complications may be interpreted as completely ordinary by others (Beck, 2004 ). Approximately 45% of women in the United States experience birth trauma (March of Dimes, 2024). Risk factors for birth trauma include experiencing a birth that did not go as hoped, birth complications, emergency cesarean section (c-section) or the use of other medical devices, the mother or infant suffering an injury during birth, required medical attention for the infant after birth, and the perception of insufficient care from hospital staff following delivery (March of Dimes, 2024). Birth trauma has been associated with postpartum challenges for the mother, such as difficulty bonding with the infant, relationship strain, emotional and psychological dysregulation, and poor physical health (Ayers et al., 2006 ; Nicholls & Ayers, 2007 ). PMHDs include a total of six disorders: perinatal depression, perinatal anxiety, perinatal post-traumatic stress disorder (PTSD), perinatal obsessive-compulsive disorder (OCD), bipolar disorder, and postpartum psychosis. The prevalence of each PMHD varies among women, ranging from approximately 20% for both perinatal depression and perinatal anxiety, to 0.7–2.3% for perinatal OCD, to 12–30% for perinatal PTSD, to 0.1 − 0.02% for perinatal psychosis (Hunter et al., 2021; Postpartum Support International, 2024 ). PMHDs have been associated with several negative mental and physical health outcomes, including detachment, inability to bond with an infant, delayed achievement of childhood developmental milestones, obesity and substance-use-related issues, such as cirrhosis (Hunter et al., 2021). Although there are overlapping risk factors for birth trauma and PMHDs, research focused on the relationship between them is limited. The majority of extant literature focused on birth trauma and PMHDs has focused on the validity and reliability of the City Birth Trauma Scale (an instrument designed to screen for the presence of birth trauma and perinatal PTSD in new mothers; Ayers et al., 2018 ) or has been concentrated on the relationship between birth trauma and the subsequent development of perinatal PTSD (Mackle et al., 2023 ; Thomas et al., 2021 ). Trauma theory explores the psychological impacts of traumatic experiences on an individual’s functioning and long-term health and experiences. Trauma theory has been used to explore associations between fear of childbirth and difficulties with mother-infant relationships (Ayers et al., 2006 ) and birth trauma and relationship strain and sexual dysfunction (Nicholls & Ayers, 2007 ). Some scholars have also utilized qualitative methods to establish relationships between birth trauma and perinatal PTSD (Bateman et al., 2017 ; Watson et al., 2021 ); but the relationships between birth trauma and perinatal depression, anxiety, OCD, bipolar disorder, and psychosis have yet to be examined. Examining associations between birth trauma and varying types of PMHDs may provide information about associations that may exist but are not well-documented. The documentation of these associations would provide a quantifiable foundation for researchers and practitioners to explore these associations in greater depth. The purpose of this study was to assess the relationship between birth trauma and five of the PMHDs recognized in the Diagnostic and Statistical Manual of Mental Disorders − 5th Edition . It was hypothesized that birth trauma would be positively associated with the development of each of the included PMHDs. Documenting the associations between birth trauma and PMHDs is essential for providing a foundation for greater understanding of these relationships and provides evidence that can be used as a catalyst to explore interventions to reduce the impact of birth trauma on the development of PMHDs. Methods Data Source and Data Collection Crowdsourcing through Amazon’s Mechanical Turk (MTurk) platform was utilized to recruit participants for this cross-sectional study. Data was collected in December 2024 via REDCap, which is a web-based, HIPAA-compliant application developed by Vanderbilt University to capture clinical research data and create databases and projects. The data is captured through surveys and forms as research capture tools. Surveys are workflow-based and allow for the export of captured data to statistical programs where it can be analyzed (Patridge & Bardyn, 2018 ). To be eligible for the study, participants needed to be: at least 18 years of age, residing in the United States, fluent in English (written and verbal), at least four weeks postpartum, less than seven months postpartum, born and currently identifying as being female, not participating in any inpatient mental health or substance use treatment program(s), and not experiencing a current mental health crisis or emergency. Eligibility was assessed through a series of questions and self-report responses via a REDCap screening survey. If eligibility requirements were met, participants then completed the eConsent process in REDCap where they reviewed the informed consent documents and provided their consent for survey participation. Eligible respondents who affirmed consent to participate in the study were advanced to the 167-item REDCap survey that collected information on demographics and mental health disorders. Upon completion of the survey, participants were compensated $ 20. Several mechanisms were used to help ensure credible and accurate survey responses. The captcha feature was used before beginning the survey, as a mechanism for ensuring human survey respondents. To ensure consistent data, the participants were asked the same question in ways that required different formats for responses, and they were asked the same question multiple times throughout the survey. For example, participants were asked “Are you at least 4 weeks postpartum?” and “Are you less than 7 months postpartum?” with the answers to select being radio buttons for “yes” and “no.” Several questions later, participants were then asked to provide the birth date of their infant in a MM/DD/YYYY format. Responses to these questions were then compared for consistency, and any inconsistent responses from participants resulted in all that participant’s data being removed from data analysis. Another check for consistency was that participants were screened for birth trauma using the same questions at the very beginning, halfway through, and at the end of the survey. Asking this question at all three time points ensured participants remained engaged in the survey and were submitting representative responses. Consistency in answers to all duplicated questions were compared and any participant’s responses that were not consistent were removed from data analysis. In total, five questions were asked in ways that required participants to submit the same answers in different formats and three questions were asked in the same way multiple times within the survey. To ensure 80% power when α = 0.05, this study required a minimum of 166 participants to detect statistical significance with the prevalence of PMHDs expected to be 40% in populations who experienced birth trauma, and 20% in populations who did not experience birth trauma. These prevalence rates were taken from a study published by Isobel et al. ( 2024 ), which is the only study to report differences of PMHD prevalence between individuals who do and do not experience birth trauma. A total of 300 respondents completed the survey. The first entry for a participant was kept and included in the analysis if duplicate responses were provided by the same participant. After removal of duplicates ( n = 7), data quality assurance checks ( n = 35), and confirmation of timing of symptom onset ( n = 9), there were 249 usable responses. Measures Birth Trauma The 29-item City Birth Trauma Scale (CBTS; Ayers et al., 2018 ) served as the measurement tool for birth trauma. The items in the scale focus on potentially traumatic events that may have occurred during or immediately after birth. The first two items in the CBTS assessed Criterion A for trauma: the real or perceived threat of death or serious injury. The two items were: 1) “During labor, birth, and immediately afterwards, did you believe you or your baby would be seriously injured?”, or, 2) “During labor, birth, and immediately afterwards, did you believe you or your baby would die?” If a study participant responded “yes” to either of these two questions, they were considered to have experienced birth trauma. The remaining items in the CBTS allowed respondents to indicate whether they experienced certain symptoms after birth, as a measure of PTSD. PTSD was not a focus of this study so these items were not included in the analysis. For a positive screening result to occur for PTSD, birth trauma was required to be present, and thus no one without birth trauma could have birth-related PTSD by definition. For this reason, PTSD was not assessed. Postpartum Depression The Edinburgh Postnatal Depression Scale (EPDS; Cox et al., 1987 ) was used to measure postpartum depression. The EPDS is a 10-item scale that asks participants to respond to prompts that assess the frequency of symptoms related to perinatal depression such as, “In the past 7 days, I have looked forward with enjoyment to things (Cox et al., 1987 ).” Another example prompt is, “In the past 7 days, I have blamed myself unnecessarily when things went wrong.” Respondents reported the frequency they experienced each item on a four-point response scale, ranging from 0 = “no, not at all” to 3 = “yes, very often”. Six items were reverse scored and all responses were summed so that higher scores represent greater frequency of depressive symptoms. The total score ranges from 0–30, with the following levels of severity for perinatal depression: 0–6 (none or minimal depression), 7–13 (mild depression), 14–19 (moderate depression), and 19–30 (severe depression). A minimum cut-off score of 13 is utilized to identify women who may potentially be at risk for a diagnosis of perinatal depression; a score of ≥ 13 is considered highly indicative of postpartum depression (Levis et al., 2020 ). Cronbach’s alpha for the EPDS is 0.83 with a one-factor model, and with Cronbach’s alpha being 0.76 and 0.78 for depressive and anxiety symptoms, respectively, in a two-factor model (Moyer et al., 2024 ). Cronbach’s alpha for this study was 0.79. Perinatal Anxiety The Perinatal Anxiety Screening Scale (PASS; Somerville et al., 2014 ) was used to measure postpartum anxiety. The PASS is a 31-item scale that asks respondents to indicate how often they have experienced symptoms of perinatal anxiety over the past month, such as “fear that harm will come to the baby, wanting things to be perfect, and feeling detached like you’re watching yourself in a movie.” Response options for each item range from 0 = ‘not at all’ to 3 = ‘almost always’, and responses are summed to create a total score that ranges from 0–93. Total scores are categorized into ranges to indicate the severity of perinatal anxiety: 0–20 (minimal anxiety), 21–41 (moderate anxiety), and 42–93 (severe anxiety) (Somerville et al., 2014 ). A positive screening result for anxiety on the PASS was set at a total score of ≥ 21 to match best practice as identified in the scale validation study (Somerville et al., 2014 ). Cronbach’s alpha for the PASS is 0.96 in women residing in the United States (Koukopoulos et al., 2021 ). Cronbach’s alpha for the PASS in this study was 0.96. Postpartum Obsessive-Compulsive Disorder The 20-item Dimensional Obsessive-Compulsive Scale (DOCS; Abramowitz, 2010) was utilized to measure four concerns experienced by individuals who experience obsessive compulsive disorder: Germs and Contamination; Responsibility for Harm, Injury, or Bad Luck; Unacceptable Thoughts, Symmetry, Completeness, and the Need for Things to Be ‘Just Right’ (Fairbrother et al., 2023 ). An example prompt from the germs and contamination category is, “About how much time have you spent each day thinking about contamination and engaging in washing or cleaning behaviors because of contamination?” with responses ranging from 0 = “none at all” to 4 = “8 hours or more each day.” Another example prompt from the responsibility for harm, injury, or bad luck is, “To what extent has your daily routine (work, school, self-care, social life) been disrupted by thoughts about harm or disasters and excessive checking or asking for reassurance?” with responses ranging from 0 = “no disruption at all” to 4 = “my life is completely disrupted and I cannot function at all.” Each 0–4 response option was summed to create a total score ranging from 0–80, with higher values indicating greater symptomatology. A positive screening result for OCD on the DOCS was set at a total score of ≥ 21, which correctly classifies about 70% of OCD patients from those experiencing anxiety disorders (Abramowitz et al., 2010 ). Cronbach’s alpha for the DOCS in this study was 0.93. Postpartum Bipolar Disorder The Mood Disorder Questionnaire (MDQ; Hirshchfield et al., 2000) was used to measure postpartum bipolar disorder. Participants first responded ‘yes’ or ‘no’ to 13 items focused on symptomology. Examples of items include: “Has there ever been a period of time when you were not your usual self and you were so irritable that you shouted at people or started fights or arguments?” and “Has there ever been a period of time when you were not your usual self and you got much less sleep than usual and found you didn’t really miss it?” Participants were then asked whether several of these symptoms happened at the same time (yes or no) and how much of a problem these symptoms were to them (no, minor, moderate or serious problem). A positive screen for bipolar disorder was met if a respondent indicated “yes” to at least 7 of the 13 items, and they responded ‘yes’ to symptoms occurring simultaneously, and they indicated the symptoms were a moderate or severe problem (Hirschfield et al., 2000). The MDQ has been used in perinatal populations to screen for perinatal bipolar disorder (American College of Obstetrics and Gynecology, 2024 ). Cronbach’s alpha for the MDQ in this study was 0.80. Postpartum Psychosis There are currently no valid and reliable screening tools for postpartum psychosis. The 16-item Psychosis Symptom Checklist (PSC; Policy Center for Maternal Mental Health, 2022 ) was utilized to measure postpartum psychosis. Participants were asked whether they had experienced any of the listed psychosis or mania symptoms, including delusions, hallucinations, suspiciousness or paranoia, and catatonia. The checklist accounts for the cumulative number of the 16 symptoms experienced, with more symptoms indicating a greater likelihood of experiencing postpartum psychosis. A positive screening result for postpartum psychosis on the PSC was set at a total score of ≥ 6. There is no previously established number of positive responses that indicate the presence of psychosis. This cut-off point was chosen because it is two standard deviations above the mean score on the PSC for the study sample. Cronbach’s alpha for the PSC in this study was 0.35. Sociodemographic and Birth-related Variables Several sociodemographic variables and birth-related variables were also included in the survey. All sociodemographic variables were self-reported by participants. Age, race, ethnicity and number of previous births were reported in open text fields. Participants selected the appropriate responses from a drop-down menu to report their state of residence, total household income, birth modality, and delivery type. Total household income was reported using standardized ranges as presented by the United States Census Bureau (United States Census Bureau, 2024 ). Race, ethnicity, and state of residence were not included in the analysis due to cell sizes being too small for inclusion. Insurance type was coded as a categorical variable where 0 = “Medicaid,” 2 = Indian Health Service,” 3 = “Private,” 9 = “Obamacare/ACA,” and 10 = “Other.” A categorical variable was used for education level where 0 = “No college,” 1 = “Some college,” 2 = “Associate’s degree,” 3 = “Bachelor’s degree,” 4 = “Master’s degree,” and 5 = “Doctoral/Professional degree.” Birth location was coded as a categorical variable where 0 = “hospital,” 1 = “birthing center,” 2 = “home,” 3 = “other.” Birth modality was coded as a binary variable where 0 = “vaginally” and 1 = “cesarean section.” Delivery type was coded as a categorical variable and participants were able to “select all that apply” where 0 = “spontaneous vaginal delivery,” 1 = “assisted vaginal delivery,” 2 = “planned induction,” 3 = “emergency induction,” 4 = “planned cesarean section,” 5 = “emergency c-section.” Data Analysis Data analysis was completed using SPSS Version 29.0.2.0 (IBM Corporation, 2023). Risk differences were determined by calculating the prevalence of each disorder in individuals who self-identified as screening positive for birth trauma, then subtracting the prevalence of each disorder in individuals who did not self-identify as screening positive for birth trauma. Regression analyses were performed to examine the association between birth trauma and PMHDs. Modified Poisson regression was used to determine the probability, (i.e., the relative risk, or RR) of development of each of the included PMHDs in those with versus without the presence of birth trauma. In the modified Poisson regression analyses, birth trauma was a binary predictor and all PMHD outcomes were entered as binary outcomes. The linear regression models were used to examine the relationship between birth trauma and the number and severity of symptoms for each PMHD. All modified Poisson and linear regression analyses were adjusted for age, income, insurance, education, birth location, birth modality, delivery type, and previous number of live births. Sample Table 1 presents descriptive sociodemographic data for the sample. The study sample included 249 individuals who resided in 35 different states. The age of the participants ranged from 22–55 years, with an average age of 29.75 ( SD = 4.301). Most of the sample identified as White ( n = 243, 97.6%) and non-Hispanic/Latino ( n = 237, 95.2%). Within the sample, 19.3% ( n = 48) of participants had a total household income of $ 25,000–34,999, 10% ( n = 25) had between $ 35,000–49,999, 22.1% ( n = 55) had between $ 50,000–74,999, 15.3% ( n = 38) had between $ 75,000–99,999, and 15.3% ( n = 38) had between $ 100,000-149,999 in total household income. Most respondents reported a Bachelor’s ( n = 166, 66.7%) or Master’s degree ( n = 77, 30.9%) as their highest educational degree. Nearly 70.2% had Medicaid insurance ( n = 181), and 22.9% had private insurance ( n = 57); 73.4% gave birth in a hospital setting ( n = 183), and 52.6% reported a vaginal delivery ( n = 131). Results Descriptive data related to participant’s birth experience and mental health are presented in Table 2. The results of the modified Poisson regressions are presented in Table 3. The results of the linear regressions are presented in Table 4. Slightly more than one-fifth of respondents reported experiencing birth trauma ( n =53, 21.3%). Among all survey respondents, the prevalence for each PMHD was as follows: depression ( n =211, 84.7%), anxiety ( n =204, 81.9%), OCD ( n =223, 93.6%), bipolar disorder ( n =25, 10%), and psychosis ( n =8, 3.2%). Just under 2% of the sample (1.6%, n =4) screened positive for no PMHDs, 10.4% ( n =26) screened positive for one PMHD, 12.0% ( n =30) screened positive for two PMHDs, 63.9% ( n =159) screened positive for three PMHDs, 9.6% ( n =24) screened positive for four PMHDs, 2.4% screened positive for five PMHDs. Each of the 53 respondents who reported birth trauma screened positive for at least one PMHD. Of the 53 participants who self-reported experiencing birth trauma, 49 (92.5%) screened positive for depression, 53 (100%) screened positive for anxiety, 8 (15.1%), 51 (96.2%) screened positive for OCD, 17 (32.1%) screened positive for bipolar disorder, and 8 (15.1%) screened positive for psychosis. For the 196 participants who did not self-report experiencing birth trauma, 82.7% ( n =162) screened positive for depression, 77.0% screened positive for anxiety, 92.9% screened positive for OCD, 4.1% screened positive for bipolar disorder, and 0% ( n =0) screened positive for psychosis. Postpartum Depression Women who screened positive for birth trauma had 9.3% percentage-point increased probability of screening positive for postpartum depression than women who did not screen positive for birth trauma (Table 3). In relative terms, women who screened positive for birth trauma had 1.15 times the risk of screening positive for postpartum depression compared with women who did not screen positive for birth trauma (95% CI: 1.00-1.32). In the adjusted linear regression model where total EPDS score was the outcome variable (Table 4), there was a statistically significant finding for the association between birth trauma and total score on the EPDS, and participants who experienced birth trauma scored an average of 2.26 points higher on the EPDS than participants who did not experience birth trauma ( p =<0.001; β=2.26 [95% CI: 0.74-3.77]). Postpartum Anxiety Women were 33.0 percentage points more likely to screen positive for postpartum anxiety if they screened positive for birth trauma than if they did not screen positive for birth trauma (Table 3). Women who screened positive for birth trauma were at 1.34 times the risk for screening positive for postpartum anxiety than women who did not screen positive for birth trauma in the adjusted modified Poisson regression model (95% CI: 1.18-1.51). In the adjusted linear regression model where total score on the PASS was the outcome (Table 4), there were statistically significant results between birth trauma and severity of anxiety symptoms, and women who experienced birth trauma scored an average of 17.40 points higher on the PASS than women who did not experience birth trauma ( p =<0.001; β=17.40 [95% CI: 12.32-22.49]). Postpartum OCD There was a risk difference of 3.4 percentage points between women who screened positive for OCD that screened positive for birth trauma and women who screened positive for OCD that did not screen positive for birth trauma (Table 3). Participants who screened positive for birth trauma had 1.03 times the risk of screening positive for OCD compared with participants who did not screen positive for birth trauma in the adjusted modified Poisson regression model (95% CI: 0.98-1.09). In the adjusted linear regression model where total score on the DOCS was the outcome and birth trauma was the predictor (Table 4), there was a statistically significant relationship, with women who experienced birth trauma scoring an average of 7.71 points higher on the DOCS when compared with women who did not experience birth trauma ( p =<0.001; β=7.71 [95% CI: 4.34-11.09]). Postpartum Bipolar Disorder Women who screened positive for birth trauma were 63.9 percentage points more likely to screen positive for postpartum bipolar disorder compared to women who did not screen positive for birth trauma (Table 3). Women who screened positive for experiencing birth trauma also had 9.59 times the risk of screening positive for postpartum bipolar disorder compared with women who did not screen positive for birth trauma in the adjusted modified Poisson regression model (95% CI: 2.77-33.16). When total score on the MDQ was the dependent variable in the adjusted linear regression model (Table 4), there was a statistically significant association between birth trauma and severity of symptoms for bipolar disorder, with women who experienced birth trauma scoring an average of 0.75 points higher on the MDQ than women who did not experience birth trauma ( p =<0.001; β= 0.75 [95% CI: 0.53-0.97]). Postpartum Psychosis Women were 15.1 percentage points more likely to screen positive for postpartum psychosis if they screened positive for birth trauma than if they did not screen positive for birth trauma (Table 3). There were statistically significant results when the total score on the PSC was the dependent variable in the adjusted linear regression model, with women who experienced birth trauma scoring 0.71 points higher on the PSC than women who did not experience birth trauma ( p =<0.001; β= 0.71 [95% CI: 0.30-1.13]). Results for postpartum psychosis were unable to be calculated in the modified Poisson regression model due to the distribution of the data, which caused the model to not converge. Discussion The goal of this study was to examine associations between birth trauma and PMHDs. Within this sample, the prevalence rates for all disorders were very high compared to prevalence rates observed in the general population, for reasons that are unclear. The adjusted modified Poisson regression findings indicated that for all the PMHDs included in the analyses, there was a positive association between birth trauma and a positive screening result. These findings expand the extant literature that has already shown associations between birth trauma and perinatal depression (Ayers et al., 2016 ; Bell & Anderson, 2016; Molloy et al. 2021 ) and perinatal PTSD (Ayers et al., 2016 ; Dekel et al., 2017; Grekin & O’Hara, 2014 ; Simpson & Catling, 2016 ), and document statistically significant associations between birth trauma and bipolar disorder and psychosis. The findings also revealed a slight increased risk for OCD; however, these did not rise to the level of statistical significance in this sample. The results for the overall relationship between birth trauma and PMHDs indicate that although birth trauma should not be used as a sole indicator for a clinically significant positive screening result for PMHDs, women who screen positive for birth trauma generally score higher on screening tools for PMHDs than women who do not screen positive for birth trauma. For example, individuals who screened positive for birth trauma scored an average of 17.4 points higher on the PASS for anxiety and 7.71 points higher on the DOCS for OCD in the adjusted modified Poisson regression models. This is an important finding because it indicates that women who screen positive for birth trauma are experiencing more symptoms of multiple PMHDs and may be at increased risk for short- and long-term health effects that are the result of exposure to trauma itself and/or an increased presentation of PMHD symptomology. Scholars in other areas of research, particularly within adverse childhood experiences (ACEs), have found that exposure to trauma increases mental health symptom presentation and symptomology (Bomysoad & Francis, 2020 ; Hughes et al., 2017 ). The findings from this study reinforce the connection between trauma exposure and the presentation of mental health symptoms. Although the symptoms that are being experienced by women who self-reported experiencing birth trauma may not always manifest at a clinically significant positive screening level for a PMHD, it is important to understand that birth trauma may result in more mental distress for individuals who experience it than individuals who do not. Among the women in this study, the prevalence rates of perinatal depression and anxiety were significantly elevated compared to what would be expected based on what has been estimated by other scholars in the field of perinatal mental health. Typically, some PMHDs would be considered rare enough that the “rare disease assumption” could be met, which would make Poisson regression a great fit for data analysis. This sample had the opposite issue where the outcomes were extremely common, leading to the use of modified Poisson regression for data analysis. The high prevalence rates would also have impacted regression models with binary outcomes significantly. Analyses with binary outcomes already significantly reduce statistical power, and with extremely prevalent outcomes in the study sample, analyses with binary outcomes would likely present null findings, even if relationships do exist between variables of interest; this is partly because power is limited when using binary outcomes. This elevated reporting of mental health symptomology from data collected when using crowdsourcing platforms aligns with findings from other scholars who have reported the same issue (Kolc et al., 2023 ). However, the prevalence rate for positive screening results for bipolar disorder and psychosis were in alignment with what has been reported by other scholars in studies that have not utilized MTurk for data collection processes (Raza & Raza, 2023; Yildiz et al., 2017 ), especially since there is no previously established cut-off score for the PSC. Study Limitations and Suggestions for Future Research Despite this study’s strengths, which include the use of valid and reliable screening tools, when available, and data quality assurance techniques, there are limitations to the study design, sample, and measurement that must be acknowledged. The cross-sectional design prohibited the ability to establish temporality in the relationship between birth trauma and the subsequent development of a PMHD. Efforts were made to mitigate this limitation by asking participants to state when their mental health symptoms began (i.e., prior to birth, during birth, immediately following birth-2 weeks after birth, 2 weeks-3 months after birth, or 3 months or more after birth), and women in this sample all indicated that their symptoms began following birth. However, it is possible that some respondents exhibited symptomology during their pregnancy, and this wasn’t reported accurately, or they were not fully aware of when their symptoms began. In addition, aspects of women’s mental health were not assessed prior to their pregnancy so the knowledge of their overall functioning and prior mental health diagnoses were not able to be considered. Finally, data on previous PMHD diagnoses were also not accounted for, which may also impact the observed relationships. Future work will explore relationships between birth trauma and onset of PMHD symptoms in each of the timeframes that were collected. The cross-sectional design also limited the ability to establish any type of increased risk or any kind of causal relationship between experiencing birth trauma and a positive screening result for PMHDs. To establish a causal relationship between birth trauma and PMHDs, temporal precedence, covariance, and non-spuriousness would need to be addressed (Celantano et al., 2024). Future research efforts in this area could include quasi-experimental, longitudinal studies following women from pregnancy through one year postpartum using a time series design to collect data about PMHD symptomology throughout the traditionally defined perinatal period. The use of crowdsourcing techniques, while convenient, meant that the sample was composed of individuals who had access to internet services and who were aware of the MTurk platform. These factors were reflected in the high percentage of White, highly educated, individuals included in the study sample. The lack of representation of women from varying socioeconomic and cultural backgrounds was a limitation that prohibited the adjustment for such factors (e.g., race, ethnicity) during data analysis due to small cell size. These other social factors may impact the relationship between birth trauma and each of the PMHDs, but these were not able to be assessed in this study. Another limitation of this study was the use of measures of symptomatology rather than PMHD diagnoses. Rather than defining the outcome as a diagnosed PMHD, screening tools were used because diagnoses of PMHDs may be an under-representation of the true burden of PMHDs among women in the United States (Womersley & Alderson, 2024 ). There is limited research on this topic, so positive screens for each PMHD were used to capture as many cases as possible. This may mean that the observed relationships were not as precise as they could be, as not everyone who screens positive for a PMHD is not diagnosed with one of these disorders. Future research efforts should focus on understanding more precise associations between birth trauma and diagnosis of PMHDs. Additionally, the specific screening measures for PMHDs have commonly been utilized by scholars in virtual settings and studies; however, there are limited studies assessing the validity of the use of these measures in these settings, which may have also impacted this study’s findings. Finally, prior mental health history was not assessed in this study, which could have a significant impact on the findings of this study; this will be considered in future research. Implications The findings from this study underscore the substantial mental health burden experienced by women who report birth trauma and highlight the need for integrated, trauma-informed approaches to perinatal care. The high prevalence of PMHDs observed—particularly depression, anxiety, and OCD—suggest that current screening and support systems may be insufficient to identify and address the needs of postpartum women, especially those who have experienced traumatic births. From a public health perspective, these results call for expanding postpartum mental health screening protocols beyond depression alone. Given that women who experienced birth trauma in this study were more likely to screen positive for multiple PMHDs, universal, multi-condition screening should be considered in perinatal settings. Public health interventions should also prioritize early identification and prevention of birth trauma through respectful maternity care, informed consent practices, and strategies to reduce unnecessary medical interventions that can contribute to traumatic experiences. The associations between birth trauma and conditions such as bipolar disorder and psychosis—disorders often considered rare in the perinatal period—are particularly noteworthy. This suggests that birth trauma screening could serve as an important adjunct to early detection efforts for these severe conditions, which, if left untreated, carry substantial risks for both maternal and infant health. Public health programs aimed at perinatal mental health should incorporate trauma history assessment into routine postpartum care, while also ensuring referral pathways to specialized psychiatric evaluation when indicated. From a clinical perspective, these findings highlight the importance of multidisciplinary care models that integrate obstetric, psychiatric, and psychological expertise. Clinicians should be trained to recognize the signs of birth trauma and its potential mental health sequelae, even when patients do not meet full diagnostic criteria for a PMHD. Furthermore, screening should be paired with immediate access to evidence-based interventions, such as trauma-focused cognitive behavioral therapy, peer support programs, and pharmacological management, when appropriate. Given the elevated symptom burden among women with birth trauma, there is a clear need for care continuity beyond the traditional six-week postpartum visit. Establishing extended follow-up intervals, especially within the first year postpartum, could facilitate timely intervention, prevent symptom escalation, and mitigate the risk of chronic mental health conditions. Finally, these findings reinforce the need for culturally responsive and equitable mental health services, particularly for populations historically underrepresented in perinatal mental health research. Conclusion This study provides compelling evidence that birth trauma is significantly associated with elevated rates and severity of multiple PMHDs, including depression, anxiety, bipolar disorder, and psychosis. While the cross-sectional design precludes causal inference, the strength and consistency of associations across disorders highlight birth trauma as a key factor in perinatal mental health profiles. Importantly, women who experienced birth trauma not only had higher rates of positive screening results but also demonstrated greater symptom severity across multiple PMHDs. These findings contribute to the growing body of literature linking traumatic experiences during childbirth with adverse mental health outcomes, extending previous research beyond depression and PTSD to include less-studied conditions such as bipolar disorder and psychosis. The results also underscore the need for broader perinatal mental health screening, trauma-informed maternity care practices, and integrated clinical pathways to address the complex needs of women affected by birth trauma. Addressing birth trauma is not solely a matter of individual patient care—it is a systemic public health imperative. Interventions aimed at prevention, early detection, and treatment of both birth trauma itself and its psychiatric sequelae have the potential to improve maternal health outcomes, enhance family well-being, and reduce the intergenerational transmission of trauma-related mental health risks. As such, these findings should inform both clinical guidelines and public health policies aimed at improving the mental health of postpartum women. Abbreviations ACEs – Adverse Childhood Experiences CNAE – Concepts Negatively Associated with Empowerment CPAE – Concepts Positively Associated with Empowerment C-section - Cesarean Section CBTS – City Birth Trauma Scale DOCS – Dimensional Obsessive-Compulsive Scale EPDS – Edinburgh Postnatal Depression Scale MDQ – Mood Disorder Questionnaire MTurk – Mechanical Turk OCD – Obsessive Compulsive Scale PASS – Postpartum Anxiety Screening Scale PMHDs – Perinatal Mental Health Disorders PSC - Psychosis Symptom Checklist PTSD – Post-Traumatic Stress Disorder SAMHSA - Substance and Mental Health Services Administration SCS – Sense of Control Scale Declarations Ethics Approval and Consent to participate: This study was approved by the IRB at South Dakota State University (IRB-2024-192). All participants completed the eConsent process in REDCap prior to study participation. Consent for publication: All authors have reviewed this manuscript and provide consent for publication. This manuscript is not under consideration at any other journal for publication. Availability of data and materials: All data and materials are available upon request. Please email [email protected] to request access to the deidentified quantitative data. Competing interests: The authors have no competing interests to declare. Funding: This study was completed with funding from the Health Resources and Services Administration, Grant A30MC50003. Author contributions: SH (Conceptualization, Methodology, Analysis, Investigation, Original Draft, Review & Editing) Acknowledgements: We would like to thank all participants for their time and contributions to this study. We also acknowledge the support of South Dakota State University for providing resources and infrastructure for data collection and analysis. We would also like to thank Dr. Lynette Renner, Dr. Mimi Choy-Brown, Dr. Joseph Merighi, and Dr. Susan Marshall Mason for their guidance and help with this work. Data Availability All data and materials are available upon request. Please email [ [email protected] ](mailto: [email protected] ) to request access to the deidentified quantitative data. References Abramowitz JS, Deacon BJ, Olatunji BO, Wheaton MG, Berman NC, Losardo D, Timpano KR, McGrath PB, Riemann BC, Adams T, Björgvinsson T, Storch EA, Hale LR. Assessment of obsessive-compulsive symptom dimensions: development and evaluation of the Dimensional Obsessive-Compulsive Scale. Psychol Assess. 2010;22(1):180–98. https://doi.org/10.1037/a0018260 . American College of Obstetrics and Gynecology. (2024). Perinatal mental health toolkit . Retrieved December 12 from https://www.acog.org/programs/perinatal-mental-health American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders (5-tr ed.). Amer Psychiatric Pub Inc. Ayers S, Eagle A, Waring H. 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Retrieved August 12 from https://policycentermmh.org/app/uploads/2024/04/PolicyCenterforMaternalMentalHealthsPsychosisSymptomChecklistPSC2.28.2022.pdf Postpartum Support International. (2024). Perinatal mental health conditions. Retrieved March 18 from https://postpartum.net/perinatal-mental-health/ Simpson M, Catling C. Understanding psychological trauma and posttraumatic stress disorder in the perinatal period. Women Birth. 2016;29(3):203–7. https://doi.org/10.1016/j.wombi.2015.10.009 . Somerville S, Dedman K, Hagan R, Oxnam E, Wettinger M, Byrne S, Coo S, Doherty D, Page AC. The Perinatal Anxiety Screening Scale: development and preliminary validation. Arch Women Ment Health. 2014;17(5):443–54. https://doi.org/10.1007/s00737-014-0425-8 . Substance Abuse and Mental Health Services Administration [SAMHSA]. (2012). Trauma and violence . Retrieved August 12 from https://www.samhsa.gov/mental-health/trauma-violence Thomas JL, Carter SE, Schetter CD, Sumner JA. Racial and ethnic disparities in posttraumatic psychopathology among postpartum women. J Psychiatr Res. 2021;137(May):36–40. https://doi.org/10.1016/j.jpsychires.2021.02.030 . United States Census Bureau. (2024). Data . Retrieved August 12 from https://www.census.gov/data.html Watson K, White C, Hall H, Hewitt A. Women's experiences of birth trauma: A scoping review. Women birth: J Australian Coll Midwives. 2021;34(5):417–24. https://doi.org/10.1016/j.wombi.2020.09.016 . Webb R, Uddin N, Ford E, Easter A, Shakespeare J, Roberts N, Alderdice F, Coates R, Hogg S, Cheyne H, Ayers S, team MA. s. (2021). Barriers and facilitators to implementing perinatal mental health care in health and social care settings: a systematic review. Lancet Psychiatry, 8(6), 521–534. https://doi.org/10.1016/S2215-0366(20)30467-3 Womersley K, Alderson H. Perinatal mental health. Medicine. 2024;52(10):632–6. doi.org/10.1016/j.mpmed.2024.07.009 . https://doi.org/https:// . World Health Organization [WHO]. (2024). Safe childbirth. Retrieved April 28 from https://www.who.int/teams/integrated-health-services/patient-safety/research/safe-childbirth#:~:text=Of%20the%20more%20than%20130,and%20most%20could%20be%20prevented 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 . Tables Table 1. Participant Demographics (N=249) n % Age 22-24 25-29 30-34 35-55 20 141 77 11 8.0 56.6 31.0 4.4 Race White Native American Alaska Native Middle Eastern 243 4 1 1 97.6 1.6 0.4 0.4 Ethnicity Hispanic/Latino Non-Hispanic/Latino 12 237 4.8 95.2 Income $0-14,999 $15,000-24,999 $25,000-34,999 $35,000-49,999 $50,000-74,999 $75,000-99,999 $100,000-149,999 $150,000-199,999 $200,000 or more 1 35 48 25 55 38 38 8 1 0.4 14.1 19.3 10.0 22.1 15.3 15.3 3.2 0.4 Insurance Medicaid IHS Private Obamacare Other 181 4 57 3 4 72.7 1.6 22.9 1.2 1.6 Education Associate Bachelor Master Doctoral/Professional 3 166 77 3 1.2 66.7 30.9 1.2 Table 2. Birthing Experience and Mental Health (N=249) n % Birth Location Hospital Birthing Center Home 183 10 56 73.5 4.0 22.5 Birth Modality Vaginal Cesarean Section (C-Section) 131 118 52.6 47.4 Number of Previous Live Births 0 1 2 3 4 5 43 153 48 3 1 1 17.3 61.4 19.3 1.2 0.4 0.4 Self-Reported Experiencing Birth Trauma 53 21.3 Experienced Birth Trauma and Screened Positive for at Least One PMHD 53 21.3 Prevalence of PMHDs Depression Anxiety OCD Bipolar Disorder Psychosis 211 204 223 25 8 84.7 81.9 93.6 10.0 3.2 Table 3. Modified Poisson Regression Results with Birth Trauma as the Predictor and PMHDs as the Outcome (N=249) Variable Unadjusted Adjusted* Risk Difference Birth trauma Depression Depression B SE p Exp(B) 95% CI B SE p Exp(B) 95% CI 0.11 0.05 0.03 1.12 1.01-1.24 0.14 0.07 0.04 1.15 1.00-1.32 9.3% Birth trauma Anxiety Anxiety B SE p Exp(B) 95% CI B SE p Exp(B) 95% CI 0.26 0.04 <0.001 1.30 1.20-1.40 0.29 0.06 <0.001 1.34 1.18-1.51 33.0% Birth trauma OCD OCD B SE p Exp(B) 95% CI B SE p Exp(B) 95% CI 0.04 0.03 0.29 1.04 0.97-1.11 0.03 0.03 0.28 1.03 0.98-1.09 3.4% Birth trauma Bipolar Bipolar B SE p Exp(B) 95% CI B SE P Exp(B) 95% CI 2.06 0.40 <0.001 7.86 3.59-17.21 2.26 0.63 <0.001 9.59 2.77-33.16 63.9% Birth trauma Psychosis Psychosis B SE p Exp(B) 95% CI B SE P Exp(B) 95% CI ** ** ** ** ** ** ** ** ** ** 15.1% *adjusted for age, income, insurance, education, birth location, birth modality, delivery type, and previous number of live births ** unable to calculate Table 4. Linear Regression Results with Birth Trauma as the Predictor and PMHDs as the Outcome (N=249) Variable Unadjusted Adjusted* Birth trauma Depression Depression SE t F p B 95% CI SE t F p B 95% CI 0.74 3.07 0.002 2.28 0.82-3.75 0.77 2.93 3.41 <0.001 2.26 0.74-3.77 Birth trauma Anxiety Anxiety SE t F p B 95% CI SE t F p B 95% CI 3.05 4.77 <0.001 14.53 8.53-20.53 2.58 6.74 20.56 <0.001 17.40 12.32-22.49 Birth trauma OCD OCD SE t F p B 95% CI SE t F p B 95% CI 1.81 3.12 0.002 5.69 2.12-9.25 1.71 4.50 9.37 <0.001 7.71 4.34-11.09 Birth trauma Bipolar Bipolar SE t F p B 95% CI SE t F p B 95% CI 0.13 5.64 <0.001 0.71 0.46-0.95 0.11 6.68 16.61 <0.001 0.75 0.53-0.97 Birth trauma Psychosis Psychosis SE t F p B 95% CI SE t F p B 95% CI 0.26 2.89 0.004 0.74 0.23-1.24 0.21 3.39 20.74 <0.001 0.71 0.30-1.13 *adjusted for age, income, insurance, education, birth location, birth modality, delivery type, and previous number of live birth Additional Declarations No competing interests reported. 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affects up to 45% of women and is linked to adverse mental health outcomes, yet its relationship with perinatal mental health disorders (PMHDs) beyond PTSD remains underexplored.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWhat is Known: Existing research primarily examines birth trauma in relation to perinatal PTSD, with limited evidence on other PMHDs such as depression, anxiety, OCD, bipolar disorder, and psychosis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWhat this Paper Adds: This study demonstrates significant associations between birth trauma and increased risk and symptom severity for multiple PMHDs, highlighting the need for integrated, trauma-informed postpartum screening and care.\u0026nbsp;\u003c/p\u003e"},{"header":"Background","content":"\u003cp\u003eGlobally, there are approximately 130\u0026nbsp;million live births each year (World Health Organization, 2024). In the United States, there were approximately 3.6\u0026nbsp;million live births in 2023 (Martin et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). For most women, an ideal birthing experience includes giving birth naturally, satisfaction with the birth experience, and easy adaptation to the post-birth period (Fahy \u0026amp; Parratt, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). For many women, the reality of their birthing experience can be traumatic.\u003c/p\u003e \u003cp\u003eTrauma is \u0026ldquo;intense physical and psychological stress reactions that result from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or threatening and that has lasting adverse effects on the individual\u0026rsquo;s functioning and physical, social, emotional, or spiritual well-being\u0026rdquo; (Substance Abuse and Mental Health Services Administration, 2012). Birth trauma is a form of psychological trauma that may result from traumatic experiences that occur during the delivery of a fetus or child (Horsch et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Birth trauma is a subjective experience: a \u0026lsquo;medically textbook\u0026rsquo; birth may be traumatic for some women, and a birth that is filled with complications may be interpreted as completely ordinary by others (Beck, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2004\u003c/span\u003e). Approximately 45% of women in the United States experience birth trauma (March of Dimes, 2024).\u003c/p\u003e \u003cp\u003eRisk factors for birth trauma include experiencing a birth that did not go as hoped, birth complications, emergency cesarean section (c-section) or the use of other medical devices, the mother or infant suffering an injury during birth, required medical attention for the infant after birth, and the perception of insufficient care from hospital staff following delivery (March of Dimes, 2024). Birth trauma has been associated with postpartum challenges for the mother, such as difficulty bonding with the infant, relationship strain, emotional and psychological dysregulation, and poor physical health (Ayers et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2006\u003c/span\u003e; Nicholls \u0026amp; Ayers, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2007\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePMHDs include a total of six disorders: perinatal depression, perinatal anxiety, perinatal post-traumatic stress disorder (PTSD), perinatal obsessive-compulsive disorder (OCD), bipolar disorder, and postpartum psychosis. The prevalence of each PMHD varies among women, ranging from approximately 20% for both perinatal depression and perinatal anxiety, to 0.7\u0026ndash;2.3% for perinatal OCD, to 12\u0026ndash;30% for perinatal PTSD, to 0.1\u0026thinsp;\u0026minus;\u0026thinsp;0.02% for perinatal psychosis (Hunter et al., 2021; Postpartum Support International, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). PMHDs have been associated with several negative mental and physical health outcomes, including detachment, inability to bond with an infant, delayed achievement of childhood developmental milestones, obesity and substance-use-related issues, such as cirrhosis (Hunter et al., 2021).\u003c/p\u003e \u003cp\u003eAlthough there are overlapping risk factors for birth trauma and PMHDs, research focused on the relationship between them is limited. The majority of extant literature focused on birth trauma and PMHDs has focused on the validity and reliability of the City Birth Trauma Scale (an instrument designed to screen for the presence of birth trauma and perinatal PTSD in new mothers; Ayers et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) or has been concentrated on the relationship between birth trauma and the subsequent development of perinatal PTSD (Mackle et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Thomas et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTrauma theory explores the psychological impacts of traumatic experiences on an individual\u0026rsquo;s functioning and long-term health and experiences. Trauma theory has been used to explore associations between fear of childbirth and difficulties with mother-infant relationships (Ayers et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2006\u003c/span\u003e) and birth trauma and relationship strain and sexual dysfunction (Nicholls \u0026amp; Ayers, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2007\u003c/span\u003e). Some scholars have also utilized qualitative methods to establish relationships between birth trauma and perinatal PTSD (Bateman et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Watson et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2021\u003c/span\u003e); but the relationships between birth trauma and perinatal depression, anxiety, OCD, bipolar disorder, and psychosis have yet to be examined. Examining associations between birth trauma and varying types of PMHDs may provide information about associations that may exist but are not well-documented. The documentation of these associations would provide a quantifiable foundation for researchers and practitioners to explore these associations in greater depth.\u003c/p\u003e \u003cp\u003eThe purpose of this study was to assess the relationship between birth trauma and five of the PMHDs recognized in the \u003cem\u003eDiagnostic and Statistical Manual of Mental Disorders \u0026minus;\u0026thinsp;5th Edition\u003c/em\u003e. It was hypothesized that birth trauma would be positively associated with the development of each of the included PMHDs. Documenting the associations between birth trauma and PMHDs is essential for providing a foundation for greater understanding of these relationships and provides evidence that can be used as a catalyst to explore interventions to reduce the impact of birth trauma on the development of PMHDs.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eData Source and Data Collection\u003c/h2\u003e \u003cp\u003eCrowdsourcing through Amazon\u0026rsquo;s Mechanical Turk (MTurk) platform was utilized to recruit participants for this cross-sectional study. Data was collected in December 2024 via REDCap, which is a web-based, HIPAA-compliant application developed by Vanderbilt University to capture clinical research data and create databases and projects. The data is captured through surveys and forms as research capture tools. Surveys are workflow-based and allow for the export of captured data to statistical programs where it can be analyzed (Patridge \u0026amp; Bardyn, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTo be eligible for the study, participants needed to be: at least 18 years of age, residing in the United States, fluent in English (written and verbal), at least four weeks postpartum, less than seven months postpartum, born and currently identifying as being female, not participating in any inpatient mental health or substance use treatment program(s), and not experiencing a current mental health crisis or emergency. Eligibility was assessed through a series of questions and self-report responses via a REDCap screening survey. If eligibility requirements were met, participants then completed the eConsent process in REDCap where they reviewed the informed consent documents and provided their consent for survey participation. Eligible respondents who affirmed consent to participate in the study were advanced to the 167-item REDCap survey that collected information on demographics and mental health disorders. Upon completion of the survey, participants were compensated \u003cspan\u003e$\u003c/span\u003e20.\u003c/p\u003e \u003cp\u003eSeveral mechanisms were used to help ensure credible and accurate survey responses. The captcha feature was used before beginning the survey, as a mechanism for ensuring human survey respondents. To ensure consistent data, the participants were asked the same question in ways that required different formats for responses, and they were asked the same question multiple times throughout the survey. For example, participants were asked \u0026ldquo;Are you at least 4 weeks postpartum?\u0026rdquo; and \u0026ldquo;Are you less than 7 months postpartum?\u0026rdquo; with the answers to select being radio buttons for \u0026ldquo;yes\u0026rdquo; and \u0026ldquo;no.\u0026rdquo; Several questions later, participants were then asked to provide the birth date of their infant in a MM/DD/YYYY format. Responses to these questions were then compared for consistency, and any inconsistent responses from participants resulted in all that participant\u0026rsquo;s data being removed from data analysis. Another check for consistency was that participants were screened for birth trauma using the same questions at the very beginning, halfway through, and at the end of the survey. Asking this question at all three time points ensured participants remained engaged in the survey and were submitting representative responses. Consistency in answers to all duplicated questions were compared and any participant\u0026rsquo;s responses that were not consistent were removed from data analysis. In total, five questions were asked in ways that required participants to submit the same answers in different formats and three questions were asked in the same way multiple times within the survey.\u003c/p\u003e \u003cp\u003eTo ensure 80% power when α\u0026thinsp;=\u0026thinsp;0.05, this study required a minimum of 166 participants to detect statistical significance with the prevalence of PMHDs expected to be 40% in populations who experienced birth trauma, and 20% in populations who did not experience birth trauma. These prevalence rates were taken from a study published by Isobel et al. (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2024\u003c/span\u003e), which is the only study to report differences of PMHD prevalence between individuals who do and do not experience birth trauma.\u003c/p\u003e \u003cp\u003eA total of 300 respondents completed the survey. The first entry for a participant was kept and included in the analysis if duplicate responses were provided by the same participant. After removal of duplicates (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;7), data quality assurance checks (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;35), and confirmation of timing of symptom onset (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;9), there were 249 usable responses.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eMeasures\u003c/h3\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eBirth Trauma\u003c/h2\u003e \u003cp\u003eThe 29-item City Birth Trauma Scale (CBTS; Ayers et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) served as the measurement tool for birth trauma. The items in the scale focus on potentially traumatic events that may have occurred during or immediately after birth. The first two items in the CBTS assessed Criterion A for trauma: the real or perceived threat of death or serious injury. The two items were: 1) \u0026ldquo;During labor, birth, and immediately afterwards, did you believe you or your baby would be seriously injured?\u0026rdquo;, or, 2) \u0026ldquo;During labor, birth, and immediately afterwards, did you believe you or your baby would die?\u0026rdquo; If a study participant responded \u0026ldquo;yes\u0026rdquo; to either of these two questions, they were considered to have experienced birth trauma. The remaining items in the CBTS allowed respondents to indicate whether they experienced certain symptoms after birth, as a measure of PTSD. PTSD was not a focus of this study so these items were not included in the analysis. For a positive screening result to occur for PTSD, birth trauma was required to be present, and thus no one without birth trauma could have birth-related PTSD by definition. For this reason, PTSD was not assessed.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePostpartum Depression\u003c/h3\u003e\n\u003cp\u003eThe Edinburgh Postnatal Depression Scale (EPDS; Cox et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e1987\u003c/span\u003e) was used to measure postpartum depression. The EPDS is a 10-item scale that asks participants to respond to prompts that assess the frequency of symptoms related to perinatal depression such as, \u0026ldquo;In the past 7 days, I have looked forward with enjoyment to things (Cox et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e1987\u003c/span\u003e).\u0026rdquo; Another example prompt is, \u0026ldquo;In the past 7 days, I have blamed myself unnecessarily when things went wrong.\u0026rdquo; Respondents reported the frequency they experienced each item on a four-point response scale, ranging from 0 = \u0026ldquo;no, not at all\u0026rdquo; to 3 = \u0026ldquo;yes, very often\u0026rdquo;. Six items were reverse scored and all responses were summed so that higher scores represent greater frequency of depressive symptoms. The total score ranges from 0\u0026ndash;30, with the following levels of severity for perinatal depression: 0\u0026ndash;6 (none or minimal depression), 7\u0026ndash;13 (mild depression), 14\u0026ndash;19 (moderate depression), and 19\u0026ndash;30 (severe depression). A minimum cut-off score of 13 is utilized to identify women who may potentially be at risk for a diagnosis of perinatal depression; a score of \u0026ge;\u0026thinsp;13 is considered highly indicative of postpartum depression (Levis et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Cronbach\u0026rsquo;s alpha for the EPDS is 0.83 with a one-factor model, and with Cronbach\u0026rsquo;s alpha being 0.76 and 0.78 for depressive and anxiety symptoms, respectively, in a two-factor model (Moyer et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Cronbach\u0026rsquo;s alpha for this study was 0.79.\u003c/p\u003e\n\u003ch3\u003ePerinatal Anxiety\u003c/h3\u003e\n\u003cp\u003eThe Perinatal Anxiety Screening Scale (PASS; Somerville et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) was used to measure postpartum anxiety. The PASS is a 31-item scale that asks respondents to indicate how often they have experienced symptoms of perinatal anxiety over the past month, such as \u0026ldquo;fear that harm will come to the baby, wanting things to be perfect, and feeling detached like you\u0026rsquo;re watching yourself in a movie.\u0026rdquo; Response options for each item range from 0 = \u0026lsquo;not at all\u0026rsquo; to 3 = \u0026lsquo;almost always\u0026rsquo;, and responses are summed to create a total score that ranges from 0\u0026ndash;93. Total scores are categorized into ranges to indicate the severity of perinatal anxiety: 0\u0026ndash;20 (minimal anxiety), 21\u0026ndash;41 (moderate anxiety), and 42\u0026ndash;93 (severe anxiety) (Somerville et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). A positive screening result for anxiety on the PASS was set at a total score of \u0026ge;\u0026thinsp;21 to match best practice as identified in the scale validation study (Somerville et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). Cronbach\u0026rsquo;s alpha for the PASS is 0.96 in women residing in the United States (Koukopoulos et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Cronbach\u0026rsquo;s alpha for the PASS in this study was 0.96.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003ePostpartum Obsessive-Compulsive Disorder\u003c/h2\u003e \u003cp\u003eThe 20-item Dimensional Obsessive-Compulsive Scale (DOCS; Abramowitz, 2010) was utilized to measure four concerns experienced by individuals who experience obsessive compulsive disorder: Germs and Contamination; Responsibility for Harm, Injury, or Bad Luck; Unacceptable Thoughts, Symmetry, Completeness, and the Need for Things to Be \u0026lsquo;Just Right\u0026rsquo; (Fairbrother et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). An example prompt from the germs and contamination category is, \u0026ldquo;About how much time have you spent each day thinking about contamination and engaging in washing or cleaning behaviors because of contamination?\u0026rdquo; with responses ranging from 0 = \u0026ldquo;none at all\u0026rdquo; to 4 = \u0026ldquo;8 hours or more each day.\u0026rdquo; Another example prompt from the responsibility for harm, injury, or bad luck is, \u0026ldquo;To what extent has your daily routine (work, school, self-care, social life) been disrupted by thoughts about harm or disasters and excessive checking or asking for reassurance?\u0026rdquo; with responses ranging from 0 = \u0026ldquo;no disruption at all\u0026rdquo; to 4 = \u0026ldquo;my life is completely disrupted and I cannot function at all.\u0026rdquo; Each 0\u0026ndash;4 response option was summed to create a total score ranging from 0\u0026ndash;80, with higher values indicating greater symptomatology. A positive screening result for OCD on the DOCS was set at a total score of \u0026ge;\u0026thinsp;21, which correctly classifies about 70% of OCD patients from those experiencing anxiety disorders (Abramowitz et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). Cronbach\u0026rsquo;s alpha for the DOCS in this study was 0.93.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePostpartum Bipolar Disorder\u003c/h3\u003e\n\u003cp\u003eThe Mood Disorder Questionnaire (MDQ; Hirshchfield et al., 2000) was used to measure postpartum bipolar disorder. Participants first responded \u0026lsquo;yes\u0026rsquo; or \u0026lsquo;no\u0026rsquo; to 13 items focused on symptomology. Examples of items include: \u0026ldquo;Has there ever been a period of time when you were not your usual self and you were so irritable that you shouted at people or started fights or arguments?\u0026rdquo; and \u0026ldquo;Has there ever been a period of time when you were not your usual self and you got much less sleep than usual and found you didn\u0026rsquo;t really miss it?\u0026rdquo; Participants were then asked whether several of these symptoms happened at the same time (yes or no) and how much of a problem these symptoms were to them (no, minor, moderate or serious problem). A positive screen for bipolar disorder was met if a respondent indicated \u0026ldquo;yes\u0026rdquo; to at least 7 of the 13 items, and they responded \u0026lsquo;yes\u0026rsquo; to symptoms occurring simultaneously, and they indicated the symptoms were a moderate or severe problem (Hirschfield et al., 2000). The MDQ has been used in perinatal populations to screen for perinatal bipolar disorder (American College of Obstetrics and Gynecology, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Cronbach\u0026rsquo;s alpha for the MDQ in this study was 0.80.\u003c/p\u003e\n\u003ch3\u003ePostpartum Psychosis\u003c/h3\u003e\n\u003cp\u003eThere are currently no valid and reliable screening tools for postpartum psychosis. The 16-item Psychosis Symptom Checklist (PSC; Policy Center for Maternal Mental Health, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) was utilized to measure postpartum psychosis. Participants were asked whether they had experienced any of the listed psychosis or mania symptoms, including delusions, hallucinations, suspiciousness or paranoia, and catatonia. The checklist accounts for the cumulative number of the 16 symptoms experienced, with more symptoms indicating a greater likelihood of experiencing postpartum psychosis. A positive screening result for postpartum psychosis on the PSC was set at a total score of \u0026ge;\u0026thinsp;6. There is no previously established number of positive responses that indicate the presence of psychosis. This cut-off point was chosen because it is two standard deviations above the mean score on the PSC for the study sample. Cronbach\u0026rsquo;s alpha for the PSC in this study was 0.35.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eSociodemographic and Birth-related Variables\u003c/h2\u003e \u003cp\u003eSeveral sociodemographic variables and birth-related variables were also included in the survey. All sociodemographic variables were self-reported by participants. Age, race, ethnicity and number of previous births were reported in open text fields. Participants selected the appropriate responses from a drop-down menu to report their state of residence, total household income, birth modality, and delivery type. Total household income was reported using standardized ranges as presented by the United States Census Bureau (United States Census Bureau, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRace, ethnicity, and state of residence were not included in the analysis due to cell sizes being too small for inclusion. Insurance type was coded as a categorical variable where 0 = \u0026ldquo;Medicaid,\u0026rdquo; 2\u0026thinsp;=\u0026thinsp;Indian Health Service,\u0026rdquo; 3 = \u0026ldquo;Private,\u0026rdquo; 9 = \u0026ldquo;Obamacare/ACA,\u0026rdquo; and 10 = \u0026ldquo;Other.\u0026rdquo; A categorical variable was used for education level where 0 = \u0026ldquo;No college,\u0026rdquo; 1 = \u0026ldquo;Some college,\u0026rdquo; 2 = \u0026ldquo;Associate\u0026rsquo;s degree,\u0026rdquo; 3 = \u0026ldquo;Bachelor\u0026rsquo;s degree,\u0026rdquo; 4 = \u0026ldquo;Master\u0026rsquo;s degree,\u0026rdquo; and 5 = \u0026ldquo;Doctoral/Professional degree.\u0026rdquo; Birth location was coded as a categorical variable where 0 = \u0026ldquo;hospital,\u0026rdquo; 1 = \u0026ldquo;birthing center,\u0026rdquo; 2 = \u0026ldquo;home,\u0026rdquo; 3 = \u0026ldquo;other.\u0026rdquo; Birth modality was coded as a binary variable where 0 = \u0026ldquo;vaginally\u0026rdquo; and 1 = \u0026ldquo;cesarean section.\u0026rdquo; Delivery type was coded as a categorical variable and participants were able to \u0026ldquo;select all that apply\u0026rdquo; where 0 = \u0026ldquo;spontaneous vaginal delivery,\u0026rdquo; 1 = \u0026ldquo;assisted vaginal delivery,\u0026rdquo; 2 = \u0026ldquo;planned induction,\u0026rdquo; 3 = \u0026ldquo;emergency induction,\u0026rdquo; 4 = \u0026ldquo;planned cesarean section,\u0026rdquo; 5 = \u0026ldquo;emergency c-section.\u0026rdquo;\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eData analysis was completed using SPSS Version 29.0.2.0 (IBM Corporation, 2023). Risk differences were determined by calculating the prevalence of each disorder in individuals who self-identified as screening positive for birth trauma, then subtracting the prevalence of each disorder in individuals who did not self-identify as screening positive for birth trauma. Regression analyses were performed to examine the association between birth trauma and PMHDs. Modified Poisson regression was used to determine the probability, (i.e., the relative risk, or RR) of development of each of the included PMHDs in those with versus without the presence of birth trauma. In the modified Poisson regression analyses, birth trauma was a binary predictor and all PMHD outcomes were entered as binary outcomes. The linear regression models were used to examine the relationship between birth trauma and the number and severity of symptoms for each PMHD. All modified Poisson and linear regression analyses were adjusted for age, income, insurance, education, birth location, birth modality, delivery type, and previous number of live births.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eSample\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;1 presents descriptive sociodemographic data for the sample. The study sample included 249 individuals who resided in 35 different states. The age of the participants ranged from 22\u0026ndash;55 years, with an average age of 29.75 (\u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;4.301). Most of the sample identified as White (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;243, 97.6%) and non-Hispanic/Latino (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;237, 95.2%). Within the sample, 19.3% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;48) of participants had a total household income of \u003cspan\u003e$\u003c/span\u003e25,000\u0026ndash;34,999, 10% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;25) had between \u003cspan\u003e$\u003c/span\u003e35,000\u0026ndash;49,999, 22.1% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;55) had between \u003cspan\u003e$\u003c/span\u003e50,000\u0026ndash;74,999, 15.3% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;38) had between \u003cspan\u003e$\u003c/span\u003e75,000\u0026ndash;99,999, and 15.3% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;38) had between \u003cspan\u003e$\u003c/span\u003e100,000-149,999 in total household income. Most respondents reported a Bachelor\u0026rsquo;s (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;166, 66.7%) or Master\u0026rsquo;s degree (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;77, 30.9%) as their highest educational degree. Nearly 70.2% had Medicaid insurance (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;181), and 22.9% had private insurance (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;57); 73.4% gave birth in a hospital setting (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;183), and 52.6% reported a vaginal delivery (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;131).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eDescriptive data related to participant’s birth experience and mental health are presented in Table 2. The results of the modified Poisson regressions are presented in Table 3. The results of the linear regressions are presented in Table 4.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSlightly more than one-fifth of respondents reported experiencing birth trauma (\u003cem\u003en\u003c/em\u003e=53, 21.3%). Among all survey respondents, the prevalence for each PMHD was as follows: depression (\u003cem\u003en\u003c/em\u003e=211, 84.7%), anxiety (\u003cem\u003en\u003c/em\u003e=204, 81.9%), OCD (\u003cem\u003en\u003c/em\u003e=223, 93.6%), bipolar disorder (\u003cem\u003en\u003c/em\u003e=25, 10%), and psychosis (\u003cem\u003en\u003c/em\u003e=8, 3.2%). Just under 2% of the sample (1.6%, \u003cem\u003en\u003c/em\u003e=4) screened positive for no PMHDs, 10.4% (\u003cem\u003en\u003c/em\u003e=26) screened positive for one PMHD, 12.0% (\u003cem\u003en\u003c/em\u003e=30) screened positive for two PMHDs, 63.9% (\u003cem\u003en\u003c/em\u003e=159) screened positive for three PMHDs, 9.6% (\u003cem\u003en\u003c/em\u003e=24) screened positive for four PMHDs, 2.4% screened positive for five PMHDs.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEach of the 53 respondents who reported birth trauma screened positive for at least one PMHD. Of the 53 participants who self-reported experiencing birth trauma, 49 (92.5%) screened positive for depression, 53 (100%) screened positive for anxiety, 8 (15.1%), 51 (96.2%) screened positive for OCD, 17 (32.1%) screened positive for bipolar disorder, and 8 (15.1%) screened positive for psychosis. For the 196 participants who did not self-report experiencing birth trauma, 82.7% (\u003cem\u003en\u003c/em\u003e=162) screened positive for depression, 77.0% screened positive for anxiety, 92.9% screened positive for OCD, 4.1% screened positive for bipolar disorder, and 0% (\u003cem\u003en\u003c/em\u003e=0) screened positive for psychosis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePostpartum Depression\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWomen who screened positive for birth trauma had 9.3% percentage-point increased probability of screening positive for postpartum depression than women who did not screen positive for birth trauma (Table 3). In relative terms, women who screened positive for birth trauma had 1.15 times the risk of screening positive for postpartum depression compared with women who did not screen positive for birth trauma (95% CI: 1.00-1.32). In the adjusted linear regression model where total EPDS score was the outcome variable (Table 4), there was a statistically significant finding for the association between birth trauma and total score on the EPDS, and participants who experienced birth trauma scored an average of 2.26 points higher on the EPDS than participants who did not experience birth trauma (\u003cem\u003ep\u003c/em\u003e=\u0026lt;0.001; β=2.26 [95% CI: 0.74-3.77]).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePostpartum Anxiety\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWomen were 33.0 percentage points more likely to screen positive for postpartum anxiety if they screened positive for birth trauma than if they did not screen positive for birth trauma (Table 3). Women who screened positive for birth trauma were at 1.34 times the risk for screening positive for postpartum anxiety than women who did not screen positive for birth trauma in the adjusted modified Poisson regression model (95% CI: 1.18-1.51). In the adjusted linear regression model where total score on the PASS was the outcome (Table 4), there were statistically significant results between birth trauma and severity of anxiety symptoms, and women who experienced birth trauma scored an average of 17.40 points higher on the PASS than women who did not experience birth trauma (\u003cem\u003ep\u003c/em\u003e=\u0026lt;0.001; β=17.40 [95% CI: 12.32-22.49]).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePostpartum OCD\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere was a risk difference of 3.4 percentage points between women who screened positive for OCD that screened positive for birth trauma and women who screened positive for OCD that did not screen positive for birth trauma (Table 3). Participants who screened positive for birth trauma had 1.03 times the risk of screening positive for OCD compared with participants who did not screen positive for birth trauma in the adjusted modified Poisson regression model (95% CI: 0.98-1.09). In the adjusted linear regression model where total score on the DOCS was the outcome and birth trauma was the predictor (Table 4), there was a statistically significant relationship, with women who experienced birth trauma scoring an average of 7.71 points higher on the DOCS when compared with women who did not experience birth trauma (\u003cem\u003ep\u003c/em\u003e=\u0026lt;0.001; β=7.71 [95% CI: 4.34-11.09]).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePostpartum Bipolar Disorder\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWomen who screened positive for birth trauma were 63.9 percentage points more likely to screen positive for postpartum bipolar disorder compared to women who did not screen positive for birth trauma (Table 3). Women who screened positive for experiencing birth trauma also had 9.59 times the risk of screening positive for postpartum bipolar disorder compared with women who did not screen positive for birth trauma in the adjusted modified Poisson regression model (95% CI: 2.77-33.16). When total score on the MDQ was the dependent variable in the adjusted linear regression model (Table 4), there was a statistically significant association between birth trauma and severity of symptoms for bipolar disorder, with women who experienced birth trauma scoring an average of 0.75 points higher on the MDQ than women who did not experience birth trauma (\u003cem\u003ep\u003c/em\u003e=\u0026lt;0.001; β= 0.75 [95% CI: 0.53-0.97]).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePostpartum Psychosis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWomen were 15.1 percentage points more likely to screen positive for postpartum psychosis if they screened positive for birth trauma than if they did not screen positive for birth trauma (Table 3). There were statistically significant results when the total score on the PSC was the dependent variable in the adjusted linear regression model, with women who experienced birth trauma scoring 0.71 points higher on the PSC than women who did not experience birth trauma (\u003cem\u003ep\u003c/em\u003e=\u0026lt;0.001; β= 0.71 [95% CI: 0.30-1.13]). Results for postpartum psychosis were unable to be calculated in the modified Poisson regression model due to the distribution of the data, which caused the model to not converge.\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe goal of this study was to examine associations between birth trauma and PMHDs. Within this sample, the prevalence rates for all disorders were very high compared to prevalence rates observed in the general population, for reasons that are unclear. The adjusted modified Poisson regression findings indicated that for all the PMHDs included in the analyses, there was a positive association between birth trauma and a positive screening result. These findings expand the extant literature that has already shown associations between birth trauma and perinatal depression (Ayers et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Bell \u0026amp; Anderson, 2016; Molloy et al. \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) and perinatal PTSD (Ayers et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Dekel et al., 2017; Grekin \u0026amp; O\u0026rsquo;Hara, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Simpson \u0026amp; Catling, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2016\u003c/span\u003e), and document statistically significant associations between birth trauma and bipolar disorder and psychosis. The findings also revealed a slight increased risk for OCD; however, these did not rise to the level of statistical significance in this sample.\u003c/p\u003e \u003cp\u003eThe results for the overall relationship between birth trauma and PMHDs indicate that although birth trauma should not be used as a sole indicator for a clinically significant positive screening result for PMHDs, women who screen positive for birth trauma generally score higher on screening tools for PMHDs than women who do not screen positive for birth trauma. For example, individuals who screened positive for birth trauma scored an average of 17.4 points higher on the PASS for anxiety and 7.71 points higher on the DOCS for OCD in the adjusted modified Poisson regression models. This is an important finding because it indicates that women who screen positive for birth trauma are experiencing more symptoms of multiple PMHDs and may be at increased risk for short- and long-term health effects that are the result of exposure to trauma itself and/or an increased presentation of PMHD symptomology.\u003c/p\u003e \u003cp\u003eScholars in other areas of research, particularly within adverse childhood experiences (ACEs), have found that exposure to trauma increases mental health symptom presentation and symptomology (Bomysoad \u0026amp; Francis, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Hughes et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). The findings from this study reinforce the connection between trauma exposure and the presentation of mental health symptoms. Although the symptoms that are being experienced by women who self-reported experiencing birth trauma may not always manifest at a clinically significant positive screening level for a PMHD, it is important to understand that birth trauma may result in more mental distress for individuals who experience it than individuals who do not.\u003c/p\u003e \u003cp\u003eAmong the women in this study, the prevalence rates of perinatal depression and anxiety were significantly elevated compared to what would be expected based on what has been estimated by other scholars in the field of perinatal mental health. Typically, some PMHDs would be considered rare enough that the \u0026ldquo;rare disease assumption\u0026rdquo; could be met, which would make Poisson regression a great fit for data analysis. This sample had the opposite issue where the outcomes were extremely common, leading to the use of modified Poisson regression for data analysis. The high prevalence rates would also have impacted regression models with binary outcomes significantly. Analyses with binary outcomes already significantly reduce statistical power, and with extremely prevalent outcomes in the study sample, analyses with binary outcomes would likely present null findings, even if relationships do exist between variables of interest; this is partly because power is limited when using binary outcomes. This elevated reporting of mental health symptomology from data collected when using crowdsourcing platforms aligns with findings from other scholars who have reported the same issue (Kolc et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). However, the prevalence rate for positive screening results for bipolar disorder and psychosis were in alignment with what has been reported by other scholars in studies that have not utilized MTurk for data collection processes (Raza \u0026amp; Raza, 2023; Yildiz et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2017\u003c/span\u003e), especially since there is no previously established cut-off score for the PSC.\u003c/p\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003e\u003cb\u003eStudy Limitations and Suggestions for Future Research\u003c/b\u003e\u003c/h2\u003e \u003cp\u003eDespite this study\u0026rsquo;s strengths, which include the use of valid and reliable screening tools, when available, and data quality assurance techniques, there are limitations to the study design, sample, and measurement that must be acknowledged. The cross-sectional design prohibited the ability to establish temporality in the relationship between birth trauma and the subsequent development of a PMHD. Efforts were made to mitigate this limitation by asking participants to state when their mental health symptoms began (i.e., prior to birth, during birth, immediately following birth-2 weeks after birth, 2 weeks-3 months after birth, or 3 months or more after birth), and women in this sample all indicated that their symptoms began following birth. However, it is possible that some respondents exhibited symptomology during their pregnancy, and this wasn\u0026rsquo;t reported accurately, or they were not fully aware of when their symptoms began. In addition, aspects of women\u0026rsquo;s mental health were not assessed prior to their pregnancy so the knowledge of their overall functioning and prior mental health diagnoses were not able to be considered. Finally, data on previous PMHD diagnoses were also not accounted for, which may also impact the observed relationships. Future work will explore relationships between birth trauma and onset of PMHD symptoms in each of the timeframes that were collected.\u003c/p\u003e \u003cp\u003eThe cross-sectional design also limited the ability to establish any type of increased risk or any kind of causal relationship between experiencing birth trauma and a positive screening result for PMHDs. To establish a causal relationship between birth trauma and PMHDs, temporal precedence, covariance, and non-spuriousness would need to be addressed (Celantano et al., 2024). Future research efforts in this area could include quasi-experimental, longitudinal studies following women from pregnancy through one year postpartum using a time series design to collect data about PMHD symptomology throughout the traditionally defined perinatal period.\u003c/p\u003e \u003cp\u003eThe use of crowdsourcing techniques, while convenient, meant that the sample was composed of individuals who had access to internet services and who were aware of the MTurk platform. These factors were reflected in the high percentage of White, highly educated, individuals included in the study sample. The lack of representation of women from varying socioeconomic and cultural backgrounds was a limitation that prohibited the adjustment for such factors (e.g., race, ethnicity) during data analysis due to small cell size. These other social factors may impact the relationship between birth trauma and each of the PMHDs, but these were not able to be assessed in this study.\u003c/p\u003e \u003cp\u003eAnother limitation of this study was the use of measures of symptomatology rather than PMHD diagnoses. Rather than defining the outcome as a diagnosed PMHD, screening tools were used because diagnoses of PMHDs may be an under-representation of the true burden of PMHDs among women in the United States (Womersley \u0026amp; Alderson, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). There is limited research on this topic, so positive screens for each PMHD were used to capture as many cases as possible. This may mean that the observed relationships were not as precise as they could be, as not everyone who screens positive for a PMHD is not diagnosed with one of these disorders. Future research efforts should focus on understanding more precise associations between birth trauma and diagnosis of PMHDs. Additionally, the specific screening measures for PMHDs have commonly been utilized by scholars in virtual settings and studies; however, there are limited studies assessing the validity of the use of these measures in these settings, which may have also impacted this study\u0026rsquo;s findings. Finally, prior mental health history was not assessed in this study, which could have a significant impact on the findings of this study; this will be considered in future research.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eImplications\u003c/h2\u003e \u003cp\u003eThe findings from this study underscore the substantial mental health burden experienced by women who report birth trauma and highlight the need for integrated, trauma-informed approaches to perinatal care. The high prevalence of PMHDs observed\u0026mdash;particularly depression, anxiety, and OCD\u0026mdash;suggest that current screening and support systems may be insufficient to identify and address the needs of postpartum women, especially those who have experienced traumatic births.\u003c/p\u003e \u003cp\u003eFrom a public health perspective, these results call for expanding postpartum mental health screening protocols beyond depression alone. Given that women who experienced birth trauma in this study were more likely to screen positive for multiple PMHDs, universal, multi-condition screening should be considered in perinatal settings. Public health interventions should also prioritize early identification and prevention of birth trauma through respectful maternity care, informed consent practices, and strategies to reduce unnecessary medical interventions that can contribute to traumatic experiences.\u003c/p\u003e \u003cp\u003eThe associations between birth trauma and conditions such as bipolar disorder and psychosis\u0026mdash;disorders often considered rare in the perinatal period\u0026mdash;are particularly noteworthy. This suggests that birth trauma screening could serve as an important adjunct to early detection efforts for these severe conditions, which, if left untreated, carry substantial risks for both maternal and infant health. Public health programs aimed at perinatal mental health should incorporate trauma history assessment into routine postpartum care, while also ensuring referral pathways to specialized psychiatric evaluation when indicated.\u003c/p\u003e \u003cp\u003eFrom a clinical perspective, these findings highlight the importance of multidisciplinary care models that integrate obstetric, psychiatric, and psychological expertise. Clinicians should be trained to recognize the signs of birth trauma and its potential mental health sequelae, even when patients do not meet full diagnostic criteria for a PMHD. Furthermore, screening should be paired with immediate access to evidence-based interventions, such as trauma-focused cognitive behavioral therapy, peer support programs, and pharmacological management, when appropriate.\u003c/p\u003e \u003cp\u003eGiven the elevated symptom burden among women with birth trauma, there is a clear need for care continuity beyond the traditional six-week postpartum visit. Establishing extended follow-up intervals, especially within the first year postpartum, could facilitate timely intervention, prevent symptom escalation, and mitigate the risk of chronic mental health conditions. Finally, these findings reinforce the need for culturally responsive and equitable mental health services, particularly for populations historically underrepresented in perinatal mental health research.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study provides compelling evidence that birth trauma is significantly associated with elevated rates and severity of multiple PMHDs, including depression, anxiety, bipolar disorder, and psychosis. While the cross-sectional design precludes causal inference, the strength and consistency of associations across disorders highlight birth trauma as a key factor in perinatal mental health profiles. Importantly, women who experienced birth trauma not only had higher rates of positive screening results but also demonstrated greater symptom severity across multiple PMHDs.\u003c/p\u003e \u003cp\u003eThese findings contribute to the growing body of literature linking traumatic experiences during childbirth with adverse mental health outcomes, extending previous research beyond depression and PTSD to include less-studied conditions such as bipolar disorder and psychosis. The results also underscore the need for broader perinatal mental health screening, trauma-informed maternity care practices, and integrated clinical pathways to address the complex needs of women affected by birth trauma.\u003c/p\u003e \u003cp\u003eAddressing birth trauma is not solely a matter of individual patient care\u0026mdash;it is a systemic public health imperative. Interventions aimed at prevention, early detection, and treatment of both birth trauma itself and its psychiatric sequelae have the potential to improve maternal health outcomes, enhance family well-being, and reduce the intergenerational transmission of trauma-related mental health risks. As such, these findings should inform both clinical guidelines and public health policies aimed at improving the mental health of postpartum women.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eACEs \u0026ndash; Adverse Childhood Experiences\u003c/p\u003e\n\u003cp\u003eCNAE \u0026ndash; Concepts Negatively Associated with Empowerment\u003c/p\u003e\n\u003cp\u003eCPAE \u0026ndash; Concepts Positively Associated with Empowerment\u003c/p\u003e\n\u003cp\u003eC-section - Cesarean Section\u003c/p\u003e\n\u003cp\u003eCBTS \u0026ndash; City Birth Trauma Scale\u003c/p\u003e\n\u003cp\u003eDOCS \u0026ndash; Dimensional Obsessive-Compulsive Scale\u003c/p\u003e\n\u003cp\u003eEPDS \u0026ndash; Edinburgh Postnatal Depression Scale\u003c/p\u003e\n\u003cp\u003eMDQ \u0026ndash; Mood Disorder Questionnaire\u003c/p\u003e\n\u003cp\u003eMTurk \u0026ndash; Mechanical Turk\u003c/p\u003e\n\u003cp\u003eOCD \u0026ndash; Obsessive Compulsive Scale\u003c/p\u003e\n\u003cp\u003ePASS \u0026ndash; Postpartum Anxiety Screening Scale\u003c/p\u003e\n\u003cp\u003ePMHDs \u0026ndash; Perinatal Mental Health Disorders\u003c/p\u003e\n\u003cp\u003ePSC - Psychosis Symptom Checklist\u003c/p\u003e\n\u003cp\u003ePTSD \u0026ndash; Post-Traumatic Stress Disorder\u003c/p\u003e\n\u003cp\u003eSAMHSA - Substance and Mental Health Services Administration\u003c/p\u003e\n\u003cp\u003eSCS \u0026ndash; Sense of Control Scale\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to participate: \u003c/strong\u003eThis study was approved by the IRB at South Dakota State University (IRB-2024-192). All participants completed the eConsent process in REDCap prior to study participation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e All authors have reviewed this manuscript and provide consent for publication. This manuscript is not under consideration at any other journal for publication.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials: \u003c/strong\u003eAll data and materials are available upon request. Please email [email protected] to request access to the deidentified quantitative data.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e The authors have no competing interests to declare.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e This study was completed with funding from the Health Resources and Services Administration, Grant A30MC50003.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions: \u003c/strong\u003eSH (Conceptualization, Methodology, Analysis, Investigation, Original Draft, Review \u0026amp; Editing)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements: \u003c/strong\u003eWe would like to thank all participants for their time and contributions to this study. We also acknowledge the support of South Dakota State University for providing resources and infrastructure for data collection and analysis. We would also like to thank Dr. Lynette Renner, Dr. Mimi Choy-Brown, Dr. Joseph Merighi, and Dr. Susan Marshall Mason for their guidance and help with this work.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eData Availability\u003c/h2\u003e\n\u003cp\u003eAll data and materials are available upon request. Please email [[email protected]](mailto:[email protected]) to request access to the deidentified quantitative data.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAbramowitz JS, Deacon BJ, Olatunji BO, Wheaton MG, Berman NC, Losardo D, Timpano KR, McGrath PB, Riemann BC, Adams T, Bj\u0026ouml;rgvinsson T, Storch EA, Hale LR. Assessment of obsessive-compulsive symptom dimensions: development and evaluation of the Dimensional Obsessive-Compulsive Scale. 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J Affect Disord. 2017;208:634\u0026ndash;45. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jad.2016.10.009\u003c/span\u003e\u003cspan address=\"10.1016/j.jad.2016.10.009\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1.\u0026nbsp;\u003c/strong\u003e\u003cem\u003eParticipant Demographics (N=249)\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"432\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 269px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003en\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 269px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e22-24\u003c/p\u003e\n \u003cp\u003e25-29\u003c/p\u003e\n \u003cp\u003e30-34\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;35-55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003cp\u003e141\u003c/p\u003e\n \u003cp\u003e77\u003c/p\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e8.0\u003c/p\u003e\n \u003cp\u003e56.6\u003c/p\u003e\n \u003cp\u003e31.0\u003c/p\u003e\n \u003cp\u003e4.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 269px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eRace\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eWhite\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Native American\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Alaska Native\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Middle Eastern\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e243\u003c/p\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e97.6\u003c/p\u003e\n \u003cp\u003e1.6\u003c/p\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 269px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eEthnicity\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eHispanic/Latino\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Non-Hispanic/Latino\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003cp\u003e237\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4.8\u003c/p\u003e\n \u003cp\u003e95.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 269px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eIncome\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;$0-14,999\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;$15,000-24,999\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;$25,000-34,999\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;$35,000-49,999\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;$50,000-74,999\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;$75,000-99,999\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;$100,000-149,999\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;$150,000-199,999\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;$200,000 or more\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003cp\u003e14.1\u003c/p\u003e\n \u003cp\u003e19.3\u003c/p\u003e\n \u003cp\u003e10.0\u003c/p\u003e\n \u003cp\u003e22.1\u003c/p\u003e\n \u003cp\u003e15.3\u003c/p\u003e\n \u003cp\u003e15.3\u003c/p\u003e\n \u003cp\u003e3.2\u003c/p\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 269px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eInsurance\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Medicaid\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;IHS\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Private\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Obamacare\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Other\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e181\u003c/p\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003cp\u003e57\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e72.7\u003c/p\u003e\n \u003cp\u003e1.6\u003c/p\u003e\n \u003cp\u003e22.9\u003c/p\u003e\n \u003cp\u003e1.2\u003c/p\u003e\n \u003cp\u003e1.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 269px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eEducation\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Associate\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Bachelor\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Master\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Doctoral/Professional\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003cp\u003e166\u003c/p\u003e\n \u003cp\u003e77\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.2\u003c/p\u003e\n \u003cp\u003e66.7\u003c/p\u003e\n \u003cp\u003e30.9\u003c/p\u003e\n \u003cp\u003e1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u0026nbsp;\u003c/strong\u003e\u003cem\u003eBirthing Experience and Mental Health (N=249)\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"618\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 455px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003en\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 455px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBirth Location\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Hospital\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Birthing Center\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Home\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e183\u003c/p\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003cp\u003e56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e73.5\u003c/p\u003e\n \u003cp\u003e4.0\u003c/p\u003e\n \u003cp\u003e22.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 455px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eBirth Modality\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eVaginal\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Cesarean Section (C-Section)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e131\u003c/p\u003e\n \u003cp\u003e118\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e52.6\u003c/p\u003e\n \u003cp\u003e47.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 455px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of Previous Live Births\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e0\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;1\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;2\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;3\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;4\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003cp\u003e153\u003c/p\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e17.3\u003c/p\u003e\n \u003cp\u003e61.4\u003c/p\u003e\n \u003cp\u003e19.3\u003c/p\u003e\n \u003cp\u003e1.2\u003c/p\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 455px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSelf-Reported Experiencing Birth Trauma\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e21.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 455px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExperienced Birth Trauma and Screened Positive for at Least One PMHD\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e21.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 455px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrevalence of PMHDs\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Depression\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Anxiety\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;OCD\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Bipolar Disorder\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Psychosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e211\u003c/p\u003e\n \u003cp\u003e204\u003c/p\u003e\n \u003cp\u003e223\u003c/p\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e84.7\u003c/p\u003e\n \u003cp\u003e81.9\u003c/p\u003e\n \u003cp\u003e93.6\u003c/p\u003e\n \u003cp\u003e10.0\u003c/p\u003e\n \u003cp\u003e3.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3. \u0026nbsp;\u003c/strong\u003e\u003cem\u003eModified Poisson Regression Results with Birth Trauma as the Predictor and PMHDs as the Outcome (N=249)\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"863\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"9\" valign=\"top\" style=\"width: 364px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnadjusted\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"10\" valign=\"top\" style=\"width: 329px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdjusted*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003eRisk \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Difference\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eBirth trauma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"9\" valign=\"top\" style=\"width: 364px;\"\u003e\n \u003cp\u003eDepression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"10\" valign=\"top\" style=\"width: 329px;\"\u003e\n \u003cp\u003eDepression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExp(B)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExp(B)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e1.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1.01-1.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e1.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e1.00-1.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e9.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"20\" valign=\"top\" style=\"width: 782px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eBirth trauma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"9\" valign=\"top\" style=\"width: 364px;\"\u003e\n \u003cp\u003eAnxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"10\" valign=\"top\" style=\"width: 329px;\"\u003e\n \u003cp\u003eAnxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExp(B)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExp(B)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e1.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1.20-1.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e0.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e1.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e1.18-1.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e33.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"21\" valign=\"top\" style=\"width: 863px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eBirth trauma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"10\" valign=\"top\" style=\"width: 364px;\"\u003e\n \u003cp\u003eOCD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"8\" valign=\"top\" style=\"width: 329px;\"\u003e\n \u003cp\u003eOCD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExp(B)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExp(B)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e1.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e0.97-1.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.98-1.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e3.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"21\" valign=\"top\" style=\"width: 863px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eBirth trauma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"10\" valign=\"top\" style=\"width: 364px;\"\u003e\n \u003cp\u003eBipolar\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"8\" valign=\"top\" style=\"width: 329px;\"\u003e\n \u003cp\u003eBipolar\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExp(B)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExp(B)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e2.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e7.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e3.59-17.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e2.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e9.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e2.77-33.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e63.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"21\" valign=\"top\" style=\"width: 863px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eBirth trauma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"10\" valign=\"top\" style=\"width: 364px;\"\u003e\n \u003cp\u003ePsychosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"8\" valign=\"top\" style=\"width: 329px;\"\u003e\n \u003cp\u003ePsychosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExp(B)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExp(B)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e**\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e15.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 89px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 1px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 1px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 1px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 1px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 0px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 2px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 63px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 3px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 3px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 1px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*adjusted for age,\u0026nbsp;income, insurance, education, birth location, birth modality, delivery type, and previous number of live births\u003c/p\u003e\n\u003cp\u003e** unable to calculate\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4. \u0026nbsp;\u003c/strong\u003e\u003cem\u003eLinear Regression Results with Birth Trauma as the Predictor and PMHDs as the Outcome (N=249)\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"863\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"10\" valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnadjusted\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"11\" valign=\"top\" style=\"width: 374px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdjusted*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" rowspan=\"3\" valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eBirth trauma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"10\" valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003eDepression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"11\" valign=\"top\" style=\"width: 374px;\"\u003e\n \u003cp\u003eDepression\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e\u003cstrong\u003et\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eF\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003et\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eF\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e0.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e3.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e2.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e0.82-3.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e2.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e3.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e2.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e0.74-3.77\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"23\" valign=\"top\" style=\"width: 863px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" rowspan=\"3\" valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eBirth trauma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"10\" valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003eAnxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"11\" valign=\"top\" style=\"width: 374px;\"\u003e\n \u003cp\u003eAnxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003et\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eF\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003et\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eF\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e3.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e4.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e14.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e8.53-20.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e2.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e6.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e20.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e17.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e12.32-22.49\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"23\" valign=\"top\" style=\"width: 863px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eBirth trauma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"12\" valign=\"top\" style=\"width: 392px;\"\u003e\n \u003cp\u003eOCD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"10\" valign=\"top\" style=\"width: 370px;\"\u003e\n \u003cp\u003eOCD\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003et\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eF\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u003cstrong\u003et\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eF\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e1.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e3.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e5.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e2.12-9.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e1.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e4.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e9.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e7.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e4.34-11.09\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"23\" valign=\"top\" style=\"width: 863px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eBirth trauma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"12\" valign=\"top\" style=\"width: 392px;\"\u003e\n \u003cp\u003eBipolar\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"10\" valign=\"top\" style=\"width: 370px;\"\u003e\n \u003cp\u003eBipolar\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003et\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eF\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u003cstrong\u003et\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eF\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e5.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e0.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.46-0.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e6.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e16.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.53-0.97\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"23\" valign=\"top\" style=\"width: 863px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eBirth trauma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"12\" valign=\"top\" style=\"width: 392px;\"\u003e\n \u003cp\u003ePsychosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"10\" valign=\"top\" style=\"width: 370px;\"\u003e\n \u003cp\u003ePsychosis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003et\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eF\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u003cstrong\u003et\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eF\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e0.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e2.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e0.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.23-1.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e0.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e3.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e20.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.30-1.13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*adjusted for age, income, insurance, education, birth location, birth modality, delivery type, and previous number of live birth\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"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":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-8107423/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8107423/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eGlobally, 130\u0026nbsp;million live births occur annually, including 3.6\u0026nbsp;million in the U.S. in 2023. While many women anticipate a positive birth experience, approximately 45% report birth trauma\u0026mdash;a subjective experience that can occur regardless of medical complications. Birth trauma may increase risk for perinatal mental health disorders (PMHDs) such as depression, anxiety, obsessive-compulsive disorder (OCD), bipolar disorder, and psychosis. Existing research primarily focuses on birth trauma and perinatal PTSD, with limited exploration of its relationship to other PMHDs. This study examined associations between birth trauma and five PMHDs.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA cross-sectional survey was conducted in December 2024 using Amazon Mechanical Turk and REDCap. Participants (N\u0026thinsp;=\u0026thinsp;249) were U.S.-based women, 4 weeks\u0026ndash;7 months postpartum. Birth trauma was assessed using the City Birth Trauma Scale; PMHDs were measured with validated tools including EPDS, PASS, DOCS, and MDQ. Modified Poisson and linear regressions, adjusted for demographic and birth variables, examined associations.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eBirth trauma was reported by 21.3% of respondents. PMHD prevalence was high: depression (84.7%), anxiety (81.9%), OCD (93.6%), bipolar disorder (10%), and psychosis (3.2%). Birth trauma was significantly associated with increased risk for depression (RR\u0026thinsp;=\u0026thinsp;1.15), anxiety (RR\u0026thinsp;=\u0026thinsp;1.34), bipolar disorder (RR\u0026thinsp;=\u0026thinsp;9.59), and psychosis; OCD risk increase was non-significant. Symptom severity scores were higher across all PMHDs among women reporting birth trauma.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eBirth trauma is positively associated with elevated risk and symptom severity of multiple PMHDs beyond PTSD. Findings highlight the need for integrated postpartum screening and trauma-informed interventions to improve maternal mental health outcomes.\u003c/p\u003e","manuscriptTitle":"The Relationship Between Birth Trauma and Perinatal Mental Health Disorders: A Cross-Sectional Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-18 18:22:17","doi":"10.21203/rs.3.rs-8107423/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-07T10:31:36+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-27T22:46:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"228074879583037592515177611775914792396","date":"2026-03-16T13:06:31+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-02T05:40:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"228074879583037592515177611775914792396","date":"2025-12-26T16:15:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"226072436721494564407568199831637540309","date":"2025-12-24T03:39:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"236556813246914306824025709313036813513","date":"2025-12-18T21:58:52+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-16T14:04:37+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-11-18T08:44:47+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-17T07:24:56+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-17T07:23:30+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2025-11-13T15:38:20+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3c64637b-2a58-4561-ae03-3e9f7b940a8e","owner":[],"postedDate":"December 18th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-14T07:23:25+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-18 18:22:17","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8107423","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8107423","identity":"rs-8107423","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}